A West-Coast / East-Coast Shared Passion for ICU Early Mobility, Reducing Morbidity including Falls

Tuesday, June 18th 2019

Karen Webb-Anderson

Sarah Crowe

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Karen Webb-Anderson, MN, RN

Sarah Crowe, MN, PMD, NP

Karen has no disclosures

Sarah has no disclosures

Sarah & Karen would like to acknowledge the Canadian Association of Critical Care Nurses for the networking opportunity that helped

initiate this shared work.

To provide a brief description of the evolution of critical care medicine

To describe the bundle approach to best practice in critical care

To describe how falls prevention is embedded in the philosophy of early mobilization in critical care

To share the Fraser Health and Nova Scotia Health Authority experience

Since the inception of ICUs, there have been dramatic improvements in the care of the critically ill

Reduced mortality rates are no longer the sole measure of success

With ~80% of patients surviving their ICU stay, the focus is on ICU-associated morbidity

With more research and attention on improving quality of life and outcomes, the focus of critical care has shifted to minimizing complications

This includes such complications as:◦ Hospital / ventilator acquired pneumonia◦ Delirium◦ Muscle wasting◦ Depression◦ Pressure injuries ◦ Falls and immobility

Commonly called “Post – ICU Care Syndrome”

A group of symptoms collectively known as post-ICU care syndrome or PICS

Any new or worsening impairment in physical, cognitive or mental health status, arising after critical illness and persisting beyond discharge from acute care

Kiernan, F. (2017). Care of ICU survivors in the community a guide for GPs. British Journal of General Practice, 67(663), 477-478.

A variable combination of cognitive, psychological & physical symptoms

Common symptoms:◦ Generalized weakness Fatigue

◦ Decreased mobility Anxiety

◦ Depressed mood Sexual dysfunction

◦ Cognitive problems – poor memory, slow processing, impaired concentration

Can last months to years

Patients’ Experiences:https://www.youtube.com/watch?v=30sbefBcjEU&feature=youtu.behttps://www.youtube.com/user/SCCM500

➢ Delirium is estimated to impact 60-80% of ventilated adult ICU patients (Brummel, Vasilevskis, Han et al., 2013)

➢ Delirium is associated with many adverse outcomes including increased mortality, falls, functional decline, cognitive impairment decline and significant costs (ANA, 2019)

➢ 96% of inpatient falls were associated with delirium on chart review (Lakatos, Capasso, Mitchell et al., 2009)

➢ Delirium experienced while hospitalized results in 6 fold increase in likelihood of falling AFTER discharge (Mahoney, Palta,

Johnson et al., 2000)

ABCDEF ICU Liberation - To counteract PICS, the Society of Critical

Care Medicine promote an ‘ABCDEF Bundle’ approach to care.

If we can reduce the mental health disturbances, cognitive decline, and physical impairment of critical illness, we can anticipate a post-ICU population with improved morbidity and an improved falls risk profile.

A ‘less is more’ approach - less drugs, less ventilation, less sedation, less bedrest.

Focuses on improved management of pain, agitation, delirium, immobility and sleep (PADIS)

AAssess, prevent and manage pain

BBreathing

(spontaneous awakening & breathing) Targeted sedation

CChoice of analgesia and sedation

DDelirium: assess, prevent and manage

EEarly mobility and exercise

FFamily engagement and empowerment

Vanderbilt University: http://www.icudelirium.org/index.html(http://www.iculiberation.org)

What is the ABCDEF Bundle?

One of the few therapies or actions that we can take as critical care nurses to help reduce PICS

Bedridden patients have an increased risk of death and other complications such as:• Delirium• Muscle wasting (including heart deconditioning)• ICU – acquired muscle weakness and falls• Skin breakdown and pressure related injuries• Pneumonia• Increased insulin resistance• Poor quality of life

Bed rest promotes immobility of the muscle fibres that can lead to shortening length of the collagen causing contractures and reducing functioning of limb◦ Contractures can occur after as little as 2 to 3 weeks of immobility

Bed rest causes cardiovascular side effects ◦ Within the first 3 days of bed rest there is an 8 – 10% reduction in plasma

volume◦ These changes result in increased cardiovascular workload, elevated

resting heart rate, decrease stroke volume leading to decrease cardiac output

◦ The heart muscle (like any other muscle) de-conditions with bed rest

Bed rest also lessens carotid-cardiac baroreflex responsiveness, contributing to postural hypotension and tachycardia caused by reductions in stroke volume and cardiac output

Increased risk of developing delirium

Long term side effects: severe weakness, self-care deficits, poor quality of life, increased 5 year mortality

Bed rest =

and bad outcomes

What do you picture when you think of mobility?

https://idiopathicmedicine.wordpress.com/category/intensive-care/

Focused on improving patient outcomes

Getting buy-in from staff

Dispelling myths about mobility in critical care◦ ‘Patients are too sick to mobilize’

◦ ‘There are very few mobility options available’

◦ ‘It is dangerous to mobilize critically ill patients’

To inspire: if we can mobilize ICU patients, any patients can get up and move

EVERYONE

Quality Initiative aimed at getting every ICU patient mobilizing – even if it means “moving mountains”

Focus on helping staff identify a barrier versus a true contraindication

Identifying challenges:◦ Defining the difference between barriers and

contraindications◦ Dispelling myths about true contraindications◦ Needed a tool to guide decision making◦ Difficult to keep people from feeling ‘at fault’ that their

patient didn’t/couldn’t mobilize

Celebrating successes:◦ Algorithm developed to distinguish barriers from

contraindications◦ New ideas and practice changes established to overcome

barriers ◦ Barriers addressed earlier◦ Mobility discussion greatly increased – discussed daily in

rounds as part of algorithm

https://www.stryker.com/us/en/acute-care/products/ivea.html

The next mobility project…

“You Want Me to What!? Mobility and Continuous

Renal Replacement (CRRT) Patients”

You want me to what!? Are you

serious?

New quality initiative that aimed at mobilizing the hard to mobilize populations such as those on continuous renal replacement therapy

◦ New protocol and algorithm developed specifically to mobilize those identified as being unable to mobilize

◦ Successful pilot project saw 11 CRRT patients mobilized without incident

Multi-Year Project for NSHA Dalhousie University Critical Care QEII ICUs

2012-13: Phase I – Background Work

❖ Assess current mobility

❖ Complete literature review & environmental scan, including resource models (identification of Fraser Health work)

❖ Propose an inter-professional (IP) best practice approach

2014: Phase II - Planning

❖ Planning for implementation and evaluation

❖ Integration with other Quality Initiatives

❖ ICU Strong Team, with ICU RN Co-Leads

❖ Evaluation of current equipment and needs

❖ Documentation tools developed / changed

❖ IP Education Plan

2014-2016: Phase III Implementation & Evaluation

❖ Frontline Peer Modeling and Coaching

2016-Present: Phase IV The ICU Early Mobility Culture Shift

❖ Supporting, sustaining & sharing

What does ICU Mobility

look like?

Evaluation of Protocol (18 mos)

❖ Safety events

• Accidental removal of pt support

equipment

• Fall to floor

• Hemodynamic (HR & BP)

• Respiratory (rate & O2 saturation)

❖ Progression towards out-of-bed

mobility

What about mobility & ICU trauma patients?

Retrospective cohort study of adult trauma patients admitted to level 1 trauma center over a 2-year period prior to and following early mobility program implementation, allowing for a 1-year transition period.

Mobility Group:◦ Lower in-hospital mortality (25.3% vs. 17.5%; p=0.031)

◦ Lower ICU mortality (21.6% vs. 12.8%; p=0.009)

1st study to demonstrate a significant

reduction in trauma mortality following

implementation of an ICU mobility

protocol

(unpublished manuscript,

Coles, Erdogan, Higgins & Green, 2018)

“…developed and implemented a very successful mobility program for

critical care patients. There is excellent uptake…The program is tied to

venous thromboembolism, pressure injury prevention, falls program,

and delirium best practices, and a significant decrease in delirium and a

reduced number of intubated days has been noted”

Debrief with provincial Critical Care Leadership, Lead Surveyor

identified our early mobility initiative as an “integrating strategy”

pulling best practice and team members together. Advocated we work

to “rapidly and aggressively” spread this good work

Mobility in NSHA ICUs as part of the CIHI EXTRA programChoosing Wisely AlignmentAdvising & supporting non-ICU environments

❖ Research evidence to support safety and effectiveness of mobility in reducing mortality and morbidity, in many populations & settings

❖ Safety advocacy changes to Falls Prevention

▪ Forced immobility causes harm

▪ 65% significant functional mobility decline by bedrest day 2 (Hirsh, 1990)

▪ Role of ‘sitter’ being redefined

▪ Delirium recognition – 4.55 times more likely to fall (IHI, 2018)

▪ Importance of non-pharmacological delirium interventions reduced falls by 62% (IHI, 2018)

▪ Question reliance on strategies such as signage, bed alarms

Integrate for SuccessEvidence-based practiceFrontline knowledge & leadership capacity

Karen.webb@nshealth.ca

Sarah.crowe@fraserhealth.ca

Brindle, C.T., Malhotra, R., O’Rouke, S., Currie, L., Chadwich, D. …& Creehan, S. (2013). Turning and repositioning the critically ill patient with hemodynamic instability. Journal of Wound, Ostomy and Continence Nursing, 40(3), 254 – 267.

Critical illness, brain dysfunction and survivorship (CIBS) centre. (2019). http://www.icudelirium.org/index.html

Delvin, J.W., Skrobik, Y., Gélinas, C. Needham, D., Slooter, A.J. … Alhazzani, W. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine 46(9), e825-e873

Ferguson, A., Uldall, K., Dunn, J., Blackmore, C.C. & Williams, B. (2018). Effectiveness of a multifaceted delirium screening, prevention, and treatment initiative on the rate of delirium falls in the acute care setting. Journal of Nursing Care Quality 33(3), 213-220.

Growdon, M.E., Shorr, R.I. & Inouye, S.K. (2017). The tension between promoting mobility and preventing falls in the hospital. JAMA Internal Medicine 177(6), 759-760.

Society of Critical Care Medicine (2019). ICU liberation. http://www.iculiberation.org

Truong, A.D., Fan, E., Brower, R.G. & Needham, D.M. (2009). Bench – to – bench review: mobilizing patients in the intensive care unit – from pathophysiology to clinical trials. Critical Care,13(216), Doi: 10.1186/cc7885

Vollman, K.M. (2010). Progressive mobility in the critically ill: introduction to progressive mobility. Critical Care Nurse, 30(2), S3 – S5. Doi:10.4037/ccn2010803.

Vollman, K.M. (2013). Understanding critically ill patients hemodynamic response to mobilization: using the evidence to make it safe and feasible. Critical Care Nursing Quarterly 36(1), 17 – 27.

Winkelman, C., Johnson, K.D., Hejal, R., Gordon, N.H., Rowbottom, J…. & Levine, A.D. (2012). Examining the positive effects of exercise in intubated adults in ICU: a prospective repeated measures clinical study. Intensive and Critical Care Nursing, 29, 307 – 320.

Questions?

Type your questions in to the Q&A.

STAY IN THE LOOP!WWW.FALLSLOOP.COM

WWW.JR.FALLSLOOP.COM

THIS WEBINAR IS BEING RECORDED.THE SLIDE DECK AND RECORDING WILL BE

EMAILED AFTER THE WEBINAR.

Fall Prevention Month 2019: Activity Implementation Webinar Series

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