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

Willigen, Zoe van; Collings, Nikki; Richardson, D. L.; Cusack, Rhodri

doi:10.1136/bmjquality.u211734.w4726

Cited by 11 publications

(14 citation statements)

References 26 publications

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“…However, their study did not describe the actual improvements in mobilization scores achieved. In a study from the UK, van Willigen et al 29 were able to demonstrate the success of an ICU-based QI program in shortening the time to first mobilization and in decreasing length of stay. While they used a predominantly education and engagement-based approach, our intervention consisted of nurse-based screening for eligibility, simple bedside placards indicating readiness, physician opt out, and goal-based physiotherapy with daily targets for improving the mobilization score.…”

Section: Discussionmentioning

confidence: 99%

Improving Mobility in Critically Ill Patients in a Tertiary Care ICU: Opportunities and Challenges

Mohan

Patodia

Kumaravel

et al. 2021

Indian Journal of Critical Care Medicine

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A bstract Background Patients in the intensive care unit (ICU) are subjected to prolonged bed rest secondary to critical illness and related therapies. Data suggest that such bed rest can have adverse consequences on the post-discharge quality of life. There is limited data from India on mobilization practices. We undertook a quality improvement (QI) initiative to understand our mobilization practices, identify challenges, and test interventions. Materials and methods We carried out a three-phase QI project, and the study was conducted in our 24-bedded ICU. Pre-intervention and post-intervention mobilization performance and scores were analyzed. We also recorded data on adverse events and barriers to mobilization. Descriptive statistics were used to report all the results. Results A total of 140 patients (1,033 patient days) and 207 patients (932 patient days) were included in our initial audit and post-implementation audit, respectively. In pre-implementation, 31.3% of patients were mobilized with an average mobility score of 2 and this improved to 57.9% with average mobility score of 3.4. Additionally, we demonstrated improvements in the mobility scores of our intubated patients (49.8% achieving a mobility score of 3–5 as compared to 16.7%). Conclusion A multidisciplinary approach is feasible and resulted in significant improvements in early mobilization among critically ill adults. How to cite this article Mohan S, Patodia S, Kumaravel S, Venkataraman R, Vijayaraghavan BKT. Improving Mobility in Critically Ill Patients in a Tertiary Care ICU: Opportunities and Challenges. Indian J Crit Care Med 2021;25(1):34–42.

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Section: Discussionmentioning

confidence: 99%

Improving Mobility in Critically Ill Patients in a Tertiary Care ICU: Opportunities and Challenges

Mohan

Patodia

Kumaravel

et al. 2021

Indian Journal of Critical Care Medicine

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“…A number of different methods of passive mechanical loading of muscle in critically ill patients have been used and report reduce wasting, increase muscle strength and being associated with reduced ventilation days and shorter hospital length of stay [23][24][25][26]. In bed cycle ergometry is one method of delivering passive muscle loading and on our unit, the early rehabilitation programme has resulted in reduced ventilation days and hospital length of stay [27].…”

Section: Discussionmentioning

confidence: 99%

An observational feasibility study - does early limb ergometry affect oxygen delivery and uptake in intubated critically ill patients – a comparison of two assessment methods

2021

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Background Early rehabilitation can reduce ventilation duration and improve functional outcomes in critically ill patients. Upper limb strength is associated with ventilator weaning. Passive muscle loading may preserve muscle fibre function, help recover peripheral muscle strength and improve longer term, post-hospital discharge function capacity. The physiological effects of initiating rehabilitation soon after physiological stabilisation of these patients can be concerning for clinicians. This study investigated the feasibility of measuring metabolic demand and the safety and feasibility of early upper limb passive ergometry. An additional comparison of results, achieved from simultaneous application of the methods, is reported. Methods This was an observational feasibility study undertaken in an acute teaching hospital’s General Intensive Care Unit in the United Kingdom. Twelve haemodynamically stable, mechanically ventilated patients underwent 30 minutes of arm ergometry. Cardiovascular and respiratory parameters were monitored. A Friedman test identified changes in physiological parameters. A metabolic cart was attached to the ventilator to measure oxygen uptake. Oxygen uptake was concurrently calculated by the reverse Fick method, utilising cardiac output from the LiDCO™ and paired mixed venous and arterial samples. A comparison of the two methods was made. Data collection began 10 minutes before ergometry and continued to recovery. Paired mixed venous and arterial samples were taken every 10 minutes. Results Twelve patients were studied; 9 male, median age 55 years, range (27–82), median APACHE score 18.5, range (7–31), median fraction inspired oxygen 42.5%, range (28–60). Eight patients were receiving noradrenaline. Mean dose was 0.07 mcg/kg/min, range (0.01–0.15). Early ergometry was well tolerated. There were no clinically significant changes in respiratory, haemodynamic or metabolic variables pre ergometry to end recovery. There was no significant difference between the two methods of calculating VO2 (p = 0.70). Conclusions We report the feasibility of using the reverse Fick method and indirect calorimetry to measure metabolic demand during early physical rehabilitation of critically ill patients. More research is needed to ascertain the most reliable method. Minimal change in metabolic demand supports the safety and feasibility of upper limb ergometry. These results will inform future study designs for further research into exercise response in critically ill patients. Trial Registration Clinicaltrials.gov No. NCT04383171. Registered on 06 May 2020 - Retrospectively registered. http://www.clinicaltrials.gov.

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“…Possible advantages of having a permanent physiotherapist in ICU is that it promotes standardization of practice, improvement in knowledge of the physiotherapist in ICU related matters, and sustainability of intervention programs. It is known that high staff turnover rates result in unsustainable interventions as in the case of early mobilization programmes 46,47 . Creation of static posts in the ICU for physiotherapists may result in greater availability of champion leaders who become key persons in the provision of patient care and should be advocating for early mobilization through their re‐training of other colleagues 48 .…”

Section: Discussionmentioning

confidence: 99%

“…In most units, there was a shortage of competent staff to safely perform out‐of‐bed patient mobilization as this is a highly demanding task that requires extensive time to plan for its execution, enough members of staff with the relevant clinical skills and the availability of suitable equipment 29,49,50 . Increased numbers of staff in ICU or the introduction of a new staff member dedicated to ICU mobilization and with access to mobilization equipment, may improve the rates and levels of active exercise therapy and out‐of‐bed mobilization of patients in public sector SA ICU settings 46,47,51 …”

Section: Discussionmentioning

confidence: 99%

Organizational structures and early mobilization practices in South African public sector intensive care units—A cross‐sectional study

Tadyanemhandu

Aswegen

Ntsiea

2020

Evaluation Clinical Practice

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Rationale Understanding current early mobilization practice of patients in intensive care unit (ICU) is critical to the design and implementation of strategies to facilitate its application in a diverse population of critically ill patients encountered in public sector hospitals. Aim To evaluate the organizational structures of South African public sector hospital ICUs and to describe early mobilization practices in these units. Methods A cross‐sectional survey was done in participating public hospitals from eight provinces in South Africa. Convenience sampling was done. Data collected included hospital and ICU structure, adult patient demographic and clinical data, and mobilization activities done in ICU over the previous 24 hours prior to the day of the survey. Results A total of 29 ICUs from 13 participating hospitals were surveyed resulting in 205 patient records. Majority of the surveyed ICUs were “open” type (n = 16; 55.2%). A standardized sedation scoring system was used in 18 units (62.1%) and only two units (6.9%) had an early mobilization protocol in place. Mean age of the patients surveyed was 43.5 (±17.7) years and 148 (72.2%) patients were on mechanical ventilation. Primary reasons for admission to ICU included traumatic injury (n = 86; 42%) and postoperative care (n = 33; 16.1%). Mobilization activities performed in the previous 24 hours included turning the patient in bed (n = 88; 42.9%), marching on the spot (n = 9; 4.4%) and walking (n = 10; 4.9%). Out‐of‐bed mobilization was done in only 40 (19.5%) patients. The most common barriers to early mobilization included patient unresponsiveness (n = 50; 24.4%) and hemodynamic instability (n = 42; 20.5%). The type of ventilation was found to have a significant positive relationship with out‐of‐bed patient mobilization (P = .000). Conclusions A small proportion of patients attained their highest level of mobilization in ICU. The type of ventilation influenced early mobilization practices in public sector ICUs in South Africa.

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

Cited by 11 publications

References 26 publications

Improving Mobility in Critically Ill Patients in a Tertiary Care ICU: Opportunities and Challenges

Improving Mobility in Critically Ill Patients in a Tertiary Care ICU: Opportunities and Challenges

An observational feasibility study - does early limb ergometry affect oxygen delivery and uptake in intubated critically ill patients – a comparison of two assessment methods

Organizational structures and early mobilization practices in South African public sector intensive care units—A cross‐sectional study

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