Improved Outcomes With a Physical Therapy and Nursing Driven Progressive Upright Mobility Protocol

Abstract

SESSION TITLE: Improving Outcomes in the ICU SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, November 1, 2017 at 02:45 PM - 04:15 PM PURPOSE: We identified an opportunity for improvement in minimizing patient sedation and maximizing mobility. The purpose of this project was to address both by focusing on improving mobility. METHODS: All Registered Nurses (RN) and Nurse’s Aides in the Intensive care unit were first educated by the ICU Clinical Nurse Specialists on the benefits of mobility on patient outcomes as well as the detrimental effects of immobility. This was done to provide the necessary context to improve nursing engagement with the importance of early mobility in the critically ill patient. Next all RNs were introduced to the “Progressive Upright Mobility Protocol”. This protocol was developed by the ICU team (physicians, nurses, physical and respiratory therapists) from the existing literature on patient mobility. The protocol was designed to be a standing order in the ICU. After 24 hours in the ICU, critically ill patients automatically had the mobility protocol implemented as part of their routine care. The protocol was designed to have an assessment and promotion of progressive mobility every 4 hours except for the hours of 11pm to 7am to facilitate sleep. Our ICU based Physical Therapist helped advise and direct mobility interventions. The bedside RN was expected to assess and document the activity level of patient. If the patient had not progressed from the previous assessment nurses were to provide documentation as to why progression was not achieved. Assessments were to continue until the patient attained the highest level of mobility. RESULTS: Mobility is measured on a 0 to 6 scale. Daily and monthly averages of all patients were calculated over a 7 month period. Daily averages were 2.8 at the study inception and 4.8 at the end (p<.001, Cox-Stuart test for trend). The monthly averages were 2.89, 3.01, 3.41, 3.67, 4.11, 3.48, and 4.4. Mobility was the highest at 1200hr and 1600hr. Most frequent barriers to mobility were contraindication due to open abdominal wounds and complex medical interventions (i.e. Extracorporeal membrane oxygenation, Continuous Renal Replacement Therapy) 27%; inability to follow commands 25%; hemodynamic or respiratory instability 12%. Sedation was a barrier in only 5% of patients. Patients on ventilators were not found to be a barrier. All patients were included in data analysis and scoring including those patients with contraindications to the protocol. CONCLUSIONS: With a dedicated Physical Therapist, engaged nurses and attention to detail, we were able to significantly improve the functional mobility of our ICU population. Overall sedation of our ventilated patients was decreased, creating a cultural shift with goals of the interdisciplinary team directed toward early activity. CLINICAL IMPLICATIONS: Using a multi-disciplinary approach, patient mobility and sedation can be optimized. More study will be required to assess any effect on ventilator days, length of stay or mortality DISCLOSURE: The following authors have nothing to disclose: Jessica Parry, Michael Allain, Russell Acevedo, David Landsberg, Daniel Polacek, Ryan Magnuson No Product/Research Disclosure Information