Grand Canyon University: NRS-441V
Developing an Implementation Plan
Immobility of the critically ill intensive care patient can produce negative adverse complications that can delay weaning from the mechanical ventilator, ICU acquired weakness, ventilator-associated pneumonia (VAP), and deep vein thrombus (DVT). These complications can increase length of vent days, ICU days and overall hospitalization days. There has been sufficient research documenting that bed rest is not beneficial and can cause harm to patient. Evidence-based practice (EBP) is proving that progressive mobility of the ICU patient is safe and feasible. To prevent the negative effects of immobility, the nurses with the support of an interdisciplinary team can safely integrate a progressive early mobility program that include positioning, mobility exercises, and progressing to out of bed while being mechanically ventilated.
Description of the Problem
When critically ill patients are admitted to the Intensive Care Unit (ICU) and are in need of a mechanical ventilator for respiratory support, this patient becomes immobile. These patients are sedated and placed on bedrest. When a patient is mechanically ventilated, sedated and immobile, they are high risk for adverse outcomes, that can include muscle deconditioning leading to or causing delayed ventilator weaning, increased risk for ventilator-associated pneumonia (VAP), deep vein thrombus (DVTs), stress and pressure ulcers (PUs)
The effects of limited mobility for these patients mobility does not consider other existing medical conditions that the patient may have prior to ventilator connection. During the patients ICU stay, they are likely to only receive movement from when repositioned, pulled up in bed or transferred to and from a diagnostic test. Mobilization prevents certain complications, but can cause various others due to the continual bedrest that ICU patients typically have.
Education Deficit on Early Progressive Mobility
The current ICU culture at this writer’s facility is to allow patient complete rest, remaining sedated and immobile. There is a lack of understanding of EBP to patient benefits for progressive early mobilization. Early mobilization can decreased the length of stay of an ICU patient. By promoting early mobilization in the mechanically ventilated patient when appropriate, this can decrease number of vent days, decrease time spent in the ICU, and decrease the total number of hospital days. When physical therapy being ordered earlier in the ICU stay did seem respiratory failure. This in turn decreased the patient’s dependency on a ventilator reduced the time spent being inactive and improves their functional capacity. To produce a positive outcome by decreasing the length of stay in the ICU for patients with a ventilated supported patient is started on a progressive mobilization protocol, the risks for adverse outcomes are decreased. When mobility is a core component of care, it can enhance key outcomes for patient . There are EBP protocols that are in place to prevent VAPS with vent bundles that include; q four hour mouth care, head of the head at 30ᴼ or greater, sedation vacations, sequential compression devices (SCDs) for prevent of DVTs, oral gastric tubes, peptic ulcer medication management and daily assessment for ventilator weaning. Vent bundles are the current culture in ICUs and with the aide of EBP for VAPS, the nurse is systematic when caring for these patients and applying vent bundles, this is standard of practice. However, a culture to mobilize the critically ill ICU patient that is supported by a mechanical ventilator is non-existent. The barriers that nurses see that interfere with mobilizing their patients are: monitoring equipment, intravenous lines (IV) /central lines, nasal/oral gastric tubes, hemodynamic monitor lines and Foley catheters. When steps are taken to mobilize the critically ill ICU patient on ventilator support, patient outcomes are favorable Through EBP, the culture in critical care units needs to be change and the bedside nurse is in a position to bring change to the culture for the benefit of the patient and improved patient outcomes.
Developing an Implementation Plan
Obtaining support for Change in Nursing Practice
Once the problem is identified and PICO statement is developed; will the critical care patient that is intubated and mechanically ventilated benefit from progressive mobility, improved patients outcomes such as decreased risks of negative adverse complications and reduced ventilator days versus current rest protocol for ventilated patient during their stay in the ICU. Within this hospital there is a unit level clinical practice committee. At this level the proposed change of practice can gain support from other members of the nursing committee. A new protocol of addressing immobility in the ICU can formulated.
Providing a literature review of evidence that supports early and progressive mobility along with the complication of immobility to the unit based clinical practice committee can provide the foundation to change the protocol and the culture with in the ICU. Critical ill patients are often immobile as a result of their illness, surgery, invasive monitoring equipment, sedation and endotracheal tubes. When the ICU patient is immobile they are at risk to develop pressure ulcers, delirium, weakness, critical illness polneuromyopathy, all of which can decrease quality of life at discharge from the hospital. Early mobility needs to be an interdisciplinary team approach to overcome the safety and barriers that nurses may feel when staring a patient on an early mobility protocol. The unit based clinical practice committee with the EBP can formulate an early mobility protocol.
Once the is rough draft of an early mobility protocol is drafted this can be present to the ICU Intensivists, respiratory therapist, physical therapist and occupational therapy that commonly practice in the ICU setting. ICU Intensivists, respiratory therapist, physical therapist and occupational therapy can have an impact of this protocol succeeding and should be asked for input. These additional stakeholders need to be an included information and implementation of an early mobility protocol.
Once there is a proposed early progressive mobility protocol this protocol can be brought to the ICU committee. This larger committee consists of critical care nurses managers, critical care nurse leaders, physicians and other members of the interdisciplinary team. At the stage there can be further review of EBP and the proposed early mobility protocol with the ICU. Once the support is gained and approved from the ICU committee the protocol can be applied to a select group of patients that are identified during daily interdisciplinary rounds in the ICU.
The current health system consists of five hospitals that have an ICU population. Once early progressive mobility protocol gains support and can be evaluated to benefit the current population if ICU patients within this facility it has the poetical to be presented to the stakeholders system wide.
Current practice in the ICU setting is when the physician feels it is appropriate for the patient to precipitate in physical therapy an order is obtained for physical therapy. There is rare occurrences that a nurse with ask a physician if they can get a mechanically ventilated patient out of bed. However, there is no continuity of care. An early progressive mobility protocol could benefit the outcomes of the patients in the ICU setting and address barriers of progressive mobility felt by the healthcare staff. The facility has the resource to implement a progressive mobility protocol with the support of ICU Intensivists, respiratory therapist, physical therapist, occupational therapy and the bedside clinical nurse.
Proposed Early Progressive Mobility Protocol
By understanding the negative effects that immobility has on an ICU patient, the nurse and the interdisciplinary team can develop mobility protocols. Recognizing the facilities current practice can be improved with EBP is the first to developing a new protocol that can benefit the patient serviced within the health system.
The standard of current practice for mechanically ventilated patient in for that patient to remain sedated while on the ventilated. By using the EBP of the ABCDE bundle to reduced patients sedation by using the Richmond Agitation Sedation Scale (RASS) the patient can be assessed for edibility for the start of early progressive mobility. Figure 1 is a table representing RASS.
Three steps have been identified through EBP to improve mobility of the ICU; continuous lateral rotation therapy (CLRT), the chair position, and out of bed to chair / ambulation. When assessing patient tolerance to reducing sedation medication while mechanically ventilated the patient can increase their immobility with aid of the bedside nurse and the interdisciplinary team. Table 1 respects the stages of early mobility based on the patient reaction to reducing the sedation and the achieved RASS level.
Recourses and Education
Within the ICU with have the equipment and resources to implement early progressive mobility; ICU total care bed provides the equipment that allows for CLRT on all patients and is the first to mobility. These bedsides also have the chair position. There is no need for purchase for new equipment. RT is staffed on the unit for ventilator management of the mechanically ventilator patients. PT and OT are providing inpatient services and can be consulted earlier in the patient acute stay in the ICU.
Education to the bedside nurse is the key to the success of this protocol. Muscle weakness can be prevented and treated in the ICU setting. Nursing staff needs to be aware of increasing EBP that is supports the use of early mobilization protocols. With the use of early mobilization protocol in the ICU setting, nurses can improve patient’s physical function and longer term quality of life.
By using a power point presentation of the effects of immobility and the steps that can be started at the bedside to increase mobility of the ICU patient can be addressed during an education session. Along with the unit based clinical practice champions, RT and PT at also provide support and address question the staff might have. Having a total care ICU bed during the education session will allow staff to learn and maneuver new function of the bed. Staff can take turns being the “patient” in the bed while others new how the added functions of the bed work. Pretest and posttests can be used to on the functions of the bed to address knowledge defects regarding the bedside and its addition features.
Once the patient has tolerated more activity in the bed, PT and OT will be consulted. There also needs to be education provide to the department to have a universal goal. RT needs to embrace the a patient that is mechanically can increase mobility with the aid on the RT. There will be barriers and resistance by evaluation along the development and implementation of the protocol these barriers and resistance can be addressed by provide staff with EBP. By having champions of nurses and respiratory therapist for early progressive mobility protocol can be provide support to other staff member that might be reluctant because of barriers felt by the staff. Conclusion:
When early mobilization is implemented in the ICU it has been shown to reduce adverse complications related to immobility. Early mobilization is safety and feasible when an interdisciplinary team is educated on early progressive mobility techniques. Mechanical ventilated patients can be successfully started on early mobility protocols that can lead to decreased delusion, increased muscle strength, decreased ventilator days, decreased hospitalization days and ultimately improving quality of life.
|Perform Initial mobility screen win 8 ICUCCU admission. Recommended to reassess Q shift||Level IRass -5 to -3||Level II Rass -3 & up PT & OT consult PRN||Level IIIRass -1 & UP PT OT consult for ADLs||Level IVRass OPT OT for ADLs||Level VRass OPT OT for ADLs|
|Refer to following criteria to assist in determing mobility level||Goal:Clinical stability passive ROM||Goal: Upright sitting increased strength & moves arms against gravity||Goal : trunk strength, moves legs against gravity & readiness to weight bear||Goal Stands w min to mod assist, able to march in place, weight bear, & transfer to chair||Goal: distance in ambulation. Ability to perform some ADLS|
|PaO2/FiO2 ≥250Peep<10O2 sat ≥90%RR 10-30HR >60 <120MAP > 55 <140||Activity:HOB ≥30°Passive ROM 2x a day & PRN||Activity:CLRTPassive & active ROM x3adayHOB 45° x15minsHOB 45 °x 15 mins||Activity:CLRT & or self turningSitting on edge of bedBed PUM 45 min 3x day or Pivot to Chair2x a day||Activity:Self or assisted turningSitting on edge of Bed Active transfer to Chair OOB 3x for 45 mins a day||Activity:Self or assisted turning OOB to Chair 3x a day or more. Meals consumed while dangling on edge Of bed or Chair|
|SBP >90 <180Rass ≥3No new or increasing vasopressor or cardiac arrhythmias||CLRTIf patient meets criteria or turn Q2||HOB 65°, legs in dependant position x15 Bed in PUM x20 mins 3x dayOr Full Chair 2xday||If patient on vent use RT & PT to assist||If patient on vent use RT & PT to assist||OOB to use BSC or toilet.If patient on vent use RT & PT to assist|
|NO YES ↓ ↓Start Start Level Level I II & progress||If tolerates Level I →||If tolerates Level II →||If tolerates Level III →||If tolerates Level IV →||Ambulate progressively 3x a day|
A. Genc, S. O. (2012). Respiratory and Hemodynamic Responses to Moblilizationn of the Critically Ill Obese Patient. Cardiopulmonary Physical Therapy Journal, Vol 23, No1, March, 14-18.
A. Ross, P. M. (2010). Safety and Barrier to Care. Critical Care Nurse Vol 30, No2, Apirl, 11-13.
A. Troung, E. F. (2009, July 13). Bench-to bedside review: Moblizing patients in the intensive are unit- from pathophysiology to clinicial trails. Retrieved June 6, 2013, from Criitcal Care 13:316: http://ccforum.com/content/13/4/216
Adler, J., & Malone, D. (2012). Early Mobilization in the Intensive Care Unit: A Systematic review. Cardiopulmonary Physical Therpay Journal, Vol 23, No1, March, 5-13.
AM, Y., & MJ., C. (2003). Early mobilization with walking aids following hospital admission with acute exacerbation of chronic obstructive pulmonary disease. Clinical Rehabilitation 17, 465-471.
Clark, D., Lowman, J., Griffin, R., & Matthews, H. (2013). Effectiveness of an Early Mobilization Protocol in a Trauma and Burns Intesive Care Unit:A Retrospective Cohort Study. Physicial Therapy Vol 93, No. 2, February, 186-196.
Fan, E. (June). Critical Iillness Neuromyopathy and the Role of Physical Therapy and Rehabilitaion in Critically Ill Patients. Respiratory Care Vol 57, No 6., June, 2012.
J. Knight, Y. N. (2009). Effects of bedrest 2: gastrointestinal, endocrine, renal, reproductive and nervous systems. NURS TIMES Vol 105, No. 22, June, 24-27.
J. Ronnedaum, J. W. (2012). Earlier Mobilization Decreases the Length of Stay in the Intensive. JACPT Vol 3, No. 2, 204-210.
K, V. L.-C. (2010). Progressive Mobility in the Critically Ill. Critical Care Nurse Vol 30, No.2, April, s3-16.
M. Balas, E. V. (2012). Critical Care nurses Role Implementing the “ABCE” Bundle Into Practice. Critical Care Nurse Vol 32, No. 2, April, 35-47.
Markey, D. &. (2002). An interdisciplinary approach to addressing patient activity and mobility in the medical-surgical patient. Journal Of Nursing Care Quality Vol 16, No.4,, 1-12.
Mundy, L., Lee, T., Schnitlzler, M., & Dunagan, W. (2003). Early mobilization of the patient hospilized with community- acquired pneumonia. Chest Vol 124, No 3, September, 883-889.
Olkowski, B. F. (2013). Safety and Feasibility of an Early Mobilization Program for Patients With Aneurysmal Subarachnoid Hemorrhage. Physical Therapy Vol 23, No. 1, March, 208-215.
The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002;166:1338–1344.
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