We know that immobility has negative reprecussions for the patient, and that being on a ventilator has even more negative repercussions. There are studies to show that PT and ambulation of patients on a ventilator is feasible and safe. So where do we go from here?
Address barriers to mobility
A few to consider from Morris and Stiller references:
- safety concerns
- dislodging lines or tubes
- reducing already low oxygenation and hemodynamic parameters (NOTE: the Stiller references and Gosselink reference contain a good flowchart to start with)
- Sedation (which reduces mentation)
- number of workers needed
- mobility aids needed (do we need to build our own?)
Changing a culture
Given the cost to the patient being immobilized and on a vent, are addressing the barriers a benefit? Even if it is, it will likely require a culture change – on the unit and in the hospital. So how to do that? Those who have gone before (Hopkins et al) have laid out a path that they believe will help with this culture change:
- Stage 1 – establish a sense of urgency
- look at pt at d/c; understand limitations they have and are faced with
- Stage 2 – create a powerful guiding coalition
- nurse manager, physician director, and a few influential people who are committed to change
- Stage 3 – create a vision
- for your job, what can you do as part of the process of care?
- Stage 4 – communicate the vision
- get the idea to other ICU’s about the importance of early ambulation
- Stage 5 – empower others to act
- being able to share small parts of your job – d/c a line or flush a tube – learn how to work with each other and what each other does
- Stage 6 – plan and create short-term wins
- e.g. as # of admissions increased to RICU, the FTE increased
- Stage 7 – consolidating improvements, making more change
- reporting adherence rates to desired action
- Stage 8 – institutionalize new approaches
- within the team (“this is how it is done”) and outside (respect for and desire to follow the new approach)
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Morris PE. Moving our critically ill patients: mobility barriers and benefits. Crit Care Clin. 2007; 23:1-20.
Choi J, Tasota FJ, Hoffman LA. Mobility interventions to improve outcomes in patients undergoing prolonged mechanical ventilation: a review of the literature. Biol Res Nurs. 2008; 10:21-33.
Stiller K, Phillips AC, Lambert P. The safety and mobilization and its effect on haemodynamic and respiratory status of intensive care patients. Physiother Theory Pract 2004; 20:175-185.
Stiller K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin. 2007; 23:35-53.
Clum SR, Rumbak MJ. Mobilizing the patient in the intensive care unit: the role of the early tracheotomy. Crit Care Clin. 2007; 23:71-79.
Hopkins RO, Spuhler VJ, Thomsen GE. Transforming ICU culture to facilitate early mobility. Crit Care Clin. 2007; 23:81-96.
Morris PE, Herridge MS. Early intensive care unit mobility: future directions. Crit Care Clin. 2007; 23:97-110.
Chiang LL, Wang LY, Wu CP, Wu HD, Wu YT. Effects of physical training on functional status in patients with prolonged mechanical ventilation. Phys Ther. 2006; 86:1271-1281.
Gosselink R, Bott J, Johnson M, et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med 2008; 34:1188-1199.
Picture Credit - Mt Hood from OHSU tram platform IMG_6439,originally uploaded by Black Dog Photography