Safety profile and feasibility of early physical therapy and mobility for critically ill patients in the medical intensive care unit: Beginning experiences in Korea

doi:10.1016/j.jcrc.2015.04.012

Journal of Critical Care

Volume 30, Issue 4, August 2015, Pages 673-677

https://doi.org/10.1016/j.jcrc.2015.04.012 Get rights and content

Abstract

Purpose

To evaluate risk factors for potential safety events during mobility physical therapy sessions in the medical intensive care unit.

Methods

The safety profiles and potential risk factors of 99 patients who were admitted to the medical intensive care unit of a single teaching hospital in Korea between May 1 and December 31, 2013, were retrospectively evaluated.

Results

A total of 26 potential safety events (5.0%; 95% confidence interval [CI], 3.4%-7.3%) during 520 mobilization sessions were observed in 17 (17.2%; 95% CI, 10.6%-26.4%) of 99 patients. The common potential safety events were as follows in order of frequency: 11 events of tachypnea or bradypnea (2.1%; 95% CI, 1.1%-3.9%), 6 events of desaturation (1.2 %; 95% CI, 0.5%-2.6%), 4 events of tachypnea or bradycardia (0.8%; 95% CI, 0.3%-2.1%), 4 events of patients' intolerance (0.8%; 95% CI, 0.3%-2.1%), and 1 event of tracheostomy tube removal (0.2%; 95% CI, 0%-1.2%). In multivariate analysis, the use of extracorporeal membrane oxygenation was associated with potential adverse events with an adjusted odds ratio of 5.8 (95% CI, 2.2-15.6), respectively.

Conclusion

Early mobility physical therapy performed by a newly established group was feasible for critically ill patients in Korea. However, potential safety events need to be monitored carefully for patients with extracorporeal membrane oxygenation support.

Introduction

Recent studies show that early physical therapy (PT) and mobilization for critically ill patients in the intensive care unit (ICU) can provide benefits [1] such as improved quality of life, physical function, and muscle strength. Furthermore, it increases ventilator-free days and decreases the duration of delirium as well as length of days in the hospital and ICU [2]. Thus, early PT and mobilization for critically ill patients is becoming an established, evidence-based practice in the ICU [3].

Several studies report that early PT and mobilization in the ICU can be performed without serious safety profiles [2], [4]. However, concerns exist about the general applicability of these results because they enrolled highly selected patients and had very specialized rehabilitation team members. Many ICUs in non-Western countries are suffering from a lack of medical resources including health care personnel and medical equipment [5]. Therefore, previous studies might not reflect the real clinical environment in non-Western countries with insufficient medical resources and newly initiated ICU rehabilitation teams that might be more vulnerable to safety events.

In the present study, we investigated the safety profile and the clinical parameters associated with possible adverse events during early PT and mobilization in the medical ICU in a single teaching hospital located in Korea, where PT had not been performed previously as a routine clinical practice.

Section snippets

Patients

Patients admitted to the medical ICU in Samsung Medical Center (a 1961-bed, university-affiliated, tertiary referral hospital in Seoul, Korea) for at least 24 hours between May 1 and December 31, 2013, were prospectively screened for the rehabilitation program using a safety screening tool. The 14-bed medical ICU had 0.5 full-time equivalents of PT for 5 days per week, and the nurse-to-patient ratio was 1:2.

Three hundred thirty-two patients admitted to the medical ICU during the study period

Baseline characteristics

Of 99 patients, 62 (62.6%) were men and the median age was 65.0 years (interquartile range [IQR], 52.0-72.0 years). The most common causes of admission to the ICU were respiratory failure (55.6%) and sepsis (24.1%). Forty-seven (47.5%) patients received mechanical ventilation. The median length of stay in the ICU and hospital was 10.0 (IQR, 7.0-24.0 days) and 35.0 (IQR, 23.0-64.0 days) days, respectively. Forty-seven (47.5%) and 21 patients (21.2%) were referred from the hospital ward and

Discussion

This study showed that early mobility PT in the ICU performed by a novice group in Korea may be performed safely without serious adverse events. However, multivariate analysis suggested that potential safety events were more likely to develop in patients with ECMO. Our results emphasize that a novice group performing active PT in the ICU should give more attention to patients with ECMO during their mobility sessions.

Although a few potential safety events developed during mobility sessions, they

Conclusion

Early mobility was feasible for critically ill patients in the medical ICU in Korea performed by a newly trained PT team. However, potential safety events were more likely to develop in patients with ECMO. Therefore, more attention and close monitoring are necessary for these patients, especially with an inexperienced PT group.

Acknowledgments

The authors thank the Samsung Medical Center ICU rehabilitation team and the staff of the medical ICU for their enthusiasm and commitment to patient care.

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Six studies were conducted in European countries including three studies in the United Kingdom (Bounds et al., 2016; McGarrigle and Caunt, 2016; McWilliams et al., 2019), two studies in Italy (Chiarici et al., 2019; Negro et al., 2018) and one study in Belgium (Hickmann et al., 2016). Two studies were conducted in both the United States of America and Europe (Austria and Germany) (Schaller et al., 2016, 2019), two studies were conducted in Korea (Ko et al., 2015; Lee et al., 2015) and one study was conducted in Australia (Sosnowski et al., 2018). All studies met more than half of the criteria of their respective quality of appraisal tools (Supplementary material file 2).
Early mobilisation is beneficial to minimise complications and promote the recovery and physical function of critically ill adult patients. An interprofessional team approach may assist in early mobilisation of these patients; however, adopting this approach may be challenging and optimal strategies to support early mobilisation are unknown. Understanding specific implementation strategies is required to effectively support its implementation in the critically ill adult patient population.
To synthesise and critically analyse the literature on interprofessional team approaches to early mobilisation in critically ill adult patients.
An integrative review
The methodology of this integrative review was guided by Whittemore and Knafl's approach. A literature search of online databases including Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica database, Medical Literature Analysis and Retrieval System Online, Physiotherapy Evidence Database, and PubMed was conducted on 13 April 2020 and updated on 2 August 2021. No date limits were applied. Backward citation searching of included articles was used to identify additional articles. Articles were screened by title and abstract following pre-specified inclusion and exclusion criteria, and then by full text using the same criteria. Data describing an interprofessional team approach to early mobilisation were extracted into a specifically designed form. Quality appraisal was undertaken using the Quality Improvement Minimum Quality Criteria Set for quality improvement studies and the Joanna Briggs Institute's critical appraisal tools was used for cohort studies, retrospective studies, and randomised controlled trials. A narrative synthesis was conducted to integrate and summarise the findings.
Thirty-seven studies were included. All studies described team compositions, roles, and responsibilities. Multiple strategies were used to support the implementation of a team approach to early mobilisation, most of which included the use of instruction tools, team meetings/team rounds, staff education, and knowledge sharing, and safety criteria. Improving patient's readiness to perform early mobilisation using clinical interventions was also described in 17 studies. Crucial factors that can help or hinder the implementation of an interprofessional team approach to early mobilisation were identified including organisational structure, staff attitudes and staff abilities.
An interprofessional team approach to early mobilisation may be a useful strategy to improve early mobilisation practice; however, team compositions, roles, and responsibilities to support its implementation in individual setting is recommended. Multiple strategies and clinical interventions should be used to overcome barriers for implementing an interprofessional team approach to early mobilisation in critically ill adult patients.
Registration number: This review was registered into PROSPERO International prospective register of systematic review (CRD42020179943).
Use of an interprofessional team approach to improve early mobilisation practice in adult critically ill patients.
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However, ICU resources, such as healthcare personnel and equipment, are limited in many non-Western ICUs. Therefore, the results of previous studies may not reflect the real-world situation and the feasibility and characteristics of ICU rehabilitation require further investigation.11,29 As the elderly population is growing, the proportion of older patients in the ICU is also increasing.
The characteristics of critically ill surgical patients differ from those of medical patients. Few studies have evaluated rehabilitation in surgical intensive care units (SICUs), particularly in non-Western countries and in elderly patients.
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Active rehabilitation in critically ill surgical patients is feasible and safe and resulted in improved mobility, regardless of age. However, the reason for SICU admission should be considered.
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Well-designed education and training procedures can lower perceived barriers to evidence-based intervention,21,22 boost competency and intervention performance,23–25 and ultimately encourage cultural changes within the workplace.26,27 As in other Asian countries, hospitals in Korea aiming to adopt EM for critically ill patients in clinical practice are in the early stages.12,28 Efforts are necessary to identify the need for practical educational programs so as to better foster a skilled and experienced workforce.29
Early mobilisation (EM) of critically ill patients is an evidence-based intervention designed to improve treatment outcomes and enhance the quality of life after intensive care. However, several barriers exist to its establishment in clinical practice. Thus, the objective of the present study was to identify barriers perceived by critical care nurses, corresponding educational needs, and provide useful information for program implementation in Korea.
A cross-sectional study was conducted from April to June 2017 using a structured, self-administered questionnaire that was completed by 151 critical care nurses from three tertiary hospitals and four secondary hospitals located in Seoul. The survey was designed to rate experiences with EM, identify educational experiences, and measure perceived barriers regarding attitudes, knowledge, behaviours, and educational needs. Data were analysed using descriptive statistics, t-tests, and analyses of variance.
The mean number of perceived barriers was 3.13 ± 0.38 out of 5 on a Likert scale. Attitude-related barriers (3.25 ± 0.49) were higher than behaviour-related (3.21 ± 0.44) and knowledge-related (2.94 ± 0.59) barriers. The top five barrier items were high workload, patients’ inability to exercise, lack of time, inappropriate nurse/patient ratio, and absence of relevant education. Educational needs for early mobilisation were rated 3.74 ± 0.78 out of 5. Educational items were prioritised as identifying potential problems in EM and possible solutions, related protocols and guidelines, and procedures for special conditions.
The present study revealed that critical care nurses in Korea perceive various barriers to successfully implementing evidence-based EM interventions for critically ill patients, as well as the educational needs necessary to overcome such challenges. Accordingly, an educational program should be developed based on the educational needs revealed in the present study. In parallel, organisational efforts should also be made to meet environmental conditions.
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This scoping review summarizes the literature on the safety and effectiveness of physiotherapy interventions in patients with neurological and/or traumatic injuries in the intensive care unit (ICU), identifies literature gaps and provides recommendations for future research.
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^☆: Conflict of interest and source of funding: None declared.

^☆☆: This work was performed at Samsung Medical Center, Seoul, Republic of Korea.

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Physiotherapy and MobilizationSafety profile and feasibility of early physical therapy and mobility for critically ill patients in the medical intensive care unit: Beginning experiences in Korea☆,☆☆

Abstract

Purpose

Methods

Results

Conclusion

Introduction

Section snippets

Patients

Baseline characteristics

Discussion

Conclusion

Acknowledgments

Lancet

J Crit Care

Arch Phys Med Rehabil

J Crit Care

J Crit Care

Physiotherapy

Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis

Crit Care Med

Physiotherapy and Mobilization
Safety profile and feasibility of early physical therapy and mobility for critically ill patients in the medical intensive care unit: Beginning experiences in Korea☆,☆☆