The results indicated that the PICU healthcare staff had a moderate level of KAP regarding ICU-AW (87.36 ± 14.241).ICU-AW has been recognized as a complication in adults, of which CIM and CIN are important causes. ICU-AW is associated with many diseases in adults, including asthma, sepsis, and systemic inflammatory response syndrome. Our team has reviewed the literature on ICU-AW in adults [15].Studies [16] have confirmed that more than 50% of adult patients experience varying degrees of ICU-AW, but ICU-AW is less explored among critically ill children due to the limited number of pediatric cases. This hinders the knowledge of PICU medical staff regarding ICU-AW (30.35 ± 6.317). The overall knowledge level of KAP regarding children with ICU-AW was moderate. Only 7.2%, 8.1%, and 11.5% of PICU medical staff knew about the diagnosis, assessment methods, and risk factors of ICU-AW. Aida Field-Ridley et al. [17] compared the differences in clinical outcomes between adults and children with ICU-AW. Their multivariate analysis showed that—similar to adults—mechanical ventilation, extracorporeal circulation, tracheotomy, and respiratory disease were risk factors for ICU-AW in pediatric populations.However, after reviewing 203875 cases, the team had only 55 cases with ICU-AW; this is inconsistent with other studies [8]. The diagnosis of ICU-AW is strictly clinical and is usually assessed by manual muscle testing or hand-held dynamometry in adults. The Medical Research Council (MRC) is used to evaluate and diagnose ICU-AW in adult ICU patients [18] but is difficult to apply in critically ill children. The MRC-Score requires the patient’s cooperation during the assessment process and is susceptible to the assessor’s subjective consciousness during the scoring process. Therefore, PICU medical staff cannot easily detect if a critically ill child has ICU-AW. Consequently, the relatively poor level of knowledge directly affects the ability of PICU medical staff to act.
Assessment barriers are likely responsible for the inferior level of behavior (26.54 ± 6.454) of the ICU-AW of the PICU medical staff. Standard procedures for assessing the neuromuscular function of children in the PICU and the appropriate level of functional exercise are lacking. Nurses in the PICU prefer to keep children in a more comfortable state to reduce the pain associated with the disease, especially when a child is mechanically ventilated. Further, children are reluctant to cooperate with rehabilitation exercises due to discomfort, and their families are reluctant to undertake the risks of rehabilitation. Consequently, ICU-AW is usually detected among children in the PICU after withdrawal of mechanical ventilation.
Thankfully, almost all survey respondents indicated a willingness to receive training related to ICU-AW. All medical staff affirmed the benefits of rehabilitation exercises, and 99.1% of the PICU medical staff believed that ICU-AW should be treated at par with complications such as pressure ulcers and infections, which confirmed results from other studies [19]. However, who should perform the assessment remains debatable. Given that nurses have the most contact with patients, 74.4% of participants believed that nurses should assess the patient, since increased contact enhances the convenience of evaluation. However, neuromuscular assessment is performed diversely. In addition to the physical function, patients’ respiratory function, cough reflex, and nutritional status must be assessed. Considering this, a single assessment of muscle strength is inadequate to observe the status of the PICU child suffering from ICU-AW. A joint evaluation in collaboration with other medical personnel is required.
The results from the univariate analysis and independent samples t-test showed large differences (p < 0.05) between gender, title, position, job title, years of experience, number of beds, and hospital level. Total KAP scores were lower for females, nurses, junior nurses, clinicians and clinical nurses, college degree holders, personnel with < 3 years of service, and personnel from level 3 Grade B hospitals. This suggests the need for hospital managers to target training to these groups. Evidence [20] suggests that highly educated people are more inquisitive compared to others, more adept at predicting the precursors of defending the conditions of critically ill children, and analyzing and summarizing the various problems arising in clinical work. Further, individuals with high education levels also have a good level of scientific thinking ability to access relevant information, as well as understand and seek solutions. The total KAP scores were also relatively higher for personnel with 16–20 years of experience and those with a senior job title. This may be because, along with the increase in years of service of PICU nurses, rank elevates due to their greater focus on improving their comprehensive ability and increasing level of work responsibility [21]. Long-term practical work broadens and enrichens knowledge related to critical care and the ability to explore difficult problems. Moreover, they are more willing to take the initiative to care for children in the PICU compared to other personnel[22].
The results of the multiple linear regression analysis showed that gender, education level, and hospital level were predictors of the KAP level of PICU healthcare workers regarding critically ill children with ICU-AW. The education level of PICU healthcare workers somewhat influenced the KAP scores of ICU-AW. Currently, ICU-AW is included neither in the content of Emergency and Critical Care Medicine or Emergency and Critical Care Nursing in Chinese medical schools nor in the continuing education training of new PICU employees. The concepts of ICU-AW and its research advances are only available in academic conferences, research reports, and journal forums. Therefore, it is suggested that managers include ICU-AW in future training and provide PICU staff with more opportunities for external study and visits, case discussions, and academic conferences to expand their perspective and improve their professionalism. In the present study, only 9.6% of the survey respondents were male, predicting that male staff would be better at assessing and preventing ICU-AW when faced with high-pressure, high-intensity, and high-risk PICU work.
Hospitals in China are classified according to their functions, facilities, and technology. According to the Measurement Standards for Hospital Grading issued by the National Health Commission, hospitals are classified into 3 levels. Each level is further divided into Grades A, B, and C. Level 3 hospitals are health service hospitals that provide medical care nationwide and medical prevention technology centers with comprehensive medical, teaching, and research capabilities [14], whereas level 2 hospitals are only regional. The level of general hospitals in terms of factors such as scale, technical level, medical equipment, and management level is generally higher than that of specialty hospitals. In China, PICUs require a certain level of hospital qualification and are mostly established in Level 3 hospitals. Only one PICU in this study was a level 2 hospital, thus a higher hospital level predicts a better level of KAP regarding ICU-AW.
The study has some limitations. First, the sample size was small. Although 38 hospitals responded, only 13 respondents on average came from each region. This is also likely related to the setup of PICUs in China. Most PICUs in the present study had around 10 beds, thus there were less personnel in the PICU. Second, the respondents in this study were mainly doctors and nurses, although some became research assistants and managers. There were no responses from rehabilitation therapists, psychotherapists, or other professionals. This may limit the generalizability of the findings. Finally, due to the impact of the COVID-19 epidemic in China, communications with survey respondents were restricted due to Chinese policy. Therefore, only online questionnaires could be conducted, which affected the quality of the survey to some extent.