ICU Early Mobilization at UCSF. Presented by Heidi Engel, PT, DPT

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1 ICU Early Mobilization at UCSF Presented by Heidi Engel, PT, DPT

2 Mobility is Life Early mobility is profoundly beneficial to your patients Dot be afraid, they do better than you expect It is a MULTIDISCIPLINE task

3 Presentation Objectives Review of patient functional decline related to an ICU stay Define early ICU mobilization Outline steps necessary to increase mobility of ICU patients Cite evidence of benefits to patients, family members, and the medical center of early ICU mobilization.

4 Why Do ICU Patients Need Physical Therapy? Clinical Outcomes for Survivors of ARDS At One Year (Median age 45, N= 83) 48% returned to work Results of 6 minute walk test are 66% of predicted normal At Five Years (Median Age 44, N=64) 77% returned to work Results of 6 minute walk test are 76% of predicted normal Herridge, M. S., C. M. Tansey, et al. (2011). "Functional disability 5 years after acute respiratory distress syndrome." N Engl J Med 364(14):

5 Can We Do Better? There appears to be significant potential for harm arising from the current ICU culture of patient immobility and an often excessive or unnecessary use of sedation. Herridge MS. Mobile, awake and critically ill. CMAJ. Mar ;178(6):

6 The Impact of an ICU Stay ICU Acquired Weakness Rapid onset Pervasive weakness Immobility myopathy myosin filament atrophy and sarcomere collapse Axonal polyneuropathy Difficulty liberating from mechanical ventilator Stevens RD, Dowdy DW, Michaels RK, Mendez-Tellez PA, Pronovost PJ, Needham DM. Neuromuscular dysfunction acquired in critical illness: a systematic review. Intensive Care Med. Nov 2007;33(11): Bolton, C. F. (2005). "Neuromuscular manifestations of critical illness." Muscle Nerve 32(2):

7 Critical Illness Myopathy (CIM) Critical Illness Polyneuropathy (CIP) Latronico, N., G. Bertolini, et al. (2007). "Simplified electrophysiological evaluation of peripheral nerves in critically ill patients: the Italian multi-centre CRIMYNE study." Crit Care 11(1): R11.

8 Critical Illness Myopathy Schefold, J. C., J. Bierbrauer, et al. (2010). "Intensive care unit-acquired weakness (ICUAW) and muscle wasting in critically ill patients with severe sepsis and septic shock." J Cachex Sarcopenia Muscle 1(2):

9 Impact of Mechanical Ventilation The combination of 18 to 69 hours of complete diaphragmatic inactivity and mechanical ventilation results in marked atrophy of human diaphragm myofibers Levine, S., T. Nguyen, et al. (2008). "Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans." N Engl J Med 358(13): Patients over 65 years of age surviving hospitalization with MV vs hospitalization without, experience 30% greater ADL disability Barnato, A. E., S. M. Albert, et al. (2011). "Disability among Elderly Survivors of Mechanical Ventilation." Am J Respir Crit Care Med 183(8):

10 Post Intensive Care Syndrome (PICS) Delirium Although estimates differ, it appears that at least 1 in 3 survivors of critical illness will experience long-term cognitive impairment of a severity consistent with mild to moderate dementia. US Department of Veterans Affairs Post Traumatic Stress Disorder (PTSD) Risk Factors- pre-icu anxiety or psychological history, length of mechanical ventilation required, type of sedation used Davydow, D. S., S. V. Desai, et al. (2008). "Psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review." Psychosom Med 70(4):

11 Cognitive Changes Related to ICU Stay 25 to 40% of patients with new onset cognitive changes Imapired learning and short term memory Executive function Attention Contributing factors Hypoxemia Variable glucose control Delirium Sepsis Iwashyna, T. J., E. W. Ely, et al. (2010). "Long-term cognitive impairment and functional disability among survivors of severe sepsis." JAMA 304(16):

12 Functional Decline Related to ICU Stay Acute Problems- Patients from the ICU fall 3 times as often during hospitalization Adults with ICU Acquired Weakness on > 5 days Mechanical Ventilation require longer MV longer hospital stay independently associated with hospital mortality. Ali NA, O'Brien JM, Jr., Hoffmann SP, et al. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med. Aug ;178(3): Flanders SAea. Falls and Patient Mobility in Critical Care: Keeping Patients and Staff Safe. AACN Advanced Critical Care. July/September 2009;20(3):

13 Functional Decline Related to ICU Stay Long Term Problem 3.3 year median follow up after d/c from trauma ICU 100 patients 70% consider themselves less active than pre-injury 49% returned to work. Livingston DH, Tripp T, Biggs C, Lavery RF. A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit. J Trauma. Aug 2009;67(2): ; discussion More than 6 years after a surgical ICU admission, HRQOL is largely reduced. Many patients still have a variety of health problems, including decreased cognitive functioning. Timmers, T. K., M. H. Verhofstad, et al. (2011). "Long-term quality of life after surgical intensive care admission." Arch Surg 146(4):

14 Mobility is Medicine Health Benefits of Physical Activity Improves blood sugar homeostasis Enhances cardiovascular function Enhances endothelial function Decreases chronic inflammation Regulates hormone levels Preserves musculoskeletal and neuromuscular integrity Decreases depression and improves cognition Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. Cmaj. Mar ;174 (6):

15 Definition of Early ICU Mobilization Early defined as initial physiologic stabilization, continuing through out ICU stay Initiating patient mobilization within 48 hours of patient admission to the ICU through: ICU cultural shift toward mobility as necessity, not optional Practice patterns of all ICU personnel emphasizing team work with mobilization Optimizing the ICU environment to allow for patient mobility Equipment Sleep Sedation Bailey PPR, ACNP; Miller, Russell R. MD, MPH; Clemmer, Terry P. Culture of Early mobility in mechanically ventilated patients. Critical Care Medicine. 2009;37(10):S429-S435.

16 ICU Early Mobilization Requires Admit to ICU with activity as tolerated orders Physical Therapy referrals are included in MD orders 60-80% of ICU patients receive consistent Physical Therapy daily Patients are awake Work of breathing is minimized

17 Steps Taken at UCSF- 9 ICU Research Promotion Role models UCSF 10 ICU/ICC Johns Hopkins Hospital LDS Medical Center Create multi-discipline team Add staffing and equipment

18 Research Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. May RCT- 104 patients on mechanical ventilation intervention group- PT median of 1.5 days intubation control group- PT median of 7.4 days. Intervention group less days of delirium and MV 59% return to independent function at hospital discharge 35% in control group

19 Research Morris, P. E., L. Griffin, et al. (2011). "Receiving Early Mobility During an Intensive Care Unit Admission Is a Predictor of Improved Outcomes in Acute Respiratory Failure." Am J Med Sci. Retrospective Survey of 280 Acute respiratory failure survivors Factors associated with readmissions or death during the first year Tracheostomy Female gender Higher Charlson Comorbidity Index Lack of early ICU mobility

20 Promotion Staff meeting in-services Visiting consultants RN Newsletter Critical care grand rounds CEO office hours updates Multi-discipline meetings Community bulletin board Sedation education Sleep and thirst studies

21 Role Models- LDS Medical Center LDS Medical Center Mobility Protocol Walk 200 prior to extubation Walk 400 prior to ICU discharge When patients appear not to have strength to do both reconditioning and weaning, support reconditioning first, then weaning. Support work of breathing during physical activity. Advance activity aggressively NOT progressively, patients will do the most that they can do at any given time.

22 Vt = 450 ml, PEEP = 16, Fio 2 = 0.6 CCM Tech Patient RT PT Wheel Chair 10/22/11 Mobility 22

23 Printed with permission Patients Walking in ICU, LDS Medical Center

24 Printed with permission In the shower at LDS ICU

25 Role Models- Johns Hopkins Needham, D. M. and R. Korupolu (2010). "Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model." Top Stroke Rehabil 17(4): There are barriers to providing early physical medicine and rehabilitation (PM&R) in the intensive care unit (ICU). Johns Hopkins Hospital presents a model for quality improvement (QI) projects The QI project was undertaken using a 4-step model (1) summarizing the evidence (2) identifying barriers (3) establishing performance measures (4) ensuring patients receive the intervention

26 Role Models- UCSF 10 ICU/ICC Mobilizing ECLS patients- centrally cannulated. Sternotomy with cannula in R atrium (inflow) to aorta (anastomosed). Both cannula tunneled out and connected to circuit. ECLS patients regularly got out of bed and walked over to chair. Spent several hours per day out of bed.

27 Adult ExtraCorporeal Life Support (ECLS)

28 VV Cannulation via the Double Lumen Cannula

29 Staffing and Equipment UCSF- one full time PT added No additional RN or RT staff ICU platform walker, ear plugs, eye masks, seating cushions PTs mobilize patients to higher level than RNs Garzon-Serrano, J., C. Ryan, et al. (2011). "Early Mobilization in Critically Ill Patients: Patients' Mobilization Level Depends on Health Care Provider's Profession." PM R 3(4):

30 Staffing and Equipment MOTO-Med Letto Deconditioned, too weak for OOB Medically fragile Femoral dialysis catheters, mechanical ventilation Aerobic work

31 Barriers to Initating Early Mobilization Sounds like a good idea, but: I cannot add staff at this time It s too much work It s not safe The evidence is not conclusive enough Verbal support without concrete follow up Skeptical managers and Medicine clinicians Practice patterns, protocols, communication, and documentation systems must be changed Endless meetings, no start date

32 ICU Early Mobilization Started March 1st, 2010 UCSF 9 ICU Physical Therapy coverage 8 hours/day 5 days/week in 9 ICU Objective- referrals for physical therapy within 48 hours of patient admission to the ICU Objective- most ICU patients ambulating during their ICU stay Goals patients wean ventilators faster sleep better/experience less delirium leave the ICU sooner

33 UCSF Exclusion Guidelines Patients with immediate plans to transfer to outside hospital Patients who require significant doses of vasopressors for hemodynamic stability (maintain MAP> 60) Mechanically ventilated patients who require FiO2.8 and/or PEEP >12, or have acutely worsening respiratory failure Patients maintained on neuromuscular paralytics Patients in an acute neurological event (CVA,SAH, ICH) with re-assessment for mobility every 24 hours Patients unresponsive to verbal stimuli Patients with unstable spine or extremity fractures Patients with a grave prognosis- transferring to comfort care Patients with a femoral dialysis catheter Patients with open abdomen, at risk for dehiscence

34 UCSF Inclusion Guidelines Patient is arousable to voice and requires skilled physical therapy intervention- PT referral written by MD or NP PT and NP will informally round on the 9 ICU patient census daily to select appropriate patients for new Physical Therapy referrals Functionally independent patients mobilize and ambulate with RN assistance All mechanically ventilated patients will be assessed by RT and assisted by both RT and PT at time of mobilization All patients ambulating in ICU will have portable telemetry set up by PT or RN

35 Barriers to Implementation- It s Not a Strength Issue. Nervous or skeptical clinicians Minimal resources allocated Awkward equipment PT referrals still too late Unclear protocol PT in the ICU now a moderate priority rather than a last priority, but not a top priority Mobility prior to extubation is difficult concept for all Constantly rotating and changing personnel Variations in sedation practices New hospital and discharge course predictions required for ICU and floor personnel

36 UCSF ICU- step 1, untangling

37 UCSF ICU- step 2, bed exercise

38 UCSF ICU- step 3, sitting on EOB

39 UCSF ICU- step 4, assisted sit to stand

40 UCSF ICU- step 5, walking

41 UCSF ICU- step 6, sit and rest as needed

42 Benefits to UCSF- ICU Early mobilization Patient lines and drains can be accommodated

43 Benefits to UCSF- ICU Early mobilization Patient lines and drains can be accommodated

44 Benefits to UCSF- ICU Early mobilization Tremendous positive feedback from family members

45 Benefits to UCSF- ICU Early mobilization Less stress experienced by family and patients

46 UCSF Experience of ICU Early Two planned tracheotomies avoided Mobilization Decreased length of stay Patients able to go home instead of to SNF

47 UCSF Experience of ICU Early Mobilization The Message: preventing deconditioning is as important as preventing skin breakdown, VAP, line infections Safety: adverse events- rectal tubes, peripheral IV access and NG tubes dislodged Safety: no central lines, catheters, or ET tubes dislodged Safety: no falls, syncope episodes or cardiac events during mobility with PT

48 UCSF Experience of ICU Early Mobilization 13 ICU- standard PT care 51 yo M ARDS pt, I community level activity 50mcg propofol PEEP 8 FiO2.6 Bed rest activity orders, PT referral on HD 10 Failed SBT, delirium LOS 1 month, 5 sessions PT d/c d to acute care able to stand 30 seconds with mina of 2 9 ICU- early mobilization 25 yo F ARDS pt, I community level activity 100mcg propofol PEEP 16 FiO2.9 Activity as tolerated orders, PT referral on HD 1 ICUAW, tracheotomy LOS 1 month, 19 sessions PT d/c d to acute rehab able to walk SBA FWW 60 X4

49 UCSF Experience of ICU Early Mobilization Improvements in discharge outcome related to Earlier mobility More intense intervention Greater distance walked

50 ICU Patients Receiving Physical Therapy Variables 3/ /2009 Pre-ICU Early Mob 3/ /2010 Post-ICU Early Mob # of PT patients, Average # PT visits 220 patients, 5 visits 33 patients intubated 397 patients, 5 visits 53 intubated Assist level scores Min A on average Mod A on average overall # of PT patients in ICU walking 77 patients walking 148 patients walking Average distance walked 87 feet 147 feet Average length of hospital stay % of PT patients walking in ICU d/c to home 24 days 10 days in ICU 55% d/c from UCSF to home 19 days 8 days in ICU 71% d/c from UCSF to home

51 Future for ICU Early Mobilization at UCSF Continue ICU Multi-discipline meetings to develop greater cross discipline collaboration, physical therapy students utilized Continue data collection for QI and research purposes emphasizing outcomes rather than tasks Case study review by all disciplines and write up RN sedation assessments- CAM- ICU and RASS Sedation education campaign Diaries project Collaboration with sleep studies Use of clinical frailty scores, frailty index

52 Future for ICU Early Mobilization at Questions to answer UCSF Are we comfortable with mobilizing patients on vasopresssors, with femoral lines, with agitation? How do we coordinate ventilation, sedation, spontaneous breathing trials, and extubation with mobilization? How do we take into account functional mobility, endurance, and physiologic reserve of the patient?

53 ICU Early Mobilization Improves patient satisfaction and outcomes

54 The Ounce of Prevention Reward

55 Thank You UCSF Critical Care- Michael Gropper, MD, Michael Matthay, MD, Kevin Thornton, MD UCSF Executive Director for Service Lines- Karen Rago, RN, MPA, FAAMA, FACCA UCSF Nursing- Steve Koster, RN, Charlotte Garwood, RN, Sarah Irvine, RN, Hildy Schell-Chaple, CNS, Cathy Schuster, RN UCSF Critical Care Nurse Practitioners- Geoffrey Latham, NP, Maureen Mary Arriola, NP, Tom Farley, NP UCSF Respiratory Therapy- Brian Daniel, RT UCSF Rehabilitative Services- Joy Devins, PT, Rebecca Mustille, PT, Shin Tatebe, PT, Sherri Heft, PT, Phil Alonzo, Johns Hopkins Hospital ICU PM&R- Dale Needham, MD, Eddy Fan, MD LDS Medical Center- Polly Bailey, NP, Louise Bezdjian, NP Photo Credits- Jim Jocoy, PTA

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