Implementation of an Early Mobility Pathway in Neurointensive Care Unit Patients With External Ventricular Devices

Moyer, Megan; Young, Bethany; Wilensky, Eileen Maloney; Borst, Joseph; Pino, William; Hart, Marisa; LoBreglio, Jesse; Zaleski, Derek; Leonor, Isaira; Kung, David; Smith, Michelle M.; Zager, Eric L.; Grady, M. Sean; Kumar, Monisha A.

doi:10.1097/jnn.0000000000000258

Cited by 31 publications

(48 citation statements)

References 4 publications

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“…However, to minimize the contribution of immobilization on complication rate, early mobilization protocols could be beneficial and appear to be safe [38,61,62]. Probably, the beneficial effect only applies to complications with a strong correlation to immobilization.…”

Section: Medical Complications and Their Relation To External Csf Dramentioning

confidence: 99%

Complications of external cerebrospinal fluid drainage in aneurysmal subarachnoid haemorrhage

et al. 2021

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Background The need for external cerebrospinal fluid (CSF) drains in aneurysmal subarachnoid haemorrhage (aSAH) patients is common and might lead to additional complications. Objective A relation between the presence of an external CSF drain and complication risk is investigated. Methods A prospective complication registry was analysed retrospectively. We included all adult aSAH patients admitted to our academic hospital between January 2016 and January 2018, treated with an external CSF drain. Demographic data, type of external drain used, the severity of the aSAH and complications, up to 30 days after drain placement, were registered. Complications were divided into (1) complications with a direct relation to the external CSF drain and (2) complications that could not be directly related to the use of an external CSF drain referred to as medical complications Results One hundred and forty drains were implanted in 100 aSAH patients. In total, 112 complications occurred in 59 patients. Thirty-six complications were drain related and 76 were medical complications. The most common complication was infection (n = 34). Drain dislodgement occurred 16 times, followed by meningitis (n = 11) and occlusion (n = 9). A Poisson model showed that the mean number of complications raised by 2.9% for each additional day of drainage (95% CI: 0.6–5.3% p = 0.01). Conclusion Complications are common in patients with aneurysmal subarachnoid haemorrhage of which 32% are drain-related. A correlation is present between drainage period and the number of complications. Therefore, reducing drainage period could be a target for further improvement of care.

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Section: Medical Complications and Their Relation To External Csf Dramentioning

confidence: 99%

Complications of external cerebrospinal fluid drainage in aneurysmal subarachnoid haemorrhage

et al. 2021

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“…Subjects for Phases I and II were prospectively identified from an IRB-approved cohort of SAH patients admitted to the Neuro ICU between 2014 and 2016. Phase I lasted for 12 months, from 2014 to 2015, and was characterized by use of a PT/OT-driven protocol [13]. Mobilization occurred only during formal PT/OT sessions with continuous presence of both the therapist and the bedside nurse.…”

Section: Phase Imentioning

confidence: 99%

“…Although mobilizing patients with invasive devices carries inherent risk, the consequences of prolonged bed rest, including significant muscle wasting and reduced functional status, are profound [23,24]. Recent literature has demonstrated that early mobilization in the ICU can be a safe and feasible intervention, with few adverse events recorded [7,13]. Both therapy-driven and nursedriven protocols have been studied with similar safety outcomes [5,19,[25][26][27][28][29][30][31][32][33][34].…”

Section: Safety/complicationsmentioning

confidence: 99%

Safety and Feasibility of Early Mobilization in Patients with Subarachnoid Hemorrhage and External Ventricular Drain

et al. 2019

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Background/objective: In November 2014, our Neurointensive Care Unit began a multi-phased progressive early mobilization initiative for patients with subarachnoid hemorrhage and an external ventricular drain (EVD). Our goal was to transition from a culture of complete bed rest (Phase 0) to a physical and occupational therapy (PT/OT)-guided mobilization protocol (Phase I), and ultimately to a nurse-driven mobilization protocol (Phase II). We hypothesized that nurses could mobilize patients as safely as an exclusively PT/OT-guided approach. Methods: In Phase I, patients were mobilized only with PT/OT at bedside; no independent time out of bed occurred. In Phase II, nurses independently mobilized patients with EVDs, and patients could remain out of bed for up to 3 h at a time. Physical and occupational therapists continued routine consultation during Phase II. Results: Phase II patients were mobilized more frequently than Phase I patients [7.1 times per ICU stay (± 4.37) versus 3.0 times (± 1.33); p = 0.02], although not earlier [day 4.9 (± 3.46) versus day 6.0 (± 3.16); p = 0.32]. All Phase II patients were discharged to home PT services or acute rehabilitation centers. No patients were discharged to skilled nursing or long-term acute care hospitals, versus 12.5% in Phase I. In a multivariate analysis, odds of discharge to home/rehab were 3.83 for mobilized patients, independent of age and severity of illness. Other quality outcomes (length of stay, ventilator days, tracheostomy placement) between Phase I and Phase II patients were similar. No adverse events were attributable to early mobilization. Conclusions: Nurse-driven mobilization for patients with EVDs is safe, feasible, and leads to more frequent ambulation compared to a therapy-driven protocol. Nurse-driven mobilization may be associated with improved discharge disposition, although exact causation cannot be determined by these data.

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“…Recent studies support the safety and feasibility of progressive mobility from in-bed activity to out of bed and walking in NCCU patients with external ventricular drainage (EVD) [14][15][16]. In nearly all reports, progressive mobility interventions begin at the time that patients demonstrate arousal, awareness and are able to follow motor commands, resulting in significant delays until mobility interventions can be implemented, if at all [17][18][19].…”

Section: Discussionmentioning

confidence: 99%

Physiological Responses to In-Bed Cycle Ergometry Treatment in Intensive Care Unit Patients with External Ventricular Drainage

et al. 2021

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Evidence suggests that early physical activity can be accomplished safely in the neurocritical care unit (NCCU); however, many NCCU patients are often maintained in a state of inactivity due to impaired consciousness, sensorimotor deficits, and concerns for intracranial pressure elevation or cerebral hypoperfusion in the setting of autoregulatory failure. Structured in-bed mobility interventions have been proposed to prevent sequelae of complete immobility in such patients, yet the feasibility and safety of these interventions is unknown. We studied neurological and hemodynamic changes before and after cycle ergometry (CE) in a subset of NCCU patients with external ventricular drains (EVDs).Methods: Patients admitted to the NCCU who had an EVD placed for cerebrospinal fluid drainage and intracranial pressure (ICP) monitoring underwent supine CE therapy with passive and active cycling settings. Neurologic status, ICP and hemodynamic parameters were monitored before and after each CE session.Results: Twenty-seven patients successfully underwent in-bed CE in the NCCU. No clinically significant changes were recorded in neurologic or in physiological parameters before or after CE. There were no device dislodgements or other adverse effects requiring cessation of a CE session. Conclusion:These data suggest that supine CE in a heterogeneous cohort of neurocritical care patients with EVDs is safe and tolerable. Larger prospective studies are needed to determine the efficacy and optimal dose and timing of supine CE in neurocritical care patients.

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Implementation of an Early Mobility Pathway in Neurointensive Care Unit Patients With External Ventricular Devices

Abstract: The mobilization of patients with EVDs is safe and feasible; it may be associated with earlier mobilization, reduced ICU LOS, and better discharge disposition. No major complications were attributable to early mobilization.

Cited by 31 publications

References 4 publications

Complications of external cerebrospinal fluid drainage in aneurysmal subarachnoid haemorrhage

Complications of external cerebrospinal fluid drainage in aneurysmal subarachnoid haemorrhage

Safety and Feasibility of Early Mobilization in Patients with Subarachnoid Hemorrhage and External Ventricular Drain

Physiological Responses to In-Bed Cycle Ergometry Treatment in Intensive Care Unit Patients with External Ventricular Drainage

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