Development and Implementation of an Early Mobility Guideline for Traumatic Brain Injury Patients in a Shock Trauma Intensive Care Unit

Traumatic brain injury (TBI) patients often remain bedbound for prolonged periods in intensive care units (ICU) due to a lack of resources and collaboration between interdisciplinary teams, in addition to poorly specified guidelines for patient mobilization. Early mobility programs have been shown to improve function, increase strength, decrease delirium, and reduce ICU and hospital length of stay. Length of stay hospital days were decreased by 45% after starting an early mobility program. A quality improvement project was developed to promote improved clinical outcomes and early mobilization for post-traumatic brain injury patients within a community hospital ICU in Utah. First, multidisciplinary team members were assessed with a pre-intervention survey to identify knowledge, attitudes, and feasibility regarding early mobilization programs. A best- practice guideline was developed and disseminated to the multidisciplinary team via in-person presentations to go over safety concerns and exclusion criteria, as well as proper use of the guideline. Post-implementation surveys were sent to the multidisciplinary team to determine the success and effectiveness of the early mobility guideline. Comparison of pre- and post-surveys results may demonstrate a significant difference in opinion regarding early mobility for TBI patients, including an improvement of early mobility guidelines understanding (p=0.0003) and increased confidence in the ability to perform out of bed mobility, range of motion, and early mobilization (p=0.038). The early mobility guideline promoted engagement of the multidisciplinary team and may have helped to improve clinical process measures for TBI patients. It provided a definitive guideline on how to safely proceed with early activity TBI patients and likely fostered empowerment within the multidisciplinary team. Continuation of this quality improvement project is needed to demonstrate strong improved patient outcomes and eradicate barriers to early mobility.

1 Development and Implementation of an Early Mobility Guideline for Traumatic Brain Injury Patients in a Shock Trauma Intensive Care Unit Marleen D. Park, Sarah D. Majercik, Scott S. Christensen College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III May 4, 2022 2 Abstract Background: Traumatic brain injury (TBI) patients often remain bedbound for prolonged periods in intensive care units (ICU) due to a lack of resources and collaboration between interdisciplinary teams, in addition to poorly specified guidelines for patient mobilization. Early mobility programs have been shown to improve function, increase strength, decrease delirium, and reduce ICU and hospital length of stay. Length of stay hospital days were decreased by 45% after starting an early mobility program. Methods: A quality improvement project was developed to promote improved clinical outcomes and early mobilization for post-traumatic brain injury patients within a community hospital ICU in Utah. First, multidisciplinary team members were assessed with a pre-intervention survey to identify knowledge, attitudes, and feasibility regarding early mobilization programs. A bestpractice guideline was developed and disseminated to the multidisciplinary team via in-person presentations to go over safety concerns and exclusion criteria, as well as proper use of the guideline. Post-implementation surveys were sent to the multidisciplinary team to determine the success and effectiveness of the early mobility guideline. Results: Comparison of pre- and post-surveys results may demonstrate a significant difference in opinion regarding early mobility for TBI patients, including an improvement of early mobility guidelines understanding (p=0.0003) and increased confidence in the ability to perform out of bed mobility, range of motion, and early mobilization (p=0.038). Conclusions: The early mobility guideline promoted engagement of the multidisciplinary team and may have helped to improve clinical process measures for TBI patients. It provided a definitive guideline on how to safely proceed with early activity TBI patients and likely fostered empowerment within the multidisciplinary team. Continuation of this quality improvement 3 project is needed to demonstrate strong improved patient outcomes and eradicate barriers to early mobility. 4 Development and Implementation of an Early Mobility Guideline for Traumatic Brain Injury Patients in a Shock Trauma Intensive Care Unit Problem Description The Shock Trauma Intensive Care Unit at Intermountain Medical Center has a large population of traumatic brain injury (TBI) patients wherein, oftentimes, they remain bedbound for days and even weeks without receiving adequate activity. An array of barriers have been shown to interfere with patients receiving early mobility, including increased sedatives, hemodynamic instability, lack of resources and collaboration between interdisciplinary teams, care-giver time, unit culture, decreased understanding of the significance of early mobility, and inadequate clear-cut guidelines for mobilization (Brissie et al., 2017). The lack of early ambulation, out-of-bed mobility, and range of motion (ROM) can lead to debilitation, atrophy, delirium, and increased length of stay for these patients (Klein et al., 2015). These outcomes illustrate the need to address barriers to mobility. Programs promoting early mobilization for critically ill patients have resulted in fewer days on mechanical ventilation, decreased length of stay, minimized delirium, and improved long-term patient outcomes (Klein et al., 2015). There are various mechanisms and guidelines specifically focusing on early mobility for generalized critically ill patients. One example of this is the ABCDE bundle (awake, breathing, coordination, delirium, and early mobility) which has proven that having critically ill patients walk and communicate is both feasible and effective (Klein et al., 2015). Available Knowledge Underserved populations are at high risk for TBI (Centers for Disease Control and Prevention, 2021). Complications from immobilization among critically ill patients with TBIs include venous thromboembolism, pneumonia, bed sores, muscle atrophy, and prolonged 5 hospital length of stay (Olkowski & Shah, 2017). Inpatient early mobility programs improve function and quality of life, increase strength, decrease depression, and reduce intensive care unit (ICU) and hospital length of stay (Kocan & Lietz, 2013). Length of stay hospital days were decreased by 45% in a Neuro ICU after starting an early mobility program (Klein et al., 2015). Rationale The framework for this quality improvement project includes the Integrated Theory of Health Behavior Change (Ryan, 2009). The Integrated Theory of Health Behavior Change supports the foundation of knowledge and beliefs, self-regulation skill and ability, and social facilitation to influence and support long-term change and improved clinical outcomes (Ryan, 2009). This theory applies to the development and implementation of an early mobilization guideline as behavior change is imperative to long-lasting engagement and outcomes. Beginning with a foundation of expanded knowledge of early mobilization guidelines facilitates understanding and empowerment to participate and foster changes. Furthermore, precise guidelines provide support and regulation of clinical decision-making to ensure the guideline is being utilized appropriately. As the guideline is implemented and enacted, clinical providers will continue to facilitate these changes and support the vision of improved long-term clinical outcomes for post-traumatic brain injury patients. Specific Aims The purpose of this quality improvement project was to promote improved clinical outcomes for post-traumatic brain injury patients in a local intensive care unit through the development and implementation of an early mobilization guideline with a focus on applying the Integrated Theory of Health Behavior Change (Ryan, 2009). 6 Methods Context The Shock Trauma ICU at Intermountain Medical Center is a level 1 trauma center located in the mountain west. This ICU is the hub for medical, surgical, and trauma patients in Utah, Idaho, Wyoming, Eastern Nevada, and Southern Montana. Clinical providers included intensivists, trauma surgeons, advanced practice providers, registered nurses, critical care technicians, occupational and physical therapists, and respiratory therapists. This multidisciplinary team was specially trained to care for post-traumatic brain injury patients during their critical illness. Intervention In phase one of this QI project, a presurvey titled Early Mobilization for TBI Patients Pre-Survey was developed to assess the multidisciplinary team’s knowledge, attitudes, and feasibility regarding early mobilization for TBI patients (see Appendix A). Next, the survey was disseminated on December 4, 2021, to the multidisciplinary team via Qualtrics through printed QR codes displayed in the ICU. This data was stored in Qualtrics. The pre-survey was closed on December 20, 2021. In phase two of this project, a best-practice guideline was developed through review of other successful projects that were pertinent to early ambulation, out of bed mobility, and range of motion, specific to the TBI patient population (see Appendix B) (Brissie et al., 2017; Falkenstein et al., 2020). The development of this guideline was overseen by content experts and presented to the multidisciplinary team with opportunity for feedback. In phase three of this project, the best-practice guideline was implemented on January 4, 2022. This included in-person education for proper use of the guideline, as well as covering safety concerns and exclusion criteria. Printed guidelines were also posted throughout the unit 7 and given to multidisciplinary teams for reference. Additionally, one on one education was implemented to each nurse caring for TBI patients that met criteria. In phase four of this project, a post-survey was disseminated to the multidisciplinary team titled Early Mobilization for TBI Patients Post-Survey (see Appendix C). This survey was also developed using Qualtrics and distributed via email and QR code. Next, a comparative analysis of the pre- and post-surveys was conducted using descriptive and analytical statistics. Utilization of the guideline was also monitored using descriptive statistics. The final phase of this project included consideration of potential patient outcomes by monitoring for project process measures, which included nurse documentation of early mobility and use of the guideline. Study of the Intervention The approach used to assess and determine barriers for the implementation of an early mobility guideline included a pre-survey and post-survey. These surveys were distributed via email and QR code to the multidisciplinary team to evaluate team’s knowledge, attitudes, and feasibility regarding early mobilization for TBI patients. After the multidisciplinary team was educated regarding the appropriate utilization of the guideline, the guideline was implemented for a period of thirty days. Chart review and a tracking sheet were used to monitor the daily use of the guideline. Following the thirty days, the post-survey was sent out to the multidisciplinary team to evaluate any changed knowledge, attitudes, and feasibility toward early mobilization for TBI patients. Additionally, a comparative analysis of the surveys was conducted using descriptive and analytical statistics, as well as process measure outcomes. 8 Measures Using the Behavior Change Theory and the Integrated Theory of Health Behavior Change, a pre-survey was adapted to evaluate the knowledge, attitudes, and feasibility toward early mobilization for TBI patients. Information from the pre-survey helped to identify existing attitudes and knowledge deficits in the participant group. A guideline was developed with these deficits in mind to assist in the ease of implementation. Daily use of the guideline was tracked for each patient with whom the early mobilization was performed. At the end of the thirty-day implementation period, a post-survey was distributed to the multidisciplinary team to assess any knowledge and attitude changes regarding this guideline. This post-survey included questions with respect to the success and satisfaction of the guideline, as well as reasons for not utilizing the guideline. Analysis Responses and data were collected from both pre- and post-survey. Responses from the pre- and post-surveys were analyzed and compared using descriptive and analytical statistics. The paired statistics and responses were compared using the Mann-Whitney U Test. Utilization of the guideline and other process outcomes were monitored using chart review and through further descriptive statistics. Additionally, the free-form responses were compared to identify continuing barriers of the newly implemented guideline. Ethical Considerations Ethical considerations throughout the implementation of the early mobility guideline included voluntary participation and do no harm. It became apparent that encouraging the multidisciplinary team to participate in the mobility guideline was an arduous task. Voluntary participation for the pre-survey was not as positive as expected and the project “go-live” date 9 was pushed back. The time spent with hands-on in-services and education regarding the guideline was crucial to patient safety and “do no harm.” It was important to provide the multidisciplinary team with safe tools and exclusion criteria to avoid sentinel events. Institutional Review Board approval was not required, and the project was categorized as quality improvement. Results Number of Participants A total of 93 people participated in either pre- or post-survey. Of the 93, 10 (10.7%) participants completed both pre- and post-survey. 62 (66%) participants completed the presurvey and 31 (33%) completed the post-survey. Initially, the plan was to evaluate paired preand post-samples using the Wilcoxon Signed-Rank Test. As only 10.7% of the sample size completed both pre- and post-surveys, we opted to use all the participant results as independent samples applying the Mann-Whitney U. This allowed for a larger population size. Demographic Information Demographic information for both pre- and post-survey results are included in Table 1. The various demographics collected included employment role, age, gender, race, ethnicity, and years of critical care experience. Registered Nurses made up 53.7% (n=50) of the participants with the second largest participant group being Occupational Therapists at 11% (n=11). Most of the population were between the ages of 20-40 years with 35% (n=33) being 20-30 and 35% (n=33) being 31-40. Of the survey participants, 35% (n=33) were male and 67% (n=62) were female. Most of the participants were White/Caucasian at 94% (n=88). The ethnicity of the participants included being 92% (n=86) people Non-Hispanic or Latino/Latina. Of the participants, 29% (n=27) had 1-3 years of critical care experience in their current role and 35% 10 (n=33) had over 10 years of experience. Table 1 demonstrates the comparison of pre- and postsurvey demographics which suggests a similar survey population. Utilization of Early Mobility Guideline During the implementation period, a total of 20 TBI patients were admitted to the Shock Trauma Intensive Care Unit. According to the daily tracking sheet, the early mobility guideline was utilized approximately 42 times. Daily activity was charted on all 20 of the TBI patients, with 8 progressing to ambulation prior to discharge from the ICU. Statistical Analysis Participants were evaluated before and after the implementation of the Early Mobility Guideline regarding their knowledge, attitudes, and feasibility of the guideline. The questions also assessed the confidence level to perform early mobility and whether they felt they were provided with the necessary training and resources to perform early mobility. Questions 8-14 were asked in both pre- and post-surveys using a 7-Point Agreement Likert Scale. Table 2 demonstrates an overview of the data and responses. Results of the study may demonstrate a significant difference in opinion amongst participants regarding early mobility for TBI patients. Specifically, there was a statistically significant increase in agreement for questions eight, ten, eleven, twelve, and thirteen. Question eight may suggest a moderately significant result (p=0.03897) after the intervention and an increase in agreement on adequate mobilization for TBI patients. Question ten may suggest a highly significant result (p=0.0002779) and an improvement in understanding of early mobility guidelines after the intervention. Question eleven may suggest a moderately significant result (p=0.03756) and an increase in confidence in ability to perform out of bed mobility, ROM 11 techniques, and early mobilization with TBI patients. Questions twelve and thirteen may suggest a moderately significant result (p=0.01341, p=0.04708) and an increase in agreement of having adequate training and resources to provide early mobility for TBI patients in the ICU after the guideline implementation. Two of the questions (questions nine and fourteen) did not demonstrate statistically significant results. In question nine (p= 0.4516), participants scored values for early mobility at high levels in both pre-and post-survey, with median values of six in both survey groups. Likewise in question fourteen (p=0.08873), participant rankings for mobility barriers in the ICU were high in both survey groups with median values of six in both groups. The pre-survey included one open-ended question: Please describe any barriers to early mobility for traumatic brain injury patients in the ICU. There were 46 responses which suggested various barriers to limit early mobility for TBI patients. Figure 1 summarizes the responses. Limited staff was the most cited barrier, seen in 39% of responses. The post-survey included an optional question regarding any possible benefits that the participant or patient may have experienced while utilizing the Early Mobility Guideline. There were six responses which suggested having a guideline unified nursing, therapy, and patients in activity goals. The post-survey also included an optional question regarding continued barriers and limitations while using the early mobility guideline. Results were similar to the pre-survey barriers and included 16 responses. Figure 2 summarizes the responses. Limited staff was again the most cited barrier, seen in 63% of post-survey responses. Discussion Summary This quality improvement project demonstrated several positive effects on not only the post-traumatic brain injury patients, but also for the multidisciplinary ICU team. Upon 12 implementation of the early mobility guideline, the multidisciplinary team demonstrated strong support and utilization of the guideline. The multidisciplinary team reported feeling more confident and knowledgeable in mobilizing their post-traumatic brain injury patients with a specific guide to follow. The pre- to post-survey analysis may suggest a significant increase in agreement for the multidisciplinary team with the statements “TBI patients are being adequately mobilized in the Shock Trauma ICU” (p=0.03897), “ I understand early mobility guidelines for TBI patients in the ICU” (p=0.0002779), “I feel confident in my ability to perform out of bed mobility, ROM techniques, and early mobilization with TBI patients” (p=0.03756), “I have the training I need to provide early mobility for TBI patients in the ICU” (p=0.01341), and “I have the resources I need to provide early mobility for TBI patients in the ICU” (p=0.04708). Using the Integrated Theory of Health Behavior Change, this quality improvement project likely fostered an increase in understanding and empowerment to participate in the early mobility guideline which then encouraged regulation of clinical decision-making to ensure safe utilization. Together, the multidisciplinary team were able to support the vision of improved long-term clinical outcomes for these TBI patients. One of the biggest strengths of the project was including in-person training to ensure understanding reasoning behind the early mobility guideline. Utilizing the guideline in real-time allowed various discussions and questions to ensure proper utilization and benefits for early mobilization. The multidisciplinary team were able to see real-time improved patient outcomes by utilizing the guideline, which can equate to quicker transfer out of the ICU and early recovery. Further, the multidisciplinary team reported having a guideline enabled everyone to anticipate similar expectations of early mobility and the various phases of care. 13 Interpretation The impact of this quality improvement project on both the multidisciplinary team and TBI patients was positive. Collaboration was key to this project’s success. The impact of this project will likely continue as the ICU chose to keep the early mobility guideline to improve long-term patient outcomes. The Early Mobility Guideline was adapted from Brissie et al. (2017), who reported similar results including multidisciplinary team participation and positive feedback. In Brissie et al. (2017), staff felt that the protocol was “simple and easy to use” and “supplies an outcome and goals to achieve for the patient.” Various feedback from the multidisciplinary team in this project included similar results including “this guideline will be an amazing benefit for Trauma patients” and “having the early mobility guideline gets nursing, therapy, and patients on the same page about their mobility goals.” Limitations A limitation of this project included team participation on the pre- and post-surveys. Originally, the plan was to compare pre- and post-survey results through the Wilcoxon-Rank test. This would have provided a direct comparison of participants’ viewpoints after utilizing the early mobility guideline. Unfortunately, it was difficult to obtain follow-up on the post-survey. The project end-date was pushed back several weeks to possibly obtain more participation on the post-survey. As a result of a limited dual survey participation, the Mann-Whitney U test was utilized to analyze all results and treat them as independent samples regardless of pairing a preand post-test. Another limitation included the various barriers staff felt that prevented them from utilizing the early mobility guideline. Figures 1 and 2 both summarize these findings and include 14 “limited staff to assist with safe patient ambulation”, “not enough time”, “sedation while intubated”, and “inexperienced staff.” Conclusions Early mobilization is imperative to long-term recovery and positive patient outcomes. The goal of this project was to facilitate early mobilization to promote improved clinical outcomes for post-traumatic brain injury patients in a local intensive care unit through the development and implementation of an early mobilization guideline with a focus on applying the Integrated Theory of Health Behavior Change (Ryan, 2009). This early mobility guideline demonstrated collaboration between the multidisciplinary team and showed an immense desire amongst team members to aid these TBI patients in their rehabilitation. Additional ICU’s at the same facility have expressed interest in implementing the early mobility guideline with their patient population, including: Respiratory ICU, Neuro Critical Care Unit, and the medical population of the Shock Trauma ICU. It is reasonable to expect the continuation of this early mobility guideline will demonstrate clear improvement of patient outcomes and eradication of barriers preventing staff to utilize the guideline. 15 Acknowledgments A special thank you to the many members of the trauma team who supported this early mobility guideline, including Dave Morris, MD; Brad Morris, PA; Don Van Boerum, MD; Colin Grissom, MD; and countless others. Management in the Shock Trauma Intensive Care Unit also provided immense support: Kira Broderick, Brad Thorup, and Daniel Kelly. The nurses, physical therapists, occupational therapists, respiratory therapists, and critical care technicians all made this project a success. Thank you for your vigilant care of these critically ill patients. You are all an inspiration. 16 References Brissie, M. A., Zomorodi, M., Soares-Sardinha, S., & Jordan, J. D. (2017). Development of a neuro early mobilisation protocol for use in a neuroscience intensive care unit. Intensive and Critical Care Nursing, 42, 30–35. https://doi.org/10.1016/j.iccn.2017.03.007 Health disparities and tbi | concussion | traumatic brain injury | cdc injury center. (2021, May 12). https://www.cdc.gov/traumaticbraininjury/health-disparities-tbi.html Falkenstein, B. A., Skalkowski, C. K., Lodise, K. D., Moore, M., Olkowski, B. F., & Rojavin, Y. (2020). The economic and clinical impact of an early mobility program in the trauma intensive care unit: A quality improvement project. Journal of Trauma Nursing, 27(1), 29–36. https://doi.org/10.1097/JTN.0000000000000479 Klein, K., Mulkey, M., Bena, J. F., & Albert, N. M. (2015). Clinical and psychological effects of early mobilization in patients treated in a neurologic icu: A comparative study*. Critical Care Medicine, 43(4), 865–873. https://doi.org/10.1097/CCM.0000000000000787 Kocan, M. J., & Lietz, H. (2013). Special considerations for mobilizing patients in the neurointensive care unit. Critical Care Nursing Quarterly, 36(1), 50–55. https://doi.org/10.1097/CNQ.0b013e3182750b12 Olkowski, B. F., & Shah, S. O. (2017). Early mobilization in the neuro-icu: How far can we go? Neurocritical Care, 27(1), 141–150. https://doi.org/10.1007/s12028-016-0338-7 Ryan, P. (2009). Integrated theory of health behavior change: Background and intervention development. Clinical Nurse Specialist CNS, 23(3), 161–170; quiz 171–172. https://doi.org/10.1097/NUR.0b013e3181a42373 17 Tables Table 1 Comparison of Pre- and Post-Survey Demographics n Post Pre 31 66 Role (%) 0.89 Advanced Practice Provider 2 (6.5) 7 (10.6) Critical Care Technician 1 (3.2) 6 (9.1) Occupational Therapist 3 (9.7) 6 (9.1) Other 2 (6.5) 2 (3.0) Physical Therapist 2 (6.5) 7 (10.6) Physician 1 (3.2) 2 (3.0) 17 (54.8) 32 (48.5) 3 (9.7) 4 (6.1) Registered Nurse Respiratory Therapist Age (%) 0.872 20 - 30 10 (33.3) 23 (35.4) 31 - 40 9 (30.0) 23 (35.4) 41 - 50 5 (16.7) 9 (13.8) 51 - 60 5 (16.7) 6 (9.2) 61+ 1 (3.3) 3 (4.6) Prefer not to say 0 (0.0) 1 (1.5) Gender (%) 0.216 Female 16 (53.3) 45 (69.2) Male 14 (46.7) 19 (29.2) 0 (0.0) 1 (1.5) Prefer not to say Race (%) p-value 0.633 18 Asian 1 (3.3) 1 (1.5) Multiple races 1 (3.3) 2 (3.1) Prefer not to answer 0 (0.0) 3 (4.6) White or Caucasian 28 (93.3) 59 (90.8) Ethnicity (%) Hispanic or Latino/Latina 0.465 1 (3.3) 3 (4.6) 27 (90.0) 58 (89.2) Prefer not to answer 1 (3.3) 4 (6.2) Unknown ethnicity 1 (3.3) 0 (0.0) Non Hispanic or Latino/ Latina Years of critical care experience (%) 0.687 1-3 years 8 (26.7) 18 (27.3) 10+ 13 (43.3) 20 (30.3) 4-6 years 6 (20.0) 17 (25.8) 7-9 years 1 (3.3) 6 (9.1) Less than one year 2 (6.7) 5 (7.6) 19 Table 2 Overview of Pre- and Post-Survey Questions Q# 8 9 10 11 12 13 14 Question TBI patients are being adequately mobilized in the Shock Trauma ICU It is important for TBI patient in the ICU to receive early mobilization I understand early mobility guidelines for TBI patients in the ICU I feel confident in my ability to perform out of bed mobility, ROM techniques, and early mobilization with TBI patients I have the training I need to provide early mobility for TBI patients in the ICU I have the resources I need to provide early mobility for TBI patients in the ICU There are barriers which limit providing early mobility for TBI patients in the ICU Pretest Median (1 – 7 scale) Posttest Median (1 – 7 scale) P value (alpha 0.05) Mann-Whitney U test 4 5 *0.03897 6 6 0.4516 5 6 *0.0002779 5 6 *0.03756 5 6 *0.01341 4 5 *0.04708 6 6 0.08873 20 Figures Figure 1 Pre-Survey Barriers Pre-Survey Barriers Time Nature of Injury/Exclusion Criteria Limited Staff 6% 2% 4% 20% 4% 2% Night Shift Equipment Inadequacy Unit Culture Family Members 23% 39% Inexperienced Staff Figure 2 Post- Survey Barriers Post-Survey Barriers 5% Time Limited Staff 5% 16% 11% Nature of Injury/Exclusion Criteria Inexperienced Staff Equipment Inadequacy 63% 21 Appendices Appendix A Early Mobility Guideline for Traumatic Brain Injury Patients in a Shock Trauma Intensive Care Unit Pre-Survey This brief pre-survey is intended to collect data regarding the implementation of a new early mobility guideline. Responses are both voluntary and anonymous. I appreciate your participation. Marleen Park, BSN, RN, DNP Student University of Utah College of Nursing 1. I am employed at Intermountain Medical Center in the Shock Trauma ICU as a: Registered Nurse Critical Care Technician Respiratory Therapist Occupational Therapist Physical Therapist Physician Advanced Practice Provider Other 2. Please enter your mother’s birthday, formatted with 6 digits (month, day, year), without spaces or slashes, i.e. 062263.This identifying information will be used to compare individual pre and post answers only. 3. What is your age? 20-30 31-40 41-50 51-60 61+ Prefer not to say 4. Do you think of yourself as: Male Female 22 Non-binary/third gender Prefer not to say 5. Which race best describes you? American Indian Alaskan Native, Aleut, or Eskimo Asian Native Hawaiian or Other Pacific Islander Black or African American White or Caucasian Eastern Indian Multiple Races Prefer not to answer 6. Which ethnicity best describes you?? Hispanic or Latino/Latina Non-Hispanic or Latino/Latina Unknown ethnicity Prefer not to answer 7. Years of critical care experience in your current role? Less than one year 1-3 4-6 7-9 10+ 8. Traumatic brain injury patients are being adequately mobilized in the Shock trauma ICU. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 9. It is important for traumatic brain injury patients in the ICU to receive early mobility. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 10. I understand early mobility guidelines for traumatic brain injury patients in the ICU. 23 Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 11. I feel confident in my ability to perform out of bed mobility, range of motion techniques, and early mobilization with TBI patients. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 12. I have the training I need to provide early mobility for traumatic brain injury patients in the ICU. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 13. I have the resources I need to provide early mobility for traumatic brain injury patients in the ICU. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 14. There are barriers which limit providing early mobility for traumatic brain injury patients in the ICU. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree 24 Strongly disagree 15. Please describe any barriers to early mobility for traumatic brain injury patients in the ICU. 25 Appendix B Early Mobility Guideline for Traumatic Brain Injury Patients in a Shock Trauma Intensive Care Unit Marleen Park, BSN, RN, DNP Student University of Utah College of Nursing Exclusion Criteria: § Acute deterioration in neurological status § Presence of ICP device or bolt § Presence of femoral arterial sheath § Hemodynamic instability § Unstable injuries/fractures/open abdomen – check with clinical team before proceeding § § § § Pharmacological/therapeutic paralysis Mechanical ventilation with PEEP >10, FiO2 > 60% Continuous Renal Replacement Therapy Transition toward End of Life Helpful Hints: ü Phases 1 and 2 to be performed on both day and night shift. ü CCT is permitted to perform PROM via nursing discretion. Are Exclusion Criteria Present? If YES, proceed with phases 1-3 as tolerated and re-assess exclusion criteria in 12-24 hours. Phase 1: Range of Motion (Goal 1x/shift) § Perform Passive Range of Motion (PROM) 10x per extremity (injuries permitting). Phase 2: Head of Bed > 45° (Goal 1x/shift) § Elevate HOB > 45° for one hour. § Always maintain HOB > 30° (injuries permitting). Phase 3: Bed in Chair Position (Goal 1 hour/day) § Place bed in chair position with HOB > 60° for at least one hour. § If patient tolerates, continue with chair position with Q2H turns. Please verify active orders for PT/OT and clarify activity restrictions related to injuries prior to proceeding with phases 4-8. If patient is on a ventilator, please coordinate with multidisciplinary team (PT/OT/RT) to ensure patient safety. Phase 4: Stroke Chair (Goal 1x/day) § Safely transfer patient to stroke chair for 1 hour as tolerated. § Maximum time in stroke chair is 4 hours, with Q1H turns. Phase 5: Dangle at Edge of Bed (Goal 10 minutes) § Assist patient to dangle at edge of bed with support (if needed). § Must be able to support themselves prior to proceeding to phase 6. Phase 6: Stand at Bedside (Goal 1x/day) § Assist patient to stand at bedside. § Do not proceed to phase 7 if patient becomes unsteady or lightheaded. ü ü ü ü Patient Safety First Maintain hemodynamic stability and ensure vital signs are within parameters Ensure stable/unchanged neurological status through continual assessment Minimize agitation and/or pain Coordinate with multidisciplinary team Phase 7: Transfer from Bed to Chair (Goal 1 hour/day) § Transfer patient from bed to chair by ambulation or pivot maneuver. § Reposition patient Q1H while in chair to prevent pressure injury. § If patient does not tolerate this phase or is unsteady during transfer, do not proceed to phase 8. Phase 8: Ambulate as Tolerated (Goal 2x/day) § Assist patient to ambulate in room and hallway if tolerated. § Document time and distance patient ambulates, and any assist devices utilized. § If patient is positive for COVID-19, do not assist them to ambulate in hallway. Adapted from M. A. Brissie, 2017, Intensive and Critical Care Nursing, 42, 30-35. Copyright 2017 by Elsevier Ltd. 26 Appendix C Early Mobility Guideline for Traumatic Brain Injury Patients in a Shock Trauma Intensive Care Unit Post-Survey This brief pre-survey is intended to collect data regarding the implementation of a new early mobility guideline. Responses are both voluntary and anonymous. I appreciate your participation. Marleen Park, BSN, RN, DNP Student University of Utah College of Nursing 1. I am employed at Intermountain Medical Center in the Shock Trauma ICU as a: Registered Nurse Critical Care Technician Respiratory Therapist Occupational Therapist Physical Therapist Physician Advanced Practice Provider Other 2. Please enter your mother’s birthday, formatted with 6 digits (month, day, year), without spaces or slashes, i.e. 062263.This identifying information will be used to compare individual pre and post answers only. 3. What is your age? 20-30 31-40 41-50 51-60 61+ Prefer not to say 4. Do you think of yourself as: Male Female Non-binary/third gender 27 Prefer not to say 5. Which race best describes you? American Indian Alaskan Native, Aleut, or Eskimo Asian Native Hawaiian or Other Pacific Islander Black or African American White or Caucasian Eastern Indian Multiple Races Prefer not to answer 6. Which ethnicity best describes you?? Hispanic or Latino/Latina Non-Hispanic or Latino/Latina Unknown ethnicity Prefer not to answer 7. Years of critical care experience in your current role? Less than one year 1-3 4-6 7-9 10+ 8. Traumatic brain injury patients are being adequately mobilized in the Shock trauma ICU. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 9. It is important for traumatic brain injury patients in the ICU to receive early mobility. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 10. I understand early mobility guidelines for traumatic brain injury patients in the ICU. Strongly agree 28 Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 11. I feel confident in my ability to perform out of bed mobility, range of motion techniques, and early mobilization with TBI patients. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 12. I have the training I need to provide early mobility for traumatic brain injury patients in the ICU. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 13. I have the resources I need to provide early mobility for traumatic brain injury patients in the ICU. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 14. There are barriers which limit providing early mobility for traumatic brain injury patients in the ICU. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 29 15. I was able to utilize the new Early Mobility Guideline for TBI Patients in the ICU. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 16. The new Early Mobility Guideline for TBI Patients was readily available and promoted positive patient outcomes. Strongly agree Agree Somewhat agree Neither agree or disagree Somewhat disagree Disagree Strongly disagree 17. Please share any benefits that you or your patients experienced in having the Early Mobility Guideline. 18. Please describe any barriers or limitations while using the early mobility guideline. Include any suggestions to help improve this workflow.