An Innovative Mobilization Framework for Delirium Management: How to Un-paralyze the Assessment and Implementation Process

Transcription

1 An Innovative Mobilization Framework for Delirium Management: How to Un-paralyze the Assessment and Implementation Process Melissa Redlich PCM RNBN Christine Filipek CNE RNBN CNCC(C) Stephanie McLeod RNBN

2 Presentation Outline Why? How Assessing the need Reviewing the literature Creation of the tool Roll-out Overcoming Barriers / challenges Feedback and Modifications Communication & education strategies Evaluation of the tool Next steps

3 Delirium Timeline 2010 Zonal ICDSC 2012 Zonal Delirium Framework 2013 SCN Collaboration 2015 Focus on Mobilization 2016 Initiation of Mobility Assessment Form 2017 Provincial Roll out

4 Provincial Key Performance Indicators

5 Assessing the Need Bakhru, R. N., Wiebe, D. J., McWilliams, D. J., Spuhler, V. J., Schweickert, W. D. (2015). An environmental scan for early mobilization practices in U.S. ICUs. Critical Care Medicine, 43(11) doi: /ccm

6 April 2016 Survey Monkey Results

7 Survey Monkey Results 90% of nurses initiated discussion on mobilization goals during rounds

8 Survey Monkey Results continued We had varied comments on how often staff feel patients should be mobilized in 24 hour. Results were: My patient is too sick to mobilize to QID Need to clarify expectations

9 Survey Monkey Results continued Barriers to mobilization included common themes: Lack of staff Barrier of physical environment Patient acuity Availability of physio Waiting for physio to complete mobility assessment Unsure of patient mobility level Lack of equipment (Chairs with belts) Lack of understanding of how to use equipment

10 Which of the following activities would you consider mobilization?

11 Analysis of Survey Monkey Results Need to clarify mobilization expectations Educate on these expectations Need a process to support initiation of mobilization by RN s

12 Why is mobilization so important? Research strongly suggests that lean muscle mass significantly decreases after only 10 days of bedrest (Kortebein et al, 2008). Patient mobilization has been proven to reduce ventilation days and delirium while increasing physical functioning at discharge (Schweichkert et al, 2009; Brahmbhat et al, 2010) Increasing duration of delirium in ICU patients was an independent predictor of worse cognitive performance at 3 and 12 months after ICU discharge (Brummel, et al, 2010)

13 Why is mobilization so important? Recent retrospective studies reveal regardless of age, half of ICU patients are unable to return to premorbid levels of activity due to weakness and lack of endurance (Engel, Needham, Morris, & Groupper, 2013). Early physical therapy and mobility of ICU patients is emerging as an evidence based strategy for preventing long term neurocognitive and physical disability (Engel, Needham, Morris & Groupper, 2013)

14 Randomized Controlled Trial (Schweickert, Pohlman, Nigos, Pawlik, Esbrook, Spears, Miller, Franczyk, Deprizio, Schmidt, Bowman, Barr, McCallister, Hall & Kress, 2009)

15 Literature Review of Barriers to Mobility (Engel, Needham, Morris & Gropper, 2013)

16 Creation of a tool supporting mobility assessment

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19 The University of San Francisco Flow Sheet (Engel et al, 2013)

20 Created May 2016

21 Implementation of the Readiness for Mobilization Flow Chart

22 Fixsen and Blase Installation Initial Implementation Full Implementation (Innovation) Sustained Implementation Exploration

23 Roll Out May 2016 Initial Implementation

24 Additional Education AROM & PROM

25 Innovation Innovation (Brain Games)

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27 Patient and Family Centered Care

28 Why Cognitive Rehab? Cognitive rehab including focusing on interventions focused at specific cognitive impairment (attention, memory, executive functioning) is commonplace in the treatment of patients with other acquired brain injuries and thus could have potential in rehabilitation of ICU survivors (Brummel, Jackson, Girard, Pandharipane, Schiro, Work, Pun, Boehm, Gill & Ely, 2012)

29 Why Cognitive Rehab? In applying the use it or loose it principle to exercises and muscle training, it is suggested that brain exercise can have a beneficial effect on reducing cognitive slowing and may stave off neuropsychological decline. (Brummel et al, 2012)

30 Positives Post Go-Live Anecdotal Guidance for assessing for initial mobilization Easy to follow Provided alternative forms of mobilization All staff trained in PROM and AROM

31 Barriers post Go-Live Staff reported inability to find form Posted as wallpaper Multiple concurrent site initiatives Monitors Change fatigue Lack of buy in from bedside staff

32 Re - Rolled Out April 2017 Focus on communication of mobilization and mobility goals on patient white boards 1:1 education

33 Readiness to Mobility Trial (September November 2017)

34 Results 100 RGH ICU Patients assessed for and received appropriate mobilization 3 X per day Percentage September October November

35 Results 70 # of Mobilization per Time Frame September October November hrs hrs hrs

36 Staff Feedback - Survey Monkey Is there anything missing or confusing on the readiness for safe mobilization tool? No I know that we are supposed to use this tool with assessments and document, but sometimes with an ICU admission they are just too sick even for PROM, not to mention busy. Just something to think about. What about patient's who have sit balance but are unable to stand at bedside. Still able to get them out of bed to chair with seatbelt. Not accounted for in this tool

37 Provincial Team Creation of a Provincial Mobility Assessment Tool

38 Full Implementation Provincial Readiness for Mobilization Tool

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40 Mobilization Readiness Tool in ecritical Metavision

41 Provincial Roll Out July 3 rd 2018

42 Education for Provincial Roll Out

43 Sustained Implementation Future Planning We continue to pull data off MetaVision and complete site specific delirium audits to evaluate and identify performance gaps which will guide our delirium team in future initiatives.

44 Ever Delirium

45 Conclusions Mobility Framework / Implementation strategies Feedback, re-evaluation to support integration Ongoing evaluation of progress Changing culture takes time Mobility Assessment form created standards for mobilization

46 Considerations Choose engaged and motivated champions to roll-out and support Choose a time that works for your unit. Change fatigue Do not overly survey staff It is a slow process to change unit culture Find unique ways to support buy-in

47 Thanks for your time!

48 References Bahkura, R. N., Wiebe, D. J., McWilliams, D. J., Spuhler, V. J., Schweickert, W. D. (2016). An environmental scan for early mobilization practices in U.S. ICU s, Society of Critical Care Medicine Journal, 43(11), doi /CCM Brambhat, N., Murugan. R., Mildbrandt, E. B. (2010). Early mobilization improves outcomes in critically ill patients. Critical Care 14(5), 321.doi /cc9262 Brummel, N. E., Jackson, J. C., Girard, T. D., Pandharipande, P. P., Schiro, E., Work, B., Pun, B. T., Boehm, L., Gill, T. M., Ely, E. W. (2012). A combined early cognitive and physical rehabilitation program for people who are critically ill: The activity and cognitive therapy in the intensive care unit (ACT-ICU) trial. Physical Therapy, 92(12), doi: /ptj Brummel, N.E., Girard, T.D. (2013). Preventing delirium in the intensive care unit. Critical Care Clinical 29(1),

49 References Engel, H. J., Needham, D. M., Morris, P. E., Cropper, M. A. (2013). ICU early mobilization: From recommendation to implementation at three medical centers. Critical Care Medicine 41(9), S69-S80. doi: /ccm.0b013e3182a240d5 Kortebein, P. Symons, T. B., Ferrando, A. (2008). Functional impact of 10 days of bed rest in healthy older adults. Journal of Gerontology, 63(10), Parry, A. (2016). Importance of early mobilization in critical care patients. British Journal of Nursing, 25(9), Sawada, Y., Sasabuchi, Y., Nakahara, Y., Matsui, H., Fushimi, K., Haga, N., Yasunaga, H. (2018). Early rehabilitation and in-hospital mortality in intensive care patients with community acquired pneumonia. American Journal of Critical Care, 27(2), doi: /ajcc Schweickert, W. D., Pohlman, M. C., Nogos, C. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomized controlled trial. Lancet, 373(9678), doi: /chest