Early Mobility: A Practical Approach Early Mobility Support Team Armstrong Institute for Patient...
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Early Mobility: A Practical Approach Early Mobility Support Team Armstrong Institute for Patient Safety and Quality Department of Anesthesia and Critical
Early Mobility: A Practical Approach Early Mobility Support
Team Armstrong Institute for Patient Safety and Quality Department
of Anesthesia and Critical Care Medicine Johns Hopkins
University
Slide 2
Outline Where are we now? Early Mobility Support Team Early
Mobility Implementation How to get started Importance of nurse-led
mobilization Readiness and mobilization techniques Resources:
Toolkit and ICU Recovery Network Whats in it for you Team
presentations Next steps Armstrong Institute for Patient Safety and
Quality 2
Slide 3
Where are we now? Early mobility implementation Link to
previous Early Mobility calls
https://armstrongresearch.hopkinsmedicine.or
g/cusp4mvp/webinars.aspx
https://armstrongresearch.hopkinsmedicine.or
g/cusp4mvp/webinars.aspx Daily Early Mobility: Overview Early
Mobility Data Collection Training Strategies for Collecting and
Entering Data Implementation webinar today Introduction of Early
Mobility Toolkit Armstrong Institute for Patient Safety and Quality
3
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Christopher Wilson PT, DPT, GCS, CCCE Coordinator of Clinical
Education Beaumont Hospital Troy Acute Care Rehab Services Margaret
Arnold, PT, CEES, CSPHP Consultant with InspireOUtcomes, LLC Anita
Bemis-Dougherty, PT, DPT, MAS Director, Department of Clinical
Practice American Physical Therapy Association Jim Smith, PT, DPT,
MA President, Acute Care Section - APTA Early Mobility Support Team
Armstrong Institute for Patient Safety and Quality 4 Dale M.
Needham, FCPA, MD, PhD Associate Professor Outcomes After Critical
Illness & Surgery Division of Pulmonary & Critical Care
Medical Director, Critical Care Physical Medicine &
Rehabilitation Program Johns Hopkins University Pat Posa RN, BSN,
MSA, FAAN System Performance Improvement Leader, St. Joseph Mercy
Hospital, Ann Arbor, MI Archana Nelliot Clinical Program
Coordinator Critical Care Physical Medicine and Rehabilitation
Program Johns Hopkins University School of Medicine
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Armstrong Institute for Patient Safety and Quality 5 Early
Mobility Implementation How to Get Started Needham and Korpolu, Top
Stroke Rehabil 2010;17(4):271281
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What Are Your Barriers? Armstrong Institute for Patient Safety
and Quality 6 Needham and Korpolu, Top Stroke Rehabil
2010;17(4):271281
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Educate / Engage at all Opportunities Armstrong Institute for
Patient Safety and Quality 7 CUSP meetings / Executive meetings
Group (Staff) meetings q6 weeks Board meetings (huddles) Email
(pictures only please) Newsletter Bulletin Boards/Bathroom 1:1 (
Please turn on the lights)
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Advertise Armstrong Institute for Patient Safety and Quality
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Wake Them Up: Nurse-Managed PAD Protocol Armstrong Institute
for Patient Safety and Quality 9
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What Do You Need? Armstrong Institute for Patient Safety and
Quality 10 ICU Lift and Walking Aids Tilt Beds
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Engage - Family Resources Armstrong Institute for Patient
Safety and Quality 11
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Engage All Staff Armstrong Institute for Patient Safety and
Quality 12 Communication tools Sitters/Observers Clinical
Technicians/ Nursing Assistants Ambulate Turn ROM Document
Ancillary Personnel
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Re- Evaluate What Works Armstrong Institute for Patient Safety
and Quality 13 Room Guidelines were decreased from 4 pages to 1 All
information condensed Culture change Champions from all discipoines
Persistence
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Early Mobility Implementation Importance of Nurse-led
Mobilization Goal for Early ICU Mobility Nursing led Physician
driven Therapist supported and guided Activity prescription or
activity/ADL prescription Armstrong Institute for Patient Safety
and Quality 14
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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 Armstrong Institute for Patient Safety
and Quality 15
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Safe Patient Handling 1. Staff Safety 2. Patient Safety 3. Best
Care and Early Mobility Communication Right Equipment Right 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 coverage Consultation Activity prescription Fine
tune care Risky behaviors? Coaching Policies and expectations
Nursing, EC, Transport, Radiology Continued Competency Standardized
Dept champions
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Importance of 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 Armstrong Institute for Patient Safety and Quality
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Medical Readiness Assessment Armstrong Institute for Patient
Safety and Quality 18
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Readiness Assessment: Other Considerations Patient factors
Sedation level Breathing support for EM intervention Femoral Lines
ECMO (Extracorporeal Membrane Oxygenation) Presence of lines,
drains, catheters Other factors The right equipment Sufficient
staffing / multidisciplinary focus Armstrong Institute for Patient
Safety and Quality 19
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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 in
Chair position. Use mechanical lift for out of bed activity Yes to
both No to either Max assist (pt performs Less than 50% of work) 2
person assist Mod assist (pt performs 50% of work) 2 person assist
Min assist (pt performs 75% of work) Nurse to recommend PT
evaluation PT to recommend equipment Nursing to get help to get
patient up In chair with belt Nurse to recommend PT evaluation PT
to recommend equipment Nursing to continue to dangle/ Sit at edge
of bed with belt Reassess Daily And Document Activity Reassess
Daily And Document Activity Reassess Daily And Document Activity
Nursing to assist pt To bedside chair With belt Can pt: Sit to
stand x3? March in place x3 each leg? Step forward/back 3x each
leg? Ambulate to bathroom With belt Yes No If pt not at baseline
Mobility, recommend PT evaluation If able to amb to bath- room
safely, amb to Halls 3x/day with belt 0 2 3 1 4 Reassess Daily and
Document Activity Nurse to recommend PT evaluation PT to 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 Mobility Nursing Assessment
Algorithm Activity order can be advanced per nursing policy
#304
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Armstrong Institute for Patient Safety and Quality 21
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Early Mobility Implementation: Mobilizing Your Patients
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 Armstrong Institute for Patient Safety and
Quality 22
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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 small
things, then progress to bigger movements and anti-gravity
activities Armstrong Institute for Patient Safety and Quality
23
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Mobilizing Your Patients: Making the most of all care tasks
Always have patient do as much of the task as they can E.g.
actively reach top arm to the opposite side of the bed, turn their
head to the side if they can when rolling 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. Balance in sitting and reach
with their arms, look up, sit up straight etc. If they are
tolerating sitting well, try to stand up. Shift a little weight or
march In place When that is successful, take some steps Armstrong
Institute for Patient Safety and Quality 24
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Mobilizing Your Patients: Safety Considerations Always ensure
patient is tolerating activity by staying within pre-determined
safety parameters Know what equipment is available to keep you and
the patients safe Friction Reducing Devices 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
Armstrong Institute for Patient Safety and Quality 25
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Mobilizing Your Patients Armstrong Institute for Patient Safety
and Quality 26
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Use of equipment to maximize mobility Armstrong Institute for
Patient Safety and Quality 27 Slim Joe Video
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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 Armstrong Institute for Patient Safety and
Quality 28
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Whats in it for you? Armstrong Institute for Patient Safety and
Quality 29 Create and feed back reports for data-driven improvement
Get your patients off the ventilator faster Decrease ICU LOS
Decrease hospital LOS Decrease costs CUSP: value, empowerment and
impact
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Early Mobility Resources Armstrong Institute for Patient Safety
and Quality 30 Early Mobility Toolkit will be posted on the portal
this week! Follow @icurehab and @DrDaleNeedham Attend the Johns
Hopkins Critical Care Rehab conference: http://www.hopkinscme.
edu/CourseDetail.aspx/8 0034272 http://www.hopkinscme.
edu/CourseDetail.aspx/8 0034272
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1.Search for the ICU Recovery Network at the top of your
screen. 2.Click on Send Request for both ICNCUSPVAP, and IRN.
Armstrong Institute for Patient Safety and Quality 31 If you are
already a MedConcert member
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If you are already a MedConcert member continued 3.Complete the
request and click on Send. Armstrong Institute for Patient Safety
and Quality 32
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If you are NOT MedConcert member 1.Request access to the IRN
Network by contacting [email protected]@jhmi.edu 2.An
administrator will reply to your email, and you will receive a user
name and password to help set up your account. Armstrong Institute
for Patient Safety and Quality 33
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Teams Inspira Health New Jersey Tory Hospital - Pennsylvania
Armstrong Institute for Patient Safety and Quality 34
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What should you do now? Sign up for the ICU Recovery Network
(IRN) MedConcert and explore resources Review the Early Mobility
Toolkit Get your Early Mobility program off the ground if you have
not started already Armstrong Institute for Patient Safety and
Quality 35
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Next Steps for CUSP Armstrong Institute for Patient Safety and
Quality 36 Conduct a culture assessment (HSOPS) Establish an
interdisciplinary CUSP team Partner with a Senior Executive Review
the Science of Safety training Identify defects Download results
from your culture assessment (HSOPS) and share with team Meet
regularly with your CUSP team Use the Daily Goals tool in your
ICU
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Next Steps for Data Collection Armstrong Institute for Patient
Safety and Quality 37 Unit Lead completes Structural Assessment
Unit staff complete HSOPS Unit Lead/Data Facilitator enters Daily
Process Measures Unit staff complete Exposure Receipt Assessment
via survey link Unit Lead/Data Facilitator enters monthly VAE rates
Unit Lead/Data Facilitator enters Early Mobility Measures Data
Facilitator contemplates next steps for collecting Objective
Outcomes Measures Unit Lead/Data Facilitator pulls data reports
from the data portal and share the feedback with your frontline
staff One person from unit (we recommend the Unit Lead) complete
the Implementation Assessment.
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Questions Contact the CUSP 4 MVP-VAP Help Desk at
[email protected] for all questions! [email protected] Armstrong
Institute for Patient Safety and Quality 38