Running head: CLINICAL PROBLEM QUESTION

Clinical Question Paper (PICOT) Kurt Freund Ferris State University

CLINICAL QUESTION PAPER Introduction Evidenced based research (EBR) is the foundation of todays nursing practice. Constant clinical evaluations and improvements are part of this process. When asking clinical questions the acronym PICOT, developed by Fineout-Overholt and Johnson, (Nieswiadomy, 2012, p. 282), will be used for this paper. PICOT stands for P-Patient or population, I-Intervention or interest area, C-Comparison intervention or current practice, O-Outcome(s) desired, T-Time to achieve outcome (which is optional), (Nieswiadomy, 2012, p. 282). PICOT utilization permits professional evidenced based clinical improvement measures amidst an overwhelming mass of knowledge, (Mamedio, Andrucioli, & Nobre, 2007). A PICOT question will be researched and discussed in regards to its clinical significance to nursing as well as the evidence that supports its rational. The Nursing 350 syllabus indicates that nurses interpret research findings and use evidence-based research to support nursing decisions. The purpose of this assignment is to reflect how nursing knowledge is disseminated for use in personal and professional practice, (Singleterry, 2014, p.8).

Clinical Question: Does early mobility and ambulation reduce post-intensive care syndrome in acutely ventilator dependent adult trauma patients?

Critically injured patients have been challenged with lack of activity due to fear of tubes and line loss, hemodynamic instability, personnel and equipment resources, patient discomfort, patient size, time involved, along with activity intolerance, ( (Drolet, et al., 2013). Prolonged bed rest in hospitalized patients leads to deconditioning, impaired mobility, and the potential for longer hospital stays (Drolet et al., 2013, p. 197). These risks add to the already critical
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CLINICAL QUESTION PAPER challenges of improvement and have led to multiple nursing research cohort studies focused on minimizing the risks of early ventilator dependent critically injured patients. Benefits of early mobilization are more than reducing the risks associated with lack of mobility. Improvement in long and short term outcomes of functionality, decreased days in the hospital, delirium reduction, and decreasing days of ventilator dependence, (Clark et al., 2013, p. 187), are also supporting factors in re-evaluating the positive effects of early mobilization of ventilator dependent critically ill patients. Researching studies to minimize the risks and concerns of early mobilization became the primary focus of this paper. A PICOT question was concluded from assessing nursing research findings from various articles. While researching studies that show strong nursing evidence to minimize the risks and concerns of early mobilization while improving prognosis of acute critical ventilator dependency the systematic, objective process of analyzing phenomena of importance to nursing, (Nieswiadomy,2012, p.3), concluded this PICO question. "Does early mobility and ambulation reduce post-intensive care syndrome in acutely ventilator dependent adult trauma patients?" Methodology The methodology used to search for evidence to answer the PICOT question, (Singleterry, 2014), started with a mind map. The starting point was considering a topic then seeking information. This entailed choosing sources, evaluating if there was enough peer reviewed information surrounding the topic, if enough information was not available then revision or changing of the topic was the next step. A revision was considered several times for this project due to insufficient peer reviewed nursing research. Then organizing knowledge followed by continued research and prioritization of essential content led to PICOT.
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CLINICAL QUESTION PAPER In the PICOT worksheet it was determined that acute ventilator dependent adult patients would be selected as the patient population of interest. Exclusion of children was due to insufficient peer reviewed studies. Early mobility and ambulation was then selected as the intervention or area of interest. Two hour turns with range of motion was selected as the comparison intervention of the group since it is the standard protocol according to the ACCN current guidelines, (Association of Critical Care Nurses, 2013). Early mobility, ambulation, turns and range of motion were selected because they are all general nursing practices and within a registered nurses scope of practice. Next prevention of post intensive care syndrome (PICS) was selected at the intended outcome. PICS is defined as functional, cognitive, and psychosocial problems, (Davidson, Harvey, Schuller, & Black, 2013, p.32), that derive from acute ventilator dependency. CINAHL, PUBMED, AHRQ, and Cochrane Reviews search engines were then searched with the level of evidence and significance to nursing being strongly considered for selection of articles. The significance to general nursing practice while considering the level of evidence were of high importance to the article critiquing process in discovering answers to the PICOT question mentioned above. The American Association of Critical-Care Nurses (AACN) created a measure of levels of evidence or grading systems that ranks research studies and other forms of evidence that have been developed to offer practitioners a reliable hierarchy to determine the strongest evidence, (Armola, et al., 2009, p.70). The purpose (of the level of evidence), was to create a tool to assist practitioners to determine whether statements about clinical practice were based on research or other reliable evidence, (Armola, et al., 2009, p. 71), which further defines levels of evidence and its value in consideration of peer reviewed sources to validate evidenced based practice.

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Discussion of Literature Early Physical and Occupational Therapy in Mechanically Ventilated, Critically Ill Patients: A Randomized Controlled Trail, (Schweichert et al., 2009, p. 1874). This is a level of evidence AACN rated level B randomized control trial, cohort study evaluating the long-term complications of critical illness include intensive care unit (ICU)acquired weakness and neuropsychiatric disease. Immobilization secondary to sedation might potentiate these problems (Schweickert et al., 2009, p. 1874). Therefore the sample setting derived from sedated ventilator dependent patients from a sample size of 100 patients. The measurement was early exercise and mobilization during periods of interrupted sedation, measuring the number of patients who were able to perform six ADLs upon discharge, shorter duration of delirium, and ventilator free days, (Schweickert et al., 2009, p. 1877). Data analysis compared the effect of the treatment protocol on the time to return to independent function using time-to-event analysis. Significant differences between groups or across time were reported at the alpha level of 0.05. All reported p values are two sided, (Schweichert et al., 2009, p. 1877). Comparison between study groups was from a two-sample rank sum t test, (Schweichert et al., 2009, p. 1877). The findings supported the strategy for whole-body rehabilitationaccomplished by interruption of sedation, protocol-driven spontaneous breathing trials, physical and occupational therapyresulted in better outcomes compared with current standard approaches to sedation and activity during mechanical ventilation and its recovery. Patients assigned to intervention had shorter duration of delirium and left the hospital with better functional status. This study
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CLINICAL QUESTION PAPER highlights outcomes that can be achieved with multiple disciplines dedicated to the survival and mental and physical recovery of critically ill patients receiving mechanical ventilation", (Schweichert et al., 2009, p. 1877). Effectiveness of an Early Mobilization Protocol in a Trauma and Burns Intensive Care Unit: A Retrospective Cohort Study, (Clark, Lowman, Griffin, Matthews, & Reiff, 2012, p.186). This is an AACN level of evidence B retrospective cohort study evaluating bed rest and immobility in patients on mechanical ventilation or in an intensive care unit (ICU), (Clark, Lowman, Griffin, Matthews, & Reiff, 2012, p. 186). The sample setting constituted adult ventilator dependent critical trauma and burn patients. Measurements assesed for early mobilization variables utilizing chi-square and t-test, (Clark, Lowman, Griffin, Matthews, & Reiff, 2012, p. 188). The chi-square test was used to determine whether the early mobility program's implementation groups differed by comorbidity status. A Cox proportional hazards model was used to estimate risk ratios (RRs) and 95% confidence intervals (CIs) for the association between early mobility program implementation and complication occurrence, (Clark, Lowman, Griffin, Matthews, & Reiff, 2012, p. 189). Findings revealed that use of a multidisciplinary approach increased collaboration, communication, and problem solving related to patient care. Nurses, physical therapists, respiratory therapists, and physicians worked together to prioritize patients' mobility needs. The early mobility program teams assumed accountability for their performance and developed selfmanagement skills that promoted ownership of goals and a shared decision-making process , (Clark, Lowman, Griffin, Matthews, & Reiff, 2012, p. 188). The results indicated that no
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CLINICAL QUESTION PAPER adverse events were related to the early mobility program. After adjusting for age and injury, there was a decrease in airway,pulmonary, and vascular complications (including pneumonia and deep vein thrombosis) post-early mobilty program. Ventilator days, ICU days, and hospital lengths of stay were not significally decreased, (Clark, Lowman, Griffin, Matthews, & Reiff, 2012, p. 186). Move to Improve: The Feasibility of Using an Early Mobility Protocol to Increase Ambulation in the Intensive and Intermediate Care Settings, (Drolet, et al., 2013, p. 197).

These are an AACN level of evidence C randomized control trials in one hospital setting intended to look into the clinical problem of prolonged bed rest in hospitalized patients leading to deconditioning, impaired mobility, and the potential for longer hospital stays, (Drolet et al., 2013, p. 197). The purpose of the study was to determine the effectiveness of a nurse-driven mobility protocol to increase the percentage of patients ambulating during the first 72 hours of their hospital stay, (Drolet et al., 2013, p. 197). A meta-analysis of 39 randomized controlled trials, (Drolet et al., 2013, p. 198), were studied and initiated the bases of the early mobility protocols for ventilator dependent adult critical care patients. A quasi-experimental design was used before and after intervention in a16-bed adult medical/surgical intensive care unit (ICU) and a 26-bed adult intermediate care unit (IMCU) at a large community hospital, (Drolet et al., 2013, p. 197). Data analysis was construed from three months of data (JanuaryMarch 2010) were collected before implementation of the mobility program to confirm consistency of baseline information. Post implementation data were collected for 6 months (MarchAugust 2011). To evaluate the impact of this initiative, we compared the frequency of ambulation for patients

CLINICAL QUESTION PAPER admitted to the ICU and IMCU, or who were transferred from the ICU to the IMCU, during these time periods, (Droplet et al., 2012, p.198). The findings showed that in the 3 months prior to implementation of the Move to Improve project,6.2% (12 of 193) of the ICU patients and 15.5% (54 of 349) of the IMCU patients ambulated during the first 72 hours of their hospitalization. During the 6 months following implementation, those rates rose to 20.2% (86 of 426) and 71.8% (257 of358), respectively, (Drolet et al., 2013, p. 197). The conclusion showed that a nurse-driven protocol significantly increased the number of patients who ambulated in the adult ICU and IMICU during the first 72 hours of their hospital stay, (Drolet et al., 2013, p. 202).

Significance to Nursing According to the research analyzed, standard nursing practice in the critical care setting can utilize this evidence in supporting rational in the implementation of early immobilization of adult ventilator dependent patients in a safe and effective way. Assessment of a patients readiness and stability is a key component to implementing early ambulation of adult ventilator dependent critical care patients. According to the American Nurses (ANA) Standards of Practice, accurate standard nursing assessment comprises prioritizing data collection based on the healthcare consumers immediate condition, or the anticipated needs of the healthcare consumer or situation, (Association, 2010, p. 32). Assessment done according to the ANA standards of practice will lead to the safe and effective implantation of early mobilization. Current nursing practice of turning ventilator dependent adult patients every two hours will change as the evidence of early mobilization is supported by strong clinical peer reviewed research like those reviewed in this project. The Quality & Safety Education for Nurses (QSEN)
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CLINICAL QUESTION PAPER conceptual model outlines how patient centered care along with teamwork and collaboration that utilizes evidenced based practice supports the quality improvement, safety, and positive patient outcomes that every registered nurse has agreed to uphold as their standards of professional nursing practice, (Byrnes, 2014). Evidence suggests that progressive mobility driven by nurses effective assessement and collaborated efforts to implement early ambulation in ventalator dependent adult patients will improve the quality and safety in the positive outcomes of acutely critical patients. This impacts the long held, yet not evidence based, rational that these patients should be minimally moved. The respected and easily assessable research discussed in this report suggests a change from current nursing practice of minimal movement into early mobilization. The benefits of early mobilization indicate improved short and long term functional outcomes, (Drolet, et al., 2013, p. 186 ), that outweigh the barriers of time involved or easily avoidable safety considerations. Early
mobility and ambulation does reduce post-intensive care syndrome in acutely ventilator dependent adult trauma patients and therefore should become a standard practice of nursing care, (Schweichert et al.,

2009, p. 1874).

CLINICAL QUESTION PAPER References

American Nursing Association. (2013, February). Online Journal of Issues in Nursing. Retrieved February 16, 2013, from Online Journal of Issues in Nursing: www.nursingworld.org/ojin Armola, R. R., Bourgault, A. M., Halm, M. A., Board, R. M., Bucher, L., Harrington, L., . . . Medina, J. (2009, August). Critical Care Nurse August 2009 vol. 29 no. 4 70-73. Critical Care Nurse, 29(4), 70-73. doi:10.4037/ccn2009969 Association of Critical Care Nurses. (2013). AACN's Healthy Work Environments Initiative. Retrieved March 21, 2013, from Association of Critical Care Nurses: http://www.aacn.org/wd/hwe/content/hwehome.pcms?menu=hwe Association, A. N. (2010). Nursing: scope and standards of practice. Silver Spring: Nursesbooks.org. Byrnes, M. (2014). A Conceptual Model of QSEN. Retrieved from QSEN Institute: http://qsen.org/aconceptual-model-of-qsen/ Clark, D. E., Lowman, J. D., Griffin, R. L., Matthews, H. M., & Reiff, D. A. (2012). Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study. Physical Therapy Journal, 93(2), 186-196. doi:10:2522/ptj.20110417 Davidson, J. E., Harvey, M. A., Schuller, J., & Black, G. (2013, May). Post-intensive care syndrome: what it is and how to prevent it. American Nurse Today, 8(5), 32-37. Retrieved from http://www.americannursetoday.com/assets/0/434/436/440/10226/10228/10232/10278/02ba 438f-5b12-484e-8165-df5d365354f5.pdf Drolet, A., DeJuilio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, E. A., . . . Williams, S. (2013). Move to Improve: The Feasibility of Using an Early Mobility Protocol to Increase Ambulation in the Intensive and Intermediate Care Settings. Journal of the American Physical Therapy Association, 197-207. doi:DOI: 10.2522/ptj.20110400 Mamedio, C., Andrucioli, C., & Nobre, M. R. (2007, May-June). pico para la contruccion de la pregunta de investigacion y la busqueda de evidencias. Rev Latino-am Enfermagem: Artigo de Atualizacao, 15(3), 508-511. Nieswiadomy, R. M. (2012). Foundations of Nursing Research. Upper Saddle River: Pearson Education. Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., Kress, J. P. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. The Lancet, 373(9678), 18741882. doi:10.1016/S01406736(09)60658-9

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Singleterry, L. (2014). NURS 350 Ferris State University springMETRO-2014.ls. Retrieved from NURS350 syllabus for METRO spring2014.: https://fsulearn.ferris.edu/bbcswebdav/pid-454933-dtcontent-rid-2851895_1/courses/12928.201401/NURS350%20syllabusMETROspring2014.ls.pdf

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