Read Full Text: Point prevalence study of mobilization practices for acute respiratory failure patients in the United States (Free to access)
Journal: Critical Care Medicine
Year Published: 2017
Ranked 69th on our 2015-2020 list of the 100 most influential OT-related articles
I’m consistently amazed by how relevant our list of influential articles is to our daily practice. Case in point: this week’s article speaks directly to why OT services are so critical in this era of COVID-19.
The article looks at early mobility for mechanically ventilated patients.
Early mobility for this group is considered safe and feasible, and might even improve functional outcomes. But, sadly, not enough patients who would benefit from this intervention actually receive it.
This relatively large study tracked how often early mobilization occurred across 17 hospitals across the US—and the results point to OT being significantly underutilized.
I think this article is an important read for all of us, in part because it highlights the importance of our role specifically during this pandemic. But, timeliness aside, the article also provides a critical look into the variation of early mobility efforts from hospital to hospital—and the authors speculate on why these differences might exist. (Hint: it involves systems and workplace cultures.)
What we already know about early mobilization for mechanically ventilated patients.
First of all, we know that patients who survive acute respiratory failure (ARF) can experience long-term medical complications, functional impairments, and decreased quality of life.
Providing early OT/PT in the ICU is intended to help counteract these risks, and it has been shown to improve functional outcomes when acute respiratory patients are ultimately discharged from the hospital.
Unfortunately, patients just aren’t being mobilized early enough, nor often enough. Studies from Germany, Australia, and New Zealand have shown that most mechanically ventilated patients do not receive early mobility at all. In fact, in one study, only 3% of patients who were mechanically ventilated were able to sit edge-of-bed during the research period, and none of them advanced to standing, transferring to a chair, or walking.
How did this study add to the body of knowledge?
Prior to this week’s study, no formal research had explored the prevalence of early mobilization in mechanically ventilated patients—well, not specifically in the US. Thus, the researchers wanted to:
- Report prevalence of OT/PT-provided mobility among respiratory failure patients in the US
- Define the types and frequencies of different kinds of ICU mobility
- Identify factors associated with mobility progression
How was the study structured?
17 hospitals in the ARDS Network committed to tracking mobility events on two separate study dates. (FYI, the NIH-NHLBI ARDS Network was a research network formed to study treatment of Acute Respiratory Distress Syndrome.)
The study dates were on different days of the week to account for staffing differences.
Real-time recording of mobility events took place at bedside on custom report forms. Study coordinators also interviewed staff members to record their rationale when mobilization was deferred.
The researchers tracked:
- All mobility events (range of motion, being passively moved to a chair, bed exercises, sitting edge of bed, standing, transferring to a chair, marching in place, walking)
- Therapist-led mobility events
- Adverse events
For statistical analysis, the researchers also gathered information from medical records, paying particular attention to the following assessments:
Patients who were included were all:
- 18+ years old
- Diagnosed with acute respiratory failure at some point during their ICU stay, requiring > 48 hours of mechanical ventilation
- Ongoing mechanical ventilation was not required, so some participating patients had already come off ventilation
What were the results?
All mobility events
Patients received some type of mobility on 65% of the tracked dates. (But, keep in mind this mobility could have simply been PROM.)
Activity delivered in the absence of OT/PT was found to be of lower intensity, overall.
Therapist-provided mobility
Therapist-provided mobility took place on 32% of tracked dates. Patients who were not mechanically ventilated were much more likely to receive OT/PT than mechanically ventilated patients (48% versus 26%).
OT/PT involvement was strongly associated with progression to out-of-bed mobility.
Adverse events
Seven potential safety events occurred on .9% of tracked dates. These included:
- New arrhythmias (3)
- Oxygen desaturation (2)
- Hypotension (1)
- Endotracheal dislodgment (1) (This occurred during an in-bed PROM session.)
Variance between hospitals
There was a significant variance in findings between the hospitals. OT/PT participation varied from 7% in one hospital to 74% in another hospital.
What did the authors discuss/conclude?
This article builds on previous studies that suggest that therapist involvement may increase mobility progression.
The findings of this article also complement previous research positing that dedicated ICU therapists may enhance access to mobility.
However, the authors caution us that staffing more therapists, alone, may not be enough to create better outcomes for patients. Systems and hospital culture also seem to play a significant role.
Stepwise progression through a therapy-driven protocol has been shown to increase mobility for patients, and even reduce mortality rates in a group of respiratory patients. A number of studies have also shown the need for broad, multidisciplinary ICU culture change in order to truly have widespread acceptance of ICU mobility.
Takeaways for OT practitioners:
1. We have a critical role to play for patients who are mechanically ventilated for ARF due to COVID.
This article provides evidence that OT may be underutilized in your ICU, which is especially critical to consider as ICUs around the globe have managed (and will continue to manage) a number of mechanically ventilated patients.
I hope this research (and the cited articles within it) is able to provide a valuable and actionable resource for you as you consider how we can better serve our ICU patients.
2. We need to remember the importance of functional early mobility.
We OTs know that mobility is just one step toward our end goal of improving long-term functional status for our patients.
So, while early mobility is important—especially for our ARF patients—do not forget about the importance of incorporating functional tasks, and beginning to think long-term for these patients. In this previous article, we discussed how early mobility, alone, is unlikely to be enough to improve long-term outcomes.
3. To really make a difference, we need to look beyond our individual care to the systems we are working in.
Again and again, we are reminded that just “doing our best” isn’t always enough for our patients. To really improve outcomes, we need to look at the culture of our workplaces—as well as the systems they have created.
Systems are hard to change. They are slow to change. But, a change in systems may be the difference between a ICU where 3% of the patients receive early mobility and an ICU where 74% receive therapist-led mobility. This kind of difference in potentially life-altering care is more than one person can achieve. It makes all of the hard work worth it.
(Possibly) Earn CEUs/PDUs for reading this article.
Many of you can receive continuing education credits for reading this article. Here’s a form to help you do it, along with information to help you understand who qualifies.
And, here’s the full APA citation you many need:
Jolley, S. E., Moss, M., Needham, D. M., Caldwell, E., Morris, P. E., Miller, R. R., … Hough, C. L. (2017). Point Prevalence Study of Mobilization Practices for Acute Respiratory Failure Patients in the United States. Critical Care Medicine, 45(2), 205–215. doi: 10.1097/ccm.0000000000002058
)
