Promoting

Ambulation in
Neurosurgical
Patients
By: Gabi M., Bri S., Kayla C., & Meghan O.
 St. Joseph’s Hospital
● Located in Tucson, Arizona at 350 N. Wilmot Rd.
● Neurology/Telemetry Unit (5P)
○ 24 Bed Unit (6:1 ratio)
○ Provides care to neurosurgical patients including stroke
patients, those with epilepsy and more.
● 2 PCTs, 4 RNs, & 1 charge on unit also staffed by:
○ RT
○ Unit clerk (3 days per week)
○ PT/OT/ST
○ Physician team
○ Case management
○ Pharmacy
○ Ancillary Staff
● Diverse patient population, ages 18+ all post-neurosurgery
● Flat organizational structure/Total patient care nursing
(Carondelet Health Network, 2024)
 Quality Improvement Issue
Issue: Lack of Ambulation for Neurosurgical Patients
Why is this an issue:
Current Actions:
● Prolonged immobilization in 30-46% patients
(pt.’s). ● Physician orders for ambulate ad lib BID
● According to Tazreean et al. (2022) prolonged ● Single nurse/tech gets patient up BID with gait
immobilization leads to:
belt (prior to physical therapy (PT)/occupational
○ Impaired GI function
○ Increased risks of DVT therapy (OT) evaluation)
○ Decreased function of musculoskeletal, ● Pt.’s must be ambulating within 2 hours post-op
respiratory, and cardiovascular systems unless contraindicated
● According to Young et al. (2021) ambulation within
● Up to chair for all meals
72 hours leads to:
○ Reduced length of stay= decreased costs ● Document every time patient is out of bed
○ Reduced pt. safety events ● All nurses signed and agreed to mobilization
○ Improved functional outcomes
protocol
 Forming the Team
Ambulation Support
Unit Manager

01 02
Oversees nursing staff and can
Tech
Facilitates bidaily ambulation
monitor implemented changes with patients and ambulation
and data collection documentation

PT/OT Clinical Educator

03 Aid in data collection through

chart reviews as well as bidaily
patient ambulation
04 Educating the nursing staff on the
importance of early ambulation and
appropriate documentation
 AIM
STATEMENT
Our aim statement is to increase the
bidaily ambulation percentage for patients
on the neurosurgical unit at St. Joseph’s
Hospital from 60% to at least 80% by
August of 2024. Aims to improve include
safety, effectiveness,
timeliness, efficiency,
equitability, and patient-
centered care!
 Establishing Measures
Month % of neurosurgical pt.s
● Percent of neurosurgical patients who ambulate ambulated during stay
during stay is 47-70 percent (from chart)
● Benchmark for ambulation after surgery is within
July 54%
24- 72 hours, but within 24 hours is preferred and
highly encouraged (Debono et al., 2021) August 47%
● Rate of individuals who ambulate after surgery
September 70%
varies greatly.
○ No specific protocol for neurosurgical October 55%
patients (Tazreean et al., 2022) November 56%
● However, compliance data should aim to be around
December 56%
80 percent or above for most surgeries (Tazreean et
al., 2022). January 59%

February 60%
 Model for Improvement: Selecting
Changes

Documentation Notification Ambulation

Modifications System Support Technician
Changes to flowsheet to Pop up reminders in Cerner Specialized in-unit role
provide easy, simple, and task sheet for RN. Unit dedicated to ambulation and
quick RN documentation. manager and Charge promote documentation of this patient
ambulation in morning population.
huddle.
 Model for Change: Testing Changes

P D S A

PLAN DO STUDY ACT

● Objective
● Stakeholders ● Evaluation
● Protocol ● Implementation ● Outcomes ● Adopt, abandon,
● Training & ● Tracking ● Challenges or adapt
Education ● Next steps
● Predictions
Model for Change: Testing Changes
● Objective
○ Increase the bidaily ambulation percentage for patients on
P the neurosurgical unit at St. Joseph’s Hospital from 60%
to at least 80% by August of 2024.
● Stakeholders
PLAN ○ Unit Manager, Clinical Educator, PT/OT, Ambulation
Support Technician
● Protocol
● Objective ○ Initiate hiring process and training of new hires
● Stakeholders
● Protocol ○ Ambulation Support Technician description
● Training & ● Training & Education
Education ○ Ambulation Support Technician orientation
● Predictions ○ Interdisciplinary team education
● Predictions
○ Increase in postoperative patient ambulation
Model for Change: Testing Changes
● Implementation
D ○ Unit will hire at least 3 Ambulation Support
Technicians to have readily available on unit
○ Interdisciplinary team is educated on role
DO ○ Review progress monthly and adjust
implementation
● Tracking
○ Percent of postoperative neurological patients
ambulation through documentation
● Implementation
● Tracking ○ Patient outcomes
○ Nursing staff feedback
○ Ambulation Support Technician role inquiries
Model for Change: Testing Changes
● Evaluation
S ○ Ambulation Support Technician feedback
○ Nursing staff feedback
○ Documentation of bidaily ambulation in postoperative
STUDY patients
● Outcomes
○ After 6 months, the percentage of bidaily ambulation in our
patients will increase by 20%
● Evaluation ● Challenges
● Outcomes ○ Identify issues encountered by ambulation support
● Challenges
● Next steps technician, nurses, and patients
● Next Steps
○ Present updated data after implementation
○ Make changes to implementation based on data
○ Expand implementation to additional postoperative units
 Potential Barriers
Two microsystems that may act as a barrier to implementation:
- Patient focus: Patient adherence (them wanting to actually get up)
- Staff focus/Organizational support: Staffing of ambulation techs or a designated staff member for
ambulating

How to mitigate these barriers:

- Providing education to patients on the harmful effects of not ambulating
- Administer pain medications/antiemetics before ambulation (cluster care)
- Going up the chain of command to advocate for the hiring of more ambulating techs (at least
3 per unit and 1 per shift)
- Offer sign on bonuses for ambulation support as an incentive
 Visual Aide
Objective/AIM: increase the bidaily ambulation percentage for patients on
the neurosurgical unit at St. Joseph’s Hospital from 60% to at least 80%
by August of 2024.

Incorporate and engage our Ensure appropriate staffing of

Training and education
stakeholders ambulation techs

Implement: Require the post neurosurgical unit at St. Joseph’s hospital to use the ambulation techs to
complete bidaily ambulation for every patient located on the unit over the next 6 months to increase the
number of patients being ambulated

Required personnel:
Closed loop
- Ambulation support tech Data tracking: Monthly tracking of the percent of communication: modify
- PT/OT (reinforce) patients being ambulated bidaily via Cerner staffing ratio of
- Nurse clinical educator documentation data ambulation techs, ensure
- Charge nurse staff feels well
- RNs on unit
supported/educated on
3 month 6 month their role, continue to
Check in with ambulation
techs and shoot to have the evaluati evaluati Feedback from staff on what track data and shoot to
can be improved/what
of patients being ambulated on on worked and gather last set of continue to increase
at this point at least 70% of
patients
ambulation percentages percentage of patients
 References
Carondelet Health Network. (2024). St. Joseph’s Hospital. Retrieved April 10, 2024, from

https://www.carondelet.org/locations/detail/st-josephs-hospital

Debono, B., Wainwright, T. W., Wang, M. Y., Sigmundsson, F. G., Yang, M. M. H., Smid-Nanninga, H., Bonnal, A., Le Huec, J. C.,

Fawcett, W. J., Ljungqvist, O., Lonjon, G., & de Boer, H. D. (2021). Consensus statement for perioperative care in lumbar spinal

fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. The Spine Journal: Official Journal of the North

American Spine Society, 21(5), 729–752. https://doi.org/10.1016/j.spinee.2021.01.001

Tazreean, R., Nelson, G., & Twomey, R. (2022). Early mobilization in enhanced recovery after surgery pathways: Current evidence and

recent advancements. Journal of Comparative Effectiveness Research, 11(2), 121–129. https://doi.org/10.2217/cer-2021-0258

Young, B., Schmidt, M., & Moyer, M. (2021). Mobilization of the patient after neurological insult. American Association of

Neuroscience Nurses. https://aann.org/uploads/Publications/CPGs/AANN21_Mobilization_CPG_v6.pdf

 Thank You!
Any Questions?