STRONG TODAY, STRONGER TOMORROW: CREATING A CULTURE … Early Mobility... · strong today, stronger...

STRONG TODAY,

STRONGER TOMORROW:

CREATING A CULTURE OF EARLY

MOBILITY IN THE MEDICAL

INTENSIVE CARE UNIT

K R I S T E N C L I F F O R D , R N ,

B S N R N 4 , F C C S

KRISTEN CLIFFORD BIO

• B.S.N Oakland University

•Rochester, Michigan

• Registered Nurse 4, Medical ICU

•9 Years

• Quality Improvement Analyst (QIA)

•1.5 years

VANDERBILT UNIVERSITY MEDICAL CENTER

• Nashville, TN

• 1,000+ Beds

• 2 million encounters

per year

• Level 1 Trauma

• Medical ICU

•35 beds

WHAT IS A QIA??

• Chart reviews/debriefs and Event Analysis

•C.diff

•CLABSI

•CAUTI

•Falls

• Hospital wide committees/projects

• Unit based quality improvement projects

• Unit Rounding on Quality Bundle Compliance

• Staff Education

• Research – EBP to bedside

WHY EARLY MOBILITY?

• Muscle strength declines 3-11% with each day of bedrest.

• ICU Acquired Weakness (ICUAW) can start within the first few

days of critical illness.

• ICUAW can lead to immobility and result in loss of strength,

endurance, and bulk.

• Immobility contributes to poor performance on falls and

hospital acquired pressure ulcers.

• Morbidity, mortality, length of stay (LOS) and cost of care may

be affected by ICUAW.

• Developing a culture of early mobility as standard care can

improve patient outcomes.

ABCDEF is a standard bundle of ICU measures that

includes spontaneous……

Assessment for and manage pain

Both Spontaneous Awakening Trials (SAT) and

Spontaneous Breathing Trials (SBT)

Choice of sedation and analgesia

Delirium monitoring and management

Early mobility

Family engagement

ICU Delirium and Cognitive Impairment Study Group

Gordon R. Bernard, MD

Nathan E. Brummel, MD, MSCI

Timothy D. Girard, MD, MSCI

E. Wesley Ely, MD, MPH

ABCDEF AND EVIDENCE BASED PRACTICE

PURPOSE

The purpose of this project was to

increase early mobility and make it

standard care in the Medical Intensive

Care Unit (MICU) to improve patient

outcomes through a campaign “Strong

Today, Stronger Tomorrow MICU Early

Mobility.”

STRATEGY AND IMPLEMENTATION

• Awareness increased with Early Mobility Protocol, using Johns Hopkins

Highest Level of Mobility (JH-HLM) Scale

• Education created for all bedside nurses, care partners, respiratory,

physical and occupational therapy.

• Nurses presented patient’s mobility during morning rounds with ICU

team to facilitate orders.

• To ensure patients were being mobilize, an early mobility tracker (JH-

HLM scale) was used to monitor daily mobility. (3 month time period)

• This scale was completed during every shift.

• Educational handouts for families regarding passive ROM

Evaluation metrics include:

1) Staff perceptions of early mobility

2) Quality metrics of unit acquired pressure

ulcers and falls.

The campaign was launched in Nov 2016.

10

COMPLETE EARLY MOBILITY SURVEY

• Email of the

URL to link you

to the survey

• 14 questions

(less than 5

minutes)

11

PRESENT MOBILITY

IN AM ROUNDING

WITH MD’S

12

EARLY MOBILITY TRACKER

• Tracking sheet is to be

filled out daily by day

and night shift, just

one simple line

• Multidisciplinary –

Filled out by Nursing

and PT/OT

INSENTIVES FOR STAFF

• Launch party for day and nightshift

• Monthly Mobility Champion for 1 year – Au Bon Pain Gift Card

RESULTS

• Daily mobilization of 65.85% (349/550)

• 90 MICU staff responded to the baseline survey, 34 completed the 6-month

follow up.

• There was an improvement in staff belief in ability to safely mobilize patients

(X2, p < .001)

• Patients mobilized once a shift more often (X2, P = .068).

• Monthly fall and pressure ulcer rates declined post implementation.

• 1 year post implementation - Average patients mobilized once a shift - 88%

0

1

2

3

4

# o

f F

alls

Months 2016 - 2017

# of MICU Falls

Pre and Post Initiation of Early Mobility

Initiation of Early Mobility

November 2016

0

0.5

1

1.5

2

2.5

3

3.5

# of MICU Patients with HAPU

Pre and Post Initiation of Early Mobility

Initation of early

mobility (Nov 16th)

occurred after Survey

8

4

3

4

3

1

0

1 1

0

1

2

3

4

5

6

7

8

9

November December January

# o

f P

ressu

re U

lce

rs

Month

# of MICU HAPU FY 15 – FY 17

FY 15

FY 16

FY 17

IMPLICATIONS FOR PRACTICE

Use of multiple strategies to improve a culture

of Early Mobility was successful in hardwiring

early mobility as standard care and increased

ownership among nursing staff. These

strategies (education, monitoring, reminders

and feedback) may be used to improve other

problems that affect patient outcomes.

Printed with permission

MOVING FORWARD

• Epic Documentation –

John Hopkins Highest

Level of Mobility (JH-

HLM) Scale

• Mosaic Study

QUESTIONS

Kristen.Clifford@vumc.org

ICUdelirium.org