Introduction: Early mobility in Pediatric Intensive Care Units (PICU) is associated with improved outcomes, however, electronic health record (EHR) documentation of mobility by nurses is limited. This study evaluates discrepancies between expected mobility, nursing-report and EHR documentation in a PICU with an early mobility program. Methods: We conducted secondary analysis of a quality improvement project to increase nurse-led mobility among 101 patients admitted to the PICU for ≥3 days. Mobility level (1 = most restrictive to 3 = most liberal), highest level of mobility achieved (HLM) and number of mobilizations were collected from EHR documentation and end-of-shift interview with nurses (RN-report). We retrospectively assigned expected mobility level, HLM and mobilization count based on protocol. Results: Median mobilizations per shift were 1 (IQR 1-3) by EHR vs. 6 (IQR 4-6) by RN-report, compared to an expected of 6. Mobility level varied by data source. EHR data showed 13% Level 1, 26% Level 2, 48% Level 3 and 14% undocumented. RN-report data showed 9% Level 1, 23% Level 2, 50% Level 3 and 28% unknown. Expected distribution was 24% Level 1, 23% Level 2 and 53% Level 3. Agreement between expected mobility level and EHR was 56.4% (κ=0.34, p< 0.001) and 53.5% (κ=0.32, p< 0.001) for RN-report. HLM also varied by source and from expected. By EHR data, HLM was 13% bedrest, 41% passive range of motion (ROM), 39% out-of-bed activity. By RN-report, HLM was 1% bedrest, 33% passive ROM, 53% out-of-bed activity. Expected HLM was 0% bedrest, 29% passive ROM and 54% out-of-bed. The agreement of expected HLM was 38% (κ=0.17, p< 0.001) with the EHR and 39% (κ=0.18, p< 0.001) with RN-report. A higher Pediatric Cerebral Performance Category Score (OR=2.07, p=0.007), sedation infusions (OR=4.25, p=0.042) and feeding tubes (OR=7.7, p=0.074) increased odds of uncertain mobility level. Feeding tubes also increased the odds of level 3 patients being moved less than expected (OR=0.019, p=0.018). Conclusions: Discrepancies between nurse-report, EHR data, and protocol expectations are common. Baseline function, sedation infusions, and feeding tubes are associated with mobilization discordance and uncertainty in PICUs. Future research should target education and human factors to improve documentation and protocol adherence.
Manikandan et al. (Sun,) studied this question.