Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: A quality improvement project

McWilliams, David; Weblin, Jonathan; Atkins, Gemma; Bion, Julian; Williams, Jenny; Elliott, Catherine; Whitehouse, Tony; Snelson, Catherine

doi:10.1016/j.jcrc.2014.09.018

Cited by 119 publications

(109 citation statements)

References 24 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…There was a median of one ICU (IQR, 1-3) present in the hospitals surveyed. There were a median of 13 ICU beds (IQR, [9][10][11][12][13][14][15][16][17][18][19][20]. Most ICUs were mixed medical-surgical units (67% overall), and 27% were medical ICUs.…”

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices. An International Survey

Bakhru¹,

et al. 2016

View full text Add to dashboard Cite

Rationale: Early mobilization (EM) improves outcomes for mechanically ventilated patients. Variation in structure and organizational characteristics may affect implementation of EM practices.Objectives: We queried intensive care unit (ICU) environment and standardized ICU practices to evaluate organizational characteristics that enable EM practice. Methods:We recruited 151 ICUs in France, 150 in Germany, 150 in the United Kingdom, and 500 in the United States by telephone. Survey domains included respondent characteristics, hospital and ICU characteristics, and ICU practices and protocols. Measurements and Main Results:We surveyed 1,484 ICU leaders and received a 64% response rate (951 ICUs). Eighty-eight percent of respondents were in nursing leadership roles; the remainder were physiotherapists. Surveyed ICUs were predominantly mixed medicalsurgical units (67%), and 27% were medical ICUs. ICU staffing models differed significantly (P , 0.001 each) by country for high-intensity staffing, nurse/patient ratios, and dedicated physiotherapists. ICU practices differed by country, with EM practices present in 40% of French ICUs, 59% of German ICUs, 52% of U.K. ICUs, and 45% of U.S. ICUs. Formal written EM protocols were present in 24%, 30%, 20%, and 30%, respectively, of those countries' ICUs. In multivariate analysis, EM practice was associated with multidisciplinary rounds (odds ratio [OR], 1.77; P = 0.001), setting daily goals for patients (OR, 1.62; P = 0.02), presence of a dedicated physiotherapist (OR, 2.48; P , 0.001), and the ICU's being located in Germany (reference, United States; OR, 2.84; P , 0.001). EM practice was also associated with higher nurse staffing levels (1:1 nurse/patient ratio as a reference; 1:2 nurse/patient ratio OR, 0.59; P = 0.05; 1:3 nurse/patient ratio OR, 0.33; P = 0.005; 1:4 or less nurse/patient ratio OR, 0.37; P = 0.005). Those responding rarely cited ambulation of mechanically ventilated patients, use of a bedside cycle, or neuromuscular electrical stimulation as part of their EM practice. Physical therapy initiation, barriers to EM practice, and EM equipment were highly variable among respondents. Conclusions:International ICU structure and practice is quite heterogeneous, and several factors (multidisciplinary rounds, setting daily goals for patients, presence of a dedicated physiotherapist, country, and nurse/patient staffing ratio) are significantly associated with the practice of EM. Practice and barriers may be far different based upon staffing structure. To achieve successful implementation, whether through trials or quality improvement, ICU staffing and practice patterns must be taken into account.

show abstract

Section: Resultsmentioning

confidence: 99%

“…Pioneering studies have demonstrated the feasibility and safety of early exercise, particularly in patients with respiratory failure undergoing mechanical ventilation (MV) (3)(4)(5)(6)(7)(8)(9)(10). Prospective trials, most conducted in single centers in U.S. and Australian intensive care units (ICUs), have yielded mixed outcomes.…”

mentioning

confidence: 99%

Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices. An International Survey

Bakhru¹,

et al. 2016

View full text Add to dashboard Cite

show abstract

“…Few centres achieve Hodgson's definition of early mobilisation within 2-5 days10 16 27. Our QI project has enabled patients to mobilise out of bed within the first five days of their intensive care stay and to be discharged earlier from the ICU.…”

Section: Resultsmentioning

confidence: 99%

Quality improvement: The delivery of true early mobilisation in an intensive care unit

Willigen

Collings

Richardson

et al. 2016

BMJ Qual Improv Report

View full text Add to dashboard Cite

Early mobilisation initiatives within the critical care environment have been shown to improve outcomes for patients. Early mobilisation has been defined as occurring within the first two to five days of the intensive care stay, but in practice this can be difficult to deliver.We conducted a quality improvement (QI) project to deliver early mobilisation in a large general intensive care unit. Mechanically ventilated medical patients received an integrated package of care involving two additional daily sessions of mobility therapy, in combination with minimal sedation where possible.Prospective baseline data was collected from January to March 2012; the QI project commenced in April 2012. Improvement cycle 1 completed in March 2015 and improvement cycle 2 in March 2016. Results have suggested a reduction in time to first mobilisation for intensive care survivors from 16.3 days in 2012, to 4.3 days at the end of improvement cycle 2. This was associated with a decrease in mean intensive care length of stay from 20.8 days in 2012, to 11.2 days at the end of improvement cycle 2.This QI project enabled patients to mobilise out of bed within the first five days of their intensive care stay and to be discharged earlier from the ICU, on going analysis is required to verify these findings.

show abstract

“…Early interventions have shown to reduce hospital length of stay,11 reduce mortality12–14 and improve long-term functional outcomes 15. QEHB replicated these findings after formally introducing an ‘ early rehabilitation team ’ in 2012 16. Examples include early (sometimes while ventilated) physiotherapy-led mobilisation, comprising sitting on the edge of the bed, sitting out and walking.…”

Section: Early Rehabilitationmentioning

confidence: 98%

Lessons learned from early rehabilitation of complex trauma at the Royal Centre for Defence Medicine

Pope

Vickerstaff

Wareham³

2016

J R Army Med Corps

View full text Add to dashboard Cite

During the recent conflicts in Iraq and Afghanistan, substantial numbers of service personnel survived devastating injuries, presenting significant challenges for early rehabilitation at Queen Elizabeth Hospital Birmingham. Royal Centre for Defence Medicine personnel augmented NHS therapy provision, gaining significant experience in rehabilitating complex trauma. Multidisciplinary working was key to delivering this service, with a unique rehabilitation coordinating officer position established to manage the rehabilitation pathway. A military exercise rehabilitation instructor provided daily gym-based rehabilitation, developing exercise tolerance. Emphasis was placed on early independence, reducing pain, eliminating complications and optimising function. Innovative solutions and non-standard combinations of rehabilitation were required, with therapy working practices redesigned that, we believe, exceed provision elsewhere, including novel applications such as unique patient transfers, specialist seating, additional equipment, problem-solving teaching and early upper limb prosthetic provision. Active pain management allowed engagement in rehabilitation. With limited evidence available, therapeutic modalities attempting to alleviate phantom limb pain centred on patients' ability to engage in treatment. Finally, the requirement to measure change in early trauma rehabilitation was identified, leading to the development of the preprosthetic functional outcome measure. This article aims to document advances made, lessons learned, encourage debate and identify priorities for future research for military complex trauma rehabilitation.

show abstract

Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: A quality improvement project

Abstract: A quality improvement strategy to promote early and enhanced rehabilitation within this European ICU improved levels of mobility at critical care discharge, and this was associated with reduced ICU and hospital LOS and reduced days of mechanical ventilation.

Cited by 119 publications

References 24 publications

Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices. An International Survey

Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices. An International Survey

Quality improvement: The delivery of true early mobilisation in an intensive care unit

Lessons learned from early rehabilitation of complex trauma at the Royal Centre for Defence Medicine

Contact Info

Product

Resources

About