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Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients

The Four Es of Early Mobility

Slide 2: 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).

Slide 3: Translating Research Into Practice¹

Image: Graphic displaying TRIP framework:

Envision the problem within the larger framework.

Engage collaborative multidisciplinary teams centrally and locally.

1. Summarize evidence.
2. Identify local barriers.
3. Measure performance.
4. Ensure all patients receive intervention.

^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.

Slide 4: Summarize the Evidence¹

Image: Graphic displaying steps to Summarize the Evidence:

1. Identify interventions.
2. Prioritize interventions with the largest benefits and lowest barriers.
3. 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.

Slide 5: Identify Local Barriers¹

Image: Graphic displaying steps to Identify Local Barriers:

1. Observe staff performing care delivery tasks.
2. Walk the process to identify defects at each step.
3. Solicit feedback from all stakeholders.
4. 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.

Slide 6: What Are Your Barriers?²

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.

Lack of referrals and standardized documentation:

• Establish screening criteria.
• Educate about appropriate referrals.
• Clarify bed rest orders versus PT consultations.
• Chart board guidelines for mobility.

^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.

Slide 7: What Are Your Barriers?²

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.

Pain and discomfort:

• Indicate a pain protocol to titrate pain medications.

Physiological instability:

• Create guidelines for screening physiological stability.

Safety:

• 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.

Slide 8: Measure Performance¹

Image: Graphic displaying steps to Measure Performance:

1. Select process and/or outcome measures.
2. Develop and pilot test measures.
3. 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.

Slide 9: Ensure All Patients Receive the Evidence (Four Es)¹

Image: Graphic displaying steps to Ensure that all patients receive interventions:

Engage: How can we engage hearts and minds?

Educate: How can we turn the evidence into behaviors?

Execute: How can we do this?

Evaluate: 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.

Slide 10: Four Es of Early Mobility

Category: 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.

Slide 11: Four Es of Early Mobility

Category: 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.

Slide 12: Four Es of Early Mobility

Category: Execute (Adaptive)

Frontline Staff:

How will we implement early mobility at our hospital give local culture and resources?

• Listen to resisters.
• Standardize care and create independent checks.
• Make it easy to do the right thing.
• Learn from mistakes.

Early Mobility:

• Update process for mobilizing patient.
• Review policies and protocols.
• Identify key stakeholders.
• Gather appropriate equipment.
• Discuss as part of interdisciplinary rounds/daily goals.
• Learn from defects.

Category: Evaluate (Technical)

Frontline Staff:

How will we know that our efforts to mobilize our patients made a difference?

• Define measures.
• Assess measures regularly.
• Provide feedback to staff and celebrate success.

Early Mobility:

• Collect data and review with staff.
• Use your data to trend performance.

Slide 13: 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.

Slide 14: Engage All Staff

• Sitters/Observers.
• Clinical Technicians/ Nursing Assistants:
  • Ambulate.
  • Turn.
  • Range of motion.
  • Document.
• Ancillary Personnel.

Slide 15: 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.

Image: A Family Involvement Menu.

Slide 16: 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.

Slide 17: 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.

Slide 18: 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.

Slide 19: 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.

Image: Visual cues chart for an early mobility protocol.

Used with permission. Adapted at St. Joseph Mercy Hospital from the American Association of Critical-Care Nurses early progressive mobility protocol.³ Learn more at www.aacn.org.

^3. Early Progressive Mobility Protocol. Aliso Viejo, CA: American Association of Critical-Care Nurses. April 2013. . Accessed June 14, 2016.

Slide 20: Sample Early Mobility Protocol⁴

Image: Progressive mobility continuum chart.

^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.

Slide 21: 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.

Slide 22: Daily Early Mobility Measures Form

Image: Daily Early Mobility Data Collection Tool.

Slide 23: Daily Early Mobility Measures Guide

Image: Second page of the Daily Early Mobility Data Collection Tool.

Slide 24: 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.

Slide 25: Perceived Barriers

1. 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.

Slide 26: 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.

Slide 27: 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 non-tunneled.
11. Dialysis catheter dislodgement (femoral site).

Slide 28: 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 patient’s highest level of mobility, barriers to higher levels of mobility, and any adverse events that occurred as a result of early mobility efforts.

Slide 29: 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. . 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.