Financial Implications of Starting a Mobility Protocol in a Surgical Intensive Care Unit

A Progressive Early Mobilization Program Is Significantly Associated With Clinical and Economic Improvement: A Single-Center Quality Comparison Study

OBJECTIVES

To determine whether a progressive early mobilization protocol improves patient outcomes, including in-hospital mortality and total hospital costs.

DESIGN

Retrospective preintervention and postintervention quality comparison study.

SETTINGS

Single tertiary community hospital with a 12-bed closed-mixed ICU.

PATIENTS

All consecutive patients 18 years old or older were eligible. Patients who met exclusion criteria or were discharged from the ICU within 48 hours were excluded. Patients from January 2014 to May 2015 were defined as the preintervention group (group A) and from June 2015 to December 2016 was the postintervention group (group B).

INTERVENTION

Maebashi early mobilization protocol.

MEASUREMENTS AND MAIN RESULTS

Group A included 204 patients and group B included 187 patients. Baseline characteristics evaluated include age, severity, mechanical ventilation, and extracorporeal membrane oxygenation, and in group B additional comorbidities and use of steroids. Hospital mortality was reduced in group B (adjusted hazard ratio, 0.25; 95% CI, 0.13-0.49; p < 0.01). This early mobilization protocol is significantly associated with decreased mortality, even after adjusting for baseline characteristics such as sedation. Total hospital costs decreased from $29,220 to $22,706. The decrease occurred soon after initiating the intervention and this effect was sustained. The estimated effect was $-5,167 per patient, a 27% reduction. Reductions in ICU and hospital lengths of stay, time on mechanical ventilation, and improvement in physical function at hospital discharge were also seen. The change in Sequential Organ Failure Assessment score and Sequential Organ Failure Assessment score at ICU discharge were significantly reduced after the intervention, despite a similar Sequential Organ Failure Assessment score at admission and at maximum.

CONCLUSIONS

In-hospital mortality and total hospital costs are reduced after the introduction of a progressive early mobilization program, which is significantly associated with decreased mortality. Cost savings were realized early after the intervention and sustained. Further prospective studies to investigate causality are warranted.

Early Mobility in the Intensive Care Unit: Evidence, Barriers, and Future Directions

Early mobility is an element of the ABCDEF bundle designed to improve outcomes such as ventilator-free days and decreased length of stay. Evidence indicates that adherence to an early mobility protocol can prevent delirium and reduce length of stay in the intensive care unit and the hospital and may decrease length of stay in a rehabilitation facility. Yet many barriers exist to implementing early mobility effectively, including patient acuity, uncertainty about when to start mobilizing the patient, staffing and equipment needs, increased costs, and limited nursing time. Implementation of early mobility requires interdisciplinary collaboration, commitment, and tools that facilitate mobility and prevent injury to nurses. This article focuses on aspects of care that can affect patient outcomes, such as preventing delirium, reducing sedation, monitoring the patient's ability to wean from the ventilator, and encouraging early mobility. It also addresses the effects of immobility as well as challenges in achieving mobility and how to overcome them.

The Relationship Between Length of Surgery and the Incidence of Pressure Ulcers in Cardiovascular Surgical Patients: A Retrospective Study

OBJECTIVE

The aim of this study was to investigate the relationship between the length of surgery and the incidence of pressure ulcers (PrUs) in cardiovascular surgical patients.

METHODS

A retrospective analysis was performed among consecutive patients with cardiac surgery in 2012. Propensity score matching was used to control differences in the baseline characteristics between with and without surgery-related pressure ulcer (SRPU) groups.

RESULTS

A total of 286 patients with cardiac surgery were included in the study: 47 patients developed 57 SRPUs, with incidence of 16.4% (95% confidence interval, 12.3%-21.2%); 97.9% of SRPUs were Stage I, and the other 2.1% were Stage II. After propensity score matching, statistically significant difference of the length of surgery between the 2 groups was found (195 minutes [30-330 minutes] vs 240 minutes [125-675 minutes], P = .003). However, the length of cardiopulmonary bypass was found to be not statistically significantly different between the 2 groups (37 minutes [15-144 minutes] vs 44 minutes [16-107 minutes], P = .830). The curve fitting showed the SRPU incidence increased gradually with the extension of length of surgery.

CONCLUSIONS

The authors' retrospective analysis showed the length of surgery was an important risk factor for PrUs in cardiovascular surgical patients, but not the length of cardiopulmonary bypass. The incidence of SRPUs increased gradually with the extension of length of surgery.