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

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 medical-surgical 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.

An Environmental Scan for Early Mobilization Practices in U.S. ICUs.

OBJECTIVE: Early mobilization improves patient outcomes. However, diffusion of this intervention into standard ICU practice is unknown. Dissemination and implementation efforts may be guided by an environmental scan to detail readiness for early mobilization, current practice, and barriers to early mobilization. DESIGN: A telephone survey. SETTING: U.S. ICUs. SUBJECTS: Five hundred randomly selected U.S. ICUs stratified by regional hospital density and hospital size. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We surveyed 687 ICUs for a 73% response rate (500 ICUs); 99% of respondents were nursing leadership. Fifty-one percent of hospitals reported an academic affiliation. Surveyed ICUs were most often mixed medical/surgical (58%) or medical (22%) with a median of 16 beds (12-24). Thirty-four percent reported presence of a dedicated physical and/or occupational therapy team for the ICU. Overall, 45% of ICUs reported early mobilization practice; two thirds of ICUs with early mobilization practice reported using a written early mobilization protocol. In ICUs with early mobilization practice, 52% began the intervention at admission and 74% enacted early mobilization for both ventilated and nonventilated patients. Early mobilization was provided a median of 6 days per week, twice daily. Factors independently associated with early mobilization protocols include dedicated physical/occupational therapy (odds ratio, 3.34; 95% CI, 2.13-5.22; p<0.01), American Hospital Association region 2 (odds ratio, 3.33; 95% CI, 1.04-10.64; p=0.04), written sedation protocol (odds ratio, 2.36; 95% CI, 1.25-4.45; p<0.01), daily multidisciplinary rounds (odds ratio, 2.31; 95% CI, 1.29-4.15; p<0.01), and written daily goals for patients (odds ratio, 2.17; 95% CI, 1.02-4.64; p=0.04). Commonly cited barriers included equipment, staffing, patient and caregiver safety, and competing priorities. In ICUs without early mobilization adoption, 78% have considered implementation but cite barriers including competing priorities and need for further planning. CONCLUSIONS: Diffusion regarding benefits of early mobilization has occurred, but adoption into practice is lagging. Mandates for multidisciplinary rounds and formal sedation protocols may be necessary strategies to increase the likelihood of successful early mobilization implementation. Methods to accurately assess and compare institutional performance via practice audit are needed.

Physical therapy on the wards after early physical activity and mobility in the intensive care unit.

BACKGROUND: Weakness and debilitation are common following critical illness. Studies that assess whether early physical activity initiated in the intensive care unit (ICU) continues after a patient is transferred to a ward are lacking. OBJECTIVE: The purpose of this study was to assess whether physical activity and mobility initiated during ICU treatment were maintained after patients were discharged from a single ICU to a ward. DESIGN: This was a cohort study. METHODS: Consecutive patients who were diagnosed with respiratory failure and admitted to the respiratory ICU (RICU) at LDS Hospital underwent early physical activity and mobility as part of usual care. Medical data, the number of requests for a physical therapy consultation or nursing assistance with ambulation at ICU discharge, and mobility data were collected during the first 2 full days on the ward. RESULTS: Of the 72 patients who participated in the study, 65 had either a physical therapy consultation or a request for nursing assistance with ambulation at ward transfer. Activity level decreased in 40 participants (55%) on the first full ward day. Of the 61 participants who ambulated 100 ft (30.48 m) or more on the last full RICU day, 14 did not ambulate, 22 ambulated less than 100 ft, and 25 ambulated 100 ft or more on the first ward day. LIMITATIONS: Limitations include lack of data regarding why activity was not performed on the ward, lack of longitudinal follow-up to assess effects of activity, and lack of generalizability to patients not transferred to a ward or not treated in an ICU with an early mobility program. CONCLUSIONS: Despite the majority of participants having a physical therapy consultation or a request for nursing assistance with ambulation at the time of transfer to the medical ward, physical activity levels decreased in over half of participants on the first full ward day. The data suggest a need for education of ward staff regarding ICU debilitation, enhanced communication among care providers, and focus on the importance of patient-centered outcomes during and following ICU treatment.

Strategies for promoting early activity in critically ill mechanically ventilated patients.

Prolonged immobilization plays a significant role in neuromuscular abnormalities and complicates the clinical course of a majority of critically ill patients. Immobilization in critically ill patients is associated with significant morbidity and impaired physical function. Overuse of sedation, sleep deprivation, immobility, and the development of delirium are all intensive care unit (ICU) factors that may negatively impact patient outcomes. Ambulation of critically ill patients is difficult with risk for adverse events. However, with a dedicated and trained team and culture change, early ICU mobility can be a feasible and safe process. Early mobility has potential as a therapy to prevent or treat the neuromuscular complications of critical illness. ICU culture can be transformed in a way that leads to improved and more reliable treatments and care, including early activity and mobility.

Transforming ICU culture to facilitate early mobility.

Growing interest in reducing costs for patients requiring long-term mechanical ventilation has led to development of different care delivery models. This article describes the development and implementation a respiratory care process model focusing on best practices and improvement in care, including early mobility. To implement the care process model, the authors had to make significant changes in the respiratory ICU (RICU), which included changes in how the RICU staff worked together. ICU culture was transformed in a way that resulted in improved and consistent care, including early mobility, while stabilizing or even decreasing cost. Involvement of front-line staff in early mobility and other components of the care process model resulted in the development of a culture of safety and teamwork.

Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005.

OBJECTIVE: To develop clinical practice guidelines for the support of the patient and family in the adult, pediatric, or neonatal patient-centered ICU. PARTICIPANTS: A multidisciplinary task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM) to include representation from adult, pediatric, and neonatal intensive care units. EVIDENCE: The task force members reviewed the published literature. The Cochrane library, Cinahl, and MedLine were queried for articles published between 1980 and 2003. Studies were scored according to Cochrane methodology. Where evidence did not exist or was of a low level, consensus was derived from expert opinion. CONSENSUS PROCESS: The topic was divided into subheadings: decision making, family coping, staff stress related to family interactions, cultural support, spiritual/religious support, family visitation, family presence on rounds, family presence at resuscitation, family environment of care, and palliative care. Each section was led by one task force member. Each section draft was reviewed by the group and debated until consensus was achieved. The draft document was reviewed by a committee of the Board of Regents of the ACCM. After steering committee approval, the draft was approved by the SCCM Council and was again subjected to peer review by this journal. CONCLUSIONS: More than 300 related studies were reviewed. However, the level of evidence in most cases is at Cochrane level 4 or 5, indicating the need for further research. Forty-three recommendations are presented that include, but are not limited to, endorsement of a shared decision-making model, early and repeated care conferencing to reduce family stress and improve consistency in communication, honoring culturally appropriate requests for truth-telling and informed refusal, spiritual support, staff education and debriefing to minimize the impact of family interactions on staff health, family presence at both rounds and resuscitation, open flexible visitation, way-finding and family-friendly signage, and family support before, during, and after a death.

Early activity is feasible and safe in respiratory failure patients.

OBJECTIVE: To determine whether early activity is feasible and safe in respiratory failure patients. DESIGN: Prospective cohort study. SETTING: From June 1, 2003, through December 31, 2003, we assessed safety and feasibility of early activity in all consecutive respiratory failure patients who required mechanical ventilation for >4 days admitted to our respiratory intensive care unit (RICU). A majority of patients were treated in another intensive care unit (ICU) before RICU admission. We excluded patients who required mechanical ventilation for < or =4 days. PATIENTS: Eight-bed RICU at LDS Hospital. INTERVENTIONS: We assessed patients for early activity as part of routine respiratory ICU care. We prospectively recorded activity events and adverse events. We defined three activity events as sit on bed, sit in chair, and ambulate. We defined six activity-related adverse events as fall to knees, tube removal, systolic blood pressure >200 mm Hg, systolic blood pressure <90 mm Hg, oxygen desaturation <80%, and extubation. MEASUREMENTS AND MAIN RESULTS: During the study period, we conducted a total of 1,449 activity events in 103 patients. The activity events included 233 (16%) sit on bed, 454 (31%) sit in chair, and 762 (53%) ambulate. In patients with an endotracheal tube in place, there were a total of 593 activity events, of which 249 (42%) were ambulation. There were <1% activity-related adverse events, including fall to the knees without injury, feeding tube removal, systolic blood pressure >200 mm Hg, systolic blood pressure <90 mm Hg, and desaturation <80%. No patient was extubated during activity. CONCLUSIONS: We conclude that early activity is feasible and safe in respiratory failure patients. A majority of survivors (69%) were able to ambulate >100 feet at RICU discharge. Early activity is a candidate therapy to prevent or treat the neuromuscular complications of critical illness.

The vortex: families' experiences with death in the intensive care unit.

BACKGROUND: Lack of communication from healthcare providers contributes to the anxiety and distress reported by patients' families after a patient's death in the intensive care unit. OBJECTIVE: To obtain a detailed picture of the experiences offamily members during the hospitalization and death of a loved one in the intensive care unit. METHODS: A qualitative study with 4 focus groups was used. All eligible family members from 8 intensive care units were contacted by telephone; 8 members agreed to participate. RESULTS: The experiences of the family members resembled a vortex: a downward spiral of prognoses, difficult decisions, feelings of inadequacy, and eventual loss despite the members' best efforts, and perhaps no good-byes. Communication, or its lack, was a consistent theme. The participants relied on nurses to keep informed about the patients' condition and reactions. Although some participants were satisfied with this information, they wishedfor more detailed explanations ofprocedures and consequences. Those family members who thought that the best possible outcome had been achieved had had a physician available to them, options for treatment presented and discussed, andfamily decisions honored. CONCLUSIONS: Uncertainty about the prognosis of the patient, decisions that families make before a terminal condition, what to expect during dying, and the extent of a patient s suffering pervade families' end-of-life experiences in the intensive care unit. Families' information about the patient is often lacking or inadequate. The best antidote for families' uncertainty is effective communication.