Early Mobilization: Clinical Competency in the ICU
Introduction:
The medical complexity of a patient in the ICU can overwhelm a therapist. The multiple lines, tubes and equipment alarms that surround the patient can heighten this. Rising healthcare costs and related cost saving measures combine to create a greater need for acute care therapists to provide skilled intervention and mobility progression for individuals in the ICU. As therapists, we are equipped with a wealth of knowledge. However, additional guidance is needed to hone necessary skills that range from the uncomplicated to the complex, while adjusting for medical acuity in the ICU.
In EBP II, I researched the PICO question “In adults with COPD requiring prolonged mechanical ventilation, does resisted leg press exercise compared to usual care increase early ambulation in the ICU?” For this project I researched competencies, learning and development, as well as a new search related to safe early mobility in the ICU setting. Here is the evidence table for the studies I found. This represents the positive trend toward the benefits and safety of early physical therapy mobility in the ICU. Also, I previewed presentation guidelines for composing my power point.
The impetus for this project stems from conversations with my committee members. I also randomly surveyed my colleagues in the inpatient acute care rehabilitation department about their comfort and readiness to rotate through the ICU. Expressed concerns include:
- Management of lines, tubes, and ventilation equipment
- Familiarity with common medications
- Common ICU terminology
- Interdisciplinary Communication
- Criteria for safe mobilization
Intervention:
Early Mobilization: Clinical Competency in the ICU is a clinical education project to develop ICU-based physical therapy competencies in an acute care facility. In particular, this project will develop topics relevant to a physical therapist that include labs, mechanical ventilation, vital signs, common lines and devices, chart review, communication, and safety. The self-study modules will contain a pre-/post-test, current evidence for review and support, and equipment identification. Case applications will be used to combine the information essential to assess the risk and benefit of PT intervention and to promote reflective practice.
This would represent the initial phase of ICU-orientation to instill comfort and ensure competence in this complex setting. My target audience includes the novice therapist, as well as colleagues who are new to providing services in the ICU. It will also be used as an additional educational tool for students in their third and fourth year clinical rotation.
Objectives:
Personal and project goals:
- Apply and connect previous clinical knowledge and evidence based practice to solve problems using new evidence related to early mobility in the ICU.
- Structure the project to transform practitioner skills in the ICU to tools for gathering data, and facilitation of safe patient movement.
- Develop technology skill to effectively convey the key concepts related to safe early mobility in the ICU.
- Upon completion of the modules the learner will:
- Determine appropriateness of early mobilization in the ICU.
- Appraise and assimilate information to improve safe therapeutic intervention in the ICU.
- Apply interpersonal and communication awareness that result in effective collaboration among patients, families, and the health-care team in the ICU.
Products
The products created for this Capstone project include the following:
- Pre-/Post- Test
- Power point education modules of ICU related topics
- Case Applications (located in power point)
- Clinical decision-making algorithm
Evaluation
I created a 10-question pre-/post-test to determine acquisition of the presented information. A score of 80% will be used as a measure of competence.
Feedback
I chose a satisfaction survey using a four-point Likert scale to provide feedback related to the ICU content. This survey will help to determine the success in achieving the objectives of each module and case applications. Additional space will be provided for comments. This feedback will improve the quality of the product and provide direction for future revisions.
Outcome
I piloted the competencies. 5 PTs and 1 PT student participated. Each person was asked to print out the pre-/ post- test and feedback form prior to start of the module; take the pre-test; view the modules and algorithm; take the post-test; appraise the module; and return the tests and feedback form to me. This returned 3 pre-/ post-tests and 4 feedback forms. Here is a summary of the feedback.
Reflection
The benefits from development of this project are many. This project provided the opportunity to initiate a standard process to integrate evidence and guide safe practice patterns in the ICU. In doing so, another benefit addressed aspects of the learner’s objective. The information provided furnishes the individual with resources that may be adapted on a case-by-case basis. This project strengthened my understanding of the value of feedback. As a first step to reinforced knowledge acquisition, it exposed a need for clarification and any knowledge gaps that may require additional guidance for safety in the ICU. It prompted conversation and exchange of ideas/research for best practice.
Acknowledgements:
I would like to thank Donna Smith PT, DPT, NCS and Devon Butts DPT for being my committee members and helping me through this process. Also, I would like to thank Karen McCulloch PT, PhD, NCS for her encouragement and guidance. An incredible amount of thanks goes to my husband, Chris, for his endless patience and support.
7 Responses to “Early Mobilization: Clinical Competency in the ICU”
Annette Kamm
Christine,
Thank you for visiting my Capstone site. I am glad you found it engaging and useful. Regards, Annette
Laxmilavanya Gullapalli
Annette,
Thanks for the clarification about INR values.
Regards,
Lavanya.
Annette Kamm
Lavanya,
Thank you for your insights. You bring up good points about the albumin and the INR. I decided against putting albumin into the chart because of all the information that was already covered. I was advised that it could be addressed in advanced topics following these initial modules. It is a good idea to watch the trend as the patient’s medical status stabilizes. I agree with you that it may impact the patient’s mobility progress.
With respect to the INR, I used 2.5-3.0 based on the literature. Values above this would stimulate one to think of the risk and benefit of mobility, to check the trends, and to initiate conversation with the medical team. These are the parameters set at my facility, I would check with your team. Best regards, Annette
Annette Kamm
Kristel,
Thank you for visiting my Capstone site. I work at Mission Hospitals in western North Carolina and am uncertain of the format for communication at UNC. Through my research, SBAR is the standard communication format used in nursing education and the hospital environment. In order to improve collaboration, in this case, I think it is a matter of communicating in the existing language. I did not seek out specific input from the nurses or physicians as to how to establish a better relationship at this time. Thanks for the recommendation. It will be something to improve upon as this program gets implemented. Thanks again, Annette
Christine Lysaght
Annette,
WOW what an informative capstone. The SBAR method of communication sounds appropriate for all settings, especially with physicians. I remember talking about bed rest vs mobility for patients under treatment for DVTs your during our orientation for this program!
Based on the feedback you received I’d say your capstone was a huge success. Congratulations!
Laxmilavanya Gullapalli
Hi Annettte,
This is a great topic for capstone project! And a very resourceful one too, for therapists like me, who work in acute care setting. I currently work in a Long term acute care hospital and have > 50% of my patients on ventilators and approximately 95% of my patients on no less than 2 tubes/ lines, at the time of facility admission. The classical patient that we usually see in our facility are those who at least have a rectal tube, PICC line, dobhoff tube or PEG tube, foley catheter, and a PEG tube, at the minimum. We do see a lot of wound care patients, so usually these patients have additional lines with wound vac lines (sometimes more than one line!). So, I do agree with you that the tubes and lines may be overwhelming, but experience makes it much easier to work in this setting.
I am sure your project is going to be helpful to not only students and novice professionals, but also for experienced acute care professionals. I found your PowerPoint to be a good revision for lab values. I realized that recently I had not been paying attention to one particular lab value, Albumin. I found it very interesting to note that Albumin level <3.5 g/dl may lead to plateau or lack of improvement in functional mobility. Few other things that I do like about your PowerPoint include your stress on doing chart audits right before seeing the patient. I completely agree with you on this, as it is a rule at our workplace that you have to see the patient within 2 hour span of doing the respective patient’s chart audit. In addition, though we do follow the SBAR approach at my workplace for communication, I had not realized that there was a specific acronym for that. So, thanks for including that information in your PowerPoint.
Furthermore, I really liked your ICU Algorithm and am going to keep a copy of the algorithm and the vent settings at my work desk, along with the copy of lab values chart that I usually have with me. Do correct me, if I am wrong, but did you by any chance mean on the ICU algorithm, the questionable INR value to be 2.5 -5.0, instead of 2.5-3.0? Lastly, I got a chance to have a perfunctory glance at your evidence table and found the two studies, one by Stiller (2013) and the other by McWilliams (2014) very interesting, as their sample population match exactly with the patient population that I see during my everyday work. I am definitely planning to read these 2 articles in detail.
Thank you for your excellent work! It was a pleasure to work with you as a fellow tDPT student.
Regards,
Lavanya.
Kristel Maes
Annette,
Excellent comprehensive project! As an outpatient PT at UNC we rotate every 4th weekend with the inpatient staff and I admit, all those complex medical problems and lines in some of the patients, makes me nervous. I really appreciate your review of normal and abnormal lab values. As it is not my area of expertise, I am always careful to get an update from the nurse prior to treatment as well as check on vitals. I will definitely look at a couple other items after reading through your presentation. I was not familiar with the SBAR communication, do you know if this is often used at UNC? Did you get any input from physicians or nurses on how to establish a better relationship with them to improve teamwork?
Again, excellent presentation, definitely a very useful tool for therapist orientation in the ICU!
Kristel