Out and About Program NICHE Conference Yolanda Shultz MSN, RN, MS-BC Anne Johnson BSN, RN MSMHC Non-Profit Hospital One out of 15 of MedStar Network hospitals and outreach facilities located in the Washington, District of Columbia/Baltimore region NICHE member since October 2013- Level 3 Designation October 2015 Monthly admission average of 90 patients >65 years Objectives The participant will be able to: 1. Gain knowledge in how to implement a mobility program utilizing a three prong approach. 2.Describe educational strategies to support staff interdisciplinary geriatric education 3. Describe how the utilization of mobility and assessment tools can promote the staff s engagement to get a patient OOB. 3. Identify the challenges in obtaining outcome metrics when evaluating the effectiveness of a mobility program. 3 nicheprogram.org 2016 Annual NICHE Conference Care Across the Continuum 1
GIAP SURVEY January 30, 2014 Clinical Staff (RNs, CNAS, Physical Therapy, Occupational Therapy, Dieticians)- reported that getting older adults out of bed as a Gap in Practice. The survey highlighted opportunities to link the knowledge between mobility and its impact on quality indicators for falls, pressure ulcers, and length of stay. PICOT for Out and About Program P-(Population): Patients over the age of 65 (bedridden patients to be excluded). I-(Intervention): Get patient OOB to chair or ambulate at least once as day C- (Comparison): Older adults who got out of OOB on a daily basis versus those that did not O- (Outcome): Older adults who got OOB will experience a decrease in the incidence of pressure ulcers, falls, and length of stay. T- (Time): 18 month duration (Data collected 6 months preceding program, 6 months during the implementation of the program and 6 months following the implementation of the program). Purpose Implement a mobility program (Out and About) to reduce the incidence of skin breakdown, falls, and length of stay. Method-Three Prong Approach: a. Education and training of current clinical staff b. Mobility Assessment and Audit Tools c. Training of new clinical staff 6 2
Prong One: Education and Training of Staff Classes are available to enhance CNAs (Certified Nursing Assistant) knowledge and ability to perform safe transfers from bed and chair Classes were conducted January 2015-March 2015. 75 participants were trained 7 Prong One: Dedicated NICHE Units 4E- Medical/Surgical, Telemetry, Orthopedic, and Oncology and 1E-Medical/Surgical, Cardiology, and Telemetry from January 2015- August 2015 (11 GRNs and 42 GPCAs ) September 2015 NICHE program expanded to include all Medical/Surgical units leading to an additional (25- GRNs and 6-GPCAs) January 2015-December 2015- Total number of GRNs- 36 Total number of GPCAs-48 Prong 2: Tools- Patient Transfer Assessment 1. Communication - able to follow directions 2. Emotional/Behavioral Status - Calm/cooperative 3. Medical Status - Blood pressure, blood sugar okay 4. Physical and Functional Status - ability to move extremities Handshake: Grip, push, pull Leg Strength: Bend knee and lift leg against force, Ability to bridge (lift hips up off bed), Straight leg raise Foot Movement: Move foot up and down at ankle Rolling: Roll side to side Sitting Abilities: Get into sitting position, Sit unassisted 10-15 seconds Standing Abilities (Transfer belt on patient and 2 nd person to assist): Prepare for standing (patient to scoot forward in chair, feet under knees & leaning forward), Shift weight from buttocks to thighs to feet nose over toes, Remain standing 15-20 seconds, Remain balanced raising one arm at a time front and side Walking Abilities: Shift weight one foot to the other Walk or march on the spot, Take effective steps 3
Prong 2: Mobility Assessment/Communication Tool Prong 2: Audit Tool Prong 3: Training of New Clinical Staff Newly hired clinical staff were enrolled in the NICHE Introduction to Gerontology Course A total of 369 clinical staff completed the course as of December 2015 12 4
Discussion Pre-program Quantity and availability of equipment Unit environment Staff knowledge and buy-in Leadership/Multidisciplinary involvement Availability of staff Financial constraints Communication of mobility status between multidisciplinary groups Lack of a method to extract data from the EMR regarding the older adult Post Program & Ongoing New walkers, gait belts, and recliners Nursing units remodeled: (paint, lighting, toilet height). Ongoing training of staff and monthly rounding of GRN on units (Audit Tool) Recognition of staff (NICHE pinning ceremonies, certificates, and celebrations) Leadership support Daily multidisciplinary rounding Investigation of methods to extract data from the EMR to evaluate older adult outcomes Conclusion Extraction of data to monitor trends data was more complicated than anticipated due to current EMR system capabilities and availability of trained staff Ongoing recognition of staff to promote staff engagement (pinning ceremonies, certificates, photos on the hospital intranet) is vital Use of the Mobility and Audit tools encourages multidisciplinary involvement when addressing the needs of older adults 14 References Ayello, E. A. & Sibbald, R. G. (2012). Preventing pressure ulcers and skin tears. In Boltz, M., Capezuti, E., Fulmer, T., Zwicker, D. (2012). Evidence-Based Geriatric Nursing Protocols for Best Practice (4th Ed.) (pp.298-323). New York: Springer. Boltz, M., Resnick, B. & Galik, E. (2012). Interventions to prevent functional decline in the acute care setting. In Boltz, M., Capezuti, E., Fulmer, T., Zwicker, D. (2012). Evidence-Based Geriatric Nursing Protocols for Best Practice (4th Ed.) (pp. 104-121). New York: Springer. Braden, B. J. (1998). The relationship between stress and pressure sore formation. Ostomy/Wound Management, 44(3A Suppl), 26S-36S. Brown, C. J., Peel, C., Bamman, M. M., & Allman, R. M. (2009). The under recognized epidemic of low mobility during hospitalization of older adults. Journal of the American Geriatrics Society, 57(9), 1660-1665. Brown, Mary M. (2013, June). Nursing Clinical Practice Guideline: Prevention of falls among hospitalized adult patients. MedStar Health Nursing Clinical Practice Guideline 2013-004. De Morton, N. A., Keating, J. L., Berlowitz, D. J., Jackson,, B. & Lim, W. K. (2007). Additional exercise does not change hospital or patient outcomes in older medical patients: A controlled clinical trial. The Australian Journal of Physiotherapy, 53(2), 105-111. Doherty-King, B. & Bowers, B. J. (2013, September). Attributing the responsibility for ambulating patients: A qualitative study. Int J Nurs Stud. 50(9) 1240-1246. Doi:10.1016/j.ijnurstu.2013.02.007. Kortebein, P., Symons, T. S., Ferrando, A., Paddon-Jones, D., Ronsen, O., Protas, E., Evans, W. J. (2008). Functional impact of 10 days bed rest in healthy older adults. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 63(10), 1076-1081. Kresevic, D. M. (2012). Assessment of physical function. In Boltz, M., Capezuti, E., Fulmer, T., Zwicker, D. (2012). Evidence-Based Geriatric Nursing Protocols for Best Practice (4th Ed.) (pp. 89-103). New York: Springer. Miake-Lye, I. M., Hemple, S., Ganz, D. A., & Shekelle, P.G. (2013). Inpatient fall prevention programs as a patient safety strategy. Annals of Internal Medicine, 158 (5 [Part 2]), 390-396. Pederson, B. K., & Saltin, B. (2006).Evidence for prescribing exercise as therapy in chronic disease. Scandinavian Journal of Medicine & Science in Sports, 16(Suppl. 1), 3-63. 5