nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 1

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1 Improve Early Mobilization Among Mechanically Ventilated (MV)Critically Ill Patients in a Trauma Intensive Care Unit Roberta Johnson MN, RN,CCRN Introduction Hospitalized critically ill patients can experience a decrease in mobility placing them at risk for developing preventable complications. A decrease in mobility can lead to a decrease in muscle strength, increased mechanical ventilation, increased length of stay, and higher mortality rates. Significance Mobilization does not occur up to 83% of the time in patients who are intubated and MV. Potential harm to patient from immobility o Delirium o Long term cognitive impairment o Long term functional decline o Inability to return to previous employment or activities of daily living nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 1

2 Significance Identified perceived barriers: o Established intensive care unit culture where early for MV patients is not practiced. o Increased workload (time management) o Safety concerns for patient and healthcare participants. Purpose Examine nurse s attitudes and beliefs for early of MV patients and address uninformed perceptions for early through an education intervention. Research Design and Methods Design o Pre-post survey design Sample o N = 55 registered nurses (RN) and charge nurses (CN) Setting o 22 bed trauma intensive care unit nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 2

3 Sample Design o Inclusion criteria: o Full time and part time RNs/CNs employed in TICU. o Exclusion criteria: o Agency, traveler or pool RNs Procedure Pre survey to measure: o Current attitudes and beliefs with early mobility among MV patients o Most reasons for restricting early mobility o Most common indicators to facilitate nurses in early mobility of patients Targeted education Review of the M.O.V.E. protocol Post survey to examine education effectiveness Education Intervention: M.O.V.E. Staging Guidelines for Nursing: Exclusion Criteria o Spinal cord injury o Long-term ventilator on prior settings o Non-ambulatory bedridden at baseline o Enrolled in donor network or plan on to withdraw care. nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 3

4 Education Intervention For bedfast patients, most common reasons for restricting patient activity Low respiratory, energy reserve Patient fear Invasive lines Vasopressors Unstable vital signs Fear of injury to self Patient complaining of pain Uncooperative Education Intervention Barriers to Early Mobility Morbid obesity Fragmented care among health care providers Resistance to change Mobility not seen as priority Delirium Lack of specific protocols to address mobility Pt too restless Lack of education on complications of immobility Pt too weak Staff perceptions of patient as too ill Excessive sedation Pt s readiness for activity Lack of staff assistance Chair position in bed count as substitute Time constraints Pt. not interacting or follows commands Multiple invasive devices Lack of adequate equipment Recent embolism Exclusion Criteria from M.O.V.E. Stage 2-5. (May meet M.O.V.E. criteria once resolved) Severe head Injury Neuromuscular blockade Intracranial pressure monitor Vasopressor drip Unstable fracture Femoral sheath Severe metabolic disorder Shock External pacemaker CRRT Suspected or active bleeding Sedation vacation not tolerated Open abdominal fascia Rotoprone bed Uncontrolled arrhythmias Acute cardiac conditions Unstable hemodynamics nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 4

5 Data Management and Analysis o Frequencies and percentages o Descriptive statistics o Group differences using paired sample t-tests. Results: Nursing Demographics N=33 (60%) Education Shift Worked MSN 3 7 a.m. 7 p.m. 14 BSN 23 7 p.m. 7 a.m. 18 ADN 4 Health Care Professional Diploma 2 Registered Nurse 30 Age Charge Nurse Years of Practice % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 79% 64% My pt.'s are too sick to mobilize 91% 94% Increasing will be harmful to pt.'s Results Early Mobilization 94% 94% 85% 88% 76% 64% P.T. or O.T. should be primary provider for I'm not sure when it is safe to mobilize pt.'s I don't feel confident in my ability to mobilize pt.'s 49% 79% Increasing will be more work for nurses 55% 42% 30% 33% Increasing will be more work for P.T./O.T. We don't have proper equipment to mobilize Pre Survey: Strongly Disagree/Disagree Post Survey: Strongly Disagree/Disagree nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 5

6 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 46% 45% 46% 36% 30% RN to pt. staffing is adequate for safe Results Early Mobilization Increasing frequency of pt. increases my risk for injury Pre Survey: Strongly Agree/Agree 61% Family members are interested in helping mobilize Post Survey: Strongly Agree/Agree 79% 91% Unless there is a contraindication I mobilize my pt.'s at least once during my shift Results for Early Mobilization 120% 100% 80% 72% 92% 85% 100% 79% 92% 100% 97% 91% 91% 85% 85% 60% 40% 20% 0% I've received training on safe I understand which pt.'s are appropriate to refer to P.T. Pre Survey (Strongly Agree/Agree) I understand which pt.'s are appropriate to refer to O.T. Unless there is a contraindication, I educate pt.'s to exercise I believe pt.'s who are mobilized TID will have better outcomes Post Survey (Strongly Agree/Agree) Physical functioning of pt.'s is regularly discussed with team Paired Sample Statistics Pre Survey Post Survey Variable n M SD n M SD I ve received training to safely mobilize pt. s I understand which pt. s are appropriate to refer to O.T I educate my pt. s to exercise or increase physical activity My leadership is very supportive of pt My pt. s are resistant to nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 6

7 Paired Sample T-tests Variable t df Sig. (2 tailed) I have received training to safely mobilize pt. s I understand which pt. s are appropriate to refer to O.T I educate pt. s to exercise or increase physical activity My dept. leadership is very supportive of <.001 My pt. s are resistant to Summary Early in mechanically ventilated patients has been shown to be both achievable and safe. The complexity of acute care patients poses a concern. Acknowledging nurses perceived barriers with early may be the catalyst to transform a culture where early is a common goal and to improve long term and short term patient outcomes. References Adler J, Malone D. Early in the intensive care unit: a systematic review. Cardiopulm Physical Ther J. 2012;23:5-13. Bailey, P. P., Miller III, R. R., & Clemmer, T. P. (2009). Culture of early mobility in mechanically ventilated patients. Critical Care Medicine, 37(10), S429-S435. Balas M, Burke W, Gannon D, et al. (2013). Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, lessons learned for implementing the ICU pain, agitation, and delirium guidelines. Crit Care Med. 41(9): Bassett R, Vollman K, Brandwene L, Murray T. (2012). Integrating a multidisciplinary mobility program into intensive care practice (IMMPTP): a multicenter collaborative. Intensive Crit Care Nurs.28: Bissett, B., Leditschke, I. A., Neeman, T., Boots, R., & Paratz, J. (2015). Weaned but weary: One third of adult intensive care patients mechanically ventilated for 7 days or more have impaired inspiratory muscle endurance after successful weaning. Heart & Lung: The Journal of Acute and Critical Care,44(1), Bourdin G, Barbier J, Burle JF, et al.(2010). The feasibility of early physical activity in intensive care unit patients: a prospective observational one-center study. Respir Care.55: Caldwell, E. S., Spece, L. J., Hough, C. L., & Strizich, L. (2015). Mechanical Ventilation Is An Important Barrier To Mobilization Of Stable ICU Patients. Am J Respir Crit Care Med, 191, A2275. nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 7

8 References Clark, D. E., Lowman, J. D., Griffin, R. L., Matthews, H. M., & Reiff, D. A. (2013). Effectiveness of an early protocol in a trauma and burns intensive care unit: a retrospective cohort study. Physical Therapy, 93(2), Drolet, A., DeJuilio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, E. A.,... & 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), Eakin, M. N., Ugbah, L., Arnautovic, T., Parker, A. M., & Needham, D. M. (2015). Implementing and sustaining an early rehabilitation program in a medical intensive care unit: A qualitative analysis. Journal of Critical Care. Garzon-Serrano, J., Ryan, C., Waak, K., Hirschberg, R., Tully, S., Bittner, E. A.,... & Eikermann, M. (2011). Early in critically ill patients: patients' level depends on health care provider's profession. PM & R, 3(4), Herridge MS, Tansey CM, Matte A, et al. (2011). Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med.364: Hoyer, E. H., Brotman, D. J., Chan, K. S., & Needham, D. M. (2015). Barriers to Early Mobility of Hospitalized General Medicine Patients: Survey Development and Results. American Journal of Physical Medicine & Rehabilitation, 94(4), Jolley, S. E., Regan-Baggs, J., Dickson, R. P., & Hough, C. L. (2014). Medical intensive care unit clinician attitudes and perceived barriers towards early of critically ill patients: a cross-sectional survey study. BMC anesthesiology, 14(1), 84. References Montagnani G, Vagheggini G, Panait VE, Berrighi D, Pantani L, Ambrosino N.(2011). Use of the functional independence measure in people for whom mechanical ventilation is difficult. Phys Ther. 91(7): Morris, P. E. (2007). Moving our critically ill patients: mobility barriers and benefits. Critical Care Clinics, 23(1), Needham D, Korupolu R. (2010). Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model. Top Stroke Rehab. 17(4): Nydahl, P., Ruhl, A. P., Bartoszek, G., Dubb, R., Filipovic, S., Flohr, H. J.,... & Needham, D. M. (2014). Early Mobilization of Mechanically Ventilated Patients: A 1-Day Point-Prevalence Study in Germany*. Critical Care Medicine, 42(5), Parker A, Lord R, Needham D. (2013). Increasing the dose of acute rehabilitation: is there a benefit? BioMed Central Med. 11:199. Pohlman, M. C., Schweickert, W. D., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L.,... & Kress, J. P. (2010). Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation*. Critical Care Medicine, 38(11), Ronnenbaum J, Weir J, Hilsabek T. (2012). Earlier decreases length of stay in the intensive care unit. J Acute Care Phys Ther. 3(2): TEAM Study Investigators. (2015). Early and recovery in mechanically ventilated patients in the ICU: a binational, multi-center, prospective cohort study. Critical Care, 19(1), 81. Truong A, Fan E, Brower R, Needham D.(2009). Bench-to-bedside review: Mobilizing patients in the intensive care unit from pathophysiology to clinical trials. Critical Care. 13: Vollman, K. M. (2010). Introduction to progressive mobility. Critical Care Nurse, 30(2), nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 8