NURS 8750 Week 10 Manuscript Draft Example

A Nurse-Led Screening and Mobilization Routine for Ventilated Adults in a Community ICU Without Dedicated Therapy Staff: A Quality Improvement Report

Student Name

College of Nursing, Walden University

NURS 8750: Doctoral Seminar V

Instructor Name

Month Day, Year

A Nurse-Led Screening and Mobilization Routine for Ventilated Adults in a Community ICU Without Dedicated Therapy Staff: A Quality Improvement Report

Target Journal and Preparation Notes

Target: BMJ Open Quality, which publishes quality improvement reports and asks authors to follow SQUIRE 2.0 (Ogrinc et al., 2016). The draft below uses the SQUIRE section order. It was cut to the journal's limit for quality improvement reports, as stated in its author instructions on the day of drafting, before any submission. Tables and the run chart are submitted as separate files and are summarized here in text.

Problem

In our community intensive care unit (ICU) of 14 beds, patients on invasive mechanical ventilation rarely sat up. Looking back over four months of charts, eligible ventilator days included edge-of-bed sitting only 18% of the time, and 31 of the 40 patients reviewed never got there while intubated. The unit shares one physical therapist with the hospital's 160 beds on weekdays and has none at weekends. Early activity is feasible and safe within consensus criteria (Hodgson et al., 2014), and its benefit appears clearest where baseline activity is low (Schweickert et al., 2009; TEAM Study Investigators, 2022). The aim was for half of all qualifying ventilator days to include sitting at the edge of the bed (scored as 3 or higher on the mobility scale) by June 30, up from 18%.

Intervention

At the 0400 assessment, night nurses screened each ventilated adult against the consensus safety criteria and wrote the result and any reason for failure on the bedside whiteboard. At the 0900 round the charge nurse read results aloud, and physicians stated any override. Once rounds ended, the day nurse called a respiratory therapist to each bedside with a pass, and the pair helped the patient as far as was safe. Sessions stopped at fixed thresholds for oxygen saturation, mean arterial pressure, heart rate, agitation or device displacement. Emergency department calls took priority over any planned session. Staff learned the routine in eight-minute huddle segments, with a paired first session for each day nurse.

Before launch, the routine was tested for two weeks on paper, and two changes followed: the whiteboard gained a line for the reason a screen failed, so day staff could recheck when the reason resolved, and the round checklist gained a prompt for the charge nurse to read the screen results before any other item for ventilated patients. Staff were not paid or given protected time beyond the huddle segments, and no new equipment was bought apart from markers and gait belts for each room.

Study of the Intervention and Measures

A four-week prospective baseline (January 5 to February 1) was followed by two Plan-Do-Study-Act cycles: the night screen alone from February 2, and the respiratory therapist call from February 9. The outcome measure was the weekly share of qualifying ventilator days (at least 24 hours of ventilation at midnight, with four clinical exclusions) on which the highest recorded level was 3 or more; days with no level recorded counted as not reaching it. Process measures counted how many screens were charted before 0600 and how many passes led to a session. Balancing measures were sessions stopped under the rules or with any fall or dislodgement per 100 sessions, and median response time to late-morning emergency department ventilator calls. Data came from a saved flowsheet report and the respiratory therapy paging log. Weekly points were plotted on run charts against the baseline median and interpreted with the published probability rules for run charts (Perla et al., 2011).

Two reviewers applied the operational definition independently to twenty baseline records and agreed on nineteen after written rulings for borderline cases. One weekday a week, chosen at random, an observer recorded the level reached for one patient without telling the nurse, and the observer's level agreed with the flowsheet entry in 11 of 12 checks.

Ethical Considerations

The hospital's quality improvement committee approved the project. The ethics board determined that the work did not require full review and approved the staff interview procedures with conditions on consent and storage.

Results

Over 276 qualifying days from 49 patients, the proportion of sitting-up days went from 22.2% (20 of 90) before the routine to 40.3% (75 of 186) over its first eight weeks. All eight protocol weeks lay above the baseline median, a shift beginning in the first week; weekly values from March ranged from 42.9% to 48.0%. On weekdays, sitting-up days rose from 15 of 64 (23.4%) to 64 of 134 (47.8%). On weekends they were 5 of 26 (19.2%) and 11 of 52 (21.2%). Screens were recorded by 0600 on 90.3% of weekday and 71.2% of weekend protocol days, and passed screens were acted on 85.4% and 50.0% of the time. Six of 81 sessions (7.4 per 100) stopped under the rules, all at or before the edge-of-bed position, with values recovering within 15 minutes; there were no falls or dislodgements of tubes or lines. Median emergency department response time was 6 minutes on seven calls, against 4 minutes on eight calls over February and March a year earlier. Counting blank-level days as successes gave 26.7% and 45.7%.

Discussion

After the routine began, weekday sitting became far more common in a unit that has no therapy staff of its own. The weekday rise is consistent in direction with trials of early physical and occupational therapy (Schweickert et al., 2009), though this project measured activity, not function. The stopped-session rate was higher than the 2.6 potential safety events per 1,000 sessions reported in a systematic review (Nydahl et al., 2017); every threshold crossing was counted, and five of six stops occurred in a patient's first session, which led to pairing first sessions with the physical therapist where possible. The weekend result reflects staffing that the routine did not address.

Limitations. Lighter default sedation orders started one day before the routine, and the design cannot separate their effect from it. The setting is a single unit, the baseline was four weeks and the response-time measure rests on seven calls. Length of stay and function at discharge were not measured.

Conclusions. A routine that gives nurses the daily decision about mobility can make sitting up ordinary on weekdays in a small ICU. Units without weekend therapy cover should expect a weekend gap and design for it separately.

References

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

Nydahl, P., Sricharoenchai, T., Chandra, S., Kundt, F. S., Huang, M., Fischill, M., & Needham, D. M. (2017). Safety of patient mobilization and rehabilitation in the intensive care unit: Systematic review with meta-analysis. Annals of the American Thoracic Society, 14(5), 766-777. https://doi.org/10.1513/AnnalsATS.201611-843SR

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

Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., Spears, L., Miller, M., Franczyk, M., Deprizio, D., Schmidt, G. A., Bowman, A., Barr, R., McCallister, K. E., Hall, J. B., & Kress, J. P. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. The Lancet, 373(9678), 1874-1882. https://doi.org/10.1016/S0140-6736(09)60658-9

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