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Implementation of Early Exercise and Progressive Mobility: Steps to Success

2015; American Association of Critical-Care Nurses; Volume: 35; Issue: 1 Linguagem: Inglês

10.4037/ccn2015701

1940-8250

Melody Campbell, Julie Fisher, L.J. Anderson, E. Kreppel,

Family and Patient Care in Intensive Care Units

A new bundle of interventions to improve the care of critically ill patients receiving mechanical ventilation has been identified.1,2 This bundle incorporates performance and coordination of spontaneous awakening trials and spontaneous breathing trials; careful selection of sedatives; assessment, prevention, and management of delirium; and early exercise with progressive mobility.1,2 In collaboration with the Institute for Healthcare Improvement, and as a part of a critical care collaborative, our hospital had implemented many parts of the bundle, but early exercise and progressive mobility had not yet been incorporated into care. In this article, we share our process for literature review, appraisal, and synthesis along with protocol development. An evidence-based performance improvement (EBPI) model was used to plan, implement, and disseminate the change.3 High-fidelity human simulation boosted confidence and teamwork and also underscored important safety aspects before implementation. Unit champions and daily multidisciplinary rounding assisted with culture change.Electronic databases searched for evidence included Cochrane, PubMed, and CINAHL. Key words included mechanical ventilation, critically ill, critical illness, early mobilization protocol, delirium, intensive care unit, early mobility, sedation, physical rehabilitation, and physical therapy. In CINAHL, limits included research, English, human, and all adults. Related citations were reviewed in PubMed with limitations of clinical trials, human, English, and publication between 2007 and 2012. References from key articles were reviewed to search for additional evidence. Articles were included in the appraisal if content focused on early mobility in critically ill patients receiving mechanical ventilation.Articles were rated by strength of evidence.4 Level 1 evidence, that established by meta-analysis or systemic review (and also the highest level of evidence) was not found. No Cochrane reviews or national practice guidelines that were related to the subject had been published between 2007 and 2012. Since that time, a clinical practice guideline2 related to pain, agitation, and delirium in the critically ill has been published. Seven keeper articles were identified.5–11The articles were shared and discussed with our multidisciplinary team. From these articles, the team determined that early activity had been demonstrated to be safe and feasible7,8 and that early mobility was associated with an increase in both delirium-free days and ventilator-free days.5,6,10 Some studies noted that the implementation of early mobility contributed to decreases in length of stay in both intensive care units (ICUs) and hospitals.9,10 An additional article11 discussed barriers and facilitators to implementation of early mobility. Barriers included sedation, decreased level of consciousness, and agitation. Factors that facilitated change were the presence of a protocol and the presence of unit champions.11 The multidisciplinary team decided that the evidence was sufficient for us to implement the practice of early mobility for our patients.While our team was planning implementation of early mobility, we elected to be a part of an expedition on early mobility sponsored by the Institute for Healthcare Improvement. The expedition was a series of webinars that included presentations of the science surrounding early mobility and assisted with protocol development and implementation planning. We invited various departments (respiratory therapy, physical and occupational therapy, pharmacy) and our medical director to attend the webinars. We ensured that ICU nursing staff, who would act as unit champions, could attend. The webinar communicated the importance of early mobility and the evidence supporting the change.Our early mobility protocol (Figure 1) was developed after careful reading of 2 key articles: a randomized controlled trial and a descriptive study that detailed the intervention arm of that same trial.5,6 The protocol was reviewed by the multidisciplinary team and by several critical care intensivists. The protocol included contraindications to initiating early mobility designated by a yellow text box indicating caution. Once the patient had no contraindications, preparation of early mobility would begin, designated by a green text box indicating that the patient was ready to go. Preparing for early mobility would include assessing and securing all devices, stopping tube feeding, and moving all catheters, intravenous pumps, and the urinary catheter drainage bag to the side of the bed with the ventilator. Activity would progress from active range-of-motion exercises to bed mobility exercises (lateral rolling, move from semirecumbent to upright), sitting on the edge of the bed, sitting to/from standing and bed to/from chair transfers, and finally ambulation. An additional red box was included in the protocol that delineated contraindications to continuing early mobility. If the patient experienced physiological changes such as hemodynamic instability, or oxygen desaturation, activity would be stopped.An additional flowchart (Figure 2) was created to visualize and teach others how early mobility would fit into our process of coordination of spontaneous awakening trials and spontaneous breathing trials.Our plan for implementation was written and reviewed by our hospital's Human Institutional Review Committee and the university's institutional review board. We wanted to collect patient data during the implementation of our project to monitor process and outcomes and wanted to ensure the safety of that data collection and dissemination of results.The final aspects of planning for practice change included creating an aim statement. Using our EBPI model, an aim statement would help us to know whether we had reached a short-term goal in our implementation. Working with our medical director, we determined that our aim statement would be: By month 3 of the project, early mobility would be incorporated into the care of 25% of patients receiving mechanical ventilation (as appropriate). The implementation steps in accordance with our EBPI model are listed in Table 1.One of our physical therapists had read an article about the use of high-fidelity human simulation to teach physical therapy students. Training with simulation helped improve the students' confidence before they started getting clinical experience in an actual ICU.13 The physical therapist expressed a desire to try our protocol by using simulation first so that the team could practice together to ensure that the protocol was easy to understand and that safety concerns were addressed. Her main concern was related to accidental extubation of a patient, and she wanted us to plan the steps of how we would care for a patient who experienced that serious adverse event. We developed 3 simulation scenarios (see Table 2 for examples):The project leader/clinical nurse specialist worked with the personnel in the simulation laboratory to prepare for practice. Intravenous pumps, a tube feeding pump, a sequential compression device, a ventilator, a manual resuscitation bag, a cardiac monitor, a walker, and a transport ventilator were transported to the laboratory. The simulation laboratory was set up with the appropriate equipment to look like one of our ICU rooms. Nursing unit champions, physical therapists, occupational therapists, and respiratory therapists participated. The clinical nurse specialist reviewed the draft protocol, including the sections on contraindications for early mobility, preparation of the patient, progression of activity, and when to stop activity if the patient's condition changed. Additionally, the flowchart of how early mobility would be incorporated into our current process was reviewed and discussed.The simulation began and the group focused on how to begin to move the patient. Discussion was intense, with brainstorming about the roles and responsibilities of each of the team members. When the patient needed to move from sitting at the edge of the bed to standing or transfering to a chair, a team member was substituted for the patient simulator so that the team could practice standing the patient at the bedside and ambulation in the hallway. Proper body mechanics and safe handling of patient were emphasized. The group thoroughly enjoyed the simulation and found that the "hands-on" approach boosted confidence. Four priorities were identified for implementation of the protocol with a "real" patient:Small tests of change were used to begin the implementation. After each test, the multidisciplinary team reviewed how things went. The protocol flowed well and was easily understood. The team, having gained confidence through the use of simulation, worked well together and the patients were safe. Next steps involved teaching others about early mobility and disseminating the practice. The physical medicine and rehabilitation department conducted several in-service training sessions with their staff and added written and oral competencies to ensure staff knowledge and patient safety. Nurses and respiratory therapists conducted training during staff meetings as well as special educational conferences focused on the bundle. We used a slogan of "Mobility Is Medicine" and provided slogan buttons to those staff members who had cared for a patient during early mobility. We also purchased cookies shaped like feet and emphasized "Feet to the Floor." This added fun and helped create some excitement regarding the change. Daily multidisciplinary rounding helped to determine which patients were ready for early mobility and supported staff during implementation. The team met every 2 weeks in conjunction with the medical director. Problems encountered with the practice change were discussed and methods to improve implementation were developed. Constant communication with all the specialties involved was done through staff meetings, electronic mail, bulletin boards, and departmental publications.The patient's experience was also explored. One patient whom we interviewed after he had been extubated indicated that he enjoyed being up while connected to the ventilator. He had severe chronic obstructive disease and had received mechanical ventilation before. He felt that he was ready to move before the team was ready, and when he began to ambulate out of his room, he felt that he could have walked much further but the team was "nervous." He walked the next day around the whole perimeter of the ICU. He stated that "it felt good to get out and walk because there is nothing else to do in the ICU" and "it made it more interesting." The exercise made him feel like he was improving.Creating organizational memory and knowledge reservoirs were important mechanisms in our hospital to help with sustaining practice.14 In our electronic medical record, we were able to create files to hold resource documents. Our early mobility protocol was placed in these files for ease of reference at each computer terminal. We revised our mechanical ventilator order set (computer physician order entry) to include prechecked orders for early mobility as well as consultation with physical and/or occupational therapists for evaluation and treatment. Then when the patient met criteria for initiation of early mobility, the appropriate orders were there. We also used documents called standards of nursing practice. These documents were a blend of nursing art and science that helped to delineate the important aspects of nursing care for a specific type of patient. They were used to help with orientation of new staff. Our standard of nursing practice for patients receiving mechanical ventilation was updated to include concepts related to early mobility. Lectures for critical care class also were updated to include early mobility.After 3 months, we were excited that we had met our aim. More than 25% of critically ill patients receiving mechanical ventilation in that third month had received early mobility. No serious adverse events had occurred. Staff were not only readily identifying patients who were appropriate for early mobility but also were obtaining orders for physical and occupational therapy for patients who were not receiving mechanical ventilation. A physical therapist and an occupational therapist were assigned to the ICU daily. We had collected data related to incidence and duration of delirium and found a problem with the flowsheet design in our electronic medical record. Additional changes were made to add detail to the 4 features of the Confusion Assessment Method-ICU (CAM-ICU) to support critical thinking and accuracy of documentation. We also noted problems with sedation and analgesia practices and are in the process of implementing a nonverbal pain assessment tool and an analgesia-first approach. As always, change continues.Our purposeful approach to the implementation of early mobility by using an EBPI model resulted in sustainment of the practice a year later. Critical appraisal and synthesis of the literature resulted in a good protocol for early mobility. High-fidelity human simulation built confidence with working together, and this translated to experiences with early mobility in actual patients. Lessons learned from others related to the use of unit champions and multidisciplinary rounding to help support the practice change. We continue to find opportunities to improve our practice related to the care of patients receiving mechanical ventilation.The authors acknowledge the leadership and support of Mary Jo Trout, PharmD, RPh, BCPS, Robyn R. Razor, RN, MSN, and Thomas M. Yunger, Jr, MD, FCCP, DABSM.