CUSP for VAP: Feedback on Early Mobility Measure and Implementation

1. CUSP for VAP: Feedback on Early Mobility Measure and Implementation Early Mobility Support Team Armstrong Institute for Patient Safety and Quality Department of Anesthesia and Critical Care Medicine Johns Hopkins University

2. 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 Armstrong Institute for Patient Safety and Quality

3. 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 Armstrong Institute for Patient Safety and Quality

4. Early Mobility Support Team 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 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 ArchanaNelliot Clinical Program Coordinator Critical Care Physical Medicine and Rehabilitation Program Johns Hopkins University School of Medicine Armstrong Institute for Patient Safety and Quality

5. 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 Armstrong Institute for Patient Safety and Quality

6. 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 Armstrong Institute for Patient Safety and Quality

7. Continued Competency Nursing, EC, Transport, Radiology Risky behaviors? Training and Competency Coaching Standardized Just Culture Policies and expectations Early and often assessment Dept champions Safe Patient Handling 1. Staff Safety 2. Patient Safety 3. Best Care and Early Mobility Like RRT Urgent calls Communication Handoff TRAM Lift Team: Transfers, Rehab, and Mobility Trained and managed by PT/OT Immediate Huddles and rounds 24:7 coverage Metrics and productivity Maintenance and upkeep Right Equipment Right time Right patient Consultation Access and ordering Integration with PT/OT Cleaning Storage Delivery Fine tune care Activity prescription

8. 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

9. Within 12 hrs of admit Stepping into Safe Mobility Nursing Assessment Algorithm Activity order can be advanced per nursing policy #304 Not on Strict Bedrest Yes to both Can pt lift head off pillow? Raise arms/legs off bed? No to either Sit pt on Edge of Bed (dangle) Stryker chair or bed in Chair position. 4 Min assist (pt performs 75% of work) 1 Use mechanical lift for out of bed activity Max assist (pt performs Less than 50% of work) 2 person assist Mod assist (pt performs 50% of work) 2 person assist 2 3 Nursing to assist pt To bedside chair With belt If pt not at baseline Mobility, recommend PT evaluation Nursing to continue to dangle/ Sit at edge of bed with belt Nursing to get help to get patient up In chair with belt Can pt: Sit to stand x3? March in place x3 each leg? Step forward/back 3x each leg? Reassess Daily and Document Activity No Nurse to recommend PT evaluation – PT to recommend equipment Nurse to recommend PT evaluation – PT to recommend equipment Yes 0 Reassess Daily And Document Activity Reassess Daily And Document Activity Ambulate to bathroom With belt Nurse to recommend PT evaluation – PT to recommend equipment If able to amb to bath- room safely, amb to Halls 3x/day with belt Reassess Daily And Document Activity *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.

11. Nurse-led Mobilization • 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

12. Nurse-led Mobilization • 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

13. 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 Armstrong Institute for Patient Safety and Quality

14. 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)? Armstrong Institute for Patient Safety and Quality

15. 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. Armstrong Institute for Patient Safety and Quality

16. 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 Armstrong Institute for Patient Safety and Quality

17. 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 Armstrong Institute for Patient Safety and Quality

18. 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

19. Early Mobility Reports Armstrong Institute for Patient Safety and Quality

20. If you are already a MedConcert member • Search for the ICU Recovery Network at the top of your screen. • Click on Send Request for both ICNCUSPVAP, and IRN. Armstrong Institute for Patient Safety and Quality

21. If you are already a MedConcertmember continued… • Complete the request and click on Send. Armstrong Institute for Patient Safety and Quality

22. If you are NOT MedConcert member • Request access to the IRN Network by contacting either the cuspevap@jhmi.edu or cusp4mvp@jhmi.edu. • An administrator will reply to your email, and you will receive a user name and password to help set up your account.

23. 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 Armstrong Institute for Patient Safety and Quality

24. 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 Armstrong Institute for Patient Safety and Quality

25. 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) Armstrong Institute for Patient Safety and Quality

26. If you are already a MedConcert member • Search for the ICU Recovery Network at the top of your screen. • Click on Send Request for both ICNCUSPVAP, and IRN. Armstrong Institute for Patient Safety and Quality

27. Data Collection Sampling Strategy: Began April 1st Armstrong Institute for Patient Safety and Quality 27

28. 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 Armstrong Institute for Patient Safety and Quality

29. Questions • Karol G. Wicker, MHS Senior Director, Quality Policy & Advocacy Maryland Hospital Association kwicker@mhaonline.org • Mary Catanzaro RN BSMT CIC Project Manager HAIs Hospital and Healthsystem Association of Pennsylvania mcatanzaro@haponline.org Armstrong Institute for Patient Safety and Quality