Walk This Way Early Progressive Mobility in the ICU

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2 Walk This Way Early Progressive Mobility in the ICU

3 Duke Raleigh Hospital: Early Progressive Mobility in the Medical-Surgical ICU Katherine Geyer, RN, BSN, CCRN, CSI Kerrie Klepfer, RN, BSN, CSI Jennifer Leblanc, RN, BSN, CCRN, CSI Craig Sibbach, RN, BSN, CCRN, CSI

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5 Our Environment Duke Raleigh Hospital Community hospital within the Duke University Health System 186 beds 15 bed Intensive Care Unit Population: Medical-Surgical Medical: Cardiac, Neurological, Pulmonary, G.I., Oncology Surgical: Neurosurgical and Neurovascular, Thoracic, Interventional Cardiology, Vascular, Orthopedic and Spine, Colorectal, Urology, General

6 Identified Problem Consulted Interdisciplinary Team Identified an area of improvement based on feedback from our surgeons, MDs, and NPs: MOBILITY Found that patients were frequently not meeting mobility goals based on standard orders alone (example: OOB to chair BID, ambulate in hall TID, etc.) Began asking why and investigating: Literature reviews, NTI 2012 ABCDE Bundle (E = Early Exercise and Progressive Mobility) After discovering for ourselves the systemic effects of immobility, we accepted the challenge of changing a practice pattern.

7 Purpose and Goals The purpose of this project was to increase the mobility in our ICU population. Goals for Target Population Increase mobility in our ICU population of mechanically ventilated and surgical patients Decrease ICU length of stay (LOS) Decrease mechanical vent days by 10% Increase positive patient outcomes (by decreasing HAIs and complications) Decrease total cost of ICU stay

8 Purpose and Goals Goals for our ID Team: Change and advance our unit practice to align with evidence-based research Educate > 50% of our Interdisciplinary Team

9 Walk This Way Not just a catchy Aerosmith tune Re-framing the way our team thinks about mobilizing the critically ill patient Providing our unit with a framework for progressing patients from bed rest to an up-right, out-of-bed position, following a series of defined positions and exercises Once a patient tolerates being out of bed, our goal is ambulation and a return to his or her baseline mobility status

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11 Action Plan Key Activity Identifying topic, conducting literature review, defining Early Progressive Mobility (EPM) Discussing Sacred Cows with key players: coaches, nursing staff, nursing administration, Intensivists, NPs, Surgeons, RT, PT, OT Protocol, Patient and Family Education Brochure, and electronic MR documentation developed Test of change conducted: First vented patient OOB and ambulating in the hallway Date October to December 2012 October to December 2012 January to March 2013 March 2013

12 Action Plan Key Activity Pre-project survey sent to gauge staff perceptions, fears, and suggestions T-shirts, rewards, wristbands, audit tools, and logo created Kick off events and staff education (All day catered event with games, prizes, and fun!) Date March 2013 March to April 2013 April 8 and 10, 2013 Protocol Go Live date in the ICU April 16, 2013 Continual staff reward board with monthly prizes and patient rewards and incentives March 2013 to Present

13 Action Plan Key Activity Date Mid-way project survey sent July 2013 Re-education at monthly staff meeting and via s July 2013 CSI project data collection end date October 16, 2013 Rewards given to outstanding mobility champions November 2013 Post-project survey sent January 2014

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18 Project Goals Short Term Goals Conduct a test of change This can be done safely, effectively, and is better for our patients. Educate > 50% of our ID Team Medium Term Goals Identify successes and barriers during re-education events and act on them Collect mid-way measurements Exceeded our initial goals

19 Project Goals Long Term Goals Continue to increase positive patient outcomes and mobility Continue utilization of an Early Progressive Mobility Protocol in our ICU

20 Challenges Data collection is time consuming Worked with performance services and utilized CSI coaches experience Surgical/post-operative outcome data difficult to measure No baseline mobility data present for broad ICU population (with exception of knowing that ventilator mobility was zero!) Mixed Patient Population in Medical-Surgical ICU Period of low census Equipment (Big Chairs) Time and workload barriers

21 Challenges Auditing Process Provider Practice Patterns Specifically RT, Rehab, Surgical Groups Fear and knowledge deficits EACH CHALLENGE WAS ADDRESSED BY RE-EDUCATION, CONSISTENT COMMUNICATION, AND INCREASED INTERDISCIPLINARY COLLABORATION

22 Budget Duke Raleigh Hospital CSI Expenses 1, CSI team salary & wages Kick-Off Food 1, , , Staff Education (badge buddies, supplies) Patient Incentives (wrist bands) Staff incentives (tshirts, gift cards) Remaining monies

23 Results Average ventilator utilization decreased from 28.3 to 25.4 Mobility in vented patients increase from 0 to 100% Outcomes in Mechanically Ventilated Patients Average Ventilator Days Average LOS on Ventilator Average ICU LOS for Vented Patients Baseline Protocol Implementation Protocol Implementation

24 Results Outcomes in Surgical Patients Average Surgical Days 641 Baseline 600 Protocol Implementation

25 Results Outcomes in Surgical Patients Average ICU Length of Stay Baseline Protocol Implementation

26 HAIs and Complication Reduction Since EPM Protocol Implementation 0 Pressure Ulcers! 0 Falls! (In patients with EPM protocol initiated) 0 VAPs! (Ventilator Associated Pneumonia) Pressure Ulcers Falls VAPs EPM Protocol not solely responsible for these numbers; these numbers reflect EPM Protocols contribution to overall quality of ICU care.

27 Fiscal Impact of our EPM Protocol in ICU Outcome Average Cost Savings Decreased vent days by 14 $1,522* $21,308 Decreased ICU LOS by 1 for vented patients (patient volume = 100) Decreased ICU LOS by 0.7 days for surgical patients (patient volume = 73) $3,500* $350,000 $3,500* $178,850 Decreased VAPs by 2 to 0 $9,076** $18,152 Decreased pressure ulcers from 1 to 0 $43,180*** $43,180 Decreased falls from 1 to 0 $9,491** $9,491 Using incremental cost with comparable control group. * Dasta, 2005 ** CMS, 2012 *** AHRQ, 2011

28 Overall Fiscal Impact The overall cost savings (adding up all cost savings for the 6 month project timeframe) = $620,981 Therefore, the fiscal impact is a cost savings for 1 year of the intervention = $1,241,962

29 Unexpected Qualitative Outcomes Protocol was met with excitement from patients and families HCAHPS Scores increased Commitment and support from ID team Support from Duke University Health System Duke Nursing QuERY Day spotlight Duke Nurses Week Posters Featured write-ups in newsletters and health system blogs Health System Triangle State Level Collaboration National Level: NTI 2014 in Denver, CO Strengthened ICU team that recognizes each others unique qualities, capabilities, and limitations.

30 Unexpected Qualitative Outcomes Duke Raleigh Hospital Intensive Care Unit HCAHPS 3 months Intensive/Critical Care Overall Info given to family while in ICU* Skill of ICU/CCU nurses* Baseline Protocol Implementation

31 Unexpected Qualitative Outcomes Duke Raleigh Hospital Intensive Care Unit HCAHPS 6 months Intensive/Critical Care Overall Info given to family while in ICU* Skill of ICU/CCU nurses* Baseline Protocol Implementation

32 Interdisciplinary Team Surveys 100% 80% 81% 100% 100% 60% 40% 20% 0% 19% 0% 0% Familiar with EPM Beneficial to Patients Important to You Yes No Pre-protocol implementation surveys were collected using Survey Monkey.

33 Interdisciplinary Team Surveys Factors that would enhance EPM in ICU 100% 95% 87% 80% 60% 73% 62% 70% 76% 40% 20% 0% Time Teamwork Physician Orders Patient/ Family Acceptance Nursing Initiative Stable Hemodynamics Pre-protocol implementation surveys were collected using Survey Monkey.

34 Post-Protocol Implementation Survey Results 100% 80% 60% 40% 20% 0% 81% 15% 2% Substantial Impact on Mobility 62% 51% 64% 26% 26% 28% Sufficient Protocol Education 9% 11% Sufficient Documentation Education Agree Neutral Disagree Satisfied with Protocol 43% 34% 6% 4% Satisfied with Documentation Mid-way and Post-protocol survey data were collected and managed using REDCap (Research Electronic Data Capture) tools hosted at Duke University.

35 Post-Protocol Implementation Survey Results 30% 25% 23% 26% EPM Obstacles 20% 15% 15% 13% 10% 5% 8% 6% 0% Equipment Collaboration Staff Comfort with Mobilizing Vented Pts. Additional Documentation Burden No Obstacles Other Mid-way and Post-protocol survey data were collected and managed using REDCap (Research Electronic Data Capture) tools hosted at Duke University.

36 Post-Protocol Implementation Survey Results Comfort Level Mobilizing Surgical and Vented Patients 4% 42% 53% Very Comfortable Neutral Uncomfortable Mid-way and Post-protocol survey data were collected and managed using REDCap (Research Electronic Data Capture) tools hosted at Duke University.

37 Provider Testimonials The EPM protocol has put mobility, which is so important to outcomes, in the forefront with VAP prevention. We are more cognizant of it as a standard part of our daily care for ALL patients instead of just some. With the EPM order set, nurses are more empowered to begin mobilizing their patients. - Maria Sealey, ICU Nurse Practitioner

38 Provider Testimonials... improvement in oxygenation, lung expansion, decrease in vent settings due to increased respiratory muscle building. Also the best outcome is the increase in patient confidence and improved quality of life. EPM has raised the bar in the ICU. - Becky Kandler, Respiratory Therapist

39 Provider Testimonials I believe patients are getting mobilized sooner overall in their stay, as well as more appropriately. The coordination between nursing, respiratory and rehab services has been much improved with greater expectations for all disciplines and to the patients' benefit, and there is a more excited anticipation versus dread of mobilizing patients which promotes staff retention... it seems there is less ICU psychosis in the longer term patients as well. - Tara Jennette, Acute Rehab Team Leader

40 Provider Testimonials It sets a standard for patient care and serves as a guideline for everyone to follow, ensuring that mobility is achieved appropriately and timely to increase patient safety and improve outcomes. As a therapist, I am thrilled to come to the ICU and find that patients have already been mobilizing with nursing staff. - Sherry Foster, Manager of Acute Rehab Services

41 Provider Testimonials Families are always so surprised that we do this, mobilize our vented patients. When we explain it to them, they are so surprised that a nurse can do this, so yes, I think it has impacted their perception of our skill level. I can visibly see the increased mobility across the entire unit. EVERYONE gets ambulated now, not just the post-operative patients whose surgeons write specific orders. So yes, I would also say that our standard of care is higher. - Robin Fichuk, BSN, RN, CCRN

42 Patient Stories It is not length of life, but depth of life. - Ralph Waldo Emerson

43 Lessons Learned Our bedside nursing team can positively affect change on a large scale. Developed and implemented a sophisticated protocol Provided interdisciplinary education Our ICU team enthusiastically supported our hard work and met challenge of practice change with excitement. Providers across the hospital are wowed each time they see a vented patient walking through the unit. We are fortunate to receive tremendous support at every level, from NA to CNO and CEO. We gained understanding and empathy for different roles played by hospital colleagues.

44 Lessons Learned The difference on the unit, to us, is palpable. RNs more directly involved in different aspects of care Increased time spent in the room with patients Enhanced skill level and standard of care across ICU spectrum Being a part of a team changing bedside practice has created and increased investment in our own nursing practice. Exposure within our health system Inspires more future change and collaboration Forces insight on the impact nurses can make

45 References Agency for Healthcare Research and Quality (AHRQ). How Will We Manage Change?: Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care Accessed March 23, American Association of Critical-Care Nurses. (2013). Early exercise and progressive mobility (E). Retrieved from Centers for Disease Control and Prevention. (2013). Costs of falls among older adults. Retrieved from Dasta, J.F., McLaughlin, T.P., Mody, S.H., & Piech, C.T. (2005). Daily cost of an intensive care unit day: The contribution of mechanical ventilation. Critical Care Medicine, 33(6), Duke Infection Control Outreach Network. (2012). Retrieved from Early Progressive Mobility Survey. (2013). Survey Monkey Inc., Palo Alto, California, USA.

46 References Harris, P.A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J.G. (2009). Research electronic data capture (REDCap): A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), Joint Commission Resources. (2013). Resources for managing hospital acquired conditions: Pressure ulcers. Retrieved from Norris, C., Jacobs, P., Rapoport, J., & Hamilton, S. (1995). ICU and non-icu cost per day. Canadian Journal of Anesthesia, 42(3), Noseworthy, T.W., Konopad, E., Shustack, A., Johston, R., & Grace, M. (1996). Cost of accounting of adult intensive care: Methods and human and capital inputs. Critical Care Medicine, 24(7), Research Triangle Institute for Center for Medicare & Medicaid Services. (April 18, 2012). Analysis report: Estimating the incremental costs of hospital-acquired conditions (HACs). Retrieved from Payment/HospitalAcqCond/index.html Pfunter, A., Wier L.M., M.P.H., & Steiner, C., M.D., M.P.H. (2013). Costs for hospital stays in the United States, Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project: Statistical Brief #146, Jan (p. 1-11).

47 Questions?