Nurse-Led Mobilization Activities in Intensive Care Unit (ICU) Settings

Stolldorf, Deonni P.; Stolldorf, Deonni P.

Purpose: Descriptions of ICU mobility practices are predominantly reported from single or multi-site quality improvement (QI) projects (Campbell, Fisher, Anderson, & kreppel, 2015; Dammeyer et al., 2013; Timmerman, 2007; Hopkins & Spuhler, 2009; Engel, Needham, Morris, & Gropper, 2013; Hopkins, Spuhler, & Thomsen, 2007; Needham & Korupolu, 2010) or review articles (Hodgson et al., 2013; Hopkins et al., 2009), both considered to be less rigorous than research studies. Bakhru et al., (2015), reported mobilization practices employed by a sample of U.S. hospitals, but lacked in-depth descriptions of the specific nurse-led mobilization. The views of direct care ICU nurses are also underrepresented in studies related to mobilization of ICU patients. For example, Bakhru et al. (2015) surveyed ICU nurse managers or clinical nurse specialists whilst Brotman et al. (2015) sampled nurses in non-ICU settings (Brotman et al., 2015). The purposeof this presentation is to describe nurse-led mobilization practices in two community hospital ICUs and to report practice differences between the two settings. This study contributes to the body of knowledge by providing an in-depth description of nurse-specific mobilization practices in the ICU, independent of interdisciplinary collaboration.To describe the frequency and variability in nurse-led mobilization activities in Intensive Care Units (ICUs) after controlling for patient characteristics.

Methods:

Design: A cross-sectional exploratory study was conducted. The population studied was critical care nurses and their patients from two medical-surgical ICUs in two Southeastern cities. The sample consisted of a convenience sample of nurses (N=18) employed in a critical care units of two hospitals caring for a total of 124 patients (Hospital A: N=12 nurses making 60 reports; Hospital B: N=6 nurses making 117 reports). Measurement: Nurses self-reported mobilization practices for one month using the Mobilization Initiatives & Levels of Exercise (MOBILE) tracking tool specifically developed and tested (face validity) for the study. The MOBILE tool includes: patient characteristics (age, gender, admitting diagnosis, comorbidities, temporal measures (date, ICU admit/discharge dates, intubation date, extubation date), nurse mobilization practices (high-flowers, semi-fowlers, beach/cardiac chair, dangle, transfer to chair, stood, ambulate, and range of motion (ROM) active versus passive, and turning), including frequency per shift, and patient acuity scorederived from the Simplified Therapeutic Intervention Scoring System (TISS-28). The TISS-28 assesses severity of illness (Muehler et al., 2010) based on 28 indicators (interventions) with point values ranging from 1 to 5 (maximum score: 85). Data analysis included descriptive statistics (median, IQR,N,%), Mann-Whitney tests, Chi-square tests of independence and general linear modeling adjusting the standard errors for data arriving from the same nurse and in many cases the same patient (e.g., the same patient reported on by the same nurse multiple times).

Results:

Patients (N=124) were a median 66 years of age (IQR: 57-74) with a median Charlson Comorbidity Index (CCI) of 4 (IQR: 3-7) and were approximately equally represented by gender (female: 52%; male: 48%). Considerably higher TISS scores were reported for patients on ICU “A” than for those on ICU “B” [median=26.5 (IQR: 18-33) vs. 17.5 (IQR: 10-17), p < 0.001]. The nurses reported that approximately 30% of the patients received more than one intervention during their shift. The most commonly reported types of interventions were mechanical ventilation (41%), tube care (39%), enteral feeding (29%), and fluid replacement (27%). The units varied in the number and types of interventions that the patients required during the nurses’ respective shifts. Specific interventions required by a higher proportion of the patients on ICU “A” included: mechanical ventilation (56% vs. 31%,p=0.006), tube care (50% vs. 31%,p=0.034), enteral feeds (42% vs. 20%,p=0.009), and arterial line (14% vs. 4%,p=0.046).

Mobilization activities for the patients during each shift in the two ICUs were also analyzed. The most commonly reported mobilization activities conducted per patient per shift were turning of the patient at least 6 times (82%) and placing the patient in semi-fowlers position (68%). After controlling for patient age, CCI, and TISS, patients in ICU “B” were more likely to be placed in semi-fowlers (88% vs. 30%,p <.001) whereas patients in ICU “A” were more likely to be placed in a beach/cardiac chair (33% vs. 3%,p=0.015), be transferred to a chair (35% vs. 16%,p <.001), and be ambulated (30% vs. 22%,p<.001).

Conclusion:

Differences in patient characteristics and nurse-led mobilization activities were observed between ICUs. After controlling for patient characteristics, we found statistically significant differences in nurse-led mobilization activities between the two units. These findings suggest that factors other than patient characteristics may explain differences in nurse-led mobilization activities. Our findings are consistent with other studies indicating that non-patient factors such as safety concerns and workload served as barriers to mobilization in ICU settings. The findings also support prior studies linking nurse-led mobilization to non-patient factors. Further research is needed to investigate specific factors associated with nurse-led mobilization practices, including unit and staff characteristics, nursing workload, and knowledge, skills, and attitude of ICU staff members. The findings of the study hold policy implications for research, practice and policy. Differences in mobilization practices based on patient-related factors reaffirm the need to risk adjust for patient acuity for assessment of mobilization practices. Differences in practices between hospitals (ICUs) highlights the need to explore organizational-level factors (e.g., policies, protocols) that influence early mobilization. National and local policies are also needed to allocate resources to investigate and address non-patient factors. Finally, policies that promote establishment of ICU mobility teams and ensure the purchase of equipment are needed to facilitate patient mobilization.