Physical Therapy in the Intensive Care Unit
Bryan Mull, SPT
Background
During my second clinical rotation in the spring of 2014, I was treating patients in a variety of acute care settings at Presbyterian Hospital in Charlotte, NC. As a student with limited experience, I found myself more comfortable treating patients that were medically stable on the general units compared to the ones with more medical involved located in the intensive care areas of the hospital. Not only did I feel a bit intimidated, but also I noticed that families and caregivers were also uneasy and nervous about having their critically ill, and in their minds fragile, loved ones participating in exercises and mobility. I realized that I came into this clinical having only briefly been lectured on the advantages of early mobility. Not only this, but most of the education on early mobility in the critical care setting is targeted towards physicians and members of the medical team. In my discussions with Benita Hall, senior trauma physical therapist at UNC Hospitals, I learned that they currently have no educational materials to provide to patients or families/caregivers about the importance of early mobility and exercise in the intensive care setting. I have also discussed with several classmates the need for student physical therapists to be more knowledgeable about these benefits prior to treating patients who are critically involved to not only increase their confidence, but to improve their abilities to provide reassurance and education to patients and their caregivers. The need for improved student education regarding the benefits and considerations for providing physical therapy in the intensive care setting and the need for effective patient/family education materials formed the basis for my Capstone project.
Purpose
This Capstone project directly relates to my desire to work as a licensed therapist in the acute care setting upon graduation. Completing a literature search and disseminating the products of this project will hopefully prepare me to provide patient and family education about the benefits of physical therapy in a critical care setting. Ultimately, I want to be a clinical instructor for future physical therapy students in a large teaching hospital. Providing education and receiving feedback at the conclusion of this project designed for physical therapy students about to begin acute care rotations will prepare me for how to effectively educate future students on their clinical affiliations.
Products
- The first product of my Capstone was an evidence table of recently published literature on the benefits, risks, indications, and contraindications of early mobility in the intensive care setting. This evidence table helped organize information and proved to be very useful in the creation of the other materials related to this Capstone project.
Evidence Table
- I created both a PowerPoint and Voicethread presentation designed for physical therapy students about to begin their first clinical rotations in an acute care setting. This presentation was designed to synthesize information from various lectures and information that are discussed during the program and to give a PT student a general idea of what to except and how to prepare for treating a patient in an intensive care setting.
PowerPoint
Voicethread
- The educational brochure I created should be provided to families and caregivers soon after their loved ones are admitted to an intensive care unit. It provides a brief overview of the goals that physical therapists have for treating patients in this setting and the benefits they can provide to combat side effects of prolonged bed rest. The health literacy assessment I conducted showed that this brochure is at a 12th grade reading level. I found it difficult to get the reading level down any lower due to the necessity of larger words when disseminating medical care-related information. Feedback from my committee was invaluable for all of the materials in my Capstone project, but especially with this brochure. The members of my committee had far more experience interacting with families and caregivers in this environment and were able to help guide me on the best topics to include in the brochure.
Brochure
Evaluation
In order to evaluate the overall effectiveness of this project, I created a brief survey for students (or therapists) to fill out after viewing the material. Please click here to provide feedback for my Capstone Voicethread presentation!
Acknowledgements
I owe a HUGE thanks to Benita Hall, senior trauma therapist and UNC hospitals, and Janet Elder, my clinical instructor and source of inspiration during my clinical rotation at Presbyterian Hospital last year. As my committee members, both of you devoted your time to provided detailed and constructive feedback that was instrumental in helping me create better educational material for both students and patients/caregivers with this Capstone project. I also want to thank Karen McCulloch for serving as my Capstone advisor.
References:
- Klein K. Clinical and Psychologic Effects of Early Mobilization in Patients Treated in a Neurologic ICU: A Comparative Study. Critical care medicine.2014-12-16;1.
- Nydahl P. Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany. Critical care medicine.2014-05;42:1178-1186.
- Witcher R. Effect of early mobilization on sedation practices in the neurosciences intensive care unit: A preimplementation and postimplementation evaluation. Journal of critical care.2014-12-11;null.
- Hodgson CL. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Critical care (London, England).2014-12-04;18:658.
- Nydahl P. Complications related to early mobilization of mechanically ventilated patients on Intensive Care Units. Nursing in critical care.2014-11-07;n-a-n/a.
- Davis J. Mobilization of ventilated older adults. Journal of geriatric physical therapy (2001).2013-10;36:162-168.
- Kayambu G. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Critical care medicine.2013-06;41:1543-1554.
- Stiller K. Physiotherapy in intensive care: an updated systematic review. 2013-09;144:825-847.
- Li Z. Active mobilization for mechanically ventilated patients: a systematic review. Archives of physical medicine and rehabilitation.2013-03;94:551-561.
- Pires-Neto RC. Very early passive cycling exercise in mechanically ventilated critically ill patients: physiological and safety aspects–a case series. PloS one.2013;8:e74182.
- Yosef-Brauner O. Effect of physical therapy on muscle strength, respiratory muscles and functional parameters in patients with intensive care unit-acquired weakness. The clinical respiratory journal.2015-01;9:1-6.
- Dong ZH. Effects of early rehabilitation therapy on patients with mechanical ventilation. World journal of emergency medicine.2014;5:48-52.
7 Responses to “Physical Therapy in the Intensive Care Unit”
Nicholas Mang
Bryan,
Your voicethread was great, and I really appreciated the supplemental lines/leads/tubes slides. During my second clinical rotation, I, too, was quite anxious when mobilizing patients in the ICU. I was especially anxious when a patient had multiple L/L/Ts. I definitely would have felt more confident and prepared if I accessed your presentation prior to my rotation. When you become a clinical instructor, I encourage you to send this excellent primer to your students as part of their preparation for working with patients in the ICU.
Your slides regarding exercise considerations (lab values slide) and indications/contraindications for ICU mobility have excellent utility. If I ever work again with individuals in the ICU, I plan on using the safety and benefits/risks information to educate and re-assure the patient and his/her family on the appropriateness of mobilization. The brochure you fabricated is an excellent tool to convey this information to someone who does not have any familiarity with early mobilization concepts and ICU care. Great work, Bryan!
-Nick
Bryan Mull
Janet,
I greatly appreciate you taking the time to not only serve as one of my committee members, but also taking the time to view my website and Voicethread and provide feedback. You set the bar very high as both a clinician and CI and I will carry many of the lessons and tidbits I learned at Presbyterian with you during my career as a physical therapist!
Thanks,
Bryan
Bryan Mull
Reid,
Thank you for checking out my Capstone, I am pleased that you found much of the information useful. I hear that you also spent a decent amount of time working in ICU settings during one of your UNC affiliations so I will have to pick your brain soon about things!
Thanks,
Bryan
janet elder
Hi Bryan – Just wanted you to know I provided some feedback on your voicethread presentation – I took the survey and also made some comments about voicethread as well as the entire capstone project. You have done an incredible job with this complex material and managed to make it easily digestible and understandable for your peers – I hope you realize what a terrific job you have done here! I am impressed how you were able to look at the huge body of information and break it down in such a logical fashion – your explanations are clear in every format – powerpoint, brochure, and especially the voicethread, which is conversational and casual but still chock full of important information that really underlines how critical it is to be on top of so many concurrent factors while treating a patient in the ICU. Even for an experienced therapist like myself, it is a little striking to see all the considerations I routinely manage written out in one place – it truly can be an intimidating mountain of information to the less experienced, but I think your fellow students should be very thankful you created such a well organized and easy to follow breakdown – your peers should be able to feel more confident and less overwhelmed by the idea of working with ICU level patients because of your really impressive and professional presentation. I know it was a lot of hard work but you truly have done an incredible job! Glad you were my student – I am so proud of you and happy that you want to be like your old CI and do clinical education in the acute care setting in a large teaching hospital too, like Presbyterian, I hope??!!!
Reid
Bryan,
Great job on your Capstone! I can tell you spent a lot of time working on this and it shows. I agree with Sabina in that I too wish we had your information before going out on our first clinicals. Your PowerPoint is very comprehensive and I especially liked how you incorporated the theme of interdisciplinary teamwork throughout your presentation. This is vital skill to have when working in the ICU or anywhere in the hospital.
Even though it may seem simple to some, I was happy to see you include all of the settings and what the abbreviations were, as I had trouble knowing these when I got to my acute rotation. Your discussion of indications and contraindications for ICU mobility is really helpful for me since I am going to an acute rotation with the possibility of working with some patients in an ICU.
As someone who might possibly be working in the ICU setting, I found myself thinking about some of the modules we completed this semester (oncology, spine, stroke, etc) and how these populations may present differently in the ICU. Your Capstone encourages me to consider how patients with certain comorbidities or diagnoses may present and the implications for physical therapy interventions. Great job!
Sabina Beckler
Hi Bryan!
I have to start by saying that I so enjoyed reviewing your materials and wish we had these materials prior to going on our clinical rotations. As I was looking through your PowerPoint presentation, I found myself using it as a way to review for my upcoming clinical rotation in the acute care setting. It’s awesome having all the major components about treating patients in ICU available in one spot instead of scattered throughout a few different lectures and class notes. One of the things that really stood out to me was the chart of lab values in relation to exercise considerations. You also really made a point to highlight the interdisciplinary team involved in patient care. This is a component of acute care and the ICU specifically that I love and is a great way for students to practice communicating with other healthcare professionals.
One suggestion I have is possibly adding a little more information in the PowerPoint about any safety concerns when it comes to various lines/leads/tubes. For example, are there specific positions a student or PT should avoid when a patient has a chest tube? Are there certain activities that may dislodge some of the lines? Beyond knowing the lines/leads/tubes a patient has, a student or PT may also benefit from knowing if certain precautions should be taken. Just a thought.
As I have an interest in acute care pediatrics, I found myself thinking about how pediatrics may differ from adults when it comes to the ICU. Obviously infants can be quite different but do you know if there are differences with children as well? Maybe someone in the future classes can look at this topic! I think the family education component you mentioned and the brochure you created would be awesome for pediatrics for parents.
Awesome job!
Sabina
Bryan Mull
Hi Sabina!
Thank you for taking the time to look at my Capstone site. I appreciate all of your positive comments and I think all of the suggestions you had are great ideas! I should have included a few of the precautions associated with certain lines, leads, and tubes…but I elected not to go down that road because I did not want to create the impression that those were all of the precautions that someone needs to know as it pertains to that topic. The presentation in general was meant to be more of a brief overview and educate students on some of the broad concepts of how physical therapists engage with patients and an interdisciplinary team in the ICU environment. It would be very wise for a student to study lines, leads, and tubes in a bit more detail than I felt I could adequately cover within the confines of my ~20 minute presentation. I should have made it more apparent in the presentation which topics would be useful for someone to go over in greater detail prior to embarking on an acute care rotation. Your inquiry about pediatric vs. adult considerations for treatment in the ICU would make a great Capstone for a future student. Good luck on your last clinical rotation and have a great service trip to Guatemala. I cannot wait to hear all about it.
Thanks,
Bryan