Comparison of a nurse-driven mobility protocol to multidisciplinary mobility protocol for subarachnoid hemorrhage patients
Megan T. Moyer, MSN, ACNP-BC, CNRN; Bethany C. Young
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Purpose: The presence of invasive neuromonitor devices, such as an external ventricular device (EVD), may be a deterrent to aggressive, early mobilization due to fear of catheter dislodgment, hemorrhage, or inappropriate cerebrospinal fluid drainage (Kocan & Lietz, 2013). These drains and monitor devices have historically required strict bedrest. Extended periods of immobility in intensive care units are linked to acquired medical complications. These complications are detrimental to the patient and can lead to higher economic costs for patients, caregivers, institutions, and third-party payers resulting from prolonged hospital lengths of stay, extended rehabilitation stays, and higher levels of disability. In contrast, early mobilization in the intensive care unit may be associated with improved peripheral and respiratory muscle strength, increased quality of life, more ventilator-free days, decreased delirium, and greater functional independence (Kayambu, Boots, & Paratz, 2013; Brahmbhatt, Murugan, & Milbrandt, 2010; Miller, Govindan, Watson, Hyzy, & Iwashyna, 2015). No definition exists in literature for the ideal time of early mobilization in general intensive care units or neurological intensive care units (McWilliams, Atkins, Hodson, & Snelson, 2016). Early mobilization in the neurological intensive care unit has been demonstrated as both safe and feasible. Varying clinical practice guidelines and standards exist for patients with external ventricular devices in the neurological intensive care unit due to the intricacies of each disease process, complexities of developing mobility algorithms, and specialized monitoring required by the staff during the mobility process. This subset of patients in neurological intensive care units with external ventriculostomy drains create an opportunity to develop and implement practice guidelines to implement nurse-driven early mobility.
In January 2016, our Neurointensive Care Unit progressed from mobilizing patients with external ventricular devices (EVDs) only with physical and occupational therapy (Phase I), to utilizing a nurse-driven mobility protocol (Phase II).
Methods: The Phase II EVD Mobility Protocol allowed nurses to independently mobilize subarachnoid hemorrhage patients with EVDs. Patients could remain out of bed with the EVD clamped for a maximum of 3 hours per session. Physical and occupational therapists (PT/OT) continued normal consultation and recommended the safest mobility method for each patient. Standard protocol for the management of Subarachnoid hemorrhage patients was maintained for the duration of the study. Patients with subarachnoid hemorrhage who also had an external ventriculosotmy drain and demonstrated tolerance to a 30-minute drain clamping trial were included in this initiative. Patients who were unable to tolerate 30 minutes of drain clamping, exhibited sustained intracranial hypertension (defined by intracranial pressure (ICP) of greater than 20), or whose code status progressed to comfort care or hospice care were excluded. Delayed cerebral ischemia was not an absolute contraindication for mobilization, however if patients were experiencing fluctuating neurologic exams due to fever, infection, medication administration, or delayed cerebral ischemia, mobilization was held for that particular day. Pulmonary and/or cardiovascular instability or patient refusal could also preclude mobility. The nursing and medical teams re-evaluated every patient on a daily basis to determine mobility readiness for that day.
Results: 6/13 patients (46%) were men. Mean age did not differ significantly between Phase I and Phase II [57.1 (27-84) versus 54.8 (19-83); p=0.67]. A total of 213 activity sessions took place over 6 months during Phase II, compared with 71 sessions during one year of Phase I. Of 213 sessions, nurses independently completed 135 sessions (63.4%); PT/OT participated in 78 sessions (36.6%). On average, mobility occurred 1.2 days earlier in Phase II [day 5.96 (1-13) versus day 4.75 (2-12); p=0.32). Phase II patients were mobilized an average of 6.7 times (+/-4.7) with their EVD compared with 2.96 times (+/-1.33) in Phase I (p=0.02). Mean hospital LOS trended lower in the Phase II group [20.5 days (+/-7.39) versus 24.6 days (+/-8.29); p=0.14]. Ventilator days also trended lower in Phase II [6.3 days (+/-3.81) versus 12.3 days (+/-10.47); p=0.14]. No Phase II patients received a tracheostomy, compared to 16.7% in Phase I (p=0.12). All patients in Phase II were discharged home or to acute rehab (p=0.18).
Conclusion: Nurse-initiated mobilization of patients with EVDs is safe, feasible, and may lead to earlier and more frequent ambulation compared to a therapy-driven protocol. Nurse-driven mobility may be associated with fewer ventilator days, shorter hospitalization, and improved discharge disposition. No major complications were attributable to early mobilization.
The primary goals of this quality improvement initiative were to promote and establish a culture of early, progressive mobility in the Neuro ICU and to demonstrate improved patient outcome. Standardizing the processes by which we mobilize our patients with external ventriculostomy drains allowed for multidisciplinary engagement in the process and embedded a new culture of mobility in our unit. Nurse-driven mobility has allowed physical and occupational therapy to engage in more complex therapy techniques with patients, such as more mobilization with ventilators, and to explore the use of other novel therapy devices.
Event Theme: Influencing Global Health Through the Advancement of Nursing Scholarship
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