title of presentation arial 50pt bold...secrets of the past –icu coverage therapists that pulled...

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Roadmap to the Development of a

Critical Care Rehab TeamCombined Sections Meeting 2018

New Orleans, LA, February 21-24, 2018

Stephanie Liebert, PT, MPT

Karoline Lubbeck, PT, DPT

Clare Nicholson, PT, DPT, CCS

Disclosures

No Disclosures

Live Polling Questions

1) What percentage of time, approximately, do you work in the ICU?

2) Does your facility have dedicated ICU therapists?

3) Are therapists seeing ICU patients in your facility required to pass

a competency?

4) Are Therapy Technicians utilized in your ICUs?

5) What percentage of the time, approximately, does OT/PT co-

treating occur?

6) What percentage of your ICU patient visits, approximately, do you

use an outcome measure in?

Learning Objectives

Examine specific strategies to assist with incorporating physical/occupational therapy and early mobility into an ICU setting

Discuss strategies to develop a Critical Care Rehab Team using outcome data to drive meaningful change, therapist efficiency, value to the patient and how implementation success was measured

Learning Objectives

Detail practical tools and strategies to utilize

in various practice settings (large teaching

hospital vs smaller community hospital) to

allow development of a Critical Care Rehab

Team despite challenges and competing

demands

Detail practical tools and strategies to initiate

the development of a comprehensive

orientation outline for Critical Care therapists

Course Outline

Review evidence for early mobility in the ICU

Discuss challenges and competing demands in the hospital setting as barriers to Critical Care team/coverage

Share results of dedicated PT in a MICU and SICU trial

Describe process to develop a Critical Care Rehab team in a large, teaching hospital

Outline the development of a Critical Care Team Orientation Program

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“Early activity is feasible and safe in respiratory failure

patients” – (Bailey et al, 2007)1

Assessed safety and feasibility during 3 activity events

Sit on edge of bed, Sit in chair, Ambulation

Results:

1, 449 activity events in 103 patients

53% ambulation, 31% sit in chair, 16% sit on edge of bed

<1% activity related adverse events

No patient was extubated during activity

PT/OT in the ICU – Literature Review

“Early activity is feasible and safe in respiratory failure

patients” – (Bailey et al, 2007)1

“We conclude that early activity is feasible and safe in

respiratory failure patients. A majority of survivors

(69%) were able to ambulate >100 feet at RICU

discharge. Early activity is a candidate therapy to

prevent or treat neuromuscular complications of critical

illness.”

PT/OT in the ICU – Literature Review

“Early intensive care unit mobility therapy in the

treatment of acute respiratory failure” – (Morris et al,

2008)2

Designed a mobility protocol to provide a mechanism for

standard and frequent administrations of PT to acute respiratory

failure patients

Included a mobility team of critical care nurse, nursing assist and PT

Protocol included 4 levels of activity

Results:

More physical therapy sessions

Shorter ICU and hospital length of stay for hospital survivors

PT/OT in the ICU – Literature

Review “Early intensive care unit mobility therapy in the

treatment of acute respiratory failure” – (Morris et al,

2008)2

“We conclude that mobility therapy delivered early in the

course of acute respiratory failure patients receiving

mechanical ventilation is feasible, safe, did not increase

cost and was associated with decreased ICU and hospital

LOS in survivors.”


Review

“Early physical and occupational therapy in mechanically

ventilated, critically ill patients: a randomised controlled

trial” – (Schweikert et al, 2009)3

Randomized early PT and OT during periods of daily interruption

of sedation

Results:

Improved return to (premorbid) independent functional status

at hospital discharge

Shorter duration of ICU associated delirium

PT and OT combined with daily interruption of sedation was

safe and well tolerated


Review Med Surg

Cardiac

Neuro

Ortho

Peds

Wound Care

Cleveland Clinic Main Campus –

Previous Team Organization

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New consults placed in a binder

Morning scheduling – Therapists pull new

consults from the binder

Last patients in the binder…..

Secrets of the past – ICU coverage

Therapists that pulled the ICU patients

became more:

Skilled

Interested in learning more about ICU

Aware of the importance of PT/OT in the ICU

Challenged by competing priorities

ASAPs

Precerts

New consults outside of the ICU


ICUs were organized within each team

Ex. Cardiac Surgery ICUs, Heart Failure ICU and

Coronary ICU were a part of the Cardiac Team

High volume of consults, ASAPs, Priority calls on

the RNFs/SDUs were seen before ICU evals and

treatments

Nursing resistance to therapy and poor MD

awareness of PT/OT in the ICU led to low

consult volume despite appropriate patients


challenges Physician, RT, and Nurse Champions

Meetings with MD, RT, and RN leadership

Collaboration with Project Manager of hospital wide

initiative: “Culture of Mobility”

Flyers in ICU staff areas to announce pilot

Immersion of 3 dedicated PTs into our MICUs and

SICUs

MICU Pilot

MICU PilotProject Timeline

DEC 2012 JAN 2013 FEB 2013 MAR 2013 APR 2013 MAY 2013 JUNE 2013 JULY 2013 AUG 2013 SEPT 2013 OCT 2013 NOV 2013

GO-LIVE for Medical

Team Mobilizing

Create educational

materials

Project Team Meetings

Nursing/PCNA

training

Data Collection

GO-LIVE for PT consult

changes in EPIC

Physician

training

GO-LIVE for EPIC Activity

order changes (TBD)

GO-LIVE for Interventions

Doc Flowsheet in EPIC

Audits for mobility

Develop tools for sustainment

PTs attending of rounds and huddles to

increase collaboration and awareness, and to

determine which ones were mission critical

Coverage of critical care patients with QD

frequency goal

Trial of BID

QD more efficient and practical for team, and

better tolerated by patients

MICU Pilot

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Non-patient care time allotted for :

Provision of training

Education of team

Development of materials

Training

Educational

Competencies

MICU Pilot MICU Pilot

Consulting team member education

Educational presentations and printed materials,

including one-page “When to consult” and

“Difference between OT and PT” guides to

physicians, PAs, NPs

MICU Pilot MICU Pilot

RN competency

Provided printed and emailed educational

materials

Hands-on training at bedside during a PT session

with their patient

MICU PilotI have observed the following with Physical Therapy:

Assisting patient to edge of bed (EOB)

Assisting patient out of bed to chair (OOBTC)

I understand and feel comfortable discerning:

Who is appropriate for early mobilization (recovery vs. survival mode)

When to direct the medical team to consult PT or OT

Where to find therapy recommendations for mobility in EPIC

How to initiate mobility for my patients who meet early mobilization criteria

When not to mobilize or to stop mobilizing a patient

I would like:

More hands-on training with PT

Other (specify): _____________________________________________

Name: _________________________________________ Date: _____________

MICU Pilot – ICU Nursing Observation Checklist

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Rehab technician competency

Development of a “Technician ICU Orientation

Manual” for education and setting of standards

Roles and Responsibilities

Early Mobilization

Communication

Equipment (ICU related and therapy equipment)

Lines, tubes, drains

Portable telemetry

MOVEO

Set-up and Re-set of patient’s room

Patient Mobility and Transfers

MICU PilotWelcome to the Intensive Care Unit PT/OT Team!

Physical and Occupational Therapy Intensive Care Unit Team

You will soon discover that your role on this team is vital to

ensure the best quality of care for the patients and that care is

delivered in a safe and efficient manner . On this service you

will be assisting the therapists with the mobility of critically ill

patients. These patients are often medically complex and

demonstrate weakness and impaired cognition. However due

to the focus on early mobility in the ICU, many critically ill

patients can safely sit edge of bed and transfer to a chair, and

even progress to ambulate. You will assist with management

of ICU lines and monitors, ventilators, ICU beds, other life

sustaining equipment during the mobility process. It will be

necessary to follow all of the Policies & Procedures that have

been put into place. These Policies & Procedures will be

reviewed throughout your orientation process. Please ask

questions throughout your orientation process to clarify any

concerns that may arise. The key roles and responsibilities of

the technician on this service are outlined in this orientation

manual. Thank you for your interest in this service and most

importantly for your continued dedication to providing quality

patient care.

Technician Roles and Responsibilities in the Intensive Care Unit

Physical and Occupational Therapy Intensive Care Unit Team

Roles & Responsibilities

• Communicate with the therapist before each patient session to understand the

treatment plan

• Identify and bring to bedside the necessary patient equipment and supplies

• Assist the therapist with preparing the room for safe mobility

• Assist the therapist with transfers and patient mobility

• Clean and reset the patient room following patient mobility

• Clean and maintain all therapy equipment and supplies per the ICU Rehab Tech Policy

& Procedure manual

• Assist the therapist with continued readiness tasks and expectations

Keys to Success

Early Mobilization in the ICU

With effective communication and teamwork, patients who are

critically ill can safely

participate in rehabilitation.

Research shows that it is safe and feasible to mobilize this

population (few adverse events

and no additional, or even decreased, costs).

Benefits of “early mobility” include DECREASED ICU and

overall hospital length of stay, days on a ventilator, pressure

ulcers, and falls, and INCREASED respiratory, cardiovascular,

and gastrointestinal functions, level of consciousness, quality of

life, psychological well-being, and rates of discharge home vs.

a rehabilitation facility.

To be a candidate for early mobility, our patients need to be:

awake, able to follow simple commands and minimally

participate with therapy, medically stable, and have rehab

potential. In other words, they need to be in “recovery mode.”

Patients who are NOT candidates for early mobility are:

comatose, unresponsive, on paralytic drugs, or medically

unstable. In other words, they are in “survival mode.”

Assist the Therapist with Treatment as Directed

Laws of Practice

Laws and Rules Regulating the Practice of Physical Therapy

4755-27-4

“Unlicensed personnel” means any person who is on the job trained and supports the delivery of physical therapy services by personally assisting the physical therapist, physical therapist assistant, student

physical therapist, and/or student physical therapist assistant while the physical therapist, physical therapist assistant, student physical

therapist, and/or student physical therapist assistant is concurrently providing services to the same patient.

Laws and Rules Regulating the Practice of Occupational Therapy

4755-7-01

“Unlicensed personnel” means any person who is on the job trained and supports the delivery of occupational therapy services by personally assisting the occupational therapist, occupational therapy

assistant, student occupational therapist, and/or student occupational therapy assistant while the occupational therapist, occupational

therapy assistant, student occupational therapist, and/or student occupational therapy assistant is concurrently providing services to

the same client.

When providing assistance to the physical or occupational therapist, it is important to be aware of the state laws of physical

and occupational therapy practice. When treating patients at the bedside, both the technicians and the therapists may look

similar if both are assisting with mobility, despite different colors of scrubs. It is not uncommon for another healthcare

practitioner (physician, nurse, etc) or a family member to inadvertently ask for information from, or delegate a task to, the

technician that may not be within their scope of practice to address.

Should you find yourself in this position, please explain to the healthcare practitioner, patient, or family member that you will

find the right person to address the matter. Do not feel pressure to perform a task that is beyond your scope of practice no

matter what. If you do perform a task that is beyond your scope of practice, it will result in corrective action.

Communication Tips

Communication in the ICU

Communicating accurate information in an efficient manner is essential for all members of the ICU team.

The technician and therapist will discuss the basic plan for the session ahead of time.

Flexibility, alertness, and ongoing communication are key. Patients require constant monitoring and

their condition may change, even during therapy. The therapist may need to adjust or change the goals

or plan for the session based on the patient’s response.

Speak up if you notice something “doesn’t look right” or “doesn’t sound right” whether it is related to the

patient or equipment. Calmly notify the therapist of concerns.

The therapist may direct instructions toward the patient to minimize the patient’s anxiety (i.e. “We are

going to help you lay down now.”).

Confused or delirious patients can be easily distracted by more than one face or voice in the room. If

this is the case, conversations and interruptions should be minimized.

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Communication Tips

Do Don’t

· Identify your patient’s RN (ideally by name) prior to

therapy, in case the RN is needed during the session.

· Don’t feel pressured to answer specific Plan of Care

questions regarding the patient’s therapy.

· Allow the therapist to initiate RN communication and

indicate to you that it is appropriate to begin setting up for

a session.

· Don’t attempt to gather RN report on a patient or initiate

set-up for a therapy session without confirmation from the

therapist.

· Refer an RN with specific questions regarding the

patient’s treatment plan to the therapist.

· Speak up if you notice something that “doesn’t look

right” or “doesn’t sound right.”

· Limit conversations and interruptions during therapy for

patients who are confused or delirious.

· Be aware and sensitive whenever “Code Calm” is in

effect.

Communication in the ICU

ICU Patient Room Preparation

Setup for the ICU Patient’s Room

The physical or occupational therapist will be the first to assess a patient’s transfer and mobility status. Once a

patient’s transfer status is determined, it will be communicated to the technician.

Only after therapist confirmation, the rehab technician may begin preparing the patient’s room for a treatment

session. This is to ensure patient safety. In the ICU setting a patient’s status can change from hour to hour, so

the treating therapist must not only check the chart, but get a nursing report to ensure nothing has occurred, or is

occurring, not yet documented in the chart, that would affect the patient’s ability to participate in therapy.

The technician’s role in organizing the ICU treatment area is vital. A well-prepared ICU treatment area increases

safety, efficiency of workflow, and allows for flexibility within a therapy session.

With practice, the technician and therapist can develop a routine that is safe and efficient.

The therapist will communicate to the technician when it is appropriate to begin Setting-Up the patient’s room.

This may occur while the therapist is getting a nursing report or recording the patient’s vitals.

ICU Patient Room Preparation

Do Don’t

· Allow the therapist to introduce him/herself to the RN,

patient, and family first. The therapist must decide if/when

it is appropriate to initiate treatment.

· Don’t initiate the probability/likeliness of a therapy

session with nursing or patient/family. Expectations

should not be set and then not met if the therapist hasn’t

had the chance to assess the patient first.

· Untangle lines and ensure proper length in case of sitting

edge of bed or transferring to a chair.

· Don’t begin setting up a patient’s room without

confirmation from the therapist.

· Remove pillows, bedding, SCDs, PRAFOs, Prevalon

boots, turning wedges, or other positioning devices not

needed for mobility

· Don’t disconnect invasive lines, tubes, or drains, even

for untangling purposes.

· Position chair with open sheet and chux. · Don’t remove patient restraints unless indicated by

therapist.

· Position urine bag in lowest possible position. · Don’t allow buildup of urine in urine bag tubing or

backflow of urine toward patient through urine bag tubing.

· Put down both side rails to prepare for edge of bed

sitting.

· Don’t initiate mobilization or exercise with the patient.

· Set up portable telemetry if indicated.

· Put socks on patient.


Identifying and Gathering Necessary Patient Care Equipment

Become familiar with where to find and how to use the following items in the various ICUs:

• Socks

• Gown

• Sheet for chair

• O2 tubing and connector

• Tape to secure lines

• Yankauer suction tip

• Recliner chair

• Transfer chair (ordered from Hill Rom)

• Sally Tube

• Wheelchair for following

• Portable telemetry

• Monitor functions: Blood pressure button, etc.

• Bed functions: boost, max inflate, seat deflate, chair position, OOB position


Specific Bed Functions

Identifies and Gathers Necessary Rehab Equipment

• MOVEO (Stored in M72 Gym)

• Shuttle Mini Press (sign-out system on Sharepoint)

ICU Team

The following rehab equipment are often used in the ICU:


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ICU Team


Contacts for locating, ordering, or servicing equipment:

• Beds and Chairs

Recliner Chair Barton Chair (Bariatric) Hausted All-Purpose

Chair

ICU Team


Contacts for locating, ordering, or servicing equipment:

•Liko Lifts

Single Lift (left) or

Double Lift (right)

Standard Equipment

ICU Room: Equipment

•Split monitor so RN can see vitals for both of his/her patients. R-side of

screen is patient in this room.

•Green = telemetry (HR, BP, pulse oximetry, RR)

•Red = arterial line

•Blue = central venous pressure line

•White = monitors ventilator settings/CO2

•Check BP: Top left gray button

BP Yankeur (top left) to attach to suction

tubing. Suction monitor below.

Above: ceiling lift (slings in equipment closet).

Below: wedge pillow for positioning.

Standard Equipment

ICU Room: Equipment

Portable Telemetry

ICU Room: Equipment

To monitor vital signs while

transferring or ambulating

a patient away from

bedside.

Above: Portable “cam” on wall

in patient’s room behind wall-

mounted black telemetry

monitor.

Above: Step 1: Use gray tab to gently

pull/slide “cam” off its track with cords

attached.

Below: Step 2: Slide “cam”

on the back of portable

telemetry monitor. May

need to use gray tab to

fully “lock” system into

place.

Portable Telemetry

ICU Room: Equipment

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Common Lines, Tubes, and Drains

ICU Room: Lines, Tubes, and Drains

• Tube feeds

• Keep HOB >/= 30 degrees

• May be put “on hold” temporarily for positioning (patient lying flat) but may need flushed by

RN if on hold > 15 min to prevent clogging





• Ventilator

• Settings may only be managed by RT/MD

• In some cases, therapist may be allowed to

temporarily increase O2

• Endotracheal tube

• Keep ETT from twisting in neck

• Watch for water in tubing, drain towards

machine or collection bag

• If dislodged, can only be re-inserted by

RT/MD



Above: Patient is intubated

with endotracheal tube (ETT)

to a ventilator.

Below: Patient has a

tracheostomy to a ventilator.

May also be transitioned to

trach collar.

• Dialysis

• Catheters may be located in neck or on chest. Ensure direct flow of line from dialysis machine.

• Large machine at bedside with dialysate fluid is sensitive to changes in weight, particularly if jostled.

• Patients may have “bear hugger” blanket for warmth (blue machine at foot of bed).





Types of

Dialysis

Machines

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Arterial Lines



Hi-Flow Oxygen (Nasal

Cannula or Mask)

Swan-Ganz

Catheter (central

line to pulmonary

artery)

AquaGuard

shield



Chest Tube: Alert therapist/RN if knocked

over


Positioning and Line Management

You may need to assist with boosting a patient higher in

bed prior to sitting at the edge of the bed. This

prevents very weak and/or morbidly obese patients

from sliding down in bed or too close to the edge of

the bed. Patients typically also require boosting

before being placed in the Chair Position of the bed.

The therapist will check the security of all lines prior to

mobility. You may be asked to assist in securing lines with

tape or hemostats. The therapist and technician will

communicate with each other regarding the set-up phase and

general plan for the session.

Some patients require a RT to monitor their airway and vent

during therapy.

You must prioritize preserving your back when mobilizing

patients to prevent back injuries. In the event that you should

sustain an injury while mobilizing a patient, you must notify

the CTL and then fill out a SERS report online. You will then

be directed to the Emergency Room for evaluation and further

instructions.

Line Management of Ventilator and Continuous

Dialysis

Positioning Wedge to Offload Sacral Wounds


Chair Position of the Bed (left) and Out of Bed Position (right)


Do Don’t

· Leave the treatment area briefly to obtain additional supplies only as

directed by the therapist.

· Don’t leave a therapist alone during a patient care treatment

UNLESS otherwise instructed by the therapist.

· Communicate appropriately with patients and family members. · Don’t discuss the patient’s medical/functional status or progress with

the patient, family, or medical team. Direct questions to the therapist

as needed.

· Provide assist to the patient’s trunk and hips whenever possible,

using the draw sheet as needed.

· Don’t pull on the patient’s extremities or neck when assisting with

mobility. Do not pull/push over the location of a line or drain insertion

site.

· During sitting activities with a patient, provide hand placement on

mid/low back and use pillow to support patient as needed.

· Don’t provide pressure on patient’s shoulders while he/she is sitting

at edge of bed. This limits upright posture and restricts lung

expansion.

· When transferring a patient, always use your hands on the gait belt. · Don’t pull upward on patient’s shoulders during transfers.

· Patients may require a slow pace during mobility activities. This will

be directed by therapist to allow for patient comfort, safety with lines,

and close monitoring of vital signs. This may include prolonged rest

breaks for patient with periods of assessment by therapist.


Guidelines for Hands-On Assistance to the Therapist

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Tips for Equipment and Lines

Do Don’t

· Keep the head of the bed greater or equal to 30

degrees, unless needed for positioning during session.

· Don’t attempt to sit a patient up or transfer a patient

without confirmation or direction from the therapist.

· Put tube feed on hold as directed by the therapist if

patient needs to be positioned flat temporarily.

· Don’t leave tube feed on hold for longer than 15

minutes at a time.

· Alert the PT/RN if tube feed left on hold greater than 15

minutes; may need to be flushed to prevent clogging.

· Allow condensation/liquids in the ventilator tubing to be

drained toward the ventilator.

· Don’t allow liquid build up or condensation in the

ventilator tubing to be drained toward the patient.

· Ensure direct flow of dialysis lines from the patient to the

machine.

· Don’t allow ETT or trach to twist in patient’s neck.

· Alert PT/RN if chest tube knocked over during session. · Don’t attempt to re-insert an ETT or tracheostomy if

accidentally dislodged (must be done by MD).

· Secure lines (e.g. tube feeds, JP drains) with tape as

directed by therapist.

· Don’t touch or adjust the ventilator controls (must be

done by RT or MD).

Resetting the ICU Patient’s Room

Resetting the Patient’s Room After a Treatment Session

Do Don’t

· Untangle lines. · Don’t leave taught lines.

· Put the patient’s pillows, bedding, Prevalon boots, call

light, TV control, and tray table in place.

· Don’t let patient lie flat (head of bed at least 30 degrees

unless instructed otherwise).

· Remove socks, unless directed as “ok” by therapist or

RN.

· Don’t leave dependent loops in urine bag, or

obstructions to flow of fecal management system tubing.

· Re-apply restraints when necessary. · Don’t leave a patient room until the treatment area has

been properly reset.

· Alert therapist if tube feed left on hold.

· Put up all 4 bedrails (all 4 rails up is not considered a

“restraint” in the ICU).

· Sanitize necessary equipment (gait belt, walker, chair,

etc).

When the session is complete, and the patient is positioned, the therapist will communicate to the technician when to

begin to Re-Set the room. While the technician is resetting the room, the therapist may begin assessing the next patient,

but will do a final “check” before you both move on.

Cleaning and Maintaining Equipment & Supplies

Cleans and Maintains All Therapy Equipment and Supplies Per Policy & Procedure Manual

● Gait belts and walkers can be cleaned with germicidal wipes (PDI Sani-

cloths) between every patient treatment session.

● Some therapists may carry portable a portable pulse-ox. These should

only be cleaned with hand sanitizer foam (inside and outside).

● Sheets/blankets and the patient’s gown should be changed if soiled

following a therapy session. Please remember to be cautious of multiple lines

when changing patient’s gowns and to maintain modesty as much as possible.

● If the patient is mobilized outside his/her ICU room and comes in contact

with horizontal surfaces (i.e. sits in chair or bench in hallway), this surface

should be cleaned with germicidal wipes (PDI Sani-cloths).

● Patients who have Contact or Droplet precautions who are mobilized

outside his/her room should wear a clean gown and avoid touching surfaces

outside the room to prevent infection from spreading.

● Recliner chairs should be cleaned with germicidal wipes (PDI Sani-cloths)

prior to entering a patient’s room to ensure cleanliness.

Everyone has a Role

Continued Readiness

Continued Readiness is the responsibility of each and every staff member that

works at the Cleveland Clinic and in our department. This means that every team

member is aware of the general policies and expectations required by Joint

Commission and CMS and make a daily effort to help contribute and ensure a

safe environment for patients, themselves, and fellow team members.

The CTL will help to review these policies periodically and perform quarterly

reviews to ensure compliance. It is the responsibility of the technician and each

and every staff member to inquire about policies and processes when questions

arise.

Everyone has an accountability and responsibility to cleanliness and order in our

department. If you see something that you think is out of order or an issue you

should do something about it or inform a CTL. One person can have an impact

and make a change in the department. On the reverse side it only takes one

person not taking responsibility to have a negative impact. Take pride in our

Department and in your role while assisting the ICU team!!!!!

Do the right thing at all times!

The Role of the Rehabilitation Technician in Applying the National Patient Safety Goals:

1. Improve the effectiveness of communication among caregivers.

-Communicate to the Therapist any safety concerns or questions.

2. Reduce the risk of a patient acquiring a health care associated infection.

-Disinfecting chairs, assistive devices, and gait belts.

-Hand washing or use of foam after every patient.

3. Reduce the risk of patient harm resulting from falls.

-Use of gait belt and safe body mechanics and guarding techniques during patient care.

-Maintain a safe room environment and manage position of lines, electrical cords, and dependent drains such as

foleys and ostomy bags to prevent patient or caregivers from stepping over these lines.

4. Prevent health care-associated pressure ulcers.

- Assist therapist with turning patients after patient care and elevating the extremities.

5. Improve recognition and response to changes in a patient’s condition.

-Notify the therapist calmly of any changes in a patient’s condition (appearance, vital signs, safety with positioning) if

you feel that it represents a change in the patient’s condition that the therapist does not seem to be aware of.

6. Universal Protocol: Correct patient and procedure.

-The therapist will provide the patient’s name and the treatment plan before each session so that the

technician is aware of patient identifiers.

Everyone has a Role

Continued Readiness

Rehab Tech training

Be prepared to have conversations and provide

emotional support to team members who may

struggle with the intensity of the critical care

environment, including patients who face end of

life decisions

MICU Pilot

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Teamwork

Communication

Respect

Mutual understanding of work flow

Nursing plan, RT weaning

Shared goals

Patient centered

Celebration of successes!

Caregiver Celebrations

MICU Pilot

Surgical ICU Trial

1 PT already treating for partial day coverage

Nursing and Physicians verbalizing the positives

of early mobility and noticing a change in the

culture of the unit

Rehab Director and SICU Medical Director

meeting and agreement to dedicate 1 PT to 30

bed ICU

SICU Pilot

SICU Pilot

Nursing collected data on patient outcomes

before and after dedicated PT for:

Length of stay in SICU

Pressure ulcer rates

Ventilator assisted pneumonia rates

Ventilator days

Patient satisfaction

SICU Pilot Data

Length of Stay

6.05

5.19

4.26

0

1

2

3

4

5

6

7

Q1 2013 Q2 2013 2013

Num

ber

of D

ays

in S

ICU

Prior to Early Mobilization After Initiation of Early Mobilization 2013

SICU Pilot Data

SICU Skin Care

8.58%

10.26%

5.81%

6.95%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

2012 Q1 2013 Q2 2013 2013

UA

PU

Rat

e

2012 Prior to Early Mobilization After Initiation of Early Mobilization 2013

SICU Pilot Data

SICU Ventilator Days

446.08

481.33

418.75

455.4

380

390

400

410

420

430

440

450

460

470

480

490

2012 Q1 2013 Q2 2013 2013

Ven

tilat

or D

ays/

Month


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SICU Pilot Data

SICU VAP Rates

1.31

2.16

0.81

1.84

0

0.5

1

1.5

2

2.5

2012 Q1 2013 Q2 2013 2013

Nu

mb

er

of

VA

Ps/M

on

th


SICU Pilot Data

Press Ganey

3.97

4.22

3.8

3.85

3.9

3.95

4

4.05

4.1

4.15

4.2

4.25

2012 2013

Mean

(A

vera

ge)

Sco

re

SICU Pilot Data

Overall Rating of SICU (Press Ganey)

75%

79.41%

89.08%

75.78%

65%

70%

75%

80%

85%

90%

95%

2012 Q1 2013 Q2 2013 2013

Perc

en

t o

f "V

ery

Go

od

or

Bett

er"

An

sw

ers


SICU Pilot

Mobility log

created for

communication

between PT

and nursing

SICU Pilot

Combined

And applied

Applied the

Delirium

Management

And Early

Mobility

Bundles4

SICU Pilot

Outcomes

Maintained staffing of 1 full time PT

Added 1 additional PT 1 year later

Opportunities for nursing education

In-service on patient mobility with orthopedic

precautions

In-service on evolving role of PT on the unit

Training with nursing technicians with simple mobility

procedures and gait belt use

17%

13

Business Proposal: Case for Change –

Increase PT in the ICU Leadership from therapy and ICU met with

Medical Operations

Provided rationale for increased therapy in

ICU

ICU therapy under-utilization

17%

ICU

83%

Non-ICU

BEDS – Main CampusSource: EBI Occupancy Dashboard

5%

ICU

95% Non-ICU

PT ACTIVITY – Main CampusSource: MediLinks Volume / Activity

ICU beds make up 17% of total inpatient beds on Main Campus, but only 5% of all physical therapy activity

MICU Pilot: Preliminary Results

Identifying the right patients and treating them with skilled therapy

is helping to improve MICU patients’ functional independence

PT FTE Sizing Methodology

MICU NICU SICU

Cardiac/

CCU TOTAL

Beds 53 22 30 98 203

# appropriate

PT Consultsper CIP model ratio

1,174(40% of

pts)

274(20% of

pts)

390(20% of

pts)

662(10% of

pts)

2,499(19% of

pts)

Total PT Visits 5,872 1,094 1,402 2,383 10,752

PT FTEs

needed (at 1,200

visits/yr/FTE)

4.9 0.9 1.2 2.0 9.0

Current PT

FTEs1.0 0.5 0.5 1.0 3.0

Incremental PT

FTEs Needed4.0 0.5 0.5 1.0 6.0

Rehab Techs (1 Tech per 2 PTs)

2.0 - - 1.0 3.0

Total Annual Cost: $644,006

Proposal

Develop a new ICU PT clinical team

Add 6 new physical therapists to the current staff of 3 PTs in the ICU

Hire 3 additional Rehab Techs to support program

Resource with new hires or pull existing staff

Current PTs New PTs Needed

MICU 1.0 4.0

NICU 0.5 0.5

SICU 0.5 0.5

Cardiac / CCU 1.0 1.0

3.0 6.0

Alternate Staffing: Pull Existing Staff

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

70%62%

77%67%

NeuroOrtho

63%

Medicine

92%

78% 76%

Cardiac

69%

TOTAL PT

77%

Current Response Time

Predicted Response Time

Impact of Reducing each Clinical Team by 1 PT FTE:

Reduced Response to PT Consults

PT

Respon

se T

ime

(% r

espon

de

d,

36

hrs

)

248 531 426 306 1,512Reduced

Consults/yr

17%

14

Business Case / ROI

MICU NICU SICU

Cardiac/

CCU TOTAL

Total Hospital

ALOS14.7 10.1 14.8 13.1

Target

Reduction(1.0) (0.5) (0.5) (0.5)

Direct Cost per

Day$2,162 $2,658 $2,830 $3,290

Total Cost

Savings ($000)$1,984 $201 $251 $516 $2,954

FTE Incremental

Costs ($000)$429 $44 $44 $125 $644

Return on

Investment362% 351% 464% 312% 359%


Increase PT in the ICU Response from hospital operations:

Favorable or not?

Agreement was in place that the value of

increasing PT in the ICU was significant

Hospital operations would not approve hiring

additional FTE as proposed


Increase PT in the ICU

During previous hospital operation meetings

the following issues were discussed:

PT response time was not being met due to

inappropriate referrals

Not all staff were meeting 100% of the expected

productivity standard


Increase PT in the ICU Hospital Operations challenged therapy

leadership:

Shift work from areas covering inappropriate

referrals

Work to improve productivity of team members

not achieving the expectation


Increase PT in the ICU


Increase PT in the ICU Initial primary focus of allocation of resources

started with areas with high 6-click scores

“6-Clicks” scores are valid for assessing patients’

activity limitations in acute care settings5

Therapy leadership utilized “6-Click” data to

identify areas with a high volume of 23-24 “6-

Click” scores

Meetings were held in these areas with

nursing and medical team leadership

17%

15

6-Clicks Data

12/2012

# of 19-24’s was 42%

6/2013

# of 19-24’s was 39%

# of 24’s (consults for mobile patients) are

down nearly 8%

Physicians

that may

need more

education

Development of the Critical Care

Team Decision was made to develop a Critical Care

Team which included:

1 Clinical Team Leader

8 Physical Therapists

4 Occupational Therapists

Positions were shifted from other teams in the

department

All ICUs throughout the hospital are covered by

the Critical Care Team

Development of the Critical Care

Team – Initial Staffing Critical Care Team Units

MICU – 5 ICUs, 64 beds

2.5 PTs, 1.5 OTs

SICU – 3 ICUs, 30 beds

2 PTs, 1 OT

NICU – 2 ICUs, 24 beds

1 PT, 0.5 OT

Cardiac ICUs (HF-ICU, CICU, CVICU) – 8 ICUs,

110 beds

3 PTs, 1 OT

Critical Care Team – First Year

0

200

400

600

800

1000

1200

1400

1600

PT / OT Critical Care VisitsYr. over Yr. Since 2012

PT Critical Care Visits

OT Critical Care Visits

Sept. 2012

OT 41 PT 272

Sept. 2013

OT 87 PT 388

Sept. 2014

OT 99 PT 370

Sept. 2015

OT 452 PT 920


3%5%

5%

21%

6%

9% 7%

19%

0%

5%

10%

15%

20%

25%

Sept. 2012 Sept. 2013 Sept. 2014 Sept. 2015

PT / OT Critical Care Visits as % of Total Visits

OT CC Visits as % of Total OT Visits PT CC Visits as % of Total PT Visits

17%

16


Mismatch

Match!


Survey

A survey was distributed via e-mail to the following professionals in the ICU:

1) ICU attendings

2) Critical care/Pulmonary critical care/cardiology and vascular surgery fellows

3) Residents with experience in our ICUs

4) Nurses (RN, ANM)

5) Midlevel practitioners (NP/PA)

6) Respiratory therapy


Survey ResultsRespondents: 226

12.6% (n=17) residents

49.6% nurses (n=67)

44.6% (n=101) did not identify their discipline

98% of respondents believed patient outcomes have improved for those patients

who worked with PT/OT in the ICU

92% consider patient readiness for therapy during their daily rounds for patient

care

96.7% of respondents (100% of physician respondents) recommended continued

PT/OT presence in ICUs

87.9% of all respondents rated PT as having significant value in the ICUs, whereas

71.1% rated OT as having significant value in the ICUs

Majority of comments were positive, while some (<5) comments were negative orrelated to adverse events as a result of working with therapy (patient fatigue or O2

desat, PT or OT “in the way” of other treatments)

Critical Care Team Orientation

Identified the need for a comprehensive and

uniform orientation process to critical care for all

PT and OT caregivers

Characteristics of ICU Critical Care Team

members when it was established: Therapists with varied levels of ICU experience (1-20+ years)

Therapists treating patients of different levels of ICU complexity at large main

tertiary hospital versus small regional hospitals

Therapists trained in variety of ways Experience. Didactic knowledge from school. Prior job setting. Other PT/OTs. Continuing Education.

Therapists experience and comfort in the ICU based on the patient population

without the knowledge base to rotate to all ICU units Cardiothoracic, Cardiac, Medical, Neuro, Surgical


Current state of orientation process when

Critical Care Team was established Therapists with ICU experience orienting therapists without ICU

experience

Therapists with ICU experience were “grandfathered in” and did

not receive orientation

Global department orientation processes were used for general

acute care knowledge and competencies

Lack of uniformity and structure with the process

Individualized by the orienting therapist

No guidelines for who could treat in the ICU considering prior

experience (i.e. new graduate)


Formal ICU orientation process developed by

the CC Rehab and Sports Therapy ICU SIG

Approximately 30 member group

20 PTs, 6 OTs, 2 STs, 1 Group leader

Began in 2011

Met quarterly for 1 hour meetings

Yearly commitment

All therapists with an interest could join and did not need

to be currently staffed in an ICU

17%

17


Role and Activities of the ICU SIG

Process Development

Piloting ICU related patient care competencies

Education of ICU therapists

Journal article presentations

Arranging for guest speakers to give CEU events

Developing internal CEU events


ICU SIG recognized the need for and chose

to develop a formal critical care orientation

process

Assigned a project coordinator

Established a timeline (1 year)

Majority of members chose to participate

Communicated by email and through quarterly

meetings (in-person and conference calls)


Established necessary components to the

orientation process through:

literature review

Mejia-Downs et al 20156

project coordinator leadership and experience

experience with clinical education

SIG member input

used in-person meeting for discussion and input of

group members


Established key components of ICU

orientation: General orientation to acute care

ICU unit and patient population specific information

Learning modules for reading and memorizing

Literature review for evidence based practice of fundamental ICU

literature

Observation of a preceptor

Patient care with a preceptor

Competency checklist

Quiz


Learning Modules Evidence for early mobility. Outcome measures.

Role of PT/OT/SLP in the ICU

Treatment ideas for PT/OT

ICU delirium definition and management

ICU lines, tubes, drains. ICU monitors. Bed functions.

Ventilators and other oxygen delivery systems

Lab values

Pharmacology

Precautions/contraindications for mobility

Strategies for chart review, documentation, communication

Room set-up considerations

Role of the rehab tech

Family role and involvement in care

Critical Care Team Education

ICU SIG organized CEU opportunities to

educate ICU clinicians with all levels of

experience

Perme Early Mobility and Walking Program in

ICU: 2013

ICU Fundamentals (2 part): 2014

Oxygen Delivery Systems: 2016

Pharmacology: 2017

17%

18


ICU Fundamentals (internally developed) Lines, tubes, drains

Oxygen delivery systems

Mechanical Ventilation

EKG

Lab Values

Pharmacology

Delirium

To treat or not to treat

PT, OT, ST treatment ideas

Utilization of support staff


Management of Oxygen Delivery Systems

and Mechanical Ventilation in the ICU

(internally developed) Identifying O2 deliver systems

Ventilator modes

Role of PT/OT in managing a patient’s respiratory status

Implementing best practice

Pharmacology (internally developed) ICU Pharmacology and Case

General Medicine Pharmacology and Case


Recognized the need for orientation and

education of therapy support staff in the ICU

7-10 rehabilitation technicians staffed at main campus

Varied levels of rehab tech experience (20+yrs to <1yr)

Varied levels of prior experience

Nursing aides

PT/OT students. Nursing students. Pre PT/OT students.

All rehab techs oriented and trained with general

acute care skills to assist therapists during patient

care on regular nursing floor units


Identified areas to enhance the training and

orientation for rehab tech support in the ICU: Role of rehab techs in the ICU setting

Brief presentation of the evidence for early mobility

Education with considerations for patient interactions specific to the ICU

such as delirium and agitation

Role of the rehab tech to maintain national patient safety goals

Instructions on the role of a rehab tech with:

Setting-up and ICU room

Assisting the therapist during patient care

Re-setting the ICU room

Sanitization of equipment


A formal multi-modal rehab tech critical care

orientation process was established

Established 3 PT preceptors to train all rehab

techs for training consistency and organization

1:1 preceptor-to-tech training during patient care

Orientation binder

Competency checklist

Simulation Lab


Created 2 page competency checklist

Yes/No assessment

Four categories of knowledge

Equipment and precaution knowledge

Room set-up and patient preparation

Patient mobility and transfer assistance

Re-set of the patient and room

17%

19


Rehabilitation technicians SIM Lab Training

Worked with Cleveland Clinic Simulation Lab to

develop and implement a simulated ICU

competency experience

Therapist acted as a standardized patient

Use of monitors, ICU lines/tubes/drains

Used competency checklist for assessment

See video

Critical Care Team – Current State

Critical Care Team Units

MICU – 5 ICUs, 64 beds

3 PTs, 1.5 OTs

SICU – 3 ICUs, 30 beds

2 PTs, 1 OT

NICU – 2 ICUs, 24 beds

1 PT, 0.5 OT

Cardiac ICUs (HF-ICU, CICU, CVICU) – 8 ICUs,

110 beds

3 PTs, 1 OT


Ongoing Education

Monthly Critical Care Team Journal Club

Peer to peer on the job shadowing/education

Team members encouraged to rotate every 4

month

Rotate to another hospital team/service

Rotate internally within the Critical Care Team

ICU SIG Journal Clubs

Providing inservices at satellite hospitals

Tech training/SIM lab training


Ongoing Quality Review

Quality Visits by Clinical Team Leader

Hand washing

Patient Identification

Appropriate Communication with patient

Treatment provided is skilled and appropriate

Billed Treatment is appropriate

Plan of Care is appropriate

Peer Audit Documentation

Performed by Clinical Team Leader, Senior or Clinical

Specialist

Critical Care Team – Current State Critical Care Team – Current State

17%

20


Challenges over the past year – 2017

Co-evaluation and Co-Treatment changes

Co-evaluations are not supported by the Cleveland

Clinic Rehabilitation and Sports Therapy Department

The decision to co-treat needs to be made on a case by

case basis and the need to co-treat needs to be well

documented for each patient. Co-treatments should be

limited.

Point after service documentation

Critical Care Team is working together to

meet these challenges


Beginning January 2018:

Team added 2 more OTs

Will increase value that OT can provide to the patient in

treatment of the Critical Care patient

OT will assess patient before PT in certain areas

OT provides a skill set that is highly needed in the

Critical Care areas as they can focus on

Communication, Cognition, Coping, etc

Studies have shown that early and intensive OT is

effective in decreasing the duration and incidence of

delirium in the ICU7

Critical Care Team – Future State

Continue to use Critical Care Team Orientation

outline/materials for new team members

Allow training in the SIM lab to be available for

new ICU PT/OT clinicians

Elevate rehab technicians to continue to assist

team in providing world class care to the

medically complex, critically ill patients Yearly competencies

Continuing education developed by internal staff

Emotional support for Critical Care Team

References

1. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible

and safe in respiratory failure patients. Crit Care Med. 2007; 35:

139-145.

2. Morris PE, Goad A, Thompson C, et al. Early intensive care unit

mobility therapy in the treatment of acute respiratory failure. Crit

Care Med. 2008; 36: 2238-2243.

3. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical

and occupational therapy in mechanically ventilated, critically ill

patients: a randomized controlled trial. Lancet. 2009; 373: 1874-

1882.

References

4. Morandi A, Brummel NE, Ely EW. Sedation, delirium, and

mechanical ventilation: The ‘ABCDE’ approach. Curr Opin Crit

Care. 2011;17:43-49.

5. Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS,

Jette AM. Validity of the AM-PAC “6-Clicks” Inpatient Daily Activity

and Basic Mobility Short Forms. Physical Therapy. 2014; 94: 379-

391.

6. Mejia-Downs A, Blake MJ, Kanetkar A. Comprehensive critical

care orientation for physical therapists in an academic medical

center. J Acute Care Phys Ther. 2015; 6:93-101.

7. Alvarez EA, Garrido MA, Tobar EA, et al. Occupational therapy for

delirium management in elderly patients without mechanical

ventilation in an intensive care unit: A pilot randomized clinical trial.

Journal of Critical Care. 2017; 37: 85-90.

Audience Learning Questions

1) Did you learn something from this presentation that you can apply

to patient care?

2) Did you learn something (strategies for workflow, staff efficiency)

that you could apply to your Critical Care Team or the formation of

one in your facility?

3) Did you learn something (strategies for data collection, outcome

measures) that you could use to increase the value therapists in

your facility bring to patients in the ICU?

4) Were the tools for therapist and staff training and orientation

presented here applicable to your specific department needs?

17%

21

title of presentation arial 50pt bold...secrets of the past –icu coverage therapists that pulled...

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