AHRQ Safety Program For Mechanically Ventilated Patients: Daily Early Mobility Data Collection Tool

AHRQ Safety Program for
Mechanically Ventilated Patients
Daily Early Mobility Data Collection Tool

Hospital ID# ___________ Unit ID#___________ Date (mm/dd/yyyy) ___________
Fill out Fill out if patient is intubated or has tracheostomy (trached) and is mechanically ventilated
for all (can use for patients not mechanically ventilated)
beds
Bed Intub/ Date of Sedation Scale Delirium Assessment Highest Perceive PT OT Events (Up to Three Events)
# Trach Intubation Level of d Barrier 0 to 25
& (mm/dd/yyyy) RASS/ Tar- Actu CAM-ICU/ CAM- ASE ICDSC Mobilit to (see daily codes on next page)
Mech SAS/ get al ASE/ ICU 0–10, P, N, X, y – 0 to Achievin
Vent Not Used If RASS – 5 ICDSC/ P, N, X, UTA, 8 ga Event 1 Event 2 Event 3
in Unit to 4, NS or X, UTA, (see Higher Required Only if Only if
NU NK
X, NK UTA, NK daily Level of Needed Needed
If SAS – NK codes Mobility
1 to 7, NS on next –
or X, NK page) 0 to 15
(see
daily
codes
on next
page)
Y N E / / RASS SAS C A I NU Y N Y N
NU NK NK
NU NK NK
NU NK NK
NU NK NK
NU NK NK
NU NK NK
NU NK NK
NU NK NK
NU NK NK
NU NK NK
ASE = Attention Screening Exam; CAM-ICU = Confusion Assessment Method for the ICU; ICDSC = Intensive Care Delirium Screening Checklist; E = Empty; Intub = Intubation; Mech Vent = Mechanical
Ventilation;
N = Negative/No; NK = Not Known; NU = Not Used in this Unit; OT = Occupational Therapy; PT = Physical Therapy; P = Positive; RASS = Richmond Agitation and Sedation Scale; SAS = Riker Sedation-
Agitation Scale; Trach = Tracheostomy; UTA = Unable to Assess; X = Not Performed; Y = Yes
Daily Codes
PERCEIVED BARRIER TO ACHIEVING A
HIGHEST LEVEL OF MOBILITY HIGHER LEVEL OF MOBILITY EVENTS
1. Nothing: passively rolled or exercised by staff, 1. Not applicable — patient at highest possible 1. None
but not actively moving (includes raising head of level of mobility 2. Endotracheal tube dislodgement
bed to upright position without patient 2. Bed rest orders 3. Tracheostomy dislodgement
participation in movement, chest physical 4. Nasal feeding tube dislodgement
3. Patient on comfort/palliative care measures
therapy, and splinting) 5. Oral feeding tube dislodgement
4. Patient sedated (Richmond Agitation Sedation
2. Transfer bed to chair without standing: hoist, 6. Percutaneous feeding tube dislodgement
Scale [RASS] -4 or -5; or Riker Sedation-
passive lift, or slide to the chair without 7. Central venous catheter dislodgment (not femoral site)
Agitation Scale [SAS] 1 or 2) and on infusion of
standing including peripherally inserted central catheter line
benzodiazepine, narcotic, propofol, or other
3. Sitting in bed/exercises in bed: any activity in sedative 8. Central venous catheter dislodgement (femoral site)
bed, including active rolling, bridging, active 9. Arterial catheter dislodgement (not femoral site)
5. Patient sedated (RASS -4 or -5; or SAS 1 or 2),
exercises, active movement from supine to 10. Arterial catheter dislodgement (femoral site)
but NOT on infusion of benzodiazepine,
sitting position, use of cycle ergometer, use of 11. Dialysis catheter dislodgement (not femoral site),
narcotic, propofol, or other sedative
tilt table, not moving out of bed or over the including tunneled or nontunneled
edge of the bed 6. Medically inappropriate (orthopedic reason,
i.e., fracture of long bone, spine, or pelvis) 12. Dialysis catheter dislodgement (femoral site)
4. Sitting at edge of bed: actively sitting over the 13. Pulmonary artery catheter dislodgement (not femoral)
AHRQ Safety Program for Mechanically Ventilated Patients Mobility Data Tool
2
side of the bed with some trunk control (may be 7. Medically inappropriate (circulatory or 14. Pulmonary artery catheter dislodgement (femoral site)
assisted) respiratory reason) as delineated in the 15. Chest tube dislodgement
5. Standing: weight bearing through feet in medical screening algorithm 16. Wound or dressing disruption or new bleeding at site
standing position with or without assistance; 8. Medically inappropriate (new deep vein 17. Cardiac device dislodgement (i.e., temporary
may include use of a standing lifter thrombosis, or DVT) as delineated in the pacemaker wire, ventricular assist device, intra-aortic
6. Transfer from bed to chair with standing: able medical screening algorithm balloon pump
to step or shuffle through standing to chair; this 9. Medically inappropriate (femoral sheath) as 18. Hypotension (change in mean arterial pressure (MAP)
involves actively transferring weight from one delineated in the medical screening algorithm to <55 mmHg, or if intervention required [i.e., fluid
leg to another to move to chair bolus or new/increased vasopressor dose])
10.Medically inappropriate (for any other reason,
7. Marching in place: able to walk in place by i.e., unstable, active gastrointestinal bleeding) 19. Hypertension (change in MAP to >140 mmHg, or if
lifting alternate feet (must be able to step at intervention required)
11. Patient unavailable throughout the day
least four times, two for each foot) with or 20. Desaturation (02 sat <85% or if intervention required
12. Staffing (registered nurse, physical therapist, [i.e., increase in Fi02])
without assistance
respiratory therapist) unavailable throughout 21. Cardiac arrest requiring cardiopulmonary resuscitation
8. Walking: walking away from the bed/chair by at the day
least four steps (two for each foot) assisted by a 22. New arrhythmia (excludes sinus tachycardia, prematur
13. Patient declined mobilization throughout the ventricular contractions (PVC), or pre-existing
person/people or gait aid, or unassisted
day arrhythmia that did not worsen during mobilization)
9. Unknown: it is unknown regarding what
14. Patient is too weak to progress to higher level 23. Fall WITH staff assisting in lowering patient
activity, if any, occurred
of mobility 24. Fall WITHOUT staff assisting in lowering patient
15. Other barrier not listed above 25. Death
16. Unknown barrier 26. Other
Instructions for Daily Early Mobility Data Collection Tool

Please complete this form once a day, every day. If possible, complete it around the same time each day, hopefully during
patient rounds.
3
Patients are considered mechanically ventilated on a specific day if they were mechanically ventilated at the time of
observation.
All of the contraindications are listed at the end of the data collection tool. Please print the data collection sheet with the
contraindications on the back for ease of data collection.
**This tool may also be used for patients who are not mechanically ventilated.**
DATA FIELD DIRECTIONS

Hospital Enter the name of your hospital.
ICU Enter the name of your unit.
Date Enter today’s date as MM/DD/YYYY format (e.g., 01/31/2014).
Bed # Enter all the bed numbers on the form, regardless of whether the patient is on mechanical ventilation. Include
empty beds.
4
Intub/Trach & Mech Enter for all patients. If the bed is empty, leave blank. Mechanical ventilation is defined as receiving ventilator
Vent: support via an endotracheal tube or tracheostomy tube.
Is the patient currently  Patients treated with noninvasive ventilation would be counted as N.
receiving mechanical  Circle Y if the patient is currently intubated/trached and mechanically ventilated.
ventilation?  Circle N if the patient is not currently intubated /trached and mechanically ventilated.
 Circle E if there is no patient in the bed.
For any specific patient, if the patient is not currently intubated/trached AND on mechanical ventilation, STOP.
Do not enter any more information regarding that bed for this date.
If you entered Y, all of the following information is required.
If you have entered N, the following information is not required. However, you may collect and enter this
information if it would be of use to your unit.
If you have entered E, STOP. Do not enter any more information regarding that bed for this date.
Date of Intubation Enter the date that the patient was intubated using an MM/DD/YYYY format (e.g., 06/01/2012).
Evaluate daily for patients receiving full vent support.
 DO NOT use dates from reintubation following self-extubation.
 If the patient is reintubated following less than 24 hours after extubation, use first intubation date.
5
Sedation Scale
RASS/SAS/Not Used in Evaluate daily for patients receiving mechanical ventilation.
This Unit:
 Circle RASS if your unit uses the Richmond Agitation Sedation Scale (RASS).
What sedation scale do  Circle SAS if your unit uses the Riker Sedation-Agitation Scale (SAS).
you use on your unit?  Circle NU if your unit either does not use a sedation scale or uses a scale other than RASS or SAS.*
*If you circle NU, skip to the Delirium Assessment column. DO NOT enter information into either the Target or
Actual columns.
Since you are a RASS or SAS user, please record the target and actual scores for RASS or SAS assessment closest to 10 a.m. If two
scores were collected equidistant from 10 a.m., choose the earlier score.
(Evaluated daily for mechanically ventilated patients with R or S entered in the RASS/SAS/Not used in this unit column).
The Society of Critical Care Medicine’s 2013 pain/agitation/delirium (PAD) clinical practice guidelines recommend the RASS and SAS
as the most valid and reliable sedation assessment tools for measuring the quality and depth of sedation in adult intensive care unit
patients.
6
RASS: Target/Actual: RASS – Only for patients receiving mechanical ventilation and where RASS/SAS/Not Used in This Unit = RASS
What are the target Enter the score closest to 10 a.m. If two scores were collected equidistant from 10 a.m., choose the earlier score.
and actual RASS scores
for this patient?  Enter the target RASS sedation numeric scale value, choosing from -5 to 4.
o Enter NS if the target RASS sedation level was not set.
o Enter NK if a target RASS sedation level was set but is not known.
o Enter NK if you don’t know whether a target RASS sedation level was actually set.
 Enter the RASS actual sedation numeric scale value, choosing from -5 to 4.
o Enter X if an actual RASS sedation level was not scored.
o Enter NK if an actual RASS sedation level was scored, but is not known.
o Enter NK if you don’t know whether an actual RASS sedation level was scored.
SAS: Target/Actual: SAS - Only for patients receiving mechanical ventilation and where RASS/SAS/Not Used in This Unit = SAS
What are the target Enter the score closest to 10 a.m. If two scores were collected equidistant from 10 a.m., choose the earlier score.
and actual SAS scores
for this patient?  Enter the target SAS sedation numeric scale value, choosing from 1 to 7.
o Enter NS if the target SAS sedation level was not set.
o Enter NK if a target SAS sedation level was set, but is not known.
o Enter NK if you don’t know whether a target SAS sedation level was actually set.
7
 Enter the actual SAS sedation numeric scale value, choosing from 1 to 7.
o Enter X if an actual SAS sedation level was not scored.
o Enter NK if an actual SAS sedation level was scored, but is not known.
o Enter NK if you don’t know whether an actual SAS sedation level was scored.
Delirium Assessment
The Society of Critical Care Medicine’s 2013 pain/agitation/delirium (PAD) clinical practice guidelines recommend the Confusion
Assessment for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) as the most valid and reliable delirium
screening tools, and that moderate- to high-risk patients be screened at least once per nursing shift.
ASE (Attention Screening Exam) is the second step of the CAM-ICU. While it is not specifically recommended for use by the SCCM
PAD Guidelines, it is a good tool to use while your unit is getting set up to do the full CAM-ICU. The results of the ASE may be
abnormal due to disease, drugs, or other causes.
8
CAM- Evaluate daily for patients receiving mechanical ventilation.
ICU/ASE/ICDSC/NU
 Circle C if your unit uses the CAM-ICU
What delirium  Circle A if your unit uses the Attention Screening Exam which is feature 2 of the CAM-ICU
assessment tool do you  Circle I if your unit uses the ICDCS
use in your unit?  Circle NU if your unit does not use any of the above methods to assess patient confusion.*
*If you circle NU, skip to the SAT column. DO NOT enter information into either the CAM-ICU or ASE columns.
If you are a CAM-ICU, ICDSC, or ASE user, please record the most recent CAM-ICU, ICDSC, or ASE assessment closest to 10 a.m. If
two scores were collected equidistant from 10 a.m., choose the earlier score. The CAM-ICU can be done while on or off
sedation/analgesics, and it is up to the clinical team to interpret the results of the delirium assessment in light of the presence
or absence of sedatives/analgesics.
(Evaluated daily for patients with C , A, or I entered in the CAM-ICU/ASE/ICDSC/NU).
9
CAM-ICU
CAM-ICU: (Only for patients receiving mechanical ventilation and where CAM-ICU/ASE/ICDSC/Not Used in This Unit = C)
Is the patient positive Enter the score closest to 10 a.m. If two scores were collected equidistant from 10 a.m., choose the earlier score.
or negative for
delirium?  Enter P if the patient is positive for delirium based on CAM-ICU assessment.
 Enter N if the patient is negative for delirium based on CAM-ICU assessment.
 Enter UTA if unable to assess (e.g., RASS = -4 or -5 OR SAS = 1 or 2).
 Enter X if CAM-ICU assessment was not completed.
 Enter NK if CAM-ICU was completed, but results are not known.
 Enter NK if CAM-ICU if you don’t know whether the exam was performed.
10
ASE - Feature 2 of the CAM-ICU
11
ASE:
(Only for patients receiving mechanical ventilation and where CAM-ICU/ASE/ICDSC/Not Used in This Unit = A)
What is the patient’s
ability to pay The goal of this 10- to 20-second test is to determine if a patient can follow a simple command (pay attention) for
attention? that period of time. Inattention is the cardinal feature of delirium and must be present to diagnose delirium. For
centers not using the full CAM-ICU, conducting the ASE is a good barometer of the presence or absence of delirium.
This test may be abnormal due to disease, drugs, or other causes.
The exam consists of the provider reading the following sequence of letters:
SAVEAHAART or CASABLANCA or ABADBADDAY
The patient is told to squeeze the provider’s hand when the letter A is stated. An error is defined as no squeeze
with letter A or a squeeze on a letter other than A. The number of errors is counted. Inattention is present if the
patient commits more than two errors. If the patient squeezes on every letter or doesn’t squeeze on any letter,
then assign an error count of 10.
Enter the score closest to 10 a.m. If two scores were collected equidistant from 10 a.m., choose the earlier score.
 Enter the number of errors, 0 to 10.
 Enter UTA if unable to assess (i.e., RASS = -4 or -5 OR SAS = 1 or 2).
 Enter X if the exam was not performed.
 Enter NK if the exam was performed, but the number of errors is not known.
 Enter NK if you don’t know whether the exam was performed.
The Society of Critical Care Medicine’s 2013 pain/agitation/delirium clinical practice guidelines recommend the
CAM-ICU or the ICDSC as the most valid and reliable delirium screening tools, and that moderate- to high-risk
patients be screened at least once per nursing shift.
If this is not yet feasible in your unit, we recommend that patients at least undergo the ASE once daily. The ASE is
12
Mobility
13
Highest level of mobility: Evaluate every day.
What was the highest Mobility codes are listed on the back of the data collection tool.
level of mobility achieved
by the patient in the last 1. Nothing: passively rolled or exercised by staff, but not actively moving (includes raising head of bed to upright
position without patient participation in movement, chest physical therapy, and splinting)
24 hours?
2. Transfer bed to chair without standing: hoist, passive lift, or slide to the chair without standing
3. Sitting in bed/exercises in bed: any activity in bed, including active rolling, bridging, active exercises, active
movement from supine to sitting position, use of cycle ergometer, use of tilt table, not moving out of bed or
over the edge of the bed
4. Sitting at edge of bed: actively sitting over the side of the bed with some trunk control (may be assisted)
5. Standing: weight bearing through feet in standing position with or without assistance; may include use of a
standing lifter
6. Transfer from bed to chair with standing: able to step or shuffle through standing to chair; this involves
actively transferring weight from one leg to another to move to chair
7. Marching in place: able to walk in place by lifting alternate feet (must be able to step at least four times, two
for each foot) with or without assistance
8. Walking: walking away from the bed/chair by at least four steps (two for each foot) assisted by a
person/people or gait aid, or unassisted
9. Unknown: it is unknown regarding what activity, if any, occurred
14
Perceived barrier to Enter the code associated with the answer. For example, enter 2 for “Patient on comfort/palliative care measures.” If
achieving a higher level multiple codes apply to a patient, please select the lowest number.
of mobility: Perceived barrier codes are listed on the back of the data collection tool.
What prevented the
patient from being 1. Not applicable – patient at highest possible level of mobility
mobilized to a higher 2. Bed rest orders
level? 3. Patient on comfort/palliative care measures
4. Patient sedated (RASS -4 or -5; or SAS 1 or 2) and on infusion of benzodiazepine, narcotic, or propofol
5. Patient sedated (RASS -4 or -5; or SAS 1 or 2), but NOT on infusion of benzodiazepine, narcotic, or propofol
6. Medically inappropriate (orthopedic reason, e.g., fracture of long bone, spine, or pelvis)
7. Medically inappropriate (circulatory or respiratory reason) as delineated in the medical screening algorithm
8. Medically inappropriate (new deep vein thrombosis) as delineated in the medical screening algorithm on page
12
9. Medically inappropriate (femoral sheath) as delineated in the medical screening algorithm
10. Medically inappropriate (for any other reason; e.g., unstable, active gastrointestinal bleeding)
11. Patient unavailable throughout the day
12. Staffing (registered nurse, physical therapist, respiratory therapist) unavailable throughout the day
13. Patient declined mobilization throughout the day
14. Patient too weak to progress to higher level of mobility
15. Other barrier not listed above
16. Unknown barrier
15
Physical Therapy:
Did a physical therapist  Circle Y if the patient was evaluated or treated by a PT in the past 24 hours.
(PT) evaluate or treat the  Circle N if the patient was NOT evaluated or treated by a PT in the past 24 hours.
patient within the last 24  Circle NK if it is not known if the patient was evaluated or treated by a PT in the past 24 hours.
hours?
Occupational Therapy:
Did an occupational  Circle Y if the patient was evaluated or treated by an OT in the past 24 hours.
therapist (OT) evaluate  Circle N if the patient was NOT evaluated or treated by an OT in the past 24 hours.
or treat the patient  Circle NK if it is not known if the patient was evaluated or treated by an OT in the past 24 hours.
within the last 24 hours?
16
Events: Enter a code in the Event 1 – Required column. If there was no event, choose 0. If multiple events occurred, you can
Did the patient have an enter up to two more events.
“event” (as defined on
Event codes are listed on the back of the data collection sheet.
the back of the data
collection sheet) while 1. None
being mobilized within 2. Endotracheal tube dislodgement
the last 24 hours? 3. Tracheostomy dislodgement
4. Nasal feeding tube dislodgement
5. Oral feeding tube dislodgement
6. Percutaneous feeding tube dislodgement
7. Central venous catheter dislodgment (not femoral site), including peripherally inserted central catheter line
8. Central venous catheter dislodgement (femoral site)
9. Arterial catheter dislodgement (not femoral site)
10. Arterial catheter dislodgement (femoral site)
11. Dialysis catheter dislodgement (not femoral site), including tunneled or nontunneled
12. Dialysis catheter dislodgement (femoral site)
13. Pulmonary artery catheter dislodgement (not femoral)
14. Pulmonary artery catheter dislodgement (femoral site)
15. Chest tube dislodgement
16. Wound or dressing disruption or new bleeding at site
17. Cardiac device dislodgement (e.g., temporary pacemaker wire, ventricular assist device, intra-aortic balloon pump)
18. Hypotension (change in mean arterial pressure to <55 mmHg, or if intervention required [e.g., fluid bolus or
new/increased vasopressor dose])
19. Hypertension (change in MAP to >140 mmHg, or if intervention required)
17
Medical Screening Algorithm
Medical screening algorithm to evaluate patient appropriateness for rehabilitation.
18
19 AHRQ Pub. No. 16(17)-0018-10-EF
January 2017

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AHRQ Safety Program for

Mechanically Ventilated Patients

Daily Early Mobility Data Collection Tool

Instructions for Daily Early Mobility Data Collection Tool

DATA FIELD DIRECTIONS

DATA FIELD DIRECTIONS

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