An Initiative to Improve the Mobility of the Critically Ill: A Nurse-Driven Protocol

More than 6 million Americans have a stay in the ICU each year frequently leading to prolonged bedrest and immobility. Research indicates that mobility is the single most important variable in maintaining and preserving short and long term physical function, yet often it's placed at the bottom of an ever-growing list of demands and duties for the Registered Nurse [RN]. Evidence-based mobility protocols remain in infancy with minimal research on their efficacy. We hypothesized that a Nurse-Driven Progressive Mobility Protocol would increase the number of times the Critical Care Nurse engaged the patient in activity. Method: In this single-center, systematic observational study nurse led mobility frequency of 202 intensive care patients was analyzed. Data was abstracted from the electronic medical record and compared to current best practice recommendations. An established mobility protocol from the American Association of Critical-Care Nurses was deemed appropriate. Education was provided to twenty-one critical care nurses followed by protocol implementation. A change statistic was calculated comparing groups 1 and 2, recognizing and accounting for variances. Results: 100% of all Intensive Care patients admitted during the research period were included in the study. Mobility frequency increased from 1.07 times/patient/day to 1.27 times/ patient/day with protocol application. Conclusion: Despite a change in frequency that the nurse employed on patient mobility, it failed to reach statistical significance. Although protocols are often used to ensure best practice with timely quality care this study suggests a nurse led mobility protocol may not be the most effective tool to increasing movement in the critically ill.

Running Head: MOBILITY OF THE CRITICALLY ILL 1 An Initiative to improve the mobility of the critically ill: a nurse-driven protocol Chantelle Elmer RN, AGACNP, DNP Student Clinton Child, DNP, MBA University of Utah Running Head: MOBILITY OF THE CRITICALLY ILL 2 Abstract Problem/Background: More than 6 million Americans have a stay in the ICU each year frequently leading to prolonged bedrest and immobility. Research indicates that mobility is the single most important variable in maintaining and preserving short and long term physical function, yet often it's placed at the bottom of an ever-growing list of demands and duties for the Registered Nurse [RN]. Evidence-based mobility protocols remain in infancy with minimal research on their efficacy. We hypothesized that a Nurse-Driven Progressive Mobility Protocol would increase the number of times the Critical Care Nurse engaged the patient in activity. Method: In this single-center, systematic observational study nurse led mobility frequency of 202 intensive care patients was analyzed. Data was abstracted from the electronic medical record and compared to current best practice recommendations. An established mobility protocol from the American Association of Critical-Care Nurses was deemed appropriate. Education was provided to twenty-one critical care nurses followed by protocol implementation. A change statistic was calculated comparing groups 1 and 2, recognizing and accounting for variances. Results: 100% of all Intensive Care patients admitted during the research period were included in the study. Mobility frequency increased from 1.07 times/patient/day to 1.27 times/ patient/day with protocol application. Conclusion: Despite a change in frequency that the nurse employed on patient mobility, it failed to reach statistical significance. Although protocols are often used to ensure best practice with timely quality care this study suggests a nurse led mobility protocol may not be the most effective tool to increasing movement in the critically ill. Running Head: MOBILITY OF THE CRITICALLY ILL 3 An Initiative to Improve Mobility of the Critically Ill More than 6 million Americans experience an ICU stay each year, often resulting in prolonged immobility and bed rest leading to significant short and long term effects on morbidity, mortality, cost and quality of life (PBS 2017). Research indicates lack of mobility leads to organ dysfunction, persistent muscle fatigue, and wasting, as well as brain and nerve disabilities (Herridge, Batt, Hopkins, 2008). Furthermore, lack of mobility results in extended hospital length of stay, with the average stay in the ICU, 3.8 days (SCCM 2014). The occurrence of these combined adverse events is so frequent that physicians have termed it "Post-Intensive Care Syndrome" (Kayambu et al., 2013). Problem Description Prolonged ICU stays are physically, emotionally and financially burdensome to both patient and families. Financial concerns are nonselective effecting hospitals as well with increased costs and difficulties in reimbursement for prolonged stays. Prolonged immobility from such a stay can incur both short and long term ailments or disabilities. Short term effects include but are not limited to delirium, muscle wasting and ventilator-associated events like pneumonia. Long term effects of immobility like behavioral and psychological dysfunctions of depression and dementia can continue for years' following an ICU stay (Schaaf, M. Beelen, A. Dongelmans, D. Vroom, M. Nollet, F. 2009). Despite mobility being the single most important variable in improving short and long term physical function of the critically ill, it is often placed at the bottom of an ever-growing list of demands and duties on the Registered Nurse (Topley, 2015). Nurses report a lack of guidelines, activity order or protocol (Topley, 2015). Compound Running Head: MOBILITY OF THE CRITICALLY ILL 4 this by a nominal 27% of ICU patients actually receiving physical therapy results in a vast chasm of mobility (Topley, 2015). Purpose of the Project The purpose of this quality improvement project is to increase the use of mobility tactics by the ICU nurse for early progressive mobilization of the critically ill, thus resulting in healthier patients by preventing the aforementioned adverse effects associated with prolonged immobility. This study investigated the efficacy of a nurse-led progressive mobility protocol to increase the frequency of movement in the critically ill patient. Clinical Question Are Critical Care Nurses moving their patients in the Intensive Care Unit, and would a nurse lead progressive mobility protocol increase the frequency of mobility? Literature Review Between 1946 and 1964 a major boom in births occurred following the Second World War. Today, this generation accounts for 40.2 million Americans aged 65 years or greater. About 60% of "Baby Boomers" have serious medical problems and comprise 35% of all hospital stays. Significant medical advances continue to lengthen years of life in the United States, and by 2030 there will be more than 80 million Americans aged 65 years and older, which in turn greatly increases the likelihood of being admitted to the ICU (Geriatric Nursing 2018). ICU survivors live with long-term effects of critical illness that may be debilitating and more difficult to endure than the disease itself (Mendez-Tellez, Nusr, Feldman & Needham, 2012). Fortunately, healthcare professionals have identified interventions such as early mobility, to reduce and combat these ill effects. One study touted, "mobility was and is the single most Running Head: MOBILITY OF THE CRITICALLY ILL 5 important variable in improving long term function of the critically ill (Topey, 2015)." Despite apparent benefits of early mobility, many U.S. hospitals are hesitant to implement mobility protocols with concerns on patient safety, time constraints and lack of available resources (Adler & Malone, 2012). Thus, an alarmingly low 27% of all ICU patients actually receive physical therapy during their stay (Topey, 2015). Conceptual and Theoretical Framework Grol and Wensing's Conceptual Model was applied to the development and intervention for this quality improvement project (Grol et al., 2007) (Figure 4). It begins with a systematic review where gaps in quality patient care are clearly identified. These chasms are analyzed, then followed by a proposal to narrow them. Often recommendations are presented in the form of a guideline or protocol. Although Integration of change into routine patient care can be challenging, Grol and Wensing anticipates many barriers and offer congruent advice for each processional step. Following integration of the protocol, continuous evaluation and adaptation are recommended. If goals are not achieved, directions to return to the previous action is advised. By following Grol and Wensing's Model successful incorporation of mobility, the protocol is likely. Adapting and implementing the mobility protocol will result in increased efforts from the ICU staff in moving the critically ill patient, thus decreasing unfavorable side effects associated with prolonged hospital length of stay and bed rest. Specific Aims The goal of this quality improvement project is to increase the use of mobility tactics by the ICU nurse for early progressive mobilization of the critically ill, thus resulting in reduced ICU length of stay and they're associated short and long term adverse effects. Utilization of the Running Head: MOBILITY OF THE CRITICALLY ILL 6 protocol provides a personalized mobility level and plan for each patient. Personalization entails identifying individuals past and current limitations of activity, setting daily goals and addressing them frequently. This report investigates if a nurse-led progressive mobility protocol can improve the frequency of movement in the critically ill. Methods Context The setting is a 12 bed Intensive Care Unit at a community hospital in a rural quant setting servicing about 1,000 inpatient admissions per year. The unit services a variety of ailments including but not limited to: cardiac events, renal failure, sepsis, all forms of shock and trauma for adults age 18 years and older. Patients are under the direction of 1 full-time nurse practitioner, 1 of 4 rotating hospitalists and 1 of 21 Registered Nurses, 6 holding critical care certifications [CCRN]. Nurse to patient ratio is 1 to 2. 100% of patients are on continuous telemetry and have a minimum of one parenteral access site, restricting mobility to a distance of four feet from monitor. Intervention Assessment of the current mobility practice was completed with a retrospective chart review for three consecutive months. The number of mobility encounters by the registered nurse and activity type was collected and documented for each patient in the study sample. Visits and length of time spent by physical therapy was not observed. Although, percent of patients in each sample who had a physical therapy order was obtained and recorded (Table 1). Findings from the chart review were compared to best practice recommendations, and an appropriate nurse-driven guideline derived from the American Association of Critical Care Running Head: MOBILITY OF THE CRITICALLY ILL 7 Nurses was developed (AACN 2014) (Figure 3). Following approval from site Chief Nursing Officer and ICU director, staff education was provided in verbal and visual methods (Figure 2). Verbal and written education was provided during the monthly staff meeting in the hospital's main classroom. Unfortunately, only 57% of ICU nurses attended the staff meeting. So, further education and reinforcement was performed in the modes of breakroom posters and an occasional on-site check-in by project lead. Patients were encouraged to take an active role in the project with goal setting using in room cue cards from AACN (Figures 2). Nursing Champions were selected from unit leads to ensure integration and sustainability. These champions encouraged protocol use by nursing staff and offered feedback to the research team on identifiable barriers. Study of Intervention Evaluation of project impact began with the identification of the number and demographics of participants. Demographic data collected during the session included gender, age, and ethnicity (Table 1). Additionally, objective data collection of ventilator support, percent of time physical therapy was ordered, the nurse reported efforts on mobility, and the preformed activity was obtained. Pertinent subjective information collected utilizing the Confusion Assessment Method, referred to as a CAM Score, was evacuated due to the wellestablished positive correlation of neuro stability and mobility. Contributing factors to the success of this project were, time and attendance of staff during the education phase, adaptability of the protocol and communication with project lead. There were no competing projects during this research session. Measures Running Head: MOBILITY OF THE CRITICALLY ILL 8 A daily assessment of mobility was automatically populated on all admissions at the research site before the study. A change statistic measurement was used for studying the process and outcome of the intervention. Statistical data collection was heavily weighted on nurse compliance to perform and document efforts. Protocol education was provided once during a staff meeting, and an attendance log was collected. Two weeks following implementation, staff provided the research team with written feedback on identified barriers and perceptions of effectiveness in the drop box on the unit. Analysis Study participants were analyzed with descriptive statistics collected during chart audit. Demographic and outcome variables were described using frequency distributions and recommended summary statistics for central tendency and variability. Quantitative methods of analysis including a change statistic were employed. A statistical T-test was used to measure the change between pre-intervention and post-intervention data. There is no assumption about the distribution of the variable population. Ethical Consideration This study was determined to be exempt from human subject review by the University of Utah Institutional Review Board. Subject's data were kept private through the collection process by close observation of the site's medical records expert. Thus, ensuring only pertinent data was obtained and recorded. Patient identifiers such as medical record number, Identification numbers, date of birth and names were excluded from data collection. Results Running Head: MOBILITY OF THE CRITICALLY ILL 9 Phase 1 of the study was a 3-month retrospective chart review from July 15, 2018, through October 15, 2018, with a sample size of 102 persons primarily Caucasian ethnicity (Table 3). The sample consisted of 58% males and 42% females with a mean age of 55 years, standard deviation 20.9. A mean BMI of 28.2, standard deviation 6.6 and average ICU length of stay, two days. Physical Therapy was ordered 32% of the time in sample 1. Data collection from this sample revealed that the RN initiated mobility an average of 2.13 times with a standard deviation of 1.69 during their entire ICU stay (Table 1). Consequently, each ICU patient was moved by the RN 1.07 times per day. The highest chosen activity reported by the RN was ambulating in the room (Table 2). Phase 2 of the study began with an informal education provided to the ICU nursing staff in both written and verbal forms. During this phase 21 registered nurses worked in the Unit of which 14 worked full time, 3 worked part time and 4 were as needed. During phase 1 and 2 there was 1 nurse who left and two new hires. Implementation of the protocol (Figure 3) and second 3-month retrospective chart review was performed from October 15, 2018, to January 15, 2019. This sample had 100 persons primarily Caucasian ethnicity. It consisted of 51% males and 49% females with a mean age of 59 years, standard deviation 17.7. A mean BMI of 29.6, standard deviation 7.84 and an average ICU length of stay, also two days. Physical Therapy was ordered 36% of the time for sample 2. Results for this sample revealed the RN initiated mobility an average of 2.43 times during their ICU stay with a standard deviation of 1.92. Thus, each ICU patient was moved 1.27 times per day by the RN. Phase 3 consists of statistical analysis comparing samples one and two (Table 1). Identification of variances between the samples is considered and weighed in the data analysis. A small variance of sample size and Running Head: MOBILITY OF THE CRITICALLY ILL 10 gender prevalence was noted between groups 1 and 2. In addition, the mean age for sample 1 was favorably lower than sample 2. These variances were calculated and scrutinized for data effects. A two-sided T-test comparing the number of times the RN initiated mobility pre-and post-protocol, resulted in a T score of -1.26, a p-value of 0.21 when alpha is <.05. Hence, failure to reach a statistically significant level of change. Education was provided to 21 ICU nurse with mean age of 36.2 years, SD 7.95. The average years of experience as a registered nurse was 6.6 years with a SD 5.15. The Intensive Care Unit underwent a complete renovation, requiring the entire unit and staff move twice during the research period. Leadership's support and focus were hindered due to the transient geographic location of the old and new units. Additionally, difficulties in navigation and data collection from the electronic medical record were not fully appreciated prior to study implementation, necessitating chart reviews by the hand of the project lead. Potential biases may have occurred due to the dual role of application and data collection from project lead. Motivation challenges were observed with an improved frequency from some participants and poor to none from others. Missing data such as length of time the RN spent engaging in activity was not available for collection. CAM scores were not collected by nursing staff on every patient limiting any observable correlation between mobility and neuro instability. Long term adverse effects were unobtainable due to time constraints of this study. Discussion Summary Our results demonstrate that, while a protocol to improve mobility tactics frequency is effective, other methods may provide better. It was anticipated that implementation of the Running Head: MOBILITY OF THE CRITICALLY ILL 11 protocol would lead to an increase in mobility tactics by the ICU nurse for early progressive mobilization of the critically ill. Despite the positive correlation between pre-and post-protocol utilization and mobility tactics, this study failed to reach statistical significance. Interpretation A positive correlation exists between protocol implementation and frequency of mobility tactics by the nurse of the critically ill patient. The American Association of Critical Care Nursing recognized the usefulness of such a protocol in motivating patients and nurses to move often (AACN 2014). It is evident early progressive mobility reduces both ICU and hospital length of stay in addition to preventing undesirable short and long term effects from prolonged bed rest. The project took a moderate amount of effort and time in implementation and education of staff. Staff was given opportunities to provide suggestions and concerns before and during the research study to ensure the buy-in of the project. Leadership feedback from the Intensive Care Unit and hospital administration were positive and supportive. Protocols are an efficient and effective tool in implementing change but may fail to address contextual factors contributing to non-compliance. These factors include space limitations in the unit, team leadership and support, unwillingness, and motivation to make changes, and a lack of integration and constraints in the documentation. The intervention as delivered was inexpensive and can continue with little maintenance or effort. Supportive staff, like Nursing Champions, were placed to ensure sustainability of the protocol. Despite unimpressive results, the protocol should continue as research supports its efficacy and the vital importance of mobility in the Intensive Care Unit. Running Head: MOBILITY OF THE CRITICALLY ILL 12 Limitations The small sample size of this study makes interpretation difficult. Findings suggest a positive correlation between protocol implementation and mobility tactics from the nurse. A larger sample size may have elevated the results to statistical significance. Efforts to maximize sample size by extending the length of the study was considered but academic time constraints made this impossible. Personal biases that may have occurred during selection, implementation or data collection was limited by following strict guidelines established prior to initiation of this research project. Limitations put upon for nursing staff due to renovation of the entire Intensive Care Unit leading to an unfamiliar working environment and limited room and unit space. Conclusions It is evident that mobility is vital to well-being for the critically ill. A nurse lead mobility protocol increases nursing tactics to move patients early and often. The sustainability is high and yields low cost in doing so. It was suggested that a small change in the EMR be made mandating nursing staff to document at least twice a shift, those efforts made towards mobility. This simple change in documentation may prove more effective than protocol utilization alone. Keywords: Mobility, Early Progressive Mobility, Nurse Lead Protocols Funding: University of Utah College of Nursing Running Head: MOBILITY OF THE CRITICALLY ILL 13 Reference Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012;23(1):5-13 Geriatric Nursing (2018). Baby Boomers and Their Effect on Healthcare. Geriatric Nursing.org. Retrieved from https://geriatricnursing.org/baby-boomers-and-their-effect-onhealthcare/ Grol, R. P., Bosch, M. C., Hulscher, M. E., Eccles, M. P., & Wensing, M. (2007). Planning and Studying Improvement in Patient Care: The Use of Theoretical Perspectives. The Milbank Quarterly, 85(1), 93-138. http://doi.org/10.1111/j.1468-0009.2007.00478.x Herridge, Batt, & Hopkins. (2008). The Pathophysiology of Long-term Neuromuscular and Cognitive Outcomes Following Critical Illness. Critical Care Clinics, 24(1), 179-199 Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013;41(6):1543-54 Mendez-Tellez, P. A., Nusr, R., Feldman, D., & Needham, D. M. (2012). Early Physical Rehabilitation in the ICU: A Review for the Neurohospitalist. The Neurohospitalist, 2(3), 96-105. http://doi.org/10.1177/1941874412447631 PBS News Hour (2017 June 16th). Why a stay in the ICU can leave patients worse off. Retrieved from https://www.pbs.org/newshour/show/stay-icu-can-leave-patients-worse-off on May 28, 2018 Schaaf, M. Beelen, A. Dongelmans, D. Vroom, M. Nollet, F. (2009). Poor functional recovery after a critical illness: A longitudinal study. J Rehabilitation Med. 2009; 41:1041-1048. Running Head: MOBILITY OF THE CRITICALLY ILL 14 Society of Critical Care Medicine [SCCM] (2014). Critical care statistics. sccm.org/Communications/Pages/CriticalCareStats.aspx Topley, D. (2015 November). Implementing a mobility protocol for ICU patients. American Nurse Association Today. ANA.org. Retrieved from https://www.americannursetoday.com/essence-mobility/ Vollman, K.M. (2010 April). Introduction to Progressive Mobility. Critical Care Nurse V. 20 No. 2. Retrieved from http://ccn.aacnjournals.org/content/30/2/S3.full.pdf+html?sid=58b0c17e-29be-40c39303-ab6be8cd1a96 on May 27, 2018 Running Head: MOBILITY OF THE CRITICALLY ILL Tables/Figures Table 1 15 Running Head: MOBILITY OF THE CRITICALLY ILL Table 2 Table 3 16 Running Head: MOBILITY OF THE CRITICALLY ILL Figure 1 Figure 2 17 Running Head: MOBILITY OF THE CRITICALLY ILL Figure 3 18 Running Head: MOBILITY OF THE CRITICALLY ILL Figure 4 19