The physiological after-effects of critical care

Early mobilisation in intensive care units in Australia and Scotland: a prospective, observational cohort study examining mobilisation practises and barriers

Introduction

Mobilisation of patients in the intensive care unit (ICU) is an area of growing research. Currently, there is little data on baseline mobilisation practises and the barriers to them for patients of all admission diagnoses.

Methods

The objectives of the study were to (1) quantify and benchmark baseline levels of mobilisation in Australian and Scottish ICUs, (2) compare mobilisation practises between Australian and Scottish ICUs and (3) identify barriers to mobilisation in Australian and Scottish ICUs. We conducted a prospective, observational, cohort study with a 4-week inception period. Patients were censored for follow-up upon ICU discharge or after 28 days, whichever occurred first. Patients were included if they were >18 years of age, admitted to an ICU and received mechanical ventilation in the ICU.

Results

Ten tertiary ICUs in Australia and nine in Scotland participated in the study. The Australian cohort had a large proportion of patients admitted for cardiothoracic surgery (43.3 %), whereas the Scottish cohort had none. Therefore, comparison analysis was done after exclusion of patients admitted for cardiothoracic surgery. In total, 60.2 % of the 347 patients across 10 Australian ICUs and 40.1 % of the 167 patients across 9 Scottish ICUs mobilised during their ICU stay (p < 0.001). Patients in the Australian cohort were more likely to mobilise than patients in the Scottish cohort (hazard ratio 1.83, 95 % confidence interval 1.38–2.42). However, the percentage of episodes of mobilisation where patients were receiving mechanical ventilation was higher in the Scottish cohort (41.1 % vs 16.3 %, p < 0.001). Sedation was the most commonly reported barrier to mobilisation in both the Australian and Scottish cohorts. Physiological instability and the presence of an endotracheal tube were also frequently reported barriers.

Conclusions

This is the first study to benchmark baseline practise of early mobilisation internationally, and it demonstrates variation in early mobilisation practises between Australia and Scotland.

Re-building life after ICU: a qualitative study of the patients' perspective

OBJECTIVE

To explore former ICU patients' views on what the key components of a post ICU rehabilitation programme should be.

RESEARCH METHODOLOGY

Thirty five participants completed an online questionnaire accessed via a link to the study from two support groups' websites. Adults (>18 years) who had been patients in ICU were invited to take part. Participants were asked open questions about their ICU experience and their views on ICU rehabilitation. Participants were: aged from 22 to 70 years; from the USA (22), the UK (8), Canada (2), Australia (1) and other (2); 30 female and five male. Findings were analysed using a thematic approach.

FINDINGS

Three themes were identified: 'Information and education', 'Personal support' and 'Assessment and therapy'. Analysis suggested that for participants the aspects of rehabilitation covered by each of the themes were of equal importance.

CONCLUSION

Healthcare professionals in ICU, acute ward and community settings need to be aware of the broad array of physical and psychological challenges faced by patients who have been critically ill. Healthcare professionals need to ensure a holistic approach is implemented to coordinate and facilitate rehabilitation, to address identified patients' needs.

Mobilisation in critical care: a concept analysis

OBJECTIVES

The aim of this paper is to analyse the concept of mobilisation within the context of the critical care setting. Mobilisation is a widely used term that belies the complexity of its use in practice. Whilst facilitating movement is a significant nursing concern, mobilisation practices vary widely amongst nurses, perhaps due to conceptual incongruence.

METHODS

Evolutionary methodology was used in this concept analysis. Medline, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews and PsycInfo databases were searched from 1966 to present. Search terms included mobilisation, mobility and passive exercise, yielding 61 articles suitable for analysis.

FINDINGS

Findings indicate that mobilisation is an interdisciplinary, goal-directed therapy used to facilitate movement and improve outcomes. It involves energy expenditure and has both physical and psychological domains. Disciplines vary in applications of mobilisation and therapy parameters are essentially undefined. The energy expenditure attribute has been well-exemplified in physical therapy literature, but only to a minimal degree in nursing literature.

CONCLUSION

In spite of the wide use of mobilisation, the concept requires further development, particularly in the critical care setting. Barriers to mobilisation require further delineation as does the psychological domain. Ongoing concept analysis can be used to inform practice and guide research activities.

Critical illness polyneuromyopathy (CIPNM); rehabilitation during critical illness. Therapeutic options in nursing to promote recovery: a review of the literature

Following critical illness requiring prolonged mechanical ventilation and sedation, intensive care patients often present with neuromuscular weakness. This results from critical illness polyneuropathy (CIP) and critical illness myopathy (CIM). A lack of diagnostic criteria for each syndrome complicates prevention and treatment. Consequently the term critical illness polyneuromyopathy (CIPNM) has emerged and is characterised by severe weakness, reduced or absent limb reflexes and marked muscle wasting. Although clinical trials report a high incidence of CIPNM, in clinical practice it often remains undetected. The pathophysiological mechanisms that lead to neuromuscular weakness are not entirely clear, however several risk factors have been identified and will be discussed. To date, there are no specific treatments or interventions available to reduce the onset or impact of CIPNM. This paper will review the strategies employed that are supportive and aimed at controlling the associated risk factors.

The effect of nurse-facilitated family participation in the psychological care of the critically ill patient

AIM

This paper is a report of a Neuman systems model-guided study of the effects of nurse-facilitated family participation in psychological care on the extent of patient delirium and psychological recovery following critical illness.

BACKGROUND

Psychological disturbances resulting from critical illness have been well documented in international literature. Few studies have tested interventions designed to alleviate such disturbances.

METHODS

A comparative time series design was used. A total of 170 critically ill patients and families participated in the study - 83 in the control group and 87 in the intervention group. Data were collected during critical illness and subsequent recovery using the Therapeutic Intervention Scoring System-28, Intensive Care Delirium Screening Checklist and the Sickness Impact Profile. The study was carried out in Northern Ireland, data collection taking place from January 2004 to December 2005.

RESULTS/FINDINGS

Nurse-facilitated family participation in psychological care did not significantly reduce the incidence of delirium among patients in critical care, but patients receiving intervention demonstrated better psychological recovery and wellbeing than the control group at 4, 8 and 12 weeks after admission to critical care.

CONCLUSION

Nurse-facilitated family participation in the psychological care may strengthen the lines of defence and resistance against the stressors experienced by the patient during critical illness and improve psychological recovery.

Development of the 3-SET 4P questionnaire for evaluating former ICU patients' physical and psychosocial problems over time: a pilot study

BACKGROUND

Current studies reveal a lack of consensus for the evaluation of physical and psychosocial problems after ICU stay and their changes over time.

OBJECTIVES

The aim was to develop and evaluate the validity and reliability of a questionnaire for assessing physical and psychosocial problems over time for patients following ICU recovery.

PATIENTS

Thirty-nine patients completed the questionnaire, 17 were retested.

METHODS AND RESULTS

The questionnaire was constructed in three sets: physical problems, psychosocial problems and follow-up care. Face and content validity were tested by nurses, researchers and patients. The questionnaire showed good construct validity in all three sets and had strong factor loadings (explained variance >70%, factor loadings >0.5) for all three sets. There was good concurrent validity compared with the SF 12 (r(s)>0.5). Internal consistency was shown to be reliable (Cronbach's alpha 0.70-0.85). Stability reliability on retesting was good for the physical and psychosocial sets (r(s)>0.5).

CONCLUSION

The 3-set 4P questionnaire was a first step in developing an instrument for assessment of former ICU patients' problems over time. The sample size was small and thus, further studies are needed to confirm these findings.

Critical illness VR rehabilitation device (X-VR-D): Evaluation of the potential use for early clinical rehabilitation

We present a new critical illness VR rehabilitation device (X-VR-D) that enables diversified self-training and is applicable early in the rehabilitation of severely injured or ill patients. The X-VR-D consists of a VR program delivering a virtual scene on a flat screen and simultaneously processing commands to a moving chair mounted on a motion system. Sitting in the moving chair and exposed to a virtual reality environment the device evokes anticipatory and reactive muscle contractions in trunk and extremities for postural control. In this study we tested the device in 10 healthy subjects to evaluate whether the enforced perturbations indeed evoke sufficient and reproducible EMG muscle activations. We found that particular fast roll and pitch movements evoke adequate trunk and leg muscle activity. Higher angular velocities and higher angles of inclination elicited broader EMG bursts and larger amplitudes. The muscle activation pattern was highly consistent between different subjects and although we found some habituation of EMG responses in consecutive training sessions, the general pattern was maintained and was predictable for specific movements. The habituation was characterized by more efficient muscle contractions and better muscle relaxation during the rest positions of the device. Furthermore we found that the addition of a virtual environment to the training session evoked more preparatory and anticipatory muscle activation than sessions without a virtual environment. We conclude that the X-VR-D is safe and effective to elicit consistent and reproducible muscle activity in trunk and leg muscles in healthy subjects and thus can be used as a training method.

Patient empowerment: does it still occur in the ICU?

The theoretical underpinnings of patient empowerment were developed through the work of educators and community psychologists, working primarily with the socially disadvantaged. Empowerment is seen as a philosophy based upon the belief of the inherent worth and creative potential of each individual. Therefore, the aim of this paper is to explore whether this creative potential associated with patient choice that encapsulates empowerment is applicable to the Intensive Care Unit.