Correlation between Initiating Time of Mobilization and Cardio Pulmonary Stability among Critical Ill Patient

Introduction

Critical illness is a life-threatening multisystem process that can result in significant morbidity or mortality. In most patients, critical illness is preceded by a period of physiological deterioration, such as frequently missing of accurate recording and documentation for vital signs, recognition and interpretation of abnormal values, patient assessment, appropriate intervention and early-warning systems are an important part that can help in identifying patients at risk of deterioration and serious adverse events ⁽¹⁾.

An intensive care unit (ICU),  or critical care unit (CCU), is a special department of a hospital  that provides  intensive treatment medicine , close observation and monitoring for seriously ill patients who are at high risk of complications and  monitors, intravenous (IV) tubes, feeding tubes, catheters, breathing machines, and other equipment which are common in critical care units .Approximately 20% of acute care admissions are to an intensive care unit while up to 58 % patients are from emergency department admissions such as Cardiac, respiratory and neurologic disorder which are common in adult ICU patients ^(2.3.4).

Prolonged immobilization of critically ill patients has negative repercussions on the musculoskeletal, cardiovascular and respiratory systems, the skin and cognition. To prevent and minimize such effects, immediate physical therapy intervention is necessary, provided the patient exhibits the clinical stability needed to meet the vascular and oxygen demands posed by this type of intervention⁽⁵⁾.

Immobilization effects on hemostasis process which are increase in blood viscosity, reduction in plasma volume and decrease in oxygen demand because of muscle atrophy as well as a hemostatic in balance between pro and anti-coagulator factors which can lead to pathological formation of thrombus and also bed rest immobilization that affect on lungs which reduce their forced vital capacity as well as bronchociliar activity which increase the risk of respiratory infections ⁽⁶⁾.

Early mobilization refers to initiating physical exercise or mobilization within the early illness phase which is an increasingly common practice in intensive care units (ICU). This proves to be feasible and safe in preventing bed-rest-associated morbidity, while improving patients’ physical function psychological condition, and quality of life. Mobilizing patients at an early time point has been associated with reduced health care costs, delirium and hospital length of stay. And improve patient outcomes.  So early mobilization should be performed within the first 24 h of ICU admission ^(7.8).

Early mobility (within 48 h of admission) with a mobility team improved patient outcomes and increased the frequency of physical therapy in ICU patients. Daily activity progressed through basis of consciousness of patients and increased strength, starting with passive range-of-motion exercises, sitting on the edge of the bed, transfers from bed to chair, and ambulation. The results of mobility there were no adverse events, such as removal of tubes or devices and decrease ICU LOS ⁽⁹⁾. 

Significance of the Study

The early  mobilization can safely occur within two to four days of admission in critically ill patients particularly those requiring mechanical ventilation (MV), who are prone to impairments in physical function associated with immobility and intensive care unit (ICU) acquired weakness. Functional impairments acquired during ICU hospitalization result in increased need for long term nursing care, greater risk of readmissions and reductions in health-related quality of life for ICU. ⁽¹⁰⁾. (Li Z, Peng and zhub 2013)

It Has been observed by the researcher over a period of one year from 2015 in intensive care units in Minia university that the critical ill patients complain from complication from lack in their mobilization, so this current study assesses correlation between initiating time of mobilization and cardiopulmonary stability among critical ill patients .

Operational definition initiating time of mobilization for critical ill patients.

The concept of mobilization of critically ill patients is energy consuming and consists of physical and psychological aspects, including activities that produce movement such as “active limbs exercising, actively moving in bed, sitting on the edge of the bed, etc.. Mobilization also is defined as “the physical activity that, is performed with the appropriate intensity, produces physiological benefits for the organism”, acting on the circulation, central and peripheral perfusion, ventilation, or state of consciousness. The term “early” refers to activities that are carried out from the initial physiological stabilization that continues during the ICU stay.^(11,12)

The effects of early rehabilitation on patients who survive their disease at the ICU, focuses on interventions aimed at preventing the (Intensive Care Unit Acquired Weakness) ICUAW, which also improves physical capacity. (^13,14)

Aim of the study

The aim of the present study was to assess correlation between initiating time of mobilization and cardiopulmonary stability among critical ill patients.

Research question

Are there correlations between initiating time of mobilization and cardiopulmonary stability among critical ill patients?

Subject and Method

Study design

The descriptive correlated research design was utilized in this study.

Study Subjects

Consecutive purposive sample who are admitted in previous intensive care units at Minia University and who are related to inclusion criteria participated in this study.

Study Setting

This study was carried out at two critical care units(traumatic intensive care unit and neurosurgery care unit at Minia university hospital . the traumatic  I C U  is located on the second flour in the building called ( G ) with 8 beds which involved thirteen nurses . the neurosurgery care unit is located in second flour in the building called ( A ) with 8 beds and involved eleven nurses .

Inclusion criteria

• Adult (less than 65) patient male and female patients.
• Recent  critical ill patients who were admitted  to I C U
• full conscious and oriented patient
• Post  operative patient admitted to I C U

Exclusion criteria

• The patient who has pelvic, long bone fracture or skeletal  traction
• Patient who has facial trauma or known difficult breathing
• Patients with spinal or cranial injuries associated with abnormal intracranial pressure.

Tools of data collection

Two tools were designed and used for data collection, these tools were formulated by the researcher after revising extensive relevant literature review and one standardized scale.

First tool: Patients' interview structured questionnaire. It covered two main parts:

• Part 1:  personal characteristics  this included  (age , gender ,……………….ect)
• Part 11 : patients medical information data which included : (past chronic illness  , chief complaint , weight  ,duration of bed rest ,  initiating time of mobility ,………………ect )

Second tool: patient’s cardiopulmonary assessment sheet that includes:

• Measuring pulmonary parameters as : respiratory (rate , rhythm and depth) , oxygen saturation , chest sound  …………..ect  before and after  mobility practices within 15 minutes .
• Measuring cardio parameters as : pulse (rate , rhythm , strength ) ,  blood pressure , ……………….ect before and after mobility practices within 15 minutes .

Perm scale 

This scale was adapted from perm (2009) ⁽¹⁵⁾ used to evaluate level of studied subjects mobility practice by the researcher's observation and included three categories as (bed mobility, transfers and gait)

System score:

The entire above category is performed by the participants in the study from the first day to third day from admission to intensive care units until the patients discharge. It is ranked into done completely which scored by (1) and not done scored by (0).

• <85% is considered unsatisfactory performance (who did practices from less than (6/9)
• 85%  is considered satisfactory performance from (7/9)

Tools validity:

Content validity was done to identify the degree to which the used tools measure what was supposed to be measured. the developed tools were  examined by a panel  of three experts in the field of  medical surgical nursing department and medical staff who are related to critically ill specialty  in { Minia university  - faculty of nursing} . All jury members (100%) agreed that the current study tools were valid and relevant to the aim of the study.

Tools reliability:

Tools reliability was done to identify the extent of consistency of the tools items with the study concept and their correlation with each other, and intraclass correlation coefficient by cronbacks test at baseline 0.9%.

Pilot study:

A pilot study was carried out on 10 % (n = 6 patients) from total study sample to test feasibility, objectivity, and applicability of the data collection tools. Carrying out the pilot study gave the investigator the experience to deal with the included subjects and to be familiar with the data collection tools. Based on the results of the pilot study, no modification or refinement were done and the subjects were included to the actual sample

Ethical consideration:

An official permission to conduct the study was obtained from the ethical committee in the faculty of nursing, Dean of nursing faculty, and the manager of Minia university hospital, the head of each unit's critical, neurosurgery care unit, and agreement from Egypt academy for research center and technology. Subjects participated in this study voluntarily and each involved subject gone oral consent to participate as was told information about the purpose, benefits, and nature of the study and that he /she had the right to withdraw from the study at any time without any rational. Confidentiality and anonymity of each subject were ensured through coding of all data and protecting the obtained data. Subjects were informed that the obtained data will not be included at any further researches without a second oral consent.

Study Procedure:

The current study was conducted by preparing different data collection tools , in addition to , obtaining oral and paper agreement which were taken in a duration of one week before conducting the study . the researcher collected the current  study data from its setting on daily basis (3-4 days / weeks ) at least two patients weekly according to inclusion criteria  during morning or afternoon shifts .

The researcher started data collection from the studied participant in the study by using the first and second tools (patients' structure questionnaire, physical and cardiopulmonary assessment sheet) and observation for third tools (perme scale) within 6-8 months at the start of the study.

The researcher observed that mobility practice was done every mid time shift starting patients mobility (three times / day)  and The researchers assessed and follow up the studied participants for mobilization within three day from admission and their cardiopulmonary stability

On the other time of  , the researcher trained the inters students who had shift in the same study  setting to observe the study participant in accurate time during specific work shift and assist the researcher in assessment of their cardiopulmonary status using the second tools , and perm scale .

Statistical analysis of data:

Data were summarized , tabulated ,and presented using descriptive statistics in form of frequency distribution , percentages , means and the standard deviation as a measure by dispersion .a statistical package for the social science (SPSS) version (20) 2017 was used for statistical analysis of data , as it contains the test of significance given in standard statistical books . Numerical data were expressed as mean and SD. Qualitative data were expressed as frequency and percentage. Probability (p- value) is the degree of significance, less than 0.05was considered significant, the smaller (p- value ) obtained . The more significant is the result (*), less than 0.001 was considered highly significant (**)   and correlation coefficient was done by using pearson –Brown's correlation test

Results

Figure (1): Distribution of the study sample according to their age  (n= 60).

Figure (2): Distribution of the study sample regarding to their gender(n= 60).

Figures (1 & 2) show that, the highest percentage of studied samples age ranged between (29 to 39 years), with Mean+ SD = 1.85 + 0.840 and more than fifty percent among them were males (53%) 

Table (1): Frequency distribution by percentage of the study samples regarding to other medical data (n=60)

Table (1) reveals that , the three quarter  among the studied participants did not have previous admission to I C U  (76.7%) with mean 1.77+0.42  and more than half among them stayed in I C U five days (51.7%) with mean 1.52+0.50 . Concerning to change position among studied participant results showed that (66.7) with mean 2.40+0.61 changed their position by staff nurses every shift and they initiated mobility practice for them in the fourth day from admission. 

Table (2): Frequency distribution by percentage for study sample’s to assess their mobility level by using Perm mobility observation checklist scale (n=60)

Table (2) shows that most of mobility practice were not done by I C U nursing staff except only two practices which were done for studied sample as to move into standing position and to use walker or assistive device constituted (86.7 % & 91.7%) respectively implemented by staff nurses  , on the other hand, the majority percentage among studied sample had not performed mobility practices in bed which were provided from their I C U nursing staff constituted (85 % &100% &93.3%) while the minority percentage was found only in transfer constituted (13.3%) .

Table (3): Correlation of respiratory characteristics among study sample through selected parameters before and after mobility (n= 60)

* p≤0.05 (significant) T-test: P – value based on independent sample t-test,   F-test P – Value based on compares mean NS= No Significant difference * Statistical significant difference

Table (3) reveals that there were significant differences in assessment of respiratory characteristics (rate & rhythm and depth) among studied sample before and after initiating mobility for them as sitting in chair respectively. While only respiratory rate had significant differences among studied sample before and after initiating mobility for them as ambulation.

Table (4) Correlation of selected cardiac parameters ( blood pressure , peripheral edema and capillary refill ) for studied sample before and after initiating  mobility practices  (n=60)

* p≤0.05 (significant) T-test: P – value based on independent sample t-test, F-test P – Value based on compares mean   NS= No Significant difference * Statistical significant difference

Table (4) shows that there is significant correlation between initiating mobility practices and normal blood pressure & no presence of peripheral edema among studied participants when they are sitting in bed (P= 0.045 &P= 0.083) respectively but table findings mentioned that there were correlation between normal capillary refill for studied group when they are sitting in bed and during sitting in chair (p= 0.32 & p= 0.15) respectively.

Table (5): The correlation between means among cardiopulmonary parameters after initiating mobility practices.

Table (11) reveals that there statistical significant correlation between mobility practice and all cardiopulmonary parameters among studied sample except pulse (rhythm & depth ) (p=0& p=0.607) respectively