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INTRODUCTION
INTRODUCTION (CONT.)
Over the past recent decades,
developments in life support
technologies have increased
the use of deep sedation and
bed rest in ICU patients
INTRODUCTION (CONT.)
While some hospitals have early mobiliza&on protocols in
place, others either do not have protocols in place or rely
solely on mobility orders. Adherence to both mobility
protocols and orders is low in many cri&cal care seYngs due
to compe&ng priori&es of care, among other factors.
As nurses, we
have the most
direct contact
with patients and
are thus most
capable of
ensuring that
early mobilization
is implemented
among patients.
PICOT
In adult ICU pa&ents, hospitalized for any
length of &me, is early mobiliza&on as
compared to immobiliza&on associated
with shorter ICU stays?
Zomorodi, M., Topley, D., & McAnaw, M. (2012). Developing a mobility protocol for early mobiliza&on of pa&ents in a surgical/
trauma ICU. Cri<cal Care Research and Prac<ce. 2012 1-10 Doi:10.1155/2012/964547
Engel, H. J., Tatebe, S. Alonzo, P. B., Mustilleand, R. L., & Rivera, M. J. (2013). Physical therapist-established intensive
care unit early mobilization program: quality improvement project for critical care at the University of California San
Francisco Medical Center. Journal of the American Physical Therapy Association, 93(7), 975-985. doi: 10.2522/ptj.
20110420
Pandullo, S., Spilman, S., Smith, J., Kingery, L., Pille, S., Rondinelli, R., & Sahr, S. (2015). Time for critically ill patients to
regain mobility after early mobilization in the intensive care unit and transition to a general inpatient floor. Journal of
Critical Care. http://dx.doi.org/10.1016/j.jcrc.2015.08.007
Clark, D. E., Lowman, J. D., Griffin, R. L., Matthews, H. M., & Reiff, D. A. (2013). Effectiveness of an Early Mobilization Protocol in a
Trauma
and Burns Intensive Care Unit: A Retrospective Cohort Study. Physical Therapy, 93(2), 186-196. doi:10.2522/ptj.20110417
Titsworth, W. L., Correia, T., Reed, R., Guin, P., Archibald, L., Layon, A. J., & J. Mocco (2012). The effect of increased mobility on
morbidity in the neurointensive care unit. Journal of Neurosurgery, 116(6), 1379-1388. doi: 0.3171/2012.2.JNS111881
Lord, R. K., Mayhew, C. R., Koruplou, R., Mantheiy, E. C., Friedman, M. A., Palmer, J. B.,
Needleham, D. M. (2015). ICU early physical rehabilitation programs: Financial modeling of cost
savings. Critical Care Medicine, 41(3), 717-724. doi:10.1097/CCM.0b013e3182711de2
hospital
Focus on physical therapy or
occupa&onal therapy
interven&ons
Specic popula&ons (i.e.
neurological)
Control Groups
Cohort study
Evidence Based
Recommenda&ons
Clark, D. E., Lowman, J. D., Grin, R. L., MaDhews, H. M., & Rei, D. A. (2013). Eec&veness of an Early Mobiliza&on
Protocol in a Trauma and Burns Intensive Care Unit: A Retrospec&ve Cohort Study. Physical Therapy, 93(2), 186-196. doi:
10.2522/ptj.20110417
Drolet, A., DeJuilio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, E. A., Williams, S.
(2013). Move to improve: The
feasibility of using an early mobility protocol to increase ambula&on in the intensive and intermediate care seYngs.
Physical Therapy, 93(2), 197-207. doi:10.2522/ptj.20110400
Engel, H. J., Tatebe, S. Alonzo, P. B., Mus&lleand, R. L., & Rivera, M. J. (2013). Physical therapist-established intensive care
unit early mobiliza&on program: quality improvement project for cri&cal care at the University of California San Francisco
Medical Center. Journal of the American Physical Therapy Associa<on, 93(7), 975-985. doi: 10.2522/ptj.20110420
Klein, K., Mulkey, M., Bena, J. F., Albert, N. M. (2015). Clinical and psychological eects of early mobiliza&on in pa&ents
treated in a neurologic ICU: A compara&ve study. Cri<cal Care Medicine 43(4), p 865873 doi:10.1097/CCM.
0000000000000787
Mah, J.M., Sta, I., Fichandler, D., & Butler, K.L. (2013). Resource-ecient mobiliza&on programs in the intensive care
unit: who stands to win? The American Journal of Surgery, 206, 488-493. Retrieved from hDp://dx.doi.org/10.1016/
j.amjrug.2013.03.001
Pandullo, S., Spilman, S., Smith, J., Kingery, L., Pille, S., Rondinelli, R., & Sahr, S. (2015). Time for cri&cally ill pa&ents to
regain mobility aler early mobiliza&on in the intensive care unit and transi&on to a general inpa&ent oor. Journal of
Cri<cal Care. hDp://dx.doi.org/10.1016/j.jcrc.2015.08.007
Titsworth, W. L., Correia, T., Reed, R., Guin, P., Archibald, L., Layon, A. J., & J. Mocco (2012). The eect of increased mobility
on morbidity in the neurointensive care unit. Journal of Neurosurgery, 116(6), 1379-1388. doi: 0.3171/2012.2.JNS111881
Wang, Y. T., Haines, T. P., Ritchie, P., Walker, C., Ansell, T. A., Ryan, D. T., Lim, P., Vij, S., Acs, R., Fealy, N., & Skinner, E. H.
(2014). Early mobiliza&on on con&nuous renal replacement therapy is safe and may improve lter life. Cri<cal Care, 18(4),
R161-R170. doi:10.1186/cc14001
Witcher, R., Stoerger, L., Dzierba, A. L., Silverstein, A., Rosengart, A., Brodie, D., & Berger, K. (2015). Eect of early
mobiliza&on on seda&on prac&ces in the neurosciences intensive care unit: A preimplementa&on and pos&mplementa&on
evalua&on. Journal of Cri<cal Care, (30), 344-347. Retrieved from
hDp://zp9vv3zm2k.search.serialssolu&ons.com/?V=1.0&sid=PubMed:LinkOut&pmid=25573283
ACTION PLAN
Create a research informed, nurse-driven mobility
protocol
A comprehensive protocol will be created using a
combina&on of mul&ple protocols from dierent
facili&es and studies and include specic parameters
and instruc&ons for ini&a&ng mobility
Protocol will be implemented at a local hospitals
medical intensive care unit
Implementa&on will focus on educa&on
TIME LINE
EDUCATION
The protocol will be implemented with educa&on as a
primary focus
All nurses and PCTs will be required to aDend one 90
minute training session
Training sessions will be held over a two week period
and sta members will have four date & &me op&ons to
choose from to aDend
Sta members will be paid for the mandatory training
Training will be led by a physical therapist
Sta members will be required to pass (>70%) a
comprehension test at the end of training
TRAINING SESSION
RNs and PCTs will be educated about the protocol, when
AMBU GURU
The protocol will include the implementa&on of an
Operation Mobilization
Pre-phase
initiation
Educate the patient
and family about
protocol and
importance of
ambulation
Phase 2
Phase 1
Passive/Active Range of
Motion
Successful
completion of
phase 1
Rotate Q 2 hours
Phase 4
Phase 3
Successful
completion of
phase 2
Successful
completion of
phase 3
Discharge
Vitals will be assessed prior to interventions and throughout mobility protocol.
Activity will be stopped immediately if the following parameters are met:
HR>150
Saturations <85% after increase in FiO2
SBP> 200 or <90
Ve> 15 L/min
Completion of
phase 4 and
discharge planning
If none of the exclusion criteria is met the nurse may initiate Operation Mobilization
Pre-phase
initiation
Educate the patient
and family about
protocol and
importance of
ambulation
Phase 1
Passive/Active Range
of Motion
Rotate Q 2 hours
Elevate HOB 30
degrees
Phase 2
If unable to
sit
unsupported
for 5 minutes
consult
Physical
Therapy
Phase 3
Level 1: stand at
edge of bed with
assistance
Level 2: Pivot to
chair
If unable to
stand <2
person assist
consult
Physical
Therapy
Phase 4
Level 1: Ambulate
with assistance (PCT/
RN) and assistive
device 50 feet
Level 2: Ambulate 50
feet unassisted
Discharge
Create an exercise
and mobility plan for
patient to complete
upon discharge
EXCLUSION CRITERIA
All pa&ents who do not meet exclusion criteria will be
EXCLUSION CRITERIA
Neurological:
Increased intracranial pressure (ICP)
Cerebral spinal uid (CSF) leak
Acute stroke within 24 hours
Unsecured, ruptured aneurysm
Respiratory:
Posi&ve end expiratory pressure (PEEP) >12
Frac&onal expired oxygen (FiO2) > .8
Minute volume > 15 L/min
Hypoxemia (satura&on <88%)
Tachypnea (respiratory rate > 30 breaths per minute)
EXCLUSION CRITERIA
Circulatory
New deep vein thrombosis (DVT) or pulmonary
embolism (PE) within 24 hours
Unstable arrhythmia within 24 hours
New onset chest pain
Tachycardia (heart rate >150)
Systolic blood pressure (SBP) >200 mmHg or <90 mmHg
Mean arterial pressure (MAP) <60 mmHg or >140
mmHg
Ac&ve bleeding
EXCLUSION CRITERIA
Musculoskeletal:
Ordered bed rest
Unstable/acute fractures
Hematological:
Hemaglobin < 7 g/dL
Platelet count <2,000
INR > 5.0
Other:
Femoral arterial line
Recent hip surgery
Transi&on to comfort care
admission
Ask your nurse about Opera&on Mobiliza&on sign will
be posted in all pa&ent rooms
The assigned Ambu Guru will enforce protocol
throughout shil
Cost Analysis
Hiring new PCT ($30,000
yearly)
Training PCT
Training nurses
$100,000.00
$383.79
$2,574.00
$20.18 x 9 hours
$181.62
$35.50 x 15 walkers
$532.50
$2.39 x 24 posters
$57.36
Total: $103,729.27
COMPARISON
Total cost of the resource-ecient mobility program
(REMP) came out to $63,750
Our cost for Opera&on Mobiliza&on $103,699.00
Will focus on educa&on throughout the protocol
Will focus on nursing aspect applying the protocol with
the help of PCT
The hospital will benet and will save money
Decrease length of hospitaliza&on
Reducing medical complica&ons associated with
prolong immobiliza&on
Mah, J.M., Sta, I., Fichandler, D., & Butler, K.L. (2013). Resource-ecient mobiliza&on programs in the intensive care
unit: who stands to win? The American Journal of Surgery, 206, 488-493. Retrieved from
hDp://dx.doi.org/10.1016/j.amjrug.2013.03.001
COST OF IMMOBILITY
900,000 pa&ents in the United States each year are
COST OF IMMOBILITY
1 million to 2.5 million pa&ents develop pressure
Indeed (2015). Pa&ent care technician salary in Tucson, AZ. Retrieved from
hDp://www.indeed.com/salary?q1=Pa&ent+Care+Technician&l1=Tucson%2C
+AZ
Payscale: Human capital (2015).Pa&ent care technician salary. Retrieved from
hDp://www.payscale.com/research/US/Job=Pa&ent_Care_Technician/
Hourly_Rate
Payscale: Human capital (2015). Physical therapist salary in Tucson. Retrieved
from hDp://www.payscale.com/research/US/
Job=Physical_Therapist_Assistant/Salary/fa2719cd/Tucson-AZ
SalaryGenius (2015). RN salary in Tucson, Arizona. Retrieved from
hDp://salarygenius.com/az/tucson/salary/rn-salary?p=2
Walkers. (2015). Allegro medical.com. Retrieved from
hDp://www.allegromedical.com/walkers-c516/2-buDon-folding-walker-with-5wheels-p565603.html?utm_campaign=Comparison
%20Shopping&utm_source=froogle&utm_medium=feed&CS_003=9164468&CS
_010=b4b946b06f18013013d52c4138899c05&gclid
=CJDY55Dy6MgCFc5efgod1icEDQ&kwid=productadsplaid^101314403053-sku^762%20565603%2001@ADL4ALLEGRO-adType^PLAdevice^c-adid^65352197773#762+565603+01
Outcomes
All nurses and PCTs will aDend one of the four mandatory
Conclusion
REFERENCES
Clark, D. E., Lowman, J. D., Grin, R. L., MaDhews, H. M., & Rei, D. A. (2013). Eec&veness of an Early Mobiliza&on
Protocol in a Trauma and Burns Intensive Care Unit: A Retrospec&ve Cohort Study. Physical Therapy, 93(2), 186-196. doi:
10.2522/ptj.20110417
Dasta, J.F., Pilon, D., Mody, S.H., LopaDo, J., Laliberte, F., Germain, G., Bookhart, B.K., Lefebvre, P., & Nutescu, E.A. (2014).
Daily hospitaliza&on costs in pa&ents with deep
vein thrombosis or pulmonary embolism treated with
an&coagulant therapy. E-Journal of Thrombosis Research Journal. 135, 303-310. Retrieved from
hDp://dx.doi.org/10.1016/j.thromres.2014.11.024
Drolet, A., DeJuilio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, E. A., Williams, S.
(2013). Move to improve: The
feasibility of using an early mobility protocol to increase ambula&on in the intensive and intermediate care seYngs.
Physical Therapy, 93(2), 197-207. doi:10.2522/ptj.20110400
Engel, H. J., Tatebe, S. Alonzo, P. B., Mus&lleand, R. L., & Rivera, M. J. (2013). Physical therapist-established intensive care
unit early mobiliza&on program: quality improvement project for cri&cal care at the University of California San Francisco
Medical Center. Journal of the American Physical Therapy Associa<on, 93(7), 975-985. doi: 10.2522/ptj.20110420
Hogan, C. (2015). Early mobiliza&on in the hospitalized pa&ent. Medical sta newsleYer: St. Josephs healthcare. Retrieved
from: hDp://www.stjosephhospital.com/Default.aspx?DN=e6d0de38-0fc4-4b3d-b94b-bde1eef3480f
Klein, K., Mulkey, M., Bena, J. F., Albert, N. M. (2015). Clinical and psychological eects of early mobiliza&on in pa&ents
treated in a neurologic ICU: A compara&ve study. Cri<cal Care Medicine 43(4), p 865873 doi:10.1097/CCM.
0000000000000787
Lord, R. K., Mayhew, C. R., Koruplou, R., Mantheiy, E. C., Friedman, M. A., Palmer, J. B., & Needham, D. M. (2015). ICU early
physical rehabilita&on programs: Financial modeling of cost savings. Cri<cal Care Medicine, 41(3), 717-724. doi: 10.1097/
CCM.0b013e3182711de2
Mah, J.M., Sta, I., Fichandler, D., & Butler, K.L. (2013). Resource-ecient mobiliza&on programs in the intensive care
unit: who stands to win? The American Journal of Surgery, 206, 488-493. Retrieved from hDp://dx.doi.org/10.1016/
j.amjrug.2013.03.001
REFERENCES
Meddings, J., Reichert, H., Rogers, M.A.M., Hofer, T.P., McMahon, L.F., Grazier, K.L. (2015). Under
pressure: Financial eect of the hospital-acquired condi&ons ini&a&ve-a statewide analysis of pressure
ulcer development and payment. The American Geriatrics Society Journal, 63, 1407-1412. doi:10.1111/
jps.13475
Pandullo, S., Spilman, S., Smith, J., Kingery, L., Pille, S., Rondinelli, R., & Sahr, S. (2015). Time for cri&cally
ill pa&ents to regain mobility aler early mobiliza&on in the intensive care unit and transi&on to a
general inpa&ent oor. Journal of Cri<cal Care. hDp://dx.doi.org/10.1016/j.jcrc.2015.08.007
Titsworth, W. L., Correia, T., Reed, R., Guin, P., Archibald, L., Layon, A. J., & J. Mocco (2012). The eect of
increased mobility on morbidity in the neurointensive care unit. Journal of Neurosurgery, 116(6),
1379-1388. doi: 0.3171/2012.2.JNS111881
Wang, Y. T., Haines, T. P., Ritchie, P., Walker, C., Ansell, T. A., Ryan, D. T., Lim, P., Vij, S., Acs, R., Fealy, N.,
& Skinner, E. H. (2014). Early mobiliza&on on con&nuous renal replacement therapy is safe and may
improve lter life. Cri<cal Care, 18(4), R161-R170. doi:10.1186/cc14001
Witcher, R., Stoerger, L., Dzierba, A. L., Silverstein, A., Rosengart, A., Brodie, D., & Berger, K. (2015).
Eect of early mobiliza&on on seda&on prac&ces in the neurosciences intensive care unit: A
preimplementa&on and pos&mplementa&on evalua&on. Journal of Cri<cal Care, (30), 344-347.
Retrieved from
hDp://zp9vv3zm2k.search.serialssolu&ons.com/?V=1.0&sid=PubMed:LinkOut&pmid=25573283
Zomorodi, M., Topley, D., & McAnaw, M. (2012). Developing a mobility protocol for early mobiliza&on of
pa&ents in a surgical/trauma ICU. Cri<cal Care Research and Prac<ce. 2012 1-10 Doi:
10.1155/2012/964547
QUESTIONS?