Physical therapy-driven quality improvement to promote early mobility in the intensive care unit

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.

Experience and Hospital Context Influence Fall Prevention Practice by Physical Therapists: A Survey Study

BACKGROUND

Falls in and following hospitalization are common and problematic. Little is understood about the factors that impede or promote effective implementation of fall prevention practices.

PURPOSE AND RELEVANCE

Physical therapists are commonly consulted for acute care patients at risk for falling. The purpose of this study is to understand therapist perceptions of their effectiveness in fall prevention and to explore the impact of contextual factors on practice patterns to prevent falls surrounding hospitalization.

METHODS

Survey questions were tailored to the constructs of hospital culture, structural characteristics, networks and communications, and implementation climate, in addition to inquiries regarding practice patterns and attitudes/beliefs.

RESULTS

Overall, 179 surveys were analyzed. Most therapists (n = 135, 75.4%) affirmed their hospital prioritizes best practices for fall prevention, although fewer agreed that therapists other than themselves provide optimal fall prevention intervention (n = 105, 58.7%). Less practice experience was associated with greater odds of affirming that contextual factors influence fall prevention practice (odds ratio 3.90, p < .001). Respondents who agreed that their hospital system prioritizes best practices for fall prevention had 14 times the odds of believing that their system prioritizes making improvements ( p = .002).

CONCLUSIONS/IMPLICATIONS

As experience influences fall prevention practice, quality assurance and improvement initiatives should be used to ensure minimum specifications of practice.

Effectiveness of a quality improvement strategy with implementation of a specific visual tool to promote ICU early mobilization

Early progressive mobilization is a safe strategy in the intensive care unit (ICU), however, it is still considered challenging by the inherent barriers and poor adherence to early mobilization protocol. The aim of this study was to evaluate the effectiveness of a quality improvement (QI) multifaceted strategy with implementation of a specific visual tool, the "mobility clock", in reducing non-compliance with the institutional early mobilization (EM) protocol in adult ICUs. A single-center QI with a retrospective before-after comparison study was conducted using data from medical records and hospital electronic databases. Patients from different periods presented similar baseline characteristics. After the QI strategy, a decline in "non-compliance" with the protocol was observed compared to the previous period (10.11% vs. 26.97%, p < 0.004). The proportion of patients walking was significantly higher (49.44% vs. 29.21%, p < 0.006) and the ICU readmission rate was lower in the "after" period (2.25% vs. 11.24%; p = 0.017). The multifaceted strategy specifically designed considering institutional barriers was effective to increase out of bed mobilization, to reduce the "non-compliance" rate with the protocol and to achieve a higher level of mobility in adult ICUs of a tertiary hospital.

The effect of passive mobilization associated with blood flow restriction and combined with electrical stimulation on cardiorespiratory safety, neuromuscular adaptations, physical function, and quality of life in comatose patients in an ICU: a randomized controlled clinical trial

Background

Intensive care unit-acquired atrophy and weakness are associated with high mortality, a reduction in physical function, and quality of life. Passive mobilization (PM) and neuromuscular electrical stimulation were applied in comatose patients; however, evidence is inconclusive regarding atrophy and weakness prevention. Blood flow restriction (BFR) associated with PM (BFRp) or with electrical stimulation (BFRpE) was able to reduce atrophy and increase muscle mass in spinal cord-injured patients, respectively. Bulky venous return occurs after releasing BFR, which can cause unknown repercussions on the cardiovascular system. Hence, the aim of this study was to investigate the effect of BFRp and BFRpE on cardiovascular safety and applicability, neuromuscular adaptations, physical function, and quality of life in comatose patients in intensive care units (ICUs).

Methods

Thirty-nine patients will be assessed at baseline (T0–18 h of coma) and randomly assigned to the PM (control group), BFRp, or BFRpE groups. The training protocol will be applied in both legs alternately, twice a day with a 4-h interval until coma awake, death, or ICU discharge. Cardiovascular safety and applicability will be evaluated at the first training session (T1). At T0 and 12 h after the last session (T2), muscle thickness and quality will be assessed. Global muscle strength and physical function will be assessed 12 h after T2 and ICU and hospital discharge for those who wake up from coma. Six and 12 months after hospital discharge, physical function and quality of life will be re-assessed.

Discussion

In view of applicability, the data will be used to inform the design and sample size of a prospective trial to clarify the effect of BFRpE on preventing muscle atrophy and weakness and to exert the greatest beneficial effects on physical function and quality of life compared to BFRp in comatose patients in the ICU.

Trial registration

Universal Trial Number (UTN) Registry UTN U1111-1241-4344. Retrospectively registered on 2 October 2019. Brazilian Clinical Trials Registry (ReBec) RBR-2qpyxf. Retrospectively registered on 21 January 2020, http://ensaiosclinicos.gov.br/rg/RBR-2qpyxf/

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05916-z.

Tradução e adaptação cultural para a língua portuguesa falada no Brasil da Canadian survey of mobilization of ICU patients

RESUMO Este estudo teve como objetivo traduzir e adaptar culturalmente o questionário Canadian survey of mobilization of intensive care unit patients para a língua portuguesa falada no Brasil. Este instrumento avalia profissionais de unidade de terapia intensiva (UTI) em relação aos conhecimentos sobre a mobilização precoce (MP) e sua importância, as percepções sobre barreiras e as práticas de reabilitação com o paciente crítico. O protocolo incluiu as etapas: autorização e cessão de direitos de uso; tradução do instrumento para a língua portuguesa; reconciliação; retrotradução para a língua original; revisão e harmonização da retrotradução; aprovação da autora principal do questionário original; revisão da versão em português; desdobramento cognitivo; e reconciliação e elaboração da versão final. Devido a algumas diferenças conceituais e culturais entre os dois países, algumas dúvidas foram discutidas com a autora principal do instrumento, a qual concordou com as alterações sugeridas. No desdobramento cognitivo, os 10 profissionais selecionados testaram a clareza, compreensão e aceitabilidade do questionário, e demonstraram suas dificuldades quanto ao conteúdo deste. Muitos entrevistados evidenciaram que o instrumento desperta reflexões importantes sobre as práticas diárias e os benefícios com a realização da MP. O questionário intitulado Pesquisa de mobilização de pacientes em unidade de terapia intensiva: conhecimento, perspectivas e práticas atuais encontra-se traduzido e adaptado culturalmente para a língua portuguesa falada no Brasil, podendo ser utilizado para avaliar aspectos da MP por profissionais que participam deste processo em UTIs adulto e pediátricas. Estudos futuros utilizando esta versão serão necessários para verificar se o questionário fornece medidas reprodutíveis e válidas.

Barriers and Facilitators to Early Rehabilitation in the ICU: A Theory Driven Delphi Study

OBJECTIVES

There is conflicting evidence for the effectiveness of early rehabilitation in the intensive care and marked variation in rates of implementation in practice. We aimed to identify barriers and facilitators to early rehabilitation in mechanically ventilated patients and their relevance to practice, as perceived by key ICU clinicians across North America.

DESIGN

A Delphi study using the Theoretical Domains Framework, consisting of an initial qualitative round and subsequent quantitative rounds, was conducted to gather clinician agreement and perceived importance of barriers and facilitators to early rehabilitation. The survey included questions on the range of individual, sociocultural, and broader organizational influence on behaviors.

SETTING

Clinical practice in North America.

SUBJECTS

Four clinician groups (intensive care physicians, nurses, therapists, and respiratory therapists).

INTERVENTIONS

A three-round Delphi study.

MEASUREMENTS AND MAIN RESULTS

Fifty of 74 (67%) of invited clinicians completed the study. Agreement and consensus with Delphi survey items were high in both rounds within and between professional groups. Agreement was highest for items related to the domain "Beliefs about Consequences" (e.g., mortality reduction) and lowest for items related to the domain "Behavioral Regulation" (e.g., team discussion of barriers). Beliefs expressed about improved mortality and improvements in a variety of other long-term outcomes were not consistent with the current evidence base. Individual agreement scores changed very little from Round 2 to Round 3 of the Delphi, suggesting stability of beliefs and existing consensus.

CONCLUSIONS

This study identified a wide range of beliefs about early rehabilitation that may influence provider behavior and the success and appropriateness of further implementation. The apparent inconsistency between the optimism of stakeholders regarding mortality reductions and a low level of implementation reported elsewhere represent the most major challenge to future implementation success. Other foci for future implementation work include planning, barriers, feedback, and education of staff.

Improving Mobility in Critically Ill Patients in a Tertiary Care ICU: Opportunities and Challenges

Background

Patients in the intensive care unit (ICU) are subjected to prolonged bed rest secondary to critical illness and related therapies. Data suggest that such bed rest can have adverse consequences on the post-discharge quality of life. There is limited data from India on mobilization practices. We undertook a quality improvement (QI) initiative to understand our mobilization practices, identify challenges, and test interventions.

Materials and methods

We carried out a three-phase QI project, and the study was conducted in our 24-bedded ICU. Pre-intervention and post-intervention mobilization performance and scores were analyzed. We also recorded data on adverse events and barriers to mobilization. Descriptive statistics were used to report all the results.

Results

A total of 140 patients (1,033 patient days) and 207 patients (932 patient days) were included in our initial audit and post-implementation audit, respectively. In pre-implementation, 31.3% of patients were mobilized with an average mobility score of 2 and this improved to 57.9% with average mobility score of 3.4. Additionally, we demonstrated improvements in the mobility scores of our intubated patients (49.8% achieving a mobility score of 3-5 as compared to 16.7%).

Conclusion

A multidisciplinary approach is feasible and resulted in significant improvements in early mobilization among critically ill adults.

How to cite this article

Mohan S, Patodia S, Kumaravel S, Venkataraman R, Vijayaraghavan BKT. Improving Mobility in Critically Ill Patients in a Tertiary Care ICU: Opportunities and Challenges. Indian J Crit Care Med 2021;25(1):34-42.

Effectiveness, Safety, and Barriers to Early Mobilization in the Intensive Care Unit

Purpose

Patients admitted to the intensive care unit (ICU) are generally confined to bed leading to limited mobility that may have detrimental effects on different body systems. Early mobilization prevents or reduces these effects and improves outcomes in patients following critical illness. The purpose of this review is to summarize different aspects of early mobilization in intensive care.

Methods

Electronic databases of PubMed, Google Scholar, ScienceDirect, and Scopus were searched using a combination of keywords. Full-text articles meeting the inclusion criteria were selected.

Results

Fifty-six studies on various aspects such as the effectiveness of early mobilization in various intensive care units, newer techniques in early mobilization, outcome measures for physical function in the intensive care unit, safety, and practice and barriers to early mobilization were included. Conclusion: Early mobilization is found to have positive effects on various outcomes in patients with or without mechanical ventilation. The newer techniques can be used to facilitate early mobilization. Scoring systems—specific to the ICU—are available and should be used to quantify patients' status at different intervals of time. Early mobilization is not commonly practiced in many countries. Various barriers to early mobilization have been identified, and different strategies can be used to overcome them.

Effectiveness of structured early mobilization protocol on mobility status of patients in medical intensive care unit

INTRODUCTION

Patients admitted to the intensive care units (ICU) have limited mobility due to their illness and its management and are at a risk for immobility-related complications. Early mobilization has been suggested to prevent or limit physical dysfunction due to these complications. Effectiveness of early mobilization protocols is studied using various outcomes.

OBJECTIVE

To study the effectiveness of an early mobilization protocol on mobility status of patients in Medical ICU.

METHODS

Patients admitted to Medical ICU were screened for eligibility and allotted into two groups. Intervention group received mobilization according to a protocol while control group received mobilization as per usual mobilization practices in our ICU. Mobility was assessed using the Perme ICU mobility score on the first day of ICU, first day of rehabilitation and last day of rehabilitation.

RESULTS

63 patients were included in the study. The median difference in the Perme ICU mobility score from first day of rehabilitation to last day of rehabilitation was 9 and 2 in the intervention group and control group respectively. Significant improvements in the mobility scores were not present from first day of ICU to first day of rehabilitation in both, the intervention (p = .069) and control group (p = .124). Improvement in the scores from first day of rehabilitation to last day of rehabilitation was significant within and between both the groups (p < .001).

CONCLUSION

Early Mobilization Protocol was effective in improving mobility status of patients in Medical ICU.

From fear to fight: Patients experiences of early mobilization in intensive care. A qualitative interview study

INTRODUCTION

Early mobilization (EM) in intensive care is frequently used to prevent physical and psychological complications, with promising results. However, the patient´s perception of EM has been sparsely investigated. Purpose: To investigate the experience of EM in patients treated in intensive care. Method: Nineteen former patients who had been treated in intensive care were interviewed. The interviews were analyzed using qualitative, inductive content analysis. Results: The analysis resulted in three categories; 1) Facing the impossible - a too demanding situation; 2) Struggling successfully on the way back; and 3) Need of having dedicated supporters. Conclusion: A considerable variety of experiences of EM were described in this study, both negative and positive. Prominent features were that pleasant emotions and great physical effort occurred simultaneously and that interaction and cooperation with the caregivers was paramount. To regain independence was another prominent feature, with EM considered to be of great importance in the recovery process. Moving to an upright position and ambulating appears to be beneficial to both body and mind. EM should therefore be among the first priorities in intensive care. EM should be practiced with respect and support, while encouraging and challenging the patient to strive for independence.

Safety and Feasibility of Early Mobilization in Patients with Subarachnoid Hemorrhage and External Ventricular Drain

BACKGROUND/OBJECTIVE

In November 2014, our Neurointensive Care Unit began a multi-phased progressive early mobilization initiative for patients with subarachnoid hemorrhage and an external ventricular drain (EVD). Our goal was to transition from a culture of complete bed rest (Phase 0) to a physical and occupational therapy (PT/OT)-guided mobilization protocol (Phase I), and ultimately to a nurse-driven mobilization protocol (Phase II). We hypothesized that nurses could mobilize patients as safely as an exclusively PT/OT-guided approach.

METHODS

In Phase I, patients were mobilized only with PT/OT at bedside; no independent time out of bed occurred. In Phase II, nurses independently mobilized patients with EVDs, and patients could remain out of bed for up to 3 h at a time. Physical and occupational therapists continued routine consultation during Phase II.

RESULTS

Phase II patients were mobilized more frequently than Phase I patients [7.1 times per ICU stay (± 4.37) versus 3.0 times (± 1.33); p = 0.02], although not earlier [day 4.9 (± 3.46) versus day 6.0 (± 3.16); p = 0.32]. All Phase II patients were discharged to home PT services or acute rehabilitation centers. No patients were discharged to skilled nursing or long-term acute care hospitals, versus 12.5% in Phase I. In a multivariate analysis, odds of discharge to home/rehab were 3.83 for mobilized patients, independent of age and severity of illness. Other quality outcomes (length of stay, ventilator days, tracheostomy placement) between Phase I and Phase II patients were similar. No adverse events were attributable to early mobilization.

CONCLUSIONS

Nurse-driven mobilization for patients with EVDs is safe, feasible, and leads to more frequent ambulation compared to a therapy-driven protocol. Nurse-driven mobilization may be associated with improved discharge disposition, although exact causation cannot be determined by these data.

Best Practices for Conducting Interprofessional Team Rounds to Facilitate Performance of the ICU Liberation (ABCDEF) Bundle

OBJECTIVES

Daily ICU interprofessional team rounds, which incorporate the ICU Liberation ("A" for Assessment, Prevention, and Manage Pain; "B" for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; "C" for Choice of Analgesia and Sedation; "D" for Delirium Assess, Prevent, and Manage; "E" for Early Mobility and Exercise; "F" for Family Engagement and Empowerment [ABCDEF]) Bundle, support both the care coordination and regular provider communication necessary for Bundle execution. This article describes evidence-based practices for conducting effective interprofessional team rounds in the ICU to improve Bundle performance.

DESIGN

Best practice synthesis.

METHODS

The authors, each extensively involved in the Society of Critical Care Medicine's ICU Liberation Campaign, reviewed the pertinent literature to identify how ICU interprofessional team rounds can be optimized to increase ICU Liberation adherence.

RESULTS

Daily ICU interprofessional team rounds that foster ICU Liberation Bundle use support both care coordination and regular provider communication within and between teams. Evidence-based best practices for conducting effective interprofessional team rounds in the ICU include the optimal structure for ICU interprofessional team rounds; the importance of conducting rounds at patients' bedside; essential participants in rounds; the inclusion of ICU patients and their families in rounds-based discussions; and incorporation of the Bundle into the Electronic Health Record. Interprofessional team rounds in the ICU ideally employ communication strategies to foster inclusive and supportive behaviors consistent with interprofessional collaboration in the ICU. Patient care discussions during interprofessional team rounds benefit from being patient-centered and goal-oriented. Documentation of ICU Liberation Bundle elements in the Electronic Health Record may help facilitate team communication and decision-making.

CONCLUSIONS

Conducting high-quality interprofessional team rounds in the ICU is a key strategy to support ICU Liberation Bundle use.

Knowledge of physiotherapists working in adult ICU on contraindications to mobilization

Abstract Introduction: Mobilization is an effective therapy to combat the deleterious effects of immobility, but not all patients are in a condition to be moved; thus, knowledge about contraindication criteria is fundamental. Objective: To evaluate the knowledge of physiotherapists working in adult ICUs on contraindications to the mobilization of critical patients. Method: This was a cross-sectional study in which a survey was applied to physiotherapists working in an adult ICU in the city of Recife. Results: Out of the 36 criteria presented, only five were considered contraindication criteria. Clinical parameters were those that obtained higher frequency for not being considered criteria for contraindication, nor were there observed differences in the relation between the time of working in the ICU. Conclusion: Most physiotherapists did not consider the criteria presented as contraindications to mobilization, so that professional training in mobilization practices and the creation of protocols are necessary.

Impact of Early Mobilization in the Intensive Care Unit on Psychological Issues

Early mobilization is an intervention protocol that can be employed in the critically ill population to effectively reduce the risks and consequences normally associated with immobility in high-acuity patients. In turn, rate and quality of recovery are improved as well as overall patient outcomes. Although there are many challenges inherent to the implementation of an early mobilization program, success of such a program is achievable through structured education of staff and diligence in its application. As a result, staff and patient experience the benefits of medical treatment that addresses a patient's immediate needs without ignoring that treatment's long-term effect.

An Early Tailored Approach Is the Key to Effective Rehabilitation in the Intensive Care Unit

OBJECTIVE

To investigate the effectiveness, feasibility, and safety of an evidence-based rehabilitation care pathway in the intensive care unit (ICU) in different patient populations.

DESIGN

Observational prospective cohort study, with retrospective controls.

SETTING

ICUs of a university hospital.

PARTICIPANTS

Patients admitted between April 1, 2015, and June 30, 2015, were compared to a retrospective cohort admitted to the same ICUs during the same 3-month period in 2014. The number of patients studied (N=285) included 152 in the prospective group and 133 in the retrospective group.

INTERVENTIONS

The prospective cohort benefited of a rehabilitation care pathway based on (1) interdisciplinary teamwork; (2) early customized and goal-oriented rehabilitation; (3) daily functional monitoring and treatment revision; (4) agreed discharge policy; and (5) continuity of care. The retrospective cohort underwent usual care.

MAIN OUTCOME MEASURES

Included the following: (1) proportions of patients undergoing rehabilitation team evaluation; (2) latency between patient admission to ICUs and rehabilitation team assessment; (3) proportions of patients undergoing rehabilitation treatment during ICU stay; (4) latency between the patient admission to ICUs and rehabilitation start; (5) ICU stay and total acute hospital stay; and (5) proportion of ventilator-free days out of ICU stay.

RESULTS

The novel rehabilitation care pathway led to (1) an increased proportion of patients receiving rehabilitative assessment (P<.0001); (2) a decreased latency from ICU admission to both rehabilitation team assessment and rehabilitation start (P<.0001); (3) an increased proportion of patients undergoing rehabilitation (P<.0001); (4) a shorter length of stay in ICUs (P<.0001) and in hospital (P=.047); and (5) a shorter mechanical ventilation duration (P<.02). A direct relationship between rehabilitation start latency and ICU length of stay was observed.

CONCLUSIONS

An early, interdisciplinary team approach, providing a customized dynamic planning of physiotherapy programs, increases ventilator-free time and reduces total hospital stay, especially in patients admitted to the ICU after general surgery. This rehabilitation care pathway can be generalized to different geopolitical scenarios, being feasible, safe and cost effective.

Management of early mobilization in intensive care units: a multicenter cross-sectional study

Objective

The aim of this study was to assess the management of early mobilization (EM) in Chinese intensive care units (ICUs).

Methods

This survey used a cross-sectional, observational design. A total of 65 tertiary and secondary hospitals were enrolled by convenience sampling and investigated using self-designed questionnaires.

Results

We identified 69 ICUs in Jiangsu, China (response rate: 94.2%). 74.2% (1,004/1,353) of the nurses and nursing managers from 65 ICUs reported mobility practice. For the mobility level, 98.1% (1,327) reported use of in-bed exercise, 5.7% (77) sitting on a side of bed, 21.7% (294) transfer to chair, and 2.4% (33) walking. The most frequently reported barriers to early mobility were unplanned extubation, nursing resource, and absence of physical therapist. Nurses’ educational backgrounds, nursing experience, the lack of nursing resources, absence of physician, and the weakness of patient were the factors that influenced ICU early rehabilitation (P<0.01).

Conclusions

Although implementation rates for EM in critically ill patients are high, the activity level is generally poor in most of the involved ICUs.

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.

Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units

Early mobilization of patients in the intensive care unit (ICU) is safe, feasible, and beneficial. However, implementation of early mobility as part of routine clinical care can be challenging. The objective of this review is to identify barriers to early mobilization and discuss strategies to overcome such barriers. Based on a literature search, we synthesize data from 40 studies reporting 28 unique barriers to early mobility, of which 14 (50%) were patient-related, 5 (18%) structural, 5 (18%) ICU cultural, and 4 (14%) process-related barriers. These barriers varied across ICUs and within disciplines, depending on the ICU patient population, setting, attitude, and ICU culture. To overcome the identified barriers, over 70 strategies were reported and are synthesized in this review, including: implementation of safety guidelines; use of mobility protocols; interprofessional training, education, and rounds; and involvement of physician champions. Systematic efforts to change ICU culture to prioritize early mobilization using an interprofessional approach and multiple targeted strategies are important components of successfully implementing early mobility in clinical practice.

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

BACKGROUND

The intensive care unit provides complex care for critically ill patients. Consequently, due to the nature of critical illness and the therapies administered in intensive care, patients are often on prolonged periods of bed rest with limited mobility. It has been recognised that mobilising critically ill patients is beneficial to patients' recovery, however implementing early mobility as a standard of care remains challenging in practice.

OBJECTIVES

To identify the key factors that underpin successful implementation and sustainability of early mobilisation in adult intensive care units.

DESIGN

Integrative Review.

DATA SOURCE

A systematic search strategy guided by SPICE framework (Setting, Perspective, Intervention, Comparison, Evaluation) was used to formulate the research question, identify study inclusion and exclusion criteria, and guide the database search strategy. Computerised databases were searched from August-September 2016. Quality improvement articles that identified project implementation of early mobilisation of mechanically ventilated adult intensive care patients were included.

REVIEW METHODS

After screening the articles, extracting project data and completing summary tables, critical appraisal of the quality improvement projects was completed using the Quality Improvement Minimum Quality Criteria Set. A modified version of the Cochrane Effective Practice and Organisation of Care taxonomy was used to synthesise the multifaceted implementation strategies the projects utilised to help bring about changes in clinician behaviour.

RESULTS

Thirteen articles, reflecting 12 projects meeting the inclusion criteria were included in the final analysis. Eleven projects were conducted in the United States, and one in the United Kingdom. Quality scores ranged from 6 to 15. A formal framework to guide the quality improvement process was used in 9 projects. The three most frequently used groups of implementation strategies were educational meetings, clinical practice guidelines and tailored interventions. Managing the change process through strong leadership, designing strategies and interventions to overcome barriers to implementation, multidisciplinary team collaboration and data collection and feedback underpinned successful and sustainable early mobility practice change.

CONCLUSION

The use of a quality improvement appraisal tool can help identify high quality projects when planning a similar mobility program. Even though projects were conducted in a variety of intensive care unit settings, and implementation frameworks and strategies varied, all began with strong leadership commitment to early mobilisation. This along with using the quality improvement process and multidisciplinary team approach ensured success and sustainability of mobilising ventilated patients.

Identifying Barriers to Delivering the Awakening and Breathing Coordination, Delirium, and Early Exercise/Mobility Bundle to Minimize Adverse Outcomes for Mechanically Ventilated Patients: A Systematic Review

BACKGROUND

Improved outcomes are associated with the Awakening and Breathing Coordination, Delirium, and Early exercise/mobility bundle (ABCDE); however, implementation issues are common. As yet, no study has integrated the barriers to ABCDE to provide an overview of reasons for less successful efforts. The purpose of this review was to identify and catalog the barriers to ABCDE delivery based on a widely used implementation framework, and to provide a resource to guide clinicians in overcoming barriers to implementation.

METHODS

We searched MEDLINE via PubMed, CINAHL, and Scopus for original research articles from January 1, 2007, to August 31, 2016, that identified barriers to ABCDE implementation for adult patients in the ICU. Two reviewers independently reviewed studies, extracted barriers, and conducted thematic content analysis of the barriers, guided by the Consolidated Framework for Implementation Research. Discrepancies were discussed, and consensus was achieved.

RESULTS

Our electronic search yielded 1,908 articles. After applying our inclusion/exclusion criteria, we included 49 studies. We conducted thematic content analysis of the 107 barriers and identified four classes of ABCDE barriers: (1) patient-related (ie, patient instability and safety concerns); (2) clinician-related (ie, lack of knowledge, staff safety concerns); (3) protocol-related (ie, unclear protocol criteria, cumbersome protocols to use); and, not previously identified in past reviews, (4) ICU contextual barriers (ie, interprofessional team care coordination).

CONCLUSIONS

We provide the first, to our knowledge, systematic differential diagnosis of barriers to ABCDE delivery, moving beyond the conventional focus on patient-level factors. Our analysis offers a differential diagnosis checklist for clinicians planning ABCDE implementation to improve patient care and outcomes.

Factors influencing physical activity and rehabilitation in survivors of critical illness: a systematic review of quantitative and qualitative studies

PURPOSE

To identify, evaluate and synthesise studies examining the barriers and enablers for survivors of critical illness to participate in physical activity in the ICU and post-ICU settings from the perspective of patients, caregivers and healthcare providers.

METHODS

Systematic review of articles using five electronic databases: MEDLINE, CINAHL, EMBASE, Cochrane Library, Scopus. Quantitative and qualitative studies that were published in English in a peer-reviewed journal and assessed barriers or enablers for survivors of critical illness to perform physical activity were included. Prospero ID: CRD42016035454.

RESULTS

Eighty-nine papers were included. Five major themes and 28 sub-themes were identified, encompassing: (1) patient physical and psychological capability to perform physical activity, including delirium, sedation, illness severity, comorbidities, weakness, anxiety, confidence and motivation; (2) safety influences, including physiological stability and concern for lines, e.g. risk of dislodgement; (3) culture and team influences, including leadership, interprofessional communication, administrative buy-in, clinician expertise and knowledge; (4) motivation and beliefs regarding the benefits/risks; and (5) environmental influences, including funding, access to rehabilitation programs, staffing and equipment.

CONCLUSIONS

The main barriers identified were patient physical and psychological capability to perform physical activity, safety concerns, lack of leadership and ICU culture of mobility, lack of interprofessional communication, expertise and knowledge, and lack of staffing/equipment and funding to provide rehabilitation programs. Barriers and enablers are multidimensional and span diverse factors. The majority of these barriers are modifiable and can be targeted in future clinical practice.

Implementation of a Progressive Mobilization Program in a Medical-Surgical Intensive Care Unit

BACKGROUND

Current literature supports implementation of progressive mobility protocols in intensive care units. Education can help nurses overcome barriers to mobility and increase knowledge about the positive effects of mobility.

OBJECTIVE

To evaluate the effect of education for a progressive mobilization program for intensive care nurses on knowledge and performance.

METHODS

A pretest-posttest evaluation was conducted for 41 nurses, and a chart review was performed before and after implementation of the educational intervention to evaluate changes in knowledge and mobilization.

RESULTS

Scores after the educational intervention were significantly higher than scores before the intervention (t = 2.02; P < .001). Overall mobilization (P = .04) and dangling (P = .01) increased significantly after the education. No significant increases occurred in ambulating or getting patients up to a chair.

CONCLUSIONS

Mobilization education was effective and increased nurses' knowledge about the benefits of mobility for critically ill patients. The educational program also affected how nurses performed mobility interventions. Although provision of education had positive effects on patients' mobility, leadership and coaching are still important components in implementing change.

Overcoming barriers to the mobilisation of patients in an intensive care unit

We conducted a quality improvement project aimed at increasing the frequency of mobilisation in our ICU. We designed a four-part quality improvement project comprising: an audit documenting the baseline frequency of mobilisation; a staff survey evaluating perceptions of the barriers to mobilisation; identification of barriers that were amenable to change and implementation of strategies to address these; and a follow-up audit to determine their effectiveness. The setting was a tertiary care, urban, public hospital ICU in South Australia. All patients admitted to the ICU during the two audit periods were included in the audits, while all permanent/semi-permanent ICU staff were eligible for inclusion in the staff survey. We found that patient- and institution-related factors had the greatest impact on the mobilisation of patients in our ICU. Barriers identified as being amenable to change included insufficient staff education about the benefits of mobilisation, poor interdisciplinary communication and lack of leadership regarding mobilisation. Various strategies were implemented to address these barriers over a three-month period. Multivariable analyses showed that three out of four mobility outcomes did not significantly change between the baseline and follow-up audits, with a significant difference in favour of the baseline audit found for the fourth mobility outcome (maximum level of mobility). We concluded that implementing relatively simple measures to improve staff education, interdisciplinary communication and leadership regarding early progressive mobilisation was ineffective at improving mobility outcomes for patients in a large tertiary-level Australian ICU. Other strategies, such as changing sedation practices and/or increasing staffing, may be required to improve mobility outcomes of these patients.

Mobility and Ambulation for Patients with Pulmonary Artery Catheters: A Retrospective Descriptive Study

PURPOSE

The purposes of this retrospective study are to: 1) describe the amount and type of documented mobility activity for patients with an indwelling Pulmonary Artery Catheter (PAC) and 2) document the frequency and type of complications that occur with an indwelling PAC during patient participation in these activities.

METHODS

This study is a single-center, retrospective, descriptive study including all patients (>18 years) between June 2010 and October 2012 with an indwelling PAC in the Cardiology Intensive Care Unit (CICU). Data was extracted on all documented mobility activity each of these patients performed with nursing or during skilled treatments provided by a physical therapist (PT), or occupational therapist (OT). Any notation of PAC-related complications while the PAC was in place was recorded.

RESULTS

In the CICU over a 29-month period, 366 patients with indwelling PACs performed bed mobility, transfers, ambulation and climbed stairs with no reports of PAC complications during or in relation to participation in mobility activity.

CONCLUSION

The data suggests that participation in mobility activities does not place patients with an indwelling PAC at increased risk of PAC related complications. This data further supports the involvement of rehabilitation specialists in the CICU. Future prospective research is necessary to measure the effects of physical therapy treatment on patients with indwelling PAC.