Construction Of Integrated Early Mobility Delivery Systems And Empirical Study In Intensive Care Unit

Objective:1.To survey knowledge and behavior of early mobilization among critical nurses and find out its factors.2.To explore the evidence related to integrated interventions.3.To develop an Integrated Early Mobility Delivery Systems for critical patients.4.To discuss and evaluate the effect of this potential model on behavior change of patents,caregivers and patient outcomes.Methods:1.A total of 1335 nurses from 65 tertiary and secondary hospitals were recruited by convenience sampling,and investigated using self-designed questionnaires.2.We performed a electronic search of PubMed,EmBASE,Medline,CINAHL,PEDro,Cochrane Library,Clinical trials.gov and Cochrane Central Register of Controlled Trials from January 1990 through June 2016.The search strategy included free text words [critical/intensive care,critical illness,ICU,early mobilization,rehabilitation,physical therapy,program,intervention] and controlled vocabulary adapted for every database.Data were extracted by one researcher using a standard format and then independently checked by two other researchers.Inconclusions were resolved by consensus.The quality of the included researches was accessed by two independent accessors who did not participated in the study.The Cochrane Collaboration tool was used to evaluate the risk of bias for RCTs and the RoBANS tool 9 for the observational,non-randomized studies.The continuous outcomes were quantified by standardized mean differences(SMD)between control and interventiongroups.The risk ratio(RR)along with the 95% confidence interval(CI)of ICU/hospital mortality and walking during ICU were presented.Mixed effects linear regression models were used to discovery which intervention component were associated with increase in patients' outcomes.For multicollinearity,we use step-wise regression effect sizes and 95%CI were accessed to compare these with observed effects from the separated analysis.Interaction intervention components and conditions were evaluated by an F-test.3.Based on systematic literature review and management of early mobilization in Jiangsu,China,Delphi method is used to develop the integrated systems.The relative weights and connotation of each level index were determined by Superiority Chart and Analytic Hierarchy Process.4.78 critical patients in the department of general intensive care units of Zhongda Hospital,Southeast University were selected,and were randomized into control group and intervention group by the cluster sampling and then observe patient outcomes,the behavior change of patient and ICU medical staff between intervention and control group.Results:1.The knowledge score of early mobilization was from 59.7% to 96.8% among intensive nurses.Regarding to behavior,only 25.36% implemented active mobility for ventilated or continuous renal replacement therapeutic patients and up to 69.47% reported no nursing experience of early mobility for extracorporeal membrane oxygenation patients.Nursing age,critical attending experience,level of hospital and training form were influenced factors for nurses' knowledge and behavior(P<0.05).2.Eight RCTs and 15 observational studies were included.Combined data analysis showed beneficial effects of EM interventions on functional status(SMD,0.40;95%CI,0.25 to 0.54),duration of mechanical ventilation(SMD,-0.45;95%CI,-0.48 to-0.42)and length of ICU stay(SMD,-1.26;95%CI,-1.29 to 1.22)in ICUs.No integrated program components was effective on mortality(RR,0.88;95%CI,0.65 to 1.18)and walking during ICU(RR,0.99;95%CI,0.96 to 1.01),but severalcharacteristics indicated an improvement on one or more outcomes.Interventions including technology/equipment(RR,-0.94;95%CI,-1.6 to-0.21)and goal directing(RR,-0.90;95%CI,-1.63 to-0.17)showed a reduced risk of mortality at ICU/hospital discharge.The improvement for interventions included team work on functional status(SMD,2.45;95%CI,0.51 to 4.38)and risk management on ventilator days in ICU(SMD,-1.47;95%CI,-2.57 to-0.37)was prospective.3.Integrated Early Mobility Delivery Systems is constructed,which contains 7core courses,22 secondary entries.We concluded the ranking order of these 7 core courses are operation(0.202)> leadership(0.200)> improvement(0.174)>performance evaluation(0.156)> plan(0.125)> support(0.079)> environment(0.064).The 22 secondary entries are Identification of organizational context,Evidence based recommendation on early mobility,Identification of needs and expectations of stakeholder,Rehabilitation team building,Defining stakeholders roles and responsibilities,Develop a feasible plan and risk management plan,Resource,Awareness,Training,Communication,Document information,Standardized process management,Daily checklist,Risk management,Record,Structure indicators,Process indicators and Outcome indicators,Barriers,Successful experience,Remaining issues.4.Empirical results of Integrated Early Mobility Delivery Systems for ICU patients(1)Patient behaviors.Active exercise level: After the intervention,the in-bed active exercise in the experimental group was significantly higher at ICU discharge(P<0.05).Wheelchairs,standing/walking,and independent walking showed an increasing trend,but the difference was not significant(P>0.05).Frequency and duration of active mobility: There was a significant difference between intervention and control group regarding the frequency of in-bed active exercise,wheelchairs,standing/walking with assistance,and duration of standing/ walking with assistance and independent walking(P<0.05).(2)Patient outcomes.Barthel Index,Peripheral muscle strength,walking,pain and sedation status,mortality,and discharge destination: Protocol patientshad improved muscle strength and functional walking at ICU discharge,with Barthel index,muscle strength,functional walking increased markedly at hospital discharge(P<0.05),and had similar CPOT and RASS score,Barthel index at ICU discharge,ICU/hospital/28-day mortality,discharge destination(P>0.05).In intervention group,there was difference in Barthel index ? muscle strength ?walking function at ICU discharge,and 28-day mortality between 3 subgroups.Barthel index,muscle strength,and walking function in advanced-exercise group were higher than low-exercise and passive-exercise group(P<0.05).Between passive-exercise group and low-exercise group,there was no difference(P>0.05).Adverse events: There was no serious events between the two groups(P>0.05).Medication Usage : There were no difference in ventilator days,ICU and hospital stay,ICU and hospital costs between intervention and control group(P>0.05).(3)Medical staff' behaviors.Team integration degree: At the end of the study,a team integration survey was conducted among ICU physicians,ICU nurses,and rehabilitation therapists,with a sample size of 60.In intervention group,ICU care givers showed a higher team integration scoring,within “team operation”,“common goal”,“integrated model”,and “shared interests” better than control group(P<0.05).Standardized early mobility ratio(SEMR): In intervention group,Standardized early mobility ration increased significantly(P<0.05),and most on the14 th day after ICU admission.Early mobility compliance : ICU care givers in intervention group had improved compliance with early mobility(P<0.05).Taking time as an independent variable and the medical staff compliance dependent variable,curve fitting was made.The compliance curve in control group showed a slow decreasing trend,with 0% on the 14 th day after ICU admission,while intervention group showed a horizontal "S" type,the compliance decreased slowly in the first 3 days,increased rapidly from 7 to 10 days,and then remained moderately during 14-28 days.(4)Pathway analysis of early mobility interventions.The path analysis showed that there were three paths associated with patient outcomes(P<0.05).The model deals with the study that early mobility compliance is an mediator factorbetween standardized early mobility ratio(SEMR),early mobility level and patient outcomes,and simultaneously early mobility compliance directly influences patient outcomes.In the total effect standardized early mobility ratio has the greatest effect,however in the direct effect is early mobility compliance,then followed by patient's early mobility level.The above finding support the path hypothesis proposed in this study,suggested an integrated approach incorporating the following indices:standardized early mobility ratio,patient's early mobility level and caregivers' compliance.Conclusion:1.Critical nurses' knowledge and behavior of early mobilization are generally poor,thus more special training,multidisciplinary team work and standardized management are urgently needed.2.Integrated interventions improved functional status,ventilator days and ICU stay,but the outcomes were highly heterogeneous.Technology/equipment,goal directing,team work and risk management were identified that positively affected critical patients' outcomes.3.The Integrated Early Mobility Delivery Systems had been proved to be effective in promoting patient and care givers behavior change,and then improving patient outcomes.