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
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 [email protected] following APTA CSM.
Activity and Mobility Promotion (AMP) Solutions
Follow us on Twitter
@hopkinsAMP
Services
Learn more: www.hopkinsmedicine.org/pmr/[email protected]
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.
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
AMP QI Model Pre-Implementation
Implementation Phase
Program Sustainability and Enhancement
Pronovost, Berenholtz, Needham, BMJ 2008; 337:a1714.
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%
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
A Common Language of Function
Monitoring function no different than blood pressure.
Reconciling function no different than medications.
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
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?
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.
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.
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/[email protected]
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