Raise your game: The UP Campaign Bruce Spurlock, M.D. Cynosure Health 1
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Can we streamline & simplify making it easier for front-line staff and still improve safety? 16
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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 Help patients recover faster and with fewer complications 18
# 1 OPIOID & SEDATION MANAGEMENT ADE FTR Delirium Falls AS VTE VAE W A K E - UP 19
# 2 EARLY PROGRESSIVE MOBILITY Falls PrU Delirium CAUTI VAE VTE Readmissions G E T - U P 20
# 3 HAND HYGIENE CDI CAUTI SSI VAE CLABSI Sepsis S O A P - U P 21
Foundational Questions: 1. Is my patient awake enough to get up? 2. Have I protected my patient from infections? 22
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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.
# 1 OPIOID & SEDATION MANAGEMENT ADE FTR Delirium Falls AS VTE VAE W A K E - UP 26
SLEEP VS SEDATION
www.iculiberation.org IMPROVE PATIENT COMFORT, SAFETY, AND OUTCOMES PAD SYMPTOMS PAIN AGITATION DELIRIUM ASSESSMENT AND MONITORING TOOLS NRS: Numeric Rating Scale BPS: Behavioral Pain Scale CPOT: Critical Care Pain Observation Tool RASS: Richmond Agitation Sedation Scale SAS: Sedation Agitation Scale CAM-ICU: Confusion Assessment Method for ICU ICDSC: Intensive Care Delirium Screening Checklist CARE IMPROVEMENT ABCDEF BUNDLE Assess, Prevent and Manage Pain Both Spontaneous Awakening Trials and Spontaneous Breathing Trials Choice of Sedation Delirium: Assess, Prevent and Manage Early Mobility and Exercise Family Engagement and Empowerment
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 15-30 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. 510. St. Louis, Mosby/Elsevier, 2011. 29
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
Just Right! Over Medicated: Hibernating Under Medicated: Not Happy #@xx!! #@xx!!
W A K E Warn Yourself: this is high risk. Assess: use tools (STOP BANG, POSS, RASS, PA-PSA). Know: Your drugs, Your patient. Engage: Patients and Families to set realistic pain expectations, use of non-sedating analgesics, risks of opioids. - U P Utilize: dose limits, layering limits, soft and hard stops. Protect: The Patient our ultimate job. 32
NOT JUST SEDATIVES AND OPIOIDS Anti-histamines/anti-cholinergics Anti-psychotics Some anti-depressants Anti-emetics Muscle relaxers 33
# 2 EARLY PROGRESSIVE MOBILITY Falls PrU Delirium CAUTI VAE VTE Readmissions G E T - U P 34
PATHOPHYSIOLOGICAL CHANGES WITHIN 24 H OF BED REST 35
WHAT IS PROGRESSIVE MOBILITY? 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 (Vollman 2010) Ambulation Dangling Elevate HOB Manual turning PROM AROM CLRT and Prone positioning Upright / leg down position Chair position 36
TEAMING UP TO MOBILIZE OT PT RN Admin CNA MD RT Family 37
G E T Go: determine the resources in your institution and how you will implement a mobility program. Evaluate: (patient capabilities): Which scale/tool/evaluation method will you standardize on? Team up for progressive mobility: rehab, nursing, and respiratory join to implement the mobility plan. - U P Unite: Engage patients, families and friends in mobility progression. Promote progress: Measure and report unit mobility performance. 38
GO DETERMINE THE RESOURCES NEEDED Assess current state of nursing skill and confidence in mobilization Mobility Aid PTA or CNA Instead of low census days pilot mobility aid Ambulate patients twice a day Unit based PT/OT staff Bedside treatment Involve nursing in transfers and ambulation to build skill and confidence. ICU Mobility Team Critical Care RN, CNA, PT Equipment Gait belts in rooms 39 Sit to stand transfer device
EVALUATE Select or develop a tool to assess patient readiness for early mobilization Exercise / Mobility Safety Screen Parameters examples AACN Protocol M Myocardial stability No myocardial ischemia x 24H No dysrhythmia requiring new antidysrhythmic x 24 H O - Oxygenation is adequate FiO2 > 6 PEEP < 10cm H2O V Vasopressors minimal No increase of any vasopressors x 2 H E Engage to voice Patient responds to verbal stimulation 40 Other Screening Prameters PaO2/FiO2 > 250 Peep < 10 RR 10-30 HR 60-120 MAP 55-140 SBP 90-180 RASS 3 or greater No new or increasing vasopressors
TEAM UP Develop the mobility protocol as a team MD NP, Clin Spec Nursing RN, CNAs Physical Therapy Occupational Therapy Respiratory Consider ICU and Med Surg Decide where to start 41
SAMPLE MOBILITY Unconscious Conscious Conscious Conscious PROTOCOL WAKE FOREST UNIVERSITY Morris P,et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crti Care Med 2008:36(8):2238-43. 42
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# 3 HAND HYGIENE CDI CAUTI SSI VAE CLABSI Sepsis S O A P - U P 44
S O A P Scrub: for 20 seconds with the right product. Remember soap for C.diff. Own: your role in preventing HAIs. Address: immediately intervene if breach is observed. Place: hand hygiene products in strategic locations. - U P Update: hand hygiene products and policies as needed to promote adherence. Protect: patient and families, get them involved. 45
TIME TO SOAP UP YOUR HAND HYGIENE GAME! 46
SCRUB Scrub: for 20 seconds with the right product. Remember soap for C.diff. Scrub hands with appropriate agents, length of time and with proper technique. Use soap and water for C.diff, minimum 15 seconds, with friction on all surfaces of the hands. Use alcohol-based gel, rub until dry on all surfaces of the hands. http://www.cdc.gov/handhygiene/ 47
OWN: Your Role in Prevention Own your role in preventing hospital acquired infections, develop automaticity in HH performance. Surveillance of yourself and others is a must. Share observation data and establish personal accountability with the health care worker. 49
ADDRESS 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. 50
PRODUCT PLACEMENT Thoughtful and strategic placement of HH products for: Healthcare workers Visitors Patients Place signage as reminders Place gloves inside patient rooms Implement a no glove zone outside patient rooms 51
UPDATE Update products, equipment and policies with staff input. Update equipment and displays of HH product frequently. 52
PROTECT PATIENT Protect our patients from HAI by performing HH. Promote patient and family engagement- give them permission to speak up for clean hands. Promote patient HH for patients. http://www.cdc.gov/handhygiene/patients/index.html 53
Foundational Questions: 1. Is my patient awake enough to get up? 2. Have I protected my patient from infections? 54
bspurlock@cynosurehealth.org 55