Early Mobility in the Intensive Care Unit

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Transcription:

Early Mobility in the Intensive Care Unit Marianne Munson, PT, DPT University of Rochester Strong Memorial Hospital Physical Medicine and Rehabilitation

Objectives Summarize the benefits of early mobility in critically ill patients Discuss the early mobility initiative at Strong Memorial Hospital Discuss the interdisciplinary approach to operationalizing early mobility Review the importance of safe patient handling Define the barriers to ICU early mobility 2

Benefits of Early Mobility Prolonged stays in the intensive care unit and mechanical ventilation are associated with functional decline and increased morbidity, mortality, cost of care, and overall length of hospital stay Perme and Chandrashekar, 2009 Save lives Improve function Improve quality of life Save money 3

Early Mobility at Strong Memorial Hospital 2010 Patient mobility retreats Retreats, trainings, team building, education 2013 Optimization of equipment and process Purchase of Hovermats and Hoyer slings OOBTC added to the daily task list 2015-2016 Dedicated unit based PT in MICU and SICU More patients evaluated and treated by a physical therapist Increased percentage of patients discharged home Decreased ICU length of stay (~1/2 day) Currently - 5 designated PTs for 7 critical/progressive care units 4

Early Mobility at Strong Memorial Hospital Change in culture 5

Progressive Mobility 7

Progressive Mobility 8

Progressive Mobility 9

Specialized Equipment 10

Limitations to Early Mobility in the ICU Staff (PT and RN) to patient ratio Equipment Expensive Nothing is perfect Tests, procedures, lines, etc. Patient medical stability Fear Patient Staff Family 11

It takes teamwork! Interdisciplinary team members involved in early mobility Morning rounding with Care Coordinator and/or charge nurse Plan with each bedside RN Pre-medication Next turn Sedation vacation/wean Coordinate with respiratory therapy Timing of pressure support Tolerance to vent wean + mobility/exercise Ambulate on portable vent vs ambu bag 12

It takes teamwork! Educate nursing During orientation and on the fly Mobility Team Specific to URMC SICU A group of motivated RNs/LPNs who are comfortable mobilizing patients Updated by PT on Friday 4 hr shift to mobilize patients Saturday and/or Sunday 13

Safe Patient Handling The use of engineering control, lifting and transfer aids, or assistive devices by staff to perform the acts of lifting, transferring and repositioning health care patients and residents AFL-CIO NYS Safe Patient Handling Act (Sections 20 & 21, Part A, S6914/A9205) NYS legislation that requires that staff utilize Safe Patient Handling equipment for patients greater than 35 pounds during transfers and repositioning Primary reason for implementation is to decrease work related injuries 14

Safe Patient Handling at Strong Memorial Hospital Hospital wide committee developed policy 50% upper management, 50% staff per NYS 400 super users underwent hands-on equipment training in January 2017 Official SPH disseminated system wide on March 8, 2017 400 super users underwent hands-on equipment training On-line learning for staff with hands-on competency sign off by super user completed by end of July 2017 Injury numbers steady through July 2017 compared to previous years New system and data collection tool to collect more information for further research 15

Equipment Supports Policy 16

Results ICU Length of Stay 7.00 ICU Length of Stay Pre vs. Post Intervention 6.00 5.00 Days 4.00 3.00 2.00 1.00 0.00 MICU SICU ICULOS Pre 5.64 4.85 ICU LOS Post 5.19 4.43

Results Hospital Length of Stay Hospital Length of Stay Pre vs. Post Intervention 25.00 20.00 Days 15.00 10.00 5.00 0.00 MICU SICU Hospital LOS Pre 19.08 17.87 Hospital LOS Post 15.27 18.15

Discharge Disposition - MICU 35.00% 30.00% % of Patients 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% EXPIRED TO SNF (SKILLED NURSING) HOME/SELF CARE TO INPT REHAB FACILITY OR UNIT Pre 18.49% 16.47% 30.92% 3.19% Post 19.76% 15.61% 33.20% 1.58%

Discharge Disposition - SICU % of Patients 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% EXPIRED TO SNF (SKILLED NURSING) HOME/SELF CARE TO INPT REHAB FACILITY OR UNIT Pre 18.15% 11.98% 30.37% 3.32% Post 17.38% 10.91% 38.63% 1.29%

Financial Impact Summary 545 ICU Days Saved by the shortened LOS 98 Additional ICU Cases (21 MICU, 77 SICU) Increase in net operating margin of $816,970 Successfully advocated for additional dedicated FTEs for all ICUs

References Kress, John P. "Clinical trials of early mobilization of critically ill patients." Critical care medicine 37.10 (2009): S442-S447. doi:10.1097/ccm.0b013e3181b6f9c0 Lord, R. K., Mayhew, C. R., Korupolu, R., Mantheiy, E. C., Friedman, M. A., Palmer, J. B., & Needham, D. M. (2013). ICU early physical rehabilitation programs: Financial modeling of cost savings. Critical Care Medicine, 41(3), 717-724. doi:10.1097/ccm.0b013e3182711de2 [doi] Perme, C., & Chandrashekar, R. (2009). Early Mobility and Walking Program for Patient in Intensive Care Units: Creating a Standard of Care. American Journal of Critical Care, Online First, 1-10. doi:10.4037/ajcc2009598 SafePatientHandlingActSummary033114.docx - SPH-summary-AFLCIO- 04032014.pdf Retrieved from http://www.asphp.org/wpcontent/uploads/2011/05/sph-summary-aflcio-04032014.pdf 22

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