1. CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Strategies for Collecting and Entering Early Mobility ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY Johns Hopkins University

2. 2 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients CUSP 4 MVP - VAP Comprehensive Unit-based Safety Program for Mechanically Ventilated Patients and Ventilator-Associated Pneumonia

3. 3 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients

4. 4 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Outline Review data entry tool and reports for Daily Early Mobility Measures Discuss reports from Cohort 1 aggregate data Review Early Mobility data from a Hopkins study Discuss scenarios for how to collect data –If you have a nurse-driven protocol –If you have a physical therapist-driven protocol

5. 5 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Polling Question Who is on the webinar? IP – infection preventionist RN – registered nurse RT – respiratory therapist PT – physical therapist OT – occupational therapist MD – medical doctor Patient safety professional Healthcare administrator Educator Hospital Engagement Network (HEN) Professional society member Coordinating entity National project team Other 

6. Strategies for Collecting and Entering Early Mobility Measures

7. 7 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Early Mobility: What Have We Learned to Date? Prolonged bed rest and immobility can lead to: –impaired physical function; –Cognitive impairment; –Psychiatric illness. Immobility can also lead to cognitive impairment (e.g. impaired executive function, inattention).

8. 8 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Daily Early Mobility: Sedation, Delirium, Mobility

9. 9 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Daily Early Mobility: Sedation, Delirium, Mobility 123

10. 10 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Daily Early Mobility: Data Submission Rates Number of Cohort 1 Units*N Total active hospital units 41 Number of hospital units that have submitted data 23 (56.1%) * As of April 7, 2015

11. 11 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Daily Early Mobility: Evidence-based Guidelines Use the Daily Early Mobility Data Collection Tool to monitor compliance with evidence-based guidelines such as: 1.performing structured assessments of sedation levels using a sedation scale (RASS or SAS); 2.performing structured assessments of delirium using a delirium scale (CAM-ICU or ASE); 3.assisting patients to achieve their highest level of mobility.

12. 12 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Daily Early Mobility: Sedation Percentage of patients achieving patients achieving RASS/SAS target

13. 13 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients NUMERATOR = Total number of patient days with Intub/Trach & Mech Vent marked “Y” (Yes) and: 1)RASS actual score = RASS target score or RASS actual score is less than or equal to +1 and is greater than the RASS target score OR 2)SAS actual score = SAS target score or SAS actual score is less than or equal to 5 and is greater than the SAS target score DENOMINATOR = Total number of patient days with Intub/Trach & Mech Vent marked “Y” and 1)A numeric RASS target score and a numeric RASS actual score OR 2)A numeric SAS target score and a numeric SAS actual score % Achieving RASS/SAS target Calculation

14. 14 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Delirium Assessments Adult ICU patients should be assessed for delirium using at least once per shift. The Confusion Assessment method for the ICU (CAM-ICU) is a recommended tool to for assessing delirium. Visit https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/processmeasures.aspx for fact sheets and literature reviews.https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/processmeasures.aspx

15. 15 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Early Mobility: Delirium Delirium assessment participation rates

16. 16 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Delirium Assessment Participation Rates: Calculations NUMERATOR = Total number of patient days with Intub/Trach & Mech Vent marked “Y” (Yes) and: 1)CAM-ICU is marked “P” (Positive) or “N” (Negative) OR 2)A numeric ASE value is recorded DENOMINATOR = Total number of patient days with Intub/Trach & Mech Vent marked “Y” and: 1)CAM-ICU is marked “P” or “N” or “X” (Not Completed) or “NK” (Not Known) OR 2)A numeric ASE value or ASE is marked “X” or “NK”

17. 17 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Daily Early Mobility: Delirium Percentage of patients screening negative for delirium (as indicated through CAM-ICU or ASE)

18. 18 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Negative Delirium Screenings (as indicated through CAM-ICU or ASE) : Calculations NUMERATOR = Total number of patient days with Intub/Trach & Mech Vent marked “Y” (Yes) and: 1)CAM-ICU is marked “N” (Negative) OR 2)ASE is less than or equal to 2 DENOMINATOR = Total number of patient days with Intub/Trach & Mech Vent marked “Y” and: 1)CAM-ICU is marked “P” or “N” OR 2)A numeric ASE value is recorded

19. 19 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Daily Early Mobility: Delirium Percentage of patient days mobilized out of bed

20. 20 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Percentage of patient days mobilized out of bed: Calculations NUMERATOR = Total number of patient days with Intub/Trach & Mech Vent marked “Y” and with highest level of mobility marked (4-standing, 5-transfer from bed to chair with standing, 6-marching in place, 7-walking) DENOMINATOR = Total number of patient days with Intub/Trach & Mech Vent marked “Y” 4, 5, 6, 7

21. 21 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Early Physical Medicine and Rehabilitation for Patients with Acute Respiratory Failure: A QI Project Objectives: –Reduce deep sedation and delirium –Increase frequency of rehab consults and treatments to improve functional mobility –Evaluate effects on length of stay Intervention: –reducing heavy sedation –increasing MICU staffing to include fulltime PT and OT with new consultation guidelines

22. 22 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Sedation, Delirium and Medication Outcomes

23. 23 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Mobility Outcomes

24. 24 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Data collection scenarios Information to collect –Sedation scale (Target and Actual) –Delirium Screening –Highest Level of Mobility –Perceived Barriers –PT –OT –Adverse Event

25. 25 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Who should collect the data? RN driven protocol –Nurses or designated data collector PT/OT driven protocol –Nurses or designated data collector (Sedation Scale information and Delirium Assessments)? –PT/OT (Mobility information only)? –PT/OT (all information)?

26. 26 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Data collection scenario 1: Nurse driven protocol - EMR Collect Sedation Scale and Delirium Assessment as before Available in EMR? –Highest Level of Mobility –Perceived Barriers (probably not available) –PT –OT –Adverse Event

27. 27 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Data collection scenario 2: Nurse driven protocol - Chart Collect Sedation Scale and Delirium Assessment as before Available in Chart? As it stands… –Highest Level of Mobility –Perceived Barriers (can add) –PT –OT –Adverse Event

28. 28 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Data collection scenario 3: Nurse driven protocol – Tablet or Paper data collection Collect Sedation Scale and Delirium Assessment as before Walk through the unit to collect the data Set policy to assure that information needed, including ‘Perceived Barriers’ is recorded at the bedside

29. 29 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Data collection scenario 1: PT driven protocol and data collection - EMR Available in EMR? –Sedation Target and Actual –Delirium Assessment –Highest Level of Mobility –Perceived Barriers (probably not available) However, PT/OT should have this information –PT –OT –Adverse Event

30. 30 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Data collection scenario 2: PT driven protocol and data collection- Chart Available in Chart? –Sedation Target and Actual –Delirium Assessment –Highest Level of Mobility –Perceived Barriers (probably not available) However, PT/OT should have this information –PT –OT –Adverse Event

31. 31 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Data collection scenario 3: PT driven protocol and data collection – Tablet or Paper data collection Available in Chart? –Sedation Target and Actual –Delirium Assessment –Highest Level of Mobility –Perceived Barriers (probably not available) However, PT/OT should have this information –PT –OT –Adverse Event

32. 32 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Data collection scenario 1: PT driven protocol and RN data collection - EMR Available in EMR? –Sedation Target and Actual –Delirium Assessment –Highest Level of Mobility –Perceived Barriers (probably not available) However, PT/OT should note this information bedside –PT –OT –Adverse Event

33. 33 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients

34. 34 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Mark Your Calendar: Upcoming Webinars For current schedule of upcoming project webinars, visit https://armstron gresearch.hopki nsmedicine.org/ cusp4mvp/sche dules.aspx

35. 35 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients CUSP 4 MVP – VAP Website Visit: https://armstrongr esearch.hopkinsm edicine.org/cusp4 mvp.aspx https://armstrongr esearch.hopkinsm edicine.org/cusp4 mvp.aspx

36. 36 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients What Can I Find on the CUSP 4 MVP – VAP Website? CUSP Tools and Guides HSOPS Resources Data Collection Tools Educational Materials –Toolkits –Literature Reviews –Fast Fact Sheets Archive of webinars led by subject matter experts

37. 37 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients