CUSP 4 MVP – VAP
Improving Care for Mechanically Ventilated Patients
Data Webinar 5
Defining the Early Mobility Measures
April 1, 2015
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
Defining the Early Mobility Measures
Polling Question
Who is on the call?
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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
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
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Defining the Early Mobility Measures
Defining the Early Mobility Measures
Nishi Rawat, MD
CUSP 4 MVP – VAP
Improving Care for Mechanically Ventilated Patients
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
Data Collection
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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)
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
Daily Early Mobility Data
Collection Tool
Download the tool from the project website:
https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/datatools.aspx
under “Daily Early Mobility”
Polling Question
• Have you begun using the Daily Early Mobility
Measures Form?
Yes
No
Unsure
This question is not applicable to me
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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 reintubated within 24 hours, use the
original date
*i.e., when from an outside institution
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
Sedation Scale
• RASS = Richmond
Agitation Sedation Scale
• SAS = Riker SedationAgitation Scale
• NU = Unit uses neither
RASS or SAS
– If NU, skip to Delirium
Assessment
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
Confusion Assessment Method
for the ICU (CAM-ICU)
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
Delirium Assessment –
Attention Screening Exam (ASE)
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
Polling Question
Which delirium assessment does your ICU use?
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CAM-ICU
ASE
Both CAM-ICU and ASE
Neither
I don’t know
This question is not applicable to me
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
Discussion
• Where can you find these data?
– Ideas?
– Suggestions?
– Barriers?
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
Next Steps
CUSP 4 MVP – VAP
Improving Care for Mechanically Ventilated Patients
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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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Infection Prevention Webinars
IP Webinar 4: Wed, Apr 22, 2015 11:00 – 12:00 PM EDT
IP Webinar 5: Wed, May 27, 2015 11:00 – 12:00pm EDT
CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures
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
Defining the Early Mobility Measures
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
Defining the Early Mobility Measures
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CUSP 4 MVP – VAP: Improving Care for Mechanically Ventilated Patients
Defining the Early Mobility Measures