Transcript - NYS Partnership for Patients

June 26, 2013VAE Best Practices in Sedation Part IIGood afternoon and thank you for joining us today. Before we begin, I briefly need to review a couple ofhousekeeping items. This program is being recorded and will be made available on the NYSPFP website,along with the transcripts, within five business days of the program. Please contact your project managerif you need to access the recording before then.Closed captioning is available with this program. To access closed captioning, expand the Media Viewerbox located in the panel to the right of your screen, enter your name and facility inside the Media Viewerbox, and hit Submit. You will also need to click on the arrow buttons to Hide Message Center and HideOptions in order to see the text.At this time, all your phones have been muted on our end. Questions and comments can be submittedthrough the Chat and Q&A box to the right of your screen throughout the program. There is time allottedat the end to address any questions you submit. If you would like to ask a question out loud, in theParticipation box click on the Raise Hand icon; and we will let you know when we have unmuted you andyou, and you can ask your question out loud.With that, I will turn the meeting over to Sara Kaplan-Levenson.Thank you, Joanie.Good afternoon, everyone. This is Sara Kaplan-Levenson, one of the New York State Partnership forPatients Project Managers. Thank you all for joining us for this educational web conference on PreventingVentilator-Associated Events.I want to just give a little bit of context for this work and all of these efforts that you've been engaged withfor many months and formerly through the Partnership since our kickoff in March of this year before wedive right into our presentations.The first thing I wanted to mention as sort of a stage-setting element is that as many, if not most of youknow, in addition to our continued focus on each of the clinical focus areas that we've been addressingthrough the Partnership, beginning in May we unveiled a new framework for thinking about reducing harmacross the board; and we're approaching that through five patient-safety commitments. And thosecommitments are all really designed to bring interdisciplinary teams together to address multiple hospitalacquiredconditions and complications, and really establish an institutional culture and practices andprocesses that can influence and reduce, as I said, harm across the board in many areas at a time.And one of those commitments is quite specific in its conception to ventilator care and management, andthat is to promote innovative practices in the management and care of patients on ventilators to reduceharm. Although I do think there is a sort of broader conceptualization that you can apply to really thinkingabout this as optimal, comprehensive ICU care. And so much of the focus that we're putting forward1

June 26, 2013through that commitment has to do with some – I don't want to call them stretch goals, but really ideals interms of the most optimal care for ventilated patients, like reducing if not eliminating sedation for certainpatients and promoting early activity and mobility. And these are practices that we know, that we've heardfrom our speakers and our clinical advisors since March, really have the potential to reduce harm, toreduce IC-related delirium and promote the best critical care for patients, especially those on ventilators.At the same time, I think we really want to continue to emphasize the basics. And while ambulation andsedation reduction are worthy as operational goals, we don't want to take anything away from that holisticview of good ICU care and the maintenance of that traditional VAP bundle that many of you have beenimplementing for years.That's sort of the context of VAE in the framework of the patient-safety commitments. And if you'll recall,we also distributed a VAE assessment of current practices to hospitals several months ago when wewere kicking off this initiative. And I think the results of that assessment really support the approach thatwe're taking and the education that we're providing and conversations that we want to facilitate among allof you.And just to give you a little bit of insight into what we've seen, these results are preliminary; and I wouldbear in mind that not all of the participating hospitals responded to the assessment. But amongst thosewho did, we can see a couple of interesting points. One is that 100% of participating hospitals have thatVAP bundle protocol and policy in place, which is great news; it's really encouraging. And I would remindyou as well that although many of you have said with the policy and the protocols in place, once we'vestarted encouraging people to go back and sort of evaluate the quality and comprehensiveness of theimplementation of each of those bundle elements, I think folks have understood that there may be someopportunity to revisit whether those are happening as they should be for all patients all of the time.And with respect to some of the more innovative practices that we're promoting and trying to promotethrough the Partnership, we've seen that somewhere around half of hospitals that responded to theassessment have policies for sedation reduction and for early mobilization. And I think it's something thatmany, many hospitals are trying to think about the most appropriate ways to get off the ground and rollout in their institutions, but it's not something that's happening yet across the board.So that's why we're bringing you these experts today and the speakers that we're featuring on this call, totalk about some different institutional approaches to making that happen. We hope that you'll be able toget some key takeaways and ask questions of the folks on the line. We are going to hold questions untilthe end, so both our featured speaker and our clinical advisors can chime in. But as Joanie mentioned,please do submit your questions through the Chat and the Q&A throughout so we can have everyonequeued up for questions at the end.And with that, I just want to give a brief introduction. You see their bios up on the screen. We're first goingto hear from Ernesto Perez-Mir, who is the Director of Nursing at Weill Cornell Medical Center, part of theNew York-Presbyterian Hospital. And Ernesto really was the leader of the multi-campus rollout of theEarly Mobilization initiative for New York-Presbyterian. So I think I'll let him speak to his own role, but Ithink he's got a lot to offer and share in their experience at Cornell.2

June 26, 2013And then after that we will hear from our faculty clinical advisors who have really been guiding andshaping this initiative for Partnership for Patients: Michael Apostolakas, who is the Director of AdultCritical Care and Professor of Medicine at the University of Rochester Medical Center, and Brian Koll, theMedical Director and Chief of Infection Prevention at Beth Israel Medical Center and Professor ofMedicine at the Albert Einstein College of Medicine.So without further ado, I will turn things over to our speakers.Ernesto?Hi, good afternoon. It's a pleasure to be here. My name is Ernesto Perez-Mir, like Cynthia said. I'm theDirector of Nursing for the Weill Cornell Medical Center. I want to give you a little context of how large weare. NYP was formed back in 1998 as a result of the merger between New York Hospital Cornell, 168 thStreet, and Presbyterian Hospital in Columbia. It's worth mentioning that we started with two campuses;now we are up to five. We are affiliated with two different medical schools, and we also have a mix ofUnion and non-Union employees; around 120,000 discharges per year; 230,000 ED visits; around 20,000employees.The reason that I mention all this is if we were able to do this in a large medical center, I have no doubtsthat this is a doable project. I have to say that a large amount of our work was based on Dale Needham.He is, I would say, the father of early mobilization. He has published a lot of his work on that. So a lot ofour work is based on the work that he did back in the early 2000s.Let me talk a little bit about the challenges that we're facing right now with health care reforms. As youknow, efficiency and standardization are the key words that we are being driven by right now. As you sawfrom the previous picture, we are located in Manhattan. We have constrained capacities. We havenowhere to build. So one of our big focuses a couple of years ago was to standardize our process, look athow we can improve throughput and being able to move patients through our institution quick.So we developed a very detailed return on investment, and this is key. Based on this, we looked at ouridentified ICUs that had the most gain for excess days. And as you're going to see later on, this was theprimary target that we used to assess the progress of our initiative.Starting in 2012, we deployed the initiative in five ICUs across two campuses. We selected a medical ICUat the Milstein Campus, and the downtown campus we selected the CCU and the medical SU. DaleNeedham's work is based mostly on medical SU; this is the reason why we picked these two units. Keythings that we wanted to focus on is improving patients' outcome. We know that if patients are moved andare exercised, their outcomes increase.Also, like I mentioned before, we had an ICU bed capacity issue; so this helped us a lot. The key thingwith all this is with our culture change -- and this means from as you'll see on the table that I'm going tohave later on -- is you have to have everyone involved in this initiative, from the Senior VP to the frontlinestaff.3

June 26, 2013So going back to the beginning, we met a couple of months before. We developed a Steering Committee.We reviewed the evidence. We created some champions at the unit level; and the champions were thenurse managers, the PCTs, the frontline staff. It was very, very good that we did role clarity; and what Imean by that was we developed role distinction. So we actually went through every single staff memberthat was involved in the initiative and what the expectations were that they needed to do.The standardized tool – this was something that we developed based on mobility, patients that wereintubated or not intubated. And the communication – as you can see, we have a copy of our newsletter;this is something that we publish monthly. This is our organizational chart. As you can see, we have theExecutive Sponsor, which is our VP of Nursing, Suzanne Boyle. I am the Team Leader, and I cannotstress enough the importance of this initiative being multidisciplinary. As you can see, respiratory is there;clinical nurse specialists; nursing; speech; rehab; pharmacy. Again, this is crucial to make sure that everyplayer that is going to be in touch with the patient is part and has a voice in the initiative.Excess reductions – this is the main target that we had when we were allowed the initiative. Excessreduction is based on the estimated length of stay versus the actual. We measure this based on eachindividual unit. We had a target of a little bit over 5,000. Overall, we were able to surpass that target. Ithink that you're going to be more impressed with this data. This is ICU specific length of stay based on2011. The purple graph that you see is from January to June of 2011, and the blue graph is 2012 year-todate.We were able to have a significant decrease from one to two days in every ICU.The Milstein MICU B – the MICU in both of the sites are a little bit different. The patient population is quitedifferent. The MICU at the Milstein Campus actually admits patients on ECMO. That's not something thatwe have at the downtown site. We were not able to impact those patients as much as other patients justbecause of the comorbidity; and actually the length of stay is around 20 to 30 days, so it's a little bit morecomplicated of a process.This is the total hospitals in reduction that we saw – patients that actually went through the ICUs thatwere participating in the early mobilization. Once again, we see a drastic reduction on length of stay –anywhere from one to two days.This is a graph that I think that we can spend some time talking about it. With early mobilization, havingpatients participate during therapy, it actually had very good intended consequences where we werehardly using any sedatives. As you can see, there is a drastic decrease in Midazolam from 2011 to 2012,and the same thing with Ativan. This is something that we were able to measure in one of the ICUs. Thedata collecting process was a bit complicated, so that's the reason why we only have it for one ICU. Wecollected this data manually.Here you have the reduction on vent days. These are based on ventilator set-up days versus the amountof days that the patient was on the vent -- again, drastic reduction on vent days from 2011 to 2012 to2013.4

June 26, 2013I would say the program successes -- there has been an extraordinary cross-campus collaboration. Thisallows for PT and OT and Pharmacy to communicate between both campuses, something that we haddone in the past but not to the level that early mobilization allows us to do. As you have seen, we haveseen a huge decrease in length of stay – not only in the ICU specific length of stay, but hospitalwidelength of stay.Some of the variance that we had in 2013 – I have to say, Sandy hit us pretty hard at the end of 2012.Our occupancy rate the first two months of the year has been off the chart. Now is when we are able tosee, again going back to our baseline of 2012 – that's one of the reasons that I put the variance of 2012.It is worth mentioning that one of the things that we did to deploy the Early Mobilization initiative in thisICU is that we dedicated PT and OT therapists on these units. Based on that, we saw an increment ofrehab treatments of almost 15 fold. We measure it before the initiative is started and post-initiative, andwe saw drastic increments on it.We made this at the first wave by, yes, having some added resources. The second wave, which includedmore ICUs, we did it by optimizing the amount of treatment that each therapist was given. We conducteda survey. We asked for Deloitte to come and help us, and we were able to obtain around the productivitytargets around eight to nine; and we saw that we had an opportunity there because our therapists werejust hitting like six to seven. So this created a little bit of opportunity for us to increase the amount oftreatments.As you saw, we had a decreasing percent of continuous infusions of sedation. The next steps that wehave – the project is doing really well. Electronic Data Report is something that we've been strugglingwith. Some of the data elements that we are currently obtaining, we are obtaining those manually; so ifwe're able to have an electronic solution to this problem, it will be amazing.Aligning this Early Mobilization initiative with other initiatives like Delirium, we were able to deploy theCAM-ICU a few months after we started Early Mobilization. We also were able to pair Early Mobilizationwith Noise Reduction. And the reason that there is a correlation here is the quality of sleep by patientsbeing out of the bed and ambulating during the day actually facilitated a more restful sleep and sustainingimprovements.One of the things that I want to call your attention here is all the patients that you see in these pictures areorally intubated, and you can see they are awake and they are participating in their activities. This is thebig difference that we were able to get the length of stay reductions and the reductions on sedatives. Asyou can see, patients are ambulating and participating in their daily activities.Here is some contact information. Lauren Pluff is the Clinical Coordinator for the downtown campus. Andthat's pretty much it. Do we have any questions?Thank you, Ernesto. Your presentation was certainly enlightening, and I'm sure we will have somequestions specifically.5

June 26, 2013If we could pass the ball to our next speaker, Dr. Mike Apostolakas.Well, thank you very much. That's a tough presentation to follow, and we're hoping to get where Ernesto'steam is; but we're working on it. And to sort of give you an example of one way to approach this problemof mobility and sedation, we'll let you know what we're doing. But I think it's important to remember asyou're listening to discussions as to how places do things that every environment is different; and you'llhave to take some of the aspects of all the presentations and hopefully put them in a frame of referencefor your institution and how you can get there as well.As you all know, the framework of preventing VAP and improving ventilator outcomes is a ventilatorbundle. And as Cynthia said at the beginning, probably 100% of places have the ventilator bundle; and Ithink as Cynthia mentioned, I think it's important and even if you think it's in place and it's been in placefor years, slippage can occur with time. And every six months or so, we go back and we look and weassess and we make sure that we're giving these standards of care that were known to improve patientoutcomes.When we first implemented the ventilator bundle, the sedation vacation was the standard; but that's beenthe standard for the last five or ten years. We're trying to move away from that as being the standard tointermittent or no sedation being the standard. We want to get away from continuous sedation.And then the other one at the bottom that we've added is the mobility protocol, and we've had that as partof our vent bundle; but we're trying to optimize our mobilization as I think a lot of you are.So why is this such an issue? I've been in critical care 20 years, and I was taught you keep the patientsedated; keep them comfortable; keep them safe in bed; and then if we're good enough to get them aliveout of the ICU, there's plenty of time for rehab and getting stronger later and that early mobility is unsafe.And now I think we know different. We know that sedation, delirium and lack of mobility contribute to pooroutcome, and that sedation leads to delirium which leads to longer mechanical ventilation which leads toincreased tracheostomies and death. And a lot of our patients, the reasons they get trach'd, the reasonsthey die, really are less related to underlying disease and more due to how we sedate them. And onething that early mobilization is shown to do is if you lighten the sedation, you can mobilize them earlier;and as you saw in Ernesto's data, if you get them up and around, their time in the hospital is going to beless and there is less chance for complications, tracheostomies and death.Now, the SCCM – our Society of Critical Care Medicine – what do they recommend? They recommendpreemptive pain medication with opioids; and if we do this, we can use the lightest level of sedationpossible. In order to avoid delirium, they recommend non-benzodiazepine sedation strategies. Theyrecommend early mobilization; and early mobilization alone will reduce your risk of delirium. And thenroutinely to assess level of pain, depth of sedation – which we've been good at here – and less well atdocumenting consistently monitoring for delirium but that's clearly recommended.So what was our approach? Well, our approach was to relook and make sure that we were doing thebasic ventilator strategies and also to update our guidelines to reflect where we want to be going. And sowe took our pain, sedation, delirium and mobilization guidelines and have updated them all. And then the6

June 26, 2013question is, "Well, you can update your policies; but how do you really implement them?" And as Ernestosaid, unless you have the frontline people involved, it's not going to be successful. And the thing I'velearned over 20 years is unless the frontline staff know why you're doing something and unless you havea vision of everyone taking care of that patient as to where you want to be, you'll never get there.So with that in mind, over the last several years, every couple of years we've had retreats to discussquality assurance strategies. And with this timeliness of wanting to try to reduce sedation more andincrease mobilization, we've set up and we've had six of eight ICU retreats. And in our ICU retreats wehave everyone there from physicians, nurses, advanced practice providers, PCTs, physical therapists,pharmacy, respiratory therapists; and everyone is mandated to go to one of these retreats to hear themessage and to have the vision and discuss how we're going to get there.We review the data on mobility and why it's important because people won't do things unless theyunderstand it's important. We reviewed the data on why benzodiazepines are bad. We reviewed how weprevent and identify and treat delirium and discussed and planned – and this is the most important part –we set aside part of the day where each individual unit, the people who work in the unit altogether fromdifferent disciplines, talk about how they can implement this strategy. And what we emphasize is, we wantto use existing resources.A lot of the data out there suggests that even though you're busy and busy and busy, other places bybetter communication – having respiratory therapy talk to nursing, talk to the PCT, talk to the chargenurse and set up a plan of mobilization for the patient. And if you sedate them less and the patient canwork with you, that with a good plan and less sedation it requires less effort, less people to get patientsmobilized. And during these retreats, we had team-building exercises where people who don't know eachother can work together from different disciplines in a way that we want them to work together in the ICU.Now, one of the things we emphasized is delirium. We were very good at monitoring sedation and pain,but not very good at delirium. And we've chosen to use the Intensive Care Delirium Screening Checklist.We spent time talking about how it's been validated and what exactly the score means; and moreimportantly, we talked about there's the screening checklist itself and if you have four or more, then you'refelt to be delirious. But we give the nurses, through the guideline, and practitioners what should they bedoing if the people do have the delirium. Consider what may cause it and should there be medicationadjustments in order to treat the underlying condition.This is what they see on the computer as far as looking at avoiding deliriogenic medications, how theycan non-pharmacologically treat patients. Nurses are always interested in what they can do even withoutan order. And then if they do need orders, what medications – you can see on the right-hand side – we'regoing to use. And we use mainly Seroquel and Haloperidol to treat delirium, but our goal is to have lesspeople that are delirious that require treatment; and we think we can do that by limiting benzodiazepineuse.Now our move is away from continuous sedation and using intermittent protocols of sedation. And wefocus first on analgesia. We use relatively higher doses of Dilaudid to make sure that pain is treated in an7

attempt to avoid using benzodiazepines. If we do use benzodiazepines, they're only to be usedintermittently and as little as possible.June 26, 2013You can see over time what's happened to our sedation days, which are in green at the bottom. What thatmeans is days that patients have had continuous sedation. And you can see over time, we're using lessand less. I would like that number to be as close to zero over time. And you can see on the top, thesedation interruption completion that our patients that are on continuous sedation – almost 100% of themget sedation interruption. But as I said, although that's still considered a current standard, we would likethat to be the old standard and the new standard be virtually no continuous sedation of benzodiazepines,possibly using other drugs that we can talk about. But if you are using benzodiazepines, they are to beused only intermittently.This is our old mobility protocol, and we had pretty good compliance with this. Now, this mobility protocolthat you see on the left didn't really give a lot of direction of when to start, when to get physical therapyinvolved and how quickly to move people forward. So we redid our mobility protocol – and this is part ofwhat we did at our retreat is discuss how to implement it. This is complicated to look at on the screen, butI can tell you it's relatively simple. And one of the most important things is that as soon as the patientopens her eyes and starts to react, we would like to get the consideration of a physical therapy consultearly and to get the patient moving early.Now, part of the time we spent talking is that not everybody on a ventilator that is mobilized willnecessarily need a physical therapy consult. We have mobilized patients and not waited for the PTconsult according to certain criteria, and you can go through the mobility protocol here at your leisure.Now, this is a VAE reduction prevention discussion; and you can see, the way we used to count was VAPrates per 1,000 days. And the way we counted them with the old criteria, virtually no or very few VAPs.Now, I want to show you our data for VAEs in four of our ICUs. Now, this is over six months. So you cansee in the MICU on the left, we've had three ventilator-associated conditions. None of them wereinfection; none of them were probable or possible VAPs.So the majority of our events, which were relatively small in these four ICUs over six months, were noninfectiousventilator-associated conditions. You can see in the burn trauma ICU and the neuro ICU, we'vehad a couple of infection-related ventilator-associated conditions and two possible – those are one ineach – burn trauma, neuro ICU – possible VAPs, but we've had no probable VAPs. Clinically, we've seenno probable ventilator-associated pneumonias.So what are our next steps? We want to complete our retreats. Previously, we've reviewed all of ourventilator-associated conditions; but we've been so busy with our retreats and training people on gettingup and planning how we're going to do mobility and sedation reduction that we've been a little neglectfulhere, but we're going to go through that.As Cynthia said at the beginning, and we always go back to basics here; and as good as I think we are,it's always good in your facility – and we find times where we slack on the bundle compliance itself. I thinkthe focus in the ICUs and the cutting edge of critical care now is to focus on preventing and identifying8

June 26, 2013and treating delirium, and that's what we're going to be focusing on. And we want to develop and trial andimplement our unit-based strategies to improve mobility. And even in our big institution, we have fourdifferent ICUs with a different makeup in each ICU. And that's why we wanted each unit to develop a planof how they're going to get to this mobility position.So the whole goal of the retreat was to talk about why it's important to get there and have the same visionof we want our ICU patients that are endotracheally intubated up and out of bed and walking if possible,and how we get there.And with that, I think I'm done. And I think we move on to Brian Koll, if I'm correct.Thank you, Mike. Yes, we do move right on to Dr. Brian Koll.Hello, everyone. Those were really two outstanding presentations. I do not have a PowerPoint, but I willspeak a little bit about what our experience in terms of increasing mobility and intermittent sedation.We've been having an intermittent sedation protocol now for, I'm going to say, over five years. And we'vebeen discussing mobility in patients who are intubated. And I think similar to what Mike presented and Ithink what Ernesto noted, this really is a true interdisciplinary team effort. And it's a big culture change.So we've been doing our own mini PDSA cycles in terms of moving this forward. The one thing for usright now, we're not in a position to have dedicated physical therapists or occupational therapists for ourunits. Our nursing staff at this point are very, very busy being nurses. And in terms of adding on aresponsibility of some PT and OT to help with mobility, we found that to be a challenge.So we're sort of in the middle right now, where we've purchased ICU beds that actually are collapsibleand easily collapsible into chairs. And the chairs are mobile. When somebody is felt not to requiresedation, we will sooner rather than later begin to collapse the beds into a chair; and then our nurses'aides are able to provide bedside PT. It's not going to be in the same caliber that I'm sure that Ernesto'sinstitutions have done with having a therapist; but that really is where we are right now, and we're movingalong.In addition to, I think, our staff getting used to the practice, I think a lot of families right now are still in theprocess of getting used to seeing their loved ones awake, on a ventilator, in a chair; and it's a goodfeeling. It's making everybody feel glad, and I think it's moving us along. And I think once everyone iscomfortable with these new protocols that we really are going to see a rapid change in terms of hopefullywhat was seen in the first presentation, where we will actually have people walking while intubated.I would like to take the opportunity to thank all three of our speakers. I think you've given us a goodpicture of different ways of addressing increasing mobility and reducing sedation and innovation withinyour facilities to address the challenges you're facing.I have a few questions coming in. I'd like to encourage everyone else to either raise your hand by hittingthe Raise Your Hand button or chat in the Q&A or Chat boxes.9

June 26, 2013Could any of the three of you or all of the three of you address if you have any data yet on the reductionof delirium versus VAP rates or any delirium statistics related to that?I can tell you at the University of Rochester Medical Center we don't have delirium data yet. We're stillworking to make sure that it's collected.Thank you, Dr. Apostolakas.But it's an excellent question, and we will have that data at some point – just not yet.And like I explained during the presentation, one of the things that we did with early mobilization is deploythe CAM-ICU which measures delirium. So we're in the process also of collecting data on the incidence ofdelirium.Thank you.And I would say that we are also in the same boat as everyone else.Either Mike or Ernesto, have you noticed any change in terms of your unplanned extubation rate?No, as of yet we have not. That was always the concern. We've always had a low level extubation rate,and what I tell the nurses in the retreat is that it wouldn't surprise me if the rate went up a little bit. But I'drather have unplanned extubations and have people reintubated than people end up with trachs anddying from oversedation.And this is really, Brian, as you know, a key issue because we are such an immediate gratification societythat if we stop sedation that day and the patient self-extubates, that nurse at the bedside feels guilty thatthey did it to the patient. The problem with oversedating someone and leading to delirium, no one takesownership of that; so that somebody who oversedates the patient one day doesn't associate that becausenothing happens bad that day with the patient getting a trach a week later or dying a week later. And ifthere was a closer association to the bedside person, to the bad outcome of the oversedation or delirium,I think we'd have less sedation.And one of the reasons people oversedate in my opinion is the fear of self-extubation. And one day,about six months ago, we did have one nurse who during a sedation lightening, both patients selfextubated;and she was having a terrible day and didn't want to be lightening sedation. And I went to herand thanked her for caring for the patient and seeing past the short-term setbacks to the overall bettergood for patients.I could tell you that at NYP, we've been measuring the adverse events since we started the EarlyMobilization a year and a half ago; and we have nothing – an increase either in lines being pulled, falls,self-extubation or anything like that. I think that this is one of those cultural misbeliefs. I can tell you thatwhen we have moved initiative to a new ICU, that's usually the first barrier I see – what about self-10

June 26, 2013extubations? I'm like, "Well, it really doesn't happen." And the literature also, through Dale Needham'swork at Hopkins, he didn't see an increase in that.And I think that's an important thing to really disseminate because that and then the use of restraints areusually the first two barriers that we have to overcome.We do in fact have a question from one of our participants related to increased use of restraints. They'reseeing an increased use of restraints with the reduction in sedation. And I think a lot of the dialog we justhad addressed some of that. But could you specifically speak to the restraint use?I can tell you at the University of Rochester, we had more restraints with lightening of sedation. But a lotof restraint use is driven by the bedside nurse, and a lot of it was concern about patient safety. And I thinksome of the initial increase in restraint use was more concern of what could happen rather than necessity.So we saw with reduction in sedation more restraints; but now restraint use is pretty close to what it wasbefore.And I think the other thing is if people are getting restraints, generally they're delirious. And I think asErnesto showed in his picture and what I've been amazed at as we've lightened sedation, is if you don'tuse continuous sedation to begin with – if you don't oversedate them to begin with – when you wake themup, they're not delirious. And so if you have someone who's not delirious, they may be a littleuncomfortable and can get some pain medication, but they can sit there and participate. If they're sittingthere participating with you, you don't need restraints.So I think some of the restraint use is caused by people initially getting oversedated with continuoussedation, stopping it, the people are delirious, and they're pulling out their tubes and needing to berestrained; whereas if we don't use the sedation up front, we don't get to that position.Mike, you're right on. That is something that we saw especially on the MICU. Initially, we saw a little spikeon restraint use; but after that, it actually went below the baseline. And again, you saw from thosepictures -- the patients are awake, they are alert, they understand they have a breathing tube, they'recooperating with their therapy. This is the big culture change even for the nursing staff because we're soused to sedating the patients overnight, and then we have to move from a continuous infusion to bolusand assessing the patient frequently.Thank you. We have an additional question for any of the facilities: Does the Early Mobilization protocoldiffer for different populations – surgical versus medical with CHF, etc., for example?Well, in our protocol, yeah – for our surgical patients, we need to make sure we check with the surgeonsto make sure there's no reason they can't be mobilized – for example, if their abdomen is open or if theyhave some sort of spinal or leg injury. So for our surgical patients, we need to talk with our surgeons andmake sure that they're mobilized.As far as whether they have heart failure – it's really not so much heart failure, but whether they havereasonable hemodynamics. And what we do is we sit them up to make sure for five or ten minutes11

June 26, 2013whether they're hemodynamically stable or not. And certainly they have to be able when you sit them upand start to move them, that their SATs remain above 90%. But we've tried to get away from exclusioncriteria. We want people to say everybody is included unless they have something; and so we've tried tolimit the exclusion criteria because I think everybody who is critically ill, if you think about it hard enoughyou can find a reason why maybe it's not a good idea to mobilize them. But we know that's not correct.I was going to say, "Great point." We also have the same protocols. Again, the Early Mobilization isinclusive for the entire unit. So if patients are not able to participate, they will have to be excluded due toclinical conditions by the attending. We conduct daily rounds of early mobilization separate to like theclinical rounds and the nursing rounds. So we do conduct early mobilization rounds on these unitsindividually. So that's an essential point.The other thing that we've been focusing on – I'd be interested if Ernesto has any question about this – isthat we've walked some patients with endotracheal tubes, and we're pushing that more. As we do it moreand more, I expect at some point that for some reason a patient is going to self-extubate while they'remobilizing. And what I've told our staff is we just have to be prepared as to what we're going to do andhow we're going to get them reintubated and where the code box is and that we always have appropriateequipment accessible wherever we're walking the people.I don't know if Ernesto has any comments about safety as far as walking people and what they would doin the event of a self-extubation. Are they just prepared to do it, or have they had any experience withthat?Mike, we haven' had a self-extubation due to early mobilization; but one of the things we do is during themorning rounds – the early mobilization rounds – we identify the patients that will require the mostassistance; and those are scheduled – like, say, two o'clock or three o'clock. So the entire team isavailable to mobilize. As we know, we have been able to mobilize patients on ECMO. It's not simple; it'snot a simple process; it requires a lot of coordination, but it can be done.Thank you.Thank you. We do have another question asking specifically about whether any of your facilities have hadan increase in staff provided to assist with this initiative. What is your nurse to patient ratio, for example,and do you have the assistance of aides?At URMC, we have one nurse to two patients; and generally we have two patient care technicians duringthe day and one at night. We have one physical therapist that shares two units – so like a half-timephysical therapist. And that's our staffing ratio. In some of the literature I went through at the kickoff of thisis a lot of places have done this with existing staff, and this is a hard concept. A lot of what I spend timetalking to the staff about at the retreat is that if we do a better job with sedation, mobilization will beeasier.I tell the story of a patient that got intubated during rounds, and we used intermittent sedation on; and thenext day when I went in the room, the guy was on 70% oxygen, 12 (inaudible), sitting in a chair reading12

June 26, 2013the paper. So it can be done. I asked the nurse how she did it. She said, "Well, he was walking yesterday.I sat him up, we stood him up, we sat him in the chair." It didn't require physical therapy. It didn't requiremore staff. It didn't require anything more.I think as you start this, people have a hard time seeing that; and they think everybody is going to be ableto be mobilized, and they're not. There are going to be some people who are so hemodynamicallyunstable and critically ill that they're going to have to be heavily sedated and treated. But there are people– and we all have to accept this – that with less sedation that came in, have an acute respiratory illness orsome illness, but their muscles are fine. And if we provide ventilatory support for them, they should beable to lift themselves up; they should be able to stand and walk with very little assistance.For us at NYP, I cannot stress enough how important it is that this becomes a multidisciplinary initiative. Ithink that the key players – nursing, occupational therapy, physical therapy, pharmacy – everybody needsto be in the room, everybody needs to be on the same page. On the first wave we did have dedicatedresources, so we were able to have five PTs per site for the five units. But when we expanded to 13,which is almost double the size of the beds, we did it through a program that we have at NYP calledOperational Excellence, and what we did was look at productivity targets – national average of what theproductivity targets were for PTs – and then compare where we were at. So we saw some opportunitiesthere, and we were able to relocate the resources from floor to step down to the ICUs.Did I hear you say five PTs per unit or one PT--?No, five PTs per site. So it was 80 beds and then 5 PTs for the uptown campus and 5 for the downtowncampus.So about one PT for 16 beds?Around that, yeah.And I think this is what you were describing. What's important for this is that you have to get it rightbecause still where I think that a lot of the culture is not there yet, that you really don't want at thebeginning to have a negative outcome. And I think you do have to set up expectations that you may beseeing a little bit of increased restraint use at the beginning to ensure that your staffing is what you needbecause I think one negative outcome in this sense could really set back a program.Right, and every single paper written on this talks – as Ernesto and Brian have mentioned – that there iscommunication, that people talk about what the plan is. And one of the things we stressed that we'd likeour charge nurse, our PT, our bedside nurse and PCT to all meet for five minutes in the morning andmake a plan of mobilization for the patient. Since we have 12-bed units, I said, "Sit down, make a plan forthree patients tomorrow and how as a team we're going to do it." And that's what we're doing right now.And I was going to say, one of the things – it is key that when you're about to embark on this initiative thatyou drive the ownership to the frontline staff. And in order to do that, the institution will have to decide onone specific, measureable data point – whether it's excess days, length of stay, increase of PT treatments13

June 26, 2013– something like that – so you can see the needle moving. Just deploying early mobilization and nothaving a measurable target, it's going to be hard to move the needle.Can I ask any or all of you – I think Dr. Apostolakas did speak to how he got staff buy in through theretreats and in-person discussions, if necessary – but I don't want to discourage Dr. Apostolakas fromspeaking up. But can both Brian and Ernesto speak a little about the challenges you faced with thebedside staff and the multidisciplinary team members? How did you overcome the old way of doingthings?This is Brian. First off, it's always important to review the literature so that people understand that thereare data and that there is evidence to support these practices. Second, I think you have to really meet –maybe not in a focus group, but the retreats as was used – to really find out what people's fears/concernsare and really in some ways to understand where they think maybe they don't have a lack of training eventhough they do because we are asking them – at least for us – to do a little bit more at this point becausewe don't have the dedicated physical therapists in our ICUs.And then lastly in terms of a big picture, you could either start off in one unit -- and if you start off in oneunit, maybe start with just one patient until people become more comfortable, and then you begin tospread. And you want to set goals; you want to set timelines, you always want to brief and debrief, etc.,etc.Thank you. Did anyone else want to comment on that?I probably agree with Mike. I was going to say even when we started, we started small; and it's key to docontinuous rounds. And one of the barriers that we heard over and over again is, "We're already doing it.We're not using that much sedation." So this is why it's key to come back to the staff and say, "No, this isthe data. This is what's showing, and this is the progress that you've been able to make."I think what we say in our retreats is there's not one person – one nurse, physical therapist, respiratorytherapist, physician – taking care of these patients that doesn't want what's best for their patients. And Ithink when you really sit down and look at the evidence, as Brian said, and it's presented, people knowthat we have to do this. And then there becomes not so much, "We can't do it," as to "How are we goingto get there?"And what I promised our staff was that if they each individually and as a unit discussed what they coulddo to make this happen, I promised that if we needed more staff to make it happen that we would bringthis to the leadership of the organization. But I'm not convinced that with appropriate sedation levels andexisting staff working together better that we can't make a lot of the improvement. And there's data thatshows that in the literature – with no extra resources, one to two nursing, one PCT and a physicaltherapist per unit – that these things can be done. And that's pretty much our staffing here.I would also add just participation in an initiative such as this. We hear from our colleagues that also goesa long way because this is all about New York, and it also is really good to get buy in to say Manhattan if14

June 26, 2013they're doing it up at New York-Pres and they're able to do it up in Rochester, that we should be able todo this too.Well, I'd like to at this time thank you again – all three of our esteemed speakers. You all brought to theforefront that there are different ways of accomplishing reducing sedation and increasing mobility withinyour facilities and dealing with the challenges that face each facility. Each facility may have differentchallenges in getting a multidisciplinary team together, and getting bedside staff input has been themessage of New York State Partnership for Patients through all of our initiatives; and I think we heardthat message from all three of our speakers today to address how to actually take these best practicesand get them started – small if necessary. Pilot, give it a try, document the improvement, and spreadthroughout the entire house.So I can't thank you enough for taking the time with us today and telling us what you're doing in yourfacilities.I'd like to thank all participants for joining us and giving us this hour of their afternoon. And everyone havea lovely day.Thank you, Maria.Okay, thank you, Maria.15