Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units

Dubb, Rolf; Nydahl, Peter; Hermes, Carsten; Schwabbauer, Norbert; Toonstra, Amy; Parker, Ann M.; Kaltwasser, Arnold; Needham, Dale M.

doi:10.1513/annalsats.201509-586cme

Cited by 306 publications

(209 citation statements)

References 56 publications

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“…According to the results of this study, it is recommended that CPT should be incorporated into ICU patient care. Historically, early mobilization in the ICU is limited due to safety concerns . However, an increasing number of studies have indicated that early CPT for ICU patients can improve patient prognosis and post‐ICU QOL.…”

Section: Discussionmentioning

confidence: 99%

Chest physiotherapy with early mobilization may improve extubation outcome in critically ill patients in the intensive care units

Wang

2018

Clinical Respiratory J

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Background: Extubation failure can lead to a longer intensive care unit (ICU) stay, higher mortality rate, and higher risk of requiring tracheostomy. Chest physiotherapy (CPT) can help patients in reducing the accumulation of airway secretion, preventing collapsed lung, improving lung compliance, and reducing comorbidities. Much research has investigated the correlation between CPT and respiratory system clearance. However, few studies have investigated the correlation between CPT and failed ventilator extubation. Therefore, this study aimed to investigate the use of CPT for reducing the rate of failed removal from mechanical ventilators. Methods: This study was an intervention study with mechanical control. Subjects were divided into two groups. The control group, which received routine nursing chest care, was selected from a retrospective chart review. The intervention group was prospectively taken into the chest physiotherapy program. The chest physiotherapy treatment protocol consisted of inspiratory muscle training, manual hyperinflation, chest wall mobilization, secretion removal, cough function training, and early mobilization. Results: A total of 439 subjects were enrolled in the intervention and control groups, with a mean age of 69 years. APACHE II score (P = .09) and GCS scores (P = .54) were similar between the two groups. Compared to the control group, patients in the intervention group had a significantly lower reintubation rate (8% vs 16%; P = .01). Conclusions:The results indicate that intensive chest physiotherapy could decrease extubation failure in mechanically ventilated patients in the ICU. In addition, chest physiotherapy could also significantly improve the rapid shallow breathing index score.

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Section: Discussionmentioning

confidence: 99%

Chest physiotherapy with early mobilization may improve extubation outcome in critically ill patients in the intensive care units

Wang

2018

Clinical Respiratory J

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“…Despite the demonstrated positive impact of PT, point of prevalence estimates show that mobility practice is not a priority for a number of ICUs (for reviews, see Cameron et al 70 and Hodgson et al 71 ). The reasons for low rates of PT practice were recently reviewed and classified as being patient‐related (50%), structural (18%), ICU cultural (18%), and process‐related (14%) barriers 72 . These authors stated, “To overcome the identified barriers .…”

Section: Physical Therapymentioning

confidence: 99%

“…. 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.” 72 Of relevance to the focus of the current review, it is posited that aside from the positive outcomes associated with early mobilization of ICU patients, 70 , 71 PT and early mobilization could also result in a small but measurable sensitization of skeletal muscle to aminoacidemia. The sensitization of skeletal muscle to amino acids would be important in highly immobile patients.…”

Section: Physical Therapymentioning

confidence: 99%

Protein Turnover and Metabolism in the Elderly Intensive Care Unit Patient

et al. 2017

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Many intensive care unit (ICU) patients do not achieve target protein intakes particularly in the early days following admittance. This period of iatrogenic protein undernutrition contributes to a rapid loss of lean, in particular muscle, mass in the ICU. The loss of muscle in older (aged >60 years) patients in the ICU may be particularly rapid due to a perfect storm of increased catabolic factors, including systemic inflammation, disuse, protein malnutrition, and reduced anabolic stimuli. This loss of muscle mass has marked consequences. It is likely that the older patient is already experiencing muscle loss due to sarcopenia; however, the period of stay in the ICU represents a greatly accelerated period of muscle loss. Thus, on discharge, the older ICU patient is now on a steeper downward trajectory of muscle loss, more likely to have ICU-acquired muscle weakness, and at risk of becoming sarcopenic and/or frail. One practice that has been shown to have benefit during ICU stays is early ambulation and physical therapy (PT), and it is likely that both are potent stimuli to induce a sensitivity of protein anabolism. Thus, recommendations for the older ICU patient would be provision of at least 1.2-1.5 g protein/kg usual body weight/d, regular and early utilization of ambulation (if possible) and/or PT, and follow-up rehabilitation for the older discharged ICU patient that includes rehabilitation, physical activity, and higher habitual dietary protein to change the trajectory of ICU-mediated muscle mass loss and weakness.

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“…Although it may be difficult to observe similarities in barriers when comparing individual studies, the use of a conceptual framework such as CFIR allows implementation researchers to classify barriers into major domains and themes. As Table 1 [10 ▪▪ ,38 ▪▪ ,39 ▪▪ ,40–42 ▪ ,48 ▪▪ ,49 ▪▪ ,53 ▪▪ ]demonstrates, the recent literature has identified a multitude of barriers that fall within all five CFIR domains, although most studies have investigated barriers in the inner setting and individuals domains. Having a systematically derived catalog of barriers allows implementation researchers and clinicians to design and evaluate implementation strategies that are targeted correctly, allowing for the greatest chance of success in improving the adoption of evidence-based practice.…”

Section: Resultsmentioning

confidence: 99%

“…Potential facilitators of early mobilization included CFIR inner setting characteristics such as multidisciplinary rounds, daily patient goals, dedicated physiotherapists, and higher nurse staffing ratios. Dubb et al [42 ▪ ] conducted a review of 40 studies reporting barriers to early mobilization, finding 28 barriers. These barriers encompassed CFIR outer setting (e.g., patient-related barriers such as condition and symptoms), inner setting (e.g., barriers such as ICU culture and structural issues such as resources, staffing, and protocol), individuals (e.g., attitudes), and process (e.g., planning and coordination).…”

Section: Bundled Management Of Mechanically Ventilated Patientsmentioning

confidence: 99%

Why do we fail to deliver evidence-based practice in critical care medicine?

Weiss

2017

Current Opinion in Critical Care

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Purpose of review The use of evidence-based practices in clinical practice is frequently inadequate. Recent research has uncovered many barriers to the implementation of evidence-based practices in critical care medicine. Using a comprehensive conceptual framework, this review identifies and classifies the barriers to implementation of several major critical care evidence-based practices. Recent findings The many barriers that have been recently identified can be classified into domains of the consolidated framework for implementation research (CFIR). Barriers to the management of patients with acute respiratory distress syndrome (ARDS) include ARDS under-recognition. Barriers to the use of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility (ABCDE) bundle for mechanically ventilated patients and the sepsis bundle include patient-related, clinician-related, protocol-related, contextual-related, and intervention-related factors. Although these many barriers can be classified into all five CFIR domains (intervention, outer setting, inner setting, individuals, and process), most barriers fall within the individuals and inner setting domains. Summary There are many barriers to the implementation of evidence-based practice in critical care medicine. Systematically classifying these barriers allows implementation researchers and clinicians to design targeted implementation strategies, giving them the greatest chance of success in improving the use of evidence-based practice.

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Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units

Cited by 306 publications

References 56 publications

Chest physiotherapy with early mobilization may improve extubation outcome in critically ill patients in the intensive care units

Chest physiotherapy with early mobilization may improve extubation outcome in critically ill patients in the intensive care units

Protein Turnover and Metabolism in the Elderly Intensive Care Unit Patient

Why do we fail to deliver evidence-based practice in critical care medicine?

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