The Effect of the implementation of Early Mobilization on ...
Transcript of The Effect of the implementation of Early Mobilization on ...
9/23/2021
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The Effect of the Implementation of Early
Mobilizationon Patient Outcomes in the Intensive Care
Setting
Amanda Grosse RN, BSN, BA, DNP Candidate
Creighton University, College of Nursing
This Photo by Unknown Author is licensed under CC BY-ND
Learning Objectives
To understand what early mobility looks like in an ICU setting
To be able to speak to the significance of early ICU mobility
To understand the benefits of early mobility in the ICU setting
To be able to describe how the MOVEN tool is utilized to assess patient’s readiness for mobility
To be able to disseminate the research from this project
To be able to apply concepts from this project towards future research and/or practice
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Financial Disclosure
• There was no cost to participate.
• The only threat was that of falls, dislodgement of vascular access lines, and staff were educated on how to mitigate these threats.
• The MOVEN tool has already been approved for use in the CHI Health St. Francis ICU setting and there was no additional cost to use this tool
• There is no cost to post reminders on computer monitors
Background
In the ICU, critically ill patients are subject to the ravages of
illness. Inflammatory responses mounted by the body increase
the rate of skin and muscle breakdown 7.
Prolonged bed rest leads to muscle breakdown, which impairs
the ability of the patient to be mobile 15.
Every day a patient spends on bedrest, an estimated 1.3% to 3%
of muscle strength is lost 14, 39. The longer the period of
immobility, the more pronounced these effects become 41.
One study suggests that up to 11% of a patient’s strength is lost for every day that they spend in
bed in the ICU 19
Patients who are mechanically ventilated are at even higher risk of tissue degradation and have a lower rate of mobilization 14, 36, 40.
These effects are exponentially pronounced in the geriatric
population, which is growing 14,40.
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Background, cont.
The incidence of death in the ICU ranges from 20% to
as high as 86% since the introduction of the novel
Coronavirus 1, 39
As the number of patients needing ICU level of care
continues to increase, so do the costs of healthcare
Early mobilization has been shown to reduce the
number of mechanical ventilation days by as many
as 3.2 days 29.
Early mobilization increases the rate of successful
ventilator weaning, and has also been shown to reduce
the length of ICU stays by up to 3 days 26,2 8
Early mobilization not only decreases direct patient
costs, but also reduces the cost of healthcare overall
4,13.
Early mobility, even of mechanically ventilated
patients, is a feasible and low risk method of reducing
mortality within the ICU setting 13.
Review of the Literature—ICU Acquired Weakness
ICU weakness can be found in up to 50% of ICU patients, and can persist long term 20,
23, 25
Deconditioning associated with a 20.4% increase in
mortality by 1 year 24.
Early mobility has been associated with decreased
incidences of CAUTIs, pressure sores, days on ventilator and ventilator
associated events 2,11, 12, 21, 27
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Significance
It is estimated that anywhere from 5%- 10% of
ventilator-dependent patients will develop a ventilator associated condition or event 4.
The emphasis on preventing ventilator associated events
and conditions has strengthened; now a quality
measure for hospitals 4.
CMS reduces the rate of reimbursement for hospitals when a patient suffers from a ventilator associated event
11.
With increased numbers of patients needing mechanical ventilation, this translates to
increased costs of healthcare overall1.
AHRQ proposes that nurse-driven, multidisciplinary
early mobility protocols are a safe and effective means
of reducing the rates of ventilator-based events 3.
Significance, cont.
The AACN created the ABCDEF early mobility bundle to stress the
importance of early mobility in ICU patients 32.
In 2013 (updated in 2018), the American College of Critical Care
Medicine, the Society of Critical Care Medicine and American Society of
Health-System Pharmacists, changed the Clinical Practice Guidelines to
include early mobility in management of ICU patients 37.
AHRQ recognizes early mobilization as having the potential to reduce
patient costs, reduce mortality, and improve patient functionality up to
12 months post hospitalization 4,12, 13,
18
CMS will increase the rate of reimbursement to hospitals that implement an evidence-based
protocol that improves outcomes for patients, such as an early mobility
protocol 11.
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Review of the Literature—Early Mobility in ICU patients
Early mobility interventions reduce the time from
admission to mobilization significantly, regardless of
type of ICU 31.
All age groups have seen benefit to early mobility, but most significantly the
geriatric population 31.
In one study, the addition of a daily huddle to discuss mobility increased patient’s
ambulation status from 43% to 70% 25.
Increased mobilization not linked with increased falls
or injury 21, 25
Literature review-Benefits of the Bundle
One study found that 95% of patient days were spent in bed. Post intervention, 65% of patients stood, 54% walked at least once per shift 27.
Not only did incidence of mobility increase, but incidence of pressure ulcers and physical restraint use decreased (39% to 23% and 30% down to 26%, respectively) 27.
Inclusion of early mobility was correlated with 23% reduction in ventilator days, 10% reduction in ICU length of stays, a 7% reduction in overall hospital length of stay, and a 25% reduction in ICU costs, and a 30% reduction in overall hospital costs27.
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Review of the Literature-- Cost reduction
•Studies suggest cost savings of over $1,600 per patient per day
•This is a result of decreased CAUTIs, falls, VAEs, pressure sores, and ICU days.
Early mobility
associated with cost reduction
Summary of the Problem
In the ICU, critically ill patients are not mobilized (or under mobilized).
This leads to increased patient-ventilator days, increased incidence of delirium, increased length of stay, and increased mortality 12, 14, 17, 20, 22, 23,
25, 26
These problems carry poor patient outcomes; as well as carry a high-cost burden, both short and long term.
There is significant evidence to support the implementation of a nurse-driven, multidisciplinary early mobility protocol, yet barriers exist that hinder the ability of the program to persist.
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Review of the Literature--Barriers to mobilization
Facility buy-in and support regardless of financial incentives 9, 22
Confidence of the staff to manage the lines, drains, and artificial airways that accompany mechanically ventilated patients 14, 33,38.
The presence of an endotracheal tube, for fear that the tube would become inadvertently dislodged 22.
Patient characteristics, including delirium and sedation 22.
Availability of staff was a prominent barrier; patient mobility efforts would fall on one discipline 22,38.
Conceptual Framework: Reciprocal Determinism
• Theory of Albert Bandura5
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Purpose / Aims
This project aimed to evaluate utilization and effectiveness of early mobility in the ICU setting as prompted by the implementation of the MOVEN tool
Methods
5 days of educational sessions (lasting 30 minutes each, held 1-3 times per day), targeted toward Nursing, Occupational Therapy, Respiratory Therapy and Physical Therapy staff members.
Education will focus on the MOVEN tool itself, how and when to use the tool, how to document patient mobilization, how to secure lines, drains, etc., and will allow extra time for staff questions.
Following the one-week educational period, the MOVEN tool was utilized with every patient, and reminders to document this were posted on each computer monitor.
This was combined with support where coaching and to staff on both Day and Night shifts. Repeat education was given at the 2 week mark.
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Methods—The MOVEN Tool
Data CollectionPrimary Outcome
• Documentation of patient mobilization
Data from 8 weeks prior to the project's initiation to 8 weeks after the MOVEN protocol’s initiation were analyzed.
Secondary Outcomes
• Number of ventilator dependent days
• Length of patient stay in the ICU and overall hospital stay
• Rate of patient mortality
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Pre data Conclusions
Average # ambulation: 5.97 times/ 24 hours
Anticipated # ambulation: 12 in 24 hours
Average # for vented: 5.86 time
Average # for non-vented: 5.99 times
Average ICU LOS: 4.12 days
Number of patients: 82
Number of patients vented: 11
Vent days: 71
Number of Pressure Ulcers: 15
Total Expired: 12
Post Data Conclusions
Average # ambulation: 9.7/ 24 hours
Anticipated # ambulation: 12 in 24 hours
Average # for vented: 10.94 times
Average # for non-vented: 10.16 times
Average ICU LOS: 3.48 days
Number of patients: 121
Number of patients vented: 25
Vent days: 125
Number of Pressure Ulcers: 10
Total Expired: 14
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0
2
4
6
8
10
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MOBILZATION EVENTS/ DAYIN ICU
MOBILZATION EVENTS/ DAYNON ICU
MOBILIZATION VENTED PT. MOBILIZATION NON VENTEDPT.
MOBILIZATION EVENTS
PRE INTERVENTION POST INTERVENTION
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14.6
12.4
11
11.5
12
12.5
13
13.5
14
14.5
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PRE INTERVENTION POST INTERVENTION
MORTALITY RATE PER INTERVENTIONAL GROUP
MORTALITY
Strengths and Limitations
• Project familiar to PT/OT
• Nursing educated PT/OT regarding ability to ambulate high-oxygen demand patients
• Documentation in familiar spot pulls to ABCDEF Bundle tab
• Future research could be done to correlate RASS scoring and ICU early mobilization
• More education sessions required by staff
• Staff desires a manual depicting how to ambulate patients
• Style of documentation misleading, not uniform among RN staff
• No clear delineation of when a patient leaves ICU within flowsheets
• Pre data set significantly smaller than the post data set (83 vs. 120).
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DNP Implications
• Understanding and dissemination of pathological processes
• Understanding and dissemination of literature
Scholarship
• Effective communication
• Conflict resolution
Leadership
• Changes to style and method of documentation, not required amounts of documentation
Policy
• Understanding clinical setting and rationale behind exceptions to mobilization
Clinical
Evaluation Plan--Sustainability
MOVEN tools laminated and present in every
patient room; Posters and informatics displayed in department post study
Patient mobility level updated on whiteboard
daily by Nursing staff (colored cards)
Patient mobility level discussed daily during
multidisciplinary rounds
Reminder card to document patient mobility present on each computer
monitor
Daily discussion between PT/OT/Nursing to discuss
plans/barriers to mobilization each day
Continued data monitoring regarding adherence to use and continued mobilization
of patients
Early mobilization of patients to become part of onboarding bundle for new
staff, including education on MOVEN tool
Department supervisors to oversee continued
adherence to use of tool
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Questions
Acknowledgements
Dr. Negri, DNP, APRN-NP, ACNP-BC
Dr. Lindsay Iverson, DNP, APRN, ACNP-BC
Ms. Toni Nielsen, BSN, CCRN
Ms. Ashley Hermesch, RN, MHA
Dr. Lauren Klein, APRN, DNP, AGAC-NP
Dr. Lori Rubarth, PhD, APRN, NNP-BC
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