Continuous Passive Motion Machine: An Evidence Based Practice Project Alicia Emaish, RN Jean Cody, MS, RN

99 Bed, Rural Community Hospital Magnet Designated since 2002

Objectives Describe the physiological evidence for CPM use Describe the state of the science of nursing care related to CPM therapy. Describe how this small, staff nurse developed project is evolving into a nursing research study. Describe how this innovation is a Magnet Nursing Exemplar for using New Knowledge and Innovation.

Leadership Opportunity Organization became involved in a long term designee leadership program Problem solving the “pebble in your shoe” Opportunity for innovation Opportunity: Improve the application of the therapy & associated outcomes Address safety Potential to decrease LOS

What is a CPM machine? Continuous Passive Motion machine Developed in late 1970’s in animals (1) Early 1980’s CPM use began after total knee replacement (TKR) (2) Allows the knee to move without engaging muscles Provides a favorable environment for the cells to grow Reduces the likelihood of the knee joint becoming stiff 1. Salter RB. The biological concept of continuous passive motion of synovial joints: The first 18 years of basic research and its clinical application. In: Ewing JW, ed. Articular Cartilage and Knee Joint Function. New York, NY: Raven Press; 1990. 2. Coutts RD, Toth C, Kaita JH. The role of continuous passive motion machine in the rehabilitation of the total knee patient. TKA: a Comprehensive Approach. Baltimore, Md: Williams & Wilkins; 1984:126-132

CPM Machine

Nursing Innovation: Creatively timing the administration of the CPM machine.

Opportunity Accuracy Safety Amount of therapy Smaller, more specialized group of caregivers Safety Less equipment Decreased risk of falls Amount of therapy Uninterrupted therapy Additional PT Less people involved in working with the machines More accurately monitored time in machines, and advancement of settings. Less need for pain meds Extended periods of time receiving range of motion, PLUS receiving PT Shorter hospital stays Better chance of going home rather than rehab Not having to take pt's in and out of machines 100 times during the day or eve for meals, PT, families, BR breaks 8

Project Developed the trial innovation Evaluated 12 pt’s that used CPM’s during the day Educated staff of trial Trialed 12 pt’s using CPM’s during the night shift hours Compared lengths of stay

Project Outcomes Post-operative length of stay was decreased by 1 day (on average). Measured by pre and post implementation data collection. 12 TKR’s reviewed on day shift use. Average length of stay = 4-6 days. 12 TKR’s trialed on night shift use. Average length of stay = 3-5 days.

Patient Significance of CPM Timing Innovation Trial Decreases the length of hospital stay Decreases clutter in patient room Increase patient safety Increase amount of therapy/ROM

Nurse Significance of CPM Timing Innovation Trial Leadership growth in developing a project of clinical interest Creative nursing to meet patients needs and goals Motivating and influencing others

Great leaders create great structures so great nurses can provide exemplary care! ANCC's Magnet Recognition Program© 2008

Evolution Started out as a leadership project “What is the pebble in your shoe?” Work fits into our “Inquiry at the Bedside” Iowa Model 14

Iowa Model of Evidence Based Practice to Promote Quality of Care (2001) Problem focused trigger: Inconsistent application of the CPM. No current consistent metrics of evaluation Safe, effective, efficient care goals Topic a priority: safe efficient effective care

Form a Team Leadership goal Multidisciplinary involvement Physician champion RN, LPN, LNA’s Physical Therapy

Physiological Evidence Cochran Database of Systematic Reviews, 2003 14 studies/952 participants Compared CPM + PT vs. PT alone Improved knee flexion LOS significantly decreased Return to OR significantly decreased Critique and synthesize evidence

Additional Research Studies up through 2008 show a wide range in outcomes; from no difference to significant decrease in LOS Major limitation of the studies: variations in the study methodology make it difficult to compare. Denis M, Moffet H, Caron F. at al. Effectiveness of continuous passive motion and conventional physical therapy after total knee arthroplasty: a randomized clinical trial. Physical Therapy 2006;86:174-185. Intervention 35 minutes per day, 2 hours a day, etc.

Nursing Research Procedure oriented literature refers to original medical research Structures and processes of delivering the care not addressed

Nursing Research Does the application of the CPM machine at night decrease length of stay, pain, and increase level of function in patients experiencing total knee replacements when compared to using it during the day? How does the timing of the CPM use effect the process of care delivery? Restricted research funds available to continue work Protocol development underway and pending IRB review

Magnet Exemplar Transformational Leadership Structural Empowerment Staff Nurse Leaders CNS, Dept. Director, CNO Structural Empowerment Frontline leadership program Nurse Scholar Program Exemplary Practice Accountability, authority, autonomy in applying and expanding nursing knowledge New Knowledge/Innovations in Practice Empower and engage staff to creatively practice EBP/Research project What is key to all this is that she had access to information, resources, & support and the opportunity to take advantage of them.

Evidence Based Practice Innovation Research New Knowledge, Innovations, Improvements Evidence Based Practice Innovation

Jean Cody CODJ@phin.org Thank you Alicia was recognized along with 5 peers across the nation for her project. In January, she will be filmed for an internet video of this project. Alicia Emaish VACA@phin.org Jean Cody CODJ@phin.org