Facilitators & Barriers to Acute Rehabilitation in the the Critically Ill

Transcription

1 Facilitators & Barriers to Acute Rehabilitation in the the Critically Ill Karen K.Y. Koo MD, FRCPC, MSc Assistant Professor, Division Critical Care Medicine Department of Medicine, Western University Critical Care Canada Forum Oct 29, 2012

2 Disclosures I have no Industry relationships. I receive grant support from Academic Medical Organization of South-western Ontario & Lawson Health Research Institute, Physicians Services Incorporated Foundation & Academic Health Sciences Centres AFP Innovation Fund

3 Overview What & Whys of Early Mobilization in ICUs National Surveys Barriers Facilitators for Early Mobilization

4 Early Mobilization = progressive series of activities - as early as possible in ICU - from active ROM ambulation

5 Early Mobilization is Safe & Feasible Study Design Intervention Main Findings Limitations Prospective cohort N = 103 (Bailey et al. CCM 2007) EM protocol 24h after RICU admission 69% patients ambulate > 100 prior ICU discharge Adverse events rare Selection bias 94% from another ICU (mean /- 9.9 days) Prospective cohort N = 104 (Thomson et al. CCM 2008) EM protocol 24h after RICU admission 88% patients ambulate > 200 prior ICU discharge Selection bias Prospective controlled trial N = 330 (Morris et al. CCM 2008)) EM protocol 48h after ICU admission by a mobility team Shortens ICU & hospital length of stay Quasi-randomization No concealment of randomization Randomized study N = 80 (Nava, S. APMR 1998, 79) Step-wise pulmonary rehabilitation vs. standard Most (52/60; 87%) regained independent ambulation & ADLs Baseline characteristics not reported

6 Early Mobilization improves functional outcomes Study Design Intervention / Control Main Findings Limitations RCT Medical ICUs N = 104 Early Mobilization during interrupted sedation vs. Standard Rehabilitation Improved Independent neuromuscular function at hospital discharge Less Delirium Patients with baseline functional impairment excluded (Schweickert et al. Lancet 2009; 373) Shorter Mechanical ventilation duration Medical ICU only RCT Medical & Surgical ICUs N = 90 (Burtin et al. - CCM 2009; 37) Bedside Cycle Ergometer vs. Standard Rehabilitation Greater 6MWD at hospital discharge No difference in Weaning time, 1 year mortality, ICU or hospital stay Time to intervention 14d Ward rehab not controlled Blinding of outcome assessors not reported

7 Barriers to Early Mobilization in ICUs

8 International Research on Barriers Many national surveys! Limited observational research Focus mostly on Institutional & Patient level Barriers Variable rigor & methodological approaches

9 King & Crowe, Physiotherapy 1998; 210 Postal survey, convenience sample: PT, RN, MD PT & RNs perceived MD restricting ambulation MD perceived patient instability & lines

10 Norrenberg et al. Intensive Care Med 2000; 26 European Postal survey to head PT 102/460 (22%) ICUs in 17 countries 25% No designated PT 33/102 (33%) evening coverage but variable [range: 0% Sweden & Germany - 79% UK] Variable role for PT: 25% managed vents [range: 0% Sweden 57% Portugal]

11 Kumar JA et al. Indian J Crit Care Med 2007:11 Postal survey to PT (2 yrs critical care experience) 89/260 (35%) ICUs - India 21% ICU no on call PT 55% ICU required MD order for rehab

12 Skinner ZH et al. Physiotherapy 2008; 223 Postal survey to PT in 126/167 (75%) ICUs Evaluated subjective & objective factors used to prescribe exercise Major perceived barrier: medical instability

13 Skinner ZH et al. Physiotherapy 2008; 223

14 Hodgin et al. Crit Care Med 2009; 37 Postal survey to PT 482/984 (49%) Response Rate < 10% ICU - initiation criteria for mobilization 1% ICU automatic PT assessments

15 Appleton et al. Intensive Care Society 2012; 223 Telephone survey in 23 ICU (96% lead MD & 100% lead PT) Top 3 barriers: Patient severity of illness Insufficient $ for rehab Sedation

16 International Surveys show Major Institutional Barriers Lack of protocols/guidelines Insufficient Equipment Insufficient Staffing No physician requests for physiotherapy consult Major Patient Barriers Medical instability Excessive sedation Lines

17 Current Barriers in Canada

18 Survey of Mobilization in Critically Adults: Knowledge, Perspectives & Stated Practices in Canadian ICUs Koo KKY, Choong K, Cook DJ, Herridge M, Newman A, Lo V, Priestap F, Campbell E, Guyatt G, Burns K, Lamontagne F, Meade MO for the Canadian Critical Care Trials Group A self administered, postal survey to PT & MD Developed a reliable & valid survey instrument Used incentive & evidence based methods Koo et al. Am J Respir Crit Care Med 2011; 183

19 Response Rates Results Response Rate: 71% Clinicians (311/436) Respondents: 87% PT (117/134) & 64% MD (194/302) Demographics 46 ICUs in 40 Canadian Teaching hospitals 18 beds/icu (Range 10-36) Type of ICU Respondents Worked in Burn 19.4% Trauma 40.7% Neuro CV Surg 39.3% 43.2% Type of ICU Med-Surg 86.5%

20 Results % Clinicians Top 3 Institutional Barriers No Written Guidelines or Protocols 57% Insufficient Equipment 52% Physician Orders required 41% Top 3 Patient Barriers Medical Instability 83% Excessive Sedation 60% Risk of Device/Line Dislodgement 42% Institutional barriers defined as customs and behavior patterns in your work environment

21 Results % Clinicians Top 3 Institutional Barriers No Written Guidelines or Protocols 57% Insufficient Equipment 52% Physician Orders required 41% Top 3 Patient Barriers Medical Instability 83% Excessive Sedation 60% Risk of Device/Line Dislodgement 42% Institutional barriers defined as customs and behavior patterns in your work environment

22 Results Q. What is (are) the most important Provider level barrier(s) to EM in YOUR ICU? If you believe that the listed barrier is important, please select ALL provider(s) who contribute to the existence of that barrier.

23 Results Q. What is (are) the most important Provider level barrier(s) to EM in YOUR ICU? If you believe that the listed barrier is important, please select ALL provider(s) who contribute to the existence of that barrier. Top 3 Provider Barriers to Early Mobilization in ICU Contributing Providers MD PT RN RT CS Limited Staffing 2% 78% 59% 30% 2% Slow to Recognize 63% 17% 59% 19% 15% Safety Concerns 31% 29% 64% 28% 12%

24 Figure 1. Knowledge of ICU Acquired Weakness & Early Mobilization Among Canadian Physiotherapists & Physicians Knowledge of ICU acquired weakness* (% correct) Self-Reported Familiarity of Early Mobilization Literature (% agree) Physiotherapists Physicians Knowledge of Clinical Trials on Early Mobilization in ICUs** (% correct) All Respondents Knowledge of intensive care unit (ICU) acquired weakness was based on prospective observational studies (17,18,19,20,21) in medical-surgical intensive care units. ** Knowledge of clinical trials (2,4,5,6) on early mobilization was evaluated using 5 true-false questions.

25 Canadian Survey shows Major Institutional Barriers Lack of protocols/guidelines Insufficient Equipment Insufficient Staffing No physician requests for physiotherapy consult Major Patient Barriers Medical instability Excessive sedation Lines

26 Canadian Survey also identifies... Major Health Care Provider Barriers Knowledge Skills set Safety concerns Delays in Recognition of suitable patients

27 Facilitators of Early Mobilization in ICUs?

28 Winkelman & Peereboom. Crit Care Nurse 2010; 30(2) Semi-structured interviews: Pre & post mobility protocol implementation in 49 patients Single US center: 33 RNs Major perceived facilitators of out of bed activity Patient co-operation Adequate oxygen reserve MD orders No outcome/performance measures

29 Hopkins et al. Crit Care Clin 2007; 23 QI - Intermountain Health Respiratory ICU Model (UT, USA) Introduced numerous interventions to promote rehabilitation Outcome Measures Length of ICU stay (Mean) 13 d 10 d Length of hospital stay (Mean) 28 d 24 d Satisfaction safety culture High Satisfaction ICU team work culture High

30 Hopkins et al. Crit Care Clin 2007; 23 Steps 1. Review of Barriers established state of urgency 2. Created powerful guiding coalition (Teamwork) 3. Created vision (Reduce sedation, prioritize activity, encourage sleep) 4. Communication of vision (Education, Mobility protocol) 5. Empowerment to act out vision (Cross-training, hiring new RNs) 6. Planning for short term wins 7. Audit & feedback 8. Institutional change (Transforming culture)

31 Needham et al. Arch Phys Med Rehabil 2010; 91 QI: John Hopkins MICU 2006, 2007 Detailed data collection (pre/baseline, post/outcome) Main Outcome Measures Pre-QI Post-QI Benzodiazepine use (% of days used) 50% 25% p=0.002 Days alert 30% 67% p<0.001 Rehabilitation Treatments (#/patient) 1 7 p<0.001 MICU Stay 7 d 5 d p=0.02 Hospital Stay 17 d 14 d p=0.03 Mortality 23% 21% p=0.55

32 Needham et al. Arch Phys Med Rehabil 2010; 91

33 Summary Important Facilitators Institutional Facilitators Leadership/Champions Administrative support Protocols/guidelines Sufficient Resources (Staff & Equipment) Patient Facilitators Sedation Interruption: Scales, Audit & feedback Delirium Screening Patient co-operation Health Care Provider Facilitators Education: seminars, bedside Cross-training

34 Take Home points Most Barriers are modifiable Facilitators for rehabilitation require educated, dedicated, & strategic interdisciplinary Team Early Mobilization improves functional outcomes in previously healthy, medical patients

35 References 1. King J, Crowe J. Mobilization practices in Canadian critical care units. Physiotherapy Canada 1998; 50: Limperopoulos C, Majnemer A. The role of rehabilitation specialists in Canadian NICUs: A national survey. Physical & Occupational Therapy in Pediatrics 2002; 22: Norrenberg M, Vincent JL. A Profile of European Intensive Care Physiotherapists. Int Care Med 2000; 26: Kumar JA, Maiya AG, Pereira D. Role of physiotherapists in intensive care units of India: A multicenter survey. Indian J Crit Care Med 2007; 11: Hodgin KE, Nordon-Craft A, McFann KK, Mealer ML, Moss M. Physical therapy utilization in intensive care units: Results from a national survey. Crit Care Med 2009; 37: Appleton RTD, MacKinnon M, Booth MG, Wells J, Quasim T. Rehabilitation within Scottish intensive care units: a national survey. The Journal of the Intensive Care Society 2011; 12: Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriquez L, Hopkins RO. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007; 35: Koo KKY, K Choong, DJ Cook, M Herridge, A Newman, V Lo, K Burns, V Schulz, MO Meade for the Canadian Critical Care Trials Group. Development of a Canadian Survey of Mobilization of Critically Ill Patients in Intensive Care Units: Current Knowledge, Perspectives and Practices. Am J Respir Crit Care Med 2011; 183: A Thompson GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med 2008; 36: Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M, Penley L, Howard A, Dixon L, Leach S, Small R, Hite RD, Haponik E. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36: Nava S. Rehabilitation of patients admitted to a respiratory intensive care unit. Arch Phys Med Rehabil 1998; 79: Schweickert WD, Pohlman MC, Polman AS, Nigos C, Pawlik A, Esbrook CL, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE, Hall J, Kress JP. Early physical and occupational therapy in mechanically ventilated critically ill patients: a randomized controlled trial. Lancet 2009; 373: Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, Hermans G, Decramer M, Gosselink R. Early Exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009; 37: