CUSP 4 MVP – VAPImproving Care for Mechanically Ventilated Patients

Data Webinar 5 Defining the Early Mobility Measures

ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITYJohns Hopkins University

April 1, 2015

2 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Defining the Early Mobility Measures

CUSP 4 MVP – VAP

Comprehensive Unit-based Safety Program for Mechanically Ventilated Patients and Ventilator-Associated Pneumonia

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Polling Question

Who is on the call? • IP – infection preventionist• RN – registered nurse• RT – respiratory therapist• PT – physical therapist• OT – occupational therapist• MD – medical doctor• Quality improvement professional• Healthcare executive• Educator• Coordinating entity• National project team• Other  

Defining the Early Mobility MeasuresNishi Rawat, MD

CUSP 4 MVP – VAPImproving Care for Mechanically Ventilated Patients

5 CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients Defining the Early Mobility Measures

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Objectives

• Discuss the data elements needed to complete the Daily Early Mobility Measures Form

• Review the definitions of those data elements• Consider and discuss strategies for finding the

data elements

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Daily Early Mobility: Key Interventions

• Use multi-disciplinary and coordinated approach• Interrupt daily sedation and minimize sedative use• Assess sedation and delirium with structured

scales • Screen for highest level of mobilization• Employ a nurse-driven protocol to achieve highest

level of mobility

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Data Collection

• Drives quality improvement efforts• Is NOT for research• Provides quantifiable measures of care practices• Guides patient safety conversations• Justifies resource allocations

– Human resources (time)– Financial resources (money)– Supplies and equipment (stuff)

Daily Early Mobility Data Collection Tool

Download the tool from the project website: https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/datatools.aspx under “Daily Early Mobility”

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Polling Question

• Have you begun using the Daily Early Mobility Measures Form?YesNoUnsureThis question is not applicable to me

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Fill out for all beds

• Track by bed, not by patient• Complete

– Bed number– Whether the patient in that bed was

intubated or trached and on mechanical ventilation at the time of observation• Y = Yes• N = No• E = Empty bed

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Date of intubation

• Enter the date the patient was intubated– If the date is not available*, enter

admission date (either to the unit or to the hospital)

– If the patient is extubated and re-intubated within 24 hours, use the original date

*i.e., when from an outside institution

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Sedation Scale

• RASS = Richmond Agitation Sedation Scale

• SAS = Riker Sedation-Agitation Scale

• NU = Unit uses neither RASS or SAS– If NU, skip to Delirium

Assessment

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Sedation Scale

If you entered ‘RASS’• Target

– What is the target RASS or SAS score for this patient?

• Actual– What is the actual RASS or

SAS score for this patient?

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Delirium Assessment

• CAM-ICU = Confusion Assessment Method for the ICU

• ASE = Attention Screening Exam

• NU = Unit uses neither CAM-ICU or ASE

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Confusion Assessment Method for the ICU (CAM-ICU)

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Confusion Assessment Method for the ICU (CAM-ICU)

The Society of Critical Care Medicine’s 2013 pain/agitation/delirium (PAD) clinical practice guidelines recommend the CAM-ICU or the Intensive Care Delirium Screening Checklist (ICDSC) as the most valid and reliable delirium screening tools, and that moderate to high risk patients be screened at least once per nursing shift.

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Delirium Assessment – Attention Screening Exam (ASE)

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Delirium Assessment – Attention Screening Exam (ASE)

• ASE is feature 2 of the CAM-ICU.• ASE is a 10-20 second test. • The goal of ASE is to determine if a patient can

follow a simple command (pay attention) for that period of time.

• Inattention is the cardinal feature of delirium and must be present to diagnose delirium.

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Delirium Assessment – Attention Screening Exam (ASE)

• If the CAM-ICU is not yet feasible in your unit, we recommend that patients at least undergo the ASE once per nursing shift.

• For centers not using the full CAM-ICU, conducting the ASE is a good barometer of the presence or absence of delirium. This test may be abnormal due to disease, drugs or other causes.

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Delirium Assessment – Attention Screening Exam (ASE)

• The exam consists of the provider reading the following sequence of letters:

‘S A V E A H A A R T’ or ‘C A S A B L A N C A’ or ‘A B A D B A D D A Y’ • The patient is told to squeeze the provider’s hand when

the letter ‘A’ is stated. • An error is defined as no squeeze with letter ‘A’ or a

squeeze on a letter other than ‘A’. The number of errors is counted. Inattention is present if the patient commits more than 2 errors. If the patient squeezes on every letter or doesn’t squeeze on any letter, then assign an error count of 10.

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Polling Question

Which delirium assessment does your ICU use? CAM-ICU ASE Both CAM-ICU and ASE Neither I don’t know This question is not applicable to me

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Mobility

• Highest Level of Mobility– What was the highest level

of mobility achieved by the patient in the last 24 hours?

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Mobility

• Perceived Barrier to Achieving a Higher Level of Mobility– What prevented the

patient from being mobilized to a higher level?

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Perceived Barrier

• Perceived barrier codes are listed on the back of the data collection sheet.

• Enter the code associated with the answer.• If multiple codes apply to a patient, please select

the LOWEST number.

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Mobility – PT/OT

• Physical Therapy– Did the physical therapist evaluate

or treat the patient within the last 24 hours?

• Occupational Therapy:– Did the occupational therapist

evaluate or treat the patient within the last 24 hours?

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Events

• Did the patient have an “event” (as defined on the back of the data collection sheet) while being mobilized within the last 24 hours?

• Event codes are listed on the back of the data collection sheet

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Discussion

• Where can you find these data? – Ideas?– Suggestions?– Barriers?

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Objectives

• Discuss the data elements needed to complete the Daily Early Mobility Process Form

• Review the definitions of those data elements• Consider and discuss strategies for finding the

data elements

Next Steps

CUSP 4 MVP – VAPImproving Care for Mechanically Ventilated Patients

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Next Steps

• Where will you find your data?– Look for data sources– Make plans for data collection processes– Practice collecting data for next call

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Going Forward

• After you have found your data sources and data collection has officially started– Collect data daily– Enter the data at least weekly

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Homework

• Determine the location of information needed to complete the Daily Early Mobility Measures.

• Determine who will gather Daily Early Mobility Measures.  

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Mark Your Calendar:Upcoming Webinars

For current schedule of

upcoming project

webinars, visithttps://armstrongresearch.hopkinsmedicine.org/cusp4mvp/schedules.aspx

Infection Prevention WebinarsIP Webinar 4: Wed, Apr 22, 2015 11:00 – 12:00 PM EDTIP Webinar 5: Wed, May 27, 2015 11:00 – 12:00pm EDT

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CUSP 4 MVP – VAP Website

Visit: https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx

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What Can I Find on the CUSP 4 MVP – VAP Website?

• CUSP Tools and Guides

• HSOPS Resources

• Data Collection Tools

• Educational Materials

– Toolkits

– Literature Reviews

– Fast Fact Sheets

• Archive of webinars led by subject matter experts

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