Evaluating the Implementation of an Early Mobility Protocol in a
Surgical Intensive Care Unit (SICU) on Pressure Ulcers (PU)
Dickinson, Sharon; Gombert, Jan; Rickelmann, Connie ; Meldrum, Craig; Hayey, Renee; Kanphade, Gomati ; Tschannen, Dana
and the nursing medical staff of the SICU
University of Michigan Hospital and Health Centers, Ann Arbor, Michigan
Purpose
Change
Evaluation
To evaluate whether the implementation
of an early mobility protocol in a busy,
high acuity, Surgical Intensive Care Unit
could reduce the incidence of pressure
ulcers.
The Clinical Nurse Specialist in conjunction with the
SICU Clinical Practice Committee developed an
evidenced based early mobility protocol that
emphasized 3x/day movement of all but the sickest
patients in progressive fashion as their condition
improved.
A total of 536 patients (4241 patient days) were evaluated for their response and readiness to progress through the
three mobility phases. Eight patients who had a PU prior to their arrival in the SICU were excluded from the analysis.
Compliance with early mobility was calculated as the percent of tasks required in the phase that were completed (e.g.
3 tasks, 3 times a day, 100% compliance if all 9 tasks completed). Initial compliance with the protocol started at 76%
with a downward trend in subsequent weeks, resulting in an average compliance of 66%. During the study 77 patients
(14.6%) developed a PU. This rate was not significantly improved from a comparison group prior to the study. Protocol
compliance was not significantly different in patients who did (67.2%) or did not develop a PU (68.8%).
Synthesis
The SICU PU rate consistently exceeds the
national benchmark of 7%. In previous
analysis, SICU patients were more likely to
develop a PU with: advanced age,
increased use of vasopressors, reduced
weight, greater mortality risk, changes in
Braden moisture and activity scores. Very
few of these risk factors are influenced by
nursing practice with the possible
exception of activity.
References
• Morris PE: Moving our critically ill patients: mobility barriers and benefits, Crit Care Clin.
2007 Jan;23(1):1-20
• Perme C, Chandrashekar R. Early mobility and walking program for patients in intensive
care units: creating a standard of care. Am J Crit Care. 2009 May;18(3):212-21. Epub 2009
Feb 20.
• Timmerman RA. A mobility protocol for critically ill adults.
Dimens Crit Care Nurs. 2007 Sep-Oct;26(5):175-9; quiz 180-1.
Goals:
SICU Mobility Protocol
1. Every patient should be evaluated
for early mobility.
Inclusion Criteria:
Early activity is initiated when the patient achieves physiological stabilization
Low dose catecholamine's drips should not preclude the patient from early
mobility (i.e. low dose norepi, phenylephrine, vasopressin)
FIO2 < or equal to 60% - Peep less than or equal to 10 cm H2O
Patient’s on CRRT with secured lines in the Internal Jugular or Femoral
*Possible criteria to withhold early mobility: hypoxia, hemodynamic instability
(escalation of vasopressors in the last 12 hours), ICP monitoring or unstable
cardiac rhythm (life threatening rhythm that compromises blood pressure in
past 24 hours) or new cardiac arrhythmia & epidural.
2. Small efforts can yield large
results.
3. Never give up! Poor tolerance
during one episode does not predict
future tolerance.
Mobility
educ.
started
Mobility
started
4. Evaluate patient readiness and
response to current therapy and
ability to progress
PHASE 0 (UNSTABLE)
PHASE I
PHASE II
Passive (3X/day, 10 repetitions)
ROM
Active (3X/day, 10 repetitions)
Passive (3X/day, 10 repetitions)
ROM
Active (3X/day, 10 repetitions)
HOB Elevated 30-45 Degrees
or Reverse Trendelenberg
HOB Elevated 30-45 Degrees
or Reverse Trendelenberg
Reposition (every 2 hours)
Reposition (every 2 hours)
Reposition (every 2 hours)
Standing (3x/day)
Continuous Lateral Rotation (18-24 hours per day)
Chair Position or OOB with sling (3x/day)
OOB (bear own weight) (3x/day)
If patient tolerates these activities, advance to next phase
Dangling (3x/day)
Walking (3x/day)
ROM ~ Resistance (3X/day, 10 repetitions)
HOB Elevated 30-45 Degrees
Implementation
Strategies
This evidenced based protocol consists of 3 phases,
initiated when the patient achieved physiological
stabilization. To enhance compliance, the protocol
was included on the admission order set. A dedicated
mobility tech was initially added to the care team,
which was later replaced by a Physical Therapy
technician (Due to budget constraints) to assist the
nurse with mobility interventions and documentation
in Centricity. An extensive education campaign was
launched through the SICU clinical practice
committee.
Significance
We conclude that partial compliance with the early mobility protocol does not
influence PU development. It is possible that more robust compliance with the
protocol might reduce the PU rate. We are currently seeking to reduce the
barriers to achieving full compliance. Most recently, mobility documentation has
been moved to the front of the flow sheet. Alternatively, it is possible that full
compliance with the protocol will have no effect on PU development in these very
sick patients. To explore this possibility, we will further analyze the data and
compare the PU rate only in patients who did not have “do not turn” orders
before and after protocol implementation. Further analysis is underway, which
will consider the effect of patient characteristics, as well as early mobility, on
pressure ulcer development.
H1N1
Patients
Chronically Critically
Ill – 20 H1N1 Pts.