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Early Mobilization on a neurological ICU
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Slides are online: www.nydahl.de > Vortrag
Early Mobilization on a neurological ICU
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Nydahl – Nursing Research
Early mobilization on a neurological ICU
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Nydahl – Nursing Research
12,000 employees 2,500 beds 16 ICUs 230 beds
NICU & SU 6 & 11 beds
Does bed rest support healing?
Immobility increases risks for … • Pressure sores, contractures, thrombosis • Atelectasis, pneumonia • Insulin resistance, loss of Ca+ • Loss of muscle strength (1-1.5%/d) • Loss of body weight (20%/2w) • ICU acquired weakness (50% sepsis, ARDS) • 80% Delirium, 28% PTSD, 28% depression, 24% anxiety • Rehabilitation after 48h mech. ventilation: up to 9-12 months (Boles et al. 2007, Brower 2009, Vollman 2010, NICE 2010, Desai, 2011)
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Modified abcdef-approach
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Mobilization
Wakefulness & Partizipation
Assisted Ventilation mode
Management of pain, anxiety,
stress
Management of delirium
Family presence
Balas et al., 2013; Pic: Strøm, Spuhler
Early Mobilization
Review incl. 52 studies (Nava, 1998 … Wang, 2014) • Early mobilisation is feasible and safe • Better strength, endurance, balance • More independence in ADL, QoL • Reduced length of MV, ICU, hospital • Reduced incidence of delirium • Reduced incidence of complications • Reduced readmissions • More admissions, more money • But: effects multifaceted & incongruent Nydahl, 2016; Pic: Spuhler, 2008
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Early Mobilization with neurological pts
n.r. not reported; ns non significant; * significant; ** highly significant, ns non significant
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Author Pts (after/before)
MV (d) ICU (d) Hosp (d) ADL
Titsworth 2012
170 (93/77)
n.r. 3 vs 4* 9 vs 12* !*
Klein 2015
637 (377/260)
n.r. 4 vs 8** 10 vs 15** !*
Witcher 2015
68 (37/31)
7 vs 5 13 vs 10ns 23 vs 22ns n.r.
Early Mobilization with neurological pts
n.r. not reported; ns non significant; * significant; ** highly significant, ns non significant
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Author Pts (after/before)
MV (d) ICU (d) Hosp (d) ADL
Titsworth 2012
170 (93/77)
n.r. 3 vs 4* 9 vs 12* !*
Klein 2015
637 (377/260)
n.r. 4 vs 8** 10 vs 15** !*
Witcher 2015
68 (37/31)
7 vs 5 13 vs 10ns 23 vs 22ns n.r.
Early Mobilization with neurological pts
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Author Pts % on MV
Inclusion Out of bed
Titsworth 2012
SAH, tumor, stroke, ICH, other
31% 94% n.r.
Klein 2015 Stroke (isch, hem, SAH), epilepsia, nm disorders
37% 73% 21% ->43%
Witcher 2015 ICH; SAH, Stroke, epilepsia, other
n.r. 37% 65% -> 72%
In- and exclusion criteria
Hodgson 2014
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• Interprofessional discussion: inclusion & exclusion criteria
• Traffic-Light-System • Red: risks outweigh benefits • Yellow: benefits may outweigh risk,
individual decision • Green: clear benefit
• Neuro: brain pressure, ongoing seizures, large bleeding, palliative
Checklist
Talley, 2013, Berry 2014, Nydahl 2016
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" Hygienic working, e.g. hands, disconnection of lines & tubes " Experienced physician nearby " Portable ventilator, monitor, suction, manual resuscitator bag " Security clips for lines, loops " Press ventilator circuit on ETT with soft/moderate pressure " Foreseeing thinking: what risks may appear with this patient and
what strategies prevent and solve events? " Check risks for clinicians, e.g. BMI > 30, hyperactive delirium " Check length of lines according to targeted mobilization level " Wheelchair behind patient in case of sudden weakness (Family?)
ICU Mobility Scale
Hodgson 2014
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0 Nothing (lying in bed) 1 Sitting in bed, exercises in bed 2 Passively moved to a chair 3 Sitting over edge of bed 4 Standing 5 Transferring bed to chair 6 Marching on spot 7 Walking, assistance ≥ 2 persons 8 Walking, assistance 1 person 9 Walking independently (gait aid) 10 Walking independently
Safety ≤ 20% variation HF, BP ≤ 5% variation sO2
Dyspnoea (Borg Scale 3-6): FiO2 + 0.2 & PEEP + 2 mbar Pressure support + 2-4 mbar
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Walking
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Documentation & Evaluation
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!Nydahl, 2013, Schreiter, 2013
Whole concept
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Approach: abcdef concept
Traffic-Light-System: daily screen for mobility
Checklist before mobilization
Stepwise mobilization incl. safety screen
Documentation & evaluation
Take home message
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Early mobilization • Is feasible for neurological pts • Is a team approach & requires
good cooperation • Reduces complications, leads
to more independency, shorter duration of MV, ICU, hospital
• More research is needed for neurological patients on ICU
Networks for early mobilization • www.mobilization-network.org • MedConcert: ICU Recovery
Network, incl. >900 clinicians, monthly newsletter etc.
Conference • 4. European conference on
Weaning & Rehabilitation: Nov,12.-13. 2016 Hamburg
Barriers to EM and how to convince them
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Dubb, Nydahl, 2016
Patient-related barriers: Safety guidelines, ampel-system, stepwise
mobilization, safety screen, feasibility studies, evaluation
Process related barriers: interprofessional rounds, sharing responsibilities, automatic order,
promoters/champions
Structural barriers: protocol & algorithm, daily goals, regular interprofessional staff
training & meetings, documentation, additional staff
Cultural barriers: training & education (Evidence), changed decision making
(RN/PT), champions, feedback
Barriers & Solutions
Dubb, Nydahl, 2016
ETT tolerance: only a very few patients want to be sedated because of the ETT
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Checklist ETT tolerance Based on syst. Review (Nydahl, 2015) Available on ICU Recovery Network or www.nydahl.de