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Comparison of a Nurse-Driven Mobility Protocol to Multidisciplinary Mobility Protocol for Subarachnoid Hemorrhage Patients Megan Moyer, MSN, RN, ACNP-BC, CNRN Penn Presbyterian Medial Center Bethany Young, MSN, RN, AGCNS-BC, CCRN Hospital of the University of Pennsylvania Sigma Theta Tau International s 28 th International Research Symposium July 30, 2017
Introduction No disclosures 2
Objectives 1. The learner will be able to explain implementation of a nursedriven approach for safely mobilizing patients with external ventricular devices (EVDs). 2. The learner will be able to describe implementation of a progressive mobility algorithm for patients with external ventricular devices (EVDs). 3. The learner will be able to compare the outcomes of patients pre-early mobility (Phase 0) versus those who were mobilized with nursing and/or PT/OT and were allowed to sit in a chair (Phase II). 3
Introduction Emerging evidence suggests that mobilization of patients may be beneficial and result in: Decreased length of stay, costs Decreased incidence of delirium Improved quality of life, better functional outcomes However, mobilization in neuro-critically ill has specific challenges: High fall risk Impulsivity Specifically, patients with subarachnoid hemorrhage (SAH) may be at particular risk: Concerns about exacerbating delayed cerebral ischemia Potential complications of mobilizing patients with an EVD (catheter dislodgement, over-drainage of CSF, infection) Historical conservative approach to activity for patients with an EVD 4
External Ventriculostomy Drains 5
Methods Phase 0: No mobilization until EVD removal Phase I (11/2014 11/ 2015) PT/OT (therapy)-driven mobility Activity only during PT/OT sessions Continuous RN and therapist observation Average duration of activity: 32 minutes Bedside activity: Sit at edge of bed Stand at bedside March in place Phase II (1/2016 08/2016) Nurse-driven mobility Nurses independently mobilize patients; able to mobilize patients prior to PT/OT evaluation Allowance to stay out of bed in a chair with intermittent nursing assessment Maximum time out of bed with drain clamped: 3 hours Progressive mobility: Lift to chair Stand and pivot Mobility in hallway 6
Hypotheses Mobilization of SAH patients with EVDs is safe and feasible. Mobilization of patients using a nurse-driven protocol leads to earlier and more frequent mobilization. Mobilization of patients is associated with improved outcomes (better discharge disposition, hospital LOS, etc.) in SAH patients with EVDs. 7
Methods Inclusion Criteria Subarachnoid hemorrhage Standard protocol was maintained for the duration of study period External Ventricular Drain Able to tolerate 30 minutes of drain clamping Strict Exclusion Criteria Unable to tolerate 30 minutes of drain clamping Sustained intracranial hypertension (ICP >20) Comfort measures/hospice care Relative Exclusion Criteria Fluctuating neurologic exam Pulmonary or cardiovascular instability, as determined by the nursing and medical team Patient refusal 8
Results: Demographics Phase 0 (12 Months) No mobility Phase 1 (12 Months) Therapy-Driven Phase 2 (8 Months) Nurse-Driven N 15 24 17 Aneurysmal SAH 13 (86.7%) 23 (95.8%) 15 (88.2%) Mean Age 58.3 (33-78) 57.1 (27-84) 54.8 (19-90) Sex (Woman) 13 (86.7%) 14 (58.3%) 8 (47.1%) Hunt Hess Grade 4-5 4 (26.7%) 6 (25%) 2 (11.8%) Modified Fisher 3-4 13 (86.7%) 24 (100%) 14 (82.4%) GCS IQR 13 (8-15) 14 (12-15) 14 (13-15) 9
Results Phase 0 (N = 15) No mobility Phase 1 (N = 24) Therapy-Driven Phase 2 (N = 17) Nurse-Driven 1 st Mobilization 20.1 days (±7.02) 6.0 days (±3.16) 4.9 days (±3.46)* No. Sessions 0 3.0 (±1.33) 7.1 (±4.37)* Hospital LOS 28.2 (±10.08) 24.6 (±8.29) 20.9 (±7.56) ICU LOS 21.4 (±8.74) 18.7 (±6.00) 16.1 (±7.53) Ventilator Days 12.3 (±13.89) 6.3 (±10.47) 3.1 (3.84) Tracheostomy 40% 16.7% 0 Discharge Disposition Home = 6.7% Rehab = 53.3% LTACH = 33.3% Acute Care Hospital = 6.7% Home = 33.3% Rehab = 54.2% LTACH = 8.3% SNF = 4.2 % Home = 29.4% Rehab = 70.6% LTACH = 0 SNF = 0 *Nurse-Driven mobilization was associated with more frequent mobility sessions (p<0.0001), but not earlier mobilization (p=0.15) 10
Results: Univariate Outcomes Phase 0 (N = 15) No mobility Phase 2 (N = 17) Nurse-Driven P value 1st Mobilization 20.1 days (±7.02) 4.9 days (±3.46) <0.0001 Hospital LOS 28.2 (±10.08) 20.9 (±7.56) 0.031 ICU LOS 21.4 (±8.74) 16.1 (±7.53) 0.078 Ventilator Days 12.3 (±13.89) 3.1 (±3.84) 0.024 Tracheostomy 40% 0 0.004 No. Sessions 0 7.1 (±4.37) <0.0001 Discharge Disposition Home = 6.7% Rehab = 53.3% LTACH = 33.3% Acute Care Hospital = 6.7% Home = 29.4% Rehab = 70.6% LTACH = 0 SNF = 0 0.004 11
Results: Multivariate Outcomes Odds Ratio P value 95% CI No. Sessions 3.83 0.041 1.06-13.90 Hunt Hess 4-5 0.003 0.016.00003-0.341 Age 0.87 0.016 0.77-0.97 GCS at first session 2.40 0.079 0.90-6.34 The odds of discharge to home/rehab were 3.83 for mobilized patients, independent of age, GCS at first mobility session, and high Hunt Hess grade. 12
Results: Multivariate Outcomes Mobilization of patients was not significantly associated with hospital length of stay, tracheostomy placement, or ventilator days. 13
Limitations Small sample size Historical controls Quality Improvement initiative versus rigorous scientific study Failed to capture total time of mobilization (minutes) Unable to exclude Hawthorne Effect 14
Conclusion Nurse-driven mobilization with EVDs: is safe. leads to more frequent ambulation. may be associated with improved discharge disposition, although causation cannot be determined by these data. may allow for PT/OT to engage in more complex therapy techniques. Although these preliminary data are encouraging, further study is warranted. 15
Thanks Neuro ICU Nurses Physical and Occupational Therapists Unit based clinical leadership (UBCL) Neuro ICU Advanced Practice Providers Neurosurgeons 16
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