• Care Of Critically Ill Patient
• Hyperglycemia In Critically Ill Patients

EARLY MOBILIZATION OF ICU PATIENTS 6 concerns of nurses when planning to mobilize critically ill patients is the safety and the feasibility of this intervention. On other units, transferring a patient into a chair may require. The benefits of early mobility extend beyond helping to maintain or improve strength. Critically ill patients are at high risk of delirium (acute brain dysfunction), pressure ulcers, central venous catheter infections (CLABSI) and catheter associated urinary tract infections (CAUTI). Early mobility gets patients out of bed as soon as possible, decreasing the risk of pressure ulcers. It also has been shown to decrease or shorten the incidence of delirium.

Early mobility benefits patients in the critical care unit, pulmonary and critical care physician, The Oregon Clinic; assistant medical director, critical care, PPMCPhysical therapists and occupational therapists are an integral part of multi-disciplinary care and can be found on every hospital unit. These skilled professionals assess the patients’ safe ability to move around and care for themselves. Many providers think of them as taking patients for a walk, providing strength exercises, teaching a stroke patient how to perform a forgotten activity of daily living, or assessing a patient’s need for rehabilitation. However, their skills are much broader and during the past three years, physical and occupational therapists – and the important job they perform – have become an integral part of care in the critical care unit.For years cardiac surgery patients have been mobilized as soon as possible after surgery.

However, until recently this approach was not extended to medical patients and non-cardiac surgery patients in the CCU. Mass effect 2 difficulty. Instead, patients were kept in bed and usually sedated if they were on a ventilator. Then a 2011 paper published in the Lancet (Schweikert et al) demonstrated that implementing an early mobility protocol for mechanically ventilated patients improved functional capacity and decreased the need for transfer to a skilled nursing facility after discharge.Early mobility means physical and occupational therapy occurs in the CCU as soon as possible (even as early as the first day of hospitalization), in partnership with nursing and respiratory therapists.

The goal is to maintain strength and muscular tone and to work on maintaining as much self care as possible. Patients are encouraged to do as much as possible (sit, stand or walk) as soon they’re able. In fact, critically ill patients still attached to a ventilator now can be seen walking in the hallways of the critical care unit!The benefits of early mobility extend beyond helping to maintain or improve strength. Critically ill patients are at high risk of delirium (acute brain dysfunction), pressure ulcers, central venous catheter infections (CLABSI) and catheter associated urinary tract infections (CAUTI). Early mobility gets patients out of bed as soon as possible, decreasing the risk of pressure ulcers. It also has been shown to decrease or shorten the incidence of delirium.

Reducing the length of time on a ventilator and in the critical care unit can decrease time needed for central venous catheters and urinary catheters, thus decreasing catheter-related infection rates. All of this happens while also helping patients maintain or improve their physical condition with minimal risk.

Although patients in the CCU early mobility program generally are sicker than those in other areas of the hospital, experience at several large medical centers and during a pilot at PPMC shows there have not been any significant falls or dislodgement of patient devices due to early mobility.Developing an early mobility program doesn’t occur overnight. It requires extensive staff training, protocol development and planning to ensure patient safety.

However, the benefit for critically ill patients has been demonstrated clearly, both nationally and locally at Providence Portland and Providence St. Vincent through early work from rehabilitation and nursing champions. Thanks to the PH&S Critical Care Clinical Focus Groups, new tools for early mobility programs throughout Providence are expected by the end of 2016, with a goal of bringing early mobility to every critical care unit in the near future.

Early mobilization in the intensive care unit (ICU) is currently a hot topic, with more than 15 randomized controlled trials (RCTs) in the past ten years including several high impact publications. However, the largest studies of early mobilization have enrolled 300 patients, and the results of phase II randomized trials, pilot studies and observational studies have been used to encourage practice change –. There are currently several international practice guidelines available, and early mobilization has consistently been reported as safe and feasible in the ICU setting. There is no doubt that this early intervention in ICU shows exciting potential.

The reported benefits of early mobilization, include reduced ICU-acquired weakness, improved functional recovery within hospital, improved walking distance at hospital discharge and reduced hospital length of stay. However, medical research has repeatedly demonstrated that the results of pilot studies and phase II studies may not result in improved patient-centered outcomes when tested in a larger trial ,. Early mobilization is a complex intervention that requires careful patient assessment and management, as well as interdisciplinary team cooperation and training. Patient safety is one of the most commonly reported barriers to delivering early mobilization, including respiratory, cardiovascular and neurological stability and the integrity of invasive lines. In a recent systematic review and meta-analysis of patient safety during early mobilization, 48 studies were identified that reported data on safety during early mobilization, including falls, removal of endotracheal tubes (ETT), removal or dysfunction of intravascular catheters, removal of catheters or tubes, cardiac arrest, hemodynamic changes and oxygen desaturation.

Five studies were not included as their data were reported in other included publications. The 43 included studies had different descriptions of safety events and, in most, the criteria for ceasing early mobilization were the same criteria used to define a safety event. The most frequently reported safety events were oxygen desaturation and hemodynamic changes, each reported in 33 (69%) of the eligible studies and removal or dysfunction of intravascular catheters reported in 31 (65%) of the eligible studies. Several studies did not report on important safety events, including falls (n = 21, 43%), ETT removal (n = 17, 35%) and cardiac arrest (n = 15, 31%).Of the 43 included studies, 23 (53%) reported consequences of potential safety events. There were 308 potential safety events from 13,974 mobilization sessions, for an incidence of 2% potential safety events during mobilization. Of these, consequences of the safety event were reported for 78 occasions (0.6%) including 49 debridement or suturing of wounds and 11 tube removals with 4 of these requiring replacement.

With regards to adverse events including a high heart rate, low blood pressure or oxygen desaturation, the pooled incidence for each was less than 2 per 1,000 episodes of mobilization. Safety events that resulted in additional care requirements or consequences were very rare.There have been several publications that recommend criteria for the safe mobilization of patients receiving mechanically ventilated. The first was published approximately 15 years ago, and later adopted as a recommendation by the European Respiratory Society and the European Society of Critical Care Medicine ,. At this time, the evidence was considered level C and D (observational studies and expert opinions). In particular, these authors recommended identification of patient characteristics that enable treatment to be prescribed and modified on an individual basis, with standardized pathways for clinical decision making.

The flow diagram detailing patient assessment prior to early mobilization is a useful tool in clinical practice, and may be used to assist with staff training.More recently, an international multidisciplinary expert consensus group developed recommendations for consideration prior to mobilization of patients in the ICU during mechanical ventilation. The panel consisted of 23 clinical or research experts from four countries, including 17 physiotherapists, five intensivists and one nurse. Following a modified Delphi process, the group developed a traffic light system for each of the identified safety criteria to determine the risk/benefit of performing early mobilization. Green indicated that there was a low risk of an adverse event, and the benefit outweighed the potential safety consequences of early mobilization. Yellow indicated a potential risk or consequence of adverse event during early mobilization, such that precautions and contraindications should be discussed with the interdisciplinary team prior to mobilization. Red indicated a significant potential risk of an adverse event, where early mobilization should not occur unless it was authorized by the medical team responsible for the overall patient management in ICU. Importantly, a ‘red’ sign was not a contraindication to early mobilization, but rather a clear message that the risks may outweigh the benefits in this instance (Fig.

The safety criteria were divided into the categories of respiratory, cardiovascular, neurological and other considerations (e.g., securing intravascular lines). Consensus was achieved on all criteria for safe mobilization with the exception of levels of vasoactive agents, where the panel agreed that more evidence was required to guide the recommendations.

At an international meeting, 94 multidisciplinary ICU clinicians concurred with the proposed expert recommendations prior to publication. 1Expert consensus color coding definitions for safe early mobilization of mechanically ventilated patients The safety criteria developed by the group were intended to be used whenever mobilization was being considered, which might be up to several times per day for an individual patient.

Care Of Critically Ill Patient

In considering the decision to mobilize a patient, the criteria should be assessed based on the status of the patient at the time of planned mobilization, but changes in condition, and direction of trends, in the preceding hours should also be taken into account. The potential consequences of an adverse event in an individual patient should also be considered as part of the overall clinical reasoning process. This group noted that further research was required to validate the traffic light system in centers of clinical expertise and in centers without clinical expertise in early mobilization. They also noted that practice may change and progress in the future, so that areas that were considered a significant potential risk (red) may change to yellow with further investigation, or vice versa.

Hyperglycemia In Critically Ill Patients

Many observational and randomized controlled trials over the past decade have demonstrated that ICU clinicians are reluctant to mobilize mechanically ventilated patients, despite the scarcity of reported adverse events and the potential benefits ,. The barriers and facilitators to early mobilization can be divided into patient factors, ICU team factors and organizational factors (Table ). A recent systematic review identified barriers to delivering the Awakening, Breathing Coordination, Delirium and Early mobility/exercise (ABCDE) bundle to minimize adverse outcomes and improve patient care for ICU patients. This study reported 107 barriers, categorized into four classes: patient-related (patient instability); clinician-related (lack of knowledge and staff safety concerns); protocol-related (unclear protocol criteria); and ICU contextual barriers (interdisciplinary team coordination).