HRET HIIN UP Campaign. Thursday, February 16, :00 a.m. 11:50 a.m. CT

Transcription

1 HRET HIIN UP Campaign Thursday, February 16, :00 a.m. 11:50 a.m. CT 1

2 Emily Koebnick, Program Manager, HRET WELCOME AND INTRODUCTIONS 2

3 Agenda for Today 11:00-11:10 a.m. Welcome and Introductions Virtual event objectives: 1. To present crosscutting strategies for reducing harm across several harm topics. 2. To challenge you to implement the UP Campaign at your facility. 11:10-11:40 a.m. Next Steps to Find Your Way UP Review the UP Campaign crosscutting interventions and the impact on harm reduction. Evaluate the must do s for each UP Campaign element to help define the implementation strategy moving forward. 11:40-11:45 a.m. Q & A 11:45-11:50 a.m. Bring it Home Resources How to tell us your story Emily Koebnick, MPH, MPA Program Manager, HRET Maryanne Whitney, RN, CNS, MSN Jackie Conrad, RN, MBA Improvement Advisors, Cynosure All participants Emily Koebnick, MPH, MPA Program Manager, HRET 3

4 Polling Question Who is in the room? Quality Physician Nurse Hospital Leader Infection Preventionist State Partner Rehab Specialist Pharmacist Respiratory Practitioner 4

5 The Way UP Jackie Conrad Maryanne Whitney Improvement Advisors, Cynosure Health 5

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14 Why the UP Campaign? Increases impact on harm reduction Generates momentum in your organization Focuses support from leadership Engages front-line staff Connects the dots Creates a vision Applies throughout organization Simplifies patient safety implementation Helps patients recover faster and with fewer complications 14

15 Can we streamline and simplify to make it easier for front-line staff and still improve safety? 15

16 #1 Opioid & Sedation Management ADE Failure to Rescue Delirium Falls Airway Safety VTE VAE WAKE UP 16

17 #2 Early Progressive Mobility Falls HAPU Delirium CAUTI VAE VTE Readmissions G E T U P 17

18 #3 Hand Hygiene CDI CAUTI SSI VAE CLABSI Sepsis MDRO S O A P U P 18

19 FOUNDATIONAL QUESTIONS: 1. Is my patient awake enough to get up? 2. Have I protected my patient from infections? 19

20 Let s hear from you! Have you been successful with: Narcotic and sedation management? Early mobility? Hand hygiene? Chat in your responses. We want to hear your successes! 20

21 # 1 Opioid & Sedation Management ADE Failure to Rescue Delirium Falls Airway Safety VTE VAE WAKE- UP 21

22 Sleep vs. Sedation 22

23 Not Just Sedatives and Opioids Antihistamines/anticholinergics Antipsychotics Some antidepressants Antiemetics Muscle relaxants 23

24 ICU Pitfalls of Sedatives and Analgesics Sedatives and analgesics may contribute to: Increased duration of mechanical ventilation Length of intensive care requirement Impede neurological examination May predispose to delirium Kollef M, et al. Chest. 114: Pandharipande et al. Anesthesiology. 2006;124:

25 Medical/Surgical Pitfalls of Sedatives and Analgesics Oversedation Transfer to ICU Hypoxic encephalopathy Death 25

26 Must Do's 26

27 WAKE-UP Must Do s 1. Establish expectations 2. Pair POSS & pain 3. Manage with multiple modalities 27

28 Must Do #1 Establish Expectations Goals of Pain Management: Relieve suffering Achieve early mobilization Reduce hospital length of stay THE GOAL IS NOT ZERO PAIN! 28

29 Must Do #2 Pair POSS & Pain Just right! Overmedicated: hibernating Undermedicated: not happy 29

30 POSS AKA GOLDILOCKS SCALE S- sleep, easy to arouse 1- awake and alert 2- slightly drowsy 3- frequently drowsy, drifts off to sleep during conversation 4- somnolent, minimal or no response to stimulation 30

31 No discharge from PACU No additional opioids S = Sleep, easy to arouse Acceptable; no action necessary; may increase opioid dose if needed 1 = Awake and alert Acceptable; no action necessary; may increase opioid dose if needed 2 = Slightly drowsy, easily aroused Acceptable; no action necessary; may increase opioid dose if needed 3 = Frequently drowsy, arousable, drifts off to sleep during conversation Unacceptable; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory; decrease opioid dose 25% to 50% 1 or notify primary 2 or anesthesia provider for orders; consider administering a non-sedating, opioid-sparing nonopioid, such as acetaminophen or a NSAID, if not contraindicated; ask patient to take deep breaths every minutes. 4 = Somnolent, minimal or no response to verbal and physical stimulation Unacceptable; stop opioid; consider administering naloxone 3,4 ; stay with patient, stimulate, and support respiration as indicated by patient status; call Rapid Response Team (Code Blue) if indicated; notify primary 2 or anesthesia provider; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory. *Appropriate action is given in italics at each level of sedation. 1 If opioid analgesic orders or hospital protocol do not include the expectation that the opioid dose will be decreased if a patient is excessively sedated, such orders should be promptly obtained. 2 For example, the physician, nurse practitioner, advanced practice nurse, or physician assistant responsible for the pain management prescription. 3 For adults experiencing respiratory depression give intravenous naloxone very slowly while observing patient response ( titrate to effect ). If sedation and respiratory depression occurs during administration of transdermal fentanyl, remove the patch; if naloxone is necessary, treatment will be needed for a prolonged period, and the typical approach involves a naloxone infusion. Patient must be monitored closely for at least 24 hours after discontinuation of the transdermal fentanyl. 4 Hospital protocols should include the expectation that a nurse will administer naloxone to any patient suspected of having life-threatening opioid-induced sedation and respiratory depression. 1994, Pasero C. Used with permission. As cited in Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management, p St. Louis, Mosby/Elsevier,

32 Two Scales are Better than One for Narcotic and Sedation Administration PAIN ALONE Risk factors may be absent Objective? Dosage based on number or range Patients and families understand the numeric dosing PAIN & POSS Two scales allow for safer dosing High pain scale with high POSS scale-no narcotics High pain scale low medical dose 32

33 Must Do #3 Multi-Modal Pain Management Pharmacological and non-pharmacological 33

34 Multimodal Pain Management Combination of opioid and one or more other drugs acetaminophen ibuprofen celecoxib ketamine gabapentin non-pharmacological interventions 34

35 Can We Manage Pain With Non-pharmacologic Methods? What do we do at home? Comfort measures: Pet therapy Warm compresses; blankets Ice packs Extra pillows Aromatherapy Massage Herbal tea Stress ball Music 35

36 Do Comfort Items Help? These modalities can: Reduce anxiety Reduce pain Reducing anxiety can reduce pain Non-pharmacologic pain reduction methods reduce the need for pain medications 36

37 Do Hospitals Offer These? ervices_amenities/services/pain-control-comfort-menu.html 37

38 Positive Results Pain scores Nausea scores Anxiety scores all decreased by more than 50 percent NEXT: looking to see if opioid usage and opioid ADEs both decrease 38

39 Putting It All Together Emma, age 13, had her third surgery for a congenital foot deformity. Pain management was problematic, so both gabapentin and pet therapy were added to lower opioid doses with excellent results, allowing discharge to home 36 hours later. 39

40 Case Study 40

41 Polling Question Which strategy presented from WAKE UP will you be most likely to adopt first? 1. Establish expectations 2. Pair POSS and pain 3. Manage with multiple multimodalities Chat in why you selected that strategy. 41

42 Thoughts about WAKE UP 42

43 #2 Early Progressive Mobility Falls PrU Delirium CAUTI VAE VTE Readmissions G E T U P 43

44 Pathophysiological Changes Within 24 Hours of Bed Rest 44

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47 Cumulative Impact on Quality of Life New Walking Dependence occurs in percent in older hospitalized patients (Hirsh 1990, Lazarus 1991, Mahoney 1998) 65 percent of patients had a significant functional mobility decline by day two (Hirsh 1990) 27 percent still dependent in walking three months post discharge (Mahoney 1998) 47

48 It s Simple If they came in walking, keep them walking. 48

49 Avoid Ageism Do not assume all elders need a bed alarm, even if they appear frail. 49

50 Use Mobility to Accelerate Progress When am I going to walk? I walked yesterday. It s better than just being in the chair. I feel better when I am walking. 50

51 Progressive mobility is defined as a series of planned movements in a sequential matter, beginning at a patient's current mobility status, with a goal of returning to his or her baseline Elevate HOB What is Progressive Mobility? (Vollman 2010) Manual turning PROM AROM CLRT and Prone positioning Upright / leg down position Chair position Dangling Ambulation 51

52 Teaming Up To Mobilize OT PT RN Admin. CNA MD RT Family 52

53 MUST DO's 53

54 Get Up Must Do s 1. Walk in, walk during, walk out! 2. Belt and bolt! 3. Three laps a day keeps the nursing home at bay! 54

55 Must Do #1 Walk In, Walk During, Walk Out! 55

56 Must Do #2 Belt & Go! Gait belts in every room Safe mobilization and patient handling training for nursing staff See CAPTURE Falls Project Website for guidance: Gait belts are used to help control the patient s center of balance. Gait belts are not intended to hold a patient up 56

57 Must Do #3 Three Laps a Day, Keeps the Nursing Home Away! 57

58 Mobility Begins on Admission Wood W, et al.(2014) A Mobility Program for an Inpatient Acute Care Medical Unit &Journal_ID=54030&Issue_ID=

59 Tips for Promoting Mobility Order modifications Delete orders for Bedrest Ad lib Replace with specific orders Times, activities, distance Promote team mobility management Delegation of patient mobility Replace sitters with a mobility aide Rehab and nursing face-to-face bedside handoffs Document plans and progress on white boards 59

60 Polling Question Who in your organization will be a partner in implementing the GET UP strategies? 1. Rehab specialists 2. Nursing 3. Physicians 4. Patient care technicians 5. Respiratory practitioners 6. Transporters 7. Environmental service personnel 8. Volunteers Chat in other partners 60

61 Ideas for GET UP Next Steps First Steps First Steps. Next Steps.. 61

62 #3 Hand Hygiene CDI CAUTI SSI VAE CLABSI Sepsis MDRO S O A P U P 62

63 Handwashing an OLD Intervention Since 1847 we have understood that hand hygiene (HH) makes a difference in the spread of infections Dr. Ignaz Semmelweis in Vienna Childbed fever Dr. Lister OR 1980 s concepts of hand hygiene in health care emerged 2002 alcohol based hand rub adopted WHO Global Clean Hands initiative Yet, the average HH compliance is 48 percent 63

64 What Works? Observation and surveillance of hand hygiene is the best way to ensure appropriate compliance. Schedule an unscheduled observation by trained observers. Intervene immediately if a breach in HH is observed. Provide scripts for reminding peers to perform HH. Promote culture of safety. 64

65 We Need to Get It Right! Protect our patients from health care-associated infections (HAIs) by performing HH. Promote patient and family engagement and give them permission to speak up for clean hands. Promote patient HH for patients. 65

66 Must Do's 66

67 SOAP UP Must Do s beyond your current plan 1. Prompt peer performance 2. Track quietly and trend loudly 3. Drive drift down 67

68 Must Do #1 Prompt Peer Performance 68

69 Must Do #2 Track Quietly and Trend Loudly Hand hygiene vs Hospital Acquired Infections 69

70 Track Quietly & Trend Loudly SOAP UP started 70

71 Must Do #3 Drive Drift Down 71

72 The Right Balance Person model System model Important to get the balance right; both extremes have their pitfalls. 72

73 Shared Accountability 73

74 Polling Question Which of the SOAP UP must do s do you feel would be easiest to implement? 1. Prompt peer performance 2. Track quietly and trend loudly 3. Drive drift down Chat in why! 74

75 Polling question Which UP will YOU start with? 1. WAKE UP 2. GET UP 3. SOAP UP 4. All three 75

76 Thoughts & Take Aways All UP interventions need: Attention focused on leadership and cultural issues Courage to HIINovate Individual accountability AND 1. Is my patient awake enough to get up? 2. Have I protected my patient from infections? 76

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78 Emily Koebnick, Program Manager, HRET BRING IT HOME 78

79 Up Campaign Resources 79

80 LISTSERV Join the LISTSERV Ask questions Share best practices, tools and resources Learn from subject matter experts Receive follow up from this event and notice of future events 80

81 Thank You! Find more information on our website: Questions or Comments: 81