CUSP for VAP: Feedback on Early Mobility Measure and Implementation

CUSP for VAP: Feedback on Early Mobility Measure and Implementation

Early Mobility Support TeamArmstrong Institute for Patient Safety and QualityDepartment of Anesthesia and Critical Care MedicineJohns Hopkins University

Armstrong Institute for Patient Safety and Quality2

Outline

• Where are we now• Early Mobility Support Team• Early Mobility Implementation

– Importance of nurse-led mobilization– Readiness assessment– Mobilization and resources

• Early Mobility Toolkit • ICU Recovery Network• Next steps• Team feedback


Where are we now?

• Early mobility program implementation• Link to previous VAP Early Mobility calls:

https://armstrongresearch.hopkinsmedicine.org/vap/calls.aspx

• Early mobility data collection and data entry according to sampling strategy

• Feedback and implementation webinar• Introduction of Early Mobility Toolkit





Early Mobility Support Team

Christopher Wilson PT, DPT, GCS, CCCECoordinator of Clinical EducationBeaumont Hospital Troy Acute Care Rehab

Services Margaret Arnold, PT, CEES, CSPHPConsultant with InspireOUtcomes, LLC Anita Bemis-Dougherty, PT, DPT, MASDirector, Department of Clinical PracticeAmerican Physical Therapy Association

Jim Smith, PT, DPT, MAPresident, Acute Care Section - APTA

Dale M. Needham, FCPA, MD, PhDAssociate ProfessorOutcomes After Critical Illness & SurgeryDivision of Pulmonary & Critical CareMedical Director, Critical Care Physical

Medicine & Rehabilitation ProgramJohns Hopkins University

Pat Posa RN, BSN, MSA, FAANSystem Performance Improvement Leader,

St. Joseph Mercy Hospital, Ann Arbor, MI

Archana NelliotClinical Program CoordinatorCritical Care Physical Medicine and

Rehabilitation ProgramJohns Hopkins University School of Medicine


Early Mobility Implementation – Importance of Nurse-led Mobilization

• Chris Wilson PT, DPT, GCS– Coordinator of Clinical Education - Beaumont Health System, Troy, MI– Clinical Assistant Professor – Oakland University, Rochester, MI

• Goal for Early ICU Mobility– Nursing led– Physician driven– Therapist supported and guided

• Activity prescription or activity/ADL prescription


Early Mobility Implementation – Importance of Nurse-led Mobilization

• Supported by key workflow infrastructure – Keystone rounds, huddles, eliminating barriers

to PT/OT involvement in ICU• PT/OT Standing Order by Med Admin

– Follow through after T/F out of ICU

Safe Patient Handling

1. Staff Safety2. Patient Safety3. Best Care and Early Mobility

Communication

Right EquipmentRight time

Right patient

Just Culture

TRAM Lift Team:

Transfers, Rehab, and

Mobility

Training and Competency

Early and often

assessment

Immediate Huddles and rounds

Access and

ordering

Storage Delivery

Cleaning

Maintenance and upkeep

Integration with PT/OT

Handoff

Like RRT Urgent

calls

Trained and

managed by PT/OT

Metrics and productivity

24:7 coverag

e

Consultation

Activity prescription

Fine tune care

Risky behaviors?

Coaching

Policies and expectations

Nursing, EC,

Transport, Radiology

Continued Competency

Standardized

Dept champions


Nurse-led Mobilization

• Most ICU nurses know why Early Mobility in the ICU is critically important

• Need to do root cause analysis of barriers and address each through education, training, policies, equipment, communication

• Barriers found upon Beaumont survey:– Safety is a high concern– Risk of injury to patient and self– Accurately dosing mobility, choosing

equipment, and communicating

Can pt lift head off pillow?Raise arms/legs off bed?

Within 12 hrs of admit

Sit pt on Edge of Bed (dangle)

Stryker chair or bed inChair position.

Use mechanical lift for out of bed activity

Yes to both

No to either

Max assist (pt performsLess than 50% of work)

2 person assist

Mod assist (pt performs50% of work)

2 person assist

Min assist (pt performs75% of work)

Nurse to recommendPT evaluation – PT to

recommend equipment

Nursing to get helpto get patient up In chair with belt


recommend equipment

Nursing tocontinue to dangle/Sit at edge of bed

with belt

Reassess DailyAnd Document Activity



Nursing to assist ptTo bedside chair

With belt

Can pt:Sit to stand x3?

March in place x3 each leg?Step forward/back

3x each leg?

Ambulate to bathroomWith belt

Yes

No

If pt not at baselineMobility, recommend

PT evaluation

If able to amb to bath-room safely, amb to

Halls 3x/day with belt

0

2 31

4

Reassess Daily and Document Activity


recommend equipment

Not on Strict Bedrest

*Adapted with permission. Shay A. Outcomes of an Activity Progression Protocol for Pneumonia and COPD Patients. San Antonio, TX: Summer Institute on Evidence Based Practice; 2006.

Stepping into Safe MobilityNursing Assessment AlgorithmActivity order can be advanced per nursing policy #304



• Stepping into Safe Mobility– Decision making algorithm– Training tool– Communication tool

• Start from the Heart– 4-8 hour SPHM training

class for all new hire nurses and nursing assistants

– Co-taught by PT and nursing educators


• Pre and post survey indicate improvement in staff perception of:– Decreased risk of injury by 48%– Comfort with their own patient’s mobility by 25%– Improvement in confidence by 32% with mobility of

patients they are unfamiliar with • After implementation of SISM, staff felt:

– Safer, less at risk of injury– More confident to move a patient , determine equipment,

and medical appropriateness for OOB activity– Less reluctant to answer call lights when it is not their

patient


Readiness Assessment

• Are my patient’s cardiopulmonary and neurological systems functioning well enough to mobilize today?

• Cardiac– No increased pressors last 2 hours– Systolic BP >90<200mmHg– HR>50<140– MAP >65<110mmHg

• Pulmonary– PEEP <10cmH2O– FiO2 <0.6– SPO2 > 88% **

• Neurological– Responds to verbal stimuli


Readiness Assessment: Other considerations• Patient factors

– Sedation level – if patients are too heavily sedated, they will not be able to participate in EM

– Breathing support for EM intervention– Femoral Lines– ECMO (Extracorporeal Membrane Oxygenation)– Presence of lines, drains, catheters– Patient ability to follow directions

• Other factors– Do you know your ventilator settings and safety parameters– Do you have the right equipment (ambubag, portable ventilator)– Does Respiratory therapy need to be there?– Do you have enough help (Staff and/or equipment)?


Early Mobility Implementation – Mobilizing Your Patients

• All Early Mobility protocols have a basic flow of 4-5 stages that progress mobility

• Some variations exist in specifics• The goal is always to work towards functional mobility

(Walking and transfers) as soon as safely possible• All patient active movement can be considered

“Mobility” • Start with having the patient help with small things,

then progress to bigger movements and anti-gravity activities.


Mobilizing Your Patients: Making the most of all care tasks• Understand ventilator settings and telemetry alarms so that you

know when a patient is or is not tolerating an activity• When repositioning or turning the patient, ask them to do as

much of the work as they can• Have them actively reach their top arm to the opposite side of

the bed if possible, turn their head to the side if they can• If they do well with bed mobility, try to sit them up• Even sitting with feet over edge of bed can be a major

accomplishment. Try to have them balance in sitting and reach with their arms, look up, sit up straight etc. If they are tolerating sitting well, try to stand up.

• When that is successful, try to shift a little weight or march In place

• When that is successful, take some steps


Mobilizing Your Patients: Safety Considerations• Always ensure that the patient is tolerating activity by staying

within pre-determined safety parameters• Know what equipment is available to keep you and the patients

safe while mobilizing• Examples of equipment include

– Friction reducing /air-assist devices for horizontal assistance– Overhead lifts with slings to lift patients into chairs or ambulate– Mobile floor lifts with slings to lift patients or ambulate patients– Powered and non-powered sit to stand assist devices to help

patients stand up– Specialty beds that assist with chair position, turning, and tilting

patients to full standing positions– Specialized walkers with seats if patient gets tired, and portable

ventilators


Early Mobility Toolkit

• Framed using the 4Es• Integrates available resources to help you educate

and engage all stakeholders• Proposes protocols to execute an Early Mobility

program: standardize the screening and mobilization of your patients

• Proposes tools to evaluate your progress• Prepared by the Early Mobility Support Team• Toolkit content will evolve based on your feedback

and experiences


Early Mobility Reports


1. Search for the ICU Recovery Network at the top of your screen.

2. Click on Send Request for both ICNCUSPVAP, and IRN.

If you are already a MedConcert member


If you are already a MedConcert member continued…

3. Complete the request and click on Send.

If you are NOT MedConcert member

1. Request access to the IRN Network by contacting either the [email protected] or [email protected].

2. An administrator will reply to your email, and you will receive a user name and password to help set up your account.

mailto:[email protected]



Next Steps for Early Mobility

• Sign up for the “ICU Recovery Network” (IRN) pm MedConcert and explore resources

• Review the Early Mobility Toolkit and provide suggestions for revisions

• Get your Early Mobility program off the ground if you have not started already


Resources for Early Mobility

• Link to previous Early Mobility calls: https://armstrongresearch.hopkinsmedicine.org/vap/calls.aspx

• This includes calls from: – 08/30/2012 - Early Mobility and IP Call #2, Early Mobility in the

Critically Ill– 09/12/2013 - Early Mobility - Designing, Conducting & Sustaining

an ICU Rehab Program– 10/03/2013 - Draft - CUSP for VAP Early Mobility Data Collection

Instrument– 01/09/2014 - Early Mobility Data Collection Instrument





Next Steps for CUSP for VAP Project

• Continue or begin implementing the Data Collection Sampling Strategy between Process Measures and Early Mobility (from April)

• Structural Assessment 3 administered (July)

• Begin data collection for Low Tidal Volume Ventilation measure (August)


1. Search for the ICU Recovery Network at the top of your screen.

2. Click on Send Request for both ICNCUSPVAP, and IRN.

If you are already a MedConcert member


Data Collection Sampling Strategy: Began April 1st

27

2014 CUSP for VAP Data Collection Calendar

January

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Key: Process Measure data collection Early Mobility data collection No data collection; use this time to catch up on missing Process Measure and Early Mobility data


Teams

• Tory Hospital - Pennsylvania• Karen Norton

• Holy Cross Hospital - Maryland• Steve Risch, MSN, RN, CCRN, CCNS• Leola Saucier, BSN MBA CNML• Elly Sullivan, MA, OT


Questions

• Karol G. Wicker, MHSSenior Director, Quality Policy & AdvocacyMaryland Hospital [email protected]

• Mary Catanzaro RN BSMT CIC Project Manager HAIs Hospital and Healthsystem Association of [email protected]



Documents

CUSP for VAP: Feedback on Early Mobility Measure and Implementation