An Arizona hospital has found that a concerted effort to get ventilated patients moving more can significantly decrease their time on a vent, resulting in better patient outcomes and cost savings.
The project at Banner-University Medical Center Phoenix (BUMCP), Arizona’s largest hospital at 688 inpatient beds, was carried by a team that included ICU Nursing Manager Joshua Lee, RN, who says that in 2015, administrators and clinical leaders identified patients experiencing a high number of days on ventilators as a key problem to address. Ventilator usage had increased steadily over the years up to that point, he says.
The 2014 estimated ventilator cost at the hospital was $15.1 million, with an average ventilator charge of $1,500 per day. The project team estimated that a 5% decrease in ventilator days would yield $758,975 in annual savings, and an 8% decrease in ventilator days would yield $1.2 million in annual savings.
Lee and his colleagues researched interventions for reducing ventilator days and found hospitals had used strategies such as early awakening, decreased sedation, and daily breathing trials. BUMCP had implemented all of those, but still had a high number of days on vents. A newer idea they came across, however, was intriguing and had not been tried yet: getting patients to be more mobile.
“The only thing that we hadn’t implemented in any meaningful way was mobilizing our patients,” Lee says. “It was being done to some extent, but not as often or as thoroughly as it should have been.”
Move More, Vent Less
The BUMCP team set a goal of decreasing mechanical ventilation days 5% by July 2016, with a stretch goal of 8%. They began with an August 2015 baseline survey on patient mobility sent to all critical care RNs, followed by the development of educational materials, including a new ventilator-specific early-mobility algorithm and a plan for rollout They obtained feedback from the hospital’s professional practice and ICU leadership teams.
The project team met its goal and doubled the early mobility rates for ventilator patients across all the hospital ICUs.
The “Move More, Vent Less” program kicked off in November 2015 with rounding education. To accommodate the irregular schedules of RNs, the project team conducted rounding education from 3 p.m. to 3 a.m. over a full week. Lee and his colleagues obtained a roster of all ICU nurses, including the float nurses that sometimes work in ICU, and checked off each name as they were included in a session.
After everyone received that initial education, there was another opportunity at the annual goal-setting meetings for the hospital’s ICUs. The meetings are mandatory for ICU staff, so the mobility team presented the education at those meetings. That meant it was second go-round for many ICU staff, but it served as a reinforcement and also covered anyone who missed the initial education because of vacation time, for instance.
The presentations at the goal-setting meetings led to the adoption of early-mobility goals for all ICUs at BUMCP.
“The biggest thing we took away from the education was the need for branding,” Lee says. “We came up with a logo a of a little breathing tube on the move, and we put placards at every nursing station as a reminder with simple questions like, ‘Did you mobilize your patient? Did you do a spontaneous breathing trial? Did you do a sedation vacation?’ These were all things that would help decrease ventilator usage over time.”
By May, the hospital held its first ICU early-mobility meeting including staff from the physical therapy department to advise on techniques to encourage and support mobility.
Chart Audits Necessary
Data collection also was an important part of the project, so the team members conducted a total of 1,369 real-time chart audits from October 2015 through July 2016. This number included 269 audits from the trauma/surgical ICU, 281 audits from the cardiovascular ICU, 381 from the neurosurgical ICU, and 438 audits from the medical ICU.
The team learned that at first they were gathering information that they really didn’t need, and it was making the audits more time-consuming. For instance, they decided they didn’t have to find out exactly what time the patient was mobile — just that the patient was mobile during a particular shift.
“We were lucky that we had a few light-duty employees who could do chart audits, but the information we were looking for was so detailed and exact that it took some time just to sit down and show them what to look for. There also are so many types of mobility, and so many reasons something like a sedation vacation wasn’t done, so there was so much information to gather,” Lee says. “Most of the chart audits were done by members of the team, in our spare time at work. We would round on every pod in the ICU, and keep a long running tab with the dates, so we could go back and do chart audits also.”
The charge audits were hugely important in re-education efforts, Lee says.
“If there were nurse names that kept popping up as not having done the mobility, those were the nurses we focused on for the re-education,” Lee says.
Continuing education also was introduced in this period for new hires and resource staff.
Pushback, Other Challenges
Though the project was successful, there were hurdles along the way. The project was rolled out during a bad flu season, which meant a busy time for the hospital, and often four or five patients on extracorporeal membrane oxygenation (ECMO). That skewed the vent days’ numbers beyond what was typical for the hospital, Lee says.
The education campaign had to address staff who knew little about mobility for vent patients and how to document it, Lee says. There also was a lack of equipment and ancillary staff to support the increased mobility. Competition from other quality initiatives also was a problem.
“There are just so many competing initiatives. It’s really hard to keep yours as the focus of attention,” Lee says. “Every month there’s a new audit for something, every month there’s a new rollout for something, so one of the biggest problems we struggled with was keeping our project on the minds of the employees. That’s one reason we learned the branding was so important — to keep our project visible and not lost in everything else going on at the hospital, all of them valid projects.”
There was some pushback from staff, Lee notes. People generally don’t like being forced to learn new things and take on new tasks, so the mobility program met some resistance. That was overcome mostly by recruiting the support of nursing leaders who believed in promoting mobility and who were influential enough to bring others on board, Lee says. In addition, staff were motivated by seeing how much patients appreciate the sense of normalcy that comes with being mobile.
The project team also created a reward system for active participation in the mobility effort. One reward was a “dream schedule,” in which the employee got to choose his or her work schedule for that month. BUMCP also named a “Mover of the Month,” recognizing an employee who had exceeded expectations in promoting mobility.
“This was someone who went beyond just range and motion, because that is extremely easy to do,” Lee says. “These were nurses who really focused on mobilizing their ventilator patients by getting them up to a chair or ambulating them. We recognized them with prizes and certificates, things that they could use in their clinical advancement later on.”
To keep up the progress, BUMCP performance reviews now require RNs to mobilize all ICU patients within 18 hours of admission.
There also was some difficulty in obtaining monthly data, and a lack of funding for staff incentives. The project team also found they did not have enough time allotted to meet during work hours.
Working well with other departments was important to the success of the project, Lee says. Physical therapy was important in helping the patients gain mobility, and respiratory therapy was needed for maintaining the portable vents on mobile patients, for instance.
“If we were getting a patient up, we let respiratory know as early as we could so they could get set up and be ready when that patient was ready to move,” Lee says. “It was very important to communicate well with everyone who plays a role in mobilizing vented patients.”
SOURCE
- Joshua Lee, RN, ICU Nursing Manager, Banner University Medical Center-Phoenix, AZ. Telephone: (623) 839-4184. Email: [email protected].
An Arizona hospital has found that a concerted effort to get ventilated patients moving more can significantly decrease their time on a vent, resulting in better patient outcomes and cost savings.
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