Early Mobility in the Intensive Care Unit: Standard Equipment vs a Mobility Platform Melanie Roberts, Laura Adele Johnson and Trent L. Lalonde Am J Crit Care 2014;23:451-457 doi: 10.4037/ajcc2014878 © 2014 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
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AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2014 by AACN. All rights reserved.
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Early Mobility in Critical Care
E
MOBILITY IN THE INTENSIVE CARE UNIT: STANDARD EQUIPMENT VS A MOBILITY PLATFORM ARLY
By Melanie Roberts, MS, APRN, CCRN, CCNS, Laura Adele Johnson, RN, BSN, CCRN, and Trent L. Lalonde, PhD
EBR
Evidence-Based Review on pp 458-459 ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2014878
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Background Despite the general belief that mobility and exercise play an important role in the recovery of functional status, mobility is difficult to implement in patients in intensive care units. Objectives To compare a mobility platform with standard equipment, assessing efficiency (decreased time and staff required to prepare patient), effectiveness (increased activity time), and safety (no falls, unplanned tube removals, or emergency situations) for intensive care patients. Methods This observational study was approved by the institutional review board, and informed consent was obtained from the patient or the medical decision maker. Intensive care patients were assigned to a room in the usual manner, with platforms in odd-numbered rooms and standard equipment in even-numbered rooms. Standardized data collection tools were designed to collect data for 24 hours for each patient. The nurses caring for the patients completed the data collection tools in real time during the activity. The stages of activity and the physiological states that would preclude mobility were very specifically defined for the research study. Results Data were collected for a total of 71 patients and 238 activities. Important (although not significant) descriptive statistics regarding early mobility in the intensive care unit were discovered. The unintended result of the research study was a change in the culture and practice regarding early mobility in the intensive care unit. Conclusions Early mobility can be implemented in intensive care units. Standard equipment can be used to mobilize such patients safely; however, for patients who ambulate, a platform may increase efficiency and effectiveness. (American Journal of Critical Care. 2014;23:451-457)
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D
espite the general belief that mobility and exercise play an important role in the recovery of functional status, mobility is difficult to implement in patients in intensive care units (ICUs). Several studies1-4 in the past 2 decades have documented the outcomes of early mobility in critical care. Early and frequent mobilization of ICU patients decreases hospital length of stay, ICU length of stay, and ventilator days.1-4 Common critical care complications, neuromuscular weakness, deconditioning, and delirium are decreased with early mobility.2,5-8 Morris et al9 demonstrated that the lack of early mobility therapy in ICUs was 1 of the 4 variables associated with readmission or death during the first year for ICU survivors of acute respiratory failure.
Hospitals nationwide are attempting to develop mobility programs, but actualizing the goal is difficult. Lack of resources, a lack of established protocols, and staff resistance prevent many facilities from implementing a successful mobility program.10 Numerous articles exist indicating the importance of mobilization; however, little detail can be found to explain how to implement a successful mobility program. Published reports demonstrate the importance of mobility protocols in determining individual patients’ appropriateness for mobility and to define progression of mobility, but few such protocols have been published.11 The culture of the ICU must be addressed early in any initiative to implement a mobility program. Successful implementation of early mobility requires a change in ICU culture, nurses’ personal perceptions, and teamwork.10 This article describes how a community-based hospital developed a mobility program despite limited resources and changed the culture of the ICU to accept the challenge of mobilizing patients.
Lack of early mobility is associated with readmission to the intensive care unit or death during the first year.
About the Authors Melanie Roberts is a critical care Clinical Nurse Specialist at Medical Center of the Rockies in Loveland, Colorado. Laura Adele Johnson is a student registered nurse anesthetist at Westminster College in Salt Lake City, Utah. Trent L. Lalonde is an associate professor of applied statistics at the University of Northern Colorado and a statistical consultant at the Medical Center of the Rockies. Corresponding author: Melanie Roberts, MS, APRN, CCRN, CCNS, Medical Center of the Rockies, 2500 Rocky Mountain Avenue, Loveland, CO 80538 (e-mail: Melanie.Roberts@ uchealth.org).
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Methods Setting The study was completed at Medical Center of the Rockies, a 136-bed nonprofit, tertiary care hospital. Clinical areas involved in the research study included a 12-bed cardiac/cardiovascular surgery ICU (CICU) and a 12-bed surgical/trauma ICU (SICU). Mobility stages had been implemented in the ICUs before the study but were not integrated into practice. A research protocol was designed to identify human resources required for early mobility in the ICU, to compare standard equipment with a platform, and to validate the safety of the protocol. Sample The study included all intensive care patients who were at least 18 years old and spoke English. Critical care patients are a vulnerable population of patients; many are unable to make decisions because of cognitive impairment from medications and critical illness. To protect the patients, informed consent was obtained from individual patients if their results on the Confusion Assessment Method12 were normal and the patient was not receiving any sedatives or pain medication. If the patient did not meet both criteria, the patient’s medical decision maker provided consent. Consent was obtained by specially trained ICU nurses at an appropriate time after the patient had been admitted to the ICU, depending on the patient’s condition and planned mobility. For planned ICU admissions, consent was obtained before admission. Data were collected for 4 months, with a total of 71 patients enrolled in the study and 238 total mobility events. Of the 71 patients, 26 (37%) were female with a mean age of 66.00 (SD, 19.76) years, whereas the 45 males (63%) had a mean age of 68.62 (SD, 12.43) years. A total of 49 patients (69%) were in the CICU and 22 (31%) were in the SICU. The
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Table 1 Stages of mobility
CICU patients consisted of 15 females (31%) and 34 males (69%), with a mean age of 69.79 (SD, 12.37) years. The platform was assigned to 23 (47%) of the CICU patients. The SICU patients consisted of 11 females (50%) and 11 (50%) males, with a mean age of 62.91 (SD, 20.24) years. The platform was assigned to 12 (55%) of the SICU patients. Design A prospective, randomized, controlled, observational research study was designed to compare a platform with standard equipment for ICU patients. The research hypothesis stated expected improvements in efficiency, effectiveness, and safety of ICU mobility when the platform was used rather than standard equipment. Effectiveness is defined as the duration of activity performed by the patient. Efficiency is defined as the time to prepare the patient for mobility as well as the number of staff required to assist the patient with the activity. Safety is defined by the number of falls or unplanned tube removals. The standard equipment used for the study includes a gait belt, no-slip socks, a walker, and a wheelchair if the patient was ambulating. The platform is a mobile support device that consolidates equipment (intravenous poles, multiple hooks for drainage bags, and a secure location for oxygen) into a small area. The patient still requires a gait belt and no-slip socks for safety. The design of the platform is to allow mobility with the assistance of fewer staff. All patients were monitored, had oxygen, and if the patient was receiving mechanical ventilation, a respiratory therapist had to be part of the mobility team. The study was approved by the organization’s institutional review board. Platforms were placed in odd-numbered rooms. Patients were admitted to rooms by the usual process. Data were collected by the ICU nurses during the activity session, and time was documented to the nearest minute. Standardized data collection sheets were used to ensure that all appropriate information was recorded. The following information was collected for each activity: date, time of day, preparation time (minutes), activity time (minutes), type of activity (chair, dangle, stand or march in place, walk), number of staff required, frequency of activities per patient per day, and unplanned tube removals or falls. Each patient had a data collection sheet for each day, starting at midnight with the new ICU flow sheet. Before the beginning of the study, the nurses had 2 weeks to practice with the platform as well as the data collection sheets to ensure that the data collection process would work as expected. This process allowed nurses
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Stage
Activity
Research requirement
1
Bed in chair position
Not part of the research study
2
Dangle legs at edge of bed
Minimum 2 min
3
Stand upright, weight bearing
Minimum 1 min
4
Chair, stand, pivot/march
Minimum 15 min in chair
5
Ambulate
Minimum 10 ft (3 m)
to reeducate themselves on the equipment and the data collection tool as needed before data collection. During the 2 weeks before the study, the nurses were given instructions by physical therapists on the proper method for assisting a patient out of bed to the chair and getting the patient back to bed using a gait belt to promote staff and patient safety. The data collection sheets were gathered weekly and correlated with informed consent. If consent had been obtained, the data sheets were entered into a data spreadsheet. If consent had not been obtained, the data collection sheet was shredded The ICU nurses determined that it was easier to collect the data sheets every day for all patients to avoid bias created by their knowledge of who was enrolled in the study. The nurses were using a mobility protocol with which they were familiar except for the addition of the platform. The mobility protocol used had 5 stages (Table 1), with specific definitions given for each stage. ICU nurses were responsible for determining whether it was safe for the patient to mobilize. The expectation of the ICU nurse is to use the absolute exclusion criteria and relative contraindications to determine the patient’s ability to mobilize. Patients start the protocol after 24 hours unless they meet 1 of the exclusion criteria. The absolute exclusion criteria are based on the patient’s physiological condition: intracranial monitor, unstable pelvic or spinal fractures, physician’s order for deep sedation, therapeutic hypothermia, vasoactive medication titration, active bleeding, intra-aortic balloon pump or ventricular assist device, comatose, open abdomen, and traction. Relative contraindications such as vasoactive infusions or changes in respiratory status or vital signs are determined by the nurse caring for the patient. Stage 1 activity, bed in chair position, would not be included in the research study as mobility. Before the research study, the ICU had determined that mobility would be defined as purposeful movement
Mobility was defined as purposeful movement with the patient’s participation.
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Table 2 Sample size of activities (n) for number of staff, by activity type No. of staff Activity
0
1
2
3
4
5
Total
Platform Chair Dangle Stand/march Walk Total
0 0 1 2 3
9 2 2 4 17
27 14 8 9 58
8 11 9 4 32
1 4 3 0 8
1 0 1 0 2
46 31 24 19 120
Standard Chair Dangle Stand/march Walk Total
0 0 0 0 0
10 0 3 4 17
44 17 8 6 75
8 9 1 4 22
1 1 0 0 2
0 2 0 0 2
63 29 12 14 118
Table 3 Activity time, preparation time, and number of staff by activity type
Results
Mean (SD) Variable
Platform
Activity time, min Chair Dangle Stand/march Walk Total Preparation time, min Chair Dangle Stand/march Walk Total No. of staff Chair Dangle Stand/march Walk Total
Standard
79.07 8.97 9.31 39.53 39.51
(68.53) (4.09) (5.39) (36.80) (54.05)
62.56 (49.30) 12.20 (7.40) 19.64 (20.48) 31.25 (40.63) 41.87 (45.03)
4.85 5.00 4.39 3.95 4.65
(4.51) (3.39) (2.97) (3.34) (3.75)
3.75 4.60 3.00 6.31 4.17
(2.81) (3.39) (4.22) (5.50) (3.55)
2.08 2.55 2.58 1.79 2.26
(0.81) (0.81) (1.10) (0.92) (0.93)
2.00 2.59 1.83 2.00 2.13
(0.60) (0.87) (0.58) (0.78) (0.73)
with the patient’s participation. Bed in chair position did not require patients to use their muscles or actively participate. This stage is a safety check to see if the patient can tolerate mobility without significant changes in their vital signs. Statistical Analysis Analysis includes a description of the activities observed. The total numbers of activities (activity sample size) for both treatments are reported. Activity sample size is further classified according to the type of activity and the number of staff required for each activity.
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To assess the impact of the platform on activity time, preparation time, number of staff, falls, and unintended tube removals (endotracheal, gastric, urinary, chest, and drains), means and standard deviations are reported for both treatments, by type of activity. To evaluate the significance of the differences in mean activity time, preparation time, number of staff, falls, and unintended tube removals between treatments, a mixed Poisson log-linear count regression model is applied.13 This model will account for the skewness inherent in the strictly positive data observed (activity and preparation times; staff, fall, and tube removal counts). The model is mixed with a normal random effect to account for repeated observation of patients. The independent variables included are treatment (platform/standard) and type of activity, along with an interaction between the 2 variables. Analyses were performed by using SAS version 9.3.
No unintended tube removals or falls were recorded, so safety is not addressed further. The data set included 118 observations of standard activities and 120 observations of platform activities. Table 2 provides descriptive statistics of the activities observed for both treatments. The table shows the number of activities according to the number of staff required, by activity type. Activities involved between 0 and 5 staff, with 2 staff the most common (133 activities with 2 staff). The type of staff was not included in the study. The ICU nurse is responsible for determining if the patient is safe for mobility and to ensure that mobility occurs. Of the 238 activities, 60 involved a dangle, 109 progressed to the chair, 38 involved standing/marching in place, and 33 involved walking. The number of stand/walk activities was greater for the platform (24 activities) than for standard equipment (12 activities). Similarly, the number of walking activities was greater for the platform (19 activities) than for standard equipment (14 activities). To assess the effectiveness of the platform, means and standard deviations of activity times by type of activity, for both treatments, are reported in Table 3. Both treatments showed large amounts of variation in activity time. Although the standard equipment showed longer mean activity times for a dangle or a stand/march in place, the mean activity times for a walk was greater for platform patients (39.53 minutes) than for standard patients (31.25 minutes). Thus the platform may be more effective in terms of activity time when patients walk. Using
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a mixed Poisson count regression (MPCR) model, accounting for repeated observation of patients and controlling for the effect of different activity types, no significant difference was found in mean activity time between the platform and standard treatments (P = .62). To assess the efficiency of the platform in terms of time, means and standard deviations of preparation times by type of activity, for both treatments, are reported in Table 3. Although the standard equipment showed faster preparation times for a sit, dangle, or stand/march, the mean preparation time was shorter for platform patients (3.95 minutes) than for standard patients (6.31 minutes) who walk. Therefore, the platform may be more efficient in terms of preparation time with patients who walk. Using another MPCR model, no significant difference was found in mean activity time between the platform and standard treatments (P = .19). To assess the efficiency of the platform in terms of staff, means and standard deviations of number of staff by type of activity, for both treatments, are reported in Table 3. Use of the platform allowed 3 patients to be active without the help of any staff (1 stand/march, 2 walk), whereas no standard patients were active without the help of any staff. For patients involved in walking, use of the platform allowed fewer staff to be involved on average (1.79) than was possible with standard treatment (2.00). This result suggests that the platform may be more efficient in terms of required staff with patients who walk and in terms of encouraging individual activity. Using another MPCR model, a marginally significant difference was found in mean activity time between the platform and standard treatments (P = .08), with the platform showing lower mean staff expected after the differences in mean staff across activity types were accounted for.
Discussion Although the study findings were not statistically significant, several very important descriptive statistics were discovered. No information documenting the resources required to mobilize ICU patients has been published; this study documents the human resources needed. Most of the time, 2 staff members were required to mobilize the patient, with a preparation time of 5 minutes. The most frequent activity is getting up and into the chair, and the patient stays up approximately 40 minutes. Mobilizing patients to the chair was also the most frequent activity in a study conducted by Bourdin et al14 published in 2010. Nurses can use this information when planning a mobility program
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and workflow in the ICU. The study did not show any significantly improved efficiency, effectiveness, or safety with the platform compared with standard equipment, proving to ICU nurses that they can mobilize ICU patients with the equipment they have available. New equipment may be less efficient for the nurses to use than equipment with which they are familiar. That possibility, coupled with the low sample size, could have affected statistical significance. The preparation for the research study provided training to the ICU nurses in using gait belts to assist with mobilizing patients out of bed, thus improving safety for both staff and patients. The safety checklist provided for the nurses to use before activity to ensure a standard process during the research study could be used in other mobility protocols. The study validated that the mobility protocol is safe; there were no falls, unplanned tube removals, or emergency events. Two other studies15,16 report similar results, an unplanned tube removal rate of 0.8% in 1 study,15 and 1 unplanned tube removal and no falls in a different study of 75 patients.16 Allowing the nurses to prove that the mobility protocol was safe had a huge impact in changing the culture of the ICU. In order to change culture, the nurses’ perceptions and teamwork must be addressed. During the research study, the nurses had the opportunity to change their perception as they witnessed successful mobility. A study done by Thomsen et al17 in 2008 illustrated the importance of culture; the strongest predictor of a patient ambulating was the ICU to which they were admitted. Patients admitted to the respiratory ICU, where mobility is a key clinical intervention, had a statistically significant increase in ambulation. Mobilizing ICU patients is demanding: the ICU nurses must be committed to coordination of care and teamwork. The nurses need to see the connection between mobilizing their ICU patients and the patients’ outcomes. The research study allowed the ICU nurses to test the protocol, determine it was safe, define how they would implement the practice, and ultimately to see the difference it made for their patients. Six months before the research study, the mobility protocol used in the research study had been implemented in the ICU; however, practice had not changed. The goal of the research study was to compare equipment needs for mobility, but the unintended result of the study was a change in the individual nurses’ perceptions and beliefs regarding
Activity time did not differ significantly between the platform and standard equipment.
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mobility. It is unclear what part of the research process created this change: increased education, changes in equipment, the rigor of a research study, or a combination of factors. The net result was an improvement in mobility of ICU patients. Although not reported as part of this research study but tracked for quality purposes, the percentage of patients who are mobilized in the ICUs has increased fourfold. Similar results were found in a study published by Drolet et al18: implementation of a nurse-driven protocol increased ambulation of ICU patients from 6.2% to 20.2%, and even bigger increases were seen in the intermediate unit. The nurses proved to themselves the value of early mobility and the value of bedside research in changing clinical practice. It has changed the culture not just with mobility but also with sedation. Patients have to be awake to participate in mobility. Numerous recently published studies5,19-24 have documented the value of lighter sedation of patients undergoing mechanical ventilation. This experience has empowered the nurses to make other decisions about changing their practice to improve patient care. Limitations and Strengths Our study had several limitations. It was a single-site study; however, both medical and surgical patients were included in the sample. The study lacked a sample size large enough to establish statistical significance, but the number was adequate for descriptive statistics. The activity times of selected patients varied, reducing the power of associated tests. Mobility was not correlated with severity of illness, use of mechanical ventilation, or sedation levels. The sample includes patients receiving mechanical ventilation and patients who were not. Results are not stratified on the basis of severity of illness, mechanical ventilation, or sedation levels. Adding this information to future studies would be important for ICU practice. The study did not address evaluation of patients’ participation or effort. The scope of the study did not include collection of data regarding readmission or post-ICU outcomes. The study results were not correlated with ICU length of stay, days of mechanical ventilation, delirium rates, or hospital length of stay. These outcomes are already well established in published reports, so our limited resources were not used for this correlation.
Conclusion Conducting the mobility research study promoted both earlier initiation and progression of mobility in the ICU. The study demonstrated that a nursedriven protocol can be effective. It is clear from this
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study as well as recent publications that early mobility is both safe and feasible. Actualizing a mobility protocol does require interruption in sedation or nonsedated ICU patients, so that the patient can participate. Further research is needed to determine the optimal amount of activity for ICU patients. FINANCIAL DISCLOSURES None reported.
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REFERENCES 1. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35(1):139-145. doi: 10.1097/01.CCM.0000251130 .69568.87 2. Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010;91:536-542. doi:10.1016/j.apmr.2010.01.002. 3. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet. 2009;373:1874-1882. doi:10.1016/S0140-6736(09)60658-9. 4. Winkelman C, Johnson KD, Hejal R, et al. Examining the positive effects of exercise in intubated adults in ICU: a prospective repeated measure clinical study. Intensive Crit Care Nurs. 2012;28:307-320. 5. Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the ‘ABCDE’ approach. Curr Opin Crit Care. 2011;17:43-49. doi:10.1097/MCC.0b013e3283427243. 6. Morris PE. Moving our critically ill patients: mobility barriers and benefits. Crit Care Clin. 2007;23(1):1-14. doi:10.1016 /j.ccc.2006.11.003. 7. Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008;300(14):1685-1690. doi:10.1001/jama .300.14.1685. 8. Truong AD, Fan E, Brower RG, Needham DM. Bench-tobedside review: mobilizing patients in the intensive care unit: from pathophysiology to clinical trials. Crit Care Forum. 2009;13:216-224. doi:10.1186/cc7885. 9. Morris PE, Griffin L, Berry M, et al. Receiving early mobility during an ICU admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci. 2011;341(5): 373-377. doi:10.1097/MAJ.0b013e31820ab4f6. 10. Bailey PP, Miller RR, Clemmer TP. Culture of early mobility in mechanically ventilated patients. Crit Care Med. 2009;37: S429-S435. doi:10.1097/CCM.0b013e3181b6e227. 11. Zomorodi M, Topley D, McAnaw M. Developing a mobility protocol for early mobilization of patients in a surgical/ trauma ICU. Crit Care Res Pract. 2012:1-10. doi:10.1155/2012 /964547. 12. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method—a new method for detection of delirium. Ann Intern Med. 1990;113(12):941-948. 13. Lee Y, Nelder JA, Pawitan Y. Generalized Linear Models With Random Effects. Boca Raton, FL: Chapman & Hall/CRC:2006. 14. Bourdin G, Barbier J, Burle J-F. The feasibility of early physical activity in intensive care unit patients: a prospective observational one-center study. Respir Care. 2010;55(4): 400-407. 15. Pohlman MC, Schweichert WD, Pohlman AS, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med. 2010; 38(11):2089-2094. doi:10.1097/CCM.0b013e3181f270c3. 16. Winkelman C, Johnson KD, Hejal R, et al. Examining the
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positive effects of exercise in intubated adults in ICU: a prospective repeated measures clinical study. Intensive Crit Care Nurs. 2012;28:307-320. Thomsen GE, Snow GL, Rodriquez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med. 2008;36(4):1119-1124. Drolet A, Dejuilio P, Harkless S, et al. Move to improve: the feasibility of using an early mobility protocol to increase ambulation in the intensive and intermediate care setting. Phys Ther J. 2012;93(2). doi:10.2522/ptj.20110400. Kress JP. Sedation and mobility: changing the paradigm. Crit Care Clin. 2013;29:67-75. doi:10.1016/j.ccc.2012.10.001. Strom T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomized controlled trial. Lancet. 2010;375(9713):475-480. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): a randomized controlled trial. Lancet. 2008;371(9607):126-134.
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22. Barr J, Gilles FL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263-306. doi:10.1097/CCM.0b013e3182783b72. 23. Skrobik Y, Ahern S, Leblanc M, et al. Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal delirium rates. Anesth Analg. 2010;111(2):451-463. 24. Salgado DR, Favory R, Goulart M, Brimiolle S, Vincent JL. Toward less sedation in the intensive care unit: a prospective observational study. J Crit Care. 2011;26(2):113-121. doi:10.1016/j.jcrc.2010.11.003.
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AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2014 by AACN. All rights reserved.
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Early Mobility in Critical Care
E
MOBILITY IN THE INTENSIVE CARE UNIT: STANDARD EQUIPMENT VS A MOBILITY PLATFORM ARLY
By Melanie Roberts, MS, APRN, CCRN, CCNS, Laura Adele Johnson, RN, BSN, CCRN, and Trent L. Lalonde, PhD
EBR
Evidence-Based Review on pp 458-459 ©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2014878
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Background Despite the general belief that mobility and exercise play an important role in the recovery of functional status, mobility is difficult to implement in patients in intensive care units. Objectives To compare a mobility platform with standard equipment, assessing efficiency (decreased time and staff required to prepare patient), effectiveness (increased activity time), and safety (no falls, unplanned tube removals, or emergency situations) for intensive care patients. Methods This observational study was approved by the institutional review board, and informed consent was obtained from the patient or the medical decision maker. Intensive care patients were assigned to a room in the usual manner, with platforms in odd-numbered rooms and standard equipment in even-numbered rooms. Standardized data collection tools were designed to collect data for 24 hours for each patient. The nurses caring for the patients completed the data collection tools in real time during the activity. The stages of activity and the physiological states that would preclude mobility were very specifically defined for the research study. Results Data were collected for a total of 71 patients and 238 activities. Important (although not significant) descriptive statistics regarding early mobility in the intensive care unit were discovered. The unintended result of the research study was a change in the culture and practice regarding early mobility in the intensive care unit. Conclusions Early mobility can be implemented in intensive care units. Standard equipment can be used to mobilize such patients safely; however, for patients who ambulate, a platform may increase efficiency and effectiveness. (American Journal of Critical Care. 2014;23:451-457)
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D
espite the general belief that mobility and exercise play an important role in the recovery of functional status, mobility is difficult to implement in patients in intensive care units (ICUs). Several studies1-4 in the past 2 decades have documented the outcomes of early mobility in critical care. Early and frequent mobilization of ICU patients decreases hospital length of stay, ICU length of stay, and ventilator days.1-4 Common critical care complications, neuromuscular weakness, deconditioning, and delirium are decreased with early mobility.2,5-8 Morris et al9 demonstrated that the lack of early mobility therapy in ICUs was 1 of the 4 variables associated with readmission or death during the first year for ICU survivors of acute respiratory failure.
Hospitals nationwide are attempting to develop mobility programs, but actualizing the goal is difficult. Lack of resources, a lack of established protocols, and staff resistance prevent many facilities from implementing a successful mobility program.10 Numerous articles exist indicating the importance of mobilization; however, little detail can be found to explain how to implement a successful mobility program. Published reports demonstrate the importance of mobility protocols in determining individual patients’ appropriateness for mobility and to define progression of mobility, but few such protocols have been published.11 The culture of the ICU must be addressed early in any initiative to implement a mobility program. Successful implementation of early mobility requires a change in ICU culture, nurses’ personal perceptions, and teamwork.10 This article describes how a community-based hospital developed a mobility program despite limited resources and changed the culture of the ICU to accept the challenge of mobilizing patients.
Lack of early mobility is associated with readmission to the intensive care unit or death during the first year.
About the Authors Melanie Roberts is a critical care Clinical Nurse Specialist at Medical Center of the Rockies in Loveland, Colorado. Laura Adele Johnson is a student registered nurse anesthetist at Westminster College in Salt Lake City, Utah. Trent L. Lalonde is an associate professor of applied statistics at the University of Northern Colorado and a statistical consultant at the Medical Center of the Rockies. Corresponding author: Melanie Roberts, MS, APRN, CCRN, CCNS, Medical Center of the Rockies, 2500 Rocky Mountain Avenue, Loveland, CO 80538 (e-mail: Melanie.Roberts@ uchealth.org).
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Methods Setting The study was completed at Medical Center of the Rockies, a 136-bed nonprofit, tertiary care hospital. Clinical areas involved in the research study included a 12-bed cardiac/cardiovascular surgery ICU (CICU) and a 12-bed surgical/trauma ICU (SICU). Mobility stages had been implemented in the ICUs before the study but were not integrated into practice. A research protocol was designed to identify human resources required for early mobility in the ICU, to compare standard equipment with a platform, and to validate the safety of the protocol. Sample The study included all intensive care patients who were at least 18 years old and spoke English. Critical care patients are a vulnerable population of patients; many are unable to make decisions because of cognitive impairment from medications and critical illness. To protect the patients, informed consent was obtained from individual patients if their results on the Confusion Assessment Method12 were normal and the patient was not receiving any sedatives or pain medication. If the patient did not meet both criteria, the patient’s medical decision maker provided consent. Consent was obtained by specially trained ICU nurses at an appropriate time after the patient had been admitted to the ICU, depending on the patient’s condition and planned mobility. For planned ICU admissions, consent was obtained before admission. Data were collected for 4 months, with a total of 71 patients enrolled in the study and 238 total mobility events. Of the 71 patients, 26 (37%) were female with a mean age of 66.00 (SD, 19.76) years, whereas the 45 males (63%) had a mean age of 68.62 (SD, 12.43) years. A total of 49 patients (69%) were in the CICU and 22 (31%) were in the SICU. The
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Table 1 Stages of mobility
CICU patients consisted of 15 females (31%) and 34 males (69%), with a mean age of 69.79 (SD, 12.37) years. The platform was assigned to 23 (47%) of the CICU patients. The SICU patients consisted of 11 females (50%) and 11 (50%) males, with a mean age of 62.91 (SD, 20.24) years. The platform was assigned to 12 (55%) of the SICU patients. Design A prospective, randomized, controlled, observational research study was designed to compare a platform with standard equipment for ICU patients. The research hypothesis stated expected improvements in efficiency, effectiveness, and safety of ICU mobility when the platform was used rather than standard equipment. Effectiveness is defined as the duration of activity performed by the patient. Efficiency is defined as the time to prepare the patient for mobility as well as the number of staff required to assist the patient with the activity. Safety is defined by the number of falls or unplanned tube removals. The standard equipment used for the study includes a gait belt, no-slip socks, a walker, and a wheelchair if the patient was ambulating. The platform is a mobile support device that consolidates equipment (intravenous poles, multiple hooks for drainage bags, and a secure location for oxygen) into a small area. The patient still requires a gait belt and no-slip socks for safety. The design of the platform is to allow mobility with the assistance of fewer staff. All patients were monitored, had oxygen, and if the patient was receiving mechanical ventilation, a respiratory therapist had to be part of the mobility team. The study was approved by the organization’s institutional review board. Platforms were placed in odd-numbered rooms. Patients were admitted to rooms by the usual process. Data were collected by the ICU nurses during the activity session, and time was documented to the nearest minute. Standardized data collection sheets were used to ensure that all appropriate information was recorded. The following information was collected for each activity: date, time of day, preparation time (minutes), activity time (minutes), type of activity (chair, dangle, stand or march in place, walk), number of staff required, frequency of activities per patient per day, and unplanned tube removals or falls. Each patient had a data collection sheet for each day, starting at midnight with the new ICU flow sheet. Before the beginning of the study, the nurses had 2 weeks to practice with the platform as well as the data collection sheets to ensure that the data collection process would work as expected. This process allowed nurses
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Stage
Activity
Research requirement
1
Bed in chair position
Not part of the research study
2
Dangle legs at edge of bed
Minimum 2 min
3
Stand upright, weight bearing
Minimum 1 min
4
Chair, stand, pivot/march
Minimum 15 min in chair
5
Ambulate
Minimum 10 ft (3 m)
to reeducate themselves on the equipment and the data collection tool as needed before data collection. During the 2 weeks before the study, the nurses were given instructions by physical therapists on the proper method for assisting a patient out of bed to the chair and getting the patient back to bed using a gait belt to promote staff and patient safety. The data collection sheets were gathered weekly and correlated with informed consent. If consent had been obtained, the data sheets were entered into a data spreadsheet. If consent had not been obtained, the data collection sheet was shredded The ICU nurses determined that it was easier to collect the data sheets every day for all patients to avoid bias created by their knowledge of who was enrolled in the study. The nurses were using a mobility protocol with which they were familiar except for the addition of the platform. The mobility protocol used had 5 stages (Table 1), with specific definitions given for each stage. ICU nurses were responsible for determining whether it was safe for the patient to mobilize. The expectation of the ICU nurse is to use the absolute exclusion criteria and relative contraindications to determine the patient’s ability to mobilize. Patients start the protocol after 24 hours unless they meet 1 of the exclusion criteria. The absolute exclusion criteria are based on the patient’s physiological condition: intracranial monitor, unstable pelvic or spinal fractures, physician’s order for deep sedation, therapeutic hypothermia, vasoactive medication titration, active bleeding, intra-aortic balloon pump or ventricular assist device, comatose, open abdomen, and traction. Relative contraindications such as vasoactive infusions or changes in respiratory status or vital signs are determined by the nurse caring for the patient. Stage 1 activity, bed in chair position, would not be included in the research study as mobility. Before the research study, the ICU had determined that mobility would be defined as purposeful movement
Mobility was defined as purposeful movement with the patient’s participation.
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Table 2 Sample size of activities (n) for number of staff, by activity type No. of staff Activity
0
1
2
3
4
5
Total
Platform Chair Dangle Stand/march Walk Total
0 0 1 2 3
9 2 2 4 17
27 14 8 9 58
8 11 9 4 32
1 4 3 0 8
1 0 1 0 2
46 31 24 19 120
Standard Chair Dangle Stand/march Walk Total
0 0 0 0 0
10 0 3 4 17
44 17 8 6 75
8 9 1 4 22
1 1 0 0 2
0 2 0 0 2
63 29 12 14 118
Table 3 Activity time, preparation time, and number of staff by activity type
Results
Mean (SD) Variable
Platform
Activity time, min Chair Dangle Stand/march Walk Total Preparation time, min Chair Dangle Stand/march Walk Total No. of staff Chair Dangle Stand/march Walk Total
Standard
79.07 8.97 9.31 39.53 39.51
(68.53) (4.09) (5.39) (36.80) (54.05)
62.56 (49.30) 12.20 (7.40) 19.64 (20.48) 31.25 (40.63) 41.87 (45.03)
4.85 5.00 4.39 3.95 4.65
(4.51) (3.39) (2.97) (3.34) (3.75)
3.75 4.60 3.00 6.31 4.17
(2.81) (3.39) (4.22) (5.50) (3.55)
2.08 2.55 2.58 1.79 2.26
(0.81) (0.81) (1.10) (0.92) (0.93)
2.00 2.59 1.83 2.00 2.13
(0.60) (0.87) (0.58) (0.78) (0.73)
with the patient’s participation. Bed in chair position did not require patients to use their muscles or actively participate. This stage is a safety check to see if the patient can tolerate mobility without significant changes in their vital signs. Statistical Analysis Analysis includes a description of the activities observed. The total numbers of activities (activity sample size) for both treatments are reported. Activity sample size is further classified according to the type of activity and the number of staff required for each activity.
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To assess the impact of the platform on activity time, preparation time, number of staff, falls, and unintended tube removals (endotracheal, gastric, urinary, chest, and drains), means and standard deviations are reported for both treatments, by type of activity. To evaluate the significance of the differences in mean activity time, preparation time, number of staff, falls, and unintended tube removals between treatments, a mixed Poisson log-linear count regression model is applied.13 This model will account for the skewness inherent in the strictly positive data observed (activity and preparation times; staff, fall, and tube removal counts). The model is mixed with a normal random effect to account for repeated observation of patients. The independent variables included are treatment (platform/standard) and type of activity, along with an interaction between the 2 variables. Analyses were performed by using SAS version 9.3.
No unintended tube removals or falls were recorded, so safety is not addressed further. The data set included 118 observations of standard activities and 120 observations of platform activities. Table 2 provides descriptive statistics of the activities observed for both treatments. The table shows the number of activities according to the number of staff required, by activity type. Activities involved between 0 and 5 staff, with 2 staff the most common (133 activities with 2 staff). The type of staff was not included in the study. The ICU nurse is responsible for determining if the patient is safe for mobility and to ensure that mobility occurs. Of the 238 activities, 60 involved a dangle, 109 progressed to the chair, 38 involved standing/marching in place, and 33 involved walking. The number of stand/walk activities was greater for the platform (24 activities) than for standard equipment (12 activities). Similarly, the number of walking activities was greater for the platform (19 activities) than for standard equipment (14 activities). To assess the effectiveness of the platform, means and standard deviations of activity times by type of activity, for both treatments, are reported in Table 3. Both treatments showed large amounts of variation in activity time. Although the standard equipment showed longer mean activity times for a dangle or a stand/march in place, the mean activity times for a walk was greater for platform patients (39.53 minutes) than for standard patients (31.25 minutes). Thus the platform may be more effective in terms of activity time when patients walk. Using
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a mixed Poisson count regression (MPCR) model, accounting for repeated observation of patients and controlling for the effect of different activity types, no significant difference was found in mean activity time between the platform and standard treatments (P = .62). To assess the efficiency of the platform in terms of time, means and standard deviations of preparation times by type of activity, for both treatments, are reported in Table 3. Although the standard equipment showed faster preparation times for a sit, dangle, or stand/march, the mean preparation time was shorter for platform patients (3.95 minutes) than for standard patients (6.31 minutes) who walk. Therefore, the platform may be more efficient in terms of preparation time with patients who walk. Using another MPCR model, no significant difference was found in mean activity time between the platform and standard treatments (P = .19). To assess the efficiency of the platform in terms of staff, means and standard deviations of number of staff by type of activity, for both treatments, are reported in Table 3. Use of the platform allowed 3 patients to be active without the help of any staff (1 stand/march, 2 walk), whereas no standard patients were active without the help of any staff. For patients involved in walking, use of the platform allowed fewer staff to be involved on average (1.79) than was possible with standard treatment (2.00). This result suggests that the platform may be more efficient in terms of required staff with patients who walk and in terms of encouraging individual activity. Using another MPCR model, a marginally significant difference was found in mean activity time between the platform and standard treatments (P = .08), with the platform showing lower mean staff expected after the differences in mean staff across activity types were accounted for.
Discussion Although the study findings were not statistically significant, several very important descriptive statistics were discovered. No information documenting the resources required to mobilize ICU patients has been published; this study documents the human resources needed. Most of the time, 2 staff members were required to mobilize the patient, with a preparation time of 5 minutes. The most frequent activity is getting up and into the chair, and the patient stays up approximately 40 minutes. Mobilizing patients to the chair was also the most frequent activity in a study conducted by Bourdin et al14 published in 2010. Nurses can use this information when planning a mobility program
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and workflow in the ICU. The study did not show any significantly improved efficiency, effectiveness, or safety with the platform compared with standard equipment, proving to ICU nurses that they can mobilize ICU patients with the equipment they have available. New equipment may be less efficient for the nurses to use than equipment with which they are familiar. That possibility, coupled with the low sample size, could have affected statistical significance. The preparation for the research study provided training to the ICU nurses in using gait belts to assist with mobilizing patients out of bed, thus improving safety for both staff and patients. The safety checklist provided for the nurses to use before activity to ensure a standard process during the research study could be used in other mobility protocols. The study validated that the mobility protocol is safe; there were no falls, unplanned tube removals, or emergency events. Two other studies15,16 report similar results, an unplanned tube removal rate of 0.8% in 1 study,15 and 1 unplanned tube removal and no falls in a different study of 75 patients.16 Allowing the nurses to prove that the mobility protocol was safe had a huge impact in changing the culture of the ICU. In order to change culture, the nurses’ perceptions and teamwork must be addressed. During the research study, the nurses had the opportunity to change their perception as they witnessed successful mobility. A study done by Thomsen et al17 in 2008 illustrated the importance of culture; the strongest predictor of a patient ambulating was the ICU to which they were admitted. Patients admitted to the respiratory ICU, where mobility is a key clinical intervention, had a statistically significant increase in ambulation. Mobilizing ICU patients is demanding: the ICU nurses must be committed to coordination of care and teamwork. The nurses need to see the connection between mobilizing their ICU patients and the patients’ outcomes. The research study allowed the ICU nurses to test the protocol, determine it was safe, define how they would implement the practice, and ultimately to see the difference it made for their patients. Six months before the research study, the mobility protocol used in the research study had been implemented in the ICU; however, practice had not changed. The goal of the research study was to compare equipment needs for mobility, but the unintended result of the study was a change in the individual nurses’ perceptions and beliefs regarding
Activity time did not differ significantly between the platform and standard equipment.
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mobility. It is unclear what part of the research process created this change: increased education, changes in equipment, the rigor of a research study, or a combination of factors. The net result was an improvement in mobility of ICU patients. Although not reported as part of this research study but tracked for quality purposes, the percentage of patients who are mobilized in the ICUs has increased fourfold. Similar results were found in a study published by Drolet et al18: implementation of a nurse-driven protocol increased ambulation of ICU patients from 6.2% to 20.2%, and even bigger increases were seen in the intermediate unit. The nurses proved to themselves the value of early mobility and the value of bedside research in changing clinical practice. It has changed the culture not just with mobility but also with sedation. Patients have to be awake to participate in mobility. Numerous recently published studies5,19-24 have documented the value of lighter sedation of patients undergoing mechanical ventilation. This experience has empowered the nurses to make other decisions about changing their practice to improve patient care. Limitations and Strengths Our study had several limitations. It was a single-site study; however, both medical and surgical patients were included in the sample. The study lacked a sample size large enough to establish statistical significance, but the number was adequate for descriptive statistics. The activity times of selected patients varied, reducing the power of associated tests. Mobility was not correlated with severity of illness, use of mechanical ventilation, or sedation levels. The sample includes patients receiving mechanical ventilation and patients who were not. Results are not stratified on the basis of severity of illness, mechanical ventilation, or sedation levels. Adding this information to future studies would be important for ICU practice. The study did not address evaluation of patients’ participation or effort. The scope of the study did not include collection of data regarding readmission or post-ICU outcomes. The study results were not correlated with ICU length of stay, days of mechanical ventilation, delirium rates, or hospital length of stay. These outcomes are already well established in published reports, so our limited resources were not used for this correlation.
Conclusion Conducting the mobility research study promoted both earlier initiation and progression of mobility in the ICU. The study demonstrated that a nursedriven protocol can be effective. It is clear from this
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study as well as recent publications that early mobility is both safe and feasible. Actualizing a mobility protocol does require interruption in sedation or nonsedated ICU patients, so that the patient can participate. Further research is needed to determine the optimal amount of activity for ICU patients. FINANCIAL DISCLOSURES None reported.
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