Early mobilization of postoperative lumbar laminectomy patients is an important aspect of preventing postoperative complications and improving clinical outcomes. Early mobilization in postoperative lumbar laminectomy patients can help prevent hospital-acquired weakness, or infection, and decrease hospital length of stay (Rupich et al., 2018). Identifying appropriate timing for initiation of mobilization and staff responsibilities can help promote early discharge and decrease complications.

Rupich et al. (2018) found that specific postprocedural physician orders and education for the staff were the prominent factors to help facilitate early mobilization. When looking at the risk versus benefits of early mobilization, Dickinson et al. (2018) found that early ambulation can contribute to the proper function and conditioning of each individual body system, which, in turn, decreases hospital-acquired complications. Finally, implementation of a nurse-driven mobility protocol can help reduce the risk of postoperative complications and accelerate the recovery of functional walking capacity, thus positively impacting potential complications and reduce hospital length of stay and overall care costs (Tazreean et al., 2022).

In a neurological focused acute care unit at a Midwest tertiary care hospital, it was found through a retrospective chart review that mobility standards did not meet the organization's benchmarks. Fifteen charts were reviewed each week over a period of 4 weeks. Only 27%-43% of the charts reflected no mobility documentation and 53%-60% charts reflected some documentation. The retrospective chart review also demonstrated that the majority of documentation related to ambulation was completed by the physical or occupational therapist in preparation for discharge and nursing documentation was lacking, incorrect, or omitted. To assess implementation and education of staff for this quality improvement (QI) project, the facility approved two types of scales including the John Hopkins Highest Level of Mobility (JH-HLM) scale (see Figure 1) and the 6-clicks scale (see Figure 2).

Figure 1. John Hopkins Highest Level of Mobility (JH-HLM) scale.

Figure 2. The 6-clicks scale.

The purpose of this QI project was to increase nurse-initiated early mobilization at 24 and 48 hours in postoperative lumbar laminectomy patients as evidence by improved electronic medical record (EMR) documentation.

Literature Review

A comprehensive literature research was conducted using primary databases of Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and Cochrane Library (see Table 1). Key words searched included "spine surgery patients," "lumbar laminectomy," "early ambulation," "physical therapy," "post-operative mobility orders," "length of stay," and "cost-effective." Data search limitations included the English language, hospital based (inpatient), surgical pathways, peer-reviewed or scholarly, evidence-based practice, full-text, and publication date between 2016 and 2022. Of the 180 articles reviewed, a total of 10 articles were deemed relevant (see Table 2).

Table 1. Search Strategy Table

Table 2. Evidence Synthesis Table

Overall, the comprehensive literature review confirmed that early ambulation improved outcomes, resulted in less postoperative complications, and promoted early discharge (Dickinson et al., 2018; Dubb et al., 2016; Rupich et al., 2018). There was less evidence in the literature related to early ambulation provided by nursing staff versus physical or occupational therapy staff (Dickinson et al., 2018; Dubb et al., 2016). Nursing staff development education programs related to early mobility have demonstrated positive outcomes related to nurses' knowledge and increased mobility documentation (Carides, 2021; Harris, 2021).

Methods and Data Analysis

Design

This QI project used a pre/posttest education intervention and a retrospective chart review.

Participants/Setting

Nursing staff were recruited to participate from a 50-bed neurological focused acute care setting in a Midwest tertiary healthcare organization. Float and travel nurses were excluded from the project.

Intervention

Nursing staff received an emailed self-paced educational PowerPoint document related to the lumbar laminectomy procedure, the importance of postoperative early mobilization, complications of decreased early mobility, introduction to the two mobility scales, and documentation in the EMR (see Appendix A in Supplemental Digital Content, available at: http://links.lww.com/ONJ/A25). The documentation scales included the JH-HLM scale and the Activity Measure for Post-Acute Care (AM-PAC) 6-clicks scale. The JH-HLM scale used for documenting observed patient mobility has excellent interrater reliability (.98) and demonstrated validity and correlation with similar scales (Hiser et al., 2021). It is an 8-point ordinal scale based on the observed levels of activity and used frequently by physical therapists (Hiser et al., 2021; Hoyer et al., 2016). The AM-PAC 6-clicks scale also has proven reliability and validity, with internal consistency reliability at .96 and .91 (Jette et al., 2014). These documentation tools were adopted by the healthcare organization but have been used inconsistently.

In addition to the education, mobility documentation reminders were posted on the EMR workstation as an additional reminder to document on the patient's mobility scales.

Instruments

Participants completed a demographic and pretest survey related to educational preparation, length of service, comfort related to mobility, and knowledge of documentation tools. The same survey was used after the intervention.

A retrospective chart audit was conducted pre- and posteducation intervention to confirm documentation using the two documentation tools.

Outcomes and Analysis

Posteducational data analysis consisted of a chart review of 15 patients per day over a 4-week period to keep consistency throughout the project. Postimplementation chart review looked at whether staff charted mobilization by completing either the JH-HLM scale or the 6-clicks scale within 24 hours, either scale within 48 hours, or no mobility documentation charted.

The data collected were documented into an Excel graph (see Figure 3) to help determine areas for improvement.

Figure 3. Four-week preintervention mobility documentation data.

Results

A total of 34 nurses completed both the education module and the posteducation survey (see Figure 4). A retrospective chart review of 15 charts a week over 4 weeks was completed within 1 month after the education module was completed. Mobility documentation consistently improved over the 4 weeks, surpassing the goal of a 5% or 10% increase. The mobility documentation improved, with consistent mobility document ranging from 66% to 86% over the 4 weeks, which was clinically significantly higher than prior to the educational intervention (see Figure 5). The mobility documentation was also more consistent in using the JH-HLM scale and the AM-PAC 6-clicks scale.

Figure 4. Demographic survey.

Figure 5. Four-week postintervention mobility documentation data.

Discussion

Assessing validity and reliability and critically appraising the collected evidence generate a strong practice change recommendation (Melnyk & Fineout-Overholt, 2019). Routine early mobilization of critically ill patients reverses the deleterious effects of bed rest by reducing hospital length of stay and improves muscle strength and functional independence (Dickinson et al., 2018). Postoperative patients should have a specific mobility nurse-led protocol to reduce risk for complications. Therefore, educating the nursing staff on proper postoperative mobility mechanics and appropriate documentation is critical to the patient's success of recovery. Postoperative protocols can enhance recovery after surgery and minimize the stress response through early mobility, oral intake, and improvement of analgesia (Fiasconaro et al., 2020). Implementation of a mobility pathway can positively affect the length of stay of postoperative lumbar laminectomy patients and requires proper documentation.

This study is not without limitations. This study was conducted during COVID-19; therefore, there was limited access to the facility for face-to-face education. This study was conducted at a single medical center and therefore the findings may have limited generalizability. Challenges of staff remained a limitation, as there were many traveling nurses and float staff who were not familiar with the patient population. This specific population of staff did not have access to staff email for the PowerPoint document and surveys; however, the chart reviews did not exclude this specific population. Nursing staff, traveling and floating, remains a similar and critical challenge for all medical facilities and should be further explored as a continued problem for patient outcomes.

Implications

Based on the findings in this QI project, all patient mobility should be documented accordingly, with great emphasis on early mobilization in the first 24-48 hours after surgery. Further identification among nursing leadership reveals lack of communication and documentation for the nursing staff caring for these patients. Therefore, increasing the staff education on patient early mobilization and the importance of documenting all mobility data will decrease patient length of stay and risk for postoperative complications. Although additional high-quality research is needed to assess the impact it has on overall patient outcomes, patient mobility documentation needs to be more thorough and consistent. Finally, this QI project supports a need for intervention to identify the reason there is a lack of patient education and documentation as healthcare systems would benefit through reducing in hospital charges, decreasing length of stay and postoperative complication rates, and increasing quality patient outcomes.

Conclusion

Early mobilization in postoperative lumbar laminectomy patients based on a nurse-led protocol can positively change patient outcomes. Future studies should focus on different postoperative patient populations, the use of standardized medical protocols related to ambulation, and impact of early ambulation on specific patient outcomes, such as complications and length of stay.

References