Mobility Daily Rounding Form
Version 6
Instructions for “CUSP for VAP: EVAP - Mobility Daily Rounding Form”
Please complete this form at least once a day, every day. If possible, complete it around the same time each day, hopefully during
patient rounds.
Patients are considered to be mechanically ventilated on a specific day if they were mechanically ventilated at the time of observation.
All of the codes to be entered are listed on the back of the data collection sheet. Please print the data collection sheet with the codes on
the back of the sheet for ease of data collection.
Hospital: Enter the number for your hospital.
ICU: Enter the number of your unit.
Date: Enter today’s date as MM/DD/YYYY format (e.g. 06/01/2013).
BED #: Enter all the bed numbers on the form, whether the patient is on mechanical ventilation or not. Include empty beds.
Intub/Trach & Mech Vent: Is the patient currently receiving mechanical ventilation?
(Enter for all patients. If the bed is empty, leave blank.) Mechanical ventilation is defined as receiving ventilator support via an ETT or tracheostomy tube.
 Patients treated with non-invasive ventilation would be counted as ‘N’
 Enter ‘Y’ if the patient is currently intubated/trached and mechanically ventilated.
 Enter ‘N’ if the patient is not currently intubated /trached and mechanically ventilated.
 Enter ‘E’ if there is no patient in the bed.
For any specific patient, if the patient is not currently intubated/trached AND on mechanical ventilation, STOP. Do not enter any more
information regarding that bed for this date.
Date of Intubation: Enter the date that the patient was intubated using a MM/DD/YYYY format (e.g. 06/01/2012)
(Only for patients currently intubated/trached and mechanically ventilated)
 DO NOT use dates from re-intubation following self-extubation.
 If the patient is re-intubated following <24 hours after extubation, use first intubation date.
Shift: Enter the shift during which the data was collected.
(Only for patients currently intubated/trached and mechanically ventilated.)
 Enter ‘AM’ if data sheet was completed during the AM hours. (Between 12 midnight and 12 noon)
E-VAP –Daily Mobility Data Collection Sheet and Instructions
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
1
Mobility Daily Rounding Form
Version 6

Enter ‘PM’ if data sheet was completed during the PM hours. (Between 12 noon and 12 midnight)
Sedation Score: To what extent was the patient sedated, on average, during the past 24 hours?
(Only for patients currently intubated/trached and mechanically ventilated)
 If your unit uses the Richmond Agitation Sedation Scale (RASS), enter the numeric scale value in the RASS column. Leave the SAS column blank.
 If your unit uses the Riker Sedation Agitation Scale (SAS), enter the numeric scale value in the SAS column. Leave the RASS column blank.
 If your unit does not use a sedation score, then enter ‘NS’ for not scored.
The Society of Critical Care Medicine’s latest sedation clinical practice guidelines (2013) recommend the RASS and SAS as the most valid and reliable
sedation assessment tools for measuring the quality and depth of sedation in adult ICU patients.
Mobility: Was this patient mobilized in the past 24 hours?
(Only for patients currently intubated/trached and mechanically ventilated)
 Enter ‘Y’ if the patient was mobilized.
 Enter ‘N’ if the patient was not mobilized.
 Enter ‘NI’ if mobilization of the patient was not medically indicated.
The ‘medical screening algorithm’ may help providers determine as to whether or not mobility is medically indicated. These criteria are based on
international consensus, and used at Johns Hopkins Hospital, but may be adapted based on patient condition and local clinical expertise.
Mobility ‘No’ or ‘Not Indicated’: Why was the patient not mobilized in the past 24 hours?
(Only for patients currently intubated/trached and mechanically ventilated AND with ‘N’ or ‘NI’ entered in Mobility)
If ‘N’ or ‘NI’ was entered in the Mobility column, answer this question. Enter the code associated with the answer in the box. For example, enter ‘1’ for sedated
(drugs). If multiple codes apply to a patient, please select the lowest number.
‘No’ and ‘Not Indicated’ codes are listed on the back of the data collection sheet.
PT (Physical Therapy): Was a physical therapist involved in mobilizing the patient in the past 24 hours?
(Only for patients currently intubated/trached and mechanically ventilated AND with ‘Y’ entered in the Mobility column)
If ‘Y’ was entered in the Mobility column, answer this question.
 Enter ‘Y’ if the patient was mobilized with the help of a physical therapist.
 Enter ‘N’ if the patient was mobilized without the help of a physical therapist, that is, by other providers, such as nursing, technicians or doctors.
Highest Level of Activity: What was the highest level of activity achieved by the patient in the past 24 hours?
(Only for patients currently intubated/trached and mechanically ventilated)
Activity codes are listed on the back of the data collection sheet.
E-VAP –Daily Mobility Data Collection Sheet and Instructions
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
2
Mobility Daily Rounding Form
Version 6
Adverse Events: Did the patient suffer from an adverse event while being mobilized in the past 24 hours?
(Only for patients currently intubated/trached and mechanically ventilated AND ‘Y’ entered in Mobility)
If ‘Y’ was entered in the Mobility column, answer this question.
Adverse event codes are listed on the back of the data collection sheet.
Please enter data from this paper-based data collection form in the CECity web-based reporting system at least once per
week.
E-VAP –Daily Mobility Data Collection Sheet and Instructions
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
3
Mobility Daily Rounding Form
Version 6
Medical screening algorithm to evaluate patient appropriateness for rehabilitation
E-VAP –Daily Mobility Data Collection Sheet and Instructions
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
4
Mobility Daily Rounding Form
Version 6
Mobility Daily Rounding Form
Hospital ID# ___________ Unit ID#___________ Date (mm/dd/yyyy) ___________
Fill out for Fill out only if intubated/trached and mechanically ventilated
all beds
Bed
#
Intub/
Trach
&
Mech
Vent
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
E
Date of
intubation
(mm/dd/yyyy)
Shift
Sedation
Score
RASS
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AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
AM/PM
E-VAP –Daily Mobility Data Collection Sheet and Instructions
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
Mobility
SAS
Y N NI
Mobility
‘No’
Or ‘Not
Indicated
’
PT
Highest
Level of
Activity
Adverse
Events
YN
5
Mobility Daily Rounding Form
Version 6
Codes – Enter the appropriate number (and letter, if indicated)
Mobility ‘No’ or ‘Not Indicated’
1) Nursing unavailable
2) PT service unavailable
3) Patient unavailable
4) Sedated (drugs)
5) Unresponsive due to primary CNS condition
6) Medically inappropriate (circulatory rationale)
7) Medically inappropriate (respiratory rationale)
8) Medically inappropriate (new DVT)
9) Medically inappropriate (femoral sheath)
10) Patient refused
11) Not needed
12) Other
13) Unknown
14) Comfort Care
Highest Level of Activity
0) Nothing: passively rolled or exercised by staff but not actively moving
6) Marching in place: able to walk in place by lifting alternate feet (must be
able to step at least 4 times (2 for each foot) with or without assistance
7) Walking: walking away from the bed/chair by at least 4 steps (2 for each
foot) assisted by a person/people or gait aid, or unassisted
8) Unknown: it is unknown regarding what activity, if any, occurred
Adverse Events
0) None
1) Airway dislodgement: A) endotracheal tube, B) tracheostomy
2) Feeding tube dislodgement: A) nasal, B) orogastric, C) percutaneous
3) Central venous catheter dislodgement: A) upper body, B) femoral
4) Arterial catheter dislodgement: A) upper body, B) femoral
5) Dialysis catheter dislodgement: A) upper body, B) femoral
6) PA catheter dislodgement: A) upper body, B) femoral
7) Chest tube dislodgement
8) Wound dressing dislodgement
9) Cardiac device dislodgement
9) Hypotension (change in MAP < 55 or if intervention required)
1) Transfer bed to chair without standing: hoist, passive lift or slide to the chair
without standing
10) Hypertension (change in MAP > 140 or if intervention required)
2) Sitting in bed/exercises in bed: any activity in bed, including rolling, bridging,
active exercises, use of cycle ergometer, use of tilt table, moving out of bed or
over the edge of the bed
12) Cardiac arrest
3) Sitting at edge of bed: actively sitting at side of bed with some trunk control
(may be assisted)
4) Standing: weight bearing through feet in standing position with or
11) Desaturation (O2 sat < 85%)
13) New arrhythmia (excludes sinus tachycardia or PVCs)
14) Fall
15) Death
16) Other
without assistance; may include use of a standing lifter
5) Transfer from bed to chair: able to step or shuffle through standing to
chair; this involves actively transferring weight from one leg to another to
move to chair.
E-VAP –Daily Mobility Data Collection Sheet and Instructions
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine
6