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World J Crit Care Med. Sep 9, 2026; 15(3): 122427
Published online Sep 9, 2026. doi: 10.5492/wjccm.122427
Discordance between early mobility protocol expectations and nurse-led mobilizations of critically ill children: A quality improvement initiative
Divya Manikandan, Hallie Lenker, Colleen Mennie, Stephanie Morgenstern, Sukaina Furniturewala, Lisa Hwang, Krista Hajnik, Kristen M Brown, Nicole Shilkofski, Sapna R Kudchadkar, Jessica M LaRosa
Divya Manikandan, Colleen Mennie, Sukaina Furniturewala, Lisa Hwang, Nicole Shilkofski, Sapna R Kudchadkar, Jessica M LaRosa, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
Hallie Lenker, Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
Stephanie Morgenstern, Department of Pediatric Nursing, Charlotte R. Bloomberg Children’s Center, Johns Hopkins Hospital, Baltimore, MD 21287, United States
Krista Hajnik, Department of Respiratory Therapy, Charlotte R. Bloomberg Children’s Hospital, Johns Hopkins Hospital, Baltimore, MD 21287, United States
Kristen M Brown, School of Nursing, Johns Hopkins University, Baltimore, MD 21287, United States
Author contributions: Manikandan D designed and conducted the quality improvement initiative and wrote the manuscript. Lenker H, Morgenstern S, Hajnik K, Brown KM, Shilkofski N, and Mennie C contributed to the initiative design; Mennie C, Furniturewala S, and Lisa H collected data. Kudchadkar SR and LaRosa JM participated in the design and supervision of the initiative, and LaRosa JM also took part in data collection.
AI contribution statement: AI tools (specifically Claude) were used for the generation of Figure
2, and
Supplementary Table 2. Forest Plots and tables were originally generated using STATA software and uploaded to Claude for the creation of editable forest plots and tables in PowerPoint format. AI was not involved in the analysis of the data, and all outputs were verified by the authors.
Supported by the National Center for Advancing Translational Sciences, No. KL2TR003099.
Institutional review board statement: This project was designated as a quality improvement initiative by our institutional review board and was reviewed and acknowledged as exempt, No. IRB00289007.
Informed consent statement: Our study was deemed exempt by the Johns Hopkins Medicine Institutional Review Board (No. IRB00289007). As such, it was given the designation of non-human subjects research/quality improvement, and informed consent was not required.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: This quality improvement project received an acknowledgement as not human subjects research by the IRB; therefore, we do not have consent for data sharing.
Corresponding author: Jessica M LaRosa, MD, Assistant Professor, Department of Anesthe
siology and Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans St, Suite 6349, Baltimore, MD 21287, United States.
jlarosa4@jhmi.edu
Received: April 20, 2026
Revised: May 26, 2026
Accepted: June 5, 2026
Published online: September 9, 2026
Processing time: 125 Days and 20.1 Hours
BACKGROUND
Early mobility in the pediatric intensive care unit (PICU) is safe and associated with improved cognitive and functional outcomes while reducing complications and hospital length of stay. Protocolized early mobility programs guide activity based on physiologic criteria and increase mobilization rates. However, critically ill children remain under-mobilized. Nurses, key agents of mobility implementation, continue to report barriers even when protocols are in place, yet the extent to which these barriers contribute to deviations from early mobility protocols remains unknown.
AIM
To evaluate discrepancies between nurse-reported mobility, electronic health record documentation, and early mobility protocol expectations in the PICU.
METHODS
We conducted an observational study evaluating nursing-led mobility in 101 patients admitted ≥ 3 days to a large, academic PICU. Key variables included physiologic mobility level (1 = most restrictive to 3 = most liberal), the highest level of mobility (HLM) achieved, and the number of mobilizations. Data were obtained from the electronic health record, end-of-shift nurse interview [registered nurse report (RN-report)], and compared with protocol-expected mobility using Cohen’s Kappa. Firth penalized logistic regression assessed age, pediatric risk of mortality score, and pediatric cerebral performance category as predictors of discordance.
RESULTS
Agreement between protocol-expected and RN-reported mobility level was moderate (53.5%; κ = 0.32) and agreement between protocol-expected and RN-reported HLM was poor (40.6%; κ = 0.20). In univariate analysis, mechanical ventilation [odds ratio (OR) = 0.34, 95% confidence interval (CI): 0.19-0.97, P = 0.016], vascular access lines (OR = 0.43, 95%CI: 0.13-0.69, P = 0.043), and sedation > 30 minutes (OR = 0.30, 95%CI: 0.13-0.69, P = 0.005) were associated with reduced odds of HLM discordance. Conversely, severe disability at baseline was associated with higher odds of having a discordant mobility level (OR = 8.33, 95%CI: 2.50-27.76, P = 0.001), and a discordant HLM (OR = 3.71, 95%CI: 1.15-12.01, P = 0.029), even after adjusting for age and illness severity.
CONCLUSION
In a longstanding PICU mobility program, discordance exists between protocol-expected and RN-reported mobility. Severe baseline disability increases this discordance, highlighting the need to evaluate the fidelity of early mobility programs.
Core Tip: This initiative found substantial discordance between protocol-expected, health record documented, and nurse-reported mobilizations in a pediatric intensive care unit with a 12-year early mobility program. Nursing uncertainty regarding mobility levels frequently resulted in patients being mobilized at a level lower than the target. Severe disability at baseline, rather than mechanical barriers like medical equipment, was associated with discordance between nurse-reported mobility and the protocol. Early mobility protocols should be modified to include unambiguous guidance for children with baseline medical complexity, and programs should assess implementation fidelity and program efficacy to ensure safe and consistent mobilizations of critically ill children.
