Clinical and psychological effects of early mobilization in patients treated in a neurologic ICU: a comparative study

Physical rehabilitation interventions in the intensive care unit: a scoping review of 117 studies

BACKGROUND

Physical rehabilitation (PR) interventions in the intensive care unit (ICU) can improve patients' functional outcomes, yet systematic reviews identified discordant effects and poor reporting. We conducted a scoping review to determine the extent of ICU PR interventions and how they were reported and measured.

METHODS

We searched five databases from inception to December 2016 for prospective studies evaluating adult ICU PR interventions. Two independent reviewers screened titles, abstracts, and full texts for inclusion. We assessed completeness of reporting using the Consolidated Standards of Reporting Trials, Strengthening the Reporting of Observational Studies in Epidemiology, or Standards for Quality Improvement Reporting Excellence guidelines, as appropriate. For planned PR interventions, we evaluated reporting with the Consensus on Exercise Reporting Template (CERT) and assessed intervention and control groups separately. We calculated completeness of reporting scores for each study; scores represented the proportion of reported items. We compared reporting between groups using Kruskal-Wallis with Bonferroni corrections and t tests, α = 0.05.

RESULTS

We screened 61,774 unique citations, reviewed 1429 full-text publications, and included 117: 39 randomized trials, 30 case series, 9 two-group comparison, 14 before-after, and 25 cohort. Interventions included neuromuscular electrical stimulation (NMES) (14.5%), passive/active exercises (15.4%), cycling (6.8%), progressive mobility (32.5%), and multicomponent (29.9%). The median (first,third quartiles) study reporting score was 75.9% (62.5, 86.7) with no significant differences between reporting guidelines. Of 87 planned intervention studies, the median CERT score was 55.6%(44.7,75.0); cycling had the highest (85.0%(62.2,93.8)), and NMES and multicomponent the lowest (50.0% (39.5, 70.3) and 50.0% (41.5, 58.8), respectively) scores. Authors reported intervention groups better than controls (p < 0.001).

CONCLUSIONS

We identified important reporting deficiencies in ICU PR interventions, limiting clinical implementation and future trial development.

Mobility Programs for the Hospitalized Older Adult: A Scoping Review

Objectives: This scoping review (a) describes programs to improve mobility in hospitalized adults and (b) determines the methods used to measure mobility. Method: The Joanna Briggs Institute Methodology for Scoping Reviews was used to conduct this review. Results: Our findings suggest that using a multidisciplinary approach may be the most effective way to promote mobility in hospitalized older adults. Most studies did not articulate how physical activity was measured, indicating that more research is needed. Discussion: The literature shows that implementation of protocols designed to improve the early and regular implementation of physical mobility activities improves the health outcomes of hospitalized older people. Costs associated with healthcare utilization are also reduced, including hospital length of stay. Mobility programs that quantified mobility through validated measurement tools or accelerometers are the most promising as they provide feedback that reinforces progress of the patient and the expected benefits of early mobility.

Physiotherapy in the neurotrauma intensive care unit: A scoping review

PURPOSE

This scoping review summarizes the literature on the safety and effectiveness of physiotherapy interventions in patients with neurological and/or traumatic injuries in the intensive care unit (ICU), identifies literature gaps and provides recommendations for future research.

MATERIALS AND METHODS

We searched five databases from inception to June 2, 2018. We included published retrospective studies, case studies, observation and randomized controlled trials describing physiotherapy interventions in ICU patients with neurotrauma injuries. Two reviewers reviewed the databases and independently screened English articles for eligibility. Data extracted included purpose, study design, population (s), outcome measures, interventions and results. Thematic analysis and descriptive numerical summaries are presented by intervention type.

RESULTS

12,846 titles were screened and 72 met the inclusion criteria. Most of the studies were observational studies (44 (61.1%)) and RCTs (14 (19.4%)). Early mobilization, electrical stimulation, range of motion, and chest physiotherapy techniques were the most common interventions in the literature. Physiotherapy interventions were found to be safe with few adverse events.

CONCLUSIONS

Gaps in the literature suggest that future studies require assessment of long term functional outcomes and quality of life, examination of homogenous populations and more robust methodologies including clinical trials and larger samples.

Safety criteria to start early mobilization in intensive care units. Systematic review

Mobilization of critically ill patients admitted to intensive care units should be performed based on safety criteria. The aim of the present review was to establish which safety criteria are most often used to start early mobilization for patients under mechanical ventilation admitted to intensive care units. Articles were searched in the PubMed, PEDro, LILACS, Cochrane and CINAHL databases; randomized and quasi-randomized clinical trials, cohort studies, comparative studies with or without simultaneous controls, case series with 10 or more consecutive cases and descriptive studies were included. The same was performed regarding prospective, retrospective or cross-sectional studies where safety criteria to start early mobilization should be described in the Methods section. Two reviewers independently selected potentially eligible studies according to the established inclusion criteria, extracted data and assessed the studies' methodological quality. Narrative description was employed in data analysis to summarize the characteristics and results of the included studies; safety criteria were categorized as follows: cardiovascular, respiratory, neurological, orthopedic and other. A total of 37 articles were considered eligible. Cardiovascular safety criteria exhibited the largest number of variables. However, respiratory safety criteria exhibited higher concordance among studies. There was greater divergence among the authors regarding neurological criteria. There is a need to reinforce the recognition of the safety criteria used to start early mobilization for critically ill patients; the parameters and variables found might contribute to inclusion into service routines so as to start, make progress and guide clinical practice.

Early mobilisation practices of patients in intensive care units in Zimbabwean government hospitals - a cross-sectional study

BACKGROUND

Recent evidence shows that early mobilisation of patients in an intensive care unit (ICU) is feasible, safe and associated with improvement in patients' clinical outcomes. However, its successful implementation is dependent on several factors, which include ICU structure and organisational practices.

OBJECTIVES

To evaluate the structure and organisational practices of Zimbabwean government hospital ICUs and to describe early mobilisation practices of adult patients in these units.

METHODS

A cross-sectional survey was conducted in all government hospitals in Zimbabwe. Data collected included hospital and ICU structure, adult patient demographic data and mobilisation activities performed in the ICU during the 24 hours prior to the day of the survey.

RESULTS

A total of five quaternary level hospitals were surveyed, with each hospital having one adult ICU. Four of the units were open-type ICUs. The majority of the units (n=3; 60%) reported that they had a permanent physiotherapist who covered their unit, but none of the physiotherapists worked solely in the ICU. The nurse-to-patient ratio across all units was 1:1. None of the units utilised a standardised sedation scoring system or a standardised outcome measure to assess patient mobility status. Only one ICU (20%) had a patient eligibility guideline for early mobilisation in place. Across the ICUs, 40 patients were surveyed. The median (interquartile range) age was 33 (23.3 - 38) years and 24 (60%) were mechanically ventilated. Indications for admission into the ICU included acute respiratory failure (n=12; 30%) and postoperative care (n=10; 25%). Mobilisation activities performed in the previous 24 hours included turning the patient in bed (n=39; 97.5%), sitting over the edge of the bed (n=10; 25%) and walking away from the bedside (n=2; 5%). The main reason listed for treatment performed in bed was patients being sedated and unresponsive (n=13; 32.5%).

CONCLUSION

Out-of-bed mobilisation activities were low and influenced by patient unresponsiveness and sedation, staffing levels and lack of rehabilitation equipment in ICU.

Defining new barriers to mobilisation in a highly active intensive care unit - have we found the ceiling? An observational study

BACKGROUND

Mobilisation of intensive care (ICU) patients attenuates ICU-acquired weakness, but the prevalence is low (12-54%). Better understanding of barriers and enablers may inform practice.

OBJECTIVES

To identify barriers to mobilisation and factors associated with successful mobilisation in our medical /surgical /trauma ICU where mobilisation is well-established.

METHODS

4-week prospective study of frequency and intensity of mobilisation, clinical factors and barriers (extracted from electronic database). Generalized linear mixed models were used to describe associations between demographics, clinical factors and successful mobilisation.

RESULTS

202 patients accounted for 742 patient days. Patients mobilised on 51% of patient days. Most frequent barriers were drowsiness (18%), haemodynamic/respiratory contraindications (17%), and medical orders (14%). Predictors of successful mobilisation included high Glasgow Coma Score (OR = 1.44, 95%CI=[1.29-1.60]), and male sex (OR = 2.29, 95%CI=[1.40-3.75]) but not age (OR = 1.05, 95%CI=[1.01-1.08]).

CONCLUSIONS

Our major barriers (drowsiness, haemodynamic/respiratory contraindications) may be unavoidable, indicating an upper limit of feasible mobilisation therapy in ICU.

Physiological Effects of Early Incremental Mobilization of a Patient with Acute Intracerebral and Intraventricular Hemorrhage Requiring Dual External Ventricular Drainage

BACKGROUND

Recent trials have challenged the notion that very early mobility benefits patients with acute stroke. It is unclear how cerebral autoregulatory impairments, prevalent in this population, could be affected by mobilization. The safety of mobilizing patients who have external ventricular drainage (EVD) devices for cerebrospinal fluid diversion and intracranial pressure (ICP) monitoring is another concern due to risk of device dislodgment and potential elevation in ICP. We report hemodynamic and ICP responses during progressive, device-assisted mobility interventions performed in a critically ill patient with intracerebral hemorrhage (ICH) requiring two EVDs.

METHODS

A 55-year-old man was admitted to the Neuroscience Critical Care Unit with an acute thalamic ICH and complex intraventricular hemorrhage requiring placement of two EVDs. Progressive mobilization was achieved using mobility technology devices. Range of motion exercises were performed initially, progressing to supine cycle ergometry followed by incremental verticalization using a tilt table. Physiological parameters were recorded before and after the interventions.

RESULTS

All mobility interventions were completed without any adverse event or clinically detectable change in the patient's neurological state. Physiological parameters including hemodynamic variables and ICP remained within prescribed goals throughout.

CONCLUSION

Progressive, device-assisted early mobilization was feasible and safe in this critically ill patient with hemorrhagic stroke when titrated by an interdisciplinary team of skilled healthcare professionals. Studies are needed to gain insight into the hemodynamic and neurophysiological responses associated with early mobility in acute stroke to identify subsets of patients who are most likely to benefit from this intervention.

A systematic review evaluating the role of nurses and processes for delivering early mobility interventions in the intensive care unit

OBJECTIVES

To investigate processes for delivering early mobility interventions in adult intensive care unit patients used in research and quality improvement studies and the role of nurses in early mobility interventions.

METHODS

A systematic review was conducted. Electronic databases PubMED, CINAHL, PEDro, and Cochrane were searched for studies published from 2000 to June 2017 that implemented an early mobility intervention in adult intensive care units. Included studies involved progression to ambulation as a component of the intervention, included the role of the nurse in preparing for or delivering the intervention, and reported at least one patient or organisational outcome measure. The System Engineering Initiative for Patient Safety (SEIPS) model, a framework for understanding structure, processes, and healthcare outcomes, was used to evaluate studies.

RESULTS

25 studies were included in the final review. Studies consisted of randomised control trials, prospective, retrospective, or mixed designs. A range of processes to support the delivery of early mobility were found. These processes include forming interdisciplinary teams, increasing mobility staff, mobility protocols, interdisciplinary education, champions, communication, and feedback.

CONCLUSION

Variation exists in the process of delivering early mobility in the intensive care unit. In particular, further rigorous studies are needed to better understand the role of nurses in implementing early mobility to maintain a patient's functional status.

Efficacy of early passive tilting in minimizing ICU-acquired weakness: A randomized controlled trial

Purpose

To investigate whether passive tilting added to a standardized rehabilitation therapy improved strength at Intensive Care Unit (ICU) discharge.

Material and methods

This single-center trial included patients admitted to an adult surgical ICU and ventilated for at least 3 days. Patients were randomized to daily standardized rehabilitation therapy alone or with tilting on a table for at least 1 h. The primary outcome was the Medical Research Council (MRC) sum score at ICU discharge. Muscular recovery was a secondary outcome.

Results

Of 145 included patients, 125 received mobilization, 65 in the Tilt group and 60 in the Control group. Total mobilization duration (median [25th–75th percentiles]) in the Tilt group was 1020 [580–1695] versus 1340 [536–2775] minutes in the Control group (p = 0.313). MRC sum scores at ICU discharge were not significantly different between groups (Tilt, 50 [45–56] versus 48 [45–54]; p = 0.555). However, the number of patients with weakness was higher in the Tilt group at baseline (Tilt: 60/65 versus 48/60, p = 0.045) and muscular recovery was better in the Tilt group (p = 0.004).

Conclusions

Passive tilting added to a standardized rehabilitation therapy did not improve muscle strength at ICU discharge in surgical patients even if a faster recovery with tilting is suggested.

Nurses and physiotherapists' experience in mobilising postoperative orthopaedic patients with altered mental status: A phenomenological study

BACKGROUND

A major goal of care for orthopaedic surgical patients is the achievement of their pre-morbid functional level or at least an improvement of their functional ability. However, patients with altered mental status can significantly impact this and other outcomes and influence the delivery of care. Patient mobilisation is a role shared by both nurses and physiotherapists.

AIMS

To enhance the understanding of nurses and physiotherapists' experience in mobilising postoperative orthopaedic patients with altered mental status.

METHOD

Three nurses and three physiotherapists were recruited using purposive sampling. Data was collected through interviews and analysed using Burnard's 14 stages of thematic content analysis.

RESULTS

Four main categories emerged from the study: altruism, interprofessional specialist practice, patient dynamics and challenges. Nurses and physiotherapists' experience have more similarities than differences under the four categories.

CONCLUSION

Nurses and physiotherapists experience numerous challenges from both patient and resources related factors such as environment, staffing and time limitations; safety risks to patient and staff; and communication barriers due to patient's altered mental state. While tensions and variations in priorities of care delivery exist between the two groups, interdisciplinary collaboration of both professional groups was clearly evident and enabled optimisation of mobilisation goals for this patient population and revealed more similarities than differences in their experience. Patient and staff safety takes precedence over mobilisation and safety risks in this patient group can be mitigated by adequate resources, competence, and teamwork.

The safety of a novel early mobilization protocol conducted by ICU physicians: a prospective observational study

BACKGROUND

There are numerous barriers to early mobilization (EM) in a resource-limited intensive care unit (ICU) without a specialized team or an EM culture, regarding patient stability while critically ill or in the presence of medical devices. We hypothesized that ICU physicians can overcome these barriers. The aim of this study was to investigate the safety of EM according to the Maebashi EM protocol conducted by ICU physicians.

METHODS

This was a single-center prospective observational study. All consecutive patients with an unplanned emergency admission were included in this study, according to the exclusion criteria. The observation period was from June 2015 to June 2016. Data regarding adverse events, medical devices in place during rehabilitation, protocol adherence, and rehabilitation outcomes were collected. The primary outcome was safety.

RESULTS

A total of 232 consecutively enrolled patients underwent 587 rehabilitation sessions. Thirteen adverse events occurred (2.2%; 95% confidence interval, 1.2-3.8%) and no specific treatment was needed. There were no instances of dislodgement or obstruction of medical devices, tubes, or lines. The incidence of adverse events associated with mechanical ventilation or extracorporeal membrane oxygenation (ECMO) was 2.4 and 3.6%, respectively. Of 587 sessions, 387 (66%) sessions were performed at the active rehabilitation level, including sitting out of the bed, active transfer to a chair, standing, marching, and ambulating. ICU physicians attended over 95% of these active rehabilitation sessions. Of all patients, 143 (62%) got out of bed within 2 days (median 1.2 days; interquartile range 0.1-2.0).

CONCLUSIONS

EM according to the Maebashi EM protocol conducted by ICU physicians, without a specialized team or EM culture, was performed at a level of safety similar to previous studies performed by specialized teams, even with medical devices in place, including mechanical ventilation or ECMO. Protocolized EM led by ICU physicians can be initiated in the acute phase of critical illness without serious adverse events requiring additional treatment.

Provider Beliefs Regarding Early Mobilization in the Pediatric Intensive Care Unit

PURPOSE

Critically ill patients are at risk for short and long term morbidity. Early mobilization (EM) of critically ill adults is safe and feasible, with improvement in outcomes. There are limited studies evaluating EM in pediatric critical care patients. Provider beliefs and concerns must be evaluated prior to EM implementation in the pediatric intensive care unit (PICU).

DESIGN AND METHODS

A survey was distributed to PICU providers assessing beliefs and concerns with regards to EM of PICU patients.

RESULTS

Seventy-one providers responded. Most staff believed EM would be beneficial. The largest perceived benefits were decreased length of both stay and mechanical ventilation. The largest perceived concerns were risk of both endotracheal tube and central venous catheter dislodgement. Surveyed clinicians felt significantly more comfortable mobilizing the oldest as compared to the youngest patients (p<0.0001). Clinicians also felt significantly more comfortable mobilizing patients receiving invasive mechanical ventilation in the oldest as compared to the youngest patients (p<0.0001).

CONCLUSION

There is clear benefit to the EM of adult ICU patients, with evidence supporting its safety and feasibility. As pediatric patients pose different challenges, it is imperative to understand provider concerns prior to the implementation of EM. Our research demonstrates similar concerns between adult and pediatric programs, with the addition of significant concern surrounding EM in very young children.

PRACTICE IMPLICATIONS

Understanding pediatric specific concerns with regards to EM will allow for the proper development and implementation of pediatric EM programs, allowing us to assess safety, feasibility, and ultimately outcomes.

Mobilization patterns of children on a hematology/oncology inpatient ward

BACKGROUND

Children being treated for cancer are admitted to the hospital for treatment of their disease or complications of therapy. Periods of bed rest during hospitalization can cause impairments detrimental to children with cancer who endure many side effects of therapy. Little is known about how these children mobilize while admitted to the hospital. The purpose of this study was to examine how children admitted to a hematology/oncology ward are mobilizing and analyze factors associated with delayed or infrequent mobility.

PROCEDURE

A retrospective chart review was conducted on 228 charts with data recorded on documented mobilization and referrals to physiotherapy. Primary outcome was related to mobility including timing, frequency, type, and nature of mobilization.

RESULTS

Almost half of children (43%) mobilized between 3 and 5 days per week, with median time to first mobilization being 2 days (interquartile range 1-3). Caregivers assisted with mobilization 91% of the time. Children isolated to their room and those reporting fever had a statistically significant decrease in the percent of admission days involving mobilization (mean difference 15 and 8%, respectively) than those not isolated and without fever. Children who were isolated also mobilized 1 day later (P = 0.016) than children who were not isolated. Percentage of time in isolation was positively correlated with timing (P = 0.04) and negatively correlated with frequency of mobilization (P < 0.001).

CONCLUSION

Most children admitted to the hospital for treatment of oncologic or hematologic conditions were noted to mobilize early, but frequency of mobilization could be improved. Periods of time in isolation appear to negatively affect mobilization.

Early mobilization reduces the atelectasis and pleural effusion in patients undergoing coronary artery bypass graft surgery: A randomized clinical trial

Atelectasis and pleural effusion are common after coronary artery bypass graft surgery (CABG). Longer stay in the bed is one of the most important contributing factors in pulmonary complications. Some studies confirm the benefits of early mobilization (EM) in critically ill patients, but the efficacy of EM on pulmonary complications after CABG is not clear. This study was designed to examine the effect of EM on the incidence of atelectasis and pleural effusion in patients undergoing CABG. In a single-blinded randomized clinical trial, 100 patients who were undergoing coronary artery bypass graft surgery were randomly assigned into two groups each consisted of 50 patients. Patients in the experimental group were enrolled in a mobilization protocol consisting of the mobilization from the bed in the first 3 days after surgery in the morning and evening. Patients in the control group were mobilized from bed in third postoperation day, according to the hospital routine. Arterial blood gases, pleural effusion, and atelectasis were compared between groups. Atelectasis and pleural effusion was reduced in experimental group. The partial pressure of oxygen in arterial blood in third postoperative day and the percentage of arterial oxygen saturation in the fourth postoperative day were higher in the intervention group (P value < .05). EM from bed could be an effective intervention in reducing atelectasis and pleural effusion in patients undergoing CABG.

Ventilator-Associated Events and Their Prevention

The Centers for Disease Control and Prevention shifted the focus of safety surveillance in mechanically ventilated patients from ventilator-associated pneumonia to ventilator-associated events (VAEs) in 2013. The shift was designed to increase the objectivity and reproducibility of surveillance and to encourage quality-improvement programs to tackle a broader array of complications in mechanically ventilated patients. Prospective intervention studies have found that minimizing sedation, increasing the use of spontaneous awakening and breathing trials, and conservative fluid management can lower VAE rates and decrease duration of mechanical ventilation. Additional strategies to prevent VAEs include early mobility programs, low tidal volume ventilation, and restrictive transfusion thresholds.

The Economic and Clinical Impact of Sustained Use of a Progressive Mobility Program in a Neuro-ICU

OBJECTIVE

To investigate a progressive mobility program in a neurocritical care population with the hypothesis that the benefits and outcomes of the program (e.g., decreased length of stay) would have a significant positive economic impact.

DESIGN

Retrospective analysis of economic and clinical outcome data before, immediately following, and 2 years after implementation of the Progressive Upright Mobility Protocol Plus program (UF Health Shands Hospital, Gainesville, FL) involving a series of planned movements in a sequential manner with an additional six levels of rehabilitation in the neuro-ICU at UF Health Shands Hospital.

SETTING

Thirty-bed neuro-ICU in an academic medical center.

PATIENTS

Adult neurologic and neurosurgical patients: 1,118 patients in the pre period, 731 patients in the post period, and 796 patients in the sustained period.

INTERVENTIONS

Implementation of Progressive Upright Mobility Protocol Plus.

MEASUREMENTS AND MAIN RESULTS

ICU length of stay decreased from 6.5 to 5.8 days in the immediate post period and 5.9 days in the sustained period (F(2,2641) = 3.1; p = 0.045). Hospital length of stay was reduced from 11.3 ± 14.1 days to 8.6 ± 8.8 post days and 8.8 ± 9.3 days sustained (F(2,2641) = 13.0; p < 0.001). The impact of the study intervention on ICU length of stay (p = 0.031) and hospital length of stay (p < 0.001) remained after adjustment for age, sex, diagnoses, sedation, and ventilation. Hospital-acquired infections were reduced by 50%. Average total cost per patient after adjusting for inflation was significantly reduced by 16% (post period) and 11% (sustained period) when compared with preintervention (F(2,2641) = 3.1; p = 0.045). Overall, these differences translated to an approximately $12.0 million reduction in direct costs from February 2011 through the end of 2013.

CONCLUSIONS

An ongoing progressive mobility program in the neurocritical care population has clinical and financial benefits associated with its implementation and should be considered.

Efficacy and Safety of Very Early Mobilization in Patients with Acute Stroke: A Systematic Review and Meta-analysis

Whether very early mobilization (VEM) improves outcomes in stroke patients and reduces immobilization-related complications (IRCs) is currently unknown. The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of VEM in acute stroke patients following admission. Medline, Embase, and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) that examined the efficacy or safety of VEM in patients with acute stroke. VEM was defined as out of bed activity commencing within 24 or 48 hours after the onset of stroke. A total of 9 RCTs with 2,803 participants were included. Upon analysis, VEM was not associated with favorable functional outcomes (modified Ranking Scale: 0–2) at 3 months [relative risk (RR): 0.96; 95% confidence interval (CI): 0.86–1.06]; VEM did not reduce the risk of IRCs during follow up. With respect to safety outcomes, VEM was not associated with a higher risk of death (RR: 1.04; 95% CI: 0.52–2.09) and did not increase the risk of neurological deterioration or incidence of falls with injury. In conclusion, pooled data from RCTs concluded that VEM is not associated with beneficial effects when carried out in patients 24 or 48 hours after the onset of a stroke.

Development of a neuro early mobilisation protocol for use in a neuroscience intensive care unit

OBJECTIVE

Through evaluation of the literature and working with a team of multidisciplinary healthcare providers, our objective was to refine an interprofessional Neuro Early Mobilisation Protocol for complex patients in the Neuroscience Intensive Care Unit.

RESEARCH METHODOLOGY

Using the literature as a guide, key stakeholders, from multiple professions, designed and refined a Neuro Early Mobilisation Protocol.

SETTING

This project took place at a large academic medical center in the southeast United States classified as both a Level I Trauma Center and Comprehensive Stroke Center.

MAIN OUTCOME MEASURES

Goals for protocol development were to: (1) simplify the protocol to allow for ease of use, (2) make the protocol more generalizable to the patient population cared for in the Neuroscience Intensive Care Unit, (3) receive feedback from those using the original protocol on ways to improve the protocol and (4) ensure patients were properly screened for inclusion and exclusion in the protocol.

RESULTS

Using expert feedback and the evidence, an evidence-based Neuro Early Mobilisation Protocol was created for use with all patients in the Neuroscience Intensive Care Unit.

CONCLUSION

Future work will consist of protocol implementation and evaluation in order to increase patient mobilisation in the Neuroscience Intensive Care Unit.

Implementing a Mobility Program to Minimize Post-Intensive Care Syndrome

Immobility in the intensive care unit (ICU) is associated with neuromuscular weakness, post-intensive care syndrome, functional limitations, and high costs. Early mobility-based rehabilitation in the ICU is feasible and safe. Mobility-based rehabilitation varied widely across 5 ICUs in 1 health care system, suggesting a need for continuous training and evaluation to maintain a strong mobility-based rehabilitation program. Early mobility-based rehabilitation shortens ICU and hospital stays, reduces delirium, and increases muscle strength and the ability to ambulate. Long-term effects include increased ability for self-care, faster return to independent functioning, improved physical function, and reduced hospital readmission and death. Factors that influence early mobility-based rehabilitation include having an interdisciplinary team; strong unit leadership; access to physical, occupational, and respiratory therapists; a culture focused on patient safety and quality improvement; a champion of early mobility; and a focus on measuring performance and outcomes.

Improving the quality of nurse-influenced patient care in the intensive care unit

BACKGROUND

Quality of care is a major focus in the intensive care unit (ICU).

AIM

To describe a nurse-initiated quality improvement (QI) project that improved the care of critically ill patients in a New Zealand tertiary ICU.

DESIGN

A framework for QI was developed and implemented as part of a practice change initiative.

METHODS

Audit data were collected, analysed and reported across seven nurse-influenced patient care standards. The seven standards were enteral nutrition delivered within 24 h of admission, timely administration of antibiotics, sedation holds for eligible patients, early mobilization and three pressure ulcer prevention strategies.

RESULTS

Comparison of audit data collected in 2014 and 2015 demonstrated improvements in five of the seven standards. Those standards with the largest practice improvements were related to the following standards: all eligible patients have enteral nutrition commenced within the first 24 h of ICU admission (3% increase); all eligible patients receive antibiotics within 30 min of prescription time (6% increase); all eligible patients have a daily sedation interruption (DSI; 24% increase); and all eligible patients are mobilized daily in their ICU stay (11% increase in percentage of patients mobilized daily).

CONCLUSIONS

The nursing-initiated QI project demonstrated improved ICU patient care in relation to early enteral nutrition commencement, DSIs and early and daily mobilizing.

RELEVANCE TO CLINICAL PRACTICE

The use of a nursing QI framework incorporating audit and feedback is one method of evaluating and enhancing the quality of care and improving patient outcomes. This initiative demonstrated the improved quality of nursing care for ICU patients, particularly in relation to early enteral nutrition commencement, timely antibiotics, DSIs and daily mobilizing. It is thus highly relevant to critical care nursing teams, particularly those working to create a culture where change is safe, achievable and valued.

[Algorithms for early mobilization in intensive care units]

Immobility of patients in intensive care units (ICU) can lead to long-lasting physical and cognitive decline. During the last few years, bundles for rehabilitation were developed, including early mobilization. The German guideline for positioning therapy and mobilization, in general, recommends the development of ICU-specific protocols. The aim of this narrative review is to provide guidance when developing a best practice protocol in one's own field of work. It is recommended to a) implement early mobilization as part of a bundle, including screening and management of patient's awareness, pain, anxiety, stress, delirium and family's presence, b) develop a traffic-light system of specific in- and exclusion criteria in an interprofessional process, c) use checklists to assess risks and preparation of mobilization, d) use the ICU Mobility Scale for targeting and documentation of mobilization, e) use relative safety criteria for hemodynamic and respiratory changes, and Borg Scale for subjective evaluation, f) document and evaluate systematically mobilization levels, barriers, unwanted safety events and other parameters.

Early mobilization of mechanically ventilated patients in the intensive care unit

Several recent studies have suggested that the early mobilization of mechanically ventilated patients in the intensive care unit is safe and effective. However, in these studies, few patients reached high levels of active mobilization, and the standard of care among the studies has been inconsistent. The incidence of adverse events during early mobilization is low. Its importance should be considered in the context of the ABCDE bundle. Protocols of early mobilization with strict inclusion and exclusion criteria are needed to further investigate its contributions.

Effectiveness of a Very Early Stepping Verticalization Protocol in Severe Acquired Brain Injured Patients: A Randomized Pilot Study in ICU

BACKGROUND AND OBJECTIVE

Verticalization was reported to improve the level of arousal and awareness in patients with severe acquired brain injury (ABI) and to be safe in ICU. We evaluated the effectiveness of a very early stepping verticalization protocol on their functional and neurological outcome.

METHODS

Consecutive patients with Vegetative State or Minimally Conscious State were enrolled in ICU on the third day after an ABI. They were randomized to undergo conventional physiotherapy alone or associated to fifteen 30-minute sessions of verticalization, using a tilt table with robotic stepping device. Once stabilized, patients were transferred to our Neurorehabilitation unit for an individualized treatment. Outcome measures (Glasgow Coma Scale, Coma Recovery Scale revised -CRSr-, Disability Rating Scale-DRS- and Levels of Cognitive Functioning) were assessed on the third day from the injury (T0), at ICU discharge (T1) and at Rehab discharge (T2). Between- and within-group comparisons were performed by the Mann-Whitney U test and Wilcoxon signed-rank test, respectively.

RESULTS

Of the 40 patients enrolled, 31 completed the study without adverse events (15 in the verticalization group and 16 in the conventional physiotherapy). Early verticalization started 12.4±7.3 (mean±SD) days after ABI. The length of stay in ICU was longer for the verticalization group (38.8 ± 15.7 vs 25.1 ± 11.2 days, p = 0.01), while the total length of stay (ICU+Neurorehabilitation) was not significantly different (153.2 ± 59.6 vs 134.0 ± 61.0 days, p = 0.41). All outcome measures significantly improved in both groups after the overall period (T2 vs T0, p<0.001 all), as well as after ICU stay (T1 vs T0, p<0.004 all) and after Neurorehabilitation (T2 vs T1, p<0.004 all). The improvement was significantly better in the experimental group for CRSr (T2-T0 p = 0.033, T1-T0 p = 0.006) and (borderline) for DRS (T2-T0 p = 0.040, T1-T0 p = 0.058).

CONCLUSIONS

A stepping verticalization protocol, started since the acute stages, improves the short-term and long-term functional and neurological outcome of ABI patients.

TRIAL REGISTRATION

clinicaltrials.gov NCT02828371.

Association Between Time to Rehabilitation and Outcomes After Traumatic Spinal Cord Injury

OBJECTIVE

To examine the relations between time to rehabilitation after spinal cord injury (SCI) and rehabilitation outcomes at discharge and 1-year postinjury.

DESIGN

Retrospective cohort study.

SETTING

Facilities designated as Spinal Cord Injury Model Systems.

PARTICIPANTS

Patients (N=3937) experiencing traumatic SCI between 2000 and 2014, who were 18 years or older, and who were admitted to a model system within 24 hours of injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rasch-transformed FIM motor score at discharge and 1-year postinjury, discharge to a private residence, and the Craig Handicap Assessment and Reporting Technique (CHART) Physical Independence and Mobility scores at 1-year postinjury.

RESULTS

After accounting for health status, a 10% increase in time to rehabilitation was associated with a 1.50 lower FIM motor score at discharge (95% confidence interval [CI], -2.43 to -0.58; P=.001) and a 3.92 lower CHART Physical Independence score at 1-year postinjury (95% CI, -7.66 to -0.19; P=.04). Compared to the mean FIM motor score (37.5) and mean CHART Physical Independence score (74.7), the above-mentioned values represent relative declines of 4.0% and 5.3%, respectively. There was no association between time to rehabilitation and discharge to a private residence, 1-year FIM motor score, or the CHART mobility score.

CONCLUSIONS

Earlier rehabilitation after traumatic SCI may improve patients' functional status at discharge.

Potential Strategies to Prevent Ventilator-associated Events

The Centers for Disease Control and Prevention (CDC) released ventilator-associated event (VAE) definitions in 2013. The new definitions were designed to track episodes of sustained respiratory deterioration in mechanically ventilated patients after a period of stability or improvement. More than 2,000 U.S. hospitals have reported their VAE rates to the CDC, but there has been little guidance to date on how to prevent VAEs. Existing ventilator-associated pneumonia prevention bundles are unlikely to be optimal insofar as pneumonia accounts for only a minority of VAEs. This review proposes a framework and potential intervention set to prevent VAEs on the basis of studies of VAE epidemiology, risk factors, and prevention. Work to date suggests that the majority of VAEs are caused by four conditions: pneumonia, fluid overload, atelectasis, and acute respiratory distress syndrome. Interventions that minimize ventilator exposure and target one or more of these conditions may therefore prevent VAEs. Potential strategies include avoiding intubation, minimizing sedation, paired daily spontaneous awakening and breathing trials, early exercise and mobility, low tidal volume ventilation, conservative fluid management, and conservative blood transfusion thresholds. Interventional studies have thus far affirmed that minimized sedation, paired daily spontaneous awakening and breathing trials, and conservative fluid management can reduce VAE rates and improve patient-centered outcomes. Further studies are needed to evaluate the impact of the other proposed interventions, to identify additional modifiable risk factors for VAEs, and to measure whether combining strategies into VAE prevention bundles confers additional benefits over implementing one or more of these interventions in isolation.

Comfort and patient-centred care without excessive sedation: the eCASH concept

We propose an integrated and adaptable approach to improve patient care and clinical outcomes through analgesia and light sedation, initiated early during an episode of critical illness and as a priority of care. This strategy, which may be regarded as an evolution of the Pain, Agitation and Delirium guidelines, is conveyed in the mnemonic eCASH—early Comfort using Analgesia, minimal Sedatives and maximal Humane care. eCASH aims to establish optimal patient comfort with minimal sedation as the default presumption for intensive care unit (ICU) patients in the absence of recognised medical requirements for deeper sedation. Effective pain relief is the first priority for implementation of eCASH: we advocate flexible multimodal analgesia designed to minimise use of opioids. Sedation is secondary to pain relief and where possible should be based on agents that can be titrated to a prespecified target level that is subject to regular review and adjustment; routine use of benzodiazepines should be minimised. From the outset, the objective of sedation strategy is to eliminate the use of sedatives at the earliest medically justifiable opportunity. Effective analgesia and minimal sedation contribute to the larger aims of eCASH by facilitating promotion of sleep, early mobilization strategies and improved communication of patients with staff and relatives, all of which may be expected to assist rehabilitation and avoid isolation, confusion and possible long-term psychological complications of an ICU stay. eCASH represents a new paradigm for patient-centred care in the ICU. Some organizational challenges to the implementation of eCASH are identified.

Time for critically ill patients to regain mobility after early mobilization in the intensive care unit and transition to a general inpatient floor

PURPOSE

The purpose of this study is to determine if patient mobility achievements in an intensive care unit (ICU) setting are sustained during subsequent phases of hospitalization, specifically after transferring to inpatient floors and on the day of hospital discharge.

MATERIALS AND METHODS

The study is an analysis of adult patients who stayed in the ICU for 48 hours or more during the second quarter of 2013. The study sample included 182 patients who transferred to a general inpatient floor after the ICU stay.

RESULTS

Patients experienced an average delay of 16 hours to regain or exceed chair level of mobility and 7 hours to regain ambulation level after transferring to an inpatient floor. One third of patients ambulated in the ICU, and those patients had significantly shorter post-ICU and hospital stays compared with patients who did not ambulate in the ICU. Delays in regaining mobility on the floor were modestly associated with initial Morse Fall Score and being male.

CONCLUSIONS

Mobility progression through the hospital course is imperative to improving patient outcomes. Study findings show the need for improvement in maintaining early ICU mobilization achievement during the crucial phase between ICU stay and hospital discharge.

Early mobilization in the critical care unit: A review of adult and pediatric literature

Early mobilization of critically ill patients is beneficial, suggesting that it should be incorporated into daily clinical practice. Early passive, active, and combined progressive mobilizations can be safely initiated in intensive care units (ICUs). Adult patients receiving early mobilization have fewer ventilator-dependent days, shorter ICU and hospital stays, and better functional outcomes. Pediatric ICU data are limited, but recent studies also suggest that early mobilization is achievable without increasing patient risk. In this review, we provide a current and comprehensive appraisal of ICU mobilization techniques in both adult and pediatric critically ill patients. Contraindications and perceived barriers to early mobilization, including cost and health care provider views, are identified. Methods of overcoming barriers to early mobilization and enhancing sustainability of mobilization programs are discussed. Optimization of patient outcomes will require further studies on mobilization timing and intensity, particularly within specific ICU populations.