Care of Critically Ill AdultsFeasibility and inter-rater reliability of the ICU Mobility Scale
Introduction
Early mobilization is a part of the rehabilitation process of patients in the intensive care unit (ICU) and is increasingly advocated for the prevention and management of ICU-acquired weakness (ICUAW) and related impairment of physical function.1, 2, 3, 4 Early mobilization is the process of improving a patients functional mobility, such as rolling, sitting, standing and walking, and has been used to reduce duration of mechanical ventilation, ICU and hospital length of stay and to improve functional recovery in ICU survivors.5, 6 This emphasis has required a cultural shift from providing deep sedation and bed rest in the ICU, to having a more awake and active patient.7, 8, 9 However, there is no gold standard in the ICU describing intensive care patients' level of mobility that can be used at the bedside by any member of the ICU multidisciplinary team in a quick, easy and reliable manner.10, 11
Early mobilization in the ICU can be provided by nursing staff or physical therapists; however physical therapists are not always employed in intensive care units internationally. Any measure of mobility milestones in the ICU must be feasible, valid and reliable across both nursing and physical therapy disciplines. A previous survey suggested that few physical therapists use any specific instrument to evaluate mobility in ICU.12 These findings may be because many other existing measures, such as the six minute walk test, were developed and validated outside of the ICU setting and are difficult to perform in the ICU.11 No previous data report the reliability and feasibility of nursing and physical therapy staff to report activities of mobilization in ICU.
Several studies have reported mobility milestones, such as sitting, standing or walking, as an important indication of patient physical function in ICU.7, 8, 13 They have not reported the level of assistance required to achieve the mobility milestone and they have not reported the same milestones. A recent systematic review described measures of physical function used in studies investigating early mobilization in the ICU.11 The ability to perform activities of mobility, or mobility milestones, was the most common end-point reported in these studies. However, there was no consensus on the activities that should be included in measures of mobility in the ICU, or reports of the feasibility or inter-rater reliability of such measures.11 No reliable scale or measure was found in the published or unpublished literature that could assess early mobilization in the ICU. One unpublished scale was identified that was used as part of the Critical Care Physical Medicine and Rehabilitation Program at Johns Hopkins Hospital (Baltimore, USA) but it included other criteria that were not mobility items, such as respiratory care, and it had not been tested for reliability.
The ability to quickly, easily and reliably report the highest level of mobilization in the ICU may be important for both research purposes and safe clinical practice. It is plausible that patients who have a higher level of physical function at ICU discharge may have reduced hospital length of stay and improved functional recovery after critical illness.6 The objectives of this study was to develop an ICU Mobility Scale (IMS), using commonly reported mobility milestones from published and unpublished literature, to report the highest level of patient mobility in ICU. The criteria for the scale was that it was feasible for use by the nursing and physical therapy staff at the bedside, and that it had good inter-rater reliability to measure the highest level of mobilization of adult ICU patients.
Section snippets
Design and setting
This prospective observational study was performed at two quaternary ICUs in Melbourne, Australia in September 2012. Both were closed units, one was a 20 bed mixed medical/surgical unit and the other was a 35 bed mixed medical/surgical/trauma unit. The study was approved by the ethics committees of Austin Health and Alfred Health. Patient consent was waived as the study was observational with no identifying data recorded, while verbal consent was gained from the nurses and physical therapists
Results
Table 2 describes results of the survey evaluating the feasibility of the IMS. The IMS was able to be used quickly by participating clinicians with 90% of them reporting that they perceived it would take <1 min to complete and that there were adequate definitions, without items that were unnecessary or repetitive. All participants (100%) reported the scale to be unambiguous. More than 90% of the participants responded that it was an appropriate length. Eighty percent of participants replied
Discussion
We aimed to identify a scale for measuring the highest level of patient mobility in the ICU, and to assess its feasibility and inter-rater reliability. The IMS was feasible, generally taking less than 1 min to complete, and was able to be used by a wide range of ICU nurses and physical therapists based on simple written definitions, without prior training or use of the scale. There was excellent agreement of the IMS scores between physical therapists and strong agreement between nursing staff
Acknowledgments
We would like to thank the other members of the TEAM study management committee for their input into the development of the IMS including Prof. Rinaldo Bellomo, A/Prof Linda Denehy, Prof. Jeff Presneill, Dr. Manoj Saxena, Dr. Elizabeth Skinner and Prof. Steve Webb. We would also like to thank the following groups: (1) members of the Critical Care Physical Medicine and Rehabilitation Program at John Hopkins Hospital, Baltimore USA, who created the original scale adapted in this study, (2) Dr.
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