An inpatient rehabilitation program utilizing standardized care pathways after paracorporeal ventricular assist device placement in children.
BACKGROUND
Structured rehabilitation programs in adults after ventricular assist device (VAD) placement result in improvements in physical function and exercise capacity, and have been shown to improve survival and accelerate post-transplant recovery. The objective of this study was to determine the safety and feasibility of an acute inpatient rehabilitation program for children utilizing standardized, age-appropriate, family-centered care pathways after paracorporeal VAD placement in both the ICU and acute-care inpatient settings.


METHODS
Between November 12, 2010 and March 15, 2013, 17 patients were referred to therapy after VAD implantation, 14 of whom were medically stable enough to participate. Beginning in the ICU, a structured physical and occupational therapy program was implemented utilizing novel age-appropriate, standardized care pathways for infants (age <1 year) and children (age 1 to 12 years). The infant and child pathways consisted of 8 and 10 goals, respectively. Retrospective review was conducted to ascertain the number of phases achieved per patient. Adverse events, defined as bleeding, physiologic instability, stroke, or device disruption during therapy, were also analyzed.


RESULTS
The median age was 1.1 (range 0.5 to 14.4) years in the 14 patients considered medically stable enough to participate in rehabilitation. Nine of them were female. Eight patients participated in the infant standardized care pathway (SCP) and 6 participated in the child SCP. Seven patients were on biventricular support. Twelve patients were transplanted and survived. Two patients died while awaiting transplantation. There were 1,473 total days on the VAD (range 40 to 229 days). The median time to extubation was 2 days (range 1 to 8) and the median ICU stay was 6.5 days (range 3 to 152). Eleven patients achieved all goals of the SCP, including all of the patients in the child group. For the infant group, 5 patients achieved all goals of the SCP (range 5 to 8), and all but 1 patient achieved at least 7 goals of the SCP. There were no adverse events related to therapy.


CONCLUSIONS
Standardized, family-centered inpatient rehabilitation care paths are safe for infants and children after paracorporeal device placement. Structured rehabilitation goals can be achieved by the majority of pediatric patients during VAD support. Early mobilization and inpatient rehabilitation in this cohort promotes normalization of function while awaiting cardiac transplantation.
Department of Pediatrics (Cardiology), Stanford University Medical Center. Electronic address: seth.hollander@stanford.edu.
Seth A
SA
Hollander
Rehabilitation Services, Lucile Packard Children's Hospital.
Amanda J
AJ
Hollander
Rehabilitation Services, Lucile Packard Children's Hospital.
Sandra
S
Rizzuto
Department of Cardiovascular Surgery, Stanford University Medical Center, Palo Alto, California.
Olaf
O
Reinhartz
Department of Cardiovascular Surgery, Stanford University Medical Center, Palo Alto, California.
Katsuhide
K
Maeda
Department of Pediatrics (Cardiology), Stanford University Medical Center.
David N
DN
Rosenthal
D000293:Adolescent; D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D019091:Critical Pathways; D005240:Feasibility Studies; D005260:Female; D006331:Heart Diseases / Q000534:rehabilitation / Q000628:therapy*; D006353:Heart-Assist Devices; D006760:Hospitalization; D006801:Humans; D007223:Infant; D008297:Male; D009788:Occupational Therapy; D018802:Patient-Centered Care; D026741:Physical Therapy Modalities; D012189:Retrospective Studies
heart transplant; occupational therapy; pediatrics; physical therapy; rehabilitation; ventricular assist device