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ntensive and Critical Care Nursing (2012) 28, 88—97

Available online at www.sciencedirect.com

j o ur nal homepage: www.elsev ier .com/ iccn

ntegrating a multidisciplinary mobility programmento intensive care practice (IMMPTP): A multicentreollaborative

ick D. Bassetta,1, Kathleen M. Vollmanb,∗, Leona Brandwenec,2,heresa Murrayd,3

190 E. Bannock St., Boise, ID 83712, United States17139 Victor Drive, Northville, MI 48168, United States1844 Autumnwood Drive, State College, PA 16801, United States1500N. Ritter Ave, Indianapolis, IN 46219, United States

KEYWORDSMobility;Early ambulation;Physical therapy;Early mobility;Immobility;Culture;Intensive care;Critical care;Performanceimprovement;Quality improvement

SummaryBackground: ICU immobility can contribute to physical deconditioning, increased ICU and hospi-tal length of stay and complications post discharge. Despite evidence of the beneficial outcomesof early mobility, many ICUs and providers lack necessary processes and resources to effectivelyintegrate early mobility into their daily practice.Objective: To create a progressive mobility initiative that will help ICU teams to address keycultural, process and resource opportunities in order to integrate early mobility into daily carepractices.Methods: An initiative to integrate the latest evidence on mobility practice into current ICUculture in 13 ICUs in eight hospitals within the US was launched. A user-friendly, physiologicallygrounded evidence-based mobility continuum was designed and implemented. Appropriate edu-cation and targeted messaging was used to engage stakeholders. To support and sustain theimplementation process, mechanisms including coaching calls and various change interventionswere offered to modify staffs’ practice behaviour. Qualitative data was collected at two timepoints to assess cultural and process issues around mobility and provided feedback to the stake-holders to support change. Quantitative date on ventilator days and timing of physical therapy

consultation was measured.Results: Qualitative reports of the mobility programme participants suggest that the methodsused in the collaborative approach improved both the culture and team focus on the process ofmobility. There were no significant differences demonstrated in any of the mobility interventiongroup measurement however, a reduction in ventilator days (3.0 days pre vs. 2.1 days post)approached significance (p = 0.06).

∗ Corresponding author. Tel.: +1 313 570 1450.E-mail addresses: bassettr@slhs.org (R.D. Bassett), kvollman@comcast.net (K.M. Vollman), leona@brandwene.com (L. Brandwene),

murray@ecommunity.com (T. Murray).1 Tel.: +1 208 381 1193.2 Tel.: +1 860 970 4418.3 Tel.: +1 317 355 4258.

964-3397/$ — see front matter © 2011 Elsevier Ltd. All rights reserved.oi:10.1016/j.iccn.2011.12.001

IMMPTP: A multicentre collaborative 89

Conclusion: This multi-centre, ICU collaborative has shown that improvements in team culture,s cans res

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Development of an evidence-based mobility

communication and resource© 2011 Elsevier Ltd. All right

Introduction

Immobility plays a significant role in Intensive Care Unit(ICU) acquired weakness and long term physical dysfunc-tion (De Jonghe et al., 2007; Greenleaf and Kozlowski,1982; Kortebein et al., 2007; Schweickert et al., 2009).Physical inactivity also contributes to the development ofatelectasis, insulin resistance and joint contractures (Clavetet al., 2008; Hamburg et al., 2007). The short-term nega-tive outcomes for critically ill patients included ventilatorand hospital acquired pneumonia, delayed weaning relatedto muscle weakness and the development of pressure ulcers(Morris, 2007; Reddy et al., 2006; Schweickert et al., 2009;Topp et al., 2002; Vollman, 2006). Lack of early ICU mobil-ity was an independent predictor for readmission or death inpatients with Acute Respiratory Failure (Morris et al., 2011).The major long term complication is the impact on qualityof life after discharge due to the physical de-conditioningthat takes place during the ICU stay (Dowdy et al., 2005,2006; Herridge et al., 2003, 2011; Hopkins et al., 2005)..

Numerous studies support the importance of incorporat-ing early mobility programmes in conjunction with sedationprotocols within the ICU to improve outcomes. Earlymobility programmes have been shown to result in greaterventilator free days, decreased incidence of VentilatorAcquired Pneumonia (VAP), fewer skin injuries, reduced ICUand hospital length of stay, decreased duration of deliriumand improved physical functioning before and after dis-charge from the hospital (Bailey et al., 2005; Greenleaf,1997; Morris et al., 2008; Martin et al., 2005; Needham,2008; Needham et al., 2010; Thomsen et al., 2008).

Mobilisation of critically ill patients must be viewedalong a progressive continuum based on readiness, specificpathology, strategies to prevent complications and abilityto tolerate the activity/movement. Progressive mobilityis a series of planned movements in a sequential mannerbeginning at a patient’s current mobility status with a goalof returning to baseline status. Progressive mobility encom-passes a wide breath of mobility techniques ranging fromhead of bed elevation, range of motion, continuous lateralrotational therapy (CLRT), tilt training, dangling, chair posi-tion and ambulation on or off the ventilator (Vollman, 2010).There are a number of barriers to progressive mobility withinan ICU environment. Barriers included clinicians’ knowledgedeficits, sedation practices, lack of human and equipmentresources, patient physiologic instability and ICU unitculture (Hopkins et al., 2007; Morris, 2007; Needham, 2008;Stiller, 2007; Vollman, 2010). The gap between researchand practice is a consistent challenge in health care(Bodenhimer, 1999), and altering well-established routinesand patterns of care requires a comprehensive approach toinstituting not only individual behaviour change, but systems

that support a shift in group norms (Grol and Grimshaw,2003). Clinicians burned out by competing demands forchange can be susceptible to responding in a minimal,‘ritualistic’ manner to new institutional demands (Cole,

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000) rather than investing the energy necessary to adopthe attitudinal and behaviour changes that accompany ahift in clinical practice, such as patient mobility.

A multicentre collaborative was undertaken to introducen evidence-based progressive mobility programme whilstimultaneously addressing cultural change within the ICU. Aollaborative is designed to help organisations close the evi-ence gap by creating a structure in which interested units,eams or organisations can easily learn from each other androm recognised experts in topic areas where they want toake improvements (Plsek, 2000).

rogramme design

he planning and implementation of the mobility initiativeook place over 14 months. Importantly, the purpose of thenitiative was not the discovery of new knowledge regardingarly mobilisation of critically ill patients, but the integra-ion of existing research into daily practice at the bedside.articipant ICUs were from organisations that belongo VHA® Inc., a national alliance of community-owned,ot-for-profit healthcare institutions consisting of largecademic centres to small rural hospitals and integratedealthcare systems. The VHA® membership represents

quarter of the Unites States (US’s) community-ownedospitals, and through the VHA® Critical Care Innovationetwork (CCIN), intensive care teams share improvementtrategies and participate collaboratively in various clinicalnitiatives. Some of the previous clinical initiatives includedmplementation of the ventilator, central line and sepsisundles. The CCIN group selected progressive mobilityhrough a voting process.

In an effort to facilitate internal buy-in for progressiveobility, VHA® staff and subject matter experts provided

ocal champions with key aspects of the initiative and thenformation to help build the business case. Executive,hysician, unit leadership and staff support were identifieds key stakeholders necessary for success in securing com-itment. Concurrently subject matter experts in intensive

are practice, mobilisation of critically ill patients, pro-ramme development and organisational change coachingompleted the initial programme design. Thirteen ICU teamsanging from trauma, medical and mixed to surgical andardiovascular ICUs, and representing eight different hospi-als, participated in the mobility initiative. The structure ofhe initiative included the creation of a progressive mobil-ty tool, a face to face workshop, development of targetessaging and continuing education, cultural interventions

o support the integration of new practice behaviours, androcess and outcomes measurement.

ontinuum

he Progressive Mobility Continuum tool (Fig. 1) waseveloped based on a review of the literature and was

90 R.D. Bassett et al.

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Figure 1 Progress

esigned to address the complete continuum of mobilityn the critically ill patient (Morris et al., 2008; Needhamt al., 2010; Schweickert et al., 2009; Thomsen et al.,008). The continuum also addressed the phases of mobilitynd related elements and provided a visual tool. The toolelped to guide mobility practice, increase consistency,acilitate team communication and enhance care processeso improve ICU mobility. Daily assessment by the staff of theatient’s mobility level was essential to evaluate changes inondition and help design daily mobility goals. The mobilityevels provided staff with objective step-based criteriahat promoted patient safety and allowed for incrementaldvancement of physical activity, based upon the staffssessment of the patient’s tolerance. (Bailey et al., 2007;onvertino et al., 1990, 1997; Stiller et al., 2004).

A central operational feature of the mobility continuum ishe use of an objective score to evaluate agitation and driveatient-specific sedation needs. If agitation is not effec-ively managed, it can impede the success of a mobilityrogramme (Morris, 2007). The Richmond Agitation Sedationcore (RASS) was the agitation sedation scoring tool inte-rated into the continuum (Ely et al., 2003). Other versions

f the mobility tool were made to accommodate for dif-erent sedation scales being used by some teams including,he Motor Activity Assessment Scale (MAAS) and Sedationgitation Scale (SAS) (Devlin et al., 1999; Riker et al., 1999).

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obility continuum.

orkshop/education

he face to face collaborative meeting ‘‘kicked off’’ thenitiative. Didactic material included background informa-ion discussing mobility in the ICU, its impact on patients,nd evidence supporting key practice elements. An emo-ionally compelling presentation during the first day wasrom a former patient who shared her experience of aurbulent ICU stay and the impact of immobility on her sub-equent recovery. Teams were presented with a ‘‘tool kit’’hich provided them with essential elements required to

mplement the initiative within each ICU. This tool kit pro-ided basic programme development guidelines designed tomphasise unit strengths and identify potential barriers toobility. Operational aspects of the collaborative, monthly

onference call schedules, data measurements and submis-ion timelines were presented, discussed and collectivelyatified. The group decided on having separate monthlyonference calls, one to address clinical strategies and ques-ions and the second to discuss operational and culturalhallenges.

On the second day of the workshop an interactive coach-

ng session provided teams with basic culture conceptsnd tools to help establish effective processes to supporthanges that would be necessary throughout the initiative.uring this time they shared challenges, questions and

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IMMPTP: A multicentre collaborative

concerns regarding changes that would need to take placein order to create a culture of progressive mobility intheir unit(s). Many of these challenges and issues providedcontent for upcoming conference calls. The workshop wasconcluded with an action planning session where eachteam was instructed to create objective goals, identifystakeholders; assign process owners and time-lines. Theteams returned home and work began within each ICU tobuild their ‘‘core’’ mobility workgroup. Common steeringcommittee roles included the programme coordinator,physician champion, physical therapy, respiratory therapy,unit leadership and nursing staff. Incorporating occupationaltherapists (OT) and physical therapists (PT) in the educa-tion process was important to help ICU staff understandthat early and safe mobility can be done. Tactics utilisedto engage and educate included presentations, posters,computer-based learning modules and 1:1 ‘‘how-to’’instruction.

Support elements

Each month, teams participated in a separate Coaching andStrategy call. The Coaching calls were designed to provideteams with tools, resources, and a discussion forum that sup-ported their ability to effect culture change (the ‘‘people’’side), whilst the Strategy calls focused on clinical content,data collection and evaluation. Both types of calls heav-ily emphasised team contribution and exchange of ideas inorder to capitalise on the strength of a collaborative com-munity. A list serv was created to support communicationand sharing amongst teams separate from the structuredcalls.

The monthly Coaching call format generally followeda three-part approach: (a) an organisational developmenttool or concept that provided teams with an opportunity tomove their culture towards the desired change, (b) teams’roundtable contributions of ideas and challenges with groupresponse and support, and (c) teams’ verbal commitment toa course of action resulting from call learnings. A strengths-based or appreciative approach which encouraged unitsto identify areas of high performance in patient mobility,examine what facilitated that high performance, and spreadit to other areas of the unit was emphasised (Cooperrideret al., 2008).

The monthly Strategy calls provided a forum for theteams to discuss planning, implementation and evaluationof the clinical aspects of the initiative. Agenda items weredesigned to encourage open discussion of potential barriersto implementation, logistical issues that teams encoun-tered, and successes experienced by individual teams. Thisexchange of ideas and experiences and the sharing ofteams’ internally-developed tools and forms, acceleratedand streamlined the improvement process. These two typesof monthly calls allowed the experts to identify issues andmitigate them.

From the beginning of the initiative, teams contributedsolutions and elements of innovation that enriched the

overall programme. Teams that were further along inthe process were able to share their experiences andserve as a resource to their peers throughout the pro-ject.

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91

uilding the culture

he sustainability of any performance improvement ini-iative relies, in part, on the degree to which behaviourhanges are integrated into a supportive culture (Schein,004). Behaviour change requires energy: attitudinalhange, practising where new skills are lacking, and estab-ishing new routines and care practices. Asking clinicianso invest this energy ‘‘in spite of’’ cultural messaging tohe contrary diminishes the likelihood of their long-termngagement; and over time, behaviours will revert (Cole,000). To maximise the likelihood of long-term sustain-bility of patient mobility, teams attended to unit culturend cultivating an environment that supported patientobility.Monthly Coaching calls focused on the following cultural

lements: involvement of the learner; positive role models,ractice fields, coaches and feedback; and rewards and dis-ipline that support the new way of behaving (Schein, 2004).uring calls, new frameworks and tools for shifting cultureere presented and discussed, and teams then customised

hese approaches. Fig. 2 shows an example of a learn-ng progression that enabled team leaders to assess staffrogress and provide them with tailored teaching, coachingr monitoring that built their competency. Teams integratedhis progression and developed unique approaches for peeroaching that created a safe environment within which toractice skills. For rewards and incentives to support mobil-ty, teams created unique incentives that both engaged staffnd made it ‘‘fun.’’ At one institution, when consistentobility efforts were noted for a single patient, the care

taff were given M&M’s® to signify effective ‘‘movementnd mobility.’’ When the whole team worked to mobilise

patient they were rewarded with a team candy called‘Three Musketeers®.’’

These creative approaches served multiple purposes:hey forged common expectations for early patient mobil-ty, they provided a visible recognition of behaviours thateflected mutual accountability amongst all team mem-ers and they created a stronger culture of respect andnderstanding of all care roles within the intensive carenit. Unique strategies such as these resulted in reportedncreases in team communication and patient care efficien-ies.

ualitative results

eams completed a single, mid-point assessment of theirhange process milestones to assist faculty in monitoringeam status and course-correct the initiative if necessary.ormal population-wide culture or climate surveys of unittaff were not conducted, due to limited consensus in the lit-rature regarding reliable tools (Gerson et al., 2004) and toimit the burden of data collection on the teams. A qualita-ive collection of teams’ effective practices was conductedt the close of the initiative. Teams reported that the mostffective strategies to engage their team or advance success

ncluded a variety of recommended practices. Foremost,ommunication and collaboration amongst all disciplinesphysicians, nurses, RT, PT) was critical, and in particular,upport from and collaboration with physical therapy was

92 R.D. Bassett et al.

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ited by many teams as a facilitator. The visual display ofhe mobility tool at the bedside as well as the use of peeroaches and mobility ‘champions’ for 1:1 and small-groupeaching and coaching to integrate and practice new learn-ngs was also identified by teams as a better practice. In 1:1ommunications, teams emphasised positive reinforcementf learning and progress rather than policing failures. Toecure buy-in, teams emphasised the evidence surrounding

arly mobility and safety through education and 1:1 com-unication. They maintained buy-in by engaging staff in theork of improvement (data collection, etc.) and integrating

fun’ elements (candy and incentives). The collection and

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haring of performance data with the unit staff on a reg-lar basis were critical in ensuring patient mobility was ariority.

Teams identified additional elements for sustainabil-ty and continued patient mobility improvement. Thesencluded: an emphasis on nurse-to-nurse reporting, integra-ion of mobility into the ‘‘fabric’’ of daily work, rounds,tandards of care, patient care plans, removing ‘‘bed rest’’

eferences from order sets, and documentation and integra-ion of mobility into electronic medical records. Many notedhey would continue to ‘‘meet staff where they are’’ andustomise coaching.

IMMPTP: A multicentre collaborative 93

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Challenges that teams faced included resourcing theincreased time and staffing demands of patient mobilityand lack of equipment (overhead lift equipment, etc.). Interms of unit culture, staff fears and perceptions, especially(1) fears of compromising patient safety and (2) percep-tions that ‘‘rest = healing’’ were barriers that needed to beaddressed. In addition, overcoming family perceptions thatloved ones were too uncomfortable being moved or ‘‘toosick’’ required discussion. Some units cited inconsistentsupport from physicians that resulted in mixed messagesfor staff members. Ensuring appropriate documentation ofpatient progress on the continuum was another constraintrelated to time investment. Staff were challenged to makesense of how patient mobility ‘‘fit’’ whilst competing withother change initiatives. Survey results to evaluate the roleof PT and OT in each respective unit identified that themajority of the organisations in the cohort have limitedresources to support the initiation of mobility in the ICU.In most cases a physician order was consistently required toinitiate the PT/OT consult.

Quantitative results

Measurements were chosen based on key elements andprocesses identified by the collaborative based on recent

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obility literature (Morris, 2007; Needham et al., 2010;chweickert et al., 2009). Two types of data were collected,etrospective chart abstraction and concurrent direct obser-ational data (Figs. 3 and 4). Each unit collected data on0 patients during a 30 day period. Patient selection washosen from a representative sample based on the typicalatient acuity in their unit. The data set was comprisedf retrospective chart abstraction data on 130 patients andver 3000 hours of direct hourly patient observations. Thisata was analysed using non-parametric statistical tests.he signed rank test was used to determine whether theverage difference between pre and post data for each unitas significantly different from zero.

A trend towards significant improvement was seen inverage number of ventilator days being shorter in the postmplementation group (3.0 vs. 2.1, P = .06). Statistically sig-ificance differences were not seen with comparing averageumber of ventilator free days (1.9 vs. 3.1, P = .11), ICU mor-ality (7.7 vs. 6.2, P = .51) hospital mortality (9.2 vs. 10.0,

= .69), ICU length of stay (LOS) (5.0 vs. 5.2, P = .60) andospital LOS (8.8 vs. 9.7, P = .31).

Compliance measurements comparisons including aver-

ge days to standing (2.4 vs. 2.2, RI = 8%), number of days tombulating (2.8 vs. 2.6, RI = 7%), number of days to transfer2.32 vs. 2.26, RI = 3%), number of days to first occupa-ional therapy (OT) session (4.7 vs. 3.7, RI = 19%) and number

94 R.D. Bassett et al.

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f days to first Physical Therapy (PT) session (3.7 vs. 3.0,I = 19%) showed no significant differences. Post implemen-ation data demonstrated 57% compliance for obtaining a PTvaluation within the first 24 hour of the patient arriving tohe ICU regardless of intubation status (Fig. 5).

Observational data was collected on each patient usingourly consecutive documentation over a 24 hour period.he ‘‘current position’’ measurement included observationf patients ambulating, dangling at the bedside or in a chair,itting in the cardiac chair or positioned in the bed chair

ode. HOB and the location of the patients position was

sed to measure mobility compliance elements whilst ined. Comparisons of pre and post implementation observa-ions showed minimal clinical improvements. However, the

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ata did help teams recognise areas for ongoing improve-ent. Prone positioning and CLRT metrics demonstrated no

ubstantial impact in this initiative due to inconsistent orack of use.

iscussion

e created a multicentre mobility collaborative to deter-ine if real life application of the evidence around early ICU

obility would be positively impacted by utilising a struc-

ured process that included; a comprehensive tool kit, bionthly team communication, expert clinical & organisa-

ional change support and coaching around implementation,

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barriers and culture change. We demonstrated a 57% con-sultation rate of physical therapy on day one of ICU staywhich is similar or higher than previously reported stud-ies. Schweickert et al., 2009 demonstrated that when earlyassessment, sedation management and PT consultation wasstructured; the patients received their first PT session anaverage of 1.5 days from time of intubation versus inthe control groups which was 7.4 days. In addition wedemonstrated similar results seen in research studies onearly mobility with a trend towards significant reduction inventilator days for patients receiving an early mobility pro-gramme (Bailey et al., 2005; Greenleaf, 1997; Martin et al.,2005; Morris et al., 2008; Needham, 2008; Needham et al.,2010; Thomsen et al., 2008). The progressive mobility toolhelped to force-function a daily structured assessment ofcurrent mobility status which supported the critical thinkingprocess by the nurse and team to ensure effective and safeevaluation of the mobility level. The success and sustain-ability of any complex practice change requires engagementof all the stakeholders; ensuring adequate evidence-basedknowledge and skill to perform the task and change per-ception of barriers as well as resources and systems built toreinforce the practice change (Vollman, 2009). To our knowl-edge, this is the first attempt at a multi-centre improvementcollaborative on early mobility. Needham et al. (2010) per-formed a similar Quality Improvement (QI) project withina Medical Intensive Care Unit (MICU) in a large academiccentre and was able to show marked improvement inICU delirium, functional mobility and reduction in hospitallength of stay.

As most studies on early mobility have shown, teamengagement is a critical component. The coaching and strat-egy calls provided a viable platform for learning, sharingof challenges/solutions and creation of common goals andaction plans. Access to content experts throughout the ini-tiative provided teams with ‘‘just-in-time’’ feedback toaddress opportunities, reinforce and re-educate within aspecific unit if needed. Mutual sharing of team experiencesthe improvement efforts. Collaboration with other key dis-ciplines positively impacted general ICU work culture inunanticipated ways, as mutual appreciation for the uniquecontributions of each discipline increased. This underscoredthe importance of the integration of all ICU team mem-bers in a complex initiative. Adoption of behaviour changewas facilitated by teams’ individual assessments of theirunique cultural challenges, and their customised strategiesto address their specific challenges. In particular, using amulti-faceted approach to education (both inservice and1:1), sharing data, engaging staff in the ‘‘work’’ of improve-ment, and focusing on positive reinforcement and expandingareas of success were success factors. Objective, easymeasurable data provided teams focus and the ability tobenchmark against themselves and other teams within thecollaborative.

Limitations

The units that participated in this initiative were a skilledand experienced group in clinical change processes: mostof them have progressed through a series of VHA®-ledclinical initiatives. As such, these particular unit staffs were

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ell-prepared and well-experienced in adopting clinicalerformance initiatives, and we cannot diminish the like-ihood of self-selection contributing to the success manyeams experienced in patient mobility. Shifts in culture as aesult of this patient mobility initiative additionally cannote quantified as a climate survey was not used. Neverthe-ess, activity and successes in creating culture change wereeported monthly by teams during calls, providing facultyith an opportunity to monitor progress and provide toolsnd strategies that met the unique needs of the teams. Theonthly reports, the mid-point assessment of progress and

he qualitative post-initiative feedback from teams paint picture of the teams’ significant progress in integratingatient mobility as a sustainable clinical practice, ratherhan a brief and unsustainable effort.

This project was designed as a performance improvementnitiative using a pre-post measurement design. Data wasollected at each participant site by hospital staff. whilstpecific data collection and entry instructions were providednd discussed on conference calls there was no additionalraining or a designated data collector. This may haveesulted in inconsistent or inaccurate data. Additionally, theata was aggregated at each site and then submitted toCIN faculty for cohort-wide data aggregation and analysis.he site aggregation limited the ability to statistically anal-se data based on individual patient process and outcomendicators which could have resulted in different statisticalignificance. Lack of inclusion of severity of illness or patientiagnosis limited our ability to measure the effect of acuityn overall results. Additionally, survey data was not statis-ically analysed, although that is in keeping with typicalerformance improvement data collection (differentiatedrom research). It did serve as a way to capture performancerends and enable teams to course-correct based on thatnformation.

ext steps

rospective randomised multicentre trials are needed torovide definitive data on the clinical, cultural and financialmpact of an integrated progressive mobility programme. Aumber of the teams that participated in this initiative havelready begun to expand mobility efforts beyond the wallsf the ICU. The value of early ICU mobility and sustainingrogressive mobility to hospital discharge on recovery, fallates, morbidity, mortality and post discharge functioningeeds to be studied.

onclusion

he ICU Progressive Mobility Collaborative provided teamsith key information on understanding the impact of early

CU mobility and the opportunities to change practice withinheir ICUs. With the emphasis on frontline caregiver empow-rment to drive mobility using an evidence-based guide,he teams were able to integrate safe mobilisation prac-ices in a shorter time frame than they had prior to the

roject. The ability to overcome barriers and demonstrate

trend towards improved outcomes helped some teamsuild the business case to add additional personal and equip-ent resources. This initiative demonstrates that focusing

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n improving early mobility also yields improvements ineam dynamics and culture within the ICU.

onflict of interest

ick Bassett VHA®, Inc. Consultant; Kathleen Vollman:ill-Rom® Inc, Speaker Bureau and Consultant & VHA®,

nc. Consultant; Leona Brandwene, VHA®, Inc. Consultant;heresa Murray VHA®, Inc. Consultant.

cknowledgements

ichele Wagner and ICU team from Ball Memorial Hospitaln Indianapolis, IN.

Pam Zinnecker and ICU team from Billings Clinic inillings, Montana.

Denise Moeschen and ICU team from Bryan LGH Healthystem in Lincoln, NE.

Lori Oross and ICU team from Franklin Square Hospital inaltimore, MD.

Cheryl Anderson and ICU team from Sanford Health inargo, ND.

Michael Terracina and ICU team from Munroe Regionaledical Center in Ocala, FL.

Rick Bassett and ICU team from St. Luke’s in Boise anderidian, ID.

Bettyann Kempin and ICU team from Valley Hospital inidgewood, NJ.

Bonnie Lind, PhD, Biostatistician, St. Luke’s Health Sys-em, Boise, ID.

Rosemary Ingle, VP, National Network Services, VHA® Inc.rving, TX.

Heather Starks, Project Manager, Network Services, VHA®

nc. Irving, TX.

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