Review of Current Mobility Practice in Non-Surgical Mechanically Ventilated Intensive Care Unit Patients

Purpose: The purpose was to: (i) conduct a retrospective electronic medical record review to evaluate current practice related to mobility, (ii) determine the association between current mobility practice patterns and characteristics specific to the patient population, and (iii) make recommendations for the implementation of an evidence-based progressive early mobility protocol for non-surgical mechanically ventilated patients. Population: Non-surgical, ventilated patients in the Intensive Care Unit (ICU) Inclusion Criteria: Ventilated patients at least 18 years old who have been ventilated for at least 48 hours and did not have major surgery lasting more than one hour at any point during their hospital stay from January 1, 2015- December 31, 2015. Design and Methods: A retrospective electronic medical record review was conducted (n=100) in a large local hospital over a one-year time span. Electronic medical records were randomly selected, and were audited for the following variables: admission diagnosis, comorbidities, age, ethnicity, sex, ventilator days, invasive catheters, use of vasoactive or inotropic medications, physical therapy (PT) intervention, occupational therapy (OT) intervention, range of motion (ROM), sitting on the side of the bed, standing on the side of the bed, ambulation, RASS, CAM-ICU, ICU length of stay (LOS), hospital LOS, and discharge disposition. Descriptive statistics were used. Results: No statistically significant relationships between the current mobility practices and characteristics specific to the patient population were found. The data revealed a low incidence of all mobility variables ICU admission. This study resulted in a recommendation for a development and implementation of a progressive early mobility program for ventilated patients in the ICU

Need Assessment for Early Identification of Delirium in Post-Operative Patients in Intensive Care Unit

Background: Delirium is an acute dysfunction of cognition, memory, and attention resulting in changes in perception, mood, and activity. Delirium is associated with increased length of hospital stay, prolonged mechanical ventilator days, increased mortality rate, and a higher number of discharge disposals to rehabilitation centers. The purpose of the study is to assess the current practice in delirium assessment and management strategies among postoperative patients in Intensive Care Units. Methods: A retrospective medical record review was conducted in postoperative patients admitted to Norton Women’s and Kosair Children Hospital between January 2015 and December 2015. Postoperative delirium was diagnosed in compliance with CAM- ICU screening. Variables focused on in the study included: length of hospital stay, length of ICU stay, discharge disposition to rehabilitation facilities, number of mechanical ventilator days, use of restraints, and use of pharmacological and non-pharmacological measures. Results: Of the 115 patients assessed, 65 (56.5%) were screened for delirium. Among the 115 patients, 61.5% were positive for delirium and 38.4% were negative. The median number of mechanical ventilator days and number of restraint days in delirium positive patients was 3.5 and four respectively. The length of ICU stay (p = .000) and the length of hospital stay (p = 0.001) were significantly associated with delirium. Sixty percent of patients diagnosed with delirium required rehabilitation placement after the ICU stay. Thirty-seven and half percent of the patients who were positive for delirium received interventions. Conclusion: The study results demonstrated that there was a significant gap in delirium screening in the ICU. Postoperative delirium was an independent risk factor for increased number of mechanical ventilator days as well as increased use of restraints. Study results indicate the need for early identification of delirium in postoperative patients in ICU and the development of evidence-based delirium management protocol

Blueprint for the Dissemination of Evidence-Based Practices in Health Care

Proposes strategies for better dissemination of best practices through quality improvement campaigns, including campaigns aligned with adopting organizations' goals, practical implementation tools and guides, and networks to foster learning opportunities

An Exploration of Nurse Adherence to Ventilator-Associated Pneumonia Bundle Interventions: A Quantitative Study

Ventilator-associated pneumonia (VAP) poses a significant health risk to patients on mechanical ventilation in hospital intensive care units (ICU). It is the responsibility of the nurse to implement VAP bundle interventions to decrease the prevalence of VAP in mechanically ventilated patients. The objective of the study was to measure nurse perception of adherence to VAP bundle interventions of oral hygiene, head-of-bed elevation, spontaneous breathing trials, daily sedation vacations, and peptic ulcer and deep vein thrombosis prophylaxis. A descriptive study involving a sample population of 28 ICU nurses at 3 hospitals in northern California was conducted. A 57-item questionnaire was developed to gather data on the degree to which VAP bundle interventions were implemented by the ICU nurses. All but one nurse reported implementing VAP bundle interventions in accordance with hospital policy. Self-reported nurse perception of adherence to VAP bundle interventions was considered met for 68% of the sample population. Self-reported adherence to VAP bundle interventions indicated nurses were appropriately implementing them in accordance with hospital policy/guidelines. More critical examination of VAP bundle hospital protocol is needed in order to identify areas for improvements in nursing practice

Increasing Adherence to Protocolized Diuresis for De-resuscitation of ICU Patients by Increasing Nursing Knowledge and Confidence

Background: Fluid overload in patients requiring intensive care leads to increased costs for hospitals and patients, increased length of intensive care unit (ICU) and total hospital stay, ventilator days, acute kidney injuries, and mortality rates. Multiple studies have indicated that aggressive de-resuscitation with diuretics can decrease length of stay, ventilator days, organ injury, and mortality rates. A nurse-driven diuresis protocol utilizing intravenous (IV) push furosemide was introduced to the University of Kentucky Medicine ICU, but patients are still commonly still over-resuscitated with no plan to diurese until organ damage has occurred. By educating bedside nurses, improving their knowledge and confidence regarding the diuresis protocol adherence to the protocol may be increased. Purpose: The purpose of this DNP project was to examine the impact a web-based educational intervention has on bedside ICU nurses’ perceived knowledge, confidence, adherence, and attitudes on using protocolized diuresis. In addition, barriers towards using a protocolized diuresis will be identified. Methods: This study used a one-group pre- and post-intervention survey design. Participants completed a 15-question survey prior to and after watching a web-based educational intervention. Unpaired t-tests and Spearman’s Correlation Coefficient via SPSS software were used to analyze the data and interpret its significance to clinical practice. Results: There were no statistically significant changes in total knowledge over time, with a p value of 0.245. Nurses were significantly more comfortable in using the MICU Diuresis protocol in the post-intervention survey (p = 0.010). Additionally, nurses more strongly agreed that excessive fluid resuscitation increased length of ICU and total hospital stay, ventilator days, acute kidney injuries, and mortality rates (p = 0.017) in the post-intervention results. There were no statistically significant changes in barriers identified by nursing staff to utilizing the MICU Diuresis Protocol. Conclusion: Results of this study indicated that MICU bedside nursing staff, while familiar with the signs of over-resuscitation, were uncomfortable using the nurse-driven Diuresis Protocol for a variety of reasons. While there was no statistical significance in the study, notably there was clinical significance, as nurses felt much more comfortable using the diuresis protocol. The study also showed that utilization of a web-based training intervention can be effective at significantly improving knowledge, comfort, and attitudes towards and determining barriers of using the MICU Diuresis Protocol. Future research should focus on assessing the knowledge, confidence, and attitudes of other MICU healthcare providers to understand the barriers surrounding multidisciplinary use of the Diuresis Protocol

Impact of Standardized Oral Health Assessment on Preventing Ventilator-Associated Events

Ventilator-associated pneumonia (VAP) is a common but preventable health-care associated infection that affects up to 20% of mechanically ventilated adult patients, resulting in estimated mortality rates ranging from 13% to 55% (Chahoud, Semaan, Almoosa, 2015; Melsen et al., 2013). In an effort to reduce morbidity, mortality and related costs, the Centers for Disease Control and Prevention (CDC) and the National Healthcare Safety Network (NHSN), proposed ventilator-associated pneumonia prevention as a national patient safety goal. In 2014, amid growing concerns that the subjectivity of existing definitions had led to inconsistent reporting, thereby impeding efforts to reduce VAP, the CDC refocused surveillance efforts on, the more broadly defined, ventilator associated events (VAE), which include VAP as well as a set of related conditions. Hospitals have been inconsistent in their adoption of evidence-based practice (EBP) to reduce the incidence of VAE. The purpose of this EBP project was to design, implement, and evaluate the use of a comprehensive oral health intervention to: (a) reduce the cumulative VAE rate at four facilities and (b) determine whether project adherence over a four month period had an impact on VAE incidence rate reduction. The Epidemiological Triangle of Infectious Disease and Everett Rogers’ Diffusion of Innovation framework guided this multisite pretest-posttest study. The study introduced oral care and biofilm elimination education for nurses, and an oral health assessment tool. Aggregated VAE data was collected from each facility’s infection preventionist. The analysis involved pooled mean comparisons of data in the pre-intervention and post-intervention periods. The data showed a decrease in pooled VAE incidence rates of 1.8 per 1,000 ventilator-days, but this difference was not statistically significant, Χ2 (1, N = 4,846) = .37, p = .54. There was also a moderate correlation between documentation compliance and reduction of VAE rate (r = .4). However, this correlation was not statistically significant (p = .6). These findings provide preliminary evidence that routine oral assessment and timely intervention in MV patients are useful components of comprehensive oral care practices to prevent VAE

Impact of Standardized Oral Health Assessment on Preventing Ventilator-Associated Events

Ventilator-associated pneumonia (VAP) is a common but preventable health-care associated infection that affects up to 20% of mechanically ventilated adult patients, resulting in estimated mortality rates ranging from 13% to 55% (Chahoud, Semaan, Almoosa, 2015; Melsen et al., 2013). In an effort to reduce morbidity, mortality and related costs, the Centers for Disease Control and Prevention (CDC) and the National Healthcare Safety Network (NHSN), proposed ventilator-associated pneumonia prevention as a national patient safety goal. In 2014, amid growing concerns that the subjectivity of existing definitions had led to inconsistent reporting, thereby impeding efforts to reduce VAP, the CDC refocused surveillance efforts on, the more broadly defined, ventilator associated events (VAE), which include VAP as well as a set of related conditions. Hospitals have been inconsistent in their adoption of evidence-based practice (EBP) to reduce the incidence of VAE. The purpose of this EBP project was to design, implement, and evaluate the use of a comprehensive oral health intervention to: (a) reduce the cumulative VAE rate at four facilities and (b) determine whether project adherence over a four month period had an impact on VAE incidence rate reduction. The Epidemiological Triangle of Infectious Disease and Everett Rogers’ Diffusion of Innovation framework guided this multisite pretest-posttest study. The study introduced oral care and biofilm elimination education for nurses, and an oral health assessment tool. Aggregated VAE data was collected from each facility’s infection preventionist. The analysis involved pooled mean comparisons of data in the pre-intervention and post-intervention periods. The data showed a decrease in pooled VAE incidence rates of 1.8 per 1,000 ventilator-days, but this difference was not statistically significant, Χ2 (1, N = 4,846) = .37, p = .54. There was also a moderate correlation between documentation compliance and reduction of VAE rate (r = .4). However, this correlation was not statistically significant (p = .6). These findings provide preliminary evidence that routine oral assessment and timely intervention in MV patients are useful components of comprehensive oral care practices to prevent VAE

Evaluating Utilization of an Early Mobility Protocol in an Adult ICU in the Veterans Administration System

Purpose: To evaluate ICU staff’s adherence to a new progressive mobility protocol as part of a quality improvement project in an adult medical-surgical intensive care unit (ICU). Background: Bedrest can lead to complications for hospitalized patients and current literature supports that mobility within the ICU is safe and feasible for critically ill patients. Current evidence based literature identifies barriers to patient mobilization which can be addressed through implementation of a mobility protocol. Utilization of mobility protocols is one way to improve quality of care and prevent common bedrest complications in the critically ill patient population. Methods: Retrospective medical record reviews were conducted pre (n=65) and post (n=54) implementation of the mobility protocol to provide descriptive data regarding staff adherence to the protocol and improvement in unit mobility practices. Activity orders, activity occurrences and type, as well as nurses’ documentation of the protocol phase in admission and daily re-assessments were evaluated. Results: Documentation of activity orders from providers was less than 70% (35 out of 54) after implementation of the protocol. Eighty-one percent (44 out of 54) of the medical records reviewed had mobility phase assessed and documented by nurses on the admission assessment. Shift re-assessment of the patients’ mobility phase was low at 41% (22 out of 54) after implementation of the mobility protocol. Conclusion: Improvement of utilization of the mobility protocol was seen over a six-month period with expanded mobility activities being documented by nursing staff. Additional refinement of the protocol will require more time and effort from key stakeholders and unit champions to improve staff adherence