Early mobilization of trauma patients admitted to intensive care units: A systematic review and meta-analyses

Orthopedic pelvic and extremity injuries increase overall hospital length of stay but not in-hospital complications or mortality in trauma ICU patients: Orthopedic Injuries in Trauma ICU Patients

BACKGROUND

The purpose of this study was to compare the ICU length of stay (LOS), overall hospital LOS, in-hospital complications, and mortality rate between trauma ICU patients with orthopedic injuries versus those without.

METHODS

This was a retrospective cohort study in which the trauma registry of a single level 1 trauma center was queried over a 6-year period for patients admitted to the ICU during hospitalization. Patients were stratified based on the presence/absence of an orthopedic fracture. Negative binomial regression was used to evaluate the effect of orthopedic injury on overall hospital and ICU LOS while controlling for confounding factors. Secondary outcomes included group differences with respect to in-hospital complications, mortality, and discharge disposition.

RESULTS

A total of 1,785 trauma patients were admitted to the ICU and included. Among all trauma ICU patients, 61.1 % (n = 1,091) had no associated orthopedic injuries whereas 38.9 % (n = 694) had at least one. Patients with orthopedic injuries had higher odds of being severely injured (ISS ≥ 16: OR [CI] =1.47 [1.2-1.8]; p < 0.001) despite presenting with a higher level of consciousness than those without orthopedic injuries (mean GCS: 13.3 ± 3.5 vs 12.5 ± 4.1, p < 0.001). Multivariable models demonstrated having an orthopedic injury did not moderate ICU LOS (IRR [CI] = 0.93 [0.9-1.0]; p = 0.110) but did contribute significantly to increasing hospital LOS (IRR [CI] = 1.23 [1.1-1.3]; p < 0.001). There was no evidence to suggest that orthopedic injury increases the risk of in-hospital complication or in-hospital mortality. Orthopedically injured trauma ICU patients were less likely to be discharged home than those without orthopedic injuries.

CONCLUSIONS

Trauma ICU patients with an associated orthopedic injury have significantly longer hospital stays compared to those without an orthopedic injury, despite no evidence to suggest that the orthopedic injury affects the duration of ICU stay or in-hospital complications.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

Assessing the impact of early progressive mobilization on moderate-to-severe traumatic brain injury: a randomized controlled trial

INTRODUCTION

Traumatic brain injury (TBI) is a major cause of neurodisability worldwide, with notably high disability rates among moderately severe TBI cases. Extensive previous research emphasizes the critical need for early initiation of rehabilitation interventions for these cases. However, the optimal timing and methodology of early mobilization in TBI remain to be conclusively determined. Therefore, we explored the impact of early progressive mobilization (EPM) protocols on the functional outcomes of ICU-admitted patients with moderate to severe TBI.

METHODS

This randomized controlled trial was conducted at a trauma ICU of a medical center; 65 patients were randomly assigned to either the EPM group or the early progressive upright positioning (EPUP) group. The EPM group received early out-of-bed mobilization therapy within seven days after injury, while the EPUP group underwent early in-bed upright position rehabilitation. The primary outcome was the Perme ICU Mobility Score and secondary outcomes included Functional Independence Measure motor domain (FIM-motor) score, phase angle (PhA), skeletal muscle index (SMI), the length of stay in the intensive care unit (ICU), and duration of ventilation.

RESULTS

Among 65 randomized patients, 33 were assigned to EPM and 32 to EPUP group. The EPM group significantly outperformed the EPUP group in the Perme ICU Mobility and FIM-motor scores, with a notably shorter ICU stay by 5.9 days (p < 0.001) and ventilation duration by 6.7 days (p = 0.001). However, no significant differences were observed in PhAs.

CONCLUSION

The early progressive out-of-bed mobilization protocol can enhance mobility and functional outcomes and shorten ICU stay and ventilation duration of patients with moderate-to-severe TBI. Our study's results support further investigation of EPM through larger, randomized clinical trials. Clinical trial registration ClinicalTrials.gov NCT04810273 . Registered 13 March 2021.

Early Mobility Index and Patient Outcomes: A Retrospective Study in Multiple Intensive Care Units

BACKGROUND

Early mobility interventions in intensive care units (ICUs) are safe and improve outcomes in subsets of critically ill adults. However, implementation varies, and the optimal mobility dose remains unclear.

OBJECTIVE

To test for associations between daily dose of out-of-bed mobility and patient outcomes in different ICUs.

METHODS

In this retrospective cohort study of electronic records from 7 adult ICUs in an academic quarternary hospital, multivariable linear regression was used to examine the effects of out-of-bed events per mobility-eligible day on mechanical ventilation duration and length of ICU and hospital stays.

RESULTS

In total, 8609 adults hospitalized in ICUs from 2015 through 2018 were included. Patients were mobilized out of bed on 46.5% of ICU days and were eligible for mobility interventions on a median (IQR) of 2.0 (1-3) of 2.7 (2-9) ICU days. Median (IQR) out-of-bed events per mobility-eligible day were 0.5 (0-1.2) among all patients. For every unit increase in out-of-bed events per mobility-eligible day before extubation, mechanical ventilation duration decreased by 10% (adjusted coefficient [95% CI], -0.10 [-0.18 to -0.01]). Daily mobility increased ICU stays by 4% (adjusted coefficient [95% CI], 0.04 [0.03-0.06]) and decreased hospital stays by 5% (adjusted coefficient [95% CI], -0.05 [-0.07 to -0.03]). Effect sizes differed among ICUs.

CONCLUSIONS

More daily out-of-bed mobility for ICU patients was associated with shorter mechanical ventilation duration and hospital stays, suggesting a dose-response relationship between daily mobility and patient outcomes. However, relationships differed across ICU subpopulations.

Perceived Barriers to Patient Mobilization Among Therapy and Nursing Acute Care Staff: A Multi-Site Survey Study

OBJECTIVE

To identify differences in perceived barriers to patient mobilization in acute care among therapy and nursing clinicians, and among hospitals of different sizes and types.

DESIGN

Cross-sectional survey study.

SETTING

Eight hospitals of various sizes and types (teaching vs non-teaching; urban vs rural), from 2 different states in the Western region of the United States.

PARTICIPANTS

A nonprobability sample of 568 acute care clinicians (N=586) involved in direct patient care were surveyed. Clinicians indicated a clinical role within the branch of therapy (physical therapy or occupational therapy) or nursing (registered nurse or nurse assistant).

MAIN OUTCOME MEASURES

The Patient Mobilization Attitudes and Beliefs Survey (PMABS) was used to assess perceived barriers to early patient mobilization among therapy and nursing staff. A PMABS total score and 3 subscale scores (knowledge, attitudes, or behaviors associated with barriers to mobilization) were calculated, with higher scores indicative of greater mobilization barriers.

RESULTS

Mean PMABS total scores were significantly lower (better) for therapy providers (24.63±6.67) than nursing providers (38.12±10.95), P<.001. Additionally, therapy providers had significantly lower scores than nursing providers on all 3 subscales (all P<.001). Item-specific analyses revealed significant differences in responses between therapy and nursing staff on 22 of 25 items, with nursing staff indicating greater perceptions of barriers than therapy staff on 20 of the 22 items. The top 5 items with the largest response differences between therapy and nursing clinicians included adequate time to mobilize patients, understanding appropriate referral to therapy staff, knowledge on when it is safe to mobilize patients, confidence in the ability to mobilize patients, and receiving training on methods of safe mobilization. While hospital type did not affect perceived barriers to early mobilization, PMABS scores were significantly higher for large and small hospitals when compared to medium-sized hospitals.

CONCLUSION

Perceived barriers to patient mobilization exist among therapy and nursing acute care clinicians, with greater barriers noted among nursing staff for knowledge, attitudes, and behaviors associated with patient mobility practices. Findings suggest future work is warranted, with opportunities for therapy providers to collaborate with nursing providers to address barriers to implementing patient mobility.

Critical Care and Occupational Therapy Practice Across the Lifespan

This AOTA Position Statement defines the distinct role and value of occupational therapy practitioners in critical care settings across the lifespan. Occupational therapy practitioners are essential interprofessional team members who address the needs of critically ill individuals by implementing evidence-based critical care guidelines that aim to improve the quality of survivorship.

The effects of early mobilization in mechanically ventilated adult ICU patients: systematic review and meta-analysis

Background

The effects of early mobilization (EM) on intensive care unit (ICU) patients remain unclear. A meta-analysis of randomized controlled trials was performed to evaluate its effect in mechanically ventilated adult ICU patients.

Methods

We searched randomized controlled trials (RCTs) published in Medline, Embase, and CENTRAL databases (from inception to November 2022). According to the difference in timing and type, the intervention group was defined as a systematic EM group, and comparator groups were divided into the late mobilization group and the standard EM group. The primary outcome was mortality. The secondary outcomes were ICU length of stay, duration of mechanical ventilation (MV), and adverse events. EM had no impact on 180-day mortality and hospital mortality between intervention groups and comparator groups (RR 1.09, 95% CI 0.89-1.33, p = 0.39). Systemic EM reduced the ICU length of stay (LOS) (MD -2.18, 95% CI -4.22--0.13, p = 0.04) and the duration of MV (MD -2.27, 95% CI -3.99--0.56, p = 0.009), but it may increase the incidence of adverse events in patients compared with the standard EM group (RR 1.99, 95% CI 1.25-3.16, p = 0.004).

Conclusion

Systematic EM has no significant effect on short- or long-term mortality in mechanically ventilated adult ICU patients, but systematic EM could reduce the ICU LOS and duration of MV.

Sustained adherence to a delirium guideline five years after implementation in an intensive care setting: A retrospective cohort study

OBJECTIVE

To explore the level of sustained adherence to a delirium guideline in a university intensive care unit setting five years after cessation of a multifaceted implementation program conducted between April 2012 and February 2015.

RESEARCH METHODOLOGY/DESIGN

A quantitative retrospective cohort study was conducted using the medical records of all eligible patients admitted to the intensive care unit from November 2019 to February 2020.

SETTING

Four adult intensive care units in a university hospital.

MAIN OUTCOME MEASURES

Primary outcome is adherence to seven performance indicators indicated in the guideline being: light sedation days, mobilisation, physical therapy, analgesics use, delirium and sedation screening and avoiding benzodiazepines. Clinical patient outcomes such as Intensive care unit stay and prevalence of delirium were also collected. Data were compared with the results of the original implementation study's using descriptive statistics and Kruskal-wallis and Chi-square tests.

RESULTS

Data of 236 patients were included. The most notable decrease in adherence concerned 'number of light sedation days' (-28 %). Adherence to three indicators had increased: 'number of days receiving out-of-bed mobilisation' (+11 %); 'number of days receiving physical therapy' (+9%); and 'use of analgesics' (+12 %). Comparison of clinical outcomes showed an increased intensive care unit length-of-stay from 3 to 5 days (P < 0.001). Prevalence of delirium increased over five years from 41 % to 43 % of patients while delirium duration decreased from a median of 3 days to a median of 2 days.

CONCLUSION

Five years after ceasing of implementation efforts regarding the delirium guideline, partial sustainability has been achieved. The decrease in adherence to 'number of light sedation days' could have contributed to the increased length-of-stay on the intensive care unit.

IMPLICATIONS FOR CLINICAL PRACTICE

After implementation, routine monitoring of performance indicators is required to evaluate the level of sustainment. Further, revisiting reasons for decrease in guideline adherence when contextual changes occur. Reassessment of the perceived barriers and facilitators can guide adaptations to sustain, or even improve, adherence.

Effects of different types and frequencies of early rehabilitation on ventilator weaning among patients in intensive care units: A systematic review and meta-analysis

OBJECTIVE

This study aimed to investigate the effects of different types and frequencies of physiotherapy on ventilator weaning among patients in the intensive care unit (ICU) and to identify the optimal type and frequency of intervention.

DATA SOURCES

PubMed, Cochrane Library, EMBASE, and Airiti Library.

STUDY SELECTION

Randomized controlled trials that provided information on the dosage of ICU rehabilitation and the parameters related to ventilator weaning were included.

DATA EXTRACTION AND MANAGEMENT

Treatment types were classified into conventional physical therapy, exercise-based physical therapy, neuromuscular electrical stimulation (NEMS), progressive mobility, and multi-component. The frequencies were divided into high (≥ 2 sessions/day or NEMS of > 60 minutes/day), moderate (one session/day, 3-7 days/week or NEMS of 30-60 minutes/day), and low (one session/day, < 3 days/week, or NEMS of < 30 minutes/day).

DATA SYNTHESIS

Twenty-four articles were included for systematic review and 15 out of 24 articles were analyzed in the meta-analysis. Early rehabilitation, especially the progressive mobility treatment exerted an optimal effect in reducing the ventilator duration in patients in the ICU (standardized mean difference [SMD] = 0.91; 95% confidence interval [CI] = 0.23-1.58; P < 0.01). Regarding the treatment frequency, the high-frequency intervention did not result in a favorable effect on ventilator duration compared with the moderate frequency of treatment (SMD = 0.75; 95% CI = -1.13-2.64; P = 0.43).

CONCLUSION

Early rehabilitation with progressive mobility is highly recommended to decrease the ventilation duration received by patients in the ICU. Depending on clinical resources and the tolerance of patients, the frequency of interventions should reach moderate-to-high frequency, that is, at least one session per day and 3 days a week.

TRIAL REGISTRATION

Registration number: PROSPERO (CRD42021243331).

Functional mobility effects of progressive early mobilization protocol on people with moderate-to-severe traumatic brain injury: A pre-post intervention study

BACKGROUND: Brain plasticity evoked by environmental enrichment through early mobilization may improve sensorimotor functions of patients with moderate-to-severe traumatic brain injury (TBI). Increasing evidence also suggests that early mobilization increases verticalization, which is beneficial to TBI patients in critical care. However, there are limited data on early mobilization interventions provided to patients with moderate-to-severe TBI. OBJECTIVE: We investigated the possible enhancing effects of revised progressive early mobilization on functional mobility and the rate of out-of-bed mobility attained by patients with moderate-to-severe TBI. METHODS: This is a quantitative study with a retrospective and prospective pre–post intervention design. We implemented a revised progressive early mobilization protocol for patients with moderate-to-severe TBI admitted to the trauma intensive care unit (ICU) within the previous seven days. The outcome parameters were the rate of patients attaining early mobilization (sitting on the edge of the bed) and the Perme ICU Mobility Score at discharge from the ICU. The outcome parameters in the intervention cohort were compared with those from a historical control cohort who received standard medical care a year previously. Differences in the Perme ICU Mobility Score between the two cohorts were assessed using univariate analysis of covariance. RESULTS: Forty-two patients were included in the progressive early mobilization program and were compared with 44 patients who underwent standard medical care. In the intervention cohort, 100% and 57.2% of the patients completed early rehabilitation and early mobilization, respectively, compared to 0% in the control cohort. The intervention cohort at ICU discharge showed significantly improved the Perme ICU Mobility Scores. CONCLUSIONS: The implementation of the revised progressive early mobilization program for patients with moderate-to-severe TBI resulted in significantly improved mobility at ICU discharge; however, the length of overall stay in the ICU may be not affected.

The Association Between Early Versus Late Physical Therapy Initiation and Outcomes of Trauma Patients With and Without Traumatic Brain Injuries

BACKGROUND

There is a lack of literature regarding the most effective timing to initiate physical therapy (PT) among traumatically injured patients. We aim to evaluate the association between early PT/mobilization versus delayed or late PT/mobilization and clinical outcomes of trauma patients.

METHODS

A retrospective cohort analysis of an urban level-I trauma center from 2014 to 2019 was performed. Univariate analyses and multivariable logistic regression were performed with significance defined as P < 0.05.

RESULTS

A total of 11,937 patients were analyzed. Among patients without a traumatic brain injury (TBI), late PT initiation times were associated with 60% lower odds of being discharged home without services (P < 0.05), significantly increased hospital and ICU length of stay (H-LOS, ICU-LOS) (P < 0.05), and significantly higher odds of complications (VTE, pneumonia, pressure ulcers, ARDS) (P < 0.001). Among patients with a TBI, late PT initiation time had 76% lower odds of being discharged home without services (P < 0.05) and significantly longer H-LOS and ICU-LOS (P < 0.05) however did not experience significantly higher odds of complications (P > 0.05).

CONCLUSIONS

Among traumatically injured patients, early PT is associated with decreased odds of complications, shorter H-LOS and ICU-LOS, and a favorable discharge disposition to home without services. Adoption of early PT initiation/mobilization protocols and establishment of prophylactic measures against complications associated with delayed PT is critical to maximize quality of care and trauma patient outcomes. Multi-center prospective studies are needed to ascertain the impact of PT initiation times in greater detail and to minimize trauma patient morbidity.

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.

A atuação do terapeuta ocupacional em Unidade de Terapia Intensiva: uma revisão sistemática

Resumo Introdução A participação do terapeuta ocupacional (TO) em Unidades de Terapia Intensiva (UTI) ainda é discreta no Brasil, talvez, por isso, haja pouca discussão das intervenções e inserção do profissional nessa área. Objetivo Sintetizar as atuações do TO para restabelecimento da função em pacientes adultos internados na UTI mais frequentemente descritas na literatura especializada. Método Revisão Sistemática baseada na recomendação PRISMA. A busca dos estudos foi realizada nas plataformas Cochrane, PubMed, OTSeek e PEDro, utilizando os termos de busca “Occupational Therapy”, no título ou resumo, (AND) “Intensive Care Unit” (OR) “Critical Illness” (OR) “Critical Care”, em outras partes do texto. Foram incluídos textos em língua inglesa e publicados nos últimos 20 anos. Excluiu-se textos que abordavam UTI pediátrica/neonatal, doenças psiquiátricas e artigos de revisão. Dois pesquisadores independentes selecionaram os artigos e a concordância foi submetida à análise Kappa. O nível de evidência e a qualidade metodológica dos estudos incluídos foram avaliados pela Escala PEDro e pela Ferramenta de Colaboração Cochrane, respectivamente. Resultados As principais intervenções foram relativas ao treino de Atividades de Vida Diária (AVDs) e tarefas relacionadas às Atividades Instrumentais de Vida Diária (AIVDs). Essas atribuições privativas da profissão ocorreram isoladamente ou com fisioterapeutas. As sessões, excluídos os critérios de contraindicação, aconteceram precocemente (24-48h). Conclusão Os achados evidenciam intervenções de mobilização precoce, seguidas por práticas de treino de AVDs/ AIVDs. Ademais, é notado que a atuação do terapeuta ocupacional na UTI está em elaboração. Estudos sobre outros efeitos da internação prolongada na UTI devem ser conduzidos. Registro PROSPERO: CRD42020214615.

Effects of early mobilization on the prognosis of critically ill patients: A systematic review and meta-analysis

BACKGROUND

Early mobilization is considered a safe and effective therapeutic strategy for accelerating the rehabilitation of patients admitted to the intensive care unit, with a proven benefit for critically ill patients.

OBJECTIVES

To evaluate the effects of early mobilization on the prognosis of critically ill patients through a meta-analysis of data pooled from studies meeting the inclusion criteria.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

Electronic databases including PubMed, EMBASE, the Cochrane Library, CINAHL, ProQuest, Web of Science, ProQuest Dissertations and Theses, Chinese BioMedical Literature Service System, WANFANG database, CNKI database, and Clinical Trial Register Platform were systematically searched from inception up to December 31, 2019.

REVIEW METHODS

Study eligibility was independently evaluated by two researchers. The title and abstract of the studies were first screened, and full-text articles of the remaining studies were screened for verification. Methodologic quality and risk of bias of the included studies were evaluated, and data were extracted from eligible studies. The meta-analysis was conducted using Review Manager v5.3 software. Key outcomes are presented as pooled risk ratio, weighted mean difference, and the corresponding 95% confidential interval .

RESULTS

A total of 39 articles were included in the meta-analysis. The results showed that early mobilization improved ventilator-associated pneumonia patients' Medical Research Council score; reduced the incidence of intensive care unit-acquired weakness and intensive care unit-related complications such as ventilator-associated pneumonia, deep vein thrombosis, and pressure sores; and shortened the duration of mechanical ventilation, length of intensive care unit stay and hospital stay. However, there were no statistically significant differences in handgrip strength, delirium rate, intensive care unit mortality, hospital mortality, and physical function- and mental health-related quality of life at 2-3 months and 6 months post-hospital discharge.

CONCLUSIONS

Early mobilization was effective in enhancing the recovery of critically ill patients, but more large-scale, multicenter randomized controlled trials are required to further confirm these findings.