Move to Improve: The Feasibility of Using an Early Mobility Protocol to Increase Ambulation in the Intensive and Intermediate Care Settings

Method

Three months of data (January–March 2010) were collected before implementation of the mobility program to confirm consistency of baseline information. Postimplementation data were collected for 6 months (March–August 2011). To evaluate the impact of this initiative, we compared the frequency of ambulation for patients admitted to the ICU and IMCU, or who were transferred from the ICU to the IMCU, during these time periods.

In February 2010, nursing management gave approval to begin the quality improvement project. A multidisciplinary team consisting of advanced practice nurses, registered nurses, physical therapists, a critical care pharmacist, a respiratory therapist, and a critical care physician was assembled in April 2010. The team adopted the Plan-Do-Check-Act framework for the development and implementation of the Move to Improve mobility program; the “Plan” stage ran from January 2010 to April 2010 (see Appendix 1 for complete time line).

Two units were selected for the pilot study. The first unit was the IMCU, a 26-bed unit with an average daily census of 21.6 patients and a nurse-to-patient ratio of 1:4. The patient population included patients with complex medical and surgical conditions as well as patients who were hemodynamically stable with a tracheostomy on a ventilator and had potential for respiratory insufficiency. These patients often required frequent vital sign monitoring and respiratory therapy management. The second pilot unit was an adult ICU, a 16-bed unit designed to provide intensive medical/surgical care to patients with acute and chronic medical diagnoses. Its average daily census was 11.3 patients and a 1:2 nurse-to-patient ratio. During the study, from March through August 2011, this ICU had a standard mortality ratio of 0.726 (observed deaths/expected deaths) utilizing the APACHE IV scoring system.¹⁶ The average length of stay was 3.2 days. For patients admitted directly to the IMCU, the average length of stay was 4.95 days.

In April 2010, the Move to Improve team reviewed current evidence and exemplary protocols to determine whether the adult ICUs were utilizing best practices for mobilizing patients. The literature review was expanded to include ambulating patients in the non-ICU areas, weaning patients from ventilators safely and efficiently, and sedation and pain management guidelines.^17–19 The team divided into small groups to focus on the multiple facets of the program.

The “Do” stage of the project ran from April through November of 2010. Multiple order sets and protocols were developed for the pilot study. A mobility order set was created that included a screening tool based on the exclusion criteria from the Critical Care Physical Medicine and Rehabilitation Program at Johns Hopkins Medical Center.²⁰ The exclusion criteria were modified to address the needs of our patient population based on recommendations from the intensivists and medical staff chairpersons. The mobility algorithm developed by the physical therapist on the planning team was embedded in the order set to guide the assessment and allowed the nurse to consult physical therapists and occupational therapists when appropriate (Appendix 2). The ventilator weaning order set was developed by ICU respiratory therapists. This order set included a protocol for pain management with appropriate sedation determined by clinical pharmacists and implemented by bedside nurses, use of the Richmond Agitation Sedation Scale,^21,22 and more frequent readiness trials to determine whether patients were capable of ventilator discontinuation.^23–28 A primary objective was to remove mechanical ventilation as soon as possible, as it is easier and safer to mobilize patients without the burden of an artificial airway. Pain that could worsen with movement was addressed to avoid patient resistance, and sedation was modified so that patients were alert enough to mobilize. The sedation protocol for ICU patients was modified from a practice of continuous infusions to a preferred practice of using intermittent dosing of sedation medications when possible to maintain goal sedation.

After careful review of the multiple order sets, approval for the 4-week pilot study was granted by the hospital's Medical Executive Committee in September 2010. The team received approval from the hospital's institutional review board in November 2010. Data would be collected on patients 18 years of age or older who were hospitalized for 72 hours or longer.

During November 2010, in preparation for the pilot study, nurses and patient care technicians completed an education program developed by the Move to Improve team. The education included verbal presentations by the advanced practice nurses and physical therapists at unit staff meetings. The staff was instructed on the exclusion criteria, the mobility algorithm, and the use of gait belts when transferring and ambulating patients. The nurses and patient care technicians also received self-learning packets, and posters were placed on the 2 units as reminders of the study. The nurses and patient care technicians had 1 month to complete the education. Respiratory therapists received mandatory education in both written and classroom formats on the use of the portable ventilator, ventilator weaning, sedation, and the mobility protocols. Physical therapists were educated on use of a custom-designed walker with fold-down seat, funded by the hospital foundation, and intravenous pole that supported the portable ventilator (Fig. 1). They also received specific instructions on handling patients who are critically ill and ventilated for safety during ambulation.

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Figure 1.

Custom-designed walker and intravenous pole (purchased from Spectrum Surgical Instruments Co, Stow, Ohio, www.spectrumsurgical.com) with ventilator (Versamed Ivent 201, GE Healthcare, www.gehealthcare.com).

Beginning the first week of December 2010, education was provided to the medical staff at their quarterly meeting along with posters outlining the program and pilot study. The physicians were made aware that the mobility protocol would be mandatory for all patients in the adult ICU and IMCU during the pilot project, which was to run from December 14, 2010, through January 11, 2011. The physicians were informed that the nurse would have the ability to order physical therapy or occupational therapy when appropriate. Decisions about ability or appropriateness of activity were made by the nurse based on the mobility algorithm coupled with the assessment of exclusion criteria. All patients in both the ICU and the IMCU were screened using the same process.

Upon completion of the pilot project, the team returned to the Medical Executive Committee in February 2011 to complete the “Check” process. Approval was granted to proceed with the program in the ICU and the IMCU with the understanding that the mobility protocol would no longer be mandatory but would now need a physician's order to implement. The Medical Executive Committee also approved hospital-wide implementation to begin in July 2011.

The “Act” process began in March 2011 at the beginning of the postimplementation period with the objective of increasing the number of adult patients ambulating during the first 72 hours of their hospital stay. For the purpose of this study, we defined ambulation as the act of walking with or without an assistive device, moving self from point A to point B. Distance was measured for each patient's ambulation efforts. Multiple assessments were performed daily by the nurse to determine activity readiness.³

Ambulation was recorded before and after implementation of the mobility protocol for patients admitted to the ICU and the IMCU, or transferred from the ICU to the IMCU. Patients who were discharged in less than 72 hours or transferred to another unit (other than the IMCU) during that time frame were excluded. Due to these exclusions, the patient census during the study period appears to be less than that seen during the preimplementation period. Nurses and patient care technicians were encouraged to ambulate all patients regardless of their length of stay in the ICU or IMCU. Collected data captured only nurse or patient care technician documentation of ambulation and did not include activity performed by the physical therapist. Aggregated and de-identified data were reviewed. Monthly collection and analysis of data were reported to the nurse managers and staff at unit meetings. The retrospective chart reviews revealed little improvement in ambulation compared with preimplementation data. For this reason, an ambulation status report (Appendix 3) was developed that would provide real-time data for the nurses. This report was distributed to the units daily, noting each patient's length of stay and the distance the patient had ambulated on a given day. The ambulation status report was embraced by the IMCU staff and reviewed at multidisciplinary rounds each morning. With the creation and use of this daily report, there was an immediate increase in the number of patients ambulating in the IMCU. However, we did not see regular use of the ambulation status report in the ICU until several months into the study.

Patient demographics such as age and sex were tracked across both departments studied. Data are presented as means (standard deviation) for descriptive variables. Comparisons of preimplementation and postimplementation data were performed using an unpaired, 2-tailed t test. Significance was set at P<.05. Analyses were performed with Microsoft Excel 2007 software (Microsoft Corporation, Redmond, Washington).