Transcript Document

The Evaluation of an Intensive
Mobilisation Program Following Major
Abdominal Surgery Administered by
Physiotherapy Assistants
Laura Browning
Early Mobilisation
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• Forms an integral component of the
postoperative management of patients
undergoing abdominal surgery
• Accepted as routine postoperative
practice in the 1940s
• Frequent and high quantities of early
mobilisation have been associated with:
– Reductions in postoperative LOS
– Prevention of postoperative complications
– Prevention of functional decline
– Improved quality of life
The Evidence
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• High levels of dependence are common in the early
postoperative period following abdominal surgery
• Assistance when mobilising was required by: (Mackay and Ellis, 2002)
– 97% of subjects on POD1
– 83% of subjects on POD3
– 57% of subjects on POD5
• In current clinical practice, physiotherapists and nursing
staff provide mobilisation assistance
– Limited by workforce shortages and pressures (Kalisch 06)
• Low quantities of mobilisation are performed in the early
postoperative period (Browning et al 2007)
Daily
Mobilisation
Duration
Page Title
/ heading goes here
Postoperative
Day
Median
Mobilisation time
(minutes)
Range
(minutes)
POD1 (n=50)
3.0
0.0 to 166.5
POD2 (n=49)
7.6
0.3 to 95.6
POD3 (n=45)
13.2
0.2 to 139.7
POD4 (n=41)
34.4
0.1 to 222.1
N.B. Statistically significant differences between uptime on
each postoperative day (p<0.001)
The Role Page
of the
Physiotherapy
Assistant
Title / heading
goes here
• A PTA is a skilled worker who assists in the delivery of
physiotherapy treatment programs
(Australian Physiotherapy Association 2004)
• The physiotherapist is responsible for advising and
supervising the PTA when carrying out delegated tasks
(Australian Physiotherapy Association 2005)
• No formal training for PTAs currently exists and many are
trained “on the job”
•
A re-evaluation of the role of the PTA has been suggested
(Locke 2007)
Research Aim
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To develop and evaluate a PTA administered intensive
early mobilisation program for clinical application in
abdominal surgery
1. Develop an intensive early mobilisation program
2. Train the PTAs to a level of competence in administering
the program
3. Evaluate the safety and feasibility of the intensive
mobilisation program when administered by trained PTAs
Intensive
Page TitleMobilisation
/ heading goes here Program
• Administered twice daily from POD2 to POD4
• Aim to increase distance and duration with each session
• Moderate to somewhat strong intensity encouraged
(modified Borg scale RPE 3 to 4) (Borg 1982)
• Pre-mobilisation assessment to determine the
appropriateness of participating in mobilisation
–
Assessment of HR, BP, SpO2, pain, nausea
– Findings compared to physiotherapy recommendations and
discussed with supervising physiotherapist
WhatPage
is Title
an/ heading
Adverse
Response?
goes here
A response that is “unfavourable or may be harmful to the patient”
(Oxford University Press 2002).
 Severe nausea or vomiting
 Severe pain requiring cessation of activity
 Inadvertent removal of a surgical attachment
 Fall
 Chest pain
 Syncope
 Decreased conscious state
 Marked dyspnoea limiting further participation
 Alterations in patient appearance requiring cessation of mobilisation
including pallor, flushing, sweating, clamminess, cyanosis or discomfort
 Any other unexpected event or symptom that for which cessation of
mobilisation is necessary
(Stiller and Phillips 2003, Stiller et al 2004, Whaley et al 2006)
PTA Training Program
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•
Undertaken at RMH
(May to July 2006)
•
Three PTAs participated
Training Schedule
Session
Format
Content
Session 1
1.5 hours
Group tutorial
Introduction and program outline
Explanation of PTA roles and aims
Session 2
2 hours
Group tutorial /
Demonstration
Measuring BP, HR, SpO2, pain, nausea
Applying the Borg RPE scale during mobilisation
Independent
task
Individual
supervised practice
10 supervised patient assessments
Recorded in logbook
Session 3
2 hours
Group tutorial /
Practical session
Surgical attachments - theory
Transporting surgical attachments
Session 4
2 hours
Group tutorial
Revision worksheet
Recommendations for postoperative mobilisation
Session 5
2 hours
Group practical
session
Patient handling skills
Application of the mobilisation program
Ongoing
(range 4-9)
Individual
supervised practice
Supervised task completion with feedback
Continued until ready for formal assessment
PTA Training Program
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Competency Assessment
• Written Assessment Task
• Practical Skills Assessment
Outcomes
• Frequent repetition of practical skills required
– Equipment handling
– Recording vital signs
•
Level of competency attained
• No adverse events occurred
n=20
Open abdominal surgery, anticipated LOS >4 days
Medically stable, on surgical ward
POD1
Physiotherapy assessment
Mobilisation commenced
DBE regimen, Information booklet provided
POD2
Physiotherapy + PTA assessment
Assisted mobilisation
POD2 to POD4
PTA administered mobilisation
program twice daily
Results
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Intensive Mobilisation Program
• Adverse events
– One subject severely nauseous on commencing mobilisation
– One subject removed IV line during pre-mobilisation assessment
• Mobilisation not attempted on 7 occasions
–
–
–
–
Hypertension
Hypotension
Severe nausea
Inadequate pain control
Study Findings
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• Following completion of a training
program, PTAs achieved a level of
competence in administering an
intensive postoperative mobilisation
program
• An intensive early mobilisation program
following UAS can be administered by
trained PTAs under the supervision of a
physiotherapist with minimal risk
Acknowledgements
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•
•
•
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Dr Linda Denehy, Dr Bec Scholes and Dr Kay Crossley
APA Physiotherapy Research Foundation
Debbie Munro, Liz Cashill and Lauren Andrew RMH
Physiotherapy Department, RMH
Physiotherapy Assistants - Tom, Courtney and Caragh
References
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Australian Physiotherapy Association (2005): The Health Workforce.
http://apa.advsol.com.au/independent/documents/submissions/WorkforceEnquiry.pdf [Accessed 1st
August, 2006].
Australian Physiotherapy Association (2004): Role definition in physiotherapy practice. APA Position
statement.
https://apa.advsol.com.au/independent/documents/position_statements/public/RoleDefinition.pdf
[Accessed 2nd May, 2006].
Borg GAV (1982): Psychological bases of perceived exertion. Medicine and Science in Sports and Exercise
14: 377-381.
Browning L, Denehy L and Scholes RL (2007): The quantity of early upright mobilisation performed
following upper abdominal surgery is low: an observational study. Australian Journal of Physiotherapy
53: 47-52.
Kalisch BJ (2006): Missed nursing care. A qualitative study. Journal of Nursing Care Quality 21: 306-313.
Locke M (2007): Moving forwards in leaps and bounds. In Motion. The magazine of the Australian
Physiotherapy Association, June: 3.
Mackay MR and Ellis E (2002): Physiotherapy outcomes and staffing resources in open abdominal surgery
patients. Physiotherapy Theory and Practice 18: 75-93.
Stiller K and Phillips A (2003): Safety aspects of mobilising acutely ill patients. Physiotherapy Theory and
Practice 19: 239-257.
Stiller K, Phillips A and Lambert P (2004): The safety of mobilisation and its effect on haemodynamic and
respiratory status of intensive care patients. Physiotherapy Theory and Practice 20: 175-185.
Whaley MH, Brubaker PH and Otto RM (2006): ACSM's guidelines for exercise testing and prescription.
(7th edition ed.) Baltimore: Lippincott Williams and Wilkins.