please see attached, 10 point strategic plan for quality improvement - this assignment also requires an annotation bibliography of 5 articles included in the assignment

Copyright © 2020 Academy of Acute Care Physical Therapy, APTA ABSTRACT Background:  Traumatically injured patients are often admitted with complex multisystem injuries requiring a lengthy stay in the intensive care unit (ICU). Mobilizing patients in the ICU has been shown to reduce the adverse effects of immobility and can reduce the patient’s length of stay in the hospital. However, little information is available about the safety of mobilizing traumatically injured patients.

Local Problem:  This quality improvement project was designed to determine whether a nurse-driven mobility pro - tocol could lead to more frequent mobilization of traumatically injured patients. We also sought to determine patient outcomes, measured by the length of stay, adverse effects, and days on mechanical ventilation.

Methods:  A multidisciplinary group developed a nurse-driven early mobility protocol. Nurses were trained on mobi - lization practices for injured patients; they then mobilized eligible patients on their unit for the subsequent 6 months.

Results:  Nurses mobilized close to 80% of eligible patients in the surgical trauma ICU (STICU) during the implemen - tation period, which was an 87.14% increase in patient mobilization from the preimplementation period. No mobili - ty-associated adverse effects were observed for the patients who were mobilized in the STICU. No significant change in length of stay or ventilator-days occurred.

Conclusion:  Interdisciplinary planning led by physical therapists can ensure that a nurse-driven mobility protocol is a safe and effective method to mobilize patients earlier and more frequently. Future studies should consider a broader range of traumatically injured patients and the long-term effects of mobilization in the STICU. Negative sequelae of intensive care unit (ICU) ad - mission include loss of skeletal muscle strength 2,3 and ICU-acquired weakness. 4,5 Weakness can lead to ongo - ing immobilization, sepsis, and organ failure. 6 Sixty-five percent of patients who are ventilated for an extended period have functional limitations long after discharge from the hospital, affecting long-term physical function - ing, strength, and quality of life, which often persist for years after their admission. 3,6 Early mobilization in ICU patients has the benefits of reduced ICU length of stay, 6,7 reduced hospital length of stay, 7 reduced ventilator-days, 6,7 and improved muscle strength. 7 Limited information supports the hypothe - sis that early mobilization also benefits patients with traumatic injuries, reducing the number of days patients require mechanical ventilation, though not influencing the patient’s length of stay in the hospital or ICU. 8 How - ever, limited adoption of robust ICU mobilization proto - cols has occurred. 9,10 Less than half of all ICUs practice early mobilization activities, and only two-thirds of those ICUs have formal policies for mobilization in place. 9 Barriers identified to adopting ICU mobilization include a perceived lack of available staff, and the lack of a clear protocol or program for providing mobilization impeded mobilization efforts. 10 The purpose of this study was to develop and assess a nurse-driven mobility protocol in the trauma ICU. We Safety of a Nurse-Driven Mobility Protocol in a Surgical Trauma Intensive Care Unit Katelyn Black, Stephanie Smith, Mohammad Frotan, Kaeli Vandertulip, Amy Miller E ach year, 2.5 million people are hospitalized for traumatic injuries and 41% of their care costs are related to the reduction in their physical ability. 1 Traumatically injured patients are often admitted with complex multisystem injuries, though they are typically younger and healthier before their injury than non - traumatically injured patients. 1 Patient care must be coordinated between numerous departments, includ - ing orthopedics, neurosurgery, cardiology, and trauma surgery. As a result, consults for physical therapy or clearance for mobilization may be missed among the patient’s complex care needs. These patients are often encumbered by external fixators for extremity fractures, halos for spinal fractures, mechanical ventilation, chest tubes, and monitoring devices, making movement and ambulation more difficult.

DOI: 10.1097/JAT.0000000000000146 ORIGINAL STUDY Copyright 2020 Academy of Acute Care Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited. 52 JACPT.COM JACPT ■ Volume 12 ■ Number 2 ■ 2021 surgeons, and the skills and scope of practice of the STICU nurses, the group developed the early mobility protocol (see the Figure). Patient inclusion and exclusion criteria are listed in Table 1. We defined “mobility” as any intervention led by a health care worker (nurse, physical therapist, occupational therapist, etc) intended to mobi - lize the patient’s skeletal muscles or joints. These inter - ventions included range-of-motion activities (passive or active), bed exercises, transfers to chair, and ambulation.

It did not include routine patient repositioning done to prevent stasis injuries. To prevent injury to patients or nurses, activities of daily living (ADL) that require OOB mobilization were only attempted for patients who could tolerate sitting in a supported position for more than 30 minutes.

The aforementioned physical therapists conducted a mandatory 30-minute in-service for all nurses who were considered trauma nurses by the unit supervisor. The physical therapists created a PowerPoint presentation, which was supplemented with videos and handouts.

All trauma ICU nurses were educated on how to read and interpret the protocol, how to perform the exercise program, and how to document on the data recording sheet. Nurses received training from the physical thera - pists on the proper use of a gait belt on various trauma populations, the flat spin-transfer technique, and the Egress Test to assess which patients are appropriate for OOB mobilization. 17,18 Nurses also received refresher instruction on the use of the Borg Rating of Perceived Exertion (RPE) Scale. 19 The Modified Borg RPE 6-20 Scale was chosen to ensure that patients would use physical effort during the mobilization without provoking hemodynamic instability or exacerbating their injuries.

The daily goal was to encourage patients to reach an RPE between 12 and 14, or activity the patient would de - scribe as requiring some effort but not enough to speed up breathing.

The supine flat-spin technique for supine-to-sit trans - fers was selected because it requires minimal patient strength, is well tolerated in patients with spine precau - tions or rib fractures, and can be performed comfortably on patients with chest tubes or lines for whom log rolling is often difficult. 17 The Egress Test allows both nurses and physical therapists to assess whether patients have sufficient strength to stand, as assessed by 3 attempts at sit-to-stand transfers. 18 If the patient can clear the buttocks off the bed, the patient likely has sufficient strength to stand and may be appropriate for trans - fers to the chair. 17 Following the education sessions, a mandatory competency checkoff was completed for each trauma nurse by the STICU physical therapists. The checkoff included the demonstration of skills for proper gait belt use, how to block the patient’s knees to prevent them from buckling, and how to perform biomechani - cally proper transfers from sitting to standing to prevent injuries to staff. hypothesized that implementation of said protocol would lead to increased frequency of patient mobilization. An an - cillary goal was to determine whether mobilization has an effect on the length of stay, adverse effects related to mobi - lization, and the number of days on mechanical ventilation.

METHODS This quality improvement study was conducted at an American College of Surgeons–verified level II trauma center in an urban area in Texas. The surgical trauma ICU (STICU) has 24 beds, and nurses typically have a 2:1 patient to nurse ratio.

This intervention received a waiver from the Texas Health Resources Institutional Review Board because this is a quality improvement program. No additional funding was sought or used to complete this project.

Intervention Successful implementation of early mobility protocols is primarily determined by the multidisciplinary collab - oration within a team of physicians, nurses, and phys - ical therapists. 9 Therefore, a multidisciplinary group of trauma surgeons, STICU nurses, physical therapists, and occupational therapists created a workgroup to deter - mine the best methods for mobilizing patients and an algorithm to determine which patients would be candi - dates for mobilization.

Two physical therapists, both board-certified car - diovascular and pulmonary clinical specialists, were designated to develop an early mobility protocol for the STICU. These therapists practice full-time in the STICU and have combined experience of greater than 25 years with this population. Existing mobilization protocols were evaluated for appropriateness with a trauma pop - ulation. 11-16 Resources from the Agency for Healthcare Research and Quality 12 and Johns Hopkins’ Activity and Mobility Promotion (AMP) Program 13 were reviewed ex - tensively. Both resources recommend a detailed process of education, implementation, and process evaluation to increase ICU mobilization safely but lack specificity for the trauma population. Traumatically injured patients of - ten have weight-bearing restrictions on multiple extrem - ities, spinal precautions, multiple surgical procedures, or specialized equipment, which often preclude mobility.

Furthermore, the AMP advances activity with the use of automated bed features, including chair position in bed and standing directly from the chair-in-bed position but does not include supine-to-sit transfers, sitting at edge of bed, or transfers out of bed (OOB). 13 As a result, the nursing staff may lack patient mobilization skills, includ - ing knowledge of biomechanically safe transfers. Finally, these protocols do not consider the fluctuations of a patient’s physical ability and alertness, which change rapidly in the trauma population.

On the basis of the physical therapists’ assessments of existing mobility protocols, the input of the trauma Safety of a Nurse-Driven Mobility Protocol in a Surgical Trauma Intensive Care Unit Copyright 2020 Academy of Acute Care Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited. JACPT ■ Volume 12 ■ Number 2 ■ 2021 JACPT.COM 53 (see the Figure) by the “running person” symbol. Mobility events recorded included the patient’s performance of the exercise program, either seated or in supine position, the performance of ADL, dangling at the edge of the bed, transfers to the chair, or ambulation.

Measures The Trauma Registry (Trauma One v4.21; Lancet Tech - nology, Inc, Boston, Massachusetts) was queried for records of all traumatically injured patients admitted to the STICU during the study period. A research nurse eval - uated patients’ records to determine whether they met the inclusion criteria; these patients were included as “eligible patients.” The data collected for both groups of eligible patients included age, sex, injury severity score, Study of the Intervention A convenience sample of traumatically injured patients admitted to the STICU was used. A retrospective prein - tervention cohort of admitted patients from July 2017 through December 2017 was compared with a prospec - tive intervention cohort from January 2018 through June 2018. Patients who expired within 72 hours of admission were omitted from data analysis in both groups.

Upon admission to the STICU, the nurse manager reviewed the patient’s chart to determine whether mobi - lizing the patient was appropriate based on the inclusion criteria (see Table 1). The unit supervisor ensured that all qualifying traumatically injured patients had mobility re - cording sheets with a patient identification sticker. Mobil - ity events are also indicated in the early mobility protocol FIGURE. The STICU early mobility flow sheet. ADL indicates activities of daily living; EVD, external ventricular drain; EOB, edge of bed; Fio 2, fraction of inspired oxygen; LE, lower extremity; OT, occupational therapist; PT, physical therapist; RPE, Rating of Perceived Exertion; STICU, surgical trauma intensive care unit; UE, upper extremity; WB, weight-bearing.

TABLE 1. Inclusion and Exclusion Criteria Inclusion Criteria Exclusion Criteria • Age ≥18 y • RASS score between −1 and 1 • Hemodynamically stable Fio 2 ≤60%  PEEP <10  Spo 2 at rest ≥90%  No increase in vasopressors in prior hour •  Appropriate consultations completed by neurosurgeons or orthopedics • Necessary braces or helmets in the room prior to mobility • Strict bed rest • Patients opting for end-of-life care • Severe TBI (GCS score <9) • Unstable fractures • Spine instability •  External ventricular drain that cannot be clamped •  Hemodynamic instability (as determined by physician) Fio 2, fraction of inspired oxygen; GCS, Glasgow Coma Scale; PEEP, positive end-expiratory pressure; RASS, Richmond Agitation and Sedation Scale; Spo 2, oxygen saturation as measured by pulse oximetry; TBI, traumatic brain injury.

ORIGINAL STUDY Copyright 2020 Academy of Acute Care Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited. 54 JACPT.COM JACPT ■ Volume 12 ■ Number 2 ■ 2021 ICU length of stay, total hospital length of stay, discharge disposition, number of ICU mobilization events, number of ventilator-days, and number of days in the ICU before the patient was mobilized. EPIC electronic health record (EPIC Hyperspace; Epic Systems Corporation, Madison, Wisconsin) was used to access patient charts for the ad - ditional or missing data, including the number of mobility events performed and documented by nurses, physical therapists, or occupational therapists.

The biggest concern surrounding the implementation of a mobilization program in the STICU is the exacer - bation of injuries and dislodgment of lines or catheters; therefore, we monitored all adverse effects. Adverse events were recorded by the nurses or physical thera - pists/occupational therapists during mobilization activi - ties and logged on the data collection sheets for only the intervention group.

Analysis We compared the data between the patients mobilized before the adoption of the early mobility protocol and af - ter. We evaluated whether the data were normally distrib - uted using the Kolmogorov-Smirnov test of normality. We compared the median between the preintervention and intervention groups using the nonparametric Mann-Whit - ney U test to compare the 2 groups because the data did not follow the normal distribution. Data were analyzed us - ing IBM SPSS Statistics v. 23.0 (Armonk, New York). We considered differences where P < .05 to be significant. RESULTS Patients from both the preintervention and intervention groups were similar in their sex and age (see Table 2).

No significant difference in the injury severity scores was observed between the preintervention group and the inter - vention group (see Table 2). No significant differences in the median number of days patients spent ventilated were found (4 days for both groups), in the STICU (3 days), or in the hospital (5 days preintervention; 6 days postintervention).

Frequency of Mobilization Events During the preintervention period, 150 patients were admitted to the STICU for trauma-related services. Of these, 62 were excluded from mobility activities based on physician orders or nurse discretion. Thirty-seven (42.5% of eligible patients) were mobilized at some point during their STICU stays.

During the implementation period, 157 patients were admitted to the STICU for trauma-related services.

Thirty-five patients were excluded from mobility activities due to our exclusion criteria, leaving 122 patients eligible for mobilization. Of these, 97 patients (79.59% of eligible patients) were mobilized during their STICU stays. We did not formally collect data on why eligible patients were not mobilized.

In the preintervention period, the median time before a patient was mobilized in the STICU was 2 days; patients had a median of 1 mobility event. After the early mobility protocol rollout, patients waited 2 days to be mobilized and were mobilized 3 times during their STICU stays.

Although the number of days until mobilization did not increase significantly ( U = 1601, P = .298), the number of mobilization events did ( U = 749, P < .001). Adverse Events One patient had a loss of consciousness while walking; upon examination by one of the trauma surgeons, this patient was discovered to have a splenic injury that had TABLE 2. Comparison of Groups Preintervention Group (Jul 2017-Dec 2017) (N = 150) Intervention Group (Jan 2018-Jun 2018) (N = 157) P a Eligible patients 87 122 Number of patients mobilized 37 97 % Eligible patients mobilized 42.53 79.59 Male, n (%) 101 (67.33) 105 (66.88) Age, median (IQR), y 64 (47-77.5) 58 (35-77.5) .321 ISS 12.5 (10-17) 16 (10-24) .442 Ventilator-days, median (IQR) 4 (2-12) 4 (2-10) .970 STICU LOS, median (IQR), d 3 (2-4) 3 (2-4.5) .943 Hospital LOS, median (IQR), d 5 (3-9.5) 6 (3-11) .452 Number of mobility events, median (IQR) 1 (1-2) 3 (1-5.5) .000 Days until mobilized, median (IQR) 2 (2-3) 2 (2-3) .298 IQR, interquartile range; ISS, injury severity score; LOS, length of stay; STICU, surgical trauma intensive care unit.

aP < .05 is significant.

Safety of a Nurse-Driven Mobility Protocol in a Surgical Trauma Intensive Care Unit Copyright 2020 Academy of Acute Care Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited. JACPT ■ Volume 12 ■ Number 2 ■ 2021 JACPT.COM 55 not been diagnosed prior to mobilization and was unre - lated to mobility activities. Information on the frequency of adverse events in the preintervention group could not be obtained because of variability in reporting so that no comparison could be made.

Nurses noted a brief occurrence of tachycardia on standing or on sitting up from supine position for 5 pa - tients. Each of these adverse events resolved once these patients rested, and the patients were again ready to partic - ipate in mobility activities. The few occurrences of tachy - cardia reported did not have concomitant diaphoresis, hy - potension, or other indications of hemodynamic instability; therefore, we do not consider these adverse events.

DISCUSSION The nurse-driven early mobility protocol provided nurses with a clear guideline of which traumatically injured patients could be mobilized in the ICU, allowing them to mobilize patients more frequently than before the intervention. No adverse events occurred related to mobilization, indicating the safety of this protocol for our trauma population. We were unable to show a significant reduction in patient length of stay or ventilator-days.

These results parallel the results shown by Clark et al, 20 which also indicated that an early mobility program for patients on a Trauma and Burns ICU could be imple - mented safely, though a concomitant reduction in length of stay or ventilator-days was not seen.

Future studies into this topic need to consider how to address these types of temporary limitations; surgical procedures are common occurrences for patients in the STICU, and the mobility protocol needs to clarify how to address this inevitability. Patients also may not have been mobilized because of hemodynamic variability.

Training on acceptable limits for hemodynamic chang - es will also be developed. Some changes are expected in severely injured traumatically injured patients; often, heart rate increases due to pain, recent surgery, and first- time mobilizing, when the patient is still hemodynamical - ly stable. The Modified Borg Scale was selected because some tachycardia was expected in these patients; addi - tional training is needed to clarify appropriate heart rate ranges, especially for patients taking β-blockers. Strengths We were able to create a protocol that was amenable to the medical, surgical, nursing, and therapy staff. This protocol did not preclude formal physical and occupa - tional therapy sessions, so therapy staff members could still work with the patients. At the same time, nurses gained added autonomy and clear guidance on which patients were appropriate to mobilize.

Limitations The first limitation of this study is its small sample size in a single hospital unit and over a limited time. We did not calculate the number of patients to include in this project to gain adequate statistical power, which means we may not have had sufficient power to deter - mine whether the length of time to mobilization was significant.

As a quality improvement program, it is also not gener - alizable to all traumatically injured patients. This project would need to be implemented in a variety of trauma ICUs to ensure that the program was generally safe.

Limited studies suggest that an early mobility program is effective for patients with burn injuries, 19 for whom we do not provide trauma services. More diverse types of trauma would need to be considered to determine whether early mobility is safe for all traumatically injured patients, such as those with burn injuries.

Furthermore, we did not provide a place on our data collection form to explain why a patient was not mo - bilized. Through conversations with the nursing staff, we understood that many patients were not mobilized because they were being prepared for surgery, were in surgery, or were in the postoperative recovery time, mak - ing mobilization activities impossible.

Finally, we only considered the patient’s hospital course in our study. Because many of the negative effects of immobilization come after discharge, we may not have been able to capture all of the long-term effects of ICU mobilization. Future studies of mobility should include follow-up after the patient has been discharged from both the hospital and post–acute care rehabilitation.

CONCLUSIONS Mobilizing patients in the ICU is not a new intervention. It has been proven safe and effective even in patients who are mechanically ventilated. However, the diverse nature of injuries sustained by trauma patients admitted to the ICU has led to a general hesitance to mobilize these patients. Our program shows that a multidisciplinary, col - laborative approach to creating a nurse-driven protocol to mobilize these patients, with the support of trauma physicians and physical therapists, can be implemented safely and effectively in our trauma population.

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