Development of a Workflow Algorithm for an Early Mobilization Protocol in a Neurologic Critical Care Unit

The benefits of early mobilization in an intensive care unit (ICU) setting have been well established. Mobilizing patients early is associated with decreased hospital length of stays, number of days on ventilators, use of sedation, and number of hospital-acquired infections. Early mobilization has also been associated with earlier return to independent functioning. Patients in neurointensive care units have their own unique problems and concerns related to their neurologic injuries and dysfunction that pose as a challenge when it comes to mobilization. Despite evidence supporting early mobilization of patients in ICUs, early mobilization is still not occurring regularly. In 2014 an early mobilization protocol (EMP) was implemented in a Neurologic Critical Care Unit (NCCU) at a local hospital and to date it has been unsuccessful. The purpose of this project was to identify current barriers and facilitators to implementing the EMP in NCCU and to develop a workflow algorithm that will facilitate future use of the current EMP. The objectives of this project were: 1) Identify barriers and facilitators to a successful implementation of an EMP in the NCCU, 2) Develop a strategy for successful implementation of an EMP in the NCCU, and 3) Disseminate project findings to NCCU staff and submit an abstract to the 40th Annual Snowbird CME Conference. A literature review revealed that advancement in technology has resulted in increased numbers of patients who survive their time in the ICU. These ICU survivors are experiencing long-term disabling side effects and are unable to return to the same levels of activity tolerated prior to admission. The literature review also supported that mobilizing ICU patients early has shown to be safe, feasible, and to prevent long-term neurocognitive and physical disability. Barriers found in other ICU settings are related to lack of staffing, equipment, leadership support, over-sedation, and knowledge deficits. Facilitators to successful implementation of early mobilization programs in other ICU settings were a supportive ICU culture as well as trained staff. Implementation included meeting with the Early Mobilization Committee (EMC) in the NCCU and development of an executive summary of the committee's ideas regarding the current EMP. The information gained from these meetings was used in conjunction with the results from literature review and input from content experts and project chair to guide the development of a survey that was administered to the NCCU nursing staff. Evaluation was completed through analysis of survey data using numbers and percents and a thematic analysis of open-ended questions. This data was used to develop a workflow algorithm to be used by NCCU staff to facilitate the implementation of the EMP into practice. The NCCU nursing staff was surveyed; the survey response rate was 41%. Thirty seven percent (14) of survey respondents perceived time/workload to be the largest barrier to EMP and 70.3% (26) felt that lunch and dinner were the best times for patient mobilization. Common themes that arose from the thematic analysis included the need for increased physical and occupational therapy availability and that mobilization before breakfast is difficult. In summary the overall goal of this project was to develop a workflow algorithm that will facilitate the successful implementation of the current EMP. The workflow algorithm was designed with feedback from members of the EMC, content expert, and project chair. The EMP workflow algorithm simplifies decisions to facilitate the use of the EMP.