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Viloria MAD, Lee SD, Takahashi T, Cheng YJ. Physical therapy in the intensive care unit: A cross-sectional study of three Asian countries. PLoS One 2023; 18:e0289876. [PMID: 37943762 PMCID: PMC10635439 DOI: 10.1371/journal.pone.0289876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 07/28/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Physical therapy (PT) is beneficial for critically ill patients, but the extent of its application in the intensive care unit (ICU) differs between countries. Here, we compared the extent of PT intervention in the ICU in Japan, the Philippines, and Taiwan by evaluating the sociodemographic and ICU-related profiles of ICU physical therapists. MATERIALS AND METHODS In this cross-sectional study, a semistructured nationwide online survey was distributed to ICU physical therapists in the three countries. RESULTS We analyzed the responses of 164 physical therapists from Japan, Philippines, and Taiwan. Significant differences were observed between the countries in all sociodemographic variables and the following ICU-related profiles of physical therapists: ICU work experience, duration of the ICU posting, number of hours per day spent in the ICU, on-call ICU PT service engagement, source of ICU patient referral, therapist-patient ratio, and ICU-related PT training participation (p < 0.05). Medical, surgical, and neurologic ICUs were the most common ICU workplaces of the ICU physical therapists, but only surgical and neurologic ICUs exhibited significant differences between the countries (p < 0.05). Standard PT techniques in the ICU were passive and active-assisted range of motion, positioning, and breathing exercises but were implemented with significantly different frequencies between the countries (p < 0.05). The most common challenge faced in ICU PT service delivery by respondents from all three countries was lack of training prior to ICU duty, and lack of training was even bigger challenge in Japan than in other two countries after adjustment of age, highest educational attainment, and work experience. CONCLUSION The differences in the health-care system between Japan, the Philippines, and Taiwan were related to differences in the compliance with internationally recommended PT practice standards in the ICU, differences in the type of PT intervention prioritized, and the challenges encountered in ICU PT service delivery.
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Affiliation(s)
- Mary Audrey Domingo Viloria
- Department of Physical Therapy, College of Health Sciences, Mariano Marcos State University, Batac City, Ilocos Norte, Philippines
- Department of Physical Therapy, Graduate Institute of Rehabilitation Science, China Medical University, Taichung City, Taiwan
| | - Shin-Da Lee
- Department of Physical Therapy, Graduate Institute of Rehabilitation Science, China Medical University, Taichung City, Taiwan
| | - Tetsuya Takahashi
- Department of Physiotherapy, Faculty of Health and Medical Sciences, Juntendo University, Tokyo, Japan
| | - Yu-Jung Cheng
- Department of Physical Therapy, Graduate Institute of Rehabilitation Science, China Medical University, Taichung City, Taiwan
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2
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Crick JP, Rethorn TJ, Beauregard TA, Summers R, Rethorn ZD, Quatman-Yates CC. The Use of Quality Improvement in the Physical Therapy Literature: A Scoping Review. J Healthc Qual 2023; 45:280-296. [PMID: 37428943 DOI: 10.1097/jhq.0000000000000394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
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.
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Noone CE, Franck LS, Staveski SL, Rehm RS. Barriers and facilitators to early mobilization programmes in the paediatric intensive care unit: A scoping literature review. Nurs Crit Care 2023. [DOI: 10.1111/nicc.12891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- Chelsea E. Noone
- Department of Family Health Care Nursing University of California at San Francisco San Francisco California USA
| | - Linda S. Franck
- Department of Family Health Care Nursing University of California at San Francisco San Francisco California USA
| | - Sandra L. Staveski
- Department of Family Health Care Nursing University of California at San Francisco San Francisco California USA
| | - Roberta S. Rehm
- Department of Family Health Care Nursing University of California at San Francisco San Francisco California USA
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Yeung MT, Tan NK, Lee GZ, Gao Y, Tan CJ, Yan CC. Perceived barriers to mobility in the intensive care units of Singapore: The Patient Mobilisation Attitudes and Beliefs Survey for the intensive care units. J Intensive Care Soc 2023; 24:32-39. [PMID: 36874293 PMCID: PMC9975807 DOI: 10.1177/17511437221099791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose Prolonged bed rest and immobility in the intensive care units (ICU) increase the risk of ICU-acquired weakness (ICUAW) and other complications. Mobilisation has been shown to improve patient outcomes but may be limited by the perceived barriers of healthcare professionals to mobilisation. The Patient Mobilisation Attitudes and Beliefs Survey for the ICU (PMABS-ICU) was adapted to assess perceived barriers to mobility in the Singapore context (PMABS-ICU-SG). Methods The 26-item PMABS-ICU-SG was disseminated to doctors, nurses, physiotherapists, and respiratory therapists working in ICU of various hospitals across Singapore. Overall and subscale (knowledge, attitude, and behaviour) scores were obtained and compared with the clinical roles, years of work experience, and type of ICU of the survey respondents. Results A total of 86 responses were received. Of these, 37.2% (32/86) were physiotherapists, 27.9% (24/86) were respiratory therapists, 24.4% (21/86) were nurses and 10.5% (9/86) were doctors. Physiotherapists had significantly lower mean barrier scores in overall and all subscales compared to nurses (p < 0.001), respiratory therapists (p < 0.001), and doctors (p = 0.001). A poor correlation (r = 0.079, p < 0.05) was found between years of experience and the overall barrier score. There was no statistically significant difference in the overall barriers score between types of ICU (χ2(2) = 4.720, p = 0.317). Conclusion In Singapore, physiotherapists had significantly lower perceived barriers to mobilisation compared to the other three professions. Years of experience and type of ICU had no significance in relation to barriers to mobilisation.
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Affiliation(s)
- Meredith T Yeung
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore
| | - Nicholas K Tan
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore
| | - Gideon Z Lee
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore
| | - Yuemian Gao
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore
| | - Chun Ju Tan
- Department of Physiotherapy, Singapore General Hospital, Singapore
| | - Clement C Yan
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore.,Department of Physiotherapy, Sengkang General Hospital, Singapore
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5
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Anderson R. Effects of an Electronic Health Record Tool on Team Communication and Patient Mobility: A 2-Year Follow-up Study. Crit Care Nurse 2022; 42:23-31. [PMID: 35362081 DOI: 10.4037/ccn2022385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Intensive care unit early mobility programs improve patients' functional status and outcomes. An electronic health record-based communication tool improved interprofessional communication within an early mobility program. Long-term sustainability of this communication tool has not been evaluated. LOCAL PROBLEM Ineffective interprofessional communication was perceived as a barrier to success of an intensive care unit early mobility program at the project institution. An electronic health record-based communication tool was successfully implemented to improve communication. Sustaining the intervention is of continued importance. METHODS Longitudinal data were collected 2 years after initial implementation of the communication tool to evaluate its continued impact on patient outcomes and staff engagement with an intensive care unit early mobility program. RESULTS Initial implementation of the electronic health record-based communication tool resulted in statistically and clinically significant improvements in patient and staff metrics. Compared with postimplementation data, 2-year longitudinal follow-up data revealed nonsignificant changes in patient outcomes (time from admission to mobility goal, mechanical ventilation duration, length of intensive care unit stay, and discharge disposition recommendations to higher independence levels). Staff reported continued use of the communication tool and positive perceptions of its impact on the intensive care unit early mobility program. CONCLUSIONS Nonsignificant changes in patient outcomes may indicate sustainment of the effect of the communication tool's original implementation. Employing appropriate sustainment techniques is essential to maintain practice change. The electronic health record-based communication tool can improve interprofessional communication within an intensive care unit early mobility program, improving patient outcomes and staff teamwork.
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Affiliation(s)
- Robert Anderson
- Robert Anderson is a pulmonary and critical care nurse practitioner, Mayo Clinic, Rochester, Minnesota
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6
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Aglawe DR, Agarwal BM, Sawant BD. Physical Function in Critically Ill Patients during the Duration of ICU and Hospital Admission. Indian J Crit Care Med 2022; 26:314-318. [PMID: 35519935 PMCID: PMC9015935 DOI: 10.5005/jp-journals-10071-24144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Impaired physical activity and functional ability is a significant problem in critical illness survivors. Measurement of physical functioning through intensive care unit (ICU) stay determines patients at risk of poor physical outcomes, monitors efficacy of intervention, and informs recovery trajectories. Objectives Study objective was to assess physical function trajectory and identify residual functional limitations in critically ill patients admitted to ICU at the point of discharge from the hospital using robust clinical measures. Materials and methods Following ethical approval, 100 patients (78 males and 22 females) admitted to medical and surgical ICUs were recruited. Scores on Functional Status Score in ICU (FSS-ICU), Physical Function ICU Test (PFIT), and Functional Independence Measure (FIM) were recorded. Day of physiotherapy reference in the ICU was considered as day of ICU admission. Data were collected at three points, namely ICU admission, ICU discharge, and hospital discharge. Results Scores on all outcome measures increased linearly, and an upward functional trajectory was observed in patients from the point of ICU admission till hospital discharge (p >0.001). Conclusion Deficits in functional recovery exist until hospital discharge, substantiating the need to implement home-based rehabilitation to recover optimum physical function and independence in activities of daily living. How to cite this article Aglawe DR, Agarwal BM, Sawant BD. Physical Function in Critically Ill Patients during the Duration of ICU and Hospital Admission. Indian J Crit Care Med 2022;26(3):314–318.
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Affiliation(s)
- Damini R Aglawe
- Department of Physiotherapy, MGM School of Physiotherapy, MGM Institute of Health Sciences, Navi Mumbai, Maharashtra, India
- Bela M Agarwal, Department of Physiotherapy, MGM School of Physiotherapy, MGM Institute of Health Sciences, Navi Mumbai, Maharashtra, India, Phone: +91 9819000674, e-mail:
| | - Bela M Agarwal
- Department of Physiotherapy, MGM School of Physiotherapy, MGM Institute of Health Sciences, Navi Mumbai, Maharashtra, India
| | - Bhoomika D Sawant
- Department of Physiotherapy, MGM School of Physiotherapy, MGM Institute of Health Sciences, Navi Mumbai, Maharashtra, India
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Kawar LN, Crawford CL, Mendoza RG, Harrison SJ, Thibodeaux MW, Spicer JE. Validity and Usefulness of an Electronic Health Care Record-Generated Mobility Ambulation Tool: The Human Body Was Designed to Move. J Nurs Care Qual 2022; 37:68-74. [PMID: 34261088 DOI: 10.1097/ncq.0000000000000580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mobility is a vital function of human life. Nurses have an essential role in preventing hospitalized patient complications through movement and ambulation. PURPOSE This study examined the integration, accuracy, and precision of a paper-based mobility/ambulation tool into an electronic health record (EHR) to assess inpatient mobility/ambulation status. METHODS This multisite mixed-methods study was a time-series correlational evaluation of a mobility/ambulation tool into the EHR. RESULTS Sustainability data revealed strong correlations between nurse responses and EHR levels (r = 0.602; scores r = 0.624). Cronbach's α values were 0.737 and 0.761. Nurses' anecdotes supported the findings. CONCLUSION Findings revealed that the EHR-Mobility Ambulation Tool is a valid, reliable, and stable tool. EHR-generated scores can assist in reducing charting burden, care planning, and inform the interdisciplinary health team at all patient care stages. Tool adoption could potentially assist nurses plan interventions suitable to maintain or increase hospitalized patients' mobility status and contribute to discharge planning.
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Affiliation(s)
- Lina Najib Kawar
- Patient Care Services, Kaiser Permanente Southern California, Pasadena, California (Drs Kawar, Crawford, and Harrison and Ms Thibodeaux); Kaiser Permanente, Baldwin Park, California (Ms Mendoza); and Kaiser Permanente Southern California & Hawai'i Market, Pasadena, California (Dr Spicer)
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Hut-Mossel L, Ahaus K, Welker G, Gans R. Understanding how and why audits work in improving the quality of hospital care: A systematic realist review. PLoS One 2021; 16:e0248677. [PMID: 33788894 PMCID: PMC8011742 DOI: 10.1371/journal.pone.0248677] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/03/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Several types of audits have been used to promote quality improvement (QI) in hospital care. However, in-depth studies into the mechanisms responsible for the effectiveness of audits in a given context is scarce. We sought to understand the mechanisms and contextual factors that determine why audits might, or might not, lead to improved quality of hospital care. METHODS A realist review was conducted to systematically search and synthesise the literature on audits. Data from individual papers were synthesised by coding, iteratively testing and supplementing initial programme theories, and refining these theories into a set of context-mechanism-outcome configurations (CMOcs). RESULTS From our synthesis of 85 papers, seven CMOcs were identified that explain how audits work: (1) externally initiated audits create QI awareness although their impact on improvement diminishes over time; (2) a sense of urgency felt by healthcare professionals triggers engagement with an audit; (3) champions are vital for an audit to be perceived by healthcare professionals as worth the effort; (4) bottom-up initiated audits are more likely to bring about sustained change; (5) knowledge-sharing within externally mandated audits triggers participation by healthcare professionals; (6) audit data support healthcare professionals in raising issues in their dialogues with those in leadership positions; and (7) audits legitimise the provision of feedback to colleagues, which flattens the perceived hierarchy and encourages constructive collaboration. CONCLUSIONS This realist review has identified seven CMOcs that should be taken into account when seeking to optimise the design and usage of audits. These CMOcs can provide policy makers and practice leaders with an adequate conceptual grounding to design contextually sensitive audits in diverse settings and advance the audit research agenda for various contexts. PROSPERO REGISTRATION CRD42016039882.
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Affiliation(s)
- Lisanne Hut-Mossel
- Centre of Expertise on Quality and Safety, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Kees Ahaus
- Department Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - Gera Welker
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rijk Gans
- Department of Internal Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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9
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Swingwood E, Tume L, Cramp F. A survey examining the use of mechanical insufflation-exsufflation on adult intensive care units across the UK. J Intensive Care Soc 2020; 21:283-289. [PMID: 34093728 PMCID: PMC8142094 DOI: 10.1177/1751143719870121] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Despite potential benefits, it is not known how widely physiotherapists use mechanical insufflation-exsufflation devices on UK adult intensive care units. This survey aimed to describe mechanical insufflation-exsufflation use in UK adult intensive care units. METHODS Cross-sectional electronic survey of physiotherapists working in a permanent post on adult intensive care units. RESULTS One hundred and sixty-six complete surveys were available for analysis, reflecting a diverse geographical spread. Nearly all (98%; 163/166) clinicians had access to mechanical insufflation-exsufflation. The estimated frequency of use varied, with the majority reporting weekly or monthly use (52/163, 32%; 50/163, 31%, respectively). Nearly all clinicians (99%) used mechanical insufflation-exsufflation with extubated patients. In contrast, around half of respondents (86/163, 53%) used mechanical insufflation-exsufflation with intubated patients, with a range of perceived barriers reported. CONCLUSIONS Mechanical insufflation-exsufflation devices are widely available on UK adult intensive care units, with use more common in extubated patients. Barriers to mechanical insufflation-exsufflation use in the intubated population warrant further investigation.
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Affiliation(s)
- Ema Swingwood
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Lyvonne Tume
- School of Health and Society, University of Salford, Salford, UK
| | - Fiona Cramp
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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10
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Dikkema Y, Nieuwenhuis MK, van der Schans CP, Mouton LJ. Questionnaires to Assess Facilitators and Barriers of Early Mobilization in Critically Ill Patients; Which One to Choose? A Systematic Review. Clin Nurs Res 2020; 30:442-454. [PMID: 32808531 DOI: 10.1177/1054773820948268] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Implementing and performing early mobilization is a complex process requiring multidisciplinary input and cooperation. To gain insight in its facilitators and barriers, various surveys have been developed. A systematic review was conducted, to identify the psychometric properties, feasibility and suitability of questionnaires to assess facilitators and barriers of early mobilization in critically ill patients. Data were extracted regarding a.o. definition of early mobilization, development, psychometric properties, content and themes, question format. The search identified 537 publications of which 13 unique questionnaires were included. The questionnaires showed wide variation in extensiveness of development. Only six questionnaires actually assessed validity and reliability. Which questionnaire to choose depends on the aim of its use, required level of detail and specifics of the ICU, though three questionnaires were recommended as their definition of early mobilization covered a broad range of activities, including nursing related mobility activities. International consensus on what constitutes early mobilization is desirable.
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Affiliation(s)
- Yvonne Dikkema
- Association of Dutch Burn Centers, Burn Center Martini Hospital, Groningen, The Netherlands.,Hanze University of Applied Sciences Groningen, Research group Healthy Ageing, Allied Health Care and Nursing, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Department for Human Movement Sciences, Groningen, The Netherlands
| | - Marianne K Nieuwenhuis
- Association of Dutch Burn Centers, Burn Center Martini Hospital, Groningen, The Netherlands.,Hanze University of Applied Sciences Groningen, Research group Healthy Ageing, Allied Health Care and Nursing, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Department for Human Movement Sciences, Groningen, The Netherlands
| | - Cees P van der Schans
- Hanze University of Applied Sciences Groningen, Research group Healthy Ageing, Allied Health Care and Nursing, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, Department of Health Psychology, Groningen, the Netherlands
| | - Leonora J Mouton
- University of Groningen, University Medical Center Groningen, Department for Human Movement Sciences, Groningen, The Netherlands
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11
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Hartley P, DeWitt AL, Forsyth F, Romero-Ortuno R, Deaton C. Predictors of physical activity in older adults early in an emergency hospital admission: a prospective cohort study. BMC Geriatr 2020; 20:177. [PMID: 32423418 PMCID: PMC7236296 DOI: 10.1186/s12877-020-01562-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/16/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Reduced mobility may be responsible for functional decline and acute sarcopenia in older hospitalised patients. The drivers of reduced in-hospital mobility are poorly understood, especially during the early phase of acute hospitalisation. We investigated predictors of in-hospital activity during a 24-h period in the first 48 h of hospital admission in older adults. METHODS This was a secondary analysis of a prospective repeated measures cohort study. Participants aged 75 years or older were recruited within the first 24 h of admission. At recruitment, patients underwent a baseline assessment including measurements of pre-morbid functional mobility, cognition, frailty, falls efficacy, co-morbidity, acute illness severity, knee extension strength and grip strength, and consented to wear accelerometers to measure physical activity during the first 7 days (or until discharge if earlier). In-hospital physical activity was defined as the amount of upright time (standing or walking). To examine the predictors of physical activity, we limited the analysis to the first 24 h of recording to maximise the sample size as due to discharge from hospital there was daily attrition. We used a best subset analysis including all baseline measures. The optimal model was defined by having the lowest Bayesian information criterion in the best-subset analyses. The model specified a maximum of 5 covariates and used an exhaustive search. RESULTS Seventy participants were recruited but eight were excluded from the final analysis due to lack of accelerometer data within the first 24 h after recruitment. Patients spent a median of 0.50 h (IQR: 0.21; 1.43) standing or walking. The optimal model selected the following covariates: functional mobility as measured by the de Morton Mobility Index and two measures of illness severity, the National Early Warning Score, and serum C-reactive protein. CONCLUSIONS Physical activity, particularly in the acute phase of hospitalisation, is very low in older adults. The association between illness severity and physical activity may be explained by symptoms of acute illness being barriers to activity. Interdisciplinary approaches are required to identify early mobilisation opportunities.
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Affiliation(s)
- Peter Hartley
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
- Department of Physiotherapy, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK.
- Forvie Site, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, CB2 0SR, UK.
| | - Amanda L DeWitt
- Department of Medicine for the Elderly, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Faye Forsyth
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology, Trinity College Dublin, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Christi Deaton
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Anekwe DE, Milner SC, Bussières A, de Marchie M, Spahija J. Intensive care unit clinicians identify many barriers to, and facilitators of, early mobilisation: a qualitative study using the Theoretical Domains Framework. J Physiother 2020; 66:120-127. [PMID: 32307308 DOI: 10.1016/j.jphys.2020.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 09/19/2019] [Accepted: 03/09/2020] [Indexed: 01/18/2023] Open
Abstract
QUESTION From the perspective of intensive care unit (ICU) clinicians, what are the barriers to and facilitators of implementing early mobilisation? DESIGN A qualitative study using focus groups, with analysis using the Theoretical Domains Framework. PARTICIPANTS Physicians, nurses, respiratory therapists and physiotherapists from the ICUs of three university-affiliated hospitals in Montreal, Canada. METHODS Four focus group meetings were conducted with 33 participating ICU clinicians. Two researchers independently performed thematic content analysis on verbatim transcriptions of the audio recordings using the Theoretical Domains Framework. RESULTS Data saturation was reached after the third focus group. Thirty-six barriers were categorised in 13 domains of the Theoretical Domains Framework. The key barriers to early mobilisation were: lack of conviction and knowledge regarding the available evidence about early mobilisation; lack of attention to the provision of optimal care; poor communication; the unpredictable nature of the ICU; and limited staffing, equipment, time and clinical knowledge. Twenty-five facilitators categorised in ten TDF domains were also identified. These included individual-level facilitators (intrinsic motivation, positive outcome expectations, conscious effort to mobilise early, good planning/coordination, the presence of ICU champions, and expert support by a physiotherapist) and organisational-level facilitators (reminder system, pro-early mobilisation culture, implementation of an early mobilisation protocol, and improved ICU organisation). CONCLUSIONS A broad array of barriers to and facilitators of early mobilisation in the ICU were identified in this study. Clinicians can consider whether these barriers and facilitators are operating in their ICU. These may inform the design of tailored knowledge translation interventions to promote early mobilisation in the ICU.
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Affiliation(s)
- David E Anekwe
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada; CIUSSS-NÎM, Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montreal, Canada
| | - Siobhan C Milner
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - André Bussières
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - Michel de Marchie
- Department of Adult Critical Care, CIUSSS West-Central Montreal, Jewish General Hospital, Montreal, Canada
| | - Jadranka Spahija
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada; CIUSSS-NÎM, Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montreal, Canada; Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR), CISSS Laval - Hôpital Juif de Réadaptation, Laval, Canada.
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13
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Sutt AL, Hay K, Kinneally T, Fisquet S, Fraser JF. Sedatives, analgesics and antipsychotics in tracheostomised ICU patients - Is less more? Aust Crit Care 2019; 33:407-411. [PMID: 31495639 DOI: 10.1016/j.aucc.2018.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 11/22/2018] [Accepted: 12/11/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Sedation and anaesthesia are used universally to facilitate mechanical ventilation - with larger cumulative doses being used in those with prolonged ventilation. Transitioning from an endotracheal to a tracheostomy tube enables the depth of sedation to be reduced. Early use of speaking valves with tracheostomised patients has become routine in some intensive care units (ICU). The return of verbal communication has been observed to improve ease of patient care and increase patient and family engagement, with a perceived reduction in patient agitation. OBJECTIVES To investigate the potential impact of speaking valve (SV) use on requirements of sedatives, analgesics and antipsychotics in ICU patients with a tracheostomy. METHODS A retrospective data audit was undertaken for all tracheostomised patients in a cardio-respiratory ICU from 2011 to 2014. Use of sedative, analgesic and antipsychotic drugs was captured for endotracheal tube, tracheostomy and SV periods, including patient demographics, disease specifics and severity. Stratified Cox regression analysis was performed to determine the effects of SV on drug dosage. RESULTS Of 257 patients, 144 (56%) received an SV. Use of an SV was associated with reduced risk of being in the upper quartile of daily dosage of analgesics (HR: 0.6; 95% CI: 0.5-0.8; p < 0.001). In the final adjusted multivariable model, analgesic dose was additionally associated with age, and attendance to operating theatre during ICU. Sedative dose was associated with age, gender and SOFA score. Antipsychotic dose was associated with gender (less likely in females: HR 0.6, 95% CI: 0.4-0.8), age and APACHE score. CONCLUSIONS There was significantly less analgesic used in patients with an SV compared to those without. However, SV use in patients with tracheostomy was not found to be associated with reduced dose of sedatives or antipsychotics, despite the clinical impression. Future prospective studies are needed to more adequately investigate the association between drugs and patients' ability to verbally participate in their care.
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Affiliation(s)
- Anna-Liisa Sutt
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medical and Biomedical Sciences, The University of Queensland, Brisbane, Australia; Barts Health NHS Trust, London, United Kingdom.
| | - Karen Hay
- QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston QLD 4006, Brisbane, Australia.
| | - Toni Kinneally
- Faculty of Medical and Biomedical Sciences, The University of Queensland, Brisbane, Australia.
| | - Stephanie Fisquet
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Pharmacy Department, The Prince Charles Hospital, Brisbane, Australia.
| | - John F Fraser
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medical and Biomedical Sciences, The University of Queensland, Brisbane, Australia.
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14
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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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15
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Nurse-Initiated Mobilization Practices in 2 Community Intensive Care Units: A Pilot Study. Dimens Crit Care Nurs 2019; 37:318-323. [PMID: 30273218 DOI: 10.1097/dcc.0000000000000320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Critical-care nurses play a vital role in promoting safe early mobilization in intensive care unit (ICU) settings to reduce the risks associated with immobility in ICUs, including the risk of delirium, ICU-acquired weakness, and functional decline. OBJECTIVE The purposes of this study were to describe nurse-led mobilization practices in 2 community hospital ICUs and to report differences and similarities between the 2 settings. METHODS This was a cross-sectional exploratory study of 18 nurses (ICU A: n = 12, ICU B: n = 6) and 124 patients (ICU A: n = 50, ICU B: n = 74). Patient-specific therapeutic intervention needs and nurse-initiated mobilization practices were tracked over a 1-month period. RESULTS Differences in patient characteristics and nurse-led mobilization activities were observed between ICUs. After controlling for patient characteristics, we found statistically significant differences in nurse-led mobilization activities between the 2 units, suggesting that factors other than patient characteristics may explain differences in nurse-led mobilization practices.
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16
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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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17
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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: 214] [Impact Index Per Article: 35.7] [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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18
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Johnson AM, Henning AN, Morris PE, Tezanos AGV, Dupont-Versteegden EE. Timing and Amount of Physical Therapy Treatment are Associated with Length of Stay in the Cardiothoracic ICU. Sci Rep 2017; 7:17591. [PMID: 29242519 PMCID: PMC5730602 DOI: 10.1038/s41598-017-17624-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 11/15/2017] [Indexed: 01/06/2023] Open
Abstract
Significant variability exists in physical therapy early mobilization practice. The frequency of physical therapy or early mobilization of patients in the cardiothoracic intensive care unit and its effect on length of stay has not been investigated. The goal of our research was to examine variables that influence physical therapy evaluation and treatment in the intensive care unit using a retrospective chart review. Patients (n = 2568) were categorized and compared based on the most common diagnoses or surgical procedures. Multivariate semi-logarithmic regression analyses were used to determine correlations. Differences among patient subgroups for all independent variables other than age and for length of stay were found. The regression model determined that time to first physical therapy evaluation, Charlson Comorbidity Index score, mean days of physical therapy treatment and mechanical ventilation were associated with increased hospital length of stay. Time to first physical therapy evaluation in the intensive care unit and the hospital, and mean days of physical therapy treatment associated with hospital length of stay. Further prospective study is required to determine whether shortening time to physical therapy evaluation and treatment in a cardiothoracic intensive care unit could influence length of stay.
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Affiliation(s)
- Audrey M Johnson
- Department of Rehabilitation Sciences, College of Health Sciences, University of Kentucky, Lexington, Kentucky, United States of America.
| | - Angela N Henning
- Rehabilitation Department, UK HealthCare, Lexington, Kentucky, United States of America
| | - Peter E Morris
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Lexington, Kentucky, United States of America
| | - Alejandro G Villasante Tezanos
- Department of Statistics, College of Arts and Sciences, University of Kentucky, Lexington, Kentucky, United States of America
| | - Esther E Dupont-Versteegden
- Department of Rehabilitation Sciences, College of Health Sciences, University of Kentucky, Lexington, Kentucky, United States of America
- Center for Muscle Biology, College of Health Sciences, University of Kentucky, Lexington, Kentucky, United States of America
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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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20
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Machado ADS, Pires-Neto RC, Carvalho MTX, Soares JC, Cardoso DM, Albuquerque IMD. Effects that passive cycling exercise have on muscle strength, duration of mechanical ventilation, and length of hospital stay in critically ill patients: a randomized clinical trial. J Bras Pneumol 2017; 43:134-139. [PMID: 28538781 PMCID: PMC5474377 DOI: 10.1590/s1806-37562016000000170] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 11/18/2016] [Indexed: 11/21/2022] Open
Abstract
Objective To evaluate the effects that passive cycling exercise, in combination with conventional physical therapy, have on peripheral muscle strength, duration of mechanical ventilation, and length of hospital stay in critically ill patients admitted to the ICU of a tertiary care university hospital. Methods This was a randomized clinical trial involving 38 patients (≥ 18 years of age) on mechanical ventilation who were randomly divided into two groups: control (n = 16), receiving conventional physical therapy; and intervention (n = 22), receiving conventional physical therapy and engaging in passive cycling exercise five days per week. The mean age of the patients was 46.42 ± 16.25 years, and 23 were male. The outcomes studied were peripheral muscle strength, as measured by the Medical Research Council scale, duration of mechanical ventilation, and length of hospital stay. Results There was a significant increase in peripheral muscle strength (baseline vs. final) in both groups (control: 40.81 ± 7.68 vs. 45.00 ± 6.89; and intervention: 38.73 ± 11.11 vs. 47.18 ± 8.75; p < 0.001 for both). However, the range of increase in strength was higher in the intervention group than in the control group (8.45 ± 5.20 vs. 4.18 ± 2.63; p = 0.005). There were no significant differences between the groups in terms of duration of mechanical ventilation or length of hospital stay. Conclusions The results suggest that the performance of continuous passive mobilization on a cyclical basis helps to recover peripheral muscle strength in ICU patients. (ClinicalTrials.gov Identifier: NCT01769846 [http://www.clinicaltrials.gov/]).
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Affiliation(s)
- Aline Dos Santos Machado
- . Curso de Especialização em Reabilitação Físico-Motora, Programa de Pós-Graduação em Gerontologia, Universidade Federal de Santa Maria - UFSM - Santa Maria (RS) Brasil
| | - Ruy Camargo Pires-Neto
- . Programa de Pós-Graduação em Ciências da Reabilitação, Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Maurício Tatsch Ximenes Carvalho
- . Programa de Pós-Graduação em Reabilitação Funcional, Departamento de Fisioterapia e Reabilitação, Universidade Federal de Santa Maria - UFSM - Santa Maria (RS) Brasil
| | - Janice Cristina Soares
- . Unidade de Terapia Intensiva Adulto, Hospital Universitário de Santa Maria, Universidade Federal de Santa Maria - UFSM - Santa Maria (RS) Brasil.,. Universidade Luterana do Brasil - ULBRA -Santa Maria (RS) Brasil
| | - Dannuey Machado Cardoso
- . Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS) Brasil
| | - Isabella Martins de Albuquerque
- . Programa de Pós-Graduação em Reabilitação Funcional, Departamento de Fisioterapia e Reabilitação, Universidade Federal de Santa Maria - UFSM - Santa Maria (RS) Brasil
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21
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An Exploratory Descriptive Study of Registered Nurse Innovation: Implications for Levels of Adoption. CLIN NURSE SPEC 2017; 31:E1-E9. [PMID: 27906736 DOI: 10.1097/nur.0000000000000264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aims of this study were to describe registered nurses' levels of personal innovativeness and registered nurses' perceived organizational innovativeness and determine the relationship between these 2 variables. BACKGROUND There is limited research to describe the levels of innovation of nurses within a hospital. The levels of innovation can determine the likelihood of adoption of evidence-based practices at the bedside. As change agents, clinical nurse specialists can determine successful implementation strategies tailored to nurse levels of innovation. DESCRIPTION This was a descriptive study at a midwest, urban, teaching, 408-bed Magnet hospital. OUTCOMES Surveys were completed by 217 nurses. The participants reported high personal innovativeness ((Equation is included in full-text article.)= 32.1; SD, 6.4), and the institution was perceived as innovative, with 90.3% of scores categorized as positive innovativeness. The statistically significant correlation was in the medical-surgical unit (r = -0.52, P < .01). There is no correlation between personal innovativeness and organizational innovativeness except for medical-surgical nurses (P = .03). They are likely to perceive the organization more innovative than themselves. CONCLUSIONS Determining adopter characteristics can be valuable to the clinical nurse specialist by adapting strategic interventions to advance nursing practice. Exploring levels of adoption can be an innovative strategy to transform nursing at the bedside and throughout the organization.
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22
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Costa DK, White MR, Ginier E, Manojlovich M, Govindan S, Iwashyna TJ, Sales AE. 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. Chest 2017; 152:304-311. [PMID: 28438605 DOI: 10.1016/j.chest.2017.03.054] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Emily Ginier
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI
| | | | - Sushant Govindan
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
| | - Anne E Sales
- VA Center for Clinical Management Research, Ann Arbor, MI; Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
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Hunter OO, George EL, Ren D, Morgan D, Rosenzweig M, Klinefelter Tuite P. Overcoming nursing barriers to intensive care unit early mobilisation: A quality improvement project. Intensive Crit Care Nurs 2017; 40:44-50. [PMID: 28190550 DOI: 10.1016/j.iccn.2016.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 10/05/2016] [Accepted: 10/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To increase adherence with intensive care unit mobility by developing and implementing a mobility training program that addresses nursing barriers to early mobilisation. DESIGN An intensive care unit mobility training program was developed, implemented and evaluated with a pre-test, immediate post-test and eight-week post-test. Patient mobility was tracked before and after training. SETTING A ten bed cardiac intensive care unit. MAIN OUTCOME MEASURES The training program's efficacy was measured by comparing pre-test, immediate post-test and 8-week post-test scores. Patient mobilisation rates before and after training were compared. Protocol compliance was measured in the post training group. RESULTS Nursing knowledge increased from pre-test to immediate post-test (p<0.0001) and pre-test to 8-week post-test (p<0.0001). Mean test scores decreased by seven points from immediate post-test (80±12) to 8-week post-test (73±14). Fear significantly decreased from pre-test to immediate post-test (p=0.03), but not from pre-test to 8-week post-test (p=0.06) or immediate post-test to 8-week post-test (p=0.46). Post training patient mobility rates increased although not significantly (p=0.07). Post training protocol compliance was 78%. CONCLUSION The project successfully increased adherence with intensive care unit mobility and indicates that a training program could improve adoption of early mobility.
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Affiliation(s)
- Oluwatobi O Hunter
- University of Pittsburgh School of Nursing, 3500 Victoria St., Pittsburgh, PA 15213, United States.
| | - Elisabeth L George
- UPMC Presbyterian, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Dianxu Ren
- University of Pittsburgh School of Nursing, 3500 Victoria St., Pittsburgh, PA 15213, United States.
| | - Douglas Morgan
- UPMC Presbyterian, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Margaret Rosenzweig
- University of Pittsburgh School of Nursing, 3500 Victoria St., Pittsburgh, PA 15213, United States.
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Abstract
When critically ill, a severe weakness of the limbs and respiratory muscles often develops with a prolonged stay in the intensive care unit (ICU), a condition vaguely termed intensive care unit-acquired weakness (ICUAW). Many of these patients have serious nerve and muscle injury. This syndrome is most often seen in surviving critically ill patients with sepsis or extensive inflammatory response which results in increased duration of mechanical ventilation and hospital length of stay. Patients with ICUAW often do not fully recover and the disability will seriously impact on their quality of life. In this chapter we discuss the current knowledge on the pathophysiology and risk factors of ICUAW. Tools to diagnose ICUAW, how to separate ICUAW from other disorders, and which possible treatment strategies can be employed are also described. ICUAW is finally receiving the attention it deserves and the expectation is that it can be better understood and prevented.
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Affiliation(s)
- J Horn
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands.
| | - G Hermans
- Department of General Internal Medicine, UZ Leuven, Leuven, Belgium
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Green M, Marzano V, Leditschke IA, Mitchell I, Bissett B. Mobilization of intensive care patients: a multidisciplinary practical guide for clinicians. J Multidiscip Healthc 2016; 9:247-56. [PMID: 27307746 PMCID: PMC4889100 DOI: 10.2147/jmdh.s99811] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives To describe our experience and the practical tools we have developed to facilitate early mobilization in the intensive care unit (ICU) as a multidisciplinary team. Background Despite the evidence supporting early mobilization for improving outcomes for ICU patients, recent international point-prevalence studies reveal that few patients are mobilized in the ICU. Existing guidelines rarely address the practical issues faced by multidisciplinary ICU teams attempting to translate evidence into practice. We present a comprehensive strategy for safe mobilization utilized in our ICU, incorporating the combined skills of medical, nursing, and physiotherapy staff to achieve safe outcomes and establish a culture which prioritizes this intervention. Methods A raft of tools and strategies are described to facilitate mobilization in ICU by the multidisciplinary team. Patients without safe unsupported sitting balance and without ≥3/5 (Oxford scale) strength in the lower limbs commence phase 1 mobilization, including training of sitting balance and use of the tilt table. Phase 2 mobilization involves supported or active weight-bearing, incorporating gait harnesses if necessary. The Plan B mnemonic guides safe multidisciplinary mobilization of invasively ventilated patients and emphasizes the importance of a clearly articulated plan in delivering this valuable treatment as a team. Discussion These tools have been used over the past 5 years in a tertiary ICU with a very low incidence of adverse outcomes (<2%). The tools and strategies described are useful not only to guide practical implementation of early mobilization, but also in the creation of a unit culture where ICU staff prioritize early mobilization and collaborate daily to provide the best possible care. Conclusion These practical tools allow ICU clinicians to safely and effectively implement early mobilization in critically ill patients. A genuinely multidisciplinary approach to safe mobilization in ICU is key to its success in the long term.
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Affiliation(s)
- Margot Green
- Physiotherapy Department, Canberra Hospital, Canberra, ACT, Australia
| | - Vince Marzano
- Physiotherapy Department, Canberra Hospital, Canberra, ACT, Australia
| | - I Anne Leditschke
- Intensive Care Unit, Canberra Hospital, Canberra, ACT, Australia; School of Medicine, Australian National University, Canberra, ACT, Australia
| | - Imogen Mitchell
- Intensive Care Unit, Canberra Hospital, Canberra, ACT, Australia; School of Medicine, Australian National University, Canberra, ACT, Australia
| | - Bernie Bissett
- Physiotherapy Department, Canberra Hospital, Canberra, ACT, Australia; Discipline of Physiotherapy, University of Canberra, Canberra, ACT, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia
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