Introduction• Early mobility of patients admitted to the
medical intensive care unit is crucial to optimal patient outcomes.
• Immobility can be detrimental to a patients’ wellness and subsequently increase their risk for additional complications.
• Nurses have a significant influence on the dynamics of patient care.
• An early mobility algorithm integrated into patient care can enhance mobilization of the critical-ill as one transition through their course of hospitalization.
Background & Significance • Patients are evaluated by a physical therapist
(PT) / occupational therapist (OT) when applicable within 24-hours of admission.
• PT/OT are not always available for patient mobilization.
• ICU patient are susceptible to complication of immobility because of inadequate patient engagement.
• Nurses are an significant constituent of the multidisciplinary team coordinating the trajectory of patient-centered care.
• Decreased mobility can subsequently translate to increase length of stay (LOS), prolonged intubation, and/or further decline in health.
Needs Assessment• A structured quality improvement (QI) project
that is nurse-driven can optimize patient engagement in meaningful activities.
• An early mobility protocol can facilitate a culture change in practice and reduce knowledge gaps through evidence-based literature.
Clinical Question• Does implementation of a Nurse Driven Early
Mobility Protocol in the Medical Intensive Care Unit facilitate a change in the attitudes and Beliefs of staff nurses?
IRB ApprovalSite IRB Approval granted: August 18,2020Rutgers IRB Approval granted: August 13, 2020
Nurse-Driven Progressive Mobility in the MICULloyd Bailey, BSN, RN
Theoretical Framework
Aims & Objectives• Enhance mobilizing patients to activity level
– 3 within 48 hours of admission to the medical intensive care unit.
• The nurse will perform active/passive range of motion three times a day.
• Reduce patients’ ICU length of stay.• Reduce patients’ ventilation days.Study population & Setting• 30 – Registered nurses• Level-1 Trauma Center in northern NJMethodology• Quality Improvement project• Pre- and post- John Hopkins Patient
Mobilization Attitudes and Beliefs survey• AHRQ Medical Screening Algorithm • AHRQ Progressive Mobility Algorithm
Results
• Vertical line indicates cut-off for successful mobility (level 3 or better)
• Within the 1st 48hrs of arriving in the ICU, 29 out of 95 patients (30.5%) reached at least level 3 of mobility
Results (cont.)• Agreement with Q14 (“My departmental
leadership is very supportive of patient mobilization”) significantly increased, p = 0.015
• Agreement with Q24 (“Unless there is a contraindication, I mobilize my inpatients at least once during my shift/work day”) significantly increased, p = 0.014
Discussion• Establish a safe and effective approach to
increasing patient mobility.• Daily meeting to reinforce routine practice.• White board for monitoring patients’ level of
mobility. • Reducing ICU days and ventilation days.• Economical cost benefits of a mobilization
protocol.Implications• Early mobility protocol can facilitate a new
care process that is conducive to increasing compliance.
• Patients are less susceptible to complications of immobility.
• Empower nurses to collaborate with interdisciplinary teams to integrate progressive mobility into routine practice.
• Emphases teamwork.• Patients spend less time in bed and less time
intubated.Reference ListDrolet, A., Dejuilio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, E. A., Lloyd, J. M., Waters, C., & Williams, S. (2013). Move to Improve: The Feasibility of Using an Early Mobility Protocol to Increase Ambulation in the Intensive and Intermediate Care Settings. Physical Therapy, 93(2), 197–207. https://www.ncbi.nlm.nih.gov/pubmed/22976447Dirkes, S. M., & Kozlowski, C. (2019). Early Mobility in the Intensive Care Unit: Evidence, Barriers, and Future Directions. Critical Care Nurse, 39(3), 33–42. https://aacnjournals.org/ccnonline/article-abstract/39/3/33/22057/Early-Mobility-in-the-Intensive-Care-Unit-Evidence?redirectedFrom=fulltextEarly Mobility Guide for Reducing Ventilator-Associated Events in Mechanically Ventilated Patients. [Technical Bundles Module—Early Mobility]. Toolkit To Improve Safety for Mechanically Ventilated Patients. Agency for Healthcare Research and Quality, Rockville, MD. January 2017. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-mvpguide.pdfEfficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial. (2015). Lancet, 386(9988), 46–55. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60690-0/fulltextFour E’s of Early Mobility: Facilitator Guide & PowerPoint®Presentation. [Technical Bundles Module—Early Mobility]. Toolkit To Improve Safety for Mechanically Ventilated Patients. Agency for Healthcare Research and Quality, Rockville, MD. January 2017. https://www.ahrq.gov/hai/tools/mvp/technical-bundles-early-mobility.htmlHester, J. M., Guin, P. R., Danek, G. D., Thomas, J. R., Titsworth, W. L., Reed, R. K., Vasilopoulos, T., & Fahy, B. G. (2017). The Economic and Clinical Impact of Sustained Use of a Progressive Mobility Program in a Neuro-ICU. Critical Care Medicine, 45(6), 1037–1044. https://www.ncbi.nlm.nih.gov/pubmed/28328648Hodgson, C. L., Bailey, M., Bellomo, R., Berney, S., Buhr, H., Denehy, L., Gabbe, B., Harrold, M., Higgins, A., Iwashyna, T. J., Papworth, R., Parke, R., Patman, S., Presneill, J., Saxena, M., Skinner, E., Tipping, C., Young, P., Webb, S., & Trial of Early Activity and Mobilization Study Investigators. (2016). A Binational Multicenter Pilot Feasibility Randomized Controlled Trial of Early Goal-Directed Mobilization in the ICU. Critical Care Medicine, 44(6), 1145–1152. https://www.ncbi.nlm.nih.gov/pubmed/26968024Kaiser Family Foundation. (2018). Hospital Adjusted Expenses per Inpatient Day. Retrieved March 22, 2020, from https://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day/?currentTimeframe=0&sortModel=%7B"colId":"Location","sort":"asc"%7DKlein, E. K., Bena, F. J., Mulkey, M., Albert, M. N. (2018). Sustainability of a nurse-driven early progressive mobility protocol and patient clinical and psychological health outcomes in s neurological intensive care unit. Intensive and Critical Care Nursing, 45, 11-17. https://www.sciencedirect.com/science/article/pii/S0964339717302768 - b0055Lee, Y., Kim, K., Lim, C., & Kim, J. (2020). Effects of the ABCDE bundle on the prevention of post‐intensive care syndrome: Aretrospective study. Journal of Advanced Nursing (John Wiley & Sons, Inc.), 76(2), 588–599. https://www.ncbi.nlm.nih.gov/pubmed/31729768Messer, A., Comer, L., & Forst, S. (2015). Implementation of a Progressive Mobilization Program in a Medical-Surgical Intensive Care Unit. Critical Care Nurse, 35(5), 28–42. https://aacnjournals.org/ccnonline/article-abstract/35/5/28/3496/Implementation-of-a-Progressive-Mobilization?redirectedFrom=fulltextNydahl, P., Sricharoenchai, T., Chandra, S., Kundt, F., Huang, M., Fischill, M., & Needham, D. (2017). Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis. Annals of the American Thoracic Society, 14(5), 766–777. https://www.ncbi.nlm.nih.gov/pubmed/28231030Schaller, S.J., Anstey, M., Blobner, M., Edrich, T., Grabitz, S. D., Gradwohl-Mathis, L., Heim, M., Houle, T., Kurth, T., Latronico, N., Lee, J., Meyer, M. J., Peponis, T., Talmor, D., Velmahos, G. C., Waak, K., Walz, J. M., Zafonte, R., Eikermann, M., & International Early SOMS-guided Mobilization Research Initiative. (2016). Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial. Lancet, 388(10052), 1377-1388. https://doi-org.proxy.libraries.rutgers.edu/10.1016/S0140-6736(16)31637-3Society of Critical Care Medicine. (n.d.). Implementing the E component of the ABCDEF Bundle. Retrieved March 1, 2020, from https://www.sccm.org/LearnICU/Resources/Implementing-the-E-component-of-the-ABCDEF-bundle
Contact InformationLloyd Bailey, BSN, RN: [email protected] DiGiulio, DNP, APN, FAANP: [email protected]
Mary DiGiulio, DNP, APN, FAANP (Chair)Anne Sutherland, MDAnna Manns, MSATC, DPT, PT
• Number of range of motion completed at each time
• Agreement with Q11(“Unless there is a contraindication, my inpatients are mobilized at least once daily by nurses”) significantly increased, p = 0.016
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