HRET HIIN GET UP Virtual Event

HRET HIIN GET UP Virtual Event Early Mobility Matters: In & Out of the ICU November 16, 2017 1

WELCOME AND INTRODUCTIONS Nerissa Legge, Program Manager HRET 2

Webinar Platform Quick Reference Mute computer audio Today s presentation Chat with participants Download slides/resources Register for upcoming events 3

Agenda for Today 4

Poll: How did you hear about this event? How did you hear about today s virtual event? a. HRET HIIN flyer b. HRET HIIN website c. HRET LISTSERV d. State hospital association e. QIN-QIO f. Your organization/colleague g. Other, please specify 5

GET UP! A CROSS CUTTING APPROACH TO ACCELERATE HARM REDUCTION Jackie Conrad, RN, MBA, RCC Improvement Advisor, Cynosure Health Maryanne Whitney, RN, CNS, MSN Improvement Advisor, Cynosure Health 6

Early Progressive Mobility Falls Pressure Injuries Delirium CAUTI Ventilator Associated Events Venous Thrombo Embolism Readmissions G E T - U P 7

Cumulative impact on quality of life New Walking Dependence occurs in 16-59% in older hospitalized patients (Hirsh 1990, Lazarus 1991, Mahoney 1998) 65% of patients had a significant functional mobility decline by day 2 (Hirsh 1990) 27% still dependent in walking 3 months post discharge (Mahoney 1998) 8

Progressive mobility is defined as a series of planned movements in a sequential matter beginning at a patient's current mobility status with goal of returning to his/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 9

MUST DO #1 Walk In, Walk During, Walk Out! Determine pre admission ambulation status Don t assume a frail appearance means weakness Use Get Up and Go or Timed Get Up and Go test to assess ambulation skills 10

MUST DO #2 Grab and Go Mobility Devices! Gait Belts in every room Patients and staff have access to mobility devices Safe mobilization and patient handling training for staff Gait belts are used to help control the patient s center of balance. 11

MUST DO #3 3 Laps a Day, Keeps the Nursing Home Away! Track mobility: document frequency, distance Create a culture of mobility Make it visible Walk of Fame Ambulation Board instructions can be accessed in file pod 12

Evidence to support mobility in ICU patients? Dale M Needham FCPA. MD, PhD Professor, Medical Director, Critical Care Physical Medicine & Rehabilitation Program John Hopkins University

Is EARLY activity in the ICU SAFE?

Safety of Patient Mobilization and Rehabilitation in the ICU: Systematic Review with Meta-Analysis Nydahl, P.; Sricharoenchai, T.; Chandra, S; Kundt, F.; Huang, M.; Fischill, M.; Needham, DM. Annals of the American Thoracic Society; 2017 Adult studies of ICU mobility with safety data Exclusion: in-bed intervention (cycle, NMES); no report of # of sessions 48 publications (n=7,546 pts; 22,351 sessions) 6 RCT, 2 non-rdm trial, 5 before-after, 22 prosp. cohort, 11 retro cohort, 2 pt prev 583 (2.6%) potential safety events Most common: De-sat, hemodynamic changes, catheter removal Only 2 ETT removals (1 without replacement; 1 with in-bed mobility) Events w/ consequence, incl. stop rehab (subset of studies): 78 (0.6%) 1 fall, 11 tube removal, 34 hemodynamic change, 18 desaturation, 14 other

Is early activity in the ICU BENEFICIAL?

Key ICU Rehab clinical trials Study Year Morris 2008 Schweicke rt 2009** Schaller 2016** Hodgson 2016 Morris 2016** Denehy 2013 Moss 2016** Wright 2017 N ICU # Type Coun try Interv. Timing 280 1 MICU USA <2 day + 104 2 MICU USA <2 day + 200 5 SICU 50 5 MS- ICU USA EU AUS NZ <3 day + 3 (2-4) + 300 1 MICU USA ~4-6? 150 1 MS- ICU AUS 7(5-11) - 120 5 MICU USA 6-11 - 308 4 MS- ICU UK ~8 - Outcomes Decreased duration of ICU & hospital stay Earlier PT consult in ICU & out of bed Improved physical function at hospital D/C Decreased duration of MV & delirium Increased ICU mobilization & func. at hosp D/C Decreased duration of ICU & delirium Increased mobility score & milestones in ICU No dif: MV, LOS; d/c location, 6 mo. outcomes No difference: hospital LOS; strength Increased at 6 mo: phys func (SPPB, SF-36, FPI) No difference at 12 mo: 6MWD, TUG, SF-36 PF (Control - PT during MV: 52% out of bed) No dif: phys func (to 6 mo); MV, ICU, hosp LOS (Control - PT during MV: 20 min., 3x week) No difference to 6 mo: SF-36, Grip, 6MWT, LOS (Control - PT during MV: 10 min/d less than interv

Key ICU Rehab clinical trials Study Year Morris 2008 Schweicke rt 2009** Schaller 2016** Hodgson 2016 N ICU # Type Coun try Interv. Timing 280 1 MICU USA <2 day + 104 2 MICU USA <2 day + 200 5 SICU 50 pilot 5 MS- ICU USA EU AUS NZ <3 day + 3 (2-4) + Outcomes Decreased duration of ICU & hospital stay Earlier PT consult in ICU & out of bed Improved physical function at hospital D/C Decreased duration of MV & delirium Increased ICU mobilization & func. at hosp D/C Decreased duration of ICU & delirium Increased mobility score & milestones in ICU No dif: MV, LOS; d/c location, 6 mo. outcomes

Key ICU Rehab clinical trials Study Year N ICU # Type Coun try Interv. Timing Outcomes Morris 2016** Denehy 2013 Moss 2016** Wright 2017 300 1 MICU USA ~4-6? 150 1 MS- ICU AUS 7(5-11) - 120 5 MICU USA 6-11 - 308 4 MS- ICU UK ~8 - No difference: hospital LOS; strength Increased at 6 mo: phys func (SPPB, SF-36, FPI) No difference at 12 mo: 6MWD, TUG, SF-36 PF (Control - PT during MV: 52% out of bed) No dif: phys func (to 6 mo); MV, ICU, hosp LOS (Control - PT during MV: 20 min., 3x week) No difference to 6 mo: SF-36, Grip, 6MWT, LOS (Control - PT during MV: 10 min/d less than interv

Full text: https://iii.hm/ddw

Lancet May 2009 Design: RCT at U of Chicago & U of Iowa Subjects: 104 MICU patients require MV Intervention vs. Control: daily sedation interruption, plus: PT & OT (7d/wk ICU & ward) starting at Day 1-2 vs. Usual care PT & OT starting at Day 6-10

Intervention PROM AAROM AROM Bed Mobility Transfers (sitting) Sitting balance ADLs Transfers (standing) Ambulation How was PT/OT provided to get Median duration of therapy: benefits? Intervention N=49 Control N=55 After MV (minutes/day) 13 [5 to 20] 11 [0 to 23] During MV (minutes/day)* 19 [10 to 29] 0 [0 to 0] * p<0.0001 Benefit is from receiving PT/OT EARLY while on mech. ventilation

The Lancet 2016 International, 5-center, RCT (USA x 3; Austria, Germany) Subjects (N=200): Mech Vent <48h & expected MV for >24h Exclusion: functionally dependent or hospital LOS >5 days Early goal-directed mobilization (w/i 1 d of consent) v. Usual care SICU Optimal Mobiliz n Score: 0-None; 1-PROM; 2-Sit; 3-Stand; 4-Ambulate Set daily SOMS goal as per ICU team & work on barriers to reach goal

The Lancet 2016 Mobility (n=104) Control (n=96) P value Total PT minutes in ICU 60 (0-110) 48 (20-128) Sedation Score (RASS) -0.7 (0.1) -0.8 (0.1) Mean SOMS in ICU 2.2 (1.0) 1.5 (0.8) <0.001 Walking at ICU D/C 52% 25% ICU / Hospital LOS 7 (5-12) / 15 (11-27) 10 (6-15) / 22 (15-30) 0.005 / 0.01 Func Indepen / DC home 51% / 51% 28% / 27% 0.003 /<0.001 ICU delirium-free days 25 (16-27) 22 (15-25) 0.016

RCT: 120 pt, MV 4-5 day, 5 hospital in Denver, CO Intervention: PT 7 d/wk (mean ~40 min) up to 28 days starting Day 6-11 (not early) same timing as Control in prior RCT Control: PT 3 d/wk (mean ~20 min) up to 28 days not usual care for most ICU Research subjects (Intervention vs. Control) Older: median 56 vs. 49 years Weaker at randomization: 11-25% lower MMT, Grip & Bed Mobility

Result: no effect on PFP-10 phys func scale at 1 month Only 33% with assessment (N = 20 & 19 in each group) 45% LTACH/facility (25% at 3 mo.) Concl:?Higher intensity, late-onset PT may not have benefit Older/weaker patients in intervention group Control more rehab than most centers decreasing treatment effect Did not measure outcomes in 50% of patients d/c to facility Focus on early start to PT (i.e., replicate Schweickert Lancet RCT) Focus on getting ICU patients to PT at least 3x/week

Single-center, assessor-blinded RCT 300 MICU MV patients Standardized Rehab Therapy (SRT) vs Usual Care Outcomes: ICU & hospital d/c + 2, 4 & 6 month SRT: 3 session/day, 7 d/week, during entire hospital stay: Passive range of motion PT: bed mobility, transfer and balance training Progressive resistance exercises Usual Care: PT on week days, if ordered

SRT Days to first therapy, median (IQR) PROM PT Strength 1 (0-2) 3 (1-6) 4 (2-7) Usual Care 7 (4-10)

SRT Days to first therapy, median (IQR) Days of therapy per patient, median (IQR) PROM PT Strength PROM PT Strength 1 (0-2) 3 (1-6) 4 (2-7) 8 (5-14) 5 (3-8) 3 (1-5) Usual Care 7 (4-10) 1 (0-8)

Primary outcome: Hospital length of stay median (IQR) SRT vs. Usual Care: 10 (6-17) vs 10 (7-16), p=0.41 Adverse Events: 1 episode asymptomatic bradycardia <1min; pt completed session 2ndary outcomes: Grip, Handheld dynamometry, MMSE No statistically significant differences at all time points

Short Physical Performance Battery Score (SPPB) Least Square Mean (95% CI) SRT Usual Care P Value Hospital D/C 4.7 (4.0-5.4) 4.7 (4.0-5.4).97 2 Months 8.7 (8.1-9.4) 7.8 (7.1-8.5).05 4 Months 8.9 (8.2-9.6) 8.0 (7.2-8.7).06 MCID (Minimal Clinically Important Difference) = 1 6 Months 9.0 (8.3-9.7) 8.0 (7.2-8.7).04

SF-36 Physical Function & Physical Health Summary Least Square Mean (95% CI) Physical Function Scale SRT Usual Care P Value Hosp D/C 39 (33-44) 38 (33-44).97 2 Months 47 (42-53) 43 (37-49).29 4 Months 52 (47-58) 47 (41-53).22 6 Months 56 (50-62) 44 (38-50).001 MCID: PF = 10; PCS = 3-5 Physical Health 2 Months 33 (31-36) 32 (31-34).43 4 Months 36 (34-38) 34 (31-36).16 6 Months 37 (35-39) 34 (31-36).05 Summary Hosp D/C 30 (28-32) 30 (28-32).96

Functional Performance Inventory (FPI) score Least Square Mean (95% CI) SRT Usual Care P Value 2 Months 2.0 (1.9-2.1) 4 Months 2.2 (2.1-2.3) 6 Months 2.2 (2.1-2.4) 2.0 (1.9-2.1) 2.1 (1.9-2.2) 2.0 (1.9-2.2).74.11.02 MCID = 0.2

Study Limitations: No sedation protocol: delayed start & # of session (esp strengthening) Up to 3.3 d for consent + 3 d for PT to start (?early enough) Loss to f/u ~30% of survivor: under-powered for post-d/c outcomes Conclusions: SRT vs. usual care did not decrease hospital LOS All physical function measures higher, increasing over 2-6 mo. Future: Pair rehab + sedation (?use cycling or NMES for early ICU)

The Importance of Sedation to Early Mobility Over-sedation compromises the ability to participate in rehabilitation Review of sedation practice is key to improving mobility Target RASS -1 to +1 rather than Daily Interruption of sedation infusion - Green J Multi-D Healthcare 2016 Mobility, sedation, delirium, and sleep are inseparably linked To successfully mobilize patients, sedation, sleep & delirium monitoring must be routine and vigorously addressed - Clemmer CCM 2014 ICUs that implemented exercise with both sedation interruption & delirium screening were 3.5 (CI 1.4-8.6) times more likely to achieve higher exercise levels in ventilated patients - Miller Annals ATS 2015

How to Start Early PM&R? The JHH MICU Experience Exposure to rehab in JHH MICU is low: - PT & OT in only 17% & 20% of ARDS pts opportunity for Quality Improvement

Barriers to Activity in ICU Time requirements and adequate staffing Need for staff training Need for team work and coordination Over-sedation of ICU patients Dislodgement of devices (CVC, ETT, feeding tubes) Worsening gas exchange Unstable hemodynamics Inadequate patient comfort, pain control

Review of 40 studies 28 unique barriers Severity of illness, pain, mental status, devices/equipment Staffing, lack of guidelines and equipment Culture, lack of knowledge 70 strategies Inter-professional team/champions with training & rounding Safety guidelines and screening Mobility protocols & daily goals sheets Creating business case, dedicated staffing 40

Topics in Stroke Rehab 2010;17:271-281 QI Project Description Multi-faceted QI focused on ventilated pts in MICU: - dedicated OT & PT in MICU (pilot test) - OT, PT, RN & MD training & education - guidelines for consultation of OT and PT in ICU - decrease over-sedation via prn vs. infusions

JHH Experience: Feasibility During 4 month period (May Aug 2007) 2-4x incr in PT & OT consult & Tx (vs prior yr) Of all PT and OT treatments 68% while ventilated 24% with ETT 13% with femoral line Archives of Physical Med & Rehab, 2010 New PM&R consults on weak patients

Our Experience with Feasibility MICU QI project D15 Walked 4 times: Max dur n 10 min Max dist. 240 feet (vs. 3 feet on QI day 1) Removed for privacy purposes

Patient interviews & Video of ambulation process at: www.hopkinsmedicine.org/oacis (OACIS = Outcomes After Critical Illness & Surgery)

JHH Experience: Safety 4 events (~1% of treatments) feeding/rectal tubes dislodged also occurred with routine RN care Update from after the QI project.

JHH MICU over 2.5 years (June 2009 Dec 2011) 1,110 admissions with >= 1 PT session 5,267 total PT tx (not individual activities) 66% of PT days: sitting at edge of bed or higher 46

JHH MICU over 2.5 years (June 2009 Dec 2011) 34 potential safety events in 25 admissions 0.6% of PT sessions (i.e., 6 per 1,000 PT tx) 80% of events = transient physiological (HR, BP, Sp02) 4 events required any Tx (8 per 10,000 PT tx) 2 NG tube, 1 A-line, 1 fall with laceration & suture 47

Journal of Critical Care (2013) Annals of ATS (2016) Physical Therapy J (2013) Cardiopulm PT (2015)

Back to QI project Benefits: Sedation & Delirium Median RASS score (scale: 0 to -5): -3 to 0 (p<0.05) Median drug dose per day (pre-qi vs. QI): Morphine 71 vs. 24 mg per day (p=0.01) Midazolam 47 vs. 15 mg per day (p=0.09) Mean daily pain (scale: 0-10): 0.6 vs. 0.6 (p=0.79) Doubled % of ICU days without delirium (21% to 53%, p=0.003)

Potential Benefits to Hospital Why so many empty MICU beds? Versus same 4-month period in 2006: 20% increase in MICU admissions 10% reduction in hospital mortality 30% (2.1 day) reduction in MICU LOS 18% (3.1 day) reduction in hosp LOS

Acknowledgements Dr. Landon King, Director PCCM for financial support Dr. Jeff Palmer, Director PM&R for PT & OT support Dr. Eddy Fan, MICU physician Dr. Roy Brower, MICU Director Drs. Radha Korupolu & Pranoti Pradhan, project coordinators Dr. Kashif Janjua & Mr. Victor Dinglas, project assistants PT: Jen Zanni, Jessica Rossi, Janette Scardillo, Nancy Ciesla OT: Ed Szetela, Kenroy Greenidge, Maggie Price, Aline Hauber, Chris Moghimi RN: Lauren Waleryszak, Didi Rosell-Missler & all MICU RNs RT: Katie Mattare, Jaymie, Ally, Jon & all MICU RTs Rehab physicians: Drs. David Pitts & Mohammad Yavari-Rad Neurology physicians: Drs. Argye Hillis, David Cornblath

Conclusions Early mobility in ICU very exciting & dynamic safe & feasible beneficial: evolving literature w/ issues (PICO): Patients: target population with most benefit Intervention: type of rehab & by who (PT, OT, RN) dose (intensity, frequency, duration) Co-interventions: sedation effect Outcome: long-term benefits? New research & clinical practice under way

For more info www.hopkinsmedicine.org/oacis Removed for privacy purposes

Monthly ICU Rehab Email Update on latest research, videos, conferences & announcements Join via email request to: gabriel.uk@jhmi.edu

ICU Rehab Resources: www.bit.ly/icurehabsol

The Future is Large-Scale Learning Networks & Collaborations www.mobilization-network.org Follow on Twitter: @icurehab @DrDaleNeedham Contribute to Twitter at: #icurehab

The ICU Recovery Network (IRN) (like a simple version of Facebook) To access & contribute to ICU Rehab content: videos, documents, website links, and event information To interact w/ other ICU Rehab clinicians from world Joining is simple (< 5 min.) You receive invitation email with link to set up account The web-based platform is provided, free-of-charge, by MedConcert. Enter basic info into web form To Join (only clinicians/researchers): gabriel.uk@jhmi.edu

Pre-ATS Meeting 11th Int l Mtg of PM&R in ICU Time: Sat. May 19, 2018 (~1.30-6.30pm) Location: Univ California San Diego Cost: Free By Invitation Only Via gabriel.uk@jhmi.edu Follow on Twitter: @icurehab @DrDaleNeedham Contribute to Twitter at: #icurehab

7 th Annual Johns Hopkins Critical Care Rehabilitation Conference Including a NEW one-day pre-conference: International ICU Diary Conference November 1-3, 2018 Johns Hopkins Hospital, Baltimore, MD For more Conference info: icurehab@jhmi.edu and bit.ly/icurehab For ICU Rehab Solutions/Resources: bit.ly/icurehabsol Follow Us on Twitter: @icurehab @DrDaleNeedham

Questions?

Developing our Culture of Mobility A Journey by Franciscan Health Michigan City, Indiana Presented by Brooke Nack, PT Inpatient Therapy Manager Mobility Program Manager

Polling Question In your hospital setting, who owns mobility? For example: When your patient needs to do his or her highest level of activity, 1. Nurses 2. Nurses aides Who do you call? 3. Therapists, physical or occupational 4. Mobility Team/Lift Team 5. Physicians 6. Ghost Busters! 62

Our Mobility Committee: We Have an idea Property of Brooke Nack, Inpatient Therapy Manager Franciscan Health Michigan City Not to be copied or reproduced without permission

Motivation to Move Our Lit Review A study of 45 elderly patients on a general medical unit, who had neither delirium or dementia and were able to walk prior to admission, found that they spent 20 out of every 24 hours in bed over the mean 5.1 days they were in the hospital. Wood et al. A mobility program for an inpatient acute care medical unit. AJN. 2014; 114(10)34-40. Property of Brooke Nack, Inpatient Therapy /Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission

What Does a Culture of Mobility Look Like? The Provider Approach All providers set patient/family expectations to MOVE Barriers to mobility are recognized and removed Providers hold each other accountable to achieve highest level of mobility Providers help each other mobilize patients All providers advocate for patient mobility Systematic use of mobility data and language Direct care providers know preadmission and current mobility levels Medical and pharmacological management supports mobility The Patient Experience Patients eat all meals in a chair unless they can t Mobile patients walk out of their room every day, including day of admission Necessary mobility equipment is at every bedside Families participate in patient mobility Mobility status, precautions, and projected discharge date is visible at bedside Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission 65

Who Owns Mobility? Physicians? Nurses? Patients? Therapists? Families? Administration? Property of Brooke Nack, Inpatient Therapy /Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission 66

What a Team Approach to Mobility Looks Like Nurse Assesses Mobility Therapy Orders generated by Mobility Reconciliation Patient performs highest mobility at least 3x/day with assistance of appropriate provider Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission 67

Rate Your Patient s Mobility Level Level Zero (0): Vital signs unstable, patient may not be conscious Level One (1): Needs two assist to sit patient on edge of bed Level Two (2): Dangles on edge of the bed with assist x 1; holds at least one leg up, indicating strength to stand Level Three (3): Stands with assist or device for 2 minutes OR walks in room with assist or device Level Four (4): Walks in the hallway ( out the door ) with or without assistance or a device Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission

Franciscan Progressive Mobility Continuum Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission

Mobility Baseline Data Activity Level at Home Activity Level by Unit Staff Number of Patients Number of Patients Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission 70

Care Map Trial Data Activity Level at Home Activity Level using Care Map Number of Patients Number of Patients Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission 71

Implementation Timeline Culture of Mobility Administrative Approval and Position Requests Mobility Team 1. Policies 2. Job Descriptions 3. Create Staff and patient Education Materials Whole House Mobility Training and Stake-Holder Buy-In 10-1-15 MOBILITY TEAM GO- LIVE 4-1-16 Assess performance June July August September October November December FIRST QTR 16 Staff Surveys: Mobility Needs and perceptions. 7-6-15 Patient Engagement Video Shoot Med Exec approval then Announce and Interview for Positions 9-1-15 MOBILITY CARE MAP GO-LIVE Analyze 4 th Quarter 2015 Results Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission 72

Cost Savings Through Reduced Adverse Events Adverse Event Current Rate Target (every year for 5 years) Pressure Ulcers Hospital- Acquired pneumonia Per 1000 patients Per 1000 patients DVT Per 1000 patients Falls Per 1000 patients 10% 10% 10% 10% Cost per Event Facility Specific Facility Specific Facility Specific Facility Specific Cost Savings If he has a bedsore, it s generally not the fault of the disease, but of the nursing -Florence Nightingale, 1859 Nightingale F. Notes on nursing. Philadelphia: Lippincott; p. 1859 Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission 73

Evidence-Based Goals for Mobility Program ROI Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission 74

Nursing Survey Results Question 1 2 Neg Response 4 5 Pos. Response I always get enough information 3 11 14 20 4 24 Inadeq I have had enough training 0 10 10 18 10 28 Mobil I have enough equipment 2 15 17 16 6 22 Gait b I believe patients are more likely to fall 17 15 32 4 1 5 I believe patients are resistant, so low satisfaction 17 16 33 5 1 6 Mobility Masters = higher job satisfaction 0 3 3 15 17 32 Schedule 8-4:30 11-7:30 10-6:30 write in 9-5:30 later s 8 20 12 1 covers Best result of Mobility Team: Job satisfaction Teamwork Pt satisfactionhealthcare OrgHope All of the above 2 10 8 2 10 8 Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission 75

Move Me : Engaging our Peers and our Patients https://www.youtube.com/embed/e6boqd0jpwc?rel=0 Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission

Skills-Development for Progressive Mobility Have a Little Fun Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission 77

Idea to reality Introducing our Mobility Team Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission

Day One Results Expectation Compliance Mobility level reported in Interdisciplinary Care Rounds 96% Mobility level written on communication board in room 53% Mobility documentation by nursing matches reported levels 63% Methods to Promote Compliance 1. Feedback of performance provided to unit managers 2. Transparency of performance across units 3. Celebration of nurses with 100% compliance 4. Leadership presence and rounding on the units 5. Mobility Committee attends interdisciplinary rounds Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission 79

Mobility Program Results *See note *Falls predominately unwitnessed unassisted, ages 45-65 years old, without injury Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission

Mobility Program Survey Results Question NURSING STAFF NON-NURSING PROFESSIONALS Patients receive more opportunities to move since Mobility Team My patients are satisfied with the Mobility Team The Mobility Team safely mobilizes patients Parts of my job are easier because we have a Mobility Team The Mobility Team has contributed to my job satisfaction The Mobility Team contributes positively to DC planning Agree/ Strongly Agree (n = 38-41) Disagree/ Strongly Disagree (n = 1-3) Agree/ Strongly Agree (n = 14-19) Disagree/ Strongly Disagree 100% 0% 100% 0% 100% 0% 100% 0% 97% 3% 100% 0% 95% 5% 100% 0% 92% 8% 100% 0% 93% 7% 100% 0% Property of Brooke Nack, Inpatient Therapy/Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission

Mobility Program Survey Results April 2016 I see so many more patients now up in chairs and walking the halls. Great job! I think as the Mobility Team continues to work with our patients the need will increase even more. It will become the norm which is wonderful. Great program! (CNA) Early Mobilization and discharge Patients do get better with early ambulation. (RN) Best results are decreased decubiti, decreased aspiration and overall reduced LOS. Excellent idea. Well managed and standardized. Easy to follow process. One of my favorite projects that has helped my patients tremendously. (Hospitalist) Property of Brooke Nack, Inpatient Therapy /Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission

Conclusion It is feasible and effective for both community and university based healthcare organizations to make great strides in developing a Culture of Mobility. A systematic team approach to mobility is key to a sustainable value and values based approach to preventing hospital acquired conditions. Franciscan Health Michigan City s Mobility Program is recognized as the Innovation Award winner by the Indiana Hospital Association at the Safety Summit on June 6, 2017. For further information on Franciscan s Mobility Program, contact Brooke Nack, Inpatient Therapy Manager Brooke.nack@franciscanallinace.org 219-877-1133 Brooke will be presenting a more detailed description of the Franciscan Mobility Program, including program development, return on investment, and corporate-wide dissemination in the Indiana Hospital Association Webinar titled: GET UP: Improving Mobility in Indiana 4 of 4 on Tuesday December 12 th at 2:00 pm CST. Property of Brooke Nack, Inpatient Therapy /Mobility Program Manager Franciscan Health Michigan City Not to be copied or reproduced without permission

You have questions? We have answers 84

BRING IT HOME Nerissa Legge, Program Manager HRET 85

Mobility Assessments GET UP Resources Get up and Go Test Timed get up and go BMAT: Banner Mobility Assessment Tool for Nurses Mobility Training Resources "CAPTURE Falls" Mobility Training Videos Mobility Protocols ICU Progressive Mobility Continuum Med Surg Mobility Protocol Implementation Guide- ICU Liberation Early Mobility Resources- Early Mobility.com 86

GET UP Resources UP Resource Page on HRET HIIN Website 87

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Upcoming Events HRET HIIN Rural CAH Affinity Group Virtual Event Topic: Rural and Critical Access Hospitals (CAH) Webinar: November 27, 2017 1:00pm - 2:00pm (CT) Register Disparity exists in access to palliative services especially in the rural and frontier regions of our country. Register for the HRET HIIN Rural CAH Affinity Group Event on Monday, November 27 th at 1pm CT to learn why this disparity exists and what rural communities are doing to address it. The event will feature Dr. Phil Lawson, an emergency room physician and palliative care director from Littleton Regional Hospital, a critical access hospital in New Hampshire. Dr. Lawson will dive into the patient, community and provider level drivers of disparity and offer strategies for organizations ready to fill the gap. We will then explore systems that support end of life conversations and advanced care planning for some practical next steps in addressing this important issue. 89

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