Implementing early mobilisation in the intensive care unit: An integrative review

Implementation and Mixed-Methods Assessment of an Early Mobility Interprofessional Education Simulation

INTRODUCTION

Extended periods of bed rest and mechanical ventilation (MV) have devastating effects on the body.

BACKGROUND

Early mobility (EM) for patients in respiratory failure is safe and feasible, and an interprofessional team is recommended. Using simulation to train EM skills improves student confidence. The purpose of this study was to enable health care student collaboration as an interprofessional team in providing safe management and monitoring during an EM simulation for a patient requiring MV.

METHODS

Nursing (n = 33), respiratory (n = 7), occupational (n = 24), and physical therapist students (n = 55) participated in an EM interprofessional education (IPE) simulation experience. A mixed-methods analytic approach was used with pre/post quantitative analysis of the Student Perceptions of Interprofessional Clinical Education-Revised, Version 2 instrument and qualitative analysis of students' guided reflection papers.

RESULTS

Pre/post surveys completion rate was 39.5% (n = 47). The Student Perceptions of Interprofessional Clinical Education-Revised, Version 2 instrument indicated a significant improvement (P = .037) in students' perceptions of interprofessional collaborative practice. Qualitative data showed a positive response to the EM simulation IPE. Themes reflected all 4 Interprofessional Education Collaborative competencies.

DISCUSSION

This study demonstrated improved perception of interprofessional collaborative practice and better understanding of the Interprofessional Education Collaborative competencies.

CONCLUSION

Students collaborated in the simulation-based IPE to provide EM for a patient requiring MV and reported perceived benefits of the experience.

The Use of Quality Improvement in the Physical Therapy Literature: A Scoping Review

INTRODUCTION

Quality improvement (QI) is a useful methodology for improving healthcare, often through iterative changes. There is no prior review on the application of QI in physical therapy (PT).

PURPOSE AND RELEVANCE

To characterize and evaluate the quality of the QI literature in PT.

METHODS

We searched four electronic databases from inception through September 1, 2022. Included publications focused on QI and included the practice of PT. Quality was assessed using the 16-point QI Minimum Quality Criteria Set (QI-MQCS) appraisal tool.

RESULTS

Seventy studies were included in the review, 60 of which were published since 2014 with most ( n = 47) from the United States. Acute care ( n = 41) was the most prevalent practice setting. Twenty-two studies (31%) did not use QI models or approaches and only nine studies referenced Revised Standards for QI Reporting Excellence guidelines. The median QI-MQCS score was 12 (range 7-15).

CONCLUSIONS/IMPLICATIONS

Quality improvement publications in the PT literature are increasing, yet there is a paucity of QI studies pertaining to most practice settings and a lack of rigor in project design and reporting. Many studies were of low-to-moderate quality and did not meet minimum reporting standards. We recommend use of models, frameworks, and reporting guidelines to improve methodologic rigor and reporting.

Success in Supporting Early Mobility and Exercise in a Cardiothoracic Intensive Care Unit

Early mobility contributes to improved patient outcomes and reduced hospital length of stay during acute and intensive care hospitalization. The Bedside Mobility Assessment Tool was implemented in a cardiothoracic intensive care unit during participation in a nationwide evidence-based quality improvement initiative. One outcome included a high level of mobility that was sustained over time. Using the Dynamic Sustainability Framework model, this article describes the key components that contributed to this sustained mobility performance over 4 years.

Facilitators & barriers and practices of early mobilization in critically ill burn patients: A survey

BACKGROUND

Early mobilization (EM) of intensive care (IC) patients is important but complex with facilitators and barriers. Compared to general IC patients, burn IC patients are more hyper-metabolic. They have extensive wounds, lengthy wound dressing changes, and repeated surgeries that may affect possibilities of EM. This study aimed to identify facilitators and barriers of EM in burn IC patients among all disciplines involved. Additionally, we assessed EM practices, i.e. when are which patients considered suitable for EM.

METHODS

A survey was sent to 139 professionals involved in EM of burn IC patients (discipline groups: Intensivists, medical doctors, registered nurses, therapists).

RESULTS

Response rate was 57 %. The majority found EM very important, yet different definitions were chosen. Perceived barriers mainly concerned patient-level factors, most frequently hemodynamic instability and excessive sedation followed by skin graft surgery, fatigue, and pain management. Most frequent barriers at the provider-level were limited staffing, safety concerns, and conflicting perceptions about the suitability of EM. At the institutional-level, we found no high barriers. Interdisciplinary variation on perceived barriers, when to initiate it, and permitted maximal activity were ascertained.

CONCLUSION

Skin grafts and pain management were barriers of EM specific for burn care. Opinions on frequency, dosage and duration of EM varied widely. Improving interdisciplinary communication is key.

Barriers and facilitators to implementation of early mobilisation of critically ill patients in Zimbabwean and South African public sector hospitals: a qualitative study

PURPOSE

Implementing early mobilisation in intensive care is challenging, and a detailed knowledge of factors that may hinder or facilitate implementation is essential for success. The study was done to explore the perceived barriers and facilitators to early mobilisation by physiotherapists in Zimbabwean and South African public sector hospital ICUs.

METHODS

A qualitative study was done in eight public sector hospitals from South Africa and four hospitals from Zimbabwe. Physiotherapists from the participating hospitals who had at least two years working experience in ICU were invited to participate in semi-structured, in-depth, face-to-face interviews. Purposive sampling was done. Data collected included interpretation of early mobilisation, perceived barriers, and facilitators to early mobilisation. Data analysis was done using the content analysis method.

FINDINGS

A total of 22 physiotherapists were interviewed. In defining the activities regarded as early mobilisation, there was diversity in relation to the specific activities and the nature of the patients in which the defined activities were suitable for. Perceived barriers which emerged included lack of professional autonomy or boundaries, motivation, and clinical skills. Perceived facilitators to early mobilisation included the availability of guidelines, good communication, adequate staff, and mobilisation equipment.

CONCLUSIONS

Barriers and facilitators to early mobilisation are multifactorial. There is need for multidisciplinary team collaboration and planning before implementing early mobilisation activities.Implications to rehabilitationProfessional roles/identity and or boundaries emerged to be a barrier that hinder implementation of early mobilisation if not clearly defined.Non-rotational physiotherapy coverage was highlighted to be important in facilitating good communication and teamwork and sustainability of services in ICU.Good communication channels and referrals between different disciplines should be employed in ICU to prevent delay in rendering services to ICU patients.

Supporting Decision-Making About Patient Mobility in the Intensive Care Unit Nurse Work Environment: Work Domain Analysis

Background

Patient mobility is an evidenced-based physical activity intervention initiated during intensive care unit (ICU) admission and continued throughout hospitalization to maintain functional status, yet mobility is a complex intervention and not consistently implemented. Cognitive work analysis (CWA) is a useful human factors framework for understanding complex systems and can inform future technology design to optimize outcomes.

Objective

The aim of this study is to understand the complexity and constraints of the ICU work environment as it relates to nurses carrying out patient mobility interventions, using CWA.

Methods

We conducted a work domain analysis and completed an abstraction hierarchy using the CWA framework. Data from documents, observation (32 hours), and interviews with nurses (N=20) from 2 hospitals were used to construct the abstraction hierarchy.

Results

Nurses seek information from a variety of sources and integrate patient and unit information to inform decision-making. The completed abstraction hierarchy depicts multiple high-level priorities that nurses balance, specifically, providing quality, safe care to patients while helping to manage unit-level throughput needs. Connections between levels on the abstraction hierarchy describe how and why nurses seek patient and hospital unit information to inform mobility decision-making. The analysis identifies several opportunities for technology design to support nurse decision-making about patient mobility.

Conclusions

Future interventions need to consider the complexity of the ICU environment and types of information nurses need to make decisions about patient mobility. Considerations for future system redesign include developing and testing clinical decision support tools that integrate critical patient and unit-level information to support nurses in making patient mobility decisions.

Barriers and perceived benefits of early mobilisation programmes in Dutch paediatric intensive care units

BACKGROUND

Early mobilisation of critically ill adults has been proven effective and is safe and feasible for critically ill children. However, barriers and perceived benefits of paediatric intensive care unit (PICU) staff involvement in mobilising critically ill children are largely unknown. In this study, we explored the barriers and perceived benefits regarding early mobilisation of critically ill children as perceived by PICU staff.

METHODS

A cross-sectional survey study among staff from seven PICUs in the Netherlands has been carried out.

RESULTS

Two hundred and fifteen of the 641 health care professionals (33.5%) who were invited to complete a questionnaire responded, of whom 159 (75%) were nurses, 40 (19%) physicians, and 14 (6%) physical therapists. Respondents considered early mobilisation potentially beneficial to shorten the duration of mechanical ventilation (86%), improve wake/sleep rhythm (86%) and shorten the length of stay in the PICU (85%). However, staff were reluctant to mobilize patients on extracorporeal membrane oxygenation (ECMO) (63%), and patients with traumatic brain injury (49%). Perceived barriers to early mobilisation were hemodynamic instability (78%), risk of dislocation of lines/tubes (74%), and level of sedation (62%). In total, 40.3% of PICU nurses stated that physical therapists provided enough support in their PICU, but 84.6% of the physical therapists believed support was sufficient.

CONCLUSION

Participating PICU staff considered early mobilisation as potentially beneficial in improving patient outcomes, although barriers were noted in certain patient groups.

RELEVANCE TO PRACTICE

We identified barriers to early mobilisation which should be addressed in implementation research projects in order to make early mobilisation in critically ill children work.

Mapping research findings on change implementation in nursing practice: A scoping literature review

AIMS

The aim of this study was to map the diverse factors impacting change implementation in nursing practices and investigate different implementation strategies.

DESIGN

Scoping literature review following PRISMA-ScR extension.

METHODS

Data were collected from PubMed, Ebsco, Scopus and ScienceDirect databases from 1990 onwards. Only English peer-reviewed studies reporting an implementation of change in nursing practice were included. Of 9,954 studies, 425 abstracts were scanned and 98 full-text articles were screened. Finally, 28 studies were selected.

RESULTS

A multifaceted approach, with a tailored intervention, was the most effective implementation strategy. Most identified factors were considered systematic, for example resource availability, leadership and knowledge. However, others related to local social and material context were identified in fewer number of studies. These seem to be operational elements for implementation processes. Both types of factors are essential and must be considered for successful implementation.

CONCLUSION

We advocate the development of framework including systematic factors and which capture the local context flexibility.

Benefits of multidisciplinary collaborative care team-based nursing services in treating pressure injury wounds in cerebral infarction patients

BACKGROUND

Cerebral infarction patients need to be bedridden for long periods of time often resulting in pressure injuries, which may represent a serious threat to patients' life and health. An effective nursing program should be adopted for timely intervention in patients with pressure wounds.

AIM

To explore the value of nursing services based on a multidisciplinary collaborative treatment team in patients with pressure injury wounds following cerebral infarction.

METHODS

Patients with cerebral infarction pressure injury wounds in our hospital from December 2016 to January 2021 were selected and divided into one study group and one control group based on the simple random number table method. The control group was treated with conventional nursing care (CNC), and the study group was treated with care services based on multidisciplinary collaborative care (MDCC). The Pressure Ulcer Scale for Healing (PUSH), healing effect, Self-Perceived Burden Score (SPBS), and satisfaction with the intervention were calculated before and after 2 and 4 wk of intervention in both groups.

RESULTS

Sixty-two patients were enrolled, and 31 patients were assigned to each group. The results of the interventions were as follows: (1) There was no significant difference between the PUSH scores of the MDCC group (11.19 ± 2.46) and CNC group (12.01 ± 2.79) before the intervention (P > 0.05), and the PUSH scores were lower after 2 and 4 wk of intervention in the MDCC group (6.63 ± 1.97 and 3.11 ± 1.04) than in the CNC group (8.78 ± 2.13 and 4.96 ± 1.35 points) (P < 0.05); (2) The rate of wound healing in the MDCC group (96.77%) was higher than that in the CNC group (80.65%) (P < 0.05); (3) There was no significant difference between the SPBS scores of emotional factors (21.15 ± 3.11), economic factors (9.88 ± 2.15), and physical factors (8.19 ± 2.23) in the two groups before the intervention. The scores of emotional factors (13.51 ± 1.88), economic factors (6.38 ± 1.44), and physical factors (5.37 ± 1.08) were lower in the MDCC group than in the CNC group (16.89 ± 2.05, 7.99 ± 1.68 and 7.06 ± 1.19) after 4 wk of intervention (P < 0.05); and (4) Satisfaction with the intervention was higher in the MDCC group (93.55%) than in the CNC group (74.19%) (P < 0.05).

CONCLUSION

Interventions for patients with cerebral infarction pressure wounds based on an MDCC treatment team can effectively reduce patients' self-perceived burden, improve pressure wound conditions, facilitate wound healing, and increase patient satisfaction with the intervention.

Development, Implementation, and Evaluation of an Early Mobility Protocol in a Regional Level II Trauma Center

The purpose of this project was to develop and evaluate a collaborative nursing/therapist protocol for early mobility in a medical-surgical intensive care unit (MICU) in a regional level II trauma center. Data for patients in the MICU were compared for the periods August 3, 2015-August 2, 2016, and August 3, 2014-August 2, 2015. Semistructured interviews were conducted with 10 nurses and 1 therapist. Average MICU length of stay decreased from 3.81 to 3.50 days (P = .057). Mean time in mobility chairs did not change (0.12 days vs 0.11 days, P = .389). Mean number of days to first documented level 2-5 activity decreased significantly, from 1.81 to 1.51 days (P = .036). The percentage of hospitalizations with any documented level 3 or 4 activity increased significantly (from 3.8% to 7.4% and from 61.5% to 66.7%, P = .003 and P = .031, respectively). Barriers/challenges to implementation included having enough people to assist, space, documentation, having to coax the physician to place order for upright mobility, availability of therapists for later stages of protocol, patient variability, fear of patient falls, availability of therapy chairs, staff changes, time, and patient refusal. A multidisciplinary approach to protocol development for early mobility in an intensive care unit was successfully implemented at a regional level II trauma center.

Multidisciplinary, early mobility approach to enhance functional independence in patients admitted to a cardiothoracic intensive care unit: a quality improvement programme

Early mobilisation following cardiac surgery is vital for improved patient outcomes, as it has a positive effect on a patient's physical and psychological recovery following surgery. We observed that patients admitted to the cardiothoracic intensive care unit (CTICU) following cardiac surgery had only bed exercises and were confined to bed until the chest tubes were removed, which may have delayed patients achieving functional independence. Therefore, the CTICU team implemented a quality improvement (QI) project aimed at the early mobilisation of patients after cardiac surgery.A retrospective analysis was undertaken to define the current mobilisation practices in the CTICU. The multidisciplinary team identified various practice gaps and tested several changes that led to the implementation of a successful early mobility programme. The tests were carried out and reported using rapid cycle changes. A model for improvement methodology was used to run the project. The outcomes of the project were analysed using standard 'run chart rules' to detect changes in outcomes over time and Welch's t-test to assess the significance of these outcomes.This project was implemented in 2015. Patient compliance with early activity and mobilisation gradually reached 95% in 2016 and was sustained over the next 3 years. After the programme was implemented, the mean hours required for initiating out-of-bed-mobilisation was reduced from 22.77 hours to 11.74 hours. Similarly, functional independence measures and intensive care unit mobility scores also showed a statistically significant (p<0.005) improvement in patient transfers out of the CTICU.Implementing an early mobility programme for post-cardiac surgery patients is both safe and feasible. This QI project allowed for early activity and mobilisation, a substantial reduction in the number of hours required for initiating out-of-bed mobilisation following cardiac surgery, and facilitated the achievement of early ambulation and functional milestones in our patients.

Multidisciplinary, early mobility approach to enhance functional independence in patients admitted to a cardiothoracic intensive care unit: a quality improvement programme

Early mobilisation following cardiac surgery is vital for improved patient outcomes, as it has a positive effect on a patient's physical and psychological recovery following surgery. We observed that patients admitted to the cardiothoracic intensive care unit (CTICU) following cardiac surgery had only bed exercises and were confined to bed until the chest tubes were removed, which may have delayed patients achieving functional independence. Therefore, the CTICU team implemented a quality improvement (QI) project aimed at the early mobilisation of patients after cardiac surgery.A retrospective analysis was undertaken to define the current mobilisation practices in the CTICU. The multidisciplinary team identified various practice gaps and tested several changes that led to the implementation of a successful early mobility programme. The tests were carried out and reported using rapid cycle changes. A model for improvement methodology was used to run the project. The outcomes of the project were analysed using standard 'run chart rules' to detect changes in outcomes over time and Welch's t-test to assess the significance of these outcomes.This project was implemented in 2015. Patient compliance with early activity and mobilisation gradually reached 95% in 2016 and was sustained over the next 3 years. After the programme was implemented, the mean hours required for initiating out-of-bed-mobilisation was reduced from 22.77 hours to 11.74 hours. Similarly, functional independence measures and intensive care unit mobility scores also showed a statistically significant (p<0.005) improvement in patient transfers out of the CTICU.Implementing an early mobility programme for post-cardiac surgery patients is both safe and feasible. This QI project allowed for early activity and mobilisation, a substantial reduction in the number of hours required for initiating out-of-bed mobilisation following cardiac surgery, and facilitated the achievement of early ambulation and functional milestones in our patients.

Smart Health-Enhanced Early Mobilisation in Intensive Care Units

Critically ill patients that stay in Intensive Care Units (ICU) for long periods suffer from Post-Intensive Care Syndrome or ICU Acquired Weakness, whose effects can decrease patients' quality of life for years. To prevent such issues and aiming at shortening intensive care treatments, Early Mobilisation (EM) has been proposed as an encouraging technique: the literature includes numerous examples of the benefits of EM on the prevention of post-operative complications and adverse events. However, the appropriate application of EM programmes entails the use of scarce resources, both human and technical. Information and Communication Technologies can play a key role in reducing cost and improving the practice of EM. Although there is rich literature on EM practice and its potential benefits, there are some barriers that must be overcome, and technology, i.e., the use of sensors, robotics or information systems, can contribute to that end. This article reviews the literature and analyses on the use of technology in the area of EM, and moreover, it proposes a smart health-enhanced scenario.

Barriers and enablers to the development and implementation of early mobility programs for children in the pediatric intensive care unit: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to gather and map the current literature associated with barriers and enablers related to the development and implementation of an early mobility program in pediatric intensive care units.

INTRODUCTION

As care for critically ill patients has evolved, strategies to optimize patient outcomes and reduce the side effects of treatment have become a rising priority for clinicians, patients, and their families. Early mobilization of patients with critical illness is the only evidence-based intervention that decreases intensive care unit-acquired weakness; it may also minimize intensive care unit-acquired delirium. Early mobility in the pediatric setting has many obstacles, and routine uptake of early mobility practice has lagged.

INCLUSION CRITERIA

This review will consider literature related to the barriers and enablers to the development and/or implementation of early mobility programs in pediatric intensive care units. The review will target programs designed for children and youth from birth to 18 years who have been admitted to a pediatric intensive care unit.

METHODS

This scoping review will search six databases and several sources of unpublished/gray literature. Studies published in English and French will be included. The search will be restricted to publications after 1980. Data will be extracted using a tool developed by the reviewers. The data extracted will be presented in a tabular manner and highlight the key findings related to the objectives of this review.

Environmental Factors Affecting Early Mobilization and Physical Disability Post-Intensive Care: An Integrative Review Through the Lens of the World Health Organization International Classification of Functioning, Disability, and Health

BACKGROUND

Early mobilization (EM) is one of few potential protective factors associated with reduced physical disability post-intensive care (PD PIC). However, only 45% of intensive care units (ICUs) in the United States routinely practice EM despite its recognized benefits.

OBJECTIVES

To analyze the evidence on the relationship between critical care EM, PD PIC, and environmental factors, using the theoretical lens of the World Health Organization's (WHO's) International Classification of Functioning, Disability, and Health (ICF).

METHOD

The Whittemore and Knafl methodology for integrative reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines were followed. Qualitative, quantitative, and mixed-methods studies (n = 38) that evaluated EM and 1 or more domains of the WHO ICF were included. Quality was appraised using the Mixed-Methods Appraisal Tool. Study characteristics were evaluated for common themes and relationships. The ICF domains and subdomains pertaining to each study were synthesized.

RESULTS

Early mobilization was related to improved functioning on the disability continuum of the WHO ICF. Early mobilization was influenced by several WHO ICF environmental factors. Dedicated physical and occupational therapy teams in the ICU, interdisciplinary rounds, and positive family and staff perception of EM facilitated intervention delivery. However, poor staffing levels, negative unit culture, perceived workload burden, and lack of equipment, education, and financial support impeded delivery of EM.

DISCUSSION

Early mobilization is a promising intervention that may reduce PD PIC. However, environmental factors negatively influence delivery of EM in the ICU. Several gaps in EM research limit its acceptability in ICU practice. Existing EM research is challenged by poor methodological quality. Further study is necessary to better understand the role of EM on PD PIC and improve patient outcomes following critical illness.

Reviewing the animal literature: how to describe and choose between different types of literature reviews

Before starting any (animal) research project, review of the existing literature is good practice. From both the scientific and the ethical perspective, high-quality literature reviews are essential. Literature reviews have many potential advantages besides synthesising the evidence for a research question. First, they can show if a proposed study has already been performed, preventing redundant research. Second, when planning new experiments, reviews can inform the experimental design, thereby increasing the reliability, relevance and efficiency of the study. Third, reviews may even answer research questions using already available data. Multiple definitions of the term literature review co-exist. In this paper, we describe the different steps in the review process, and the risks and benefits of using various methodologies in each step. We then suggest common terminology for different review types: narrative reviews, mapping reviews, scoping reviews, rapid reviews, systematic reviews and umbrella reviews. We recommend which review to select, depending on the research question and available resources. We believe that improved understanding of review methods and terminology will prevent ambiguity and increase appropriate interpretation of the conclusions of reviews.

Organizational structures and early mobilization practices in South African public sector intensive care units-A cross-sectional study

RATIONALE

Understanding current early mobilization practice of patients in intensive care unit (ICU) is critical to the design and implementation of strategies to facilitate its application in a diverse population of critically ill patients encountered in public sector hospitals.

AIM

To evaluate the organizational structures of South African public sector hospital ICUs and to describe early mobilization practices in these units.

METHODS

A cross-sectional survey was done in participating public hospitals from eight provinces in South Africa. Convenience sampling was done. Data collected included hospital and ICU structure, adult patient demographic and clinical data, and mobilization activities done in ICU over the previous 24 hours prior to the day of the survey.

RESULTS

A total of 29 ICUs from 13 participating hospitals were surveyed resulting in 205 patient records. Majority of the surveyed ICUs were "open" type (n = 16; 55.2%). A standardized sedation scoring system was used in 18 units (62.1%) and only two units (6.9%) had an early mobilization protocol in place. Mean age of the patients surveyed was 43.5 (±17.7) years and 148 (72.2%) patients were on mechanical ventilation. Primary reasons for admission to ICU included traumatic injury (n = 86; 42%) and postoperative care (n = 33; 16.1%). Mobilization activities performed in the previous 24 hours included turning the patient in bed (n = 88; 42.9%), marching on the spot (n = 9; 4.4%) and walking (n = 10; 4.9%). Out-of-bed mobilization was done in only 40 (19.5%) patients. The most common barriers to early mobilization included patient unresponsiveness (n = 50; 24.4%) and hemodynamic instability (n = 42; 20.5%). The type of ventilation was found to have a significant positive relationship with out-of-bed patient mobilization (P = .000).

CONCLUSIONS

A small proportion of patients attained their highest level of mobilization in ICU. The type of ventilation influenced early mobilization practices in public sector ICUs in South Africa.

A survey examining the use of mechanical insufflation-exsufflation on adult intensive care units across the UK

INTRODUCTION

Despite potential benefits, it is not known how widely physiotherapists use mechanical insufflation-exsufflation devices on UK adult intensive care units. This survey aimed to describe mechanical insufflation-exsufflation use in UK adult intensive care units.

METHODS

Cross-sectional electronic survey of physiotherapists working in a permanent post on adult intensive care units.

RESULTS

One hundred and sixty-six complete surveys were available for analysis, reflecting a diverse geographical spread. Nearly all (98%; 163/166) clinicians had access to mechanical insufflation-exsufflation. The estimated frequency of use varied, with the majority reporting weekly or monthly use (52/163, 32%; 50/163, 31%, respectively). Nearly all clinicians (99%) used mechanical insufflation-exsufflation with extubated patients. In contrast, around half of respondents (86/163, 53%) used mechanical insufflation-exsufflation with intubated patients, with a range of perceived barriers reported.

CONCLUSIONS

Mechanical insufflation-exsufflation devices are widely available on UK adult intensive care units, with use more common in extubated patients. Barriers to mechanical insufflation-exsufflation use in the intubated population warrant further investigation.

Impact of an early mobilization protocol on outcomes in trauma patients admitted to the intensive care unit: A retrospective pre-post study

BACKGROUND

Prolonged immobility has detrimental consequences for critically ill patients admitted to the intensive care unit (ICU). Previous work has shown that early mobilization of ICU patients is a safe, feasible and effective strategy to improve outcomes; however, few of these studies focused on trauma ICU patients. Our objective was to assess the impact of implementing an ICU early mobilization protocol (EMP) on trauma outcomes.

METHODS

We conducted a retrospective pre-post study of adult trauma patients (>18 years old) admitted to ICU at a Level I trauma center over a 2-year period prior to and following EMP implementation, allowing for a 1-year transition period. Data were collected from the Nova Scotia Trauma Registry. We compared outcomes (mortality, length of stay [LOS], ventilator-free days) between patients admitted during pre-EMP and post-EMP periods, and assessed for factors associated with outcomes using binary logistic regression and generalized linear models.

RESULTS

Overall, 526 patients were included in the analysis (292 pre-EMP, 234 post-EMP). Ages ranged from 18 years to 92 years (mean, 49.0 ± 20.4 years) and 74.3% were men. The post-EMP group had lower ICU mortality (21.6% vs. 12.8%; p = 0.009) and in-hospital mortality (25.3% vs. 17.5%; p = 0.031). After controlling for confounders, patients in the post-EMP group were less likely to die in the ICU (odds ratio, 0.43; 95% confidence interval, 0.24-0.79; p = 0.006) or in-hospital (odds ratio, 0.55; 95% confidence interval; 0.32-0.94; p = 0.03). In-hospital LOS, ICU LOS, ICU-free days, and number of ventilator-free days were similar between the two groups.

CONCLUSION

Trauma patients admitted to ICU during the post-EMP period had decreased odds of ICU mortality and in-hospital mortality. This is the first study to demonstrate a significant reduction in trauma mortality following implementation of an ICU mobility protocol.

LEVEL OF EVIDENCE

Therapeutic, level III.

The use of national collaborative to promote advanced practice registered nurse-led high-value care initiatives

BACKGROUND

High-value healthcare focuses on improving healthcare to produce cost effective care, however limited information on the role of advanced practice registered nurses (APRNs) exists.

PURPOSE

This descriptive report describes APRN-led initiatives implemented as part of a national collaborative promoting the Choosing Wisely® campaign and high-value care measures.

METHOD

An APRN national collaborative focuses on developing and implementing high-value care initiatives. Monthly calls, podcasts, and a file sharing platform are used to facilitate the work of the national collaborative.

FINDINGS

A total of 16 APRN teams from 14 states are participating and have implemented a number of initiatives to reduce unnecessary testing and treatments, promote appropriate antibiotic use, and promote optimal clinical practices such as mobility for hospitalized elderly patients, among others.

DISCUSSION

A national collaborative has proven to be a successful way to engage APRN teams to focus on targeting high-value care and promoting evidence-based practices in clinical care.

Early Mobilization in the ICU: A Collaborative, Integrated Approach

To develop and implement a protocol to increase patient mobility in three adult ICUs using an interdisciplinary approach and existing resources.

Delirium in intensive care: A stepped-wedge cluster randomised controlled trial for a nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the intensive care unit (protocol)

BACKGROUND

Delirium is an acute disorder of attention and cognition with the highest rates among adults receiving intensive care. An acute episode of delirium is associated with morbidity and mortality, as well as a significant psychological sequela. Importantly, an increasing body of evidence supports the benefit of nonpharmacological, nurse-led interventions to reduce the incidence and duration of delirium among adults cared for in the intensive care unit (ICU).

OBJECTIVES

This study will evaluate the impact of a nursing-led delirium prevention protocol that is aimed at reducing the incidence and duration of delirium among adults admitted to the ICU. The delirium prevention nursing protocol specifically targets risk factors for delirium.

STUDY PLAN

A stepped-wedge cluster randomised controlled trial approach will be used to assess the effectiveness of the nurse-led intervention, in four adult ICUs across the South Western Sydney Local Health District (SWS-LHD), over a 12-month period. The primary outcomes of interest are (i) the incidence of delirium before and after the implementation of the nurse-led intervention and (ii) the number of delirium-free days during an ICU stay, before and after the implementation of the nurse-led intervention.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): (ACTRN12618000411246p).

Safety, Feasibility, and Efficacy of Early Rehabilitation in Patients Requiring Continuous Renal Replacement: A Quality Improvement Study

INTRODUCTION

Early rehabilitation in critically ill patients is associated with improved outcomes. Recent research demonstrates that patients requiring continuous renal replacement therapy (CRRT) can safely engage in mobility. The purpose of this study was to assess safety and feasibility of early rehabilitation with focus on mobility in patients requiring CRRT.

METHODS

Study design was a mixed methods analysis of a quality improvement protocol. The setting was an intensive care unit (ICU) at a tertiary medical center. Safety was prospectively recorded by incidence of major adverse events including dislodgement of CRRT catheter, accidental extubation, bleeding, and hemodynamic emergency; and minor adverse events such as transient oxygen desaturation >10% of resting. Limited efficacy testing was performed to determine if rehabilitation parameters were associated with clinical outcomes.

RESULTS

A total of 67 patients (54.0 ± 15.6 years old, 44% women, body mass index 29.2 ± 9.3 kg/m²) received early rehabilitation under this protocol. The median days of CRRT were 6.0 (interquartile range [IQR], 2-11) and 72% of patients were on mechanical ventilation concomitantly with CRRT at the time of rehabilitation. A total of 112 rehabilitation sessions were performed of 152 attempts (74% completion rate). No major adverse events occurred. Patients achieving higher levels of mobility were more likely to be alive at discharge (P = 0.076).

CONCLUSIONS

The provision of early rehabilitation in critically ill patients requiring CRRT is safe and feasible. Further, these preliminary results suggest that early rehabilitation with focus on mobility may improve patient outcomes in this susceptible population.

Effectiveness of an early mobility protocol for stroke patients in Intensive Care Unit

Objectives:

To evaluate the effectiveness of an early mobility protocol for stroke patients in the intensive care unit.

Methods:

Participants were patients with first or recurrent stroke (n=60, age=49.02±6.36 years, body mass index=32.95±5.67 kg/m²) admitted to the intensive care stroke unit in general hospitals, Riyadh during October and December 2016. Single group pretest-posttest design involving an early mobility protocol was started within first 24 hours admission. Pre and post measurements of muscle strength, pulmonary function and quality of life were carried out.

Results:

There were significant improvements in muscle strength of upper and lower extremities´ muscles after treatment (p<0.05), pulmonary functions including Forced Vital Capacity, Forced Expiratory Volume 1 (p<0.05) and quality of life, namely, Barthel Index and modified Rankin Scale (p<0.01).

Conclusion:

This study demonstrates that initiating an early mobility protocol is safe and effective for intensive care unit stroke patients and supports introducing the current protocol as a standard protocol in neurogenic Intensive Care Units.

Factors Associated With Inability to Bear Weight Following Hip Fracture Surgery: An Analysis of the ACS-NSQIP Hip Fracture Procedure Targeted Database

Introduction:

While the benefits of early mobility for prevention of complications such as pneumonia, thromboembolic events, and improved mortality have been well studied in postsurgical patients, it is unclear which patients may struggle to achieve full weight-bearing on the first postoperative day.

Materials and Methods:

The 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Hip Fracture Database was queried regarding the ability to achieve weight-bearing on first postoperative day for older adults. Cases that occurred secondary to malignancy were excluded or for which weight-bearing was unachievable on the first postoperative day due to medical reasons were excluded.

Results:

A total of 6404 patients met inclusion and exclusion criteria for the study, with 1640 (25.6%) patients unable to bear weight on the first postoperative day. Following adjusted analysis, nonmodifiable patient factors such as dependent (partial or total) functional health status, dyspnea with moderate exertion (odds ratio [OR]: 1.31 [95% confidence interval, CI: 1.04-1.65]), ventilator dependency, and preoperative dementia on presentation to hospital were associated with lack of achievement of weight-bearing on the first postoperative day. Modifiable patient factors such as presence of systemic inflammatory response syndrome (OR: 1.35 [95% CI: 1.11-1.64]), delirium, and low preoperative hematocrit and modifiable system factors including delayed time to surgery, total postoperative time >90 minutes, and transfer from an outside emergency department were also associated with inability to achieve weight-bearing on the first postoperative day.

Discussion:

Medical teams can utilize the results from this study to better identify patients preoperatively who may be at risk of not achieving early mobilization and proactively employ implement strategies to encourage mobility as soon as possible for hip fracture patients.

Early mobilisation of ventilated patients in the intensive care unit: A survey of critical care clinicians in an Australian tertiary hospital

INTRODUCTION

Mobilising mechanically ventilated patients is safe and beneficial and improves outcomes. However, early mobilisation is not widely practiced and barriers to its implementation still exist.

OBJECTIVE

The objective of this study was to assess clinician perceptions, knowledge, attitudes, and behaviours towards mobilising critically ill ventilated patients in the intensive care unit, as well as perceived barriers and facilitators towards mobilisation.

METHODS

A prospective questionnaire based on three existing questionnaires was administered to nurses, physicians, and physiotherapists from a single mixed medical/surgical intensive care unit in an Australian tertiary hospital. The 32-item questionnaire focused on knowledge, attitudes, behaviour, and perceived facilitators and barriers. Various response options were used, and data were analysed using descriptive statistics.

RESULTS

The overall response rate was 56.6% (82 of 145). Overall, clinicians' knowledge score was 4.1 (standard deviation = 1.4) out of a possible score of 6. Early mobilisation was not perceived as a top priority by 40.2% of participants. One important facilitator was that majority of the participants perceived early mobilisation was important. The most common perceived barriers to early mobilisation were medical instability, delirium, sedation, and limited staffing. Clinicians' opinions varied on the timing and appropriateness for instituting early mobilisation.

CONCLUSIONS

Clinicians had various levels of knowledge on early mobilisation as a therapy for critically ill patients. Most clinicians believed that early mobility was important and were willing to reduce sedation; however, several key barriers were identified which need to be addressed by using targeted interventions. This will reduce or close the gap between knowledge and practice.

Survey of Respiratory Care Professionals' Knowledge in Early Mobilization: A Pilot Study

Early mobilization (EM) is practiced for intensive care unit (ICU) patients in many hospitals in the Eastern Province in Saudi Arabia. Respiratory care professionals’ knowledge about using EM was, therefore, surveyed and investigated to improve and update its practice and ultimately to develop related regulations and policies. A survey including 156 respiratory care professionals was conducted using a validated questionnaire. The focus was on collecting information on participants’ relevant backgrounds and on proper use of EM. Knowledge and proper use of EM were calculated in relation to participants’ demographic and professional characteristics. The statistical analysis using analysis of variance and Student t-test showed that factors that affected knowledge of EM were the respiratory care professional’s age, gender, nationality, and years of experience in intensive care medicine. How many patients these professionals treated using EM also significantly correlated with their knowledge of EM. The survey showed the extent of respiratory care professionals’ knowledge about the proper use of EM. More importantly, the survey also identified important shortfalls in practice of some experienced medical practitioners.

Early mobilisation in mechanically ventilated patients: a systematic integrative review of definitions and activities

Background

Mechanically ventilated patients often develop muscle weakness post-intensive care admission. Current evidence suggests that early mobilisation of these patients can be an effective intervention in improving their outcomes. However, what constitutes early mobilisation in mechanically ventilated patients (EM-MV) remains unclear. We aimed to systematically explore the definitions and activity types of EM-MV in the literature.

Methods

Whittemore and Knafl’s framework guided this review. CINAHL, MEDLINE, EMBASE, PsycINFO, ASSIA, and Cochrane Library were searched to capture studies from 2000 to 2018, combined with hand search of grey literature and reference lists of included studies. The Critical Appraisal Skills Programme tools were used to assess the methodological quality of included studies. Data extraction and quality assessment of studies were performed independently by each reviewer before coming together in sub-groups for discussion and agreement. An inductive and data-driven thematic analysis was undertaken on verbatim extracts of EM-MV definitions and activities in included studies.

Results

Seventy-six studies were included from which four major themes were inferred: (1) non-standardised definition, (2) contextual factors, (3) negotiated process and (4) collaboration between patients and staff. The first theme indicates that EM-MV is either not fully defined in studies or when a definition is provided this is not standardised across studies. The remaining themes reflect the diversity of EM-MV activities which depends on patients’ characteristics and ICU settings; the negotiated decision-making process between patients and staff; and their interdependent relationship during the implementation.

Conclusions

This review highlights the absence of an agreed definition and on what constitutes early mobilisation in mechanically ventilated patients. To advance research and practice an agreed and shared definition is a pre-requisite.