Nurse-Driven Safe Patient Early Mobility: Making it Happen In Your ICU Kathleen Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist/Educator/Consultant ADVANCING NURSING LLC kvollman@comcast.net www.vollman.com ADVANCING NURSING LLC 2014 Disclosures Sage Products Inc Hill-Rom Inc Eloquest Healthcare, Inc 1
Learning Objectives At the completion of this activity, the participant will be able to: 1. Identify and discuss key in-bed and out of bed mobility techniques to successfully achieve your early mobility protocol to improve patient outcomes. 2. Overcoming barriers and feeling empowered to own patient mobility within your unit. Impact of Immobility Increase atelectasis and risk for VAP/HAP Fluid shifts, cardiac deconditioning and orthostatic intolerance Pressure ulcers from shear, friction, moisture and pressure risk factors 74% of patients developed delirium during hospital stay & at 3 months 40% had global cognition scores 1.5 SD below population mean ICU patients up to 5 years experience severe weakness & deficits in self care, poor quality of life & readmission. One day of bed rest requires two weeks of reconditioning to restore baseline muscle strength Reddy, M,et al. JAMA, 2006; 296(8): 974-984 Convertino V, et al. Med Sci Sports Exercise, 1997;29:191-196 Fortney SM, et al. Physiology of bedrest (Vol 2). New York: Oxford University Press. 1996. Pandharipande, PP. et al. N Engl J Med;369:1306:1316 Herridge MS, et al. N Engl M, 2011;364(14):1293-304 2
Outcomes of Early Mobility Programs incidence of VAP time on the ventilator days of sedation incidence of skin injury delirium ambulatory distance Improved function Staudinger t, et al. Crit Care Med, 2010;38. Abroung F, et al. Critical Care, 2011;15:R6 Morris PE, et al. Crit Care Med, 2008;36:2238-2243 Pohlman MC, et al. Crit Care Med, 2010;38:2089-2094 Schweickert WD, et al. Lancet, 373(9678):1874-82. Thomsen GE, et al. CCM 2008;36;1119-1124 Winkelman C et al, CCN,2010;30:36-60 A B C D E AWAKE BREATHE CHOICE OF SEDATION DELIRIUM EARLY MOBILITY Balas MC, et al. Crit Care Nurse. 2012 Apr;32(2):35-8, 40-7 3
ABCDE Bundle Reduces Ventilation, Delirium & OOB 18 month, prospective, cohort, before-after study 5 adult ICU s, 1 step down, 1 oncology unit Compared 296 patients (146 pre-bundle) & 150 post bundle) Intervention: ABCDE Measured: For mechanical ventilation patients (187) examined ventilator free days All patients examined incidence of delirium, mortality, time to discharge and compliance with the bundle Balas MC, et al. Crit Care Med, 2014;42(5):1024-36. Balas Balas MC, M et al. Crit Care Med, 2014; 2014;42(5):1024-36 online 4
Driving Change Gap analysis Build the Will Protocol Development Structure Make it Prescriptive Overcoming barriers Daily Integration Process Outcomes Early Mobility Progressive Mobility: Planned movement in a sequential manner beginning at a patients current mobility status and returning them to baseline & includes: Head elevation Manual turning Passive & Active ROM Continuous Lateral Rotation Therapy/Prone Positioning Movement against gravity Physiologic adaptation to an upright/leg down position (Tilt table, Bed Egress) Chair position Dangling Ambulation Vollman KM. Crit Care Nurse.2010 Apr;30(2):S3-5. 5
The Mobility Initiative Objective To create a progressive mobility initiative that will help ICU teams to address key cultural, process and resource opportunities in order to integrate early mobility into daily care practices. Methods Multi-center implementation of key clinical interventions An evidence-based, user-friendly progressive mobility continuum was developed, lead by the Clinical Nurse Specialist faculty Implementation plan: process design, culture work & education 130 patients/3120 prospectively collected hourly observations Qualitative and quantitative data collected 15 process and 5 outcome metrics Results reported as cohort and unit specific data Bassett RD, et al.intensive Crit Care Nurs (2012) 2012 Apr;28(2):88-97 Determining Readiness Perform Initial mobility screen w/in 8 hours of ICU admission & daily Yes Patient Stable, Start at Level II & progress PaO2/FiO2 > 250 Peep <10 O2 Sat > 90% RR 10-30 No new onset cardiac arrhythmias or ischemia HR >60 <120 MAP >55 <140 SBP >90 <180 No new or increasing vasopressor infusion RASS > -3 Bassett RD, et al.intensive Crit Care Nurs (2012) 2012 Apr;28(2):88-97 Needham DM, et al. Arch Phys Med Rehabil. 2010 Apr;91(4):536-42 No Patient is unstable, start at Level I & progress 6
START HERE Includes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated Progressive Mobility Continuum Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V Perform Initial mobility screen w/in 8 hours of ICU admission Reassess mobility level at least every 24 hours (Recommended at shift ) Refer to the following criteria to assist in determining mobility level o PaO2/FiO2 > 250 o Peep <10 o O2 Sat > 90% o RR 10-30 o No new onset cardiac arrythmias or ischemia o HR >60 <120 o MAP >55 <140 o SBP >90 <180 o No new or increasing vasopressor infusion o RASS > 3 NO Start at level I* YES Start at level II and progress* RASS -5 to - 3 RASS -3 & up RASS -1 & up Goal: clinical stability; passive ROM ACTIVITY: HOB > 30º *Passive ROM 2X/d performed by RN, or UAP CLRT/Pronation initiated if patient meets criteria based on institutional practice OR Q 2 hr turning Tolerates Level I Activities Goal: upright sitting; increased strength and moves arm against gravity PT consultation prn OT consultation prn ACTIVITY: Q 2 hr turning *Passive /Active ROM 3x/d 1. HOB 45º X 15 min. 2. HOB 45º,Legs in dependant position X 15 min. 3. HOB 65º,Legs in dependant position X 15 min. 4. Step (3) & full chair mode X20 min. 3X/d Or Full assist into cardiac chair 2X/day Tolerates Level II Activities Goal: Increased trunk strength, moves leg against gravity and readiness to weight bear PT: Active Resistance Once a day, strength exercises OT consultation prn ACTIVITY: Self or assisted Q 2 hr turning 1.Sitting on edge of bed w/rn, PT, RT assist X 15 min. 2.Progressive bed sitting Position Min.20 min. 3X/d Or Pivot to chair position 2X/d Tolerates Level III Activities RASS 0 & up Goal: stands w/ min. to mod. assist, able to march in place, weight bear and transfer to chair PT x 2 daily OT consult for ADL s ACTIVITY: Self or assisted Q 2 hr turning 1.Bed sitting Position Min.20 min. 3X/d; 2.Sitting on edge of bed; stand w/ RN, PT, RT assist 3.Active Transfer to Chair (OOB) w/ RN/PT/RT assist Min. 3X/d Tolerates Level IV Activities RASS 0 & up Goal: Increase distance in ambulation & ability to perform some ADLs PT x 2 daily & OT x1 daily ACTIVITY: Self or assisted Q 2 hr turning 1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day 2.Meals consumed while dangling on edge of bed or in chair Ambulate progressively longer distances with less assistance x2 or x3/day with RN/PT/RT/UAP For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant ***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level*** *Mobility is the responsibility of the RN, with the assistance from the RT s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment. Do We Even Achieve the Minimum Mobility Standard Q2 Hours? 7
Body Position: Clinical Practice vs. Standard Multicenter study: 74 patients/566 total hours of observation Change in body position recorded every 15 minutes for 8hrs 2.7% had a q 2 hour body position change 49.3% of observed time no body position change Prospectively recorded, 2 days, 40 ICU s in the UK Analysis on 393 sets of observations Average time between turns 4.85 hrs (3.3 SD) Krishnagopalan S. Crit Care Med 2002;30:2588-2592 Goldhill DR et al. Anaesthesia 2008;63:509-515 Achieving In-Bed Mobility 8
Transfer Device Current Practice: Turn & Reposition Lift Device 70% Draw Sheet /Pillows/Layers of Linen Disposable Slide Sheets Specialty Beds 50% of nurses required to do repositioning suffered back pain High physical demand tasks 31.3% up in bed or side to side 37.7% transfers in bed 40% of critical care unit caregivers performed repositioning tasks more than six times per shift REPOSITIONING THE PATIENT CAREGIVER INJURY Number one injury causation activity: Repositioning patients in bed Smedley J, et al. J Occupation & Environmental Med,1995;51:160-163) (Knibbe J, et al. Ergonomics1996;39:186-198) Harber P, et al. J Occupational Medicine, 27;518-524) Fragala G. AAOHN, 2011;59:1-6 9
Occupational Injuries RN s with Musculoskeletal Disorders in US, 2003 2011 2010 Private industry RNs 9,260 53.7 6 2011 Private industry RN s 10,210 8 Bureau of Labor Statistics, U.S. Department of Labor, February 14, 2011. Numbers for local and state government Unavailable prior to 2008/Nov 2011, Release 10:00 a.m. (EST) Thursday, November 8, 2012 10
Achieving the Use of the Evidence For In-Bed & Out of Bed Mobility for Maximum Outcomes Factors Impacting the ability to Achieve Quality Nursing Outcomes at the Point of Care Resource & System Breathable glide sheet/stays Foam Wedges Microclimate control Wick away moisture body pad Protects the caregiver Value Value Attitude & Accountability Vollman KM. Intensive Care Nurse.2013;29(5):250-5 Comparative Study of Two Methods of Turning & Positioning Blocked design with convenience sample of 60 patients SOC: pillows/draw sheet TAP: breathable glide sheet/foam wedges/wick away pad Results: Nurse satisfaction 87% versus 34% 30 turn achieved versus -0-15 in SOC SOC group required more resources Powers J, Presented at 27 th Annual Symposium of Advances in Skin and Wound Care, Las Vegas, NV; 10/20-23, 2012..in press 11
Safe Patient Handling Initiative: Decreases Staff Musculoskeletal Injuries & Patient Pressure Ulcers QI: before & after study Metrics; number of HAPUs, the number of healthcare worker injuries associated with repositioning. 10 months pre and 10 months post The EB Cost of HCW injury was $22,500. The EB cost for HAPUs was $2,000 for stage I and II ulcers and $43,180 for stage III and IV ulcers. Comparison: SOC: Offloading with chucks, pillows, and rolled blankets as necessary. Intervention: Use of a heel offloading device* and patient turning and repositioning device**. Way H. Presented at the 2014 Safe Patient Handling East Conference on March 27, 2014 Safe Patient Handling Initiative: Decreases Staff Musculoskeletal Injuries & Patient Pressure Ulcers 28% 58% $184,720 savings $247,500 savings Way H Presented at the 2014 Safe Patient Handling East Conference on March 27, 2014 12
Out of Bed Technology Current Seating Positioning Challenges Uncomfortable Airway & Epiglottis compressed Lack of Body Alignment Frequent repositioning & potential caregiver injury Potential fall risk Shear/Friction Sacral Pressure 13
Repositioning Patients in Chairs: An Improved Method (SPS) Study the exertion required for 3 methods of repositioning patients in chairs 31 care giver volunteers Each one trial of all 3 reposition methods Reported perceived exertion using the Borg tool, a validated scale. Method 1: 2 care givers using old method of repositioning 246% greater exertion than SPS Method 2: 2 caregivers with SPS Method 3: 1 caregiver with SPS 52% greater exertion than method 2 Fragala G, et al. Workplace Health & Safety, 2013;61:141-144 Progressive Mobility: Use of Technology to In- Bed & Out of Bed Mobility Journey to tolerating upright position, turning, tilt, sitting, standing and walking and out of bed chair sitting can occur quicker through the use of technology 14
Early Mobility: Can We Do It? Is it Safe? 15
Challenges to Mobilizing Critically Ill Patients Human or Technological Resources Knowledge/Priority Safety Hemodynamic instability Safety < 1 % adverse events during 1449 sitting, standing and walking sessions with patients on ventilators. Underwent daily sedation interruption followed by PT & OT daily until achieving physical function independence Safety events occurred in 16% of all sessions Loss of 1 arterial line, 1 nasogastric tube, 1 rectal tube Therapy was stopped on 4% of all sessions for vent asynchrony, agitation, or both Delirium present 53% of the time during therapy sessions Bailey P, et al. Crit care Med, 2007;35:139-145 Pohlman MC, et al. Crit Care Med, 2010;38:2089-2094 16
Hemodynamic Instability??? Is it a Barrier to Positioning? Hemodynamic Instability At Risk Elderly Diabetes with neuropathy Prolonged bedrest Low Hb an cardiovascular reserve Prolonged gravitational equilibrium Vollman KM. Crit Care Nurs Q. 2013 Jan;36(1):17-2 Winslow, E.H. Heart and Lung, 1990 Volume 19, 557-561. Price P. CACCN, 2006, 17(1):12-19. 17
It Takes a Village Ensuring Safety & Success Mobility readiness assessment Determining absolute contraindications for any mobility protocol Criteria for stopping a mobility session Changing the culture Sufficient resources and equipment to make it easy & safe to do 18
Be Courageous We all are responsible for the safety of our patients and ourselves Own the Issues If not this, then what?? If not now, then when? If not me, then who?? 19