This paper is a project based on PICO. The clinical question that serves as the foundation for this data-based design is; for immobile critical care patients, does the use of a nurse driven progressive mobility protocol reduce ICU LOS compared to every hour of repositioning? In this paper, the adult patients admitted to an ICU represent the population (P) of interest. The nurse driven progressive mobility represents the intervention (I), the comparison (C) is the critical care patients repositioned every two hours, and the reduction in LOS represents the result.
Most hospitals place critically ill patients on bed rest and reposition them every two hours in the intensive care unit. Some literature reviews provide evidence in favor of progressive mobility protocols. In addition, the paper also reviews the safety of mobilization of the critical patients and the negative effects bed rest may have on the patient’s outcome and length of stay (LOS). The analysis of literature aims at providing evidence and validates the establishment of an evidence-based progressive mobility protocol (Plis, 2009).
Online research used Ovid Medline, Mosby Nursing Index and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The terms used for searching include critical care, immobility, results, LOS, and positioning. The search results from each search engine showed similar results (Plis, 2009). The literature review depended on articles based on their appropriateness to the PICO question: for immobile critical care patients, does the use of a nurse driven progressive mobility protocol decrease ICU LOS compared to every hour of repositioning?
Evidence from Reviewed Literature
A study on the hemodynamic changes experienced by critical patients when mobilized involved 31 ICU patients deemed favorable for mobilization based on a screening criterion. This study involved the auditing of medical records looking for information on heart rate, blood pressure, and oxygen saturation. In conclusion, the study reveals that, with the appropriate screening mobilization of critically ill patients, the process produces positive results without major deterioration in their clinical status. Therefore, this study demonstrates that mobilizing critical patients can be established safely. Another study that demonstrates the benefits of mobilization was a prospective research that focused on the effects of kinetic therapy on pulmonary complications (Plis, 2009).
Kinetic therapy (A Continuous Side-to-Side Turning Utilizing Specialty Patient Beds) study had 234 critically ill patients in the ICU with ventilation ratios of less than 250, Glascow Coma Scale Score of less than 11, and patients in need of mechanical ventilation (Plis, 2009). A comparison between kinetic therapies and standard repositioning reveals that pneumonia was lower in patients who received kinetic therapy to those of standard repositioning. In addition, the study reveals significance differences in LOS loss, and the cost of stay was less with kinetic therapy. The study points out that kinetic therapy did not influence impact LOS (Plis, 2009).
Another study on the effects of manual turning of patients diagnosed with pneumonia included 284 critically ill patients under mechanical ventilation and tube feeding. This study was not randomized, and the Clinical Pulmonary Infection Score was to establish the incidence of the disease after 3 days of intubation (Plis, 2009). The investigators observed patients for proof of repositioning every two hours and concluded that pneumonia development was higher in the patients who did not undergo repositioning as frequently (Plis, 2009).
Further evidence was from a study that focused on the effect of ICU acquired paresis on mechanical ventilation weaning. This study involved 95 ICU patients who had no history of neuromuscular disease and who were being weaned using mechanical ventilation after seven or more days of mechanical ventilation (Plis, 2009). The research looked at the strength of muscles after awakening the patients. In conclusion, the research suggested that preventing ICU acquired neuromuscular deterioration mechanical ventilation could offer a quick service. The study is a good demonstration that sedating patients followed by long periods of paralyzing, may lead to significant increase in LOS and mechanical ventilation weaning times (Goldhill et. al., 2007).
It is evident that early mobility in and out of the body can both occur successfully. In addition, reduction in progress of problems can lead to a decrease in LOS, and promoting increased healing may influence LOS. Lack of mobilizing patients may be costly in regards of LOS, complications and rehabilitation periods. The research from the review suggests that repositioning, which should occur every two hours happens for 2.7% of the time.
Nurses hesitate to get critically ill patients out of bed from fear of patient deteriorating. Based on the reviewed evidence, establishing a progressive mobility protocol has significant ability to improve the patient’s outcome including reducing their LOS. In addition, a nurse driven mobility protocol will enhance management of the patient’s mobility while providing them with succinct order to develop the patients (Plis, 2009). The protocol will help in changing the culture from one of sedation to one of progressive mobility to decrease LOS.
Conceptual Model for the Evidence-Based Practice Change
Using of evidence-based practice model provides a framework for practice change. In order to understand and implement findings from an evidence-based practice, there is a need to recognize the difference between research utilization and evidence-based practice. “Research utilization is the dependence on research knowledge, often a single study in clinical practice, whereas evidence-based practice depends on a larger skill set and considers many aspects.” In addition, the use of evidence-based practice allows for the integration of the available evidence in conjunction with practice skills, patient preferences, and available resources (Melnyk and Fineout-Overholt, 2005).
Stettler Model in Evidence-Based Practice
The Stetler model is ideal for the implementation of a nurse driven progressive mobility protocol. This is because the model concentrates on critical thinking and application of findings by the individual practitioner. In addition, the model is relevant to this project because it aims at promoting critical thinking and the application of findings in practice. The Stetler model has five progressive phases of activity including preparation, validation, evaluation, translation and evaluation. The preparation phase involves identifying the aim, validation phase involves establishing whether the research is relevant, and the evaluation phase assesses the research for relevance concerning the aim. The translation phase involves making of a decision what research to retain, and the final evaluation involves establishing the influence the findings may have on the aim of the problem (Melnyk and Fineout-Overholt, 2005).
The evidence supporting the significance and safety of mobility in the critically ill patients is enough to boost development of a nurse driven progressive mobility protocol. This protocol will be a useful tool for nursing practice especially for the development of patient’s mobility. In addition, the protocol will empower nurses/practitioners by providing them necessary tools to provide safe therapeutic mobility for their patients (Plis, 2009). The protocol further is based on the progression from a recumbent to an upright out of bed position. However, the transition towards an erect position depends on the patient’s psychological response to the mobility. If successful, the protocol will allow safe progress in patient mobility and decreased LOS.
Development of a Progressive Mobility Protocol
The staff experiences, patient needs and availability of resources guided the establishment of this mobility protocol. The progressive mobility protocol developed in this paper is based on prior studies that support the safety and positive outcomes of patients. In addition, the project development included input from ICU nurses. The development includes elevating the head of patient care beds higher than the feet in 15 degrees. To achieve this, head of the bed is elevated and subsequent lowering the bottom of the bed. This helps to decreases pressure on the abdomen by eliminating the sitting in the bed (Plis, 2009).
Description of the Progressive Mobility Protocol
The design of the progressive mobility protocol aimed at making it a standing order in the ICU. Critically ill patients had the protocol prescribed as part of their Medicare. In addition, its design aimed at promoting the protocol three times a day. The mobility protocol recognizes the significance of sleep in the healing process; therefore, it is implemented three times during the day and evening hours. The nurses are to determine the exact timing of the progressive mobility protocol to promote nursing management of the protocol while supporting individual needs of the critically ill patients (Plis, 2009).
The awaited outcome is the effect of early mobilization on LOS for critically ill patients. In this case, the LOS (Length of Stay) for patients in the ICU for the preceding year was 13.5 days. Evaluation of LOS happened 12 months before implementation (Plis, 2009). The plan aimed to evaluate LOS for 1 month, 3 months, 6 months and 12 months post implementation. However, such data needs a comparison with another hospital to establish whether the progressive mobility had a direct influence to the LOS in the hospital for patients spending time in the intensive care unit (Plis, 2009).
The critically ill patients face long periods of immobility, which may result in prolonged intubation and increased LOS in the ICU. Development of an early mobility aimed to decrease the LOSS in the ICU, and the project used an evidence-based practice change, recognizing available studies, applying experiences of the ICU nurses, specific needs of the patients, and the availability of resources to generate a progressive mobility protocol. The application of response from nursing and medicine to this evidence-based practice provided support to establish the ICU’s patient’s mobility (Plis, 2009).
Plis, L. (2009). The Effectiveness of A Nurse-Driven Progressive Mobility Protocol on Reducing
Length of Stay in the Adult Intensive Care Unit. Retrieved from https://www.chatham.edu/ccps/pdf/Plis.L.Final_Capstone.pdf
Melnyk, B.M. & Fineout-Overholt, E. (2005). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice.Philadelphia, PA: Lippincott Williams & Wilkins
Goldhill, D., Imhoff, M., McLean, B., & Waldmann, C. (2007). Rotational Bed Therapy to Prevent and Treat Respiratory Complications: A Review and Meta-analysis. American Journal of Critical Care, 16(1), 50-61.
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