Research Analysis
This is a research analysis of an article titled “STEP-UP: Study of the Effectiveness of a Patient Ambulation Protocol” by authors C. R. Teodoro, K. Breault, C. Garvey, C. Klick, J. Obrien, T. Purdue, A. Stolaronek, H. W. Wilbur and L. Matney. This article is a study of the effects of implementing a patient ambulation protocol on a medical-surgical floor in a community hospital.
Problem
The problem identified by the researchers was the lack of an effective ambulation protocol in hospitals for patients with ambulation orders. Immobility results in a plethora of secondary issues such as deep vein thrombose, pressure ulcers, and loss of mobility; these can lead to increased length of stay and costs to both patients and the
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hospital. Often ambulation orders are in place but for many reasons (too few staff, ineffective delegation, etc.) these orders are not carried out. Previous attempts at fixing this problem have focused on starting ambulation earlier. This has shown to be effective in multiple studies however the authors felt that a different approach, increased ambulation education, and encouragement, could lead to better results. By increasing ambulation, we can decrease the risk for secondary issues, provide improved physical and mental health and increase patient satisfaction. This study is significant to nursing because experts suggest that ambulation programs are important in increasing ambulation at hospitals and having specified programs can help orient healthcare personnel to ambulation goals and help to make it a necessary part of a nurse’s routine. The purpose of the study was to determine if a formalized ambulation program consisting of videotaped instruction and daily patient reminders could improve ambulation order compliance in hospitalized medical-surgical patients (Teodoro et al., 2016). Method Study Design The study was conducted on a 30-bed medical-surgical unit of a community-based hospital in northeastern united states. Before beginning study, approval was obtained from the Institutional Review Board of the facility the study occurred a time period of 5 months (September 2011 – February 2014 ). A pretest/posttest, randomized, experimental design was used to Comair a planned ambulation program to usual care. the two modes of care were defined as follows. Ambulatory program: daily goals for walking an educational videotape walking reminders. Usual care included no formal program. The primary outcome variable was the amount of patient ambulation measured in steps per hour (Teodoro at al., 2016). Sample Selection The sample was selected from patients on an inpatient medical-surgical unit with the following criteria: an estimated length of stay of greater than or equal to three days, an age of eighteen years or older, medical order for ambulation, no restrictions, ability to ambulate and alert and oriented times three.
Following informed consent, the patients were studied over a three-day period. Group assignment was determined via computer randomization program on the first day of monitoring (Teodoro et al., 2016).
Instrument
Amount of ambulation was determined by recording distance traveled in steps captured with a pedometer (ShrinQ, Model 304, Sportline, Hazleton, PA). this device was clipped to the gown by researcher and not removed until study conclusion. The number of steps recorded was transcribed as an average number of steps walked per hour for designated period of the day (Teodoro et al., 2016)
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Procedure Prior to the study, all investigators were trained in proper use of pedometer including clearing memory and recording. During the pre-test period on the first day, the study consenting patients had pedometers attached to their gown at 1100 after memory was cleared, no special instruction was given to the patient. The pedometer was removed by a researcher at 1800 on the same day and steps were recorded. These first day steps were to establish a baseline for both groups and to ensure similarity. at the end of the first day, patients were randomly assigned, groups. During 1800 to 2100 the ambulation group was asked to watch a two and a half min educational video on ambulation importance and to set goals for the next two days by asking the patient to estimate how far they would walk and double it for the third day. On the second and third day of the study the pedometer was placed at 0700 and removed at 1100 by a researcher, and steps were recorded. Data was then entered into a data analysis program (ANOVA) which summarized it using descriptive statistics (Teodoro et al., 2016) Findings Results The main findings of the study are that patients in the ambulation increased ambulation and the patients in the usual care group decreased ambulation, whereas before the program no significant difference was found. The ambulatory group increased from 244± 228.9 Steps/hr to 279.5 ± 214.2 then to 290.6± 238.7 Steps/hr, however, the usual care patients fell nearly the same amount from 238.8±205.2 Steps/hr to 203.9±155.4 Steps/hr then to 155.5±103.3 steps/hr. The authors stated that these results showed that this was a successful program, however they state that the decrease in the non-ambulation group was unexpected and the reason why this happened was not known (Teodoro et al., 2016). Objectivity The statistics were provided upfront with data and graphs, the data appears to match the data provided. Some equations weren’t provided, such as their equation for choosing a sample size which was able to show a 133% increase, their rationale for choosing this number is unclear. Later it is stated that “Student’s t-test and chi-square analysis were used to compare demographic and patient characteristic data between the two groups” (Teodoro et al. 2016, p 114); however, there was no other mention of students in the article, and this data is not made available. Another problem I see with their objectivity is their lack of discussion about their unexpected drop in the usual care group. They discuss why they assumed it would not change, but did not discuss reasons why it might have changed, and in fact state that this is a study that could easily be implemented despite the drop-in care for usual care patients (Teodoro et al., 2016). This lack of acknowledgment of a possible failure in their study and persistent push of the efficacy of this program could show bias. Finally, are that there was an uneven split of patients into the two groups (Teodoro et al., 2016), this could change the statistics for both groups to look different than what they originally were providing. A smaller ambulation sample size allows you to see the increase more clearly than if an additional two patients had been added, it also mutes the decline of the usual care group by spreading out the averages by two more patients. Limitations The authors stated they had two limitations, the first being that the education materials were limited and that different results might have occurred with longer education programs. the second limitation they indicated was that the study was short, only looking at two days of data. (Teodoro et al., 2016) These limitations could have affected the results by causing lower outcomes than could have been achieved with longer educational material, and the length of time limits our assessment of long-term applicability. Other limitations in the article are the sample size, there were only 48 patients overall and only 22 patients in the ambulation group.
This smells sample size could limit the studies applicability to the general population. There is also a significantly higher percentage of post-surgery patients than other admission types, this could skew the results to be more representative of post-op patients than of other kinds of patients. The research only occurred on one floor of a community hospital in one part of the united states (Teodoro et al., 2016). These same results might not be applicable to other hospitals or even other floors of the same
hospital. Another major limitation was the multiple areas of possible bias. Researchers themselves collected the data, it is unknown if they correctly used the pedometer, cleared the data or transferred the data from the pedometer into their statistical analysis program. The pedometer could be inaccurate due to the quality of the pedometer and the style of its data collection (movement vs distance). Finally, the nurses are not factored into the study as a variable, it is unclear in the study description if they are aware of the study. The nurses could have been affected by the reminders as well as the patient causing them to encourage patients additionally to the materials provided, they could have also spent more time with the ambulation group at the expense of the usual care group. It is unclear how specifically how all of these limitations may have influenced the results. Applicability The results of the study are clinically significant while requiring little effort implementing their ambulation program is of negligible risk to the patient and in fact is an incredible benefit. It also requires little from the hospital cost wise and may actually improve costs by reducing morbidity and mortality. This lack of risk and high benefits paired with the results of the ambulation group give this program high efficacy in a clinical setting. This study produced evidence that ambulation protocols are effective in improving patient ambulation which is highly applicable to all hospitals as lack of ambulation is an issue in most hospitals. There is a clearly significant increase in ambulation and while there is no way to know the long-term benefits of this program without further study, we can look at the effects of immobility to see why this may be beneficial to clinical practice. There is also evidence that use of a pedometer could improve our goal setting based on steps rather than distance and monitoring of patient ambulation improving charting and record keeping of steps traveled. It can provide a more concrete look at patient improvement over a hospital stay, and make these statistics available to all members of the healthcare team. With pedometers, we are able to intervene earlier in patients who are not improving and provide additional assistance and physical therapy. Finally, while it was not intended, evidence from the study suggests that more staff may be needed for an effective ambulation protocol as seen with the drop in the ambulation of the usual care patients; however, further study is needed to see if this drop is due to other factors than nurse time spent with patients
Once the mandate was given to area hospitals not to divert MH patients, each hospital had to figure out how to deal with MH patients in their own organization. This entailed a safe environment for the MH patient, safety for the staff, and the ability to “board” MH patients in the ED. “Boarding” patients in ED’s became necessary because of the lack of inpatient MH beds in the State of Washington.
Melling, C. A., Baqar, A., Eileen, M. S., & David, J. L. (2001, September 15). Effects of preoperative warming on the incidence of wound infection after clean surgery; a randomised control trial. The Lancet, 358, 876-880.
Hinkle, J., Cheever, K., & , (2012). Textbook of medical-surgical nursing. (13 ed., pp. 586-588). Philadelphia: Wolters Kluwer Health
Hospital readmission can impact the patient, nursing practice, the hospital, and the health care system. The patient’s quality of life can be altered physically, psychologically, and economically (Whittaker, 2014) and recurrent hospitalization is a good predictor of increased risk of mortality (Hummel, Katrapati, Gillespie, DeFranco, & Koellig, 2013). Moreover, a patient in an acute care setting has an increased risk of contracting hospital-acquired infections such urinary tract infections, sepsis, C. difficile, and methicillin resistant Staphylococcus aureus (medicare.gov|Hospital Compare, 2013). Nursing practice is impacted as patients spend the majority of their acute care stay with the bedside nursing staff. According to...
Subacute units offer a transition point between a hospital stay and their journey home or a nursing facility. Emerging to fill the gap between intensive hospital care and the care that can be given in the home or a nursing facility, and provide a more cost-effective form of care than hospital care (Pratt, 2017, p. 113). Subacute care’s focus on the quality of care given at the cheapest price possible allows subacute care to stay relevant in our ever-changing healthcare system. While also ensuring the patient’s care and overall quality of life are the best it can be. Say you have a stroke, after your stay in the hospital you may need physical therapy, this therapy is received in a subacute care facility (can be a part of hospital or nursing facility). When you enter the subacute care facility you enter with a projected check out date, with a set structured plan of action. I believe subacute care should be offered in hospitals and nursing facilities so that no matter what the finical situation of the patient they can receive quality regulated care at a cheaper price than acute
The hospital promised early ambulation following hernia surgery. The hospital facility was designed to encourage movement without unnecessarily causing discomfort. Postoperative regimen designed and communicated by the medical team to patients
Although there are some similarities between an ambulatory care and an acute care facility there is a difference among the skills needed to provide the level of care. When thinking about clinical care there is additional training and education that is needed for clinical staff members who transition between caring for patient within the two different settings. Ambulatory care is more outpatient setting including clinics that operate during the day treating non-emergent patients. Acute care is inpatient care provided at bed side because they require continuous care. Their work mainly driven by hospital protocols and physician orders (Swan, 2007).
Davenport, Joan M., Stacy Estridge, and Dolores M. Zygmont. Medical-surgical nursing. 2nd ed. Upper Saddle River, N.J.: Pearson Prentice Hall, 2008, 66-88.
The healthcare world has simply grown too large, too quickly and, as a result, has forgotten the reason behind which it stands: the patient. Continuity of care is in dire need of repair and without effective communication and coordination of care, the problem will not be corrected.
Within this set, the investigators randomized how many trials the participants would complete: 7, 10, or 13. Then, they were giving the chance to do 3 or 6 more trials and were ask to record their results.
Preventable hospital admission is a key patient safety and quality concern. A major cause of preventable readmission is poor coordination and communication of care during transitions. Transitions beteeen settings are vulnerable periods for patients. Transition contains admission and discharge between skilled nursing facilities, long-term care facilities, acute care hospitals, and assisted living facilities. Indigent coordination between a cure setting and primary care provider can results in poor longitudinal planning. About 50% of patients go see their primary care providers within a two week time period after discharge. Comprehensive programs can improve care while transitioning between setting, which can reduce a thirty day hospital readmission.
Brunner, L.S. & Suddarth, D. S Textbook of Medical- Surgical Nursing, 1988 6th ed. J. B. Lippincott Company, Philadelphia
and was reassessed after 3 months. After 3 months subjects were randomly assigned to two
1.I currently work in the surgical unit and one of the major recovery enhancements is early ambulation after any surgery, especially orthopedic and abdominal. Early ambulation will accelerate the return of bowel function (as evidenced by passage of stool and flatus) reduce the rate of overall complications and decrease the length of hospital stays. Evidence-based practices have shown that early post-operative ambulation contributes to decreased pulmonary complications. “When exploring postoperative activity in the general and orthopedic nursing literature, there is sparse evidence outlining nursing's critical thinking skills associated with decreasing the first postoperative activity from the historical 14-day mark to the most current model of day 1 or 2 for the joint replacement population. Also, there were no recently published reports describing a contemporary
When the patient has followed the instructions, things at the surgery center go much smoother. There are decreased incidents of high pressure, pain issues, and/or low/high blood sugar. Escorts and transportation home is readily available to the patient. Post surgery medications are handled. The whole experience is pleasant for the patient. Patient’s that have good encounters are happier patients. Content patients tell their friends, family, and co-workers, which in turn may influence that person at the end of the year to change health insurance plans.