Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): A multicentre collaborative

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1 Intensive and Critical Care Nursing (2012) 28, Available online at j o ur nal homepage: Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): A multicentre collaborative Rick D. Bassett a,1, Kathleen M. Vollman b,, Leona Brandwene c,2, Theresa Murray d,3 a 190 E. Bannock St., Boise, ID 83712, United States b Victor Drive, Northville, MI 48168, United States c 1844 Autumnwood Drive, State College, PA 16801, United States d 1500N. Ritter Ave, Indianapolis, IN 46219, United States KEYWORDS Mobility; Early ambulation; Physical therapy; Early mobility; Immobility; Culture; Intensive care; Critical care; Performance improvement; Quality improvement Summary Background: ICU immobility can contribute to physical deconditioning, increased ICU and hospital length of stay and complications post discharge. Despite evidence of the beneficial outcomes of early mobility, many ICUs and providers lack necessary processes and resources to effectively integrate early mobility into their daily practice. Objective: To create a progressive mobility initiative that will help ICU teams to address key cultural, process and resource opportunities in order to integrate early mobility into daily care practices. Methods: An initiative to integrate the latest evidence on mobility practice into current ICU culture in 13 ICUs in eight hospitals within the US was launched. A user-friendly, physiologically grounded evidence-based mobility continuum was designed and implemented. Appropriate education and targeted messaging was used to engage stakeholders. To support and sustain the implementation process, mechanisms including coaching calls and various change interventions were offered to modify staffs practice behaviour. Qualitative data was collected at two time points to assess cultural and process issues around mobility and provided feedback to the stakeholders to support change. Quantitative date on ventilator days and timing of physical therapy consultation was measured. Results: Qualitative reports of the mobility programme participants suggest that the methods used in the collaborative approach improved both the culture and team focus on the process of mobility. There were no significant differences demonstrated in any of the mobility intervention group measurement however, a reduction in ventilator days (3.0 days pre vs. 2.1 days post) approached significance (p = 0.06). Corresponding author. Tel.: addresses: bassettr@slhs.org (R.D. Bassett), kvollman@comcast.net (K.M. Vollman), leona@brandwene.com (L. Brandwene), tmurray@ecommunity.com (T. Murray). 1 Tel.: Tel.: Tel.: /$ see front matter 2011 Elsevier Ltd. All rights reserved. doi: /j.iccn

2 IMMPTP: A multicentre collaborative 89 Conclusion: This multi-centre, ICU collaborative has shown that improvements in team culture, communication and resources can improve adoption of early mobility in ICU patients Elsevier Ltd. All rights reserved. Introduction Immobility plays a significant role in Intensive Care Unit (ICU) acquired weakness and long term physical dysfunction (De Jonghe et al., 2007; Greenleaf and Kozlowski, 1982; Kortebein et al., 2007; Schweickert et al., 2009). Physical inactivity also contributes to the development of atelectasis, insulin resistance and joint contractures (Clavet et al., 2008; Hamburg et al., 2007). The short-term negative outcomes for critically ill patients included ventilator and hospital acquired pneumonia, delayed weaning related to muscle weakness and the development of pressure ulcers (Morris, 2007; Reddy et al., 2006; Schweickert et al., 2009; Topp et al., 2002; Vollman, 2006). Lack of early ICU mobility was an independent predictor for readmission or death in patients with Acute Respiratory Failure (Morris et al., 2011). The major long term complication is the impact on quality of life after discharge due to the physical de-conditioning that takes place during the ICU stay (Dowdy et al., 2005, 2006; Herridge et al., 2003, 2011; Hopkins et al., 2005).. Numerous studies support the importance of incorporating early mobility programmes in conjunction with sedation protocols within the ICU to improve outcomes. Early mobility programmes have been shown to result in greater ventilator free days, decreased incidence of Ventilator Acquired Pneumonia (VAP), fewer skin injuries, reduced ICU and hospital length of stay, decreased duration of delirium and improved physical functioning before and after discharge from the hospital (Bailey et al., 2005; Greenleaf, 1997; Morris et al., 2008; Martin et al., 2005; Needham, 2008; Needham et al., 2010; Thomsen et al., 2008). Mobilisation of critically ill patients must be viewed along a progressive continuum based on readiness, specific pathology, strategies to prevent complications and ability to tolerate the activity/movement. Progressive mobility is a series of planned movements in a sequential manner beginning at a patient s current mobility status with a goal of returning to baseline status. Progressive mobility encompasses a wide breath of mobility techniques ranging from head of bed elevation, range of motion, continuous lateral rotational therapy (CLRT), tilt training, dangling, chair position and ambulation on or off the ventilator (Vollman, 2010). There are a number of barriers to progressive mobility within an ICU environment. Barriers included clinicians knowledge deficits, sedation practices, lack of human and equipment resources, patient physiologic instability and ICU unit culture (Hopkins et al., 2007; Morris, 2007; Needham, 2008; Stiller, 2007; Vollman, 2010). The gap between research and practice is a consistent challenge in health care (Bodenhimer, 1999), and altering well-established routines and patterns of care requires a comprehensive approach to instituting not only individual behaviour change, but systems that support a shift in group norms (Grol and Grimshaw, 2003). Clinicians burned out by competing demands for change can be susceptible to responding in a minimal, ritualistic manner to new institutional demands (Cole, 2000) rather than investing the energy necessary to adopt the attitudinal and behaviour changes that accompany a shift in clinical practice, such as patient mobility. A multicentre collaborative was undertaken to introduce an evidence-based progressive mobility programme whilst simultaneously addressing cultural change within the ICU. A collaborative is designed to help organisations close the evidence gap by creating a structure in which interested units, teams or organisations can easily learn from each other and from recognised experts in topic areas where they want to make improvements (Plsek, 2000). Programme design The planning and implementation of the mobility initiative took place over 14 months. Importantly, the purpose of the initiative was not the discovery of new knowledge regarding early mobilisation of critically ill patients, but the integration of existing research into daily practice at the bedside. Participant ICUs were from organisations that belong to VHA Inc., a national alliance of community-owned, not-for-profit healthcare institutions consisting of large academic centres to small rural hospitals and integrated healthcare systems. The VHA membership represents a quarter of the Unites States (US s) community-owned hospitals, and through the VHA Critical Care Innovation Network (CCIN), intensive care teams share improvement strategies and participate collaboratively in various clinical initiatives. Some of the previous clinical initiatives included implementation of the ventilator, central line and sepsis bundles. The CCIN group selected progressive mobility through a voting process. In an effort to facilitate internal buy-in for progressive mobility, VHA staff and subject matter experts provided local champions with key aspects of the initiative and the information to help build the business case. Executive, physician, unit leadership and staff support were identified as key stakeholders necessary for success in securing commitment. Concurrently subject matter experts in intensive care practice, mobilisation of critically ill patients, programme development and organisational change coaching completed the initial programme design. Thirteen ICU teams ranging from trauma, medical and mixed to surgical and cardiovascular ICUs, and representing eight different hospitals, participated in the mobility initiative. The structure of the initiative included the creation of a progressive mobility tool, a face to face workshop, development of target messaging and continuing education, cultural interventions to support the integration of new practice behaviours, and process and outcomes measurement. Development of an evidence-based mobility continuum The Progressive Mobility Continuum tool (Fig. 1) was developed based on a review of the literature and was

3 90 R.D. Bassett et al. Figure 1 Progressive mobility continuum. designed to address the complete continuum of mobility in the critically ill patient (Morris et al., 2008; Needham et al., 2010; Schweickert et al., 2009; Thomsen et al., 2008). The continuum also addressed the phases of mobility and related elements and provided a visual tool. The tool helped to guide mobility practice, increase consistency, facilitate team communication and enhance care processes to improve ICU mobility. Daily assessment by the staff of the patient s mobility level was essential to evaluate changes in condition and help design daily mobility goals. The mobility levels provided staff with objective step-based criteria that promoted patient safety and allowed for incremental advancement of physical activity, based upon the staff assessment of the patient s tolerance. (Bailey et al., 2007; Convertino et al., 1990, 1997; Stiller et al., 2004). A central operational feature of the mobility continuum is the use of an objective score to evaluate agitation and drive patient-specific sedation needs. If agitation is not effectively managed, it can impede the success of a mobility programme (Morris, 2007). The Richmond Agitation Sedation Score (RASS) was the agitation sedation scoring tool integrated into the continuum (Ely et al., 2003). Other versions of the mobility tool were made to accommodate for different sedation scales being used by some teams including, the Motor Activity Assessment Scale (MAAS) and Sedation Agitation Scale (SAS) (Devlin et al., 1999; Riker et al., 1999). Workshop/education The face to face collaborative meeting kicked off the initiative. Didactic material included background information discussing mobility in the ICU, its impact on patients, and evidence supporting key practice elements. An emotionally compelling presentation during the first day was from a former patient who shared her experience of a turbulent ICU stay and the impact of immobility on her subsequent recovery. Teams were presented with a tool kit which provided them with essential elements required to implement the initiative within each ICU. This tool kit provided basic programme development guidelines designed to emphasise unit strengths and identify potential barriers to mobility. Operational aspects of the collaborative, monthly conference call schedules, data measurements and submission timelines were presented, discussed and collectively ratified. The group decided on having separate monthly conference calls, one to address clinical strategies and questions and the second to discuss operational and cultural challenges. On the second day of the workshop an interactive coaching session provided teams with basic culture concepts and tools to help establish effective processes to support changes that would be necessary throughout the initiative. During this time they shared challenges, questions and

4 IMMPTP: A multicentre collaborative 91 concerns regarding changes that would need to take place in order to create a culture of progressive mobility in their unit(s). Many of these challenges and issues provided content for upcoming conference calls. The workshop was concluded with an action planning session where each team was instructed to create objective goals, identify stakeholders; assign process owners and time-lines. The teams returned home and work began within each ICU to build their core mobility workgroup. Common steering committee roles included the programme coordinator, physician champion, physical therapy, respiratory therapy, unit leadership and nursing staff. Incorporating occupational therapists (OT) and physical therapists (PT) in the education process was important to help ICU staff understand that early and safe mobility can be done. Tactics utilised to engage and educate included presentations, posters, computer-based learning modules and 1:1 how-to instruction. Support elements Each month, teams participated in a separate Coaching and Strategy call. The Coaching calls were designed to provide teams with tools, resources, and a discussion forum that supported their ability to effect culture change (the people side), whilst the Strategy calls focused on clinical content, data collection and evaluation. Both types of calls heavily emphasised team contribution and exchange of ideas in order to capitalise on the strength of a collaborative community. A list serv was created to support communication and sharing amongst teams separate from the structured calls. The monthly Coaching call format generally followed a three-part approach: (a) an organisational development tool or concept that provided teams with an opportunity to move their culture towards the desired change, (b) teams roundtable contributions of ideas and challenges with group response and support, and (c) teams verbal commitment to a course of action resulting from call learnings. A strengthsbased or appreciative approach which encouraged units to identify areas of high performance in patient mobility, examine what facilitated that high performance, and spread it to other areas of the unit was emphasised (Cooperrider et al., 2008). The monthly Strategy calls provided a forum for the teams to discuss planning, implementation and evaluation of the clinical aspects of the initiative. Agenda items were designed to encourage open discussion of potential barriers to implementation, logistical issues that teams encountered, and successes experienced by individual teams. This exchange of ideas and experiences and the sharing of teams internally-developed tools and forms, accelerated and streamlined the improvement process. These two types of monthly calls allowed the experts to identify issues and mitigate them. From the beginning of the initiative, teams contributed solutions and elements of innovation that enriched the overall programme. Teams that were further along in the process were able to share their experiences and serve as a resource to their peers throughout the project. Building the culture The sustainability of any performance improvement initiative relies, in part, on the degree to which behaviour changes are integrated into a supportive culture (Schein, 2004). Behaviour change requires energy: attitudinal change, practising where new skills are lacking, and establishing new routines and care practices. Asking clinicians to invest this energy in spite of cultural messaging to the contrary diminishes the likelihood of their long-term engagement; and over time, behaviours will revert (Cole, 2000). To maximise the likelihood of long-term sustainability of patient mobility, teams attended to unit culture and cultivating an environment that supported patient mobility. Monthly Coaching calls focused on the following cultural elements: involvement of the learner; positive role models, practice fields, coaches and feedback; and rewards and discipline that support the new way of behaving (Schein, 2004). During calls, new frameworks and tools for shifting culture were presented and discussed, and teams then customised these approaches. Fig. 2 shows an example of a learning progression that enabled team leaders to assess staff progress and provide them with tailored teaching, coaching or monitoring that built their competency. Teams integrated this progression and developed unique approaches for peer coaching that created a safe environment within which to practice skills. For rewards and incentives to support mobility, teams created unique incentives that both engaged staff and made it fun. At one institution, when consistent mobility efforts were noted for a single patient, the care staff were given M&M s to signify effective movement and mobility. When the whole team worked to mobilise a patient they were rewarded with a team candy called Three Musketeers. These creative approaches served multiple purposes: they forged common expectations for early patient mobility, they provided a visible recognition of behaviours that reflected mutual accountability amongst all team members and they created a stronger culture of respect and understanding of all care roles within the intensive care unit. Unique strategies such as these resulted in reported increases in team communication and patient care efficiencies. Qualitative results Teams completed a single, mid-point assessment of their change process milestones to assist faculty in monitoring team status and course-correct the initiative if necessary. Formal population-wide culture or climate surveys of unit staff were not conducted, due to limited consensus in the literature regarding reliable tools (Gerson et al., 2004) and to limit the burden of data collection on the teams. A qualitative collection of teams effective practices was conducted at the close of the initiative. Teams reported that the most effective strategies to engage their team or advance success included a variety of recommended practices. Foremost, communication and collaboration amongst all disciplines (physicians, nurses, RT, PT) was critical, and in particular, support from and collaboration with physical therapy was

5 92 R.D. Bassett et al. Figure 2 Organisational development tool. cited by many teams as a facilitator. The visual display of the mobility tool at the bedside as well as the use of peer coaches and mobility champions for 1:1 and small-group teaching and coaching to integrate and practice new learnings was also identified by teams as a better practice. In 1:1 communications, teams emphasised positive reinforcement of learning and progress rather than policing failures. To secure buy-in, teams emphasised the evidence surrounding early mobility and safety through education and 1:1 communication. They maintained buy-in by engaging staff in the work of improvement (data collection, etc.) and integrating fun elements (candy and incentives). The collection and sharing of performance data with the unit staff on a regular basis were critical in ensuring patient mobility was a priority. Teams identified additional elements for sustainability and continued patient mobility improvement. These included: an emphasis on nurse-to-nurse reporting, integration of mobility into the fabric of daily work, rounds, standards of care, patient care plans, removing bed rest references from order sets, and documentation and integration of mobility into electronic medical records. Many noted they would continue to meet staff where they are and customise coaching.

6 IMMPTP: A multicentre collaborative 93 Figure 3 Direct observation data collection tool. Challenges that teams faced included resourcing the increased time and staffing demands of patient mobility and lack of equipment (overhead lift equipment, etc.). In terms of unit culture, staff fears and perceptions, especially (1) fears of compromising patient safety and (2) perceptions that rest = healing were barriers that needed to be addressed. In addition, overcoming family perceptions that loved ones were too uncomfortable being moved or too sick required discussion. Some units cited inconsistent support from physicians that resulted in mixed messages for staff members. Ensuring appropriate documentation of patient progress on the continuum was another constraint related to time investment. Staff were challenged to make sense of how patient mobility fit whilst competing with other change initiatives. Survey results to evaluate the role of PT and OT in each respective unit identified that the majority of the organisations in the cohort have limited resources to support the initiation of mobility in the ICU. In most cases a physician order was consistently required to initiate the PT/OT consult. Quantitative results Measurements were chosen based on key elements and processes identified by the collaborative based on recent mobility literature (Morris, 2007; Needham et al., 2010; Schweickert et al., 2009). Two types of data were collected, retrospective chart abstraction and concurrent direct observational data (Figs. 3 and 4). Each unit collected data on 10 patients during a 30 day period. Patient selection was chosen from a representative sample based on the typical patient acuity in their unit. The data set was comprised of retrospective chart abstraction data on 130 patients and over 3000 hours of direct hourly patient observations. This data was analysed using non-parametric statistical tests. The signed rank test was used to determine whether the average difference between pre and post data for each unit was significantly different from zero. A trend towards significant improvement was seen in average number of ventilator days being shorter in the post implementation group (3.0 vs. 2.1, P =.06). Statistically significance differences were not seen with comparing average number of ventilator free days (1.9 vs. 3.1, P =.11), ICU mortality (7.7 vs. 6.2, P =.51) hospital mortality (9.2 vs. 10.0, P =.69), ICU length of stay (LOS) (5.0 vs. 5.2, P =.60) and hospital LOS (8.8 vs. 9.7, P =.31). Compliance measurements comparisons including average days to standing (2.4 vs. 2.2, RI = 8%), number of days to ambulating (2.8 vs. 2.6, RI = 7%), number of days to transfer (2.32 vs. 2.26, RI = 3%), number of days to first occupational therapy (OT) session (4.7 vs. 3.7, RI = 19%) and number

7 94 R.D. Bassett et al. Figure 4 Direct observation data collection tool. of days to first Physical Therapy (PT) session (3.7 vs. 3.0, RI = 19%) showed no significant differences. Post implementation data demonstrated 57% compliance for obtaining a PT evaluation within the first 24 hour of the patient arriving to the ICU regardless of intubation status (Fig. 5). Observational data was collected on each patient using hourly consecutive documentation over a 24 hour period. The current position measurement included observation of patients ambulating, dangling at the bedside or in a chair, sitting in the cardiac chair or positioned in the bed chair mode. HOB and the location of the patients position was used to measure mobility compliance elements whilst in bed. Comparisons of pre and post implementation observations showed minimal clinical improvements. However, the data did help teams recognise areas for ongoing improvement. Prone positioning and CLRT metrics demonstrated no substantial impact in this initiative due to inconsistent or lack of use. Discussion We created a multicentre mobility collaborative to determine if real life application of the evidence around early ICU mobility would be positively impacted by utilising a structured process that included; a comprehensive tool kit, bi monthly team communication, expert clinical & organisational change support and coaching around implementation, % % % 40% 57% % 0.0 Ave. days to first PTAve. days to first session OT session Ave. days to standing Ave. days to transfer Ave. days to ambulating 0% % patients w/pt eval w/in 24 hours Pre Post VHA CCIN Figure 5 Chart abstraction process data.

8 IMMPTP: A multicentre collaborative 95 barriers and culture change. We demonstrated a 57% consultation rate of physical therapy on day one of ICU stay which is similar or higher than previously reported studies. Schweickert et al., 2009 demonstrated that when early assessment, sedation management and PT consultation was structured; the patients received their first PT session an average of 1.5 days from time of intubation versus in the control groups which was 7.4 days. In addition we demonstrated similar results seen in research studies on early mobility with a trend towards significant reduction in ventilator days for patients receiving an early mobility programme (Bailey et al., 2005; Greenleaf, 1997; Martin et al., 2005; Morris et al., 2008; Needham, 2008; Needham et al., 2010; Thomsen et al., 2008). The progressive mobility tool helped to force-function a daily structured assessment of current mobility status which supported the critical thinking process by the nurse and team to ensure effective and safe evaluation of the mobility level. The success and sustainability of any complex practice change requires engagement of all the stakeholders; ensuring adequate evidence-based knowledge and skill to perform the task and change perception of barriers as well as resources and systems built to reinforce the practice change (Vollman, 2009). To our knowledge, this is the first attempt at a multi-centre improvement collaborative on early mobility. Needham et al. (2010) performed a similar Quality Improvement (QI) project within a Medical Intensive Care Unit (MICU) in a large academic centre and was able to show marked improvement in ICU delirium, functional mobility and reduction in hospital length of stay. As most studies on early mobility have shown, team engagement is a critical component. The coaching and strategy calls provided a viable platform for learning, sharing of challenges/solutions and creation of common goals and action plans. Access to content experts throughout the initiative provided teams with just-in-time feedback to address opportunities, reinforce and re-educate within a specific unit if needed. Mutual sharing of team experiences the improvement efforts. Collaboration with other key disciplines positively impacted general ICU work culture in unanticipated ways, as mutual appreciation for the unique contributions of each discipline increased. This underscored the importance of the integration of all ICU team members in a complex initiative. Adoption of behaviour change was facilitated by teams individual assessments of their unique cultural challenges, and their customised strategies to address their specific challenges. In particular, using a multi-faceted approach to education (both inservice and 1:1), sharing data, engaging staff in the work of improvement, and focusing on positive reinforcement and expanding areas of success were success factors. Objective, easy measurable data provided teams focus and the ability to benchmark against themselves and other teams within the collaborative. Limitations The units that participated in this initiative were a skilled and experienced group in clinical change processes: most of them have progressed through a series of VHA -led clinical initiatives. As such, these particular unit staffs were well-prepared and well-experienced in adopting clinical performance initiatives, and we cannot diminish the likelihood of self-selection contributing to the success many teams experienced in patient mobility. Shifts in culture as a result of this patient mobility initiative additionally cannot be quantified as a climate survey was not used. Nevertheless, activity and successes in creating culture change were reported monthly by teams during calls, providing faculty with an opportunity to monitor progress and provide tools and strategies that met the unique needs of the teams. The monthly reports, the mid-point assessment of progress and the qualitative post-initiative feedback from teams paint a picture of the teams significant progress in integrating patient mobility as a sustainable clinical practice, rather than a brief and unsustainable effort. This project was designed as a performance improvement initiative using a pre-post measurement design. Data was collected at each participant site by hospital staff. whilst specific data collection and entry instructions were provided and discussed on conference calls there was no additional training or a designated data collector. This may have resulted in inconsistent or inaccurate data. Additionally, the data was aggregated at each site and then submitted to CCIN faculty for cohort-wide data aggregation and analysis. The site aggregation limited the ability to statistically analyse data based on individual patient process and outcome indicators which could have resulted in different statistical significance. Lack of inclusion of severity of illness or patient diagnosis limited our ability to measure the effect of acuity on overall results. Additionally, survey data was not statistically analysed, although that is in keeping with typical performance improvement data collection (differentiated from research). It did serve as a way to capture performance trends and enable teams to course-correct based on that information. Next steps Prospective randomised multicentre trials are needed to provide definitive data on the clinical, cultural and financial impact of an integrated progressive mobility programme. A number of the teams that participated in this initiative have already begun to expand mobility efforts beyond the walls of the ICU. The value of early ICU mobility and sustaining progressive mobility to hospital discharge on recovery, fall rates, morbidity, mortality and post discharge functioning needs to be studied. Conclusion The ICU Progressive Mobility Collaborative provided teams with key information on understanding the impact of early ICU mobility and the opportunities to change practice within their ICUs. With the emphasis on frontline caregiver empowerment to drive mobility using an evidence-based guide, the teams were able to integrate safe mobilisation practices in a shorter time frame than they had prior to the project. The ability to overcome barriers and demonstrate a trend towards improved outcomes helped some teams build the business case to add additional personal and equipment resources. This initiative demonstrates that focusing

9 96 R.D. Bassett et al. on improving early mobility also yields improvements in team dynamics and culture within the ICU. Conflict of interest Rick Bassett VHA, Inc. Consultant; Kathleen Vollman: Hill-Rom Inc, Speaker Bureau and Consultant & VHA, Inc. Consultant; Leona Brandwene, VHA, Inc. Consultant; Theresa Murray VHA, Inc. Consultant. Acknowledgements Michele Wagner and ICU team from Ball Memorial Hospital in Indianapolis, IN. Pam Zinnecker and ICU team from Billings Clinic in Billings, Montana. Denise Moeschen and ICU team from Bryan LGH Health System in Lincoln, NE. Lori Oross and ICU team from Franklin Square Hospital in Baltimore, MD. Cheryl Anderson and ICU team from Sanford Health in Fargo, ND. Michael Terracina and ICU team from Munroe Regional Medical Center in Ocala, FL. Rick Bassett and ICU team from St. Luke s in Boise and Meridian, ID. Bettyann Kempin and ICU team from Valley Hospital in Ridgewood, NJ. 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