North Dakota Nurse - April 2021

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Page 8 The North Dakota Nurse April, May, June 2021 Appraised by: Kyra Lind SN, Sarah Huentelman SN, Chloe Evenson SN, and Samantha Eckroth SN (NDSU School of Nursing in Bismarck) Allison Sadowsky MSN,RN Assistant Professor of Practice (Faculty) Clinical Question: In intensive care patients, what are the effects of early mobilization on patient outcomes compared with intensive care patients not receiving early mobilization? Sources of Evidence: Clark, Diane E, Lowman, John D., Griffin, Russell L., Matthews, Helen M., Reiff, Donald A. (2013). Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: A retrospective cohort study. PubMed, 93(2), 186- 196. pubmed.ncbi.nlm.nih.gov/22879442/ Engel, H. J., Needham, D. M., Morris, P. E., & Gropper, M. A. (2013). ICU early mobilization: From recommendation to implementation at three medical centers. Critical Care Medicine, 41, 69- 79. doi:10.1097/ccm.0b013e3182a240d5 Engel, H. J., Tatebe, S., Alonzo, P. B., Mustille, R. L., & Rivera, M. J. (2013). Physical therapist– established intensive care unit early mobilization program: Quality improvement project for critical care at the University of California San Francisco Medical Center. Physical Therapy, 93(7), 975-985. doi:10.2522/ptj.20110420 Zafonte, R., Eikermann, M. (2016). Early, goal-directed mobilisation in the surgical intensive care unit: A randomised controlled trial. Lancet, 388(10052), 1377–1388. https://doi-org.ezproxy.lib.ndsu. nodak.edu/10.1016/S0140-6736(16)31637-3 Synthesis of Evidence: Intensive Care patients who do not receive early mobilization are at an increased risk for death or hospital readmission within one year of hospital discharge compared to those who receive early ICU physical therapy. Early mobility and rehabilitation of critically ill patients is associated with significant improvements in both short and long-term physical and neurocognitive outcomes in ICU survivors and resulted in shorter length of stays for patients in both the ICU and generalized hospital stays. Four articles were reviewed as evidence in this report: A retrospective analysis of a quality improvement project, a retrospective cohort study, a multicenter blinded randomized control trial, and a systematic review with an integrative approach. Engel & Tatebe et al. (2013) conducted a nine-month retrospective analysis of a quality improvement project. The analysis included patients admitted to the 9th floor medicalsurgical ICU at the UCSF medical center that were referred to the early mobility program by nurse practitioners. There was a total of 179 By: Jarren Fallgatter Featuring: Heidi Hilz, SN and CNA No one imagines living and working during a pandemic, however, as usual, healthcare workers persist on. The COVID pandemic has brought on a lot of change to the healthcare field, and it certainly had an effect on nurses, physicians, pharmacists, therapists, and assistants. One population that got put on the back burner in a lot of cases were the student nurses. In order to gain a better perspective, I chose to interview a fellow coworker, Heidi Hilz, on working and learning during this time. Heidi is a second-semester senior nursing student at North Dakota State University (NDSU) in Bismarck. In order to help pay for college and gain bedside experience, she also works as a certified nursing assistant (CNA) in the intensive care unit (ICU) at Sanford. Luckily, Bismarck was delayed compared to the rest of the country with the pandemic surge, but when COVID first hit in March, classes and clinical changed significantly; it all went online. When asked about the transition, Hilz said, “It was quite unfortunate and frustrating because nursing is a profession that requires a lot of hands-on work that a book doesn’t teach you. Therefore, having clinical online wasn’t ideal for learning. Early Mobilization for ICU Patients patients included in 2009 and 294 patients included in 2010. The intervention promoted was early mobilization. The findings compared patients from 2009 to 2010 and they showed that initiation of physical therapy decreased from three to two, distance walked in the ICU increased from 40 to 140 ft, ICU length of stay decreased from six to 4 days, hospital length of stay decreased from 14 to 12 days, percentage of patients discharged home increased from 55-77%, ICF rating level of assistance increased from three to four, and percentage of patients ambulating increased from 43 to 50. The project was ultimately successful, and the implementation was continued. The second study by Clark et al. (2013) created a retrospective cohort study of an interdisciplinary quality-improvement program. This study showed that patients who participated in early mobility demonstrated a decrease in hospital stay, as well as in nosocomial complications and adverse events. The study included 2,176 patients in the trauma and burns ICU at University of Alabama at Birmingham hospital. 1,044 of them were treated before the implementation of the early mobility program, and 1,132 were treated after. Overall, the study found that the hospital stays decreased by 2.4 days, and decreased occurrences of airway, pulmonary, and vascular complications. The third study by Zafonte and Kikermann (2016), conducted a multicenter, international, parallel-group assessory blinded randomized controlled trial. This randomized controlled study included a total of 200 participants, ages 18 years and older. Using these participants, this study examined the effects of early, goal direct mobilization on three main outcomes such as the mean Surgical Intensive Care Unit Optimal Mobilisation Score (SOMS) level patients achieved during their SICU stay, patient’s length of stay on SICU, and the Mini-Modified Functional Independence Measure Score (mmFIM) at hospital discharge. The interventions of this study involved a daily mobilization goal defined in morning rounding and early, goal directed mobilization implementation across shifts. It was implemented through closedloop communication of inter-professionals. In conclusion, the results showed a decreased length of SICU days, increased independent function-ability, and increased delirium free days in the interventional group compared to those in the control group. In the last article by Engel et al. (2013), three ICU early mobilization quality improvement projects are summarized utilizing the Institute for Healthcare Improvement Framework of Plan-Do- Study-Act. The article reviewed three different Learning and Working Through a Pandemic I missed clinical in specialty areas such as OB and NICU, which was hard because that would have been my only chance to experience that specific population of patients.” Meanwhile, as a CNA in the ICU, Hilz continued to provide patient care. In fact, the ICU cohort got the opportunity to work with and care for some of the sickest COVID patients in the area. Hilz was essentially living a double life. She understood that the school wanted to keep students safe and to decrease exposure to the patients, but she also saw first-hand the learning experiences that her classmates, that did not work directly in healthcare, were missing out on. She stated, “I work the COVID unit in the hospital and noticed that people with COVID sometimes needed much more care. I think that the pandemic could have been a great learning opportunity to see how the hospital and staff had to come together and adapt to such a dramatic change.” One year after COVID first impacted Bismarck, the virus is still not completely gone, nor is it going anywhere fast. Hilz is grateful that school is back to normal for the most part, even though the students are still not allowed to care for COVID patients. She stated, “COVID has brought on a lot of change to the healthcare field, and I am thankful to be back to class in person and attending clinical as usual.” Upon institutions that implemented early mobilization programs. The institutions reviewed included the medical ICU at Wake Forest University, the medical ICU at Johns Hopkins Hospital, and the mixed medical-surgical ICU at the University of California San Francisco Medical Center. The systematic review included a total sample size of 860 ICU patients. Outcome measures included frequency of therapy, adverse events, ICU and hospital length of stays, days until out of bed, pain and delirium scores, distance walked, discharge disposition, medication dosing, number of physical therapy consultations obtained, frequency and type of mobility used for each patient, days on a ventilator, and number of readmissions. Findings concluded that early mobilization in ICU patients is safe and feasible, patients received an increased number of treatments, decreased ICU and hospital length of stay, net cost savings for the hospital, decreased dosages of sedating medications made early mobilization possible, decreased delirium rates were found in ICU patients receiving early mobilization, no change in patient reported pain scores, patients were able to walk increased distances, and there was an increase in the number of patients who were able to discharge home rather than to a rehabilitation facility. Conclusions: All four articles indicated a decreased length of ICU stay with the implementation of early mobilization. Engel & Tatebe et al. (2013) showed sooner implementation of physical therapy as well as a decreased overall hospital stay. Clark et al. (2013) did not find a decrease in ICU length of stay but did find a decrease in overall length of hospital stay as well as a decrease in patient complications. Zafonte et al. (2016) showed an increase in functional independence at discharge with a decrease in delirium. Engel et al. (2013) showed early mobilization resulting in multiple positive patient outcomes including but not limited to decreased delirium, increased distances tolerated while walking, an increase in number of patients able to discharge home rather than to a rehabilitation facility, and overall net cost savings for the hospital. Implications for Nursing Practice: There is evidence to suggest implementing early mobilization in ICU patients could improve patient outcomes. An early mobilization program could help reduce patient length of stay in the ICU, increase the percentage of patients discharged home from the hospital, and save the hospital money. The effects of early mobility in ICU patients improves patient outcomes and should be a recommendation for practice. graduation, Hilz will become a nurse in the same ICU where she is a CNA, and she will assume care at a higher level for patients, including COVID patients. Overall, nurses have noticed the lack of skills and experience in new graduates, due to no fault of their own; online clinical and class proved to be not as effective as the handson clinical. But just like anything, nurses will continue to roll with the punches, educate the new, and adapt to whatever comes. Jarren and Heidi
April, May, June 2021 The North Dakota Nurse Page 9 Noise Reduction in NICU Patients Appraised By: Kelsie Gustin SN, Heidi Hilz SN, Lisa Wentz SN, Kaitlynn Fuhrmann SN, and Katherine German SN (NDSU School of Nursing at Sanford Bismarck) Allison Sadowsky MSN, RN Assistant Professor of Practice (Faculty) Clinical Question: - Does noise reduction/quiet environment influence the overall health status of NICU patients during their stay in the NICU? Sources of Evidence: Abdeyazdan, Z., Ghasemi, S., Marofi, M., & Berjis, N. (2014). Motor Responses and Weight Gaining in Neonates through Use of Two Methods of Earmuff and Receiving Silence in NICU. The Scientific World Journal, 2014, 1-5. doi:10.1155/2014/864780 Abdeyazdan, Z., Ghassemi, S., & Marofi, M. (2014). The effects of earmuff on physiologic and motor responses in premature infants admitted in neonatal intensive care unit. Iranian journal of nursing and midwifery research, 19(2), 107–112. Casavant, S. G., Bernier, K., Andrews, S., & Bourgoin, A. (2017). Noise in the Neonatal Intensive Care Unit: What Does the Evidence Tell Us? Advances in Neonatal Care, 17(4), 265-273. Khalesi, N., Khosravi, N., Ranjbar, A., Godarzi, Z., & Karimi, A. (2017). The effectiveness of earmuffs on the physiologic and behavioral stability in preterm infants. International Journal of Pediatric Otorhinolaryngology, 98, 43-47. doi:10.1016/j.ijporl.2017.04.028 Smith, S., Ortmann, A., & Clark, W. (2018). Noise in the neonatal intensive care unit: A new approach to examining acoustic events. Retrieved October 25, 2020, from https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC6122266 Synthesis of Evidence: Five articles were reviewed as evidence in this report. A thorough review was conducted resulting in three randomized control trials, one correlational study, and one systematic review relevant to the clinical question. Compared to the intrauterine environment, the NICU is an excessively complex and noise-filled environment. The immature auditory systems in preterm infants make them highly susceptible to excess noise, which can negatively affect their ability to self-regulate. This inability to self-regulate the body can lead to prolonged ventilation, apnea, sleep disturbances, changes in respiratory and heart rates, and nutritional requirements. Furthermore, the excessive noises prevalent in the NICU setting have shown to be negatively impactful on preterm infant’s developmental and health statuses. In the first study by Abdeyazdan, Z., Ghassemi, S., & Marofi, M. (2014) a randomized control trial was conducted. This study showed the effects between earmuffs and silence versus normal routine cares, and how those interventions affected preterm infant’s weight gain and motor responses. 108 preterm infants who stayed in the NICU were included in the study. There were 12 total dropouts due to discharges and apnea spells. Infants were placed into the three different groups by a coin toss. Silence hours and earmuffs were implemented from 9-11 am, 4-6pm and 11pm- 5am as well as during routine cares. The study concluded that implementation of both silence hours and earmuffs were effective in increasing weight gain and decreasing motor responses in preterm infants in the NICU. The second study by Abdeyazdan, Z., Ghassemi, S., & Marofi, M. (2014) was a randomized control trial. The study was conducted to examine the effects of earmuffs on the physiologic and motor responses of premature infants in the NICU. The study consisted of 64 premature infants who were randomly assigned to study and control groups. Within the study group there were 22 males and 10 females, and within the control group there were 19 males and 13 females. The study group’s intervention consisted of wearing earmuffs from 9:00am-11:00am and 4:00-6:00pm along with routine treatments and care. The control group received only routine treatments and care. The results of the study concluded that the use of earmuffs on premature infants during the morning and afternoon periods improves physiologic and motor responses, including increased arterial O2 saturations, decreased heart and respiratory rates, and decreased motor responses. The study by Khalesi, N., Khosravi, N., Ranjbar, A., Godarzi, Z., & Karimi, A. (2017) was a crossed over controlled trial. The study was conducted at Aliasghar Hospital (Tehran, Iran) in 2014. Thirty-six preterm infants who were cared for in closed incubators were assigned to group A or B. On the first day group “A” wore a pair of silicon earmuffs while group “B” wore nothing. On the second day the groups switched, and group “B” wore the earmuffs while “A” wore nothing. During the two consecutive days, all subjects were observed as their own controls (without earmuffs). Throughout the study physiologic (body temperature, heart rate, respiratory rate, systolic, diastolic pressures, arterial oxygen saturation) and behavioral responses (according to the Anderson Behavioral State Scoring System) were assessed every two hours from 8am-4pm for the two consecutive days. The results showed that the application of earmuffs could decrease heart and respiratory rate while also increasing the amount of oxygen saturation. Smith, S., Ortmann, A., & Clark, W. (2018) conducted a correlational study, to see if reducing the noise in the neonatal intensive care unit had an effect on the infants. The study was conducted in a level IV NICU at St. Louis Children’s Hospital, which included three critically ill infants. Two infants were placed in a shared room, and the third infant was in a private room. A Greenwhich Mean Time (GMT) synced clock was used to track the onset and duration of the acoustic events. Different sound levels were tested at various times and the infants physiological state was assessed by their heart rate and oxygenation status. Several times there were changes in the heart rate during an acoustic event. However, respiratory responses were inconsistent. The infants did have large disturbances when the acoustic environment was stable, however the patients are critically ill they are more easily susceptible for physiological changes. Both baby B (in an open room) and C (in a private room) showed significant physiological changes during acoustic events but baby A (in an open room) remained stable. The results showed that noise does overall effect the physiological state of the infant, by decreasing the noise levels the infants physiological state would remain relatively stable. Casavant, Bernier, and Andrews (2017) looked at twenty different studies comparing noise reduction measures within the NICU setting. They searched four different databases: ScienceDirect, PubMed, CINAHL, as well as the Cochrane Database of Systematic Reviews. Bottineau, ND Full-Time RN/LPN Also hiring CNAs and CS/ER Technicians Competitive Salary, Shift Differential ND licensure/certification required. SIGN-ON BONUS For more information or an application, please contact Human Resources at 228-9314 or visit our website at www.standrewshealth.com The studies that were included in the review consisted of NICU departments that were level three (respiratory support, intravenous fluids, and care for babies born 28 weeks or greater), or above, as well as neonates having been born before 32 weeks gestational age at birth. The studies that were conducted found that education and awareness to staff was a crucial aspect of decreasing noise levels as well as the need to implement these interventions in order to promote neonatal neurodevelopment and growth. Conclusions: Critically ill infants in the neonatal intensive care unit (NICU) go through extensive amounts of stress and physiological changes as they are developing. Excessive environmental changes can impact the infants and cause stress; there are various strategies to decrease environmental stressors such as excessive noise. Through the use of earmuffs on infants in the NICU for a minimum of two hours in the morning and afternoon periods, significant improvements in both physiological and motor responses can be made. In addition, making an effort to minimize preventable noises from the nurses working in the NICU and implementing “quiet time” periods can improve infant physiologic responses as well. Although eliminating all noises is not possible, as some are emergency alarms, reducing the amount of added noise is beneficial. Implications for Nursing Practice: Specific techniques that can be implemented to reduce the effects of noise on NICU patients would include earmuffs, quiet time periods, private rooms, clustering cares, and decreasing traffic through patient rooms. By decreasing the amount of noise, it can reduce an infant’s stress response and improve their overall health status during their stay in the NICU, therefore, benefiting the patient. JOIN OUR WINNING TEAM! Up to $15,000 student loan repayment with a 5 year commitment as well as a $5,000 sign on bonus Now Recruiting! STAFF RNs, OB & SURGERY CIRCULATING APPLY ONLINE AT www.wrhs.com
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