Disclosures. Live Polling Questions. Course Outline 17%

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1 Disclosures Roadmap to the Development of a Critical Care Rehab Team Combined Sections Meeting 2018 New Orleans, LA, February 21-24, 2018 No Disclosures Stephanie Liebert, PT, MPT Karoline Lubbeck, PT, DPT Clare Nicholson, PT, DPT, CCS Live Polling Questions Learning Objectives 1) What percentage of time, approximately, do you work in the ICU? 2) Does your facility have dedicated ICU therapists? 3) Are therapists seeing ICU patients in your facility required to pass a competency? 4) Are Therapy Technicians utilized in your ICUs? 5) What percentage of the time, approximately, does OT/PT cotreating occur? 6) What percentage of your ICU patient visits, approximately, do you use an outcome measure in? Examine specific strategies to assist with incorporating physical/occupational therapy and early mobility into an ICU setting Discuss strategies to develop a Critical Care Rehab Team using outcome data to drive meaningful change, therapist efficiency, value to the patient and how implementation success was measured Learning Objectives Detail practical tools and strategies to utilize in various practice settings (large teaching hospital vs smaller community hospital) to allow development of a Critical Care Rehab Team despite challenges and competing demands Detail practical tools and strategies to initiate the development of a comprehensive orientation outline for Critical Care therapists Course Outline Review evidence for early mobility in the ICU Discuss challenges and competing demands in the hospital setting as barriers to Critical Care team/coverage Share results of dedicated PT in a MICU and SICU trial Describe process to develop a Critical Care Rehab team in a large, teaching hospital Outline the development of a Critical Care Team Orientation Program 1

2 PT/OT in the ICU Literature Review PT/OT in the ICU Literature Review Early activity is feasible and safe in respiratory failure patients (Bailey et al, 2007) 1 Assessed safety and feasibility during 3 activity events Sit on edge of bed, Sit in chair, Ambulation Results: 1, 449 activity events in 103 patients 53% ambulation, 31% sit in chair, 16% sit on edge of bed <1% activity related adverse events No patient was extubated during activity Early activity is feasible and safe in respiratory failure patients (Bailey et al, 2007) 1 We conclude that early activity is feasible and safe in respiratory failure patients. A majority of survivors (69%) were able to ambulate >100 feet at RICU discharge. Early activity is a candidate therapy to prevent or treat neuromuscular complications of critical illness. PT/OT in the ICU Literature Review Early intensive care unit mobility therapy in the treatment of acute respiratory failure (Morris et al, 2008) 2 Designed a mobility protocol to provide a mechanism for standard and frequent administrations of PT to acute respiratory failure patients Included a mobility team of critical care nurse, nursing assist and PT Protocol included 4 levels of activity Results: More physical therapy sessions Shorter ICU and hospital length of stay for hospital survivors PT/OT in the ICU Literature Review Early intensive care unit mobility therapy in the treatment of acute respiratory failure (Morris et al, 2008) 2 We conclude that mobility therapy delivered early in the course of acute respiratory failure patients receiving mechanical ventilation is feasible, safe, did not increase cost and was associated with decreased ICU and hospital LOS in survivors. PT/OT in the ICU Literature Review Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial (Schweikert et al, 2009) 3 Randomized early PT and OT during periods of daily interruption of sedation Results: Improved return to (premorbid) independent functional status at hospital discharge Shorter duration of ICU associated delirium PT and OT combined with daily interruption of sedation was safe and well tolerated Cleveland Clinic Main Campus Previous Team Organization Med Surg Cardiac Neuro Ortho Peds Wound Care 2

3 Secrets of the past ICU coverage Secrets of the past ICU coverage New consults placed in a binder Morning scheduling Therapists pull new consults from the binder Last patients in the binder.. Therapists that pulled the ICU patients became more: Skilled Interested in learning more about ICU Aware of the importance of PT/OT in the ICU Challenged by competing priorities ASAPs Precerts New consults outside of the ICU Secrets of the past ICU coverage challenges Physician, RT, and Nurse Champions ICUs were organized within each team Ex. Cardiac Surgery ICUs, Heart Failure ICU and Coronary ICU were a part of the Cardiac Team High volume of consults, ASAPs, Priority calls on the RNFs/SDUs were seen before ICU evals and treatments Nursing resistance to therapy and poor MD awareness of PT/OT in the ICU led to low consult volume despite appropriate patients Meetings with MD, RT, and RN leadership Collaboration with Project Manager of hospital wide initiative: Culture of Mobility Flyers in ICU staff areas to announce pilot Immersion of 3 dedicated PTs into our MICUs and SICUs Project Timeline DEC 2012 JAN 2013 FEB 2013 MAR 2013 APR 2013 MAY 2013 JUNE 2013 JULY 2013 AUG 2013 SEPT 2013 OCT 2013 NOV 2013 Create educational materials Nursing/PCNA training Physician training GO-LIVE for Medical Team Mobilizing Project Team Meetings GO-LIVE for Interventions Doc Flowsheet in EPIC GO-LIVE for PT consult changes in EPIC Audits for mobility Develop tools for sustainment Data Collection GO-LIVE for EPIC Activity order changes (TBD) PTs attending of rounds and huddles to increase collaboration and awareness, and to determine which ones were mission critical Coverage of critical care patients with QD frequency goal Trial of BID QD more efficient and practical for team, and better tolerated by patients 3

4 Non-patient care time allotted for : Provision of training Education of team Development of materials Training Educational Competencies Consulting team member education Educational presentations and printed materials, including one-page When to consult and Difference between OT and PT guides to physicians, PAs, NPs RN competency Provided printed and ed educational materials Hands-on training at bedside during a PT session with their patient ICU Nursing Observation Checklist I have observed the following with Physical Therapy: Assisting patient to edge of bed (EOB) Assisting patient out of bed to chair (OOBTC) I understand and feel comfortable discerning: Who is appropriate for early mobilization (recovery vs. survival mode) When to direct the medical team to consult PT or OT Where to find therapy recommendations for mobility in EPIC How to initiate mobility for my patients who meet early mobilization criteria When not to mobilize or to stop mobilizing a patient I would like: More hands-on training with PT Other (specify): Name: Date: 4

5 Rehab technician competency Development of a Technician ICU Orientation Manual for education and setting of standards Roles and Responsibilities Early Mobilization Communication Equipment (ICU related and therapy equipment) Lines, tubes, drains Portable telemetry MOVEO Set-up and Re-set of patient s room Patient Mobility and Transfers Welcome to the Intensive Care Unit PT/OT Team! Physical and Occupational Therapy Intensive Care Unit Team You will soon discover that your role on this team is vital to ensure the best quality of care for the patients and that care is delivered in a safe and efficient manner. On this service you will be assisting the therapists with the mobility of critically ill patients. These patients are often medically complex and demonstrate weakness and impaired cognition. However due to the focus on early mobility in the ICU, many critically ill patients can safely sit edge of bed and transfer to a chair, and even progress to ambulate. You will assist with management of ICU lines and monitors, ventilators, ICU beds, other life sustaining equipment during the mobility process. It will be necessary to follow all of the Policies & Procedures that have been put into place. These Policies & Procedures will be reviewed throughout your orientation process. Please ask questions throughout your orientation process to clarify any concerns that may arise. The key roles and responsibilities of the technician on this service are outlined in this orientation manual. Thank you for your interest in this service and most importantly for your continued dedication to providing quality patient care. Technician Roles and Responsibilities in the Intensive Care Unit Physical and Occupational Therapy Intensive Care Unit Team Early Mobilization in the ICU Keys to Success Roles & Responsibilities Communicate with the therapist before each patient session to understand the treatment plan Identify and bring to bedside the necessary patient equipment and supplies Assist the therapist with preparing the room for safe mobility Assist the therapist with transfers and patient mobility Clean and reset the patient room following patient mobility Clean and maintain all therapy equipment and supplies per the ICU Rehab Tech Policy & Procedure manual Assist the therapist with continued readiness tasks and expectations With effective communication and teamwork, patients who are critically ill can safely participate in rehabilitation. Research shows that it is safe and feasible to mobilize this population (few adverse events and no additional, or even decreased, costs). Benefits of early mobility include DECREASED ICU and overall hospital length of stay, days on a ventilator, pressure ulcers, and falls, and INCREASED respiratory, cardiovascular, and gastrointestinal functions, level of consciousness, quality of life, psychological well-being, and rates of discharge home vs. a rehabilitation facility. To be a candidate for early mobility, our patients need to be: awake, able to follow simple commands and minimally participate with therapy, medically stable, and have rehab potential. In other words, they need to be in recovery mode. Patients who are NOT candidates for early mobility are: comatose, unresponsive, on paralytic drugs, or medically unstable. In other words, they are in survival mode. Assist the Therapist with Treatment as Directed Laws of Practice When providing assistance to the physical or occupational therapist, it is important to be aware of the state laws of physical and occupational therapy practice. When treating patients at the bedside, both the technicians and the therapists may look similar if both are assisting with mobility, despite different colors of scrubs. It is not uncommon for another healthcare practitioner (physician, nurse, etc) or a family member to inadvertently ask for information from, or delegate a task to, the technician that may not be within their scope of practice to address. Should you find yourself in this position, please explain to the healthcare practitioner, patient, or family member that you will find the right person to address the matter. Do not feel pressure to perform a task that is beyond your scope of practice no matter what. If you do perform a task that is beyond your scope of practice, it will result in corrective action. Laws and Rules Regulating the Practice of Physical Therapy Unlicensed personnel means any person who is on the job trained and supports the delivery of physical therapy services by personally assisting the physical therapist, physical therapist assistant, student physical therapist, and/or student physical therapist assistant while the physical therapist, physical therapist assistant, student physical therapist, and/or student physical therapist assistant is concurrently providing services to the same patient. Communication in the ICU Communication Tips Communicating accurate information in an efficient manner is essential for all members of the ICU team. The technician and therapist will discuss the basic plan for the session ahead of time. Flexibility, alertness, and ongoing communication are key. Patients require constant monitoring and their condition may change, even during therapy. The therapist may need to adjust or change the goals or plan for the session based on the patient s response. Speak up if you notice something doesn t look right or doesn t sound right whether it is related to the patient or equipment. Calmly notify the therapist of concerns. The therapist may direct instructions toward the patient to minimize the patient s anxiety (i.e. We are going to help you lay down now. ). Confused or delirious patients can be easily distracted by more than one face or voice in the room. If this is the case, conversations and interruptions should be minimized. Laws and Rules Regulating the Practice of Occupational Therapy Unlicensed personnel means any person who is on the job trained and supports the delivery of occupational therapy services by personally assisting the occupational therapist, occupational therapy assistant, student occupational therapist, and/or student occupational therapy assistant while the occupational therapist, occupational therapy assistant, student occupational therapist, and/or student occupational therapy assistant is concurrently providing services to the same client. 5

6 Communication in the ICU Communication Tips Setup for the ICU Patient s Room ICU Patient Room Preparation Do Don t Identify your patient s RN (ideally by name) prior to Don t feel pressured to answer specific Plan of Care therapy, in case the RN is needed during the session. questions regarding the patient s therapy. Allow the therapist to initiate RN communication and Don t attempt to gather RN report on a patient or initiate indicate to you that it is appropriate to begin setting up for set-up for a therapy session without confirmation from the a session. therapist. Refer an RN with specific questions regarding the patient s treatment plan to the therapist. Speak up if you notice something that doesn t look right or doesn t sound right. Limit conversations and interruptions during therapy for patients who are confused or delirious. Be aware and sensitive whenever Code Calm is in effect. The physical or occupational therapist will be the first to assess a patient s transfer and mobility status. Once a patient s transfer status is determined, it will be communicated to the technician. Only after therapist confirmation, the rehab technician may begin preparing the patient s room for a treatment session. This is to ensure patient safety. In the ICU setting a patient s status can change from hour to hour, so the treating therapist must not only check the chart, but get a nursing report to ensure nothing has occurred, or is occurring, not yet documented in the chart, that would affect the patient s ability to participate in therapy. The technician s role in organizing the ICU treatment area is vital. A well-prepared ICU treatment area increases safety, efficiency of workflow, and allows for flexibility within a therapy session. With practice, the technician and therapist can develop a routine that is safe and efficient. The therapist will communicate to the technician when it is appropriate to begin Setting-Up the patient s room. This may occur while the therapist is getting a nursing report or recording the patient s vitals. Setup for the ICU Patient s Room ICU Patient Room Preparation Setup for the ICU Patient s Room Identifying and Gathering Necessary Patient Care Equipment Do Don t Become familiar with where to find and how to use the following items in the various ICUs: Allow the therapist to introduce him/herself to the RN, Don t initiate the probability/likeliness of a therapy patient, and family first. The therapist must decide if/when session with nursing or patient/family. Expectations it is appropriate to initiate treatment. should not be set and then not met if the therapist hasn t had the chance to assess the patient first. Untangle lines and ensure proper length in case of sitting Don t begin setting up a patient s room without edge of bed or transferring to a chair. confirmation from the therapist. Remove pillows, bedding, SCDs, PRAFOs, Prevalon Don t disconnect invasive lines, tubes, or drains, even boots, turning wedges, or other positioning devices not for untangling purposes. needed for mobility Position chair with open sheet and chux. Don t remove patient restraints unless indicated by therapist. Position urine bag in lowest possible position. Don t allow buildup of urine in urine bag tubing or backflow of urine toward patient through urine bag tubing. Put down both side rails to prepare for edge of bed Don t initiate mobilization or exercise with the patient. sitting. Set up portable telemetry if indicated. Socks Gown Sheet for chair O2 tubing and connector Tape to secure lines Yankauer suction tip Recliner chair Transfer chair (ordered from Hill Rom) Sally Tube Wheelchair for following Portable telemetry Monitor functions: Blood pressure button, etc. Bed functions: boost, max inflate, seat deflate, chair position, OOB position Put socks on patient. Identifies and Gathers Necessary Rehab Equipment Specific Bed Functions Identifies and Gathers Necessary Rehab Equipment ICU Team The following rehab equipment are often used in the ICU: MOVEO (Stored in M72 Gym) Shuttle Mini Press (sign-out system on Sharepoint) 6

7 Identifies and Gathers Necessary Rehab Equipment Identifies and Gathers Necessary Rehab Equipment ICU Team Contacts for locating, ordering, or servicing equipment: Beds and Chairs ICU Team Contacts for locating, ordering, or servicing equipment: Liko Lifts Single Lift (left) or Double Lift (right) Recliner Chair Barton Chair (Bariatric) Hausted All-Purpose Chair ICU Room: Equipment ICU Room: Equipment Standard Equipment Standard Equipment BP Yankeur (top left) to attach to suction tubing. Suction monitor below. Above: ceiling lift (slings in equipment closet). Below: wedge pillow for positioning. Split monitor so RN can see vitals for both of his/her patients. R-side of screen is patient in this room. Green = telemetry (HR, BP, pulse oximetry, RR) Red = arterial line Blue = central venous pressure line White = monitors ventilator settings/co2 Check BP: Top left gray button ICU Room: Equipment ICU Room: Equipment Portable Telemetry Portable Telemetry Below: Step 2: Slide cam on the back of portable telemetry monitor. May need to use gray tab to fully lock system into place. To monitor vital signs while transferring or ambulating a patient away from bedside. Above: Portable cam on wall in patient s room behind wallmounted black telemetry monitor. Above: Step 1: Use gray tab to gently pull/slide cam off its track with cords attached. 7

8 ICU Room: Lines, Tubes, and Drains Common Lines, Tubes, and Drains ICU Room: Lines, Tubes, and Drains Common Lines, Tubes, and Drains Tube feeds Keep HOB >/= 30 degrees May be put on hold temporarily for positioning (patient lying flat) but may need flushed by RN if on hold > 15 min to prevent clogging ICU Room: Lines, Tubes, and Drains Common Lines, Tubes, and Drains Ventilator Settings may only be managed by RT/MD In some cases, therapist may be allowed to temporarily increase O2 Endotracheal tube Keep ETT from twisting in neck Watch for water in tubing, drain towards machine or collection bag If dislodged, can only be re-inserted by RT/MD ICU Room: Lines, Tubes, and Drains Common Lines, Tubes, and Drains Below: Patient has a tracheostomy to a ventilator. May also be transitioned to trach collar. Above: Patient is intubated with endotracheal tube (ETT) to a ventilator. ICU Room: Lines, Tubes, and Drains Common Lines, Tubes, and Drains Dialysis Catheters may be located in neck or on chest. Ensure direct flow of line from dialysis machine. Large machine at bedside with dialysate fluid is sensitive to changes in weight, particularly if jostled. Patients may have bear hugger blanket for warmth (blue machine at foot of bed). ICU Room: Lines, Tubes, and Drains Common Lines, Tubes, and Drains Types of Dialysis Machines 8

9 ICU Room: Lines, Tubes, and Drains Common Lines, Tubes, and Drains ICU Room: Lines, Tubes, and Drains Common Lines, Tubes, and Drains Swan-Ganz Catheter (central line to pulmonary artery) Arterial Lines Chest Tube: Alert therapist/rn if knocked over AquaGuard shield Hi-Flow Oxygen (Nasal Cannula or Mask) Patient Mobility and Transfers Positioning and Line Management Line Management of Ventilator and Continuous Dialysis Patient Mobility and Transfers Positioning Wedge to Offload Sacral Wounds You may need to assist with boosting a patient higher in bed prior to sitting at the edge of the bed. This prevents very weak and/or morbidly obese patients from sliding down in bed or too close to the edge of the bed. Patients typically also require boosting before being placed in the Chair Position of the bed. The therapist will check the security of all lines prior to mobility. You may be asked to assist in securing lines with tape or hemostats. The therapist and technician will communicate with each other regarding the set-up phase and general plan for the session. Some patients require a RT to monitor their airway and vent during therapy. You must prioritize preserving your back when mobilizing patients to prevent back injuries. In the event that you should sustain an injury while mobilizing a patient, you must notify the CTL and then fill out a SERS report online. You will then be directed to the Emergency Room for evaluation and further instructions. Patient Mobility and Transfers Chair Position of the Bed (left) and Out of Bed Position (right) Patient Mobility and Transfers Guidelines for Hands-On Assistance to the Therapist Do Don t Leave the treatment area briefly to obtain additional supplies only as Don t leave a therapist alone during a patient care treatment directed by the therapist. UNLESS otherwise instructed by the therapist. Communicate appropriately with patients and family members. Don t discuss the patient s medical/functional status or progress with the patient, family, or medical team. Direct questions to the therapist as needed. Provide assist to the patient s trunk and hips whenever possible, Don t pull on the patient s extremities or neck when assisting with using the draw sheet as needed. mobility. Do not pull/push over the location of a line or drain insertion site. During sitting activities with a patient, provide hand placement on mid/low back and use pillow to support patient as needed. Don t provide pressure on patient s shoulders while he/she is sitting at edge of bed. This limits upright posture and restricts lung expansion. When transferring a patient, always use your hands on the gait belt. Don t pull upward on patient s shoulders during transfers. Patients may require a slow pace during mobility activities. This will be directed by therapist to allow for patient comfort, safety with lines, and close monitoring of vital signs. This may include prolonged rest breaks for patient with periods of assessment by therapist. 9

10 Patient Mobility and Transfers Resetting the ICU Patient s Room Tips for Equipment and Lines Resetting the Patient s Room After a Treatment Session Do Don t When the session is complete, and the patient is positioned, the therapist will communicate to the technician when to begin to Re-Set the room. While the technician is resetting the room, the therapist may begin assessing the next patient, but will do a final check before you both move on. Keep the head of the bed greater or equal to 30 degrees, unless needed for positioning during session. Don t attempt to sit a patient up or transfer a patient without confirmation or direction from the therapist. Do Don t Put tube feed on hold as directed by the therapist if Don t leave tube feed on hold for longer than 15 patient needs to be positioned flat temporarily. minutes at a time. Alert the PT/RN if tube feed left on hold greater than 15 minutes; may need to be flushed to prevent clogging. Allow condensation/liquids in the ventilator tubing to be Don t allow liquid build up or condensation in the drained toward the ventilator. ventilator tubing to be drained toward the patient. Ensure direct flow of dialysis lines from the patient to the Don t allow ETT or trach to twist in patient s neck. machine. Alert PT/RN if chest tube knocked over during session. Don t attempt to re-insert an ETT or tracheostomy if accidentally dislodged (must be done by MD). Secure lines (e.g. tube feeds, JP drains) with tape as Don t touch or adjust the ventilator controls (must be directed by therapist. done by RT or MD). Untangle lines. Don t leave taught lines. Put the patient s pillows, bedding, Prevalon boots, call Don t let patient lie flat (head of bed at least 30 degrees light, TV control, and tray table in place. unless instructed otherwise). Remove socks, unless directed as ok by therapist or Don t leave dependent loops in urine bag, or RN. obstructions to flow of fecal management system tubing. Re-apply restraints when necessary. Don t leave a patient room until the treatment area has been properly reset. Alert therapist if tube feed left on hold. Put up all 4 bedrails (all 4 rails up is not considered a restraint in the ICU). Sanitize necessary equipment (gait belt, walker, chair, etc). Cleans and Maintains All Therapy Equipment and Supplies Per Policy & Procedure Manual Cleaning and Maintaining Equipment & Supplies Gait belts and walkers can be cleaned with germicidal wipes (PDI Sanicloths) between every patient treatment session. Some therapists may carry portable a portable pulse-ox. These should only be cleaned with hand sanitizer foam (inside and outside). Sheets/blankets and the patient s gown should be changed if soiled following a therapy session. Please remember to be cautious of multiple lines when changing patient s gowns and to maintain modesty as much as possible. If the patient is mobilized outside his/her ICU room and comes in contact with horizontal surfaces (i.e. sits in chair or bench in hallway), this surface should be cleaned with germicidal wipes (PDI Sani-cloths). Patients who have Contact or Droplet precautions who are mobilized outside his/her room should wear a clean gown and avoid touching surfaces outside the room to prevent infection from spreading. Recliner chairs should be cleaned with germicidal wipes (PDI Sani-cloths) prior to entering a patient s room to ensure cleanliness. Continued Readiness Everyone has a Role Continued Readiness is the responsibility of each and every staff member that works at the Cleveland Clinic and in our department. This means that every team member is aware of the general policies and expectations required by Joint Commission and CMS and make a daily effort to help contribute and ensure a safe environment for patients, themselves, and fellow team members. The CTL will help to review these policies periodically and perform quarterly reviews to ensure compliance. It is the responsibility of the technician and each and every staff member to inquire about policies and processes when questions arise. Everyone has an accountability and responsibility to cleanliness and order in our department. If you see something that you think is out of order or an issue you should do something about it or inform a CTL. One person can have an impact and make a change in the department. On the reverse side it only takes one person not taking responsibility to have a negative impact. Take pride in our Department and in your role while assisting the ICU team!!!!! Continued Readiness Everyone has a Role Do the right thing at all times! The Role of the Rehabilitation Technician in Applying the National Patient Safety Goals: 1. Improve the effectiveness of communication among caregivers. -Communicate to the Therapist any safety concerns or questions. 2. Reduce the risk of a patient acquiring a health care associated infection. -Disinfecting chairs, assistive devices, and gait belts. -Hand washing or use of foam after every patient. 3. Reduce the risk of patient harm resulting from falls. -Use of gait belt and safe body mechanics and guarding techniques during patient care. -Maintain a safe room environment and manage position of lines, electrical cords, and dependent drains such as foleys and ostomy bags to prevent patient or caregivers from stepping over these lines. Rehab Tech training Be prepared to have conversations and provide emotional support to team members who may struggle with the intensity of the critical care environment, including patients who face end of life decisions 4. Prevent health care-associated pressure ulcers. - Assist therapist with turning patients after patient care and elevating the extremities. 5. Improve recognition and response to changes in a patient s condition. -Notify the therapist calmly of any changes in a patient s condition (appearance, vital signs, safety with positioning) if you feel that it represents a change in the patient s condition that the therapist does not seem to be aware of. 6. Universal Protocol: Correct patient and procedure. -The therapist will provide the patient s name and the treatment plan before each session so that the technician is aware of patient identifiers. 10

11 Teamwork Communication Respect Mutual understanding of work flow Nursing plan, RT weaning Shared goals Patient centered Celebration of successes! Caregiver Celebrations SICU Pilot Surgical ICU Trial 1 PT already treating for partial day coverage Nursing and Physicians verbalizing the positives of early mobility and noticing a change in the culture of the unit Rehab Director and SICU Medical Director meeting and agreement to dedicate 1 PT to 30 bed ICU SICU Pilot SICU Pilot Data Nursing collected data on patient outcomes before and after dedicated PT for: Length of stay in SICU Pressure ulcer rates Ventilator assisted pneumonia rates Ventilator days Patient satisfaction Number of Days in SICU Length of Stay Q Q Prior to Early Mobilization After Initiation of Early Mobilization 2013 SICU Pilot Data SICU Pilot Data SICU Skin Care SICU Ventilator Days 12.00% 10.26% UAPU Rate 10.00% 8.00% 6.00% 4.00% 8.58% 5.81% 6.95% Ventilator Days/Month % % Q Q Q Q Prior to Early Mobilization After Initiation of Early Mobilization Prior to Early Mobilization After Initiation of Early Mobilization

12 SICU Pilot Data SICU Pilot Data SICU VAP Rates Press Ganey Number of VAPs/Month Mean (Average) Score Q Q Prior to Early Mobilization After Initiation of Early Mobilization SICU Pilot Data SICU Pilot Percent of "Very Good or Better" Answers 95% 90% 85% 80% 75% 70% 65% Overall Rating of SICU (Press Ganey) 89.08% 79.41% 75.78% 75% 2012 Q Q Mobility log created for communication between PT and nursing 2012 Prior to Early Mobilization After Initiation of Early Mobilization 2013 SICU Pilot SICU Pilot Combined And applied Applied the Delirium Management And Early Mobility Bundles 4 Outcomes Maintained staffing of 1 full time PT Added 1 additional PT 1 year later Opportunities for nursing education In-service on patient mobility with orthopedic precautions In-service on evolving role of PT on the unit Training with nursing technicians with simple mobility procedures and gait belt use 12

13 PT Response Time (% responded, 36 hrs) 17% Business Proposal: Case for Change Increase PT in the ICU Leadership from therapy and ICU met with Medical Operations Provided rationale for increased therapy in ICU ICU therapy under-utilization BEDS Main Campus Source: EBI Occupancy Dashboard 17% ICU PT ACTIVITY Main Campus Source: MediLinks Volume / Activity ICU 5% 83% Non-ICU 95% Non-ICU ICU beds make up 17% of total inpatient beds on Main Campus, but only 5% of all physical therapy activity : Preliminary Results PT FTE Sizing Methodology MICU NICU SICU Cardiac/ CCU TOTAL Beds # appropriate PT Consults per CIP model ratio 1,174 (40% of pts) 274 (20% of pts) 390 (20% of pts) 662 (10% of pts) 2,499 (19% of pts) Total PT Visits 5,872 1,094 1,402 2,383 10,752 PT FTEs needed (at 1,200 visits/yr/fte) Identifying the right patients and treating them with skilled therapy is helping to improve MICU patients functional independence Current PT FTEs Incremental PT FTEs Needed Rehab Techs (1 Tech per 2 PTs) Total Annual Cost: $644,006 Proposal Develop a new ICU PT clinical team Add 6 new physical therapists to the current staff of 3 PTs in the ICU Current PTs New PTs Needed MICU NICU SICU Cardiac / CCU Hire 3 additional Rehab Techs to support program Resource with new hires or pull existing staff Alternate Staffing: Pull Existing Staff 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Reduced Consults/yr Impact of Reducing each Clinical Team by 1 PT FTE: Reduced Response to PT Consults 92% Ortho 77% 78% 76% 69% 63% Neuro Medicine 70% 62% 77% Cardiac Current Response Time Predicted Response Time 67% TOTAL PT ,512 13

14 Business Case / ROI Total Hospital ALOS Target Reduction Direct Cost per Day Total Cost Savings ($000) MICU NICU SICU Cardiac/ CCU (1.0) (0.5) (0.5) (0.5) $2,162 $2,658 $2,830 $3,290 TOTAL $1,984 $201 $251 $516 $2,954 Business Proposal: Case for Change Increase PT in the ICU Response from hospital operations: Favorable or not? Agreement was in place that the value of increasing PT in the ICU was significant Hospital operations would not approve hiring additional FTE as proposed FTE Incremental Costs ($000) $429 $44 $44 $125 $644 Return on Investment 362% 351% 464% 312% 359% Business Proposal: Case for Change Increase PT in the ICU During previous hospital operation meetings the following issues were discussed: PT response time was not being met due to inappropriate referrals Not all staff were meeting 100% of the expected productivity standard Business Proposal: Case for Change Increase PT in the ICU Hospital Operations challenged therapy leadership: Shift work from areas covering inappropriate referrals Work to improve productivity of team members not achieving the expectation Business Proposal: Case for Change Increase PT in the ICU Business Proposal: Case for Change Increase PT in the ICU Initial primary focus of allocation of resources started with areas with high 6-click scores 6-Clicks scores are valid for assessing patients activity limitations in acute care settings 5 Therapy leadership utilized 6-Click data to identify areas with a high volume of Click scores Meetings were held in these areas with nursing and medical team leadership 14

15 6-Clicks Data 6/2013 # of s was 39% # of 24 s (consults for mobile patients) are down nearly 8% 12/2012 # of s was 42% Physicians that may need more education Development of the Critical Care Team Decision was made to develop a Critical Care Team which included: 1 Clinical Team Leader 8 Physical Therapists 4 Occupational Therapists Positions were shifted from other teams in the department All ICUs throughout the hospital are covered by the Critical Care Team Development of the Critical Care Team Initial Staffing Critical Care Team Units MICU 5 ICUs, 64 beds 2.5 PTs, 1.5 OTs SICU 3 ICUs, 30 beds 2 PTs, 1 OT NICU 2 ICUs, 24 beds 1 PT, 0.5 OT Cardiac ICUs (HF-ICU, CICU, CVICU) 8 ICUs, 110 beds 3 PTs, 1 OT Critical Care Team First Year Critical Care Team First Year PT / OT Critical Care Visits Yr. over Yr. Since 2012 PT / OT Critical Care Visits as % of Total Visits Sept OT 41 PT % 21% 1200 Sept OT 87 PT % 19% Sept OT 99 PT 370 Sept OT 452 PT % 10% 6% 9% 7% % 0% 5% 5% 3% Sept Sept Sept Sept OT CC Visits as % of Total OT Visits PT CC Visits as % of Total PT Visits 0 PT Critical Care Visits OT Critical Care Visits 15

16 Critical Care Team First Year Critical Care Team First Year Survey Mismatch A survey was distributed via to the following professionals in the ICU: 1) ICU attendings 2) Critical care/pulmonary critical care/cardiology and vascular surgery fellows 3) Residents with experience in our ICUs 4) Nurses (RN, ANM) 5) Midlevel practitioners (NP/PA) 6) Respiratory therapy Match! Critical Care Team First Year Survey Results Respondents: % (n=17) residents 49.6% nurses (n=67) 44.6% (n=101) did not identify their discipline 98% of respondents believed patient outcomes have improved for those patients who worked with PT/OT in the ICU 92% consider patient readiness for therapy during their daily rounds for patient care 96.7% of respondents (100% of physician respondents) recommended continued PT/OT presence in ICUs 87.9% of all respondents rated PT as having significant value in the ICUs, whereas 71.1% rated OT as having significant value in the ICUs Majority of comments were positive, while some (<5) comments were negative or related to adverse events as a result of working with therapy (patient fatigue or O2 desat, PT or OT in the way of other treatments) Identified the need for a comprehensive and uniform orientation process to critical care for all PT and OT caregivers Characteristics of ICU Critical Care Team members when it was established: Therapists with varied levels of ICU experience (1-20+ years) Therapists treating patients of different levels of ICU complexity at large main tertiary hospital versus small regional hospitals Therapists trained in variety of ways Experience. Didactic knowledge from school. Prior job setting. Other PT/OTs. Continuing Education. Therapists experience and comfort in the ICU based on the patient population without the knowledge base to rotate to all ICU units Cardiothoracic, Cardiac, Medical, Neuro, Surgical Current state of orientation process when Critical Care Team was established Therapists with ICU experience orienting therapists without ICU experience Therapists with ICU experience were grandfathered in and did not receive orientation Global department orientation processes were used for general acute care knowledge and competencies Lack of uniformity and structure with the process Individualized by the orienting therapist No guidelines for who could treat in the ICU considering prior experience (i.e. new graduate) Formal ICU orientation process developed by the CC Rehab and Sports Therapy ICU SIG Approximately 30 member group 20 PTs, 6 OTs, 2 STs, 1 Group leader Began in 2011 Met quarterly for 1 hour meetings Yearly commitment All therapists with an interest could join and did not need to be currently staffed in an ICU 16

17 Role and Activities of the ICU SIG Process Development Piloting ICU related patient care competencies Education of ICU therapists Journal article presentations Arranging for guest speakers to give CEU events Developing internal CEU events ICU SIG recognized the need for and chose to develop a formal critical care orientation process Assigned a project coordinator Established a timeline (1 year) Majority of members chose to participate Communicated by and through quarterly meetings (in-person and conference calls) Established necessary components to the orientation process through: literature review Mejia-Downs et al project coordinator leadership and experience experience with clinical education SIG member input used in-person meeting for discussion and input of group members Established key components of ICU orientation: General orientation to acute care ICU unit and patient population specific information Learning modules for reading and memorizing Literature review for evidence based practice of fundamental ICU literature Observation of a preceptor Patient care with a preceptor Competency checklist Quiz Critical Care Team Education Learning Modules Evidence for early mobility. Outcome measures. Role of PT/OT/SLP in the ICU Treatment ideas for PT/OT ICU delirium definition and management ICU lines, tubes, drains. ICU monitors. Bed functions. Ventilators and other oxygen delivery systems Lab values Pharmacology Precautions/contraindications for mobility Strategies for chart review, documentation, communication Room set-up considerations Role of the rehab tech Family role and involvement in care ICU SIG organized CEU opportunities to educate ICU clinicians with all levels of experience Perme Early Mobility and Walking Program in ICU: 2013 ICU Fundamentals (2 part): 2014 Oxygen Delivery Systems: 2016 Pharmacology:

18 Critical Care Team Education Critical Care Team Education ICU Fundamentals (internally developed) Lines, tubes, drains Oxygen delivery systems Mechanical Ventilation EKG Lab Values Pharmacology Delirium To treat or not to treat PT, OT, ST treatment ideas Utilization of support staff Management of Oxygen Delivery Systems and Mechanical Ventilation in the ICU (internally developed) Identifying O2 deliver systems Ventilator modes Role of PT/OT in managing a patient s respiratory status Implementing best practice Pharmacology (internally developed) ICU Pharmacology and Case General Medicine Pharmacology and Case Recognized the need for orientation and education of therapy support staff in the ICU 7-10 rehabilitation technicians staffed at main campus Varied levels of rehab tech experience (20+yrs to <1yr) Varied levels of prior experience Nursing aides PT/OT students. Nursing students. Pre PT/OT students. All rehab techs oriented and trained with general acute care skills to assist therapists during patient care on regular nursing floor units Identified areas to enhance the training and orientation for rehab tech support in the ICU: Role of rehab techs in the ICU setting Brief presentation of the evidence for early mobility Education with considerations for patient interactions specific to the ICU such as delirium and agitation Role of the rehab tech to maintain national patient safety goals Instructions on the role of a rehab tech with: Setting-up and ICU room Assisting the therapist during patient care Re-setting the ICU room Sanitization of equipment A formal multi-modal rehab tech critical care orientation process was established Established 3 PT preceptors to train all rehab techs for training consistency and organization 1:1 preceptor-to-tech training during patient care Orientation binder Competency checklist Simulation Lab Created 2 page competency checklist Yes/No assessment Four categories of knowledge Equipment and precaution knowledge Room set-up and patient preparation Patient mobility and transfer assistance Re-set of the patient and room 18

19 Critical Care Team Current State Rehabilitation technicians SIM Lab Training Worked with Cleveland Clinic Simulation Lab to develop and implement a simulated ICU competency experience Therapist acted as a standardized patient Use of monitors, ICU lines/tubes/drains Used competency checklist for assessment See video Critical Care Team Units MICU 5 ICUs, 64 beds 3 PTs, 1.5 OTs SICU 3 ICUs, 30 beds 2 PTs, 1 OT NICU 2 ICUs, 24 beds 1 PT, 0.5 OT Cardiac ICUs (HF-ICU, CICU, CVICU) 8 ICUs, 110 beds 3 PTs, 1 OT Critical Care Team Current State Critical Care Team Current State Ongoing Education Monthly Critical Care Team Journal Club Peer to peer on the job shadowing/education Team members encouraged to rotate every 4 month Rotate to another hospital team/service Rotate internally within the Critical Care Team ICU SIG Journal Clubs Providing inservices at satellite hospitals Tech training/sim lab training Ongoing Quality Review Quality Visits by Clinical Team Leader Hand washing Patient Identification Appropriate Communication with patient Treatment provided is skilled and appropriate Billed Treatment is appropriate Plan of Care is appropriate Peer Audit Documentation Performed by Clinical Team Leader, Senior or Clinical Specialist Critical Care Team Current State Critical Care Team Current State 19

20 Critical Care Team Current State Critical Care Team Current State Challenges over the past year 2017 Co-evaluation and Co-Treatment changes Co-evaluations are not supported by the Cleveland Clinic Rehabilitation and Sports Therapy Department The decision to co-treat needs to be made on a case by case basis and the need to co-treat needs to be well documented for each patient. Co-treatments should be limited. Point after service documentation Critical Care Team is working together to meet these challenges Beginning January 2018: Team added 2 more OTs Will increase value that OT can provide to the patient in treatment of the Critical Care patient OT will assess patient before PT in certain areas OT provides a skill set that is highly needed in the Critical Care areas as they can focus on Communication, Cognition, Coping, etc Studies have shown that early and intensive OT is effective in decreasing the duration and incidence of delirium in the ICU 7 Critical Care Team Future State References Continue to use outline/materials for new team members Allow training in the SIM lab to be available for new ICU PT/OT clinicians Elevate rehab technicians to continue to assist team in providing world class care to the medically complex, critically ill patients Yearly competencies Continuing education developed by internal staff Emotional support for Critical Care Team 1. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007; 35: Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008; 36: Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet. 2009; 373: References Audience Learning Questions 4. Morandi A, Brummel NE, Ely EW. Sedation, delirium, and mechanical ventilation: The ABCDE approach. Curr Opin Crit Care. 2011;17: Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS, Jette AM. Validity of the AM-PAC 6-Clicks Inpatient Daily Activity and Basic Mobility Short Forms. Physical Therapy. 2014; 94: Mejia-Downs A, Blake MJ, Kanetkar A. Comprehensive critical care orientation for physical therapists in an academic medical center. J Acute Care Phys Ther. 2015; 6: Alvarez EA, Garrido MA, Tobar EA, et al. Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial. Journal of Critical Care. 2017; 37: ) Did you learn something from this presentation that you can apply to patient care? 2) Did you learn something (strategies for workflow, staff efficiency) that you could apply to your Critical Care Team or the formation of one in your facility? 3) Did you learn something (strategies for data collection, outcome measures) that you could use to increase the value therapists in your facility bring to patients in the ICU? 4) Were the tools for therapist and staff training and orientation presented here applicable to your specific department needs? 20

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