ICU Early Mobility Program VHA Quarterly Meeting

ICU Early Mobility Program VHA Quarterly Meeting WellStar Kennestone Hospital February 14, 2013

History of the Team Initial push for the formation of this group was after Windy Hill Senior Vice President Lou Little and Vice President and CNO Betsy Brakovich attended a critical care conference fall 2011, meeting Dr. Dale Needham of John s Hopkins. Became acutely aware of the push for this type of program across the country Initial team was identified and began meeting in February of 2012 Literature review, brainstorming and strategic planning ensued Site visit to Methodist Hospital in Houston TX by Wendy and Caroline in June 2012: shadowed Christiane Perme, PT, gained contacts as resources from all disciplines Budget approval was obtained in July 2012 Small work group within the team developed a research proposal which was accepted by the Nursing Research Committee and IRB through Kennesaw State University, July 2012 Phase 1: Data collection began August 6, 2012 IHI Expedition on Sedation and Delirium began August, 2012 September 21-22, Attended John s Hopkins Critical Care Conference Phase 2 : Non-vented patient mobility began October 1, 2012 2

Mobility Work Group Multidisciplinary Team: Administration, Physicians, Physical Therapy, Nursing, Respiratory Therapy, Quality, Care Coordination, Behavioral Health Nutrition, Pharmacy, LTAC, Home Health 3

SBAR: Situation Critically ill patients in the ICUs at Wellstar Kennestone Hospital are at risk for increased complications, delirium, morbidity and mortality due to increased sedation and prolonged bedrest. This in turn leads to increased cost per case for the hospital system. 4

Background "Patients in critical care are usually kept immobile and heavily sedated, but there's growing evidence that these practices can seriously damage patients' long-term recovery," Institute for Healthcare Improvement, 2012 IHI annual report. Evidence based research supports the reality that these patients can safely be mobilized at an earlier point in their recovery process. Early mobility in the ICU leads to better patients outcomes, shorter length of stays and decreased overall cost per case. Improve patient functional and medical status Decrease ICU LOS/admission LOS reduction in cost of care Reduced re-admission rates Reduced delirium, morbidity, mortality, secondary illnesses HELP OUR PATIENTS GET BETTER! 5

Assessment Our current resources, culture and practices do not allow for early mobility in the ICU. Resources- Current ICU RN to patient ratio 1:2. With sedation lifted, RN s time/patient will increase Current patients on PT census in ICU 6% average Opportunity for patients to be mobilized in the program 50% of ICU population Will see 6-8 patients daily, 30-45 min direct patient care each. TIME INTENSIVE Equipment < 1 hoyer lift per ICU 1 stretcher chair and/or wheelchair per ICU Sedation protocols Prn ordering, RN driven meds GEMBA MD activity orders vs. nursing practice? Standard order set is bedrest Leadership support We have full MD buy in from intensivists. Active participation from Drs. Muster, McMinn and Chen 6

History of the Team Initial push for the formation of this group was after Windy Hill Senior Vice President Lou Little and Vice President and CNO Betsy Brakovich attended a critical care conference fall 2011, meeting Dr. Dale Needham of John s Hopkins. Became acutely aware of the push for this type of program across the country Initial team was identified and began meeting in February of 2012 Literature review, brainstorming and strategic planning ensued Site visit to Methodist Hospital in Houston TX by Wendy and Caroline in June 2012: shadowed Christiane Perme, PT, gained contacts as resources from all disciplines Budget approval was obtained in July 2012 Small work group within the team developed a research proposal which was accepted by the Nursing Research Committee and IRB through Kennesaw State University, July 2012 Phase 1: Data collection began August 6, 2012 IHI Expedition on Sedation and Delirium began August, 2012 September 21-22, Attended John s Hopkins Critical Care Conference Phase 2 : Non-vented patient mobility began October 1, 2012 7

Recommendation We have proposed the development of a critical care specific mobility team. Resources approved: Dedicated PT, Critical Care RN, CCP/mobility tech (in the process of hiring). RT on floor to assist as needed during phase 3 (vented patients) as coordinated with normal course of the day Equipment and Supplies approved: 5-6 new stretcher chairs, Moveo table, mini Shuttle-press, various exercise and ambulatory aides. Three Phased approach 8

The Rollout : 4 North-3 North-CCU Phase 1: Data Collection, August-September 2012 Phase 2: Non-vented Patients, October-December 2012 Phase 3: Vented Patients, January 2013-Ongoing 9

History of the Team Initial push for the formation of this group was after Windy Hill Senior Vice President Lou Little and Vice President and CNO Betsy Brakovich attended a critical care conference fall 2011, meeting Dr. Dale Needham of John s Hopkins. Became acutely aware of the push for this type of program across the country Initial team was identified and began meeting in February of 2012 Literature review, brainstorming and strategic planning ensued Site visit to Methodist Hospital in Houston TX by Wendy and Caroline in June 2012: shadowed Christiane Perme, PT, gained contacts as resources from all disciplines Budget approval was obtained in July 2012 Small work group within the team developed a research proposal which was accepted by the Nursing Research Committee and IRB through Kennesaw State University, July 2012 Phase 1: Data collection began August 6, 2012 IHI Expedition on Sedation and Delirium began August, 2012 September 21-22, Attended John s Hopkins Critical Care Conference Phase 2 : Non-vented patient mobility began October 1, 2012 10

Data what are we collecting? Retrospective x 1 year: age/demographics LOS both ICU and admission ventilator days DRG cost per case mortality rate discharge disposition incidence of pressure ulcers/skin breakdown Implementation of program: all of the above, plus: RASS score, APACHE II score CAM-ICU, delirium days amount of sedatives and analgesics infused Functional status (ROM, edge of bed, standing, ambulation) Barthel Index vent day to OOB/admission day to OOB adverse events 11

What we ve asked of nursing: How can your documentation help? Activity documented in Assessment/ADL s: there will soon be choices in HED that mirror our Mobility Algorithm. Please include the activity and the time. Special events: any acute decline in status, adverse events, date/time for extubation, date/time for transfer CAM ICU: positive vs. negative based on SAVE A HAART RASS scores: be aware of RASS goals (aiming for 0 but can usually mobilize between -1 to +1) 12

What we ve asked of nursing: How else can you help? Being aware of the process and being on board with the goals of the program is essential! Screen for mobility using the exclusion criteria Make sure that if pt is appropriate, MD activity orders read up with assist rather than bedrest Assist with sedation weaning when needed Help patients back to bed when appropriate (we will do our best to make this process a smooth one!) Following Blue Sheet (Activity Recommendations) posted in the room 13

Criteria for Exclusion from Mobility Session Neurologic Criteria No patient response to verbal stimulation, RASS score -4 or -5 Evidence of elevated intracranial pressure Patient agitation requiring increased sedative administration in the last 30 minutes Respiratory Criteria Inability to maintain O 2 saturation 86% FiO 2 > 0.6 or PEEP > 12 Active escalation of ventilator settings (clear with physician prior to session) RR > 40 Acidosis: arterial ph < 7.25 Insecure airway, nasal intubation, or difficult airway/intubation Circulatory Criteria MAP < 60 (clear with physician prior to session) or MAP > 115 HR > 120 or < 50 at rest Administration of a new vasopressor agent within the past 4 hours Increase in the dose of any vasopressor infusion within the past 2 hours Dysrhythmia requiring the addition of a new antiarrhythmic agent within the past 12 hours Continuous infusion of a vasodilator medication Suspected active cardiac ischemia (clear with physician prior to session) New DVT (clear with physician prior to session) Active GI blood loss Other Therapies that restrict mobility (open abdomen, intracranial monitoring/drainage, CRRT) Injuries in which mobility is contraindicated (i.e., unstable fractures) Exceptions Exceptions are determined by the physician on an individual basis Patients that do not meet the criteria above but who otherwise appear ready for activity, clear with physician first and then begin a careful trial of activity with close monitoring for adverse events 14

Criteria for Termination of Mobility Session Neurologic Criteria Request of patient to stop Patient distress (nonverbal cues, gestures, physically combative) Deterioration of mental status Respiratory Criteria Sustained O 2 saturation < 86% Severe intolerable dyspnea with sustained RR > 40 Change in breathing pattern with an increase in accessory muscle use, paradoxical pattern, nasal flaring, or an appearance of facial distress Marked ventilator dyssynchrony Concern for airway device integrity or extubation Circulatory Criteria MAP < 60 or > 115 Sustained HR > 140 or < 50 Change in heart rhythm or new arrhythmia Significant chest pain Excessive pallor, flushing of skin, or diaphoresis 15

Nurse s Quotes from Methodist: Ultimately, the patient feels better after moving around. They just rest so much better after sitting or walking. If she s anxious, I sit her up and it helps her calm down. After any surgery, I always make sure they walk [if patient meets the criteria]. It gets those bowels going again, you know. If the surgical site starts oozing some, just change the dressing. Yeah, we still do have psychosis. We treat it with meds. It s almost a peer pressure to get patients out of bed by a certain time. It does take a lot of time trying to communicate with a non-sedated vented patient. Frustrating, but what can you do? If the patient is not getting extubated in the morning, we will sedate them at night. Patient s and families just want a little hope. And having the tape measure on the floor let s them see some sort of progress. 16

With less sedation: Nurses encourage patient to keep occupied. Ideas: ipods Books on tape Magazines Laptops/ipad movies Communication boards utilized Physical therapy helps patient, gives patient something to look forward to, and wears them out! Afterwards, the patients often rests better. 17

Quote from our own patient: I was crying this morning, but when I got up my world came back. 18

Gold Standard Other currents initiatives: Nursing mobility, Get up and Go Delirium reduction, CAM assessment WOCN Core Measures Patient safety, fall prevention Nationwide focus on early mobility as supported through Society for Critical Care Medicine timing is perfect. 19

Future Directions Other ICUs at Kennestone and systemwide Inpatient Outpatient LTAC Home 1 year later 20

Evidence Based Practice Balas MC, Vasilevskis EE, Burke WJ, Boehm L, Pun BT, Olsen KM, Peitz GJ, Ely EW: Critical care nurses role in implementing the ABCDE Bundle into practice. CriticalCareNurse 2012 Vol 32, No. 2:35-47. Korupolu R, Gifford J, Needham D: Early mobilization of critically ill patients: reducing neuromuscular complications after intensive care. Cont Crit Care 2009 Vol. 6, No. 9:1-12. 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 Vol. 36, No. 8:2238-2243. Perme C, Chandrashekar R: Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care 2009 May;18(3):212-221. Pohlman MC, Schweickert WD, Pohlman AS, et al: Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med 2010 Vol. 38, No. 11:2089-2094. 21

Websites Society of Critical Care Medicine: www.sccm.org The Center for Medicine in the Public Interest: www.cmpi.org Institute for Healthcare Improvement: www.ihi.org SEDATION education: www.sedation-cme.org DELIRIUM education: www.icudelirium.org International Mobilization Network: www.mobilization-network.org Outcomes After Critical Illness and Surgery (OACIS): http://www.hopkinsmedicine.org/pulmonary/research/outcomes_afte r_critical_illness_surgery/ Case study: http://webmm.ahrq.gov/case.aspx?caseid=251 Phyllis Recovery: http://youtu.be/raejjcjob-y 22

1/2/2014 ICU Early Mobility Project-Executive Summary Future Timeline/Tasks to be Accomplished Program Development to Date February 2012: Committee formed, began bimonthly team meetings with workgroup development for strategic planning, literature review, development of metrics and criteria. March-June 2012: Planning and writing draft of research proposal, continued defining methods, resources and equipment needs June 2012: Site visit to Methodist Hospital in Houston, TX July 2012: Obtained Nursing Research Committee and IRB approval for research proposal; met with senior leadership and obtained budget approval for FTE s and capital equipment August 2012: Began Phase 1 Data Collection for research study; participated in IHI Expedition on Sedation and Delirium September 2012: Attended conference at Johns Hopkins; provided nursing education on 4N ICU; submitted grant application for research proposal funding October 2012: Began implementing mobility program with nonventilated population on 4N ICU; provided physician education to WPM; provided nursing education to 3N ICU and CCU; provided rehab inservice on program; Began implementing mobility program with non-ventilated population on 3N ICU and CCU November 2012: IHI Expedition on Mobility; physician education to GA Lung Group; clinician education to Wellstar Temps Task: Deadline: Hire Mobility Tech November 30, 2012 Order Capital Equipment November 30, 2012 Implement Phase 3, Mobility with ventilated Population January 2013 Review Resource needs and Program Statistics June 2013 Order FY 14 equipment July 2013 Complete Research October 2013 Review Resource needs and Program Statistics June 2014-annually thereafter Program Cost and ProjectedSavings $352,365 cost/ FY 13 (proforma) $4,336,500 savings/year (budget request) Executive Sponsor: Dan Woods Sponsor: Sandra Lucius Process Owner: Wendy Forman Physician Champions: Dr. Kathy McMinn and Dr. Jonathan Chen

Questions? 24