Gaps occur in various situations. They can be in lesson plans or healthcare. When it comes to the MICU, practice gaps happen. To implement a quality improvement proposal one needs to see what works and how to use it to meet the needs of the proposal. Early Progressive Mobility in a Medical Intensive Care Unit has shown to be helpful in meeting the medical goals of patients. In this proposal, evidence as well as strategies will show how important it is for patients to gain mobility early on in recovery and the problems these kinds of programs face.
The MICU or ICU is for patients who are very ill. When in the ICU, it's been demonstrated patients acquire weakness from the acute onset of neuromuscular/functional impairment caused by unknown factors other than their critically ill condition. This weakness impairs ventialtor wearing and functional mobility. (AACN PEARL, n.d., p. 20) The weakness although acute in the beginning, continues after release in 60% of patients. " In addition to weakness, other factors in the critical care environment such as sleep deprivation, lack of social interaction, nutritional state, sedation, and an ICU culture that promotes bed rest contribute further to functional decline." (Perme, 2009, p. 212-221) Some even experience continued muscle disyfunction for as long as up to one year after their illness.
"Considerable published evidence indicates that patients in intensive care units have high morbidity and mortality, high costs of care, and a marked decline in functional status. " (Perme, 2009, p. 212-221) To combat this issue, early mobilty must be implemented. Evidence-based information proves early physical and occupational therapy shows decrease in hospital LOS up to three days as well as reduced delirium incidences and best of all, kncrease return to independent functioning. Most who adopt early mobility protocols use active or passive range of motion, then progress to sitting position, then sitting towards edge of bed, standing, and as the patient gets stronger, transferring and walking.
Patients who should participate in Early Mobility protocols are all mechanically ventilated patients as well as anyone who wishes to. "Health care professionals who work in ICUs face complex challenges in caring for critically ill patients, many of whom receive mechanical ventilation for prolonged periods. " (Perme, 2009, p. 212-221) Overall this kind of program benefits all patients who have participated. Patients must be screened and assessed in order to participate. "The Early Mobility Protocol consists of a two-step process that starts with a safety screen and moves to the mobility protocol for those who pass. " (European Society of Intensive Care Medicine., 2011, p. 65) Ultimately the goal of this program is to get patients moving, not necessarily to walk, although that is the ultimate goal.
A lot of the issues in attempting to implement such a program is the lack of availiability of physical therapists to treat the patients. Physical therapy is in high demand in several areas of the hospital. (Duarte, 2012, p. 181) To acquire physical therapists for the MICU from a limited pool proves difficult. If more people train to become physical therapists, availability would increase along with treated patients. There is a need for physical therapy, especially from patients getting mechanical ventiliation. ("A framework for diagnosing and classifying int... [Crit Care Med. 2009] - PubMed - NCBI", n.d., p. 2)
A key part of the program is the evaluation by the physical therapist in order to set mobility goals and focus on individual functional capability. A plan of care for mobility is a crucial step to get things started. A long with the need for physical therapists, is the need for physicians and nurses to work together with the physical therapist to develop a treatment plan. Patients have varying medical issues and mobility may be harder for some than others.
Here is a plan from a hospital proven to have positive results from the Early Mobility Program:
"This early mobility and walking program has been used by one of us (C.P.) at the Methodist Hospital, Houston, Texas, since 1996. No scientific data have been reported, but the program has been well accepted by patients, physicians, physical therapists, nurses, and family members. We think that early mobility in the ICU can lead to the following positive outcomes:
Minimizing complications of bed rest
Promoting improved function for patients
Promoting weaning from ventilatory support as a patient's overall strength and endurance improve
Reducing length of hospital stay
Reducing overall hospital cost
Improving patients' quality of life" (Perme, 2009, p. 212-221)
Early mobility is crucial in improving the overall health of the patient and reducing the costs of healthcare in Intensive Care Units. If some funding is allocated to hiring and training more physical therapists, the costs of patients in the ICU as a whole will be reduced. Seeing things from a different perspective offers ways for people to understand how to solve a problem. To allow for others to see the benefits of early mobility, one must generate a global aim statement to promote awareness of the need for personnel and communication to create a successful program.
"Global Aim Statement"
We aim to improve Early Progressive Mobility in a Medical Intensive Care Unit in various hosptial settings. The process begins with screening and evaluating critically ill patients with multiple medical problems on life-support or receiving various medications. Examples of this would be: Such noticeably unstable cardiovascular status, sedation, paralysis, burns, comatose state, and severe orthopedic or neurological deficits. These patients are more susceptible to losing mobility long term and require immediate intervention.
The goal is identify them and when they reach stable condition, begin proggreive movement therapy. Supine based therapeutic are emphasized, especially during Phase 1 of the program. The goals for this phase are for patients to gain the ability to turn side to side and unsupported sitting.The goal for out-of-bed activities is to improve orthostatic tolerance such as standing and sitting. Later on in Phase 2 patients will learn to walk with the assistance of a walker to a chair and then across a larger distance.If a patient is too critical, just developing better orthostatic tolerance is preferred. The application of consistent verbal cues for sequencing allows for greater patient' participation.
Phase 3 includes patients able to walk with a walker or with assistance. Here the aim is to increase walking distance and develop muscle endurance. Clinicians who mobilize patients need to be aware of how much assistance is required, as well as hemodynamic responses to activity, and ventilatory and oxygen requirements. Evaluation containing this information is important when developing treatment options and safety mesaures. Communication between the team of heathcare personnel is a must to determine adequate ventilatory and/or oxygen support so patients can withstand increased activity.
Phase 4 are for patients no longer in need of ventilatory support and/or have been transferred out of the ICU. Patients in this phase still have weakness and limitations but can participate more in therapy. Supplemental oxygen is provided via a tracheostomy collar or through a nasal cannula if the tracheostomy is closed. For independence to be achieved after hospital discharge, patients undergoing therapy in this phase must be trained to perform functional actions.
By working on this process we expect to decrease overall healthcare costs. We also expect increased mobility in patients in the program. Patients will have less symptoms than when not in the program. And most importantly, the recovery time for patients will be shortened. "When mobility is a corecomponent of care, it can enhance key outcomes for patients, improving gas exchange, reducing rates of VAP, shortening the duration of mechanical ventilation, and enhancing long-term functional ability" (Vollman, n.d., p. s3-s16)
It is important we work on this now because people are suffering needlessly. A simple movement regime could better the lives of thousands of patients. This program allows for better communication between healthcare personnel which in places like the ICU could save lives. Finally, it will allow for higher patient satisfaction. "Progressive mobility is the term used to describe the graded application of the following positioning and mobility techniques: elevation of the head of the bed, manual turning, passive and active range-of-motion exercises, continuous lateral rotation therapy (CLRT) and prone positioning (if criteria met), movement against gravity, upright/leg-down position (tilt table and bed egress), chair position, dangling, and ambulation."(Vollman, n.d., p. s3-s16)
"Often, they are left in a stationary position for a prolonged period and establish a "gravitational equilibrium" over time, making it more difficult to adapt to a position change." (Vollman, n.d., p. s3-s16) In terms of the issue on a microsystem level, first one is to look at what a microsystem improvement framework is and how it can be utilized to continually improve unit perforances as well as enhance comprehension of quality improvement methods. A micro-system as defined in a healthcare setting: "is a small group of people who work together on a regular basis to provide care to discrete subpopulation of patients. It has clinical and business aims, linked processes, shared…