Mobilization of ventilated older adults

Implementation and Mixed-Methods Assessment of an Early Mobility Interprofessional Education Simulation

INTRODUCTION

Extended periods of bed rest and mechanical ventilation (MV) have devastating effects on the body.

BACKGROUND

Early mobility (EM) for patients in respiratory failure is safe and feasible, and an interprofessional team is recommended. Using simulation to train EM skills improves student confidence. The purpose of this study was to enable health care student collaboration as an interprofessional team in providing safe management and monitoring during an EM simulation for a patient requiring MV.

METHODS

Nursing (n = 33), respiratory (n = 7), occupational (n = 24), and physical therapist students (n = 55) participated in an EM interprofessional education (IPE) simulation experience. A mixed-methods analytic approach was used with pre/post quantitative analysis of the Student Perceptions of Interprofessional Clinical Education-Revised, Version 2 instrument and qualitative analysis of students' guided reflection papers.

RESULTS

Pre/post surveys completion rate was 39.5% (n = 47). The Student Perceptions of Interprofessional Clinical Education-Revised, Version 2 instrument indicated a significant improvement (P = .037) in students' perceptions of interprofessional collaborative practice. Qualitative data showed a positive response to the EM simulation IPE. Themes reflected all 4 Interprofessional Education Collaborative competencies.

DISCUSSION

This study demonstrated improved perception of interprofessional collaborative practice and better understanding of the Interprofessional Education Collaborative competencies.

CONCLUSION

Students collaborated in the simulation-based IPE to provide EM for a patient requiring MV and reported perceived benefits of the experience.

Efficacy of Early Enhanced Occupational Therapy in an Intensive Care Unit (EFFORT-ICU): A Single-Site Feasibility Trial

IMPORTANCE

This research trial contributes to the evidence for occupational therapy service delivery in intensive care settings.

OBJECTIVE

To explore the feasibility of a trial to evaluate the impact of early enhanced occupational therapy on mechanically ventilated patients in intensive care.

DESIGN

Single-site assessor-blinded randomized controlled feasibility trial.

SETTING

Level 5 8-bed adult medical-surgical intensive care unit (ICU) at Logan Hospital, Brisbane, Australia.

PARTICIPANTS

Participants were 30 mechanically ventilated patients randomly allocated to two groups.

OUTCOMES AND MEASURES

We compared standard care with enhanced occupational therapy with outcomes measured at discharge from the ICU, hospital discharge, and 90 days post randomization. The primary outcome measure was the FIM®. Secondary outcomes included the Modified Barthel Index (MBI); Montreal Cognitive Assessment; grip strength, measured using a dynamometer; Hospital Anxiety and Depression Scale; and the 36-Item Short-Form Health Survey (Version 2). The intervention group received daily occupational therapy, including cognitive stimulation, upper limb retraining, and activities of daily living. Data were analyzed using independent groups t tests and effect sizes.

RESULTS

Measures and procedures were feasible. A significant difference was found between groups on FIM Motor score at 90 days with a large effect size (p = .05, d = 0.76), and MBI scores for the intervention group approached significance (p = .051) with a large effect size (d = 0.75) at 90 days. Further moderate to large effect sizes were obtained for the intervention group for cognitive status, functional ability, and quality of life.

CONCLUSIONS AND RELEVANCE

This trial demonstrated that occupational therapy is feasible and beneficial in the ICU. Criteria to progress to a full-scale randomized controlled trial were met. This study contributes to embedding ongoing consistency of practice and scope of service delivery for occupational therapy in this field. What This Article Adds: Occupational therapists should be considered core team members in the critical care-ICU, with funding to support ongoing service provision and optimization of patient outcomes based on effective and feasible service delivery.

The effects of early mobilization in mechanically ventilated adult ICU patients: systematic review and meta-analysis

Background

The effects of early mobilization (EM) on intensive care unit (ICU) patients remain unclear. A meta-analysis of randomized controlled trials was performed to evaluate its effect in mechanically ventilated adult ICU patients.

Methods

We searched randomized controlled trials (RCTs) published in Medline, Embase, and CENTRAL databases (from inception to November 2022). According to the difference in timing and type, the intervention group was defined as a systematic EM group, and comparator groups were divided into the late mobilization group and the standard EM group. The primary outcome was mortality. The secondary outcomes were ICU length of stay, duration of mechanical ventilation (MV), and adverse events. EM had no impact on 180-day mortality and hospital mortality between intervention groups and comparator groups (RR 1.09, 95% CI 0.89-1.33, p = 0.39). Systemic EM reduced the ICU length of stay (LOS) (MD -2.18, 95% CI -4.22--0.13, p = 0.04) and the duration of MV (MD -2.27, 95% CI -3.99--0.56, p = 0.009), but it may increase the incidence of adverse events in patients compared with the standard EM group (RR 1.99, 95% CI 1.25-3.16, p = 0.004).

Conclusion

Systematic EM has no significant effect on short- or long-term mortality in mechanically ventilated adult ICU patients, but systematic EM could reduce the ICU LOS and duration of MV.

A Step Forward for Intensive Care Unit Patients: Early Mobility Interventions and Associated Outcome Measures

Background

Critical illness survivors have impairments across physical, psychological, and cognitive health domains known as post–intensive care syndrome. Although physical activity can improve outcomes across all health domains, most intensive care unit early mobility studies focus solely on physical outcomes.

Objective

To explore the role of early mobility for adult patients in the intensive care unit by analyzing early mobility intervention studies with physical, psychological, or cognitive outcome measures.

Methods

This integrative review used Whittemore and Knafl’s methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, Embase, PubMed, PsycINFO, and Scopus databases were searched for primary research articles published from 2005 through 2021 on adult intensive care unit early mobility interventions evaluated by physical, cognitive, or psychological outcome measures during or after intervention delivery. Interventions comprising only passive mobility were excluded.

Results

Of 1009 articles screened, 20 were included. Variations in outcome measures, measurement timing, instruments, and control groups made synthesis difficult. No study evaluated an intervention using outcome measures from all 3 health domains. Five studies measured physical and cognitive outcomes; 6 studies measured physical and psychological outcomes.

Conclusion

Early mobility is primarily addressed objectively and unidimensionally, limiting understanding of the implications of early mobility for patients. Post–intensive care syndrome prevention begins in the intensive care unit; early mobility is a promising intervention for targeting multiple risk factors. Studies that measure outcomes in all health domains during or after early mobility are needed to better evaluate the comprehensive effects of early mobility.

A Constructivist Grounded Theory of Staff Experiences Relating to Early Mobilisation of Mechanically Ventilated Patients in Intensive Care

Early mobilisation of mechanically ventilated patients has been suggested to be effective in mitigating muscle weakness, yet it is not a common practice. Understanding staff experiences is crucial to gain insights into what might facilitate or hinder its implementation. In this constructivist grounded theory study, data from two Scottish intensive care units were collected to understand healthcare staff experiences relating to early mobilisation in mechanical ventilation. Data included observations of mobilisation activities, individual staff interviews and two focus groups with multidisciplinary staff. Managing Risks emerged as the core category and was theorised using the concept of risk. The middle-range theory developed in this study suggests that the process of early mobilisation starts by staff defining patient status and includes a process of negotiating patient safety, which in turn enables performing accountable mobilisation within the dynamic context of an intensive care unit setting.

Lessons Learned From the COVID-19 Pandemic: Occupational Therapy on the Front Line

The pandemic caused by coronavirus disease 2019 (COVID-19) highlighted the insufficient public health policies and lack of a national pandemic response strategy. Rehabilitation departments faced barriers to providing care in the traditional manner and needed to consider protection of patients and staff, staffing and personal protective equipment shortages, and uncertainty about best practices to address a novel health condition. This article highlights the strategies implemented by acute care occupational therapy leaders to support their staff; facilitate efficient care provision; and pivot with constantly changing policies, procedures, and research during the COVID-19 crisis. Occupational therapy's distinct value in caring for this population and role in responding to the pandemic are shared to provide a guidepost for future health care crises.

A atuação do terapeuta ocupacional em Unidade de Terapia Intensiva: uma revisão sistemática

Resumo Introdução A participação do terapeuta ocupacional (TO) em Unidades de Terapia Intensiva (UTI) ainda é discreta no Brasil, talvez, por isso, haja pouca discussão das intervenções e inserção do profissional nessa área. Objetivo Sintetizar as atuações do TO para restabelecimento da função em pacientes adultos internados na UTI mais frequentemente descritas na literatura especializada. Método Revisão Sistemática baseada na recomendação PRISMA. A busca dos estudos foi realizada nas plataformas Cochrane, PubMed, OTSeek e PEDro, utilizando os termos de busca “Occupational Therapy”, no título ou resumo, (AND) “Intensive Care Unit” (OR) “Critical Illness” (OR) “Critical Care”, em outras partes do texto. Foram incluídos textos em língua inglesa e publicados nos últimos 20 anos. Excluiu-se textos que abordavam UTI pediátrica/neonatal, doenças psiquiátricas e artigos de revisão. Dois pesquisadores independentes selecionaram os artigos e a concordância foi submetida à análise Kappa. O nível de evidência e a qualidade metodológica dos estudos incluídos foram avaliados pela Escala PEDro e pela Ferramenta de Colaboração Cochrane, respectivamente. Resultados As principais intervenções foram relativas ao treino de Atividades de Vida Diária (AVDs) e tarefas relacionadas às Atividades Instrumentais de Vida Diária (AIVDs). Essas atribuições privativas da profissão ocorreram isoladamente ou com fisioterapeutas. As sessões, excluídos os critérios de contraindicação, aconteceram precocemente (24-48h). Conclusão Os achados evidenciam intervenções de mobilização precoce, seguidas por práticas de treino de AVDs/ AIVDs. Ademais, é notado que a atuação do terapeuta ocupacional na UTI está em elaboração. Estudos sobre outros efeitos da internação prolongada na UTI devem ser conduzidos. Registro PROSPERO: CRD42020214615.

An Established Early Rehabilitation Therapy Demonstrating Higher Efficacy and Safety for Care of Intensive Care Unit Patients

BACKGROUND Although survival rates of critically ill patients in Intensive Care Units (ICUs) have improved in recent years, many risk factors cause a few serious complications. This study aimed to evaluate efficacy and safety of comprehensive early rehabilitation therapy for ICU patients. MATERIAL AND METHODS This study recruited ICU patients who were diagnosed as having cerebral hemorrhage or traumatic brain injury. ICU patients were randomly divided into an early rehabilitation therapy group (Observation group, n=21) and a Control group (n=21). Patients in the Control group underwent persistent monitoring of respiratory functions and blood oxygen saturation, as well as electrocardiographic monitoring. ICU patients in the Observation group underwent individualized treatments based on conventional treatments. APACHE II scores, MRC scores, and consciousness improvement rates of ICU patients were evaluated. Incidences of adverse events and complications were also assessed. RESULTS Early rehabilitation therapy significantly decreased APACHE II scores and significantly increased MRC scores compared to the Control group (p<0.05). Early rehabilitation therapy significantly improved consciousness of ICU patients compared to the Control group (p<0.05). Early rehabilitation therapy significantly reduced the incidence of complications compared to the Control group (p<0.05). Early rehabilitation therapy significantly shortened ICU or total hospital stay and mechanical ventilation time compared to the Control group (p<0.05). CONCLUSIONS Early rehabilitation therapy decreased APACHE II scores, enhanced MRC scores, and improved consciousness of ICU patients. Moreover, early rehabilitation therapy also reduced the incidence of complications and shortened ICU or total hospital stay and mechanical ventilation time of ICU patients. Therefore, early rehabilitation therapy was shown to be effective and safe for ICU patients.

Feasibility, safety, and functional recovery after active rehabilitation in critically ill surgical patients

BACKGROUND

The characteristics of critically ill surgical patients differ from those of medical patients. Few studies have evaluated rehabilitation in surgical intensive care units (SICUs), particularly in non-Western countries and in elderly patients.

OBJECTIVE

The objective of this study was to investigate the rehabilitation characteristics, safety, and functional recovery in non-Western SICU patients.

METHODS

Data from patients who received active rehabilitation in 2016 were retrospectively reviewed. Clinical characteristics, functional recovery, and safety were investigated and compared in patients aged <65 or ≥65 years. Potential safety events were also compared between the two age groups and according to the reason for SICU admission.

RESULTS

Data from 157 patients were included in the analysis. The number of patients who were able to stand or walk increased from the beginning of rehabilitation to the time of ICU discharge (from 52 to 102 patients, P < 0.01). The Activity Measure for Post-Acute Care (AM-PAC) score also increased during rehabilitation (from 11.6 to 13.9, P < 0.01). Functional recovery did not differ between the two age groups. During 780 rehabilitation sessions, 23 potential safety events (3.0%) were noted; no significant differences were seen between the two age groups. A significant difference was noted when patients were grouped according to the reason for SICU admission (1.7% in postoperative care patients vs 4.5% in patients admitted for other reasons, P = 0.02).

CONCLUSIONS

Active rehabilitation in critically ill surgical patients is feasible and safe and resulted in improved mobility, regardless of age. However, the reason for SICU admission should be considered.

[PROtocol-based MObilizaTION on intensive care units : Design of a cluster randomized pilot study]

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.

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.

Physical rehabilitation interventions in the intensive care unit: a scoping review of 117 studies

BACKGROUND

Physical rehabilitation (PR) interventions in the intensive care unit (ICU) can improve patients' functional outcomes, yet systematic reviews identified discordant effects and poor reporting. We conducted a scoping review to determine the extent of ICU PR interventions and how they were reported and measured.

METHODS

We searched five databases from inception to December 2016 for prospective studies evaluating adult ICU PR interventions. Two independent reviewers screened titles, abstracts, and full texts for inclusion. We assessed completeness of reporting using the Consolidated Standards of Reporting Trials, Strengthening the Reporting of Observational Studies in Epidemiology, or Standards for Quality Improvement Reporting Excellence guidelines, as appropriate. For planned PR interventions, we evaluated reporting with the Consensus on Exercise Reporting Template (CERT) and assessed intervention and control groups separately. We calculated completeness of reporting scores for each study; scores represented the proportion of reported items. We compared reporting between groups using Kruskal-Wallis with Bonferroni corrections and t tests, α = 0.05.

RESULTS

We screened 61,774 unique citations, reviewed 1429 full-text publications, and included 117: 39 randomized trials, 30 case series, 9 two-group comparison, 14 before-after, and 25 cohort. Interventions included neuromuscular electrical stimulation (NMES) (14.5%), passive/active exercises (15.4%), cycling (6.8%), progressive mobility (32.5%), and multicomponent (29.9%). The median (first,third quartiles) study reporting score was 75.9% (62.5, 86.7) with no significant differences between reporting guidelines. Of 87 planned intervention studies, the median CERT score was 55.6%(44.7,75.0); cycling had the highest (85.0%(62.2,93.8)), and NMES and multicomponent the lowest (50.0% (39.5, 70.3) and 50.0% (41.5, 58.8), respectively) scores. Authors reported intervention groups better than controls (p < 0.001).

CONCLUSIONS

We identified important reporting deficiencies in ICU PR interventions, limiting clinical implementation and future trial development.

Safety criteria to start early mobilization in intensive care units. Systematic review

Mobilization of critically ill patients admitted to intensive care units should be performed based on safety criteria. The aim of the present review was to establish which safety criteria are most often used to start early mobilization for patients under mechanical ventilation admitted to intensive care units. Articles were searched in the PubMed, PEDro, LILACS, Cochrane and CINAHL databases; randomized and quasi-randomized clinical trials, cohort studies, comparative studies with or without simultaneous controls, case series with 10 or more consecutive cases and descriptive studies were included. The same was performed regarding prospective, retrospective or cross-sectional studies where safety criteria to start early mobilization should be described in the Methods section. Two reviewers independently selected potentially eligible studies according to the established inclusion criteria, extracted data and assessed the studies' methodological quality. Narrative description was employed in data analysis to summarize the characteristics and results of the included studies; safety criteria were categorized as follows: cardiovascular, respiratory, neurological, orthopedic and other. A total of 37 articles were considered eligible. Cardiovascular safety criteria exhibited the largest number of variables. However, respiratory safety criteria exhibited higher concordance among studies. There was greater divergence among the authors regarding neurological criteria. There is a need to reinforce the recognition of the safety criteria used to start early mobilization for critically ill patients; the parameters and variables found might contribute to inclusion into service routines so as to start, make progress and guide clinical practice.

A systematic review evaluating the role of nurses and processes for delivering early mobility interventions in the intensive care unit

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.

Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis

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.

A feasibility study of a randomised controlled trial to examine the impact of the ABCDE bundle on quality of life in ICU survivors

Background

Early rehabilitation has been found to prevent delirium and weakness that can hamper the recovery of intensive care unit (ICU) survivors. Integrated clinical practice guidelines for managing patient pain, agitation and delirium (PAD) have been developed. The Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle provides a strategy to implement PAD guidelines into everyday clinical practice. However, there is limited evidence on the effectiveness of the ABCDE bundle in the literature.

The purpose of this study was to evaluate the feasibility of conducting a full-scale randomised controlled trial comparing the ABCDE bundle to standard care in an ICU. Trial feasibility was defined as the successful recruitment and retention of trial participants, adherence to the intervention, identification of barriers to the intervention, and the rigorous collection of outcome data.

Methods

A prospective, single-centre, randomised controlled feasibility study was conducted. Thirty adult mechanically ventilated participants were recruited from an eight-bed ICU in south east Queensland, Australia, between April 2015 and December 2015. Participants were randomised to receive either the ABCDE bundle or standard routine management. The ABCDE bundle integrated prescribed awakening and breathing trials, delirium monitoring and management, and prescribed exercise and mobility regimes. Feasibility outcomes measured included recruitment and retention rates, intervention fidelity, and the feasibility of participant outcome data collection. Outcome measurement assessors were blinded to participant assignment. It was not possible to blind the research team or the participant to group assignment.

Results

In total, 30 (81.1%) of 37 eligible participants consented and were randomised to the intervention group (n = 15) or the control group (n = 15). Of these, 23 (76.6%) participants successfully completed the 90-day post discharge assessment. A lengthy recruitment period of 8 months was related to overly stringent inclusion and exclusion criteria. Intervention adherence exceeded defined success rates with participation in awakening and breathing trials, delirium monitoring and exercise interventions performed on 80.2, 97.4 and 90.2% of ventilated days respectively. Outcome assessments were successfully and accurately performed at ICU and hospital discharge and 90-day post hospital discharge. Intervention participants were deemed to be delirious on 39.6% of mechanically ventilated days indicating a requirement for a scripted regime to prevent delirium.

Conclusions

With minor adjustment of inclusion and exclusion criteria, the inclusion of delirium management protocols, and encouragement of family engagement and involvement, a large-scale definitive randomised controlled trial to test the impact of the ABCDEF bundle will be feasible.

Trial registration

Australian New Zealand Clinical Trials Registry 12614000763640 Date registered 17/08/2014

Electronic supplementary material

The online version of this article (10.1186/s40814-017-0224-x) contains supplementary material, which is available to authorized users.

Pain, agitation, and delirium guidelines: nurses' involvement in development and implementation

The 2013 American College of Critical Care Medicine/Society of Critical Care Medicine clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit serves as a living example of nurses' involvement in the development and implementation of professional guidelines. Nurses who served on this guideline-writing panel describe their experiences. Specific examples from the pain, agitation, and delirium guidelines for care are used to explore the roles of the nurse leader, nurse informaticist, staff nurse, and nurse researcher in relationship to guideline implementation.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Algorithms for early mobilization in intensive care units]

Immobility of patients in intensive care units (ICU) can lead to long-lasting physical and cognitive decline. During the last few years, bundles for rehabilitation were developed, including early mobilization. The German guideline for positioning therapy and mobilization, in general, recommends the development of ICU-specific protocols. The aim of this narrative review is to provide guidance when developing a best practice protocol in one's own field of work. It is recommended to a) implement early mobilization as part of a bundle, including screening and management of patient's awareness, pain, anxiety, stress, delirium and family's presence, b) develop a traffic-light system of specific in- and exclusion criteria in an interprofessional process, c) use checklists to assess risks and preparation of mobilization, d) use the ICU Mobility Scale for targeting and documentation of mobilization, e) use relative safety criteria for hemodynamic and respiratory changes, and Borg Scale for subjective evaluation, f) document and evaluate systematically mobilization levels, barriers, unwanted safety events and other parameters.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

Complications related to early mobilization of mechanically ventilated patients on Intensive Care Units

AIMS AND OBJECTIVES

To compare international literature on the detection of complications associated with early mobilization of mechanically ventilated patients in intensive care units (ICUs).

BACKGROUND

Early mobilization of mechanically ventilated ICU patients is considered to be a more beneficial approach to treatment in intensive care; however, it remains unclear how safe this approach is and what complications to expect.

SEARCH STRATEGIES

A systematic literature research in English and German was conducted in June 2013 in the databases Pubmed, CINAHL, Cochrane library and MedPilot without limiting by year of publication. References of the included studies were screened and supplemented by manual search.

INCLUSION AND EXCLUSION CRITERIA

Inclusion criteria were studies about mechanically ventilated adult patients on ICU, who were mobilized and reported complications. Excluded were studies that (a) did not differentiate between non-ventilated and ventilated patients, (b) did not report complications and (c) focused on in-bed mobilization.

CONCLUSIONS

Of 952 titles, 16 articles fit the criteria including 3 reviews and 13 clinical trials. The percentage of complications in clinical trials ranged between 0% and 16%. In total, 453 patients were mobilized 3613 times (up to walking with ventilation) with a complication mean rate of 3·9% (n = 144) using the inherent safety limits. No fall, cardiac arrest, or death was reported. Most complications were pulmonary, followed by haemodynamic ones. Serious complications that led to further consequences were observed in 0·3% (n = 10) of all mobilizations. The clinical studies have been carried out in trained, interdisciplinary teams with most of them using adapted algorithms for safety.

RELEVANCE TO CLINICAL PRACTICE

Despite a low complication rate, a frame for safety during early mobilization including team training and adapted criteria is recommended.