Early Mobilization in Pediatric Critical Care: Exploring the Gap between Theory and Practice in Saudi Arabia

doi:10.21203/rs.3.rs-3244302/v1

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Early Mobilization in Pediatric Critical Care: Exploring the Gap between Theory and Practice in Saudi Arabia

https://doi.org/10.21203/rs.3.rs-3244302/v1

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Background:Advancements in critical care have improved survival rates for children in PICUs, but many survivors suffer long-term morbidity and lower quality of life due to ICU-acquired weakness, cognitive impairment, and immobility-related issues. Early mobilization (EM) is a promising intervention to reduce these negative consequences. This study evaluates the knowledge, views, and practices of physicians and care providers regarding EM in Saudi Arabia's pediatric critical care units.

Study Design: A survey was conducted from July 2020 to February 2021 to gather information on early mobilization practices for critically ill children in the pediatric intensive care unit in Saudi Arabia. The survey was sent to 110 doctors, 200 nurses, 30 respiratory therapists, and 20 physiotherapists. The survey aimed to explore rehabilitation aspects, including the challenges faced during early mobilization, suitable timing and types of rehabilitation, and healthcare personnel workload.

Results:A survey with a 72.78% response rate, primarily from registered nurses (65.7%), indicated strong support for early mobilization in Pediatric Intensive Care Unit (PICU) patient care among healthcare professionals. Over 80% of respondents considered it crucial or important. However, institutional and healthcare provider-level barriers exist, including lack of equipment (63.5%), medical instability (67.3%), endotracheal intubation (65.4%), and limited staff (56.4%). Concerns about safety (47.4%) and insufficient physical space (38.9% physicians, 24.7% non-physicians) were also raised. Routine bed rest orders upon PICU admission were more common among non-physicians (26.8%) compared to physicians (12.5%). As illness severity increased, clinicians' comfort with early mobilization decreased. Most common rehabilitation interventions were respiratory physiotherapy and passive range of motion (77.8%). Healthcare professionals in Saudi Arabia regularly use daily sedation interruptions in pediatric ICUs. However, only 38.7% of respondents referred patients with suspected ICU-acquired weakness to outpatient clinics for long-term rehabilitation.

Conclusion: Early mobilization is crucial in pediatric critical care in Saudi Arabia, but its implementation faces challenges. Healthcare institutions must navigate these challenges with strategic intent and a multidisciplinary ethos. Future research should focus on optimal timelines and interventions tailored to specific pediatric cohorts. This approach can improve patient outcomes and elevate the caliber of pediatric critical care, refining healthcare quality and providing a blueprint for excellence globally.

Early Mobilization

Pediatric critical care

survey

Children

Saudi Arabia

Advances in understanding and technology have significantly improved the survival rate of children in PICUs. However, this has negatively impacted the quality of life for survivors and their families, leading to the post-intensive care syndrome (PICS). [1- 4]It is poorly understood in pediatrics with limited case series and longitudinal studies.[5] However, it is thought that ICU acquired weakness involves decreased contractility, muscle atrophy, anabolic resistance, mitochondrial dysfunction, and calcium homeostasis issues.[6]A considerable increase in survivors with moderate or severe disabilities has been observed over the past three decades, despite a decline in mortality rates and stability in the length of stays in paediatric critical care units and the severity of illnesses.[7] Yuan C (2021) cited that more than half of patients who are discharged from critical care units suffer from post-intensive care syndrome.[8] Knoester (2008) with other co-workers , using the TNO-AZL Preschool Children Quality of Life Questionnaire, a study evaluated the health-related quality of life (HRQoL) of PICU survivors. In children aged 1-6 years and 6-12 years, the results revealed substantial disparities in lung function abnormalities , problem behaviour, and motor performance.[9] 3.4%-10.5% of patients who developed global functional and cognitive disability following admission to the PICU were found in a cohort of 29,352 admissions.[10] PICS is likely caused by a number of interrelated risk factors, including the critical illness itself, mechanical ventilation, sedation, delirium, prolonged bed rest, and immobility during the illness.[11]. It has been published that Polyneuropathy [12- 13],muscle wasting[12, 14], physical and mental function impairment common, even among sepsis survivors.[6,15]Our current understanding of Post intensive care syndrome in pediatrics (PICs-P) has several holes. Disparate research techniques have hampered a comprehensive approach to screening, preventing, and treating PICs-related morbidity.[16]Recent discoveries about the biological basis of PICS-specific features highlight the importance of reassessing our patient trajectories in the long run. [17]The post-intensive care syndrome paradigm, which incorporates numerous multidimensional morbidities, was developed at the 2010 Society of Critical Care Medicine meeting on improving long-term outcomes following critical illness for survivors and their families.[18]

Early physical therapy and mobilisation during critical illness is a safe, realistic, and effective technique of reducing long-term morbidity, which is referred to as post-intensive care syndrome.[19]The benefits of early mobilisation of critically sick patients suggest that it should be included into daily therapeutic practise. In intensive care units, early passive, active, and combined progressive mobilisations can be initiated safely.[20–22]In paediatric critical care units, a survey was conducted to assess the knowledge, views, and stated practises of early mobilisation among physicians and physiotherapists practising in Canada by Karen Choong(2013)[23] by Ista E (2020) Europe, Thompson J (2022) [24]the United Kingdom and Bakhru R[25] in USA . Additionally, a international survey were conducted that indicated international ICU organisation and practice vary significantly, with characteristics like multidisciplinary rounds, patient goals, specialized physiotherapists, and country staffing ratios influencing EM practice. Staffing and practice patterns must be considered for successful implementation for early mobilization practices in pediatric critical care unit.[26]Similar survey was conducted and revealed that the prevalence of EM for mechanically ventilated adult patients in Saudi Arabia was 47%, even though only 36% of ICU staff had previous EM training. Modifiable impediments to EM, such as a lack of training, rules and protocols, and staffing, will aid in the promotion of EM in Saudi Arabian ICUs.[27]We conducted national wide survey on this regard to explore more deeper knowledge of the current gap between theory and practise in Saudi Arabia is critical for developing methods and tactics to reduce PICS and, eventually, improve patient recovery.

Study Design and Setting and sample: From July 2021 to February 2022, a cross-sectional, self-administered survey was undertaken, adapted from a "Survey of Canadian Practice Study in Early Mobilization."[23] The survey was distributed to 110 doctors, 200 nurses, 30 respiratory therapists, and 20 physiotherapists. 14 different cities from Saudi Arabia participated in the survey. This study was approved by unit of biomedical ethics, King Abdulaziz University, Faculty of medicine, No.446-19. The survey sought information on the current state of early mobilization practices in Saudi Arabia for critically ill children admitted to the pediatric intensive care unit, as well as to investigate various aspects of rehabilitation, such as the difficulties encountered when attempting early mobilization, the appropriate timing and nature of rehabilitation, and the workload of healthcare provider.

Measurement: The survey collected data on several aspects of early mobilization practice, such as demographics, perspectives (personal opinions), impediments at various levels, and the best time for early mobilization. Data from the survey also revealed attitudes toward practices in 12 important clinical settings in Saudi Arabia, pediatric critical care units. Furthermore, established procedures for determining the need for rehabilitation after discharge from the unit Furthermore, the referral mechanism and services utilized in this procedure.

Statistical Analysis: All analysis were performed using R version 4.1.1 (2021-08-10), primarily the tableone package, to create "Table 1". This package summarized both categorical and numerical variables. Categorical variables were counted or expressed as percentages. We used one of two methods to summarize continuous variables: a normally distributed method using means and standard deviations; or a non-normal method using medians and intervals. There are two standard hypothesis tests by default: the chi-square test for categorical variables and the one-way test for continuous variables. T-tests are equivalent to two-group ANOVAs. The exact argument specified Fisher tests for categorical variables, and Kruskal tests for nonnormal continuous variables. In the two-group case, Kruskal’s test considered the equivalent of Wilcox’s test. Signiﬁcant differences between groups were reported at the a-level of 0.05 and 95% confident level.

Respondents: A survey of 266 Saudi Arabian respondents found that Jeddah had the largest percentage of respondents (54.1%), followed by Riyadh (78.3%), Tabuk (5.6%), and Madinah (3.4%). Most respondents were registered nurses (64.7%), followed by consultants and attending physicians (16.5%) and physicians undergoing clinical training (7.1%). The lowest percentage was specialists and registrars. (Table-1) Most respondents 34.6% had one to five years of experience, with 28.6% having 6-10 years, 18.4% having 11-15 years, and 8.6% having 16-20 years. The remaining respondents had less than a year, 21-25 years, or more than 25 years of experience. The poll shows 127(47.7%) respondents work in ICUs with a mix of medical and surgical care, with 86 (32.3%) in the second-largest group. Only 1.9% worked in exclusively medical ICUs, while 16.2% worked exclusively cardiac ICUs. (Table-1) The majority of facilities have 5-15 beds, with 184 (69.2%) having them, followed by 50 (18.8%) with 16-25 beds. 9.8% have more than 25 beds, while only 2.3% have fewer than 5 beds. Most respondents admit 200-500 patients annually, with 29.3% unaware of the number. Most respondents work in academic teaching hospitals connected to universities, while the remaining 33.8% work in non-academic hospitals. (Table-1)

Personal view of Early Mobilization in the PICU: The results of the survey indicated that most respondents believe that early mobilization should be a priority in the care of PICU patients, with over 80% of respondents indicating that it is either very important, 108(40.6%) important, 59(22.2%) or crucial 51 (19.2%).

Perceptions and Barriers to EM: The data regarding patient level barriers to early mobilization in the PICU indicates that medical instability 54(76.1%) and endotracheal intubation 40(56.3%) were the most cited barriers. Risk of dislodgement of devices or lines 43 (60.6%) and excessive sedation 32 (45.1%) were also reported as significant barriers. Other patient level barriers included cognitive impairment/cognitive age 20 (28.2%), weakness 25(35.2%), and inadequate nutritional status 10 (14.1%). Physical restraints 20 (28.2%), inadequate analgesia 10(14.1%), and obesity 5 (07.0%) were identified as relatively minor barriers. A small minority of respondents 4 (5.6%) reported that no patient barriers existed. This survey data suggests that both physicians and non-physicians in Saudi Arabia have similar perceptions of patient-level barriers for early mobilization practice. No significant differences were found between the two groups. (Table-2)

The findings indicate that there are significant discrepancies in physician and non-physician perspectives on institutional-level impediments. Non-physicians, for example, were more likely than physicians to order routine bed rest on ICU admission (27.2% vs. 12.7%, p = 0.019), and physicians were more likely than non-physicians to require physician orders prior to mobilisation (40.8% vs. 54.9%, p = 0.059), though this difference did not reach statistical significance. Non-physicians were also less likely than physicians to have written guidelines or protocols for early mobilisation (34.0% vs. 59.2%, p 0.001), and physicians had significantly more clinician champions or advocates for early mobilisation (39.4% vs. 24.6%, p = 0.027). Physicians were more likely than non-physicians to recognise when patients should begin early mobilisation (38.0% vs. 10.3%, p 0.001) and to have conflicting perceptions about the suitability of early mobilisation in some patients (31.0% vs. 14.4%, p = 0.004). Non-physicians were more likely than physicians to report inadequate training to support early mobilisation (14.4% vs. 47.9%, p 0.001). (Table-3) Overall, the findings indicate that physicians and non-physicians have different perspectives on the hurdles to implementing early mobilisation in the paediatric ICU in Saudi Arabia. These findings may be beneficial in devising focused treatments to overcome these discrepancies and promote early mobilisation in this situation.

Timing and Thresholds for EM: There are varying opinions among healthcare providers regarding when to initiate mobilization in the PICU. The most cited approach was to wait until the patient's cardio-respiratory status has stabilized (61.7%), which suggests that many clinicians prioritize medical stability before initiating mobilization interventions. Other commonly cited approaches included waiting until the patient is conscious and can cooperate (44.7%) and waiting until the patient is ready to be transferred out of the ICU (33.1%). Some respondents indicated that mobilization should be initiated as soon as possible following PICU admission (30.1%), while others believed that it should be initiated as soon as the patient is extubated (25.9%), off all vasoactive infusions (24.8%), or as soon as all sedative infusions are discontinued (24.1%). Most respondents (53.4%) considered early mobilization in the PICU to occur within the first 0-3 days of admission. A significant minority of respondents (29.7%) considered early mobilization to occur between 4-7 days after admission, while a smaller minority (5.3%) considered it to occur between 8-14 days after admission. A small percentage of respondents did not respond to this question (11.7%).

Most healthcare professionals (132%) chose bed rest as the minimum level of activity for patients with head trauma and increased intracranial pressure. Active range of motion (44%) and passive range of motion exercises (48%) were the second most common responses. Ambulatory activities were not chosen by 75% of respondents, suggesting that ambulation may be too strenuous for the patient. Additionally, 11.7% of respondents did not provide a response, indicating uncertainty or a lack of consensus on the appropriate minimum level of activity for this patient population. The most common response for patients with cardiac shock was bed rest, followed by passive range of motion exercises (25.6%). A significant proportion of respondents did not provide a response, and there may be a lack of consensus on the appropriate minimum level of activity for patients with cardiac shock.

Saudi Practice: Majority (64.3%) of pediatric critical care unit does not have any screening procedure or tools for assessment of need for early mobilization and subsequent rehabilitation. Moreover, bulk of the participant stated that there is no provision of automatically assessed for appropriateness to begin mobilization by the physiotherapist in in their institutes. Physician (42.5%) and 38.0% were registered nurses first health care provider to identify if a patient is ready for mobilization. 42.1% Critical care unit do not have written protocols or policies that provide guidelines on when a patient should begin mobilization. Interestingly, 21.1% participant were not sure on this regard. The frequency of passive range of motion performed by physiotherapists in the surveyed PICUs varies widely. The most frequent response was "Once daily" with a frequency of 55 (20.7%), followed by "Unsure" with a frequency of 47 (17.7%), and "None" with a frequency of 38 (14.3%). However, 36 participants (13.5%) did not provide a response, which could indicate a lack of knowledge or data on this topic. (Table-4)

Interestingly, Saudi practice for the duration of passive range of motion performed by physiotherapists in the surveyed PICUs varies widely. The most frequent response was "<15 min" with a frequency of 70 (26.3%), followed by "16-30 min" with a frequency of 64 (24.1%), and "Unsure" with a frequency of 48 (18.0%). However, 36 participants (13.5%) did not provide a response, which could indicate a lack of knowledge or data on this topic. (Figure-1) Registered nurse 218 (82.0%) participates in the mobilization of patients in the critical care unit. Majority of the institutes designated physiotherapist not working (47.4%) and 23.3% Provider not sure about it. The majority (61.7%) of the 266 healthcare professionals polled did not respond to the question. (Figure-2) Physiotherapists were the most frequently mentioned (14.7%) as being in charge of referring patients with probable ICU-acquired weakness. Potential referral sources included rehabilitation specialists (5.3%), neurologists (4.1%), and paediatricians (4.9%). Only a small percentage of responders (1.5%) said family physicians were in charge of referring these patients. Overall, the data imply that there may be some variation in referral practises for patients with suspected ICU-acquired weakness, with physiotherapists being the most often identified referral source among the healthcare professionals polled. (Figure-3)

Saudi practice regarding the usage of daily sedation interruption or sedation procedures in their paediatric ICU. 37 (13.9%) of the 266 healthcare professionals polled did not respond to the question. The most prevalent response among respondents was "routinely" (33.5%), indicating that daily interruption of sedation or sedation regimens are utilised in their PICU on a regular basis. Other answers included "sometimes" (22.2%), "frequently" (12.0%), "unsure" (8.6%), "never" (5.3%), and "infrequently never" (4.5%). Overall, the data reveal that healthcare professionals' usage of daily interruption of sedation or sedation procedures in PICUs varies, with the majority saying that they utilise these protocols on a regular basis. The statistics imply that there is some scepticism among healthcare professionals about routinely referring patients with suspected ICU-acquired weakness to an outpatient clinic following release for long-term rehabilitation, with a sizable proportion (31.2%) expressing doubt. However, according to most responders (38.7%), these patients are usually referred to an outpatient clinic for long-term therapy. (Figure-4)

Early mobilisation to be potentially beneficial to shorten the duration of mechanical ventilation, improve wake/sleep rhythm, and shorten the length of stay in the PICU, and post ICU acquired weakness.[28–30]Balas et al. (2014) suggested the ABCDE bundle which is evidence-based and includes three main components: Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility. Overall, the ABCDE bundle is a comprehensive approach to improving patient outcomes by addressing key factors that can contribute to delirium and weakness in critically ill patients.[31]The safety and practicality of a PICU rehabilitation programme to alleviate post-intensive care syndrome were found to be safe and effective with no unexpected adverse events. [28,32-33]The practice of early mobilization (EM) in the ICU can vary significantly depending on factors such as the country, multidisciplinary rounds, setting daily goals for patients, presence of a dedicated physiotherapist, and the nurse/patient staffing ratio. The heterogeneity of international ICU structure and practice can also result in differences in barriers to implementing EM. Therefore, to successfully implement EM, it is important to consider on several aspects of early mobilization practice, such as perspectives opinion, impediments at various levels, ICU staffing and practice patterns of individual countries. This may involve tailoring implementation strategies to specific settings, such as through trials or quality improvement initiatives that are sensitive to the local context.[26] The survey in Saudi Arabia explored 266 healthcare professionals, revealed the following key finding.

First, the baseline characteristics of respondents in the Saudi Arabia survey on early mobilization in pediatric critical care provide useful insights into the region's healthcare landscape and practices. Understanding these demographics and institutional features is critical for contextualizing the study's findings and assessing the effectiveness of early mobilization tactics. The distribution of responders among Saudi cities demonstrates differing levels of participation with the survey. Jeddah had the most responses (54.1%), followed by Riyadh (78.3%), Tabuk (5.6%), and Madinah (3.4%). These regional differences may have an impact on the generalizability of the study's findings and should be considered when interpreting the findings. The survey data also reveals the respondents' professional backgrounds, with registered nurses constituting the majority (64.7%). Consultants, attending physicians, and physicians undertaking clinical training all made substantial contributions. On the other side, Jacqueline Y. Thompson (2022) reported a physician majority (27%) in the UK; Erwin Ista (2020) stated that nurses were involved in 72% of the European Survey, whereas 59.8% of the respondents in the Canadian Survey were physicians.[34–36] Despite having the lowest number, specialists and registrars are a key subset of responders in our survey, who can provide valuable insights regarding early mobilization strategies from their unique viewpoints. The respondents' years of experience varied, with the greatest share (34.6%) having one to five years of experience. This distribution represents the wide spectrum of healthcare experts working in pediatric critical care, offering a blend of new viewpoints and seasoned knowledge. In terms of the type of ICUs where respondents work, a sizable proportion (47.7%) work in units that provide both medical and surgical care, with 32.3% working in the second-largest group. The lower percentages in solely medical ICUs (1.9%) and exclusively cardiac ICUs (16.2%) suggest that the survey covers a wide range of ICU settings. This variety of ICU types can help us better understand early mobilization techniques in different patient populations. The distribution of the number of beds in the facilities reflects the diversity of healthcare settings even further. Most facilities (69.2%) contain 5-15 beds, followed by 16-25 beds (18.8%). Odetola and Folafoluwa (2005) stated that in the United States, PICUs had a median of 4.5 pediatric beds (IQR: 2-10 beds).[27] Moreover, Bakhru R, Wiebe D. (2015) cited, fifty-one percent of the hospitals surveyed said they were affiliated with an academic institution. Most of the ICUs surveyed (58%) were either mixed medical/surgical ICUs or medical ICUs (22%) with a median of 16 beds in USA.[25]

This distribution provides useful insights on the scope of activities and resource availability across various facilities, which may influence the feasibility and implementation of early mobilization programs. The number of patients admitted each year fluctuates, with the bulk of respondents admitting 200-500 people (29.3%) and a sizable minority not knowing the precise figure. This variance in patient volumes may have an impact on the workload and manpower requirements for implementing early mobilization procedures. A striking finding is that most responders (66.2%) work in academic teaching hospitals affiliated with universities. This implies that the study is likely to gather opinions from healthcare professionals involved in research and education, perhaps leading to a greater understanding of evidence-based treatments like early mobilization. Finally, the baseline characteristics of the respondents in the Saudi Arabia survey on early mobilization in pediatric critical care provide a full overview of the region's healthcare landscape and practices. These demographics and institutional contexts are critical for understanding the study's findings and the potential influence of early mobilization methods. When compared to current literature, the survey population's specific characteristics should be evaluated to find similarities, variations, and potential for strengthening early mobilization methods in the country.

Secondly, the findings from the survey on the personal views of healthcare professionals regarding early mobilization in the PICU in Saudi Arabia are encouraging, as they reflect a strong belief in the importance of early mobilization for pediatric patients. The high percentage of respondents who consider early mobilization to be very important (40.6%), important (22.2%), or crucial (19.2%) underscores the growing recognition of the potential benefits of mobilization in critically ill children. The results of this survey align with the available relevant articles on the subject, which have consistently highlighted the positive impact of early mobilization in the PICU. Early mobilization enhanced muscle strength, walking chances, and days alive outside the hospital; [37]it reduced delirium; it reduced the risk of readmission or mortality; and it reduced ventilator-assisted pneumonia, central line, and catheter infections.[38] Several studies on early mobilization found that the period spent in the intensive care unit was considerably reduced, and the child may be able to return to his or her prior state of good health.[39] The findings from our survey support these research findings, as healthcare professionals in Saudi Arabia acknowledge the crucial role of early mobilization in mitigating the adverse effects of prolonged immobility on pediatric patients. Despite the overwhelming support for early mobilization expressed in our survey, there might still be challenges in translating this belief into consistent practice.

Thirdly, our survey has revealed insightful findings on the perceptions and impediments surrounding early mobilization (EM) in the pediatric intensive care unit (PICU) in Saudi Arabia. The data underscores the barriers at both patient and institutional levels, delineating the variances in viewpoints between physicians and non-physicians. These insights carry substantial relevance for enriching early mobilization methodologies and augmenting patient outcomes in critical care settings. Patient-level hurdles predominantly include medical instability (76.1%) and endotracheal intubation (56.3%). Comparative data from Australian and Scottish cohorts indicate sedation as the principal obstacle, along with physiological instability and the presence of an endotracheal tube. [40]Disease severity, physicians' orders, human resources, and patient mobilization devices were additional constraints, according to Nardo et al. (2021).[41] Staff limitations, time constraints, insufficient planning and coordination, and inadequate staff training were among other challenges identified.[42] Our study data aligns with Thompson et al. (2022) from the UK, highlighting physiological instability, insufficient staffing, required sedation, lack of resources and equipment, failure to recognize patient readiness, and limited funds as key impediments. [35]Additionally, the patient's medical condition, potential dislodgment of devices, and the presence of an endotracheal tube were reported barriers from a Canadian perspective.[34]

Notably, our survey pinpointed the risk of device dislodgement (60.6%), excessive sedation (45.1%), cognitive impairment (28.2%), weakness (35.2%), and inadequate nutritional status (14.1%) as considerable barriers. To enhance mobilization feasibility, these aspects require monitoring and intervention through tailored protocols, nutrition support, and appropriate sedation strategies. Other less cited barriers such as physical restraints, inadequate analgesia, and obesity, should be addressed proactively to mitigate their potential impact on patient mobilization. Institutional-level barriers highlighted a significant divide between physicians and non-physicians. The latter were more likely to prescribe bed rest, necessitating education and communication to align practices with evidence-based guidelines favoring early mobilization. Physicians requiring prior orders before mobilization, although not statistically significant, may impede the timely commencement of interventions. In response, initiatives to streamline procedures and authorize non-physician healthcare providers should be considered. Non-physicians, in comparison to physicians, were less likely to have written early mobilization guidelines. The implementation of evidence-based protocols is crucial to standardize practices and encourage a culture of mobilization. Physicians, having more clinician champions for early mobilization, suggest that fostering more advocates among non-physicians could promote EM adoption. Physicians and non-physicians displayed differences in identifying the appropriate timing and suitability of early mobilization. This underscores the necessity for interdisciplinary communication and consensus to ensure patients receive suitable and timely interventions. Non-physicians reported a higher frequency of inadequate training for early mobilization, signaling the need for comprehensive training programs. Our study underlines the need for targeted strategies to tackle both patient and institutional-level barriers to EM in Saudi Arabia's pediatric critical care environment. Collaborative efforts, evidence-based protocols, and champion involvement across disciplines are crucial in bridging the theory-practice gap. Emphasizing a multidisciplinary approach to early mobilization can optimize patient outcomes and enhance the quality of pediatric critical care in ICUs.

Finally, the survey results indicate a considerable diversity of opinions among respondents regarding the appropriate timing for early mobilization. A bulk of clinicians prioritized medical stability before initiating mobilization interventions, while others advocate early mobilization should not be delayed, but its appropriateness and safety should be evaluated as soon as possible. [43] Interestingly, a subset of our respondents supported early mobilization either immediately after PICU admission or following specific medical milestones, such as extubation or discontinuation of sedative and vasoactive infusions. Choong et al.(2014) cited Early mobilization to be initiated with in 2 days. [44]Dubb et al. (2016) suggested that EM in pediatrics be defined as "mobility interventions initiated within 72 hours of PICU admission, intended for children and adolescents in spontaneous breathing or in invasive or non-invasive ventilatory support. [45]Moreover, Tsuboi et al. (2019) reported children should undergo EM within 2 to 5 days of being diagnosed with a significant disease or issue causing their PICU admission.[46]Regarding the minimum level of activity for patients with head trauma and increased intracranial pressure, bed rest was the most chosen option, followed by passive range of motion exercises. Ambulatory activities were rarely considered, possibly due to concerns about their potential strain on the patients. A lack of consensus was evident among respondents, indicating the need for further research and guidelines. Similarly, for patients with cardiac shock, bed rest was the most preferred activity level, with passive range of motion exercises being the second most common response. A notable proportion of respondents did not provide a response, indicating uncertainty surrounding the appropriate level of activity for this patient population.

The wide range of opinions on the timing and thresholds for early mobilization in the PICU underscores the need for standardized guidelines based on evidence-based practices. While most respondents prioritize medical stability before initiating mobilization interventions, some advocate for early mobilization as soon as certain clinical milestones is achieved. These contrasting views highlight the complexity of decision-making in critical care settings and call for further research to establish best practices. Furthermore, the variation in opinions regarding the minimum activity levels for patients with head trauma and increased intracranial pressure and cardiac shock reflects the lack of clear evidence guiding such practices. Standardized protocols are essential to ensure consistent, safe, and effective mobilization strategies. This study provides valuable insights into the varying opinions among healthcare providers in Saudi Arabian PICUs concerning the timing and thresholds for early mobilization. The lack of consensus on these critical aspects of patient care underscores the need for evidence-based guidelines and protocols in pediatric critical care settings. Future research should focus on establishing the optimal timing for early mobilization and defining the appropriate activity levels for specific patient populations to enhance the quality of care and improve outcomes in the PICU.

This study adds to the field of pediatric critical care in Saudi Arabia by providing a comprehensive review of the healthcare landscape, perspectives, and challenges to early mobilization. Recognizing the value of early mobilization and comprehending the challenges associated with its implementation, healthcare institutions can work toward a consistent and evidence-based approach, ultimately leading to improved patient outcomes and higher quality of care. Future study should concentrate on determining the best time and activity levels for certain patient types to increase the evidence-based practice of early mobilization in the PICU.There findings of this study have important implications for clinical practice, policy, and future research in pediatric critical care. Addressing the highlighted hurdles and adopting a multidisciplinary approach to early mobility will help healthcare providers bridge the gap between theory and reality, ensuring that pediatric patients in the PICU receive the best possible care and achieve better outcomes. Finally, these initiatives have the potential to progress the field of pediatric critical care and improve the quality of healthcare services in Saudi Arabia and beyond.

Acknowledgement: I would like to express my deepest gratitude to Dr. Mohammed Shahab Uddin for his invaluable assistance with the statistical analysis, inference, visual graphs, and tables for this research. His expertise and guidance have been instrumental in the success of this project. I am truly grateful for his patience, dedication, and willingness to help at every stage of the research process. Without his support, this work would not have been possible. Thank you, Dr. Mohammed Shahab Uddin, for your contributions and commitment to excellence.

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Table-1: Demographic characteristics of Survey data.

Variable	N(%)
Top 6 Location
Jeddah	144 (54.1)
Riyadh	78 (29.3)
Tabuk	15 ( 5.6)
Madinah	9 ( 3.4)
Buraidah	5 ( 1.9)
Dammam	3 ( 1.1)
Job Title
Physician	72 (27.1)
Non-Physician	194(72.9)
Experience
<1 Year	12 ( 4.5)
1-5 Year	92 (34.6)
6-10 Year	76 (28.6)
11- 15 Year	49 (18.4)
16-20 Year	23 ( 8.6)
21-25 Year	9 ( 3.4)
>25 Year	5 ( 1.9)
PICU Type
Mixed medical-surgical ICU	127 (47.7)
Mixed medical-surgical and cardiac ICU	86 (32.3)
Exclusive Cardiac ICU	43 (16.2)
Exclusive medical ICU	5 ( 1.9)
Other	5 ( 1.9)
Number of ICU Beds
< 5	6 ( 2.3)
5-15	184 (69.2)
16-25	50 (18.8)
>25	26 ( 9.8)
Number of Admission per Year
< 200	25 ( 9.4)
200-500	106 (39.8)
501-1000	40 (15.0)
1001-2000	13 ( 4.9)
>2000	4 ( 1.5)
Unknown	78 (29.3)
Academic Profile of Hospital
Academic teaching hospital (Affiliated with a university)	176 (66.2)
Non academic hospital (Military, MOH, other..)	90 (33.8)

Table-2: Patients level barriers perception regarding early mobilization in Pediatric ICU with comparison of opinion between Non-Physician and Physician.

PATIENT LEVEL barriers.	Physician	Non-Physician	P- value
Medical instability
Yes	54 ( 76.1)	125 ( 64.1)	0.091
No	17(23.9)	70(35.9)
Endotracheal intubation
Yes	40 ( 56.3)	134 ( 68.7)	0.083
No	31(43.7)	61(31.3)
Physical restraints
Yes	20(28.2)	53(27.2)	0.813
No	51(71.8)	142(72.8)
Risk of dislodgement of devices or lines
Yes	43 ( 60.6)	112 ( 57.4)	0.764
No	28(39.4)	83(42.6)
Cognitive impairment/cognitive age
Yes	20 ( 28.2)	66 ( 33.8)	0.467
No	51(71.8)	129(66.2)
Excessive sedation
Yes	32(45.1)	74(37.9)	0.375
No	39(54.9)	121(62.1)
Inadequate analgesia
Yes	10 ( 14.1)	35 ( 17.9)	0.576
No	61(85.9)	160(82.1)
Obesity
Yes	5 ( 07.0)	28 ( 14.4)	0.164
No	66(93.0)	167(85.6)
Weakness
Yes	25 ( 35.2)	73 ( 37.4)	0.780
No	46(64.8)	122(62.6)
Inadequate nutritional status
Yes	6 ( 8.5)	32 ( 16.4)	0.149
No	65(91.5)	163(83.6)
No patient barriers
Yes	4 ( 5.6)	11 ( 5.6)	1.000
No	67(94.4)	184(94.4)

Table-3: Institutional and Healthcare provider level barriers perception regarding early mobilization in Pediatric ICU with comparison of opinion between Non-Physician and Physician

INSTUTIONAL BARRIERS.	Physician(N=71)	Non-Physician(N=195)	P-value
Routine bed rest orders on ICU admission
Yes	9 (12.7)	53 (27.2)	0.019
No	62 (87.3)	142(72.8)
Physician orders required prior to mobilization
Yes	29 (40.8)	107 (54.9)	0.059
No	42(59.2)	88(45.1)
Insufficient equipment for early mobilization
Yes	30 (42.3)	65 (33.3)	0.231
No	41(57.7)	130(66.7)
No written guidelines/ protocols for early mobilization
Yes	42 (59.2)	66 (34.0)	<0.001
No	29(40.8)	129(66.0)
Not enough physical space
Yes	14 (19.7)	26 (13.3)	0.241
No	57(80.3)	169(86.7)
No clinician champion/advocate to promote early mobilization in the ICU
Yes	28 (39.4)	48 (24.6)	0.027
No	43(60.6)	147(75.4)
Perceived to be non cost effective by administrators
Yes	4 ( 5.8)	8 ( 4.1)	0.813
No	67(94.2)	187(95.9)
No institutional barriers
Yes	10 (14.1)	21 (10.8)	0.597
NO	61(85.9)	174(89.2)
Healthcare provider level barriers.
Limited staffing to routinely mobilize patients
Yes	38 (53.5)	112 (57.4)	0.667
No	33(46.5)	83(42.6)
EM not percived as a priority in the care plan of criticaly ill Pt
Yes	30 (42.3)	70 (35.9)	0.422
No	41(57.7)	125(64.10
EM perceived as important but it is not supported by some specific individuals
Yes	12 (16.9)	25 (12.8)	0.515
No	59(83.1)	170(87.2)
Slow to recognize when patients should begin EM
Yes	27 (38.0)	20 (10.3)	<0.001
No	44(62.0)	175(89.7)
Conflicting perceptions about suitability of EM in some patients
Yes	22 (31.0)	28 (14.4)	0.004
No	49(69.0)	167(85.6)
Safety concerns about EM
Yes	38 (53.5)	82 (42.1)	0.128
No	33(46.5)	113(57.9)
Inadequate training to facilitate EM
Yes	34 (47.9)	28 (14.4)	<0.001
NO	37(52.1)	167(85.6)

Table-4: Saudi Practice for assessment for Rehabilitation for Early Mobilization in Pediatric ICU

Assessment for Need of Rehabilitation Saudi Practice		Total N=266

Screening criteria/screening tool to select appropriate patients for early mobilization and rehabilitation?	Yes No Not Responded	64(24.1) 171(64.3) 31(11.6)
Are all patients automatically assessed for appropriateness to begin mobilization by the physiotherapist in your PICU	Yes No Not Sure Not Responded	45 (16.9) 143 (53.8) 42 (15.8) 36(13.5)
Who is generally the first health care provider to identify if a patient is ready for mobilization?	Physician Registered nurse Physiotherapist Respiratory therapist Occupational therapist Others No response	113 (42.5) 101 (38.0) 10 (3.8) 2 (0.8) 2 (0.8) 2 (0.8) 36 (13.5)
Does your PICU have written protocols or policies that provide guidelines	Yes No Not Sure Not response	62 (23.3) 112 (42.1) 56 (21.1) 36 (13.5)
On average, what is the FREQUENCY of PASSIVE range of motion performed by physiotherapists	None <1 /week 1-2 /Week 3-4 /week 5-6 /week Once daily Twice daily > twice daily Not sure No response	38 (14.3) 23 (8.6) 23 (8.6) 23 (8.6) 9 (3.4) 55 (20.7) 6 (2.3) 6 (2.3) 47 (17.7) 36 (13.5)

No competing interests reported.

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Early Mobilization in Pediatric Critical Care: Exploring the Gap between Theory and Practice in Saudi Arabia

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