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The Effect of the Implementation of Early

Mobilizationon Patient Outcomes in the Intensive Care

Setting

Amanda Grosse RN, BSN, BA, DNP Candidate

Creighton University, College of Nursing

This Photo by Unknown Author is licensed under CC BY-ND

Learning Objectives

To understand what early mobility looks like in an ICU setting

To be able to speak to the significance of early ICU mobility

To understand the benefits of early mobility in the ICU setting

To be able to describe how the MOVEN tool is utilized to assess patient’s readiness for mobility

To be able to disseminate the research from this project

To be able to apply concepts from this project towards future research and/or practice

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Financial Disclosure

• There was no cost to participate.

• The only threat was that of falls, dislodgement of vascular access lines, and staff were educated on how to mitigate these threats.

• The MOVEN tool has already been approved for use in the CHI Health St. Francis ICU setting and there was no additional cost to use this tool

• There is no cost to post reminders on computer monitors

Background

In the ICU, critically ill patients are subject to the ravages of

illness. Inflammatory responses mounted by the body increase

the rate of skin and muscle breakdown 7.

Prolonged bed rest leads to muscle breakdown, which impairs

the ability of the patient to be mobile 15.

Every day a patient spends on bedrest, an estimated 1.3% to 3%

of muscle strength is lost 14, 39. The longer the period of

immobility, the more pronounced these effects become 41.

One study suggests that up to 11% of a patient’s strength is lost for every day that they spend in

bed in the ICU 19

Patients who are mechanically ventilated are at even higher risk of tissue degradation and have a lower rate of mobilization 14, 36, 40.

These effects are exponentially pronounced in the geriatric

population, which is growing 14,40.

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Background, cont.

The incidence of death in the ICU ranges from 20% to

as high as 86% since the introduction of the novel

Coronavirus 1, 39

As the number of patients needing ICU level of care

continues to increase, so do the costs of healthcare

Early mobilization has been shown to reduce the

number of mechanical ventilation days by as many

as 3.2 days 29.

Early mobilization increases the rate of successful

ventilator weaning, and has also been shown to reduce

the length of ICU stays by up to 3 days 26,2 8

Early mobilization not only decreases direct patient

costs, but also reduces the cost of healthcare overall

4,13.

Early mobility, even of mechanically ventilated

patients, is a feasible and low risk method of reducing

mortality within the ICU setting 13.

Review of the Literature—ICU Acquired Weakness

ICU weakness can be found in up to 50% of ICU patients, and can persist long term 20,

23, 25

Deconditioning associated with a 20.4% increase in

mortality by 1 year 24.

Early mobility has been associated with decreased

incidences of CAUTIs, pressure sores, days on ventilator and ventilator

associated events 2,11, 12, 21, 27

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Significance

It is estimated that anywhere from 5%- 10% of

ventilator-dependent patients will develop a ventilator associated condition or event 4.

The emphasis on preventing ventilator associated events

and conditions has strengthened; now a quality

measure for hospitals 4.

CMS reduces the rate of reimbursement for hospitals when a patient suffers from a ventilator associated event

11.

With increased numbers of patients needing mechanical ventilation, this translates to

increased costs of healthcare overall1.

AHRQ proposes that nurse-driven, multidisciplinary

early mobility protocols are a safe and effective means

of reducing the rates of ventilator-based events 3.

Significance, cont.

The AACN created the ABCDEF early mobility bundle to stress the

importance of early mobility in ICU patients 32.

In 2013 (updated in 2018), the American College of Critical Care

Medicine, the Society of Critical Care Medicine and American Society of

Health-System Pharmacists, changed the Clinical Practice Guidelines to

include early mobility in management of ICU patients 37.

AHRQ recognizes early mobilization as having the potential to reduce

patient costs, reduce mortality, and improve patient functionality up to

12 months post hospitalization 4,12, 13,

18

CMS will increase the rate of reimbursement to hospitals that implement an evidence-based

protocol that improves outcomes for patients, such as an early mobility

protocol 11.

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Review of the Literature—Early Mobility in ICU patients

Early mobility interventions reduce the time from

admission to mobilization significantly, regardless of

type of ICU 31.

All age groups have seen benefit to early mobility, but most significantly the

geriatric population 31.

In one study, the addition of a daily huddle to discuss mobility increased patient’s

ambulation status from 43% to 70% 25.

Increased mobilization not linked with increased falls

or injury 21, 25

Literature review-Benefits of the Bundle

One study found that 95% of patient days were spent in bed. Post intervention, 65% of patients stood, 54% walked at least once per shift 27.

Not only did incidence of mobility increase, but incidence of pressure ulcers and physical restraint use decreased (39% to 23% and 30% down to 26%, respectively) 27.

Inclusion of early mobility was correlated with 23% reduction in ventilator days, 10% reduction in ICU length of stays, a 7% reduction in overall hospital length of stay, and a 25% reduction in ICU costs, and a 30% reduction in overall hospital costs27.

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Review of the Literature-- Cost reduction

•Studies suggest cost savings of over $1,600 per patient per day

•This is a result of decreased CAUTIs, falls, VAEs, pressure sores, and ICU days.

Early mobility

associated with cost reduction

Summary of the Problem

In the ICU, critically ill patients are not mobilized (or under mobilized).

This leads to increased patient-ventilator days, increased incidence of delirium, increased length of stay, and increased mortality 12, 14, 17, 20, 22, 23,

25, 26

These problems carry poor patient outcomes; as well as carry a high-cost burden, both short and long term.

There is significant evidence to support the implementation of a nurse-driven, multidisciplinary early mobility protocol, yet barriers exist that hinder the ability of the program to persist.

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Review of the Literature--Barriers to mobilization

Facility buy-in and support regardless of financial incentives 9, 22

Confidence of the staff to manage the lines, drains, and artificial airways that accompany mechanically ventilated patients 14, 33,38.

The presence of an endotracheal tube, for fear that the tube would become inadvertently dislodged 22.

Patient characteristics, including delirium and sedation 22.

Availability of staff was a prominent barrier; patient mobility efforts would fall on one discipline 22,38.

Conceptual Framework: Reciprocal Determinism

• Theory of Albert Bandura5

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Purpose / Aims

This project aimed to evaluate utilization and effectiveness of early mobility in the ICU setting as prompted by the implementation of the MOVEN tool

Methods

5 days of educational sessions (lasting 30 minutes each, held 1-3 times per day), targeted toward Nursing, Occupational Therapy, Respiratory Therapy and Physical Therapy staff members.

Education will focus on the MOVEN tool itself, how and when to use the tool, how to document patient mobilization, how to secure lines, drains, etc., and will allow extra time for staff questions.

Following the one-week educational period, the MOVEN tool was utilized with every patient, and reminders to document this were posted on each computer monitor.

This was combined with support where coaching and to staff on both Day and Night shifts. Repeat education was given at the 2 week mark.

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Methods—The MOVEN Tool

Data CollectionPrimary Outcome

• Documentation of patient mobilization

Data from 8 weeks prior to the project's initiation to 8 weeks after the MOVEN protocol’s initiation were analyzed.

Secondary Outcomes

• Number of ventilator dependent days

• Length of patient stay in the ICU and overall hospital stay

• Rate of patient mortality

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Pre data Conclusions

Average # ambulation: 5.97 times/ 24 hours

Anticipated # ambulation: 12 in 24 hours

Average # for vented: 5.86 time

Average # for non-vented: 5.99 times

Average ICU LOS: 4.12 days

Number of patients: 82

Number of patients vented: 11

Vent days: 71

Number of Pressure Ulcers: 15

Total Expired: 12

Post Data Conclusions

Average # ambulation: 9.7/ 24 hours

Anticipated # ambulation: 12 in 24 hours

Average # for vented: 10.94 times

Average # for non-vented: 10.16 times

Average ICU LOS: 3.48 days

Number of patients: 121

Number of patients vented: 25

Vent days: 125

Number of Pressure Ulcers: 10

Total Expired: 14

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0

2

4

6

8

10

12

MOBILZATION EVENTS/ DAYIN ICU

MOBILZATION EVENTS/ DAYNON ICU

MOBILIZATION VENTED PT. MOBILIZATION NON VENTEDPT.

MOBILIZATION EVENTS

PRE INTERVENTION POST INTERVENTION

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14.6

12.4

11

11.5

12

12.5

13

13.5

14

14.5

15

PRE INTERVENTION POST INTERVENTION

MORTALITY RATE PER INTERVENTIONAL GROUP

MORTALITY

Strengths and Limitations

• Project familiar to PT/OT

• Nursing educated PT/OT regarding ability to ambulate high-oxygen demand patients

• Documentation in familiar spot pulls to ABCDEF Bundle tab

• Future research could be done to correlate RASS scoring and ICU early mobilization

• More education sessions required by staff

• Staff desires a manual depicting how to ambulate patients

• Style of documentation misleading, not uniform among RN staff

• No clear delineation of when a patient leaves ICU within flowsheets

• Pre data set significantly smaller than the post data set (83 vs. 120).

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DNP Implications

• Understanding and dissemination of pathological processes

• Understanding and dissemination of literature

Scholarship

• Effective communication

• Conflict resolution

Leadership

• Changes to style and method of documentation, not required amounts of documentation

Policy

• Understanding clinical setting and rationale behind exceptions to mobilization

Clinical

Evaluation Plan--Sustainability

MOVEN tools laminated and present in every

patient room; Posters and informatics displayed in department post study

Patient mobility level updated on whiteboard

daily by Nursing staff (colored cards)

Patient mobility level discussed daily during

multidisciplinary rounds

Reminder card to document patient mobility present on each computer

monitor

Daily discussion between PT/OT/Nursing to discuss

plans/barriers to mobilization each day

Continued data monitoring regarding adherence to use and continued mobilization

of patients

Early mobilization of patients to become part of onboarding bundle for new

staff, including education on MOVEN tool

Department supervisors to oversee continued

adherence to use of tool

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Questions

Acknowledgements

Dr. Negri, DNP, APRN-NP, ACNP-BC

Dr. Lindsay Iverson, DNP, APRN, ACNP-BC

Ms. Toni Nielsen, BSN, CCRN

Ms. Ashley Hermesch, RN, MHA

Dr. Lauren Klein, APRN, DNP, AGAC-NP

Dr. Lori Rubarth, PhD, APRN, NNP-BC

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References

1. Abate, S., Ahmed Ali, S., Mantfardo, B., & Basu, B. (2020). Rate of intensive care unit admission and outcomes among patients with coronavirus: A systematic review and meta-analysis. PLOS ONE, 15(7), e0235653. https://doi.org/10.1371/journal.pone.0235653

2. Aggarwal, R., Chauhan, S., Behari, M., Gupta, C., & Dua, V. (2020). Effect of early mobility in mechanically ventilated patients with myasthenia crisis on duration of mechanical ventilation and length of intensive care unit stay. Physiotherapy - The Journal of Indian Association of Physiotherapists, 14(2), 74. https://doi.org/10.4103/pjiap.pjiap_40_20

3. AHRQ. (2017a). Nurse-driven early mobility protocols: Facilitator guide. https://www.ahrq.gov/hai/tools/mvp/modules/technical/nurse-early-mobility-protocols-fac-guide.html

4. AHRQ. (2017b, January). Early mobility guide for reducing ventilator-associated events in mechanically ventilated patients. Retrieved February 6, 2021, from https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/early-mobility-mvpguide.pdf

5. Bandura, A. (1989). Human agency in social cognitive theory. American Psychologist, 44(9).

References

6. Barnes-Daly, M., Phillips, G., & Ely, E. (2017). Improving hospital survival and reducing brain dysfunction at seven california community hospitals. Critical Care Medicine, 45(2), 171–178. https://doi.org/10.1097/ccm.0000000000002149

7. Bennett, J. M., Reeves, G., Billman, G. E., & Sturmberg, J. P. (2018). Inflammation–nature's way to efficiently respond to all types of challenges: Implications for understanding and managing “the epidemic” of chronic diseases. Frontiers in Medicine, 5. https://doi.org/10.3389/fmed.2018.00316

8. Betters, K. A., Hebbar, K. B., Farthing, D., Griego, B., Easley, T., Turman, H., Perrino, L., Sparacino, S., & deAlmeida, M. L. (2017). Development and implementation of an early mobility program for mechanically ventilated pediatric patients. Journal of Critical Care, 41, 303–308. https://doi.org/10.1016/j.jcrc.2017.08.004

9. Bognar, K., Chou, J., McCoy, D., Sexton Ward, A., Hester, J., Guin, P., & Jena, A. (2015). Financial implications of a hospital early mobility program. Intensive Care Medicine Experimental, 3(Suppl 1), A758. https://doi.org/10.1186/2197-425x-3-s1-a758

10. Bounds, M., Kram, S., Speroni, K. G., Brice, K., Luschinski, M. A., Harte, S., & Daniel, M. G. (2016). Effect of abcde bundle implementation on prevalence of delirium in intensive care unit patients. American Journal of Critical Care, 25(6), 535–544. https://doi.org/10.4037/ajcc2016209

11. Centers for Medicare and Medicaid Services. (2020, January 6). Value based programs. Retrieved February 7, 2021, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing

9/23/2021

17

References

12. Cocoros, N. M., & Klompas, M. (2016). Ventilator-associated events and their prevention. Infectious Disease Clinics of North America, 30(4), 887–908. https://doi.org/10.1016/j.idc.2016.07.002

13. Coles, S., Erdogan, M., Higgins, S. D., & Green, R. S. (2020). Impact of an early mobilization protocol on outcomes in trauma patients admitted to the intensive care unit. Journal of Trauma and Acute Care Surgery, 88(4), 515–521. https://doi.org/10.1097/ta.0000000000002588

14. Dirkes, S. M., & Kozlowski, C. (2019). Early mobility in the intensive care unit: Evidence, barriers, and future directions. Critical Care Nurse, 39(3), 33–42. https://doi.org/10.4037/ccn2019654

15. Drolet, A., DeJuilio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, E. A., Lloyd, J. M., Waters, C., & Williams, S. (2013). Move to improve: The feasibility of using an early mobility protocol to increase ambulation in the intensive and intermediate care settings. Physical Therapy, 93(2), 197–207. https://doi.org/10.2522/ptj.20110400

16. Dubb, R., Nydahl, P., Hermes, C., Schwabbauer, N., Toonstra, A., Parker, A. M., Kaltwasser, A., & Needham, D. M. (2016). Barriers and strategies for early mobilization of patients in intensive care units. Annals of the American Thoracic Society, 13(5), 724–730. https://doi.org/10.1513/annalsats.201509-586cme

References

17. Ely, E. (2017). The abcdef bundle. Critical Care Medicine, 45(2), 321–330. https://doi.org/10.1097/ccm.0000000000002175

18. Escalon, M. X., Lichtenstein, A. H., Posner, E., Spielman, L., Delgado, A., & Kolakowsky-Hayner, S. A. (2020). The effects of early mobilization on patients requiring extended mechanical ventilation across multiple icus. Critical Care Explorations, 2(6), e0119. https://doi.org/10.1097/cce.0000000000000119

19. Fan, E., Cheek, F., Chlan, L., Gosselink, R., Hart, N., Herridge, M. S., Hopkins, R. O., Hough, C. L., Kress, J. P., Latronico, N., Moss, M., Needham, D. M., Rich, M. M., Stevens, R. D., Wilson, K. C., Winkelman, C., Zochodne, D. W., & Ali, N. A. (2014). An official american thoracic society clinical practice guideline: The diagnosis of intensive care unit–acquired weakness in adults. American Journal of Respiratory and Critical Care Medicine, 190(12), 1437–1446. https://doi.org/10.1164/rccm.201411-2011st

20. Ferrante, L. E., Pisani, M. A., Murphy, T. E., Gahbauer, E. A., Leo-Summers, L. S., & Gill, T. M. (2016). Factors associated with functional recovery among older intensive care unit survivors. American Journal of Respiratory and Critical Care Medicine, 194(3), 299–307. https://doi.org/10.1164/rccm.201506-1256oc

21. Fraser, D., Spiva, L., Forman, W., & Hallen, C. (2015). Original research: Implementation of an Early Mobility Program in an ICU. American Journal of Nursing, 115(12), 49–58. https://doi.org/10.1097/01.naj.0000475292.27985.fc

9/23/2021

18

References

22. Green, M., Marzano, V., Leditschke, I., Mitchell, I., & Bissett, B. (2016). Mobilization of intensive care patients: A multidisciplinary practical guide for clinicians. Journal of Multidisciplinary Healthcare, 247. https://doi.org/10.2147/jmdh.s99811

23. Hermans, G., De Jonghe, B., Bruyninckx, F., & Van den Berghe, G. (2014). Interventions for preventing critical illness polyneuropathy and critical illness myopathy. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd006832.pub3

24. Hermans, G., Van Mechelen, H. & Bruyninckx, F. (2015). Predictive value for weakness and 1-year mortality of screening electrophysiology tests in the ICU. Intensive Care Medicine 41(12):2138–2148.

25. Hodgson, C., Bellomo, R., Berney, S., Bailey, M., Buhr, H., Denehy, L., Harold, M., Higgins, A., Presnell, J., Saxena, M., Skinner, E., Young, P., & Webb, S. (2015). Early mobilization and recovery in mechanically ventilated patients in the ICU: A bi-national, multi-centre, prospective cohort study. Critical Care, 19(1), 81. https://doi.org/10.1186/s13054-015-0765-4

26. Hoyer, E. H., Friedman, M., Lavezza, A., Wagner-Kosmakos, K., Lewis-Cherry, R., Skolnik, J. L., Byers, S. P., Atanelov, L., Colantuoni, E., Brotman, D. J., & Needham, D. M. (2016). Promoting mobility and reducing length of stay in hospitalized general medicine patients: A quality-improvement project. Journal of Hospital Medicine, 11(5), 341–347. https://doi.org/10.1002/jhm.2546

References

27. Hsieh, S., Otusanya, O., Gershengorn, H. B., Hope, A. A., Dayton, C., Levi, D., Garcia, M., Prince, D., Mills, M., Fein, D., Colman, S., & Gong, M. (2019). Staged implementation of awakening and breathing, coordination, delirium monitoring and management, and early mobilization bundle improves patient outcomes and reduces hospital costs. Critical Care Medicine, 47(7), 885–893. https://doi.org/10.1097/ccm.0000000000003765

28. Johnson, K., Petti, J., Olson, A., & Custer, T. (2017). Identifying barriers to early mobilisation among mechanically ventilated patients in a trauma intensive care unit. Intensive and Critical Care Nursing, 42, 51–54. https://doi.org/10.1016/j.iccn.2017.06.005

29. Lai, C.-C., Chou, W., Chan, K.-S., Cheng, K.-C., Yuan, K.-S., Chao, C.-M., & Chen, C.-M. (2017). Early mobilization reduces duration of mechanical ventilation and intensive care unit stay in patients with acute respiratory failure. Archives of Physical Medicine and Rehabilitation, 98(5), 931–939. https://doi.org/10.1016/j.apmr.2016.11.007

30. LaMorte, W. (2019). Behavioral change models. https://sphweb.bumc.bu.edu/otlt/mph-modules/sb/behavioralchangetheories/behavioralchangetheories5.html

31. Linke, C. A., Chapman, L. B., Berger, L. J., Kelly, T. L., Korpela, C. A., & Petty, M. G. (2020). Early mobilization in the ICU. Critical Care Explorations, 2(4), e0090. https://doi.org/10.1097/cce.0000000000000090

9/23/2021

19

References

32. Marra, A., Ely, E., Pandharipande, P. P., & Patel, M. B. (2017). The abcdef bundle in critical care. Critical Care Clinics, 33(2), 225–243. https://doi.org/10.1016/j.ccc.2016.12.005

33. Nydahl, P., Sricharoenchai, T., Chandra, S., Kundt, F., Huang, M., Fischill, M., & Needham, D. M. (2017). Safety of patient mobilization and rehabilitation in the intensive care unit. systematic review with meta-analysis. Annals of the American Thoracic Society, 14(5), 766–777. https://doi.org/10.1513/annalsats.201611-843sr

34. Ota, H., Kawai, H., Sato, M., Ito, K., Fujishima, S., & Suzuki, H. (2015). Effect of early mobilization on discharge disposition of mechanically ventilated patients. Journal of Physical Therapy Science, 27(3).https://www.jstage.jst.go.jp/article/jpts/27/3/27_jpts-2014-614/_pdf

35. Puthucheary, Z. A., Rawal, J., McPhail, M., Connolly, B., Ratnayake, G., Chan, P., Hopkinson, N. S., Padhke, R., Dew, T., Sidhu, P. S., Velloso, C., Seymour, J., Agley, C. C., Selby, A., Limb, M., Edwards, L. M., Smith, K., Rowlerson, A., Rennie, M.,...Montgomery, H. E. (2013). Acute skeletal muscle wasting in critical illness. JAMA, 310(15), 1591. https://doi.org/10.1001/jama.2013.278481

36. Sibilla, A., Nydahl, P., Greco, N., Mungo, G., Ott, N., Unger, I., Rezek, S., Gemperle, S., Needham, D. M., & Kudchadkar, S. R. (2017). Mobilization of mechanically ventilated patients in switzerland. Journal of Intensive Care Medicine, 35(1), 55–62. https://doi.org/10.1177/0885066617728486

References

37. Society of Critical Care Medicine. (2019, February 14). 2018 PADIS guideline. Retrieved February 7, 2021, from https://www.sccm.org/ICULiberation/News/Hot-off-the-Press-New-PADIS-Guideline

38. Stolldorf, D. P., Dietrich, M. S., Chidume, T., McIntosh, M., & Maxwell, C. A. (2018). Nurse-initiated mobilization practices in 2 community intensive care units. Dimensions of Critical Care Nursing, 37(6), 318–323. https://doi.org/10.1097/dcc.0000000000000320

39. Topp, R., Ditmyer, M., King, K., Doherty, K., & Hornyak, J. (2002). The effect of bed rest and potential of prehabilitation on patients in the intensive care unit. AACN Clinical Issues: Advanced Practice in Acute and Critical Care, 13(2), 263–276. https://doi.org/10.1097/00044067-200205000-00011

40. Unal, A. (2016). Prognosis of patients in a medical intensive care unit. Northern Clinics of Istanbul. https://doi.org/10.14744/nci.2015.79188

41. van Wagenberg, L., Witteveen, E., Wieske, L., & Horn, J. (2017). Causes of mortality in icu-acquired weakness. Journal of Intensive Care Medicine, 35(3), 293–296. https://doi.org/10.1177/0885066617745818

42. World Health Organization. (2021). International classification of functioning, disability and health (ICF) framework to facilitate interprofessional education and collaborative practice.