The Evaluation of an Intensive Mobilisation Program Following Major Abdominal Surgery Administered by Physiotherapy Assistants

Laura Browning

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Early Mobilisation

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

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The Evidence

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 Title / heading goes here Page Mobilisation Duration

Postoperative Day POD1 (n=50) POD2 (n=49) POD3 (n=45) Median Mobilisation time (minutes) Range (minutes) 0.0 to 166.5 0.3 to 95.6 0.2 to 139.7

3.0
7.6 13.2

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 the/ heading goes here of Title Physiotherapy Assistant
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)

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Research Aim

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 Mobilisation Program Page Title / heading goes here

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

What is Title / heading goes here Page an Adverse Response?

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)

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PTA Training Program

Undertaken at RMH
(May to July 2006)

Three PTAs participated

Training Schedule
Session
Session 1 1.5 hours Session 2 2 hours Independent task Session 3 2 hours Session 4 2 hours Session 5 2 hours Ongoing (range 4-9)

Format
Group tutorial Group tutorial / Demonstration Individual supervised practice Group tutorial / Practical session Group tutorial Group practical session Individual supervised practice

Content
Introduction and program outline Explanation of PTA roles and aims Measuring BP, HR, SpO2, pain, nausea Applying the Borg RPE scale during mobilisation 10 supervised patient assessments Recorded in logbook Surgical attachments - theory Transporting surgical attachments Revision worksheet Recommendations for postoperative mobilisation Patient handling skills Application of the mobilisation program Supervised task completion with feedback Continued until ready for formal assessment

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PTA Training Program

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

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Results

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

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Study Findings

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

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Acknowledgements

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

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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.

References