We used a structured QI model,20 which included the following components: (1) understanding the problem within the larger healthcare system, (2) creating a multidisciplinary improvement team, (3) enlisting all stakeholders to identify barriers to change and appropriate solutions, and (4) creating a change in practice through a “4 Es” approach: engage, educate, execute, and evaluate. Many meetings, led by the project leader (DMN), were click here required to reach the full complement of 66 MICU nurses, 45 respiratory therapists, 13 attending physicians, and 12 pulmonary and critical care fellows who work in the MICU. Moreover, within the

Department of PM&R, meetings were held with the director (JBP), physicians, and PT and OT supervisors and staff. Similar meetings were held with the leadership and

resident physicians within the Department of Neurology and its neuromuscular subspecialty physician group. These meetings aimed at presenting the problem (as previously outlined) and identifying barriers and solutions for reaching the project goals. A multidisciplinary QI team with representatives from each relevant clinician group in the MICU and PM&R was created and met on a weekly basis to plan, execute, and evaluate the QI project. The process for improving practice was based on a “4 Es” model (engage, educate, execute, and evaluate).20 First, in addition to the multidisciplinary meetings previously described, further steps were taken to engage all relevant stakeholders in the QI process, Lumacaftor manufacturer including (1) providing information about the project in separate MICU and hospital-wide newsletters, (2) creating informational posters, (3) conducting didactic conferences and presentations, and (4) arranging visits by patients to

share their stories of neuromuscular weakness after MICU discharge. Furthermore, patients who participated in early PM&R therapy returned to the MICU to provide positive feedback to clinicians about their MICU experiences and subsequent recovery process. Patient interviews and visits reinforced the perceived benefits of decreased sedation and increased PM&R therapy and activity level, without increased patient anxiety, distress, or pain (videos of patient interviews available PD184352 (CI-1040) at www.hopkinsmedicine.org/oacis). Second, education was provided via meetings, presentations, and communications that summarized research publications on long-term neuromuscular complications after critical illness and benefits of early PM&R activities in the ICU. A published expert in this field was invited for a 2-day visit to our institution to give presentations and meet with all stakeholder groups. In addition, a PT leader (JMZ), the MICU physician director (RGB), and a senior MICU nurse visited an ICU that was highly successful with early mobilization and shared the learning from this site visit with their clinical colleagues at our institution.