Safe Patient Handling and Mobility (SPHM) programs have been mandatory in Veterans Affairs Medical Centers since 2010. These programs have reduced musculoskeletal injuries related to the lifting and repositioning of patients by 50%.1 Safe Patient Handling and Mobility evidence shows improved employee safety,2 patient outcomes, and systems outcomes (cost, staff, and patient's satisfaction).3–5 Safe Patient Handling and Mobility programs may also affect the quality of inpatient care by reducing adverse events related to immobility, decreasing falls, improving patients' strength, and preventing skin breakdown.6
The complications of immobility have been well documented7 and negatively affect patients' length of stay, quality of life, and cost of care.8–10 The cascade of physiological effects begins within the first 24 hours,11 and each day of immobility is predictive of a relative decrease in strength of 3% to 11% up to 2 years after discharge from the intensive care unit (ICU).12 Early exercise and mobility are safe and feasible.13,14 Benefits include reduced length of stay; decreased venous thromboembolism, pressure injuries, and pneumonia; improved functional status at discharge; reduced hospital admissions, cost of care, and mortality; and positive effects on neuromuscular and pulmonary status and psychological well-being.15–24
Global point prevalence studies demonstrate low numbers of patients being mobilized in the ICU, especially patients who are mechanically ventilated.25–29 Reported barriers, especially for out-of-bed activities, include lack of resources (time, staffing, and equipment) and concerns about patient and staff safety.30,31 Exceeding the biomechanical limits of the back can result in acute and/or cumulative trauma,32 and manually assisting patients to reposition in bed, sit, stand, and walk exposes caregivers to the risk of musculoskeletal injury.
Reframing SPHM equipment as mobilization tools and not just passive transfer devices can help overcome barriers of insufficient staff and patient's safety and help staff mobilize patients to their highest level of mobility safely. Given the strong evidence for effectiveness of both early mobility (EM) and SPHM, integrating these individual quality initiatives is logical; however, literature describing best practice for seamless assimilation is limited.33,34
The purpose of this article is to describe a quality improvement project integrating a successful SPHM program with a multidisciplinary EM program at the Phoenix Veterans Affairs Health Care System, a clinical referral level 1b facility serving more than 95 000 Veterans, with 177 acute care beds including 20 beds in a mixed ICU. The Phoenix Veterans Affairs Health Care System is one of 170 VA medical centers across the country. This project, guided by the Iowa model of evidence-based practice,35 aimed to strategically implement an Early Exercise and Progressive Mobility (EEPM) intervention while maintaining staff health associated with SPHM practices in one 20-bed combined medical and surgical ICU. The facility institutional review board granted exemption, since this was a quality improvement project.
Defining the opportunity
The first step was to assemble a multidisciplinary team of key stakeholders. The ICU nurse educator served as lead with essential team collaboration from SPHM, ICU nursing, quality, physical therapists (PTs), occupational therapists (OTs), respiratory therapists (RTs), and critical care providers. An EM and SPHM external expert provided additional project support.
The team evaluated current status for both SPHM and EM programs and planned the implementation strategy. Critical SPHM program elements included unit-based multidisciplinary staff SPHM champions (unit peer leaders), staff training and engagement, injury review process, equipment availability with centralized sling distribution, and leadership support (Supplemental Digital Content Table 1, available at: http://links.lww.com/JNCQ/A606). Using the American Association of Critical-Care Nurses best practice ABCDEF bundle of care as our benchmark, specific gaps and opportunities for the EEPM program were identified36 (Supplemental Digital Content Table 2, available at: http://links.lww.com/JNCQ/A607).
Creating awareness and interest
Awareness and interest included formal and informal processes. Approval was received from special care and clinical practice committees (including medical providers, multidisciplinary managers, and frontline staff) and the nurse executive and clinical executive boards. Early Exercise and Progressive Mobility education included information about the rapid onset of immobility complications (Supplemental Digital Content Table 3, available at: http://links.lww.com/JNCQ/A608). Informal feedback from staff indicated that this information particularly helped achieve high levels of staff engagement and a sense of urgency for mobilizing patients early and often.
Building knowledge and commitment
Knowledge and commitment across all disciplines were developed through education and implementation strategies designed to solicit input from and incorporate the perspective of each discipline. Team members researched EM protocols, safety and feasibility, implementation guides, tool kits including the ABCDEF bundle36 tools from resource Web sites,37,38 and shared best practice toward achieving and sustaining a standardized, evidence-based approach. There was unanimous consensus that the safety afforded through using SPHM equipment for mobility activities was vital to the EEPM program success. The EEPM interventions were therefore seamlessly integrated into current SPHM processes.
Planning the EEPM intervention
The work group met with the critical care team to develop patient eligibility inclusion and exclusion criteria based on previously published parameters.13,39,40 Nursing staff agreed to collect baseline information about the stated or reported patient's prior level of function during the admission assessment. An order to initiate EEPM was triggered by the multidisciplinary team when the patient met inclusion criteria according to the predetermined guidelines. The EEPM guidelines articulated the patient's expected clinical presentation and mobility tolerance, guidelines for mobility progression, interventions to be implemented at least 3 times a day, and appropriate SPHM equipment for each phase of mobility, from bed mobility through independent ambulation.
Many facilities struggle with achieving a true interdisciplinary team approach to EEPM. In recent years, patient mobility has mostly been the responsibility of rehabilitation professionals. A 2011 survey of 3143 registered nurses (RNs) indicated that “ambulation of patients was the most frequently reported missed nursing care.”41 Another study found that 32% of the patients had no RN-assisted mobilization activity during an 8-hour period.42 However, there are nurse-led EM programs that have been successful.43,44 Conversely, the SPHM movement was primarily nurse-driven, with references to nursing back injuries in the writings of Florence Nightingale. Originally designed to prevent nursing back injuries, the use of SPHM devices specifically for promoting active patient mobility is a relatively new concept.
Each discipline contributed uniquely to the EEPM program. The team proactively addressed role clarification by asking all stakeholders, “How do you envision your discipline's role in EEPM?” Each discipline defined its own responsibilities and guidelines toward a common goal of restoring highest level of function for each patient. The EEPM work group then refined these to ensure seamless coordination of care. The Standard Operating Procedure reflected the specific roles for each discipline.
Providing education and simulation
Training included standardized patient assessment, safety and exclusion/inclusion criteria, mobility protocols and interventions, and equipment selection process. The exclusion/inclusion criteria are described in Supplemental Digital Content Table 4, available at: http://links.lww.com/JNCQ/A609. Visual cues including EEPM flow maps, PowerPoint presentations, copies of guidelines for each discipline, and posters were developed to aid education. Checklists were developed to evaluate knowledge and performance following training. All disciplines then participated in a collaborative EEPM simulation for determining mobility level and appropriate mobility equipment. To help foster a collaborative environment for the frontline staff and to engage and empower patients' families, PTs helped train RNs, RTs, and families on activities to perform outside of therapy, such as passive range of motion.
Determining mobility level and selecting equipment
The Bedside Mobility Assessment Tool (BMAT) is a valid and reliable tool that guides clinicians in equipment selection according to what the patient is able to do and helps promote standardized communication45 (Supplemental Digital Content Figure 1, available at: http://links.lww.com/JNCQ/A610). The BMAT assesses 4 levels of mobility. If patients pass 1 level, they are then assessed for the next progressive mobility level. If they fail an assessment level, they are placed in that mobility category and staff are guided to select equipment from the appropriate category to help their patient progress safely to the next level as seen in Supplemental Digital Content Figure 2, available at: http://links.lww.com/JNCQ/A611. Clinical judgment is always used if there is doubt in the ability to perform each task with default to the safest lifting technique and equipment.
Level 1 (sit and shake) assesses patients' ability to maintain sitting balance at the edge of the bed while they cross midline with their hand. Level 2 (stretch and point) tests leg strength and range of motion necessary to stand up from sitting. Level 3 (stand) tests patients' ability to clear buttocks from bed or chair to stand. Assistive devices such as walker, cane, or crutches are available during the assessment if needed. Level 4 (step) tests patients' ability to safely step forward and back with each foot without loss of balance. The highest level possible is 3 if the patient uses an assistive device or has medical or physical problems that increase fall risk. Staff were trained by SPHM unit peer leaders on how to use equipment in novel ways to promote active patient participation and progress through mobility levels toward independent mobility or prior level of function. Vendors also supported the process as resources for knowledge and training.
Ensuring clear communication and tools
Multiple measures were developed to ensure sustainability. For example, visual reminders were posted in the provider conference room to evaluate every ICU patient for initiation of EEPM and guidelines were posted in the ICU for all staff. Patient mobility status and appropriateness for EEPM were discussed during daily interdisciplinary bedside rounds, which include critical care and surgical providers, the ICU case manager, bedside nurses, charge nurse, PT, OT, RT, and pharmacy. All disciplines documented activities on the bedside whiteboards and in the electronic health record. Registered nurses were primarily responsible for entering the screening information, BMAT level, interventions implemented, and tolerance to activity in the chart at least once per shift and after mobility interventions. Standardized communication incorporated into the EHR documentation templates and mobility orders was built by facility clinical application coordinators. Whiteboards in all patient rooms facilitated communication between disciplines, including patients and families, to empower participation in daily mobility goals and activities.
Promote action and adoption
Ten EEPM champions representing multiple disciplines, on all shifts, assisted with smooth transition, staff questions, and troubleshooting. During Go-Live week, champions audited their own discipline to ensure competency at the point of care, with their agreed upon discipline-specific roles. Baseline measures of length of stay, functional status at discharge, discharge disposition, and number of ventilator days were collected prior to implementation to assess the contributions of the intervention role components and effectiveness of the EEPM with SPHM on patient outcomes.
Pursue integration and sustained use
To promote ongoing success with the integrated SPHM and EEPM program, simulation training has been incorporated into new employee orientation for nurses, PTs, OTs, RTs, and residents. New employees must complete EEPM competency checkoffs with a preceptor. Ongoing assessment of competency is planned for the annual education days for nursing and related staff, and a standardized checklist is being developed to examine SPHM compliance and documentation adherence. Tracking of baseline measures and staff feedback will be used to drive continuous process improvement. The goal is to discharge as many patients as possible at the same BMAT (functional) level or higher than at admission while preserving patient and caregiver safety. Standardized, objective, and evidence-based patient assessment of mobility by nursing staff will continue to foster interdepartmental communication.
A multidisciplinary collaborative effort was used to integrate guidelines for SPHM with best practices for early and progressive mobility in an adult ICU at the Phoenix Veterans Affairs Health Care System. Important elements in successfully combining these initiatives included standardized assessment and use of a structured implementation framework, early and continuous engagement of all involved disciplines with focus on program goals, clear communication including use of visual cues, reframing use of SPHM equipment from patient transfer devices to mobilization tools to progress patients to higher levels of mobility, and recognizing that it is everyone's responsibility to consistently promote a culture of safety and mobility. Interdisciplinary training with simulation facilitated a standardized process to implement early and progressive mobility while preventing patient and staff injuries.
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