Annotated Bibliography on Early Patient Mobilization in the ICU

Early mobilization (EM) performed for patients in the intensive care unit (ICU) has been used as an intervention that is necessary to attenuate critical illness that is linked to muscle weakness. However, it has been argued that the long-term value of the procedure has remained controversial. To provide a comprehensive assessment of the existing knowledge on the EM especially in critically ill patients, Hodgson et al. (2013) performed a detailed analytical review of the literature. The authors found out that EM is not only controversial but also comprise a variety of different interventions that have been either used alone or in a combination. Available literature suggests that various forms of EM may be both feasible and safe in ICU patients which include those receiving mechanical ventilation. Unfortunately, the authors found out that the studies of EM are mainly single centered in their design, have highly variable control treatment and have limited external validity. Additionally, new technology to facilitate EM such as video therapy, transcutaneous muscle stimulation, and cycle ergometry are increasingly being used to achieve EM in spite of limited evidence of efficacy. Consequently, there is a need for more research to identify appropriate outcome measures, optimal EM techniques, and current standard practice.

Truong, A. D., Fan, E., Brower, R. G., & Needham, D. M. (2009). Bench-to-bedside review: Mobilizing patients in the intensive care unit from pathophysiology to clinical trials. Critical Care, 13(4), 216- 223. doi:10.1186/cc7885

The authors, researchers at Johns Hopkins University, examined ways in which patient outcomes following critical care, particularly how neuromuscular weakness developed in intensive care unit, can be improved. Some of the risk factors associated with neuromuscular weakness include organ failure, disease severity, prolonged bed rest, organ failure, and systemic inflammatory response syndrome. Some of the ways through which critical weakness or immobility causes neuromuscular weakness include increased inflammation, disuse atrophy of skeletal muscle, and a shift in cytokines. The preventive and treatment approaches of ICU-related weakness include encouraging early mobility through moderate exercise, which can also aid in improving muscular strength and physical functioning. Other important clinical outcomes of early mobility include reduced length of mechanical ventilation, shortened duration of stay in hospital and ICU, early ambulation, and decreased hospital mortality. Despite the beneficial health outcomes of early mobilization, inadequate resources, inadequate knowledge, and sedation methods are some of the barriers to its successful implementation.

Yim, W. (2012). Evidence-based eye care protocol for ICU patients with altered level of consciousness. doi:10.5353/th_b4325177

The author, Yim, recognizes that advancement in technology and medicine has played a major role in enhancing patients survival rates. However, the author opines that a lot has to be done to improve patients outcome and recovery, especially following critical care (ICU). Critical injuries and care are often associated with limited physical exercises as a result of patients diagnosis, health status, and equipment. Following physical inactivity, most of these patients often develop new infections, fatigue, and physical deconditioning. The primary focus of the study was an improvement in patients mobility, which the researcher associated with decreased morbidity and mortality, through development and evaluation a pilot mobility protocol program. Implementation of the new mobility control in a clinical setting was found to be highly effective in addressing immobility, awakening, delirium, and ventilator management. Because this was a pilot mobility program, there is a need for further research on the efficacy of the new program compared to the standard of care.

Ogan, T. (2016). Early mobilization improves outcomes, shortens length of stay in surgical ICUs. Retrieved from http://www.massgeneral.org/News/pressrelease.aspx?id=1994Ogan emphasizes reported the importance of early mobilization in patients health outcomes. The study, published in The Lancet, outlines the successes achieved in ensuring that patients hospitalized following a critical injury or a major surgery have achieved healthy stay in ICUs. Despite successes of early mobilization, there exist challenges related to the development of muscle weakness which comes about as a result of prolonged hospital stay and which can have detrimental health consequences for the affected patient, such as impaired mobility. In the study, conducted in surgical ICUs, early mobilization of patients in surgical ICUs was found to lead to decreased length of hospital and ICU stay and enhanced patients autonomy following discharge from the hospital.

Halpern, N. (2010). Early mobilization in the ICU: improving patient outcomes. Retrieved January 01, from http://enableme.com/wp-content/uploads/2016/01/motomed-icu_article_chest-physician-june-2010_johns-hopkins_usa.pdfMany intensive care units (ICUs) implement early mobility programs with the objective of promoting activity as well as improving functional recovery. Although mobility programs are common in ICUs, how early should ICU patients be mobilized has been a subject of concern to investigators? Kleinpell (2011) pointed out that since nursing workloads in the ICU do not usually provide nurses with enough time to direct early mobilization, it is only dedicated mobility teams through which there is a better chance of promoting progressive mobility. Despite the fact that there are several protocols that can be employed for implementing progressive mobility, a dedicated mobility team comprising a physical therapist, nursing assistant, and a critical care nurse, using a structured protocol, has been shown to be a practical method for promoting early mobility among ICU patients. The most recent study about progressive mobility showed that it has the potential to reduce not only ICU but also hospital length of stay. However, it did not result in an increased cost of care suggesting that the use of a dedicated mobility team is very beneficial in improving not only patient outcomes but also the added benefits of cost-effectiveness.

Kleinpell, R. (2011). How early should we mobilize ICU patients? Retrieved from http://www.medscape.com/viewarticle/750458

Patients who are usually critically ill usually survive due to the care they receive in the ICU, but they are often faced with problems that may be made worse as a result of immobility. While pain experienced by people in the ICU with critical illness may be relieved by bed rest, the physical and psychological impact of immobility on a patient can be made worst. Hunter, Johnson, and Coustasse (2014) analyzed the effects of early mobilization for patients who have been admitted to the ICU. Their study was to determine if early mobilization has an impact on various factors such as length of stay (LOS), medical complications, and cost of care. Rather than carrying out the experiment in their methodology, the authors used literature review with a total of five electronic data and 26 articles. The authors found out that early mobilization has an impact of decreasing delirium by a period of two days, minimize the risk of death or readmission, and also reduce ventilator assisted pneumonia. Further, there was also reduced ICU LOS, but there is limited research on the cost of LOS on ICU cases suggesting there is a potential to save during early mobilization.

Nydahl, P., Ewers, A., & Brodda, D. (2014). Complications related to early mobilization of mechanically ventilated patients on Intensive Care Units. Nursing in Critical Care, 21(6), 323-333. doi:10.1111/nicc.12134

Nydahl, Ewers, and Brodda (2014) examine the challenges faced during implementation of early mobilization as well as ways in which these problems can be addressed. Some of the problems are structural, cultural, and process-related. Structural challenges include inadequate staff and equipment, time constraints, poor training of staff, discharge prior to mobilization, and absence of early mobility program. Cultural barriers include the absence of mobility culture, inadequate knowledge by staff on the pros and cons of mobility, failure of staff to embrace early mobility, and lack of awareness by patient or family. Lastly, process-related barriers include poor planning and coordination; undefined roles, expectations, and responsibilities of different healthcare staff; failure to screen for eligibility on a daily basis; and risks faced by staff in providing mobility services to patients. The authors provided evidence-based strategies to address the challenges or barriers outlined above. Implementation of the strategies is expected to enhance patients health outcomes.

Frieden, J. (2017). Early activity benefits ICU patients -- but which ones? Retrieved from https://www.medpagetoday.com/meetingcoverage/ats/65538The author stresses on the need that cost/benefit analysis is conducted when providing early mobilization to intensive care unit patients due to the high cost associated with the process and the limited resources available for physical therapy. Because of this, resources should be provided to only those patients who will are highly likely to benefit the most from. Studies carried out to investigate the benefits of physical therapy have reported mixed findings. For instance, some studies have noted that it led to the achievement of independent functional status and increased mobility, which are important outcome variables. In carrying out cost/benefit analysis of physical therapy, some of the factors to consider include time of starting the program, duration of the program, the intensity of the program, and the personnel tasked with providing therapy. It is also important to consider if different types of ICU-acquired weaknesses exist, and their effect on early mobilization and physical therapy.

Hodgson, C. L., Berney, S., Harrold, M., Saxena, M., & Bellomo, R. (2012). Clinical review: Early patient mobilization in the ICU. Critical Care, 17(1), 207. doi:10.1186/cc11820

Hodgson, Berney, Harrold, Saxena, and Bellomo (2013) examines the current status of early mobilization of ICU patients, needed to treat muscle weakness associated and major functional impairment, through analytical review of the literature. Some of the early mobilization techniques administered to critically ill patients include Video games; sitting on a chair, tilting of the table, and walking; decreased sedation; sitting on the bed; active mobilization; and early activity protocol. Apart from these approaches, the modern techniques of early mobilization include video therapy; cycle ergometer used to alter the amount of work done by the patient; technological aids used to enhance functional recovery; and transcutaneous electrical muscle stimulation used to conserve muscle mass and strength in patients with cardiovascular diseases. The key barriers to successful implementation of early mobilization include concerns about patients safety, the use of sedation, and lack of enough staff and equipment to facilitate the process. Despite these barriers, early mobility is considered safe and has many clinical benefits.

References

Frieden, J. (2017). Early activity benefits ICU patients- but which ones? Retrieved from https://www.medpagetoday.com/meetingcoverage/ats/65538Halpern, N. (2010). Early mobilization in the ICU: improving patient outcomes. Retrieved January 01, from http://enableme.com/wp-content/uploads/201...