Case study management of a medical unit
Sign in. October , Volume Number 10 , p 34 - Overview: For many patients, hospitalization brings prolonged periods of bed rest, which are associated with such adverse health outcomes as increased length of stay, increased risk of falls, functional decline, and extended-care facility placement. Most studies of progressive or early mobility protocols designed to minimize these adverse effects have been geared toward specific patient populations and conducted by multidisciplinary teams in either ICUs or surgical units. Very few mobility programs have been developed for and implemented on acute care medical units.
This evidence-based quality improvement project describes how a mobility program, devised for and put to use on a general medical unit in a large Midwestern academic health care system, improved patient outcomes. Bed rest is well known to have numerous adverse effects on the human body see Table 1. For a variety of reasons, however, hospitalized patients spend most of their time in bed, even when they are able to walk. For example, a study of 45 elderly patients on a general medical unit, who had neither delirium nor dementia and were able to walk prior to admission, found that they spent an average of 20 out of every 24 hours in bed over the mean 5.
Patients, nurses, and physicians have identified the following barriers to patient mobility 5 :. Most literature related to mobility programs or protocols focuses on patients in ICUs.
In such settings, multidisciplinary early mobility programs have reduced ventilation days, rates of hospital-acquired infection, and lengths of both ICU and hospital stays. The few mobility studies that have been conducted outside of an ICU have been limited in scope, focusing on the impact of mobility in specific patient populations, such as postsurgical patients and those with deep vein thrombosis, community-acquired pneumonia, or functional decline. A review of studies that compared the effects of early mobilization and compression versus bed rest on patients with acute deep vein thrombosis suggested that mobilization and compression significantly reduced the incidence, severity, and recurrence of postthrombotic syndrome while posing no greater risk of thrombus.
There is little literature on use of mobility protocols on acute care medical units like ours, a bed general medical unit in a Midwestern hospital that primarily treats adults with medical conditions such as sepsis, hypertension, acute and end-stage renal disease, end-stage liver disease, diabetes, diabetic ketoacidosis, and dementia, and cares for relatively few surgical patients. Findings common to the various mobility studies, however, include the need for collaboration among disciplines and sustainable, standardized mobility guidelines.
These findings, in combination with the limited activity noted among patients on our general medical unit, prompted us an interdisciplinary team to consider intervening through the initiation of a quality improvement project. The purpose of this project was to determine whether an early mobility program would improve patient outcomes on our unit. We would determine the efficacy of the program by comparing patient lengths of stay, hospital readmission rates, and the incidence of unit falls and pressure ulcers both before and after program implementation.
According to the institutional review board, this quality improvement project did not require human subjects approval. The framework for this project was the Iowa Model of Evidence-Based Practice to Promote Quality Care, which incorporates research utilization and emphasizes the application of current best evidence to guide the delivery of health care services. Together, we decided that it would be appropriate to develop and pilot an early mobility program on our unit.
Planning the intervention. Team members possessed both clinical expertise and knowledge of quality improvement methodologies. The school of nursing representative assisted in design, data collection, and data interpretation. Led by the CNS, the team met on several occasions to review current literature, develop inclusion and exclusion criteria, and create the program's protocol and interventions. Exclusion criteria, developed to ensure patient and staff safety, were as follows:.
With these exceptions, all patients admitted to the unit between April and June of were eligible to participate and were expected to benefit from the program. Depending on whether they could walk independently, patients who participated in the program were assigned to one of two activity tiers and encouraged to perform activities in their assigned tier at least three times daily with assistance or oversight see Table 2 for more details on the program.
While the specific activities each patient performed daily were based on the physical therapist's recommendations, the protocol tiers were developed by the multidisciplinary team and derived from mobility literature. The 'mobility aide' role. The unit nurse manager assigned the team's nursing assistant to function as a mobility aide during her scheduled shifts.
Under the direction of the nursing staff and the unit physical therapist, the mobility aide assisted patients with appropriate interventions three times a day and performed regular nursing assistant duties the rest of the time. The project team set a kickoff date of April 2, , and provided patients and family members with handouts a day in advance that described the mobility protocol and the importance of being active.
Although the mobility aide carried out the majority of the interventions, nurses and family members were asked to encourage patients to participate in the program and to assist them when the aide was unavailable. Before program initiation, the physical therapist taught the mobility aide about body mechanics, active and passive range of motion, use of a gait belt, and how to perform basic transfers helping patients move from bed to chair, for example.
She also taught the aide terms commonly used by physical therapists to describe assistance requirements such as "minimum assistance" to refer to a one-hand assist and reviewed these terms with the nursing staff.
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The physical therapist also met with the unit nurses to describe the mobility protocol and address any questions or concerns. When such a formal evaluation was needed, the physical therapist would notify the patient's nurse, who in turn would notify the physician.
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After a patient received a formal evaluation, the physical therapist communicated with the nurses and mobility aide by hanging a mobility instruction sheet in the patient's room to specify any mobility precautions and the required level of assistance. Although the hospital provides a standard form for use by all physical and occupational therapists, this form was modified for the purpose of the mobility program to indicate the patient's tier level.
The mobility aide would then assist or supervise the patient in performing activities prescribed on the modified instruction sheet. The physical therapist evaluated and treated only patients who had a physician's order for skilled therapy. Both process and outcome measures were collected for the purpose of program evaluation.
The primary process metric was the frequency of patient completion of activity sessions. Each patient received an overall early mobility achievement score, which was calculated by dividing the number of activity sessions in which a patient participated by the number of sessions in which she or he should have participated. A patient hospitalized for four days, for example, should have participated in at least three activity sessions per day, or a total of 12 sessions for the entire stay.
First, s he must adopt the stance suggested by the characteristics of the naturalist paradigm. However, every construct of each paradigm has different connotations depending on the underpinning theoretical framework.
A Mobility Program for an Inpatient Acute Care Medical Unit
A paradigm is the set of beliefs or world-view that frames how a researcher sees, studies and interprets knowledge McKenzie and Knipe, , which influences what they will research and how they will conduct their research. Students have to conduct case studies when undertaking their studies, especially; in the social sciences and business field because this research methodology is more applicable in these fields.
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Fewer patients assigned to the intervention group were discharged to long-term care institutions or lived in them during the three months after discharge. For every 15 patients treated in the intervention unit, 1 more patient was returned home than from the usual-care units, and 1 less patient was admitted to a long-term care institution.
The beneficial effects we observed were apparently achieved without increasing in-hospital or post-discharge costs.
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Nevertheless, it is important to emphasize that the functional status of the majority of patients in both groups was unchanged or worse at the time of discharge. Three months after discharge, the groups did not differ significantly in terms of their ability to perform basic or instrumental activities of daily living. Despite the dramatic benefits of geriatric evaluation and management at the end of acute care hospital stays for at least some patients, 34,35 consultative and unit-based interventions to improve the functional outcomes of acutely ill hospitalized older persons have had little benefit.
Two earlier studies 44,45 also involved nurse-initiated interventions; both of these studies found evidence of beneficial effects. We recognize potential limits to the validity of our findings. The impracticality of blinding patients and interviewers to the treatment assignments may have biased the reports of outcomes. To obtain reports about health status for all patients, proxy reports were required in many cases, and reports from patients and proxies may differ.
Different outcome measures consistently indicated that the intervention had a beneficial effect. The better function in the intervention group than in the usual-care group at the time of discharge was consistent in subgroup and multivariable analyses. Finally, bias in the design and conduct of the study was reduced by the random assignment of patients, the use of measures with established validity and reliability, and the complete follow-up data for the main outcome variable.
Our study was designed to test the efficacy of the Acute Care for Elders program as a whole, rather than to determine the relative efficacy of its different components, its cost effectiveness, or its long-term effects. Further evaluation will be necessary to address these issues and to test the effectiveness of this approach in other settings.
The loss of functional independence is not an inevitable consequence of acute illness and hospitalization among older patients. The intervention we studied can serve as a model for improving aspects of overall function — indicated by the ability to care for oneself — that are not specifically related to a particular disease or treatment.
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Although functional outcomes are rarely the focus of conventional medical care, they may be critical determinants of the quality of life, independence, cost of care, and prognosis among older patients. Supported by grants from the John A. We are indebted to Michael Vender, M. Reuben, M.