Early Mobility (EM) in the ICU: A Focus on Interventions Impacting Culture Change

Despite evidence supporting the importance of early mobility (EM) in the intensive care unit (ICU), many hospitals do not have EM practices in place. It is unclear why ICUs are unable to successfully implement and sustain protocol when many perceived barriers have been proven not to inhibit EM as originally thought. (Bakru et al., 2015; Dubb et al., 2016; Jolley et al., 2014; Leditschki et al., 2012). The purpose of this systematic review was to understand strategies that occupational therapists can use to influence staff behavior to facilitate EM in the ICU.

STUDY SELECTION: Searches were performed July 2018, in MEDLINE (Ovid), the Cochrane Library (Wiley), Embase (Elsevier), and CINAHL with Full Text (EBSCOhost). Search strategies incorporated a combination of controlled vocabulary and text words for intensive care units, health personnel, and mobility. Searches were limited to peer-reviewed studies. No restriction was placed on date of publication.

SCREENING METHODS: Inclusion criteria included: (a) studies published in peer-reviewed journals (b) articles describing an intervention to improve EM compliance conducted in at least one adult ICU setting (c) articles reporting ICU-specific data on EM compliance outcomes. Exclusion criteria included: (a) studies not published in English (b) pediatric settings.

Screening was conducted by six researchers and uploaded to the Rayyan QCRI database. Titles were screened through an unblinded group process, and any disagreements were resolved with group discussion. Abstracts and full text articles were screened in pairs using the same eligibility criteria. Each pair conducted an initial review in a blinded individual process, and post-review disagreements among pairs were discussed with the entire review team.

DATA EXTRACTION: After reading full text articles, the Behavior Change Wheel (Michie et al, 2011) (BCW) was used to qualify and extract specific change related behaviors. The BCW was chosen after a literature search of implementation models addressing specific behaviors to affect change. We piloted this model against four separate studies to ensure interrater reliability amongst researchers and content validity with our research question.

RESULTS: Our initial database search yielded 3,619 articles. 503 articles met inclusion criteria after title review. Abstract review yielded 53 articles, and 23 full articles were then screened, with 19 meeting all inclusion criteria for the review.

DATA SYNTHESIS: BCW intervention strategies utilized in the articles were education (89%), enablement (84%), training (63%), restriction (57%), persuasion (42%), environmental restructuring (42%), modeling (42%), incentivisation (31%), coercion (0%). 63% of the articles included occupational therapy as part of the EM team.

CONCLUSION: Interventions most utilized for culture change focused on positive reinforcement such as education, enablement, and training while interventions used the least on the BCW were incentivisation and coercion. The only form of restriction used in all studies were the mobility protocols put in place. ICUs looking to increase mobility can utilize these BCW interventions to implement culture change. 58% of studies utilized occupational therapists in their EM practices. This suggests that while occupational therapy plays an important role on the EM team, they are not utilized to their fullest capacity given the field’s expertise in functional improvement. Results of this study will provide occupational therapists with the opportunity to appeal to leadership and members of the interdisciplinary team with evidence based strategies to champion, develop, and implement successful culture change for early mobilization in the ICU.

References

Michie, S., Van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science, 6(1), 42.

Downs, S. H., & Black, N. (1998). The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Journal of Epidemiology & Community Health, 52(6), 377-384.

Ouzzani, M., Hammady, H., Fedorowicz, Z., and Elmagarmid, A., (2016). Rayyan - A web and mobile app for systematic reviews. Systematic Reviews 5:210, DOI:10.1186/s13643-016-0384-4.