Award Title: Identifying and understanding risk factors for instability and adverse events associated with chest physiotherapy in ventilated children: A mixed methods study.
Funder: Health Education England

Abstract: Background Paediatric intensive care units (PICU) support the complex medical needs of children with life threatening conditions. There are 20000 admissions annually within the United Kingdom (UK). Chest physiotherapy (CPT) is considered an integral part of care for these patients and national standards report that PICUs require 24 hour access to physiotherapy. Despite the role of CPT being widely acknowledged the overall clinical impact is unknown. CPT has been associated with instability and adverse events. Significant fluctuations in stability can contribute to organ failure or lung damage, with the potential to lead to a prolonged PICU admission or even death. At present the risks and benefits of CPT in ventilated children are unknown. It is therefore important to identify which patients are likely to benefit most and in which situations CPT may present a significant risk. Aim To identify and understand the risk factors for physiological instability and adverse events associated with chest physiotherapy in ventilated children. Objectives	To describe current chest physiotherapy practice in UK paediatric intensive care units. 	To gain an in-depth understanding of the decision making processes used by physiotherapists and perceived risk factors for instability and adverse events. 	To quantitatively assess the physiological instability and adverse events associated with CPT and identify risk factors that predict instability. 	To evaluate if physiological instability associated with CPT is related to poorer long-term PICU outcomes.Methods This is a convergent parallel mixed methods study, comprising of two work packages which will run concurrently. Work Package 1 This consists of two phases: phase 1 will inform phase 2.Phase 1 - An electronic survey will be sent to physiotherapists working in the 22 UK PICUs. Key survey content will include CPT techniques used, referral criteria, and perceived risk factors. Descriptive analyses will be undertaken for the objective data and thematic analysis used for the open questions. Phase 2 - Semi-structured interviews, with 16-24 physiotherapists, will be used to gain an in-depth understanding of the decision making processes and perceived risk factors for physiological instability and adverse events. Thematic analysis will be used to identify and explore themes. Work Package 2 An observational cohort study will be completed to assess the prevalence of physiological instability and adverse events associated with CPT and identify risk factors that predict instability. Routinely collected physiological outcomes and adverse events will be collected prior to, during and after CPT intervention, using high resolution monitor data and electronic patient records managed in a digital research environment. Data will be collected over one year, providing an approximate sample of 1144. Multilevel analysis will be used to investigate change in the physiological variables and allow risk modelling. Dissemination and anticipated Impact The dissemination strategy includes publications, presentations, and a dissemination event. The study findings have the potential to minimise instability and adverse events associated with CPT, and improve outcomes for the individual patient. Impact will also be through improved consistency of CPT across the NHS. This project will create a new network of PICU physiotherapists, increasing collaboration.

Lay Abstract: Background Paediatric intensive care units support the complex medical needs of children with life threatening conditions. There are 20000 admissions to paediatric intensive care units each year in the United Kingdom (UK) and 65% require life support through the use of a breathing machine. Chest physiotherapy is considered part of routine care for these patients. The goals of chest physiotherapy are to re-expand the lungs and clear lung secretions, which prevents complications and helps children breathe on their own. National and international standards report that patients on paediatric intensive care units require access to a physiotherapist 24 hours a day.There is a small amount of evidence providing support for the effectiveness of physiotherapy on paediatric intensive care. However in some circumstances chest physiotherapy has been linked with children becoming more unstable, including problems with oxygen levels, heart function and pain. How physiotherapists make decisions and manage the risks of instability and harmful events in children on intensive care has not been studied. Hence there are no guidelines to support these complicated decisions. At present it is not clear which patients are likely to benefit most from chest physiotherapy and in which situations it may present a risk. Aim To identify and understand the risk factors for instability and harmful events which may occur due to chest physiotherapy in children on intensive care. This will inform the development of recommendations for clinical practice. Design and Methods This study will have two work packages, which will run at the same time.Work Package 1 Phase 1 - An electronic survey will be sent to all physiotherapists who work in paediatric intensive care in the UK. Questions will include what chest physiotherapy techniques are used, how patients are referred, and the risk factors assessed and monitored by the physiotherapists.Phase 2 -h; Interviews with 16-24 physiotherapists will take place. We will use the findings from phase 1 to guide the questions. This phase will provide a more in-depth understanding about how physiotherapists make decisions on paediatric intensive care, what they consider as risks, and how these risks are managed. Work Package 2 This part of the study will use health related measures (e.g. oxygen levels, heart rate and blood pressure) to examine the effects of chest physiotherapy and potential risk factors for instability. Routinely collected data from three intensive care units at a specialist children's hospital will be used. No contact with patients or their families will be required, and no change to care will occur. Data from approximately 1000 patients will be collected over one year.Values and measurements will be taken from patient monitors and electronic patient records. These will be recorded before, during and after chest physiotherapy treatment.Patient and Public Involvement In the design phase of this study the parents/carers of children on intensive care were asked where they felt more research was needed. Investigation into everyday procedures was highlighted as being important, with one parent suggesting a focus on 'the effect of treatments; to determine the best results and outcome for the child'.A steering group will be set up at the start of the project and will include parents/carers and relevant medical and nursing staff. They will provide guidance and support for study management and dissemination. Dissemination The results from the study will be shared with families, professionals and other researchers through publications, presentations, a dissemination event, and the use of social media. It is expected that the study findings will provide evidence for clinical decision making and improve the quality of care for children on intensive care.

Research Activity Codes: 6.7 PHYSICAL
Health Categories: RESPIRATORY