Presentation: Program Overview

Presentation: Program Overview

AHRQ Safety Program for Mechanically Ventilated Patients The Four Es of Early Mobility AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-50-EF Four Es of Early Mobility 1 January 2017 Learning Objectives After this session, you will be able to List the four Es from TRIP framework (engage, educate, execute, and evaluate) Apply each E intervention to early mobility (EM) AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 2

Translating Research Into Practice1 Envision the problem within the larger system Engage collaborative multidisciplinary teams centrally and locally 1 Summarize the evidence 2 Identify local barriers to implementation 3

Measure performance 4 Ensure that all patients receive the interventions 1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008 Oct 6;337:a1714. PMID: 18838424. AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 3 Summarize the Evidence1 Identify interventions 1 Summarize the Evidence Prioritize interventions with

the largest benefits and lowest barriers Implement interventions to foster new behaviors 1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008 Oct 6;337:a1714. PMID: 18838424. AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 4 Identify Local Barriers1 Observe staff performing care delivery tasks 2 Identify local barriers to implementation

Walk the process to identify defects at each step Solicit feedback from all stakeholders Identify potential gains or losses 1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008 Oct 6;337:a1714. PMID: 18838424. AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 5 What Are Your Barriers?2 BARRIER STRATEGY TO OVERCOME BARRIER Lack of leadership Designate an overall leader who is involved and committed to quality improvement

Involve a champion from every discipline Lack of staffing and equipment Identify equipment rental process Obtain grants and review capital budget for purchase of equipment Apply for nursing grants to fund dedicated physical and occupational therapists (PT/OT) and PT technicians Lack of knowledge and training Educate multidisciplinary team on evidence for early mobility interventions Create simple guidelines for PT/OT consultants Crosstrain staff Establish screening criteria Educate about appropriate referrals Clarify bed rest orders versus PT consultations Chart board guidelines for mobility Lack of referrals and standardized

documentation 2. Needham DM, Korupolu R. Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model. Top Stroke Rehabil. 2010 Jul-Aug;17(4):271-81. PMID: 20826415. AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 6 What Are Your Barriers?2 BARRIER STRATEGY TO OVERCOME BARRIER Oversedation Educate interdisciplinary staff about continuous versus bolus sedation Standardize approach to sedation management Delirium

Screen with validated assessment tool Minimize use of benzodiazepines Consider use of antipsychotics to treat delirium Indicate a pain protocol to titrate pain medications Pain and discomfort Physiological instability Safety Create guidelines for screening physiological stability Screen daily for PT/OT safety before initiating therapy Initiate any therapy beyond feet dangling with respiratory therapist at bedside Untangle lines prior to therapy to avoid accidental dislodgement 2. Needham DM, Korupolu R. Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model. Top Stroke Rehabil. 2010 Jul-Aug;17(4):271-81. PMID: 20826415. AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 7

Measure Performance1 Select process and/or outcome measures 3 Measure performance Develop and pilot test measures Measure baseline performance 1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008 Oct 6;337:a1714. PMID: 18838424. AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 8

Ensure All Patients Receive the Evidence (Four Es)1 4 Ensure that all patients receive interventions Engage Educate Execute Evaluate How can we engage hearts and minds? How can we turn the

evidence into behaviors? How can we do this? How do we know if we made a difference? 1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008 Oct 6;337:a1714. PMID: 18838424. AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 9 Four Es of Early Mobility Engage

ADAPTIVE FRONTLINE STAFF Ask, how will early mobility make the world a better place? Explain preventable harm to staff Share stories about patients Develop a business case Include executive and physician leadership EARLY MOBILITY Define evidence related to preventing ventilator-associated events (short- and long-term cognitive effects, and physical and psychological disabilities) Share success stories and videos

Visit a site with experienced units or facilities Create business case related to the impact of early mobility including decreased time on ventilator, in intensive care unit, and in hospital Share business case with executive and provider champions AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 10 Four Es of Early Mobility Educate TECHNICAL FRONTLINE STAFF What do we need to mobilize critically ill patients? Convert evidence into behaviors

Evaluate awareness and agreement EARLY MOBILITY Discuss post-intensive care syndrome Review the literature Develop mobility criteria and progressive mobility protocols Develop education plan including hands-on workshops, presentations, conferences, and interactive discussions Identify support through outreach to the leadership team AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 11 Four Es of Early Mobility FRONTLINE STAFF EARLY MOBILITY

Execute ADAPTIVE Evaluate TECHNICAL How will we implement early mobility at Update process for mobilizing patient our hospital give local culture and Review policies and protocols resources? Identify key stakeholders Gather appropriate equipment Listen to resisters Discuss as part of interdisciplinary Standardize care and create rounds/daily goals

independent checks Learn from defects Make it easy to do the right thing Learn from mistakes How will we know that our efforts to Collect data and review with staff mobilize our patients made a difference? Use your data to trend performance Define measures Assess measures regularly Provide feedback to staff and celebrate success AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 12

Engage and Educate Frequently Share at multidisciplinary safety program meetings Discuss at staff meetings every 6 weeks Present at board meetings Clarify expectations at daily huddles Reinforce with email Publish newsletter Post on bulletin boards Talk with staff while collecting data AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 13

Engage All Staff Sitters/Observers Clinical Technicians/ Nursing Assistants Ambulate Turn Range of motion Document Ancillary Personnel AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 14 Engage Family Resources Consider a Family Involvement Menu: Invites family members to assist in EM exercises Encourages family members to partner

with nurses Facilitates connection with the sick relative AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 15 Educate: Turn Evidence Into Behaviors Define and approve mobilization readiness criteria Develop early/progressive mobility protocols and guidelines Review the literature Develop education plan including hands-on workshops, presentations, conferences, and interactive discussions Identify support through outreach to the leadership team AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 16 Readiness Assessment: Other Considerations Patient factors

Sedation level Breathing support for EM interventions Femoral lines Presence of lines, drains, catheters Other factors The right equipment Sufficient staffing/multidisciplinary focus AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 17 Execute: Make It Easy To Do the Right Thing What is the process for mobilizing a patient? Is there a policy on the unit? Who should be involved? Do we have all the equipment? Discuss as part of interdisciplinary rounds/daily goals

Add mobility level to report sheet and nursing handoff AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 18 Early Progressive Mobility Protocol Use visual cues to communicate daily mobility goals Place near patient on white board, door, or bedside Laminate cues and write custom goals when appropriate Used with permission. Adapted at St. Joseph Mercy Hospital from the American Association of CriticalCare Nurses early progressive mobility protocol.3 Learn more at www.aacn.org. AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 19 Sample Early Mobility Protocol4

4. Bassett RD, Vollman KM, Brandwene L, et al. Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): a multicentre collaborative. Intensive Crit Care Nurs. 2012 Apr;28(2):88-97. PMID: 22227355. AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 20 Evaluate: Measure Your Success Collect process measures data Review at monthly safety program meetings Post prominently for frontline staff Use your data to trend performance AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 21 Daily Early Mobility Measures Form AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 22

Daily Early Mobility Measures Guide AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 23 Highest Level of Mobility 0. Nothing passively rolled or exercised by staff but not actively moving 1. Transfer from bed to chair without standing hoist, passive lift, or slide to the chair without standing 2. Sitting in bed/exercises in bed any activity in bed, including active rolling, bridging, active exercises, use of tilt table 3. Sitting at edge of bed actively sitting over the side of the bed with some trunk control 4. Standing weight bearing through feet in standing position with or without assistance 5. Transfer from bed to chair with standing able to step or shuffle through standing to chair 6. Marching in place able to walk in place by lifting alternate feet (at least four times, two for each foot) 7. Walking walking away from the bed/chair by at least four steps 8. Unknown AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 24

Perceived Barriers 0. Not applicable patient at highest possible level of mobility 1. Bed rest orders 2. Patient on comfort/palliative care measures 3. Patient sedated (Richmond Agitation-Sedation Score [RASS] -4 or -5; or Riker Sedation-Agitation Scale [SAS] 1 or 2) and on infusion of benzodiazepine, narcotic, or propofol 4. Patient sedated (RASS -4 or -5; or SAS 1 or 2), but NOT on infusion of benzodiazepine, narcotic, or propofol 5. Medically inappropriate (orthopedic reason, e.g., fracture of long bone, spine, or pelvis) 6. Medically inappropriate (circulatory or respiratory reason) as delineated in the medical screening algorithm AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 25 Perceived Barriers 7. Medically inappropriate (new deep vein thrombosis) as delineated in the medical screening algorithm 8. Medically inappropriate (femoral sheath) as delineated in the medical screening algorithm

9. Medically inappropriate (for any other reason; e.g., unstable, active gastrointestinal bleeding) 10. Patient unavailable throughout the day 11. Staffing (registered nurse, PT, and OT) unavailable throughout the day 12. Patient declined mobilization throughout the day 13. Patient is too weak to progress to higher level of mobility 14. Other barrier not listed above 15. Unknown barrier AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 26 Adverse Events During Mobilization 0. None 1. Endotracheal tube dislodgement 2. Tracheostomy dislodgement 3. Nasal feeding tube dislodgement 4. Oral feeding tube dislodgement 5. Percutaneous feeding tube dislodgement 6. Central venous catheter dislodgement (not femoral site), including peripherally inserted central catheter line 7. Central venous catheter dislodgement (femoral site)

8. Arterial catheter dislodgement (not femoral site) 9. Arterial catheter dislodgement (femoral site) 10. Dialysis catheter dislodgement (not femoral site), including tunneled or nontunneled 11. Dialysis catheter dislodgement (femoral site) AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 27 Summary The TRIP framework assists in making sure all patients receive the appropriate interventions by using the Four Es (engage, educate, execute, evaluate) The Four Es can be specifically applied to the practice of early mobility Engage your frontline staff by appealing to intrinsic motivators Educate your care team through the use of progressive mobility protocols and by reviewing current literature Execute by reviewing policy and procedures, implementing multidisciplinary rounds, and learning from defects Evaluate your progress by assessing measures regularly and using data to follow

performance trends To apply the Four Es, use a daily early mobility data collection form to easily record information on a patients highest level of mobility, barriers to higher levels of mobility, and any adverse events that occurred as a result of early mobility efforts AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 28 References 1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008 Oct 6;337:a1714. PMID: 18838424. 2. Needham DM, Korupolu R. Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model. Top Stroke

Rehabil. 2010 Jul-Aug;17(4):271-81. PMID: 20826415. 3. Early Progressive Mobility Protocol. Aliso Viejo, CA: American Association of Critical-Care Nurses. April 2013. http://www.aacn.org/wd/practice/docs/tool%20kits/early-progressive-mobilityprotocol.pdf . Accessed June 14, 2016. 4. Bassett RD, Vollman KM, Brandwene L, et al. Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): a multicentre collaborative. Intensive Crit Care Nurs. 2012 Apr;28(2):88-97. PMID: 22227355. AHRQ Safety Program for Mechanically Ventilated Patients Four Es of Early Mobility 29

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