A team approach to the introduction of safe early mobilisation in an adult critical care unit

Abstract

Delirium and intensive care unit acquired weakness are common in patients requiring critical care and associated with higher mortality and poor long-term outcomes. Early mobilisation has been shown to reduce the duration of both conditions and is recommended as part of a strategy of rehabilitation of critically ill patients starting during their stay in intensive care. Our aim was to achieve 95% reliability with a standardised mobilisation process. Multidisciplinary involvement through the use of regular focus groups lead to the development of a standardised process of sitting a ventilated or non-ventilated patient at the side of the bed for a set period of time, which was called the daily dangle. Team learning from Plan, Do, Study, Act (PDSA)cycles, as well as feedback from both staff and patients, allowed us to develop the process and achieve a median 87% reliability. Delirium rates fell from 54.1% to 28.8%. There was no change in average length of stay, and no adverse events. Ownership by the staff, development of the process by staff, iterative testing and learning, and designs for reliability were the factors behind the successful adoption of a new and challenging process. Particular changes which drove reliability were standardisation of the criteria for a dangle, standardisation of the dangle itself and a reminder included on the daily goals checklist.

Keywords: Continuous Quality Improvement; Critical Care; Pdsa; Quality Improvement; Teams.

Figure 1

Initial protocol for daily dangle. BMI, body mass index; ICU, intensive care unit; ETT, endotracheal tube; FiO₂, inspired oxygen fraction; PEEP, positive end expiratory pressure.

Figure 2

Revised protocol for daily dangle. BMI, body mass index; ETT, endotracheal tube; FiO2, inspired oxygen fraction; ICU, intensive care unit; PEEP, positive end expiratory pressure.

Figure 3

Proportion of patients who had a daily dangle. (PM - afternoon)

Figure 4

U chart average length of stay. (PM - afternoon)

Figure 5

Proportion of all patients included in the delirium sample. ICU, intensive care unit.

Figure 6

Proportion of patients screened for delirium who had delirium. (PM - afternoon)

Figure 7

U chart average length of stay on ventilator. PM, afternoon.

Figure 8

Monthly proportion of patients who had a dangle, with delirium, and average length of stay. ALOS, average length of stay; ICU, intensive care unit.