Teamwork enables high level of early mobilization in critically ill patients

Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study

BACKGROUND

Physical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based on robust safety data. To develop this information, a uniform definition of relevant adverse events is required. The assessment of cardiovascular stability is particularly relevant before physical activity as there is uncertainty over when it is safe to start rehabilitation with patients receiving vasoactive drugs.

METHODS

A three-stage Delphi study was carried out to (a) define adverse events for a general ICU cohort, and (b) to define which risks should be assessed before physical rehabilitation of patients receiving vasoactive drugs. An international group of intensive care clinicians and clinician researchers took part. Former ICU patients and their family members/carers were involved in generating consensus for the definition of adverse events. Round one was an open round where participants gave their suggestions of what to include. In round two, participants rated their agreements with these suggestions using a five-point Likert scale; a 70% consensus agreement threshold was used. Round three was used to re-rate suggestions that had not reached consensus, whilst viewing anonymous feedback of participant ratings from round two.

RESULTS

Twenty-four multi-professional ICU clinicians and clinician researchers from 10 countries across five continents were recruited. Average duration of ICU experience was 18 years (standard deviation 8) and 61% had publications related to ICU rehabilitation. For the adverse event definition, five former ICU patients and one patient relative were recruited. The Delphi process had a 97% response rate. Firstly, 54 adverse events reached consensus; an adverse event tool was created and informed by these events. Secondly, 50 risk factors requiring assessment before physical rehabilitation of patients receiving vasoactive drugs reached consensus. A second tool was created, informed by these suggestions.

CONCLUSIONS

The adverse event tool can be used in studies of physical rehabilitation to ensure uniform measurement of safety. The risk assessment tool can be used to inform clinical practise when risk assessing when to start rehabilitation with patients receiving vasoactive drugs. Trial registration This study protocol was retrospectively registered on https://www.researchregistry.com/ (researchregistry2991).

Physical and respiratory therapy in the critically ill patient with obesity: a narrative review

Obesity has become increasingly prevalent in the intensive care unit, presenting a significant challenge for healthcare systems and professionals, including rehabilitation teams. Caring for critically ill patients with obesity involves addressing complex issues. Despite the well-established and safe practice of early mobilization during critical illness, in rehabilitation matters, the diverse clinical disturbances and scenarios within the obese patient population necessitate a comprehensive understanding. This includes recognizing the importance of metabolic support, both non-invasive and invasive ventilatory support, and their weaning processes as essential prerequisites. Physiotherapists, working collaboratively with a multidisciplinary team, play a crucial role in ensuring proper assessment and functional rehabilitation in the critical care setting. This review aims to provide critical insights into the key management and rehabilitation principles for obese patients in the intensive care unit.

The diverse invitations to participate in early rehabilitation - A qualitative study of nurse-patient interactions in the intensive care unit

OBJECTIVES

To gain insight into the interaction between nurses and patients in early rehabilitation and the role of patient participation in this context.

RESEARCH DESIGN AND SETTING

A qualitative study with a phenomenological-hermeneutic approach was conducted in two units/hospitals from January 2022 to January 2023, utilizing observations and video recordings of eight nurse/patient dyads combined with post observation interviews with the nurses. The study was analysed by systematic text condensation and video analysis, informed by interaction theory.

FINDINGS

Two contrasting categories emerged: 1) Absent invitations: the nurse performed procedures without involving the patient; in other situations, the nurse informed the patient without requesting participation. Simultaneously, spontaneous patient movements were not acknowledged by the nurse. The nurses explained that this practice occurred due to time pressure, oversights, a lack of belief regarding patients' capacities, the unit's culture and little training. 2) Invitations that strengthened participation: the nurse verbally requested activity that often resulted in an inadequate response, or bodily extended invitations that sometimes led to joint active movement. Patients were the most active participants when nurses combined verbal prompts, eye contact, physical handling, and dialogue. In the interviews, the nurses emphasized giving patients enough time to participate and repeatedly encouraged participation because the patient's condition and capacity constantly fluctuated.

CONCLUSION

Interactions that combine verbal and bodily invitations appear crucial for patient participation in early rehabilitation in the intensive care unit, emphasizing the importance of integrated tailored bodily communication. The nurses' lack of insight into and attention to the patient's bodily potential for active movement combined with a paternalistic approach to the patient's situation may hinder patients' active participation.

IMPLICATIONS FOR CLINICAL PRACTICE

Integrated forms of interaction that explore patients' capacity and potential for participation should be employed in line with verbal communication. Developing competence in early rehabilitation should be emphasized in critical care nurses' education and training.

Does the level of mobility on ICU discharge impact post-ICU outcomes? A retrospective analysis

PURPOSE

Mobilisation is a common intervention in Intensive Care (ICU). However, few studies have explored the relationship between mobility levels and outcomes. This study assessed the association of the level of mobility on ICU discharge with discharge destination from the hospital and hospital length of stay.

MATERIALS AND METHODS

A retrospective analysis of data from 522 patients admitted to a single UK general ICU who were ventilated for ≥5 days was performed. The level of mobility was assessed using the Manchester Mobility Score (MMS). Multivariable regression analysed demographic and clinical variables for the independence of association with discharge destination and hospital length of stay.

RESULTS

MMS ≥5 on ICU discharge was independently associated with discharge destination and hospital LOS (p < 0.001). Patients achieving MMS ≥5 on ICU discharge were more likely to be discharged home (OR 3.86 95% CI 2.1 to 6.9, p < 0.001), and had an 11.8 day shorter hospital LOS (95% CI -17.6 to -6.1, p < 0.001).

CONCLUSIONS

The ability to step transfer to a chair (MMS ≥5) before ICU discharge was independently associated with discharge to usual residence and hospital LOS, irrespective of preadmission morbidity. Increasing the level of patient mobility at ICU discharge should be a key focus of rehabilitation interventions.

Body-weight support gait training in neurological intensive care: safety, feasibility, and delays before walking with or without suspension

BACKGROUND

Early Mobilization in Intensive Care Units (ICUs) enhances patients' evolution, but has been rarely studied in neurological ICUs. The aim of this study was to assess gait training with body-weight support (BWS) in neuroICU, and to report on its safety, feasibility and on delays before walking with and without BWS.

METHODS

This study was an observational one-year single-center study. Inclusion criteria were adults with a neurological injury requiring mechanical ventilation. Exclusion criteria were early death or ICU transfer. After weaning from ventilation, patients were screened for indications of BWS walking using predefined criteria.

RESULTS

Patients' conditions were mostly brain injuries: 32% subarachnoid hemorrhages, 42% focal strokes, and 12% traumatic brain injuries. Out of 272 admissions, 136 patients were excluded, 78 were eligible, and 33 performed BWS walking. Among non-eligible patients, 36 walked unsuspended upon ventilation weaning, 17 presented too severe impairments. Among the 45 eligible patients who did not receive BWS training, main reasons were workload and weekends (31%), medical barriers (29%), and early ICU discharge (22%). 78 BWS sessions were performed on the 33 beneficiaries (median sessions per patient 2, max 10). Pre-session, most patients had inadequate response to pain, orders, or simple orientation questions. Sitting without support was impossible for 74%. Most pre-post changes in hemodynamic, respiratory, and pain parameters were small, and recovered spontaneously after the session. Eight sessions were interrupted; reasons were pain, fatigue or major imbalance (4), syncope (1), occurrence of stool (2), and battery failure (1). None of these adverse events required medical intervention, patients recovered upon session interruption. Median session duration was 31 min, patients walked on median 17 m. First BWS session occurred on median 3 days after ventilation weaning, and 11 days before patients were able to walk unsuspended.

CONCLUSIONS

Verticalization and walking using a suspension device in patients in neuroICU allows early gait training, despite challenging neurological impairments. It is safe and generally well tolerated.

TRIAL REGISTRATION

ClinicalTrials database (ID: NCT04300491).

Multidisciplinary Teamwork Perceptions When Mobilizing Ventilated Neurosurgery Patients

ABSTRACT

BACKGROUND: Multidisciplinary teamwork is essential in delivering holistic care to critically ill populations, including ventilated neurosurgery patients. Although it is considered a safe and feasible aspect of patient care, mobilization is often missed in this population because of negative healthcare provider perceptions regarding barriers and patient safety. Nurse-led teamwork has been suggested to overcome these barriers and to achieve earlier mobilization for patients, as well as positive provider perceptions, which may affect the culture and frequency of mobilization on neurointensive care units. Quantitative studies analyzing multidisciplinary teamwork perceptions to mobilize ventilated neurosurgery patients with or without a nurse-led protocol have not been previously conducted. Analyzing such perceptions may provide insight to team-related barriers related to missed mobility. This pilot quasi-experimental study aimed to determine whether the use of a nurse-led mobility protocol affects teamwork perceptions when mobilizing ventilated neurosurgery patients. METHODS: A sample of multidisciplinary teams, composed of nurses, patient care technicians, and respiratory therapists, mobilized ventilated neurosurgery patients according to either standard of care (for the control group) or a nurse-led mobility protocol (for the interventional group). Teamwork perceptions were measured via the reliable and valid Nursing Teamwork Survey tool. RESULTS: Linear mixed model analyses revealed that multidisciplinary teams in the nurse-led mobility protocol group had significantly higher levels of overall perceived teamwork than those in the control group, t3 = -3.296, P = .038. Such differences were also noted for teamwork variables of team leadership and mutual trust. CONCLUSION: Nurse-led mobility protocols should be considered to increase teamwork when performing multidisciplinary teamwork-based mobility for ventilated neurosurgery patients. Future studies should continue to evaluate teamwork perceptions after nurse-led mobility.

Effect of an early mobilisation programme on pain intensity after laparoscopic surgery: a randomised clinical trial

BACKGROUND

Pain is a common complication after laparoscopic surgery. This study aimed to examine the effect of an early mobilisation programme on postoperative pain intensity after laparoscopic surgery.

METHODS

A randomised controlled clinical trial was conducted on 80 patients who underwent laparoscopic surgery in Shahid Beheshti Hospital in Kashan, Iran. The patients were randomly allocated to intervention (n=40) and a control (n=40) group. In the intervention group, an early mobilisation programme was implemented in two rounds. The patient's perceived pain was assessed using a Visual Analogue Scale 15 min before and 30 min after each round of early mobilisation. Data were analysed through the independent samples t, χ2 and Fisher's exact tests and the repeated measures analysis.

RESULTS

The repeated measures analysis showed that the mean pain scores have been decreased over time (F=98.88, p<0.001). Considering the observed interaction between time and the intervention, the t test was used for pairwise comparisons and showed that the mean pain score was not significantly different between the two groups in 15 min before the first round of early mobilisation (p=0.95). However, the mean pain in the intervention group was significantly less than the control group in all subsequent measurements (p<0.05).

CONCLUSION

Early mobilisation programmes such as the one implemented in the current study are easy and inexpensive and can be implemented safely for the reduction of pain after laparoscopic surgeries.

Prevention and management of critical care complications in cardiogenic shock: a narrative review

BACKGROUND

Cardiogenic shock (CS) is a common cause of morbidity and mortality in cardiac intensive care units (CICUs), even in the contemporary era.

MAIN TEXT

Although mechanical circulatory supports have recently become widely available and used in transforming the management of CS, their routine use to improve outcomes has not been established. Transportation to a high-volume center, early reperfusion, tailored mechanical circulatory supports, regionalized systems of care with multidisciplinary CS teams, a dedicated CICU, and a systemic approach, including preventing noncardiogenic complications, are the key components of CS treatment strategies.

CONCLUSIONS

This narrative review aimed to discuss the challenges of preventing patients from developing CS-related complications and provide a comprehensive practical approach for its management.

Early Mobilization for Critically Ill Patients

Advances in the field of critical care medicine have helped improve the survival rate of these ill patients. Several studies have demonstrated the potential benefits of early mobilization as an important component of critical care rehabilitation. However, there have been some inconsistent results. Moreover, the lack of standardized mobilization protocols and the associated safety concerns are a barrier to the implementation of early mobilization in critically ill patients. Therefore, determining the appropriate modalities of implementation of early mobilization is a key imperative to leverage its potential in these patients. In this paper, we review the contemporary literature to summarize the strategies for early mobilization of critically ill patients, assess the implementation and validity based on the International Classification of Functioning, Disability and Health, as well as discuss the safety aspects of early mobilization.

Hemodynamic impact of early mobilization in critical patients receiving vasoactive drugs: A prospective cohort study

BACKGROUND

Vasoactive drugs are one of the most common patient-related barriers to early mobilization. Little is known about the hemodynamic effects of early mobilization on patients receiving vasoactive drugs. This study aims to observe and describe the impact of mobilization on the vital signs of critical patients receiving vasoactive drugs as well as the occurrence of adverse events.

METHODS

This is a cohort study performed in an Intensive Care Unit with patients receiving vasoactive drugs. All patients, either mobilized or non-mobilized, had their clinical data such as vital signs [heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation], type and dosage of the vasoactive drug, and respiratory support collected at rest. For mobilized patients, the vital signs were also collected after mobilization, and so was the highest level of mobility achieved and the occurrence of adverse events. The criteria involved in the decision of mobilizing the patients were registered.

RESULTS

53 patients were included in this study and 222 physiotherapy sessions were monitored. In most of the sessions (n = 150, 67.6%), patients were mobilized despite the use of vasoactive drugs. There was a statistically significant increase in heart rate and respiratory rate after mobilization when compared to rest (p<0.05). Only two (1.3%) out of 150 mobilizations presented an adverse event. Most of the time, non-mobilizations were justified by the existence of a clinical contraindication (n = 61, 84.7%).

CONCLUSIONS

The alterations observed in the vital signs of mobilized patients may have reflected physiological adjustments of patients' cardiovascular and respiratory systems to the increase in physical demand imposed by the early mobilization. The adverse events were rare, not serious, and reversed through actions such as a minimal increase of the vasoactive drug dosage.

Mobilisation of critically ill patients receiving norepinephrine: a retrospective cohort study

BACKGROUND

Mobilisation and exercise intervention in general are safe and feasible in critically ill patients. For patients requiring catecholamines, however, doses of norepinephrine safe for mobilisation in the intensive care unit (ICU) are not defined. This study aimed to describe mobilisation practice in our hospital and identify doses of norepinephrine that allowed a safe mobilisation.

METHODS

We conducted a retrospective single-centre cohort study of 16 ICUs at a university hospital in Germany with patients admitted between March 2018 and November 2021. Data were collected from our patient data management system. We analysed the effect of norepinephrine on level (ICU Mobility Scale) and frequency (units per day) of mobilisation, early mobilisation (within 72 h of ICU admission), mortality, and rate of adverse events. Data were extracted from free-text mobilisation entries using supervised machine learning (support vector machine). Statistical analyses were done using (generalised) linear (mixed-effect) models, as well as chi-square tests and ANOVAs.

RESULTS

A total of 12,462 patients were analysed in this study. They received a total of 59,415 mobilisation units. Of these patients, 842 (6.8%) received mobilisation under continuous norepinephrine administration. Norepinephrine administration was negatively associated with the frequency of mobilisation (adjusted difference -0.07 mobilisations per day; 95% CI - 0.09, - 0.05; p ≤ 0.001) and early mobilisation (adjusted OR 0.83; 95% CI 0.76, 0.90; p ≤ 0.001), while a higher norepinephrine dose corresponded to a lower chance to be mobilised out-of-bed (adjusted OR 0.01; 95% CI 0.00, 0.04; p ≤ 0.001). Mobilisation with norepinephrine did not significantly affect mortality (p > 0.1). Higher compared to lower doses of norepinephrine did not lead to a significant increase in adverse events in our practice (p > 0.1). We identified that mobilisation was safe with up to 0.20 µg/kg/min norepinephrine for out-of-bed (IMS ≥ 2) and 0.33 µg/kg/min for in-bed (IMS 0-1) mobilisation.

CONCLUSIONS

Mobilisation with norepinephrine can be done safely when considering the status of the patient and safety guidelines. We demonstrated that safe mobilisation was possible with norepinephrine doses up to 0.20 µg/kg/min for out-of-bed (IMS ≥ 2) and 0.33 µg/kg/min for in-bed (IMS 0-1) mobilisation.

Early mobilization of mechanically ventilated ICU patients in Saudi Arabia: Results of an ICU-wide national survey

BACKGROUND

Improved outcomes for patients on mechanical ventilation may be achieved with early mobilization (EM). However, it is not clear how widely this strategy is adopted into routine intensive care unit (ICU) practice in Saudi Arabia.

OBJECTIVES

This study was conducted to describe the present practices and challenges to providing EM for mechanically ventilated patients, which may drive dissemination and implementation activities.

METHODS

We approached 205 ICUs across Saudi Arabia using a validated tool to assess ICU characteristics, the practices of EM for mechanically ventilated patients, and the barriers to providing EM.

RESULTS

We approached 205 ICU persons in charge and achieved a 65% response rate (133 ICUs). The prevalence of EM for mechanically ventilated patients was 47% (63 ICUs). A total of 85 (64%) of the respondents reported having no previous training in EM. The absence of a written protocol was reported by 55% of the ICU practitioners in charge, 36% started EM within 2 to 5 days of critical illness, and 35% reported that performing EM for mechanically ventilated patients was totally dependent on physicians' orders. Forty-seven percent of the ICUs that practised EM had at least one coordinator or person in charge of facilitating EM. The highest level of EM with mechanically ventilated patients was 35/63 (55%) with patients remaining in-bed and 28/63 (45%) with patient getting out of bed. A majority of the respondents (39, 64%) performed EM once daily for an interval period of more than 15 min. Previous training in EM and years of experience of the ICU person in charge were significant factors that promoted EM for mechanically ventilated ICU patients (OR: 7.6 (3.37-17.26); p < 0.001 and OR: 1.07 (1.01-1.14), p = 0.004, respectively). Existing protocols increased the odds of starting EM within 2 to 5 days of critical illness by six-fold (OR: 6.03 (1.79-20.30); p = 0.004). No written guidelines/protocols available for EM, medical instability, and limited staff were the most common hospital-, patient- and health care provider-related barriers to EM in the ICUs, respectively.

CONCLUSION

The prevalence of EM for mechanically ventilated patients across Saudi Arabia was 47%, although only 36% of the ICU staff had previous training in EM. Targeting modifiable barriers to EM, including a lack of training, guidelines and protocols, and staffing, will help to promote EM in Saudi Arabian ICUs.

Knowledge, Attitude, and Perceived Barriers of Newly Graduated Registered Nurses Undergoing Standardized Training in Intensive Care Unit Toward Early Mobilization of Mechanically Ventilated Patients: A Qualitative Study in Shanghai

Aim: To explore the knowledge and attitudes of newly graduated registered nurses, who have undergone standardized training in the intensive care unit, about the early mobilization of mechanically ventilated patients and identify perceived barriers to the application of early mobilization.

Background: Early mobilization of mechanically ventilated patients has been gradually gaining attention, and its safety and effectiveness have also been verified. Nurses in intensive care units are the implementers of early mobilization, and the quality of their care is closely related to patient prognosis. However, the knowledge and attitude of newly graduated registered nurses undergoing standardized training, in intensive care units, on the early mobilization of mechanically ventilated patients and the obstacles they face in clinical implementation are still unclear.

Methods: This qualitative study utilized the phenomenological method to explore the experiences of 15 newly graduated registered nurses undergoing standardized training in intensive care units in a 3rd hospital in Shanghai, China. Semi-structured face-to-face interviews were conducted in June 2020. The Colaizzi seven-step framework was used for data analysis.

Findings: A total of 15 new nurses comprised the final sample after data saturation. Three main themes emerged from the analysis and seven subthemes: perceived importance, low implementation rate, and perceived barriers.

Conclusions: Newly graduated registered nurses undergoing standardized training in intensive care units have a high level of awareness of the importance of early mobilization of mechanically ventilated patients and are willing to implement it. However, there is a lack of relevant knowledge and other obstacles that restrict clinical implementation. Early mobilization should be included in the standardized training of new nurses in intensive care units.

Impact of protocol-based physiotherapy on insulin sensitivity and peripheral glucose metabolism in critically ill patients

BACKGROUND

The impact of physiotherapy on insulin sensitivity and peripheral glucose metabolism in critically ill patients is not well understood.

METHODS

This pooled analysis investigates the impact of different physiotherapeutic strategies on insulin sensitivity in critically ill patients. We pooled data from two previous trials in adult patients with sequential organ failure assessment score (SOFA)≥ 9 within 72 h of intensive care unit (ICU) admission, who received hyperinsulinaemic euglycaemic (HE) clamps. Patients were divided into three groups: standard physiotherapy (sPT, n = 22), protocol-based physiotherapy (pPT, n = 8), and pPT with added muscle activating measures (pPT+, n = 20). Insulin sensitivity index (ISI) was determined by HE clamp. Muscle metabolites lactate, pyruvate, and glycerol were measured in the M. vastus lateralis via microdialysis during the HE clamp. Histochemical visualization of glucose transporter-4 (GLUT4) translocation was performed in surgically extracted muscle biopsies. All data are reported as median (25th/75th percentile) (trial registry: ISRCTN77569430 and ISRCTN19392591/ethics approval: Charité-EA2/061/06 and Charité-EA2/041/10).

RESULTS

Fifty critically ill patients (admission SOFA 13) showed markedly decreased ISIs on Day 17 (interquartile range) 0.029 (0.022/0.048) (mg/min/kg)/(mU/L) compared with healthy controls 0.103 (0.087/0.111), P < 0.001. ISI correlated with muscle strength measured by medical research council (MRC) score at first awakening (r = 0.383, P = 0.026) and at ICU discharge (r = 0.503, P = 0.002). Different physiotherapeutic strategies showed no effect on the ISI [sPT 0.029 (0.019/0.053) (mg/min/kg)/(mU/L) vs. pPT 0.026 (0.023/0.041) (mg/min/kg)/(mU/L) vs. pPT+ 0.029 (0.023/0.042) (mg/min/kg)/(mU/L); P = 0.919]. Regardless of the physiotherapeutic strategy metabolic flexibility was reduced. Relative change of lactate/pyruvate ratio during HE clamp is as follows: sPT 0.09 (-0.13/0.27) vs. pPT 0.07 (-0.16/0.31) vs. pPT+ -0.06 (-0.19/0.16), P = 0.729, and relative change of glycerol concentration: sPT -0.39 (-0.8/-0.12) vs. pPT -0.21 (-0.33/0.07) vs. pPT+ -0.21 (-0.44/-0.03), P = 0.257. The majority of ICU patients showed abnormal localization of GLUT4 with membranous GLUT4 distribution in 37.5% (3 of 8) of ICU patients receiving sPT, in 42.9% (3 of 7) of ICU patients receiving pPT, and in 53.8% (7 of 13) of ICU patients receiving pPT+ (no statistical testing possible).

CONCLUSIONS

Our data suggest that a higher duration of muscle activating measures had no impact on insulin sensitivity or metabolic flexibility in critically ill patients with sepsis-related multiple organ failure.

Clinical effects of neuroendoscopic hematoma evacuation for hypertensive intracerebral hemorrhage

OBJECTIVE

To analyze the clinical effects of neuroendoscopic hematoma evacuation for the treatment of hypertensive intracerebral hemorrhage (ICH).

METHODS

A total of 80 patients with hypertensive ICH who were admitted to our hospital were included as the subjects of this retrospective study. The patients were assigned into a neuroendoscopic hematoma evacuation group (n=35) and a small bone window craniotomy group (n=45). The post-operative hematoma residues and the clearance rate of the hematoma were compared between the two groups. The intraoperative blood loss, duration of the surgery, and Glasgow Coma Scale (GSC) scores before and after surgery were compared between the two groups. The operation time, intraoperative blood loss, the time consumed to stop bleeding, clearance rate of hematoma, manifestation of complications, and the prognosis 6 months after surgery were analyzed statistically. Self-made questionnaires were used to evaluate the satisfaction degree of patients with their lives and to assess the quality of life after surgery.

RESULTS

The operation time, blood loss, and the time consumed to stop bleeding were less in the neuroendoscopic hematoma evacuation group than those in the small bone window craniotomy group (all P<0.05). The GCS scores in the neuroendoscopic hematoma evacuation group were significantly higher than those in the small bone window craniotomy group (P<0.05). The clearance rate of hematoma was higher in the neuroendoscopic hematoma evacuation group than that in the small bone window craniotomy group (P<0.05).

CONCLUSION

As compared with small bone window craniotomy for removing hematoma, neuroendoscopic hematoma evacuation showed a better outcome in treating patients with hypertensive ICH. It could improve patients' clinical indications, which is worthy of being widely applied in clinical settings.

Mobilizing Ventilated Neurosurgery Patients: An Integrative Literature Review

ABSTRACT

BACKGROUND: Lack of mobilization in ventilated neurosurgery patients is problematic due to significant consequences. Although early mobility addresses these complications, few studies have been conducted in this population, resulting in infrequent mobilization efforts. Nurses prioritize and implement patient care interventions, including mobilization, with multidisciplinary teams. This integrative literature review examines what is known regarding nursing perceptions on mobilization and their role within a multidisciplinary team for mobilization in ventilated neurosurgery patients. METHODS: A comprehensive literature search was conducted using online databases to identify research articles on early mobility studies in ventilated critically ill and neurosurgical patients from 2010 to 2020. RESULTS: Twenty studies were identified and indicated a paucity of research specific to mobilizing ventilated neurosurgery patients. Nurses understand the purpose and benefits of early mobility in critically ill and mechanically ventilated patients. Mixed perceptions exist regarding the responsibility for prioritizing and initiating mobilization. Main barriers include patient safety concerns, untimeliness due to limited resources, unit culture, lack of nursing knowledge, and need for improved teamwork. Associations between teamwork-based interventions and decreased length of stay, increased rates of mobility, and faster time to early mobilization exist. Nurse-led interventions showed additional benefits including positive perceptions such as empowerment, confidence, increased knowledge, and a progressive shift in unit culture. CONCLUSION: This review demonstrates a continued need for understanding nursing perceptions and role in teamwork to mobilize ventilated neurosurgery patients. Future research should focus on testing nurse-led mobility interventions so higher rates of mobilization and provision of holistic patient care can be achieved.

Delivery of Acute Rehabilitation to a Postcoronary Artery Bypass Graft COVID-19 Patient in a Pandemic Environment

During the first wave of the coronavirus disease (COVID-19) pandemic, a 57-year-old COVID-19 male patient was diagnosed with non-ST-elevation myocardial infarction and required urgent coronary artery bypass graft. In-patient cardiac rehabilitation following cardiac surgery was inevitable to limit or prevent various postoperative complications. A routine rehabilitation program was not feasible because of the strict COVID-19 isolation procedures, the high risk of cross infections, and the lack of various resources. Moreover, the detrimental effects of COVID-19 infection on multiple body systems reduced his exercise tolerance, limiting his engagement in physical activity. This case report highlights the various challenges encountered during the rehabilitation of these patients and strategies adopted to overcome them, illustrating the feasibility of a modified rehabilitation program to ensure early functional recovery.

Multidisciplinary, early mobility approach to enhance functional independence in patients admitted to a cardiothoracic intensive care unit: a quality improvement programme

Early mobilisation following cardiac surgery is vital for improved patient outcomes, as it has a positive effect on a patient's physical and psychological recovery following surgery. We observed that patients admitted to the cardiothoracic intensive care unit (CTICU) following cardiac surgery had only bed exercises and were confined to bed until the chest tubes were removed, which may have delayed patients achieving functional independence. Therefore, the CTICU team implemented a quality improvement (QI) project aimed at the early mobilisation of patients after cardiac surgery.A retrospective analysis was undertaken to define the current mobilisation practices in the CTICU. The multidisciplinary team identified various practice gaps and tested several changes that led to the implementation of a successful early mobility programme. The tests were carried out and reported using rapid cycle changes. A model for improvement methodology was used to run the project. The outcomes of the project were analysed using standard 'run chart rules' to detect changes in outcomes over time and Welch's t-test to assess the significance of these outcomes.This project was implemented in 2015. Patient compliance with early activity and mobilisation gradually reached 95% in 2016 and was sustained over the next 3 years. After the programme was implemented, the mean hours required for initiating out-of-bed-mobilisation was reduced from 22.77 hours to 11.74 hours. Similarly, functional independence measures and intensive care unit mobility scores also showed a statistically significant (p<0.005) improvement in patient transfers out of the CTICU.Implementing an early mobility programme for post-cardiac surgery patients is both safe and feasible. This QI project allowed for early activity and mobilisation, a substantial reduction in the number of hours required for initiating out-of-bed mobilisation following cardiac surgery, and facilitated the achievement of early ambulation and functional milestones in our patients.

Multidisciplinary, early mobility approach to enhance functional independence in patients admitted to a cardiothoracic intensive care unit: a quality improvement programme

Early mobilisation following cardiac surgery is vital for improved patient outcomes, as it has a positive effect on a patient's physical and psychological recovery following surgery. We observed that patients admitted to the cardiothoracic intensive care unit (CTICU) following cardiac surgery had only bed exercises and were confined to bed until the chest tubes were removed, which may have delayed patients achieving functional independence. Therefore, the CTICU team implemented a quality improvement (QI) project aimed at the early mobilisation of patients after cardiac surgery.A retrospective analysis was undertaken to define the current mobilisation practices in the CTICU. The multidisciplinary team identified various practice gaps and tested several changes that led to the implementation of a successful early mobility programme. The tests were carried out and reported using rapid cycle changes. A model for improvement methodology was used to run the project. The outcomes of the project were analysed using standard 'run chart rules' to detect changes in outcomes over time and Welch's t-test to assess the significance of these outcomes.This project was implemented in 2015. Patient compliance with early activity and mobilisation gradually reached 95% in 2016 and was sustained over the next 3 years. After the programme was implemented, the mean hours required for initiating out-of-bed-mobilisation was reduced from 22.77 hours to 11.74 hours. Similarly, functional independence measures and intensive care unit mobility scores also showed a statistically significant (p<0.005) improvement in patient transfers out of the CTICU.Implementing an early mobility programme for post-cardiac surgery patients is both safe and feasible. This QI project allowed for early activity and mobilisation, a substantial reduction in the number of hours required for initiating out-of-bed mobilisation following cardiac surgery, and facilitated the achievement of early ambulation and functional milestones in our patients.

Choosing Wisely For Critical Care: The Next Five

OBJECTIVES

To formulate new "Choosing Wisely" for Critical Care recommendations that identify best practices to avoid waste and promote value while providing critical care.

DATA SOURCES

Semistructured narrative literature review and quantitative survey assessments.

STUDY SELECTION

English language publications that examined critical care practices in relation to reducing cost or waste.

DATA EXTRACTION

Practices assessed to add no value to critical care were grouped by category. Taskforce assessment, modified Delphi consensus building, and quantitative survey analysis identified eight novel recommendations to avoid wasteful critical care practices. These were submitted to the Society of Critical Care Medicine membership for evaluation and ranking.

DATA SYNTHESIS

Results from the quantitative Society of Critical Care Medicine membership survey identified the top scoring five of eight recommendations. These five highest ranked recommendations established Society of Critical Care Medicine's Next Five "Choosing" Wisely for Critical Care practices.

CONCLUSIONS

Five new recommendations to reduce waste and enhance value in the practice of critical care address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care. These recommendations supplement the initial critical care recommendations from the "Choosing Wisely" campaign.

Analysis of rehabilitation in stroke patients in a High Dependency Unit

OBJECTIVE

To analyze the rehabilitation effict of stroke patients in the High Dependency Unit (HDU).

METHODS

A retrospective study was conducted on 96 ischemic stroke patients who met the inclusion criteria and were hospitalized in the Department of Rehabilitation Medicine of Qujing No. 1 Hospital by convenience sampling. All patients were divided into two groups according to the inclusion and exclusion criteria: experimental group (n=49) and control group (n=47). The experimental group was admitted to the HDU and treated with the whole-process of full cycle rehabilitation management and treatment, and the control group was admitted to the general ward and treated with the conventional treatment model of the Department of Rehabilitation Medicine.

RESULTS

The improvement of muscle strength at discharge was compared between the two groups. The results showed that the muscle strength effective rate was 85.7% in the experimental group and 55.3% in the control group, and the difference had statistical significance (P<0.01). The Barthel index score at admission and at discharge were compared between the two groups, the results showed that there was no significant difference in the Barthel index score at admission between the two groups (t=0.668, P>0.05). The Barthel index score at discharge in the experimental group was higher than that in the control group, and the difference had statistical significance (t=7.969, P<0.05). The Montreal Cognitive Assessment (MoCA) score of the experimental group before treatment was (25.67±3.11) points, and the MoCA score after treatment was (29.01±2.21) points; the MoCA score of the control group before treatment was (24.11±4.65) points, and the MoCA score after treatment was (25.35±2.29) points. After implementation of the clinical nursing pathway, the improvement in cognitive function in the experimental group of patients was significantly higher than that in the control group, and the difference had statistical significance (P<0.01). Through the investigation of the satisfaction rate of nursing work in the two groups, it was found that the satisfaction rate in the experimental group was better than that in the control group, and the difference had statistical significance (P<0.05); there was 1 case of pressure sores that occurred in the experimental group, and 3 cases that occurred in the control group, χ²=1.133, P=0.287, and the difference had no statistical significance (P>0.05). The length of hospital stay was compared between the two groups, the results showed that the length of hospital stay was (11.76±2.06) days in the experimental group and (14.21±2.40) days in the control group, thus, the average length of hospital stay in the experimental group was less than that in the control group, and the difference had statistical significance (P<0.001).

CONCLUSION

The whole-process of full cycle rehabilitation management and treatment can improve the activities of daily living, limb muscle strength and cognitive function of patients, as well as shorten the length of hospital stay and improve the satisfaction of patients with treatment. Thus, it is worthy of being widely popularized in clinical application.

Implementation of an Interdisciplinary AACN Early Mobility Protocol

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.

Safety and Feasibility of Physical Rehabilitation and Active Mobilization in Patients Requiring Continuous Renal Replacement Therapy: A Systematic Review

OBJECTIVES

To evaluate the safety and feasibility of physical rehabilitation and active mobilization in patients requiring continuous renal replacement therapy in the ICU.

DATA SOURCES

Medline, CINAHL, PubMed, Pedro, and Cochrane Library were used to extract articles focused on physical activity and mobility in this population.

STUDY SELECTION

Research articles were included in this review if 1) included adult patients greater than or equal to 18 years old requiring continuous renal replacement therapy located in the ICU; 2) described physical rehabilitation, active mobilization, or physical activity deliverables; 3) reported data on patient safety and/or feasibility. The primary outcome was safety, defined as number of adverse events per total number of sessions.

DATA EXTRACTION

Five-hundred seven articles were evaluated based on title and abstract with reviewers selecting 46 to assess by full text. Fifteen observational studies were included for final analysis with seven studies focused solely on physical activity in patients requiring continuous renal replacement therapy.

DATA SYNTHESIS

Four-hundred thirty-seven adult ICU patients requiring continuous renal replacement therapy participated in some form of physical rehabilitation, physical activity, or active mobilization. Two major adverse events (hypotension event requiring vasopressor and continuous renal replacement therapy tube disconnection, pooled occurrence rate 0.24%) and 13 minor adverse events (pooled occurrence rate 1.55%) were reported during a total of 840 individual mobility or activity sessions. Intervention fidelity was limited by a low prevalence of higher mobility with only 15.5% of incidences occurring at or above level 5 of ICU Mobility Scale (transfer to chair, marching in place or ambulation away from bed, 122/715 reports). Feasibility in the provision of these interventions and/or continuous renal replacement therapy-specific deliverables was inconsistently reported.

CONCLUSIONS

Early rehabilitation and mobilization, specifically activity in and near the hospital bed, appears safe and mostly feasible in ICU patients requiring continuous renal replacement therapy. A cautious interpretation of these data is necessary due to limited aggregate quality of included studies, heterogeneous reporting, and overall low achieved levels of mobility potentially precluding the occurrence or detection of adverse events.

The experiences of cardiac surgery critical care clinicians with in-bed cycling in adult patients undergoing complex cardiac surgery

PURPOSE

In-bed cycling is a novel modality that permits the early initiation of rehabilitation in the intensive care unit. We explored clinicians' experiences and perceptions of in-bed cycling with critically ill cardiac surgery patients.

MATERIALS AND METHODS

We used an interpretive description methodology. All critical care clinicians who had been present for at least 2 cycling sessions were eligible. Data were collected using semi-structured, audio-recorded, face-to-face interviews transcribed verbatim. Content analysis was used to identify themes.

RESULTS

Nine clinicians were interviewed. Our sample was predominantly female (77.8%) with a median [IQR] age of 40 [21.5] years. Critical care experience ranged from <5 years to ≥30 years. Acceptability was influenced by previous cycling experiences, identifying the "ideal" patient, and the timing of cycling within a patient's recovery. Facilitators included striving towards a common goal and feeling confident in the method. Barriers included inadequate staffing, bike size, and the time to deliver cycling.

CONCLUSIONS

Clinicians supported the use of in-bed cycling. Concerns included appropriate patient selection and timing of the intervention. Teamwork was integral to successful cycling. Strategies to overcome the identified barriers may assist with successful cycling implementation in other critical care environments.IMPLICATIONS FOR REHABILITATIONIn-bed cycling is a relatively novel rehabilitation modality that can help initiate physical rehabilitation earlier in a patient's recovery and reduce the iatrogenic effects of prolonged admissions to an intensive care unit.Clinicians found in-bed cycling to be an acceptable intervention with a population of critically ill cardiac surgery patients.Teamwork and interprofessional communication are important considerations for successful uptake of a relatively new rehabilitation modality.Identified barriers to in-bed cycling can assist with developing strategies to encourage cycling uptake in similar critical care environments.

Prone Positioning in Spontaneously Breathing Subjects With Moderate or Severe ARDS During Invasive Ventilation

BACKGROUND

Prone positioning (PP) during invasive mechanical ventilation improves outcomes of patients with severe ARDS. Recent studies suggest that PP in spontaneously breathing, nonintubated patients with acute respiratory failure is well tolerated and improves oxygenation. However, little is known regarding patient triggered ventilation in intubated patients with ARDS undergoing PP. We conducted a retrospective review of our experience with placing patients in the prone position in 2 cohorts of subjects with moderate and severe ARDS (ie, one cohort with ARDS related to COVID-19, the other with ARDS unrelated to COVID-19), many of whom were receiving pressure support ventilation (PSV).

METHODS

We conducted a retrospective analysis in a single 22-bed mixed ICU. The subjects included in the analysis were ≥ 18 y old, met the Berlin definition for moderate or severe ARDS (whether related COVID-19 or not), and underwent PP during invasive ventilation.

RESULTS

39 subjects were included in the analysis: 20 subjects had ARDS related to COVID-19, while 19 had ARDS related to other etiologies. A total of 113 PP episodes were analyzed: 84 during PSV and 29 during volume control continuous mandatory ventilation. PP during PSV was well tolerated and was effective in improving arterial oxygenation (ie, an increase of median [Formula: see text] from 100 mm Hg [interquartile range 75-120] before PP to 135 mm Hg [interquartile range 111-161] at the end of the PP session, P < .0001). No significant difference between continuous mandatory ventilation and PSV was noted regarding arterial oxygenation during PP. Compared with continuous mandatory ventilation mode, PP during PSV was associated with a significant decrease in the use of neuromuscular blocking agents (4% vs 69% of subjects, P < .001), while sedative requirements remained unchanged.

CONCLUSIONS

In a retrospective analysis of consecutive intubated subjects with moderate or severe ARDS, related or not to COVID-19, spontaneous breathing during PP was well tolerated and achieved significant improvement in arterial oxygenation.

Nurses' perceptions of early mobilisation in the adult Intensive Care Unit: A qualitative study

OBJECTIVE

To explore nurses' perceptions of early mobilisation of patient in the adult intensive care unit.

DESIGN AND METHODS

An exploratory descriptive qualitative research design was used. Three focus group interviews were conducted in 2018-2019. Audiotaped interviews were transcribed verbatim and content analysis was used to extract emerging categories and sub-categories.

SETTING

Thirteen female intensive care nurses were interviewed from one university-affiliated public hospital in Singapore.

FINDINGS

The first category was barriers to early mobilisation with sub-categories: time constraints, safety concerns, resistance from patients. The second category was facilitators to early mobilisation with sub-categories: practical training, teamwork and positive outcomes.

CONCLUSION

Early mobilisation is a multifaceted process. A dynamic team approach is needed if early mobilisation is to be integrated as part of routine care in the intensive care unit. Findings suggest the need for a well-established protocol integrating standard mobility policy and set clear, achievable and patient-oriented goals for each patient as well as effective communication among nurses but also other healthcare professional involved in the care of patients.

Respiratory Support Adjustments and Monitoring of Mechanically Ventilated Patients Performing Early Mobilization: A Scoping Review

Supplemental Digital Content is available in the text.

Objectives:

This scoping review is aimed to summarize current knowledge on respiratory support adjustments and monitoring of metabolic and respiratory variables in mechanically ventilated adult patients performing early mobilization.

Data Sources:

Eight electronic databases were searched from inception to February 2021, using a predefined search strategy.

Study Selection:

Two blinded reviewers performed document selection by title, abstract, and full text according to the following criteria: mechanically ventilated adult patients performing any mobilization intervention, respiratory support adjustments, and/or monitoring of metabolic/respiratory real-time variables.

Data Extraction:

Four physiotherapists extracted relevant information using a prespecified template.

Data Synthesis:

From 1,208 references screened, 35 documents were selected for analysis, where 20 (57%) were published between 2016 and 2020. Respiratory support settings (ventilatory modes or respiratory variables) were reported in 21 documents (60%). Reported modes were assisted (n = 11) and assist-control (n = 9). Adjustment of variables and modes were identified in only seven documents (20%). The most frequent respiratory variable was the Fio₂, and only four studies modified the level of ventilatory support. Mechanical ventilator brand/model used was not specified in 26 documents (74%). Monitoring of respiratory, metabolic, and both variables were reported in 22 documents (63%), four documents (11%) and 10 documents (29%), respectively. These variables were reported to assess the physiologic response (n = 21) or safety (n = 13). Monitored variables were mostly respiratory rate (n = 26), pulse oximetry (n = 22), and oxygen consumption (n = 9). Remarkably, no study assessed the work of breathing or effort during mobilization.

Conclusions:

Little information on respiratory support adjustments during mobilization of mechanically ventilated patients was identified. Monitoring of metabolic and respiratory variables is also scant. More studies on the effects of adjustments of the level/mode of ventilatory support on exercise performance and respiratory muscle activity monitoring for safe and efficient implementation of early mobilization in mechanically ventilated patients are needed.

Acute Effects of Sitting Out of Bed and Exercise on Lung Aeration and Oxygenation in Critically Ill Subjects

BACKGROUND

Early mobilization during critical illness is safe and has beneficial effects on functional outcomes. However, its impact on pulmonary function has not been thoroughly explored. We hypothesized that a sitting position out of bed coupled with exercise could result in an improvement in oxygenation and lung aeration.

METHODS

The study was conducted on a cohort of adult subjects within a week of their admission to an ICU. Subjects were transferred to a chair and undertook a 15-min session of exercise, either active or passive. Subjects in the control group were only transferred to a chair. Electrical impedance tomography, a reliable bedside technique monitoring regional lung aeration and the distribution of ventilation, was continuously performed, and blood gases were assessed at baseline and 20 min post-exercise.

RESULTS

The cohort included 40 subjects, 17 of whom were mechanically ventilated and 23 spontaneously breathing. The control group for each modality consisted of 5 mechanically ventilated or 5 spontaneously breathing subjects. Mild hypoxemia was present in 45% of the spontaneously breathing cohort, whereas the mechanically ventilated subjects demonstrated moderate (50%) or severe (12%) hypoxemia. Compared with the control group, early mobilization induced a significant increase in lung aeration. In mechanically ventilated subjects, lung aeration increased, especially in the anterior lung regions (mean impedance [95% CI]: T1 (baseline in bed) = 1,265 [691-1,839]; T2 (chair sitting) = 2,003 [1,042-2,963]; T3 (exercise) = 1,619 [810 2,427]; T4 (post exercise in chair) = 2,320 [1,186-3,455]). In spontaneously breathing subjects, lung aeration increased mainly in the posterior lung regions (mean impedance [95% CI]: T1 = 380 [124-637]; T2 = 655 [226-1,084]; T3 = 621 [335-906]; T4 = 600 [340-860]). [Formula: see text] increased, especially in subjects with lower [Formula: see text] at baseline (< 200) (133 ± 31 to 158 ± 48, P = .041).

CONCLUSIONS

For critically ill subjects, a sitting position and exercise increased lung aeration and were associated with an improvement in [Formula: see text] in the more severely hypoxemic subjects.

Assessment of mobilization capacity in 10 different ICU scenarios by different professions

Background

Mobilization of intensive care patients is a multi-professional task. Aim of this study was to explore how different professions working at Intensive Care Units (ICU) estimate the mobility capacity using the ICU Mobility Score in 10 different scenarios.

Methods

Ten fictitious patient-scenarios and guideline-related knowledge were assessed using an online survey. Critical care team members in German-speaking countries were invited to participate. All datasets including professional data and at least one scenario were analyzed. Kruskal Wallis test was used for the individual scenarios, while a linear mixed-model was used over all responses.

Results

In total, 515 of 788 (65%) participants could be evaluated. Physicians (p = 0.001) and nurses (p = 0.002) selected a lower ICU Mobility Score (-0.7 95% CI -1.1 to -0.3 and -0.4 95% CI -0.7 to -0.2, respectively) than physical therapists, while other specialists did not (p = 0.81). Participants who classified themselves as experts or could define early mobilization in accordance to the “S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders” correctly selected higher mobilization levels (0.2 95% CI 0.0 to 0.4, p = 0.049 and 0.3 95% CI 0.1 to 0.5, p = 0.002, respectively).

Conclusion

Different professions scored the mobilization capacity of patients differently, with nurses and physicians estimating significantly lower capacity than physical therapists. The exact knowledge of guidelines and recommendations, such as the definition of early mobilization, independently lead to a higher score. Interprofessional education, interprofessional rounds and mobilization activities could further enhance knowledge and practice of mobilization in the critical care team.

Progressive active mobilization with dose control and training load in critically ill patients (PROMOB): Protocol for a randomized controlled trial

The dose of progressive active mobilization is still uncertain. The purpose of this study is to identify if the addition of a protocol of progressive active mobilization with dose and training load control to usual care is effective in reducing the length of stay in intensive care unit (ICU) and the improvement of the functioning, incidence of ICU-acquired weakness (ICUAW), mechanical ventilation duration and mortality rate in patients hospitalized in ICU. It is Double-blind randomised clinical trial. The setting for this trial will be medical and surgical ICU of a university hospital. The study participants will be 118 patients aged> 18 years admitted to ICU for less than 72 hours. Participants will be randomized to either an experimental or control group. The experimental group will undertake addition of a protocol of progressive active mobilization with dose and training load control to usual care, while the control group will undertake only usual care. The primary outcome will be length of ICU stay. The secondary outcomes will be Cross-sectional area and muscle thickness of the rectus femoris and biceps brachii, Change in muscle strength from the baseline, Functional Status, incidence of ICUAW, Days with mechanical ventilation and Mortality. All statistical analyses will be conducted following intention-to-treat principles. It has a detailed description of the dose of exercise, was designed with the strictest methodological criteria. These characteristics allow to investigate with greater certainty the results progressive active mobilization in critical patients, allowing replication and future combinations in meta-analyzes.

Early mobilization in clinical practice: the reliability and feasibility of the 'Start To Move' Protocol

PURPOSE

The properties of a local Intensive Care Unit early mobilization protocol ('Start To Move As Soon As Possible') in critically ill patients, consisting of an objective diagnostic assessment linked to six treatment levels were evaluated. This study aimed to investigate whether the protocol can be reliably applied by different health-care providers (reliability), to examine the associations between prescribed and delivered treatments (feasibility) and to explore safety and patient satisfaction with the protocol.

METHODS

Cross-sectional observational study evaluating the reliability of the protocol between physiotherapist was evaluated with Cohen's kappa, percentage of agreement, and intraclass correlation coefficients in 61 patients. Feasibility was analyzed as agreement between prescribed and delivered treatments with Spearman's rank correlation coefficients in 60 patients. A satisfaction survey was used to evaluate patient satisfaction with the protocol.

RESULTS

Excellent agreement was observed between physiotherapists for diagnostic level assignment (Kappa = 0.92), while the majority of the treatment proposals per level showed moderate to substantial agreement between the physiotherapists (Kappa range: 0.40-0.89). Three hundred and thirteen treatments were prescribed. Perfect agreement was observed between prescribed and delivered treatments in level 0 (Spearman's rho 1.00) and excellent associations for levels 1-5 (0.941, 0.995, 0.951, 0.998, and 0.999), respectively. Unwanted safety events rate was 3%. Most patients (92%) were very satisfied with physiotherapy.

CONCLUSION

Excellent inter-rater agreement for diagnostic level assignment and moderate to substantial agreement for proposed treatments support the reliability of the protocol. Perfect to excellent associations between prescribed and delivered treatments supports its feasibility. Complications were rare, and most patients were very positive regarding the care provided by physiotherapists during their stay in the ICU.

Brazilian Guidelines for Early Mobilization in Intensive Care Unit

Immobility can cause several complications, including skeletal muscle atrophy and weakness, that influence the recovery of critically ill patients. This effect can be mitigated by early mobilization. Six key questions guided this research: Is early mobilization safe? Which patients are candidates for early mobilization? What are the contraindications? What is the appropriate dose, and how should it be defined? What results are obtained? What are the prognostic indicators for the use of early mobilization? The objective of this guideline was to produce a document that would provide evidence-based recommendations and suggestions regarding the early mobilization of critically ill adult patients, with the aim of improving understanding of the topic and making a positive impact on patient care. This guideline was based on a systematic review of articles conducted using the PICO search strategy, as recommended by the Guidelines Project of the Associação Médica Brasileira. Randomized clinical trials, prognostic cohort studies, and systematic reviews with or without meta-analysis were selected, and the evidence was classified according to the Oxford Center for Evidence-based Medicine Levels of Evidence. For all the questions addressed, enough evidence was found to support safe and well-defined early mobilization, with prognostic indicators that support and recommend the technique. Early mobilization is associated with better functional outcomes and should be performed whenever indicated. Early mobilization is safe and should be the goal of the entire multidisciplinary team.

Walking While Dialyzing: A Retrospective Observation of Early Mobility and Ambulation for Patients on Continuous Renal Replacement Therapy

Objectives

To describe the practice of physical therapy for patients requiring continuous renal replacement therapy and assess data related to the safety and feasibility of physical therapy interventions.

Design

A retrospective observational cohort study.

Patients

Surgical and cardiovascular patients receiving continuous renal replacement therapy during a 2-year period from December 2016 to November 2018.

Setting

Two ICUs at a single academic medical center.

Intervention

Physical mobility and ambulation while on continuous renal replacement therapy.

Measurements and Main Results

Therapy data including ICU Mobility Scale score, number of physical therapy sessions with and without ambulation and gait distance, along with safety data including filter life, safety events, and mortality were analyzed. The cohort of patients receiving continuous renal replacement therapy during the 2-year period was 206. Of these, 172 (83.49%) received simultaneous physical therapy. The median ICU Mobility Scale was 5 (interquartile range, 4-7) over a total of 1,517 physical therapy sessions. Ambulation with concomitant continuous renal replacement therapy connected was achieved in 78 patients (37.86%). There were 377 ambulation sessions (24.85% of all sessions) with a mean of 4.83 (sds 4.94) ambulation sessions per ambulatory patient. Patients walked an average of 888.53 feet (sd 1,365.50) while on continuous renal replacement therapy and a daily average of 150.61 feet (sd 133.50). In-hospital mortality was lowest for patients who ambulated (17.95%) and highest for patients who received no therapy (73.53%). Continuous renal replacement therapy filter life was longest for patients who ambulated (2,047.20 min [sd 1,086.50 min]), and shortest in patients who received no therapy (1,682.20 min [sd 1,343.80 min]). One safety event was reported during this time (0.0007% of all physical therapy sessions).

Conclusions

Ambulation while on continuous renal replacement therapy was not associated with an increased risk of safety events and was feasible with the use of nonfemoral catheters and dialysis equipment with internal batteries.

A Progressive Early Mobilization Program Is Significantly Associated With Clinical and Economic Improvement: A Single-Center Quality Comparison Study

OBJECTIVES

To determine whether a progressive early mobilization protocol improves patient outcomes, including in-hospital mortality and total hospital costs.

DESIGN

Retrospective preintervention and postintervention quality comparison study.

SETTINGS

Single tertiary community hospital with a 12-bed closed-mixed ICU.

PATIENTS

All consecutive patients 18 years old or older were eligible. Patients who met exclusion criteria or were discharged from the ICU within 48 hours were excluded. Patients from January 2014 to May 2015 were defined as the preintervention group (group A) and from June 2015 to December 2016 was the postintervention group (group B).

INTERVENTION

Maebashi early mobilization protocol.

MEASUREMENTS AND MAIN RESULTS

Group A included 204 patients and group B included 187 patients. Baseline characteristics evaluated include age, severity, mechanical ventilation, and extracorporeal membrane oxygenation, and in group B additional comorbidities and use of steroids. Hospital mortality was reduced in group B (adjusted hazard ratio, 0.25; 95% CI, 0.13-0.49; p < 0.01). This early mobilization protocol is significantly associated with decreased mortality, even after adjusting for baseline characteristics such as sedation. Total hospital costs decreased from $29,220 to $22,706. The decrease occurred soon after initiating the intervention and this effect was sustained. The estimated effect was $-5,167 per patient, a 27% reduction. Reductions in ICU and hospital lengths of stay, time on mechanical ventilation, and improvement in physical function at hospital discharge were also seen. The change in Sequential Organ Failure Assessment score and Sequential Organ Failure Assessment score at ICU discharge were significantly reduced after the intervention, despite a similar Sequential Organ Failure Assessment score at admission and at maximum.

CONCLUSIONS

In-hospital mortality and total hospital costs are reduced after the introduction of a progressive early mobilization program, which is significantly associated with decreased mortality. Cost savings were realized early after the intervention and sustained. Further prospective studies to investigate causality are warranted.

Exercise is feasible in patients receiving vasoactive medication in a cardiac surgical intensive care unit: A prospective observational study

BACKGROUND

Patients may require vasoactive medication after cardiac surgery. The effect and safety profile of exercise on haemodynamic parameters in these patients is unclear.

OBJECTIVES

The objective of this study was to measure the effect of upright positioning and low-level exercise on haemodynamic parameters in patients after cardiac surgery who were receiving vasoactive therapy and to determine the incidence of adverse events.

METHODS

This was a prospective, single-centre, observational study conducted in an adult intensive care unit of a tertiary, cardiothoracic university-affiliated hospital in Australia. The Flotrac-Vigileo™ system was used to measure haemodynamic changes, including cardiac output, cardiac index, and stroke volume. Normally distributed variables are presented as n (%) and mean (standard deviation), and non-normally distributed variables are presented as median [interquartile range].

RESULTS

There were a total of 20 participants: 16 (80%) male, with a mean age of 65.9 (10.6) years. Upright positioning caused significant increases (p = 0.018) in the mean arterial pressure (MAP), with MAP readings increasing from baseline (supine), from 72.31 (11.91) mmHg to 77.44 (9.55) mmHg when back in supine. There were no clinically significant changes in cardiac output, heart rate, stroke volume, or cardiac index with upright positioning. The incidence of adverse events was low (5%). The adverse event was transient hypotension of low severity.

CONCLUSIONS

Low-level exercise in patients after cardiac surgery receiving vasoactive medication was well tolerated with a low incidence of adverse events and led to significant increases in MAP. Upright positioning and low-level exercise appeared safe and feasible in this patient cohort.

Knowledge of physiotherapists working in adult ICU on contraindications to mobilization

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

Safety, Feasibility, and Efficacy of Early Rehabilitation in Patients Requiring Continuous Renal Replacement: A Quality Improvement Study

INTRODUCTION

Early rehabilitation in critically ill patients is associated with improved outcomes. Recent research demonstrates that patients requiring continuous renal replacement therapy (CRRT) can safely engage in mobility. The purpose of this study was to assess safety and feasibility of early rehabilitation with focus on mobility in patients requiring CRRT.

METHODS

Study design was a mixed methods analysis of a quality improvement protocol. The setting was an intensive care unit (ICU) at a tertiary medical center. Safety was prospectively recorded by incidence of major adverse events including dislodgement of CRRT catheter, accidental extubation, bleeding, and hemodynamic emergency; and minor adverse events such as transient oxygen desaturation >10% of resting. Limited efficacy testing was performed to determine if rehabilitation parameters were associated with clinical outcomes.

RESULTS

A total of 67 patients (54.0 ± 15.6 years old, 44% women, body mass index 29.2 ± 9.3 kg/m²) received early rehabilitation under this protocol. The median days of CRRT were 6.0 (interquartile range [IQR], 2-11) and 72% of patients were on mechanical ventilation concomitantly with CRRT at the time of rehabilitation. A total of 112 rehabilitation sessions were performed of 152 attempts (74% completion rate). No major adverse events occurred. Patients achieving higher levels of mobility were more likely to be alive at discharge (P = 0.076).

CONCLUSIONS

The provision of early rehabilitation in critically ill patients requiring CRRT is safe and feasible. Further, these preliminary results suggest that early rehabilitation with focus on mobility may improve patient outcomes in this susceptible population.

Impact of Very Early Physical Therapy During Septic Shock on Skeletal Muscle: A Randomized Controlled Trial

Supplemental Digital Content is available in the text.

Objectives:

As the catabolic state induced by septic shock together with the physical inactivity of patients lead to the rapid loss of muscle mass and impaired function, the purpose of this study was to test whether an early physical therapy during the onset of septic shock regulates catabolic signals and preserves skeletal muscle mass.

Design:

Randomized controlled trial.

Setting:

Tertiary mixed ICU.

Patients:

Adult patients admitted for septic shock within the first 72 hours.

Interventions:

Patients were assigned randomly into two groups. The control group benefited from manual mobilization once a day. The intervention group had twice daily sessions of both manual mobilization and 30-minute passive/active cycling therapy.

Measurements and Main Results:

Skeletal muscle biopsies and electrophysiology testing were performed at day 1 and day 7. Muscle biopsies were analyzed for histology and molecular components of signaling pathways regulating protein synthesis and degradation as well as inflammation markers. Hemodynamic values and patient perception were collected during each session. Twenty-one patients were included. Three died before the second muscle biopsy. Ten patients in the control and eight in the intervention group were analyzed. Markers of the catabolic ubiquitin-proteasome pathway, muscle atrophy F-box and muscle ring finger-1 messenger RNA, were reduced at day 7 only in the intervention group, but without difference between groups (muscle atrophy F-box: –7.3% ± 138.4% in control vs –56.4% ± 37.4% in intervention group; p = 0.23 and muscle ring finger-1: –30.8% ± 66.9% in control vs –62.7% ± 45.5% in intervention group; p = 0.15). Muscle fiber cross-sectional area (µm²) was preserved by exercise (–25.8% ± 21.6% in control vs 12.4% ± 22.5% in intervention group; p = 0.005). Molecular regulations suggest that the excessive activation of autophagy due to septic shock was lower in the intervention group, without being suppressed. Markers of anabolism and inflammation were not modified by the intervention, which was well tolerated by the patients.

Conclusions:

Early physical therapy during the first week of septic shock is safe and preserves muscle fiber cross-sectional area.

Negotiated mobilisation: An ethnographic exploration of nurse-patient interactions in an intensive care unit

AIMS AND OBJECTIVES

To explore nurse-patient interactions in relation to the mobilisation of nonsedated and awake, mechanically ventilated patients in the intensive care unit.

BACKGROUND

Lighter sedation has enabled the early mobilisation of mechanically ventilated patients, but little is known about the nurses' role and interaction with critically ill patients in relation to mobilisation.

DESIGN AND METHODS

The study had a qualitative design using an ethnographic approach within the methodology of interpretive description. Data were generated in two intensive care units in Denmark, where a strategy of no sedation was applied. Participant observation was conducted during 58 nurse-patient interactions in relation to mobilisation between nurses (n = 44) and mechanically ventilated patients (n = 25). We conducted interviews with nurses (n = 16) and patients (n = 13) who had been mechanically ventilated for at least 3 days. The data were analysed using inductive, thematic analysis. The report of the study adhered to the COREQ checklist.

FINDING

We identified three themes: "Diverging perspectives on mobilisation" showed that nurses had a long-term and treatment-oriented perspective on mobilisation, while patients had a short-term perspective and regarded mobilisation as overwhelming in their present situation. "Negotiation about mobilisation" demonstrated how patients actively negotiated the terms of mobilisation with the nurse. "Inducing hope through mobilisation" captured how nurses encouraged mobilisation by integrating aspects of the patient's daily life as a way to instil hope for the future.

CONCLUSIONS

Exploring the nurse-patient interactions illustrated that mobilisation is more than physical activity. Mobilisation is accomplished through nurse-patient collaborations as a negotiated, complex and meaningful achievement, which is driven by the logic of care, leading to hope for the future.

RELEVANCE TO CLINICAL PRACTICE

The study demonstrated the important role of nurses in achieving mobilisation in collaboration and through negotiation with mechanically ventilated patients in the intensive care unit.

Early mobilisation in mechanically ventilated patients: a systematic integrative review of definitions and activities

Background

Mechanically ventilated patients often develop muscle weakness post-intensive care admission. Current evidence suggests that early mobilisation of these patients can be an effective intervention in improving their outcomes. However, what constitutes early mobilisation in mechanically ventilated patients (EM-MV) remains unclear. We aimed to systematically explore the definitions and activity types of EM-MV in the literature.

Methods

Whittemore and Knafl’s framework guided this review. CINAHL, MEDLINE, EMBASE, PsycINFO, ASSIA, and Cochrane Library were searched to capture studies from 2000 to 2018, combined with hand search of grey literature and reference lists of included studies. The Critical Appraisal Skills Programme tools were used to assess the methodological quality of included studies. Data extraction and quality assessment of studies were performed independently by each reviewer before coming together in sub-groups for discussion and agreement. An inductive and data-driven thematic analysis was undertaken on verbatim extracts of EM-MV definitions and activities in included studies.

Results

Seventy-six studies were included from which four major themes were inferred: (1) non-standardised definition, (2) contextual factors, (3) negotiated process and (4) collaboration between patients and staff. The first theme indicates that EM-MV is either not fully defined in studies or when a definition is provided this is not standardised across studies. The remaining themes reflect the diversity of EM-MV activities which depends on patients’ characteristics and ICU settings; the negotiated decision-making process between patients and staff; and their interdependent relationship during the implementation.

Conclusions

This review highlights the absence of an agreed definition and on what constitutes early mobilisation in mechanically ventilated patients. To advance research and practice an agreed and shared definition is a pre-requisite.

Impressions of Early Mobilization of Critically Ill Children-Clinician, Patient, and Family Perspectives

OBJECTIVES

To understand patient, family caregiver, and clinician impressions of early mobilization, the perceived barriers and facilitators to its implementation, and the use of in-bed cycling as a method of mobilization.

DESIGN

A qualitative study, conducted as part of the Early Exercise in Critically ill Youth and Children, a preliminary Evaluation (wEECYCLE) Pilot randomized controlled trial.

SETTING

McMaster Children's Hospital PICU, Hamilton, ON, Canada.

PARTICIPANTS

Clinicians (i.e., physicians, nurses, and physiotherapists), family caregivers, and capable patients age greater than or equal to 8 years old who were enrolled in a clinical trial of early mobilization in critically ill children (wEECYCLE).

INTERVENTION

Semistructured, face-to-face interviews using a customized interview guide for clinicians, caregivers, and patients respectively, conducted after exposure to the early mobilization intervention.

MEASUREMENTS AND MAIN RESULTS

Thirty-seven participants were interviewed (19 family caregivers, four patients, and 14 clinicians). Family caregivers and clinicians described similar interrelated themes representing barriers to mobilization, namely low prioritization of mobilization by the medical team, safety concerns, the lack of physiotherapy resources, and low patient motivation. Key facilitators were family trust in the healthcare team, team engagement, an a priori belief that physical activity is important, and participation in research. Increased familiarity and specific features such as the virtual reality component and ability to execute passive and or active mobilization helped to engage critically ill children in in-bed cycling.

CONCLUSIONS

Clinicians, patients, and families were highly supportive of mobilization in critically ill children; however, concerns were identified with respect to how and when to execute this practice. Understanding key stakeholder perspectives enables the development of strategies to facilitate the implementation of early mobilization and in-bed cycling, not just in the context of a clinical trial but also within the culture of practice in a PICU.

Mobilisation is feasible in intensive care patients receiving vasoactive therapy: An observational study

BACKGROUND

Mobilisation of intensive care unit (ICU) patients reduces ICU-acquired weakness and is associated with better functional outcomes. However, the prevalence of mobilisation of ICU patients remains low. A known barrier to mobilisation is haemodynamic instability, frequently with patients requiring vasoactive therapy. There is a lack of published data to guide clinicians about the safety and feasibility of mobilising patients receiving vasoactive therapy.

OBJECTIVES

To describe our mobilisation practice in ICU patients receiving vasoactive therapy and identify factors associated with mobilisation and adverse events.

METHODS

Retrospective cohort study of patients undergoing vasoactive therapy in a 31-bed tertiary ICU (October-December, 2016). Details of vasoactive drug dosage, mobilisation, and adverse events were extracted from databases, including mobilisation intensity (ICU Mobility Scale [IMS]). Two generalised linear mixed models were used: first, to describe factors associated with mobilisation and second, to describe factors associated with adverse events during mobilisation, adjusting for age, gender, and acute physiology and chronic health evaluation II score as co-variates.

RESULTS

In 119 patients undergoing vasoactive therapy on 371 cumulative vasoactive days, 195 mobilisation episodes occurred (37.5% of vasoactive days). Low (76.8%) and moderate (13.7%) dose vasoactive therapies were associated with a higher probability of mobilisation relative to high (9.4%) dose therapy (odds ratio = 5.50, 95% confidence interval = 2.23-13.59 and odds ratio = 2.50, 95% confidence interval = 0.95-6.59, respectively). For patients who mobilised on vasoactive therapy (n = 72), maximum mobilisation intensity was low (IMS = 1-2) in 31%, moderate (IMS = 3-5) in 51%, and high (IMS = 6-10) in 18% of vasoactive days. While no serious adverse events occurred, there were 14 occurrences of reversible hypotension requiring transient escalation of vasoactive therapy (7.3%), associated with lower mean arterial pressure (p = 0.001).

CONCLUSION

In our ICU, patients mobilised on approximately one-third of vasoactive days. Clinicians should anticipate a higher risk of hypotension during mobilisation in patients receiving vasoactive therapy, which may require transient escalation of vasoactive therapy.

Early Exercise in Critically Ill Youth and Children, a Preliminary Evaluation: The wEECYCLE Pilot Trial

OBJECTIVES

To determine the feasibility of conducting a full trial evaluating the efficacy of early mobilization using in-bed cycling as an adjunct to physiotherapy, on functional outcomes in critically ill children.

DESIGN

Single center, pilot, randomized controlled trial.

SETTING

Twelve-bed tertiary care, medical-surgical PICU at McMaster Children's Hospital, Hamilton, ON, Canada.

PATIENTS

Children 3-17 years old who were limited to bed-rest with an expected PICU stay of at least 48 hours. Patients were excluded if they were at their baseline level of function, already mobilizing out of bed or expected to do so within 24 hours.

INTERVENTIONS

Patients were randomized in a 2:1 ratio to early mobilization using in-bed cycling in addition to usual care physiotherapy (cycling arm) or to usual care physiotherapy alone (control). Usual care was according to institutional practice guidelines. The primary outcome was feasibility and safety.

MEASUREMENTS AND MAIN RESULTS

Thirty patients were enrolled (20 to the cycling and 10 to control) over a 12-month period, at a 93.7% consent rate. The median (interquartile range) time from PICU admission to mobilization was 1.5 days (1-3) in the cycling arm and 2.5 days (2-7) in the control arm. Total duration of mobilization therapy in PICU was 210 (152-380) and 136 minutes (42-314 min) in cycling and control arms, respectively. Total number of PICU days mobilized was 5.0 (3-6) with cycling and 2.5 (2-4.8) with usual care. No adverse events occurred in either arm. The main threat to feasibility of mobilization was the availability of physiotherapists or research personnel.

CONCLUSIONS

Early mobilization is safe and feasible in the PICU. In-bed cycling may facilitate greater duration and intensity of mobilization, in critically ill children. A full-scale randomized controlled trial is warranted to evaluate the efficacy of this intervention on PICU-acquired morbidities and functional outcomes in this population.

Early mobilization: Why, what for and how?

Early mobilization strategies in the intensive care unit may result in the prevention and reduction of polyneuromyopathy in the critical patient, improved quality of life, shortened ICU and hospital stay, and lesser mortality during hospitalization. However, it is well known that factors such as the protocol used, the population included in the studies, the timing of the strategy, the severity of the patients and different barriers directly influence the outcomes. This study examines the main protocols described in the literature and their associated results. The main techniques used were kinesitherapy, transfer and locomotion training, as well as neuromuscular electrical stimulation and cycle ergometry. Although two trials and a meta-analysis found no positive results with mobilization, programs that focus on specific populations, such as patients with weakness due to immobility and with preserved neuromuscular excitability can derive more positive effects from such treatment.