School of Nursing and Midwifery, Griffith University, Australia.
School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Australia.
Int J Nurs Stud. 2018 Jan;77:91-105. doi: 10.1016/j.ijnurstu.2017.09.019. Epub 2017 Oct 2.
The intensive care unit provides complex care for critically ill patients. Consequently, due to the nature of critical illness and the therapies administered in intensive care, patients are often on prolonged periods of bed rest with limited mobility. It has been recognised that mobilising critically ill patients is beneficial to patients' recovery, however implementing early mobility as a standard of care remains challenging in practice.
To identify the key factors that underpin successful implementation and sustainability of early mobilisation in adult intensive care units.
Integrative Review.
A systematic search strategy guided by SPICE framework (Setting, Perspective, Intervention, Comparison, Evaluation) was used to formulate the research question, identify study inclusion and exclusion criteria, and guide the database search strategy. Computerised databases were searched from August-September 2016. Quality improvement articles that identified project implementation of early mobilisation of mechanically ventilated adult intensive care patients were included.
After screening the articles, extracting project data and completing summary tables, critical appraisal of the quality improvement projects was completed using the Quality Improvement Minimum Quality Criteria Set. A modified version of the Cochrane Effective Practice and Organisation of Care taxonomy was used to synthesise the multifaceted implementation strategies the projects utilised to help bring about changes in clinician behaviour.
Thirteen articles, reflecting 12 projects meeting the inclusion criteria were included in the final analysis. Eleven projects were conducted in the United States, and one in the United Kingdom. Quality scores ranged from 6 to 15. A formal framework to guide the quality improvement process was used in 9 projects. The three most frequently used groups of implementation strategies were educational meetings, clinical practice guidelines and tailored interventions. Managing the change process through strong leadership, designing strategies and interventions to overcome barriers to implementation, multidisciplinary team collaboration and data collection and feedback underpinned successful and sustainable early mobility practice change.
The use of a quality improvement appraisal tool can help identify high quality projects when planning a similar mobility program. Even though projects were conducted in a variety of intensive care unit settings, and implementation frameworks and strategies varied, all began with strong leadership commitment to early mobilisation. This along with using the quality improvement process and multidisciplinary team approach ensured success and sustainability of mobilising ventilated patients.
重症监护病房为危重症患者提供复杂的护理。因此，由于危重病的性质以及重症监护中使用的治疗方法，患者通常需要长时间卧床休息，活动受限。人们已经认识到，让危重症患者活动对患者的康复有益，然而，在实践中，将早期活动作为护理标准仍然具有挑战性。
确定成功实施和维持成人重症监护病房早期活动的关键因素。
综合审查。
一项系统的搜索策略，由 SPICE 框架（环境、视角、干预、比较、评估）指导，用于制定研究问题，确定研究纳入和排除标准，并指导数据库搜索策略。计算机数据库于 2016 年 8 月至 9 月进行搜索。纳入了确定机械通气的成年重症监护患者早期活动项目实施情况的质量改进文章。
筛选文章、提取项目数据并完成摘要表后，使用质量改进最低质量标准集对质量改进项目进行了批判性评价。使用 Cochrane 有效实践和护理组织分类法的修改版本，对项目用于帮助改变临床医生行为的多方面实施策略进行了综合分析。
最终分析纳入了 13 篇符合纳入标准的文章，反映了 12 个项目。11 个项目在美国进行，1 个在英国进行。质量评分范围为 6 至 15。9 个项目使用了正式的框架来指导质量改进过程。使用最频繁的三组实施策略是教育会议、临床实践指南和针对性干预。通过强有力的领导管理变革过程、设计克服实施障碍的策略和干预措施、多学科团队合作以及数据收集和反馈，为早期活动的成功和可持续实践变革提供了支持。
在规划类似的活动项目时，使用质量改进评估工具可以帮助确定高质量的项目。尽管这些项目是在各种重症监护病房环境中进行的，并且实施框架和策略也有所不同，但所有项目都始于对早期活动的强有力领导承诺。这一点，加上使用质量改进过程和多学科团队方法，确保了动员呼吸机患者的成功和可持续性。
