JHNEBP Evidence Rating Scales

Use of Early Mobilization to Minimize Length of Stay for ICU Patients University of Maryland School of Nursing Running head: USE OF EARLY MOBILIZATION 1 USE OF EARLY MOBILIZATION 5 Can early mobilization minimize length of stay for ICU patients who are on mechanical ventilation compared to standard of care? Author(s) and year Type of study (design) Population characteristics & sample size (n) Independent variable Dependent variable Results Evidence Strength & Quality Rating (JHNEBP) Eakin et al (2015). Quasi-experimental The study included 20 staff and faculty involved in the early rehabilitation program at Johns Hopkins Hospital Medical Intensive Care Unit. 12 out of the 20 participants were female while the rest were male. These participants had worked in a healthcare facility and any ICU for a period of between 1 and 20 years. Early rehabilitation program Outcomes of early rehabilitation programs on staff The study also looked at how to engage a multidisciplinary team in implementing and sustaining early rehabilitation programs. Interview transcripts were reviewed using the Consolidated Framework of Implementation Research Theory. These transcripts were also coded by two independent raters (TA, LU) using NViVo 10.0 software (QSR International Pty Ltd, 2013, Doncaster, Australia). 90% of participants found that a multidisciplinary team with good communication among its members is helpful. While 100% of participants stated that improved patient outcome was a vital benefit, 95% reported enhanced job satisfaction. However, 80% of participants noted that increased staff workload is the major barrier to successful implementation of early rehabilitation programs. The researchers concluded that incorporating a multidisciplinary team before implementation is crucial towards enhancing job satisfaction and changing work culture in a hospital unit. Level II Quality B. The study utilized a suitable sampling size for a qualitative research. The data analysis tools were suitable and valid in generating reliable findings on the research issue. Additionally, the study correlated with the findings of previous researches on barriers to early rehabilitation and generates new barriers. However, the study lacked randomization. Engel, Needham, Morris & Gropper (2013) Non-experimental, qualitative study The study did not include a group of participants since it focused on comparing three ICU early mobility quality improvement projects. The researchers reviewed and compared early mobility quality improvement projects utilized in medical ICUs at Wake University, the University of California San Francisco Medical Center, and Johns Hopkins Hospital. Early mobilization quality improvement projects Implementation of the projects and impact on clinical outcomes in critically ill patients The implementation of each of these three ICU early mobilization quality improvement projects required an interdisciplinary team-based approach. The team plays a critical role in planning, educating and implementing the early mobility program in the ICU setting. The researchers also found that establishing ICU early mobilization quality improvement program reduces hospital and ICU stay among critically ill patients. Moreover, such programs lessen the rates of delirium and need for sedation. Level III, Quality C. This non-experimental qualitative study did not have a sufficient sample size given that the three programs were not adequate enough to draw reliable conclusions on the research issue. The researchers did not provide the theoretical framework for the study though the review was carried out using Institute for Healthcare Improvement framework of Plan-Do-Study-Act. The researchers did not correlate their findings with results of previous studies and did not discuss study limitations. Li et al. (2013) Non-experimental, qualitative study The study did not include a group of participants since it was a systematic review of existing literature on active mobilization for mechanically ventilated patients. The literature was obtained through a search on different data sources including CINAHL, PubMed, CENTRAL, Embase, Physiotherapy Evidence Database, ISI Web of Knowledge, and SinoMed. Active mobilization Impact on effectiveness, safety, and clinical outcomes in mechanically ventilated patients The researchers identified17 eligible studies from a possible 14,678 relevant articles. The 17 studies were deemed eligible for the systematic review since they met the inclusion criteria and had sample sizes ranging between 17 and 510 participants. The researchers utilized some of these studies to examine effectiveness of active mobilization in mechanically ventilated patients while others were utilized to examine safety. The systematic review on these 17 studies demonstrated that active mobilization has significant impacts on clinical outcomes in patients receiving mechanical ventilation for over 24 hours. These improved clinical outcomes include enhanced muscle strength, ability to wean from ventilation, functional independence, and decrease length of hospital and ICU stay. Level III, Quality A. This study had clear discussions on the research methodology including inclusion criteria. In this case, the researchers utilized a rigorous approach for defining the research methods and reliable and valid measures in conducting the systematic review. While the researchers provided definitive conclusions, the determination of consistent results in the study is difficult since it’s the first research to examine the effectiveness and safety of active mobilization in mechanically ventilated patients. The researchers also discussed the limitations of the study. Needham et al. (2010) Quasi-experimental, pretest-posttest study This study was conducted in a 16-bed medical intensive care unit (MICU) in academic hospital. The study population comprised 57 patients who had received mechanical ventilation for at least 4 days. The participants were subjected to a seven-month prospective quality improvement project. Early physical medicine and rehabilitation Primary: Effect on deep sedation and delirium Secondary: Impact on length of hospital and ICU stay Benzodiazepine use decreased significantly after the quality improvement project was initiated as the proportion of MICU days that patients obtained benzodiazepine was 50% vs 25%, P=.002. Improved sedation and delirium status was also evident with (MICU days alert [30% vs 67%, P,<.001] and not delirious [21% vs 53%, P=.003]). The experiment also showed a greater median number of rehabilitation treatments per patient (1 vs 7, P<.001) with a higher level of functional mobility (treatments involving sitting or greater mobility, 56% vs 78%, P=.03). All MICU patients showed a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4 –3.8) and 3.1 (0.3–5.9) days, respectively. The researchers concluded that the use of a quality improvement program for early physical medicine and rehabilitation improves functional mobility, reduces ICU and hospital length of stay, and lessens deep sedation and delirium. Level II, Quality A. This quasi-experimental study utilized suitable research methodologies and a sufficient sample size. The researchers also utilized valid and reliable data collection and analysis. The researchers provided reasonably consistent results that were generated through a rigorous approach. While the study did not include recommendations, the investigators included a discussion of its limitations. References Eakin, M.N., Ugbah, L., Arnautovic, T., Parker, A.M. & Needham, D.M. (2015). Implementing and Sustaining an Early Rehabilitation Program in a Medical Intensive Care Unit: A Qualitative Analysis. Journal of Critical Care, 30, 698-704. Engel, H.J., Needham, D.M., Morris, P.E. & Gropper, M.A. (2013, September). ICU Early Mobilization: From Recommendations to Implementation at Three Medical Centers. Critical Care Medicine, 41(9), S69-S80. Li, Z., Peng, X., Zhu, B., Zhang, Y. & Xi, X. (2013). Active Mobilization for Mechanically Ventilated Patients: A Systematic Review. Archives of Physical Medicine and Rehabilitation, 94, 551-561. Needham, D.M., Korupolu, R., Zanni, J.M., Pradhan, P., Colantuoni, E., Palmer, J.B., Brower, R.G. & Fan, E. (2010, April). Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project. Archives of Physical Medicine and Rehabilitation, 91, 536-542.