CUSP 4 MVP – VAP
Improving Care for Mechanically Ventilated Patients
Strategies for Collecting and Entering Early
Mobility
ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY
Johns Hopkins University
CUSP 4 MVP - VAP
Comprehensive Unit-based Safety Program
for Mechanically Ventilated Patients and
Ventilator-Associated Pneumonia
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Outline
• Review data entry tool and reports for Daily Early
Mobility Measures
• Discuss reports from Cohort 1 aggregate data
• Review Early Mobility data from a Hopkins study
• Discuss scenarios for how to collect data
– If you have a nurse-driven protocol
– If you have a physical therapist-driven protocol
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Polling Question
Who is on the webinar?
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IP – infection preventionist
RN – registered nurse
RT – respiratory therapist
PT – physical therapist
OT – occupational therapist
MD – medical doctor
Patient safety professional
Healthcare administrator
Educator
Hospital Engagement Network (HEN)
Professional society member
Coordinating entity
National project team
•
Other
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients

Strategies for Collecting and
Entering Early Mobility
Measures
Early Mobility:
What Have We Learned to Date?
• Prolonged bed rest and immobility can lead to:
– impaired physical function;
– Cognitive impairment;
– Psychiatric illness.
• Immobility can also lead to cognitive impairment
(e.g. impaired executive function, inattention).
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Daily Early Mobility:
Sedation, Delirium, Mobility
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Daily Early Mobility:
Sedation, Delirium, Mobility
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
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Daily Early Mobility:
Data Submission Rates
Number of Cohort 1 Units*
N
Total active hospital units
41
Number of hospital units that have submitted data
* As of April 7, 2015
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
23 (56.1%)
Daily Early Mobility:
Evidence-based Guidelines
• Use the Daily Early Mobility Data Collection Tool
to monitor compliance with evidence-based
guidelines such as:
1. performing structured assessments of sedation
levels using a sedation scale (RASS or SAS);
2. performing structured assessments of delirium
using a delirium scale (CAM-ICU or ASE);
3. assisting patients to achieve their highest level of
mobility.
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Daily Early Mobility:
Sedation
Percentage of patients achieving patients achieving RASS/SAS target
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
% Achieving RASS/SAS target
Calculation
NUMERATOR =
Total number of patient days with Intub/Trach & Mech Vent
marked “Y” (Yes) and:
1)
RASS actual score = RASS target score or RASS actual score is less than
or equal to +1 and is greater than the RASS target score
OR
2)
SAS actual score = SAS target score or SAS actual score is less than or
equal to 5 and is greater than the SAS target score
DENOMINATOR =
marked “Y” and
1)
Total number of patient days with Intub/Trach & Mech Vent
A numeric RASS target score and a numeric RASS actual score
OR
2)
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A numeric SAS target score and a numeric SAS actual score
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Delirium Assessments
• Adult ICU patients should be assessed for delirium
using at least once per shift.
• The Confusion Assessment method for the ICU
(CAM-ICU) is a recommended tool to for
assessing delirium.
Visit https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/processmeasures.aspx for fact sheets
and literature reviews.
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Early Mobility:
Delirium
Delirium assessment participation rates
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Delirium Assessment
Participation Rates: Calculations
NUMERATOR =
Total number of patient days with Intub/Trach & Mech Vent
marked “Y” (Yes) and:
1)
CAM-ICU is marked “P” (Positive) or “N” (Negative)
OR
2)
A numeric ASE value is recorded
DENOMINATOR =
marked “Y” and:
1)
Total number of patient days with Intub/Trach & Mech Vent
CAM-ICU is marked “P” or “N” or “X” (Not Completed) or “NK” (Not Known)
OR
2)
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A numeric ASE value or ASE is marked “X” or “NK”
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Daily Early Mobility:
Delirium
Percentage of patients screening negative for delirium (as indicated
through CAM-ICU or ASE)
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Negative Delirium Screenings (as
indicated through CAM-ICU or ASE) :
Calculations
NUMERATOR =
Total number of patient days with Intub/Trach & Mech Vent
marked “Y” (Yes) and:
1)
CAM-ICU is marked “N” (Negative)
OR
2)
ASE is less than or equal to 2
DENOMINATOR =
marked “Y” and:
1)
Total number of patient days with Intub/Trach & Mech Vent
CAM-ICU is marked “P” or “N”
OR
2)
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A numeric ASE value is recorded
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Daily Early Mobility:
Delirium
Percentage of patient days mobilized out of bed
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Percentage of patient days mobilized
out of bed: Calculations
NUMERATOR =
Total number of patient days with Intub/Trach & Mech Vent
marked “Y” and
with highest level of mobility marked (4-standing, 5-transfer from
bed to chair with standing, 6-marching in place, 7-walking)
DENOMINATOR =
Total number of patient days with Intub/Trach & Mech Vent
marked “Y”
4, 5, 6, 7
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Early Physical Medicine and Rehabilitation
for Patients with Acute Respiratory Failure:
A QI Project
• Objectives:
– Reduce deep sedation and delirium
– Increase frequency of rehab consults and
treatments to improve functional mobility
– Evaluate effects on length of stay
• Intervention:
– reducing heavy sedation
– increasing MICU staffing to include fulltime PT and
OT with new consultation guidelines
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Sedation, Delirium and Medication
Outcomes
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Mobility Outcomes
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data collection scenarios
• Information to collect
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–
–
–
–
–
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Sedation scale (Target and Actual)
Delirium Screening
Highest Level of Mobility
Perceived Barriers
PT
OT
Adverse Event
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Who should collect the data?
• RN driven protocol
– Nurses or designated data collector
• PT/OT driven protocol
– Nurses or designated data collector (Sedation
Scale information and Delirium Assessments)?
– PT/OT (Mobility information only)?
– PT/OT (all information)?
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data collection scenario 1:
Nurse driven protocol - EMR
• Collect Sedation Scale and Delirium Assessment
as before
• Available in EMR?
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–
–
–
–
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Highest Level of Mobility
Perceived Barriers (probably not available)
PT
OT
Adverse Event
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data collection scenario 2:
Nurse driven protocol - Chart
• Collect Sedation Scale and Delirium Assessment
as before
• Available in Chart? As it stands…
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–
–
–
–
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Highest Level of Mobility
Perceived Barriers (can add)
PT
OT
Adverse Event
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data collection scenario 3:
Nurse driven protocol – Tablet or
Paper data collection
• Collect Sedation Scale and Delirium Assessment
as before
• Walk through the unit to collect the data
• Set policy to assure that information needed,
including ‘Perceived Barriers’ is recorded at the
bedside
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data collection scenario 1:
PT driven protocol and data collection
- EMR
• Available in EMR?
–
–
–
–
Sedation Target and Actual
Delirium Assessment
Highest Level of Mobility
Perceived Barriers (probably not available)
However, PT/OT should have this information
– PT
– OT
– Adverse Event
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data collection scenario 2:
PT driven protocol and data collectionChart
• Available in Chart?
–
–
–
–
Sedation Target and Actual
Delirium Assessment
Highest Level of Mobility
Perceived Barriers (probably not available)
However, PT/OT should have this information
– PT
– OT
– Adverse Event
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data collection scenario 3:
PT driven protocol and data collection
– Tablet or Paper data collection
• Available in Chart?
–
–
–
–
Sedation Target and Actual
Delirium Assessment
Highest Level of Mobility
Perceived Barriers (probably not available)
However, PT/OT should have this information
– PT
– OT
– Adverse Event
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Data collection scenario 1:
PT driven protocol and RN data
collection - EMR
• Available in EMR?
–
–
–
–
Sedation Target and Actual
Delirium Assessment
Highest Level of Mobility
Perceived Barriers (probably not available)
However, PT/OT should note this information
bedside
– PT
– OT
– Adverse Event
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Mark Your Calendar:
Upcoming Webinars
For current
schedule of
upcoming
project
webinars, visit
https://armstron
gresearch.hopki
nsmedicine.org/
cusp4mvp/sche
dules.aspx
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
CUSP 4 MVP – VAP Website
Visit:
https://armstrongr
esearch.hopkinsm
edicine.org/cusp4
mvp.aspx
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients