1. CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Data Webinar 5 Defining the Early Mobility Measures ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY Johns Hopkins University April 1, 2015

2. 2 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures 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 PatientsDefining the Early Mobility Measures Polling Question Who is on the call? IP – infection preventionist RN – registered nurse RT – respiratory therapist PT – physical therapist OT – occupational therapist MD – medical doctor Quality improvement professional Healthcare executive Educator Coordinating entity National project team Other 

4. Defining the Early Mobility Measures Nishi Rawat, MD CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

5. 5 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures

6. 6 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Objectives Discuss the data elements needed to complete the Daily Early Mobility Measures Form Review the definitions of those data elements Consider and discuss strategies for finding the data elements

7. 7 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Daily Early Mobility: Key Interventions Use multi-disciplinary and coordinated approach Interrupt daily sedation and minimize sedative use Assess sedation and delirium with structured scales Screen for highest level of mobilization Employ a nurse-driven protocol to achieve highest level of mobility

8. 8 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Data Collection Drives quality improvement efforts Is NOT for research Provides quantifiable measures of care practices Guides patient safety conversations Justifies resource allocations –Human resources (time) –Financial resources (money) –Supplies and equipment (stuff)

9. Daily Early Mobility Data Collection Tool Download the tool from the project website: https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/datatools.aspx under “Daily Early Mobility” https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/datatools.aspx

11. 11 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Polling Question Have you begun using the Daily Early Mobility Measures Form?  Yes  No  Unsure  This question is not applicable to me

12. 12 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Fill out for all beds Track by bed, not by patient Complete –Bed number –Whether the patient in that bed was intubated or trached and on mechanical ventilation at the time of observation Y = Yes N = No E = Empty bed

13. 13 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Date of intubation Enter the date the patient was intubated –If the date is not available*, enter admission date (either to the unit or to the hospital) –If the patient is extubated and re- intubated within 24 hours, use the original date *i.e., when from an outside institution

14. 14 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Sedation Scale RASS = Richmond Agitation Sedation Scale SAS = Riker Sedation- Agitation Scale NU = Unit uses neither RASS or SAS –If NU, skip to Delirium Assessment

15. 15 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Sedation Scale If you entered ‘RASS’ Target –What is the target RASS or SAS score for this patient? Actual –What is the actual RASS or SAS score for this patient?

16. 16 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Delirium Assessment CAM-ICU = Confusion Assessment Method for the ICU ASE = Attention Screening Exam NU = Unit uses neither CAM-ICU or ASE

17. 17 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Confusion Assessment Method for the ICU (CAM-ICU)

18. 18 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Confusion Assessment Method for the ICU (CAM-ICU) The Society of Critical Care Medicine’s 2013 pain/agitation/delirium (PAD) clinical practice guidelines recommend the CAM-ICU or the Intensive Care Delirium Screening Checklist (ICDSC) as the most valid and reliable delirium screening tools, and that moderate to high risk patients be screened at least once per nursing shift.

19. 19 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Delirium Assessment – Attention Screening Exam (ASE)

20. 20 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Delirium Assessment – Attention Screening Exam (ASE) ASE is feature 2 of the CAM-ICU. ASE is a 10-20 second test. The goal of ASE is to determine if a patient can follow a simple command (pay attention) for that period of time. Inattention is the cardinal feature of delirium and must be present to diagnose delirium.

21. 21 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Delirium Assessment – Attention Screening Exam (ASE) If the CAM-ICU is not yet feasible in your unit, we recommend that patients at least undergo the ASE once per nursing shift. For centers not using the full CAM-ICU, conducting the ASE is a good barometer of the presence or absence of delirium. This test may be abnormal due to disease, drugs or other causes.

22. 22 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Delirium Assessment – Attention Screening Exam (ASE) The exam consists of the provider reading the following sequence of letters: ‘S A V E A H A A R T’ or ‘C A S A B L A N C A’ or ‘A B A D B A D D A Y’ The patient is told to squeeze the provider’s hand when the letter ‘A’ is stated. An error is defined as no squeeze with letter ‘A’ or a squeeze on a letter other than ‘A’. The number of errors is counted. Inattention is present if the patient commits more than 2 errors. If the patient squeezes on every letter or doesn’t squeeze on any letter, then assign an error count of 10.

23. 23 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Polling Question Which delirium assessment does your ICU use?  CAM-ICU  ASE  Both CAM-ICU and ASE  Neither  I don’t know  This question is not applicable to me

24. 24 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Mobility Highest Level of Mobility –What was the highest level of mobility achieved by the patient in the last 24 hours?

25. 25 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures

26. 26 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Mobility Perceived Barrier to Achieving a Higher Level of Mobility –What prevented the patient from being mobilized to a higher level?

27. 27 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Perceived Barrier Perceived barrier codes are listed on the back of the data collection sheet. Enter the code associated with the answer. If multiple codes apply to a patient, please select the LOWEST number.

28. 28 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures

29. 29 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Mobility – PT/OT Physical Therapy –Did the physical therapist evaluate or treat the patient within the last 24 hours? Occupational Therapy: –Did the occupational therapist evaluate or treat the patient within the last 24 hours?

30. 30 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Events Did the patient have an “event” (as defined on the back of the data collection sheet) while being mobilized within the last 24 hours? Event codes are listed on the back of the data collection sheet

31. 31 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures

32. 32 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Discussion Where can you find these data? –Ideas? –Suggestions? –Barriers?

33. 33 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Objectives Discuss the data elements needed to complete the Daily Early Mobility Process Form Review the definitions of those data elements Consider and discuss strategies for finding the data elements

34. Next Steps CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

35. 35 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Next Steps Where will you find your data? –Look for data sources –Make plans for data collection processes –Practice collecting data for next call

36. 36 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Going Forward After you have found your data sources and data collection has officially started –Collect data daily –Enter the data at least weekly

37. 37 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Homework Determine the location of information needed to complete the Daily Early Mobility Measures. Determine who will gather Daily Early Mobility Measures.

38. 38 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures Mark Your Calendar: Upcoming Webinars For current schedule of upcoming project webinars, visit https://armstron gresearch.hopki nsmedicine.org/ cusp4mvp/sche dules.aspx Infection Prevention Webinars IP Webinar 4: Wed, Apr 22, 2015 11:00 – 12:00 PM EDT IP Webinar 5: Wed, May 27, 2015 11:00 – 12:00pm EDT

39. 39 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures CUSP 4 MVP – VAP Website Visit: https://armstrongr esearch.hopkinsm edicine.org/cusp4 mvp.aspx https://armstrongr esearch.hopkinsm edicine.org/cusp4 mvp.aspx

40. 40 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures 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

41. 41 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated PatientsDefining the Early Mobility Measures