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MOVE iT/MOVE ONMOVE iT/MOVE ONMobilization of Vulnerable Elders and Local Implementation at SHSC

April 25th, 2012April 25th, 2012RGP Workshop 

B b Li MD FRCPCBarbara Liu, MD, FRCPCJocelyn Denomme, PT, MSc

Objectives

To review the rationale behind a provincial earlyTo review the rationale behind a provincial early mobilization strategy

To provide an overview of the implementation and To provide an overview of the implementation and identify the QI and KT principles on which it is built 

Describe the experience and unique features of implementation at SHSC 

RGP Senior FriendlyRGP Senior Friendly Hospital Framework

Processes of Care

Emotional & Behavioural Environment

Ethics in Clinical Care & 

Research

Organizational Support

Physical Environment

What we do How Who Why Where

3

Provincial Summary Report

•D ib i ti t t•Describes existing state of SFH care in Ontario based on self reportsbased on self reports from 155 hospitals 

•Identifies promisingIdentifies promising practices 

•Recommends priority•Recommends priority areas for action 

4

Provincial SFH Action Priorities Functional Decline

– Implement interprofessional early mobilization protocols across hospital departments to optimize physical functionacross hospital departments to optimize physical function

DeliriumDelirium– Implement interprofessional delirium screening,

prevention, and management protocols across hospital d t t t ti i iti f ti

T iti I C

departments to optimize cognitive function

Transitions In Care– Implement practices and developing partnerships that

promote interorganizational collaboration with community

5

p g yand post-acute services

Patient &

Alignment and momentumPatient & 

Care Teammomentum

Hospital pPriorities

LHIN improvement plans HSAA

LHIN priorities

Sustain

Provincial Improvement Priorities 

Provincial Senior Friendly Hospital Strategy A dit ti

66

Strategy Accreditation Canada

A web of hospital‐acquired complications d i l d i k fand inter‐related risk factors

Ri k F t

IatrogenesisComplications

SolutionsProcesses of CareRisk Factors Complications  

Safety IssuesProcesses of Care

Quality Improvement

Early Mobilization

Sleep Management

Mobilization

Optimizing Hydration / Nutrition

Managing Challenging Behaviors

Sensory Optimization Social Stim’n

Psychological

Complications of ImmobilityRespiratory System• Decreased lung volume• Pooling of mucous• Cilia less effective

y g• Anxiety• Depression• Sensory deprivation• Learned helplessness

Circulatory System

• Decreased oxygen saturation• Aspiration• Atelectasis

• Delirium

Circulatory System• Loss of plasma volume• Loss of orthostatic compensation• Increased heart rate• Development of DVT

Gastrointestinal System• Reflux• Loss of appetite• Decreased peristalsis

Constipation• Constipation

Musculoskeletal System

Genitourinary System• Incomplete bladder emptying• Formation of calculi in

• Weakness• Muscle atrophy• Loss of muscle strength by 3-5%• Calcium loss from bones• Increased risk of falls due to weakness

Formation of calculi in kidneys and infection

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• Increased risk of falls due to weakness

“...rest in bed is anatomically, physiologically and psychologically unsound. Look at a patient lying long in

bed. What a pathetic picture he makes! The blood clotting in his veins the lime draining from his The blood clotting in his veins, the lime draining from his

bones, the scybala stacking up in his colon, the flesh rotting from his seat, the urine leaking from his

distended bladder and the spirit evaporating from his soul.”

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Lying

Sitting

Walking

Brown, C et al JAGS 2009;57:1660

Lying

Sitting

83% of measured hospital stay spent in bed

WalkingMedian time spent standing or walking 

= 43 minutes or 3% of day

Brown, C et al JAGS 2009;57:1660

Baseline Data

% in bed  unit 1 % in bed Unit 2

Selected RCT evidence for early mobilization

Surgical Dx

Many RCTsDx

Pneumonia LOS 5.8 vs. 6.9 days(Mundy Chest 2003;124:883 889)(Mundy Chest 2003;124:883‐889)

Stroke Barthel Index at 3 monthsEarlier return to walking 3.5 vs. 7 days P=0.03(Cumming TB Stroke 2011; 42 :153)

Cochrane Review (2009)

Discharge to home, NNT=16 LOS by 1.08 days (‐1.93 to ‐0.22)

Patient‐relatedTreatment‐related

Patient related

Illness severity, comorbidity, 

pain, delirium

Activity order, devices, 

medicationsProcesses of C

Processes of Carepain, delirium

Barriers to 

Care Care

Institution‐related

Mobilization

Institution related

Staffing, time constraints, equipment

Attitudinal factors

Patient or staff, expectations concern falling

Emotional & Behavioural 

Ethics in Clinical Care & 

Organizational Support

Physical Environment expectations, concern fallingEnvironmentResearch

Support Environment

1414

Brown, C et al J Hosp Med 2007;2:305

Barrier assessment

1515

O i f th i l t tiOverview of the implementation

Goals of intervention 

1. Encourage mobilization three times a day1. Encourage mobilization three times a day

2. Mobilization should be progressive and scaledscaled

3. Mobility assessments should be implemented within 24 hours of theimplemented within 24 hours of the decision to admit

4. Interprofessional team collaboration 

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Educational Interventions

Interprofessional group education/in‐service

Huddles 1:1 knowledge‐to‐ practice coaching

Fairs

Education days

E‐modules

Knowledge‐to‐practice coaching 

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Mobilization Assessment Algorithm

202020

Simplified Mobility Assessment Algorithm

1. Can they respond to verbal stimuli?2 C th ll id t id ?

Mobility Level

ed 

2. Can they roll side to side?3. Can they sit at edge of bed?4 Can they straighten one or both legs?

C

vidu

alize

e plan

4. Can they straighten one or both legs?5. Can they stand?

p an

 indiv

bility care

6. Can they transfer to a chair? B

A

Develop

mob

7. Can they walk a short distance? A

2121

Enabling Tools

2222

Mobility Volunteer ProgramProgramMVPNew Support Partnerspp

MVP supported Exercise Routines

Specially trained volunteers will remind and p yencourage the patient to do: 

1. Bed/Chair Exercises

2. Ambulate

While providing social stimulation

MVP Cue Cards

MVP Don’t s

MVP Volunteers do not see patients who are:

• Palliative care or dyingPalliative care or dying

• On isolation precautions• Aggressive or violent• Aggressive or violent• Unable to follow instructions

Will NEVER f d ti t Will NEVER feed a patient

Will not physically support a patient to mobilizef h l h h f If a patient requires more than a light touch of a hand ask the patient’s nurse or team leader

Physical EnvironmentReducing Clutter

27

28

PCU Plan Designated space for stretchers (up to 3)

Designated f l

Linen hampers

space for large equipment

3 small linen carts

Storage room for wheelchairs, walkers

Vernacare supply cart

Phlebotomy Cart

Crash Cart

Providing FeedbackProviding Feedback

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Unit chart audits30

Short loop feedback to staff

Supplementary data that is patient‐specificSupplementary data that is patient specific

Includes measures related to documentation

Documentation Capturing mobility level in documention

Meeting the standard

80

100

ed c

hart

s

Alignment of CVB with Documention

60

80

100

mpl

ed c

hart

s

20

40

60

enta

ge o

f sam

ple

20

40

60

erce

ntag

e of

sam

0

20

0 2 5 7

Pece

Week

00 2 5 7

Pe

Week

Feedback to Units31

Meeting the Standard 3X/daybaseline End of Intervention Period

708090

100

ited

40506070

hart

s au

di

10203040

% o

f ch

010

1 2 3 4Unit

Y itYour unit

29/02/2012 = Yes = No

Item AM PM[Linen cart is stored in the recessed portion of the wall next to room D362]

No

]

No linen carts in the hallways Three small linen carts outside rooms D536 D551 and D526 Three small linen carts outside rooms D536, D551 and D526 No idle wheelchairs and walkers in hallways Phlebotomy cart is stored in front of servery near D519 Crash cart is stored opposite room D561 Maximum of three stretchers stored in the back end of the unit No medical supply carts stored in the hallways No medical supply carts stored in the hallways Equipment awaiting repair (beds, wheelchairs, etc) are pushed down to Plant Operations & Maintenance and not left in the hallways

Clinical Outcomes33

Pre Post

i f b d i l diPatients out of bed on visual audit 13% 44%

Falls / Injury QuarterlyFalls / Injury  Qua te yAnalysis Pending

Delirium Incidence Pending N 2012Nov 2012

ALC Monitoring

LOSg

LOS

Discharge destination 

Interrupted time series

% in bed  unit 1

d% in bed

Interventioni d

Pre Postperiod

Time

34

Is it feasible to mobilize frailmobilize frail older patients on medical 

3535

units?

First step is to dangle To ChairRespiratory ICUIntermountain Medical CenterSalt Lake City, UtahSalt Lake City, Utah

Respiratory ICUIntermountain Medical CenterSalt Lake City, Utah

Globe & Mail                   Feb 14, 2012

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Summary

Mobilization of patients is a good thing and we need to do more of itto do more of it 

Successful template for implementation 

S pported b process and o tcome indicators Supported by process and outcome indicators  Positive changes in process of care 

Positive changes in interprofessional collaboration & teamworkg p

Positive changes in unit culture

Positive changes in physical environment / clutter

Senior friendly care is a continuous quality improvement strategy 

40

Acknowledgements

• SFH Steering Committee • R Taggar (Chair) • B Liu (Co‐PI) D Brown Farrell J Denomme

Mobilization of Vulnerable Elders in Toronto/Ontariogg ( )

• D. Brown‐Farrell (Chair)• B O’Leary• J Denomme• Et al. 

• B. Liu (Co‐PI), D Brown Farrell, J Denomme• S Straus (Co‐PI), M. Zorzitto, D Knight, C Johnson• T Izukawa, J Ritchie• S Sinha, R Ramsden, • U Almaawiy W Chan J Moore et alU Almaawiy, W Chan, J Moore et al.

K W• K. Wong• M. Awad• D. Ryan • B. Liu • The RGPs of OntarioThe RGPs of Ontario