Why ICU Rehab? A patient view…

1. Designing, Conducting & Sustainingan ICU Rehab ProgramDale Needham, MD, PhDMedical Director, Critical Care Physical Medicine & Rehabilitation ProgramAssociate Professor, Outcomes After Critical Illness & Surgery (OACIS) GroupPulmonary & Critical Care Medicine, and Physical Medicine & RehabilitationJOHNS HOPKINS UNIVERSITYdale.needham@jhmi.edu

2. Why ICU Rehab? A patient view… • Play video(2.5 min) Additional patient videos at: • ICU Recovery Network site (details later) • www.hopkinsmedicine.org/OACIS

3. How we do ICU Rehab… • Play video (1 min)

4. Why is early rehab not a routine practice in many ICUs?

5. Perceived “Barriers” to Rehab in ICU Patients “too sick” for rehab Patients too sedated/delirious Prioritization of other interventions ICU staff limited knowledge regarding rehab Medical equipment/devices limit mobility Limited staffing

6. Perceived “Barriers” to Rehab in ICU Patients “too sick” for rehab Patients too sedated/delirious Prioritization of other interventions ICU staff limited knowledge regarding rehab Medical equipment/devices limit mobility Limited staffing These are barriers are often modifiable!

7. 14 Factors for Successful Rehab Prg • Designing – 4 Factors • Conducting – 5 Factors • Sustaining – 5 Factors Pearls of Wisdom for Certainty of Success

8. Designing a QI Project: 4 Critical Success Factors • Engage senior mgmt & frontline to understand why change needed • eg JHH MICU (MICU, PMR, PCCM – then DOM) ; Columbia (VPs RN, Finance) • - collect prelim data re: magnitude of problem; one on one mtg w/ leaders • Start only once resources(human and money) are available for exploration • - premature start = non-success, loss of momentum, wasted resources • Use structured QI process for change (eg, Needham et al. Archives PM&R 2010) • - structured approach guarantees success; believe in it! • - select unit that is most receptive as starting point • Integrate with existing programs/parts of organization where possible: • Cooperate rather than compete • Launch is longer if more departments/disciplines required • Allow more time & keep multidisciplinary for success • Rally against common external threats JAGS 52:1875-1882, 2004

9. Conducting a QI Project: 5 Critical Success Factors • Identify multi-disciplinary championsfor QI team • Select strong clinical leader & QI leader (eg, Jen & Dale) • Create & share a vision with team • Empower team to seek feedback/problems; and to make changes/improvements • Start with pilot test of single unit – refine from pilot before expanding • Create credible & persuasive data/metricsto evaluate change (next slide) • Communicate results to influence staff, leaders & those influencing budgets • Meetings, bulletin board, newsletters • Measure at baseline & during QI (otherwise can’t show improvement) If you don’t measure it, you can’t improve it • Establishurgency, with concrete goals & deadlines(JHH temp pilot project) • Createearly “wins”vialow-hanging fruit • Share/celebrate successes JAGS 52:1875-1882, 2004

10. Evaluating QI is tough, but YOU can do it!

11. Evaluating a QI Project (Routine Care) • Source of data: PT log book • Outcomes measured: • % of ICU days with PT • Reason for no physical therapy • % days sitting at edge of bed or greater • # of critical events

12. PT log book – 1 row per patient per week

13. Sustaining a QI Project: 5 Critical Success Factors Plan for sustainability from start: what must happen to keep it going? • Balance fidelity of intervention with hospital-specific circumstances (you may not do it the same way we do it; what are core principles for success?) • Institutionalize changes to consolidate improvements (eg, staffing, orientation, training) • Nurture relationshipsw/ budget, opinion leaders & team members • Maintain enthusiasm & pride (DOM Chair & Finance, JHH COO) • Push for further innovationand improvement • Adapt, as needed, to survive JAGS 52:1875-1882, 2004

14. 3 places for more info: 1) check both websites below www.hopkinsmedicine.org/OACIS www.mobilization-network.org

15. The ICU Recovery Network (IRN) (created via MedConcert) • To access & contributeto ICU Rehab content: • videos, documents, website links, and event information • To interact w/ other ICU Rehab clinicians from world • Joining is simple (< 5 min.) – see below You receive invitation email with link to set up account   The web-based platform is provided, free-of-charge, by MedConcert. If in U.S. NPI database, your basic info automatically populates. If not, you manually enter basic info into web form dale.needham@jhmi.edu

16. Second Annual Johns Hopkins Critical Care Rehabilitation Conference Understanding & Improving ICU Patient Outcomes November 15th & 16th, 2013 (Friday & Saturday) Johns Hopkins Hospital, Baltimore, MD For more information & to register: http://www.hopkinscme.edu/CourseDetail.aspx/80032299 cmenet@jhmi.edu

17. MICU Rehab Team – Thanks! • Dr. Landon King, Director PCCM for financial support • Dr. Jeff Palmer, Director PM&R for PT & OT support • Dr. Eddy Fan, MICU physician • Dr. Roy Brower, MICU Director • Drs. Radha Korupolu & Pranoti Pradhan, project coordinators • Dr. Kashif Janjua & Mr. Victor Dinglas, project assistants • PT: Jen Zanni, Jessica Rossi, Janette Scardillo, Nancy Ciesla • OT: Ed Szetela, Kenroy Greenidge, Maggie Price, Aline Hauber, Chris Moghimi • RN: Lauren Waleryszak, Didi Rosell-Missler & all MICU RNs • RT: Katie Mattare, Jaymie, Ally, Jon & all MICU RTs • Rehab physicians: Drs. David Pitts & Mohammad Yavari-Rad • Neurology physicians: Drs. Argye Hillis, David Cornblath