Progressive Mobility In Nursing

Progressive Mobility
Similarly to the previous article, In October 2015 an article by April Messer, Linda Comer, and Steve Forst, used an instructional teaching plan design similar to the Plan-Do-Study-Act model to implement a progressive mobilization program in a medical-surgical intensive care unit. They also wanted to evaluate the effect of education for a progressive mobilization program for intensive care nurses on knowledge and performance. A total of 45 nurses worked on the unit at the time of the educational sessions. Out of the 45 nurses 41 participated in the progressive mobility education. A random chart review was conducted for 3 weeks before and 3 weeks after the educational intervention. The objective of the education aspect of
this study was for learners to be able to:
1) “State 3 consequences of immobility in ICU patients
2) State 3 benefits of early mobility in ICU patients
3) Demonstrate how to safely perform mobility activities with ICU patients (range-of-motion exercises, sitting position, Egress test, ambulation)
4) Assess patients’ need for mobility and level of mobility a patient is able to participate in (based on patient status and physical therapy notes)
5) Acknowledge the importance of working in a team atmosphere to increase mobility for ICU patients” (Messer, A., Comer, L., & Forst, S., 2015). A paired t test was used to compare the mean of the pretest scores with the mean of the posttest scores (N = 41). Scores after the educational intervention were significantly higher than scores before the intervention (t = 2.02; P < .001). Overall mobilization (P = .04) and dangling (P = .01) increased significantly after the education.
This study had some limitations which limited the validity of the results. The tool used in the study was based on low recognition recall instead of synthesis or application. This tool was also not tested for reliability or validity (Messer, A., Comer, L., & Forst, S., 2015). Using qualitative methods, Messer, A., et al. (2015) found that “Education can be an effective strategy to increase nurses’ knowledge about mobility and may change the way nurses mobilize their patients”.
Even if education can influence change for patients’ mobility in the ICU, guidance and coaching are essential agents to make sure mobility program can be successful. (Messer, A., Comer, L., & Forst, S., 2015). This level I study was conducted relatively well. This research is limited to one hospital and was not tested for reliability/validity. The results are plausible, believable and can be transferred to other ICUs.
In a randomized control trial done by Schaller, S. J., Anstey, M., Blobner, M., Edrich, T., Grabitz, S. D., Gradwohl-Matis, I., et al. (2016), they found that “early, goal-directed mobilization improved patient mobilization throughout SICU admission, shortened patient length of stay in the SICU, and improved patients’ functional mobility at hospital discharge”. Often times immobilization in critically ill patients are restricted but Schaller, S. J., et al. (2016), wanted to find out whether or not early mobilization lead to improve mobility, decreased SICU length of stay and increased functional independence by the time a patient was discharged.
The study involved patients 18 years or older, who were mechanically ventilated for less than 48 h, and expected to require mechanical ventilation for at least another 24 h at the time of screening. Patients were included if they were functionally independent at baseline with a Barthel Index Score of at least 70 at 2 weeks before admission to the SICU, based on patient or proxy completion of the measure. This research trial was international, and done at five universities one of which is located in the U.S.A The data analysis showed that the intervention improved the mobilization level (mean achieved surgical optimal mobilization score (SOMS) 2•2 [SD 1•0] in intervention group vs. 1•5 [0•8] in control group, p<0•001; ), compared with those in the control group. In the intervention group 52 (52%) patients had achieved a SOMS level 4 (ambulating) at ICU discharge compared with 24 (25%) patients in the control group” (Schaller, S. J., et al.2016). The evidence in this literature is very strong and plausible. This is a level one study, with great strengths of evidence. Data in this study was extensive and it included multiple tables and charts related to the results and interventions. The surgical optimal mobilization score (SOMS) algorithm used this research was validated in three languages (English, Italian, and German).
When it comes to ambulation, going back to the basics is always a good place to start.
In 2012, Kibler, V. A., Hayes, R. M., Johnson, D. E., Anderson, L. W., Just, S. L., & Wells, N. L. used a quality improvement design to increase ambulation and documentation in postoperative patients. This project was conducted at Vanderbilt University Medical Center. This hospital is a 918-bed academic medical center in Nashville, Tennessee. The intervention was implemented on four surgical units with a total of 60 beds. Evaluation data were obtained from patients with specific diagnosis-related groupings (DRGs) pertaining to colorectal and urologic surgeries, the predominant patient populations on the four intervention
unit.
Using quantitative and some qualitative methods, along with a multi linear regression analysis, Kibler, V.
A., Hayes, R. M., Johnson, D. E., Anderson, L. W., Just, S. L., & Wells, N. L. (2012) found some improvement on the intervention units. “The proportion of patients with documented ambulation increased from 62% before the intervention to 96% afterward, while documented ambulation on control units remained unchanged. In the post intervention period, the total documented distance ambulated on the intervention units also increased significantly, from 176 feet per patient day to 264 feet per patient day” (Kibler, V. A.,et al, 2012). It was also important to know that falls did not increase from the pre-intervention period to the post intervention period despite the increased in ambulation. This study was very easy to understand. It included some of the most common setbacks most nurses faced when it came to ambulating patients.
In a clinical guidance practice guideline written in the journal of orthopedic nursing, early ambulation is the most significant general nursing measure to prevent postoperative complications. This CPG was a “comprehensive, multidisciplinary team effort conducted as an observational, quality improvement project. Approval was reviewed and approved from the internal review board and a waiver of individual informed consent was obtained.”(Morris, B., Benetti, M., Marro, H., & Rosenthal, C., 2010). This literature provides step by step guidelines practitioners
can follow to increase early mobilization in patients.
In an another literature related to post operative ambulation, van, d. L., Huijsmans, R., Geleijn, E., de Lange-de Klerk, E. S. M., Dekker, J., Bonjer, H. J., et al. (2016), found that early enforced ambulation increased GI motility and decreased LOS for patients that underwent gastrointestinal surgery. This same type of results could also be applied to women that underwent a C-section. In a 2015 research, Sahin, E., & Terzioglu found that Bowel sounds after cesarean section were heard 7.89 ± 1.20 hours later on average in the first group where all three interventions (gum chewing, early oral hydration, and early mobilization) were used and 16.00 ± 1.69 later in the control group in the study. This study involved 240 females divided into 8 groups of 30.
In summary, throughout literature, there has been evidence that ambulating patients decrease their risks of complications. However though evidence may support the benefits of early ambulation, we still have a long way to go in order to make this a reality in most hospitals. Some of the barriers nurse may face when implementing this is time, lack of resources such as adequate staffing and proper education. Patients can also serve as a barrier when they refuse to get out of bed. With the proper staffing, resources and education we can decrease complications and length of stay for patients through early ambulation programs.