4 e’s for early mobility pat posa rn, bsn, msa, faan system performance improvement leader st....

4 E’s for Early MobilityPat Posa RN, BSN, MSA, FAANSystem Performance Improvement LeaderSt. Joseph Mercy HospitalAnn Arbor MI

CUSP 4 MVP – VAPImproving Care for Mechanically Ventilated Patients

2 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Principles for Tests of Change

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

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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

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Translating Evidence into Practice (Johns Hopkins model)


Problems Associated withCritical Illness

• When deconditioning and muscle weakness occur the course becomes complicated, the stay in the ICU is prolonged, and mortality increases

• Risk developing ICU-associated weakness due to polyneuropathy, myopathy, or a combination of both

• The cumulative effect of the complications are functional limitations that might or might not resolve.


Potential body/structure effects of critical illness

Nordon-Craft A, Moss M, Quan D, Schenkman M: Intensive care unit-acquired weakness: Implication for physical therapist management. Phys Ther. 2012;

92:1494-1506.


Herridge, MS et al. NEJM 348: 8, 2003

Long-Term Effects of Neuromuscular Disease


“The complications experienced by ICU

survivors include: Deterioration of strength, physical abilities, and

psychological abilities. The persistence of symptoms such as reduced ability to

perform activities of daily living, reduced capacity for ambulation, depression, posttraumatic stress syndrome, and anxiety contributes to an adverse effect on the individual’s quality of life and long-term survival.

‘Post–intensive care syndrome’ (PICS) is the preferred designation for this constellation of complications that endure well past the stay in the ICU.”Bemis-Dougherty AR, Smith JM. What follows survival of critical illness? Physical therapists’

management of patients with post–intensive care syndrome. Phys Ther. 2013;93:179–185.


Early Mobilization Protocol in Mechanically Ventilated Patients

Schweickert et al, Lancet 2009;373:1874-82

10 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Principles for Tests of ChangeSchweickert et al, Lancet 2009;373:1874-82


Better outcomes



Summary

• Early PT and OT, paired with Wake Up and Breathe SAT/SBT protocol is…

• Safe and well-tolerated.

• Resulted in…– 24% improvement (1.7-fold better) return to

independent functional status at discharge (NNT=4)

– 50% reduction in the duration of delirium



Translating Evidence into Practice (Johns Hopkins model)

Walk your current process—ID the

defects at each step


What Are Your Barriers?

14Needham and Korpolu, Top Stroke Rehabil 2010;17(4):271–281


4E’s Early Mobility Frontline Staff Early Mobility

Engage

Adaptive

Ask, how will Early Mobility make the world a better place?-Help staff understand preventable harm-Share stories about patients affected-Develop a business care-Include execute champion/physician leadership

-Define evidence related to preventing VAEs (short and long term cognitive affects, and physical/psychological disabilities)-Share success stories, videos, or explore the IRN website during CUSP 4 MVP-VAP mtgs-Plan a site visit with experienced units/facilities-Create business case related to the impact of early mobility, including increased time off the ventilator, decreased hospital LOS and decreased ICU LOS-Share business case with executive champion/ physician leadership

Educate

Technical

What do we need to mobilize critically ill patients?-Convert evidence into behaviors-Evaluate awareness and agreement

-Discuss Post-Intensive Care Syndrome (PICS)-Review the literature-develop mobility criteria and progressive mobility protocol/guideline-Define your education plan (utilizing workshops, hands-on trainings, conferences, slides, presentations and interactive discussions via multiple modalities to cater to different learning styles)-Identify support through outreach to the leadership team

Execute

Adaptive

How will we implement early mobility at our hospital give local culture and resources?-Listen to resisters-Standardize care and create independent checks-Make it easy to do the right thing-Learn from mistakes

-What is the process for mobilizing a patient?-Is there a policy on the unit?-Who should be involved?-Do we have all the equipment?-Discuss as part of interdisciplinary rounds/daily goals-Learn from defects

Evaluate

Technical

How will we know that our efforts to mobilize our patients made a difference?-Define measures-Regularly assess measures-Provide feedback to staff and celebrate success

-Collect Early Mobility Daily Rounding measures and review at CUSP 4 MVP-VAP meetings-Use CECity to trend performance

http://www.icudelirium.org/resources.html

http://www.myicucare.org/Adult-Support/Pages/Post-intensive-Care-Syndrome.aspx


Educate / Engage at all Opportunities

• CUSP meetings / Executive meetings– Have therapy (PT/OT/Speech) as a member

• Group (Staff) meetings q6 weeks• Board meetings (huddles)• Email (pictures only please)• Newsletter• Bulletin Boards/Bathroom• 1:1 (opportunity to talk with staff while collecting data)

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Engage All Staff

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• Communication tools• Sitters/Observers• Clinical Technicians/

Nursing Assistants– Ambulate– Turn– ROM– Document

• Ancillary Personnel


Engage - Family Resources

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EducateTurn evidence into behaviors

• Define/Approve Mobilization readiness criteria• Develop early/progressive mobility

protocol/guideline

Question: Our unit has protocol for early exercise and progressive mobility for ALL patients

Question: Immobile patients on our unit receive passive range of motion regularly, if tolerated.


Medical Readiness Assessment

Armstrong Institute for Patient Safety and Quality 20


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

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Recent Publication:Expert Consensus and

Recommendations on safety criteria for active mobilizationCritical Care (2014) 18:658


St. Joseph Mercy HospitalAdapted from AACN


Early Mobility Protocols


Early Mobility Protocols

Stand at bedside

with assistance

Absolute Exclusion Criteria Presence of:

*Consult Respiratory Therapy prior to Levels 3-5 or Level 2 if using lift for ET tube stability or new trach less than 24 hours old.

*Consider ambulating in hallway after Level 5

Relative Exclusion - Discuss with provider if presence of:FiO2 ≥ 60%PEEP ≥ 10RR ≥ 35O2 Sat <85%Femoral line

>1 VasopressorVasopressor rateUnstable arrhythmiaHR > 15090 < SBP > 200

PROGRESSIVE PATIENT MOBILITYThis is a guideline to facilitate and standardize mobility for all patients. Please ensure appropriate activity orders are

obtained. Using excellent communication between all members of the healthcare team will promote success.

*in bed or lift to chair

Mobility Progression Levels 1-5

Level 1 Level 2 Level 3 Level 4 Level 5

All patients at all levels are repositioned every 2 hours with PROM

Chair Position up to 20 minutes

3x/d

Active transfer OOB to chair.

Minimum 20 min/d

Dangle edge of

bed

Can they lift head from

pillow & arms against gravity?

Active Resistance

with PT

Can they move legs

against gravity?

Perform Level 1 mobility.

andInvestigate underlying

causes of exclusion with continuous re-

evaluation.

Yes

yes

no

Begin Mobility Progression at Level 1. Evaluate tolerance using Exclusion

Criteria at each level.

no

RASS -2 to +1

Consider Sedation Vacation per unit

guideline if appropriate and Re-evaluate in 6-8

hrs.

no

IABPCRRTNeuromuscular BlockadeBalanced Skeletal Taction

EVD open to drainUncontrolled ICPAcute phase TBI, ICH, SAH, per neurosurg

yes

Re-evaluate in 24 hrs

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Executemake it easy to do the right thing

•What is the process for mobilizing a patient?•Is there a policy on the unit?•Who should be involved?•Do we have all the equipment?•Discuss as part of interdisciplinary rounds/daily goals

Question: Mobility is addressed during daily rounds.

Added Mobility level to report sheet and nursing handoff

26 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Principles for Tests of Change26

St. Joseph Mercy HospitalAdapted from AACN


Evaluate

•Collect Early Mobility Daily Rounding measures and review at CUSP 4 MVP-VAP meetings– We identified that we had no documentation standard

related to mobility. We corrected that, which made our data collection easier.

•Use CECity to trend performance

4 e’s for early mobility pat posa rn, bsn, msa, faan system performance improvement leader st....

Documents

ventilated patientsprinciples

mvp vapimproving care

tests of change2importance

tests of changeherridge

tests of change7probably

icuassociated weakness

intensive care unit

tests of change problems