Barriers and Challenges to the Successful Implementation of an Intensive Care Unit Mobility Program: Understanding Systems and Human Factors in Search for Practical Solutions

Patient, Practice, and Organizational Factors Associated With Early Mobility Performance in Critically Ill Adults

BACKGROUND

Adoption of early mobility interventions into intensive care unit (ICU) practice has been slow and varied.

OBJECTIVES

To examine factors associated with early mobility performance in critically ill adults and evaluate factors' effects on predicting next-day early mobility performance.

METHODS

A secondary analysis of 66 ICUs' data from patients admitted for at least 24 hours. Mixed-effects logistic regression modeling was done, with area under the receiver operating characteristic curve (AUC) calculated.

RESULTS

In 12 489 patients, factors independently associated with higher odds of next-day mobility included significant pain (adjusted odds ratio [AOR], 1.16; 95% CI, 1.09-1.23), documented sedation target (AOR, 1.09; 95% CI, 1.01-1.18), performance of spontaneous awakening trials (AOR, 1.77; 95% CI, 1.59-1.96), spontaneous breathing trials (AOR, 2.35; 95% CI, 2.14-2.58), mobility safety screening (AOR, 2.26; 95% CI, 2.04-2.49), and prior-day physical/occupational therapy (AOR, 1.44; 95% CI, 1.30-1.59). Factors independently associated with lower odds of next-day mobility included deep sedation (AOR, 0.44; 95% CI, 0.39-0.49), delirium (AOR, 0.63; 95% CI, 0.59-0.69), benzodiazepine administration (AOR, 0.85; 95% CI, 0.79-0.92), physical restraints (AOR, 0.74; 95% CI, 0.68-0.80), and mechanical ventilation (AOR, 0.73; 95% CI, 0.68-0.78). Black and Hispanic patients had lower odds of next-day mobility than other patients. Models incorporating patient, practice, and between-unit variations displayed high discriminant accuracy (AUC, 0.853) in predicting next-day early mobility performance.

CONCLUSIONS

Collectively, several modifiable and nonmodifiable factors provide excellent prediction of next-day early mobility performance.

Supporting Decision-Making About Patient Mobility in the Intensive Care Unit Nurse Work Environment: Work Domain Analysis

Background

Patient mobility is an evidenced-based physical activity intervention initiated during intensive care unit (ICU) admission and continued throughout hospitalization to maintain functional status, yet mobility is a complex intervention and not consistently implemented. Cognitive work analysis (CWA) is a useful human factors framework for understanding complex systems and can inform future technology design to optimize outcomes.

Objective

The aim of this study is to understand the complexity and constraints of the ICU work environment as it relates to nurses carrying out patient mobility interventions, using CWA.

Methods

We conducted a work domain analysis and completed an abstraction hierarchy using the CWA framework. Data from documents, observation (32 hours), and interviews with nurses (N=20) from 2 hospitals were used to construct the abstraction hierarchy.

Results

Nurses seek information from a variety of sources and integrate patient and unit information to inform decision-making. The completed abstraction hierarchy depicts multiple high-level priorities that nurses balance, specifically, providing quality, safe care to patients while helping to manage unit-level throughput needs. Connections between levels on the abstraction hierarchy describe how and why nurses seek patient and hospital unit information to inform mobility decision-making. The analysis identifies several opportunities for technology design to support nurse decision-making about patient mobility.

Conclusions

Future interventions need to consider the complexity of the ICU environment and types of information nurses need to make decisions about patient mobility. Considerations for future system redesign include developing and testing clinical decision support tools that integrate critical patient and unit-level information to support nurses in making patient mobility decisions.

Nurses' Perceptions of Barriers to Out-of-Bed Activities Among Patients Receiving Mechanical Ventilation

BACKGROUND

Delays in early patient mobility are common in critical care areas. Oral intubation with mechanical ventilation is negatively associated with out-of-bed activities.

OBJECTIVES

To explore nurses' mobility practices for patients with oral intubation and mechanical ventilation and identify barriers related to patient, nurse, and environment-of-care factors specific to this population.

METHODS

In this cross-sectional, descriptive study in a medical intensive care unit, mobility was defined as standing, sitting in a chair, or walking. A total of 105 patients who met predefined mobility criteria and their 48 nurses were enrolled. Nurses were interviewed about mobility practices at the ends of shifts. Descriptive statistics summarized nurse and patient characteristics and mobility barriers.

RESULTS

Patients were deemed ready to begin mobility within a mean (SD) of 41.5 (34.8) hours after oral endotracheal intubation. Two-thirds of nurses reported that they never or rarely got these patients out of bed. Only 12.4% of patients had a clinician's activity order. Common patient-related barriers were uncooperative behavior (21.9%) and active medical issues (15%), even in patients who met mobility criteria. Nurse-related barriers were concerns for patient safety, specifically falls (14.3% of patients) and harm (9.5%). The environment of care posed very few barriers; nurses rarely mentioned that lack of help (13.3% of patients) or lack of clinician's activity order (5.7%) impeded mobility.

CONCLUSIONS

Mobility practices were nonexistent in these patients despite patients' being deemed ready to begin out-of-bed activities. Nurses must be attentive to their unit's mobility culture to overcome these barriers.

Mobility and clinical outcome of patients admitted to an intensive care unit

Abstract Introduction: The hospital environment exacerbates the effects of immobility due to several exposure factors, and the functional assessment of individuals using reliable instruments is vital. Objective: To determine the relationship between functional mobility and the clinical outcome of patients admitted to an intensive care unit. Method: This is a prospective quantitative longitudinal study, approved by the institutional research ethics committee, carried out in the intensive care unit of a University Hospital. Clinical data and the Acute Physiology and Chronic Health Evaluation (APACHE II) score were collected 24 hours after admission. The Perne Score was used to analyze patient mobility. Results: 33 patients participated, 63% female. With respect to mobility and transfers, 69.7% required total assistance from the supine to the sitting position and 70% to maintain balance, 9.1% needed minimum assistance from sitting to standing, and 100% total assistance for walking and endurance exercises. The main barriers to mobility were invasive ventilation (60%), assistive devices and intravenous infusion (100%). The following Perne Score domains were significantly associated with the outcome: mental status (p = 0.040), barriers to mobility (p = 0.016), strength (p = 0.010), mobility in bed (p = 0.024) and the total Perme Score ( p = 0.002). There were also significant associations between invasive ventilation and low Perme Scores (p = 0.000), and the Richmond Agitation-Sedation Scale (RASS) (-5 and -4) and death in 66.7% of patients (p = 0.011). The Perme Score and RASS (R = 0.745) were moderately correlated and APACHE II and Perme Score inversely moderately correlated (R = -0.526). Conclusion: Mobility assessed by the Perme Score was related to the clinical outcome and strongly associated with sedation level and patient severity.

Staged Implementation of Awakening and Breathing, Coordination, Delirium Monitoring and Management, and Early Mobilization Bundle Improves Patient Outcomes and Reduces Hospital Costs

OBJECTIVES

To measure the impact of staged implementation of full versus partial ABCDE bundle on mechanical ventilation duration, ICU and hospital lengths of stay, and cost.

DESIGN

Prospective cohort study.

SETTING

Two medical ICUs within Montefiore Healthcare Center (Bronx, NY).

PATIENTS

One thousand eight hundred fifty-five mechanically ventilated patients admitted to ICUs between July 2011 and July 2014.

INTERVENTIONS

At baseline, spontaneous (B)reathing trials (B) were ongoing in both ICUs; in period 1, (A)wakening and (D)elirium (AD) were implemented in both full and partial bundle ICUs; in period 2, (E)arly mobilization and structured bundle (C)oordination (EC) were implemented in the full bundle (B-AD-EC) but not the partial bundle ICU (B-AD).

MEASUREMENTS AND MAIN RESULTS

In the full bundle ICU, 95% patient days were spent in bed before EC (period 1). After EC was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (-22.3%; 95% CI, -22.5% to -22.0%; p < 0.001), ICU length of stay (-10.3%; 95% CI, -15.6% to -4.7%; p = 0.028), and hospital length of stay (-7.8%; 95% CI, -8.7% to -6.9%; p = 0.006). Total ICU and hospital cost were also reduced by 24.2% (95% CI, -41.4% to -2.0%; p = 0.03) and 30.2% (95% CI, -46.1% to -9.5%; p = 0.007), respectively.

CONCLUSIONS

In a clinical practice setting, the addition of (E)arly mobilization and structured (C)oordination of ABCDE bundle components to a spontaneous (B)reathing, (A)wakening, and (D) elirium management background led to substantial reductions in the duration of mechanical ventilation, length of stay, and cost.

Factors Nurses in the Intensive Care Unit Consider When Making Decisions About Patient Mobility

BACKGROUND

Early mobility interventions in the intensive care unit can improve patients' outcomes, yet they are not routinely implemented in many intensive care units. In an effort to identify opportunities to implement and sustain evidence-based practice, prior work has demonstrated that understanding the decision-making process of health professionals is critical for identifying opportunities to improve program implementation. Nurses are often responsible for mobilizing patients, but how they overcome barriers and make decisions to mobilize patients in the intensive care unit is not understood.

OBJECTIVE

To describe processes that nurses in intensive care units use to make decisions and barriers that influence their decision-making about patient mobility.

METHODS

An exploratory descriptive approach using semi-structured interviews of a purposive sample of registered nurses in 2 intensive care units at 2 hospitals was used. Interviews were transcribed and analyzed by using directed content analysis to identify categories that describe nurses' decision-making about patient mobility.

RESULTS

Semistructured interviews were conducted with 20 nurses in a 1-on-1 setting. Four main categories that influenced nurses' decision-making about mobility were identified in the directed content analysis: purpose of mobility, gathering information, establishing and activating the plan, and barriers to progressing the plan.

CONCLUSIONS

Deciding to mobilize patients in the intensive care unit is a multifaceted, individualized decision made by nurses, and numerous patient-, nurse-, and unit-related factors influence that decision. Future studies that target unit culture and interprofessional perspectives are needed.

Instituting a Standardized Mobility Aid in the Cardiovascular Intensive Care Unit

The complexity of ambulation increases when patients are challenged with acute illness in the cardiovascular intensive care unit (CVICU). The difficulties in this setting entailed limited ancillary assistance, proper equipment, and complex medical devices. It was imperative that mobility was made a priority in the CVICU despite multiple barriers. To improve mobility functionality, mobility aids were obtained. To evaluate the effectiveness of the mobility aids, data were collected, including staff surveys, time studies, and chart audits. The outcomes from implementing the mobility aids revealed a reduction in the number of staff required to ambulate medically complex patients from an average of 2.3 to 1.9 staff members and in medically noncomplex patients remained unchanged from 1.4 to 1.6 staff members. Preparation time for ambulation was reduced from 12.8 to 8.3 minutes on average for medically noncomplex patients and from 14 to 9.7 minutes for the medically complex patients. Ambulation sessions for medically noncomplex patients increased on average from 1.5 to 2.8 sessions per day and for medically complex patients decreased from 1.2 to 0.5 sessions per day. Overall, clinically significant improvements were noted with both preparation time for ambulation and the number of mobility sessions that support the use of a standardized mobility aid.

A systematic review evaluating the role of nurses and processes for delivering early mobility interventions in the intensive care unit

OBJECTIVES

To investigate processes for delivering early mobility interventions in adult intensive care unit patients used in research and quality improvement studies and the role of nurses in early mobility interventions.

METHODS

A systematic review was conducted. Electronic databases PubMED, CINAHL, PEDro, and Cochrane were searched for studies published from 2000 to June 2017 that implemented an early mobility intervention in adult intensive care units. Included studies involved progression to ambulation as a component of the intervention, included the role of the nurse in preparing for or delivering the intervention, and reported at least one patient or organisational outcome measure. The System Engineering Initiative for Patient Safety (SEIPS) model, a framework for understanding structure, processes, and healthcare outcomes, was used to evaluate studies.

RESULTS

25 studies were included in the final review. Studies consisted of randomised control trials, prospective, retrospective, or mixed designs. A range of processes to support the delivery of early mobility were found. These processes include forming interdisciplinary teams, increasing mobility staff, mobility protocols, interdisciplinary education, champions, communication, and feedback.

CONCLUSION

Variation exists in the process of delivering early mobility in the intensive care unit. In particular, further rigorous studies are needed to better understand the role of nurses in implementing early mobility to maintain a patient's functional status.

An Exploratory Descriptive Study of Registered Nurse Innovation: Implications for Levels of Adoption

PURPOSE

The aims of this study were to describe registered nurses' levels of personal innovativeness and registered nurses' perceived organizational innovativeness and determine the relationship between these 2 variables.

BACKGROUND

There is limited research to describe the levels of innovation of nurses within a hospital. The levels of innovation can determine the likelihood of adoption of evidence-based practices at the bedside. As change agents, clinical nurse specialists can determine successful implementation strategies tailored to nurse levels of innovation.

DESCRIPTION

This was a descriptive study at a midwest, urban, teaching, 408-bed Magnet hospital.

OUTCOMES

Surveys were completed by 217 nurses. The participants reported high personal innovativeness ((Equation is included in full-text article.)= 32.1; SD, 6.4), and the institution was perceived as innovative, with 90.3% of scores categorized as positive innovativeness. The statistically significant correlation was in the medical-surgical unit (r = -0.52, P < .01). There is no correlation between personal innovativeness and organizational innovativeness except for medical-surgical nurses (P = .03). They are likely to perceive the organization more innovative than themselves.

CONCLUSIONS

Determining adopter characteristics can be valuable to the clinical nurse specialist by adapting strategic interventions to advance nursing practice. Exploring levels of adoption can be an innovative strategy to transform nursing at the bedside and throughout the organization.

Factors influencing physical activity and rehabilitation in survivors of critical illness: a systematic review of quantitative and qualitative studies

PURPOSE

To identify, evaluate and synthesise studies examining the barriers and enablers for survivors of critical illness to participate in physical activity in the ICU and post-ICU settings from the perspective of patients, caregivers and healthcare providers.

METHODS

Systematic review of articles using five electronic databases: MEDLINE, CINAHL, EMBASE, Cochrane Library, Scopus. Quantitative and qualitative studies that were published in English in a peer-reviewed journal and assessed barriers or enablers for survivors of critical illness to perform physical activity were included. Prospero ID: CRD42016035454.

RESULTS

Eighty-nine papers were included. Five major themes and 28 sub-themes were identified, encompassing: (1) patient physical and psychological capability to perform physical activity, including delirium, sedation, illness severity, comorbidities, weakness, anxiety, confidence and motivation; (2) safety influences, including physiological stability and concern for lines, e.g. risk of dislodgement; (3) culture and team influences, including leadership, interprofessional communication, administrative buy-in, clinician expertise and knowledge; (4) motivation and beliefs regarding the benefits/risks; and (5) environmental influences, including funding, access to rehabilitation programs, staffing and equipment.

CONCLUSIONS

The main barriers identified were patient physical and psychological capability to perform physical activity, safety concerns, lack of leadership and ICU culture of mobility, lack of interprofessional communication, expertise and knowledge, and lack of staffing/equipment and funding to provide rehabilitation programs. Barriers and enablers are multidimensional and span diverse factors. The majority of these barriers are modifiable and can be targeted in future clinical practice.

Overcoming nursing barriers to intensive care unit early mobilisation: A quality improvement project

OBJECTIVES

To increase adherence with intensive care unit mobility by developing and implementing a mobility training program that addresses nursing barriers to early mobilisation.

DESIGN

An intensive care unit mobility training program was developed, implemented and evaluated with a pre-test, immediate post-test and eight-week post-test. Patient mobility was tracked before and after training.

SETTING

A ten bed cardiac intensive care unit.

MAIN OUTCOME MEASURES

The training program's efficacy was measured by comparing pre-test, immediate post-test and 8-week post-test scores. Patient mobilisation rates before and after training were compared. Protocol compliance was measured in the post training group.

RESULTS

Nursing knowledge increased from pre-test to immediate post-test (p<0.0001) and pre-test to 8-week post-test (p<0.0001). Mean test scores decreased by seven points from immediate post-test (80±12) to 8-week post-test (73±14). Fear significantly decreased from pre-test to immediate post-test (p=0.03), but not from pre-test to 8-week post-test (p=0.06) or immediate post-test to 8-week post-test (p=0.46). Post training patient mobility rates increased although not significantly (p=0.07). Post training protocol compliance was 78%.

CONCLUSION

The project successfully increased adherence with intensive care unit mobility and indicates that a training program could improve adoption of early mobility.

PICU Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children

OBJECTIVE

To determine the safety and feasibility of an early mobilization program in a PICU.

DESIGN

Observational, pre-post design.

SETTING

PICU in a tertiary academic hospital in the United States.

PATIENTS

Critically ill pediatric patients admitted to the PICU.

INTERVENTION

This quality improvement project involved a usual-care baseline phase, followed by a quality improvement phase that implemented a multicomponent, interdisciplinary, and tiered activity plan to promote early mobilization of critically ill children.

MEASUREMENTS AND MAIN RESULTS

Data were collected and analyzed from July to August 2014 (preimplementation phase) and July to August 2015 (postimplementation). The study sample included 200 children 1 day through 17 years old who were admitted to the PICU and had a length of stay of at least 3 days. PICU Up! implementation led to an increase in occupational therapy consultations (44% vs 59%; p = 0.034) and physical therapy consultations (54% vs 66%; p = 0.08) by PICU day 3. The median number of mobilizations per patient by PICU day 3 increased from 3 to 6 (p < 0.001). More children engaged in mobilization activities after the PICU Up! intervention by PICU day 3, including active bed positioning (p < 0.001), and ambulation (p = 0.04). No adverse events occurred as a result of early mobilization activities. The most commonly reported barriers to early mobilization after PICU Up! implementation was availability of appropriate equipment. The program was positively received by PICU staff.

CONCLUSIONS

Implementation of a structured and stratified early mobilization program in the PICU was feasible and resulted in no adverse events. PICU Up! increased physical therapy and occupational therapy involvement in the children's care and increased early mobilization activities, including ambulation. A bundled intervention to create a healing environment in the PICU with structured activity may have benefits for short- and long-term outcomes of critically ill children.

Reliability and utility of the Acute Care Index of Function in intensive care patients: An observational study

OBJECTIVES

To establish the inter-rater reliability of the Acute Care Index of Function (ACIF) in intensive care unit (ICU) patients and determine whether ACIF scores have predictive utility beyond ICU discharge.

BACKGROUND

Accurate and reliable measures of physical function are required to describe the recovery trajectory of ICU survivors. The clinimetric properties of the ACIF are yet to be established in ICU patients.

METHODS

Prospective observational study in a single tertiary ICU. ACIF scores were recorded independently by 2 physiotherapists across a convenience sample of 100 physiotherapy assessments, and at ICU discharge.

RESULTS

Inter-rater reliability of total ACIF scores was very strong (ICC = 0.94). ACIF <0.40 at ICU discharge predicted hospital discharge to a destination other than home (area under ROC = 0.79, 95% CI 0.64-0.89) (sensitivity 0.78).

CONCLUSION

The ACIF has excellent inter-rater reliability in ICU patients and scores at ICU discharge predict the likelihood of discharge home.

TRIAL REGISTRATION

ACTRN12614001008617 (September 18 2014).