Interdisciplinary ICU Early Mobility: Development, implementation and Value at Scotland Memorial Hospital; A Pilot Protocol and 2-year follow-up Assessment

Interdisciplinary ICU Early Mobility: Development, implementation and Value
Scotland Memorial Hospital Pilot Protocol and 2-year follow-up

By: Chris Ball
UNC DPT class of 2015

Statement of Need:

Rural and underserved areas are proven to have higher incidence of chronic disease conditions of cardiovascular, pulmonary, metabolic and cerebrovascular origin. These conditions may elicit the initial ICU admission or act as catalysts of functional decline post admission. Each aspect may be controlled or reversed by increased levels of physical activity, increased functional mobility and clearly show there relevance to physical therapists practicing in rural and underserved areas as well as the inpatient settings.  These same regions severely lack alternate recourses in the community or means to outpatient care, which promote successful transition of positive outcomes outside primary healthcare entities, and provide means of prevention. Overall, this same patient population tends to demonstrate decreased knowledge and awareness regarding the seriousness of chronic disease conditions they currently possess or are at risk of developing.

Furthermore, large “up-stream” organizations and public policy continue to predispose rural and underserved populations to a lower heath-related quality of life. Hospitals such as SMH, which are located in, underserved and rural communities are often not-for-profit facilities where a large percentage of patients served receive publicly funded healthcare (Medicaid and/or Medicare) throughout their life span. Those who are not Medicare eligible typically rely on Medicaid, which presently offers limited coverage and allocates inappropriate amounts of skilled rehabilitation and sources for preventative care. This allocation is based on patient diagnosis and/or disease rather than socio-ecological factors related to the patient or patient population. These insufficiencies interact in a feed-forward negative fashion and are present throughout the lifespan, further promoting inactivity, multi-morbidity, and frailty upon reaching elder-adulthood. Additionally, at SMH these interactions have resulted in increased total hospital admission, longer duration/greater costs of inpatient stay, and higher incidence of hospital readmission. This in turn, places enormous financial burdens on SMH independently as well as the public healthcare system as a whole.

The negative correlation between functional mobility impairment, long-term functional independence and instance of prolonged critical care affirm its relevance to the profession of physical therapy in and out of the critical care unit. Physical and cognitive decline during ICU stay is often manifested and exacerbated by over sedation and prolonged bed-rest, leading to conditions such as ICU related weakness, sarcopenia, polymyopathy or hospital acquired pneumonia. This knowledge illustrates the potential value of achieving a unified culture of early mobility throughout the healthcare continuum and increased implementation of programs centered upon functional mobility such as ICU early mobilization protocols.

Introduction and overview of my Capstone:
I have never perceived this project as in-service presentation or a “capstone” but rather, an opportunity. An opportunity to gain first hand experience within the entire process of leading as well as coordinating the initial effort to bridge the last gap between primary care health professions and skilled rehabilitation. Due to substantial evidence based research regarding ICU early mobility in the recent years and guidance of my clinical instructor Jennifer Sanford, we were able build the foundations for a true health care continuum at Scotland Memorial Hospital (SMH).

I chose to complete a 2-year follow-up assessment of the pilot protocol I helped to develop at SMH, located in Laurinburg, NC. In doing so I hope to identify and share what is necessary to research, advocate, develop, implement and sustain an early mobility program and more importantly a culture which embraces mobilization early and often when indicated within any and all inpatient facilities. Lastly I hope this will become a dual opportunity for other students and clinicians by introducing a new perspective regarding clinical practice in rural areas by highlighting the ability clinicians and student clinicians have to be creative, and possess a voice of great weight and value.

This is made possible through an open culture of interdisciplinary communication and collaboration to ensure optimal care for  current and future patient populations we will encounter. Your personal opinions, clinical rationale, constructive feedback, ideas and/or recommendations are encouraged so that we may learn and build upon my experience together in the hopes of facilitating further growth of such programs in the future. Early mobility protocols evolve and are based around, mutual understanding and acceptance of different ideas, motivations as well as personal initiatives to co-educate and inform one another of professional roles and scope of practice. This enables absolute safety of the patient and care professionals involved along with promoting consistency of implementation and greater degree of success.

Taking individual layers of the socio-ecological model model into account is imperative for successful implementation of any health and wellness program. This approach is especially warranted for successful implementation within underserved and rural communities. In developing an ICU mobility team/protocol at SMH we identified conditions and population of focus, etiological factors behind these conditions, and community/organizational structure of SMH, Scotland County and the community of Laurinburg NC. Furthermore we assessed the overall need of early mobility at SMH as well as factors that may facilitate or hinder the implementation of early intervention, patient education and effective behavior change strategies. These factors previously mentioned were identified initially though in-service meetings conducted by my clinical instructor and myself and again upon 2-year follow-up assessment through face-to face interviews with original mobility team members and development/implementation of a SMH survey. Both the interview questions and survey are based on principles of the SEM model as to:

1. Obtain information regarding the overall awareness and health literacy regarding early mobility protocols and associated benefits with implementation

2. Obtain Subjective information from SMH employees involved in the early mobility program as to assist in the follow-up assessment regarding the initial implementation of SMH early mobility protocol by the interdisciplinary mobility team July of 2013 up until today.

3. Consideration of barriers, benefits, feasibility, safety, and necessary resources most suited to enable effective early rehabilitation interventions in small rural hospitals

Through my personal experiences, evidence based research and ongoing follow up assessment I hope to co-write a research paper including the methodology used to develop SMH’s interdisciplinary pilot protocol with 2-year follow up assessment. I also plan to provide a Lecture presentation for PHYT 736 (PT for the Older Adult) which will cover the large breadth of research advocating the use of ICU early mobility, the process of developing a early mobility protocol tailored to an individual inpatient facility and the importance of interdisciplinary collaboration of clinicians and student-clinicians alike to best serve those residing in rural and underserved regions of NC.

I want to give my upmost thanks and appreciation to everyone at Scotland Memorial Hospital for giving me this opportunity. To Jennifer, Kim, Maynar, Harry and Iris, your trust and confidence in my ability to lead this effort has been nothing short of significant. In doing so you facilitated personal affirmation in my convoluted path from wild land fire crews and industrial steel mills to the profession of physical therapy and has proven invaluable in shaping my motivation to practice and serve the rural and underserved of NC. I also would like to thank my committee members Kelly McCall and Jennifer Sanford for providing feedback and assistance to develop this capstone project.

Finally, I would like to give special thanks Carol Giuliani. You have and continue to provide the spark, insight and guidance which has made this capstone possible and opened doors to additional opportunities and experiences to become a leader and advocate for the physical therapy profession and its potential value in all environments and settings.