Objectives 10/3/16. Transforming Collegial Relationships in Critical Care. Disclosures

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1 Transforming Collegial Relationships in Critical Care Kathleen M Vollman, MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist/Consultant ADVANCING NURSING LLC kvollman@comcast.net ADVANCING NURSING 2016 Disclosures Sage Products Speaker Bureau & Consultant Hill-Rom Speaker Bureau Eloquest Healthcare Speaker Bureau & Consultant No discussion off label and/or investigational use of any medications Objectives Discuss transforming a culture that creates safety for the patient and staff while achieving evidence based outcomes Identify and discuss the Physiology of motion in critically ill patients Outline strategies to overcome the barrier of hemodynamic instability 1

2 Notes on Hospitals: 1859 It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. Florence Nightingale Advocacy = Safety Protect The Patient From Bad Things Happening on Your Watch Interventional Patient Hygiene Hand Hygiene Comprehensive Oral Care Plan Hygiene the science and practice of the establishment and maintenance of health Interventional Patient Hygiene.nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies Incontinence Associated Dermatitis Prevention Program Pressure Injury Prevention Catheter Care Bathing & Assessment 2

3 INTERVENTIONAL PATIENT HYGIENE(IPH) VAP/HAP Oral Care/ Mobility HAND Patient HYGIENE Catheter Care Skin Care/ Bathing/Mobility CA-UTI CA-BSI SSI Falls HASI Vollman KM. Intensive Crit Care Nurs, 2013;22(4): Just Culture of Safety Safety is avoiding both short- and long-term harm to people resulting from unsafe acts and preventable adverse events. Current infrastructure silos safety programs, creating one for patients, another for workers, and yet another for others who may be at risk. (Quality department, Risk Management, Employee Health, SPH) The organizational culture, principles, methods, and tools for creating safety are the same, regardless of the population whose safety is the focus. A true culture of safety and the organization leaders who create and sustain it will not be considered legitimate and genuine if the culture excludes some groups within the organization Comprehensive Unit Safety Program (CUSP) Health Work Environment Safe Patient Handling Program The Joint Commission. Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation. Oakbrook Terrace, IL: Nov What Does it Mean to Be in A Safe Culture for You & Your Patient? 3

4 Changing the Paradigm Culture of Safety in Health Care Culture of Safety for Healthcare Workers Patient Safety Healthcare Worker Safety Safety Culture for the Patient & the HCW Core Organizational Value Changing the Perception of Safety on Your Unit Safety for the patient and healthcare worker are integrated Transcends individual improvement initiatives and departmental walls High reliable unit/organization: engaged leadership, culture of safety, organizational processes and infrastructure to support safe practices Implement and maintain successful worker and patient safety improvement initiatives within your unit & organization. Create measurements that integrate patient safety and healthcare worker safety The Joint Commission. Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation. Oakbrook Terrace, IL: Nov Castro GM. Am J SPHM, 2015;5(1)34-35 Add ANA- The Goal: Patient & Caregiver Safety Patient Progressive Mobility Safe Patient Handling Prevention of Pressure Injuries 4

5 How Well Are We Doing? REPOSITIONING /MOBILZATION OF THE PATIENT PATIENT SKIN INJURY CAREGIVER INJURY Do We Even Achieve the Minimum Mobility Standard Q2 Hours..? 5

6 Body Position: Clinical Practice vs. Standard Methodology 74 patients/566 total hours of observation 3 tertiary hospitals Change in body position recorded every 15 minutes Average observation time 7.7 hours Online MD survey Results 49.3% of observed time no body position change 2.7% had a q 2 hour body position change 80-90% believed q 2 hour position change should occur but only 57% believed it happened in their ICU Krishnagopalan S. Crit Care Med 2002;30: Positioning Prevalence Methodology Prospectively recorded, 2 days, 40 ICU s in the UK Analysis on 393 sets of observations Turn defined as supine position to a right or left side lying Results: 5 patients prone at any time, 3.8% (day 1) & 5% (day 2) rotating beds Patients on back 46% of observation Left 28.4% Right 25% Head up 97.4% Average time between turns 4.85 hrs (3.3 SD) No significant association between time and age, wt, ht, resp dx, intubation, sedation score, day of wk, nurse/patient ratio, hospital Goldhill DR et al. Anaesthesia 2008;63: Environmental Scan of EM Practices 687 randomly selected ICU s stratified by regional density & size- 500 responded (73% response rate) Demographics: 51% academic affiliation, mixed medical/surgical (58%) or medical (22%) with a median of 16 beds (12 24) 34% dedicated PT or OT for the ICU Performed a median of 6 days, 52% began on admission Factors associated with EMP: Dedicated PT/ OT Written sedation protocol Daily MDR Daily written goals Bakhru RN, et al. Crit Care Med 2015; 43:

7 Outcomes of Early Mobility Programs â incidence of VAP â time on the ventilator â days of sedation â incidence of skin injury â delirium á ambulatory distance Improved function Staudinger t, et al. Crit Care Med, 2010;38. Abroung F, et al. Critical Care, 2011;15:R6 Morris PE, et al. Crit Care Med, 2008;36: Pohlman MC, et al. Crit Care Med, 2010;38: Schweickert WD, et al. Lancet, 373(9678): Thomsen GE, et al. CCM 2008;36; Winkelman C et al, CCN,2010;30:36-60 Body Position: Clinical Practice vs. Standard Methodology 74 patients/566 total hours of observation 3 tertiary hospitals Change in body position recorded every 15 minutes Average observation time 7.7 hours Online MD survey Results 49.3% of observed time no body position change 2.7% had a q 2 hour body position change 80-90% believed q 2 hour position change should occur but only 57% believed it happened in their ICU Krishnagopalan S. Crit Care Med 2002;30: Positioning Prevalence Methodology Prospectively recorded, 2 days, 40 ICU s in the UK Analysis on 393 sets of observations Turn defined as supine position to a right or left side lying Results: 5 patients prone at any time, 3.8% (day 1) & 5% (day 2) rotating beds Patients on back 46% of observation Left 28.4% Right 25% Head up 97.4% Average time between turns 4.85 hrs (3.3 SD) No significant association between time and age, wt, ht, resp dx, intubation, sedation score, day of wk, nurse/patient ratio, hospital Goldhill DR et al. Anaesthesia 2008;63:

8 Hospital Acquired Skin Injury HAPU are the 4 th leading preventable medical error in the United States 2.5 million patients are treated annually in Acute Care NDNQI data base: critical care: 7% med-surg: 1-3.3% Acute care: 0-12%, critical care: 3.3% to 53.4% (International Guidelines) Most severe pressure injury: sacrum (44.8%) or the heels (24.2%) 60,000 persons die from pressure injury complications each yr. National health care cost $11 billion annually Dorner, B., Posthauer, M.E., Thomas, D. (2009), Whittington K, Briones R. Advances in Skin & Wound Care. 2004;17: Reddy, M,et al. JAMA, 2006; 296(8): Vanderwee KM, et al., Eval Clin Pract 13(2): National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure ulcers :clinical practice guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia; % of nurses required to do repositioning suffered back pain High physical demand tasks 31.3% up in bed or side to side 37.7% transfers in bed 40% of critical care unit caregivers performed repositioning tasks more REPOSITIONING than six times per shift THE PATIENT CAREGIVER INJURY Number one injury causation activity: Repositioning patients in bed Smedley J, et al. J Occupation & Environmental Med,1995;51: ) (Knibbe J, et al. Ergonomics1996;39: ) Harber P, et al. J Occupational Medicine, 27; ) Fragala G. AAOHN, 2011;59:1-6 8

9 Injury Facts Back and other musculoskeletal injuries are the result of repeated exposure to ergonomic risk factors rather than a single, instantaneous event In an eight hour shift, the cumulative weight that nurses lift equal to an average of 1.8 tons per day or 3600 lbs. per shift Tuohy-Main, K. (1997). Geriaction, 15, ANA SPH and Mobility Standards 2014 Number, Incidence Rate, & Median Days Away From Work for Occupational Injuries RN s with Musculoskeletal Disorders in US, Private industry RNs 9, Private industry RN s 10, Private industry RN s Private Industry RN Private Industry RN Private Industry NA 18,510 6 * * Incidence rate per 10,000 FTE Bureau of Labor Statistics, U.S. Department of Labor, February 14, Numbers for local and state government Unavailable prior to 2008/Nov 2011, Release 10:00 a.m. (EST) Thursday, November 8, 2012, 2013 data Accessed 01/07/ Factors Associated With Safe Patient Handling Behaviors Among Critical Care Nurses Patient handling is a major risk factor for musculoskeletal (MS) injury among nurses. A cross-sectional study conducted nationwide involving 361 critical care nurses More than half of participants had no lifting equipment on their unit 74% reported that they performed all patient lift or transfer tasks manually STUDY MAJOR CONCLUSSION: safety of work behaviors among critical care nurses is shaped by the organizational safety culture and psychosocial work environment. Ref: AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 53: (2010) 9

10 Skin Risk Factors Skin & Immobility Prevention Strategies Care Giver Risk Moisture Clean & Protect Repetitive motion, Lifting Pressure Shear Hemodynamic Instability Can Create a Barrier to Achieving Skin and Immobility Prevention Strategies Reduce Pressure & Shear Repetitive motion, Lifting & Limb holding Friction In-bed & Out of Bed Mobility Repetitive motion, Dragging, patient weight START HERE Progressive Mobility Continuum Includes complex, intubated, hemodynamically unstable Includes intubated, non intubated hemodynamically stable/stabilizing, no and stable intubated patients; may include non-intubated contraindications LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V Perform Initial mobility RASS -5 to - 3 RASS -3 & up RASS -1 & up RASS 0 & up RASS 0 & up screen w/in 8 hours of ICU Goal: clinical stability; Goal: upright sitting; Goal: Increased trunk Goal: stands w/ min. Goal: Increase admission passive ROM increased strength and strength, moves leg to mod. assist, able to distance in ambulation Reassess mobility level at moves arm against gravity against gravity and march in place, & ability to perform least every 24 hours readiness to weight bear weight bear and some ADLs (Recommended at shift Δ) transfer to chair PT consultation prn PT: Active Resistance PT x 2 daily & OT x1 PT x 2 daily Refer to the following OT consultation prn Once a day, strength daily OT consult for ADL s criteria to assist in exercises ACTIVITY: determining mobility level Q 2 hr turning OT consultation prn o PaO2/FiO2 > 250 *Passive /Active ROM ACTIVITY: 3x/d o Peep <10 HOB > 30º 1. HOB 45º X 15 min. o O2 Sat > 90% *Passive ROM 2X/d 2. HOB 45º,Legs ACTIVITY: ACTIVITY: ACTIVITY: o RR performed by RN, or in dependant Self or assisted Self or assisted Self or assisted UAP position X 15 min. Q 2 hr turning Q 2 hr turning Q 2 hr turning o No new onset cardiac 3. HOB 65º,Legs 1.Sitting on edge of 1.Bed sitting Position arrythmias or ischemia in dependant bed w/rn, PT, RT Min.20 min. 3X/d; 1.Chair (OOB) w/ o HR >60 <120 CLRT/Pronation position X 15 min. assist X 15 min. 2.Sitting on edge of RN/PT/RT assist initiated if patient 4. Step (3) & full 2.Progressive bed bed; stand w/ RN, Min. 3X/day o MAP >55 <140 meets criteria based chair mode sitting Position PT, RT assist 2.Meals consumed Min.20 min. 3X/d o SBP >90 <180 on institutional X20 min. 3X/d 3.Active Transfer to while dangling on practice Or Or Chair (OOB) w/ edge of bed or in o No new or increasing OR Full assist into cardiac Pivot to chair RN/PT/RT assist chair vasopressor infusion Q 2 hr turning chair 2X/day position 2X/d Min. 3X/d o RASS > 3 Ambulate NO YES progressively longer Tolerates Tolerates Tolerates distances with less Tolerates Level II Level III Level IV assistance x2 or x3/ Level I Activities Activities Activities day with RN/PT/RT/ Start at Start at Activities UAP level I* level II and progress* For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant ***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level*** *Mobility is the responsibility of the RN, with the assistance from the RT s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment. Challenges to Mobilizing Critically Ill Patients Potentially Modifiable Barriers Patient related barriers (50%) Hemodynamic instability, ICU devices, physical & neuropysch Structural (18%) Human or Technological Resources ICU culture (18%) Knowledge/Priority/Habits Process related (14%) Service delivery/lack of coordination Clinician function Dubb R, et al, Annual ATS, 2016 in press 10

11 Staff Perceived Barriers & Facilitators 33 nurses participated in 49 interviews (10 interviews before protocol & 39 after) Results/Interview 41/49 in-bed activities Unstable VS (59%) & low respiratory and energy reserves (46%) most common reasons for restricting activity 34% stated safety issues/ falling or tube/catheter integrity 27% reported sedation 9 out of Bed activities (7/9 after protocol launch 100%- pt cooperative today 44% - MD order &/or good O2 reserve Winkelman C, et al. Crit Care Nurse, 2010;30(2):S13-S16 Hemodynamic Instability??? Is it a Barrier to Positioning? Hemodynamic Instability Defined Hemodynamic instability is typically characterized by; Blood pressure lability Bradycardia Tachycardia, Hypoxemia Hypoperfusion, and Affected by blood loss, decreased systemic vascular resistance from sepsis, decreased cardiac output, as well as supportive measures such as extracorporeal circulation. 11

12 Physiological Response to Movement The Effects of Immobility on Cardiovascular Function Fluid Shift Fluid shift from upright to sitting 500cc shift from the lower extremities to the thoracic cavity of plasma volume of 8-10% that occurs in the first 3 days of bedrest Stabilizes at 15-20% volume loss by the 4 th week of bedrest Winslow, E.H. Heart and Lung, 1990 Volume 19, Greenleaf JE. Et. al. J of Applied Physiology 1977;42:59-66 Knight J, et al. Nurs Times. 2009;105(21): Harms MP, et al. Exp Physiol. 2003;88: Sjostrand T. Physiol Rev. 1953;33: The Effects of Immobility on Cardiovascular Function Cardiac Effects workload (fluid shift) resting heart rate & cardiac output Decrease preload from venous pooling Decrease volume secondary to renal losses Cardiac Deconditioning & Decreased Maximum Oxygen Uptake Falls 23% after 3 weeks of strict bedrest with no change in peripheral oxygen extraction Winslow, E.H. Heart and Lung, 1990 Volume 19, Knight J, et al. Nurs Times. 2009;105(21): Convertino V, et al. Med Sci Sports Exercise, 1997;29:

13 The Effects of Immobility on Cardiovascular Function Orthostatic Intolerance Deteriorates rapidly with bed rest Occurs within 1-2 days with maximum effect at 3 weeks Results from decreased autonomic tone & fluid shifts Winkelman C. AACN Adv Crit Care. 2009;20: Knight J, et al. Nurs Times. 2009;105(21):16-20 Luthi, J.M., et. al. Sports Medicine, 1990, Vol. 10;1. Melada, G.A., et. al. Space and Environmental Medicine, August 1976 Rosemeyer, B., et.al. International Journal of Sports Medicine, 1986a, 7:1-5 Selikson, S. et. al. Journal of American Geriatric Society, August 1988, 36 (8) Risk for Intolerance Factors that put patients at risk for intolerance to positioning: Elderly Diabetes with neuropathy Prolonged bed rest Low hemoglobin and cardiovascular reserve Prolonged gravitational equilibrium Bed rest lessens carotid-cardiac baroreflex responsiveness Vestibular system influences the regulation of cardiovascular function during movement and changes in posture. Vollman KM. Crit Care Nurs Q. 2013;36:17-27 Overcoming Intolerance Slowing the turn Training to turn 13

14 Goldhill DR et al. Amer J Crit Care, 2007;16:50-62 CLRT to Prevent VAP: Controlling the Variables 1 Methodology Prospective randomized controlled trial, 3 medical ICUs at a single center Eligible if ventilated <48 hours and free from pneumonia, ALI, or in ARDS 150 patients with 75 in each group 35 patients with CLRT allocated to undergo percussion before suctioning Measures to prevent VAP were standardized for both groups including head of bed Results: CLRT vs control VAP: 11% vs 23% P=0.048 Ventilation duration: 8 ± 5 days vs 14 ± 23 days, P=0.02 LOS: 25 ± 22 vs 39 ± 45 days, P=0.01 Mortality: no difference ALI=acute lung injury; ARDS=acute respiratory distress syndrome; CLRT=continuous lateral rotation therapy; VAP=ventilator-associated pneumonia. Staudinger T, et al. Crit Care Med. 2010;38: Introducing CLRT Into Patient Care Introduction of CLRT into patient care can provide an efficient way of providing early mobility to those critically ill patients whose condition or instability prevents implementation of other forms of mobility 1,2 Systematic method of approaching placement and removal of CLRT therapy a protocol CLRT=continuous lateral rotation therapy. 1. Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31: Basham KA, et al. Respir Care Clin N Am. 1997;3:

15 CLRT Protocol for Hemodynamically Unstable Patients * This tool is provided for education and discussion only. Each facility is responsibility for the development, adoption and implementation of its own protocols. Follow protocols and rules adopted by your facility. Moving Those Who Cannot Move Themselves: Which Patients Should Receive CLRT? Target high-risk patient populations Pulmonary-hemodynamic instability with manual turning FiO 2 50% or more Positive end-expiratory pressure (PEEP) 8 or more Existing pulmonary complications FiO 2 increases by 20% (20 points) or PEEP >3 cm H 2 O from baseline within 2 calendar days Which patients should NOT receive CLRT? Those with unstable spines Those with long bone fractures or patients requiring traction Those with unstable intracranial pressure Marked agitation without therapeutic management Those with severe, uncontrolled diarrhea and patients that weigh more than 300lbs CLRT=continuous lateral rotation therapy. Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31: Basham KA, et al. Respir Care Clin N Am. 1997;3: Ongoing Monitoring/Evaluation and Documentation Assess for potential complications frequently Malposition of endotracheal tube Positional transient desaturation Positional hemodynamic instability Every 2 hours check to see if patient is in optimal position to promote effective turn Every 2 hours manually turn patient and evaluate skin and lungs, then resume rotational therapy Document in medical record: degree of rotation, pause time settings, hours of rotation, turn for skin check and lung evaluation every 2 hours Discontinue CLRT when the patient: May be mobilized safely using other means (head of bed, chair position, out-of-bed chair, and/or ambulation) Shows improvement in respiratory status Has agitation that is not therapeutically managed CLRT=continuous lateral rotation therapy. 15

16 10/3/16 CLRT Strategies for Success Early CLRT intervention The therapy must be driven by a protocol and changes in settings are nursing orders Monitor initial rotation cycle to ensure one lung is above the other Automation of rotation requires insertion of usual assessment practices Minimum of 18 hours per day and 6 cycles per hour If done incorrectly, can cause skin injury Shorter pause times Assessment to ensure one lung above the other Every two-hour assessment of the lungs and skin Yearly competency-based education to ensure proper use of the therapy CLRT=continuous lateral rotation therapy. Balancing Oxygen Supply and Demand O2 Supply Debt 16

17 Activities That Increase VO 2 Dressing change 10% Physical exam 20% Agitation 18% Bath 23% Chest X-ray 25% Suctioning 27% Increased work of breathing 40% Weigh on sling scale 36% Position change 31% Linen change occupied bed 22% Chest physiotherapy 35% White, KM. AACN Clin Issues Crit Care Nurs Feb;4(1): Strategies to Optimize Patient s Tolerance to Activities Space activities Monitor for signs of intolerance Pre/post hyperoxygenate Determine if the intervention is essential Control variables that increase consumption Pain management Agitation management Partial temp regulation Shivering Lateral Positon & Dangling Lateral turn results in a 3%-9% decrease in SVO 2, which takes 5-10 minutes to return to baseline Appears the act of turning has the greatest impact on any instability seen Studies show similar impact with dangling Mechanical ventilation impact within chest wall Winslow EH, et al. Heart Lung. 1990;19: Price P. Dynamics. 2006;17:

18 Balance the Risk & Benefit Determining the timing of the mobility session in relation to other care activities Monitoring for tolerance 5 to 10 minutes after the mobilization If using the left lateral position potential for greater cardiovascular compromise may necessitate a temporary decision to use supine (head-ofbed elevation) and the right lateral position until able to tolerate Vollman KM. Crit Care Nurs Q. 2013;36:17-27 Determining Readiness Perform Initial mobility screen w/in 8 hours of ICU admission & daily Yes Patient Stable, Start at Level II & progress PaO2/FiO2 > 250 Peep <10 O2 Sat > 90% RR No new onset cardiac arrhythmias or ischemia HR >60 <120 MAP >55 <140 SBP >90 <180 No new or increasing vasopressor infusion RASS > -3 Bassett RD, et al.intensive Crit Care Nurs (2012) 2012 Apr;28(2):88-97 Needham DM, et al. Arch Phys Med Rehabil Apr;91(4): No Patient is unstable, start at Level I & progress 18

19 Consensus on Safe Criteria for Active Mobilization Systematic review performed than 23 international experts gather to reach consensus Categories Respiratory Cardiovascular Neurological Other Considerations Consensus reach on all criteria. If no other contraindications; vasoactives, endotracheal tube, FIO2 < 60% with SaO2 90% & RR < 30/min were considered safe criteria Hodgson CL, et. al Critical Care, 2014;18:658 Decision-Making Tree for Patients Who Are Hemodynamically Unstable With Movement 1,2 Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible Is the patient hemodynamically unstable with manual turning? O 2 saturation < 90% New onset cardiac arrhythmias or ischemia HR < 60 <120 MAP < 55 >140 SPB < 90 >180 New or increasing vasopressor infusion Yes Is the patient still hemodynamically unstable after allowing 5-10 minutes adaption post-position change before determining tolerance? Yes Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible Yes Has the manual position turn or HOB elevation been performed slowly? Yes Initiate continuous lateral rotation therapy via a protocol to train the patient to tolerate turning No No No No Begin in-bed mobility techniques and progress out-ofbed mobility as the patient tolerates Begin in-bed mobility techniques and progress out-ofbed mobility as the patient tolerates Allow the patient a minimum of 10 minutes of rest between activities, then try again to determine tolerance Try the position turn or HOB maneuver slowly to allow adaption of cardiovascular response to the inner ear position change HOB=head of bed; HR=heart rate; MAP=mean arterial pressure; SPB=systolic blood pressure. Vollman KM. Crit Care Nurse. 2012;32: Vollman KM. Crit Care Nurs Q. 2013;36: Brindle TC, et al. WOCN, 2013;40(3):

20 Example Protocol When patient is not able to tolerate manual turning; Attempt a trial q 2 hrs, slowly Provide mini turns slowly Elevate heels off the surface of the bed Slight reposition hourly of the heads, arms and legs Consider CLRT with q2 hr assessment Provide linen changes, hygiene checks and reposition with wedges/pillows Add specialty surface if needed The Goal: Patient & Caregiver Safety Patient Progressive Mobility Safe Patient Handling Prevention of Pressure Injuries Achieving In Bed Mobility with Critically Ill Patients 20

21 What is Safe Patient Handling? Manual Patient Handling The transporting or supporting of a patient by hand or bodily force, including pushing, pulling, carrying, holding, and supporting of the patient or a body part. Safe Patient Handling Evidence-based approach to reducing risk to caregivers. Includes risk assessment, use of equipment, patient assessment, algorithms, peer safety leaders, and afteraction reviews. Nelson, A.L., Motacki, K., & Menzel, N. (2009). The Illustrated Guide to Safe Pa3ent Handling and Movement. New York: Springer. NIOSH (National Institute of Occupational Safety and Health) Recommendations for Safe Patient Handling Maximum recommended weight limit set for patient lifting 1 The weight being lifted can be estimated When patient is cooperative The lift is smooth and slow Maximum recommended limits set for patient push/ pull activity Proper body mechanics alone will not prevent patient handling injury (Hignett, 2003) Safe Work Practices IT IS NOT SAFE TO MANUALLY MOVE PATIENTS 1.Waters, T.R. (2007). When is it safe to manually lik a palent? American Journal of Nursing, 107(8), Evidence Based Strategies for a Comprehensive SPHM Program 1. Ergonomic Assessment Protocol 2. Patient Handling Assessment Criteria and Decision Algorithms 3. Peer Leaders 4. State-of-the-art Equipment 5. After Action Reviews 6. No Lift Policy Nelson, A.L. (2006). Consequences of unsafe palent handling praclces. In A.L. Nelson (Ed.), Safe pa3ent handling and movement : a guide for nurses and other health care providers (pp ). New York: Springer. 21

22 EBP Recommendations to Achieve Offloading & Reduce Pressure (A) Turn & reposition every (2) hours (avoid positioning patients on a pressure injury) Repositioning should be undertaken to reduce the duration & magnitude of pressure over vulnerable areas Consider right surface with right frequency* Cushioning devices to maintain alignment /30 side-lying & prevent pressure on boney prominences Between pillows and wedges, the wedge system was more effective in reducing pressure in the sacral area (healthy subjects) (Bush T, et al. WOCN, 2015;42(4): ) Assess whether actual offloading has occurred Use lifting device or other aids to reposition & make it easy to achieve the turn Reger SI et al, OWM, 2007;53(10):50-58, National Pressure injury Advisory Panel, European Pressure injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure injurys :clinical practice guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;2014 *McNichol L, et al. J Wound Ostomy Continence Nurse, 2015;42(1): EBP Recommendations to Reduce Shear & Friction Loose covers & increased immersion in the support medium increase contact area Prophylactic dressings: emerging science Use lifting/transfer devices & other aids to reduce shear & friction. Mechanical lifts Transfer sheets 2-4 person lifts Turn & assist features on beds Do not leave moving and handling equip underneath the patient National Pressure injury Advisory Panel, European Pressure injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure injuries :clinical practice guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;2014. Prophylactic Dressings: Emerging Therapies Consider applying a polyurethane foam dressing to bony prominences in the areas frequently subjected to friction and share (B) Consider placement prior to prolonged procedures or continuous head elevation (B) Consider ease of application and removal and the ability to reassess the skin. Continue to use all of other preventative measures necessary when using prophylactic dressings (C) Black J, et al. International Wound Journal. 2014;doi:10.111/iwj National Pressure injury Advisory Panel, European Pressure injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure injurys :clinical practice guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;2 22

23 Systematic Review: Use of Prophylactic Dressing in Pressure Injury Prevention 21 studies met the criteria for review 2 RCTs, 9 had a comparator arm, five cohort studies, 1 within-subject design where prophylactic dressings were applied to one trochanter with the other trochanter dressing free Evaluated nasal bridge device injury prevention Evaluated sacral pressure injury prevention Clark M, Black J, et al. Int Wound J 2014; 11: EBP Recommendations to Reduce Shear & Friction Loose covers & increased immersion in the support medium increase contact area Prophylactic dressings: emerging science Use lifting/transfer devices & other aids to reduce shear & friction. Mechanical lifts Transfer sheets 2-4 person lifts Turn & assist features on beds Breathable slide stay in bed glide sheet Do not leave moving and handling equip underneath the patient National Pressure injury Advisory Panel, European Pressure injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention & treatment of pressure injurys :clinical practice guideline. Emily Haesler (Ed) Cambridge Media: Osborne Park: Western Austrlia;2014. Achieving the Use of the Evidence For Pressure injury Reduction Skills & Knowledge Resources & System Factors Impacting the ability to Achieve Quality Nursing Outcomes at the Point of Care Resource & System Breathable glide sheet/stays Foam Wedges Microclimate control Reduce layers of linen Wick away moisture body pad Protects the caregiver Attitude Value & Accountability Vollman KM. Intensive Care Nurse.2013;29(5):

24 Comparative Study of Two Methods of Turning & Positioning Non randomized comparison design 59 neuro/trauma ICU mechanically ventilated patients Compared SOC: pillows/draw sheet vs turn and position system (breathable glide sheet/foam wedges/wick away pad) Measured PU incidence, turning effectiveness & nursing resources Demographic Comparison Powers J, J Wound Ostomy Continence Nur, 2016;43(1):46-50 Comparative Study of Two Methods of Turning & Positioning Results: Nurse satisfaction 87% versus 34% 30 ο turn achieved versus in SOC/7.12 degree difference at 1hr (p<.0001) SOC PPS P PU development 6 1 a.04 # of times patients pulled up in bed # of staff required to turn patient < a PU development with 24hrs of admission Powers J, J Wound Ostomy Continence Nur, 2016;43(1):46-50 Safe Patient Handling Initiative: Decreases Staff Musculoskeletal Injuries & Patient Pressure injurys 28%â 58%â $184,720 savings $247,500 savings Way H Presented at the 2014 Safe Patient Handling East Conference on March 27,

25 Combining Patient Safety & Staff Safety Salsbury S, Presented at AACN National Teaching Institute, May th, 2016 New Orleans, LA Turn Clock 25

26 It is not enough to do your best, you have to know what to do and then do your best. E Deming Driving Change Gap analysis Build the Will Protocol Development Structure Make it Prescriptive Overcoming barriers Daily Integration Process Outcomes 26

27 Safety Culture: Patient & Caregiver Hospital LOS ICU LOS Skin Injury CAUTI Delirium Time on the vent Patient Progressive Mobility Safe Patient Handling Repetitive motion injury Musculoskeletal injury Days away from work Staffing challenges Loss of experienced staff Nursing shortage Prevention of Pressure injurys Skin Injury Costs Pain and suffering Hospital LOS ICU LOS Contact Kathleen Vollman at 27