Evaluating the Implementation of an Early Mobility Protocol in a Surgical Intensive Care Unit (SICU) on Pressure Ulcers (PU)

Dickinson, Sharon; Gombert, Jan; Rickelmann, Connie ; Meldrum, Craig; Hayey, Renee; Kanphade, Gomati ; Tschannen, Dana and the nursing medical staff of the SICU

University of Michigan Hospital and Health Centers, Ann Arbor, Michigan

Purpose

Synthesis

Change

Implementation Strategies

Evaluation

Significance

To evaluate whether the implementation of an early mobility protocol in a busy, high acuity, Surgical Intensive Care Unit could reduce the incidence of pressure ulcers.

The SICU PU rate consistently exceeds the national benchmark of 7%. In previous analysis, SICU patients were more likely to develop a PU with: advanced age, increased use of vasopressors, reduced weight, greater mortality risk, changes in Braden moisture and activity scores. Very few of these risk factors are influenced by nursing practice with the possible exception of activity.

This evidenced based protocol consists of 3 phases, initiated when the patient achieved physiological stabilization. To enhance compliance, the protocol was included on the admission order set. A dedicated mobility tech was initially added to the care team, which was later replaced by a Physical Therapy technician (Due to budget constraints) to assist the nurse with mobility interventions and documentation in Centricity. An extensive education campaign was launched through the SICU clinical practice committee.

A total of 536 patients (4241 patient days) were evaluated for their response and readiness to progress through the three mobility phases. Eight patients who had a PU prior to their arrival in the SICU were excluded from the analysis. Compliance with early mobility was calculated as the percent of tasks required in the phase that were completed (e.g. 3 tasks, 3 times a day, 100% compliance if all 9 tasks completed). Initial compliance with the protocol started at 76% with a downward trend in subsequent weeks, resulting in an average compliance of 66%. During the study 77 patients (14.6%) developed a PU. This rate was not significantly improved from a comparison group prior to the study. Protocol compliance was not significantly different in patients who did (67.2%) or did not develop a PU (68.8%).

References

The Clinical Nurse Specialist in conjunction with the SICU Clinical Practice Committee developed an evidenced based early mobility protocol that emphasized 3x/day movement of all but the sickest patients in progressive fashion as their condition improved.

PHASE 0 (UNSTABLE) PHASE I PHASE II

Passive (3X/day, 10 repetitions) ROM

Active (3X/day, 10 repetitions)

Passive (3X/day, 10 repetitions) ROM

Active (3X/day, 10 repetitions)

ROM ~ Resistance (3X/day, 10 repetitions)

HOB Elevated 30-45 Degrees

HOB Elevated 30-45 Degreesor Reverse Trendelenberg

HOB Elevated 30-45 Degreesor Reverse Trendelenberg Reposition (every 2 hours)

Reposition (every 2 hours) Reposition (every 2 hours) Standing (3x/day)

Continuous Lateral Rotation (18-24 hours per day) Chair Position or OOB with sling (3x/day) OOB (bear own weight) (3x/day)

If patient tolerates these activities, advance to next phase Dangling (3x/day) Walking (3x/day)

Goals:

1. Every patient should be evaluated for early mobility.

2. Small efforts can yield large results.

3. Never give up! Poor tolerance during one episode does not predict future tolerance.

4. Evaluate patient readiness and response to current therapy and ability to progress

Inclusion Criteria:Early activity is initiated when the patient achieves physiological stabilizationLow dose catecholamine's drips should not preclude the patient from early mobility (i.e. low dose norepi, phenylephrine, vasopressin)FIO2 < or equal to 60% - Peep less than or equal to 10 cm H2O Patient’s on CRRT with secured lines in the Internal Jugular or Femoral

*Possible criteria to withhold early mobility: hypoxia, hemodynamic instability (escalation of vasopressors in the last 12 hours), ICP monitoring or unstable cardiac rhythm (life threatening rhythm that compromises blood pressure in past 24 hours) or new cardiac arrhythmia & epidural.

SICU Mobility Protocol

We conclude that partial compliance with the early mobility protocol does not influence PU development. It is possible that more robust compliance with the protocol might reduce the PU rate. We are currently seeking to reduce the barriers to achieving full compliance. Most recently, mobility documentation has been moved to the front of the flow sheet. Alternatively, it is possible that full compliance with the protocol will have no effect on PU development in these very sick patients. To explore this possibility, we will further analyze the data and compare the PU rate only in patients who did not have “do not turn” orders before and after protocol implementation. Further analysis is underway, which will consider the effect of patient characteristics, as well as early mobility, on pressure ulcer development.

• Morris PE: Moving our critically ill patients: mobility barriers and benefits, Crit Care Clin. 2007 Jan;23(1):1-20

• Perme C, Chandrashekar R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care. 2009 May;18(3):212-21. Epub 2009 Feb 20.

• Timmerman RA. A mobility protocol for critically ill adults. Dimens Crit Care Nurs. 2007 Sep-Oct;26(5):175-9; quiz 180-1.

Mobilityeduc.

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H1N1 Patients

Chronically Critically Ill – 20 H1N1 Pts.