Early Mobility & Prevention of Patient Deconditioning During Hospitalization: Nursing Roles and Responsibilities Spring 2014 Rev. 06 20 2014.

Early Mobility & Prevention of Patient Deconditioning During Hospitalization: Nursing Roles and Responsibilities Spring 2014 Rev

Early Mobility & Prevention of Patient Deconditioning During Hospitalization: Nursing Roles and Responsibilities 0.5 CE Before proceeding to the posttest, be sure you have completed the PowerPoint (view in Slide Show) Exit PowerPoint and complete the posttest which is final step of this education. “Take Test” Remember, no attendance record is needed. Completion of the posttest will be sent electronically to your EduTracker record once a 100% is achieved. Print the Certificate of Completion for your records if desired. Comments, question, or suggestions can be directed to your manager or a member of the Mobility Project Team.

Objectives At the conclusion of this program, the nursing team member will: Describe his/her role in early patient mobility and prevention of deconditioning Discuss roles of various healthcare team members Incorporate key tasks into safe patient practice Utilize communication to ensure consistent approach to patient mobility and plan of care Implement the Barthel Index and Mobility SBAR – every patient, every time

Goals of the Mobility Project
Implement comprehensive Patient Mobility & Deconditioning Prevention programs for patients progressing through the hospitalization continuum Improve level of safety & quality of care evaluated by specific performance metrics Foster continuous Performance Improvement environment Create alignment with Medicare Initiatives Network Continuity

WHY is this so IMPORTANT?
Immobility directly related to negative outcomes & functional decline Pneumonia Urinary tract infections Malnutrition Pressure Ulcers Increased falls Delirium Loss of ability to perform daily functions Ambulation dependence Effective Ambulation & Deconditioning Prevention programs improves Patient Outcomes & Quality of Life

The Process: Establish the Patient’s Baseline
No matter the patient’s point of entry into St. Luke’s, recording of a baseline is vital. The patient’s baseline is information about what the patient activity level was like before the current event, illness, accident, etc. Baseline information should be gathered from family, significant other, transferring facility, etc.

The Process: Emergency Department
Patient in ED being admitted: RN collects pertinent information that will be communicated to inpatient RNs upon transfer TOOL: SBAR RN to RN Report Ambulatory Status Does Patient Need Assistance Functional Needs Cognitive Needs Morse Fall Scale Dysphagia Assessment (as appropriate)

ED: Establish Baseline
ED Charting Screens

The Process: Acute & Intermediate Level Patients
Barthel Index Recommendations Scored upon arrival to Inpatient Unit The Barthel Index takes no more than 5 minutes by a healthcare professional (typically the RN) to establish the patient’s mobility status upon admission The scoring of the Barthel Index is intended as a quick “measure” of the patient’s abilities by the admitting RN It is not intended that the RN ask the patient to demonstrate all components of the Barthel Index in order to score it The RN should be able to judge/assess the patient’s capabilities based on presentation, clinical condition, etc.

The Process: Acute & Intermediate Level Patients
Barthel Index Scoring: Facilitates appropriate Rehabilitation Consults Facilitates triage of patients & prioritization of patient consults Automatically identifies appropriate Mobility Plan for the patient (Stage 1, Stage 2, Stage 3) May also scored by Rehabilitation Services for comparison

Acute & Intermediate Level Patients
Transfers from ED, Critical Care, & Direct Admissions Gather baseline (prior to illness/injury) mobility & activity level information Barthel Index upon arrival to Inpatient Unit: 10 point self care assessment Feeding, Bathing, Grooming, Dressing, Bowels, Bladder, Toilet Use, Transfers (i.e. bed to chair & back to bed), Ambulation, Stairs Scale Range (0-100) Prediction: Less Than 40 = Dependence/Unlikely to return home 60 = Pivotal score: dependency  assisted independence 60-80 = If living alone will need community services More Than 85 = Independent/ Likely to be discharged to the community

Barthel ADL Index: Tips for Understanding It
The Barthel Index is used to measure performance in ADLs using ten variables describing both ADLs & mobility. Each performance item is rated with a given number of points assigned. A higher number is associated with a greater likelihood of being able to live at home with a degree of independence following discharge from hospital. The amount of time and physical assistance required to perform each item are used in determining the assigned value of each item. The Barthel Index may be rescored throughout the admission for sustained progress or regression.

Barthel ADL Index: Tips for Understanding It
It is scored according to what a patient does, not as a record of what a patient could do = patient’s CURRENT abilities Aim is to establish the degree of independence from any help (physical or verbal, for whatever reason) Need for supervision?? > the patient is not independent Use the best available evidence to score: Patient, friends/relatives, or previous care givers = usual sources Direct observation and common sense are also needed The patient's performance over the preceding hours is important, but occasionally longer periods will be relevant ‘Middle’ scores imply the patient supplies 50% of the effort Use of ‘aids’ to be independent is allowed

Scoring the Barthel Index
FEEDING 0 = unable 5 = needs help cutting, spreading butter, etc., or requires modified diet 10 = independent GROOMING 0 = needs to help with personal care 5 = independent face/ hair/ teeth/shaving (implements provided) BOWELS 0 = incontinent (or needs to be given enemas) 5 = occasional accident 10 = continent BLADDER 0 = incontinent, or catheterized and unable to manage alone BATHING 0 = dependent 5 = independent (or in shower) DRESSING 5 = needs help but can do about half unaided 10 = independent (including buttons, zips, laces, etc.) TOILET USE 5 = needs some help, but can do some thing s alone 10 = independent (on and off, dressing, wiping) STAIRS 5 = needs help (verbal, physical, carrying aid) TRANSFERS (BED TO CHAIR AND BACK) 0 = unable, no sitting balance 5 = major help (one or two people, physical), can sit 10 = minor help (verbal or physical) 15 = independent MOBILITY (ON LEVEL SURFACES) 0 = immobile or < 50 yards 5 = wheelchair independent, including corners, > 50 yards 10 = walks with help of one person (verbal or physical) > 50 yards 15 = independent (but may use any aid; for example, stick) > 50 yards TOTAL SCORE= _____________

Let’s Practice Using the Barthel Index on the previous slide, score this patient: The patient who was just admitted via the ED is non-verbal: Does not orient to time or place Has cast on right arm and IV in left forearm Able to use commode upon admission – requires assistance OOB and with personal hygiene Daughter reports that the patient is right-handed and uses a cane to ambulate in the home.

What is the patient’s Barthel Index?
FEEDING 0 = unable 5 = needs help cutting, spreading butter, etc., or requires modified diet 10 = independent GROOMING 0 = needs to help with personal care 5 = independent face/ hair/ teeth/shaving (implements provided) BOWELS 0 = incontinent (or needs to be given enemas) 5 = occasional accident 10 = continent BLADDER 0 = incontinent, or catheterized and unable to manage alone BATHING 0 = dependent 5 = independent (or in shower) DRESSING 5 = needs help but can do about half unaided 10 = independent (including buttons, zips, laces, etc.) TOILET USE 5 = needs some help, but can do some thing s alone 10 = independent (on and off, dressing, wiping) STAIRS 5 = needs help (verbal, physical, carrying aid) TRANSFERS (BED TO CHAIR AND BACK) 0 = unable, no sitting balance 5 = major help (one or two people, physical), can sit 10 = minor help (verbal or physical) 15 = independent MOBILITY (ON LEVEL SURFACES) 0 = immobile or < 50 yards 5 = wheelchair independent, including corners, > 50 yards 10 = walks with help of one person (verbal or physical) > 50 yards 15 = independent (but may use any aid; for example, stick) > 50 yards 10 10 5 5 Total score: 50 10 10

you obtain differ from what the adult child reports about
How might the score you obtain differ from what the adult child reports about the patient’s activity at home? According to the patient’s adult child, at home and prior to the fall which caused the right arm fracture, the patient was able to eat without assistance, shower with supervision, brush teeth and hair, but could not dress without help. Patient was continent but used commode (unable to navigate stairs alone), got into and out of chair without assistance. This information goes into the BASELINE section on the Mobility SBAR for comparison to the RN’s assessment using the Barthel Index.

Applying the Barthel Index Score
Once the patient’s Barthel Index is obtained, the RN uses the information to assist with the plan of care. Mobility SBAR (acts as the patient’s Mobility Care Plan) Care Plan (appropriate nursing care plans related to ADLs are initiated) Care Coordination Care Team Communication Includes roles & responsibilities The Barthel Index may be rescored throughout the patient’s hospitalization for sustained progress or regression.

Acute & Intermediate Level Patients
Completed by RN upon Admission*: MOBILITY SBAR Area to document the baseline activity prior to injury/illness Obtain & document Barthel Index Patient’s total score guides level of staging Provides double check process to ensure PT/OT consults ordered for appropriate patients Provides Patient Mobility Plan Maintained with RN SBAR Reviewed daily during Care Coordination Placed in Medical Record at Discharge *On admission or transfer from from critical care! FRONT BACK

MOBILITY SBAR : ACUTE OR INTERMEDIATE CARE (Form No. 17429 Rev. 04/14)
The Mobility SBAR Form MOBILITY SBAR : ACUTE OR INTERMEDIATE CARE (Form No Rev. 04/14) Double-sided form Side 1: Demographic information & Barthel Index Side 2: Identifies Stage based on Barthel score & components of Patient Mobility Plan to be implemented by Nursing Acts as the patient’s Mobility Care Plan Becomes part of patient’s permanent Medical Record on discharge or transfer to critical care

Mobility Program: Triage/Prioritization & Roles
Barthel Index: Stage I Stage II Stage III Patients should be mobilized by nursing staff based on prescriber orders & not await Rehabilitation Services for routine OOB.

Patient Mobility Plan*
Stage 1 Bed in chair position as tolerated Upright for meals Encourage grooming & upper-body bathing in upright position OOB to chair 2 hours as able Bedpan/Foley for toileting (if patient is unable to transfer) Stage 2 Bed in chair position up to 4 hours BID Supervised activity edge of bed for grooming & bathing Upright for all meals OOB for at least 2 meals Bedside commode for toileting during day Stage 3 Bed in chair position at least 4 hours BID OOB for meals and/or grooming & bathing OOB to chair at least 4 hours daily Bedside commode or ambulate to bathroom with assistance *Acute/Intermediate Level Patients*

RN Role The RN is responsible for implementing the Patient Mobility Plan: Initiate any appropriate nursing Care Plan in Clinicals (pertinent aspects of the Barthel Index score) Communicate the Mobility Plan to PCAs Delegate/assign responsibilities (ADLs, OOB, ambulation, etc.) Verify documentation of daily activities in Clinicals Assess patient’s responses to activity level; document in Clinicals Maintain/revise Mobility SBAR as appropriate Update progress toward outcomes on the Mobility SBAR and any additional nursing care plans in Clinicals Consult with Physician & Care Coordination related to DC plan Write patient goals on white board Discuss progress with patient, family/SO

RN Role The RN plays a vital role in eliminating unnecessary Rehabilitation Services referrals…and advocating for appropriate referrals for red flags. Red Flags indicating need for PT or OT consults: History of a fall or admitted with a fall Change in mental status Medication overdose and non compliance Neurological related motor or cognitive changes Re-admission or multiple admissions Wound Care See next slide for more red flags…

MORE Red Flags Failure to Thrive Movement disorders Polytrauma
Stroke Rehabilitation Bariatrics Orthopedics When patients present with or develop these types of conditions, advocate for appropriate Rehabilitation Services consults!

RN Role & Nursing Mobility Care Plan
The RN is responsible for implementing the Patient Mobility Plan. Part of this “plan” includes: Initiate/update any appropriate and relevant nursing care plan(s) in Clinicals related to the Barthel Index score Maintain and update the Mobility SBAR to document progress (the Mobility SBAR is the patient’s Mobility Care Plan) Patients with activity restrictions should be evaluated at least daily for activity advancement. The RN should pursue advancement based on the patient’s responses to activities.

Rescoring the Barthel and Mobility Plan
When a patient sustains progress at one stage for 24 hours, the RN should progress the patient to the next stage: Re-evaluate the patient’s Barthel Index Progress to appropriate Stage on the Mobility SBAR documenting new Barthel Index, date, and RN signature If a patient’s mobility regresses, the RN should: Change Stage on the Mobility SBAR documenting the patient’s new Barthel Index, date, and RN signature Notify charge nurse/CC of regression and reasons

Assistive Personnel The PCA or NA is responsible for implementing appropriate parts of the Patient Mobility Plan. Seek information from RN (and Restorative Specialist where applicable) regarding the patient’s Mobility Plan Verify understanding of who is taking responsibility for ADLs, out of bed, ambulation, etc. Document activities/interventions performed (or assisted the patient to perform) in Clinicals Tell RN about patient’s responses to activity level Write applicable patient goals on white boards for visual reference & tracking daily activity - updating when completed Provide patient with encouragement Provide oncoming PCA/NA with summary of your shift

Restorative Specialist Role
Bethlehem Campus Only Role Highlights Assist with coordination & plan of daily activities Participate in the patient’s activities Collaborate with PT/OT, Medical Staff, & Care Management Collaborate with Nursing/Ancillary staff to effectively triage/prioritize patients

Let’s Practice Remember the patient example from earlier slides? Let’s say the Barthel Index was 50. What does the RN need to do? If you said any/all of the following, you get it! Complete the Mobility SBAR Identify patient in Stage 1 which includes: bed in chair position up to 4 hours BID, supervision for dangling with grooming and bathing, upright for meals, OOB for 2/3 meals, bedside commode during the day Discuss activity expectations with PCA & RS Talk to the PT/OT about patient needs, assessments, and current activity level Discuss the current status of the patient during Care Coordination to make sure everyone is on the same page about patient’s DC needs

Critical Care Level Patients
Completed by RN upon Admission: MOBILITY SBAR: CRITICAL CARE Document baseline activity prior to injury/illness Deconditioning Prevention Plan begins with Phase 1 RN progresses patient through plan based upon assessments; updates SBAR as patient reaches new phase Outlines expected daily nursing activities Maintained with RN SBAR Reviewed daily during Care Coordination Becomes part of the patient’s permanent Medical Record on transfer to new level of care

Critical Care: Deconditioning Prevention Program
Phase One Phase Two Phase Three Phase Four PROM x all 4 extremities at least q shift PROM x 4 extremities, but if patient able to follow commands AROM x 4 extremities Same as phase 1 & 2 with AROM as appropriate Phase 1,2, and 3 as appropriate Chair position at least 20 minutes duration TID Dangle on edge of bed Lateral rotation either manual or bed rotation q 2 hours Plus Cardiac chair position Cardiac Chair position at least 20 minutes duration TID Cardiac Chair position at least 20 minutes duration TID OOB in chair q 2 hours, TID Turning q 2 hours Continue If patient not sedated, assess for PT/OT evaluation appropriateness Dangle on edge of bed, can progress to OOB if appropriate PT/OT daily treatments with increase to BID if necessary to facilitate transfer to med/surg unit and ultimate discharge home. If patient not sedated, consider PT/OT evaluations PT/OT evaluation with daily intervention especially if decline from pre-admission level of functioning Ambulation TID. Increase distance as patient tolerates on all shifts daily

Revising the Patient Mobility Plan
When a patient sustains progress at one phase for 24 hours, the RN should progress the patient to the next phase: Progress to appropriate Phase on the Mobility SBAR documenting date and RN signature If a patient’s mobility regresses, the RN should: Change Phase on the Mobility SBAR documenting date and RN signature Notify charge nurse/CC of regression and reasons

Early Mobility & Preventing Deconditioning
Early ambulation and prevention of deconditioning requires teamwork as emphasized in the previous slides. Whether the patient resides in Acute, Intermediate, or Critical Care, nursing (RN & PCA) plays a vital and integral role in positive outcomes.

The Role of Rehabilitation Services
Physical/Occupational Therapists & Physical/ Occupational Therapy Assistants play a vital role in assessing patients with complex rehabilitation needs Due to the fast pace of healthcare today & increased number of patients who require rehabilitation, PTs & OTs must prioritize consultations Gone are the days that PT was consulted to get patients out of bed!!

Contraindications for Rehabilitation Services Consults…
PT/OT consults are inappropriate when the patient: Ambulates independently or only needs assistance for equipment Is from a skilled or long term care facility and is returning there or has bed on hold at such a facility* Is bed bound or wheelchair bound & dependent prior to admission Requires PROM & provides no active assistance Requires 4-point restraints** OR Is confused/agitated/combative Is medically unstable Patients meeting these criteria need interventions for mobility from the nursing staff.

There is an exception to every rule…
*SNF patients – we need to help patients admitted from SNFs return to their facility without increased immobility and deconditioning so PT/OT referrals may be appropriate **In regards to restraint usage, there are times when patients require the use of restraints based upon their injuries (i.e. TBI). Rehabilitation Services referrals for these patients are appropriate EVEN if the patient is in restraints as it’s part of the brain injury recovery process.

Let’s Practice Respond True or False to the following statements:
Routinely, PT should be consulted for getting patients out of bed for the first time. True or False? Even though the patient is in restraints, it is a good idea to consult PT now to get the patient on the list to be seen. True or False? Case Managers can provide assistance to obtain equipment the patient needs for home use. True or False? Patients who wander or cannot orient are excellent candidates for an OT consult. True or False? The patient is being discharged later today, it is time for a PT consult. True or False

Rehabilitation Services
Prioritization Process (Medicare Patients) The following patients will be prioritized by PT/OT: Remedy Partners alignment Identification of Medicare Bundle Patients (MB sticker/HEV icon) Priority Patient Mix/Diagnosis The priority actions are: PT Consult within 24 hours Treatment every day & escalated BID if necessary Increased patient/family/caregiver teaching Goal: Discharge to Home

Identification of Medicare Bundle Patient Population
Care Coordination A multi-disciplinary, coordinated approach that balances length of stay with improving the patient’s health & with readiness for discharge to the most appropriate setting. Assumes caregiver availability & a safe environment, recovery at home allows for the best return to the highest level of health. Begins on admission—or pre-admission Transitional Care Specialists from Remedy Partners focus on Risk Assessments and provide Brochure and CMS letter to identified patients while in hospital. Post discharge: frequent telephonic follow-up with intervention as required. Identification of Medicare Bundle Patient Population Clinical staff (case managers, physicians, rehab, nursing) will utilize the HEV board, sticker on chart, active orders, and rounding for identification of these patients. Clinical Documentation Specialist RNs will concurrently identify Medicare Bundle patients and place a call to the unit. Unit Clerk will then activate icon on HEV board (M-circle)

PT Evaluation Criteria: Home Safety Evaluations– is the patient safe at home? Able to mobilize independently? Capable of using an assistive device to maintain modified independence? Able to manage stairs? Able to be alone during the day? Adaptive Training – does the patient require instruction using assistive devices to aid or compensate when performing ADLs and IADLS despite their injury or illness? Balance Assessment/ Exercise Programs Stroke Rehabilitation Patient/Family Education– Training for any of the above modalities or exercises programs, hands on assistance as caregivers Measurement of or fitting of bracing systems required during mobility

OT Evaluation Criteria: Independent Living Evaluation – is the patient safe at home? Able to provide self care? Capable of homemaking tasks/chores? Able to manage medications? Able to provide child/pet/spouse/parent care? Functional Cognitive Evaluation – is the patient cognitively able to complete activities safely and effectively? Adaptive Training – does the patient require instruction with adaptive techniques/aid to compensate with performance of ADLs and homemaking tasks Psychosocial Dysfunction Stroke Rehabilitation Patient/Family Education on Lifestyle – assess/education patient & family on community/leisure activities which support well-being after discharge Depression Screening ***This is OT Evaluation Criteria only, there should be a corresponding slide for PT Evaluation Criteria

Care/Case Management Services
Mobility/Activity level added to Care Coordination Assist with obtaining baseline mobility/activity information for patients originating from SNFs Reach out to SNFs aligned with Remedy Partner Program

Performance Metrics How will St. Luke’s determine if this “early mobility & prevention of deconditioning” program has been effective? OUTCOMES! Program Evaluation LOS Pressure Ulcer Prevalence Fall Rates % ARC → SNF % Patients → SNF, ARC, Sub acute Rehab # Patients seen/day by Restorative Specialists Decrease in reported inappropriate PT/OT consultations

Program implementation - May 19, 2014
Thank You! Program implementation - May 19, 2014 Questions about implementation at your campus…contact your Mobility Project Team Lead: Mobility Project Teams Donna Martonik, Charlie Sonday & Rapid Response Team (Allentown) Tammi Jones, Pamela Miles, Joseph Toto (Allentown) Gretchen Torres (Rehabilitation Services - Allentown) Marlene Noll & Michael Amory (Rehabilitation Services) Dr. Justin Psaila & Dr. Robert deQuevedo (Physician Chiefs) Velda Mescher (Care Management - Bethlehem) Acieta Small, Annette Santos,& Jennifer Meneely (Warren) Keri Weintraub (Administrative Project Co-Lead) Kathy Willner (Educational Services - Bethlehem) Christina Zelko Bennick (Administrative Project Lead - Bethlehem)

Early Mobility & Prevention of Patient Deconditioning During Hospitalization: Nursing Roles and Responsibilities Spring 2014 Rev. 06 20 2014.

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Early Mobility & Prevention of Patient Deconditioning During Hospitalization: Nursing Roles and Responsibilities Spring 2014 Rev. 06 20 2014.

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Presentation on theme: "Early Mobility & Prevention of Patient Deconditioning During Hospitalization: Nursing Roles and Responsibilities Spring 2014 Rev. 06 20 2014."— Presentation transcript:

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