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El Kaim A, Serra M, De Noray H, Lallemant A, Gobatto C, Degos V, Carpentier A, Riche M, Apra C. Safety and practicality study of using an exoskeleton in acute neurosurgery patients. Acta Neurochir (Wien) 2024; 166:221. [PMID: 38763932 DOI: 10.1007/s00701-024-06112-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 05/01/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Early mobilization is key in neurologically impaired persons, limiting complications and improving long-term recovery. Self-balanced exoskeletons are used in rehabilitation departments to help patients stand and walk. We report the first case series of exoskeleton use in acute neurosurgery and intensive care patients, evaluating safety, clinical feasibility and patients' satisfaction. METHODS We report a retrospective observational study including individuals hospitalized in the neurosurgical intensive care and neurosurgery departments. We included patients with a medical prescription for an exoskeleton session, and who met no contraindication. Patients benefited from standing sessions using a self-balanced exoskeleton (Atalante, Wandercraft, France). Patients and sessions data were collected. Safety, feasibility and adherence were evaluated. RESULTS Seventeen patients were scheduled for 70 standing sessions, of which 27 (39%) were completed. They were typically hospitalized for intracranial hemorrhage (74%) and presented with unilateral motor impairments, able to stand but with very insufficient weight shifting to the hemiplegic limb, requiring support (MRC 36.2 ± 3.70, SPB 2.0 ± 1.3, SPD 0.7 ± 0.5). The average duration of standing sessions was 16 ± 9 min. The only side effect was orthostatic hypotension (18.5%), which resolved with returning to seating position. The most frequent reason for not completing a session was understaffing (75%). All patients were satisfied and expressed a desire to repeat it. CONCLUSIONS Physiotherapy using the exoskeleton is safe and feasible in the acute neurosurgery setting, although it requires adaptation from the staff to organize the sessions. An efficacy study is ongoing to evaluate the benefits for the patients.
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Affiliation(s)
- Audrey El Kaim
- Neurosurgery Department, Pitié Salpêtrière Hospital, Paris, France
- Institute of Myology, Pitié Salpêtrière Hospital, Paris, France
| | - Manon Serra
- Brain Machine Interface Clinical Research Group, Sorbonne University, Paris, France
- Physical and Rehabilitation Medicine Unit, Pitié Salpêtrière Hospital, Paris, France
- Department of Anesthesia, Critical Care and Perioperative Care, Pitié Salpêtrière Hospital, Paris, France
| | - Henri De Noray
- Neurosurgery Department, Pitié Salpêtrière Hospital, Paris, France
- Department of Anesthesia, Critical Care and Perioperative Care, Pitié Salpêtrière Hospital, Paris, France
| | - Audrey Lallemant
- Neurosurgery Department, Pitié Salpêtrière Hospital, Paris, France
- Department of Anesthesia, Critical Care and Perioperative Care, Pitié Salpêtrière Hospital, Paris, France
| | - Corentin Gobatto
- Neurosurgery Department, Pitié Salpêtrière Hospital, Paris, France
- Department of Anesthesia, Critical Care and Perioperative Care, Pitié Salpêtrière Hospital, Paris, France
| | - Vincent Degos
- Department of Anesthesia, Critical Care and Perioperative Care, Pitié Salpêtrière Hospital, Paris, France
- Sorbonne Université, Paris, France
- Université de Paris, NeuroDiderot, Inserm, 75019, Paris, France
- PremUP, 75006, Paris, France
| | - Alexandre Carpentier
- Neurosurgery Department, Pitié Salpêtrière Hospital, Paris, France
- Brain Machine Interface Clinical Research Group, Sorbonne University, Paris, France
- Sorbonne Université, Paris, France
| | - Maximilien Riche
- Neurosurgery Department, Pitié Salpêtrière Hospital, Paris, France
- Brain Machine Interface Clinical Research Group, Sorbonne University, Paris, France
- Sorbonne Université, Paris, France
| | - Caroline Apra
- Neurosurgery Department, Pitié Salpêtrière Hospital, Paris, France.
- Neurosurgery Department, Henri Mondor Hospital, Créteil, France.
- Université Paris Est Créteil Val de Marne, Créteil, France.
- Mondor Institute of Biomedical Research, INSERM U955, Créteil, France.
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Warmbein A, Rathgeber I, Seif J, Mehler-Klamt AC, Schmidbauer L, Scharf C, Hübner L, Schroeder I, Biebl J, Gutmann M, Eberl I, Zoller M, Fischer U. Barriers and facilitators in the implementation of mobilization robots in hospitals from the perspective of clinical experts and developers. BMC Nurs 2023; 22:45. [PMID: 36797701 PMCID: PMC9936640 DOI: 10.1186/s12912-023-01202-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/07/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Early mobilization can help reduce severe side effects such as muscle atrophy that occur during hospitalization. However, due to time and staff shortages in intensive and critical care as well as safety risks for patients, it is often difficult to adhere to the recommended therapy time of twenty minutes twice a day. New robotic technologies might be one approach to achieve early mobilization effectively for patients and also relieve users from physical effort. Nevertheless, currently there is a lack of knowledge regarding the factors that are important for integrating of these technologies into complex treatment settings like intensive care units or rehabilitation units. METHODS European experts from science, technical development and end-users of robotic systems (n = 13) were interviewed using a semi-structured interview guideline to identify barriers and facilitating factors for the integration of robotic systems into daily clinical practice. They were asked about structural, personnel and environmental factors that had an impact on integration and how they had solved challenges. A latent content analysis was performed regarding the COREQ criteria. RESULTS We found relevant factors regarding the development, introduction, and routine of the robotic system. In this context, costs, process adjustments, a lack of exemptions, and a lack of support from the manufacturers/developers were identified as challenges. Easy handling, joint decision making between the end-users and the decision makers in the hospital, an accurate process design and the joint development of the robotic system of end-users and technical experts were found to be facilitating factors. CONCLUSION The integration and preparation for the integration of robotic assistance systems into the inpatient setting is a complex intervention that involves many parties. This study provides evidence for hospitals or manufacturers to simplify the planning of integrations for permanent use. TRIAL REGISTRATION DRKS-ID: DRKS00023848; registered 10/12/2020.
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Affiliation(s)
- Angelika Warmbein
- Clinical Nursing Research and Quality Management Unit, University Hospital LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Ivanka Rathgeber
- grid.411095.80000 0004 0477 2585Clinical Nursing Research and Quality Management Unit, University Hospital LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Janesca Seif
- grid.411095.80000 0004 0477 2585Clinical Nursing Research and Quality Management Unit, University Hospital LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Amrei C. Mehler-Klamt
- grid.440923.80000 0001 1245 5350Professorship of Nursing Science, Faculty of Social Work, Catholic University of Eichstätt-Ingolstadt, Eichstätt, Germany
| | - Lena Schmidbauer
- grid.440923.80000 0001 1245 5350Professorship of Nursing Science, Faculty of Social Work, Catholic University of Eichstätt-Ingolstadt, Eichstätt, Germany
| | - Christina Scharf
- grid.411095.80000 0004 0477 2585Department of Anesthesiology, University Hospital LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Lucas Hübner
- grid.411095.80000 0004 0477 2585Department of Anesthesiology, University Hospital LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Ines Schroeder
- grid.411095.80000 0004 0477 2585Department of Anesthesiology, University Hospital LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Johanna Biebl
- grid.5252.00000 0004 1936 973XDepartment of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Marcus Gutmann
- grid.5252.00000 0004 1936 973XDepartment of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital LMU Munich, Munich, Germany
| | - Inge Eberl
- grid.440923.80000 0001 1245 5350Professorship of Nursing Science, Faculty of Social Work, Catholic University of Eichstätt-Ingolstadt, Eichstätt, Germany
| | - Michael Zoller
- grid.411095.80000 0004 0477 2585Department of Anesthesiology, University Hospital LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Uli Fischer
- grid.411095.80000 0004 0477 2585Clinical Nursing Research and Quality Management Unit, University Hospital LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
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Daigné D, Blanchard PY, Allain MC, Lambert G, Rodriguez S, Tessier B, Blayau C, Voiriot G, Bérard L, Rousseau A, Fartoukh M. Feasibility of a repositioning schedule on pressure ulcer prevention in a French Intensive Care Unit: A pre and post-intervention pilot study. J Tissue Viability 2023; 32:20-25. [PMID: 36599729 DOI: 10.1016/j.jtv.2022.12.007] [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: 06/29/2022] [Revised: 12/10/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
AIMS As a prerequisite of a multicentre study, we conducted a pilot study to assess the feasibility of a daily repositioning schedule in critically ill patients. The schedule was adapted to the patient's clinical condition, and the estimated risk for developing a pressure ulcer using the Braden scale. DESIGN A single-center pre and post-intervention pilot study in a French Intensive Care Unit of a university teaching hospital. This study followed TREND guidelines. METHODS During the first period (March to May 2018), pressure ulcer prevention was performed according to usual care. During the second period (June to August 2018), the repositioning schedule was adapted to the estimated risk for developing a pressure ulcer according to the Braden scale. Eligible patients had no pressure ulcer at baseline, were intubated within 24 hours of admission and expected to receive mechanical ventilation for at least 24 hours. The primary outcome was the rate of pressure ulcer development at 28 days of hospitalization or at discharge or death, as compared with usual care. Secondary outcomes included the feasibility and safety of the schedule, as assessed by caregivers' adherence and workload, and the rate of adverse events. RESULTS In the pre-intervention period 20 participants were included, and 14 patients were included in the post-intervention period. There was no decrease in the pressure ulcers incidence with the intervention (25% vs. 28.6%; P = 1). The number of daily repositioning performed increased from 3.3 [IQR 3.0; 3.9] during the pre-intervention period to 4.3 [IQR 3.8; 5.2] during the post-intervention period (P < 0.05), where it differed from the number scheduled by 0.6 [IQR 0.1; 1.4] per day, indicating satisfactory adherence of caregivers to the protocol. Adverse events rate did not differ between the two periods (55.9% vs. 57.1%; P = 0.90). CONCLUSION A personalised daily repositioning schedule in critically ill patients is feasible and safe. The efficacy of such a strategy, together with its economic impact, need to be assessed in a multicentre randomized trial.
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Affiliation(s)
- Daisy Daigné
- Assistance Publique - Hôpitaux de Paris. Sorbonne Université, DMU APPROCHES, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France.
| | - Pierre-Yves Blanchard
- Assistance Publique - Hôpitaux de Paris. Sorbonne Université, DMU APPROCHES, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France.
| | - Marie-Cécile Allain
- Assistance Publique - Hôpitaux de Paris. Sorbonne Université, DMU APPROCHES, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France.
| | - Gwendoline Lambert
- Assistance Publique - Hôpitaux de Paris. Sorbonne Université, DMU APPROCHES, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France.
| | - Séverine Rodriguez
- Assistance Publique - Hôpitaux de Paris. Sorbonne Université, DMU APPROCHES, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France.
| | - Benjamin Tessier
- Assistance Publique - Hôpitaux de Paris. Sorbonne Université, DMU APPROCHES, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France.
| | - Clarisse Blayau
- Assistance Publique - Hôpitaux de Paris. Sorbonne Université, DMU APPROCHES, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France.
| | - Guillaume Voiriot
- Assistance Publique - Hôpitaux de Paris. Sorbonne Université, DMU APPROCHES, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France.
| | - Laurence Bérard
- Assistance Publique - Hôpitaux de Paris. Sorbonne Université, Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), Hôpital Saint-Antoine, Paris, France.
| | - Alexandra Rousseau
- Assistance Publique - Hôpitaux de Paris. Sorbonne Université, Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), Hôpital Saint-Antoine, Paris, France.
| | - Muriel Fartoukh
- Assistance Publique - Hôpitaux de Paris. Sorbonne Université, DMU APPROCHES, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France.
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Warmbein A, Schroeder I, Mehler-Klamt A, Rathgeber I, Huber J, Scharf C, Hübner L, Gutmann M, Biebl J, Lorenz A, Kraft E, Zoller M, Eberl I, Fischer U. Robot-assisted early mobilization of intensive care patients: a feasibility study protocol. Pilot Feasibility Stud 2022; 8:236. [PMCID: PMC9636622 DOI: 10.1186/s40814-022-01191-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
Early mobilization positively influences the outcome of critically ill patients, yet in clinical practice, the implementation is sometimes challenging. In this study, an adaptive robotic assistance system will be used for early mobilization in intensive care units. The study aims to evaluate the experience of the mobilizing professionals and the general feasibility of implementing robotic assistance for mobilization in intensive care as well as the effects on patient outcomes as a secondary outcome.
Methods
The study is single-centric, prospective, and interventional and follows a longitudinal study design. To evaluate the feasibility of robotic-assisted early mobilization, the number of patients included, the number of performed VEM (very early mobilization) sessions, and the number and type of adverse events will be collected. The behavior and experience of mobilizing professionals will be evaluated using standardized observations (n > 90) and episodic interviews (n > 36) before implementation, shortly after, and in routine. Patient outcomes such as duration of mechanical ventilation, loss of muscle mass, and physical activity will be measured and compared with a historical patient population. Approximately 30 patients will be included.
Discussion
The study will provide information about patient outcomes, feasibility, and the experience of mobilizing professionals. It will show whether robotic systems can increase the early mobilization frequency of critically ill patients. Within ICU structures, early mobilization as therapy could become more of a focus. Effects on the mobilizing professionals such as increased motivation, physical relief, or stress will be evaluated. In addition, this study will focus on whether current structures allow following the recommendation of mobilizing patients twice a day for at least 20 min.
Trial registration
ClinicalTrials.gov, NCT05071248. Date: 2021/10/21
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Fernald MM, Smyrnios NA, Vitello J. Early Mobility for Critically Ill Patients: Building Staff Commitment Through Appreciative Inquiry. Crit Care Nurse 2021; 40:66-72. [PMID: 32737490 DOI: 10.4037/ccn2020251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Immobility contributes to many adverse effects in critically ill patients. Early progressive mobility can mitigate these negative sequelae but is not widely implemented. Appreciative inquiry is a quality improvement method/change philosophy that builds on what works well in an organization. OBJECTIVES To explore whether appreciative inquiry would reinvigorate an early progressive mobility initiative in a medical intensive care unit and improve and sustain staff commitment to providing regular mobility therapy at the bedside. Secondary goals were to add to the literature about appreciative inquiry in health care and to determine whether it can be adapted to critical care. METHODS Staff participated in appreciative inquiry workshops, which were conducted by a trained facilitator and structured with the appreciative inquiry 4-D cycle. Staff members' attitudes toward and knowledge of early progressive mobility were evaluated before and after the workshops. Performance of early progressive mobility activities was recorded before and 3 and 10 months after the workshops. RESULTS Sixty-seven participants completed the program. They rated the workshops as successfully helping them to understand the importance of early progressive mobility (98%), explain their responsibility to improve patient outcomes (98%), and engender a greater commitment to patients and the organization (96%). Regarding mobility treatments, at 3 months orders had improved from 62% to 88%; documentation, from 52% to 89%; and observation, from 39% to 87%. These improvements were maintained at 10 months. CONCLUSION Participation in the workshops improved the staff's attitude toward and performance of mobility treatments. Appreciative inquiry may provide an adjunct to problem-based quality improvement techniques.
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Affiliation(s)
- Michelle M Fernald
- Michelle M. Fernald is a nurse manager in the medical intensive care unit, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Nicholas A Smyrnios
- Nicholas A. Smyrnios is a professor, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, and Medical Director, medical intensive care unit, Division of Pulmonary, Allergy, and Critical Care Medicine, UMass Memorial Medical Center
| | - Joan Vitello
- Joan Vitello is Dean and a professor, University of Massachusetts Medical School Graduate School of Nursing
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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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Najjar C, Dima D, de Boer J, Goldfarb M. Beliefs, attitudes and knowledge of cardiovascular healthcare providers on mobilization. Nurs Open 2021; 8:1587-1592. [PMID: 33543837 PMCID: PMC8186684 DOI: 10.1002/nop2.775] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/23/2020] [Accepted: 08/19/2020] [Indexed: 12/21/2022] Open
Abstract
Aim To assess the beliefs, attitudes and knowledge of nurses, physicians and physiotherapists in a cardiovascular intensive care unit (CICU) on patient mobilization. Design Survey of CV healthcare providers in the CICU at two academic tertiary care hospitals. Methods The validated Patient Mobilization Attitudes and Beliefs Survey was distributed to CV providers. The survey is a 26‐item self‐administered questionnaire that assesses providers' perceived barriers in three domains: attitude, behaviour and knowledge. Results Participants (N = 142) completed the survey (nurses, N = 67, physicians, N = 59 and physiotherapists, N = 16; 155 eligible participants, 91.6% overall completion rate). Nurses had lower overall knowledge, attitude and behaviour barriers to mobilization than physicians, but higher than physiotherapists (all p < .001). The highest barriers to mobilization for nurses were adequate staffing, patient‐level and time restraint. These findings should inform efforts to overcome existing barriers and to transform acute cardiovascular mobility culture.
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Affiliation(s)
| | - Diana Dima
- Department of Nursing, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Jane de Boer
- Department of Nursing, Royal Victoria Hospital, McGill University, Montreal, QC, Canada
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC, Canada
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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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Anekwe DE, Milner SC, Bussières A, de Marchie M, Spahija J. Intensive care unit clinicians identify many barriers to, and facilitators of, early mobilisation: a qualitative study using the Theoretical Domains Framework. J Physiother 2020; 66:120-127. [PMID: 32307308 DOI: 10.1016/j.jphys.2020.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 09/19/2019] [Accepted: 03/09/2020] [Indexed: 01/18/2023] Open
Abstract
QUESTION From the perspective of intensive care unit (ICU) clinicians, what are the barriers to and facilitators of implementing early mobilisation? DESIGN A qualitative study using focus groups, with analysis using the Theoretical Domains Framework. PARTICIPANTS Physicians, nurses, respiratory therapists and physiotherapists from the ICUs of three university-affiliated hospitals in Montreal, Canada. METHODS Four focus group meetings were conducted with 33 participating ICU clinicians. Two researchers independently performed thematic content analysis on verbatim transcriptions of the audio recordings using the Theoretical Domains Framework. RESULTS Data saturation was reached after the third focus group. Thirty-six barriers were categorised in 13 domains of the Theoretical Domains Framework. The key barriers to early mobilisation were: lack of conviction and knowledge regarding the available evidence about early mobilisation; lack of attention to the provision of optimal care; poor communication; the unpredictable nature of the ICU; and limited staffing, equipment, time and clinical knowledge. Twenty-five facilitators categorised in ten TDF domains were also identified. These included individual-level facilitators (intrinsic motivation, positive outcome expectations, conscious effort to mobilise early, good planning/coordination, the presence of ICU champions, and expert support by a physiotherapist) and organisational-level facilitators (reminder system, pro-early mobilisation culture, implementation of an early mobilisation protocol, and improved ICU organisation). CONCLUSIONS A broad array of barriers to and facilitators of early mobilisation in the ICU were identified in this study. Clinicians can consider whether these barriers and facilitators are operating in their ICU. These may inform the design of tailored knowledge translation interventions to promote early mobilisation in the ICU.
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Affiliation(s)
- David E Anekwe
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada; CIUSSS-NÎM, Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montreal, Canada
| | - Siobhan C Milner
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - André Bussières
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada
| | - Michel de Marchie
- Department of Adult Critical Care, CIUSSS West-Central Montreal, Jewish General Hospital, Montreal, Canada
| | - Jadranka Spahija
- School of Physical and Occupational Therapy, McGill University, Montreal, Canada; CIUSSS-NÎM, Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montreal, Canada; Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR), CISSS Laval - Hôpital Juif de Réadaptation, Laval, Canada.
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Zhu YP, Xia LX, Li GH. Management of early mobilization in intensive care units: a multicenter cross-sectional study. FRONTIERS OF NURSING 2018. [DOI: 10.1515/fon-2018-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
- Yan-Ping Zhu
- Intensive Care Units, Zhongda Hospital , Southeast University , Nanjing , Jiangsu 210009 , China
| | - Li-Xia Xia
- Department of Nursing , Jiangsu Provincial Hospital , Nanjing , Jiangsu 210009 , China
| | - Guo-Hong Li
- Department of Nursing , Zhongda Hospital , Southeast University , Nanjing , Jiangsu 210009 , China
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Scientific and Clinical Abstracts From the WOCN® Society's 50th Annual Conference. J Wound Ostomy Continence Nurs 2018. [DOI: 10.1097/won.0000000000000432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis. Ann Am Thorac Soc 2018; 14:766-777. [PMID: 28231030 DOI: 10.1513/annalsats.201611-843sr] [Citation(s) in RCA: 198] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Early mobilization and rehabilitation of patients in intensive care units (ICUs) may improve physical function, and reduce the duration of delirium, mechanical ventilation, and ICU length of stay. However, safety concerns are an important barrier to widespread implementation. OBJECTIVES To synthesize safety data regarding patient mobilization and rehabilitation in the ICU, including falls, removal of endotracheal tubes, removal or dysfunction of intravascular catheters, removal of other catheters/tubes, cardiac arrest, hemodynamic changes, and desaturation. DATA SOURCES Systematic literature review, including searches of five databases. Eligible studies evaluated patients who received mobilization-related interventions in the ICU. Exclusion criteria included: (1) case series with fewer than 10 patients; (2) majority of patients under 18 years of age; and (3) data not reported to permit calculation of incidence of safety events. DATA EXTRACTION Number of patients, mobilization/rehabilitation sessions, potential safety events, and events with negative consequences (e.g., requiring intervention or additional therapy). SYNTHESIS Heterogeneity was assessed by I2 statistics, and bias assessed by the Newcastle-Ottawa Scale and Cochrane risk of bias assessment. The literature search identified 20,660 titles. There were 48 eligible publications evaluating 7,546 patients, with 583 potential safety events occurring in 22,351 mobilization/rehabilitation sessions. There was a total of 583 (2.6%) potential safety events with heterogeneity in the definitions for these events. For the safety event types that could be meta-analyzed, pooled incidences per 1,000 mobilization/rehabilitation sessions (95% confidence interval), were: hemodynamic changes, 3.8 (1.3-11.4), and desaturation, 1.9 (0.9-4.3). A total of 24 studies of 3,404 patients reported on any consequences of potential safety events (e.g., needing to increase dose of vasopressor due to mobility-related hypotension), with a frequency of 0.6% in 14,398 mobilization/rehabilitation sessions. CONCLUSIONS Patient mobilization and physical rehabilitation in the ICU appears safe, with a low incidence of potential safety events, and only rare events having any consequences for patient management. Heterogeneity in the definition of safety events across studies emphasizes the importance of implementing existing consensus-based definitions.
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Liu K, Ogura T, Takahashi K, Nakamura M, Ohtake H, Fujiduka K, Abe E, Oosaki H, Miyazaki D, Suzuki H, Nishikimi M, Lefor AK, Mato T. The safety of a novel early mobilization protocol conducted by ICU physicians: a prospective observational study. J Intensive Care 2018; 6:10. [PMID: 29484188 PMCID: PMC5819168 DOI: 10.1186/s40560-018-0281-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/12/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND There are numerous barriers to early mobilization (EM) in a resource-limited intensive care unit (ICU) without a specialized team or an EM culture, regarding patient stability while critically ill or in the presence of medical devices. We hypothesized that ICU physicians can overcome these barriers. The aim of this study was to investigate the safety of EM according to the Maebashi EM protocol conducted by ICU physicians. METHODS This was a single-center prospective observational study. All consecutive patients with an unplanned emergency admission were included in this study, according to the exclusion criteria. The observation period was from June 2015 to June 2016. Data regarding adverse events, medical devices in place during rehabilitation, protocol adherence, and rehabilitation outcomes were collected. The primary outcome was safety. RESULTS A total of 232 consecutively enrolled patients underwent 587 rehabilitation sessions. Thirteen adverse events occurred (2.2%; 95% confidence interval, 1.2-3.8%) and no specific treatment was needed. There were no instances of dislodgement or obstruction of medical devices, tubes, or lines. The incidence of adverse events associated with mechanical ventilation or extracorporeal membrane oxygenation (ECMO) was 2.4 and 3.6%, respectively. Of 587 sessions, 387 (66%) sessions were performed at the active rehabilitation level, including sitting out of the bed, active transfer to a chair, standing, marching, and ambulating. ICU physicians attended over 95% of these active rehabilitation sessions. Of all patients, 143 (62%) got out of bed within 2 days (median 1.2 days; interquartile range 0.1-2.0). CONCLUSIONS EM according to the Maebashi EM protocol conducted by ICU physicians, without a specialized team or EM culture, was performed at a level of safety similar to previous studies performed by specialized teams, even with medical devices in place, including mechanical ventilation or ECMO. Protocolized EM led by ICU physicians can be initiated in the acute phase of critical illness without serious adverse events requiring additional treatment.
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Affiliation(s)
- Keibun Liu
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, 3-21-36 Asahi-cho, Maebashi, Gunma 371-0014 Japan
| | - Takayuki Ogura
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, 3-21-36 Asahi-cho, Maebashi, Gunma 371-0014 Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Tsurumai-cho 64, Syowa-ku, Nagoya, Aichi 466-8560 Japan
| | - Mitsunobu Nakamura
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Tsurumai-cho 64, Syowa-ku, Nagoya, Aichi 466-8560 Japan
| | - Hiroaki Ohtake
- Department of Rehabilitation Medicine, Japan Red Cross Maebashi Hospital, 3-21-36 Asahi-cho, Maebashi, Gunma 371-0014 Japan
| | - Kenji Fujiduka
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, 3-21-36 Asahi-cho, Maebashi, Gunma 371-0014 Japan
| | - Emi Abe
- Department of Nursing, Intensive Care Unit, Japan Red Cross Maebashi Hospital, 3-21-36 Asahi-cho, Maebashi, Gunma 371-0014 Japan
| | - Hitoshi Oosaki
- Department of Rehabilitation Medicine, Japan Red Cross Maebashi Hospital, 3-21-36 Asahi-cho, Maebashi, Gunma 371-0014 Japan
| | - Dai Miyazaki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, 3-21-36 Asahi-cho, Maebashi, Gunma 371-0014 Japan
| | - Hiroyuki Suzuki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, 3-21-36 Asahi-cho, Maebashi, Gunma 371-0014 Japan
| | - Mitsuaki Nishikimi
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, 3-21-36 Asahi-cho, Maebashi, Gunma 371-0014 Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsukeshi, Tochigi, 329-0498 Japan
| | - Takashi Mato
- Department of Emergency Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsukeshi, Tochigi, 329-0498 Japan
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Barriers and facilitators to early rehabilitation in mechanically ventilated patients-a theory-driven interview study. J Intensive Care 2018; 6:4. [PMID: 29403646 PMCID: PMC5781271 DOI: 10.1186/s40560-018-0273-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 01/08/2018] [Indexed: 02/07/2023] Open
Abstract
Background Despite a supportive evidence base and a push to implement, the uptake of early rehabilitation in critical care has been inconsistent. The objective of this study was to explore barriers and facilitators to early rehabilitation for critically ill patients receiving invasive mechanical ventilation. Methods Using the Theoretical Domains Framework (TDF) of behavior change, we conducted semi-structured interviews exploring barriers and facilitators to early rehabilitation among four purposively sampled ICU clinician groups (nurses, rehabilitation professionals, respiratory therapists, and physicians). The TDF is a comprehensive framework of 14 “construct domains,” synthesized from 33 theories of behavior that was developed to study determinants of behavior and to design interventions to improve evidence-based healthcare practice. A topic guide was developed and piloted based on the TDF and expert knowledge. Interviews were audio-recorded and transcribed verbatim. Transcripts were content analyzed by coding items into domains and then synthesized into more specific, over-arching themes or “beliefs.” An expert consensus group used structured decision rules to classify beliefs as high, moderate, or low in importance. Results We interviewed 40 stakeholders from the four clinician groups and identified 135 separate beliefs. Of these, 19 were classified as high, 40 as moderate, and 76 of low importance as barriers or facilitators. All beliefs classified as highly important fell within one of seven TDF domains: skills, social/professional role and identity, beliefs about capabilities, beliefs about consequences, environmental context/resources, social influences, and behavioral regulation. Beliefs of lower importance fell under the following seven domains: knowledge; optimism; reinforcement; intention; goals; memory, attention, and decision processes; and emotion. Quantitative differences in stated beliefs about early rehabilitation between professional groups were not common. Conclusions This study identified important barriers and facilitators to early rehabilitation in critical care patients. Domains identified as important should be considered when designing interventions to increase uptake of early rehabilitation. Electronic supplementary material The online version of this article (10.1186/s40560-018-0273-0) contains supplementary material, which is available to authorized users.
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Abstract
Early mobilization of patients in the intensive care unit (ICU) is safe, feasible, and beneficial. However, implementation of early mobility as part of routine clinical care can be challenging. The objective of this review is to identify barriers to early mobilization and discuss strategies to overcome such barriers. Based on a literature search, we synthesize data from 40 studies reporting 28 unique barriers to early mobility, of which 14 (50%) were patient-related, 5 (18%) structural, 5 (18%) ICU cultural, and 4 (14%) process-related barriers. These barriers varied across ICUs and within disciplines, depending on the ICU patient population, setting, attitude, and ICU culture. To overcome the identified barriers, over 70 strategies were reported and are synthesized in this review, including: implementation of safety guidelines; use of mobility protocols; interprofessional training, education, and rounds; and involvement of physician champions. Systematic efforts to change ICU culture to prioritize early mobilization using an interprofessional approach and multiple targeted strategies are important components of successfully implementing early mobility in clinical practice.
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Reducing Pressure Injury Incidence Using a Turn Team Assignment: Analysis of a Quality Improvement Project. J Wound Ostomy Continence Nurs 2017; 43:477-82. [PMID: 27607743 DOI: 10.1097/won.0000000000000258] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to analyze outcomes of a quality improvement project that evaluated a turning intervention for prevention of facility-acquired pressure injuries. DESIGN A descriptive correlational study design examined the effectiveness of using a "turn team assignment" on pressure injury incidence and staff perceptions. SUBJECTS AND SETTING The study sample comprised RNs and patient care associates assigned to provide care for patients admitted on the first or any subsequent day of hospitalization to a surgical intensive care unit at a Midwest inner-city teaching hospital. METHODS Direct observation by expert clinicians occurred in 2-hour increments over a 14-day period using an 11-item, unit-designed process improvement tool. We collected information regarding cueing, concurrent turning, independent turning in lieu of the cue, staff support, and possible barriers to turning and repositioning. Staff perceptions were collected using an online tool via survey. The survey utilized a 14-item questionnaire, and a 5-point Likert Scale to identify staff perceptions and beliefs about the turn team intervention. Pressure injury occurrences were measured using data from our monthly prevalence study. RESULTS Pressure injury occurrences declined from 24.9% to 16.8% over the data collection period. There was a strong positive correlation between verbal cueing and turning (r = 0.815; P < .05). Staff perceptions supported preintervention education (64.3%) and cueing (93%; 78%) as effective interventions in completing patient turning. CONCLUSIONS Findings suggest that turn team assignments using verbal cueing are an effective intervention that decreases pressure injury occurrence. This intervention required no increase in staffing personnel, making this type of intervention reasonable and effective in improving frequency of repositioning and decreasing pressure injury prevalence rates.
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Johnson K, Petti J, Olson A, Custer T. Identifying barriers to early mobilisation among mechanically ventilated patients in a trauma intensive care unit. Intensive Crit Care Nurs 2017; 42:51-54. [PMID: 28743548 DOI: 10.1016/j.iccn.2017.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 06/09/2017] [Accepted: 06/12/2017] [Indexed: 11/30/2022]
Abstract
Mechanically ventilated patients can be at risk for functional decline (Cameron et al., 2015). Early mobilisation of mechanically ventilated patients can improve outcomes after critical illness to prevent this decline. Although registered nurses understand the importance of early mobilisation there are nurses who are unwilling to mobilise patients. AIM The aim of this study is to examine whether nurses' attitudes and beliefs are barriers for early mobilisation and evaluate whether an education intervention can improve early mobilisation. METHOD Pre-test, post-test intervention with registered nurses and charge nurses in a 22 bed trauma intensive care setting. PROCEDURE Pre-test, post-test survey assessed perceived barriers in knowledge, attitudes, and behaviours followed by targeted education. RESULTS Dependent Sample T-test revealed a statistically significant increase in post-test responses for the subscales knowledge, attitudes, and behaviours with early mobilisation. This over-all increase in post-test results support that understanding barriers can improve patient outcomes. CONCLUSION Use of structured surveys to identify barriers for early mobilisation among nursing can assist in providing targeted education that address nurse's perception. The education intervention appeared to have a positive impact on attitudes but it is unknown if the difference was sustained over time or affected participants practice or patient outcomes.
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Affiliation(s)
- Kari Johnson
- Honor Health Thompson Peak Medical Center, 7400 E. Thompson Peak Parkway, Scottsdale, AZ, 85255, United States.
| | - Jamie Petti
- Trauma Intensive Care Unit, Honor Health John C Lincoln Medical Center, 250 East Dunlap Avenue, Phoenix, AZ, 85020, United States.
| | - Amy Olson
- Trauma Intensive Care Unit, Honor Health John C Lincoln Medical Center, 250 East Dunlap Avenue, Phoenix, AZ, 85020, United States.
| | - Tina Custer
- Trauma Intensive Care Unit, Honor Health John C Lincoln Medical Center, 250 East Dunlap Avenue, Phoenix, AZ, 85020, United States.
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An Exploratory Descriptive Study of Registered Nurse Innovation: Implications for Levels of Adoption. CLIN NURSE SPEC 2017; 31:E1-E9. [PMID: 27906736 DOI: 10.1097/nur.0000000000000264] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aims of this study were to describe registered nurses' levels of personal innovativeness and registered nurses' perceived organizational innovativeness and determine the relationship between these 2 variables. BACKGROUND There is limited research to describe the levels of innovation of nurses within a hospital. The levels of innovation can determine the likelihood of adoption of evidence-based practices at the bedside. As change agents, clinical nurse specialists can determine successful implementation strategies tailored to nurse levels of innovation. DESCRIPTION This was a descriptive study at a midwest, urban, teaching, 408-bed Magnet hospital. OUTCOMES Surveys were completed by 217 nurses. The participants reported high personal innovativeness ((Equation is included in full-text article.)= 32.1; SD, 6.4), and the institution was perceived as innovative, with 90.3% of scores categorized as positive innovativeness. The statistically significant correlation was in the medical-surgical unit (r = -0.52, P < .01). There is no correlation between personal innovativeness and organizational innovativeness except for medical-surgical nurses (P = .03). They are likely to perceive the organization more innovative than themselves. CONCLUSIONS Determining adopter characteristics can be valuable to the clinical nurse specialist by adapting strategic interventions to advance nursing practice. Exploring levels of adoption can be an innovative strategy to transform nursing at the bedside and throughout the organization.
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Costa DK, White MR, Ginier E, Manojlovich M, Govindan S, Iwashyna TJ, Sales AE. Identifying Barriers to Delivering the Awakening and Breathing Coordination, Delirium, and Early Exercise/Mobility Bundle to Minimize Adverse Outcomes for Mechanically Ventilated Patients: A Systematic Review. Chest 2017; 152:304-311. [PMID: 28438605 DOI: 10.1016/j.chest.2017.03.054] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Improved outcomes are associated with the Awakening and Breathing Coordination, Delirium, and Early exercise/mobility bundle (ABCDE); however, implementation issues are common. As yet, no study has integrated the barriers to ABCDE to provide an overview of reasons for less successful efforts. The purpose of this review was to identify and catalog the barriers to ABCDE delivery based on a widely used implementation framework, and to provide a resource to guide clinicians in overcoming barriers to implementation. METHODS We searched MEDLINE via PubMed, CINAHL, and Scopus for original research articles from January 1, 2007, to August 31, 2016, that identified barriers to ABCDE implementation for adult patients in the ICU. Two reviewers independently reviewed studies, extracted barriers, and conducted thematic content analysis of the barriers, guided by the Consolidated Framework for Implementation Research. Discrepancies were discussed, and consensus was achieved. RESULTS Our electronic search yielded 1,908 articles. After applying our inclusion/exclusion criteria, we included 49 studies. We conducted thematic content analysis of the 107 barriers and identified four classes of ABCDE barriers: (1) patient-related (ie, patient instability and safety concerns); (2) clinician-related (ie, lack of knowledge, staff safety concerns); (3) protocol-related (ie, unclear protocol criteria, cumbersome protocols to use); and, not previously identified in past reviews, (4) ICU contextual barriers (ie, interprofessional team care coordination). CONCLUSIONS We provide the first, to our knowledge, systematic differential diagnosis of barriers to ABCDE delivery, moving beyond the conventional focus on patient-level factors. Our analysis offers a differential diagnosis checklist for clinicians planning ABCDE implementation to improve patient care and outcomes.
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Affiliation(s)
| | | | - Emily Ginier
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI
| | | | - Sushant Govindan
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
| | - Anne E Sales
- VA Center for Clinical Management Research, Ann Arbor, MI; Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
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Anekwe DE, Koo KKY, de Marchie M, Goldberg P, Jayaraman D, Spahija J. Interprofessional Survey of Perceived Barriers and Facilitators to Early Mobilization of Critically Ill Patients in Montreal, Canada. J Intensive Care Med 2017; 34:218-226. [PMID: 28355933 DOI: 10.1177/0885066617696846] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Early mobilization is safe, feasible, and associated with better outcomes in patients with critical illness. However, barriers to mobilization in clinical practice still exist. The objective of this study was to assess the knowledge and practice patterns of intensive care unit (ICU) clinicians, as well as the barriers and facilitators to early mobilization. DESIGN Cross-sectional survey. SETTING Intensive care units of 3 university-affiliated hospitals in Montreal, Canada. PARTICIPANTS One hundred and thirty-eight ICU clinicians, including nurses, physicians, respiratory therapists, and physiotherapists. INTERVENTIONS None. MEASUREMENTS Perceived barriers, facilitators, knowledge, and practice patterns of early mobilization were assessed using a previously validated mobility survey tool. MAIN RESULTS The overall response rate was 50.0% (138 of 274). Early mobilization was not perceived as a top priority in 49% of respondents. Results showed that clinicians were not fully aware of the benefits of early mobilization as per the current literature. About 58% of clinicians did not feel well trained and informed to mobilize mechanically ventilated patients. Perceptions on patient-level barriers varied with clinicians' professional training, but there was a high degree of interprofessional and intraprofessional disagreement on the permissible maximal level activity in different scenarios of critically ill patients. CONCLUSIONS Our survey shows limited awareness, among our respondents, of the clinical benefits of early mobilization and high level of disagreement on the permissible maximal level of activity in the critically ill patients. Future studies should evaluate the role of knowledge translation in modifying these barriers and improving early mobilization.
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Affiliation(s)
- David E Anekwe
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada.,Research Center, Sacré-Coeur Hospital, Montreal, Quebec, Canada.,Center for Interdisciplinary Research in Rehabilitation in Montreal, Jewish Rehabilitation Hospital, Laval, Quebec, Canada
| | - Karen Kin-Yue Koo
- Department of Medicine, Western University, London, Ontario, Canada.,Swedish Medical Group, Seattle, Washington, DC, USA
| | - Michel de Marchie
- Department of Adult Critical Care, Jewish General Hospital, Montreal, Quebec, Canada
| | - Peter Goldberg
- Adult Critical Care, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Dev Jayaraman
- Adult Critical Care, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jadranka Spahija
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada.,Research Center, Sacré-Coeur Hospital, Montreal, Quebec, Canada.,Center for Interdisciplinary Research in Rehabilitation in Montreal, Jewish Rehabilitation Hospital, Laval, Quebec, Canada
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Factors influencing physical activity and rehabilitation in survivors of critical illness: a systematic review of quantitative and qualitative studies. Intensive Care Med 2017; 43:531-542. [PMID: 28210771 DOI: 10.1007/s00134-017-4685-4] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/10/2017] [Indexed: 10/20/2022]
Abstract
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.
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Hunter OO, George EL, Ren D, Morgan D, Rosenzweig M, Klinefelter Tuite P. Overcoming nursing barriers to intensive care unit early mobilisation: A quality improvement project. Intensive Crit Care Nurs 2017; 40:44-50. [PMID: 28190550 DOI: 10.1016/j.iccn.2016.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 10/05/2016] [Accepted: 10/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To increase adherence with intensive care unit mobility by developing and implementing a mobility training program that addresses nursing barriers to early mobilisation. DESIGN An intensive care unit mobility training program was developed, implemented and evaluated with a pre-test, immediate post-test and eight-week post-test. Patient mobility was tracked before and after training. SETTING A ten bed cardiac intensive care unit. MAIN OUTCOME MEASURES The training program's efficacy was measured by comparing pre-test, immediate post-test and 8-week post-test scores. Patient mobilisation rates before and after training were compared. Protocol compliance was measured in the post training group. RESULTS Nursing knowledge increased from pre-test to immediate post-test (p<0.0001) and pre-test to 8-week post-test (p<0.0001). Mean test scores decreased by seven points from immediate post-test (80±12) to 8-week post-test (73±14). Fear significantly decreased from pre-test to immediate post-test (p=0.03), but not from pre-test to 8-week post-test (p=0.06) or immediate post-test to 8-week post-test (p=0.46). Post training patient mobility rates increased although not significantly (p=0.07). Post training protocol compliance was 78%. CONCLUSION The project successfully increased adherence with intensive care unit mobility and indicates that a training program could improve adoption of early mobility.
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Affiliation(s)
- Oluwatobi O Hunter
- University of Pittsburgh School of Nursing, 3500 Victoria St., Pittsburgh, PA 15213, United States.
| | - Elisabeth L George
- UPMC Presbyterian, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Dianxu Ren
- University of Pittsburgh School of Nursing, 3500 Victoria St., Pittsburgh, PA 15213, United States.
| | - Douglas Morgan
- UPMC Presbyterian, 200 Lothrop St., Pittsburgh, PA 15213, United States.
| | - Margaret Rosenzweig
- University of Pittsburgh School of Nursing, 3500 Victoria St., Pittsburgh, PA 15213, United States.
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Messer A, Comer L, Forst S. Implementation of a Progressive Mobilization Program in a Medical-Surgical Intensive Care Unit. Crit Care Nurse 2017; 35:28-42. [PMID: 26427973 DOI: 10.4037/ccn2015469] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- April Messer
- April Messer is a staff nurse in a medical-surgical intensive care unit at Mission Health, Asheville, North Carolina, and previously served as chairperson of the nurse practice council for the hospital where she practices.Linda Comer is the executive associate director, School of Nursing, Western Carolina University. She is also the coordinator for the nurse educator master's program and teaches the nurse educator specialty courses.Steve Forst is an assistant professor, School of Nursing, Western Carolina University.
| | - Linda Comer
- April Messer is a staff nurse in a medical-surgical intensive care unit at Mission Health, Asheville, North Carolina, and previously served as chairperson of the nurse practice council for the hospital where she practices.Linda Comer is the executive associate director, School of Nursing, Western Carolina University. She is also the coordinator for the nurse educator master's program and teaches the nurse educator specialty courses.Steve Forst is an assistant professor, School of Nursing, Western Carolina University
| | - Steve Forst
- April Messer is a staff nurse in a medical-surgical intensive care unit at Mission Health, Asheville, North Carolina, and previously served as chairperson of the nurse practice council for the hospital where she practices.Linda Comer is the executive associate director, School of Nursing, Western Carolina University. She is also the coordinator for the nurse educator master's program and teaches the nurse educator specialty courses.Steve Forst is an assistant professor, School of Nursing, Western Carolina University
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Campbell MR, Fisher J, Anderson L, Kreppel E. Implementation of early exercise and progressive mobility: steps to success. Crit Care Nurse 2016; 35:82-8. [PMID: 25639581 DOI: 10.4037/ccn2015701] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Melody R Campbell
- Melody R. Campbell is a critical care clinical nurse specialist and trauma program manager at Kettering Medical Center, Kettering, Ohio.Julie Fisher is a physical therapist and the lead therapist in the physical medicine and rehabilitation department at Good Samaritan Hospital, Dayton, Ohio.Lyndsey Anderson is an occupational therapist in the physical medicine and rehabilitation department at Good Samaritan Hospital, Dayton, Ohio.Erin Kreppel is a physical therapist in the physical medicine and rehabilitation department at Little Company of Mary Hospital, Evergreen Park, Illinois.
| | - Julie Fisher
- Melody R. Campbell is a critical care clinical nurse specialist and trauma program manager at Kettering Medical Center, Kettering, Ohio.Julie Fisher is a physical therapist and the lead therapist in the physical medicine and rehabilitation department at Good Samaritan Hospital, Dayton, Ohio.Lyndsey Anderson is an occupational therapist in the physical medicine and rehabilitation department at Good Samaritan Hospital, Dayton, Ohio.Erin Kreppel is a physical therapist in the physical medicine and rehabilitation department at Little Company of Mary Hospital, Evergreen Park, Illinois
| | - Lyndsey Anderson
- Melody R. Campbell is a critical care clinical nurse specialist and trauma program manager at Kettering Medical Center, Kettering, Ohio.Julie Fisher is a physical therapist and the lead therapist in the physical medicine and rehabilitation department at Good Samaritan Hospital, Dayton, Ohio.Lyndsey Anderson is an occupational therapist in the physical medicine and rehabilitation department at Good Samaritan Hospital, Dayton, Ohio.Erin Kreppel is a physical therapist in the physical medicine and rehabilitation department at Little Company of Mary Hospital, Evergreen Park, Illinois
| | - Erin Kreppel
- Melody R. Campbell is a critical care clinical nurse specialist and trauma program manager at Kettering Medical Center, Kettering, Ohio.Julie Fisher is a physical therapist and the lead therapist in the physical medicine and rehabilitation department at Good Samaritan Hospital, Dayton, Ohio.Lyndsey Anderson is an occupational therapist in the physical medicine and rehabilitation department at Good Samaritan Hospital, Dayton, Ohio.Erin Kreppel is a physical therapist in the physical medicine and rehabilitation department at Little Company of Mary Hospital, Evergreen Park, Illinois
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Parry SM, Remedios L, Denehy L, Knight LD, Beach L, Rollinson TC, Berney S, Puthucheary ZA, Morris P, Granger CL. What factors affect implementation of early rehabilitation into intensive care unit practice? A qualitative study with clinicians. J Crit Care 2016; 38:137-143. [PMID: 27902947 DOI: 10.1016/j.jcrc.2016.11.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/19/2016] [Accepted: 11/06/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE To identify the barriers and enablers that influence clinicians' implementation of early rehabilitation in critical care. MATERIALS AND METHODS Qualitative study involving 26 multidisciplinary participants who were recruited using purposive sampling. Four focus groups were conducted using semistructured questions to explore attitudes, beliefs, and experiences. Data were transcribed verbatim and thematic analysis was performed. RESULTS Six themes emerged, as follows: (1) the clinicians' expectations and knowledge (including rationale for rehabilitation, perceived benefits, and experience), (2) the evidence for and application of rehabilitation (including beliefs regarding when to intervene), (3) patient factors (including prognosis, sedation, delirium, cooperation, motivation, goals, and family), (4) safety considerations (including physiological stability and presence of devices or lines), (5) environmental influences (staffing, resources, equipment, time, and competing priorities), and (6) culture and teamwork. Key strategies identified to facilitate rehabilitation included addressing educational needs for all multidisciplinary team members, supporting junior nursing staff, and potential expansion of physiotherapy staffing hours to closer align with the 24-hour patient care model. CONCLUSIONS Key barriers to implementation of early rehabilitation in critical care are diverse and include both clinician- and health care system-related factors. Research targeted at bridging this evidence-practice gap is required to improve provision of rehabilitation.
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Affiliation(s)
- Selina M Parry
- Department of Physiotherapy, The University of Melbourne, Level 7 Alan Gilbert Bldg, 161 Barry St, Parkville 3010, Victoria, Australia.
| | - Louisa Remedios
- Department of Physiotherapy, The University of Melbourne, Level 7 Alan Gilbert Bldg, 161 Barry St, Parkville 3010, Victoria, Australia
| | - Linda Denehy
- Department of Physiotherapy, The University of Melbourne, Level 7 Alan Gilbert Bldg, 161 Barry St, Parkville 3010, Victoria, Australia; Institute for Breathing and Sleep, Bowen Centre, Austin Hospital, 145 Studley Rd, Heidelberg 3084, Victoria, Australia
| | - Laura D Knight
- Department of Physiotherapy, Royal Melbourne Hospital, 300 Grattan St, Parkville 3050, Victoria, Australia
| | - Lisa Beach
- Department of Physiotherapy, Royal Melbourne Hospital, 300 Grattan St, Parkville 3050, Victoria, Australia
| | - Thomas C Rollinson
- Department of Physiotherapy, Austin Hospital, 145 Studely Rd, Heidelberg 3084, Victoria, Australia
| | - Sue Berney
- Department of Physiotherapy, Austin Hospital, 145 Studely Rd, Heidelberg 3084, Victoria, Australia
| | | | - Peter Morris
- Department of Critical Care, University of Kentucky, Lexington, KY
| | - Catherine L Granger
- Department of Physiotherapy, The University of Melbourne, Level 7 Alan Gilbert Bldg, 161 Barry St, Parkville 3010, Victoria, Australia; Institute for Breathing and Sleep, Bowen Centre, Austin Hospital, 145 Studley Rd, Heidelberg 3084, Victoria, Australia; Department of Physiotherapy, Royal Melbourne Hospital, 300 Grattan St, Parkville 3050, Victoria, Australia
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26
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Parisien RB, Gillanders K, Hennessy EK, Herterich L, Saunders K, Lati J, Dos Santos S, Hassall A, O'Brien KK. Experiences of four parents with physical therapy and early mobility of their children in a pediatric critical care unit: A case series. J Pediatr Rehabil Med 2016; 9:159-68. [PMID: 27285809 DOI: 10.3233/prm-160374] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The aim of this study was to conduct a preliminary investigation into parents' experiences of physical therapy and early mobility (EM) for their children in a pediatric critical care unit (PCCU). METHODS We conducted a series of four qualitative case studies using in-depth semi-structured face-to-face interviews. We recruited parents of children who had undergone surgery and received at least one EM physical therapy intervention while intubated. We conducted a thematic analysis of transcribed interviews to illuminate the factors that influenced EM experiences. RESULTS Four parents participated in the study. We developed an overview of Parental Experiences with Physical Therapy and Early Mobility in a PCCU, which includes four themes that parents believed influenced their experiences: (1) environmental factors; (2) awareness of physical therapist and health care professional (HCP) roles; (3) communication among parents and HCPs; and (4) parental participation in their child's EM, within the overarching parental experiences in the PCCU. CONCLUSION This study affords a preliminary understanding of parents' experiences with physical therapy and EM in a PCCU setting. Results provide an important foundation for future research on mobility in the context of pediatric critical care research and practice.
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Affiliation(s)
- Rachel B Parisien
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Kirstie Gillanders
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Erin K Hennessy
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Lisa Herterich
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Kendra Saunders
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Jamil Lati
- Hospital for Sick Children, Toronto, ON, Canada
| | | | | | - Kelly K O'Brien
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
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Nickels M, Aitken LM, Walsham J, Watson L, McPhail S. Clinicians' perceptions of rationales for rehabilitative exercise in a critical care setting: A cross-sectional study. Aust Crit Care 2016; 30:79-84. [PMID: 27105830 DOI: 10.1016/j.aucc.2016.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/07/2016] [Accepted: 03/09/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Rehabilitative exercise for critically ill patients may have many benefits; however, it is unknown what intensive care unit (ICU) clinicians perceive to be important rationale for the implementation of rehabilitative exercise in critical care settings. OBJECTIVE To identify which rationales for rehabilitative exercise interventions were perceived by ICU clinicians to be important and determine whether perceptions were consistent across nursing, medical and physiotherapy clinicians. METHODS A cross-sectional study was undertaken among clinicians (nursing, medical, physiotherapy) working in a mixed medical surgical ICU in an Australian metropolitan tertiary hospital. Participants completed a customised web-based questionnaire developed by a clinician working-group. The questionnaire consisted of 11 plausible rationales for commencing rehabilitative exercise in ICUs based on prior literature and their own clinical experiences grouped into 4 over-arching categories (musculoskeletal, respiratory, psychological and facilitation of discharge). Participants rated their perceived importance for each potential rationale on a 5-point Likert scale. RESULTS Participants (n=76) with a median (interquartile range) 4.8 (1.5, 15.5) years of experience working in ICUs completed the questionnaire. Responses were consistent across professional disciplines. Clinicians rated rehabilitative exercise as either 'very much' or 'somewhat' important for facilitating discharge (n=76, 100%), reducing muscle atrophy (n=76, 100%), increasing muscle strength (n=76, 100%), prevention of contractures (n=73, 96%), reducing the incidence of ICU acquired weakness (n=62, 82%), increasing oxygenation (n=71, 93%), facilitating weaning (n=72, 97%), reducing anxiety (n=60, 80%), reducing depression (n=64, 84%), reducing delirium (n=53, 70%), and increasing mental alertness (n=65, 87%). CONCLUSIONS Any shortcoming in implementation of rehabilitation exercise is unlikely attributable to a lack of perceived importance by nursing, medical or physiotherapy clinicians who are the most likely clinicians to influence rehabilitation practices in ICUs. It is noteworthy that this study examined self-reported perceptions, not physiological or scientific legitimacy of rationales, or clinician behaviours in practice.
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Affiliation(s)
- Marc Nickels
- Intensive Care Unit and Physiotherapy Department, Princess Alexandra Hospital, Brisbane, Australia; School of Public Health & Social Work and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.
| | - Leanne M Aitken
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Australia; NHMRC Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia; School of Health Sciences, City University London, London, United Kingdom
| | - James Walsham
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia
| | - Lisa Watson
- Intensive Care Unit and Physiotherapy Department, Princess Alexandra Hospital, Brisbane, Australia
| | - Steven McPhail
- School of Public Health & Social Work and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia; Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia
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Dafoe S, Chapman MJ, Edwards S, Stiller K. Overcoming barriers to the mobilisation of patients in an intensive care unit. Anaesth Intensive Care 2016; 43:719-27. [PMID: 26603796 DOI: 10.1177/0310057x1504300609] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We conducted a quality improvement project aimed at increasing the frequency of mobilisation in our ICU. We designed a four-part quality improvement project comprising: an audit documenting the baseline frequency of mobilisation; a staff survey evaluating perceptions of the barriers to mobilisation; identification of barriers that were amenable to change and implementation of strategies to address these; and a follow-up audit to determine their effectiveness. The setting was a tertiary care, urban, public hospital ICU in South Australia. All patients admitted to the ICU during the two audit periods were included in the audits, while all permanent/semi-permanent ICU staff were eligible for inclusion in the staff survey. We found that patient- and institution-related factors had the greatest impact on the mobilisation of patients in our ICU. Barriers identified as being amenable to change included insufficient staff education about the benefits of mobilisation, poor interdisciplinary communication and lack of leadership regarding mobilisation. Various strategies were implemented to address these barriers over a three-month period. Multivariable analyses showed that three out of four mobility outcomes did not significantly change between the baseline and follow-up audits, with a significant difference in favour of the baseline audit found for the fourth mobility outcome (maximum level of mobility). We concluded that implementing relatively simple measures to improve staff education, interdisciplinary communication and leadership regarding early progressive mobilisation was ineffective at improving mobility outcomes for patients in a large tertiary-level Australian ICU. Other strategies, such as changing sedation practices and/or increasing staffing, may be required to improve mobility outcomes of these patients.
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Affiliation(s)
- S Dafoe
- Acute Care and surgery, Physiotherapy Department, Royal Adelaide Hospital, Adelaide, South Australia
| | - M J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia
| | - S Edwards
- Data Management and Analysis Centre, University of Adelaide, Adelaide, South Australia
| | - K Stiller
- Physiotherapy Department, Royal Adelaide Hospital, Adelaide, South Australia
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Harrold ME, Salisbury LG, Webb SA, Allison GT. Early mobilisation in intensive care units in Australia and Scotland: a prospective, observational cohort study examining mobilisation practises and barriers. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:336. [PMID: 26370550 PMCID: PMC4570617 DOI: 10.1186/s13054-015-1033-3] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 08/14/2015] [Indexed: 01/07/2023]
Abstract
Introduction Mobilisation of patients in the intensive care unit (ICU) is an area of growing research. Currently, there is little data on baseline mobilisation practises and the barriers to them for patients of all admission diagnoses. Methods The objectives of the study were to (1) quantify and benchmark baseline levels of mobilisation in Australian and Scottish ICUs, (2) compare mobilisation practises between Australian and Scottish ICUs and (3) identify barriers to mobilisation in Australian and Scottish ICUs. We conducted a prospective, observational, cohort study with a 4-week inception period. Patients were censored for follow-up upon ICU discharge or after 28 days, whichever occurred first. Patients were included if they were >18 years of age, admitted to an ICU and received mechanical ventilation in the ICU. Results Ten tertiary ICUs in Australia and nine in Scotland participated in the study. The Australian cohort had a large proportion of patients admitted for cardiothoracic surgery (43.3 %), whereas the Scottish cohort had none. Therefore, comparison analysis was done after exclusion of patients admitted for cardiothoracic surgery. In total, 60.2 % of the 347 patients across 10 Australian ICUs and 40.1 % of the 167 patients across 9 Scottish ICUs mobilised during their ICU stay (p < 0.001). Patients in the Australian cohort were more likely to mobilise than patients in the Scottish cohort (hazard ratio 1.83, 95 % confidence interval 1.38–2.42). However, the percentage of episodes of mobilisation where patients were receiving mechanical ventilation was higher in the Scottish cohort (41.1 % vs 16.3 %, p < 0.001). Sedation was the most commonly reported barrier to mobilisation in both the Australian and Scottish cohorts. Physiological instability and the presence of an endotracheal tube were also frequently reported barriers. Conclusions This is the first study to benchmark baseline practise of early mobilisation internationally, and it demonstrates variation in early mobilisation practises between Australia and Scotland.
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Affiliation(s)
- Meg E Harrold
- School of Physiotherapy and Exercise Science, Faculty of Health Science, Curtin University, GPO Box U1987, Perth, 6845, Australia. .,Intensive Care Unit and Physiotherapy Department, Royal Perth Hospital, Perth, Australia.
| | - Lisa G Salisbury
- School of Health in Social Science, University of Edinburgh, Edinburgh, UK.
| | - Steve A Webb
- Intensive Care Unit and Physiotherapy Department, Royal Perth Hospital, Perth, Australia. .,Department of Medicine and Pharmacology, University of Western Australia, Perth, Australia.
| | - Garry T Allison
- School of Physiotherapy and Exercise Science, Faculty of Health Science, Curtin University, GPO Box U1987, Perth, 6845, Australia. .,Intensive Care Unit and Physiotherapy Department, Royal Perth Hospital, Perth, Australia.
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Nydahl P, Dewes M, Dubb R, Filipovic S, Hermes C, Jüttner F, Kaltwasser A, Klarmann S, Klas K, Mende H, Rothaug O, Schuchhardt D. [Early mobilization. Competencies, responsibilities, milestones]. Med Klin Intensivmed Notfmed 2015; 111:153-9. [PMID: 26346679 DOI: 10.1007/s00063-015-0073-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 07/20/2015] [Accepted: 07/21/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Early mobilization is an evident, interprofessional concept to improve the outcome of intensive care patients. It reduces psychocognitive deficits and delirium and attenuates a general deconditioning, including atrophy of the respiratory pump and skeletal muscles. In this regard the interdisciplinary approach of early mobilization, taking into account different levels of mobilization, appears to be beneficial. The purpose of this study was to explore opinions on collaboration and tasks between different professional groups. METHOD During the 25th Bremen Conference on Intensive Medicine and Nursing on 20 February 2015, a questionnaire survey was carried out among the 120 participants of the German Early Mobilization Network meeting. RESULTS In all, 102 questionnaires were analyzed. Most participants reported on the interdisciplinarity of the approach, but none of the tasks and responsibilities concerning early mobilization can be assigned to a single professional group. The practical implementation of mobilizing orally intubated patients may require two registered nurses as well as a physical therapist. Implementation in daily practice seems to be heterogeneous. CONCLUSIONS There is no consensus regarding collaboration, competencies, and responsibilities with respect to early mobilization of intensive care patients. The approach to date has been characterized by a lack of interprofessional communication, which may lead to an inefficient use of the broad and varied base of knowledge and experienceof the different professions.
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Affiliation(s)
- P Nydahl
- Pflegeforschung, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Haus 31, Brunswiker Str. 10, 24105, Kiel, Deutschland.
| | - M Dewes
- Anästhesie und Intensivpflege, ALIAR - Association luxemburgeoise des Infirmier(e)s en Anästhesie et Réanimation, Dudelange, Luxemburg
| | - R Dubb
- Akademie der Kreiskliniken Reutlingen, Kreiskliniken Reutlingen GmbH, Steinenbergstr. 31, 72764, Reutlingen, Deutschland
| | - S Filipovic
- Abteilung Physiotherapie, Universitätsklinikum Gießen und Marburg (UKGM) Standort Marburg, Baldinger Straße, 35033, Marburg, Deutschland
| | - C Hermes
- Anästhesie und Intensivpflege, HELIOS Klinikum Siegburg, Ringstraße 49, 53721, Siegburg, Deutschland
| | - F Jüttner
- Anästhesie und Intensivpflege, Asklepios Klinik Langen, Röntgenstraße 20, 63325, Langen, Deutschland
| | - A Kaltwasser
- Akademie der Kreiskliniken Reutlingen, Kreiskliniken Reutlingen GmbH, Steinenbergstr. 31, 72764, Reutlingen, Deutschland
| | - S Klarmann
- Fachleitung Zentrale Einrichtung Physiotherapie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Haus 31, Brunswiker Str. 10, 24105, Kiel, Deutschland
| | - K Klas
- Gesundheits- und Krankenpflege, IMC Fachhochschule Krems, Am Campus Krems, 3500, Krems, Österreich
| | - H Mende
- Anästhesiologie & Intensivmedizin, Neurologische Intensivstation, Klinik für Neurologie, Christophsbad Göppingen, Faurndauerstrasse 6-28, 73035, Göppingen, Deutschland
| | - O Rothaug
- Intensiv- und Anästhesiepflege, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37077, Göttingen, Deutschland
| | - D Schuchhardt
- Zentrum für Anästhesie, Intensiv- und Notfallmedizin, Zentralklinik Bad Berka GmbH, Robert-Koch-Allee 9, 99437, Bad Berka, Deutschland
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Barriers to early mobility of hospitalized general medicine patients: survey development and results. Am J Phys Med Rehabil 2015; 94:304-12. [PMID: 25133615 DOI: 10.1097/phm.0000000000000185] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Functional status decline commonly accompanies hospitalization making patients vulnerable to complications. Such decline can be mitigated through hospital-based early mobility programs. Success in implementing patient mobility quality improvement processes requires evaluating providers' knowledge, attitudes, and behaviors. DESIGN A cross-sectional, self-administered survey in two different hospital settings was completed by 120 nurses and physical and occupational therapists (rehabilitation therapists, 38; nurses, 82) from six general medicine units. The survey was developed using published guidelines, literature review, and provider meetings and refined through pilot testing. Psychometric properties were assessed, and regression analyses were conducted to examine barriers to early mobility by hospital site, provider discipline, and years of experience. RESULTS Internal consistency reliability, item consistency, and discriminant validity psychometric characteristics were acceptable. In multivariable regression analysis, overall perceived barriers were similar between the two hospitals (P = 0.25) and significantly higher for staff with less experience (P = 0.02) and for nurses vs. rehabilitation therapists (P < 0.001).The survey identified specific barriers common to both nurses and rehabilitation therapists and other barriers that were discipline specific. CONCLUSIONS This novel survey identified important barriers to mobilizing medical inpatients that were similar across two hospital settings. These results can assist with the implementation of quality improvement projects for increasing early hospital-based patient mobility.
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Barber EA, Everard T, Holland AE, Tipping C, Bradley SJ, Hodgson CL. Barriers and facilitators to early mobilisation in Intensive Care: a qualitative study. Aust Crit Care 2014; 28:177-82; quiz 183. [PMID: 25533868 DOI: 10.1016/j.aucc.2014.11.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/24/2014] [Accepted: 11/27/2014] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To determine the barriers and facilitators of early mobilisation in the Intensive Care Unit. BACKGROUND It is well established that mobilising critically ill patients has many benefits, however it is not occurring as frequently as expected. The causes and ways to change this are not clearly understood. METHODS A qualitative descriptive study involving focus groups with medical, nursing and physiotherapy clinicians, from an Australian quaternary hospital Intensive Care Unit. RESULTS The major themes related to barriers included the culture of the Intensive Care Unit; communication; and a lack of resources. Major themes associated with facilitating early mobilisation included organisational change; improved communication between medical units; and improved resources. CONCLUSIONS Early mobilisation was considered an important aspect of critically ill patient's care by all clinicians. Several major barriers to mobilisation were identified, which included unit culture, lack of resources, prioritisation and leadership. A dedicated mobility team led by physiotherapists in the ICU setting could be a viable option to address the identified barriers related to mobility.
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Affiliation(s)
| | | | | | | | | | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Australia; The Alfred, Australia.
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Jolley SE, Regan-Baggs J, Dickson RP, Hough CL. Medical intensive care unit clinician attitudes and perceived barriers towards early mobilization of critically ill patients: a cross-sectional survey study. BMC Anesthesiol 2014; 14:84. [PMID: 25309124 PMCID: PMC4192294 DOI: 10.1186/1471-2253-14-84] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 09/25/2014] [Indexed: 01/22/2023] Open
Abstract
Background Early mobilization (EM) of patients on mechanical ventilation (MV) is shown to improve outcomes after critical illness. Little is known regarding clinician knowledge of EM or multi-disciplinary barriers to use of EM in the intensive care unit (ICU). The goal of this study was to assess clinician knowledge regarding EM and identify barriers to its provision. Methods Simultaneous cross-sectional surveys of medical ICU (MICU) nurses (RN)/physical therapists (PT) respondents and physician (MD) respondents in a single MICU at an academic hospital in Seattle, WA in 2010–2011. Responses were indicated on a 5 point Likert scale and reported as proportion of respondents agreeing or disagreeing. Chi-square testing and Fisher’s exact testing was performed to determine whether responses differed by duration of employment or prior EM experience. Results A total of 120 clinicians responded to the survey (91 MDs (response rate 82% (91/111)), 17 RNs (response rate 22%, (17/78)), and 12 PTs (response rate 86%, (12/14)), overall response rate 86%). Most clinicians indicated knowledge regarding benefits of EM. More attending physicians reported knowledge of EM benefits, but also that risks of EM outweigh the benefits compared to trainees (p = 0.02 and 0.01). Clinicians across disciplines reported near universal agreement to use of EM for patients on MV, while the minority reported agreement to EM for patients on vasoactive agents. The most frequently reported cross-disciplinary barriers to EM were staffing and time. Risk of self-injury and excess work stress were indicated as barriers by RN and PT respondents. Conclusions MICU clinicians, at our institution, reported knowledge of EM in the ICU. Staffing and clinician time were frequently identified cross-disciplinary barriers. Risk of self-injury and excess work stress were frequently reported RN and PT barriers. Electronic supplementary material The online version of this article (doi:10.1186/1471-2253-14-84) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah E Jolley
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA USA ; Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Campus Box 356522, Seattle, WA 98195-6522 USA
| | | | - Robert P Dickson
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA USA
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Clements L, Moore M, Tribble T, Blake J. Reducing Skin Breakdown in Patients Receiving Extracorporeal Membranous Oxygenation. Nurs Clin North Am 2014; 49:61-8. [DOI: 10.1016/j.cnur.2013.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Understanding critically ill patients hemodynamic response to mobilization: using the evidence to make it safe and feasible. Crit Care Nurs Q 2013; 36:17-27. [PMID: 23221438 DOI: 10.1097/cnq.0b013e3182750767] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In today's critical care environment, we face a difficult but essential task. We must provide comprehensive, compassionate, complex, technological care without causing harm to our patients. To foster a patient-safe environment, we must examine care practices and processes to reduce the chance of error. Successful early mobilization of critically ill patients can reduce several complications including atelectasis and ventilator-associated pneumonia and shorten ventilator time along with cognitive and functional limitations that linger 1 to 5 years after discharge from the intensive care unit. A long-standing challenge to successful mobilization of critically ill patients is the safety concern of hemodynamic instability. An in-depth exploration of what happens to a critically ill patient physiology during mobilization was done to foster a better understanding of strategies that promote adaptation. The article examines the evidence supporting the need to assess readiness for mobilization to reduce the risk of adverse events. Evidence-based tools and techniques to help clinicians prevent hemodynamic instability before, during, and after in-bed or out-of-bed mobilization are discussed. With safety serving as the overriding goal, we can overcome the barriers and succeed in creating and sustaining a culture of early progressive mobility programs within the intensive care unit.
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Turning and Repositioning the Critically Ill Patient With Hemodynamic Instability. J Wound Ostomy Continence Nurs 2013; 40:254-67. [DOI: 10.1097/won.0b013e318290448f] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Prise en charge de la mobilisation précoce en réanimation, chez l’adulte et l’enfant (électrostimulation incluse). ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s13546-013-0658-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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TAKIGUCHI C, INOUE T, SASAKI Y. The Structure of Nurses’ Function to Coordinate a Multi-professional Team in the Management of Patients with an Artificial Ventilator. ACTA ACUST UNITED AC 2013. [DOI: 10.11153/jaccn.9.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Grap MJ, McFetridge B. Critical care rehabilitation and early mobilisation: an emerging standard of care. Intensive Crit Care Nurs 2012; 28:55-7. [PMID: 22445174 DOI: 10.1016/j.iccn.2012.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 02/11/2012] [Indexed: 11/17/2022]
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Abstract
A significant portion of critical care patients experience delirium. This form of acute brain dysfunction is associated with increased hospital stay, increased mortality, and greater long-term cognitive deficits. Critical care nurses are on the frontline with these patients and can make a significant impact on patient outcomes, including reducing the negative outcomes and experience of delirium. It is, therefore, imperative that nurses be equipped with a solid knowledge base of understanding delirium, which includes what has been reported specifically unique to delirium in the intensive care unit. This article will provide an overview of delirium and describe an interdisciplinary model of care combining multiple evidence-based practice strategies that nurses can and should use to help systematically reduce modifiable delirium risk factors. In addition, this article will provide an overview of recent reports concerning pharmacologic management of delirium in the intensive care unit.
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Affiliation(s)
- Brenda T Pun
- Vanderbilt University School of Nursing, Department of Medicine, Division of Allergy/Pulmonary/Critical Care Medicine, and Center for Health Services Research, 1215 21st Ave S, Nashville, TN 37232, USA.
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