Development & Implementation of A Progressive Mobility Protocol for Hospitalized Veterans Presented by: Rebecca R. Parks MSN, RN, ANP-BC Earlie Hale DNP, RN, CNS-BC, CMSRN, VHA-CM Richard L. Roudebush VA Medical Center
Co-Authors & Workgroup Members: Cathy C. Schubert MD Anna Bober DNP, RN, CMSRN, GNP-BC Aleksandra Radovanovich PhD, RN, CCRN, CCNS Colleen Bach PT, DPT
Objectives 1. Describe possible negative outcomes from immobility during hospitalization. 2. Describe successful interventions to minimize low mobility.
Institute of Medicine: Recommendation #2 Expand Opportunities for Nurses to Lead and Diffuse Collaborative Improvement Efforts
Background and Significance Variable provider practices for activity orders Unnecessary bedrest 4 Prevalence of low mobility 80% of time in bed 1 Ambulation of patients is frequently missed nursing care 2,3 Lack of standardized assessment, communication and documentation
Negative Outcomes Creditor MC Ann Intern Med 1995
Purpose of the Progressive Mobility Protocol Prevent and/or mitigate negative outcomes Promote safe mobility Standardization Nurse Driven!
Methods Obtained buy-in of stakeholders from beginning Built on existing tools and protocols in place Congruent use of mobility language in nursing documentation Created autogenerated nursing order for activity protocol Educated nursing & medicine staff
Stoplight
PROGRESSIVE MOBILITY PROTOCOL The Progressive Mobility Protocol was designed in effort to encourage and promote mobility and reduce the chance of a fall on the unit and reduce the possibility of further injury affecting the discharge timeline. *Progression & regression through protocol will be nurse driven with guidance from physical therapy as needed. Family should NOT assist with any above tasks unless they have been properly trained by staff. T O O L F O R T H E R O O M Color Indicator RED LIGHT YELLOW LIGHT GREEN LIGHT 10/23/13 Mobility Level Level 1: Unable to follow commands or only follows simple commands. Baseline function bed or w/c bound Staff hands on assistance to get out of bed, walk, sit into chair or into bathroom. Passive ROM 3 times/day Turn q2hrs HOB 30-60 degrees Splints/boots for contracture prevention as needed Up to chair position at least 20 min 3 times/day Dangle at side of bed PT consult as needed Progress to next level as tolerated Level 2: Able to follow commands, moves extremities against gravity. Baseline ambulator with device and/or use of motorized w/c or manual w/c for community mobility. Staff must be present for supervision to get out of bed, walk, sit into chair or into bathroom. Includes level 1 interventions Active transfer to chair minimum 20 min 3 times/day Sit in chair for all meals Advance to standing position Ambulate in room (toileting, ADLs) Progress to next level as tolerated Level 3: Able to move all extremities against gravity. Baseline independent ambulator with or without assistive device or independently wheelchair mobile. Perform any tasks in room or on the unit, using the proper prescribed device as instructed. Include level 1 & 2 interventions Active transfer to chair Sit in chair for all meals Ambulate in hallways twice daily Ambulate in room (toileting, ADLs)
FOR THE CHART Protocol Order for the Chart
Outcomes Elimination of unnecessary bedrest orders Consistent provider ordering of protocol (85%) Reduction of patient days in restraints (40%) Protocol education during staff orientation Decreased indwelling urinary catheter use Nurse driven
Conclusion THE FUTURE OF HEALTH CARE Nurses are strategically positioned to lead Empowered nurses champion collaborative improvement efforts Reduce and eliminate negative patient care outcomes http://www.theamericannurse.org/wp-content/uploads/2014/02/future-of-nursing3.jpg
Questions?
References 1. Brown CJ, et al. (2004). Prevalence and outcomes of low mobility in hospitalized older patients. Journal of American Geriatrics Society, 52, 1263-1270. 2. Kalisch, B.J., Tschannen, D. and Lee, K. (2012). Missed nursing care, staffing and patient falls. Journal of Nursing Care Quality, 27(1), 6-12. 3. Kalisch, B.J., Xie, B. & Waller Dabney, B. (2014). Patient-reported missed nursing care correlated with adverse events. American Journal of Medical Quality, 29(5), 415-422. 4. Padula, C.A., Hughes, C. & Baumhover, L. (2009). Impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults. Journal of Nursing Care Quality, 24(4), 325-331.