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Fazio SA, Cortés-Puch I, Stocking JC, Doroy AL, Black H, Liu A, Taylor SL, Adams JY. Early Mobility Index and Patient Outcomes: A Retrospective Study in Multiple Intensive Care Units. Am J Crit Care 2024; 33:171-179. [PMID: 38688854 DOI: 10.4037/ajcc2024747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Early mobility interventions in intensive care units (ICUs) are safe and improve outcomes in subsets of critically ill adults. However, implementation varies, and the optimal mobility dose remains unclear. OBJECTIVE To test for associations between daily dose of out-of-bed mobility and patient outcomes in different ICUs. METHODS In this retrospective cohort study of electronic records from 7 adult ICUs in an academic quarternary hospital, multivariable linear regression was used to examine the effects of out-of-bed events per mobility-eligible day on mechanical ventilation duration and length of ICU and hospital stays. RESULTS In total, 8609 adults hospitalized in ICUs from 2015 through 2018 were included. Patients were mobilized out of bed on 46.5% of ICU days and were eligible for mobility interventions on a median (IQR) of 2.0 (1-3) of 2.7 (2-9) ICU days. Median (IQR) out-of-bed events per mobility-eligible day were 0.5 (0-1.2) among all patients. For every unit increase in out-of-bed events per mobility-eligible day before extubation, mechanical ventilation duration decreased by 10% (adjusted coefficient [95% CI], -0.10 [-0.18 to -0.01]). Daily mobility increased ICU stays by 4% (adjusted coefficient [95% CI], 0.04 [0.03-0.06]) and decreased hospital stays by 5% (adjusted coefficient [95% CI], -0.05 [-0.07 to -0.03]). Effect sizes differed among ICUs. CONCLUSIONS More daily out-of-bed mobility for ICU patients was associated with shorter mechanical ventilation duration and hospital stays, suggesting a dose-response relationship between daily mobility and patient outcomes. However, relationships differed across ICU subpopulations.
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Affiliation(s)
- Sarina A Fazio
- Sarina A. Fazio is a clinical nurse scientist, Center for Nursing Science, UC Davis Health, Sacramento; Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Davis (UC Davis), Sacramento, California; and Data Center of Excellence, UC Davis Health, Sacramento
| | - Irene Cortés-Puch
- Irene Cortés-Puch is a project scientist, Division of Pulmonary, Critical Care, and Sleep Medicine, UC Davis
| | - Jacqueline C Stocking
- Jacqueline C. Stocking is an assistant professor of medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, UC Davis
| | - Amy L Doroy
- Amy L. Doroy is an associate chief nursing officer, UC Davis Medical Center, UC Davis Health
| | - Hugh Black
- Hugh Black is a professor of medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, UC Davis
| | - Anna Liu
- Anna Liu is an informatics specialist, Data Center of Excellence, UC Davis Health
| | - Sandra L Taylor
- Sandra L. Taylor is a principal biostatistician, Department of Public Health Sciences, UC Davis, Sacramento
| | - Jason Y Adams
- Jason Y. Adams is an associate professor of medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, UC Davis, and medical director, Data Center of Excellence, UC Davis Health
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Woodbridge HR, McCarthy CJ, Jones M, Willis M, Antcliffe DB, Alexander CM, Gordon AC. Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study. Crit Care 2024; 28:144. [PMID: 38689372 PMCID: PMC11061934 DOI: 10.1186/s13054-024-04919-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 04/17/2024] [Indexed: 05/02/2024] Open
Abstract
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).
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Affiliation(s)
- Huw R Woodbridge
- Imperial College Healthcare NHS Trust, London, UK.
- Department of Surgery and Cancer, Imperial College London, London, UK.
| | | | | | | | - David B Antcliffe
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Caroline M Alexander
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Anthony C Gordon
- Imperial College Healthcare NHS Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
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Facilitators & barriers and practices of early mobilization in critically ill burn patients: A survey. Burns 2023; 49:42-54. [PMID: 36202684 DOI: 10.1016/j.burns.2022.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/23/2022] [Accepted: 08/30/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Early mobilization (EM) of intensive care (IC) patients is important but complex with facilitators and barriers. Compared to general IC patients, burn IC patients are more hyper-metabolic. They have extensive wounds, lengthy wound dressing changes, and repeated surgeries that may affect possibilities of EM. This study aimed to identify facilitators and barriers of EM in burn IC patients among all disciplines involved. Additionally, we assessed EM practices, i.e. when are which patients considered suitable for EM. METHODS A survey was sent to 139 professionals involved in EM of burn IC patients (discipline groups: Intensivists, medical doctors, registered nurses, therapists). RESULTS Response rate was 57 %. The majority found EM very important, yet different definitions were chosen. Perceived barriers mainly concerned patient-level factors, most frequently hemodynamic instability and excessive sedation followed by skin graft surgery, fatigue, and pain management. Most frequent barriers at the provider-level were limited staffing, safety concerns, and conflicting perceptions about the suitability of EM. At the institutional-level, we found no high barriers. Interdisciplinary variation on perceived barriers, when to initiate it, and permitted maximal activity were ascertained. CONCLUSION Skin grafts and pain management were barriers of EM specific for burn care. Opinions on frequency, dosage and duration of EM varied widely. Improving interdisciplinary communication is key.
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Fuest KE, Ulm B, Daum N, Lindholz M, Lorenz M, Blobner K, Langer N, Hodgson C, Herridge M, Blobner M, Schaller SJ. Clustering of critically ill patients using an individualized learning approach enables dose optimization of mobilization in the ICU. Crit Care 2023; 27:1. [PMID: 36597110 PMCID: PMC9808956 DOI: 10.1186/s13054-022-04291-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/21/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND While early mobilization is commonly implemented in intensive care unit treatment guidelines to improve functional outcome, the characterization of the optimal individual dosage (frequency, level or duration) remains unclear. The aim of this study was to demonstrate that artificial intelligence-based clustering of a large ICU cohort can provide individualized mobilization recommendations that have a positive impact on the likelihood of being discharged home. METHODS This study is an analysis of a prospective observational database of two interdisciplinary intensive care units in Munich, Germany. Dosage of mobilization is determined by sessions per day, mean duration, early mobilization as well as average and maximum level achieved. A k-means cluster analysis was conducted including collected parameters at ICU admission to generate clinically definable clusters. RESULTS Between April 2017 and May 2019, 948 patients were included. Four different clusters were identified, comprising "Young Trauma," "Severely ill & Frail," "Old non-frail" and "Middle-aged" patients. Early mobilization (< 72 h) was the most important factor to be discharged home in "Young Trauma" patients (ORadj 10.0 [2.8 to 44.0], p < 0.001). In the cluster of "Middle-aged" patients, the likelihood to be discharged home increased with each mobilization level, to a maximum 24-fold increased likelihood for ambulating (ORadj 24.0 [7.4 to 86.1], p < 0.001). The likelihood increased significantly when standing or ambulating was achieved in the older, non-frail cluster (ORadj 4.7 [1.2 to 23.2], p = 0.035 and ORadj 8.1 [1.8 to 45.8], p = 0.010). CONCLUSIONS An artificial intelligence-based learning approach was able to divide a heterogeneous critical care cohort into four clusters, which differed significantly in their clinical characteristics and in their mobilization parameters. Depending on the cluster, different mobilization strategies supported the likelihood of being discharged home enabling an individualized and resource-optimized mobilization approach. TRIAL REGISTRATION Clinical Trials NCT03666286, retrospectively registered 04 September 2018.
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Affiliation(s)
- Kristina E. Fuest
- grid.15474.330000 0004 0477 2438Technical University Munich, School of Medicine, Klinikum Rechts der Isar, Department of Anaesthesiology & Intensive Care Medicine, Munich, Germany
| | - Bernhard Ulm
- grid.15474.330000 0004 0477 2438Technical University Munich, School of Medicine, Klinikum Rechts der Isar, Department of Anaesthesiology & Intensive Care Medicine, Munich, Germany
| | - Nils Daum
- grid.6363.00000 0001 2218 4662Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Berlin, Germany
| | - Maximilian Lindholz
- grid.6363.00000 0001 2218 4662Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Berlin, Germany
| | - Marco Lorenz
- grid.6363.00000 0001 2218 4662Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Berlin, Germany
| | - Kilian Blobner
- grid.6363.00000 0001 2218 4662Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Berlin, Germany ,grid.15474.330000 0004 0477 2438Technical University Munich, School of Medicine, Klinikum Rechts der Isar, Department of Orthopedics, Munich, Germany
| | - Nadine Langer
- grid.6363.00000 0001 2218 4662Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Berlin, Germany
| | - Carol Hodgson
- grid.1002.30000 0004 1936 7857Acute and Critical Care, Monash University, Melbourne, VIC Australia
| | - Margaret Herridge
- grid.231844.80000 0004 0474 0428Interdepartmental Division of Critical Care Medicine, University of Toronto, University Health Network, Toronto, ON Canada
| | - Manfred Blobner
- grid.15474.330000 0004 0477 2438Technical University Munich, School of Medicine, Klinikum Rechts der Isar, Department of Anaesthesiology & Intensive Care Medicine, Munich, Germany ,grid.410712.10000 0004 0473 882XFaculty of Medicine, Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Stefan J. Schaller
- grid.15474.330000 0004 0477 2438Technical University Munich, School of Medicine, Klinikum Rechts der Isar, Department of Anaesthesiology & Intensive Care Medicine, Munich, Germany ,grid.6363.00000 0001 2218 4662Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Berlin, Germany
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Borges LF, Fraga Righetti R, de Souza Francisco D, Pereira Yamaguti W, Barros CFD. Hemodynamic impact of early mobilization in critical patients receiving vasoactive drugs: A prospective cohort study. PLoS One 2022; 17:e0279269. [PMID: 36538515 PMCID: PMC9767358 DOI: 10.1371/journal.pone.0279269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 12/03/2022] [Indexed: 12/24/2022] Open
Abstract
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.
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Tadyanemhandu C, van Aswegen H, Ntsiea V. Barriers and facilitators to implementation of early mobilisation of critically ill patients in Zimbabwean and South African public sector hospitals: a qualitative study. Disabil Rehabil 2022; 44:6699-6709. [PMID: 34461792 PMCID: PMC9183945 DOI: 10.1080/09638288.2021.1970827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/21/2021] [Accepted: 08/15/2021] [Indexed: 01/13/2023]
Abstract
PURPOSE Implementing early mobilisation in intensive care is challenging, and a detailed knowledge of factors that may hinder or facilitate implementation is essential for success. The study was done to explore the perceived barriers and facilitators to early mobilisation by physiotherapists in Zimbabwean and South African public sector hospital ICUs. METHODS A qualitative study was done in eight public sector hospitals from South Africa and four hospitals from Zimbabwe. Physiotherapists from the participating hospitals who had at least two years working experience in ICU were invited to participate in semi-structured, in-depth, face-to-face interviews. Purposive sampling was done. Data collected included interpretation of early mobilisation, perceived barriers, and facilitators to early mobilisation. Data analysis was done using the content analysis method. FINDINGS A total of 22 physiotherapists were interviewed. In defining the activities regarded as early mobilisation, there was diversity in relation to the specific activities and the nature of the patients in which the defined activities were suitable for. Perceived barriers which emerged included lack of professional autonomy or boundaries, motivation, and clinical skills. Perceived facilitators to early mobilisation included the availability of guidelines, good communication, adequate staff, and mobilisation equipment. CONCLUSIONS Barriers and facilitators to early mobilisation are multifactorial. There is need for multidisciplinary team collaboration and planning before implementing early mobilisation activities.Implications to rehabilitationProfessional roles/identity and or boundaries emerged to be a barrier that hinder implementation of early mobilisation if not clearly defined.Non-rotational physiotherapy coverage was highlighted to be important in facilitating good communication and teamwork and sustainability of services in ICU.Good communication channels and referrals between different disciplines should be employed in ICU to prevent delay in rendering services to ICU patients.
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Affiliation(s)
- Cathrine Tadyanemhandu
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Parktown, South Africa
| | - Heleen van Aswegen
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Parktown, South Africa
| | - Veronica Ntsiea
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Parktown, South Africa
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Nydahl P, Jeitziner MM, Vater V, Sivarajah S, Howroyd F, McWilliams D, Osterbrink J. Early mobilisation for prevention and treatment of delirium in critically ill patients: Systematic review and meta-analysis. Intensive Crit Care Nurs 2022. [DOI: 10.1016/j.iccn.2022.103334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kawar LN, Crawford CL, Mendoza RG, Harrison SJ, Thibodeaux MW, Spicer JE. Validity and Usefulness of an Electronic Health Care Record-Generated Mobility Ambulation Tool: The Human Body Was Designed to Move. J Nurs Care Qual 2022; 37:68-74. [PMID: 34261088 DOI: 10.1097/ncq.0000000000000580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mobility is a vital function of human life. Nurses have an essential role in preventing hospitalized patient complications through movement and ambulation. PURPOSE This study examined the integration, accuracy, and precision of a paper-based mobility/ambulation tool into an electronic health record (EHR) to assess inpatient mobility/ambulation status. METHODS This multisite mixed-methods study was a time-series correlational evaluation of a mobility/ambulation tool into the EHR. RESULTS Sustainability data revealed strong correlations between nurse responses and EHR levels (r = 0.602; scores r = 0.624). Cronbach's α values were 0.737 and 0.761. Nurses' anecdotes supported the findings. CONCLUSION Findings revealed that the EHR-Mobility Ambulation Tool is a valid, reliable, and stable tool. EHR-generated scores can assist in reducing charting burden, care planning, and inform the interdisciplinary health team at all patient care stages. Tool adoption could potentially assist nurses plan interventions suitable to maintain or increase hospitalized patients' mobility status and contribute to discharge planning.
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Affiliation(s)
- Lina Najib Kawar
- Patient Care Services, Kaiser Permanente Southern California, Pasadena, California (Drs Kawar, Crawford, and Harrison and Ms Thibodeaux); Kaiser Permanente, Baldwin Park, California (Ms Mendoza); and Kaiser Permanente Southern California & Hawai'i Market, Pasadena, California (Dr Spicer)
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Zhang H, Liu H, Li Z, Li Q, Chu X, Zhou X, Wang B, Lyu Y, Lin F. Early mobilization implementation for critical ill patients: A cross-sectional multi-center survey about knowledge, attitudes, and perceptions of critical care nurses. Int J Nurs Sci 2022; 9:49-55. [PMID: 35079604 PMCID: PMC8766783 DOI: 10.1016/j.ijnss.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/10/2021] [Accepted: 10/14/2021] [Indexed: 11/01/2022] Open
Abstract
Objective Design Results Conclusions
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Popoola M, Dingle M, MacLaren J, Dyson J. What are the barriers to nurses mobilising adult patients in intensive care units? An integrative review. Aust Crit Care 2021; 35:595-603. [PMID: 34756801 DOI: 10.1016/j.aucc.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/08/2021] [Accepted: 09/05/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES There is a need for early mobilisation of patients in intensive care units to prevent acquired weaknesses which can have a long-term impact on health and quality of life. This need is not always fulfilled. We therefore sought to conduct an integrative review of international evidence to answer the question: What are the barriers to nurses mobilising adult patients in intensive care units? REVIEW METHOD USED We conducted a systematic search and thematic analysis. We were able to present a descriptive quantitative synthesis of the survey articles included. DATA SOURCES We searched CINAHL, MEDLINE, and PsycINFO databases between and including 2010 and 2020 using search terms synonymous with "intensive care unit" and "nurse" and "early mobilisation" and "barrier using Boolean operators" and "truncation". We completed backwards and forwards citation searches on included studies. RESULTS We included seven articles which we synthesised into three themes and 13 subthemes as follows: (i) organisational barriers (subthemes were staffing levels, time and workload, resources, and care coordination), (ii) individual barriers (subthemes were self and team safety, knowledge and training, beliefs about the consequences of early mobilisation, stress, and other barriers), and (iii) patient-related barriers (subthemes were medical instability/physical status, patient safety, neurological deficits and sedation, and nonconcordance of patients). CONCLUSION Nurses' barriers were wide ranging, and interventions to improve concordance with early mobilisation need to be tailored to address this group's specific barriers.
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Affiliation(s)
| | - Maria Dingle
- City, University of London, Northampton Square, London, EC1V 0HB, UK.
| | - Julie MacLaren
- City, University of London, Northampton Square, London, EC1V 0HB, UK.
| | - Judith Dyson
- Birmingham City University, Westbourne Road, Edgbaston, Birmingham, B15 3TN, UK.
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Cooper D, Gasperini M, Parkosewich JA. Nurses' Perceptions of Barriers to Out-of-Bed Activities Among Patients Receiving Mechanical Ventilation. Am J Crit Care 2021; 30:266-274. [PMID: 34195779 DOI: 10.4037/ajcc2021801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delays in early patient mobility are common in critical care areas. Oral intubation with mechanical ventilation is negatively associated with out-of-bed activities. OBJECTIVES To explore nurses' mobility practices for patients with oral intubation and mechanical ventilation and identify barriers related to patient, nurse, and environment-of-care factors specific to this population. METHODS In this cross-sectional, descriptive study in a medical intensive care unit, mobility was defined as standing, sitting in a chair, or walking. A total of 105 patients who met predefined mobility criteria and their 48 nurses were enrolled. Nurses were interviewed about mobility practices at the ends of shifts. Descriptive statistics summarized nurse and patient characteristics and mobility barriers. RESULTS Patients were deemed ready to begin mobility within a mean (SD) of 41.5 (34.8) hours after oral endotracheal intubation. Two-thirds of nurses reported that they never or rarely got these patients out of bed. Only 12.4% of patients had a clinician's activity order. Common patient-related barriers were uncooperative behavior (21.9%) and active medical issues (15%), even in patients who met mobility criteria. Nurse-related barriers were concerns for patient safety, specifically falls (14.3% of patients) and harm (9.5%). The environment of care posed very few barriers; nurses rarely mentioned that lack of help (13.3% of patients) or lack of clinician's activity order (5.7%) impeded mobility. CONCLUSIONS Mobility practices were nonexistent in these patients despite patients' being deemed ready to begin out-of-bed activities. Nurses must be attentive to their unit's mobility culture to overcome these barriers.
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Affiliation(s)
- Dawn Cooper
- Dawn Cooper is a clinical nurse specialist in the medical intensive care unit, York Street Campus, New Haven, Connecticut
| | - Monica Gasperini
- Monica Gasperini is a clinical nurse III in the medical intensive care unit and a clinical instructor at the Center for Professional Practice, New Haven, Connecticut
| | - Janet A. Parkosewich
- Janet A. Parkosewich is the nurse researcher for the Division of Nursing, Yale New Haven Hospital, New Haven, Connecticut
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12
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Zhou W, Ruksakulpiwat S, Fan Y, Ji L. Nutritional Interventions on Physical Functioning for Critically Ill Patients: An Integrative Review. J Multidiscip Healthc 2021; 14:1489-1507. [PMID: 34177267 PMCID: PMC8219235 DOI: 10.2147/jmdh.s314132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 05/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background Poor physical functioning (PF) is a common issue among critically ill patients. It was suggested that reasonable nutrition accelerates PF recovery. However, the details and types of nutritional interventions on the PF of different intensive care unit (ICU) patients at present have not been well analyzed yet. This study aimed to systematically synthesize nutritional interventions on PF in different ICU populations. Methods Whittemore and Knafl’s framework was employed. PubMed, EMBASE, Web of Science, CINAHL Plus with Full Text, and Cochrane Library were searched to obtain studies from January 2010 to September 2020, with a manual search of the included studies’ references. Record screening, data extraction, and quality appraisal were conducted independently by each reviewer before reaching an agreement after discussion. Results Twelve studies were included reporting the effects of early parenteral nutrition, early enteral nutrition, early goal-directed nutrition, early adequate nutrition, higher protein delivery, higher energy delivery, low energy delivery, energy and protein delivery, intermittent enteral feeding on PF like muscle mass, muscle strength, and function. Function was the most common outcome but showed little improvements. Muscle strength outcomes improved the most. The mechanically ventilated were the most popular target ICU population. The commenced time of the interventions is usually within 24 to 48 hours after ICU admission. Conclusion Research on nutritional interventions on critically ill patients’ PF is limited, but most are of a high level of evidence. Few intervention studies specified their evidence basis. Qualitative studies investigating timeframe of initiating feeding, perspectives of the patients’ perspectives and caregivers are warranted to advance research and further discuss this topic.
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Affiliation(s)
- Wendie Zhou
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China.,Office of General Affairs, School of Nursing, Harbin Medical University, Harbin, People's Republic of China
| | - Suebsarn Ruksakulpiwat
- Department of Medical Nursing, Faculty of Nursing, Mahidol University, Bangkok, Thailand
| | - Yuying Fan
- Clinical Nursing Teaching Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China.,Office of General Affairs, School of Nursing, Harbin Medical University, Harbin, People's Republic of China
| | - Lingling Ji
- Department of Pediatrics, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
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13
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Raurell-Torredà M, Arias-Rivera S, Martí JD, Frade-Mera MJ, Zaragoza-García I, Gallart E, Velasco-Sanz TR, San José-Arribas A, Blazquez-Martínez E. Variables associated with mobility levels in critically ill patients: A cohort study. Nurs Crit Care 2021; 27:546-557. [PMID: 34008238 DOI: 10.1111/nicc.12639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Early mobilization in the intensive care unit (ICU) helps improve patients' functional status at discharge. However, many barriers hinder this practice. AIM AND OBJECTIVES To identify mobility levels acquired by critically ill patients and their variables. DESIGN A multi-centre cohort study was conducted in adult patients receiving invasive mechanical ventilation for at least 48 hours. METHODS The primary outcome was level of mobility according to the ICU mobility scale. The secondary outcome was human resource availability and existence of ABCDEF bundle guidelines. A logistic regression was performed, based on days 3 to 5 of the ICU stay and significant association with active mobility. RESULTS Six hundred and forty-two patients were included from 80 ICUs. Active moving in and out of bed was found on 9.9% of patient-days from day 8 of the ICU stay. Bed exercises, or passive transfers, and immobility were observed on 45.6% and 42.2% of patient-days, respectively. Patients achieving active mobility (189/642, 29.4%) were in ICUs with more physiotherapist hours. Active mobility was more likely with a 1:4 nurse-patient ratio (odds ratio [OR] 3.7 95% confidence interval [CI] [1.2-11.2]), high MRC sum-score (OR 1.05 95% CI [1.04-1.06]) and presence of delirium (OR 1.01 95% CI [1.00-1.02]). By contrast, active mobility was hindered by higher BMI (OR 0.92 95% CI [0.88-0.97]), a 1:3 nurse-patient ratio (OR 0.54 95% CI [0.32-0.93]), or a shift-dependent nurse-patient ratio (OR 0.27 95% CI [0.12-0.62]). CONCLUSIONS Immobility and passive mobilization were prevalent. A high MRC sum-score and presence of delirium are protective factors of mobilization. A 1:4 nurse-patient ratio shows a stronger association with active mobility than a 1:3 ratio. RELEVANCE TO CLINICAL PRACTICE Severity-criteria-based nurse-patient ratios hinder mobilization. Active mobilization may be enhanced by using nursing-intervention-based ratios, increasing physiotherapist hours, and achieving wider application of the ABCDEF bundle, resulting in more awake, cooperative patients.
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Affiliation(s)
- Marta Raurell-Torredà
- Department of Fundamental and Medical Surgical Nursing, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | - Susana Arias-Rivera
- Department of Nursing Management, University Hospital of Getafe, Madrid, Spain.,Research Department, CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Joan Daniel Martí
- Cardiovascular Surgery Intensive Care Department, Instituto Clínico Cardiovascular, Clinic University Hospital, Barcelona, Spain
| | - María Jesús Frade-Mera
- Critical Care Department, 12 Octubre University Hospital, Madrid, Spain.,Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain
| | - Ignacio Zaragoza-García
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain.,Research department (Invecuid), Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Centro de Actividades Ambulatorias, Madrid, Spain
| | - Elisabet Gallart
- Critical Care Department, Vall Hebron University Hospital, Barcelona, Spain
| | - Tamara Raquel Velasco-Sanz
- Department of Nursing, Faculty of Nursing, Physiotherapy and Podology, University Complutense of Madrid, Madrid, Spain.,Critical Care Department, San Carlos University Hospital, Madrid, Spain
| | - Alicia San José-Arribas
- Department of Nursing, Escola Universitaria d'Infermeria Sant Pau (Hospital de la Santa Creu i Sant Pau), Barcelona, Spain
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Environmental Factors Affecting Early Mobilization and Physical Disability Post-Intensive Care: An Integrative Review Through the Lens of the World Health Organization International Classification of Functioning, Disability, and Health. Dimens Crit Care Nurs 2021; 40:92-117. [PMID: 33961378 DOI: 10.1097/dcc.0000000000000461] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Early mobilization (EM) is one of few potential protective factors associated with reduced physical disability post-intensive care (PD PIC). However, only 45% of intensive care units (ICUs) in the United States routinely practice EM despite its recognized benefits. OBJECTIVES To analyze the evidence on the relationship between critical care EM, PD PIC, and environmental factors, using the theoretical lens of the World Health Organization's (WHO's) International Classification of Functioning, Disability, and Health (ICF). METHOD The Whittemore and Knafl methodology for integrative reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines were followed. Qualitative, quantitative, and mixed-methods studies (n = 38) that evaluated EM and 1 or more domains of the WHO ICF were included. Quality was appraised using the Mixed-Methods Appraisal Tool. Study characteristics were evaluated for common themes and relationships. The ICF domains and subdomains pertaining to each study were synthesized. RESULTS Early mobilization was related to improved functioning on the disability continuum of the WHO ICF. Early mobilization was influenced by several WHO ICF environmental factors. Dedicated physical and occupational therapy teams in the ICU, interdisciplinary rounds, and positive family and staff perception of EM facilitated intervention delivery. However, poor staffing levels, negative unit culture, perceived workload burden, and lack of equipment, education, and financial support impeded delivery of EM. DISCUSSION Early mobilization is a promising intervention that may reduce PD PIC. However, environmental factors negatively influence delivery of EM in the ICU. Several gaps in EM research limit its acceptability in ICU practice. Existing EM research is challenged by poor methodological quality. Further study is necessary to better understand the role of EM on PD PIC and improve patient outcomes following critical illness.
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Patient-Level Barriers and Facilitators to Early Mobilization and the Relationship With Physical Disability Post-Intensive Care: Part 2 of an Integrative Review Through the Lens of the World Health Organization International Classification of Functioning, Disability, and Health. Dimens Crit Care Nurs 2021; 40:164-173. [PMID: 33792276 DOI: 10.1097/dcc.0000000000000470] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Early mobilization (EM) is associated with reduced physical disability post-intensive care (PD PIC). Yet, contextual factors facilitate or impede delivery of EM in the intensive care unit (ICU). Only 45% of ICUs in the United States routinely practice EM despite its recognized benefits. OBJECTIVES To analyze the evidence on the relationship between critical care EM, PD PIC, and personal (patient-level) factors, using the theoretical lens of the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). METHOD The Whittemore and Knafl methodology for integrative reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) reporting guidelines were followed. Qualitative, quantitative, and mixed-methods studies (n = 38) that evaluated EM and 1 or more domains of the World Health Organization ICF were included. Quality was appraised using the Mixed-Methods Appraisal Tool. Study characteristics were evaluated for common themes and relationships. The ICF domains and subdomains pertaining to each study were synthesized. RESULTS Early mobilization delivery was influenced by personal factors. Deeper sedation level, the presence of delirium, higher patient acuity, the presence of medical devices, and patient weight were identified barriers to EM delivery. Patient engagement in EM was associated with improved delivery. Patients who enjoyed rehabilitation were more likely to demonstrate improvement in functional impairment than those who did not enjoy rehabilitation. DISCUSSION Early mobilization is associated with reduced PD PIC, yet numerous contextual factors affect the delivery of EM in the ICU. Further study of patient-level factors and EM must explore the relationship between patient engagement, baseline demographics, and functional status at ICU admission, patient-level considerations for decisions to mobilize, and EM in the ICU. This research is critical to improving the delivery of EM in the ICU and reducing PD PIC.
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Tadyanemhandu C, van Aswegen H, Ntsiea V. Organizational structures and early mobilization practices in South African public sector intensive care units-A cross-sectional study. J Eval Clin Pract 2021; 27:42-52. [PMID: 32141685 PMCID: PMC7483254 DOI: 10.1111/jep.13378] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/15/2020] [Accepted: 02/03/2020] [Indexed: 12/12/2022]
Abstract
RATIONALE Understanding current early mobilization practice of patients in intensive care unit (ICU) is critical to the design and implementation of strategies to facilitate its application in a diverse population of critically ill patients encountered in public sector hospitals. AIM To evaluate the organizational structures of South African public sector hospital ICUs and to describe early mobilization practices in these units. METHODS A cross-sectional survey was done in participating public hospitals from eight provinces in South Africa. Convenience sampling was done. Data collected included hospital and ICU structure, adult patient demographic and clinical data, and mobilization activities done in ICU over the previous 24 hours prior to the day of the survey. RESULTS A total of 29 ICUs from 13 participating hospitals were surveyed resulting in 205 patient records. Majority of the surveyed ICUs were "open" type (n = 16; 55.2%). A standardized sedation scoring system was used in 18 units (62.1%) and only two units (6.9%) had an early mobilization protocol in place. Mean age of the patients surveyed was 43.5 (±17.7) years and 148 (72.2%) patients were on mechanical ventilation. Primary reasons for admission to ICU included traumatic injury (n = 86; 42%) and postoperative care (n = 33; 16.1%). Mobilization activities performed in the previous 24 hours included turning the patient in bed (n = 88; 42.9%), marching on the spot (n = 9; 4.4%) and walking (n = 10; 4.9%). Out-of-bed mobilization was done in only 40 (19.5%) patients. The most common barriers to early mobilization included patient unresponsiveness (n = 50; 24.4%) and hemodynamic instability (n = 42; 20.5%). The type of ventilation was found to have a significant positive relationship with out-of-bed patient mobilization (P = .000). CONCLUSIONS A small proportion of patients attained their highest level of mobilization in ICU. The type of ventilation influenced early mobilization practices in public sector ICUs in South Africa.
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Affiliation(s)
- Cathrine Tadyanemhandu
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Heleen van Aswegen
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Veronica Ntsiea
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Mohan S, Patodia S, Kumaravel S, Venkataraman R, Vijayaraghavan BKT. Improving Mobility in Critically Ill Patients in a Tertiary Care ICU: Opportunities and Challenges. Indian J Crit Care Med 2021; 25:34-42. [PMID: 33603299 PMCID: PMC7874286 DOI: 10.5005/jp-journals-10071-23438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Patients in the intensive care unit (ICU) are subjected to prolonged bed rest secondary to critical illness and related therapies. Data suggest that such bed rest can have adverse consequences on the post-discharge quality of life. There is limited data from India on mobilization practices. We undertook a quality improvement (QI) initiative to understand our mobilization practices, identify challenges, and test interventions. Materials and methods We carried out a three-phase QI project, and the study was conducted in our 24-bedded ICU. Pre-intervention and post-intervention mobilization performance and scores were analyzed. We also recorded data on adverse events and barriers to mobilization. Descriptive statistics were used to report all the results. Results A total of 140 patients (1,033 patient days) and 207 patients (932 patient days) were included in our initial audit and post-implementation audit, respectively. In pre-implementation, 31.3% of patients were mobilized with an average mobility score of 2 and this improved to 57.9% with average mobility score of 3.4. Additionally, we demonstrated improvements in the mobility scores of our intubated patients (49.8% achieving a mobility score of 3-5 as compared to 16.7%). Conclusion A multidisciplinary approach is feasible and resulted in significant improvements in early mobilization among critically ill adults. How to cite this article Mohan S, Patodia S, Kumaravel S, Venkataraman R, Vijayaraghavan BKT. Improving Mobility in Critically Ill Patients in a Tertiary Care ICU: Opportunities and Challenges. Indian J Crit Care Med 2021;25(1):34-42.
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Affiliation(s)
- Sneha Mohan
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Sristi Patodia
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Sudha Kumaravel
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Ramesh Venkataraman
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
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Fazio SA, Doroy AL, Anderson NR, Adams JY, Young HM. Standardisation, multi-measure, data quality and trending: A qualitative study on multidisciplinary perspectives to improve intensive care early mobility monitoring. Intensive Crit Care Nurs 2020; 63:102949. [PMID: 33199104 DOI: 10.1016/j.iccn.2020.102949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/27/2020] [Accepted: 08/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To explore multi-clinician perspectives on intensive care early mobility, monitoring and to assess the perceived value of technology-generated mobility metrics to provide user feedback to inform research, practice improvement, and technology development. METHODS We performed a qualitative descriptive study. Three focus groups were conducted with critical care clinicians, including nurses (n = 10), physical therapists (n = 8) and physicians (n = 8) at an academic medical centre that implemented an intensive care early mobility programme in 2012. Qualitative thematic analysis was used to code transcripts and identify overarching themes. FINDINGS Along with reaffirming the value of performing early mobility interventions, four themes for improving mobility monitoring emerged, including the need for: 1) standardised indicators for documenting mobility; 2) inclusion of both quantitative and qualitative metrics to measure mobility 3) a balance between quantity and quality of data; and 4) trending mobility metrics over time. CONCLUSION Intensive care mobility monitoring should be standardised and data generated should be high quality, capable of supporting trend analysis, and meaningful. By improving measurement and monitoring of mobility, future researchers can examine the arc of activity that patients in the intensive care unit undergo and develop models to understand factors that influence successful implementation.
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Affiliation(s)
- Sarina A Fazio
- Division of Pulmonary, Critical Care, & Sleep Medicine, School of Medicine, University of California, Davis, USA; Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, USA; Medical ICU, UC Davis Medical Center, UC Davis Health, Sacramento, USA.
| | - Amy L Doroy
- Medical ICU, UC Davis Medical Center, UC Davis Health, Sacramento, USA
| | - Nicholas R Anderson
- Division of Health Informatics, School of Medicine, University of California, Davis, Sacramento, USA
| | - Jason Y Adams
- Division of Pulmonary, Critical Care, & Sleep Medicine, School of Medicine, University of California, Davis, USA; Medical ICU, UC Davis Medical Center, UC Davis Health, Sacramento, USA
| | - Heather M Young
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, USA
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Early physiotherapy experience with a biodegradable polyurethane dermal substitute: Therapy guidelines for use. Burns 2020; 47:1074-1083. [PMID: 33339655 DOI: 10.1016/j.burns.2020.10.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/08/2020] [Accepted: 10/21/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate and develop range of motion (ROM) and mobilisation guidelines in adult patients where a newly developed synthetic dermal substitute was applied in our adult burn centre. METHOD A retrospective case note audit was conducted on the first 20 acute burn injured patients who had a synthetic dermal substitute applied. Data collected included days to commencement of ROM, days to clearance for mobilisation, and joint ROM achieved after dermal substitute application (prior to delamination) and after split skin grafting (SSG) for the elbow, knee and shoulder joints. Scar assessments were completed at 12 months after injury using two scar assessment scales. RESULTS Clearance to mobilise occurred at mean 10.4 and 4.9 days after dermal substitute and after skin graft application to lower limbs respectively. ROM commenced at a mean of 9.9 (upper limbs) and 12.7 (lower limbs) days after dermal substitute application. Following skin grafting, ROM commenced at a mean of 6.6 and 6.5 days for upper limbs and lower limbs respectively. Prior to dermal substitute delamination mean flexion at the knee (86.3°), elbow (114.0°) and shoulder (143.4°) was achieved. Mean ROM continued to improve after grafting with knee (133.2°), elbow (126.1°) and shoulder (151.0°) flexion approaching normal ROM in most cases. Mean extension of the elbow (-4.6°) was maintained close to normal levels after skin grafting. There were no recorded instances of knee extension contracture. Patient and Observer Scar Assessment Scale and Matching Assessment of Photographs of Scars scores indicated good cosmetic outcomes with relatively low levels of itch and minimal pain reported at 12 months after injury. CONCLUSION A steep learning curve was encountered in providing therapy treatment for patients managed with this relatively new synthetic dermal substitute. Trends indicated that as experience with this new dermal substitute grew, patients progressed toward active therapy earlier. A guideline for therapy treatment has been developed but will continue to be evaluated and adjusted when required.
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Hermes C, Nydahl P, Blobner M, Dubb R, Filipovic S, Kaltwasser A, Ulm B, Schaller SJ. Assessment of mobilization capacity in 10 different ICU scenarios by different professions. PLoS One 2020; 15:e0239853. [PMID: 33057435 PMCID: PMC7561080 DOI: 10.1371/journal.pone.0239853] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 09/14/2020] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
| | - Peter Nydahl
- Nursing Research, Department of Anesthesiology and Intensive Care Medicine, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Manfred Blobner
- Department of Anesthesiology and Intensive Care, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Rolf Dubb
- Academy of District Clinics Reutlingen, Reutlingen, Germany
| | - Silke Filipovic
- Department of Physiotherapy, University Hospital of Giessen and Marburg, Marburg, Germany
| | | | - Bernhard Ulm
- Department of Anesthesiology and Intensive Care, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Stefan J. Schaller
- Department of Anesthesiology and Intensive Care, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Corporate Member of Freie Universität Berlin, Charité –Universitätsmedizin Berlin, Berlin, Germany
- Humboldt-Universität zu Berlin, Charité –Universitätsmedizin Berlin, Berlin, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine, Berlin Institute of Health, Berlin, Germany
- * E-mail:
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Adaptación y validación de la ICU Mobility Scale en España. ENFERMERIA INTENSIVA 2020; 31:131-146. [DOI: 10.1016/j.enfi.2019.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/31/2019] [Accepted: 10/05/2019] [Indexed: 01/05/2023]
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Nickels MR, Aitken LM, Walsham J, Crampton LJ, Barnett AG, McPhail SM. Exercise interventions are delayed in critically ill patients: a cohort study in an Australian tertiary intensive care unit. Physiotherapy 2019; 109:75-84. [PMID: 31648779 DOI: 10.1016/j.physio.2019.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 03/27/2019] [Accepted: 06/28/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study aims to (i) describe the time to exercise commencement (sitting and upright activities) relative to ICU admission and relative to achievement of initial neurological, respiratory and cardiovascular stability; (ii) examine factors associated with whether sitting and upright activities occurred in ICU; and (iii) examine factors associated with time taken to commence these activities after stability has been achieved. DESIGN Five-year historical cohort study. SETTING An Australian tertiary mixed medical, surgical, trauma ICU. PARTICIPANTS The cohort (n=3222, mean (SD) age 54 (18) years, 67% male) included consecutive ICU patients with length of stay over 48hours admitted to a tertiary ICU who achieved stability. MAIN OUTCOME MEASURES Time from stability to patients' first completed sitting and upright activities was calculated. Logistic regression (and Cox proportional hazard models) examined whether sitting and upright activities in ICU occurred (and time to these events). INTERVENTIONS None. RESULTS For patients who completed exercise interventions (n=1845/3222, 57%), this commenced a median (IQR) 2.3 (1.3-4.4) days after stability for upright activities and 2.7 (1.5-5.7) days for sitting. A large proportion of patients did not complete exercise interventions despite achieving stability (n=1377/3222, 43%). Elective surgical admissions, lower illness severity and older age were associated with completion (and earlier completion) of sitting and upright activity (P<0.01). CONCLUSIONS Many stable patients did not commence sitting or upright activity in ICU despite known benefits, or commencement was somewhat delayed. Opportunities may exist to improve patient outcomes through timely implementation of exercise-based interventions.
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Affiliation(s)
- Marc R Nickels
- Physiotherapy Department, Princess Alexandra Hospital, Metro South Health, Brisbane, Queensland, Australia; Australian Centre for Health Services Innovation, Institute of Health & Biomedical Innovation, and School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia; Centre for Functioning and Health Research, Metro South Health, Brisbane, Queensland, Australia; Intensive Care Unit, Princess Alexandra Hospital, Metro South Health, Brisbane, Queensland, Australia.
| | - Leanne M Aitken
- School of Health Sciences, City, University of London, London, United Kingdom; Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia; Intensive Care Unit, Princess Alexandra Hospital, Metro South Health, Brisbane, Queensland, Australia.
| | - James Walsham
- Intensive Care Unit, Princess Alexandra Hospital, Metro South Health, Brisbane, Queensland, Australia; School of Medicine, University of Queensland, Brisbane, Queensland, Australia.
| | - Lisa J Crampton
- Physiotherapy Department, Princess Alexandra Hospital, Metro South Health, Brisbane, Queensland, Australia; Intensive Care Unit, Princess Alexandra Hospital, Metro South Health, Brisbane, Queensland, Australia.
| | - Adrian G Barnett
- Australian Centre for Health Services Innovation, Institute of Health & Biomedical Innovation, and School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia.
| | - Steven M McPhail
- Physiotherapy Department, Princess Alexandra Hospital, Metro South Health, Brisbane, Queensland, Australia; Australian Centre for Health Services Innovation, Institute of Health & Biomedical Innovation, and School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia; Centre for Functioning and Health Research, Metro South Health, Brisbane, Queensland, Australia.
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Amundadottir OR, Jónasdóttir RJ, Sigvaldason K, Gunnsteinsdottir E, Haraldsdottir B, Sveinsson T, Sigurdsson GH, Dean E. Effects of intensive upright mobilisation on outcomes of mechanically ventilated patients in the intensive care unit: a randomised controlled trial with 12-months follow-up. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2019. [DOI: 10.1080/21679169.2019.1645880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Olof R. Amundadottir
- School of Health Sciences, University of Iceland, Reykjavik, Iceland
- Department of Physiotherapy, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
| | - Rannveig J. Jónasdóttir
- Department of Anaesthesiology and Intensive Care Medicine, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
| | - Kristinn Sigvaldason
- Department of Anaesthesiology and Intensive Care Medicine, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
| | - Ester Gunnsteinsdottir
- Department of Physiotherapy, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
| | - Brynja Haraldsdottir
- Department of Physiotherapy, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
| | | | - Gisli H. Sigurdsson
- School of Health Sciences, University of Iceland, Reykjavik, Iceland
- Department of Anaesthesiology and Intensive Care Medicine, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
| | - Elizabeth Dean
- School of Health Sciences, University of Iceland, Reykjavik, Iceland
- Department of Physical Therapy, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
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Nydahl P, Günther U, Diers A, Hesse S, Kerschensteiner C, Klarmann S, Borzikowsky C, Köpke S. PROtocol-based MObilizaTION on intensive care units: stepped-wedge, cluster-randomized pilot study (Pro-Motion). Nurs Crit Care 2019; 25:368-375. [PMID: 31125163 DOI: 10.1111/nicc.12438] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/06/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Early mobilization of patients in intensive care units (ICUs) improves patient recovery, but implementation remains challenging. Protocols may enhance the rate of out-of-bed mobilizations. AIM To evaluate the effect of implementing a protocol for early mobilization on the rate of out-of-bed mobilizations and other outcomes of ICU patients. STUDY DESIGN Multicentre, stepped-wedge, cluster-randomized pilot study. METHODS After a control period, five ICUs were allocated to the implementation of an inter-professional protocol for early mobilization in a randomized, monthly order. Mobilization of ICU patients was evaluated by monthly 1-day point prevalence surveys using the ICU Mobility Scale. The primary outcome was the percentage of patients mobilized out of bed, defined as level 3 on the ICU Mobility Scale (sitting on edge of bed) or higher. Secondary outcomes were mechanical ventilation, delirium and ICU- and hospital-days, as well as unwanted safety events. RESULTS Out-of-bed mobilizations increased non-significantly from 36·2% (n = 55) of 152 patients during the control period to 45·8% (n = 55) of 120 patients during the intervention period (difference 9·6%; 95% confidence interval -2·1 to 21·3%). Of 55 mobilized patients per group, more patients were mobilized once per day during the intervention period (intervention: n = 41 versus control: n = 23 patients). Multiple daily mobilizations decreased (control: n = 32 control versus intervention: n = 14 patients). Secondary outcomes, such as days with mechanical ventilation, delirium and in ICU and hospital, did not significantly differ. Adherence to the protocol was >90%; unwanted safety events were rare. CONCLUSIONS Implementing a protocol for early mobilization of ICU patients showed a trend towards more patients being mobilized. Without additional staff in participating ICUs, a significant increase in ICU mobilizations was not to be anticipated. More research should address whether more staff would increase the number of frequent mobilizations and if this is relevant to outcomes. RELEVANCE TO CLINICAL PRACTICE Implementing inter-professional protocols for mobilization is feasible and safe and may contribute to an increase of ICU patients mobilized out of bed.
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Affiliation(s)
- Peter Nydahl
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Schleswig-Holstein, Kiel, Kiel, Germany
| | - Ulf Günther
- University Clinic of Anaesthesiology, Intensive Care, Emergency Medicine, Pain Therapy, Klinikum Oldenburg AöR, and European Medical School Oldenburg-Groningen, Oldenburg, Germany
| | - Anja Diers
- University Clinic of Anaesthesiology, Intensive Care, Emergency Medicine, Pain Therapy, Klinikum Oldenburg AöR, and European Medical School Oldenburg-Groningen, Oldenburg, Germany
| | - Stephanie Hesse
- Department of Intensive Care, Städtisches Krankenhaus, Kiel, Germany
| | | | - Silke Klarmann
- Department of Physical Therapy, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Christoph Borzikowsky
- Institute of Medical Informatics and Statistics, Kiel University, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Sascha Köpke
- Nursing Research Unit, Institute of Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
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Laerkner E, Egerod I, Olesen F, Toft P, Hansen HP. Negotiated mobilisation: An ethnographic exploration of nurse-patient interactions in an intensive care unit. J Clin Nurs 2019; 28:2329-2339. [PMID: 30791156 DOI: 10.1111/jocn.14828] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 01/09/2019] [Accepted: 02/12/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Eva Laerkner
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark.,Department of Public Health, Faculty of Health, University of Southern Denmark, Odense, Denmark
| | - Ingrid Egerod
- Intensive Care Unit 4131, Health & Medical Sciences, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Finn Olesen
- School of Communication and Culture-Information Studies, University of Aarhus, Aarhus, Denmark
| | - Palle Toft
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Helle Ploug Hansen
- Department of Public Health, Faculty of Health, University of Southern Denmark, Odense, Denmark
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Mattioli E, Tabuzo B, Sangkachand P, Parkosewich J, Reyes L, Funk M. Safety and Patients' Response to Ambulation With a Pulmonary Artery Catheter in the Cardiac Intensive Care Unit. Am J Crit Care 2019; 28:101-108. [PMID: 30824513 DOI: 10.4037/ajcc2019339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Early mobilization of patients in the intensive care unit can be beneficial, but evidence is insufficient to indicate whether allowing patients with an indwelling pulmonary artery catheter to walk is safe. OBJECTIVE To describe the physiological and emotional responses to ambulation in patients with heart failure and a pulmonary artery catheter. METHODS This prospective, descriptive study included 19 patients with heart failure monitored with a pulmonary artery catheter in a cardiac intensive care unit. Each patient, accompanied by a nurse, walked with continuous observation of heart rate and rhythm and pulmonary artery tracing on a transport monitor. Pulmonary artery catheter position and waveform, arrhythmias, and perceived levels of exertion and fatigue were recorded before and after each walk. The distance ambulated was documented. One to 3 times per week, nurses administered a questionnaire addressing patients' sense of well-being. RESULTS The 19 patients had 303 walks (range, 1-68; median, 7). During 7 patient walks (2.4%), catheter migration of 1 to 5 cm occurred, but no arrhythmias or waveform changes were observed. Changes in exertion and fatigue were significant (P < .001, paired t test), but levels of both were minimal after walking. Patients expressed physical and emotional benefits of walking. CONCLUSIONS This study provides preliminary evidence that for hemodynamically stable patients with heart failure, ambulating with a pulmonary artery catheter is safe and enhances their sense of well-being. The presence of an indwelling pulmonary artery catheter should not preclude walking.
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Affiliation(s)
- Elisa Mattioli
- Elisa Mattioli and Bienvenido Tabuzo Jr are both a clinical nurse III and Liberty Reyes is a clinical nurse II in the cardiac intensive care unit, Yale New Haven Hospital, New Haven, Connecticut. Prasama Sangkachand is a service line educator, Heart and Vascular Center, and Janet Parkosewich is the nurse researcher, Yale New Haven Hospital. Marjorie Funk is the Helen Porter Jayne and Martha Prosser Jayne Professor Emerita of Nursing, Yale School of Nursing, West Haven, Connecticut
| | - Bienvenido Tabuzo
- Elisa Mattioli and Bienvenido Tabuzo Jr are both a clinical nurse III and Liberty Reyes is a clinical nurse II in the cardiac intensive care unit, Yale New Haven Hospital, New Haven, Connecticut. Prasama Sangkachand is a service line educator, Heart and Vascular Center, and Janet Parkosewich is the nurse researcher, Yale New Haven Hospital. Marjorie Funk is the Helen Porter Jayne and Martha Prosser Jayne Professor Emerita of Nursing, Yale School of Nursing, West Haven, Connecticut
| | - Prasama Sangkachand
- Elisa Mattioli and Bienvenido Tabuzo Jr are both a clinical nurse III and Liberty Reyes is a clinical nurse II in the cardiac intensive care unit, Yale New Haven Hospital, New Haven, Connecticut. Prasama Sangkachand is a service line educator, Heart and Vascular Center, and Janet Parkosewich is the nurse researcher, Yale New Haven Hospital. Marjorie Funk is the Helen Porter Jayne and Martha Prosser Jayne Professor Emerita of Nursing, Yale School of Nursing, West Haven, Connecticut
| | - Janet Parkosewich
- Elisa Mattioli and Bienvenido Tabuzo Jr are both a clinical nurse III and Liberty Reyes is a clinical nurse II in the cardiac intensive care unit, Yale New Haven Hospital, New Haven, Connecticut. Prasama Sangkachand is a service line educator, Heart and Vascular Center, and Janet Parkosewich is the nurse researcher, Yale New Haven Hospital. Marjorie Funk is the Helen Porter Jayne and Martha Prosser Jayne Professor Emerita of Nursing, Yale School of Nursing, West Haven, Connecticut
| | - Liberty Reyes
- Elisa Mattioli and Bienvenido Tabuzo Jr are both a clinical nurse III and Liberty Reyes is a clinical nurse II in the cardiac intensive care unit, Yale New Haven Hospital, New Haven, Connecticut. Prasama Sangkachand is a service line educator, Heart and Vascular Center, and Janet Parkosewich is the nurse researcher, Yale New Haven Hospital. Marjorie Funk is the Helen Porter Jayne and Martha Prosser Jayne Professor Emerita of Nursing, Yale School of Nursing, West Haven, Connecticut
| | - Marjorie Funk
- Elisa Mattioli and Bienvenido Tabuzo Jr are both a clinical nurse III and Liberty Reyes is a clinical nurse II in the cardiac intensive care unit, Yale New Haven Hospital, New Haven, Connecticut. Prasama Sangkachand is a service line educator, Heart and Vascular Center, and Janet Parkosewich is the nurse researcher, Yale New Haven Hospital. Marjorie Funk is the Helen Porter Jayne and Martha Prosser Jayne Professor Emerita of Nursing, Yale School of Nursing, West Haven, Connecticut
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What's old is new: Commentary on the state of mobilization of patients in the intensive care unit setting with recommendations for future practice. Heart Lung 2018; 47:386. [DOI: 10.1016/j.hrtlng.2018.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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