Ronda Fritz Safe Patient Handling amp Mobility Facility Champion VA NebraskaWestern Iowa Health Care System May 2016 Objectives Identify the hazards of patient immobility in an acute care setting ID: 934682
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Slide1
Advancing Mobility Across the Continuum of Care: The NWI Journey
Ronda Fritz, Safe Patient Handling & Mobility Facility ChampionVA Nebraska-Western Iowa Health Care System
May 2016
Slide2ObjectivesIdentify the hazards of patient immobility in an acute care setting.
Describe one facility’s process to improve patient mobility.Apply the principles of SPHM to design a meaningful approach to progressive mobility.Compare the cost of mobilizing patients manually vs. using SPHM equipment
1
Slide3Hazards of ImmobilityImpact every organ and body systemLead to Hospital-Acquired Conditions
Conditions that patients acquire while receiving treatment for another condition in an acute care health setting.
Stage III and IV Pressure Ulcers
Falls and Trauma
Manifestations of Poor Glycemic Control
Catheter-Associated Urinary Tract Infection (UTI
)
Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)Hospital acquired infectionsIncrease cost of careDecrease level of patient function and may never return to baseline
2
Slide4The Journey Begins
Early and Progressive Mobility revival
Clinicians and providers recognized patients were not being mobilized
Started getting frequent anecdotal reports from staff
R
isks for injury with patient discharges
Post-op patients not getting up enough or early enough
Inappropriate PT/OT referralsIntensivist unhappy with lack of mobilization in the ICU
Missed opportunities for safe mobilization of patients
Overemphasis on leaving patients in bed due to focus on falls prevention
Manual handling of patients persists
High fall rates Injuries from falls High readmission ratesConcern over current hospital acquired conditions
3
Slide5Gaining SupportPatient Safety Committee monthly meetingsConnecting with Patient Safety Office/ACOS
Reconnecting with PM&RSContinuing conversations with Nursing and SPHM Unit Peer Leaders (UPLs)Tapping into national expertise of SPHM Consultants Leveraging strengths to add new partners
Open, frequent communication
Actively sought input from direct patient care givers
Fostered a spirit of collaboration and inclusion
Leaving no stone unturned
Following leads to identify all the stakeholders
4
Slide6Raising AwarenessTargeted education
SPHM UPLsFalls CommitteePatient Safety CommitteeACOS/Patient SafetyADPCS
Nursing
Venues
Meetings
Formal presentations with CEU
Emailed articles on mobility
Posted flyers in break rooms, staff restrooms, units targeted, physician meeting spacesNursing Education & Training DaysFocus Groups
5
Slide7Initial StrengthsExecutive level support – Associate Director Patient Care Services
Identified key stakeholders and formed a working group Communicated to Patient Care Services this was a priorityAssociate Chief of Staff/Patient Safety – very supportive
SPHM Program – strong program already in place
Physical Medicine & Rehab Services (PM&RS) – strong support
Intensivist – strong desire to get early mobility program in place
Patient Safety Committee
Falls Committee
6
Eileen Kingston, NEA-BC, BSN, MPA, RN
Associate Director, Patient Care and Nurse Executive
Slide8Taking ActionReviewed existing dataCollected additional data
Mobility Protocol Project Working Group started meeting weeklyExecutive sponsoredLed by SPHM Facility ChampionMulti-disciplinary Team
MD (Medicine, Patient Safety/ACOS, Intensivist, Surgeons, Polytrauma, Safety, Safety/Informatics)
RN 7East
UPL/CNA 5East
QM
RN Patient Care/Informatics
RN 6East/Falls Committee Chair
PM&RS Director
PM&RS/Falls Committee Co-Chair
7
Nurse Managers
Wound Care
Nursing Education
Social Work
Discharge Planning
Travel & Finance
Surgical Case Managers
Slide9Taking Action – Defined GoalsAdvancing patient mobility using resources we already have, as well as to make current process more efficient without unnecessarily increasing workload of staff
.Develop/implement a mobility protocol which includes:Evidence-based, validated nursing assessment of mobility
Connecting the mobility level with the appropriate mobility safety tools
Common mobility language for the facility
Mobility activities appropriate for each mobility level
Order templates for providers and surgeons that clearly define mobility activities
Incorporate discharge mode of transportation appropriate for each mobility level
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Slide10Taking Action – Decisions to MakeReviewed our optionsUse existing protocol?
Create our own?Merge existing with our own twist?Process improvement or research?Outcomes to measure?
How long would the trial last?
What Unit(s) would be in the trial?
What needs to be in the patient record? Where do we put it?
Do we make a trial template or let the trial determine the template?
Who else needs to know about the trial?
What educational materials do we need for staff? Patients? Family?9
Slide1110
Debilitated patient
Independent Walking
Lift Sheet + Ceiling Lift for positioning/repositioning/lateral transfers
Limb Strap + Ceiling Lift for passive ROM
Bed Mobility
Continue independent ROM exercises
Friction Reducing Sheet for bed mobility exercises & when patient can
boost self up in bed but needs help overcoming friction
Friction Reducing Sheet for active ROM
Limb Strap + Ceiling Lift for active ROM
Supine to Sit
Poor Trunk Control…patient can’t sit up without assistance & maintain a sitting position
= Seated Sling + Ceiling/Portable Lift
Sit to Stand
Assisted Ambulation
OT/PT Pager – 525
SPHM – 402-580-5636
SPHM SharePoint Site
https://
vaww.visn23.portal.va.gov/nwi/SiteDirectory/NWIPNS/management/safept/default.aspx
NWI Mobility Continuum Tool
Resources
* More information on back
Slide12NWI Mobility Continuum Tool
The intent of this tool is to assist the healthcare worker (HCW) in determining what SPHM technology to use for safely mobilizing a patient.
The
tool displays the Mobility Status Continuum
starting with lower levels of mobility on the bottom of the page and progressing to higher levels of mobility as one moves up the page.
Debilitated Patient –
has very limited or no bed mobility and is identified on the bottom of the Mobility Status Continuum
Bed Mobility
– defined as the patient’s ability to roll side-to-side in bed, reach/grab side rails, bridge using hip extensors to lift hips off bed while lying supine, scoot up/around in bed. Debilitated and weakened patients should be working to improve their bed mobility either passively or actively unless provider orders otherwise.
Supine to Sit –
as the patient progresses or is progressed from supine positioning to sitting, the bed can be positioned in the chair position and/or the Seated Sling and Ceiling Lift can be used to sit the patient into a chair, wheelchair or commode. The sling/lift combo can also be used for strengthening trunk control by placing patient in seated sling at edge of bed while patient practices maintaining an upright, seated posture.
Sit to Stand –
once the patient is able to maintain an upright, seated posture independently (good trunk control) then the motorized sit-to-stand lift can be used to try standing. Various strengthening and balance activities can be performed using this lift (see PT/OT or SPHM Facility Champion for activities). Once patient is strong enough to clear hips from bed/chair in sit-to-stand lift, can use Ambulation Sling and Ceiling/Portable Lift to, march in place, side step or other pre-ambulation activities (see PT/OT for activities).
Assisted Ambulation –
use Ambulation Sling/Lift to ambulate patient then walker/cane/brace and progress to independent ambulation
Independent Ambulation –
patient is able walk without any assistance
Slide13Step – Level 4
Bed Mobility – Level 0
Patients who do not pass the Mobility Safety Screening (above) or fail the Sit & Shake assessment are Bed Mobility – Level 0
Sit & Shake – Level 1
Assessed
in Bed:
Sit
From a semi-reclined position, ask patient to sit upright and rotate to a seated position at the side of the bed;
may use the bedrail.
Shake
Ask patient to reach out and grab your hand and shake making sure patient reaches across his/her midline
.
Assessed
in Chair:
Sit
ask patient to sit upright (not leaning on back of chair or sides of chair)
Shake
Ask patient to reach out and grab your hand and shake making sure patient reaches across his/her midline
.
Stretch & Point –
Level 2
Assessed
in Seated Position at Side of Bed or Chair:
With
patient in seated position, have patient place both feet on the floor (or stool) with knees no higher than hips.
Ask
patient to stretch one leg and straighten the knee, then bend the ankle/flex and point the toes. If appropriate, repeat with the other
leg.
May
test only one leg and proceed accordingly
(
e.g.,
stroke
patient, patient with ankle in cast
).
Stand – Level 3
Assessed
from Bed or Chair:
Ask
patient to elevate off the bed or chair (seated to standing). May use an assistive device (Stedy, walker, cane, bedrail) for safety.
Patient should be able to raise buttocks off bed and hold for a count of five.
May repeat once
.
NOTE:
If patient requires assistive device to ambulate or cognitive assessment indicates poor safety awareness,
patient is Mobility Level 3
.
***********************
INR
>
6.0 = Patient does NOT progress to Level 4.
Ambulation in room ONLY with assistance .
***********************
Mobility Assessment Tool
Mobility Safety
Screening
(Patient must meet all
criteria prior to initiating Mobility Assessment)
M
– Myocardial stability
No evidence of active myocardial ischemia x 24 hrs.
No dysrhythmia requiring new antidysrhythmic agent x 24 hrs.
O
– Oxygenation adequate on:
FiO2 < 0.6
PEEP < 10 cm
H2O
O2 Sats > 88% (if
COPD)
V -
Vasopressor(s) minimal
No increase of any vasopressor x 2 hrs.
E–
Engages to voice
Patient responds to verbal stimulation
Ask patient to march in place at bedside. Then ask patient to advance step and return each foot. Assess for stability and safety awareness. Patient is Mobility Level 4/modified independence = no assistance is needed to ambulate.Use your best clinical judgment to determine need for supervision during ambulation.
Start HERE
OT/PT Pager – 525
SPHM – 402-580-5636
Trial Start Date: 1 March
Safety Screening – ABCDE Protocol
BMAT Assessment Validated by Banner Health Systems
Slide14Bed Mobility –
Level 0
Sit & Shake – Level
1
Stretch & Point
– Level 2
Stand – Level
3
Mobility Safety
Step
– Level 4
Patient is Mobility Level 4/modified independence
=
no assistance is needed
to ambulate
.
Use your best clinical judgment to determine need for supervision during ambulation.
DATE:
Personal slide board
(if at baseline)
NOTE:
If patient requires assistive device to ambulate or cognitive assessment indicates poor safety awareness,
patient is Mobility Level 3.
Slide15Slide16Early Outcomes
Positive feedback from the staff right out of the gateImproved satisfaction Improved communicationPositive feedback from patients and familiesIncreased patient ambulation in the hallways
No longer waiting on PT to get patient up for the first time
Immediate impact and significant decrease in falls
Improved care
Safer delivery of care
Unexpected needs identified through this process that we were able to address
Improper delegation RN to CNAEducation needs of RNs/CNAs Communication gaps between servicesDamaged relationships between services and people
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Slide17Early Outcomes16
Slide18ChallengesSetting a meeting time that worked with everyone’s schedule
Supporting direct care providers (RNs, CNAs, PT/OT, SW, D/C Planners, Case Managers) to enable their active participationGetting the education and training to the RNs, CNAs, PT/OT throughout the processData collection throughout the trialData management from the trial
Managing the trial - Fighting the urge to go too fast or get too big
Determining how/where to document in the medical record
Rotating physicians/therapists/nurses/etc
.
“Footing
the bill” for appropriate discharge mode of transportation
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Slide19NWI Journey18
2008 SPH Program Initiated
2013 Mobility focus added to SPH Program
2014 BMAT Validated
NWI Mobility Journey
Part 1
NWI Mobility Journey
Part 3
NWI Mobility Journey
Part 2
April 2015 Engaged with National Consultant
Jul 2015 Consultant Mobility Presentation
Aug 2015 Ongoing stakeholder discussions
Sept 2015 First Mobility Protocol Working Group meeting
Sept 2015 - Feb2016 Mobility Protocol Working Group meeting
Jan 2016 Focus Groups with Trial Units
Feb 2016 Mobility Protocol Trial Phase 1 Training
1 Mar 2016 Mobility Protocol Trial Phase 1 Initiated – 2 Med/Surg Units
Apr 2016 Mobility Protocol Trial Phase 1 Training for additional Trial Units
11 Apr 2016 Mobility Protocol Trial Phase 1 Initiated – 1 Med/Surg Unit
14 Apr 2016 Mobility Protocol Trial Phase 1 Initiated - ICU
Slide20Next StepsTrain and implement Phase 2 – Mobility ProtocolTemplate for medical record
Implement system-wide
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Slide21What’s the difference?Manual Mobilization
Staff injuriesPatient injuriesDelayed mobilization of patients
No mobilization of patients
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HCW
get injured at nearly twice the rate as other types of workers
(
BLS 2011)
Manual
lifting injuries are the # 1 cause of lost work days for health techs/orderlies/aides nationwide over the past decade
(
BLS 2011)
Worker back injuries cost the
health care
industry
more than $7 billion a year, cause
thousands
of
missed workdays
, and may end
some
careers in bedside care
May 11,
2010
http
://
www.cdc.gov/washington/testimony/2010/t20100511.htm
2.7
%
of ICU patients had
an every-2-hour demonstrable body position change
(
Krishnagopalan
2002)
Slide22What’s the difference?SPH Mobilization
Reduced or eliminated Staff injuries
Reduced or eliminated Patient injures
Earlier mobilization of patients
More frequent mobilization of patients
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2006-2012 – 36% reduction in PH injury rate across VHA
(
Hodgson, 2013)
Worst-case scenario, a SPHM program will add $2 million in value over a 5 year period
(
Nelson, 2006)
Best-case scenario, the value added could be as high as $10 or $12 million
(Nelson, 2006)
ROI – average 4.3 yrs.
(Nelson, 2006)
Investment in equipment/raining was recouped in <3 years due to lower worker compensation claims
(
NIOSH, 2007)
Slide2322
https://www.osha.gov/dsg/hospitals/documents/3.5_SPH_effectiveness_508.pdf
Slide24What does that cost?
Can you afford not to?
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Slide2524
Slide26References
American Nurses Association. Safe patient handling and mobility: Interprofessional national standards. 2013.
Arnold
, Margaret, et al. “Integrating Mobility and Safe Patient Handling: Practical Considerations For Interdisciplinary Care.” American Journal of Safe Patient Handling and Mobility 5.2 (2015): S1-S21.
Arnstein
, Margaret G. "Florence Nightingale's influence on nursing." Bulletin of the New York Academy of Medicine 32.7 (1956): 540.
Balas, Michele C., et al. "Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility (ABCDE) bundle." Critical care medicine 42.5 (2014): 1024.
Barr, Juliana, et al. "Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit." Critical care medicine 41.1 (2013): 263-306.
Hodgson, Matz and Nelson: Patient Handling in the Veterans Health Administration: Facilitating Change in the Health Care Industry, JOEM Volume 55, Number 10, pp. 1230-1237, October 2013
Lee
, Soo‐Jeong, et al. "Factors associated with safe patient handling behaviors among critical care nurses." American journal of industrial medicine 53.9 (2010): 886-897.
Lee, Soo-Jeong, et al. "Musculoskeletal pain among critical-care nurses by availability and use of patient lifting equipment: An analysis of cross-sectional survey data." International journal of nursing studies 50.12 (2013): 1648-1657
.
O’Keeffe, Valerie J., Michelle R. Tuckey, and Anjum Naweed. "Whose safety? Flexible risk assessment boundaries balance nurse safety with patient care." Safety Science 76 (2015): 111-120.
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Slide27References
Nelson, Matz, Chen, Siddharthan, Lloyd, & Fragala (2006). Development and Evaluation of a Multifaceted Ergonomics Program To Prevent Injuries Associated with Patient Handling Tasks. Inter Journal of Nursing Studies. 43:717-733
NIOSH
(2007). The NIOSH Traumatic Injury and Prevention Program Evidence Package. March, 2007.
Poole
Wilson, Tiffany, et al. "Quantification of patient and equipment handling for nurses through direct observation and subjective perceptions." Advances in Nursing 2015 (2015
).
Randall, Stephen B., et al. "Expanded Occupational Safety and Health Administration 300 log as metric for bariatric patient-handling staff injuries." Surgery for Obesity and Related Diseases 5.4 (2009): 463-468.
Retsas, Andrew, and Jaya Pinikahana. "Manual handling practices and injuries among ICU nurses.” Journal of advanced nursing 17.1 (1999): 37-41
.
Shever, Leah L., et al. "Fall prevention practices in adult medical-surgical nursing units described by nurse managers." Western Journal of Nursing Research (2010): 0193945910379217.
Stevens, Linda, et al. "Creating a culture of safety for safe patient handling." Orthopaedic Nursing 32.3 (2013): 155-164
.
Titsworth
, W. Lee, et al. "The effect of increased mobility on morbidity in the neurointensive care unit: Clinical article." Journal of neurosurgery 116.6 (2012): 1379-1388.
Winkelman, Chris. "Bed rest in health and critical illness: a body systems approach." AACN advanced critical care 20.3 (2009): 254-266.
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