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Move to Improve: The Feasibility of Using an Early Mobility Protocol to Increase Ambulation in the Intensive and Intermediate Care Settings

Anne Drolet, Patti DeJuilio, Sherri Harkless, Sherry Henricks, Elizabeth Kamin, Elizabeth A. Leddy, Joanna M. Lloyd, Carissa Waters, Sarah Williams

Abstract

Background Prolonged bed rest in hospitalized patients leads to deconditioning, impaired mobility, and the potential for longer hospital stays.

Objective The purpose of this study was to determine the effectiveness of a nurse-driven mobility protocol to increase the percentage of patients ambulating during the first 72 hours of their hospital stay.

Design A quasi-experimental design was used before and after intervention in a 16-bed adult medical/surgical intensive care unit (ICU) and a 26-bed adult intermediate care unit (IMCU) at a large community hospital.

Method A multidisciplinary team developed and implemented a mobility order set with an embedded algorithm to guide nursing assessment of mobility potential. Based on the assessments, the protocol empowers the nurse to consult physical therapists or occupational therapists when appropriate. Daily ambulation status reports were reviewed each morning to determine each patient's activity level. Retrospective and prospective chart reviews were performed to evaluate the effectiveness of the protocol for patients 18 years of age and older who were hospitalized 72 hours or longer.

Results In the 3 months prior to implementation of the Move to Improve project, 6.2% (12 of 193) of the ICU patients and 15.5% (54 of 349) of the IMCU patients ambulated during the first 72 hours of their hospitalization. During the 6 months following implementation, those rates rose to 20.2% (86 of 426) and 71.8% (257 of 358), respectively.

Limitations The study was carried out at only one center.

Conclusion The initial experience with a nurse-driven mobility protocol suggests that the rate of patient ambulation in an adult ICU and IMCU during the first 72 hours of a hospital stay can be increased.

Physical inactivity associated with hospital care for a range of medical conditions can have many unfavorable consequences. They include neuromuscular dysfunction, metabolic disturbances, and other organ system abnormalities that add to the disease burden.1 Prolonged bed rest is associated with extended hospital stays and persistent physical and neuropsychiatric disabilities in intensive care unit (ICU) settings.1 A meta-analysis of 39 randomized controlled trials revealed bed rest was not beneficial and may be harmful.2 Studies also have demonstrated that reducing the use of sedation and introducing physical activity as soon as clinically feasible can decrease the frequency and severity of these complications.3,4

Although these problems have been carefully studied in ICU settings, few studies are available about the complications of inactivity outside the ICU. Studies of the consequences of prolonged bed rest have been conducted in volunteers without illness.5 Skeletal muscle changes can be documented within 72 hours of physical inactivity.6 In addition, physiologic dysfunction has been found across a range of organ systems and metabolic processes. When non-ICU patients are subjected to bed rest, it is reasonable to assume they will experience similar degrees of dysfunction.7

The application of bed rest in hospital-based medical care is widespread and enduring. There exists a time-honored impression that bed rest is therapeutic and physical activity harmful in the presence of illness. There are practical barriers to mobilizing some patients due to monitoring or life support equipment, frailty, and weakness. In such circumstances, considerable resources may be needed for safe mobilization.8

At our 313-bed acute care community hospital, we were concerned about the adverse effects of inactivity in both our adult ICU and intermediate care populations. Increasing patient activity through mobilization is associated with improved respiratory function, reducing adverse effects of immobility, increased levels of consciousness, increased functional independence, improved cardiovascular fitness, and psychological well-being.9

Prior to the early mobility protocol initiative, common practice was a slower approach to mobilizing patients who are critically ill. Often the physical therapist was the first member of the health care team to begin mobilizing the patient. The physical therapist is only with the patient for approximately 30 minutes per day in our setting. As the nurses are the primary caregivers for 8 to 12 hours at a time, we hypothesized that a nurse-driven mobility protocol could provide important benefits. Little is known about how nurses make decisions about whether to ambulate, how they ambulate, and when they ambulate older patients. In a recent qualitative study, factors that seemed to have a greater impact on nurses' decisions regarding patient ambulation were the risk/opportunity assessment, preventing complications, and the presence of unit expectation to ambulate patients.10 Furthermore, Kalisch11 found that ambulation was regularly missed in the provision of nursing care. Reasons given by nurses were related to time required to carry out ambulation, ease of omitting ambulation, and believing that ambulation was the job of a physical therapist. Barriers to ambulation most frequently cited by nurses were related to patients' physical symptoms such as weakness, pain, and fatigue; presence of devices such as intravenous line and urinary catheters; concerns about falls; and lack of staff to assist with out-of-bed activity.12 A recent study showed that 83% of patient time is spent lying in bed,13 and during one observational study, 73% of patients considered able to walk did not walk.14 Ambulation should be viewed as a priority and as a vital component of quality nursing care.15

Considering the deleterious effects of bed rest, the emerging literature on ambulation of patients with acute illness, and the potential for nursing staff to engage in ambulation activities with their patients, the Move to Improve team decided to develop a quality improvement study. We hypothesized that implementation of a mobility program would increase the likelihood of early mobilization in our ICU and intermediate care unit (IMCU) patients.

Method

Three months of data (January–March 2010) were collected before implementation of the mobility program to confirm consistency of baseline information. Postimplementation data were collected for 6 months (March–August 2011). To evaluate the impact of this initiative, we compared the frequency of ambulation for patients admitted to the ICU and IMCU, or who were transferred from the ICU to the IMCU, during these time periods.

In February 2010, nursing management gave approval to begin the quality improvement project. A multidisciplinary team consisting of advanced practice nurses, registered nurses, physical therapists, a critical care pharmacist, a respiratory therapist, and a critical care physician was assembled in April 2010. The team adopted the Plan-Do-Check-Act framework for the development and implementation of the Move to Improve mobility program; the “Plan” stage ran from January 2010 to April 2010 (see Appendix 1 for complete time line).

Two units were selected for the pilot study. The first unit was the IMCU, a 26-bed unit with an average daily census of 21.6 patients and a nurse-to-patient ratio of 1:4. The patient population included patients with complex medical and surgical conditions as well as patients who were hemodynamically stable with a tracheostomy on a ventilator and had potential for respiratory insufficiency. These patients often required frequent vital sign monitoring and respiratory therapy management. The second pilot unit was an adult ICU, a 16-bed unit designed to provide intensive medical/surgical care to patients with acute and chronic medical diagnoses. Its average daily census was 11.3 patients and a 1:2 nurse-to-patient ratio. During the study, from March through August 2011, this ICU had a standard mortality ratio of 0.726 (observed deaths/expected deaths) utilizing the APACHE IV scoring system.16 The average length of stay was 3.2 days. For patients admitted directly to the IMCU, the average length of stay was 4.95 days.

In April 2010, the Move to Improve team reviewed current evidence and exemplary protocols to determine whether the adult ICUs were utilizing best practices for mobilizing patients. The literature review was expanded to include ambulating patients in the non-ICU areas, weaning patients from ventilators safely and efficiently, and sedation and pain management guidelines.1719 The team divided into small groups to focus on the multiple facets of the program.

The “Do” stage of the project ran from April through November of 2010. Multiple order sets and protocols were developed for the pilot study. A mobility order set was created that included a screening tool based on the exclusion criteria from the Critical Care Physical Medicine and Rehabilitation Program at Johns Hopkins Medical Center.20 The exclusion criteria were modified to address the needs of our patient population based on recommendations from the intensivists and medical staff chairpersons. The mobility algorithm developed by the physical therapist on the planning team was embedded in the order set to guide the assessment and allowed the nurse to consult physical therapists and occupational therapists when appropriate (Appendix 2). The ventilator weaning order set was developed by ICU respiratory therapists. This order set included a protocol for pain management with appropriate sedation determined by clinical pharmacists and implemented by bedside nurses, use of the Richmond Agitation Sedation Scale,21,22 and more frequent readiness trials to determine whether patients were capable of ventilator discontinuation.2328 A primary objective was to remove mechanical ventilation as soon as possible, as it is easier and safer to mobilize patients without the burden of an artificial airway. Pain that could worsen with movement was addressed to avoid patient resistance, and sedation was modified so that patients were alert enough to mobilize. The sedation protocol for ICU patients was modified from a practice of continuous infusions to a preferred practice of using intermittent dosing of sedation medications when possible to maintain goal sedation.

After careful review of the multiple order sets, approval for the 4-week pilot study was granted by the hospital's Medical Executive Committee in September 2010. The team received approval from the hospital's institutional review board in November 2010. Data would be collected on patients 18 years of age or older who were hospitalized for 72 hours or longer.

During November 2010, in preparation for the pilot study, nurses and patient care technicians completed an education program developed by the Move to Improve team. The education included verbal presentations by the advanced practice nurses and physical therapists at unit staff meetings. The staff was instructed on the exclusion criteria, the mobility algorithm, and the use of gait belts when transferring and ambulating patients. The nurses and patient care technicians also received self-learning packets, and posters were placed on the 2 units as reminders of the study. The nurses and patient care technicians had 1 month to complete the education. Respiratory therapists received mandatory education in both written and classroom formats on the use of the portable ventilator, ventilator weaning, sedation, and the mobility protocols. Physical therapists were educated on use of a custom-designed walker with fold-down seat, funded by the hospital foundation, and intravenous pole that supported the portable ventilator (Fig. 1). They also received specific instructions on handling patients who are critically ill and ventilated for safety during ambulation.

Figure 1.

Custom-designed walker and intravenous pole (purchased from Spectrum Surgical Instruments Co, Stow, Ohio, www.spectrumsurgical.com) with ventilator (Versamed Ivent 201, GE Healthcare, www.gehealthcare.com).

Beginning the first week of December 2010, education was provided to the medical staff at their quarterly meeting along with posters outlining the program and pilot study. The physicians were made aware that the mobility protocol would be mandatory for all patients in the adult ICU and IMCU during the pilot project, which was to run from December 14, 2010, through January 11, 2011. The physicians were informed that the nurse would have the ability to order physical therapy or occupational therapy when appropriate. Decisions about ability or appropriateness of activity were made by the nurse based on the mobility algorithm coupled with the assessment of exclusion criteria. All patients in both the ICU and the IMCU were screened using the same process.

Upon completion of the pilot project, the team returned to the Medical Executive Committee in February 2011 to complete the “Check” process. Approval was granted to proceed with the program in the ICU and the IMCU with the understanding that the mobility protocol would no longer be mandatory but would now need a physician's order to implement. The Medical Executive Committee also approved hospital-wide implementation to begin in July 2011.

The “Act” process began in March 2011 at the beginning of the postimplementation period with the objective of increasing the number of adult patients ambulating during the first 72 hours of their hospital stay. For the purpose of this study, we defined ambulation as the act of walking with or without an assistive device, moving self from point A to point B. Distance was measured for each patient's ambulation efforts. Multiple assessments were performed daily by the nurse to determine activity readiness.3

Ambulation was recorded before and after implementation of the mobility protocol for patients admitted to the ICU and the IMCU, or transferred from the ICU to the IMCU. Patients who were discharged in less than 72 hours or transferred to another unit (other than the IMCU) during that time frame were excluded. Due to these exclusions, the patient census during the study period appears to be less than that seen during the preimplementation period. Nurses and patient care technicians were encouraged to ambulate all patients regardless of their length of stay in the ICU or IMCU. Collected data captured only nurse or patient care technician documentation of ambulation and did not include activity performed by the physical therapist. Aggregated and de-identified data were reviewed. Monthly collection and analysis of data were reported to the nurse managers and staff at unit meetings. The retrospective chart reviews revealed little improvement in ambulation compared with preimplementation data. For this reason, an ambulation status report (Appendix 3) was developed that would provide real-time data for the nurses. This report was distributed to the units daily, noting each patient's length of stay and the distance the patient had ambulated on a given day. The ambulation status report was embraced by the IMCU staff and reviewed at multidisciplinary rounds each morning. With the creation and use of this daily report, there was an immediate increase in the number of patients ambulating in the IMCU. However, we did not see regular use of the ambulation status report in the ICU until several months into the study.

Patient demographics such as age and sex were tracked across both departments studied. Data are presented as means (standard deviation) for descriptive variables. Comparisons of preimplementation and postimplementation data were performed using an unpaired, 2-tailed t test. Significance was set at P<.05. Analyses were performed with Microsoft Excel 2007 software (Microsoft Corporation, Redmond, Washington).

Results

Data were collected for 193 ICU patients and 349 IMCU patients during the 3-month preimplementation period and for 426 ICU patients and 358 IMCU patients during the 6-month postimplementation period (Table). During the preimplementation period, patients in the ICU had an average (SD) age of 67.0 (15.7) years; 42% were female. In the IMCU, the average (SD) patient age was 65.7 (17.5) years; 55% were female. Patients followed in the ICU during the postimplementation period had an average (SD) age of 64.4 (17.0) years of age; 48% were female. In the IMCU, the average (SD) patient age was 68.0 (16.1) years; 51% were female. There were no differences in average patient age or sex distribution between the 2 data collection periods.

Table.

Summary of Patient Demographicsa

During the preimplementation period, only 6.2% (12 of 193) of the ICU patients and 15.5% (54 of 349) of the IMCU patients ambulated within 72 hours of hospital admission. In contrast, following implementation of the Move to Improve program, 20.2% (86 of 426) of the ICU patients (P<.001) and 71.8% (257 of 358) of the IMCU patients (P<.001) ambulated within 72 hours of admission (Fig. 2).

Figure 2.

Patient ambulation in the intensive care unit (ICU) and the intermediate care unit (IMCU) before and after implementation of the Move to Improve early mobility program. Preimplementation of Move to Improve early mobility program: January–March 2010; postimplementation of Move to Improve early mobility program: March–August 2011.

Discussion

This quality improvement study was undertaken to determine whether routine patient care could be modified to include mobility. The project utilized current evidence that a significant change in clinical practice could be effected, as demonstrated in a quality research study by Needham et al.29 The Move to Improve project was a vision of health care professionals who knew more needed to be done to improve patients' ability to overcome illness. The mobility initiative has enabled nurses to drive the care for the patient through an evidence-based protocol. Within our institution, patient activity levels were frequently not addressed until many days into their hospital stay. Some patients became deconditioned, which led to the cancellation of discharges or transfer to a rehabilitation facility. Upon realization of this hospital-wide problem, it was brought to the attention of the ICU leadership and the quality committee in the IMCU.

The Move to Improve committee met biweekly from April through November 2010 to develop order sets and algorithms to formulate a mobility pathway to be used across the continuum of care. A major lesson learned was that in order to implement practice changes, the leadership and staff needed an environment and culture that supported learning and a commitment to best practice.30 Initially, the ICU staff and physicians felt the patients with critical illness were too sick to move, that it was too risky to mobilize them, or that it was the role of the physical therapist to do the required exercises. During the pilot study in the adult ICU, there was a change in the leadership structure and a higher than normal staff turnover rate. These factors posed additional challenges to the implementation of change.

Despite the challenges, after focusing on the topic in staff meetings and through education, nurses realized the importance of the mobility program, and it became a priority. The staff of the IMCU and ICU gathered to discuss the successes and obstacles of the program. During the open discussion, the nurses stressed the importance of teamwork and making ambulation a priority as they provided care to patients. It is now a daily expectation to discuss the mobility plan for patients who are critically ill.

Upon completion of the pilot study, the data were presented to the hospital's Medical Executive Committee to obtain approval for a house-wide Move to Improve initiative, which began in July 2011. After receiving approval, the committee focused on implementation to all remaining adult patient care units. The marketing department facilitated communication and organizational support for this project through posters and Intranet communications. The Move to Improve team encouraged physicians to order the mobility protocol on admission orders so that nurses would become familiar with the exclusion criteria and begin to think of mobility as part of the daily clinical routine. The physicians supported this change, as it streamlined care for their patients and reduced the number of telephone calls for the nurses and medical staff.

The outcomes of our initial data collection were as expected. We predicted that with nurses assessing the patient's ability to ambulate, more patients will be walking during their hospital stay. Our data support Bailey and colleagues' findings in patients with respiratory failure that early activity is feasible and can be used to prevent or treat neuromuscular complications of critical illness.31 We have determined that modifications to our protocol are not needed at this time; however, it is critical to maintain protocol use in daily routine patient care.

In our study, we showed that implementing a practice and culture change led to an improvement in the number of patients ambulating within 72 hours of their admission in both the ICU and the IMCU. Our data indicate that it is feasible to ambulate these patients.

Limitations

One limitation of this study is that it was carried out at only one center. There is a lack of detailed data on patient demographics and illness severity. However, all patients were screened for appropriateness of mobility using the criteria presented in Appendix 2; therefore, all patients in this study met these physiologic parameters. Applicability of our results may be limited by changes made to the practice of sedation management in the ICU to support the mobility initiative, which posed a challenge to nursing and physician staff. Inconsistent practice patterns as well as variations in levels of sedation may have affected the patients' ability to participate in mobility and subsequent ambulation trials.

Conclusion

A nurse-driven protocol significantly increased the number of patients who ambulated in the adult ICU and IMCU during the first 72 hours of their hospital stay. The health care team consisting of nurses, physicians, physical therapists, respiratory therapists, and pharmacists approached this project with enthusiasm and a commitment to provide outstanding care. When this project was introduced to hospital leadership 2 years previously, there was little thought given to patients' activity level. Today it has become a priority throughout the hospital. Although this study was conducted in a single community hospital setting without additional staffing, we feel strongly that it could be replicated in other settings. The ancillary staff utilized at our hospital for this program is present at other hospitals, and the biases our staff had regarding mobility of patients are likely to be common at other institutions. As only initial ambulation was investigated in this study, future studies may be useful in determining overall distance improvements, impact on length of stay, the number of inappropriate physical therapist evaluation orders, incidence of falls, and the number of patients discharged to rehabilitation facilities.

Appendix 1.

Appendix 1.

Move to Improve Early Mobility Protocol Time Linea

a ICU=intensive care unit, IMCU=intermediate care unit, IRB=institutional review board.

Appendix 2.

Appendix 2.

Non–Intensive Care Unit Mobililty Order and Mobility Protocola

a ICU=intensive care unit, Fio2=fraction of inspired oxygen, PEEP=positive end-expiratory pressure (cm H2O), MAP=mean arterial pressure, DVT=deep vein thrombosis, CSF=cerebrospinal fluid, INR=international normalized ratio, Sao2=arterial oxygen saturation, BVM=bag value mark, PT=physical therapist, OT=occupational therapist, PCT=patient care technician, AFB=acid fast bacilli, WOB=work of breathing. 1 ft=0.3048 m.

Appendix 3.

Appendix 3.

Intermediate Care Unit (IMCU) Ambulation Status Reporta

a LOS=length of stay. 1 ft=0.3048 m.

Footnotes

  • Ms Drolet, Ms Harkless, Ms Henricks, Ms Kamin, Dr Leddy, Ms Waters, and Ms Williams provided concept/idea/research design. Ms Drolet, Ms DeJuilio, Ms Harkless, Ms Henricks, Dr Leddy, Ms Waters, and Ms Williams provided writing. Ms Drolet, Ms Harkless, Ms Henricks, and Ms Waters provided data collection. Ms Drolet, Ms Henricks, and Ms Lloyd provided data analysis. Ms Drolet provided project management and facilities/equipment. Ms Drolet, Ms Harkless, and Dr Leddy provided consultation (including review of manuscript before submission).

  • The authors thank the following individuals for their expertise, guidance, and assistance in the design and performance of the study and in preparation and editing of the manuscript: Jeffrey Huml, MD; David Cooke, MD; Jeffrey Hinchman, BS, MS; Patricia Raetz, APN, CNRN; Alice Siehoff, RN, MSN, DNP; and Julie Stielstra, MLS.

  • The project was presented at the International ICU Physical Medicine & Rehabilitation meeting, May 14, 2011; Denver, Colorado.

  • Received November 14, 2011.
  • Accepted September 4, 2012.

References

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