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Service Delivery Innovation Profile

Team-Administered Protocol Encourages Mobility in Respiratory Intensive Care Unit Patients, Leading to Shorter Length of Stay


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Summary

LDS Hospital implemented a protocol designed to encourage early physical activity in respiratory intensive care unit patients, including those requiring mechanical ventilation. A multidisciplinary care team assesses patients to determine their readiness for mobility. Eligible patients receive two mobility interventions daily, progressing from sitting at the edge of the bed to standing by the bed to walking up to 200 feet. A prospective cohort study found that the vast majority (almost 98 percent) of participating patients completed at least one step in the protocol, and more than two-thirds successfully walked more than 100 feet. Since implementation, intensive care unit and total hospital length of stay for respiratory failure patients declined, while rates of weaning failure and use of tracheotomies also decreased.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on patient activity levels along with before-and-after comparisons of key outcomes measures, including respiratory ICU and total hospital LOS, use of tracheotomies, and weaning failure rates.
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Developing Organizations

LDS Hospital
Salt Lake City, UTend do

Date First Implemented

1999
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Patient Population

Vulnerable Populations > Intensive care unit patientsend pp

Problem Addressed

Intensive care unit (ICU) patients, particularly those with acute respiratory failure who can breathe only with the assistance of a ventilator, often suffer a loss of systemic physical conditioning and other negative consequences as a result of immobility and heavy sedation.1 Although early mobility can help minimize the degree of deconditioning, most institutions lack formal processes to encourage it.
  • A common problem, with negative health consequences: Deconditioning and weakness are common problems in immobile ICU patients.1 In fact, the vast majority of patients on ventilators experience at least some degree of deconditioning, leading to poor physical outcomes and decreased health-related quality of life,2 including a decline in musculoskeletal functioning, nerve systems, and cardiovascular and other organ systems.1 Up to one-fourth of patients on a mechanical ventilator for more than 7 days experience critical illness polymyoneuropathy, an extreme weakness or numbness in one or more extremities.3
  • Leading to longer length of stay (LOS): Physical deconditioning and weakness may contribute to an extended ICU LOS of 25 days or more.4 Before the development of the mobility protocol, respiratory failure patients at LDS Hospital had a mean overall LOS of more than 21 days, accounting for 29 percent of ICU patient days and 53 percent of mechanical ventilation days.5
  • Unrealized benefits of early mobility: Early mobility can improve functional outcomes in ICU patients but may not be promoted consistently, or at all, particularly in medical ICU patients on mechanical ventilation.4 The failure to encourage mobility in the ICU may be associated with concerns related to apparatus dislodgement, difficulties in incorporating physical therapy given sedation use, the perceived high costs of providing such therapy, staffing constraints, and lack of a uniform protocol for physical therapy.1 Overall, clinician concerns that critically ill patients are "too sick" to tolerate activity may limit mobility and lead to unnecessarily prolonged immobilization.2

What They Did

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Description of the Innovative Activity

LDS Hospital implemented a protocol designed to encourage early physical activity in respiratory ICU patients, including those requiring mechanical ventilation. A multidisciplinary care team assesses the patient to determine his or her readiness for mobility. Eligible patients receive two mobility interventions daily, progressing from sitting at the edge of the bed to standing by the bed to walking up to 200 feet. Key elements include the following:
  • Broad population targeted: Although the protocol initially targeted those on mechanical ventilation for more than 5 days, LDS Hospital now considers use of the protocol for the vast majority of patients in the 12-bed respiratory ICU. The only exceptions are those patients who have neuromotor impairment (e.g., stroke patients) or are comatose; any other justification for not implementing the protocol must be written specifically by the physician.
  • Assessment by multidisciplinary care team: A multidisciplinary care team assesses the patient's readiness for mobility. The team includes a physical therapist who assesses the patient's physical ability to participate, a nurse who assesses physiologic stability, and a respiratory therapist who is responsible for maintaining the patient's airway. In addition, a critical care physician confirms that there are no clinical contraindications to physical activity. Each patient is assessed on admission to the unit, and those who qualify immediately begin on the protocol. Those who are not eligible are reassessed during daily rounds; if activity has been halted due to an acute event, the patient is reevaluated each day until the protocol can be reinstated. For those who are cleared to participate, a critical care technician assists with patient mobility and prepares equipment for patient movement.
  • Protocol execution: Each eligible patient is encouraged to be mobile twice a day, with the specific level of activity geared to his or her readiness. Patients progress through a three-step process, embarking on the highest level of physical activity they can tolerate, as outlined below:
    • Sitting on edge of bed: As a first step, the care team helps patients sit at the edge of the bed with their feet planted on the floor or on a platform. This step is appropriate for patients who are still on sedation and/or critically ill and for others for whom it is risky to leave the bed. Care team members stay with patients for as long as they can tolerate the position, monitoring the patients for physiological signs and symptoms of distress such as fatigue and/or changes in blood pressure, heart rate, respiratory rate, and oxygen saturation level. A caregiver may support the patient from behind, but the position is discontinued after a few minutes if the patient cannot hold his or her torso upright. The goal is to maintain this position for 10 minutes with minimal support. The patient moves to the second step after accomplishing this goal twice.
    • Standing at bedside and sitting in chair: As a next step, the care team helps the patient stand at the bedside, bear some weight (by lifting each leg), and pivot into a chair by the bed. The patient is encouraged to sit in the chair for as long as he/she can tolerate it, up to 2 hours. If the patient is stable and awake, the care team departs after approximately 15 minutes, but checks in periodically; equipment allows all patients to be monitored from a central station. If the patient becomes disconnected or declines physiologically, the care team returns immediately. If the care team is concerned about the patient's ability to tolerate the sitting position, they remain with the patient. The patient moves to the next step after accomplishing this step twice.
    • Walking a short distance: The final step is for the care team to help the patient walk, beginning with a few steps (e.g., to the doorway) and ultimately reaching 200 feet. The nurse and physical therapist support the patient; canes and walkers may be used as needed. The patient care technician follows the patient with a wheelchair in case of fatigue or medical need, and equipment also accompanies the patient as needed. For example, the ventilator (which can work for a short period of time without electricity) can be detached from the wall and carried by a patient care technician for those who need significant ventilator support. For patients who have only a small oxygen requirement, the respiratory therapist uses a ventilation bag to ventilate the patient while walking.
  • Sedation reduction and oxygen support: Application of the protocol requires that sedation be reduced and oxygen levels be supported, as outlined below:
    • Reduction of sedation: The nurse attempts to enhance a patient's alertness and responsiveness by decreasing sedation, with the goal of instigating the protocol within 24 hours of admission. Strategies include avoiding use of continuous sedation when the patient's oxygen level is at 60 percent or below; limiting the amount of benzodiazepine used, particularly if oxygen levels drop to 40 to 50 percent, in preparation for weaning off the ventilator; and substituting enteral for intravenous narcotics so that the patient's pain can be treated without altering consciousness.
    • Oxygenation: The respiratory therapist adjusts the ventilator to ensure that the patient has a sufficiently high oxygen saturation rate to support the increased oxygen demands of activity.
  • Discontinuation upon ICU discharge: Use of the protocol ends when the patient is discharged from the respiratory ICU. Readiness for discharge depends on clinical considerations, not the patient's ability to walk 200 feet.

Context of the Innovation

LDS Hospital is part of Intermountain Healthcare, a nonprofit health system based in Salt Lake City, UT. The hospital has 520 beds, approximately 60 of which are critical care beds, including a 12-bed respiratory ICU. The impetus for the program came from critical care nurses, who were surprised and disturbed by how long it took former respiratory ICU patients to recover functional status after discharge from the unit. For example, one teenage boy who spent 4 months on a ventilator after a dirt-bike accident was still in a wheelchair 1 year after discharge, primarily because of the drastic weakness caused by prolonged immobility. As a result of this story and others like it, the nurses decided to develop a program to encourage early activity as a way to avoid extensive deconditioning.

Did It Work?

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Results

A prospective cohort study conducted from June to December 2003 found that the vast majority (almost 98 percent) of participating patients completed at least one step in the protocol, and more than two-thirds successfully walked more than 100 feet.2 In addition, since program implementation in 1999, respiratory ICU LOS and total hospital LOS for respiratory failure patients declined, while rates of weaning failure and use of tracheotomies also decreased.
  • Vast majority achieving some degree of mobility: A prospective cohort study involving 103 patients and a total of 1,449 activity interventions (16 percent sitting on the bed, 31 percent sitting in a chair, and 53 percent ambulating) found that by the last full day of stay in the respiratory ICU, nearly 98 percent of patients had completed at least one step in the protocol, including 69.4 percent who had walked more than 100 feet, 15.3 percent who sat in a chair, and 4.7 percent who sat on the bed; only 2.4 percent had no activity.2
  • Lower ICU and overall LOS: Between 2000 and 2005, mean respiratory ICU LOS declined from 13 to 10 days, whereas total hospital LOS for respiratory failure patients fell from 28 to 19 days.5
  • Less weaning failure, tracheotomy use: Between 2000 and 2005, weaning failure rates declined from 12 to 3 percent, while use of tracheotomies declined from 29 percent to less than 5 percent of mechanically ventilated patients.5 Although a direct association between the mobility protocol and these declines cannot be drawn, clinicians assume that early activity and reductions in sedation (which facilitate patients' ability to control secretions and protect the airway) have been key contributors.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on patient activity levels along with before-and-after comparisons of key outcomes measures, including respiratory ICU and total hospital LOS, use of tracheotomies, and weaning failure rates.

How They Did It

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Planning and Development Process

The planning and development process was relatively informal. Key elements included the following:
  • Informal discussion: The respiratory ICU nurses informally discussed the idea of promoting early activity in patients with other critical care clinicians. Because LDS Hospital encourages quality improvement efforts at the unit level, no administrative approval process was required.
  • Design of test protocol: The respiratory ICU nurses, respiratory therapist, and physical therapist designed a test protocol and reviewed it with critical care physicians to gather feedback.
  • Test on one patient: The clinicians tried the protocol on one patient, and then refined it based on this experience.
  • Adoption by unit: The protocol was adopted by LDS Hospital's respiratory ICU. (Note: The respiratory ICU that initially existed at LDS Hospital has moved to the new Intermountain Medical Center.)
  • Spread to other units: Clinicians adopted the protocol at the 16-bed medical–surgical ICU at LDS Hospital. Clinicians are also working to implement the protocol at Intermountain Medical Center's shock trauma ICU and neurological care ICU. Information provided in January 2011 indicates that the same process of care has been implemented in the respiratory ICU at Intermountain Medical Center.

Resources Used and Skills Needed

  • Staffing: No new staff have been hired as a result of the protocol. The 12-bed respiratory ICU already had one full-time equivalent (FTE) respiratory therapist and two FTE physical therapists, who facilitated implementation of the protocol. The respiratory ICU staff typically works with eight or nine patients twice a day.
  • Costs: No additional costs were incurred in the development or operation of the protocol. Use of the protocol is part of the daily routine for unit staff.
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Funding Sources

LDS Hospital
The services provided under the protocol are generally covered by insurance.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Involve a multidisciplinary group: Critical care nurses, respiratory therapists, and physical therapists must work together as a team to ensure safe activity for the patient.
  • Start small: Start by trying the mobility protocol with one or a few patients, and then refine it based on actual experience.
  • Start with supporters: Not all clinicians will initially support the concept of early mobility. By starting with clinician "champions," other clinicians will have the chance to observe the protocol in action and see its benefits.
  • Hire dedicated physical therapists: Implementing a mobility protocol requires support and commitment from the staff, along with significant staff time. Units with dedicated physical therapists will find it easier to implement the protocol from both a practical and cultural standpoint.
  • Communicate importance of mobility to other units: Patients discharged to other units can deteriorate quickly if they are not continuously encouraged to get up and walk. At LDS Hospital, once patients can walk 200 feet, they no longer meet the criteria for physical therapy assistance. As a result, nurses and aides on the acute care units must take responsibility for promoting mobility, which can become a low priority given heavy unit workloads. To encourage a continued focus on mobility, critical care unit caregivers should educate their colleagues on other units about the benefits of mobility in preventing functional deterioration, and help identify strategies (e.g., enlisting family member support) to promote such activity.

Sustaining This Innovation

  • Be patient: Implementing a mobility protocol can initially be a labor-intensive process. However, over time, caregivers become more efficient at getting patients moving and organizing equipment to facilitate mobility.

Spreading This Innovation

This process is now being used by staff at the LDS Hospital Medical Surgical ICU and at the Intermountain Medical Center Respiratory ICU. These units are both part of the Intermountain Healthcare system.

Additional Considerations

  • The ability to mobilize patients is closely connected to sedation management. Many critical care patients are oversedated due to clinician fears that agitated patients will pull their tubes out or concerns about patient comfort. Although LDS Hospital's mobility protocol does not specify sedation levels, a patient must be responsive to participate. Sedation levels, therefore, must be minimized to allow patients to respond to stimuli.

More Information

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Contact the Innovator

Polly Bailey, RN, APRN - BC, CCRN
Intermountain Medical Center
5121 South Cottonwood Street
Murray, UT 84157
Phone: (801) 408-8689
E-mail: Polly.Bailey@imail.org

Innovator Disclosures

Ms. Bailey has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Thomsen GE, Snow GL, Rodriquez, et al. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med. 2008;36(4):1119-1124. [PubMed]

Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35(1):139-145. [PubMed]

Hopkins RO, Spuhler VJ, Thomsen GE. Transforming ICU culture to facilitate early mobility. Crit Care Clin. 2007;23:81-96. [PubMed]

ICU-acquired weakness: Proceedings of a Round Table Conference in Brussels, Belgium, March 2009. Crit Care Med. 2009;37(10):S295-461. [PubMed]

Herridge MS. Legacy of intensive care unit-acquired weakness. Crit Care Med. 2009;37:S457-461. [PubMed]

Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36:2238-43. [PubMed]

Hopkins RO, Spuhler VJ. Strategies for promoting early activity in critically ill mechanically ventilated patients. AACN Advanced Critical Care. 2009;20:277-289. [PubMed]

Footnotes

1 Morris PE, Goad A, Thompson C, et al. Early intensive care unity mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-43. [PubMed]
2 Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35(1):139-145. [PubMed]
3 De Jonghe B, Sharshar T, Lefaucheur JP, et al. Paresis acquired in the intensive care unit: a prospective multicenter study. JAMA. 2002;288(22):2859-67. [PubMed]
4 Herridge MS, Cheung AM, Tansey CM, et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. 2003;348(8):683-93. [PubMed]
5 Hopkins RO, Spuhler VJ, Thomsen GE. Transforming ICU culture to facilitate early mobility. Crit Care Clin. 2007;23:81-96. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 30, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 13, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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