Early mobilization in the management of critical illness

Survey of Respiratory Care Professionals' Knowledge in Early Mobilization: A Pilot Study

Early mobilization (EM) is practiced for intensive care unit (ICU) patients in many hospitals in the Eastern Province in Saudi Arabia. Respiratory care professionals’ knowledge about using EM was, therefore, surveyed and investigated to improve and update its practice and ultimately to develop related regulations and policies. A survey including 156 respiratory care professionals was conducted using a validated questionnaire. The focus was on collecting information on participants’ relevant backgrounds and on proper use of EM. Knowledge and proper use of EM were calculated in relation to participants’ demographic and professional characteristics. The statistical analysis using analysis of variance and Student t-test showed that factors that affected knowledge of EM were the respiratory care professional’s age, gender, nationality, and years of experience in intensive care medicine. How many patients these professionals treated using EM also significantly correlated with their knowledge of EM. The survey showed the extent of respiratory care professionals’ knowledge about the proper use of EM. More importantly, the survey also identified important shortfalls in practice of some experienced medical practitioners.

Lactate production without hypoxia in skeletal muscle during electrical cycling: Crossover study of femoral venous-arterial differences in healthy volunteers

BACKGROUND

Aim of the study was to compare metabolic response of leg skeletal muscle during functional electrical stimulation-driven unloaded cycling (FES) to that seen during volitional supine cycling.

METHODS

Fourteen healthy volunteers were exposed in random order to supine cycling, either volitional (10-25-50 W, 10 min) or FES assisted (unloaded, 10 min) in a crossover design. Whole body and leg muscle metabolism were assessed by indirect calorimetry with concomitant repeated measurements of femoral venous-arterial differences of blood gases, glucose, lactate and amino acids.

RESULTS

Unloaded FES cycling, but not volitional exercise, led to a significant increase in across-leg lactate production (from -1.1±2.1 to 5.5±7.4 mmol/min, p<0.001) and mild elevation of arterial lactate (from 1.8±0.7 to 2.5±0.8 mM). This occurred without widening of across-leg veno-arterial (VA) O2 and CO2 gaps. Femoral SvO2 difference was directly proportional to VA difference of lactate (R2 = 0.60, p = 0.002). Across-leg glucose uptake did not change with either type of exercise. Systemic oxygen consumption increased with FES cycling to similarly to 25W volitional exercise (138±29% resp. 124±23% of baseline). There was a net uptake of branched-chain amino acids and net release of Alanine from skeletal muscle, which were unaltered by either type of exercise.

CONCLUSIONS

Unloaded FES cycling, but not volitional exercise causes significant lactate production without hypoxia in skeletal muscle. This phenomenon can be significant in vulnerable patients' groups.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Factors Influencing Weaning Older Adults From Mechanical Ventilation: An Integrative Review

This study aim was to describe the influences that affect weaning from mechanical ventilation among older adults in the intensive care unit (ICU). Adults older than 65 years comprised only 14.5% of the US population in 2014; however, they accounted up to 45% of all ICU admissions. As this population grows, the number of ICU admissions is expected to increase. One of the most common procedures for hospitalized adults 75 years and older is mechanical ventilation. An integrative review methodology was applied to analyze and synthesize primary research reports. A search for the articles was performed using the PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases; using the keywords and Boolean operators "older adults," "weaning," "mechanical ventilation," and intensive care unit. Although physiologic changes that occur with aging place older adults at higher risk for respiratory complications and mortality, there are many factors, other than chronological age, that can determine a patient's ability to be successfully weaned from mechanical ventilation. Of the 6 studies reviewed, all identified various predictors of weaning outcome, which included maximal inspiratory pressure, rapid shallow breathing index, fluid balance, comorbidity burden, severity of illness, emphysematous changes, and low serum albumin. Age, in and of itself, is not a predictor of weaning from mechanical ventilation. More studies are needed to describe the influences affecting weaning older adults from mechanical ventilation.

Terapia ocupacional en unidad de cuidados intensivos

Introducción. Desde su inicio, la terapia ocupacional ha actuado en ambientes intrahospitalarios. En la actualidad, una de las metas para la consolidación de campos de conocimiento, atención y prospectiva es profundizar en la intervención que realiza el respectivo profesional en la unidad de cuidados intensivos (UCI).Objetivo. Mostrar la evidencia científica de la intervención de terapia ocupacional en una UCI de adulto a través de una revisión bibliográfica entre el 2010 y 2015, durante la cual se analizaron las categorías de evaluación, modalidades de intervención y resultados.Materiales y métodos. Estudio de carácter investigativo mixto, el cual busca especificar las fuentes teóricas y prácticas que relacionan los términos de la investigación. Además, se realizó un proceso de análisis selectivo a partir de los intereses y la significancia.Resultados. La terapia ocupacional hace una caracterización de las actividades basándose en la movilización, cambios posicionales, actividades de la vida diaria, estimulación, ferulaje, tecnología de asistencia, entre otras; además trae beneficios como reducción de estancia, complicaciones y costos.Conclusión. Se evidencia la importancia del trabajo del terapeuta ocupacional en la UCI de adulto, pues beneficios como reducción de la estancia y mejora funcional de las personas, al momento del egreso, son claros en las investigaciones internacionales.

Progressive mobility as a team effort in transitional care

With changing health care, progressive care nurses are working in diverse practice settings to meet patient care needs. Progressive care is practiced along the continuum from the intensive care unit to home. The benefits of early progressive mobility are examined with a focus on the interdisciplinary collaboration for care in a transitional care program of a skilled nursing facility. The program's goals are improved functional status, self-care management, and home discharge with reduced risk for hospital readmission. The core culture of the program is interdisciplinary collaboration and team partnership for care of patients and their families.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Implementation of the physical function ICU test tool in a resource constrained intensive care unit to promote early mobilisation of critically ill patients- a feasibility study

Background

The shift of focus in outcome measures from mortality to assessment of functional status in intensive care unit (ICU) patients has resulted in the emergence of mobilisation of critically ill patients as a standard physiotherapy practice in most medium and high income countries. The aim of this study was to determine the feasibility of an early mobilisation program and to report on the changes in patient clinical outcomes following the intervention in a low income country.

Methods

A prospective cohort study was carried out at one public hospital. An adult cohort of 35 patients was recruited within 24 h of being admitted into the unit, irrespective of ventilation method over a period of three months. An early mobilisation programme was implemented and prescribed using the Physical Function ICU Test (PFIT-s) which commenced in either the ICU or high dependent unit.

Results

The median age of the 35 patients was 29 years (IQR = 24–45 years). More than half of the patients had undergone surgery due to either gastrointestinal problems or obstetrical complications. A total of 94 out of a possible of 219 exercise sessions were delivered to the patients (43.0 %). The tool was implemented in 32 (91.4 %) patients on the initial PFIT-s measurement and 16 (45.7 %) of the patients required the assistance of two people to stand. The Initial PFIT-s mean score was 5.3 ± 1.8. On final PFIT-s measurement, out of the 30 (85.7 %) patients seen, 15 (42.9 %) of the patients did not require any assistance to stand and the final PFIT-s mean score was 7.0 ± 1.9. There was a significant difference in both the initial PFIT-s total score (t-value = 2.34, df = 30, p = .03) and the final PFIT-s score (t-value = 3.66, df = 28, p = .001) between males and females. During the treatment, no adverse event occurred in any of the patients.

Conclusion

An early mobilisation program using PFIT-s was feasible and safe. There was a difference in functional capability based on gender, with males being more functionally active. Specific inclusion and exclusion criteria can lead to a delayed early mobilisation activities in ICU patients.

Trial registration

Pan African Clinical Trials Registry PACTR201408000829202. Registered 15 August 2014.