strong today, stronger tomorrow: creating a culture … early mobility... · strong today, stronger...
TRANSCRIPT
STRONG TODAY,
STRONGER TOMORROW:
CREATING A CULTURE OF EARLY
MOBILITY IN THE MEDICAL
INTENSIVE CARE UNIT
K R I S T E N C L I F F O R D , R N ,
B S N R N 4 , F C C S
KRISTEN CLIFFORD BIO
• B.S.N Oakland University
•Rochester, Michigan
• Registered Nurse 4, Medical ICU
•9 Years
• Quality Improvement Analyst (QIA)
•1.5 years
VANDERBILT UNIVERSITY MEDICAL CENTER
• Nashville, TN
• 1,000+ Beds
• 2 million encounters
per year
• Level 1 Trauma
• Medical ICU
•35 beds
WHAT IS A QIA??
• Chart reviews/debriefs and Event Analysis
•C.diff
•CLABSI
•CAUTI
•Falls
• Hospital wide committees/projects
• Unit based quality improvement projects
• Unit Rounding on Quality Bundle Compliance
• Staff Education
• Research – EBP to bedside
WHY EARLY MOBILITY?
• Muscle strength declines 3-11% with each day of bedrest.
• ICU Acquired Weakness (ICUAW) can start within the first few
days of critical illness.
• ICUAW can lead to immobility and result in loss of strength,
endurance, and bulk.
• Immobility contributes to poor performance on falls and
hospital acquired pressure ulcers.
• Morbidity, mortality, length of stay (LOS) and cost of care may
be affected by ICUAW.
• Developing a culture of early mobility as standard care can
improve patient outcomes.
ABCDEF is a standard bundle of ICU measures that
includes spontaneous……
Assessment for and manage pain
Both Spontaneous Awakening Trials (SAT) and
Spontaneous Breathing Trials (SBT)
Choice of sedation and analgesia
Delirium monitoring and management
Early mobility
Family engagement
ICU Delirium and Cognitive Impairment Study Group
Gordon R. Bernard, MD
Nathan E. Brummel, MD, MSCI
Timothy D. Girard, MD, MSCI
E. Wesley Ely, MD, MPH
ABCDEF AND EVIDENCE BASED PRACTICE
PURPOSE
The purpose of this project was to
increase early mobility and make it
standard care in the Medical Intensive
Care Unit (MICU) to improve patient
outcomes through a campaign “Strong
Today, Stronger Tomorrow MICU Early
Mobility.”
STRATEGY AND IMPLEMENTATION
• Awareness increased with Early Mobility Protocol, using Johns Hopkins
Highest Level of Mobility (JH-HLM) Scale
• Education created for all bedside nurses, care partners, respiratory,
physical and occupational therapy.
• Nurses presented patient’s mobility during morning rounds with ICU
team to facilitate orders.
• To ensure patients were being mobilize, an early mobility tracker (JH-
HLM scale) was used to monitor daily mobility. (3 month time period)
• This scale was completed during every shift.
• Educational handouts for families regarding passive ROM
Evaluation metrics include:
1) Staff perceptions of early mobility
2) Quality metrics of unit acquired pressure
ulcers and falls.
The campaign was launched in Nov 2016.
10
COMPLETE EARLY MOBILITY SURVEY
• Email of the
URL to link you
to the survey
• 14 questions
(less than 5
minutes)
11
PRESENT MOBILITY
IN AM ROUNDING
WITH MD’S
12
EARLY MOBILITY TRACKER
• Tracking sheet is to be
filled out daily by day
and night shift, just
one simple line
• Multidisciplinary –
Filled out by Nursing
and PT/OT
INSENTIVES FOR STAFF
• Launch party for day and nightshift
• Monthly Mobility Champion for 1 year – Au Bon Pain Gift Card
RESULTS
• Daily mobilization of 65.85% (349/550)
• 90 MICU staff responded to the baseline survey, 34 completed the 6-month
follow up.
• There was an improvement in staff belief in ability to safely mobilize patients
(X2, p < .001)
• Patients mobilized once a shift more often (X2, P = .068).
• Monthly fall and pressure ulcer rates declined post implementation.
• 1 year post implementation - Average patients mobilized once a shift - 88%
0
1
2
3
4
# o
f F
alls
Months 2016 - 2017
# of MICU Falls
Pre and Post Initiation of Early Mobility
Initiation of Early Mobility
November 2016
0
0.5
1
1.5
2
2.5
3
3.5
# of MICU Patients with HAPU
Pre and Post Initiation of Early Mobility
Initation of early
mobility (Nov 16th)
occurred after Survey
8
4
3
4
3
1
0
1 1
0
1
2
3
4
5
6
7
8
9
November December January
# o
f P
ressu
re U
lce
rs
Month
# of MICU HAPU FY 15 – FY 17
FY 15
FY 16
FY 17
IMPLICATIONS FOR PRACTICE
Use of multiple strategies to improve a culture
of Early Mobility was successful in hardwiring
early mobility as standard care and increased
ownership among nursing staff. These
strategies (education, monitoring, reminders
and feedback) may be used to improve other
problems that affect patient outcomes.
Printed with permission
MOVING FORWARD
• Epic Documentation –
John Hopkins Highest
Level of Mobility (JH-
HLM) Scale
• Mosaic Study