Final Evidence Based Paper

Description


These are the parts I need to be done: Appendices will include a conceptual model for the
project, handouts, data and evaluation collection tools, a budget, a
timeline, resource lists, and approval forms.

Throughout this course you will be developing a formal,
evidence-based practice proposal.

The proposal is the plan for an evidence-based practice project
designed to address a problem, issue, or concern in the professional
work setting. Although several types of evidence can be used to
support a proposed solution, a sufficient and compelling base of
support from valid research studies is required as the major component
of that evidence. Proposals are submitted in a format suitable for
obtaining formal approval in the work setting. Proposals will vary in
length depending upon the problem or issue addressed; they can be
between 3,500 and 5,000 words. The cover sheet, abstract, references
page, and appendices are not included in the word limit.

Section headings and letters for each section component are
required. Responses are addressed in narrative form in relation to
that number. Evaluation of the proposal in all sections is based upon
the extent to which the depth of content reflects graduate-level
critical-thinking skills.

This project contains seven formal sections:

  1. Section A: Organizational Culture and Readiness
    Assessment
  2. Section B: Problem Description
  3. Section C:
    Literature Support
  4. Section D: Solution Description
  5. Section E: Change Model
  6. Section F: Implementation
    Plan
  7. Section G: Evaluation of Process

Each section (A-G) will be submitted as separate assignments so your
instructor can provide feedback (refer to applicable modules for
further descriptions of each section).

The final paper will consist of the completed project (with
revisions to all sections), title page, abstract, reference list, and
appendices. Appendices will include a conceptual model for the
project, handouts, data and evaluation collection tools, a budget, a
timeline, resource lists, and approval forms.

Prepare this assignment according to the APA guidelines found in the
APA Style Guide, located in the Student Success Center. An abstract is required.

This assignment uses a rubric. Please review the rubric prior to
beginning the assignment to become familiar with the expectations for
successful completion.

You are required to submit this assignment to Turnitin. Please refer
to the directions in the Student Success Center.

GET UP AND GO HOME
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Get Up and Go Home
Julie Braylock
Grand Canyon University: NUR:699
March 7, 2018
Professor Cindy Boyle
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TABLE OF CONTENTS
Section Page
ACKNOWLEDGMENTS ……………………………………………………………………………………..iii
TABLE OF CONTENTS ……………………………………………………………………………………… iv
ABSTRACT ………………………………………………………………………………………………………… v
SECTIONS
1. Introduction ……………………………………………………………………………………. 1
2. Review of Literature and Synthesis of the Evidence …………………………….. 3
3. Plan for Implementation …………………………………………………………………. 18
4. Plan for Evaluation ………………………………………………………………………… 28
5. Conclusions, Recommendations and Implications ……………………………… 36
REFERENCES …………………………………………………………………………………………………… 38
APPENDICES
APPENDIX A – Progressive Mobility Continuum ………………………………………………….. 43
LIST OF TABLES
Table
Page
Table 1 Summary of Reviewed Evidence………………………………………………………………. 10
Table 2 Estimated Timetable Blueprint for Implementation …………………………………….. 26
Table 3 EBP Evaluation Plan ………………………………………………………………………………. 33
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Abstract
An abstract is a brief, comprehensive summary of the contents of a paper (American
Psychological Association, 2010) that runs a maximum of 120 words. It should contain a
synopsis of the points in the paper, but also be readable and well organized. To use this page of
the template, simply delete this paragraph and start typing. The formatting should stay the same.
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Spring Valley Hospital was established in 2003 as the first acute care hospital in Southern
Nevada in Las Vegas. The hospital has recorded outrageous growth regarding community that
they provide their services. Currently, the hospital has a bed capacity of 292. The services that
are offered are inclusive of emergency services offered in 24 hours, maternity services, inpatient
and outpatient rehabilitation, wound care and cardiovascular services. An evidence-based
practice readiness survey was conducted. The mission of the hospital is to “provide a culture of
excellence with committed employees, physicians, and volunteer deliver safe quality patient care
for their community” (Spring Valley Hospital 2018). Working at Spring Valley for several years,
it is evident that the hospital is striving to provide optimal care to the patients which includes
best practice guidelines to insure the best possible patient outcomes. Knowing this, the facility
was scored facility a 5 for this category.
The organization’s level of readiness lies in interprofessional collaboration. The hospital
is part of six acute care hospitals that are responsible for providing patient care within Southern
Nevada and Las Vegas at large. The other hospitals that take part include Desert Springs
Hospital Medical Center, Summerlin Hospital Medical Center, Valley Hospital Medical Center,
Henderson Hospital and Centennial Hills Hospital Medical Center (Spring Valley Hospital
Medical Center, 2018). Interprofessional collaboration is essential since it improves the outcome
of patients. Additionally, teamwork is vital in reducing workload and thus improves job
satisfaction for both the healthcare workers and the patients (Bosch & Mansell, 2015). As an
employee at the facility, it was noted that when the workers were relieved of workload and this
increased work efficiency. The program also helped in interprofessional-based education among
the workers in the hospital.
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The hospital is not a Magnet Hospital but does have some evidence-based practice (EBP)
guidelines in effect. Nurses are educated and responsible to adhere to the guidelines daily. The
hospital did score a 5 because the most recent EBP guidelines are put into practice. The hospital
scored a 3 for the degree in which nursing staff is dedicated to EBP. This score the fact that the
staff does fall short in committing to guidelines. Some of the barriers does tie in with lack of
education. The hospital also offers minimal training opportunities to nurses. The facility scored a
3 in this area. Training is crucial since it improves skills and knowledge. Through training,
nurses can improve their basic understanding and thus become more robust when faced with
challenges in their daily activities. The hospital use of electronic health records requires people
who are trained. The electronic records make the work easy as the files are easy to find and thus
time conscious. The hospital has fewer staff members than the required number. However, to
curb this issue, the hospital allows volunteers who fill the gap to ensure that workload is
minimized, and the patients stay in the hospital is reduced. This is mainly because of the training
that is offered to ensure that the serviced offered are of good quality and up-to-date. Evidencebased practiced (EBP) in nursing at Spring Valley Hospital is apparent. EBP aims to make
available valuable and practical care to the patients with the intent to improve the outcome. The
hospital fulfills this by ensuring that the EBP in nursing is practiced (Spring Valley Hospital
Medical Center, 2018). The patients who were admitted to the hospital give feedback stating
that they received the most effective care based on available facts.
Possible project barriers for EBP in the hospital include misunderstanding of the
statistics, scarce time to carry out the EBP and to read the literature and lack of power to change
the care given to the patients. Barrier facilitators include support from peers and colleagues as
well as managerial support. Insufficient authority to prompt a change in the practice setting has
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been a major barrier in the hospital. The organization should be willing to support the
implementation of research in the six facilities that are within the Valley system. Lack of time to
implement and review the findings was also another barrier in the hospital. I scored the facility at
a 4 in this area. There are less training opportunities and support policies that are in the hospital,
and this makes it hard for the hospital to promote EBP at regular intervals.
Promoting clinical inquiry and generating an interest in EBP is significant in a hospital
setup. This is because they facilitate positive outcomes such as build of interdisciplinary
relationships, creating rapport and generating a continuing trustworthy structure. One of the
methods to improve clinical inquiry is through coaching and mentorship of the steps involved in
EBP. Another method is to change the authority among the nurses to provide a platform to ask
what is not understood. Moreover, encourage the nurses to identify patients who are interested in
taking part in the EBP.
Problem Statement
According to (Truong et al, 2009) “In the Intensive Care Unit, critically ill mechanically
ventilated patients have been considered too ill to move leaving them to traditional bed rest to
which can lead to detrimental effects on the patients physical, emotional, and social health. ICU
acquired weakness (ICU-AW) is an accumulative effect of prolonged bed rest, malnutrition, and
systemic inflammation”. The author goes on to explain that “Once a patient has been
compromised by ICU-AW, the patient may experience prolonged mechanical ventilation,
prolonged hospitalization due to secondary diagnoses from hospital acquired injuries (HAIs),
muscle wasting requiring ECF placement, and decreased quality of life due to prolonged effects
of immobility” (Truong et al 2009). The general weakness of the muscles develops in patients
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admitted in the ICU due to acute illness or treatment of the disease. The loss of muscle mass and
muscle strength in patients in the ICU was first recorded in the nineteenth century (Hermans &
Berghe, 2015). The main complications related to ICU-AW are critical illness polyneuropathy
and critical illness myopathy. The incidence rate of ICU-AW is reported to be 25% to 100%
(Zororwitz, 2016). It is a frequent complication of a critical illness which is linked to high
morbidity and mortality rates. Additionally, the condition has long-term consequences in patients
who are discharged from the hospital for an instance post-intensive care syndrome which
comprise of mental, physical and cognitive dysfunction. ICU-AW is associated with multiple
dysfunctions of organs, and thus patients have activity limitations. These patients require
physical assistance mostly from the nurses to perform even the most basic activities related to
bed movement. The purpose of this paper is to provide a proposed evidence-based project whose
aim is to reduce the effects of ICU-AW and decrease hospitalization duration for patients with
mechanical intubation in Spring Valley Hospital.
The proposed problem is an issue not only in the US but a globally. Patients in ICU are at
a higher risk of losing muscle mass and mass strength due to reduced physical inactivity and
increased metabolism. Additionally, decreased pathophysiological mechanisms which include
metabolic, microvascular, electrical and bioenergetic adaptation give rise to muscle atrophy and
reduced muscle mass and strength (Zhou et al, 2014). From the proposed problem, researching
Spring Valley Hospital would be of great importance as there would be an evidence-based
project that will be used in the field of nursing. Moreover, the hospital will receive a good
reputation. Weaning off mechanical ventilation is related to problems of the diaphragm,
intercostals muscles, phrenic nerves and other accessory respiratory muscles. In rare cases, facial
muscles may be affected, and thus paralysis of the muscles surrounding the eye may occur. The
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research will benefit patients who are in the ICU all over the world as well as nurses. EBP in the
hospital will only be possible if there is collaboration among hospital workers and support from
peers and colleagues as well as managerial support.
When conducting this research, it is essential to develop a PICOT statement to enable
useful interview due to this epidemic. The question could be: In critically ill mechanically
ventilated patients (P), does the implementation of early mobility to reduce the risk of ICU
acquired weakness (ICU-AW) (I) compared to use of complete bed rest (C) decrease hospital
stay (O) over time (T)? The purpose of conducting this research is to find out practical
interventions that will facilitate reduction of the effects of ICU-AW and aid in the reduction of
hospital stay for patients with mechanical intubation. This will, therefore, reduce morbidity and
mortality rate in the US as well as reduce the long-term complications for patients who are
discharged. The EBP is essential in the field of nursing as it provides practical care for patients
with similar conditions with the intention of improving the outcome of the patients.
Evaluation of the Evidence
Immobility in the ICU is a contributing factor to an increased hospital stay, complications
upon discharge, and physical deconditioning. Even though early mobility has shown great
improvements in ICU patients, research shows that there is lack of necessary resources that
would significantly lead to the implementation of early mobility. It is a frequent complication of
a critical illness which is linked to high morbidity and mortality rates. Additionally, the condition
has long-term consequences in patients who are discharged from the hospital for an instance
post-intensive care syndrome which comprise of mental, physical and cognitive dysfunction.
ICU-AW is associated with multiple dysfunctions of organs and thus patients have activity
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limitations. Risks factors associated with bed rest include poor response to stress responses for
patients with muscle wasting and immobility. Early mobilization seeks to decrease the effects of
ICU-AW and decrease hospitalization duration for patients in ICU.
There was an initiative carried out by 13 ICUs in eight hospitals in the US which aimed
at integrating the most recent evidence on the practice of mobility into the modern ICU culture
(Bassett, Vollman, Brandwene, & Murray, 2012). This was done through designing and
implementing evidence-based mobility continuum that was physiologically grounded and
friendly to its users. Targeted messages and appropriate education was given to the stakeholders
and change interventions were given to the staffs to modify their behaviors in their field of
practice for it to be long term.
Another study was carried out that involved 106 patients. The inclusion criteria of the
study were patients had to be in ICU, the APACHE II score should not be below 14.7. The
duration of the research was four weeks. The outcome measures used were number of days that
the patient was mobilized, reasons why the patients were not mobilized and adverse events that
took place during the search (Leditschke, Green, Irvine, Bissett, & Mitchell, 2012). Early
mobilization therapy has been closely linked to improved survival in critically ill and
mechanically ventilated patients. Prolonged lack of mobility and total bed rest increases
catabolism and muscle wasting. These are the major reasons why patients in ICU have
neuropathy and ICU-AW (Lipshutz & Gropper, 2013). Various equipment and expertise exist to
ensure that there is compliance with early mobilization programs. Research and EBP should be
conducted to find out the drugs that will reduce muscle atrophy for patients in ICU.
Collection of qualitative data was used to evaluate issues that surround mobility as well
as providing feedback to the stakeholders who were expected to support the change. Early
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mobilization is associated with reduced skin injuries, reduced longevity of hospital stays,
improved ventilation-free days, decreased hallucinations and reduced cases of complications
after discharge. The validity of the research was not correct since this study had fewer
participants and a short period of time (Bassett, Vollman, Brandwene, & Murray, 2012).
Analysis of benefits, safety, and feasibility of early mobility on critically ill patients compared to
traditional bed rest. It had 10 studies with 868 participants. The study involved two prospective
studies and two observational studies. From the reviews, the study showed that mobilization can
be directed to the patients as to the patients as per their level of tolerance to the activity
(Schweickert, et al., 2009). It thus promoted safety and positive effects of the therapy. There was
also reduced the number of free ventilation.
Presence of family was shown to be a motivational factor and beneficial in early
mobilization. Engaging of the family together with the patients serve as a standard of care but in
ICU, this is not allowed. The research was done to identify the role that the family plays to help
in the recovery of the patients. This is beneficial for both the patients and the staff since
workload for the staff is significantly lessened (Rukstele & Gagnon, 2013). Active presence,
protection, facilitation, history, coaching, and volunteering of caregivers is important.
From the randomized control trials, it is evident that early mobilization of ICU patients is
important as it helps in reducing hospital stay, reduces complications after discharge, reduced
muscle atrophy and ICU-AW (Vollman, 2013). These studies, however, did not address adverse
effects of immobility such as increased hallucinations, atelectasis, and skin injuries. However,
there was improved muscle tone. Implementations of measures that reduce sedation and improve
mobility are therefore important. This will significantly reduce the mortality rate associated with
ICU acquired weakness. These trials provide techniques that are used to evaluate and implement
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treatments using evidence-based practices for patients in the ICU to provide the progressive
guidelines that should be used in search cases.
Insert PICO Question–“For mechanically intubated patients does the implementation of early
mobility decrease the length of hospitalization compared to traditional bed rest?”
Insert Keywords– Early mobility, mobilization, intensive care acquired weakness, intensive
care, and mechanical ventilation.
Insert Databases Searched—CINHAL, JBI Connect+, PubMed, Science Direct, PROQUEST,
Cochrane Library, Google Scholar
Authors/Year of Citation
Amidei, C. (2012).
Measurement of
physiologic responses
to mobilization in
critically ill adults.
Intensive and Critical
Care Nursing, (28), 5872.
Research Design
Sample: N=
567 Adults >
239 patients
mechanically
ventilated.
Data Collection
Methods
Vital signs
monitored pre,
post, and
during
intervention
include heart
5 out of 12
rate, blood
studies RCT
pressure,
setting: ICU
Respiratory
setting, post
rate, Sa02,
ICU setting
SV02, C02
and
production,
community
IL-6 & IL-10
setting
inflammation
markers, Borg
Design/Metho
rating of
d: Systematic
perceived
Review:
exertion
twelve articles
surveys, and
were retrieved
muscle
from
strength
electronic
measurement
databases,
tests, (MMT)
from 1990manual
2011,
Key Findings
Characteristics
All the studies
included in the
systemic
review
assessed
physiologic
responses to
mobilization
on critically ill
patients. The
SR explained
in depth to
what extend
that all the
noted
evaluation
tools may be
performed and
how the
reliability of
each
evaluation tool
may be altered
by
Strengths:
There was a
mixture of
studies
presented and
evaluated.
identified
cytokine as the
only evaluation
variable that is a
safety measure
and a desired
outcome.
Weaknesses:
No evaluation
for
measurements
was focused on
comfort or sleep
related to
mobilization or
length of
hospitalization
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Bassett, R., Vollman,
K., Brandwene, L., &
Murray, T. (2012).
Integrating a
multidisciplinary
mobility program into
intensive care practice
(IMMPTP): A
multicenter
collaborative. Intensive
and Critical Care
Nursing, (28), 88-97.
doi:
10.1016/j.iccn.2011.12.
001
12
including
CINAHL,
MEDLINE,
PubMed, and
Cochrane
Database of
Systematic
Reviews.
muscle
testing,
(MRC)
medical
research
council
muscle
strength
grading scale,
and PFT’s for
respiratory
muscle
strength.
medications,
techniques,
performance
by technicians,
or the patients
understanding
of the surveys.
The SR also
stressed on the
patient safety
before
evaluation of
efficacy.
Despite each
measurement
tool having the
ability to be
inaccurate to
some extent, it
is the
collaboration
of multiple
measurement
tools to
evaluate an
accurate
assessment of
mobility on a
critically ill
patient.
address in this
review.
Sample:
N=130
nonspecific
ICU patients
10 from each
facility studied
over a 30-day
period
Qualitative
surveys from
team members
on culture of
change
Quantitative
results from
retrospective
chart
abstractions
and
concurrent
direct
observational
data Monthly
conference
The literature
review suggest
that early
mobilization
has been
shown to
decrease VAP,
skin injuries,
length of
hospital stay,
decreased
delirium and
improve the
amount of
ventilator free
days as well as
Strengths:
This study
addresses the
critical illness of
patients while
giving an
algorithm like
protocol to
follow for
severity of
illness and
amount of PT
the patient can
follow. It
addresses the
culture to which
Setting: 8
hospitals, a
mixture of
large
academic
centers to
small rural
Conclusion:
The SR does not
answer the
clinical
question, but it
does give
beneficial
evaluation tools
and guidance to
monitor for
safety and
effects of
mobility on
critically ill
patients.
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community
hospitals 13
ICU setting
from trauma to
CVICU,
MICU, to
SICU
Method:
Literature
review, study
design,
qualitative and
quantitative,
no
randomization
.
calls for
Coaching
(culture) and
Strategy
(clinical
content, date
collection, and
evaluation).
Progressive
mobility
continuum,
RASS or
MASS scales
to monitor
agitation and
motor activity
scales.
physical
function after
hospital
discharge. In
this qualitative
and quantitate
study, the
trend towards
decreased
length of
ventilator days
decreased
P=0.06
improved.
the ICU can
present as a
barrier to EPB
and
implemented
techniques to
improve
compliance and
promote
exuberance of
the treatment
team.
Weakness: The
study was not
However, no
randomized, and
statically
the culture of
significant
the treatment
were shown in settings were
the number of already using to
ventilator free implementing
days P=1.1,
new changes
ICU mortality within the
P=0.69, ICU
institution.
length of stay
sample data was
(LOS) P=0.6
small, 10
and hospital
participants per
LOS P=0.31.
institution 13
The qualitative over a 30-day
study
interval.
evaluated the
barriers to the Conclusion:
This study does
change of
answer the
culture and
safety of early clinical question
but more
mobilization.
importantly give
57% of
an algorithm
patients
like measure
received PT
tool to be
consults on
utilized for
day 1 of ICU
education for
stay. Patients
patients, family,
who receive
and staff. It also
early PT
addresses
assessment
techniques that
will usually
may be used to
receive
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Leditschke, A., Green,
M., Irvine, J. A.,
Bissett, B., & Mitchell,
I. (2012). What are the
barriers to mobilizing
intensive care patients?
Cardiopulmonary
Physical Therapy
Journal, 23(1), 26-29.
14
Sample:
N=106 ICU
patients – a
mixture of
mechanically
intubate and
spontaneously
breathing.
Setting:
Mixed ICU
setting
including
trauma and
surgical
patients
Design: 4week
prospective
audit
Demographics
, APACHE II
scores,
number of
patients
mobilized a
day, type of
mobilization,
adverse
events, and
reasons for
inability to
mobilize. each
patient was
counted each
day for a total
of 327
patients/days
audited.
treatment on
day 1.5 days
facilitate
compliance
when
implementing
the EBP project.
54% of all
patient days
involved
mobility. The
staff felt that
this was a low
number but
when
compared to
recent
literature this
amount of
participation is
well above the
standards
reported. The
reasons for
inactive where
accounted for
mostly by
avoidable
measures such
as IV access
(femoral
lines),
scheduling
conflict,
agitation or
over sedation,
and lack of
MD order.
Strengths: This
study examined
mechanically
intubated
patients along
with other ICU
patients. It
identified what
the barriers to
mobility were. It
also identified
that despite low
numbers of
patients who
participate in
mobilization,
mobilization can
be completed
safely despite
mechanical
ventilation.
Weakness:
Limited number
of studies
identifying
barriers to
mobilization.
Conclusion:
The study did
not answer the
clinical question
but did give
evidence to
some barriers
that may need
be
assessed before
mobilization
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care
commenced.
Lipshutz, A., &
Gropper, M. (2013).
Acquired
neuromuscular
weakness and early
mobilization in the
intensive care unit.
Anesthesiology, 118(1),
202-215.
Sample:
N=868 10
studies; 2
prospective
cohort studies,
2 prospective
observational
studies,
descriptive
study of RCT,
case series, 2
RCT,
prospective
before/after
study, and
retrospective
analysis.
Setting:
Academic
health centers,
community
hospitals and
rural hospitals
MICUs,
RICUs,
M/SICUs
Design:
Systematic
Review
Demographics
, Vital Signs,
APACHE II
score,
Ventilator
settings, types
of mobility
treatments,
adverse
effects, GCS,
Diagnosis,
BMI,
medications
and restrictive
mobility
orders. ICU
LOS, LOS
hospital, level
of active
achieved,
ventilator free
days
This review
outlines the
physiological
effects of
prolonged bed
rest, the
pathophysiolo
gical effects
on the body,
potential
effects of
critical illness,
the
developments
of ICU
acquired
weakness and
possible
treatments for
the
neuromuscular
weakness. The
review also
analysis the
safety,
feasibility, and
potential
benefits of
early mobility
on critically ill
patients versus
traditional bed
rest. 50% of
ICU patients
with Sepsis,
MOF and
prolonged
intubation will
suffer
neuromuscular
weakness, the
presents of
SIRS increase
to 100% when
Strength: A
wide array of
research studies,
comprehensive
presentation of
pathophysiologi
cal need of early
mobility and
complete follow
up on feasibility
and measurable
outcomes
Weakness:
Further research
is needed in the
technological
and medicinal
aspects of
treatments for
ICUAW.
Conclusion: I
found this
review very
helpful. It
directly
answered the
clinical question
and provides the
background
information on
ICU acquired
weakness, the
potential
complication
that may arise
from prolonged
bed rest,
potential
interventions to
prevent
ICUAW, and
research studies
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Rukstele, C., &
Gagnon, M. (2013).
Making strides in
preventing icuacquired weakness:
Involving family in
16
Sample: N/A
Setting: Large
Academic
None
accompanied
with the above
diagnoses.
diaphragmic
weakness is
seen 18 hours
after
intubation, 2
days of ICU
stay 25% of
patients will
present with
some ICUacquired
weakness
(ICUAW).
Studies
reviewed show
that
mobilization
can be directed
to the “as
tolerated”
activity to
promote safety
and
therapeutic
effects, LOS
does show a
downward
trend but the
RCTs differ in
results of
statistical
significances.
Number of
days ventilator
free has shown
a significant
decrease.
that provide the
basis for
feasibility, and
outcomes.
This article
addresses the
presence of
family as a
motivational
factor and
Strength: the
use of the
patient and
family centered
care model
(PFCC) is
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early progressive
mobility. Critical Care
Nursing Quarterly,
36(1), 141-147. doi:
10.1097/CNQ.0b
013e31827539cc
17
Hospital 20
bed SICU
Design:
Literature
Review
benefit for
early mobility.
Engaging
family and
patient in the
plan of care
has always
been a
standard of
care, but in an
ICU setting
families are
traditionally
not overtly
welcomed.
This article
identifies the
roles in which
family may
participate in
to help both
the patient and
staff on the
road to
recovery. The
six roles of
active
presence,
protector,
facilitator,
historian,
coach and
voluntary
caregiver are
spelled out and
ways to invite,
educate, and
support family
care is
encouraged.
identified to
increase
compliance and
decrease
stressor for all
parties involved,
family, patient
and healthcare
professionals
Weakness: This
article is not a
study and does
provide
rationale for
steps taken but
no sustainable
evidence on
how the
families,
patients, or staff
valued the
PFCC model
approach. A
qualitative study
would be
suggested.
Worth: I find
this article
extremely useful
considering
providing
patient centered
care. Not only
are we in need
to provide the
best care
evident but also
provide that
care around the
patient
continuum.
GET UP AND GO HOME
Schweickert, W.,
Pohlman, M., Pholman,
A. J., Nigos, C.,
Pawlik, A., Esbrook,
C., Spears, L., &
Miller, M. (2009).
Early physical and
occupational therapy in
mechanically
ventilated, critically ill
patients: A randomized
controlled trial. Lancet,
373,
1874-1882.
doi:10.1016/501406736(09)60658-9
18
Sample:
N=104
mechanically
intubated
MICU patients
49 in
intervention
group and 55
in control
group
Demographics
APACHE II
score, Barthel
index score
pre and post
interventions,
Richmond
Agitation
Sedation Scale
(RASS),
Confusion
Setting: 2
Assessment
large Midwest method for the
Academic
ICU for
Health Centers delirium and
coma (CAMDesign:
ICU),
Random
Functional
control trial
independence
measures,
distance
walked, Days
ventilator free,
LOS ICU and
LOS hospital,
and hand-grip
strength
scores.
Random
control trial
monitored 104
intubated
critical care
patients who
had an
independent
active 2 week
prior to illness
by history
obtained by
family.
separated into
2 groups,
control group
intent to treat
and
intervention
group with
early mobility.
All patients
were started
on enteral
feeding and
tight glycemic
control was
monitored.
There was no
statistical
significance in
days ventilator
free, LOS ICU or LOS
hospital
between
groups, a
statistical
significance
was noted in
the BI, CAMICU, and
return of
independent
function
scores. ICU
Strength: the
random control
trial was set
with comparable
participants with
similar
APACHE II &
BI scores to
diminish any
bias. The study
monitored
physical
strength at
discharge and
QOL
Weakness: The
study did not
address any
evidence of
adverse effects
of ICU acquired
immobility such
as atelectasis,
skin injuries or
an increase in
delirium.
Conclusion:
This study
shows
significant
improvement in
increasing
muscle tone and
subsequently
decreasing ICU
psychosis but
implementing
measures to
reduce sedation
and increase
mobility. It may
have been a
secondary act
but proved very
beneficial to
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Truong, A., Fan, E.,
Brower, R., &
Needham, D. (2009).
Bench- to-bedside
review: Mobilizing
patients in the intensive
care unit – from
pathophysiology to
clinical trials. Critical
Care Alert, 13(4), doi:
10.1186/cc7885
19
Sample: None
Setting: ICU
Design:
Expert
appraisal with
critical review
of scientific
literature.
No data
measured,
only reported
expert
opinions from
recent trial
study
outcomes.
acquired
weakness and
ICU acquired
delirium is
associated
with higher
rates of
morbidity with
early mobility
showing
significant
reduction of
incidences
upon
participants
and increased
QOL
patient’s overall
mortality.
This review
gives a full
spectrum of
the associated
disease
process of
immobility,
pathophysiolo
gical responses
to stress and
critical
illnesses to a
body, potential
treatments and
interventions
to prevent ICU
acquired
weakness and
muscle
wasting. The
therapeutic
effects of early
mobility in
critically ill
patients, safety
and feasibility,
barriers to
mobility such
as ICU culture,
Strength: A full
spectrum of
associated risk
factors of bed
rest, including
pathophysiologi
cal response on
muscle wasting
to stress
responses and
immobility.
Weakness: The
author did not
clearly identify
the trials he
reported results
from, “Recent
studies”.
Conclusion:
This review
provides and
overall
assessment of
the clinical
question and
suggests further
research
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Vollman, K. (2013).
Understanding
critically ill patient’s
hemodynamic response
to mobilization: Using
the evidence to make it
safe and feasible.
Critical Care Nursing
Quarterly, 36(1), 1727. doi:
10.1097/CNQ.0b
013e3182750767
20
Sample: N=33
ICU RNs for a
qualitative
study on
barriers to
mobility.
N=184 ICU
patients in 3
random trials
for safety, and
feasibility.
Setting: ICU
Design:
Systematic
Review with
qualitative and
quantitative
study designs
Progress
Mobility
Continuum,
Mobility
Assessment
for Readiness
tool, which is
an initial
mobility
screen and a
reassessment
screen to be
used Q24
hours.
inadequate
staffing and/or
training, and
low priority.
avenues and
comparison in
cost to
stakeholders.
This paper
gives in depth
explanation to
the
physiological
responses a
critically ill
body under
goes during
mobility, how
to counteract,
and re-train
the critically
ill body to
tolerate
movement.
The review
discusses at
length the
cardiovascular
response to
bed rest and
posture
changes, the
lateral turn and
response and
recovery
phenomena,
the review also
introduces 3
tools used in
EBP for
assessment of
readiness,
progression
toward further
mobility
according to
the patient’s
tolerance, and
an algorithm
Strength:
provides in
depth
explanation of
the prolonged
effects of
gravitational
equilibrium
disruption on a
patient. provides
techniques to
assess and
implement
treatments for
such disruptions
and includes
evidence-based
guidelines for
progressive
mobility for
patients.
Weakness:
author discusses
the use of the
assessment tool
in a 14-month
13 ICU quality
improvement
project but does
not relay any
results of the
said trial except
for the comment
“no ICU team
reported adverse
events.” study
seems
undisclosed.
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Winkelman, C.,
Johnson, K., Hejal, R.,
Gordon, N.,
Rowbottom, J., Daly,
J., Peereboom, K., &
Levine, A. (2012).
Examining the positive
effects of exercise in
intubated adults in icu:
A prospective repeated
measures clinical study.
Intensive and Critical
Care Nursing, (28),
307-320. doi:
10.1016/j.iccn.2012.02.
007
21
Sample: N=
75 mechanical
ventilation >
48 hours
Setting: Large
Academic
hospitals
MICU/SICU
Design:
Prospective,
repeated
measures
study with a
control and
intervention
period.
APACHE 3
scale,
demographics,
diagnosis, VS,
medications,
Charlson
Comorbidity
Index, Pa02,
Fi02, MRC
measures at
ICU d/c, Katz
ADL
screening,
CAM- ICU at
ICU d/c, and
chart audited
for diagnosis
of VAP and/or
VTE. IL-6 and
IL-10
for
reassessment
of unstable
subjects.
Conclusion:
This review is
very helpful and
offers guidelines
and assessment
tools to be used
to incorporate
early mobility
on critical ill
patients. The
physiological
responses
provide insight
on why the
patient becomes
unstable during
movement and
why we should
implement early
mobility to
prevent further
compromise to
the already
critically ill
patient.
This control
study
examined
physiological
effects of
exercise on an
intervention
group and
control group.
The control
group of 20,
who was
prescribed
standard
treatment and
an intervention
group of 55
had early
mobility
consisting of
20 minutes of
Strength: The
study pointed
out that once
daily mobility
may not be
enough to show
significant
changes
compared to
other studies
that had
mobility 2-3
daily. The
significance of
decreased IL-10
on inflammation
is positive
finding that
exercise does
counteract the
effects
GET UP AND GO HOME
22
inflammatory
biomarkers.
therapy once a
day for 2-7
days. This
study
demonstrated
no significant
change in VS,
pain/fatigue
scores, IL-10
did show a
significant
response in
association of
exercise
duration in
both control
and
intervention
groups p=
0.01, but no
associated
significance in
type of
mobility, ICU
LOS, MV,
hospital LOS,
or
pain/fatigue.
inflammation
causes on the
neuromuscular
wasting found
in ICUs.
Weakness:
Inequality in
number of
control subjects
compared to
intervention
subjects.
Inabilities to
accurate obtain
data on muscle
strength with all
participants due
to mental status.
Worth: This
study is
significant in
proving the
physiological
effects of
exercise on the
inflammation
responses of the
body leading to
ICU acquired
weakness.
Solution Description
Different studies have been carried out to identify safe and effective ways that will
minimize cases of ICU-AW for mechanically intubated patients. The most common method that
has been tried through EBP is early mobilization. Nonetheless, few patients can reach
recommendable levels of active mobility and the studies are inconsistent making it hard to
GET UP AND GO HOME
23
understand the optimum outcome of the EBP (Taito, Shime, Ota, & Yasuda, 2016). The
proposed solution for ICU-AW in Spring Valley Hospital is consistent early mobility for all
patients in the ICU which aims at reducing hospital stay and avoiding or reducing cases of ICUAW. This will significantly reduce cases of muscle wasting, critical illness polyneuropathy, and
critical illness myopathy. Also, it will provide a platform with reliable, valid and up-to-date
evidence that will help the nursing profession worldwide. The research will serve as a
convincing and evident proof that early mobilization which is consistent, for mechanically
ventilated patients is safe and effective.
The proposed intervention of consistent early mobility in Spring Valley Hospital is
realistic. This is because there are interprofessional collaboration and the fact that the hospital is
part of a system that constitutes six other hospitals (Spring Valley Hospital Medical Center,
2018). The cost of the intervention is high due to proper training prior, during and after the EBP
has taken place. However, the organization should ensure that the requirements are provided as
the study will provide more advantages to both the hospital and the patients. The collaboration of
the six hospitals makes it easier for the study to be conducted and has promising outcomes. The
workload of the health caregivers will be reduced as more nurses will be trained on the necessary
measures and the speculated method to be used that will promote the effectiveness of the study.
Teamwork is vital in reducing workload and thus improves job satisfaction for both the
healthcare workers and the patients (Bosch & Mansell, 2015). The organization will ensure that
protocol is followed in terms of inclusion and exclusion criteria of the patients who will be used
for the study to reduce cases of mortality while the study is in progress. The organization is also
adamant to changes that will improve the effectiveness of the healthcare that is given in the
GET UP AND GO HOME
24
facility and thus this will ensure that the study will have minimal barriers especially in terms of
support.
The expected outcome is to reduce the hospital stay, reduce adverse effects upon
discharge, and reduce cases of ICU-AW. From the previous studies that have been conducted,
several studies have documented that there was reduced hospital stay, reduced cases of muscle
wasting and reduced cases of complications after the patients were discharged from the hospital
(Leditschke, Green, Irvine, Bissett, & Mitchell, 2012). Early mobilization in ICU has proved to
improve the health status of the patients compared to traditional bed rest. The outcomes are
expected to fruition through training of nurses who will ensure that mobility of patients in the
ICU is introduced early and it is consistent with the stipulated period. Barriers such as few staff
members, lack necessary equipment, insufficient authority and misunderstanding of statistics will
have to be eliminated. The hospital should be in readiness to carry out the study by ensuring that
all the team members and the patients are responsive. Additionally, it should ensure that all the
necessary resources are available before the study commences.
The study will greatly improve the health of patients by ensuring that there are no cases
of complications such as post-intensive care syndrome which comprises of mental, physical and
cognitive dysfunction. There will also be no or minimal cases of multiple dysfunctions of the
organs which are attributed to ICU-AW which limit the patients (Zhou, Wu, Ni, Wu, Ji, &
Zhang, 2014). The patients will also not experience muscle atrophy because of increased
metabolism and immobility. The expected outcome will not only improve the care given in the
ICU in Spring Valley Hospital but will also serve to offer an evidence-based practice that can be
embraced in the nursing care globally.
A Case for Change
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25
Change is not an easy thing but nonetheless, it is essential in any healthcare organization
to improve the care that is being given. Change within an organization follows a series of events
which are expected. Many healthcare organizations don’t change because of new processes,
systems, and structures but because of the willingness of the people in the organization to adapt
and embrace change. The benefits of change will be felt when healthcare workers and patients in
Spring Valley Hospital make their own personal transition about EBP. “The Duck’s Change
Curve Model involves five stages namely; stagnation, preparation, implementation,
determination, and fruition” (Melnyk & Fineout-Overholt, 2011). The respondents go through
related responses when change is presented to them even though their understanding of the
responses may have varying times. Making the journey to change easier for those involved
reduces the time the organization will take to notice the benefits and thus the success of EBP.
Nonetheless, approaching this from the wrong angle increases the chances of failure. The
Change Curve is an important tool which helps individuals to understand the stages involved in
both personal transition and organization (Duck, 2001). It provides a prediction of the reaction
when change is presented.
Stage 1: Stagnation
This stage is caused by poor strategizing, lack of appropriate leadership, lack of training
for nurses, lack of collaboration from the other five hospitals and inability to explain properly the
importance of EBP in Spring Valley Hospital. At this stage, the team becomes hopeless and
discouraged. Effective communication is very important at this stage and thus the team who will
take part in EBP should be encouraged to often communicate. At the same time ensure that the
team is not overwhelmed by providing a limited amount of information (Duck, 2001). For
GET UP AND GO HOME
26
example, explain why early mobilization is preferred and why it should be conducted in the
hospital. It is important to ensure that all the questions are addressed as this is also critical.
Stage 2: Preparation
Operational issues are addressed at this stage such as how training will be conducted,
roles and responsibilities of the team members, and inclusion and exclusion criteria of the
patients. It is important to assess the commitment and feelings of the team members regarding
the EBP. Team members should endorse the need for conducting the EBP in the hospital. This
stage, therefore, requires proper planning and training. At this stage, it is important to get support
from colleagues and organizational support.
Stage 3: Implementation
At this stage, it is likely that one-third of the team members will be enthusiastic about the
change, one third will not be willing to take part in the study and one third will oppose the study
especially since it will be conducted in a critical area within the hospital where the mortality rate
is high. It is important to ensure all the team members agree to take part in the study. The three
groups should be on one page as this will ensure that there is avoidance conflict in the future.
Communication is also crucial in this step to avoid ignoring the parts of EBP that may be
challenging.
Stage 4: Determination
The team members are fatigued by the study since it requires daily monitoring despite the
cumulative effort of the team. This is because those involved in the study think of new ways and
the frequency of mobilization of the patients. Additionally, the patient may be uncooperative
GET UP AND GO HOME
27
making it harder for the nurses to do what they are expected to do. Some members will quit if
they are not continuously motivated to sustain the commitment level.
Stage 5: Fruition
This is the stage where all the hard work of the team members and the cooperation of the
patients is witnessed. The team members are encouraged and energized as they can see that their
hard work has paid off and they are able to see the accomplishment of their work. The study
indicates if early mobility reduces the risk of ICU-AW compared to bed rest. The success of EBP
motivates the team and they can understand their capabilities and attitudes towards their careers.
The Duck’s change curve model is important as it helps people become aware of the fact
that efforts of team members who took part in the study may be turned into self-congratulations.
Fruition can raise gratification and belief that change is important and if a healthcare
organization wants to change its care, then change is essential.
Time for Implementation
The objectives of the project will be to reduce the hospital stay, reduce complications
after discharge, reduced muscle atrophy and ICU-AW within a period of one year. The target
group will be patients in the ICU. The staff members that will take place in the study will include
project manager and other support staff. Consent is required from the patient or the family, from
the hospital’s medical superintendent and from the ministry of health. The staff will undergo a
training session prior to the EBP. The study will take place at Spring Valley Hospital and the
funding will be from the government through the ministry of health. Networking is also an
important part of the study as it promotes efficient information sharing.
GET UP AND GO HOME
28
The proposed project will take place over a period of six months and the training of the
staff members will also take a period of six months. Extensive training is important to the
success of the training is an indicator of a successful completion of the study. The human
resource needed for the EBP include physicians, project manager, nurses, and other staff
members. Funding for the study will come from the government and the hospital which will cater
for the training that will be conducted prior, during and after the study. Interviews and
questionnaires will be used for monitoring and evaluation of the implementation plan. It is
important to collect the data during each phase of the study (pre-implementation,
implementation, and sustainability). This is important as it gives a clear picture indicating if the
study is acceptable and if it is conducted as per the requirements (Fineout-Overholt et al, 2011).
With the improved effort and focus to implement the EBP in Spring Valley Hospital, there is a
need for recognition of the complex task that requires planning, interaction, training, and quality
assurance for all those involved in the study. The implementation process will take more than
two years to determine the success of the study. It is therefore important to understand the steps
that are needed for successful outcomes of the EBP.
Data manager will be responsible for analysis of the data using appropriate tools.
Participation in data analysis should be from all the staff who took part to suggest the best
method to be used in the analysis of the data. For instance, use of SPSS. Barriers and questions
to implementation are likely to arise during the delivery of the study. These may come from the
patients, team members or the organization. Resistance can be avoided by ensuring that there are
effective management and good communication plan which aim at avoiding conflicts.
Implementation of the project will be easy once all the individuals who will take part in
the study are aware of their responsibilities. Conflict can deter the implementation process and
GET UP AND GO HOME
29
thus the project manager should be aware that they may arise at any point. It is also important to
consider the needs of the patients to avoid resistance from the family or the patient (Saldana,
2014). This will help in the success of the outcome. The patient should be provided with choices
and the barriers should be addressed. The cost should also be minimized, and thus high
satisfaction is likely. Support for a new study is essential since there will be reduced pressure to
implement the proposed intervention. Using questionnaires and interviews during meetings and
training is important. Collection of this data and information from the key informants and other
knowledgeable people will provide a basis for the expectations and the possible outcome of the
EBP.
Evaluating the Process
Sustaining EBP may be difficult due to factors such as lack of sufficient research that is
based on the efforts of implementation. In such a case, other sources of evidence may be required
to implement the EBP. Evaluation of the initiatives aiming at insights which regard several types
and levels of EBP outcomes is important. Evaluation is the basis of development of any
particular plan as it offers the required information on the methods of improving the set plans.
Analysis and evaluation of the data collected is an important process as it measures the
achievements of the plan. The main subject of concern is the objectives of the EBP and the steps
required to make the study a success. Several methods are employed to measure the success of
the study through analysis of the collected data. Conclusions and recommendations are drawn
from the analyzed data and this is essential to ensure that future research in improved.
The rationale for the methods used in collecting the outcome data
Several methods of collecting data were used to ascertain the effectiveness of early
mobility for mechanically ventilated patients in the ICU compared to the traditional bed rest.
GET UP AND GO HOME
30
Questionnaires were one of the methods for collecting data. The questionnaires were both openended and closed-ended and were issued to the healthcare workers and the caretakers in Spring
Valley Hospital. The questionnaires were anonymous as this ensured that those involved in the
process gave their answer as per what they believed in. This method was important as it helped
to understand if the healthcare professionals believed that the study can be successful if
conducted (Koo, et al., 2016). Another method was interviews which aimed at the healthcare
providers.
Measuring outcome
The positive outcome of the study shows that the study was successful. The positive
outcomes for this study include reduced effects of ICU-AW and decreased hospitalization
duration for patients. Additionally, reduced long-term consequences in patients who are
discharged from the hospital is a measure of the success of the EBP. The outcome of the project
was measured by analyzing the data that was collected during the study from the hospital and
compared to when initiation had not begun.
Measurement of the Outcome using Validity, Reliability, and Applicability
The tools used for the collection of data for EBP should be reliable and valid. The tool
should also measure and standardize the assessment of the status of mobility for the patients in
the ICU (Perme et al, 2014). The results of the study should be consistent and stable when testretest is carried out. The evidence provided is measured using statistical methods which indicate
the importance of reliability. The applicability of the study is based on the outcomes that are
practical and achievable. Validity is measured when the designs and the methods of collection in
the EBP represent the phenomenon under study. In this case, the phenomenon is early mobility
of mechanically intubated patients in ICU.
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31
Strategies to take if outcomes do not provide positive results
An alternative design should be created to improve the results if there will be no positive
results. Analysis of negative results is crucial so as to come up with recommendations that will
improve the outcomes of the study. Data analysis is important as it indicates if the objectives are
achievable or if the EBP should be discontinued. This is one of the strategies that is used to show
the effectiveness of early mobility for the patients in ICU.
Implications for practice and future research
The results are used to indicate what future researchers should consider if the EBP on
early mobility for mechanically intubated patients in ICU is carried out again. A positive result
from the study then is a clear indication that early mobility is effective for mechanically
intubated patients in the ICU compared to traditional bed rest. A negative result then is an
indication that the research can be improved by using other methods or by addressing the
omissions from the research (Holdslworth et al, 2015). Future researchers should be able to
analyze past research that was carried out and find one common method or step that was omitted
to show that the research did not provide a positive outcome.
Conclusion
Project evaluation is a method that can be used to show that the proposed EBP will have
the expected outcomes. It is also important as it facilitates decision making in terms of
continuation or discontinuation of the topic under study. It mainly focuses on the analysis of the
collected data.
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32
Appendices
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33
References
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Intensive and Critical Care Nursing, (28), 58-72. doi: 10.1016/j.iccn.2011.09.002
Amidei, C. (2012). Mobilization in critical care: A concept analysis. Intensive and Critical Care
Nursing, (28), 73-81. doi: 10.1016/j.iccn.2011.12.006
Bassett, R., Vollman, K., Brandwene, L., & Murray, T. (2012). Integrating a multidisciplinary
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Bosch, B., & Mansell, H. (2015). Interprofessional collaboration in health care. Retrieved
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Duck, J. D. (2001). The Change Monster: The Human Forces that Fuel or Foil Corporate
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Fineout-Overholt, E., Williamson, K., Gallagher-Ford, L., Melnyk, B., & Stillwell, S. (2011).
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Holdsworth, C., Haines, K., Francis, J., & Skinner, E. (2015). Mobilization of ventilated patients
in the Intensive Care Unit: an elicitation study using the Theory of Planned Behaviour.
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Koo, K., Choong, K., Cook, D., Herridge, M., Newman, A., Lo, V., et al. (2016). Early
mobilization of critically ill adults: a survey of knowledge, perceptions, and practices of
Canadian physicians and physiotherapists. Canadian Medical Association Journal, 4 (3),
E448-E454.
Leditschke, I., Green, M., Irvine, J., Bissett, B., & Mitchell, A. (2012). What are the barriers to
mobilizing intensive care patients? Cardiopulmonary Physical Therapy Journal.
Lipshutz, A., & Gropper, M. (2013). Acquired neuromuscular weakness and early mobilization
in the intensive care unit. Retrieved February 9, 2018, from PubMed:
https://www.ncbi.nlm.nih.gov/pubmed/22929731
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based Practice in Nursing and
Healthcare: A Guide to BestPractice (3 rd ed.). Philadelphia: Wolters Kluwer Health.
Perme, C., & Chandrashekar, R. K. (2008). Managing the patient on mechanical ventilation in
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Perme, C., & Chandrashekar, R.K. (2009). Early mobilization and walking program for patients
in intensive care units: Creating a standard of care. American journal of Critical care: an
official publication, American Association of Critical Care Nurses, 18(3), 212-221. doi:
10.4037/ajcc200959
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Perme, C., Nawa, R., Winkelman, C., & Masud, F. (2014). A Tool to Assess Mobility Status in
Critically Ill Patients: The Perme Intensive Care Unit Mobility Score. Methodist DeBakey
Cardiovascular Journal, 10 (1), 41-49.
Rukstele, C., & Gagnon, M. (2013). Making strides in preventing ICU- acquired weakness:
Involving family in early progressive mobility. Critical Care Nursing Quarterly.
Saldana, L. (2014). The stages of implementation completion for evidence-based practice:
protocol for a mixed methods study. Implementation Science.
Schweickert, W., Pohlman, M., Pohlman, A., Nigos, C., Pawlik, A., Esbrook, C., et al. (2009).
Early physical and occupational therapy in mechanically ventilated, critically ill patients:
a randomized controlled trial. Lancet.
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https://www.springvalleyhospital.com/careers
Truong, A., Fan, E., Brower, R., & Needham, D. (2009). Bench-to-bedside review: Mobilizing
patients in the intensive care unit – from pathophysiology to clinical trials. Critical Care
Alert, 13(4), doi: 10.1186/cc7885
Vollman, K. (2013). Understanding critically ill patients hemodynamic response to mobilization:
Using the evidence to make it safe and feasible. Critical Care Nursing Quarterly.
Winkelman, C., Johnson, K., Hejal, R., Gordon, N., Rowbottom, J., Daly, J., Peereboom, K., &
Levine, A. (2012). Examining the positive effects of exercise in intubated adults in icu: A
GET UP AND GO HOME
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prospective repeated measures clinical study. Intensive and Critical Care Nursing, (28),
307-320. doi: 10.1016/j.iccn.2012.02.007
Zhou, C., Wu, L., Ni, F., Wu, J., Ji, W., & Zhang, H. (2014). Critical illness polyneuropathy and
myopathy: a systematic review. Neural Regeneration Research, 9 (1).
GET UP AND GO HOME
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Get Up and Go Home
Julie Braylock
Grand Canyon University: NUR:699
March 7, 2018
Professor Cindy Boyle
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TABLE OF CONTENTS
Section Page
ACKNOWLEDGMENTS ……………………………………………………………………………………..iii
TABLE OF CONTENTS ……………………………………………………………………………………… iv
ABSTRACT ………………………………………………………………………………………………………… v
SECTIONS
1. Introduction ……………………………………………………………………………………. 1
2. Review of Literature and Synthesis of the Evidence …………………………….. 3
3. Plan for Implementation …………………………………………………………………. 18
4. Plan for Evaluation ………………………………………………………………………… 28
5. Conclusions, Recommendations and Implications ……………………………… 36
REFERENCES …………………………………………………………………………………………………… 38
APPENDICES
APPENDIX A – Progressive Mobility Continuum ………………………………………………….. 43
LIST OF TABLES
Table
Page
Table 1 Summary of Reviewed Evidence………………………………………………………………. 10
Table 2 Estimated Timetable Blueprint for Implementation …………………………………….. 26
Table 3 EBP Evaluation Plan ………………………………………………………………………………. 33
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3
Abstract
An abstract is a brief, comprehensive summary of the contents of a paper (American
Psychological Association, 2010) that runs a maximum of 120 words. It should contain a
synopsis of the points in the paper, but also be readable and well organized. To use this page of
the template, simply delete this paragraph and start typing. The formatting should stay the same.
GET UP AND GO HOME
4
Spring Valley Hospital was established in 2003 as the first acute care hospital in Southern
Nevada in Las Vegas. The hospital has recorded outrageous growth regarding community that
they provide their services. Currently, the hospital has a bed capacity of 292. The services that
are offered are inclusive of emergency services offered in 24 hours, maternity services, inpatient
and outpatient rehabilitation, wound care and cardiovascular services. An evidence-based
practice readiness survey was conducted. The mission of the hospital is to “provide a culture of
excellence with committed employees, physicians, and volunteer deliver safe quality patient care
for their community” (Spring Valley Hospital 2018). Working at Spring Valley for several years,
it is evident that the hospital is striving to provide optimal care to the patients which includes
best practice guidelines to insure the best possible patient outcomes. Knowing this, the facility
was scored facility a 5 for this category.
The organization’s level of readiness lies in interprofessional collaboration. The hospital
is part of six acute care hospitals that are responsible for providing patient care within Southern
Nevada and Las Vegas at large. The other hospitals that take part include Desert Springs
Hospital Medical Center, Summerlin Hospital Medical Center, Valley Hospital Medical Center,
Henderson Hospital and Centennial Hills Hospital Medical Center (Spring Valley Hospital
Medical Center, 2018). Interprofessional collaboration is essential since it improves the outcome
of patients. Additionally, teamwork is vital in reducing workload and thus improves job
satisfaction for both the healthcare workers and the patients (Bosch & Mansell, 2015). As an
employee at the facility, it was noted that when the workers were relieved of workload and this
increased work efficiency. The program also helped in interprofessional-based education among
the workers in the hospital.
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5
The hospital is not a Magnet Hospital but does have some evidence-based practice (EBP)
guidelines in effect. Nurses are educated and responsible to adhere to the guidelines daily. The
hospital did score a 5 because the most recent EBP guidelines are put into practice. The hospital
scored a 3 for the degree in which nursing staff is dedicated to EBP. This score the fact that the
staff does fall short in committing to guidelines. Some of the barriers does tie in with lack of
education. The hospital also offers minimal training opportunities to nurses. The facility scored a
3 in this area. Training is crucial since it improves skills and knowledge. Through training,
nurses can improve their basic understanding and thus become more robust when faced with
challenges in their daily activities. The hospital use of electronic health records requires people
who are trained. The electronic records make the work easy as the files are easy to find and thus
time conscious. The hospital has fewer staff members than the required number. However, to
curb this issue, the hospital allows volunteers who fill the gap to ensure that workload is
minimized, and the patients stay in the hospital is reduced. This is mainly because of the training
that is offered to ensure that the serviced offered are of good quality and up-to-date. Evidencebased practiced (EBP) in nursing at Spring Valley Hospital is apparent. EBP aims to make
available valuable and practical care to the patients with the intent to improve the outcome. The
hospital fulfills this by ensuring that the EBP in nursing is practiced (Spring Valley Hospital
Medical Center, 2018). The patients who were admitted to the hospital give feedback stating
that they received the most effective care based on available facts.
Possible project barriers for EBP in the hospital include misunderstanding of the
statistics, scarce time to carry out the EBP and to read the literature and lack of power to change
the care given to the patients. Barrier facilitators include support from peers and colleagues as
well as managerial support. Insufficient authority to prompt a change in the practice setting has
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6
been a major barrier in the hospital. The organization should be willing to support the
implementation of research in the six facilities that are within the Valley system. Lack of time to
implement and review the findings was also another barrier in the hospital. I scored the facility at
a 4 in this area. There are less training opportunities and support policies that are in the hospital,
and this makes it hard for the hospital to promote EBP at regular intervals.
Promoting clinical inquiry and generating an interest in EBP is significant in a hospital
setup. This is because they facilitate positive outcomes such as build of interdisciplinary
relationships, creating rapport and generating a continuing trustworthy structure. One of the
methods to improve clinical inquiry is through coaching and mentorship of the steps involved in
EBP. Another method is to change the authority among the nurses to provide a platform to ask
what is not understood. Moreover, encourage the nurses to identify patients who are interested in
taking part in the EBP.
Problem Statement
According to (Truong et al, 2009) “In the Intensive Care Unit, critically ill mechanically
ventilated patients have been considered too ill to move leaving them to traditional bed rest to
which can lead to detrimental effects on the patients physical, emotional, and social health. ICU
acquired weakness (ICU-AW) is an accumulative effect of prolonged bed rest, malnutrition, and
systemic inflammation”. The author goes on to explain that “Once a patient has been
compromised by ICU-AW, the patient may experience prolonged mechanical ventilation,
prolonged hospitalization due to secondary diagnoses from hospital acquired injuries (HAIs),
muscle wasting requiring ECF placement, and decreased quality of life due to prolonged effects
of immobility” (Truong et al 2009). The general weakness of the muscles develops in patients
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7
admitted in the ICU due to acute illness or treatment of the disease. The loss of muscle mass and
muscle strength in patients in the ICU was first recorded in the nineteenth century (Hermans &
Berghe, 2015). The main complications related to ICU-AW are critical illness polyneuropathy
and critical illness myopathy. The incidence rate of ICU-AW is reported to be 25% to 100%
(Zororwitz, 2016). It is a frequent complication of a critical illness which is linked to high
morbidity and mortality rates. Additionally, the condition has long-term consequences in patients
who are discharged from the hospital for an instance post-intensive care syndrome which
comprise of mental, physical and cognitive dysfunction. ICU-AW is associated with multiple
dysfunctions of organs, and thus patients have activity limitations. These patients require
physical assistance mostly from the nurses to perform even the most basic activities related to
bed movement. The purpose of this paper is to provide a proposed evidence-based project whose
aim is to reduce the effects of ICU-AW and decrease hospitalization duration for patients with
mechanical intubation in Spring Valley Hospital.
The proposed problem is an issue not only in the US but a globally. Patients in ICU are at
a higher risk of losing muscle mass and mass strength due to reduced physical inactivity and
increased metabolism. Additionally, decreased pathophysiological mechanisms which include
metabolic, microvascular, electrical and bioenergetic adaptation give rise to muscle atrophy and
reduced muscle mass and strength (Zhou et al, 2014). From the proposed problem, researching
Spring Valley Hospital would be of great importance as there would be an evidence-based
project that will be used in the field of nursing. Moreover, the hospital will receive a good
reputation. Weaning off mechanical ventilation is related to problems of the diaphragm,
intercostals muscles, phrenic nerves and other accessory respiratory muscles. In rare cases, facial
muscles may be affected, and thus paralysis of the muscles surrounding the eye may occur. The
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8
research will benefit patients who are in the ICU all over the world as well as nurses. EBP in the
hospital will only be possible if there is collaboration among hospital workers and support from
peers and colleagues as well as managerial support.
When conducting this research, it is essential to develop a PICOT statement to enable
useful interview due to this epidemic. The question could be: In critically ill mechanically
ventilated patients (P), does the implementation of early mobility to reduce the risk of ICU
acquired weakness (ICU-AW) (I) compared to use of complete bed rest (C) decrease hospital
stay (O) over time (T)? The purpose of conducting this research is to find out practical
interventions that will facilitate reduction of the effects of ICU-AW and aid in the reduction of
hospital stay for patients with mechanical intubation. This will, therefore, reduce morbidity and
mortality rate in the US as well as reduce the long-term complications for patients who are
discharged. The EBP is essential in the field of nursing as it provides practical care for patients
with similar conditions with the intention of improving the outcome of the patients.
Evaluation of the Evidence
Immobility in the ICU is a contributing factor to an increased hospital stay, complications
upon discharge, and physical deconditioning. Even though early mobility has shown great
improvements in ICU patients, research shows that there is lack of necessary resources that
would significantly lead to the implementation of early mobility. It is a frequent complication of
a critical illness which is linked to high morbidity and mortality rates. Additionally, the condition
has long-term consequences in patients who are discharged from the hospital for an instance
post-intensive care syndrome which comprise of mental, physical and cognitive dysfunction.
ICU-AW is associated with multiple dysfunctions of organs and thus patients have activity
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9
limitations. Risks factors associated with bed rest include poor response to stress responses for
patients with muscle wasting and immobility. Early mobilization seeks to decrease the effects of
ICU-AW and decrease hospitalization duration for patients in ICU.
There was an initiative carried out by 13 ICUs in eight hospitals in the US which aimed
at integrating the most recent evidence on the practice of mobility into the modern ICU culture
(Bassett, Vollman, Brandwene, & Murray, 2012). This was done through designing and
implementing evidence-based mobility continuum that was physiologically grounded and
friendly to its users. Targeted messages and appropriate education was given to the stakeholders
and change interventions were given to the staffs to modify their behaviors in their field of
practice for it to be long term.
Another study was carried out that involved 106 patients. The inclusion criteria of the
study were patients had to be in ICU, the APACHE II score should not be below 14.7. The
duration of the research was four weeks. The outcome measures used were number of days that
the patient was mobilized, reasons why the patients were not mobilized and adverse events that
took place during the search (Leditschke, Green, Irvine, Bissett, & Mitchell, 2012). Early
mobilization therapy has been closely linked to improved survival in critically ill and
mechanically ventilated patients. Prolonged lack of mobility and total bed rest increases
catabolism and muscle wasting. These are the major reasons why patients in ICU have
neuropathy and ICU-AW (Lipshutz & Gropper, 2013). Various equipment and expertise exist to
ensure that there is compliance with early mobilization programs. Research and EBP should be
conducted to find out the drugs that will reduce muscle atrophy for patients in ICU.
Collection of qualitative data was used to evaluate issues that surround mobility as well
as providing feedback to the stakeholders who were expected to support the change. Early
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10
mobilization is associated with reduced skin injuries, reduced longevity of hospital stays,
improved ventilation-free days, decreased hallucinations and reduced cases of complications
after discharge. The validity of the research was not correct since this study had fewer
participants and a short period of time (Bassett, Vollman, Brandwene, & Murray, 2012).
Analysis of benefits, safety, and feasibility of early mobility on critically ill patients compared to
traditional bed rest. It had 10 studies with 868 participants. The study involved two prospective
studies and two observational studies. From the reviews, the study showed that mobilization can
be directed to the patients as to the patients as per their level of tolerance to the activity
(Schweickert, et al., 2009). It thus promoted safety and positive effects of the therapy. There was
also reduced the number of free ventilation.
Presence of family was shown to be a motivational factor and beneficial in early
mobilization. Engaging of the family together with the patients serve as a standard of care but in
ICU, this is not allowed. The research was done to identify the role that the family plays to help
in the recovery of the patients. This is beneficial for both the patients and the staff since
workload for the staff is significantly lessened (Rukstele & Gagnon, 2013). Active presence,
protection, facilitation, history, coaching, and volunteering of caregivers is important.
From the randomized control trials, it is evident that early mobilization of ICU patients is
important as it helps in reducing hospital stay, reduces complications after discharge, reduced
muscle atrophy and ICU-AW (Vollman, 2013). These studies, however, did not address adverse
effects of immobility such as increased hallucinations, atelectasis, and skin injuries. However,
there was improved muscle tone. Implementations of measures that reduce sedation and improve
mobility are therefore important. This will significantly reduce the mortality rate associated with
ICU acquired weakness. These trials provide techniques that are used to evaluate and implement
GET UP AND GO HOME
11
treatments using evidence-based practices for patients in the ICU to provide the progressive
guidelines that should be used in search cases.
Insert PICO Question–“For mechanically intubated patients does the implementation of early
mobility decrease the length of hospitalization compared to traditional bed rest?”
Insert Keywords– Early mobility, mobilization, intensive care acquired weakness, intensive
care, and mechanical ventilation.
Insert Databases Searched—CINHAL, JBI Connect+, PubMed, Science Direct, PROQUEST,
Cochrane Library, Google Scholar
Authors/Year of Citation
Amidei, C. (2012).
Measurement of
physiologic responses
to mobilization in
critically ill adults.
Intensive and Critical
Care Nursing, (28), 5872.
Research Design
Sample: N=
567 Adults >
239 patients
mechanically
ventilated.
Data Collection
Methods
Vital signs
monitored pre,
post, and
during
intervention
include heart
5 out of 12
rate, blood
studies RCT
pressure,
setting: ICU
Respiratory
setting, post
rate, Sa02,
ICU setting
SV02, C02
and
production,
community
IL-6 & IL-10
setting
inflammation
markers, Borg
Design/Metho
rating of
d: Systematic
perceived
Review:
exertion
twelve articles
surveys, and
were retrieved
muscle
from
strength
electronic
measurement
databases,
tests, (MMT)
from 1990manual
2011,
Key Findings
Characteristics
All the studies
included in the
systemic
review
assessed
physiologic
responses to
mobilization
on critically ill
patients. The
SR explained
in depth to
what extend
that all the
noted
evaluation
tools may be
performed and
how the
reliability of
each
evaluation tool
may be altered
by
Strengths:
There was a
mixture of
studies
presented and
evaluated.
identified
cytokine as the
only evaluation
variable that is a
safety measure
and a desired
outcome.
Weaknesses:
No evaluation
for
measurements
was focused on
comfort or sleep
related to
mobilization or
length of
hospitalization
GET UP AND GO HOME
Bassett, R., Vollman,
K., Brandwene, L., &
Murray, T. (2012).
Integrating a
multidisciplinary
mobility program into
intensive care practice
(IMMPTP): A
multicenter
collaborative. Intensive
and Critical Care
Nursing, (28), 88-97.
doi:
10.1016/j.iccn.2011.12.
001
12
including
CINAHL,
MEDLINE,
PubMed, and
Cochrane
Database of
Systematic
Reviews.
muscle
testing,
(MRC)
medical
research
council
muscle
strength
grading scale,
and PFT’s for
respiratory
muscle
strength.
medications,
techniques,
performance
by technicians,
or the patients
understanding
of the surveys.
The SR also
stressed on the
patient safety
before
evaluation of
efficacy.
Despite each
measurement
tool having the
ability to be
inaccurate to
some extent, it
is the
collaboration
of multiple
measurement
tools to
evaluate an
accurate
assessment of
mobility on a
critically ill
patient.
address in this
review.
Sample:
N=130
nonspecific
ICU patients
10 from each
facility studied
over a 30-day
period
Qualitative
surveys from
team members
on culture of
change
Quantitative
results from
retrospective
chart
abstractions
and
concurrent
direct
observational
data Monthly
conference
The literature
review suggest
that early
mobilization
has been
shown to
decrease VAP,
skin injuries,
length of
hospital stay,
decreased
delirium and
improve the
amount of
ventilator free
days as well as
Strengths:
This study
addresses the
critical illness of
patients while
giving an
algorithm like
protocol to
follow for
severity of
illness and
amount of PT
the patient can
follow. It
addresses the
culture to which
Setting: 8
hospitals, a
mixture of
large
academic
centers to
small rural
Conclusion:
The SR does not
answer the
clinical
question, but it
does give
beneficial
evaluation tools
and guidance to
monitor for
safety and
effects of
mobility on
critically ill
patients.
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13
community
hospitals 13
ICU setting
from trauma to
CVICU,
MICU, to
SICU
Method:
Literature
review, study
design,
qualitative and
quantitative,
no
randomization
.
calls for
Coaching
(culture) and
Strategy
(clinical
content, date
collection, and
evaluation).
Progressive
mobility
continuum,
RASS or
MASS scales
to monitor
agitation and
motor activity
scales.
physical
function after
hospital
discharge. In
this qualitative
and quantitate
study, the
trend towards
decreased
length of
ventilator days
decreased
P=0.06
improved.
the ICU can
present as a
barrier to EPB
and
implemented
techniques to
improve
compliance and
promote
exuberance of
the treatment
team.
Weakness: The
study was not
However, no
randomized, and
statically
the culture of
significant
the treatment
were shown in settings were
the number of already using to
ventilator free implementing
days P=1.1,
new changes
ICU mortality within the
P=0.69, ICU
institution.
length of stay
sample data was
(LOS) P=0.6
small, 10
and hospital
participants per
LOS P=0.31.
institution 13
The qualitative over a 30-day
study
interval.
evaluated the
barriers to the Conclusion:
This study does
change of
answer the
culture and
safety of early clinical question
but more
mobilization.
importantly give
57% of
an algorithm
patients
like measure
received PT
tool to be
consults on
utilized for
day 1 of ICU
education for
stay. Patients
patients, family,
who receive
and staff. It also
early PT
addresses
assessment
techniques that
will usually
may be used to
receive
GET UP AND GO HOME
Leditschke, A., Green,
M., Irvine, J. A.,
Bissett, B., & Mitchell,
I. (2012). What are the
barriers to mobilizing
intensive care patients?
Cardiopulmonary
Physical Therapy
Journal, 23(1), 26-29.
14
Sample:
N=106 ICU
patients – a
mixture of
mechanically
intubate and
spontaneously
breathing.
Setting:
Mixed ICU
setting
including
trauma and
surgical
patients
Design: 4week
prospective
audit
Demographics
, APACHE II
scores,
number of
patients
mobilized a
day, type of
mobilization,
adverse
events, and
reasons for
inability to
mobilize. each
patient was
counted each
day for a total
of 327
patients/days
audited.
treatment on
day 1.5 days
facilitate
compliance
when
implementing
the EBP project.
54% of all
patient days
involved
mobility. The
staff felt that
this was a low
number but
when
compared to
recent
literature this
amount of
participation is
well above the
standards
reported. The
reasons for
inactive where
accounted for
mostly by
avoidable
measures such
as IV access
(femoral
lines),
scheduling
conflict,
agitation or
over sedation,
and lack of
MD order.
Strengths: This
study examined
mechanically
intubated
patients along
with other ICU
patients. It
identified what
the barriers to
mobility were. It
also identified
that despite low
numbers of
patients who
participate in
mobilization,
mobilization can
be completed
safely despite
mechanical
ventilation.
Weakness:
Limited number
of studies
identifying
barriers to
mobilization.
Conclusion:
The study did
not answer the
clinical question
but did give
evidence to
some barriers
that may need
be
assessed before
mobilization
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15
care
commenced.
Lipshutz, A., &
Gropper, M. (2013).
Acquired
neuromuscular
weakness and early
mobilization in the
intensive care unit.
Anesthesiology, 118(1),
202-215.
Sample:
N=868 10
studies; 2
prospective
cohort studies,
2 prospective
observational
studies,
descriptive
study of RCT,
case series, 2
RCT,
prospective
before/after
study, and
retrospective
analysis.
Setting:
Academic
health centers,
community
hospitals and
rural hospitals
MICUs,
RICUs,
M/SICUs
Design:
Systematic
Review
Demographics
, Vital Signs,
APACHE II
score,
Ventilator
settings, types
of mobility
treatments,
adverse
effects, GCS,
Diagnosis,
BMI,
medications
and restrictive
mobility
orders. ICU
LOS, LOS
hospital, level
of active
achieved,
ventilator free
days
This review
outlines the
physiological
effects of
prolonged bed
rest, the
pathophysiolo
gical effects
on the body,
potential
effects of
critical illness,
the
developments
of ICU
acquired
weakness and
possible
treatments for
the
neuromuscular
weakness. The
review also
analysis the
safety,
feasibility, and
potential
benefits of
early mobility
on critically ill
patients versus
traditional bed
rest. 50% of
ICU patients
with Sepsis,
MOF and
prolonged
intubation will
suffer
neuromuscular
weakness, the
presents of
SIRS increase
to 100% when
Strength: A
wide array of
research studies,
comprehensive
presentation of
pathophysiologi
cal need of early
mobility and
complete follow
up on feasibility
and measurable
outcomes
Weakness:
Further research
is needed in the
technological
and medicinal
aspects of
treatments for
ICUAW.
Conclusion: I
found this
review very
helpful. It
directly
answered the
clinical question
and provides the
background
information on
ICU acquired
weakness, the
potential
complication
that may arise
from prolonged
bed rest,
potential
interventions to
prevent
ICUAW, and
research studies
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Rukstele, C., &
Gagnon, M. (2013).
Making strides in
preventing icuacquired weakness:
Involving family in
16
Sample: N/A
Setting: Large
Academic
None
accompanied
with the above
diagnoses.
diaphragmic
weakness is
seen 18 hours
after
intubation, 2
days of ICU
stay 25% of
patients will
present with
some ICUacquired
weakness
(ICUAW).
Studies
reviewed show
that
mobilization
can be directed
to the “as
tolerated”
activity to
promote safety
and
therapeutic
effects, LOS
does show a
downward
trend but the
RCTs differ in
results of
statistical
significances.
Number of
days ventilator
free has shown
a significant
decrease.
that provide the
basis for
feasibility, and
outcomes.
This article
addresses the
presence of
family as a
motivational
factor and
Strength: the
use of the
patient and
family centered
care model
(PFCC) is
GET UP AND GO HOME
early progressive
mobility. Critical Care
Nursing Quarterly,
36(1), 141-147. doi:
10.1097/CNQ.0b
013e31827539cc
17
Hospital 20
bed SICU
Design:
Literature
Review
benefit for
early mobility.
Engaging
family and
patient in the
plan of care
has always
been a
standard of
care, but in an
ICU setting
families are
traditionally
not overtly
welcomed.
This article
identifies the
roles in which
family may
participate in
to help both
the patient and
staff on the
road to
recovery. The
six roles of
active
presence,
protector,
facilitator,
historian,
coach and
voluntary
caregiver are
spelled out and
ways to invite,
educate, and
support family
care is
encouraged.
identified to
increase
compliance and
decrease
stressor for all
parties involved,
family, patient
and healthcare
professionals
Weakness: This
article is not a
study and does
provide
rationale for
steps taken but
no sustainable
evidence on
how the
families,
patients, or staff
valued the
PFCC model
approach. A
qualitative study
would be
suggested.
Worth: I find
this article
extremely useful
considering
providing
patient centered
care. Not only
are we in need
to provide the
best care
evident but also
provide that
care around the
patient
continuum.
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Schweickert, W.,
Pohlman, M., Pholman,
A. J., Nigos, C.,
Pawlik, A., Esbrook,
C., Spears, L., &
Miller, M. (2009).
Early physical and
occupational therapy in
mechanically
ventilated, critically ill
patients: A randomized
controlled trial. Lancet,
373,
1874-1882.
doi:10.1016/501406736(09)60658-9
18
Sample:
N=104
mechanically
intubated
MICU patients
49 in
intervention
group and 55
in control
group
Demographics
APACHE II
score, Barthel
index score
pre and post
interventions,
Richmond
Agitation
Sedation Scale
(RASS),
Confusion
Setting: 2
Assessment
large Midwest method for the
Academic
ICU for
Health Centers delirium and
coma (CAMDesign:
ICU),
Random
Functional
control trial
independence
measures,
distance
walked, Days
ventilator free,
LOS ICU and
LOS hospital,
and hand-grip
strength
scores.
Random
control trial
monitored 104
intubated
critical care
patients who
had an
independent
active 2 week
prior to illness
by history
obtained by
family.
separated into
2 groups,
control group
intent to treat
and
intervention
group with
early mobility.
All patients
were started
on enteral
feeding and
tight glycemic
control was
monitored.
There was no
statistical
significance in
days ventilator
free, LOS ICU or LOS
hospital
between
groups, a
statistical
significance
was noted in
the BI, CAMICU, and
return of
independent
function
scores. ICU
Strength: the
random control
trial was set
with comparable
participants with
similar
APACHE II &
BI scores to
diminish any
bias. The study
monitored
physical
strength at
discharge and
QOL
Weakness: The
study did not
address any
evidence of
adverse effects
of ICU acquired
immobility such
as atelectasis,
skin injuries or
an increase in
delirium.
Conclusion:
This study
shows
significant
improvement in
increasing
muscle tone and
subsequently
decreasing ICU
psychosis but
implementing
measures to
reduce sedation
and increase
mobility. It may
have been a
secondary act
but proved very
beneficial to
GET UP AND GO HOME
Truong, A., Fan, E.,
Brower, R., &
Needham, D. (2009).
Bench- to-bedside
review: Mobilizing
patients in the intensive
care unit – from
pathophysiology to
clinical trials. Critical
Care Alert, 13(4), doi:
10.1186/cc7885
19
Sample: None
Setting: ICU
Design:
Expert
appraisal with
critical review
of scientific
literature.
No data
measured,
only reported
expert
opinions from
recent trial
study
outcomes.
acquired
weakness and
ICU acquired
delirium is
associated
with higher
rates of
morbidity with
early mobility
showing
significant
reduction of
incidences
upon
participants
and increased
QOL
patient’s overall
mortality.
This review
gives a full
spectrum of
the associated
disease
process of
immobility,
pathophysiolo
gical responses
to stress and
critical
illnesses to a
body, potential
treatments and
interventions
to prevent ICU
acquired
weakness and
muscle
wasting. The
therapeutic
effects of early
mobility in
critically ill
patients, safety
and feasibility,
barriers to
mobility such
as ICU culture,
Strength: A full
spectrum of
associated risk
factors of bed
rest, including
pathophysiologi
cal response on
muscle wasting
to stress
responses and
immobility.
Weakness: The
author did not
clearly identify
the trials he
reported results
from, “Recent
studies”.
Conclusion:
This review
provides and
overall
assessment of
the clinical
question and
suggests further
research
GET UP AND GO HOME
Vollman, K. (2013).
Understanding
critically ill patient’s
hemodynamic response
to mobilization: Using
the evidence to make it
safe and feasible.
Critical Care Nursing
Quarterly, 36(1), 1727. doi:
10.1097/CNQ.0b
013e3182750767
20
Sample: N=33
ICU RNs for a
qualitative
study on
barriers to
mobility.
N=184 ICU
patients in 3
random trials
for safety, and
feasibility.
Setting: ICU
Design:
Systematic
Review with
qualitative and
quantitative
study designs
Progress
Mobility
Continuum,
Mobility
Assessment
for Readiness
tool, which is
an initial
mobility
screen and a
reassessment
screen to be
used Q24
hours.
inadequate
staffing and/or
training, and
low priority.
avenues and
comparison in
cost to
stakeholders.
This paper
gives in depth
explanation to
the
physiological
responses a
critically ill
body under
goes during
mobility, how
to counteract,
and re-train
the critically
ill body to
tolerate
movement.
The review
discusses at
length the
cardiovascular
response to
bed rest and
posture
changes, the
lateral turn and
response and
recovery
phenomena,
the review also
introduces 3
tools used in
EBP for
assessment of
readiness,
progression
toward further
mobility
according to
the patient’s
tolerance, and
an algorithm
Strength:
provides in
depth
explanation of
the prolonged
effects of
gravitational
equilibrium
disruption on a
patient. provides
techniques to
assess and
implement
treatments for
such disruptions
and includes
evidence-based
guidelines for
progressive
mobility for
patients.
Weakness:
author discusses
the use of the
assessment tool
in a 14-month
13 ICU quality
improvement
project but does
not relay any
results of the
said trial except
for the comment
“no ICU team
reported adverse
events.” study
seems
undisclosed.
GET UP AND GO HOME
Winkelman, C.,
Johnson, K., Hejal, R.,
Gordon, N.,
Rowbottom, J., Daly,
J., Peereboom, K., &
Levine, A. (2012).
Examining the positive
effects of exercise in
intubated adults in icu:
A prospective repeated
measures clinical study.
Intensive and Critical
Care Nursing, (28),
307-320. doi:
10.1016/j.iccn.2012.02.
007
21
Sample: N=
75 mechanical
ventilation >
48 hours
Setting: Large
Academic
hospitals
MICU/SICU
Design:
Prospective,
repeated
measures
study with a
control and
intervention
period.
APACHE 3
scale,
demographics,
diagnosis, VS,
medications,
Charlson
Comorbidity
Index, Pa02,
Fi02, MRC
measures at
ICU d/c, Katz
ADL
screening,
CAM- ICU at
ICU d/c, and
chart audited
for diagnosis
of VAP and/or
VTE. IL-6 and
IL-10
for
reassessment
of unstable
subjects.
Conclusion:
This review is
very helpful and
offers guidelines
and assessment
tools to be used
to incorporate
early mobility
on critical ill
patients. The
physiological
responses
provide insight
on why the
patient becomes
unstable during
movement and
why we should
implement early
mobility to
prevent further
compromise to
the already
critically ill
patient.
This control
study
examined
physiological
effects of
exercise on an
intervention
group and
control group.
The control
group of 20,
who was
prescribed
standard
treatment and
an intervention
group of 55
had early
mobility
consisting of
20 minutes of
Strength: The
study pointed
out that once
daily mobility
may not be
enough to show
significant
changes
compared to
other studies
that had
mobility 2-3
daily. The
significance of
decreased IL-10
on inflammation
is positive
finding that
exercise does
counteract the
effects
GET UP AND GO HOME
22
inflammatory
biomarkers.
therapy once a
day for 2-7
days. This
study
demonstrated
no significant
change in VS,
pain/fatigue
scores, IL-10
did show a
significant
response in
association of
exercise
duration in
both control
and
intervention
groups p=
0.01, but no
associated
significance in
type of
mobility, ICU
LOS, MV,
hospital LOS,
or
pain/fatigue.
inflammation
causes on the
neuromuscular
wasting found
in ICUs.
Weakness:
Inequality in
number of
control subjects
compared to
intervention
subjects.
Inabilities to
accurate obtain
data on muscle
strength with all
participants due
to mental status.
Worth: This
study is
significant in
proving the
physiological
effects of
exercise on the
inflammation
responses of the
body leading to
ICU acquired
weakness.
Solution Description
Different studies have been carried out to identify safe and effective ways that will
minimize cases of ICU-AW for mechanically intubated patients. The most common method that
has been tried through EBP is early mobilization. Nonetheless, few patients can reach
recommendable levels of active mobility and the studies are inconsistent making it hard to
GET UP AND GO HOME
23
understand the optimum outcome of the EBP (Taito, Shime, Ota, & Yasuda, 2016). The
proposed solution for ICU-AW in Spring Valley Hospital is consistent early mobility for all
patients in the ICU which aims at reducing hospital stay and avoiding or reducing cases of ICUAW. This will significantly reduce cases of muscle wasting, critical illness polyneuropathy, and
critical illness myopathy. Also, it will provide a platform with reliable, valid and up-to-date
evidence that will help the nursing profession worldwide. The research will serve as a
convincing and evident proof that early mobilization which is consistent, for mechanically
ventilated patients is safe and effective.
The proposed intervention of consistent early mobility in Spring Valley Hospital is
realistic. This is because there are interprofessional collaboration and the fact that the hospital is
part of a system that constitutes six other hospitals (Spring Valley Hospital Medical Center,
2018). The cost of the intervention is high due to proper training prior, during and after the EBP
has taken place. However, the organization should ensure that the requirements are provided as
the study will provide more advantages to both the hospital and the patients. The collaboration of
the six hospitals makes it easier for the study to be conducted and has promising outcomes. The
workload of the health caregivers will be reduced as more nurses will be trained on the necessary
measures and the speculated method to be used that will promote the effectiveness of the study.
Teamwork is vital in reducing workload and thus improves job satisfaction for both the
healthcare workers and the patients (Bosch & Mansell, 2015). The organization will ensure that
protocol is followed in terms of inclusion and exclusion criteria of the patients who will be used
for the study to reduce cases of mortality while the study is in progress. The organization is also
adamant to changes that will improve the effectiveness of the healthcare that is given in the
GET UP AND GO HOME
24
facility and thus this will ensure that the study will have minimal barriers especially in terms of
support.
The expected outcome is to reduce the hospital stay, reduce adverse effects upon
discharge, and reduce cases of ICU-AW. From the previous studies that have been conducted,
several studies have documented that there was reduced hospital stay, reduced cases of muscle
wasting and reduced cases of complications after the patients were discharged from the hospital
(Leditschke, Green, Irvine, Bissett, & Mitchell, 2012). Early mobilization in ICU has proved to
improve the health status of the patients compared to traditional bed rest. The outcomes are
expected to fruition through training of nurses who will ensure that mobility of patients in the
ICU is introduced early and it is consistent with the stipulated period. Barriers such as few staff
members, lack necessary equipment, insufficient authority and misunderstanding of statistics will
have to be eliminated. The hospital should be in readiness to carry out the study by ensuring that
all the team members and the patients are responsive. Additionally, it should ensure that all the
necessary resources are available before the study commences.
The study will greatly improve the health of patients by ensuring that there are no cases
of complications such as post-intensive care syndrome which comprises of mental, physical and
cognitive dysfunction. There will also be no or minimal cases of multiple dysfunctions of the
organs which are attributed to ICU-AW which limit the patients (Zhou, Wu, Ni, Wu, Ji, &
Zhang, 2014). The patients will also not experience muscle atrophy because of increased
metabolism and immobility. The expected outcome will not only improve the care given in the
ICU in Spring Valley Hospital but will also serve to offer an evidence-based practice that can be
embraced in the nursing care globally.
A Case for Change
GET UP AND GO HOME
25
Change is not an easy thing but nonetheless, it is essential in any healthcare organization
to improve the care that is being given. Change within an organization follows a series of events
which are expected. Many healthcare organizations don’t change because of new processes,
systems, and structures but because of the willingness of the people in the organization to adapt
and embrace change. The benefits of change will be felt when healthcare workers and patients in
Spring Valley Hospital make their own personal transition about EBP. “The Duck’s Change
Curve Model involves five stages namely; stagnation, preparation, implementation,
determination, and fruition” (Melnyk & Fineout-Overholt, 2011). The respondents go through
related responses when change is presented to them even though their understanding of the
responses may have varying times. Making the journey to change easier for those involved
reduces the time the organization will take to notice the benefits and thus the success of EBP.
Nonetheless, approaching this from the wrong angle increases the chances of failure. The
Change Curve is an important tool which helps individuals to understand the stages involved in
both personal transition and organization (Duck, 2001). It provides a prediction of the reaction
when change is presented.
Stage 1: Stagnation
This stage is caused by poor strategizing, lack of appropriate leadership, lack of training
for nurses, lack of collaboration from the other five hospitals and inability to explain properly the
importance of EBP in Spring Valley Hospital. At this stage, the team becomes hopeless and
discouraged. Effective communication is very important at this stage and thus the team who will
take part in EBP should be encouraged to often communicate. At the same time ensure that the
team is not overwhelmed by providing a limited amount of information (Duck, 2001). For
GET UP AND GO HOME
26
example, explain why early mobilization is preferred and why it should be conducted in the
hospital. It is important to ensure that all the questions are addressed as this is also critical.
Stage 2: Preparation
Operational issues are addressed at this stage such as how training will be conducted,
roles and responsibilities of the team members, and inclusion and exclusion criteria of the
patients. It is important to assess the commitment and feelings of the team members regarding
the EBP. Team members should endorse the need for conducting the EBP in the hospital. This
stage, therefore, requires proper planning and training. At this stage, it is important to get support
from colleagues and organizational support.
Stage 3: Implementation
At this stage, it is likely that one-third of the team members will be enthusiastic about the
change, one third will not be willing to take part in the study and one third will oppose the study
especially since it will be conducted in a critical area within the hospital where the mortality rate
is high. It is important to ensure all the team members agree to take part in the study. The three
groups should be on one page as this will ensure that there is avoidance conflict in the future.
Communication is also crucial in this step to avoid ignoring the parts of EBP that may be
challenging.
Stage 4: Determination
The team members are fatigued by the study since it requires daily monitoring despite the
cumulative effort of the team. This is because those involved in the study think of new ways and
the frequency of mobilization of the …
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