Early Mobility Issues in the Intensive Care Unit

Early mobilization therapy issue became an area of concern after researchers discovered the negative consequences of bed rest following sickness or trauma. These consequences can be versatile and dangerous for a patient’s health condition. The most prominent of them are cardiovascular deconditioning, increased risk of pressure ulcer development, muscle weakness and atrophy, neurological dysfunction. Thus, the given reasons are enough to support the need for developing an EBP project in this area (Patel, Pohlman, Hall, & Kress, 2014).

The nursing issue that has been chosen is the early mobility in the intensive care unit (ICU). Particularly, the advantages and the disadvantages of early mobility therapy compared to non-early mobility therapy for patients who are in intensive care will be analyzed. The reason for choosing this particular topic is that it is a significantly important issue in nursing practice. However, the amount of evidence that has studied the early mobilization of seriously ill patients is rather small. A few randomized and controlled researches have been conducted including only several hundred patients which significantly limits the strength of the evidence.

Therefore, since the early mobilization therapy is considered safe and feasible, it is important to pay more attention to it (Schaller et al., 2016). Thus, this assignment consists of the following sections: Introduction, The Connection between FNP and Early Mobility Therapy, Nursing Issue, PICO Question, Research Literature Support, Theoretical Framework, and Change Model, Research Approach and Design, Sampling Method, Conclusion, and References.

The Connection between FNP and Early Mobility Therapy

The specialty track that has been chosen is the Family Nurse Practitioner (FNP). FNPs are advanced practice nurses who work autonomously or in cooperation with other healthcare professionals to provide family-focused care. They provide a wide range of healthcare services for particular family units on a long-term basis. FNPs’ objective is to promote health, prevent diseases, treat patients, and counsel them across the lifespan. The role of an FNP in early mobility therapy in the ICU is significant. FNPs look after patients when they are in intensive care. In this regard, they can help implement early mobility therapy during the treatment of their patients (Bernhardt, 2017).

Thus, depending on the type of illness or injury, FNPs can determine whether to use early or non-early mobility therapy on their patients. Although in general, early mobility therapy helps prevent negative consequences caused by bed rest, in certain cases, it can lead to the relapse of a disease or the opening of an undertreated wound. Therefore, FNPs’ purpose is to decide whether this therapy will harm a patient in a particular case or improve patient’s health, accelerate the healing process, and help avoid pernicious consequences connected with the non-early mobility therapy (Clark, Lowman, Griffin, Matthews, & Reiff, 2013).

Nursing Issue

The nursing issue on which this project is focused is the early mobility program in the ICU. There has recently been an increase in the movement to begin research that focuses on the physical therapy utilization within the ICU establishment and the outcomes of the early intervention program with patients within this establishment. Progressive or early mobilization includes a system of movements that increase the activity of a patient beginning with the passive set of movements and ending with the independent ambulation. After the implementation of early mobility therapy, patients will begin a special movement therapy in 24-48 hours after the mechanical ventilation (Schaller et al., 2016).

The early mobility therapy had been implemented until recently. For several years, many types of research were conducted to identify the advantages and disadvantages of this therapy. Eventually, a couple of years ago, some hospitals started to implement it. Thus, as for the frequency of the occurrence of this therapy, it is not frequent, as it is a new therapy, but those who have started to use it demonstrate chiefly the positive results (Reade & Finfer, 2014).

The initiation of the therapy begins after the establishment of the clearance from a physician or a medical team responsible for the ICU patients (approximately a week) and after the occupational therapy and/or the physical therapy has been consulted. Currently, numerous attempts are being made to launch more trials of the early mobility therapy for the ICU patients in combination with the interruption of sedation during the therapy time. In this regard, this therapy becomes more frequent, and it may soon be fully introduced in nursing practice (Engel, Tatebe, Alonzo, Mustille, & Rivera, 2013).

Additionally, the implementation of the early mobilization protocol requires a multidisciplinary approach that includes collaboration between physicians, nurses, respiratory therapists, rehabilitation therapists, and administrators. Thus, this issue will engage all stakeholders, including improvement team leaders, senior leaders, and frontline staff who will be involved in the process of its implementation (Schaller et al., 2016).

Thus, this project will attempt to present evidence on the advantages and the disadvantages of early mobility therapy in the ICU in contrast to non-early mobility therapy. The rationale for choosing this particular nursing issue is that it is important and relevant now and requires much attention and effort on the side of all the stakeholders to be successfully implemented in nursing practice. Additionally, due to the lack of practical evidence of the positives and negatives of early mobilization therapy, it is crucial to conduct further research on this issue to accelerate its overall implementation. Moreover, this therapy has already proved to be safe and efficacious (Bernhardt, 2017).

PICO Question

Currently, the problem of the implementation of early mobility therapy in the ICU is relevant. Many types of research have been made since the first attempts to introduce this new program. Recent literature supports the need for this program, stating that it will help avoid the undesirable effects that can be caused by long bed rest and improve patient’s health (Reade & Finfer, 2014).

Based on the identified need for the early mobility therapy development in the ICU and the current relevance of the identified nursing issue the following PICO question is created to guide this project: In the severely ill or injured patient in the ICU does early mobilization therapy results in ameliorated functional state and decrease ICU stay as compared to the non-early mobilization therapy? The main criterion for the search was the scholarly or peer-reviewed articles and journals using reliable databases like CINAHL, EBSCO, Medline Complete, PubMed, and Google Scholar Search. The key terms used in the literature search were critically ill patients, early ambulation, early mobility, bed rest, intensive care units, physical therapy, quality improvements, rehabilitation, therapy, and mechanical ventilation.

Research Literature Support

Leditschke, Green, Irvine, Bissett, and Mitchell (2012) conducted a quantitative study, with the purpose to find out the benefits of early mobilization of critically ill patients in the ICU and identify the frequency of this therapy. The research was a 4-week prospective audit on 106 patients from a mixed medical-surgical tertiary ICU, whose mean age was 60 years, median ICU length of stay was one day, and median hospital length of stay was 12.5 days. They were subject to

1. active mobilization, which consisted of marching on the spot for more than 30 seconds);
2. active transfer from bed to a chair;
3. passive transfer.

The researchers collected de-identified data on the number of days the patient was mobilized, the type of mobilization used, adverse factors, and reasons mobilization could not take place. It was found out that participants were mobilized on 176 of 327 days spent in ICU. 2 adverse events occurred during 176 mobilization episodes (1.1%). It was concluded that it was possible to mobilize critically ill patients for the majority of days of their stay in the ICU starting from the first (which supports the PICO of the study at hand). The key strength of the study is its scope and practical recommendations. Its major limitation is that no evidence proves that early mobilization is more effective than non-early therapy. The solution is to perform a similar study to compare the effects of the two approaches.

Engel, Needham, Morris, and Gropper, (2013) performed a qualitative study of the three selected medical centers for the success of their ICU early mobilization programs. The major purpose of the research was to compare and contrast the impact of an early mobility program produced on severely ill patients in three hospitals. The researchers used an interprofessional approach based on teamwork. As a result, the length of stay was reduced both in the ICU and in general care. Moreover, in all the three medical centers, this intervention also managed to lower the level of delirium and practically eliminated the need for sedation for the participants.

This allowed concluding that ICU early mobility quality improvement program is capable of improving patient outcomes, which supports the PICO. The strength is that the described program can easily be applied to other types of care units. Yet, there are no exact numeric indicators of improvement, which is a limitation. The solution is to conduct a quantitative study to obtain statistical evidence.

Sricharoenchai, Parker, Zanni, Nelliot, Dinglas, and Needham, (2014) conducted a prospective observational study aimed to identify whether it is safe to use early mobilization therapy interventions in the ICU for reducing impaired physical functioning. The authors of the study explored how often and under what conditions some of 12 kinds of physiological abnormalities and safety risks presented by the implementation of mobilization therapy could appear. As a result of the experiment, 1787 patients with an ICU stay lasting a minimum of 24 hours, 1110 (62%) took part in 5267 mobilization sessions.

All sessions were organized and performed by 10 therapists during 4580 days. A total of 34 (0.6%) of these sessions revealed safety risks or physiological abnormalities. None of these required any additional costs or prolonged stay, which supports the effectiveness of the therapy indicated in the PICO. The strength of the study is its huge sample size increasing the liability and validity of the experiment. Its limitation is that only one hospital was involved in the research. The solution is to repeat the experiment in other hospitals which will include the influence of clinical factors as a variable.

Lord et al. (2013) performed a quantitative study, collecting data from articles and the actual implementation of the program and created their model of net financial savings. The researchers’ major goal was to evaluate how much annual cost implementation of the ICU early mobilization therapy allows saving. The intervention consisted of financial modeling of results for the implementation of the early mobilization program. The researcher presented the results of using the developed model for ICUs with 200, 600, 900, and 2,000 annual admissions. It was identified that $817,836 of cost savings could be achieved through the implementation of the program in the example scenario with 900 patients per year. These savings were generated through stay reductions of 22% (for ICU) and 19% (for the floor).

This implies that the program indeed allows saving costs through the amelioration of patients’ condition (which again supports the PICO). The key strength of the study is that a new model was developed that relies on actual experiments of the program implementation. The limitation is that there is hardly any novelty except for the implementation of a new tool. The solution would be to apply the same tool to compare the effects of different types of mobilization therapy as this may give unprecedented results.

Theoretical Framework and Change Model

For this project, Lewin’s Change Theory was selected as a theoretical framework as it provides a method to successfully implement a planned change (the one occurring by design). The main concepts of the theory are field and force. The former is a system, which means that in case one of its elements changes, the whole body of it is affected. Change is viewed in a disrupted balance of driving and restraining forces.

While a driving force initiates movement or shifts towards transformation, a restraining force is the one hindering the process. In the case of the early mobility issue, the driving forces include educational programs for staff and patients, evidence-based literature supporting early mobilization, administration support, etc. Restraining forces are numerous: patients’ reluctance to try early mobilization as a part of general resistance to change, nurses’ unwillingness due to the fear of accident extubation, patients’ delirium, oversedation, lack of specific policies and comprehensive programs, etc. Thus, according to the chosen theory, it is needed to:

1. unfreeze the status quo;
2. gradually introduce changes;
3. freeze the change making it durable by assimilating in the system (Shirey, 2013).

The success and sustainability of the project intervention will be ensured by the capability of the framework to allow a better understanding of patients’ needs and fears and developing an implementation plan by these factors. An education program will be required to integrate early mobilization into practice since it cannot simply be imposed upon ICU patients if they opt for non-early intervention or no mobility at all. Lewin’s framework will make it possible to change the entire system through an individual change.

The implementation of the proposed change will be guided by the Logic Model for Program Development since it allows planning the desired outputs, outcomes, and the general impact of the change in advance. The model also makes it possible to measure both patients’ and nurses’ knowledge concerning the benefits of early mobilization in the ICU to assess what training will be required (Chen, 2014).

Research Approach and Design

Since the research goal is to answer whether a severely ill or injured patient will have an ameliorated functional state and a decreased stay in hospital with the realization of the early mobilization therapy compared to the non-early mobilization therapy, it would be reasonable to opt for a quantitative approach. The design is going to be experimental. It will test a hypothesis through intervention, the impact of which will be the major focus of the study. Furthermore, the experiment is required to look for ways to improve the condition of real patients. The choice of this approach is accounted for by the fact that it allows controlling the study conditions using precise measures and strict regulations of all variables. The major advantage of the quantitative study is that it is possible to generalize the results from a sample to a larger group of the population. Yet, there is also a disadvantage: The research design does not allow discovering anything new since it is purely deductive.

Sampling Method

The target population that the study is going to address will include severely ill or injured patients from 25 to 65 years of age undergoing treatment in the ICU. Non-probability sampling will be used, which is supported by the fact that only patients of a particular age group who currently suffer from acute diseases or injuries will be eligible to participate in the research. This type of sampling was selected because it allows researchers to focus on a particular group of patients (as it would be wrong to involve patients from the general care unit in the same experiment).

The following steps will constitute the sampling procedure:

• establishing eligibility criteria;
• choosing a random sample of patients from 25 to 65 undergoing treatment in the ICU;
• informing the participants about the goals of the research and obtaining their informed consent;
• collecting background information about the participants to decide on variables;
• dividing the patients into the control (receiving non-early mobilization therapy) and intervention groups (undergoing early mobilization); each group will include approximately 50 participants.

The two major advantages of this sampling procedure is that: 1) non-probability sampling implies that only patients meeting the criteria will be able to participate–therefore, the intervention will be thoroughly controlled and the results will be precise; 2) at the same time, randomized trial will eliminate bias. Yet, there is also a disadvantage: Non-probability samplings practically do not take into account extraneous variables, which can be influential.

Institutional Review Board help researchers protect participants’ rights relying on the following principles:

• obtaining informed consent;
• respecting confidentiality and privacy;
• discussing the limits of confidentiality (informing participants what data will be made public and how it will be used) and preventing their violation;
• informing participants about federal and state laws that protect their rights.

Data Collection Procedure

Since the key goal is to identify whether early mobilization therapy is more effective than non-early interventions, I decided to opt for a quantitative approach. This decision is accounted for by the fact that I need statistics to be able to address the study issue. I believe that exactly this study approach has the biggest potential to answer the research question as it will allow assessing the impact of both alternative methods and make conclusions having compared numerical data (Grove, Burns, & Gray, 2014).

As far as data collection method is concerned, it will be performed through the following steps (Creswell, 2013):

• collecting background information about the participants;
• dividing the patients into the control (receiving non-early mobilization therapy) and intervention groups (undergoing early mobilization); each group will include approximately 50 participants;
• organizing an intervention, during which the control group will receive non-early mobilization therapy whereas the intervention group will be subjected to early mobility;
• performing the same examination as before the intervention in both groups to compare the effectiveness of the two types of therapy.

A randomized controlled trial will allow identifying which type of intervention is more effective. Yet, to make sure that the effects are lasting, it will be necessary to assess the impact of early and non-early mobilization on ICU length of stay for a period exceeding 2 years. The data collection procedure will start by measuring ICU mobilization activity among patients aged 25-65. To minimize the impact of extraneous variables, patients who have aggravating conditions (neuromuscular disease, post-cardiac arrest, increased intracranial pressure, obesity, etc.) will not be eligible for participation in the research.

The following data collection points are important to obtain:

• demographic data (age, gender, etc.);
• ICU length of stay;
• first out-of-bed mobilization (if any);
• duration of therapy;
• medical stability (heart rate, blood pressure, arterial pressure, electrocardiogram, respiratory rate).

The members of the intervention group are to receive a 30-minute session of mobilization therapy twice a day for a minimum of five days per week starting from their admission to ICU until discharge. On the contrary, members of the control group will be subject to non-early intervention (approximately 1 month before the discharge).

To obtain the most accurate results possible, it will be necessary not only to collect the above-mentioned physiologic data but also to self-reports provided by patients. The point is that it is always recommendable to support statistical reports with patients’ perception of the intervention. That is why the participants will fill out open questionnaires to report their physical and emotional state before and after the intervention. Their self-reports will be compared with the statistics obtained as per their physiologic indicators.

The quality of data will be fostered through the following:

• eliminating bias through randomized sampling;
• obtaining the consent of the participants (ensuring their willingness to contribute);
• reducing the impact of extraneous variables;
• comparing the effects of both types of therapy;
• using both objective and subjective reports of the results.

Analysis

For the study at hand, the T-test was selected. The major reason for this is that it suits the small sample size (100-200 participants) and clearly shows differences in research outcomes for all groups involved. Moreover, it is advisable to use this type of statistics when two normal distributions are unidentified. Mean or the arithmetic average is a typical measure of central tendency applied in t-tests.

It is calculated as a sum of the value of every observation conducted in the selected sample divided by a number of all observations during the period covered by the research. Since the participants of the experiments will have to be tested more than once, it would be reasonable to use an inferential test–a type of statistical test that involves repeated measures. Each participant of the two research groups will be measured on the same variables: various physical reactions to early and non-early mobilization therapy. This strategy seems to be the most appropriate for the given research since it makes it possible to assess the impact of each intervention in its relation to the chosen study variables together with the type of therapy for each group.

Yet, it is not enough to obtain statistical data since patient-reported information may be quite different. For comparison purposes, it is recommended to collect information via open questionnaires. Patients will be offered to answer several questions about their condition before the experiment and their perception of the result of the intervention. Afterward, the data obtained from the statistics will be compared to those answers to make sure that no misinterpretation took place.

Other advantages of t-tests include:

• The simplicity of interpretation. Since any t-test demonstrates how different the mean of one group of participants is from the other group, it is much easier to calculate the average difference between the control and the intervention group. Furthermore, it is also easy to identify whether this difference is significant from the statistical point of view.
• Robustness. It means that even though two populations are supposed to be distributed normally, the test still allows two samples from population groups having quite different incoming data.
• Ease of data gathering. In fact, despite the seeming complexity of the t-test in comparison to descriptive analysis, it requires very little data without which it cannot be performed. The only integral measure is one value from each subject.
• Ease of calculation. Since people who were easily allowed to selected and participate will test in all suggested procedures, it would be much easier to make them take part in the research (Parahoo, 2014).

Conclusion

It has long been unclear whether early or non-early mobilization therapy is preferable for patients in the ICU. The problem is that opting for the former is fraught with consequences if the patient is not ready for the therapy. On the contrary, the latter is usually implemented when it is already too late to be effective. The role of FNPs is hard to overestimate as the success of the intervention will largely depend on their ability to estimate which patient should be subject to which type of therapy.

Yet, despite some hesitations in terms of early mobilization, it has been proven by the majority of studies that this intervention typically brings about considerable improvements in patients’ condition. This gives grounds to state that the project at hand is going to give positive results and confirm the necessity of early mobility in ICU. Furthermore, the selected methods of data collection are to ensure that the results of the experiment will be precise, accurate, and relevant. It is not enough, in this case, collect exclusively statistics since the patients’ conditions will be determined not only by objective indicators. That is why alongside statistical tests showing the patients’ biophysical condition questionnaires will be implemented to collect self-reported information.

From doing this assignment I have learned that even the most effective types of medical intervention must be checked as per their side effects. What is effective in patients of one age group might be harmful to others. That is why it is highly important to opt for randomized trials since they allow demonstrating the results of the same therapy in different recipients. I also learned a lot about research ethics and its considerable role in sampling.

References

Bernhardt, J. (2017). Early mobilisation and rehabilitation in the intensive care unit–Ready for implementation? Annals of Translational Medicine, 5(3), 57-59.

Chen, H. T. (2014). Practical program evaluation. Thousand Oaks, CA: Sage.

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 the intensive care unit: A retrospective cohort study. Physical Therapy, 93(2), 186-196.

Engel, H. J., Needham, D. M., Morris, P. E., & Gropper, M. A. (2013). ICU early mobilization: From recommendation to implementation at three medical centers. Critical Care Medicine, 41(9), S69-S80.

Engel, H. J., Tatebe, S., Alonzo, P. B., Mustille, R. L., & Rivera, M. J. (2013). Physical therapist–established the intensive care unit early mobilization program: Quality improvement project for critical care at the University of California San Francisco Medical Center. Physical Therapy, 93(7), 975-985.

Grove, S. K., Burns, N., & Gray, J. (2014). Understanding nursing research: Building an-based practice. Amsterdam, Netherlands: Elsevier Health Sciences.

Leditschke, I. A., Green, M., Irvine, J., Bissett, B., & Mitchell, I. A. (2012). What are the barriers to mobilizing intensive care patients? Cardiopulmonary Physical Therapy Journal, 23(1), 26-29.

Lord, R. K., Mayhew, C. R., Korupolu, R., Mantheiy, E. C., Friedman, M. A., Palmer, J. B., & Needham, D. M. (2013). ICU early physical rehabilitation programs: Financial modeling of cost savings. Critical Care Medicine, 41(3), 717-724.

Parahoo, K. (2014). Nursing research: Principles, process and issues. Basingstoke, UK: Palgrave Macmillan.

Patel, B. K., Pohlman, A. S., Hall, J. B., & Kress, J. P. (2014). Impact of early mobilization on glycemic control and ICU-acquired weakness in critically ill patients who are mechanically ventilated. CHEST Journal, 146(3), 583-589.

Reade, M. C., & Finfer, S. (2014). Sedation and delirium in the intensive care unit. New England Journal of Medicine, 370(5), 444-454.

Schaller, S. J., Anstey, M., Blobner, M., Edrich, T., Grabitz, S. D., Gradwohl-Matis, I.,… Lee, J. (2016). Early, goal-directed mobilisation in the surgical the intensive care unit: A randomised controlled trial. The Lancet, 388(10052), 1377-1388.

Shirey, M. R. (2013). Lewin’s theory of planned change as a strategic resource. Journal of Nursing Administration, 43(2), 69-72.

Sricharoenchai, T., Parker, A. M., Zanni, J. M., Nelliot, A., Dinglas, V. D., & Needham, D. M. (2014). Safety of physical therapy interventions in critically ill patients: A single-center prospective evaluation of 1110 intensive care unit admissions. Journal of Critical Care, 29(3), 395-400.