Michael Friedman, PT, MBAErik Hoyer, MDEleni D. Flanagan, DNP, MBA, RN-BCJason Seltzer PT, DPT

Taking on the Immobility Harm Together: An Inter-professional Collaborative Model

Department of Physical Medicine and Rehabilitation

Disclosure

No relevant financial or other relationships to disclose.

Handouts

Please be advised handouts are a condensed version of material.

Handouts do not include proprietary and copyrighted material.

For a more complete presentation handout contact hopkinsamp@jhmi.edu following APTA CSM.

Activity and Mobility Promotion (AMP) Solutions

Follow us on Twitter

@hopkinsAMP

Services

Learn more: www.hopkinsmedicine.org/pmr/amphopkinsAMP@jhmi.edu

Education @ Hopkins

2nd Annual AMP Workshop: Implementing a Culture of Hospital Mobility March 11-12, 2019For more info: bit.ly/AMP-workshop

8th Annual Johns Hopkins Critical Care Rehabilitation ConferenceOctober 11-12, 2019For more info: bit.ly/icurehab

• Tools and Resources• E-learning• Visitor Program• On-site Consulting

Learning Objectives

1. Demonstrate the value of integrating a common interdisciplinary language of function into nursing documentation.

2. Employ strategies for assessing and addressing systemic and local barriers to patient activity and mobility.

3. Describe an inter-professional collaborative model to staff training and engagement in activity and mobility promotion.

4. Demonstrate the role of physician involvement in patient engagement in activity and mobility.

INTRODUCTION TO HOSPITAL ACTIVITY AND MOBILITY PROMOTION (AMP)

Bedrest is Bad

Hospital-acquired physical impairment is associated with INCREASED:

• Hospital-acquired complications• falls, pressure ulcers, DVT, aspiration

• Hospital LOS

• 30-Day readmissions

• Nursing home and rehab stays

• Long-term impaired physical function

Aiming for Better Outcomes at Lower CostCovinsky et al. J Am Geriatr Soc. 2003; 51: 451-458. Brown et al. J Am Geriatr Soc. 2004; 52: 1263-1270. Brown et al. JAMA. 2013; 310: 1168-1177.Hoyer et al. J. Hosp. Med. 2014; May;9(5):277-82

Disease

DebilityCo-morbidity

The Catalyst…Critical Care Rehabilitation Quality Improvement Project 2008

• Shown decrease in:– average length of stay in the MICU (4.9 vs. 7.0 days) and

hospital (14.1 vs. 17.2) compared to the prior year.Needham DM et al. (2010, July). Top Stroke Rehab 2010;17(4):271–281

2

IF WE CAN MOBILIZE PEOPLE IN THE ICU WHY CAN’T WE THROUGHOUT THE HOSPITAL?

AMP QI Model Pre-Implementation

Implementation Phase

Program Sustainability and Enhancement

Pronovost, Berenholtz, Needham, BMJ 2008; 337:a1714.

EVIDENCE SUPPORTING HOSPITAL

Johns Hopkins AMP Program SummaryQuality Improvement and Research within JHHS:

• Why understanding mobility/activity matters – Hopkins data:• Low mobility patients at hospital admit have:

• 1.5 day longer LOS, relative rate of d/c home: 25% lower• Low mobility while in-hospital:

• Relative rates: 60% higher for injurious fall & 85% higher pressure injury• Inpatients who decline in mobility:

• ~3.5x higher odds of prolonged LOS (>7d), ~4x facility placement

• Medicine• Patients ambulating on daily basis increased: 43% to 70% (p<0.001)• For all, LOS reduced 0.4 day; for expected LOS >7 day, reduced 1.1 day• Falls did NOT increase

• Neurology• 42% decrease in “low value” PT/OT referrals• 27% increase in patients meeting daily mobility goals • LOS reduced by 0.2 day

• Community Hospital• LOS reduced 0.6 day for project unit • 30-day readmission reduced: 15% to 12%

The Evidence

Why Is This Important – Hospital Outcomes

Especially in elders and patients with chronic diseases,Hospital-acquired physical impairment associated with

INCREASED :

• Hospital LOS• Hospital-acquired complications • Nursing home and in-patient rehab stay• Impaired physical functioning even years after

hospitalization Covinsky et al. J Am Geriatr Soc. 2003; 51: 451-458. Brown et al. J Am Geriatr Soc. 2004; 52: 1263-1270. Brown et al. JAMA. 2013; 310: 1168-1177.

Systems Affected By Bed Rest• Skeletal muscle atrophy and weakness

– Muscle mass decreases by ~1.5-2% per day during bed rest.– Likely via increased oxidative stress and degradation of proteins.

• Joint contractures– One study found 61 of 155 patients with contractures who survived a critical illness,

commonly in elbow and ankle.

• Thromboembolic disease– Virchow’s triad includes the three categories of factors that contribute to

thromboembolic disease: blood flow; vascular injury; and coagulopathy.

• Atelectasis– Many ill patients, atelectasis of the left lower lobe is apparent on chest radiographs.

Atelectasis may predispose to pneumonia, and it raises pulmonary vascular resistance.

• Pressure ulcers– In supine subjects, raising the head of the bed causes greater pressure at the skin-

bed interface in the sacral region, increasing the risk of skin ulcers

Brower. CCM 2009

COMMON LANGUAGE OF FUNCTION

A Common Language of Function

Monitoring function no different than blood pressure.

Reconciling function no different than medications.

METRIC - The Problems

Functional Assessment Strategy

AM-PAC Functional Stages: Mobility Score

Range

Very Limited MobilityYour score suggests you may have a lot of difficulty or are unable to get out of your bed, to stand for several minutes and/or to walk short distances. You might have some difficulty completing the most basic mobility tasks including repositioning yourself in bed.

Your Score

30

67-100

Out and About

Doing OK Indoors, Limited Outdoors

Limited Mobility at Home

Very Limited Mobility

Your score suggests a high level of independence in moving about both at home and in the community. You may be able to participate in most physical activities without much difficulty

53-66

Your score suggests some limitation in your ability to move about without assistance. You may be about to move about on the ground floor of your home where you are familiar with the environment. Activities that might be difficult to manage without assistance include climbing a full flight of stairs or moving about in the community. Strenuous activities such as walking several blocks may be very difficult to complete.

35-52

Your score suggests significant difficulty in moving about independently and the need for assistance. You be able to move about in a small area of your home that has been adapted to eliminate safety hazards. You may have difficulty moving from sitting to standing position, climbing stairs and you may have a great deal of difficulty moving about outdoors and in the community.

0-34

Your score suggests you may a lot of difficultly or are unable to get out of your bed, to stand for several minutes and/or to walk short distances. You might have some difficulty completing the most basic mobility tasks including repositioning yourself in bed.

Acknowledge Alan Jette, PT, PhD

Johns Hopkins Highest Level of Mobility (JH-HLM)

BED

CHAIR

STAND

WALK

250+ FEET

25+ FEET

10+ STEPS

1 MINUTE

TRANSFER

SIT AT EDGE

TURN SELF / ACTIVITY

LYING

MO

BILI

TY L

EVEL

8

7

6

5

4

3

2

1

Score

Visit www.Hopkinsmedicine.ogr/pmr/amp for permissions and for use.

• Easy to use and educate staff

• Records mobility patient actually does

• Standardizes descriptors across providers

Daily Mobility Goals

Problem• Often a patient is capable

(AM-PAC) of achieving a greater level of mobility than performed (JH-HLM)

Action• Integrate daily mobility

goals into clinical workflows

AM

-PA

C M

OB

ILIT

Y S

CO

RE

DAILY MOBILITY SCORE (JOHNS HOPKINS HIGHEST LEVEL OF MOBILITY)

Today’s Goal

24 8 WALK 250 FEET OR MORE

22-2

3 7 WALK 25 FEET OR MORE

18-2

1 6 WALK 10 STEPS OR MORE

16-1

7 5 STANDING (1 OR MORE MINUTES)

10-1

5 4 MOVE TO CHAIR/COMMODE

8-9 3 SIT AT EDGE OF BED

6-7 2 BED ACTIVITIES / DEPENDENT

TRANSFER

1 LYING IN BED

Visit hopkinsmedicine.org/pmr/ampfor permission for use

Conclusions.

Klein L, et al. Increasing patient mobility through an individualized goal-centered hospital mobility program: a Quasi-Experimental Quality Improvement Project. Nursing Outlook. 2018.

Make Mobility Louder:Hardwire Operations and Workflow

• Activity Order Sets efficient design• JH-HLM and AM-PAC tools built in EMR• Documentation Roles and Frequency

– JH-HLM• RN or Tech, PT, OT

– AM-PAC• Nursing • PT and OT

• Communication reinforced by EMR– Surgical Pathway order sets– Daily mobility goals– Patient level trend lines– Care transition documents– Patient lists

What do I do with this number?Hardwire Clinical Value

METHODS TO ASSESS BARRIERS

Attitudes, Beliefs, and Knowledge

Barriers Survey

Hoyer EH, Brotman DJ, Chan KS, Needham DM. Barriers to early mobility of hospitalized general medicine patients: Survey development and results. American Journal of PM&R. 2014, Aug 15.

1. Although hospital falls can lead to harm, treating them as “never events” has led to overimplementation of measures with little efficacy for falls yet profound contribution to immobility.

2. Promoting mobility in the hospital may actually help to prevent injurious falls, thus calling into question the practice of immobilizing patients for the sake of fall prevention.

3. Promoting mobility in the hospital while preventing falls aligns well with the broader health care missions of maintaining quality, decreasing costs, and enhancing patient-centered care.

Reality Check – It takes a village!

Everyone agrees people need to move?Does it take a therapist?

If not then who and how?

CONDUCTING A BARRIERS SURVEY DEBRIEF

Staff Debrief

OBSERVATION AND ASSESSMENT OF LOCAL BARRIERS

Young DL, Seltzer J, Glover M, Outten C, Lavezza A, Mantheiy E, Parker AM, Needham DM. identifying Barriers to Nurse-facilitated Patient Mobility in the Intensive Care Unit. American Journal of Critical Care. 2018;27(3):186–193.

CREATING A PLAN TO ADDRESS BARRIERS

Tran

slat

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Res

earc

h in

to

Prac

tice

(TR

IP)

The “4 E’s”

ENGAGE

EDUCATE

EXECUTE

EVALUATE

ENGAGE

Understanding “The Why”

Role of Rehabilitation

EDUCATION

Documentation of AM-PAC

Documentation of JH-HLM

Development of Education

Development of Education: Webinars

Rehab and RN Super Users Roles

Role of Nursing Superusers

Education For Rehabilitation Staff

EXECUTE

Targeting PT and OT Acute Hospital Consultation Wisely

Probasco JC, et al. Choosing Wisely Together: Physical and Occupational Therapy Consultation for Acute Neurology Inpatients. The Neurohospitalist. 2017.

Evaluate

Tran

slat

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Res

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h in

to

Prac

tice

(TR

IP)

Move the Culture: “Without Data you cannot do QI”

Accountability Tools

Resources to support AMP@yourhospital?

• Patient & Clinician Engagement and Education/Training Materials

• Validated Mobility Barriers Survey

• JH-HLM & AM-PAC mobility measures for EMR integration

• Data, Analytics and Informatics

• Assistance with problem-solving

• Experience with integration into existing hospital initiatives:– Capacity Optimization– Care Redesign/Pathway development– Care Coordination– Hospital Acquired Complications (e.g. falls, pressure injury, etc.)– Safe Patient Handling

Activity and Mobility Promotion (AMP) Solutions

Follow us on Twitter

@hopkinsAMP

Services

Learn more: www.hopkinsmedicine.org/pmr/amphopkinsAMP@jhmi.edu

Education @ Hopkins

2nd Annual AMP Workshop: Implementing a Culture of Hospital Mobility March 11-12, 2019For more info: bit.ly/AMP-workshop

8th Annual Johns Hopkins Critical Care Rehabilitation ConferenceOctober 11-12, 2019For more info: bit.ly/icurehab

• Tools and Resources• E-learning• Visitor Program• On-site Consulting