Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices. An International Survey

Abstract

Rationale: Early mobilization (EM) improves outcomes for mechanically ventilated patients. Variation in structure and organizational characteristics may affect implementation of EM practices.Objectives: We queried intensive care unit (ICU) environment and standardized ICU practices to evaluate organizational characteristics that enable EM practice. Methods:We recruited 151 ICUs in France, 150 in Germany, 150 in the United Kingdom, and 500 in the United States by telephone. Survey domains included respondent characteristics, hospital and ICU characteristics, and ICU practices and protocols. Measurements and Main Results:We surveyed 1,484 ICU leaders and received a 64% response rate (951 ICUs). Eighty-eight percent of respondents were in nursing leadership roles; the remainder were physiotherapists. Surveyed ICUs were predominantly mixed medicalsurgical units (67%), and 27% were medical ICUs. ICU staffing models differed significantly (P , 0.001 each) by country for high-intensity staffing, nurse/patient ratios, and dedicated physiotherapists. ICU practices differed by country, with EM practices present in 40% of French ICUs, 59% of German ICUs, 52% of U.K. ICUs, and 45% of U.S. ICUs. Formal written EM protocols were present in 24%, 30%, 20%, and 30%, respectively, of those countries' ICUs. In multivariate analysis, EM practice was associated with multidisciplinary rounds (odds ratio [OR], 1.77; P = 0.001), setting daily goals for patients (OR, 1.62; P = 0.02), presence of a dedicated physiotherapist (OR, 2.48; P , 0.001), and the ICU's being located in Germany (reference, United States; OR, 2.84; P , 0.001). EM practice was also associated with higher nurse staffing levels (1:1 nurse/patient ratio as a reference; 1:2 nurse/patient ratio OR, 0.59; P = 0.05; 1:3 nurse/patient ratio OR, 0.33; P = 0.005; 1:4 or less nurse/patient ratio OR, 0.37; P = 0.005). Those responding rarely cited ambulation of mechanically ventilated patients, use of a bedside cycle, or neuromuscular electrical stimulation as part of their EM practice. Physical therapy initiation, barriers to EM practice, and EM equipment were highly variable among respondents. Conclusions:International ICU structure and practice is quite heterogeneous, and several factors (multidisciplinary rounds, setting daily goals for patients, presence of a dedicated physiotherapist, country, and nurse/patient staffing ratio) are significantly associated with the practice of EM. Practice and barriers may be far different based upon staffing structure. To achieve successful implementation, whether through trials or quality improvement, ICU staffing and practice patterns must be taken into account.

Early mobilization practices of mechanically ventilated patients: a 1-day point-prevalence study in southern Brazil

“…The organizational and structural characteristics may also explain the low levels of mobility observed. Previous studies have identified the nurse/patient ratio, physiotherapy staffing and the use of protocols to standardize care as significant predictors of ICU mobility 29 , 30 . Despite the use of protocols, the proportion of ICUs in our study with early mobilization protocols was greater than those reported in France (24%), Germany (30%), the United Kingdom (20%) and the United States (30%) 30 .…”

Physical Therapy and Rehabilitation in Chronic Obstructive Pulmonary Disease Patients Admitted to the Intensive Care Unit

“…A recent survey of current practice, including 951 ICUs from four countries, provided useful insights into the key components required to support early mobility programs. 119 The presence of a dedicated physical therapist, written sedation protocols, MDT ward rounds, and daily goal setting for rehabilitation were significantly associated with the presence of established early mobility practice within the ICUs surveyed. Establishing an open forum for MDT communication is vital to support these processes.…”

“…Given the complex nature of early rehabilitation in patients with AECOPD, these rounds provide team members with the opportunity to discuss the patients' rehabilitation in the context of medical stability, any current plan for weaning of sedation and respiratory support, management of delirium, and to highlight other team member tasks which may require completion. 119 This process allows the generation of individualized rehabilitation plans and the setting of goals to support recovery. Conversely, failure to develop consistent treatment goals among ICU staff has been identified as a key source of intrateam conflict, which, in turn, probably impacts on outcomes such as decreased quality of patient care, staff burnout, and wasted resources.…”

Quality indicators in intensive care medicine for Germany – third edition 2017

“…The positive effect of early mobilization on ICU patients has been demonstrated in various publications [ 45 ], [ 46 ], [ 47 ], [ 48 ], [ 49 ]. The indicator emphasizes on the early start of mobilization measures, which must be defined in local standards [ 50 ]. The safety of mobilization measures is sometimes doubted.…”