Ventilated Patients: Early Mobility and Sedation Management

Leslie Bruchey 

Abstract

Critically ill patients that need intubated and mechanical ventilation often to have increased hospital length of stay. Throughout this paper, the hospital length of stay in this patient population will be analyzed by research articles to see how early mobility and sedation management effect the hospitalization. Research shows that early mobility in the intensive care unit often decreases the length of stay of a patient who was critically ill and on a ventilator. Nursing plays a large role in providing early mobility to these patients along with sedation management. The implementation of a sedation protocol often allows nurses to control how much sedation is used on a mechanically ventilated patient. The research also shows that with nurse driven sedation protocols, there is a decreased length of stay for these patients. Early mobility and sedation management have effects on the length of stay in the hospital for the critically ill patients that require ventilator management.

Keywords: mechanically ventilated, critically ill, length of stay, sedation, early mobility

Hospital Length of Stay in Critically Ill Mechanical Ventilated Patients: Early Mobility and Sedation Management

In the United States, approximately 5.7 million people are admitted to an intensive care unit every year. According to the Society of Critical Care Medicine, of those patients admitted to the intensive care unit, 20-30% will need mechanical ventilation intervention (“Critical Care,” n.d). One of the biggest problems faced in the Intensive Care is decreasing the length of stay in those critically ill patients that require ventilator support. Nursing plays a critical role in providing quality care and needed interventions to improve the length of stay within the intensive care unit. Throughout this paper, the effects of early mobilization and sedation management will be analyzed in relation to the hospital length of stay in the critically ill population that needs mechanical support provided by the ventilator.

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Early mobility consists of range of motion, sitting in a chair or the side of the bed and possibly walking as a patient is able to tolerate activity. Clark et al. performed a research study on the effectiveness of early mobilization in an intensive care unit. In this study, the results demonstrated that the hospital length of stay was decreased by 2.4 days with early mobilization (Clark et al., 2013). Early mobility in a hot topic in intensive care units throughout the country to decrease prolonged ventilator time and the risk for infections. In another research study by Stefan et al., early mobilization was tested in a randomized controlled trial. The end results showed early mobility to improve patients mobility by discharge and shorten the length of stay (Schaller et al., 2016). Nursing can utilize this concept to help reduce the length of stay for a patient in the hospital and improve overall patient outcomes for this critically ill population. Sedation management is another great variable to focus on in the critically in intubated patients in relationship to the length of stay. In a research article by Jakob et al., a sedation protocol was analyzed to support vent weaning and the length of stay. The results showed that the time mechanical ventilation was needed decreased by six hours and the length of stay in the intensive care unit reduced from thirty-seven hours to twenty-five hours, P=0.049, which indicated the statistics were significant (Jakob et al., 2007). Oversedation can delay the ventilator weaning progress and prevent patients from participating in early mobilization and extubating, which would increase the length of stay.

Background

Patients that require mechanical ventilation in the intensive care unit, unfortunately, have a prolonged hospital length of stay. In 2005, 790,000 people that were hospitalized needed mechanical ventilation. The average duration of stay for one of these patients was 14 plus or minus 16.9 days, which only accounted for 7% of the days spent in the hospital. Not only is the length of stay extended for a patient that needs ventilator support, but also this intervention is very costly. The average hospital cost is $32,000 which the possibility of increasing that cost by $40,000 (Kirton, 2011). As the population continues to grow and lives longer, more and more patients come to the hospital, the number of patients needing mechanical ventilation and the length of stay will continue to increase. It is important to look at key variables so see how they affect the length of stay, such as early mobility and sedation management. Research studies will be analyzed to evaluate the importance of mobility and sedation management in relation to hospital length of stay for those patients who are critically ill and need mechanical ventilation.

Review of Quantitative Research

McWilliams et al. provided research on enhancing rehabilitation of patients who are on the ventilator in the intensive care unit.The purpose of this study was to evaluate the importance of early mobility in a quality improvement project in a large intensive care in those who are being supported by mechanical ventilation. When reviewing the literature, the authors used 30 different references that were relevant to the study and provided adequate information to support the topic. All but three of the references were from the time range of 2003-2014. The other three articles ranged from 1985-1998.The literature discusses that neuromuscular dysfunction was identified in 46% of critically ill patients, including those who needed mechanical ventilation which was associated with a longer length of stay in the hospital. Also, included in the literature, a decrease in stay in the intensive care unit and hospital has been associated with early mobility The author has a good understanding of research and problem related to the study (McWilliams et al., 2015).

The research design for this was a quality improvement program that analyzed the data before and after the project was implemented. Data was taken from a 75-bed intensive care unit that included people who had been intubated and needed mechanical ventilation for at least five days. The data was then analyzed by SPSS v 21, which is software for statistics. Significance was decided to be 0.05 of probability. A Student t test or Wilcoxon signed rank test was used for a basic comparison of groups and outcomes. Descriptive statistics were utilized in this study. The total length of stay for patients that received early mobility that were also on the ventilator for at least five days was decreased from 35.5 days to 30.1, P=0.016, along with a decrease in ventilator days. The statistics showed the association of decreased ventilator time as P=0.12 (McWilliams et al., 2015). Implementing an early mobility program can be difficult due to lack of funding and available resources. Other limitations consist of patients with comorbidities prior to entering the intensive care unit and being on bed rest for an extended period of time. In summary, in this study, early mobility was found to decrease length of stay for those patients who had been intubated for more than five days and could participate in rehabilitation efforts (McWilliams et al., 2015).

Morris et al., conducted a research study for the purpose of investigate the patient outcomes of variations in the frequency of physical therapy, where treatment begins during the hospitalization which was considered usual care for those who have respiratory failure compared with patients with the same diagnosis who received therapy from the mobility team using a mobility protocol in the intensive care unit (Morris et al., 2008).In the literature review, eighteen different references were used in the study. In the references that were used, early mobility was discussed in the intensive care setting in those who were intubated and ranged from the years of 1985-2007.The majority of the literature and references that are provided are from the early 2000s. There is sufficient information to support the purpose of the study along with a strong understanding of the problem from the authors.  The authors state that common problem from being mechanically ventilated consists of an increased length of stay, and while physical therapy has been said to help with early extubations, there is information supporting early mobility in the intensive care unit (Morris et al., 2008). The research design consisted a cohort study also known as a longitudinal study. A mobility protocol was created to be used in the intensive care setting, which participants were assigned by block allocation. The mobility team rotated through seven different intensive care units until fifty patients had been enrolled and then would move to the next block of patients. Various units were assigned interventions and control groups in every block while three blows were used in the study. Patients who were not part of the intervention group received regular physical therapy (Morris et al., 2008).

Descriptive statistics were used in this study. There was a total of 330 patients that met criteria that were either assigned to usual care or the mobility team. It was discovered through this research that those who received usual care spend an average of 14.5 days in the hospital and those who received care from the mobility team had an average of 11.2 days spent in the hospital, P=0.006 (Morris et al., 2008). Early mobility was found to decrease hospital length of stay for the critically ill patient that required mechanical ventilation. Although there were 3000 patients admitted to the medicine intensive care unit, only 330 of those patients were eligible to participate in the study. Also, another limitation that is discussed is that the mobility team only saw patients in the intensive care setting.The length of stay for patients was found to be decreased without increasing the cost to the hospital (Morris et al., 2008).

Pandullo et al., research article served the purpose of discovering is patient mobility in intensive care is sustained throughout different phases of the hospitalization to other inpatient floors till discharge. The author provided a lot of literature throughout the article to provide background information to the problem of critically ill patients needing progressive mobility to decrease the length of stay and mechanical ventilation days. Thirty-three references were used from the time frame of 1989-2015). The research was collected by a retrospective study in a 24-bed intensive care unit. Those who were included in the study were 18 years or older, admitted to the intensive care unit in the second quarter of 2013, had a length of stay for at least 48 hours and went to an inpatient unit after critical care was needed. Chart reviews were completed by a multi-disciplinary team. Data was recorded to include intensive care length of stay, hospital length of stay and readmission to the intensive care unit along with what therapy disciplines participated in the patient’s care during the intensive care unit stay (Pandullo et al., 2015)

Analysis of the data was performed by IMB SPSS which included descriptive statistics which were categorized in recorded as percentages. Variance tests were used with Bonferroni correction and Spearman correlation.  A significance level of 0.05 was used. The length of hospital stay was rs=-0.22 and p=0.002. In this study, it was confirmed that early mobilization decreases hospital length of stay for those patients who were critically ill in the intensive care unit and received early mobility. Limitations are discussed in this study. Data was collected in a chart rather than direct observation, and charting was sometimes inconsistent. Also, therapy was grouped, and different roles were not considered such as cardiac rehabilitation or nurse-driven early mobility. Overall, the authors believe that early mobility has a positive impact on patient outcomes (Pandullo et al., 2015).

Jones, Newhouse, Johnson & Seidl, authored a research article that addresses health outcomes that are associated with spontaneous awakening and breathing trials. The purpose of this study was to evaluate the evidence-based practice protocols that include spontaneous breathing and awakening trials for mechanically ventilated patients and its effects on length of stay in the intensive care unit, hospital, and reintubations. While reviewing the literature, the authors included twenty-six references ranging from the years of 2002-2013. Mechanical ventilation is discussed prolonging intubation can cause mortality and morbidity. The author provides a lot of background information for the research with a good understand of each variable of the study (Jones et al., 2014).

The research study used a retrospective chart review of discharged patients using a descriptive comparative of those before and after the spontaneous breathing trial and awakening trial was implemented on April 2010. Data included age, sex, race, admitting medical service, date and time of admitting, intubation information and discharge from the intensive care unit. The protocol is used every morning where sedation would be turned off. This study states that a convenience sample included 112 participants. The intensive care unit has 23 beds and was a level 2 trauma center. Data was analyzed by SPSS and a chi-square test was used to gather further information on characteristics of the before and after implementing the new protocol. Mann-Whitney U test was also used to investigate age, weight, and length of stay and medical treatment duration while on the ventilator. The fisher exact test was used for more data on self-extubation and reintubation data (Jones et al., 2014). Of the 112 participants, there were 56 subjects looked at prior to the spontaneous awakening and breathing trial protocol and 56 patients after implementation. Descriptive data was used in the statistical analysis. When the length of stay was investigated, there was no significant data to support the spontaneous awakening and breathing trial affecting the hospitalization course, P=0.29 (Jones et al., 2014). A few limitations are discussed within the research article. Because the data was gathered through a chart review, staff education and follow-up of the protocol was not able to be completed. Also, the authors included that information bias could have been an issue due to measurement errors. The prior power was 0.08, but post analysis showed that power was 0.36, which would affect the number of medical records needed. Another limitation listed is nursing, and the respiratory therapist did not follow the protocol. In conclusion, there was no difference in a patient who follows the spontaneous awakening and breathing trial or does not in relation to the length of stay in a critically ill mechanical ventilated patient (Jones et al., 2014).

Rafiei, Ahmadinejad, Amiri & Abdar provided a research article that focuses on nursing-implemented sedation and pain protocol that is used on opium-addicted critically ill patients. The purpose of this study is to increase the quality of nursing care, and the effects of nursing-implemented sedation and pain protocols and the amounts of medications that are used on patients who are addicted to opium. The authors use a variety of references within the research article. Twenty-two articles are utilized in the year range of 1998-2012. During the intro, sedation and pain control are discussed from a nursing perspective for the critically ill intubated patients in the intensive care unit. The research provided addresses that the sedation protocol may decrease ventilator time and length of stay. The introduction also claims that sedation protocol use has limited information along with the protocol being used in patients who are critically ill and have an opium addiction (Rafiei, Ahmadinejad, Amiri & Abdar, 2013).

The study utilized a randomized controlled trial that took place during September 2011 to June 2012, in three different intensive care units in Iran, which had approximately 33 beds. Criteria for the study consisted of mechanical ventilation, being in the intensive care unit for at least two days, addiction and being between the ages of 15-45. Patients were also hemodynamically stable, and the study excluded those with heart, lung, liver and kidney disease. The random assignment took place and put patients in either the control group or intervention group. Data was collected during the admission; the level of sedation was assessed six times in twenty-four hours on all patients in the trial. Data was analyzed by Statistical Package for the Social Sciences. A t-test was used for comparing the mean of normally distributed samples (Rafiei et al., 2013). Inferential statistics were used in this study. P <0.05 was used to demonstrate statistical significance. The statistics show that the group with the nurse-driven sedation and pain protocol used less sedation P <0.05(Rafiei et al, 2013). Authors discuss that nurse-driven sedation and pain protocols are not only beneficial in those who have opium dependence but also those without. Nurses used less sedation to meet a target sedation goal. Oversedation is related to increasing in length of stay, delayed vent weaning and pneumonia. Limitations of this study consisted of a small sample size and not accurately measuring duration of stay, delirium, and pneumonia created by being on the ventilator (Rafiei et al., 2013).

Summary of Statistical Results

Throughout the research articles discussed above, information can be gathered to see if early mobility and sedation management play a role in the critically ill mechanical ventilated patients. In the research study by McWilliams et al., it was found that by using a t-test and Wilcoxon signed rank test that the length of stay for patients that received early mobility decreased the hospital length of stay P=0.016, which demonstrates statistical significance (McWilliams et al., 2015). The t-test is used to analyze two variables and can be used to verify a hypothesis. A Wilcoxon signed-rank test is used to calculate data into ranks and disregards variances (Gray, Grove & Sutherland, 2017). Overall, the research results supported early mobility in the critically ill population to improve the length of stay within the hospital. Also, descriptive data was used in this research article to analyze how early mobility affects length of stay for those critically ill and required intubation.

In the second article by Morris et al., a longitudinal study was completed. Descriptive statistics were provided. Those who received usual care n=136 and those who had the protocol were represented by n=145. All results were presented by confidence intervals. The usual care patients had 12.7-16.7 hospital length of stays while those who had the protocol were 9.7-12.8.1, P=0.006. These numbers were adjusted to factor in BMI, vasopressors and APACHE II. A linear regression was mentioned for other data within the study, but test used for the length of stay data was not indicated (Morris et al., 2008). The results provided by this article also supports that the length of stay was decreased by early mobility. In the third research article discussed by Pandullo et al., indicated variance tests such as Bonferroni and Spearman correlation was used. Descriptive statistics are used in this study. These tests would assess relationships between two variables. Spearman correlation is used to test two ranked variables. The research that was completed demonstrated that early mobility and the length of the hospital stay was p=0.002. With a significance level of 0.05 used in this study, this indicated that there was a statistical relationship between early mobility in the intubated critically ill population and a decreased length of stay (Pandullo et al., 2015). The fourth research article discussed above by Jones et al., used descriptive data to compare spontaneous breathing trials with the length of stay in the hospital in the problem population. A Mann-Whitney U test which is similar to a t-test and used to compare two variables. There was no relationship between having spontaneous awaking trials every day and length of stay in those patients, P=0.29 (Jones et al., 2014). Finally, inferential statistics were also used in the study by Rafieji et al. The nurse-driven protocol was found to be better for patients because less sedation was used and patients could spend less time on the ventilator. The statistics showed that patients had less sedation P< 0.05 which the authors came to the conclusion that because patients were not overly sedated, a decrease in hospital length of stay, delirium, and ventilator acquired pneumonia would occur (Rafiei et al., 2013).

Conclusion

Throughout this paper, literature has been discussed along with the statistical findings of each study to demonstrate the effect of early mobility and sedation management on the length of stay for critically ill patients that require mechanical ventilation. Minhas et al. performed a randomized controlled trial that viewed the effects of a sedation protocol and clinical outcomes. During this study, it was found that with a sedation protocol, the hospital length of stay was decreased by 3.5 days. P=0.004 demonstrated that the statistics were very relevant in this case (Minhas et al., 2015). Hunter, Johnson & Coustasse performed a randomized control trial of 90 patients showed that in an early mobility program in the intensive care setting, there was a significant decrease in length of hospital stay by 13% (Hunter, Johnson& Coustasse, 2014).

References

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Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit:

A retrospective cohort study.Physical Therapy, 93(2), 186-96. Retrieved from

http://www.library.drexel.edu/

Critical Care Statistics. (n.d.). Retrieved from http://www.sccm.org/

Gray, J., Grove, S., & Sutherland, S. (2017). The Practice of Nursing Research: Appraisal,

Synthesis and Generation of Evidence (8th ed.). Elsevier: St. Louis, Mo.

Hunter, A., M.Sc, Johnson, Leslie, DPT,P.T., M.Sc, & Coustasse, Alberto, DrPH, MD,M.B.A.,

M.P.H. (2014). Reduction of intensive care unit length of stay: The case of early

mobilization. The Health Care Manager, 33(2), 128. Retrieved from

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McWilliams, D., Weblin, J., Atkins, G., Bion, J., Williams, J., Elliott, C., . . . Snelson, C. (2015).

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doi:http://dx.doi.org/10.1016/j.jcrc.2014.09.018