Hospital of the University of Pennsylvania, Philadelphia, USA.
University of Pennsylvania, Philadelphia, USA.
Neurocrit Care. 2019 Aug;31(1):88-96. doi: 10.1007/s12028-019-00670-2.
BACKGROUND/OBJECTIVE: In November 2014, our Neurointensive Care Unit began a multi-phased progressive early mobilization initiative for patients with subarachnoid hemorrhage and an external ventricular drain (EVD). Our goal was to transition from a culture of complete bed rest (Phase 0) to a physical and occupational therapy (PT/OT)-guided mobilization protocol (Phase I), and ultimately to a nurse-driven mobilization protocol (Phase II). We hypothesized that nurses could mobilize patients as safely as an exclusively PT/OT-guided approach.
In Phase I, patients were mobilized only with PT/OT at bedside; no independent time out of bed occurred. In Phase II, nurses independently mobilized patients with EVDs, and patients could remain out of bed for up to 3 h at a time. Physical and occupational therapists continued routine consultation during Phase II.
Phase II patients were mobilized more frequently than Phase I patients [7.1 times per ICU stay (± 4.37) versus 3.0 times (± 1.33); p = 0.02], although not earlier [day 4.9 (± 3.46) versus day 6.0 (± 3.16); p = 0.32]. All Phase II patients were discharged to home PT services or acute rehabilitation centers. No patients were discharged to skilled nursing or long-term acute care hospitals, versus 12.5% in Phase I. In a multivariate analysis, odds of discharge to home/rehab were 3.83 for mobilized patients, independent of age and severity of illness. Other quality outcomes (length of stay, ventilator days, tracheostomy placement) between Phase I and Phase II patients were similar. No adverse events were attributable to early mobilization.
Nurse-driven mobilization for patients with EVDs is safe, feasible, and leads to more frequent ambulation compared to a therapy-driven protocol. Nurse-driven mobilization may be associated with improved discharge disposition, although exact causation cannot be determined by these data.
背景/目的：2014 年 11 月，我们的神经重症监护病房开始对蛛网膜下腔出血和外部脑室引流（EVD）患者进行多阶段渐进性早期活动倡议。我们的目标是从完全卧床休息的文化（第 0 阶段）过渡到物理治疗和职业治疗（PT/OT）指导的活动方案（第 I 阶段），并最终过渡到护士驱动的活动方案（第 II 阶段）。我们假设护士可以像完全由 PT/OT 指导的方法一样安全地移动患者。
在第 I 阶段，仅在床边由 PT/OT 移动患者；没有独立的下床时间。在第 II 阶段，护士独立地移动 EVD 患者，患者一次可以在床外停留长达 3 小时。物理治疗师和职业治疗师在第 II 阶段继续进行常规咨询。
与第 I 阶段相比，第 II 阶段患者的移动频率更高[每 ICU 住院次数为 7.1 次（±4.37）与 3.0 次（±1.33）；p=0.02]，但并不更早[第 4.9 天（±3.46）与第 6.0 天（±3.16）；p=0.32]。所有第 II 阶段患者均出院到家庭物理治疗服务或急性康复中心。与第 I 阶段的 12.5%相比，没有患者出院到熟练护理或长期急性护理医院。在多变量分析中，移动患者出院回家/康复的可能性是未移动患者的 3.83 倍，与年龄和疾病严重程度无关。第 I 阶段和第 II 阶段患者的其他质量结果（住院时间、呼吸机使用天数、气管切开术放置）相似。没有早期活动导致的不良事件。
与治疗驱动的方案相比，EVD 患者的护士驱动活动是安全、可行的，并导致更频繁的活动。护士驱动的活动可能与改善出院处置有关，但这些数据无法确定确切的因果关系。
