Title: When should clinicians start early mobilisation on intensive care? Exploring the barriers to early mobilisation and developing tools to study the safety of mobilisation of Intensive Care Unit patients.
Funder: Health Education England

Abstract: When should clinicians start early mobilisation on intensive care? Exploring the barriers to early mobilisation and developing tools to study the safety of mobilisation of Intensive Care Unit patients.Knowing when to start early mobilisation on an intensive care unit (ICU) has been set as a top research priority (Reay et al., 2014). There is promising evidence for the safety of early mobilisation (Adler, Malone, 2012) and an updated systematic review is required. However recent evidence has shown a lack of early ICU mobilisation (Nydahl et al., 2014) and therefore an understanding of mobilisation barriers in a UK setting is required. One barrier to implementation of early mobilisation could be a perception of the risk of adverse events. A definition of an adverse event is required because of a lack of a standardised outcome. One factor influencing the risk of adverse events is the use of vasoactive drugs. Further, recent expert recommendations (Hodgson et al., 2014) identify the safety of mobilisation on vasoactive drugs as a priority area' for research. My long-term aim is to evaluate this in a future study by observing groups of patients at a perceived lower, medium and higher risk as defined by factors such as the types and dosage of vasopressor drugs received. However before this, definitions of at risk groups are required and the feasibility of the use of the adverse event definition and patient risk groups needs to be tested. Systematic review Aim: To complete a review asking: Is the mobilisation of patients on an adult intensive care unit safe? Method: A systematic review and analysis of the literature using an appropriate framework. Work stream 1: Defining the problem a) Aim: To explore clinician and patient perceptions of risks and barriers to mobilisation in an ICU in the United Kingdom. Methods: Semi-structured interviews with ICU clinicians and patient representatives. b) Aim: To develop an expert clinician and patient representative consensus agreement on the definition of an adverse event whilst an adult patient is mobilised on an ICU. Method: A three-stage Delphi process with international expert ICU clinicians and patient representatives. c) Aim: To determine an expert clinician and patient consensus on the defining characteristics of three adult ICU patient groups, considered to have a high, medium and low risk of adverse events when being mobilised whilst receiving vasoactive drugs. Method: A three-stage Delphi process as above. Work stream 2: Feasibility study a) Aim: To describe the feasibility of the use of an adverse event definition measuring the safety of mobilising adult ICU patients, during clinical practice by ICU clinicians. Method: Clinicians will use the definition to evaluate 50 mobilisation treatments to test its feasibility in terms of frequency of clinician use, accuracy of use and the time taken to complete. b) Aim: To describe the feasibility of the measurement of adverse events of ICU patients mobilised on vasoactive drugs in low, medium and high risk groups during clinical practice. Method: Mobilisation treatments on vasoactive drugs will be observed for an adverse event by clinicians and then assigned by the researcher to a risk group. Feasibility will be measured by recruitment/adverse event rate and time taken to complete data collection. Potential benefits Identified barriers to mobilisation can be addressed to increase early mobilisation. A standardised adverse event definition would enable accurate evaluation of the safety of current practice and the identification of patient risk groups is useful to guide clinical decision making for when to being mobilisation. The feasibility study provides vital information to develop the protocol for a definitive study.

Lay abstract: When should clinicians start early mobilisation on intensive care? Exploring the barriers to early mobilisation and developing tools to study the safety of mobilisation of Intensive Care Unit patients.Understanding when to start getting patients out of bed and walking (mobilisation) on Intensive Care Units (ICU) is a top priority for research set by a large group of UK patients, carers and clinicians (Reay et al., 2014). Indeed, there is growing evidence that early mobilisation can help minimise the substantial physical problems experienced by ICU survivors (Stiller, 2013). However recent evidence has emerged showing that early mobilisation is not used enough (Nydahl et al., 2014). An exploration of the barriers to early mobilisation uptake is required. If we know what the barriers are in a UK setting, we can address them to improve mobilisation uptake. Evidence for the safety of early mobilisation in an ICU is promising (Adler, Malone, 2012). However, this is a fast growing area of research therefore an updated review of the literature is required. Furthermore, previous studies have assessed safety through the measurement of unsafe events. However agreement is required on what exactly constitutes an unsafe event from mobilising in an ICU. Barriers to early mobilisation are likely to include factors that may affect safety. A vital factor is poor heart system function requiring drug therapy support. These drugs include vasoactive drugs, which stop blood pressure from falling. However the detail of this risk remains unclear, reflected by a recent group of expert physiotherapists and doctors who could not decide when it is safe to mobilise ICU patients on such drugs (Hodgson et al., 2014). They recommended this as a key priority for future research, including the risk of unsafe events associated with factors such as different vasoactive drug types and dosages. I hope to explore this in the future using groups of patients perceived to be at differing risk of unsafe events when mobilised on vasoactive drugs. However, before this can occur an agreement is required on what factors define these patient groups. Further, the adverse event and patient risk group definitions need to be tested to ensure they are feasible to use in future studies. Systematic review A review will be carried out of current evidence to see if mobilisation of patients on an adult intensive care unit is safe. Work stream 1: Exploring the problem a) ICU clinicians at Imperial College Healthcare NHS Trust and ICU patient representatives will be interviewed to discover what they think the risks and barriers to mobilisation are. b) A international group of expert ICU doctors, nurses, physiotherapists and former patients will decide on the definition of an unsafe event. This will be achieved by a Delphi process made up of three rounds. In the first round, the group will produce a list of possible factors to include in the adverse event definition. In the second round each group member will decide what factors they want to include in the definition. In the third round, every group member will be told what the others think and can reconsider their choices. The factors that 70% of the group agree on become the unsafe event definition. c) A second three round Delphi process will occur with the same expert group. They will be asked to reach agreement on factors that define groups of patients that pose a lower, medium and higher risk of mobilising on vasoactive drugs. This is likely to include factors such as types of vasoactive drug and dosage. Work stream 2: Feasibility study a) The feasibility of physiotherapists using the unsafe event definition in routine clinical practice will be tested. This will occur during a selection of 50 mobilisation treatments. We will measure the amount of treatments where the definition is used by a physiotherapist, how often a researcher agrees with the use of the definition and whether the physiotherapist considers they had enough time to use it. b) The feasibility of the measurement of unsafe events in lower, medium and higher risk groups will be tested. Mobilisation treatments that happen whilst a patient is receiving vasoactive drugs will be observed for an adverse event. These treatments will then be allocated to one of the three groups. We will describe how many treatments and unsafe events are in each group and how much time it takes physiotherapists to complete the assessment of unsafe events. The work produced will be published in relevant journals, presented at relevant conferences and fed back to local clinicians and patients.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE