Today we speak with Dr. Michael DiMare PT DPT GCS MSOM, a manager of rehabilitation services at Geisinger Wyoming Valley Medical Center. He is joined by a nursing colleague, Dr. Lauren Murphy DNP RN ACNS-BC, who oversees nursing quality improvement at the hospital.

What first caught my eye about the work that this hospital was putting in to improve their inpatient mobility outcomes was the manner in which they were able to 'gamify' and encourage competition among caregivers to execute mobility for their patients. Since implementing their Golden Sneaker program in the ICU in 2016, it has since evolved into a house-wide initiative to seek improvement and better patient outcomes.

I think their example gives a good representation of the buy-in and commitment it takes to successfully collaborate among all disciplines from nursing to physical therapy as well as quality and hospital leadership.

We also dive into the impacts that the pandemic has had on their mobility program and how they've adapted to ensure mobility is still a priority.

“As we had been working on mobility for a couple of years, I think it was time for us to invigorate the efforts and create something that was more fun. We’ve had tremendous engagement from our nursing leaders. Our collaboration between the therapists and nurses has continued to grow over the years.”

Listen to the full podcast here.

Note: Podcast transcript below is generated using a combination of speech recognition software and human transcribers, and may contain errors. Please check the corresponding audio before quoting in print.

Hi Lauren and Michael, thanks for joining us today. Can you let our listeners know a little about your mobility program at Geisinger and how you knew there was an opportunity to improve patient mobility prior to implementation?

Michael DiMare PT DPT GCS MSOM: We’ve been working on mobility for a couple of years now at Geisinger Wyoming Valley going back to 2017. We had noticed that many of our patients who were coming into the hospital from a home setting were not up and moving efficiently enough which resulted in the patient going to some type of post-acute care facility when they were leaving the hospital. That was something that we did not want to continue and we wanted to address knowing mobility was the prime reason as to why those patients were not returning home. From a visual standpoint and by walking in the hospital, we oftentimes found many patients were in bed or not in a chair. There were a lot of patients who were up and moving with therapy, but we knew there was an opportunity to (implement) a multidisciplinary approach to get those patients moving a little bit more

Lauren Murphy DNP RN ACNS-BC: We also felt that this was an obligation for us because one of our strategic priorities as a system is managing total health so this fits perfectly into that category. And then what do we do next from there? We recognize there’s an issue so we turn to the literature to see if there’s any support that we can get from any of the data that’s out there and relevant. (There are) a number of studies out there (saying) a loss of mobility in the hospital occurs and how quickly it happens. So what does that do? It increases the length of stay, increases patient falls and makes (patients) decline in their daily living when they would be at home. From the literature is where we helped support these changes in practice focusing on a multidisciplinary professional team to help move this forward.

From my understanding, your program really started in the ICU and has since evolved to almost every unit it seems in the hospital. When did you realize there was an impact, and when did you decide to take it housewide?

MD: We started our mobility program in February of 2016. Our ICU Director, Dr. Alvin Sharma, and I collaborated to try to increase our mobility, particularly of our patients in the ICU setting who were under mechanical ventilation. We looked at our data internally and realized that only 2% of our patients were awake, alert, and active enough to participate in therapy sessions. We created a process in the ICU that was centered on reducing the use of medications that cause the patient to be sedated and establishing a process and a protocol to identify patients who were appropriate to move.

In 2017, we looked into the hospital and recognized that our patients in the ICU had a clear process (for mobility), and it was time to bring it to the rest of the hospital. If we could do it in the ICU setting where it was more difficult, we should be able to work collaboratively together to make it occur in the Med-Surg setting.

LM: Moving (the program) to Med-Surg, we were seeing a higher number of falls that were happening. Patients were being mobilized early in the ICU and it wasn’t happening (elsewhere).

How did you judge whether there was a loss of mobility after patients left the ICU and went to Step Down or Med-Surg?

MD: That was very easy, our patients were telling us! We literally had patients that were in our ICU (and they were) up and accustomed to moving. They were going to the (other) floors and being less mobile. Also - in the ICU we had realized the effect of mobility because we had seen our ‘observed-to-expected’ ICU time on a vent go down after we implemented our mobility program. Patients were getting off a ventilator as they were moving more. We knew there was an opportunity to expand it to the floor.

LM: Right. We weren’t seeing those patients moving like we’d like to see them in the hallways.

That’s fantastic! So how did you approach establishing the gaps prior to implementation? What were some of the key drivers that kickstarted the Golden Sneaker program?

LM: We looked at it from a quality perspective. We would have a friendly competition between units. We (measured) how we performed in a number of things; pressure injuries, central line infections, and catheter-associated urinary tract infections. With that, we wanted to build in a little friendly competition between units when it came to mobility.

MD: I think we had a unique opportunity because we had implemented the John Hopkins model of mobility documentation (AM-PAC) out of Boston University and the John Hopkins highest level of mobility. We entered that into our electronic medical record (EMR). When we built it, we built the flow sheet row so it was shared between the nursing team and the therapy team so that there was not a single group that was responsible for the mobility; however, it was a shared focus.

As we had been working on mobility for a couple of years, I think it was time for us to invigorate the efforts and create something that was more fun. We were able to leverage our EMR to pull a row that had specifically documented the distance a patient had walked. We were (then) able to identify which unit had the greatest average distance ambulated on any given month. We would award them with a sneaker trophy, a banner, and the bragging rights in the hospital for the month because it stays on their unit to be displayed.

It has to be impactful as a caregiver to see those mobility scores and standings right in front of you and all of your competition. That’s awesome!

How did you encourage collaboration and communication for all of this among all disciplines?

MD: We had created a mobility dashboard that was a system dashboard that each platform could access for their specific units. What we were looking for in that dashboard was the number of times mobility was documented on any given day for each patient. We had set a goal that each patient would be moving at least three times a day. Since creating that dashboard in 2018, we saw that our numbers had trended upward as our program has matured.

Subsequently, we have seen a rather dramatic increase in the number of patients who are able to return back to their homes after coming into our hospital. We have not seen any effect on patients being readmitted back to the hospital. So we feel as though the communication between the multidisciplinary team, the focus on mobility, and patients not declining with their physical function allows them to return to their previous living conditions when their medical condition has been stabilized from what brought them into the hospital.

LM: From a nursing perspective, the culture had to change a little bit. We needed to get away from the fact that if the patient had a therapy consult that therapy is the only one that moves them or ambulates them. That has to be a shared responsibility so that’s why this flow sheet and the dashboard were built to look at everyone who’s moving patients. Not just nurses, but also nursing assistants, and giving them the empowerment to move patients and get credit for it in the documentation. With a focus on mobility, we saw a decrease in our fall rate and a reduction in pressure injuries.

MD: With our Golden Sneaker competition we look at the total number of feet documented by our care team. As a team, we usually set a goal for each month. We’ve been able to attain over 1 million feet documented for many of our months, with the highest amount being 1.5 million. We continue to look at (that number) internally to drive us to make sure we are hitting that mark each and every month with our patients.

Yeah, and I’m sure you see all of these things in the hospital, but being able to have metrics around and know that you’ve walked over 1 million feet, that’s fantastic! Those hospital-acquired metrics can really tell a story and many can be directly related back to immobility and deconditioning. What are some of the unorthodox ways in which you encouraged your staff to keep up with this mobility?

LM: Obviously the traveling trophy and banner. Some of the units have added momentos to the trophy itself so it develops into a rivalry of sorts. When it’s taken away from one area, they want it back.

MD: We’ve had tremendous engagement from our nursing leaders. Our collaboration between the therapists and nurses has continued to grow over the years. Any time there’s a trend down we try to evaluate why that occurred and then bringing that back to the team to make them more aware of it.

You two seem to be the champions for this from both a PT and nursing leadership standpoint. Outside of those disciplines - how did you get buy-in from other stakeholders throughout the entire hospital?

MD: We very early on created a progressive mobility forum consisting of a truly multidisciplinary team starting from the very top. Our administration was involved. Our Chief Administration Officer, our Chief Medical Officer, our Chief Nursing Officer have all been involved with that forum from the very beginning. I truly believe that having that level of support from an administration really set the tone for the entire team to understand that this was an important task and that it wasn’t being taken on individually, but you had the true support of the entire system.

Also in that forum, we have nursing leaders, therapy leadership, physician leadership, and case management. It really became a task that everyone was empowered to discuss and own. (Once this happened), it stopped being just the therapist speaking about mobility. The physicians, nurses, and our administration started speaking about it.

Traditionally, mobility is thought about as a physical therapy task solely. People kind of groan when the physical therapist comes to the floor and asks why things are not going as we would want them to. Breaking that down and creating shared ownership across all members of the team was really crucial in the success.

That’s the hard part, right? Getting that sense of importance and priority felt throughout the whole building.

Now, I would be remiss if I didn’t ask about the major shift we’ve seen in healthcare over the past year or so. How has the pandemic impacted this relatively new program for you, and what have you done to overcome some of the challenges it has presented?

MD: When the pandemic started, across the system we were all very concerned about the conservation of PPE and only allowing certain individuals in the room that were vital because we really didn’t know how much of it we would have. We did not involve therapy in patients who were COVID positive the first two weeks that we had seen our surge. We very quickly saw a negative impact from not involving a therapist and losing track of mobility.

We quickly changed that scenario and a therapist began to get involved when it was medically appropriate. I think we’ve created challenges with mobility because patients are placed with airborne precaution and they’re not able to come out of their rooms. But, we continue to work on it so that (mobility) is occurring on a daily basis.

We did pause our Golden Sneaker trophy during the first couple of months of the pandemic because of the massive changes in the hospital. We very quickly picked that back up because we know it continues to be important. Today, we continue to make mobility a priority regardless of the setting or diagnosis.

LM: Even if we couldn’t go into those rooms as much as we’d like to, it’s (about) tailoring the care so we can make sure the patient is at least out of bed for every meal and that they’re ambulating to and from the bathroom. This allows us to really take credit for the care.

ABOUT THE AUTHOR

DREW MARTIN

Drew works as marketing manager and takes care of digital and content marketing efforts for Recovery Force Health. He enjoys learning about and discussing newer medical technologies and adopting them into everyday marketing practices.