The intensive care unit is that place you think of for the sickest patients, full of tubes and wires — patients who are comatose, unmoving, unaware. Yet a collaborative through Partners Healthcare in Massachusetts has created a program — now in its fifth year — that has critically ill patients getting up sooner rather than later, getting rid of those tubes and wires, and getting better sooner because of it.
Colleen Ryan, MSN, RN, CCRN, a nurse educator in the intensive care unit at Newton-Wellesley Hospital in Newton, MA, and her colleagues Michele Wescott, BSN, RN, CCRN, Ann Mulligan, RN, and Maureen Sullivan, RN, created the program after attending a conference in 2011 put on by the Institute for Healthcare Improvement (IHI) that covered the very topic. Speaking at the conference were people from Vanderbilt University in Tennessee and Intermountain Healthcare in Utah who implemented early mobility programs in their critical care units.
Ryan went with her nursing colleagues as well as a physical therapist, a respiratory therapist, and a critical care physician. “I was sold,” she says. But not everyone was. The group created a survey to find out what some of the concerns were among other providers and staff. They tried to address them through education, but what worked best was seeing the program in action, Ryan says. One patient off the vent and doing well was the best way to create converts and evangelists.
The program focuses on the ABCDE bundle: Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility, she says.
Effects of being in the ICU can be long term, particularly for patients who experience delirium, something that is more likely to happen to patients who are sedated for long periods of time in order to be on a ventilator. Studies have shown that sedated, intubated patients who become delirious, even if they are young, often are not back to their old selves a year later, Ryan says. One study she remembers of more than 100 patients who were critically ill found that over half did not return home, nor were they able to function normally a year after they were discharged.
What’s physically good for the patients is also mentally good for the patients and their families, Ryan says. They want nothing more than to be out of the ICU, if not the hospital. “They think they are going to die on the ventilator,” she says. “They want to be out of bed, and are so appreciative when they get up.”
The core group of nurses and physicians was very engaged in 2012, and early mobility was given to 80% of eligible patients in 2012. In 2013, things slowed down a bit, and the enthusiasm waned, Ryan says. Only half the eligible patients got the early mobility treatment. However, a grant from the American Association of Critical-Care Nurses (AACN) helped regain the momentum, identify barriers, and promote best practices has put the team back on track, she says. They are excited and engaged enough to be doing poster presentations across the country during the year, Ryan says.
At Newton-Wellesley at the peak of the program, ventilator days were down an average of 4.2 per patient, about the same as the reduction in the length of stay in the ICU. The total savings was over $1.5 million. There, 60% of eligible patients were moving early as part of the program. At Massachusetts General Hospital, early ventilator removal saved $300,000, and at North Shore Medical, 81% of patients were out of bed early.
Another benefit of the re-engagement is a follow-on project being planned to help patients sleep better at night with fewer interruptions, Ryan says. This could help decrease delirium further, she hopes.
For more information on this topic, contact Colleen Ryan, RN, MSN, CCRN, Nurse Educator, Intensive Care Unit, Newton-Wellesley Hospital, Newton, MA. Email: firstname.lastname@example.org.