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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
29
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
38
39
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