Ambulation on a vent – Part IV

Mt Hood from OHSU tram platform IMG_6439

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)
  • Cost
    • number of workers needed
    • mobility aids needed (do we need to build our own?)
  • Obesity
  • Time

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)

References

  • Needham DM.  Mobilizing patients in the intensive care unit.  JAMA.  2008; 300:1685-1690.
  • 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
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One response to “Ambulation on a vent – Part IV

  1. You are quite the motivated student. Ironically, this is an area of interest to me and possible topic for my dissertation.

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