Nurse Driven Mobility Protocol

Sandy Gandee RN, ACNS-BC Cristiane Fukuda RN-C, ANP-BC

Objectives

• Describe the effects of immobilization in the overall health outcomes of hospitalized adults.

• Present Northside Hospital Mobility Protocol (PM) “STEP IN”.

• Discuss recommendations for successful implementation of a MP.

• Review patient outcomes related to the MP implementation in 2 medical-surgical pilot units.

The Need for MP

• Literature review:– Bed rest in hospitalized patients

leads to an increase in hospital acquired complications such as venous thrombosis, falls and hospital acquired pneumonia.

– There are benefits of an early mobility protocol for ICU patients but comparably little has been published regarding the benefits of mobility for the med-surgical population.

– Early mobilization through standardized mobility protocols or programs can improve patient outcomes.

• Our own observations:– Pneumonia DSC Program

Indicators.– Falls and Readmission data

• Evidence of functional decline.

Functional Decline

• Occurs when a patient is unable to perform activities such as eat, bathe, dress, walk and take medications.

• Deconditioning and functional decline from baseline have been found to occur by day 2 of hospital stay in older patients.

• One day of bed rest requires 3-5 days to regain strength.• Function does not return to baseline by the time of

discharge without aggressive intervention to prevent the loss.

Fischer, S.R., Kue, Y.F., Graham, J.E., Ottenbacher, J.K., & Ostir, G.V. (2011). Early ambulation and length of stay in older adultshospitalized for acute illness. Archives of Internal Medicine, 170, 1942-1943

Winkelman, C. (2009). Bed rest in health and critical illness. AACN Advanced Critical Care, 20, 254-266

Functional Decline

• Hospitalization poses a risk for altered functional status due to acute illness and decreased mobility– Use of prolonged bed rest.– Physical restraints.– Use of devices such as Foley catheters and

intravenous lines.

The Impact of Immobility

• Affects all systems• Significant effects in 2-3 days• Increases morbidity & mortality• Recovery time measured in months → years• Often overlooked

Days of Immobility Days of full recovery

0 18

7 52

14 121

21 300

Slide courtesy of Varsha M. Kanvinde

Mobility Protocol Goals “STEP IN”

S: Support independenceT: Train for care at homeE: Encourage ADLP: Prevent functional decline

I: Interdisciplinary approachN: No exclusion, no excuses

Assessment of Mobility Level

• On admission– Modified Barthel Index (MBI)– Risk to Fall Assessment– “Get-Up-and-Go-Test

• Ongoing– Risk to Fall Assessment– “Get-Up-and-Go-Test

• On Discharge– MBI– Correlate to the prediction

scores and discharge planning

Modified Barthel Index (MBI)

• Modified Barthel ADL index is a scale used to measure performance in activities of daily living (ADL).

• Each performance item is rated on this scale with a given number of points assigned to each level or ranking.

• We can use information from caregivers and family members.

• Variables addressed in the Barthel

scale are:– Chair/bed transfers– Ambulation/ Wheelchair– Stair climbing– Toilet transfers– Bowel control– Bladder control– Bathing– Dressing– Personal hygiene (grooming)– Feeding

• MBI was built into EMR

MBI

Score Interpretation

0-20 Total Dependency

21-60 Severe Dependency

61-90 Moderate Dependency

91-99 Slight Dependency

100 Independence

Shah, S., Vanclay, F., & Cooper, B. (1989a). Improving the sensitivity of the Barthel Index for stroke rehabilitation. Journal of Clinical Epidemiology, 42, 703 - 709.

Score Prediction

Less than 40

Unlikely to go homeDependent in mobilityDependent in Self Care (ADLs)

60 Pivotal score where patients move from dependency to assisted independence

60 - 80

If living alone, will probably need a number of community services to cope

More than 85

Likely to be discharged to community livingIndependent in transfers and able to walk or use wheelchair independently.

“STEP IN” Mobility ProgramFunctional Assessment

MBIGet-up-and-go

Risk to FallLevel 1

MBI: 0-60 Severe -Total DependenceGet-up-and-go: 4

- Assist to chair, wheelchair, or neuro chair at least twice a day - Use mechanical lift system

- Consider PT/OT consult

Level 2MBI: 61-99 Slight – Moderate Dependence

Get-up-and-go: 1,3- Assist to chair, wheelchair, or neuro chair at least twice a day

- Use gait belt- Ambulate in hallways, at least 2 X a day using a gait belt and or

assistive devices (as necessary)- Consider PT/OT consult

- Monitor for Functional Decline

Level 3MBI: 100 Independent

Get-up-and-go:0- Sit up in a chair and ambulate in hallways at least 3 X a day. - Ambulate with an assistive device, as necessary

- Pedometer to record progress- Monitor for Functional Decline

Road Map for Success

1. Getting unit and leadership ready2. Getting staff ready3. Identifying and managing barriers4. Monitoring Outcomes

1. Getting the Unit Ready

Meet leadership to explain components of the program. Culture change versus a program implementation. Leadership commitment and follow up with staff daily. Identification of stakeholders and “Super Users”. Identification of unique factors related to mobility for the

unit patient population. Equipment Inventory. Patient education.

2. Getting Staff Ready

Education Small Groups Didactic

Led by RNs/ PT/OT• Risk of Immobility• Benefits of Mobility• Focus-Function Care• Tools and Resources• Safe Patient Handling

– “Hands on” skill session

Follow Up Daily Huddles Staff Counseling “Mobility tips” Disciplinary action

New Hire Orientation

Resnick,B.; Galik,E.; Boltz,M. Function Focused Care approaches: Literature Review of progress and future possibilities. JAMDA 14(2013) 313-318

3. Identifying & Managing Barriers

Unit Assessment

Readiness for change

Patient Population

Resources

Culture

Organization Commitment

Unit Commitment

Interdisciplinary Team

Evidenced Based Practice

Engaged Leadership

Unit Champions

Compliance Monitoring

Data Sharing

Outcomes Revealed

Road Map for Success

Hardwiring

Recognize Success

Focus

IOFI’s

4. Monitoring Outcomes

Examples of Outcomes to Measure Length of Stay Readmission Rates Fall Rates Morbidity Delirium Sitter Rates Functional Scores Discharge Status Rehab consults

Mobility Protocol Pilot Results

Can it Make a Difference?

November

December

Jan 2nd-16th

Jan 17th-31st

Feb 1st-

7th

Feb 10-28th

Mar-14

Apr-14

May-14

Jun-14Jul-1

4

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ambulatory Linear (Ambulatory) Chair Linear (Chair)

5 C Mobility Protocol Documentation Compliance Nov 2013 - Dec 2014

Jan Feb Mar April May June July August September October November December0

2

4

6

8

10

12

14

16

18

20

2013 5C - Fall Rate/1000 Pt Days Linear (2013 5C - Fall Rate/1000 Pt Days) 2014 5C - Fall Rate/1000 Pt Days

Linear (2014 5C - Fall Rate/1000 Pt Days)

Pre-Implementation

Post Implementation

5C Falls Rate

5C Aggregate Fall Rate Jan 13- Dec 13 compared to Jan 14 –Dec 14

Aggregate Fall Rate July13-Jan14 compared to July14 -Jan15

2013 20140

2

4

6

8

10

12

10.18

6.82

33% reduction

71%

21%

8%

Modified Barthel Index ScoresCompare of scores

Upon admission to unit and discharge from unitN= 300 patients

No change In MBI Improvement in MBI Decline in MBI

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

Pre Mobility Protocol Post Mobility Protocol

2013

Decrease of 0.86 Days

2014

5 C Length of Stay Pre and Post “STEP IN” Protocol

* November and December data based on a week sample

Mobility Documentation Compliance 4W

July August September October November December January

Patient Falls per 1000 patient days 9.58 4.07 1.95 7.71 6.24 4.96 1.62

1

3

5

7

9

11

Mob

ility

Pro

toco

l

Patient Fall Rates before and after Mobility Protocol - 4W/Cherokee

4W Aggregate Fall Rate July13-Jan14 compared to July14 -Jan15

2013 20140

1

2

3

4

5

6

7

6.05

5.16

15% reduction

Questions?