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Steven Tremain, MDAugust 9, 2016
GET UP WEBINAR: “MOVE IT OR LOSE IT”CROSS-CUTTING INTERVENTIONS TO ACCELERATE IMPROVEMENT
ASHNHA
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• Edith V. Olson published this hallmark article in the American Journal Of Nursing in April, 1967
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THE HAZARDS OF IMMOBILITY
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PATHOPHYSIOLOGICAL CHANGES WITHIN 24 H OF BED REST
• Loss of bone density due to calcium loss• Risk for hip fracture doubles by week 3 of bed rest due to bone
and balance issues. (Knight 2009)• Decreased protein synthesis leads to muscle catabolism
resulting in decreased muscle mass• Muscle groups that lose the most strength are involved in
maintaining posture, transferring and ambulation • One third of ICU patients with LOS > 2 weeks had at least 2
functionally significant joint contractures. (Clavet, 2008)
Knight J, Nugam Y, Jones A. Effects of bedrest 2: gastrointestinal, endocrine, renal, reproductive and nervous systems. Nurs Times . 2009:105(22): 24-7Clavet H, et al. Joint contractures following prolonged stays in the ICU. CMAJ. 2008:178(6):691-697
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MUSCULOSKELETAL
Pressure Injury risk factors:
• Immobility - #1 risk factor for pressure injuries• Immobility contributes to pressure, shear, friction
and moisture
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INTEGUMENTARY
• “New Walking Dependence” occurs in 16-59% in older hospitalized patients (Hirsh 1990, Lazarus 1991, Mahoney 1998)
• Functional decline in older patients – 65% of patients had a significant functional mobility decline by day 2
(Hirsh 1990)• 67% showed no improvement by discharge• 10% deteriorated further
– 27% still dependent in walking 3 months post discharge (Mahoney 1998)
Hirsch C, Sommers L, Olsen A, Mullen L, Winogard C. The natural history of functional morbidity in hospitalized older patients. Journal of the American Geriatric Society 1990;38:1296-1303.Lazarus BA, Murphy JB, Coletta EM, McQuade WH, Culpepper L. The provision of physical activity to hospitalized elderly patients. Archives of Internal Medicine 1991;151:2452-2456.Mahoney JE, Sager MA, Jalaluddin M. New walking dependence associated with hospitalization for acute medical illness: Incidence and significance. Journals of Gerontology: Series A, Biological Sciences and Medical Sciences 1998;53A:M307-
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CUMULATIVE IMPACT ON QUALITY OF LIFE
• Despite what we know, hospitals are failing at mobilizing patients– Only 27% of patients who CAN walk DO walk in the hospital (Callen 2004)– Average time between manual turns in ICU 4.85 hrs (Goldhill 2008)– In an 8 hour period only 3% of the ICU patients were turned according to
the 2 hour standard and close to 50% of the patients had no change in body position (Krishnagopalan 2002)
Callen BL, Mahoney J, Grieves CB, Wells TJ, Enloe M. Frequency of hallway ambulation by hospitalized older adults on a medical unit of an academic hospital. Geriatric Nursing 2004;25:212-217.GoldhillDR,BadacsonyiA,GoldhillAA,WaldmannC.Aprospective observational study of ICU patient position and frequency of turning. Anaesthesia. 2008;63:509-515. Krishnagopalan S, Johnson W, Low LL, Kaufman LJ. Body position of intensive care patients: clinical practice versus standards. CritCare Med. 2002;30:2588-2592.
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THIS IS OLD NEWS
• 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)
Vollman, KM. Introduction to Progressive Mobility. Crit Care Nurs. 2010;30(2):53-55.
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WHAT IS PROGRESSIVE MOBILITY?
Elevate HOB
Manual turning
PROM AROM
CLRT and Prone positioning
Upright / leg down position
Chair position
Dangling
Ambulation
PROM = passive range of motion AROM= active range of motion CLRT = continuous lateral rotation therapy
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STEP 1 – SAFETY SCREENING
http://www.aacn.org/wd/practice/docs/tool%20kits/early-progressive-mobility-protocol.pdf
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STEP 2 – PROGRESS MOBILITY
http://www.aacn.org/wd/practice/docs/tool%20kits/early-progressive-mobility-protocol.pdf
• Decreased Pressure Injuries• Decreased time on Ventilator• Decreased VAP rate• Decreased days of sedation• Decreased delirium• Increased ambulatory distance• Decreased LOS
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PROGRESSIVE MOBILITY OUTCOMES
Staudinger T, Crit Care Med 2010Abroung F, Crit Care Med 2011Pohlman MC, Crit Care Med 2010Thomsen GE, CCM 2008Winkelman C, CCN 2010
• ICU Outcomes - Morris 2008– Patients out of bed earlier – Day 5 vs Day 11– Reduced ICU LOS from 6.9 to 5.5 days– Reduced hospital LOS from 14.5 to 11.2 days– No adverse outcomes
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PROGRESSIVE MOBILITY OUTCOMES
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SAMPLE MOBILITY 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.
Unconscious ConsciousConsciousConscious
• Facts:– Mobility interventions are regularly missed
• Nursing perceptions– Lack of time– Ease of omission– Belief it is PTs responsibility
• Survey results– Concern for patients level of weakness, pain and fatigue– Presence of devices – IVs and Urinary Catheters– Lack of staff to assist
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WHAT GETS IN THE WAY?
Doherty-King, B Bowers, B. How nurses decide to ambulate hospitalized older adults: development of a conceptual model. Gerontologist. 2011 Dec:51(6): 786-97
• Nursing focus in the phases of hospitalization:– Acute illness – focus is on VAP, HAPU prevention through turning– Recovery period – concern for DVT– Getting ready for D/C – functional ambulation
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FACTORS INFLUENCING NURSES MOBILIZING PATIENTS
Doherty-King, B Bowers, B. How nurses decide to ambulate hospitalized older adults: development of a conceptual model. Gerontologist. 2011 Dec:51(6): 786-97
• Unit or Organizational Factors– Availability of resources
• CNAs• Equipment
– Unit activity• High activity / acuity shifts interfere with getting patients up
– Unit or Organizational Expectations• Is expectation explicitly communicated to staff and patients
– White boards– Handoffs
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FACTORS INFLUENCING NURSES MOBILIZING PATIENTS
Doherty-King, B Bowers, B. How nurses decide to ambulate hospitalized older adults: development of a conceptual model. Gerontologist. 2011 Dec:51(6): 786-97
• RN Skill / Experience– Size matters– Rehab and LTC experienced RNs more likely to ambulate
• Patient “label”– Nursing Home residents ambulated less or not at all– Anticipated d/c to community – more likely to ambulate
• Accountability– Documentation of mobilization activities– Visibility of ambulation
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FACTORS INFLUENCING NURSES MOBILIZING PATIENTS
Doherty-King, B Bowers, B. How nurses decide to ambulate hospitalized older adults: development of a conceptual model. Gerontologist. 2011 Dec:51(6): 786-97
Falls PrU Delirium CAUTI VAE VTE Readmissions
EARLY PROGRESSIVE MOBILITY
G E T - U P
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G Go: determine the resources in your institution and how you will implement a mobility program.
E Evaluate: (patient capabilities):Which scale/tool/evaluation method will you standardize on?
T Team up for progressive mobility: rehab, nursing, and respiratory join to implement the mobility plan.
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U Unite: Engage patients, families and friends in mobility progression.
PPromote progress: Measure and report unit mobility performance.
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• 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– Sit to stand transfer device
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GO – DETERMINE THE RESOURCES NEEDED
• Select or develop a tool to assess patient readiness for early mobilization– Exercise / Mobility Safety Screen Parameters– examples
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EVALUATE
Other Screening PrametersPaO2/FiO2 > 250Peep < 10RR 10-30HR 60-120MAP 55-140SBP 90-180RASS 3 or greaterNo new or increasing vasopressors
AACN ProtocolM – Myocardial stability
• No myocardial ischemia x 24H• No dysrhythmia requiring
new antidysrhythmic x 24 HO - Oxygenation is adequate
• FiO2 > 6• PEEP < 10cm H2O
V – Vasopressors minimal• No increase of any
vasopressors x 2 HE – Engage to voice
• Patient responds to verbal stimulation
• 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
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TEAM UP
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UNITE PATIENTS FAMILIES AND FRIENDS
• Use whiteboards• Teach mobilization skills
using teach back• Proper footwear
• For individual patients– Document progression towards baseline in medical record
• Current mobility level• Activities performed• Patient tolerance• Required support and assistance• Education Given
– Use whiteboard to document current level and activity goals• Celebrate the Team’s Progress
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PROMOTE PROGRESS
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HOW DO WE GET THEM MOVING??
• http://www.hret-hen.org/topics/up_campaign/20160526-getupwebinar-english.shtml
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RESOURCES
• Position paper: Advancing the Science and Technology of Progressive Mobility http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/SafePatient/Advancing-the-Science-and-Technology-of-Progressive-Mobility.PDF
• Article: Morris P (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure. http://www.socati.org.br/aulas/fisioterapia_em_uti.pdf
• Article: Vollman K.(2010) Introduction to Progressive Mobility http://ccn.aacnjournals.org/content/30/2/S3.full.pdf
• Article: Doherty-King B (2011) How nurses decide to ambulate hospitalized older adults http://gerontologist.oxfordjournals.org/content/51/6/786.long
• John Hopkins Early Mobility Toolkit https://cdn.community360.net/app/jh/VAP/resources_e/Early_Mobility_Toolkit%206.10.14nr.docx
• Case study: Duke Raleigh Hospital: Early Progressive Mobility in the Medical-Surgical ICU http://www.aacn.org/wd/csi/docs/FinalProjects/EarlyProgressiveMobilityinICU-DukeRaleighHosp-Raleigh-Presentation.pdf28
RESOURCES
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Duke Raleigh HospitalCase Study
http://www.aacn.org/wd/csi/docs/FinalProjects/EarlyProgressiveMobilityinICU-DukeRaleighHosp-Raleigh-Presentation.pdf
