This paper presents an evidence-based practice project examining whether a nurse-driven progressive mobility protocol reduces length of stay (LOS) for immobile critical care patients compared to standard two-hour repositioning. Using a PICO framework, the author reviews literature sourced from Ovid Medline, Mosby Nursing Index, and CINAHL, evaluating studies on hemodynamic changes, kinetic therapy, pneumonia incidence, and ICU-acquired neuromuscular deterioration. The Stetler Model guides the evidence-based practice change framework. The paper concludes with a proposed progressive mobility protocol designed as a standing ICU order, along with a plan to evaluate its impact on LOS over 12 months post-implementation.
The paper demonstrates systematic literature synthesis in the context of a clinical practice change project. Rather than summarizing individual studies in isolation, it uses each piece of evidence to build a cumulative case for safety and efficacy, then connects that evidence directly to a protocol design. This integration of research findings with practice implications is a hallmark of evidence-based nursing scholarship.
The paper opens with a PICO question and background rationale, proceeds through a methodology section describing database searches, then presents findings from four key studies. A conceptual model section introduces the Stetler framework, followed by project design and protocol description sections. The paper concludes with planned outcome measurements and a summary of the project's purpose and expected impact. This structure mirrors a standard evidence-based practice proposal format used in graduate nursing programs.
This paper is a project based on the PICO framework. The clinical question that serves as the foundation for this evidence-based design is: for immobile critical care patients, does the use of a nurse-driven progressive mobility protocol reduce ICU length of stay (LOS) compared to repositioning every two hours? In this paper, adult patients admitted to an ICU represent the population (P) of interest. The nurse-driven progressive mobility represents the intervention (I), the comparison (C) is critical care patients repositioned every two hours, and the reduction in LOS represents the outcome (O).
Most hospitals place critically ill patients on bed rest and reposition them every two hours in the intensive care unit. Some literature reviews provide evidence in favor of progressive mobility protocols. This paper also reviews the safety of mobilizing critically ill patients and the negative effects bed rest may have on patient outcomes and length of stay (LOS). The analysis of the literature aims to provide evidence validating the establishment of an evidence-based progressive mobility protocol (Plis, 2009).
Online research utilized Ovid Medline, Mosby Nursing Index, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). The search terms included critical care, immobility, outcomes, LOS, and positioning. The search results from each database yielded similar findings (Plis, 2009). The literature review focused on articles based on their relevance to the PICO question: for immobile critical care patients, does the use of a nurse-driven progressive mobility protocol decrease ICU LOS compared to repositioning every two hours?
A study on the hemodynamic changes experienced by critically ill patients when mobilized involved 31 ICU patients deemed appropriate for mobilization based on a screening criterion. This study involved auditing medical records for information on heart rate, blood pressure, and oxygen saturation. The study concluded that, with appropriate screening, mobilization of critically ill patients produces positive results without major deterioration in clinical status. Therefore, this study demonstrates that mobilizing critically ill patients can be achieved safely. Another study demonstrating the benefits of mobilization was a prospective investigation focused on the effects of kinetic therapy on pulmonary complications (Plis, 2009).
The kinetic therapy study — which involved continuous side-to-side turning using specialty patient beds — included 234 critically ill ICU patients with ventilation ratios of less than 250, a Glasgow Coma Scale score of less than 11, and a need for mechanical ventilation (Plis, 2009). A comparison between kinetic therapy and standard repositioning revealed that pneumonia rates were lower in patients who received kinetic therapy. The study also found significant differences in LOS, with the cost of stay being lower in the kinetic therapy group. However, the study noted that kinetic therapy did not independently influence LOS (Plis, 2009).
Another study examined the effects of manual turning on patients diagnosed with pneumonia and included 284 critically ill patients under mechanical ventilation and tube feeding. This study was not randomized, and the Clinical Pulmonary Infection Score was used to establish the incidence of the disease after three days of intubation (Plis, 2009). The investigators observed patients for evidence of repositioning every two hours and concluded that pneumonia development was higher in patients who were not repositioned as frequently (Plis, 2009).
Further evidence came from a study focused on the effect of ICU-acquired paresis on mechanical ventilation weaning. This study involved 95 ICU patients with no history of neuromuscular disease who were being weaned from mechanical ventilation after seven or more days of ventilatory support (Plis, 2009). The researchers assessed muscle strength after patients were awakened. The study suggested that preventing ICU-acquired neuromuscular deterioration could expedite mechanical ventilation weaning. It demonstrated that sedating patients followed by prolonged periods of immobility may lead to a significant increase in both LOS and mechanical ventilation weaning times (Goldhill et al., 2007).
Based on the evidence reviewed, it is apparent that early mobility — whether in-bed or out-of-bed — can be achieved safely. Reducing the progression of complications can decrease LOS, and promoting healing may further influence LOS. Failing to mobilize patients can be costly in terms of LOS, complications, and rehabilitation duration. The reviewed research suggests that the repositioning that should occur every two hours actually occurs only approximately 2.7% of the time.
Nurses often hesitate to mobilize critically ill patients out of bed due to fear of clinical deterioration. Based on the reviewed evidence, establishing a progressive mobility protocol has significant potential to improve patient outcomes, including reducing LOS. A nurse-driven mobility protocol will also enhance management of patient mobility while providing nurses with clear orders to guide patient progression (Plis, 2009). Such a protocol can help shift the culture from one of sedation to one of progressive mobility, ultimately decreasing LOS.
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