Problem

This project was carried out in an adult ICU located in a hospital in an urban area just outside Glasgow. The unit had six beds and looked after only level 3 patients, defined as ’patients receiving advanced respiratory support alone, or a minimum of 2 organ supports'.1 The unit admitted between 300 and 350 patients per year, and was located in a district general hospital with a busy emergency department and a range of acute surgical and medical specialties. The majority of the patients was intubated and ventilated (more than 90%—data from the national database Ward Watcher). In April 2016, the unit relocated to a new facility in the same building which now takes level 2 (patients needing extended postoperative care or single organ support1—high dependency unit (HDU)) and level 3 patients, and has expanded its capacity to 10 beds, taking approximately 650 admissions per year. It is staffed full time by nursing and medical staff, and Monday to Friday by dedicated physiotherapists, with on-call physiotherapy staff at weekends. The unit had achieved reliability (greater than 95% of patient days) of daily interruption of sedation as part of the Scottish Patient Safety Programme by the end of 2012. The standard sedation/analgesia medications in our ICU are propofol with an opioid, usually morphine or alfentanil. Benzodiazepines are rarely used. ICU acquired weakness (ICUAW) is common in critically ill patients and is associated with poor outcomes. The duration and severity of this condition can be reduced by the early mobilisation of patients. We did not have the resources to measure the incidence, duration and recovery from ICUAW in our patient population, but it was regularly diagnosed during ward rounds. Delirium is a common complication of critical illness associated with poor patient outcomes. Daily screening for delirium was introduced in the ICU in March 2013 using the confusion assessment method for the ICU (CAM-ICU) delirium screening tool, a validated tool for use in intensive care.2 Between April and August 2014, a baseline measurement of delirium rates found that approximately 60% of critical care patients were delirious at the time of measurement. All patients had multiple recognised risk factors for the delirium present. Staff focus groups were formed to try to identify which of the risk factors for delirium we believed were present in our patients, and that we would want to reduce or eliminate. Noise, disturbed sleep and mobilisation were identified as areas where we could improve processes. A number of measures to reduce noise levels were introduced such as reducing the number of machine alarms, and efforts to improve sleep including the use of ear plugs and eye masks, but these did not affect delirium rates. We therefore decided to introduce processes to ensure that patients were mobilised as early as possible as a way to potentially reduce delirium rates, and to reduce the duration and severity of ICUAW. We were aware of work in other ICUs that had introduced mobilisation processes including sitting patients at the edge of the bed, and walking, both very challenging while intubated and ventilated. These processes were not part of the normal work routine in our ICU, although they had both occurred on a few occasions when agreed by the clinical team.

Background

Delirium is an acute, fluctuating syndrome of inattention, impaired level of consciousness and disturbed cognition (National Institute for Health and Care Excellence (NICE)).3 Delirium is a non-specific but generally reversible manifestation of acute illness.4 It is classified in three subgroups; hypoactive, hyperactive and mixed delirium. Delirium incidence in the ICU varies between 16% and 89%.5 6 NICE guidelines, as well as published critical care guidelines on the management of pain agitation and delirium recommend daily screening of patients for delirium and treatment of underlying causes.3 7 There are multiple risk factors for delirium including sedation, hypertension, alcoholism, severity of illness, age and infection, with many patients having more than one risk factor,8 9 although the exact mechanism of its development remains unclear. Delirium is associated with increased risk of death, decreased long-term cognitive function, and increased length of hospital stay.10–14

ICUAW is the name given to the consequence of acute illness that may include a neuropathy, myopathy or some combination of the two.15 It is defined as ’a clinically detected weakness in critically ill patients in whom there is no plausible aetiology other than critical illness'.15 The incidence of ICUAW has been estimated between 25% and 100% with multiple risk factors including sepsis, the use of neuromuscular blocking agents, hyperglycaemia and physical inactivity.16 17 Functional disability can persist for years after recovery from the acute illness.18

Early mobilisation and physiotherapy has received increasing attention as a process which may improve these outcomes. A trial of physiotherapy and occupational therapy within 72 hours of intubation and ventilation showed that patients in the intervention group had half the number of days with delirium than those who received usual care.19 A quality improvement project which focused on reducing deep sedation and mobilising patients early in their ICU stay showed a reduction in the number of patient days with delirium and coma.20 In both studies, it is unclear if the effect on delirium was due to mobilisation or to intended or unintended change in sedative use. A strong possibility raised by these studies is that introduction of early mobilisation itself prompted a change in sedation practice.

A systematic review of active mobilisation of patients who were ventilated for more than 24 hours found that active mobilisation may improve muscle strength, functional independence, weaning from the ventilator, and reduce hospital length of stay.21 No serious adverse events were reported in the studies reviewed. A more recent systematic review which included studies of active therapies including sitting at the edge of the bed, and active exercises, hoisting to a chair, standing and walking, found that active mobilisation led to better muscle strength at ICU discharge, greater probability of walking without assistance at hospital discharge, and more days alive and out of hospital at 180 days. It found no difference in ICU or hospital length of stay, quality of life, or duration of mechanical ventilation.22 A randomised control trial of goal-directed mobilisation examined the effect of graded mobilisation in ICU patients. Patients who were functionally independent prior to ICU admission, and who were ventilated for less than 48 hours during their ICU stay, were mobilised according to goals set on ward rounds, either no mobilisation, passive movements, sitting, standing or walking. Interprofessional planning and working was assured by a facilitator who ensured the delivery of the mobilisation protocol. The intervention led to higher mobilisation scores, shorter length of stay and greater functional mobility at hospital discharge.23 A pilot study randomised patients expected to be ventilated for more than 48 hours to usual physiotherapy or early goal-directed mobilisation. This was a protocolised graded intervention consisting of 30–60 min of activity consisting of sitting in bed, sitting at the edge of the bed, sitting in a chair, standing or walking, depending on the mobility assessed by a scoring system. The study found that this approach was feasible and safe, and improved mobilisation rates with double the proportion of patients in the intervention group walking. Although not powered to look at other outcomes, there was no difference in ICU or hospital length of stay or duration of ventilation.24

Results of trials so far have not been consistent in showing improved outcomes although the research so far has led to widespread attempts to adopt early mobilisation in ICU. NICE guidelines in 2009, subsequently updated in 2017, recommend that rehabilitation start as early as possible during a patient’s stay as part of a structured rehabilitation programme.25

Questions remain on the optimal patient group, which outcomes are affected and the optimal mobilisation process.

Thus far, mobilisation of ICU patients has been found to be safe, with events with any real patient consequence being rare, although there is heterogeneity in the definition of safety events in different studies.26

There are a number of barriers to mobilisation. A 2015 study found that in Scottish ICUs, 40.1% of ventilated patients were mobilised. The study examined barriers to mobilisation, and found that sedation, an endotracheal tube in place and cardiovascular instability were the most common.27 A systematic review examining the barriers to mobilisation looked at qualitative and quantitative studies, predominantly focused on mobilisation in the ICU as opposed to the post-ICU setting, and found that patient physical and psychological factors, safety concerns, culture, leadership, motivation, beliefs regarding risks, and environment all acted as barriers. The majority is modifiable and could be addressed in a programme aimed at introducing early mobilisation.28 Another systematic review found that patient, clinician, protocol related and ICU contextual factors all have an influence on the adoption of early mobilisation.29 A number of the studies cited used designs to address barriers to mobilisation, such as mobilisation teams, goal setting on ward rounds, criteria for mobilisation, interprofessional working and mobilisation protocols.

Measurement

The primary purpose of this project was to introduce a new process and so reliability with the mobilisation process was our primary measure. We decided to measure average length of stay and delirium rates as outcome measures, although both outcomes are affected by multiple factors, not just mobilisation. However, both could potentially be affected by mobilisation, and were established measures in ICU. We chose average length of stay as the primary outcome measure based on the evidence of the impact of ICUAW and the potential of early mobilisation to improve muscle weakness. Data were extracted from the national ICU database (Wardwatcher) and calculated by dividing the total number of ICU patient days per calendar month divided by the number of patients discharged from the ICU that month, a standard metric in Scottish ICUs.30 The baseline average length of stay was 3.5 days.

Daily screening for delirium was introduced in March 2013 prior to the start of this project, in line with guidelines. Initially screening for delirium was sporadic.31 A project team of nurse practitioner, a junior doctor and ICU consultant designed a multifaceted teaching package on ICU delirium and CAM-ICU. This comprised an introductory poster relating a patient’s experience of ICU delirium, a slide show presentation, desktop information leaflet outlining the impact of ICU delirium, bedside demonstrations, supervised performance of the CAM-ICU and provision of a pocket card to aid continued delirium screening. Nursing staff were surveyed on their attitudes to and knowledge of ICU delirium before and after teaching. Spot checks were also undertaken to confirm competency in performing the CAM-ICU postintervention. The project team continued to monitor the recording of the presence or absence of delirium, and the accuracy of screening. Feedback to staff on the results continued. Screening was found to be reliable and accurate in early 2014. Weekly data were collected on random days by the project team. The accuracy of screening was checked at the time of data collection. Random days for data collection were identified using a random number generator on Microsoft Excel. On those days, all patients were included in the initial sample, with patients being then excluded if they did not meet criteria for delirium screening. The numbers of patients with and without delirium were recorded, and rates calculated by dividing the number of patients with delirium by the total number of patients eligible for delirium screening. The baseline median rate was 60%. As the project progressed, data were aggregated and rates calculated for each calendar month.

Process data on mobilisation rates were collected one random day per week. Data were collected on:

• Number of patients in ICU at that time.

• Number of patients who met the criteria for three mobilisation processes—the dangle, the stand and sitting in a chair (see next section for operational definition) before 10:00.

• The number of patients who mobilised according to a standardised process (see below for operational definition) before 17:00 when data were collected.

All data were collected by a core team of three staff members which ensured validity and reliability of measurement. Data were plotted as a time series to make run charts, initially weekly (sample size 1–3), and later aggregated to give monthly data (sample size 5–10). The sample size approximately doubled from April 2016 when the unit moved from a 6-bedded facility to a 10-bedded facility. Outcome data were plotted on statistical process control charts later in the project.

As a balancing measure, we counted the number of adverse events, such as dislodgement of endotracheal tubes, or central lines that occurred during mobilisation. In the early part of the project, staff were initially concerned that mobilisation sometimes seemed to leave patients exhausted and may have ’set them back'. We therefore also measured average length of stay on a ventilator as a balancing measure. This is defined as the total number of ventilator days provided by the ICU each month, divided by the total number of patients who were ventilated during that month.

Feedback from patients and staff was collected in the form of quotes and presented at focus groups for discussion.

Design

A core project team of an advanced nurse practitioner, ICU consultant and physiotherapist was formed. We began by examining mobilisation practice in other ICUs, and seeking advice on how they went about introducing the process. In addition, one of the team members (author SC) had visited ICUs in Inter Mountain Health, Salt Lake City and seen their work on mobilisation. This group has particular experience and knowledge of mobilisation.32 This group had adopted the nomenclature ’The daily dangle' for the process of sitting a ventilated patient at the edge of the bed for a set period of time, and this name was unofficially adopted by our unit. The group also reviewed the published literature to help plan the project. Roger’s theory on the diffusion of innovations, which examines factors affecting the adoption of new technology or processes, suggests that some people will be more willing than others to try a new process, and that its further adoption will be dependent on, among other factors, the ability to test it, observe its effects and adapt it for local needs.33 A Health Foundation evidence scan examined the barriers to successful quality improvement in the National Health Service (NHS), and found many factors, including lack of ownership by professionals and their lack of autonomy to make changes to the process.34 The project team understood that the mobilisation process would be delivered and experienced by nursing and physiotherapy staff, and by patients. We therefore decided to ask the staff to design and test the changes with feedback from patients and families. We instituted weekly staff focus groups, led by one of the project team, within the clinical area, thus minimising disruption to clinical care, of about 10–15 min each, where the results of tests of change could be discussed and new tests agreed. Frequent focus groups ensured the input of broad groups of staff. At the first set of focus groups, the background to the project and the supporting evidence were shared with the staff and their views solicited. Although staff expressed a number of reservations around the difficulty of mobilising ventilated patients, and the risk and benefits, agreement was reached to test changes cautiously. The staff identified four mobilisation processes: sitting a patient at the edge of the bed (‘the daily dangle'), sitting a patient in a chair, standing up beside their bed and walking. The dangle was chosen as the first area to focus on. Nursing staff wanted the involvement of physiotherapists in the process of mobilising patients, at least initially, to provide some expert guidance on an unfamiliar process, which was arranged. In the next set of focus groups, staff chose the patient selection criteria for a dangle to be modified though testing. Thereafter, they defined the process of a dangle, again with the expectation of modifying this through testing. Tests of change were carried out using Plan, Do, Study, Act (PDSA) methodology. Results were shared at focus groups. Data, as well as feedback from patients and staff in the form of word clouds and free text, were posted on the quality improvement board in the ICU.

Strategy and improvement cycles

Our tests of change using PDSA cycles are described below. Some of these contain a number of PDSA cycles but have been grouped together. Our aim was that 95% of patients, who met the criteria for a dangle, would be mobilised according to the dangle process by December 2016. Our strategy was first to define the eligible patient group, then to standardise the dangle process, and then to test a series of reminders to improve reliability.

PDSA 2

After sharing the results of PDSA 1, we decided to repeat the above test with a series of individual patients, reviewing the results after each dangle to inform the next. Our hypothesis was that as staff gained confidence and experience with mobilising ventilated patients, the initially cautious criteria and process would develop to include a larger group of patients who might benefit. These were carried out over a number of weeks, with a variety of different staff but always with a physiotherapist, with no adverse events. As staff gained confidence, the team found that the staff had chosen to mobilise patients who did not strictly meet our initial criteria, but instead were requiring more physiological support than had been initially agreed on. The eligibility criteria were modified iteratively (figures 1 and 2). Staff believed the process to be easier than expected, to have sometimes led to the similar phenomenon of patients becoming more alert, to be comfortable for patients and to be safe. Teamwork with physiotherapists was welcome and enjoyable. Feedback from two patients had both (one after extubation and one in writing) reporting that they did not experience any adverse symptoms from the dangle. One patient had asked for more equipment and opportunity to exercise to help his recovery.

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Figure 1

Initial protocol for daily dangle. BMI, body mass index; ICU, intensive care unit; ETT, endotracheal tube; FiO₂, inspired oxygen fraction; PEEP, positive end expiratory pressure.

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Figure 2

Revised protocol for daily dangle. BMI, body mass index; ETT, endotracheal tube; FiO2, inspired oxygen fraction; ICU, intensive care unit; PEEP, positive end expiratory pressure.