Date of Award

Fall 5-18-2020

Degree Type

Dissertation

Degree Name

PhD Health Sciences

Department

Health and Medical Sciences

Advisor

Genevieve Pinto Zipp, Ed.D.

Committee Member

Ning J. Zhang, Ph.D.

Committee Member

Fortunato Battaglia, Ph.D.

Keywords

early mobility; early mobilization; ICU-acquired weakness; multidisciplinary; outcomes; physical rehabilitation; quality improvement, barriers; critical care;

Abstract

Background: More than 4 million people are admitted annually to intensive care units (ICUs). Due to immobility, many ICU survivors experience significant cognitive, psychological, and physically disabling side effects regardless of admitting diagnosis. Multiple studies and quality improvement projects have shown the safety, feasibility, and benefits of early mobilization in the ICU setting. Hodgson et al (2014) published consensus recommendations for safe active mobilization of mechanically ventilated critically ill adults. To date, there is no standardized and simple triage protocol for identifying patients for early mobilization. No study so far has described operationalizing and implementing the Red-Yellow-Green system described by Hodgson et al. NYU Langone- Brooklyn initiated a Quality improvement project from January 2018 to June 2018 to overcome this barrier in clinical practice. The project implemented early mobilization in the Medical and Surgical ICUs at NYU Langone-Brooklyn hospital by operationalizing the Red-Yellow-Green system described in Hodgson et al. This evidenced based project was guided by the Translating Research Into Practice (TRIP) model and the multidisciplinary team approach. Methods: A retrospective chart review of all ICU patients during the early mobilization period from January to June 2019 was used to conduct a within group pre-test posttest analyses for the primary functional and behavioral outcomes (IMS, FSS, AMPAC, RASS and CAM-ICU). A between groups design was used to assess the secondary outcomes of all ICU patients from a historical comparison period of January to June 2017 and all ICU patients during the early mobilization period of January to June 2018, regarding ICU and hospital lengths of stay and discharge recommendation. The sample was obtained from patients admitted to MICU and SICU at an urban community teaching hospital with 28 beds. Chart review was performed for 388 patients in MICU and 293 patients in SICU to include the data of all patients who participated in the early mobilization protocol. Results: During the early mobilization period, MICU functional scales improved significantly as measured by functional scales: IMS from 5.9 to 6.2 (p < .001); FSS-ICU from 14.5 to 15.5 (p < .001); and AMPAC from 12.6 to 13.1 (p < .001). Behavioral scales improved significantly in the MICU: There was a significant difference in MICU RASS score (Z = -2.27, p = .023) and upon discharge majority of the patients were alert and calm with RASS score clustered towards middle at score 0; There was a significant difference between MICU initial and final CAM-ICU scores (χ2 (1, N=388) = 54.14, p < .001). 49.3% of the patients that had pretest confusion did not have posttest confusion. SICU functional scales improved significantly as measured by functional scales: IMS from 6.2 to 7.1 (p < .001); FSS-ICU from 16.5 to 19.0 (p < .001); and AMPAC from 13.8 to 15.2 (p < .001). Behavioral scales: There was a non-significant difference in SICU RASS score (Z = -1.83, p = .067) however upon discharge majority of the patients were alert and calm with RASS score clustered towards middle at score 0; There was a non-significant difference between SICU initial and final CAM-ICU scores (χ2 (1, N=293) = 0.16, p = .690). 22 % of the patients that had pretest confusion, did not have posttest confusion, however upon discharge majority of the patients scored negative in CAM-ICU indicating less confusion/delirium upon ICU discharge. Both overall hospital LOS and ICU length of stay decreased compared to the historical comparison period: MICU patients’ hospital LOS decreased from 10.6 to 8.4 days (p < 0.001); MICU LOS decreased from 2.9 to 2.5 (p = .002); SICU patients’ hospital LOS decreased from 12.0 to 9.3 days (p < .001); SICU LOS decreased from 5.7 to 3.7 days (p < .001). Discharge to community increased compared to the historical control from 48% to 52% in MICU and from 39.9% to 60.1% in SICU. No adverse events occurred during the pilot period. Conclusion: Based upon this retrospective review the Interdisciplinary Early Mobilization team demonstrated consistent and reliable implementation of the Hodgson Red Yellow Green Mobilization system. Accurately identifying candidates for Early Mobilization yielded statically significant and robust outcomes for several Functional and Behavioral outcome measures. Early mobilization should be part of routine care during patient’s ICU stay. The results from the QI project showed that, in addition to reducing ICU and hospital LOS, early ICU intervention enabled more patients to be discharged to community instead of post-acute care facilities. A hospital wide cultural change is essential to unleash the full potential of early mobilization in the ICUs. Having a protocol that is simple and feasible enables hospitals to achieve such goals safely without clinical complications.

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