Page 89 - ACCCN's Critical Care Nursing

66 S C O P E O F C R I T I C A L C A R E

INTERVENTIONS TO IMPROVE hospital discharge. 111,115,116 Table 4.6 outlines recent studies
PSYCHOLOGICAL RECOVERY examining physical activity and mobility strategies for
Although there is now strong empirical evidence that patients in ICU.
some patients experience significant psychological dys-
functions after a critical illness, it is less clear how to treat MOBILITY AND WALKING
these symptoms. Systematic follow-up services may offer Testing of ‘early’ activity for ICU patients relates to after
appropriate assessment support during recovery for indi- clinical stabilisation is evident, and includes those still
viduals identified with psychological disturbances. Inten- intubated. 110,112 Factors to ensure patient safety during
sive care follow-up clinics where patients have the mobilisation have been identified, including confirming
opportunity to discuss their intensive care experiences that a patient has sufficient cardiovascular and respiratory
117
and receive information about what had happened to reserve and cognitive function, and subsequently
them could be a useful intervention, although there are tested. 111,118 Potential barriers to mobilisation during
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currently no empirical data to support this, and further mechanical ventilation (e.g. acute lung injury, vasoactive
research work is required. infusions) have also been examined. 112
Patient diaries were also thought to be important in pro- Physiotherapy recommendations for physical de-
viding missing pieces of information that might help a conditioning include development of ‘exercise prescrip-
119
patient make sense of their critical illness experience. A tions’ and ‘mobilising plans’. Activities range from
diary approach has been adopted in a number of Euro- passive stretching and range of motion exercises for limbs
pean ICUs, 106,107 and while there has been some variation and joints, positioning, resistive muscle training to
in how the diaries were compiled and then viewed by a aerobic training and muscle strengthening and ambula-
patient, there is emerging evidence that supports their tion. 119,120 Specific mobility activities include:
108
use. Note however that not all patients may wish to be ● in-bed (range of motion, roll, bridge, sitting on edge
reminded of their ICU experience; this is especially the of bed)
case for patients who demonstrate avoidant behaviours. ● standing at side of bed
Others may wish not to be reminded of being critically ● transfer to and from bed to chair
53
ill but wish to concentrate on recovery. Further research ● marching on the spot
that incorporates these issues during assessment of post- ● walking. 117
traumatic stress symptoms will further establish the effec-
tiveness of diary use (see Research Vignette later in this Patient support for each activity ranges from assistance
chapter). with 1–2 staff through to independence under supervi-
121
sion. Rehabilitation devices can also include a tilt-table,
The recent UK NICE guidelines emphasised regular neuromuscular electrical stimulation (NMES), bedside
109
assessment of patient recovery including psychological cycle ergometry and adapted walking frames. 122 Inspira-
recovery. Assessment periods include during intensive tory muscle training (IMT) has been used for weakness
care, ward-based care, before discharge home or commu- associated with prolonged mechanical ventilation, 123
nity care and 2–3 months after ICU discharge, with the using resistance and threshold-training devices. There is
use of existing referral pathways and stepped care models however no current strong evidence 124 supporting an
to treat identified psychological dysfunctions. These ser- independent benefit of IMT, but it can be used as adjunc-
vices are usually well established and allow patients to be tive therapy. 125,126
treated by appropriately qualified practitioners. The role
of critical care practitioners may therefore be to establish A survey of practices in Australian ICUs noted that 94%
the causes of psychological disturbances associated with of physiotherapists prescribed exercise frequently for
critical illness, identifying at-risk patients through system- both ventilated and non-ventilated patients, but practices
atic and standardised screening activities, closely moni- did vary widely and no validated functional outcome
toring identified patients and referring to appropriate measures were used. 127 As noted earlier, a culture of
specialties where appropriate, to optimise their recovery patient wakefulness and early in-ICU activity and mobil-
trajectory while not introducing any further harm. ity is advocated but challenged by the status quo of
work practices and health professional role delinea-
REHABILITATION AND tions. 113,118,128-130 A re-engineering of work processes and
practices to promote patient activity is therefore required
MOBILITY IN ICU to ensure optimal outcomes for survivors of a critical
illness.
Interventions to minimise ICU-AW, particularly in rela-
tion to muscle de-conditioning from disuse (e.g. seda- Further development and testing of candidate interven-
tion; bed-rest) have recently focused on active exercises tions also remain, particularly in terms of patient selec-
and mobility, even while patients are intubated and ven- tion, when to commence, and the duration, intensity and
26
tilated. Early studies of in-ICU mobility have demon- frequency of the rehabilitation interventions. Activities
131
strated safe and feasible interventions, 110-112 although this may also be adopted and adapted from other established
focus requires a cultural shift with a multi-disciplinary rehabilitation programs in pulmonary stroke cohorts.
128
team approach and changes in care processes. 26,113,114 Technological devices, such as virtual reality rehabilita-
In-ICU rehabilitation has also reduced ICU and hospital tion 132 may also prove to be beneficial in this cohort with
lengths of stay and improved physical function at further development and testing.