36C26119Q0345-0003001.pdf

Early mobility in the intensive care unit (ICU) is critical to a patient’s short- and long-term recovery. Studies show early mo-bility programs result in more venti-lator-free days, fewer skin injuries, shorter ICU and hospital stays, re-duced delirium duration, and im-proved physical functioning.

But accomplishing early mobili-ty requires significant coordina-tion, commitment, and physical ef-fort by the multidisciplinary team.

How do we balance the benefits of early mobilization against the potential risk of staff or patient in-jury during the mobilization activi-ty? Part of the solution to ensuring safe mobilization of critically ill patients is to view mobilization along a continuum based on pa-tient readiness, progression based on goals, strategies to prevent complications, and assessment of activity tolerance. This view keeps safety at the forefront.

Within the ICU, barriers to ear-ly mobility may include clinicians’ knowledge deficits and fears, in-sufficient human and equipment resources, patients’ physiologic in-stability, lack of emphasis on the value and priority of mobilizing patients, and the ICU culture relat-ed to mobility. A 2014 internation-al survey of early mobilization practices in 833 ICUs found only 27% had formal early mobility protocols, 21% had adopted mo-www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 7

Transforming the culture: The key to hardwiring early mobility and safe patient handling Culture change requires deliberate focus, staff education, and full engagement.

By Kathleen M. Vollman, MSN, RN, CCNS, FCCM, FAAN, and Rick Bassett, MSN, RN, APRN, ACNS-BC, CCRN bility practices without a protocol, and 52% hadn’t incorporated ear-ly mobility into routine care prac-tices. Barriers to implementation of mobility initiatives included com-peting staffing priorities, insuffi-cient physical therapy staff, and concern about patient and care-giver injury. The study found that a standardized protocol may pro-mote successful implementation of an early mobility program.

36C26119Q0345 Reference Information on Early Mobility

Importance of a culture change Sustaining any clinical improve-ment initiative requires an organi-zational culture change. Baseline assessment of the current culture as well as early engagement of team members is the starting point. In 2012, the authors led a VHA, Inc.

critical care improvement team col-laborative of 13 ICUs from eight organizations to implement safe and effective early patient mobility in the ICU. Efforts focused on elements central to sustainable change. First, team members acquired key knowledge to under-stand why ICU mobility is impor-tant. Next, strategies for organiza-tional, leadership, and clinical staff engagement were discussed. To promote the transition in practice and the required culture change, ICU clinicians needed guidance.

An organizational development tool was designed to help teams create an effective culture change.

Although it was adapted specifical-ly to integrate with early patient mobility efforts in the ICU, this tool can be applied to other settings.

(See Learning progression for pa-tient mobility.)

Three elements are crucial to successfully implementing and sus-taining an improvement initiative:

• Team members must understand and be able articulate what’s being proposed. To help them understand, they must receive evidence-based literature and other relevant information.

• Team members must grasp why the initiative is important to the patient, themselves, and the or-ganization. Clinicians typically respond favorably to change when they can connect it to real impacts.

• The leader of the initiative must

8 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com

Learning progression for patient mobility This diagram shows the four stages of staff learning regarding early patient mobility and safe patient handling.

2 3

Right type of support, right time

To progress to the next level: Educate regarding evidence and progressive mobility continuum, use scenarios to build problem-solving skills around contingencies and high-risk patients.

Leverage physical therapy in teaching nurses specific skills.

STAGE 2: Conscious, unskilled

“I care now, but I feel clueless.”

• Staff are receptive to progressive mobility concepts.

• Staff may be fearful of process and risks.

STAGE 3: Conscious, skilled

“I know but need support and extra time to execute.”

• Staff are ready to put progressive mobility into daily practice.

• Staff are motivated by sense of efficacy and success/failure experiences.

STAGE 1: Subconscious, unskilled

“I don’t know why I should care about patient mobility.”

• Staff are unclear on purpose behind progressive mobility.

• Old paradigms and assumptions around immobility are present.

STAGE 4: Subconscious, skilled

“I am skilled and can help others.”

• Staff skillfully put progressive mobility into daily practice.

• Further staff learning is enhanced by teaching and mentoring others.

To support process:

educate staff regarding how to effectively mentor, coach.

Exapnd role:

storyteller, champion, and mentor.

SkilledUnskilled

Co ns cio us

Su bc on sc io us

Co ns cio us ne ss

© 2010 Brandwene Associates

To progress to the next level:

Overcome staff's emotional and intellectual barriers by using storytelling and evidence, engage in discussions and address positive/negative aspects of immobility. Include sources (evidence and experience) outside the organization as well.

To progress to the next level:

Coach and mentor staff during execution. Encourage through failure experiences (such as patient not tolerating mobility), and build sense of competence by recognizing successes.

define the role of each team member and discipline. Under-standing team roles creates a solid platform on which the cul-ture change builds.

Four stages of learning To learn a skill or concept, a per-son progresses through four stages, according to a learning model attributed to Abraham Maslow. This model can be ap-plied to clinicians learning about safe patient handling and mobility

(SPHM).

Stage 1: Subconscious, unskilled In this stage, team members are unaware of how little they know and don’t realize a change is nec-essary. Also, they may have fears and misconceptions about the change. For example, some criti-cal care clinicians believe reposi-tioning or mobilizing critically ill patients threatens the security of vital tubes and lines. But with the proper knowledge, training, and resources, staff can mobilize and reposition ICU patients safely with-out jeopardizing tubes and lines.

In one study, 1,449 activity events (such as sitting up in bed, sitting in a chair, and ambulating) were performed with mechanically venti-lated patients; fewer than 1% ex-perienced adverse events. As part of the culture change, misconcep-tions about SPHM need to be ad-dressed through education and coaching. Once the purpose of SPHM is defined clearly and mis-conceptions have been addressed, team members are ready to move on to stage 2.

Stage 2: Conscious, unskilled In the conscious, unskilled stage, team members understand why SPHM is important but don’t know how to accomplish it. Al-though open to new learning, they may have fears about specif-ic processes or actions involved in patient mobilization. For in-stance, they may fear certain www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 9

Decision tree for mobilizing hemodynamically unstable patients This diagram helps clinicians determine whether and when an intensive care unit patient is ready to begin mobility activities.

Begin in-bed mobility techniques and progress to out-of-bed mobility as the patient tolerates.

No

No

No

No

Screen for mobility readiness within 8 hours of admission to the ICU and daily and initiate in-bed mobility strategies as soon as possible.

Is the patient hemodynamically unstable with manual turning?

• O2 Sat ≤ 90%

• New-onset cardiac arrhythmias or ischemia

• HR < 60 or >120

• MAP < 55 or >140

• SBP < 90 or >180

• New or increasing vasopressor infusion

Yes

Begin in-bed mobility techniques and progress to out-of-bed mobility as the patient tolerates.

Yes

Yes

Yes

Allow the patient a minimum of 10 minutes of rest between activities and then try again to determine tolerance.

Is the patient still hemodynamically unstable after allowing a 5- to 10-minute adaptation after position change before determining tolerance?

Have activities been spaced sufficiently to allow rest?

Has the manual position turn or head-of-bed elevation been performed slowly?

Initiate continuous lateral rotation therapy via a protocol to train the patient to tolerate turning.

Try the position turn or head-of-bed maneuver slowly to allow adaptation of cardiovascular response to the inner-ear postiion change.

Key HR: heart rate ICU: intensive care unit MAP: mean arterial pressure SBP: systolic blood pressure O2 sat: oxygen saturation

© 2012 Kathleen Vollman-Advancing Nursing LLC.

types of mobilization activities can cause hemodynamic instabili-

ty. Education and practical appli-cation experiences can help them overcome this fear. Another way educators can break through such barriers is to use a decision tree that incorporates the latest scien-tific knowledge to help clinicians minimize the hemodynamic im-pact or retrain patients to tolerate movement. (See Decision tree for mobilizing hemodynamically un-stable patients.)

A critical resource used with the VHA team was a nurse-driven, evidence-based multidisciplinary progressive mobility continuum tool that addresses mobility phas-es and corresponding interven-tions. The team received education on the tool and how to apply it in practice. The tool provided a visu-al foundation to guide safe mobili-ty practices, create consistency, promote team communication, and enhance processes.

Numerous studies show that ed-ucation, skill building, and proto-cols may not be enough to create sustainable change. Using strate-gies to evaluate available nursing resources and systems that can produce change makes it easier for clinicians to provide the right care for the right patient at the right time while balancing these needs against caregivers’ needs for safety.

In bed and out-of-bed activities Strategies to promote patient and caregiver safety during mobiliza-tion can be divided into two basic categories—those used when the patient is in bed and those used when the patient is out of bed. In-bed mobility encompasses reposi-tioning activities, lateral-rotation therapy, tilt-table exercises, and bed-chair sitting. Modern critical-care beds should be capable of ro-tating the patient continuously, cre-ating a tilt table through the use of a reverse Trendelenburg position and an adjustable footboard, pro-gressing the body through the head elevation–foot down position to a chair, and ultimately assisting the patient with standing. These features reduce the risk of patient and caregiver injury and make it easier to perform mobility actions.

For in-bed repositioning from side to side and moving up, using a breathable glide sheet and spe-cially designed foam wedges helps reduce shear and friction for the patient and help prevents in-juries to caregivers because they require a pulling rather than lifting motion. In one study, implementa-tion of this turn-and-position system reduced hospital-acquired pres-sure ulcers by 28% and reduced staff injuries by 58%. Lifts can be used for some in-bed mobility ac-tivities and are effective during ambulation and the transition from in-bed to out-of-bed activities.

Stage 3: Conscious, skilled Stage 3 learning focuses on imple-menting the change, with attention to fine-tuning the process. Coach-ing, mentoring, and maintaining engagement are critical. In previ-ous stages, much effort was ex-pended in educating and training staff. During the transition from stage 3 to stage 4, the skills and knowledge required for the SPHM initiative must become “hard-wired” or ingrained into care-givers’ subconscious. This requires deliberate, focused energy on con-tinued engagement. However, staff energy, resource availability, and competing priorities may pose barriers to sustaining the change.

Throughout stage 3, positive feedback, motivation, and sharing of successes and challenges are important for driving continual im-provement and culture change.

These goals can be accomplished in various ways. Here are some examples:

• Networking with other organi-zations in various stages of the practice change can be ex-tremely useful. It allows collabo-rative identification and sharing of challenges, struggles, effec-tive strategies, and success sto-ries. This process creates syner-gistic energy among the team members, helping to motivate them and accelerate the change.

• Within the VHA mobility collab-orative network, teams shared reward strategies. One team gave out M&Ms® when “caught in the act” of Moving and Mo-bilizing patients. Such moments present crucial coaching oppor-tunities. For example, after a mobility event, staff can huddle briefly to discuss the event and what, if any, improvements could be made to make the process more effective.

Stage 4: Subconscious, skilled During this stage, the practice and culture changes are well on their

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In-bed mobility encompasses repositioning activities lateral-rotation therapy, tilt-table exercises, and bed-chair sitting.

units. On the other hand, using a PAR system means slings will be readily available on all shifts, which leads to better compliance with the SPHM program.

Centralized distribution With this system, access to slings may not be available when need-ed, especially on evenings, nights, weekends, and holidays.

A staff member must be put in charge of maintaining central stor-age for efficient distribution, and a process for obtaining slings must be established. For instance, is a runner needed? If so, who supplies the runner?

Nonetheless, a well-organized centralized distribution process can be highly effective if commu-nication is clear and consistent.

Also, lack of unit storage for slings isn’t a concern.

Sling tracking Sling tracking promotes return of slings to the proper unit. Tracking can be handled in several ways:

• Slings can be labeled with an indelible marker, barcoded, or embroidered. A simple mark-ing system can yield valuable benefits.

• Vendors may have sling track-ing systems your facility can use.

Support for the SPHM program A well-developed sling manage-ment system supports a facility’s SPHM program. The SPHM must elicit input from units that will use the system and from the laundry department or outsourced laun-dry company to ensure all par-ties’ needs are met. It must choose sling styles and fabric and put in place procedures for sling purchase, inventory mainte-nance, care, laundering, track-ing, and replacement. Once these issues have been addressed, the facility is ready to embark on an SPHM program that can improve patient care and help prevent staff injuries. 8

Selected references The Facility Guidelines Institute. 2010 Health Guidelines Revision Committee Specialty Sub-committee on Patient Movement. Patient han-dling and movement assessments: A white pa-per. April 2010. https://www.dli.mn.gov/wsc/ PDF/FGI_PHAMAwhitepaper_042710.pdf. Ac-cessed June 24, 2014.

Occupational Safety and Health Administration.

Lift program policy and guide: Introduction to the lift program. https://www.osha.gov/ CWSA-attachment/beverlyliftprogramguide.pdf.

Accessed July 3, 2014.

Jan DuBose is director of Safe Patient Handling Programs and Services at Hill-Rom.

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 25 way to becoming firmly rooted and incorporated into caregivers’ daily practice. Although the prac-tice change is becoming the new norm, coaching and mentoring are needed to help maintain mo-mentum. Stories learned along the journey should be used to inspire both novice and expert clinicians.

Objective evaluation of the im-provement process should contin-ue, focusing on outcome measures and identifying improvement op-portunities to promote refinement.

Team members are now doing things they never thought were possible—and previously believed to be unsafe. Recently, I learned of a ventilator patient at St. Luke’s Medical Center, Boise/Meridian (Idaho) who was receiving contin-uous renal replacement therapy (CRRT). Staff safely mobilized the patient to the chair using the hos-pital’s mobility protocol. In many ICUs, such a patient would be bedbound. But at St. Luke’s, early mobility is now routine practice even for these patients. Conversa-tion about mobility occurs in daily rounds and often is a major focus of daily patient goals.

In fact, staff members are likely to comment that they no longer ask the question “Can we mobilize this patient?” Instead, they ask, “Is there a reason why we can’t mobi-lize the patient?” Key lessons learned to promote and maintain this cultural transformation include the importance of testing new prac-tices on a small scale, getting regu-lar feedback of performance and outcome data, providing sufficient education, and increasing care-givers’ will to mobilize patients by seeing the work in action.

Deliberate focus, full engagement Incorporating new evidence into daily practice isn’t enough to sus-tain a culture change to empha-size early mobility and SPHM.

Such a change comes only with a deliberate focus on three key ques-tions: What are we are doing?

Why are we doing it? What’s my role? Full engagement and cultural transformation can occur only when all team members can re-spond to these questions with full understanding. 8

Visit www.AmericanNurseToday.com/Archives/ aspx for a multidisciplinary progressive mobility continuum tool and a list of selected references.

Kathleen M. Vollman is a clinical nurse specialist, educator, and consultant with Advancing Nurs-ing, LLC in Northville, Michigan. Rick Bassett is a cardiovascular clinical nurse specialist in adult critical care at St. Luke’s Medical Center, Boise/Meridian, Idaho.

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