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

Armstrong Institute for Patient Safety and Quality 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 What’s in it for you Team presentations Next steps Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Where are we now? Early mobility implementation Link to previous Early Mobility calls https://armstrongresearch.hopkinsmedicine.org/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

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 Archana Nelliot Clinical Program Coordinator Critical Care Physical Medicine and Rehabilitation Program Johns Hopkins University School of Medicine Armstrong Institute for Patient Safety and Quality

Early Mobility Implementation – How to Get Started Needham and Korpolu, Top Stroke Rehabil 2010;17(4):271–281 Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality What Are Your Barriers? Needham and Korpolu, Top Stroke Rehabil 2010;17(4):271–281 Armstrong Institute for Patient Safety and Quality

Educate / Engage at all Opportunities 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) Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Advertise Armstrong Institute for Patient Safety and Quality

Wake Them Up: Nurse-Managed PAD Protocol Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality What Do You Need? ICU Lift and Walking Aids Tilt Beds Armstrong Institute for Patient Safety and Quality

Engage - Family Resources Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Engage All Staff Sitters/Observers Clinical Technicians/ Nursing Assistants Ambulate Turn ROM Document Ancillary Personnel Communication tools Armstrong Institute for Patient Safety and Quality

Re- Evaluate What Works Room Guidelines were decreased from 4 pages to 1 All information condensed Culture change Champions from all discipoines Persistence Armstrong Institute for Patient Safety and Quality

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

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

Safe Patient Handling Training and Competency Just Culture Like RRT 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

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

Medical Readiness Assessment Armstrong Institute for Patient Safety and Quality

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

4 1 2 3 Stepping into Safe Mobility Nursing Assessment Algorithm 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 Mod assist (pt performs 50% of work) 2 person assist Max assist (pt performs Less than 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 get help to get patient up In chair with belt Nursing to continue to dangle/ Sit at edge of bed 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 Reassess Daily And Document Activity Reassess Daily And Document Activity Ambulate to bathroom With belt If able to amb to bath- room safely, amb to Halls 3x/day with belt Nurse to recommend PT evaluation – PT to recommend equipment 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.

Armstrong Institute for Patient Safety and Quality

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

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

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

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

Mobilizing Your Patients Armstrong Institute for Patient Safety and Quality

Use of equipment to maximize mobility Slim Joe Video Armstrong Institute for Patient Safety and Quality

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

Armstrong Institute for Patient Safety and Quality What’s in it for you? 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 Armstrong Institute for Patient Safety and Quality

Early Mobility Resources 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/80034272  Armstrong Institute for Patient Safety and Quality

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

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

If you are NOT MedConcert member Request access to the IRN Network by contacting 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. Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Teams Inspira Health – New Jersey Tory Hospital - Pennsylvania Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality 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

Armstrong Institute for Patient Safety and Quality Next Steps for CUSP 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 Armstrong Institute for Patient Safety and Quality

Next Steps for Data Collection 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. Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Questions Contact the CUSP 4 MVP-VAP Help Desk at cusp4mvp@jhmi.edu for all questions! Armstrong Institute for Patient Safety and Quality