Phase 3: RESULTS

Group 3: Rehabilitation

• Clinical algorithm for the Active and Passive Mobilization of Patients
  

• Issues Raised
  
  
• Best Practice Recommendation Consensus

Issues Raised

EXPERT OPINION:

Patients that have not reached the minimal physiologic stability (do not have the pulmonary; cardiovascular or neurological reserve described by Stiller et al 2004 and Bailey et al 2007) to actively partake in activities should not be excluded from a mobility plan. Because the goal of a mobility plan is to progress to patient initiated activity as soon as possible, each patient’s physiological stability needs to be assessed at least once daily. The effect of medication on patient’s ability to respond to verbal commands as well as the need for sedation should be discussed with the interdisciplinary team members. The core elements of a mobility plan for this group of patients should include semi-recumbent positioning with the goal of 45 degree head up; regular position change (current standard is turning every two hours), and daily passive movement of all joints. Expert opinion of nurses; therapists and intensivists. (Topp et al 2002; Thomas et al 2006; Krishnagopalan et al 2002; Morris 2007; Winkelman 2007; Nava 2002)

POSTED COMMENTS:

• Need to clarify what you mean by patients ability to respond to verbal commands - this is too vague. the should be alert and not comatose. Sedation needs to be addressed. is there a plan to manage sedation? It patients capable of activity/mobility may be renedered unable to participate or respond by the sedatives.
  
  
• Again, just a bit uncertain about saying each patient's physiological stability needs to be assessed AT LEAST ONCE DAILY. Does this mean weekdays? What about weekends and public holidays. Surely it is unrealistic and impractical to provide this level of service 7 days a week, every day of the year? I think it needs to be worded more guardedly.
  
  
• I sort of agree with this, but at the end the statement needs to go further. That body positioning as indicated by the assessment and on-going monitoring should include extreme body positions from side to side if patient does not respond well to progressively upright positions, or if she or he does, then progressively upright positions should be attempted to challenge the patient hemodynamically with respect to gravitational challenge. Such position changes then progress to sitting up over the edge of the bed, standing, stepping in place (with varying support as needed), transfer to chair, and taking steps.
  
  The time-honored every two hour turn is just that, time honored and has nothing to do with therapeutic indications or responses. What are the goals? In certain patients this will be too long, and others too short. What are the goals, what are the outcomes? How is the patient responding. Range of motion every day even though it does not hurt, is overrated. Many patients without neurological complications do perfectly well without this. Neurological problems are different. Concentrate on the oxygen delivery priorities and prevention of major complications need to be the goals, and need for range of motion assessed in terms of priority and need.