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Liu Y, Hao H, Sharma MM, Harris Y, Scofi J, Trepp R, Farmer B, Ancker JS, Zhang Y. Clinician Acceptance of Order Sets for Pain Management: A Survey in Two Urban Hospitals. Appl Clin Inform 2022; 13:447-455. [PMID: 35477148 PMCID: PMC9045963 DOI: 10.1055/s-0042-1745828] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Order sets are a clinical decision support (CDS) tool in computerized provider order entry systems. Order set use has been associated with improved quality of care. Particularly related to opioids and pain management, order sets have been shown to standardize and reduce the prescription of opioids. However, clinician-level barriers often limit the uptake of this CDS modality. OBJECTIVE To identify the barriers to order sets adoption, we surveyed clinicians on their training, knowledge, and perceptions related to order sets for pain management. METHODS We distributed a cross-sectional survey between October 2020 and April 2021 to clinicians eligible to place orders at two campuses of a major academic medical center. Survey questions were adapted from the widely used framework of Unified Theory of Acceptance and Use of Technology. We hypothesize that performance expectancy (PE) and facilitating conditions (FC) are associated with order set use. Survey responses were analyzed using logistic regression. RESULTS The intention to use order sets for pain management was associated with PE to existing order sets, social influence (SI) by leadership and peers, and FC for electronic health record (EHR) training and function integration. Intention to use did not significantly differ by gender or clinician role. Moderate differences were observed in the perception of the effort of, and FC for, order set use across gender and roles of clinicians, particularly emergency medicine and internal medicine departments. CONCLUSION This study attempts to identify barriers to the adoption of order sets for pain management and suggests future directions in designing and implementing CDS systems that can improve order sets adoption by clinicians. Study findings imply the importance of order set effectiveness, peer influence, and EHR integration in determining the acceptability of the order sets.
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Affiliation(s)
- Yifan Liu
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, United States
| | - Haijing Hao
- Department of Computer Information Systems, Bentley University, Waltham, Massachusetts, United States
| | - Mohit M Sharma
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, United States
| | - Yonaka Harris
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, United States
| | - Jean Scofi
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, United States
| | - Richard Trepp
- Department of Emergency Medicine, Columbia University, New York, New York, United States
| | - Brenna Farmer
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, United States
| | - Jessica S Ancker
- Department of Biomedical Informatics, Vanderbilt University Medical Center, New York, New York, United States
| | - Yiye Zhang
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, United States.,Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, United States
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2
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Schallom M, Tymkew H, Vyers K, Prentice D, Sona C, Norris T, Arroyo C. Implementation of an Interdisciplinary AACN Early Mobility Protocol. Crit Care Nurse 2021; 40:e7-e17. [PMID: 32737495 DOI: 10.4037/ccn2020632] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Increasing mobility in the intensive care unit is an important part of the ABCDEF bundle. Objective To examine the impact of an interdisciplinary mobility protocol in 7 specialty intensive care units that previously implemented other bundle components. METHODS A staggered quality improvement project using the American Association of Critical-Care Nurses mobility protocol was conducted. In phase 1, data were collected on patients with intensive care unit stays of 24 hours or more for 2 months before and 2 months after protocol implementation. In phase 2, data were collected on a random sample of 20% of patients with an intensive care unit stay of 3 days or more for 2 months before and 12 months after protocol implementation. RESULTS The study population consisted of 1266 patients before and 1420 patients after implementation in phase 1 and 258 patients before and 1681 patients after implementation in phase 2. In phase 1, the mean (SD) mobility level increased in all intensive care units, from 1.45 (1.03) before to 1.64 (1.03) after implementation (P < .001). Mean (SD) ICU Mobility Scale scores increased on initial evaluation from 4.4 (2.8) to 5.0 (2.8) (P = .01) and at intensive care unit discharge from 6.4 (2.5) to 6.8 (2.3) (P = .04). Complications occurred in 0.2% of patients mobilized. In phase 2, 84% of patients had out-of-bed activity after implementation. The time to achieve mobility levels 2 to 4 decreased (P = .05). Intensive care unit length of stay decreased significantly in both phases. CONCLUSIONS Implementing the American Association of Critical-Care early mobility protocol in intensive care units with ABCDEF components in place can increase mobility levels, decrease length of stay, and decrease delirium with minimal complications.
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Affiliation(s)
- Marilyn Schallom
- Marilyn Schallom is director, Heidi Tymkew and Donna Prentice are research scientists, Kara Vyers is a research coordinator, and Cassandra Arroyo is lead statistical analyst, Department of Research for Patient Care Services, Barnes-Jewish Hospital, St Louis, Missouri
| | - Heidi Tymkew
- Marilyn Schallom is director, Heidi Tymkew and Donna Prentice are research scientists, Kara Vyers is a research coordinator, and Cassandra Arroyo is lead statistical analyst, Department of Research for Patient Care Services, Barnes-Jewish Hospital, St Louis, Missouri
| | - Kara Vyers
- Marilyn Schallom is director, Heidi Tymkew and Donna Prentice are research scientists, Kara Vyers is a research coordinator, and Cassandra Arroyo is lead statistical analyst, Department of Research for Patient Care Services, Barnes-Jewish Hospital, St Louis, Missouri
| | - Donna Prentice
- Marilyn Schallom is director, Heidi Tymkew and Donna Prentice are research scientists, Kara Vyers is a research coordinator, and Cassandra Arroyo is lead statistical analyst, Department of Research for Patient Care Services, Barnes-Jewish Hospital, St Louis, Missouri
| | - Carrie Sona
- Carrie Sona is a clinical nurse specialist, surgical/burn/trauma intensive care unit, Barnes-Jewish Hospital
| | - Traci Norris
- Traci Norris is a clinical specialist, Rehabilitation Department, Barnes-Jewish Hospital
| | - Cassandra Arroyo
- Marilyn Schallom is director, Heidi Tymkew and Donna Prentice are research scientists, Kara Vyers is a research coordinator, and Cassandra Arroyo is lead statistical analyst, Department of Research for Patient Care Services, Barnes-Jewish Hospital, St Louis, Missouri
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3
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Rehabilitation Practices in Patients With Moderate and Severe Traumatic Brain Injury. J Head Trauma Rehabil 2020; 34:E66-E72. [PMID: 30829824 DOI: 10.1097/htr.0000000000000477] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To characterize the indications, timing, barriers, and perceived value of rehabilitation currently provided for individuals with moderate or severe traumatic brain injury (TBI) admitted to the intensive care unit (ICU) based on the perspectives of providers who work in the ICU setting. PARTICIPANTS Members (n = 66) of the Neurocritical Care Society and the American Congress of Rehabilitation Medicine. DESIGN An anonymous electronic survey of the timing of rehabilitation for patients with TBI in the ICU. MAIN MEASURES Questions asked about type and timing of rehabilitation in the ICU, extent of family involvement, participation of physiatrists in patient care, and barriers to early rehabilitation. RESULTS Sixty-six respondents who reported caring for patients with TBI in the ICU completed the survey; 98% recommended rehabilitative care while patients were in the ICU. Common reasons to wait for the initiation of physical therapy and occupational therapy were normalization of intracranial pressure (86% and 89%) and hemodynamic stability (66% and 69%). CONCLUSIONS The majority of providers caring for patients with TBI in the ICU support rehabilitation efforts, typically after a patient is extubated, intracranial pressure has normalized, and the patient is hemodynamically stable. Our findings describe current practice; future studies can be designed to determine optimal timing, intensity, and patient selection for early rehabilitation.
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4
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Rosa RG, Teixeira C, Sjoding M. Novel approaches to facilitate the implementation of guidelines in the ICU. J Crit Care 2020; 60:1-5. [PMID: 32731099 DOI: 10.1016/j.jcrc.2020.07.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/03/2020] [Accepted: 07/13/2020] [Indexed: 12/12/2022]
Abstract
The effective implementation of evidence-based recommendations in routine intensive care unit (ICU) practice is challenging. Barriers related to the proposed recommendations, local contexts and processes can make the adoption of evidence-based practices difficult, contributing to healthcare inefficiency and worse patient and family outcomes. This review discusses the common barriers to guideline implementation in critical care settings, explores how implementation science provides an important framework for guiding implementation interventions, and discusses some specific and proven implementation strategies to improve adherence to evidence-based practices in the ICU.
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Affiliation(s)
- Regis Goulart Rosa
- Intensive Care Unit,Hospital Moinhos de Vento (HMV), Porto Alegre, RS, Brazil.
| | - Cassiano Teixeira
- Intensive Care Unit, Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS, Brazil
| | - Michael Sjoding
- Department of Internal Medicine, Pulmonary and Critical Care Medicine and Institute for Healthcare Policy & Innovation, Michigan Center for Integrated Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
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Powers EM, Shiffman RN, Melnick ER, Hickner A, Sharifi M. Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review. J Am Med Inform Assoc 2019; 25:1556-1566. [PMID: 30239810 DOI: 10.1093/jamia/ocy112] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/26/2018] [Indexed: 11/13/2022] Open
Abstract
Objective Clinical decision support (CDS) hard-stop alerts-those in which the user is either prevented from taking an action altogether or allowed to proceed only with the external override of a third party-are increasingly common but can be problematic. To understand their appropriate application, we asked 3 key questions: (1) To what extent are hard-stop alerts effective in improving patient health and healthcare delivery outcomes? (2) What are the adverse events and unintended consequences of hard-stop alerts? (3) How do hard-stop alerts compare to soft-stop alerts? Methods and Materials Studies evaluating computerized hard-stop alerts in healthcare settings were identified from biomedical and computer science databases, gray literature sites, reference lists, and reviews. Articles were extracted for process outcomes, health outcomes, unintended consequences, user experience, and technical details. Results Of 32 studies, 15 evaluated health outcomes, 16 process outcomes only, 10 user experience, and 4 compared hard and soft stops. Seventy-nine percent showed improvement in health outcomes and 88% in process outcomes. Studies reporting good user experience cited heavy user involvement and iterative design. Eleven studies reported on unintended consequences including avoidance of hard-stopped workflow, increased alert frequency, and delay to care. Hard stops were superior to soft stops in 3 of 4 studies. Conclusions Hard stops can be effective and powerful tools in the CDS armamentarium, but they must be implemented judiciously with continuous user feedback informing rapid, iterative design. Investigators must report on associated health outcomes and unintended consequences when implementing IT solutions to clinical problems.
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Affiliation(s)
- Emily M Powers
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Richard N Shiffman
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Edward R Melnick
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew Hickner
- Cushing/Whitney Medical Library, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mona Sharifi
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
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Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med 2019; 46:e825-e873. [PMID: 30113379 DOI: 10.1097/ccm.0000000000003299] [Citation(s) in RCA: 1808] [Impact Index Per Article: 361.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.
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7
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Seo YJ, Park SR, Lee JH, Jung C, Choi KH, Hong SK, Kim W. Feasibility, safety, and functional recovery after active rehabilitation in critically ill surgical patients. Aust Crit Care 2019; 33:281-286. [PMID: 31522973 DOI: 10.1016/j.aucc.2019.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/22/2019] [Accepted: 07/30/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The characteristics of critically ill surgical patients differ from those of medical patients. Few studies have evaluated rehabilitation in surgical intensive care units (SICUs), particularly in non-Western countries and in elderly patients. OBJECTIVE The objective of this study was to investigate the rehabilitation characteristics, safety, and functional recovery in non-Western SICU patients. METHODS Data from patients who received active rehabilitation in 2016 were retrospectively reviewed. Clinical characteristics, functional recovery, and safety were investigated and compared in patients aged <65 or ≥65 years. Potential safety events were also compared between the two age groups and according to the reason for SICU admission. RESULTS Data from 157 patients were included in the analysis. The number of patients who were able to stand or walk increased from the beginning of rehabilitation to the time of ICU discharge (from 52 to 102 patients, P < 0.01). The Activity Measure for Post-Acute Care (AM-PAC) score also increased during rehabilitation (from 11.6 to 13.9, P < 0.01). Functional recovery did not differ between the two age groups. During 780 rehabilitation sessions, 23 potential safety events (3.0%) were noted; no significant differences were seen between the two age groups. A significant difference was noted when patients were grouped according to the reason for SICU admission (1.7% in postoperative care patients vs 4.5% in patients admitted for other reasons, P = 0.02). CONCLUSIONS Active rehabilitation in critically ill surgical patients is feasible and safe and resulted in improved mobility, regardless of age. However, the reason for SICU admission should be considered.
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Affiliation(s)
- Yu Jin Seo
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
| | - Sae Rom Park
- Division of Acute Care Surgery, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
| | - Jung Hoon Lee
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
| | - Chul Jung
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
| | - Kyoung Hyo Choi
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea.
| | - Won Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea.
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8
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[PROtocol-based MObilizaTION on intensive care units : Design of a cluster randomized pilot study]. Med Klin Intensivmed Notfmed 2019; 113:581-592. [PMID: 29026932 DOI: 10.1007/s00063-017-0358-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Despite convincing evidence for early mobilization of patients on intensive care units (ICU), implementation in practice is limited. Protocols for early mobilization, including in- and exclusion criteria, assessments, safety criteria, and step schemes may increase the rate of implementation and mobilization. HYPOTHESIS Patients (population) on ICUs with a protocol for early mobilization (intervention), compared to patients on ICUs without protocol (control), will be more frequently mobilized (outcome). METHODS A multicenter, stepped-wedge, cluster-randomized pilot study is presented. Five ICUs will receive an adapted, interprofessional protocol for early mobilization in randomized order. Before and after implementation, mobilization of ICU patients will be evaluated by randomized monthly one-day point prevalence surveys. Primary outcome is the percentage of patients mobilized out of bed, operationalized as a score of ≥3 on the ICU Mobility Scale. Secondary outcome parameters will be presence and/or length of mechanical ventilation, delirium, stay on ICU and in hospital, barriers to early mobilization, adverse events, and process parameters as identified barriers, used strategies, and adaptions to local conditions. EXPECTED RESULTS Exploratory evaluation of study feasibility and estimation of effect sizes as the basis for a future explanatory study.
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9
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The Benefits of Implementing an Early Mobility Protocol in Postoperative Neurosurgical Spine Patients. Am J Nurs 2019; 118:46-53. [PMID: 29794923 DOI: 10.1097/01.naj.0000534851.58255.41] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Background: Despite the known benefits of early postsurgical mobility, there are no clear recommendations on early mobility among uncomplicated postoperative neurosurgical spine patients. PURPOSE The purpose of this quality improvement initiative was to establish an NP-led early mobility protocol to reduce uncomplicated postsurgical spine patients' length of stay (LOS) in the hospital and eliminate the variability of postsurgical care. A secondary objective was to educate and empower nursing staff to initiate the early mobility protocol independently and incorporate it in their practice to improve patient care. METHODS Two neurosurgery NPs led an interprofessional team to develop the early mobility protocol. Team members provided preadmission preoperative education to communicate the necessity for early mobility and provide information about the protocol. New nursing guidelines called for patient mobility on the day of surgery, within six hours of arrival on the medical-surgical unit. Nurses were empowered to get patients out of bed independently, without a physical therapy consultation; they also removed urinary catheters and discontinued IV opioids when patients' status permitted. RESULTS Over a one-year period, implementation of the protocol resulted in a nine-hour reduction in LOS per hospitalization in neurosurgical spine patients who underwent lumbar laminectomies. The protocol also allowed nurses more autonomy in patient care and was a catalyst for patient involvement in their postoperative mobility. Given the success of the protocol, it is being replicated by other surgical services throughout the organization. CONCLUSIONS This low-cost, high-reward initiative aligns with the strategic plan of the organization and ensures that high-quality, patient-centered care remains the priority. NPs in other institutions can modify this protocol to promote postoperative mobility in their organizations.
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Sowan AK, Leibas M, Tarriela A, Reed C. Nurses' Perceptions of a Care Plan Information Technology Solution With Hundreds of Clinical Practice Guidelines in Adult Intensive Care Units: Survey Study. JMIR Hum Factors 2019; 6:e11846. [PMID: 30747713 PMCID: PMC6390187 DOI: 10.2196/11846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/22/2018] [Accepted: 11/22/2018] [Indexed: 12/31/2022] Open
Abstract
Background The integration of clinical practice guidelines (CPGs) into the nursing care plan and documentation systems aims to translate evidence into practice, improve safety and quality of care, and standardize care processes. Objective This study aimed to evaluate nurses’ perceptions of the usability of a nursing care plan solution that includes 234 CPGs. Methods A total of 100 nurses from 4 adult intensive care units (ICUs) responded to a survey measuring nurses’ perceptions of system usability. The survey included 37 rated items and 3 open-ended questions. Results Nurses’ perceptions were favorable with more than 60.0% (60/100) in agreement on 12 features of the system and negative to moderate with 20.0% (20/100), to 59.0% (59/100) in agreement on 19 features. The majority of the nurses (80/100, 80.0% to 90/100, 90.0%) agreed on 4 missing safety features within the system. More than half of the nurses believed they would benefit from refresher classes on system use. Overall satisfaction with the system was just above average (54/100, 54.0%). Common positive themes from the narrative data were related to the system serving as a reminder for complete documentation and individualizing patient care. Common negative aspects were related to duplicate charting, difficulty locating CPGs, missing unit-specific CPGs, irrelevancy of information, and lack of perceived system value on patient outcomes. No relationship was found between years of system use or ICU experience and satisfaction with the system (P=.10 to P=.25). Conclusions Care plan systems in ICUs should be easy to navigate; support efficient documentation; present relevant, unit-specific, and easy-to-find information; endorse interdisciplinary communication; and improve safety and quality of care.
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Affiliation(s)
- Azizeh Khaled Sowan
- School of Nursing, University of Texas Health at San Antonio, San Antonio, TX, United States
| | - Meghan Leibas
- Center for Clinical Excellence, University Health System, San Antonio, TX, United States
| | - Albert Tarriela
- Transplant Cardiac Intensive Care Unit, University Health System, San Antonio, TX, United States
| | - Charles Reed
- Center for Clinical Excellence, University Health System, San Antonio, TX, United States
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11
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Zhu YP, Xia LX, Li GH. Management of early mobilization in intensive care units: a multicenter cross-sectional study. FRONTIERS OF NURSING 2018. [DOI: 10.1515/fon-2018-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
- Yan-Ping Zhu
- Intensive Care Units, Zhongda Hospital , Southeast University , Nanjing , Jiangsu 210009 , China
| | - Li-Xia Xia
- Department of Nursing , Jiangsu Provincial Hospital , Nanjing , Jiangsu 210009 , China
| | - Guo-Hong Li
- Department of Nursing , Zhongda Hospital , Southeast University , Nanjing , Jiangsu 210009 , China
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Reid JC, Unger J, McCaskell D, Childerhose L, Zorko DJ, Kho ME. Physical rehabilitation interventions in the intensive care unit: a scoping review of 117 studies. J Intensive Care 2018; 6:80. [PMID: 30555705 PMCID: PMC6286501 DOI: 10.1186/s40560-018-0349-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/22/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Physical rehabilitation (PR) interventions in the intensive care unit (ICU) can improve patients' functional outcomes, yet systematic reviews identified discordant effects and poor reporting. We conducted a scoping review to determine the extent of ICU PR interventions and how they were reported and measured. METHODS We searched five databases from inception to December 2016 for prospective studies evaluating adult ICU PR interventions. Two independent reviewers screened titles, abstracts, and full texts for inclusion. We assessed completeness of reporting using the Consolidated Standards of Reporting Trials, Strengthening the Reporting of Observational Studies in Epidemiology, or Standards for Quality Improvement Reporting Excellence guidelines, as appropriate. For planned PR interventions, we evaluated reporting with the Consensus on Exercise Reporting Template (CERT) and assessed intervention and control groups separately. We calculated completeness of reporting scores for each study; scores represented the proportion of reported items. We compared reporting between groups using Kruskal-Wallis with Bonferroni corrections and t tests, α = 0.05. RESULTS We screened 61,774 unique citations, reviewed 1429 full-text publications, and included 117: 39 randomized trials, 30 case series, 9 two-group comparison, 14 before-after, and 25 cohort. Interventions included neuromuscular electrical stimulation (NMES) (14.5%), passive/active exercises (15.4%), cycling (6.8%), progressive mobility (32.5%), and multicomponent (29.9%). The median (first,third quartiles) study reporting score was 75.9% (62.5, 86.7) with no significant differences between reporting guidelines. Of 87 planned intervention studies, the median CERT score was 55.6%(44.7,75.0); cycling had the highest (85.0%(62.2,93.8)), and NMES and multicomponent the lowest (50.0% (39.5, 70.3) and 50.0% (41.5, 58.8), respectively) scores. Authors reported intervention groups better than controls (p < 0.001). CONCLUSIONS We identified important reporting deficiencies in ICU PR interventions, limiting clinical implementation and future trial development.
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Affiliation(s)
- Julie C. Reid
- Faculty of Health Sciences, School of Rehabilitation Science, McMaster University, Institute of Applied Health Sciences, Room 403, 1400 Main Street West, Hamilton, ON L8S 1C7 Canada
| | - Janelle Unger
- Rehabilitation Sciences Institute, University of Toronto, Rehabilitation Sciences Building, 500 University Avenue, Suite 160, Toronto, ON M5G 1V7 Canada
| | - Devin McCaskell
- Department of Physiotherapy, St. Joseph’s Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada
| | - Laura Childerhose
- Faculty of Health Sciences, School of Rehabilitation Science, McMaster University, Institute of Applied Health Sciences, Room 403, 1400 Main Street West, Hamilton, ON L8S 1C7 Canada
| | - David J. Zorko
- Department of Pediatrics, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Michelle E. Kho
- Faculty of Health Sciences, School of Rehabilitation Science, McMaster University, Institute of Applied Health Sciences, Room 403, 1400 Main Street West, Hamilton, ON L8S 1C7 Canada
- Department of Physiotherapy, St. Joseph’s Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada
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Moon M. Identifying Nursing Diagnosis Patterns in Three Intensive Care Units Using Network Analysis. Int J Nurs Knowl 2018; 30:137-146. [PMID: 30318754 DOI: 10.1111/2047-3095.12226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE This study aimed to analyze the patterns of nursing diagnoses used in three different types of intensive care units (ICUs) using network analysis. METHODS A secondary analysis was conducted using clinical datasets of 582 patients. Frequency, degree/betweenness centrality, and subgroup analysis were performed. FINDINGS AND CONCLUSIONS The findings illuminated core nursing diagnoses with high centrality as well as high frequency. The centrality analysis identified the differences between and unique characteristics of each ICU. The subgroup analysis revealed the nursing problem groups related to the specific nursing care delivered to ICU patients. IMPLICATIONS FOR NURSING PRACTICE Theses results provide a knowledge base to aid ICU nurses' prompt decision making regarding nursing diagnoses.
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Affiliation(s)
- Mikyung Moon
- College of Nursing, The Research Institute of Nursing Science, Kyungpook National University, Daegu, South Korea
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Krupp A, Steege L, King B. A systematic review evaluating the role of nurses and processes for delivering early mobility interventions in the intensive care unit. Intensive Crit Care Nurs 2018; 47:30-38. [PMID: 29681432 DOI: 10.1016/j.iccn.2018.04.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 03/29/2018] [Accepted: 04/04/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To investigate processes for delivering early mobility interventions in adult intensive care unit patients used in research and quality improvement studies and the role of nurses in early mobility interventions. METHODS A systematic review was conducted. Electronic databases PubMED, CINAHL, PEDro, and Cochrane were searched for studies published from 2000 to June 2017 that implemented an early mobility intervention in adult intensive care units. Included studies involved progression to ambulation as a component of the intervention, included the role of the nurse in preparing for or delivering the intervention, and reported at least one patient or organisational outcome measure. The System Engineering Initiative for Patient Safety (SEIPS) model, a framework for understanding structure, processes, and healthcare outcomes, was used to evaluate studies. RESULTS 25 studies were included in the final review. Studies consisted of randomised control trials, prospective, retrospective, or mixed designs. A range of processes to support the delivery of early mobility were found. These processes include forming interdisciplinary teams, increasing mobility staff, mobility protocols, interdisciplinary education, champions, communication, and feedback. CONCLUSION Variation exists in the process of delivering early mobility in the intensive care unit. In particular, further rigorous studies are needed to better understand the role of nurses in implementing early mobility to maintain a patient's functional status.
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Affiliation(s)
- Anna Krupp
- University of Wisconsin-Madison, School of Nursing, Madison, WI, United States.
| | - Linsey Steege
- University of Wisconsin-Madison, School of Nursing, Madison, WI, United States
| | - Barbara King
- University of Wisconsin-Madison, School of Nursing, Madison, WI, United States
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Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis. Ann Am Thorac Soc 2018; 14:766-777. [PMID: 28231030 DOI: 10.1513/annalsats.201611-843sr] [Citation(s) in RCA: 215] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Early mobilization and rehabilitation of patients in intensive care units (ICUs) may improve physical function, and reduce the duration of delirium, mechanical ventilation, and ICU length of stay. However, safety concerns are an important barrier to widespread implementation. OBJECTIVES To synthesize safety data regarding patient mobilization and rehabilitation in the ICU, including falls, removal of endotracheal tubes, removal or dysfunction of intravascular catheters, removal of other catheters/tubes, cardiac arrest, hemodynamic changes, and desaturation. DATA SOURCES Systematic literature review, including searches of five databases. Eligible studies evaluated patients who received mobilization-related interventions in the ICU. Exclusion criteria included: (1) case series with fewer than 10 patients; (2) majority of patients under 18 years of age; and (3) data not reported to permit calculation of incidence of safety events. DATA EXTRACTION Number of patients, mobilization/rehabilitation sessions, potential safety events, and events with negative consequences (e.g., requiring intervention or additional therapy). SYNTHESIS Heterogeneity was assessed by I2 statistics, and bias assessed by the Newcastle-Ottawa Scale and Cochrane risk of bias assessment. The literature search identified 20,660 titles. There were 48 eligible publications evaluating 7,546 patients, with 583 potential safety events occurring in 22,351 mobilization/rehabilitation sessions. There was a total of 583 (2.6%) potential safety events with heterogeneity in the definitions for these events. For the safety event types that could be meta-analyzed, pooled incidences per 1,000 mobilization/rehabilitation sessions (95% confidence interval), were: hemodynamic changes, 3.8 (1.3-11.4), and desaturation, 1.9 (0.9-4.3). A total of 24 studies of 3,404 patients reported on any consequences of potential safety events (e.g., needing to increase dose of vasopressor due to mobility-related hypotension), with a frequency of 0.6% in 14,398 mobilization/rehabilitation sessions. CONCLUSIONS Patient mobilization and physical rehabilitation in the ICU appears safe, with a low incidence of potential safety events, and only rare events having any consequences for patient management. Heterogeneity in the definition of safety events across studies emphasizes the importance of implementing existing consensus-based definitions.
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Abstract
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.
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Nydahl P, Wilkens S, Glase S, Mohr LM, Richter P, Klarmann S, Perme CS, Nawa RK. The German translation of the Perme Intensive Care Unit Mobility Score and inter-rater reliability between physiotherapists and nurses. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2017. [DOI: 10.1080/21679169.2017.1401660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Peter Nydahl
- Department of Nursing Research, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Sandra Wilkens
- Department of Nursing Research, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Susanne Glase
- Department of Nursing Research, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Lisa Marie Mohr
- Department of Nursing Research, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Peter Richter
- Department of Nursing Research, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Silke Klarmann
- Department of Nursing Research, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Christiane S. Perme
- Department of Rehabilitation Services, Houston Methodist Hospital, Houston, TX, USA
| | - Ricardo Kenji Nawa
- Department of Rehabilitation Services, Hospital Sírio-Libanês, São Paulo, Brazil
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Hopkins RO, Mitchell L, Thomsen GE, Schafer M, Link M, Brown SM. Implementing a Mobility Program to Minimize Post-Intensive Care Syndrome. AACN Adv Crit Care 2017; 27:187-203. [PMID: 27153308 DOI: 10.4037/aacnacc2016244] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Immobility in the intensive care unit (ICU) is associated with neuromuscular weakness, post-intensive care syndrome, functional limitations, and high costs. Early mobility-based rehabilitation in the ICU is feasible and safe. Mobility-based rehabilitation varied widely across 5 ICUs in 1 health care system, suggesting a need for continuous training and evaluation to maintain a strong mobility-based rehabilitation program. Early mobility-based rehabilitation shortens ICU and hospital stays, reduces delirium, and increases muscle strength and the ability to ambulate. Long-term effects include increased ability for self-care, faster return to independent functioning, improved physical function, and reduced hospital readmission and death. Factors that influence early mobility-based rehabilitation include having an interdisciplinary team; strong unit leadership; access to physical, occupational, and respiratory therapists; a culture focused on patient safety and quality improvement; a champion of early mobility; and a focus on measuring performance and outcomes.
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Affiliation(s)
- Ramona O Hopkins
- Ramona O. Hopkins is Professor, Department of Psychology and Neuroscience Center, Brigham Young University, Provo, Utah, and Clinical Research Investigator, Center for Humanizing Critical Care, and Department of Medicine, Pulmonary and Critical Care Division, Intermountain Healthcare, 5121 South Cottonwood St, Murray, UT 84107 . Lorie Mitchell is Nurse Manager, Shock Trauma Intensive Care Unit, Department of Medicine, Intermountain Medical Center. George E. Thomsen is Medical Director, Coronary Intensive Care Unit, Department of Medicine, Intermountain Medical Center. Michele Schafer is Member, Intensive Care Unit Patient-Family Advisory Council, Intermountain Medical Center. Maggie Link is Physical Therapist, Shock Trauma Intensive Care Unit, Intermountain Medical Center. Samuel M. Brown is Director, Center for Humanizing Critical Care, Assistant Professor of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Healthcare, and University of Utah School of Medicine, Salt Lake City, Utah
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Davidson JE, Winkelman C, Gélinas C, Dermenchyan A. Pain, agitation, and delirium guidelines: nurses' involvement in development and implementation. Crit Care Nurse 2017; 35:17-31; quiz 32. [PMID: 26033098 DOI: 10.4037/ccn2015824] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The 2013 American College of Critical Care Medicine/Society of Critical Care Medicine clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit serves as a living example of nurses' involvement in the development and implementation of professional guidelines. Nurses who served on this guideline-writing panel describe their experiences. Specific examples from the pain, agitation, and delirium guidelines for care are used to explore the roles of the nurse leader, nurse informaticist, staff nurse, and nurse researcher in relationship to guideline implementation.
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Affiliation(s)
- Judy E Davidson
- Judy E. Davidson is evidence-based practice and research liaison at UCSD Health System, San Diego, California.Chris Winkelman is an associate professor at Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.Céline Gélinas is an assistant professor at Ingram School of Nursing, McGill University and a nurse scientist at Jewish General Hospital, Montréal, Québec, Canada.Anna Dermenchyan is a clinical quality specialist at UCLA Health, Los Angeles, California.
| | - Chris Winkelman
- Judy E. Davidson is evidence-based practice and research liaison at UCSD Health System, San Diego, California.Chris Winkelman is an associate professor at Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.Céline Gélinas is an assistant professor at Ingram School of Nursing, McGill University and a nurse scientist at Jewish General Hospital, Montréal, Québec, Canada.Anna Dermenchyan is a clinical quality specialist at UCLA Health, Los Angeles, California
| | - Céline Gélinas
- Judy E. Davidson is evidence-based practice and research liaison at UCSD Health System, San Diego, California.Chris Winkelman is an associate professor at Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.Céline Gélinas is an assistant professor at Ingram School of Nursing, McGill University and a nurse scientist at Jewish General Hospital, Montréal, Québec, Canada.Anna Dermenchyan is a clinical quality specialist at UCLA Health, Los Angeles, California
| | - Anna Dermenchyan
- Judy E. Davidson is evidence-based practice and research liaison at UCSD Health System, San Diego, California.Chris Winkelman is an associate professor at Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio.Céline Gélinas is an assistant professor at Ingram School of Nursing, McGill University and a nurse scientist at Jewish General Hospital, Montréal, Québec, Canada.Anna Dermenchyan is a clinical quality specialist at UCLA Health, Los Angeles, California
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Messer A, Comer L, Forst S. Implementation of a Progressive Mobilization Program in a Medical-Surgical Intensive Care Unit. Crit Care Nurse 2017; 35:28-42. [PMID: 26427973 DOI: 10.4037/ccn2015469] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- April Messer
- April Messer is a staff nurse in a medical-surgical intensive care unit at Mission Health, Asheville, North Carolina, and previously served as chairperson of the nurse practice council for the hospital where she practices.Linda Comer is the executive associate director, School of Nursing, Western Carolina University. She is also the coordinator for the nurse educator master's program and teaches the nurse educator specialty courses.Steve Forst is an assistant professor, School of Nursing, Western Carolina University.
| | - Linda Comer
- April Messer is a staff nurse in a medical-surgical intensive care unit at Mission Health, Asheville, North Carolina, and previously served as chairperson of the nurse practice council for the hospital where she practices.Linda Comer is the executive associate director, School of Nursing, Western Carolina University. She is also the coordinator for the nurse educator master's program and teaches the nurse educator specialty courses.Steve Forst is an assistant professor, School of Nursing, Western Carolina University
| | - Steve Forst
- April Messer is a staff nurse in a medical-surgical intensive care unit at Mission Health, Asheville, North Carolina, and previously served as chairperson of the nurse practice council for the hospital where she practices.Linda Comer is the executive associate director, School of Nursing, Western Carolina University. She is also the coordinator for the nurse educator master's program and teaches the nurse educator specialty courses.Steve Forst is an assistant professor, School of Nursing, Western Carolina University
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A quality improvement project sustainably decreased time to onset of active physical therapy intervention in patients with acute lung injury. Ann Am Thorac Soc 2015; 11:1230-8. [PMID: 25167767 DOI: 10.1513/annalsats.201406-231oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
RATIONALE Rehabilitation started early during an intensive care unit (ICU) stay is associated with improved outcomes and is the basis for many quality improvement (QI) projects showing important changes in practice. However, little evidence exists regarding whether such changes are sustainable in real-world practice. OBJECTIVES To evaluate the sustained effect of a quality improvement project on the timing of initiation of active physical therapy intervention in patients with acute lung injury (ALI). METHODS This was a pre-post evaluation using prospectively collected data involving consecutive patients with ALI admitted pre-quality improvement (October 2004-April 2007, n = 120) versus post-quality improvement (July 2009-July 2012, n = 123) from a single medical ICU. MEASUREMENTS AND MAIN RESULTS The primary outcome was time to first active physical therapy intervention, defined as strengthening, mobility, or cycle ergometry exercises. Among ICU survivors, more patients in the post-quality improvement versus pre-quality improvement group received physical therapy in the ICU (89% vs. 24%, P < 0.001) and were able to stand, transfer, or ambulate during physical therapy in the ICU (64% vs. 7%, P < 0.001). Among all patients in the post-quality improvement versus pre-quality improvement group, there was a shorter median (interquartile range) time to first physical therapy (4 [2, 6] vs. 11 d [6, 29], P < 0.001) and a greater median (interquartile range) proportion of ICU days with physical therapy after initiation (50% [33, 67%] vs. 18% [4, 47%], P = 0.003). In multivariable regression analysis, the post-quality improvement period was associated with shorter time to physical therapy (adjusted hazard ratio [95% confidence interval], 8.38 [4.98, 14.11], P < 0.001), with this association significant for each of the 5 years during the post-quality improvement period. The following variables were independently associated with a longer time to physical therapy: higher Sequential Organ Failure Assessment score (0.93 [0.89, 0.97]), higher FiO2 (0.86 [0.75, 0.99] for each 10% increase), use of an opioid infusion (0.47 [0.25, 0.89]), and deep sedation (0.24 [0.12, 0.46]). CONCLUSIONS In this single-site, pre-post analysis of patients with ALI, an early rehabilitation quality improvement project was independently associated with a substantial decrease in the time to initiation of active physical therapy intervention that was sustained over 5 years. Over the entire pre-post period, severity of illness and sedation were independently associated with a longer time to initiation of active physical therapy intervention in the ICU.
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22
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Clinical and psychological effects of early mobilization in patients treated in a neurologic ICU: a comparative study. Crit Care Med 2015; 43:865-73. [PMID: 25517476 DOI: 10.1097/ccm.0000000000000787] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine if an early mobilization protocol increased mobility and improved clinical and psychological outcomes. Currently, there is minimal research on the effects of early mobilization in patients with primary neurologic injury. DESIGN Prospective, two-group pre/post comparative design with data collection 4 months pre- and postintervention with a 4-month run-in period. SETTING Twenty-two-bed neurologic ICU in a 1,200-bed urban, quaternary-care, academic hospital in Northeast Ohio. SUBJECTS Critically ill patients with primary neurologic injury admitted to the neurologic ICU. INTERVENTION An early mobility program included a progressive mobility protocol, written orders, and staff (clinical nurse specialist clinical technician) who advocated for and assisted with mobility. Highest mobility achieved was assessed daily for 13 days, clinical outcomes were retrieved from electronic databases, and psychological profile was collected by valid, reliable questionnaire at/after neurologic ICU discharge. Analyses included comparative statistics and multivariable modeling. MEASUREMENTS AND MAIN RESULTS Of 637 patients, 260 were preintervention and 377 were postintervention. Patient characteristics were similar between groups, except postintervention group patients had less history of using walking aids and more gait abnormalities, and were less likely to require mechanical ventilation in the neurologic ICU (all p≤0.006). Compared with preintervention, postintervention patients had higher mobility levels and decreased hospital and neurologic ICU length of stay; were more likely to be discharged home (all p≤0.002); had decreased bloodstream infection, hospital-acquired pressure ulcer, and anxiety rates (all p<0.03); and had no change in mortality, ventilator-associated pneumonia, deep vein thrombosis, depression, and hostility. In multivariable analyses, postintervention patients had higher mobility levels (p<0.001), had shorter mean hospital and neurologic ICU length of stay (both p<0.001), and were more likely to be discharged home (p=0.033) compared with preintervention patients. CONCLUSIONS A neurologic ICU early mobility protocol increased highest neurologic ICU mobility and discharge home and decreased length of stay, but did not improve quality metrics or psychological profile.
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Eakin MN, Ugbah L, Arnautovic T, Parker AM, Needham DM. Implementing and sustaining an early rehabilitation program in a medical intensive care unit: A qualitative analysis. J Crit Care 2015; 30:698-704. [PMID: 25837800 DOI: 10.1016/j.jcrc.2015.03.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 03/10/2015] [Accepted: 03/15/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE Early rehabilitation programs in a medical intensive care unit can improve patient outcomes, but clinicians face barriers in implementing and sustaining such programs. We sought to describe a multidisciplinary team perspective regarding how to implement and sustain a successful early rehabilitation program. METHODS Semistructured interviews were conducted with 20 staff and faculty who were involved in the early rehabilitation program at the Johns Hopkins Hospital Medical Intensive Care Unit. Transcripts were evaluated using the Consolidated Framework of Implementation Research Theory. RESULTS Four major constructs emerged as important, as follows: (1) necessary components, (2) implementation strategies, (3) perceived barriers, and (4) positive outcomes. All participants reported that staff buy-in was necessary, whereas having a multidisciplinary team with good communication among team members was reported as helpful by 90% of participants. The most common barrier reported was increased staff workload (80%). All participants (100%) noted improved patient outcomes as an important benefit, and 95% reported improved job satisfaction. CONCLUSIONS This qualitative study of a successful early rehabilitation program highlights the importance of assessing and engaging a multidisciplinary team before implementation and the positive outcomes of early rehabilitation on staff by improving job satisfaction and changing the culture of a hospital unit.
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Affiliation(s)
- Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Linda Ugbah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Tamara Arnautovic
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ann M Parker
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA; Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA; Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, USA
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Jolley SE, Regan-Baggs J, Dickson RP, Hough CL. Medical intensive care unit clinician attitudes and perceived barriers towards early mobilization of critically ill patients: a cross-sectional survey study. BMC Anesthesiol 2014; 14:84. [PMID: 25309124 PMCID: PMC4192294 DOI: 10.1186/1471-2253-14-84] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 09/25/2014] [Indexed: 01/22/2023] Open
Abstract
Background Early mobilization (EM) of patients on mechanical ventilation (MV) is shown to improve outcomes after critical illness. Little is known regarding clinician knowledge of EM or multi-disciplinary barriers to use of EM in the intensive care unit (ICU). The goal of this study was to assess clinician knowledge regarding EM and identify barriers to its provision. Methods Simultaneous cross-sectional surveys of medical ICU (MICU) nurses (RN)/physical therapists (PT) respondents and physician (MD) respondents in a single MICU at an academic hospital in Seattle, WA in 2010–2011. Responses were indicated on a 5 point Likert scale and reported as proportion of respondents agreeing or disagreeing. Chi-square testing and Fisher’s exact testing was performed to determine whether responses differed by duration of employment or prior EM experience. Results A total of 120 clinicians responded to the survey (91 MDs (response rate 82% (91/111)), 17 RNs (response rate 22%, (17/78)), and 12 PTs (response rate 86%, (12/14)), overall response rate 86%). Most clinicians indicated knowledge regarding benefits of EM. More attending physicians reported knowledge of EM benefits, but also that risks of EM outweigh the benefits compared to trainees (p = 0.02 and 0.01). Clinicians across disciplines reported near universal agreement to use of EM for patients on MV, while the minority reported agreement to EM for patients on vasoactive agents. The most frequently reported cross-disciplinary barriers to EM were staffing and time. Risk of self-injury and excess work stress were indicated as barriers by RN and PT respondents. Conclusions MICU clinicians, at our institution, reported knowledge of EM in the ICU. Staffing and clinician time were frequently identified cross-disciplinary barriers. Risk of self-injury and excess work stress were frequently reported RN and PT barriers. Electronic supplementary material The online version of this article (doi:10.1186/1471-2253-14-84) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah E Jolley
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA USA ; Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Campus Box 356522, Seattle, WA 98195-6522 USA
| | | | - Robert P Dickson
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA USA
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Safety of physical therapy interventions in critically ill patients: A single-center prospective evaluation of 1110 intensive care unit admissions. J Crit Care 2014; 29:395-400. [DOI: 10.1016/j.jcrc.2013.12.012] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 12/19/2013] [Accepted: 12/22/2013] [Indexed: 01/04/2023]
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Parker A, Sricharoenchai T, Needham DM. Early Rehabilitation in the Intensive Care Unit: Preventing Physical and Mental Health Impairments. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2013; 1:307-314. [PMID: 24436844 DOI: 10.1007/s40141-013-0027-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Survivors of critical illness often experience new or worsening impairments in physical, cognitive and/or mental health, referred to as post-intensive care syndrome (PICS). Such impairments can be long-lasting and negatively impact survivors' quality of life. Early rehabilitation in the intensive care unit (ICU), while patients remain on life-support therapies, may reduce the complications associated with PICS. This article addresses evidence-based rehabilitation interventions to reduce the physical and mental health impairments associated with PICS. Implementation of effective early rehabilitation interventions targeting physical impairments requires consideration of 5 factors: barriers, benefits, feasibility, safety, and resources. Mental health impairments may be addressed by the following interventions: ICU diaries, early in-ICU psychological intervention, and post-ICU coping skills training. In both cases, a multidisciplinary team-based approach is paramount to the successful incorporation of early rehabilitation into routine practice in the ICU.
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Brown M, Kuhlman D, Larson L, Sloan K, Ablah E, Konda K, Owings CS. Does availability of expanded point-of-care services improve outcomes for rural diabetic patients? Prim Care Diabetes 2013; 7:129-134. [PMID: 23523626 DOI: 10.1016/j.pcd.2013.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 01/28/2013] [Indexed: 11/22/2022]
Abstract
AIMS The purpose of this study was to assess compliance with American Diabetes Association screening recommendations at Salina Family Healthcare (SFHC) in Salina, Kansas, a large rural town, and to evaluate the impact of point-of-care (POC) dilated eye exams for uninsured patients. POC exams are those performed in the location where patients are treated. METHODS There were 462 type II diabetic (DM2) patients seen at SFHC in 2009 and 537 DM2 patients seen in 2010. A chart review of all patients with DM2 was done to assess rates of recommended screening exams, including dilated eye exams and foot exams. RESULTS In 2009/2010 urine microalbumin was checked in 57%/75% of DM2 patients. HbA1c and low density lipoprotein (LDL) levels at goal were 46%/48% and 58%/58%, respectively. 47%/67% of DM@ patients received foot exams and 21%/30% received eye exams. In 2009, 23% of the 155 uninsured diabetic patients at SFHC received a dilated eye exam. The following year, after implementation of on-site ophthalmologic services, rates of dilated eye exams increased 1.6 fold to 37% of the 196 uninsured patients. CONCLUSIONS SFHC performed similarly to national rates on some diabetic screening exams, but there is room for improvement in all recommended screening exams. The implementation of a novel approach to increasing dilated eye exam rates indicates that expanded POC services can improve outcomes for diabetic patients.
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Affiliation(s)
- Megan Brown
- University of Kansas School of Medicine-Salina, Salina, KS, USA
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Translating research into clinical practice: the role of quality improvement in providing rehabilitation for people with critical illness. Phys Ther 2013; 93:128-33. [PMID: 23378659 DOI: 10.2522/ptj.2013.93.2.128] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study. Phys Ther 2013; 93:186-96. [PMID: 22879442 PMCID: PMC3563027 DOI: 10.2522/ptj.20110417] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bed rest and immobility in patients on mechanical ventilation or in an intensive care unit (ICU) have detrimental effects. Studies in medical ICUs show that early mobilization is safe, does not increase costs, and can be associated with decreased ICU and hospital lengths of stay (LOS). OBJECTIVE The purpose of this study was to assess the effects of an early mobilization protocol on complication rates, ventilator days, and ICU and hospital LOS for patients admitted to a trauma and burn ICU (TBICU). DESIGN This was a retrospective cohort study of an interdisciplinary quality-improvement program. METHODS Pre- and post-early mobility program patient data from the trauma registry for 2,176 patients admitted to the TBICU between May 2008 and April 2010 were compared. RESULTS No adverse events were reported related to the early mobility program. After adjusting for age and injury severity, there was a decrease in airway, pulmonary, and vascular complications (including pneumonia and deep vein thrombosis) post-early mobility program. Ventilator days and TBICU and hospital lengths of stay were not significantly decreased. LIMITATIONS Using a historical control group, there was no way to account for other changes in patient care that may have occurred between the 2 periods that could have affected patient outcomes. The dose of physical activity both before and after the early mobility program were not specifically assessed. CONCLUSIONS Early mobilization of patients in a TBICU was safe and effective. Medical, nursing, and physical therapy staff, as well as hospital administrators, have embraced the new culture of early mobilization in the ICU.
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Grap MJ, McFetridge B. Critical care rehabilitation and early mobilisation: an emerging standard of care. Intensive Crit Care Nurs 2012; 28:55-7. [PMID: 22445174 DOI: 10.1016/j.iccn.2012.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 02/11/2012] [Indexed: 11/17/2022]
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Improving trauma care in the ICU: best practices, quality improvement initiatives, and organization. Surg Clin North Am 2012; 92:893-901, viii. [PMID: 22850153 DOI: 10.1016/j.suc.2012.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Optimal care of critically ill trauma patients remains a challenge within modern medical systems. During the past decade, emerging technologies and organizational improvements have greatly advanced the care of these patients. The effective implementation of best practice initiatives has led to measurable improvement in outcomes while also reducing health care costs. Continued advances in the implementation of these initiatives and ICU organization are required, however, to insure that optimal care is provided to this unique patient population.
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Winkelman C, Johnson KD, Hejal R, Gordon NH, Rowbottom J, Daly J, Peereboom K, Levine AD. Examining the positive effects of exercise in intubated adults in ICU: a prospective repeated measures clinical study. Intensive Crit Care Nurs 2012; 28:307-18. [PMID: 22458998 DOI: 10.1016/j.iccn.2012.02.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 02/28/2012] [Accepted: 02/29/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Determining the optimal timing and progression of mobility exercise has the potential to affect functional recovery of critically ill adults. This study compared standard care with care delivered using a mobility protocol. We examined the effects of exercise on vital signs and inflammatory biomarkers and the effects of the nurse-initiated mobility protocol on outcomes. METHODS Prospective, repeated measures study with a control (standard care) and intervention (protocol) period. RESULTS 75 heterogeneous subjects admitted to a Medical or Surgical intensive care unit (ICU) were enrolled. In <5% of exercise periods, there was a concerning alteration in respiratory rate or peripheral oxygen saturation; no other adverse events occurred. Findings suggested the use of a protocol with one 20 minute episode of exercise daily for 2 or more days reduced ICU length of stay. Duration of exercise was linked to increased IL-10, suggesting brief episodes of low intensity exercise positively altered inflammatory dysregulation in this sample. CONCLUSION A growing body of evidence demonstrates that early, progressive exercise has significant benefits to intubated adults. These results should encourage clinicians to add mobility protocols to the care of ICU adults and lead to future studies to determine optimal "dosing" of exercise in ICU patients.
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Affiliation(s)
- Chris Winkelman
- Case Western Reserve University, Frances Payne Bolton School of Nursing, 10900 Euclid Ave, Cleveland, OH 44016, USA.
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