Keywords

critical care, early mobility, mobility, physical therapy, quality improvement

 

Authors

  1. Fraser, Danielle MS, RN, GCNS-BC
  2. Spiva, LeeAnna PhD, RN
  3. Forman, Wendy DPT, PT
  4. Hallen, Caroline BSN, RN

Abstract

ABSTRACT: Objective: Research is needed to determine the feasibility of implementing a dedicated ICU mobility team in community hospital settings. The purpose of this study was to assess, in one such hospital, four nurse-sensitive quality-of-care outcomes (falls, ventilator-associated events, pressure ulcers, and catheter-associated urinary tract infections [CAUTIs]), as well as hospital costs, sedation and delirium measures, and functional outcomes by comparing ICU patients who received physical therapy from a dedicated mobility team with ICU patients who received routine care.

 

Methods: We conducted a retrospective longitudinal study at a community acute care hospital; patients were randomly assigned to intervention or routine care groups. The mobility team screened patients Monday through Friday using a mobility algorithm to determine eligibility for participation in each early mobility session. Based on their strength, balance, hemodynamic stability, and ability to participate in early mobility activities, patients advanced through four progressively difficult phases of mobility. Data were collected and analyzed after patients were discharged from the hospital.

 

Results: The 66 patients who received the mobility intervention had significantly fewer falls, ventilator-associated events, pressure ulcers, and CAUTIs than the 66 patients in the routine care group. The mobility group also had lower hospital costs, fewer delirium days, lower sedation levels, and improved functional independence compared with the routine care group. Patients in the mobility group got out of bed on 2.5 more days than patients in the routine care group. There were also no adverse events in the mobility group.

 

Conclusions: It is feasible for a community hospital to create and implement a dedicated ICU mobility team. Early mobilization of ICU patients contributed to fewer delirium days and improved patient outcomes, sedation levels, and functional status.

 

Article Content

Early mobilization of critically ill patients has not been standard care in our ICU, despite the fact that bed rest and immobility contribute to muscle deconditioning in ICU patients.1 Recent research has shown that muscle strength declines 3% to 11% with each additional day of bed rest.1 Once muscular dysfunction occurs, it can take weeks, even months, to alleviate its effects.2 Prolonged immobility and bed rest are associated with physical weakness,1 functional decline,3 higher mortality rates,4 and increased duration of mechanical ventilation.5 Therefore, in recent years, there has been increased interest in mobilizing critically ill patients as soon as possible and evaluating the effectiveness of early mobility in the ICU setting.

 

LITERATURE REVIEW

While there is no standard definition of early mobility, researchers have used the term, and others like it, to refer to the proactive provision of physical therapy to critically ill patients on ICUs. For example, in a study of an early activity protocol, Bailey and colleagues defined "early" as "the interval starting with initial physiologic stabilization and continuing through the ICU stay" and noted, "This interval is early compared with activity that usually begins after ICU discharge."6 The beneficial effects of early mobility in critically ill patients include shorter duration of delirium7 and reduced postoperative complications.8 Early mobility also reduces length of stay9-119-119-11 and mechanical ventilation days,7 thus lowering costs.12, 1312, 13 Researchers have demonstrated that physical therapy can be safely provided to critically ill patients in intensive care.6, 14, 156, 14, 156, 14, 15

 

Published studies of early mobility interventions in critically ill patients have examined a wide variety of mobility protocols and instruments to measure functional outcomes. They have also evaluated the effects of various mobility initiation times and frequencies and the use of existing versus additional staff members to provide early mobility interventions. Morris and colleagues initiated a four-level mobility protocol, delivered seven days per week by an independent mobility team that included a physical therapist (PT), an ICU nurse, and a nursing assistant.10 The mobility protocol was started within 48 hours of mechanical ventilation in patients with acute respiratory failure. Findings indicated that, compared with patients who received routine care, patients treated with the mobility protocol were out of bed earlier and had a reduced length of stay with no additional costs. More recently, Clark and colleagues evaluated a mobility protocol implemented by an additional full-time PT in patients upon admission to a university trauma and burn ICU.14 The findings included no adverse events and a reduced frequency of deep vein thrombosis and pulmonary and vascular complications. The hospital length of stay, adjusted for illness severity, was reduced by 1.5 days, but this change was not statistically significant.

 

In a similar study conducted at two university hospitals, Schweickert and colleagues assessed functional outcomes in mechanically ventilated patients treated in the ICU for less than 72 hours.7 Daily interruption of sedation was followed by therapy provided by PTs and occupational therapists. Patients who received early therapy had improved Barthel Index scores (a measure of functional outcomes) at discharge, fewer delirium days, and fewer ventilator days compared with patients who received standard care. Following this study, Pohlman and colleagues, working in the same two hospitals, assessed daily interruption of sedation followed by therapy delivered by a PT and an occupational therapist in patients on mechanical ventilation for less than 72 hours.16 Therapy progressed from active range-of-motion exercises to activities of daily living, including sitting, standing, and ambulating. The researchers concluded that early physical and occupational therapy was feasible, with a minimal occurrence of adverse events.

 

In another study, researchers tested the use of a set of evidence-based practices known as the ABCDE bundle (Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility) and found that patients who received the intervention "spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay" than patients treated with routine care.17

 

Several researchers have implemented early mobility programs without adding ICU staff. In respiratory failure patients who required mechanical ventilation for more than 96 hours, Bailey and colleagues initiated early activity that included sitting on the edge of the bed, sitting on a chair, and ambulating; no additional staff was added.6 The findings indicated that early activity was safe and a majority of patients ambulated more than 100 feet at discharge. Similarly, Drolet and colleagues implemented a nurse-driven mobility protocol and found a 14% increase in the number of adult ICU patients who ambulated during the first 72 hours after ICU admission.18

 

Garzon-Serrano and colleagues examined whether treatment by critical care nurses or PTs resulted in different levels of ICU patient mobilization, and compared the barriers to mobilization progress the two clinician groups identified.19 The researchers found that, compared with nurses, PTs mobilized their patients to higher levels. The two clinician groups also identified different barriers to mobilization, a finding that suggests that PTs should be involved in the care of ICU patients to achieve higher levels of mobility.

 

While evidence from randomized controlled trials supports the mobilization of critically ill patients as soon as possible, it can be challenging to put the knowledge gained by such studies into practice.20, 2120, 21 Before we began our study, several members of our hospital leadership team attended a conference and learned about the benefits of early mobility; still, further research was needed to determine the feasibility of implementing a dedicated ICU mobility team in a community hospital with fewer resources than an academic medical setting. This study's purpose was to assess four nurse-sensitive quality-of-care indicators (falls, ventilator-associated events, pressure ulcers, and catheter-associated urinary tract infections [CAUTIs]), as well as hospital costs, sedation levels using Richmond Agitation-Sedation Scale (RASS) scores, delirium days, and functional outcomes using Barthel Index scores by comparing ICU patients who received an early mobility intervention from a dedicated mobility team with ICU patients who received routine care.

 

METHODS

Setting and sample. We conducted a retrospective longitudinal study at a community acute care hospital in the southeastern United States. The health care system's institutional review board and nursing research committee provided ethics approval. The research procedure involved retrospective chart review and data collection and analysis of deidentified data. Informed consent was not required. In addition, senior leadership and the hospital's mobility committee approved the implementation of the mobility program. The mobility committee included a multidisciplinary team of nurses, PTs, physicians, respiratory therapists (RTs), and administrators responsible for the development, implementation, and oversight of the ICU mobility team.

 

Patients enrolled in the study had been admitted to three critical care units-medical, surgical, and coronary care-with a total of 50 beds. To meet the inclusion criteria, a patient had to be a male or female adult at least 18 years of age, admitted directly to an ICU, and have an intensivist as attending or consulting physician. Exclusion criteria included a patient's inability to walk without assistance before ICU admission (use of a cane or walker did not result in exclusion), neuromuscular disease that would prevent weaning from mechanical ventilation, acute stroke, body mass index greater than 45 kg/m2, admission by the trauma service, acute lower extremity fracture, unstable cervical spine or pathologic fracture, hospitalization within 30 days prior to admission, hospice care, immediate plans to transfer to an outside hospital, and a score greater than 60 on the initial Barthel Index at ICU admission or within 24 hours of extubation. With a power of 80%, an [alpha] of 0.05, and an effect size of 0.35, at least 129 patients were needed for the sample.22, 2322, 23

 

We obtained baseline measurements from a random sample of 66 patients admitted from August through September 2012, prior to implementation of the early mobility intervention. We also collected baseline data on 66 patients admitted from October 2012 through August 2013 who received the early mobility intervention.

 

Intervention. Routine management of all ICU patients, including monitoring arterial oxygen saturation using pulse oximetry, heart rhythm using five-lead electrocardiography, and blood pressure using noninvasive (cuff) or invasive (arterial line) measurement or both, was in accordance with institutional standards. (No additional monitoring technology was used in the intervention group.) The hospital's evidence-based mechanical ventilation order set was followed for daily spontaneous awakening trials and spontaneous breathing trial procedures.

 

The dedicated ICU mobility team included a PT (one of us, WF), a critical care RN (one of us, CH), and a mobility technician (a rehabilitation aide trained in the ICU environment). The RT assigned to a mechanically ventilated patient on a given day assisted the mobility team as part of that day's assignment. The team provided coverage Monday through Friday on the day shift, and screened all patients within 24 to 72 hours of ICU admission to determine their ability to participate in the early mobility intervention.

 

Patients were excluded from mobility sessions if they met the criteria shown in Table 1.6, 7, 10, 16, 24-276, 7, 10, 16, 24-276, 7, 10, 16, 24-276, 7, 10, 16, 24-276, 7, 10, 16, 24-276, 7, 10, 16, 24-276, 7, 10, 16, 24-276, 7, 10, 16, 24-27 These criteria were recorded in a draft document developed by the clinical nurse specialist (one of us, DF) based on inclusion and exclusion criteria described in the literature; the draft was then revised in consultation with two physician champions who served on the early mobility committee. The criteria were finally reviewed and approved by the whole mobility committee.

  
Table 1 - Click to enlarge in new window Mobility Session Exclusion and Termination Criteria

The early mobility team designed the program based on interventions described in the literature and adapted them for our purposes. The interventions were grouped into four phases that required successively greater strength, balance, hemodynamic stability, and ability in order to participate in the activity.10, 16, 2710, 16, 2710, 16, 27 Phase 1 included passive range-of-motion exercises and repositioning every two hours-activities that nurses, nursing assistants, and family members could perform without the mobility team's assistance. Phases 2, 3, and 4 consisted of sitting on the edge of the bed and standing, transferring from bed to chair, and ambulating, respectively. The PT's evaluation of the patient determined the appropriate mobility phase and corresponding interventions.

 

Every morning the mobility team generated a daily census: a list of patients the team was already following as well as "new consults"-patients for whom the physician had requested a mobility evaluation. The mobility team nurse screened each of these patients for medical stability and then confirmed the day's census. The order in which patients received treatment varied each day because of spontaneous breathing trials, surgeries, dialysis and the like; therefore, the time of day at which therapy sessions took place changed daily for each patient. The mobility team nurse and technician would prepare the patient for therapy while the PT reconfirmed the patient's medical stability and completed the initial screening assessment and documentation. The nurse's preparations included, but were not limited to, disconnecting appropriate iv drips and tube feeds, securing ventilator tubing and other lines, and administering antihypertensive, antianxiety, and pain medications as needed. The technician helped to set up for the exercises developed by the PT as part of the treatment plan: gathering and cleaning equipment for the session, placing slip-proof socks on the patient, and removing sequential compression devices. If time allowed, the nurse or technician conducted range-of-motion and stretching exercises until the PT began the session. Proper body mechanics and several devices were used during mobility sessions to promote safe patient handling, including a HoverMatt (an inflatable mattress that aids in repositioning patients), gait belt, portable ventilator, stand-assist lift, platform exercise table, portable in-bed leg press, cardiac chair, ceiling-mounted lift, and walker equipped with portable monitor and oxygen tank. Each device was incorporated into the session according to the PT's assessment of the patient's strength, balance, and coordination to ensure safety for both the patient and the mobility team during therapy. Generally, each therapy session lasted between 30 and 45 minutes. The team was able to see approximately seven to eight patients per day. The PT or the RN also provided customized education to the patient and family caregivers.

 

Quality measures. Using a data collection tool we developed, we manually extracted clinical and demographic data from electronic medical records and the hospital's administrative database between August 4, 2012, and August 14, 2013. The database also provided diagnostic codes based on the International Classification of Diseases, Ninth Revision, Clinical Modification; ICU readmissions during the previous 30 days; total number of mechanical ventilation days; total hospital charges; disposition at hospital discharge; and hospital and ICU lengths of stay. We followed the National Database of Nursing Quality Indicators data collection and submission guidelines to indicate the presence of hospital-acquired conditions (falls, ventilator-associated events, pressure ulcers, and CAUTIs).28

 

We also conducted a retrospective chart review for patients who received the early mobility program intervention. As part of this, we recorded each patient's worst Acute Physiology and Chronic Health Evaluation (APACHE) II score in the first 24 hours of the ICU stay.29 (This measure uses age, chronic health status, and a dozen other physiologic variables to provide an estimate of in-hospital mortality.)

 

Sedation and delirium measures. We reviewed the patients' medical records from admission to ICU discharge and recorded the lowest RASS score in each 24-hour period (from 7 am one day to 6:59 am the following day). The RASS is used in titrating sedation medication30 and has been validated.31 In addition, each patient's ICU nurse conducted the Confusion Assessment Method for ICU patients (CAM-ICU)32 at least twice per day and documented results in the patient's medical record. If the documentation included both positive and negative results in separate assessments, we recorded the CAM-ICU positive result to indicate that delirium was present in that 24-hour period.

 

Functional measures. A Barthel Index score was obtained for each patient at ICU admission and prior to discharge or transfer from the ICU. The Barthel Index is a widely used 10-item assessment instrument developed to evaluate patients' degree of independence in performing activities of daily living; it can be used in all patient populations.33 The Barthel Index has undergone extensive validity and reliability testing.34, 3534, 35 Scores are summed and range from 0 to 100; lower scores indicate greater disability, and 0 indicates complete dependency.

 

We only recorded adverse events in patients who received the mobility intervention. An adverse event was defined as an unexpected safety event that occurred during the mobility session, and included a fall, a cardiac event, an extubation, a decannulation, or a respiratory event. In addition, the following data were collected only for patients enrolled in the mobility intervention group: the number of mobility sessions completed, the number of days at each mobility phase, advancement to specific phases of the mobility protocol, and reasons for exclusion from the daily mobility session.

 

Data analysis. Data were analyzed using PASW software, version 18 (SPSS), and methods included means, standard deviations, frequencies, [chi]2 tests, independent t tests, analysis of variance (ANOVA), and repeated-measures ANOVA. A P value of less than 0.05 was considered statistically significant. Post hoc comparisons were performed using the Tukey test to evaluate group differences.

 

RESULTS

Sample. A total of 66 patients were included in the routine care group prior to the mobility intervention: 26 from the medical ICU, 14 from the surgical ICU, and 26 from the coronary care unit. Another 66 patients received the mobility intervention: 31 from the medical ICU, 17 from the surgical ICU, 17 from the coronary care unit, and one from the neurologic ICU (a medical overflow patient). Baseline characteristics in the two groups were similar; however, race or ethnicity, the primary reason for ICU admission, and the number of mechanically ventilated patients were significantly different between groups (see Table 2). The mean age was 64.7 years and 77% of patients were white. Each patient had at least one comorbid condition, and most were admitted for respiratory problems (36%). The mean APACHE II score was 20.7.

  
Table 2 - Click to enlarge in new window Baseline Characteristics of the Sample

Quality and cost outcomes. As shown in Table 3, 15 of the 66 patients (23%) in the routine care group were readmitted to the ICU within 30 days, whereas only seven of the 66 patients (11%) in the mobility group were readmitted. The routine care group had two falls, one ventilator-associated event, two pressure ulcers, and 12 CAUTIs compared with the mobility group, which had only one CAUTI. The mean ICU length of stay was slightly shorter in the mobility group than in the routine care group (6.4 versus 6.5 days). However, the mean hospital length of stay was longer in the mobility group than in the routine care group (12.6 versus 10.6 days). In-hospital mortality occurred in nine of the 66 routine care patients (14%); no deaths occurred in the mobility patients. Compared with the routine care group, 12 additional mobility group patients were discharged to rehabilitation.

  
Table 3 - Click to enlarge in new window Quality and Cost Outcomes in the Routine Care and Mobility Groups

Inpatient hospital costs were $8,382,001 for the routine care group and $8,270,435 for the mobility group, representing a savings of $111,566 ($1,690 per patient) for the mobility group. The mean cost per patient was lower in the mobility group than in the routine care group ($125,309 versus $127,000; t130 = -0.42; P = 0.68), despite that the mobility group had a slightly longer hospital length of stay.

 

Sedation and delirium outcomes. There was a significant difference between RASS scores in the two groups (see Table 4). The overall mean RASS score for the routine care group was -2.18, indicating deeper sedation levels in these patients. The mobility group's overall mean RASS score was -0.82, indicating greater wakefulness. The mobility group also had significantly fewer delirium days, as measured by CAM-ICU, than the routine care group.

  
Table 4 - Click to enlarge in new window Sedation and Delirium Outcomes in the Routine Care and Mobility Groups

Functional outcomes. There were no adverse events among patients in the mobility group, and the intervention program was effective in improving the level of functional independence at discharge. The mean Barthel Index score for the mobility group increased significantly from 45.9 at ICU admission to 85 at ICU discharge. Although the routine care group's mean Barthel Index score also increased significantly from ICU admission to ICU discharge, neither score was as high as those of the mobility group.

 

Patients assigned to the mobility group completed a total of 238 mobility sessions. All 66 mobility group patients completed one or more mobility sessions, compared with 36 of 66 patients (54.5%) in the routine care group, a statistically significant difference. Mechanical ventilation days in the routine care and mobility groups were 3.3 and 3.8 days, respectively. However, patients in the mobility group got out of bed on 2.5 more days than patients in the routine care group, also a significant difference (any day on which a patient's feet touched the floor was counted as a "day out of bed"). The numbers of patients able to achieve each phase of the mobility intervention were as follows: two of 66 patients (3.03%) participated only in phase 1; two (3.03%) participated in phases 1 and 2; three (4.55%) participated in phases 1 through 3; and 59 patients (89.39%) were able to participate in all four intervention phases. The mean numbers of days patients spent in each phase were 1.3 days at phase 1, 1.7 days at phase 2, 1.7 days at phase 3, and 2.4 days at phase 4. The mean number of days patients were eligible to participate in a mobility session was 4.21 days. Patients were excluded from the daily mobility sessions based on whether they met the exclusion criteria.

 

DISCUSSION

This study evaluated the creation and implementation of a dedicated ICU mobility team at a community acute care hospital. Similar to previous researchers, we determined that early mobility can be safe and viable in a community hospital setting.6, 15-176, 15-176, 15-176, 15-17 Strengths of the program included the participation of an interdisciplinary committee of physicians, PTs and RTs, nurses, pharmacists, and hospital administrators. Our main goals were to determine whether it was feasible to implement this program in our community hospital, support existing evidence that early mobility is associated with improved patient outcomes, and thereby reduce hospital costs. While our outcomes were not as dramatic as those that might be achieved in a large academic institution, we met our goals.

 

Through the development and implementation of a dedicated ICU mobility team, we reduced the rates of 30-day ICU readmission and hospital-acquired conditions. The duration of mechanical ventilation, although longer in the mobility group than in the routine care group, was not significantly different between groups. The fact that more patients in the mobility group had a respiratory diagnosis as the primary reason for ICU admission may have contributed to the longer duration of mechanical ventilation, which in itself may have contributed to the two days' longer hospital length of stay in the mobility group, although the difference between groups wasn't statistically significant. The longer length of stay in the mobility group may also have been the result of the mobility group patients' longer survival; all of the mobility group patients were discharged alive, whereas nine patients in the routine care group died in the hospital. However, despite the early mobility group patients having more ventilator days and a longer length of stay, their hospital costs were lower than those of the routine care patients-although the mean cost per patient was not significantly lower. Consistent with previous research findings, there was a decrease in unadjusted hospital mortality among the early mobility group patients,10 and they were more likely than the routine care group patients to be discharged home or to a rehabilitation facility.7 Early mobility group patients got out of bed on more days during their ICU stay, and most patients were able to progress to phase 4 of the mobility protocol. These outcomes are similar to the findings of Morris and colleagues.10

 

The routine care group had deeper sedation levels compared with the mobility group, a finding consistent with that of Needham and colleagues.26 Mobility group patients were not as heavily sedated, as evidenced by higher RASS scores. This may have been because participation in the mobility sessions required more consistent lightening of sedation and analgesia. Also, as compared with the routine care group, the mobility group had fewer delirium days, but not significantly so, whereas previous researchers had found significant differences.7, 267, 26

 

Limitations. The study was limited to one hospital and the mobility intervention occurred only five days per week. The ICU units and staff were not blinded to the mobility intervention. The intensivist groups were restructured during the course of the intervention program, resulting in a change in providers. This may have had an effect on our results because of differences in individual physicians' preferences regarding early mobility, sedation, analgesia, and ventilator management.

 

A comparison of the cumulative amounts of sedatives and analgesics administered to patients in the two groups was part of the research design; but, although we collected these data, an unexpected shortage of our first-line sedative, propofol (Diprivan), resulted in the use of an alternate, dexmedetomidine (Precedex), in February and March of 2013. This two-month change in sedatives prevented a meaningful comparison of the amounts of sedative and analgesic medications administered to the two groups; it's also possible that it affected hospital costs, as the alternative sedative was much more expensive.

 

With the initiation of the early mobility intervention, ICU nurses who weren't part of the research team also began to provide more mobility activities to the patients in their care, including those patients who were in the early mobility group. The mobility activities they provided could be completed without the assistance of the mobility team, such as range-of-motion exercises, transferring from the bed to a chair, and even ambulation, depending on the acuity of the patient. However, while this nursing initiative and change in the culture of the ICU are desirable side effects of the early mobility program, they do contribute to the limitations of the study, as we were unable to measure the outcomes associated only with the activity of the early mobility team.

 

During the early mobility intervention, nurses were also educated on the importance of minimizing sedation and on the negative outcomes of oversedation. The mobility intervention was provided to patients only while they were in the ICU; when patients transferred to a medical-surgical unit, the mobility intervention may not have been provided as frequently, possibly contributing to longer hospital lengths of stay. Future studies should consider tracking patient mobility activities throughout the hospital stay, the effects of mobility team coverage seven days per week, and the impact of having a dedicated RT as part of the mobility team. Future studies could also focus on long-term outcomes in patients who receive an early mobility intervention, including functional status, cognitive impairment, and psychological effects.

 

It is possible for a community hospital to create and implement a dedicated ICU mobility team by promoting the culture of early mobility, motivating clinicians to change practice patterns, and having supportive administrative and physician leadership. The effects of an early mobilization program delivered to critically ill patients in our acute care hospital by a dedicated mobility team contributed to fewer delirium days and improved quality outcomes, sedation levels, and functional status.

 

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