Patients sustaining orthopaedic injuries or orthopaedic surgery represent a significant and growing proportion of patients in intensive care units (ICUs; Taylor & Gropper, 2006). Admission rates of orthopaedic patients to ICUs are rising because of increases in hip and knee arthroplasties in an aging population with a rising prevalence of significant comorbid conditions (Weissman, 2000). Critically ill patients in ICUs are often placed on strict bed rest and heavily sedated, greatly increasing the risk for complications associated with immobility. To prevent immobility-associated complications, more intensive care settings are using progressive mobility protocols to increase activity in critically ill patients. Progressive mobility protocols promote a collaborative, multidisciplinary approach between physicians, nurses, and physical, occupational, and respiratory therapists to provide early mobility for critically ill patients, many of whom are mechanically ventilated.
To promote best practice through the dissemination of research findings, this article addresses the usefulness to orthopaedic nurses of an innovative nurse-driven, evidence-based protocol developed to increase ICU patient mobility in a small community hospital. Immobility-associated complications are reviewed and the steps for developing a progressive mobility activity protocol (PMAP) are discussed with strategies for its continuation after discharge from the ICU. The acronym PMAP was chosen to appropriately describe the protocol purpose, to map a course of direction for the critically ill patient's progressive mobility on the road to recovery. The PMAP provides nurses and interdisciplinary team members a roadmap for increasing patient movement through a series of progressive steps from passive range of motion to ambulating independently as their medical stability increases (Hopkins & Spuhler, 2009; Kubo, 2008; Perme & Chandrashekar, 2009). A pilot study is to be implemented later this year and additional data will be gathered. The expected patient outcomes of the PMAP include improved physical conditioning, prevention of complications associated with deconditioning and immobility, and return to activity levels prior to hospitalization.
Effects of Immobility
Although consequences of immobility are well known to orthopaedic nurses, gaps in nurses' knowledge and theoretical understanding of deconditioning may lead to prolonged periods of bed rest in patients (Gillis, MacDonald, & MacIssac, 2008). Deconditioning is a term that is used to describe the complex physiological and potentially reversible effects that result from periods of inactivity or immobility (O'Keefe, 2002). Many nurses may be unaware of how quickly physiological changes can lead to functional decline (Figure 1).
Sarcopenia, a loss of muscle mass, can begin after only 2 days of bed rest, decreasing muscle strength by 1%-3% per day. One week of bed rest can result in a 20% decrease in muscle strength and an additional 20% muscle strength loss for each week on bed rest (De Jonghe et al., 2007; Topp, Ditmyer, King, Doherty, & Hornyak, 2002). Lack of weight bearing is known to accelerate bone demineralization leading to fractures and kidney stones (Winkleman, 2009). Profound loss of lean muscle mass and strength, particularly in the lower extremities, was found by Kortebein, Ferrando, Lombeida, and Evans (2007), in 12 healthy older adults after 10 days of bed rest. Deconditioning has a significant effect on the skeletal muscles used in standing and walking and has been linked to falls, functional decline, increased frailty, and immobility (Gillis et al., 2008).
Signs of cardiovascular deconditioning are apparent within 3-4 days of bed rest (Winkleman, 2009). Baroreceptors, located in the aorta and the carotid sinus, regulate blood pressure by responding to smooth muscle fiber length with position changes. The baroreceptors stimulate the autonomic nervous system to constrict or dilate blood vessels with changes in body position. When an individual changes position from lying to sitting, the body goes through a series of physiological adaptations to maintain cardiovascular homeostasis. However, when an individual is lying immobile, the baroreceptor sensitivity decreases. Orthostatic intolerance and syncope develop from a loss of baroreceptor responsiveness (McCance & Heuther, 2006).
Additional complications from immobility (Figure 2) include pneumonia, atelectasis, pressure ulcers, constipation, urinary stasis, and depression. Immobility-associated metabolic changes are hypoglycemia, insulin resistance, decreased protein synthesis, and decreased fatty acid metabolism. Reductions in skeletal muscle contraction can lead to venous stasis and deep vein thrombosis as well as decreased venous return to the heart (Hamburg et al., 2007; Winkleman, 2009).
A Model for Planned Change
To develop the PMAP, Rosswurm and Larrabee's (1999) model for evidence-based practice was used. This model, based on research utilization and change theory, provides a framework for integrating evidence-based interventions into practice. There are six steps in the model: (1) assess the need for a change in practice, (2) link the problem with interventions and outcomes, (3) synthesize the best evidence, (4) design the practice change, (5) implement and evaluate the change in practice, and (6) integrate and maintain the change in practice. The PMAP was formulated using these steps as follows.
Assess the Need for a Change in Practice
In this first step, a retrospective audit of 30 patient charts was conducted to assess the need for a practice change. The charts were reviewed for PMAP eligibility and contraindications. All patients admitted to the ICU for more than 24 hours and free of contraindications were considered eligible for PMAP. Contraindications included cardiovascular, respiratory, or neurological instability, temporary femoral lines, traction as determined by the physician and do-not-resuscitate comfort care (DNRCC) patients. Of the 30 records audited, most patients were ineligible because of ICU stays less than 24 hours and DNRCC status. Eight patients met eligibility criteria. Their medical records were examined for ICU length of stay (LOS), total hospital LOS, activity orders, physical therapy (PT) and occupational therapy (OT) referrals, and documented activity. Institutional review board approval was obtained for the use of these existing data.
The audit results revealed an average patient age of 71.4 years. All of the patients were ambulatory before their hospitalization, two with the use of a walker and one with a cane. The average ICU LOS was 4.13 days and the average total hospital LOS was 11.7 days. Physical therapy and OT referrals were ordered on five of the eight patients. All patients met PMAP eligibility for most of their stay; however, three patients remained on bed rest during their entire hospital LOS without documented indication. One patient chart had no physician orders for activity. The audit results also showed a lack of nursing documentation for patient activity, indicating little or no activity in each of the eight eligible patients during their ICU stay and after transfer to step-down and regular units. Six of the eight patients lived at home prior to hospitalization, and seven patients were discharged to skilled nursing facilities or long-term acute care facilities. Only one patient returned home after discharge.
Rosswurm and Larrabee's (1999) first step includes identifying potential barriers. There are several potential barriers for maintaining PMAP that include lack of mobility education, safety concerns, and lack of interdisciplinary collaboration. Time constraints due to increased patient acuity and limits in staffing have lowered the priority and time available for basic mobility (Gillis et al., 2008; Markey & Brown, 2002). A lack of nursing education on deconditioning and patients' perceptions that they need to rest; being passive recipients of care is also an impediment to activity (Bynon, Wilding, & Eyres, 2007). Nurses and physicians have identified that patient symptoms of weakness and pain, safety concerns related to maintaining airways, feeding tubes, intravenous lines or urinary catheters, fear of patient falls, lack of mobility equipment, and lack of patient motivation are common barriers to patient mobility (Brown, Williams, Woodby, Davis, & Allman, 2007; Winkelman, Johnson, Peereboom, Hejal, & Rowbottom, 2009).
Step-down, orthopaedic, and general floor nurses may also be concerned about the safety in mobilizing the patient recently transferred from the ICU because of substantial functional disabilities in walking ability, muscle strength, cognitive functioning, and activities of daily living in patients not participating in early activity in the ICU (VanDerSchaaf et al., 2007). Patients have identified that a lack of assistance in getting out of bed was a major barrier to their activity (Brown et al., 2007; Winkelman et al., 2009).
Additional potential deterrents to patient activity are concerns for physical harm to staff when mobilizing patients, especially the obese patient. A hospital lift team was formed in the past year to assist with the movement of larger patients and will be used with progressive mobility in ICU patients as appropriate. The hospital education department recently provided education with active participation of all nursing care staff on proper body mechanics with the proper use of mobility aids including standing lifts and pneumatic lifts. Mobility equipment needs for their patient care areas were assessed, and budget requests were submitted. The National Association of Orthopaedic Nurses (2011) has long advocated for safe nursing practices and developed evidence-based guidelines for safe patient handling and movement. These guidelines include algorithms for selecting the safest equipment and techniques based on specific patient characteristics and provide best safety practices for orthopaedic nurses (Sedlak, Doheny, Nelson, & Waters, 2009).
Lack of collaboration among interdisciplinary team members is a potential barrier and can lead to inconsistencies in patient functional and mobility interventions. When the patient is seen by an occupational or physical therapist, there is often confusion where the responsibility for activity lies (Markey & Brown, 2002). The PMAP is written so that roles are clearly delineated using language familiar to all disciplines.
Hospital administrators may be reluctant to justify possible expenditures for workforce and equipment related to PMAP. A cost-benefit analysis for LOS was done to link potential outcome data with cost data as a method for communicating the value of the protocol. If each of the eight PMAP eligible patients, as identified in the medical record audit, had outcomes of a 1.4-day decrease in ICU LOS and hospital LOS by 3.3 days as demonstrated in recent studies (Bailey et al., 2007; Morris et al., 2008; Pennington Caraviello, Nemeth, & Dumas, 2010; Winkelman et al., 2009), the total healthcare cost could be reduced by $18,544.80 in 1 month. This conservative estimate is based on current hospital charges and represents a significant potential financial impact from just eight patients.
Administrative support and sanctioning are vital to the success of practice changes. A summary of the progressive mobility evidence, audit findings, and potential financial considerations was presented to several key stakeholders within the hospital. Approval to proceed with PMAP development was received from all.
Link the Problem With Interventions and Outcomes
The second step in developing the PMAP was to link the problem, lack of mobility in ICU patients, with interventions and outcomes. Recent studies have indicated that early progressive activity for ICU patients is safe and cost-effective, resulting in decreased immobility-related complications. Functional mobility was increased and functional independence was more likely in patients receiving early mobility (Bailey et al., 2007; Morris et al., 2008; Pennington Caraviello et al., 2010; Schweickert et al., 2009; Winkelman et al., 2009).
The PMAP intervention is to be initiated if the patient is at risk for deconditioning from immobility and is free from any contraindications. Each patient will be assessed upon admission and every 8 hours for inclusion in PMAP. At the initiation of PMAP, patients may require life support equipment, such as mechanical ventilators, or interventions, such as drugs for sedation. Patients receiving sedatives will have sedation decreased as their condition allows for participation in PMAP. Patient cardiovascular, neurologic, and respiratory status is assessed before, during, and after each activity.
The PMAP begins with nursing interventions that include turning from side to side every 2 hours (Institute for Clinical Systems Improvement, 2010), range of motion three times per day, and orthostatic conditioning to an upright position. The primary purpose of orthostatic conditioning is to prevent orthostatic intolerance by inducing orthostatic stress caused by raising the patient gradually to a sitting position (Kubo, 2008). The PMAP steps (Figure 3) include orthostatic conditioning progressing from elevating the head of the bed 30[degrees] to 45[degrees] and then lowering the foot of the bed to a partial sitting position. The beds in this hospital ICU can be placed in a partial sitting and full sitting position to facilitate activity to occur in a comfortable manner for the patient. When the patient is able to follow commands and perform active range of motion, occupational and physical therapists begin working with the patient.
As the patient's condition allows, activity is to be progressed to elevating the head of the bed to 65[degrees] and lowering the foot of the bed to a full-sitting position. Once the patient is conscious and following commands, activity should progress to the patient's feet touching the floor. In collaboration with PT and respiratory therapy as appropriate, the patient should be assisted in the standing position and advance to taking one to two steps to a chair and sitting for 30 minutes or longer. The next step is to walk with assistance, using a walker if necessary, and finally, independent ambulation.
The PMAP is evaluated through data comparison of activity documentation, immobility-related complications, ventilator-associated pneumonia and deep vein thrombosis rates, and ICU LOS, days of mechanical ventilation (MV), and total hospital LOS before and after implementation. Outcome data on immobility-related complications and LOS for PMAP patients will be reported quarterly to administrators. Demonstrating a meaningful impact of PMAP will be helpful to hospital administrators who seek optimal patient outcomes but must weigh costs for multiple competing programs throughout the hospital.
Synthesizing Best Evidence
In the third step of the model for change (Rosswurm & Larrabee, 1999), a literature review was conducted. A synthesis of several studies demonstrates the benefits of early progressive mobility in critical care patients. Morris et al. (2008) conducted a prospective cohort study of mobility in ICU patients with acute respiratory failure requiring MV. Patients who received early progressive mobility were out of bed 5 days earlier, the average length of ICU stay was decreased by 1.4 days, and overall length of hospital stay was decreased by 3.3 days. There was a lower incidence of ventilator-associated pneumonia and deep vein thrombosis in the intervention group. There were no untoward events during the mobility sessions, and there was a reduction of costs averaging more than $3,000.00 per patient even with additional costs associated with the mobility team. Winkelman et al. (2009) demonstrated similar results with a significant reduction in ICU LOS by 4.1 days and the duration of MV was reduced by 3.4 days in patients receiving early mobility.
In a study of 1,449 activity events in 103 MV patients, Bailey et al. (2007) found that 69% were able to ambulate more than 100 feet upon transfer from the ICU. There were less than 1% activity-related adverse events, all resolved quickly with no additional treatment. Daily interruption of sedation and PT and OT was well tolerated and resulted in better functional outcomes, shorter duration of delirium, and decreased days on ventilation, as demonstrated by Schweickert et al. (2009). The evidence indicates that progressive mobility prevents complications and is feasible, safe, and cost-effective in critically ill patients.
With attention consumed by higher acuity patients in the general hospital units, many nurses have lost focus on the importance of basic care such as ambulation (Markey & Brown, 2002). In studies of mobility in hospitalized patients, 72.9%-83% of patient hospital stays were spent lying in bed, despite an ability to walk independently, and there were no documented medical indications for bed rest in 60% of patients with physician-ordered bed rest (Brown, Friedkin, & Inouye, 2004; Brown, Redden, Flood, & Allman, 2009; Callen, Mahoney, Grieves, Wells, & Enloe, 2004).
Design the Practice Change
The presence of an activity protocol to provide clear guidelines and assessment parameters for patients has been shown to facilitate out-of-bed activity in ICU patients (Winkelman & Peereboom, 2010). The PMAP was drafted from a synthesis of current research and approved by the director of critical care and the critical care clinical nurse specialist in the community hospital where PMAP will be implemented. An interdisciplinary team of additional stakeholders from OT, PT, respiratory therapy, and ICU registered nurse (RN) staff was gathered to obtain input for further development and implementation of the protocol. After several revisions, the PMAP and standard of care (Table 1) were approved by the interdisciplinary team. Protocol champions have been shown to facilitate out-of-bed activity in ICU patients (Winkelman & Peereboom, 2010). Two RNs were identified as PMAP champions in the ICU. The role of the champions is to oversee and promote PMAP in ICU. The intensive care RN champions rotate to the step-down unit regularly and promote continuation of PMAP after ICU transfer.
The PMAP will be added to the ICU standard orders and to the ICU daily rounding tool when adopted, where the interdisciplinary team can discuss each patient's progress and coordinate activity for the day. A daily PMAP documentation record (Figure 4) was developed to assist in documenting the patient assessment before and after activity, the step attempted and achieved, and the patient's tolerance.
Progressive mobility protocols should be maintained until the patient is ambulating independently or discharged from the hospital (Hopkins & Spuhler, 2009; Kubo, 2008; Perme & Chandrashekar, 2009). The last steps of the PMAP often occur after the patient is transferred out of the intensive care unit (ICU); however, there was no discussion in the literature of barriers or facilitators in continuing progressive mobility after ICU. Studies indicating low levels of mobility in patients on general hospital units and lack of documented activity found in the chart audit are reasons for concern regarding potential gaps in the continuation of PMAP after ICU transfer (Brown et al., 2009; Callen et al., 2004; Markey & Brown, 2002).
To facilitate PMAP progression after ICU transfer, a nursing care plan (Figure 5) was developed to bridge continuation of activity after transfer from the ICU. The PMAP care plan includes the progressive mobility steps and strategies for mobility after transfer from the ICU. These include the following: patient out of bed for meals, ambulation three times a day, discouraging daytime sleeping, reducing or eliminating barriers such as urinary catheters, and increasing sensory stimulation by encouraging the wearing of eye glasses and hearing aids (Markey & Brown, 2002). The care plan is individualized for each patient through interdisciplinary collaboration with daily activity goals. Patient and family PMAP education material was developed to promote understanding and cooperation with activity.
The RNs will review PMAP education, care plan, and daily activity goals with patients and families. Each patient's progress with activity goals will be reported daily by the RN in shift reports and in interdisciplinary meetings. Assistive devices such as lifts and walkers were placed in convenient locations on each patient care unit.
Education was provided for stakeholders hospital-wide, which included a review of the complications of immobility and deconditioning, early progressive mobility studies, and evidence-based PMAP interventions. Continuing education hour presentations, flyers, bulletin boards, and communication in team meetings were used to disseminate information. An independent study continuing education consisting of a PMAP PowerPoint presentation with narration on compact discs and digital versatile discs with handouts, posttest, and evaluation was available for staff unable to attend education offerings in person.
Implement and Evaluate the Change in Practice
It was determined that a pilot study for PMAP will be used to determine the results of the protocol, the costs and feasibility data, and feedback from the stakeholders. A 3-month pilot is scheduled to be implemented this year. On the basis of the results of the pilot study, the PMAP interdisciplinary team will decide to adapt, adopt, or reject the protocol.
Integrate and Maintain the Change in Practice
If adopted, the sixth step of Rosswurm and Larrabee's (1999) is to integrate and maintain the change in practice by using the organization's mechanisms to integrate new practice as policies, protocols, or standards of care. Communication of any PMAP changes to stakeholders needs to occur, and the information needs to be disseminated to the staff. To maintain the protocol, ongoing monitoring of the process and outcomes is warranted.
Summary
The importance of activity to prevent the hazards of immobility has been known to nurses for decades. However, attention to this basic aspect of patient care is often overshadowed by other more urgent patient care needs, resulting in a lack of ambulation in hospitalized patients. The presence of an evidence-based activity protocol provides clear guidelines and assessment parameters for nurses to facilitate patient out-of-bed activity in ICU patients. Using a model for planned change is an effective way for nurses to facilitate new evidence-based patient interventions in the practice setting. This nurse-driven protocol is a key intervention to improve nurse-sensitive patient outcomes, reduce immobility complications, reduce LOS, and decrease cost to the patient and organization. The PMAP empowers the nurse to regain direction of this critical element in the care of ICU patients.
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