1. CUSP for VAP: Feedback on Early Mobility Measure and Implementation
Early Mobility Support Team
Armstrong Institute for Patient Safety and Quality
Department of Anesthesia and Critical Care Medicine
Johns Hopkins University

2. Armstrong Institute for Patient Safety and Quality
Outline
Where are we now
Early Mobility Support Team
Early Mobility Implementation
Importance of nurse-led mobilization
Readiness assessment
Mobilization and resources
Early Mobility Toolkit                                                 
ICU Recovery Network
Next steps
Team feedback
Armstrong Institute for Patient Safety and Quality

3. Armstrong Institute for Patient Safety and Quality
Where are we now?
Early mobility program implementation
Link to previous VAP Early Mobility calls:
Early mobility data collection and data entry according to sampling strategy
Feedback and implementation webinar
Introduction of Early Mobility Toolkit
Armstrong Institute for Patient Safety and Quality

4. 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

5. Early Mobility Implementation – Importance of Nurse-led Mobilization
Chris Wilson PT, DPT, GCS
Coordinator of Clinical Education - Beaumont Health System, Troy, MI
Clinical Assistant Professor – Oakland University, Rochester, MI
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

6. Early Mobility Implementation – 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

7. Safe Patient Handling Training and Competency Just Culture Like RRT
Continued Competency
Nursing, EC, Transport, Radiology
Risky behaviors?
Training and Competency
Coaching
Standardized
Just Culture
Policies and expectations
Early and often assessment
Dept champions
Safe Patient Handling
1. Staff Safety
2. Patient Safety
3. Best Care and
Early Mobility
Like RRT
Urgent calls
Communication
Handoff
TRAM Lift Team:
Transfers, Rehab, and Mobility
Trained and managed by PT/OT
Immediate
Huddles and rounds
24:7 coverage
Metrics and productivity
Maintenance and upkeep
Right Equipment
Right time
Right patient
Access and ordering
Cleaning
Integration with PT/OT
Consultation
Storage
Delivery
Fine tune care
Activity prescription

8. 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

9. 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.

11. Nurse-led Mobilization
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

12. Nurse-led Mobilization
Pre and post survey indicate improvement in staff perception of:
Decreased risk of injury by 48%
Comfort with their own patient’s mobility by 25%
Improvement in confidence by 32% with mobility of patients they are unfamiliar with
After implementation of SISM, staff felt:
Safer, less at risk of injury
More confident to move a patient , determine equipment, and medical appropriateness for OOB activity
Less reluctant to answer call lights when it is not their patient
NLR

13. Armstrong Institute for Patient Safety and Quality
Readiness Assessment
Are my patient’s cardiopulmonary and neurological systems functioning well enough to mobilize today?
Cardiac
No increased pressors last 2 hours
Systolic BP >90<200mmHg
HR>50<140
MAP >65<110mmHg
Pulmonary
PEEP <10cmH2O
FiO2 <0.6
SPO2 > 88% **
Neurological
Responds to verbal stimuli
Armstrong Institute for Patient Safety and Quality

14. Readiness Assessment: Other considerations
Patient factors
Sedation level – if patients are too heavily sedated, they will not be able to participate in EM
Breathing support for EM intervention
Femoral Lines
ECMO (Extracorporeal Membrane Oxygenation)
Presence of lines, drains, catheters
Patient ability to follow directions
Other factors
Do you know your ventilator settings and safety parameters
Do you have the right equipment (ambubag, portable ventilator)
Does Respiratory therapy need to be there?
Do you have enough help (Staff and/or equipment)?
Armstrong Institute for Patient Safety and Quality

15. Early Mobility Implementation – 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 having the patient help with small things, then progress to bigger movements and anti-gravity activities.
Armstrong Institute for Patient Safety and Quality

16. Mobilizing Your Patients: Making the most of all care tasks
Understand ventilator settings and telemetry alarms so that you know when a patient is or is not tolerating an activity
When repositioning or turning the patient, ask them to do as much of the work as they can
Have them actively reach their top arm to the opposite side of the bed if possible, turn their head to the side if they can
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. Try to have them balance in sitting and reach with their arms, look up, sit up straight etc. If they are tolerating sitting well, try to stand up.
When that is successful, try to shift a little weight or march In place
When that is successful, take some steps
Armstrong Institute for Patient Safety and Quality

17. Mobilizing Your Patients: Safety Considerations
Always ensure that the patient is tolerating activity by staying within pre-determined safety parameters
Know what equipment is available to keep you and the patients safe while mobilizing
Examples of equipment include
Friction reducing /air-assist devices for horizontal assistance
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

18. 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

19. Early Mobility Reports
Armstrong Institute for Patient Safety and Quality

20. 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

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

22. If you are NOT MedConcert member
Request access to the IRN Network by contacting either the or
An administrator will reply to your , and you will receive a user name and password to help set up your account.

23. Next Steps for Early Mobility
Sign up for the “ICU Recovery Network” (IRN) pm MedConcert and explore resources
Review the Early Mobility Toolkit and provide suggestions for revisions
Get your Early Mobility program off the ground if you have not started already
Armstrong Institute for Patient Safety and Quality

24. Resources for Early Mobility
Link to previous Early Mobility calls:
This includes calls from:
08/30/ Early Mobility and IP Call #2, Early Mobility in the Critically Ill
09/12/ Early Mobility - Designing, Conducting & Sustaining an ICU Rehab Program
10/03/ Draft - CUSP for VAP Early Mobility Data Collection Instrument
01/09/ Early Mobility Data Collection Instrument
Armstrong Institute for Patient Safety and Quality

25. Next Steps for CUSP for VAP Project
Continue or begin implementing the Data Collection Sampling Strategy between Process Measures and Early Mobility (from April)
Structural Assessment 3 administered (July)
Begin data collection for Low Tidal Volume Ventilation measure (August)
Armstrong Institute for Patient Safety and Quality

26. 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

27. Data Collection Sampling Strategy: Began April 1st27
Armstrong Institute for Patient Safety and Quality

28. Armstrong Institute for Patient Safety and Quality
Teams
Tory Hospital - Pennsylvania
Karen Norton
Holy Cross Hospital - Maryland
Steve Risch, MSN, RN, CCRN, CCNS
Leola Saucier, BSN MBA CNML
Elly Sullivan, MA, OT
Armstrong Institute for Patient Safety and Quality

29. Armstrong Institute for Patient Safety and Quality
Karol G. Wicker, MHS
Senior Director, Quality Policy & Advocacy
Maryland Hospital Association
Mary Catanzaro RN BSMT CIC
Project Manager HAIs
Hospital and Healthsystem Association of Pennsylvania
Questions
Armstrong Institute for Patient Safety and Quality