Interprofessional Survey of Perceived Barriers and Facilitators to Early Mobilization of Critically Ill Patients in Montreal, Canada.

OBJECTIVE: Early mobilization is safe, feasible, and associated with better outcomes in patients with critical illness. However, barriers to mobilization in clinical practice still exist. The objective of this study was to assess the knowledge and practice patterns of intensive care unit (ICU) clinicians, as well as the barriers and facilitators to early mobilization. DESIGN: Cross-sectional survey. SETTING: Intensive care units of 3 university-affiliated hospitals in Montreal, Canada. PARTICIPANTS: One hundred and thirty-eight ICU clinicians, including nurses, physicians, respiratory therapists, and physiotherapists. INTERVENTIONS: None. MEASUREMENTS: Perceived barriers, facilitators, knowledge, and practice patterns of early mobilization were assessed using a previously validated mobility survey tool. MAIN RESULTS: The overall response rate was 50.0% (138 of 274). Early mobilization was not perceived as a top priority in 49% of respondents. Results showed that clinicians were not fully aware of the benefits of early mobilization as per the current literature. About 58% of clinicians did not feel well trained and informed to mobilize mechanically ventilated patients. Perceptions on patient-level barriers varied with clinicians' professional training, but there was a high degree of interprofessional and intraprofessional disagreement on the permissible maximal level activity in different scenarios of critically ill patients. CONCLUSIONS: Our survey shows limited awareness, among our respondents, of the clinical benefits of early mobilization and high level of disagreement on the permissible maximal level of activity in the critically ill patients. Future studies should evaluate the role of knowledge translation in modifying these barriers and improving early mobilization.

Early rehabilitation reduces the likelihood of developing intensive care unit-acquired weakness: a systematic review and meta-analysis.

BACKGROUND: Intensive care unit-acquired weakness (ICUAW) is associated with significant impairments in body structure and function, activity limitation, and participation restriction. The etiology and management of ICUAW remain uncertain. OBJECTIVE: To estimate the extent to which early rehabilitation interventions (early mobilization [EM] and/or neuromuscular electrical stimulation [NMES]) compared to usual care reduce the incidence of ICUAW in critically ill patients. DATA SOURCES: We searched MEDLINE, EMBASE, CINAHL, Cochrane Central and Physiotherapy Evidence Database databases from inception to May 1st, 2017. ELIGIBILITY CRITERIA: Randomized controlled trials of EM and/or NMES interventions in critically ill adults. DATA EXTRACTION AND DATA SYNTHESIS: Data on the incidence of ICUAW and secondary outcomes were extracted. Both odds and risk ratios for ICUAW were pooled using the random-effects model. RESULTS: We identified 1421 reports after duplicate removal. Nine studies including 841 patients (419 intervention and 422 usual care) were included in the final analysis. The interventions involved EM in five trials, NMES in three trials, and both EM and NMES in one trial. Early rehabilitation decreased the likelihood of developing ICUAW: odds ratio of 0.63 (95% CI: 0.43 to 0.92) in the screened population, and 0.71 (95% CI: 0.53 to 0.95) in the randomized population. CONCLUSION, IMPLICATIONS OF KEY FINDINGS: Early rehabilitation was associated with a decreased likelihood of developing ICUAW. Our findings support early rehabilitation in the ICU. While results were consistent in both the screened and randomized populations, the wide confidence intervals suggest that well-conducted trials are needed to validate our findings. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO registration ID: CRD42017065031.

Intensive care unit clinicians identify many barriers to, and facilitators of, early mobilisation: a qualitative study using the Theoretical Domains Framework.

QUESTION: From the perspective of intensive care unit (ICU) clinicians, what are the barriers to and facilitators of implementing early mobilisation? DESIGN: A qualitative study using focus groups, with analysis using the Theoretical Domains Framework. PARTICIPANTS: Physicians, nurses, respiratory therapists and physiotherapists from the ICUs of three university-affiliated hospitals in Montreal, Canada. METHODS: Four focus group meetings were conducted with 33 participating ICU clinicians. Two researchers independently performed thematic content analysis on verbatim transcriptions of the audio recordings using the Theoretical Domains Framework. RESULTS: Data saturation was reached after the third focus group. Thirty-six barriers were categorised in 13 domains of the Theoretical Domains Framework. The key barriers to early mobilisation were: lack of conviction and knowledge regarding the available evidence about early mobilisation; lack of attention to the provision of optimal care; poor communication; the unpredictable nature of the ICU; and limited staffing, equipment, time and clinical knowledge. Twenty-five facilitators categorised in ten TDF domains were also identified. These included individual-level facilitators (intrinsic motivation, positive outcome expectations, conscious effort to mobilise early, good planning/coordination, the presence of ICU champions, and expert support by a physiotherapist) and organisational-level facilitators (reminder system, pro-early mobilisation culture, implementation of an early mobilisation protocol, and improved ICU organisation). CONCLUSIONS: A broad array of barriers to and facilitators of early mobilisation in the ICU were identified in this study. Clinicians can consider whether these barriers and facilitators are operating in their ICU. These may inform the design of tailored knowledge translation interventions to promote early mobilisation in the ICU.