Professional experience and wisdom have taught us that immobility is a risk factor for various adverse outcomes, such as deep vein thrombosis, joint contractures, pulmonary dysfunction, and bone demineralization to name a few. Balancing bed rest and mobility may improve both short- and long-term outcomes for our patients. Moreover, early, routine mobilization of critically ill patients is safe and reduces hospital length of stay, shortens the duration of mechanical ventilation, improves muscle strength, and functional independence. At the University of Michigan, we have turned the tides by creating a structured process to get our patients moving through the use of a standardized mobility protocol. Our protocol is simple and can easily be adapted for all patient populations by simply modifying some of the inclusion and exclusion criteria. The activities are grounded in the evidence and well thought out to prevent complications and promote mobilization. The purpose of this article was to present the science behind the development of a multidisciplinary protocol for early mobilization of critically ill patients that can be adapted to any intensive care unit patient with minor modifications.
Background: Bed rest of 24 hours post-thrombolysis is recommended for acute ischemic stroke patients. We sought to compare outcomes and in-hospital complications of 12- and 24-hour bed rest protocols following thrombolysis in minor stroke patients. Methods: Consecutive patients age >18 years with a diagnosis of ischemic stroke that received tPA only and who had an initial National Institute of Health Stroke Scale (NIHSS) 0-5 between 1/1/2017 and 3/30/2019 were included. Stroke mimics and patients who underwent mechanical thrombectomy were excluded. The standard practice bed rest order for the 24 hour protocol prior to 07/15/2017 was compared with the 12 hour bed rest order protocol after that date. The primary outcome was length of stay. Secondary outcome measures included symptomatic intracerebral hemorrhage (sICH), deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days and modified rankin scale (mRS) at 90 days. Results: Of the 106 patients identified, 36 patients were in the 24-hour protocol and 70 were in the 12-hour bed rest protocol group. There was significant difference for length of stay in the 24-hour bed rest protocol (2.9 days) compared with the 12-hour bed rest protocol (2.0 days) (p=0.032). Compared with the 24-hour bed rest group, the rates of sICH (p=NS), DVT (p=NS), PE (p=NS), pneumonia (p=NS), favorable discharge disposition (p=NS), 30 day readmission (p=0.NS) and 90 day mRS 0-2 (p=NS) were not different between the groups. Time to mobilization was significantly different between the two groups (24 hour group:2043.2 ± 680.1 minutes; 12 hour group:1221.0 ± 527.8) (p<0.0001). Conclusion: Compared with 24-hour bed rest, 12-hour bed rest after thrombolysis for minor acute ischemic stroke was associated with significantly earlier patient mobilization and reduced length of stay without any adverse outcomes. A randomized trial is needed to verify these findings.
Background: Current guidelines recommend 24 hours of hospital bed rest after thrombolysis for acute ischemic stroke. We sought to compare outcomes and in-hospital complications of 12- and 24-hour bed rest protocols following thrombolysis in minor stroke patients. Methods: Consecutive patients age >18 years with a diagnosis of ischemic stroke with initial National Institute of Health Stroke Scale (NIHSS) 0-6 who received intravenous thrombolysis only from 1/1/2017 until 4/30/2018 were included. Standard practice bed rest order for 24 hour protocol prior to 07/15/2017 was compared with 12 hour bed rest order protocol after that date. Primary outcome was length of stay. Secondary outcome measures included symptomatic intracerebral hemorrhage (sICH), deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days and modified rankin scale (mRS) at 90 days. Results: 77 patients were identified, 36 patients in the 24-hour protocol and 41 in 12-hour bed rest protocol groups. There was no significant difference for length of stay in the 24-hour bed rest protocol (2.8 days) compared with the 12-hour bed rest protocol (2.3 days) (p=0.37) (Table). Compared with the 24-hour bed rest group, the rates of sICH (p=1.00), DVT (p=NS), PE (p=NS), pneumonia (p=1.00), favorable discharge disposition (p=0.69), 30 day readmission (p=0.80) and 90 day mRS 0-2 (p=0.36) were also not different between the groups (Table). Time to mobilization was significantly different between the two groups (p<0.001) (Table). Conclusion: Compared with 24-hour bed rest, 12-hour bed rest after thrombolysis for minor acute ischemic stroke was associated with significantly earlier patient mobilization without any adverse outcomes. A randomized trial is needed to verify these findings.
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