NURS 8730 Week 11 Final Implementation Plan Example

One Argument From Aim to Routine: The Implementation Plan for Nurse-Led Early Mobilization of Ventilated Adults in a Fourteen-Bed Community ICU

Student Name

College of Nursing, Walden University

NURS 8730: Doctoral Seminar III

Instructor Name

Month Day, Year

One Argument From Aim to Routine: The Implementation Plan for Nurse-Led Early Mobilization of Ventilated Adults in a Fourteen-Bed Community ICU

Aim and Problem

Aim. By June 30, half of all qualifying ventilator days in the ICU will include a seated position at the bedside or better, up from 18% in the retrospective review.

Problem. Patients ventilated in this 14-bed community ICU rarely move. In the four months reviewed before the project, they reached sitting at the bedside on fewer than one day in five, and 31 of 40 patients never did so while ventilated. Larger trials show that structured mobilization improves function at discharge when patients would otherwise receive little, and that within agreed safety criteria it rarely causes serious harm, while adding more activity where patients already move a good deal has not helped later outcomes (TEAM Study Investigators, 2022). This unit is a low-baseline unit, and that is where the evidence is most favorable. What the unit lacks is not knowledge but a routine that makes mobilization happen on ordinary days without a dedicated therapist.

The Unit in Operational Terms

The ICU runs with six or seven nurses per shift, most caring for two patients, a charge nurse without an assignment, respiratory therapists shared with the emergency department and one physical therapist for the whole hospital on weekdays only. An average day has four or five ventilated patients. The working day leaves a realistic window for mobilization between 1000 and 1200, after handover, medications, breathing trials and the 0900 interdisciplinary round. Nights carry the 0400 full assessment and have no therapist cover after midnight beyond one shared respiratory therapist. About a tenth of shifts are filled by agency nurses, more on weekends. These facts shape every element below.

The Intervention

At the 0400 assessment, the night nurse screens every ventilated adult using the consensus criteria for mobilizing ventilated adults (Hodgson et al., 2014), covering respiratory, cardiovascular, neurological and other conditions, and writes pass or not pass, with the reason, on the bedside whiteboard and in the flowsheet. At the 0900 round, the charge nurse reads each result aloud; a physician who overrides a passed screen says why, and the board is updated. After the round, the day nurse pages the respiratory therapist for each patient who passed, and together they help the patient reach the highest level that is safe, starting with a seated position on the side of the mattress. Sessions stop under fixed thresholds for saturation, heart rate, blood pressure, distress or dislodgement, and every stopped session is reported on a half-page form. At 1800, the day nurse enters the highest level reached that day on the ICU Mobility Scale. Emergency department pages always take priority over a scheduled mobilization.

People and Preparation

Nine roles carry the plan: the medical director, who signs the protocol; the nurse manager, who owns huddles and the event review; the educator, who teaches; two champions, one on nights and one on days; the three night charge nurses, who make sure the screen happens on nights without the champion; the respiratory therapy supervisor; the intensivists, who agree to state overrides aloud; and the project lead. Preparation is done in eight-minute huddle segments, repeated across two weeks so every nurse attends, with a separate segment for respiratory therapists and a paired first session for every day nurse. Agency nurses find a one-page summary at each ventilated bedside. Competence is checked inside existing work: weekly observation of one mobilization attempt, nightly review of five whiteboards and the paired first session.

Schedule

The plan runs fourteen weeks before routine operation. Weeks 1 to 5 secure approvals, meet each night charge nurse, revise the screen from their feedback and build the flowsheet field. Weeks 6 to 10 teach recording and run a four-week prospective baseline in which the scale is recorded and nothing else changes, with screen and stopping-rule teaching in the last two baseline weeks. Week 11 tests the night screen alone; week 12 adds the respiratory therapist call; week 13 completes paired sessions; week 14 reviews the first month and chooses the third cycle. Two dependencies govern the order: the flowsheet field, without which nothing can be measured, and the night charge nurses, without whom the first step does not happen. If the field is late, the baseline runs on paper tally sheets.

Measures

Five measures are charted, weekly for the first eight weeks of data and monthly after that. The outcome measure is the aim itself, qualifying days at scale level 3 or above divided by all qualifying days, with failed screens and blank entries kept in the denominator. Two process measures separate the protocol's two links: screens recorded by 0600, and passed screens followed by an attempt. Two balancing measures watch for cost: sessions stopped under the safety rules or with any dislodgement or fall, per 100 sessions, and the median response time of respiratory therapists when the emergency department pages them for a ventilator during the 0900 to 1200 window. Contextual records note three-patient assignments, sedation assessment documentation and any other practice change, including the new sedation order set that begins the same month as the protocol. Data come from a saved flowsheet report and the paging log, extracted on Mondays by a written routine that someone other than the project lead can run.

How Results Will Be Read

Change will be judged on run charts using published rules for shifts, trends, runs and astronomical points (Perla et al., 2011), with each improvement cycle marked on the chart. A shift in the outcome measure will be read alongside the process measures to see which link moved, and alongside the balancing measures to see what it cost. Because the sedation order set changes in the same month, the plan does not claim that the protocol alone caused any rise; it will report the overlap. The plan also does not claim effects on function at discharge or later, which the unit is too small to detect.

Oversight

The quality improvement review committee approves the protocol and the safeguards for staff interviews planned for month three. Because results are intended for presentation and publication following SQUIRE 2.0 (Ogrinc et al., 2016), the hospital's ethics board will also be asked for a determination before any interview is recorded. The nurse manager looks at every adverse event during a session by the end of the next day.

Keeping It Running

A plan that works for a project term and then stops has not changed the unit. Three steps aim to keep the routine going after the doctoral project ends. The flowsheet field and the saved report stay in place, so the measure keeps producing itself. The screen becomes part of the 0400 assessment template rather than a separate task, so it survives turnover. And a line is added to the night charge nurse role description making the charge nurse responsible for the screen on nights without a champion. Implementation research describes this movement from initial use to full operation, where a practice no longer depends on the people who introduced it, as the stage at which most changes are lost (Fixsen et al., 2005). The plan is written so that the unit, not the project, owns the routine by the time the run charts reach June.

References

Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network.

Hodgson, C. L., Stiller, K., Needham, D. M., Tipping, C. J., Harrold, M., Baldwin, C. E., Bradley, S., Berney, S., Caruana, L. R., Elliott, D., Green, M., Haines, K., Higgins, A. M., Kaukonen, K.-M., Leditschke, I. A., Nickels, M. R., Paratz, J., Patman, S., Skinner, E. H., . . . Webb, S. A. (2014). Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Critical Care, 18(6), Article 658. https://doi.org/10.1186/s13054-014-0658-y

Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992. https://doi.org/10.1136/bmjqs-2015-004411

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895

TEAM Study Investigators and the ANZICS Clinical Trials Group. (2022). Early active mobilization during mechanical ventilation in the ICU. New England Journal of Medicine, 387(19), 1747-1758. https://doi.org/10.1056/NEJMoa2209083