5/30/2014

1

Early Mobility in the ICU, How is It Going?

UCSF Critical Care & Trauma Medicine Conference May 29-31 2014

Presented by Heidi Engel, PT, DPT

heidi.engel@ucsfmedctr.org

Why Early ICU Patient Mobility?

Diaphragm muscle thinning and atrophy begins within 18 to 48 hours after intubation

Levine, S., T. Nguyen, et al. (2008). "Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans." N Engl J Med 358 (13): 1327-1335.

Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM: Diaphragm muscle thinning in patients who are mechanically ventilated. Chest 2012, 142(6):1455-1460.

Rectus Femoris protein breakdown begins within 24 hours of ICU admission, cross sectional area declining rapidly during first week Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS et al: Acute Skeletal Muscle Wasting in Critical Illness. Jama 2013.

Why Early ICU Patient Mobility?

The duration of bed rest during critical illness was consistently associated with weakness throughout 24-month follow-up. Fan E, Dowdy DW, Colantuoni E, Mendez-Tellez PA, Sevransky JE, Shanholtz C, Himmelfarb CR, Desai SV, Ciesla N, Herridge MS et al: Physical Complications in Acute Lung Injury Survivors: A 2-Year Longitudinal Prospective Study. Crit Care Med 2013.

Based on available evidence, early exercise/PT seems to be the only treatment yet shown to improve long-term physical function of ICU survivors. Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA: Interventions to improve the physical function of ICU survivors: a systematic review. Chest 2013, 144(5):1469-1480.

Astronauts are on Bed Rest

They exercise for at least 2 hours/day to counter the adverse effects to their bone density and muscles

5/30/2014

2

An Image of ICU Delirium

Gunther ML, Morandi A, Krauskopf E, Pandharipande P, Girard TD, Jackson JC, Thompson J, Shintani AK, Geevarghese S, Miller RR, 3rd et al: The association between brain volumes, delirium duration, and cognitive outcomes in intensive care unit survivors: the VISIONS cohort magnetic resonance imaging study*. Crit Care Med 2012, 40(7):2022-2032. Page 20

Delirium Prevention

• We recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium (+1B)

• Barr J, Fraser GL, Puntil lo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al: Clinical practice guidelines for the

management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013, 41(1):263-306.

• Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D et al: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009, 373(9678):1874-1882.

• Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E: Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010, 91(4):536-542.

ICU Liberation Project of SCCM SYMPTOMS

PAD GUIDELINES MONITORING

TOOLS

CARE

ABCDEF BUNDLE

PAIN

BPS

NPS

CPOT

Assess / Treat Pain

Awakening Trials - SATs

Breathing Trials - SBTs Coordination of Care Choice of Sedatives Delirium Reduction Diseases, Drug Removal, Environment e.g., sleep, noise, eye glasses, hearing aids Early mobility and Exercise Family - Communication and Involvement

AGITATION

RASS

SAS

DELIRIUM

CAM-ICU

ICDSC

www.iculiberation.org & www.icudelirium.org How Are We Doing?

Point Prevalence Studies:

Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, Kaltwasser A, Mende H, Rothaug O, Schuchhardt D et al: Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany*. Crit Care Med 2014, 42(5):1178-1186.

In this 1-day point-prevalence study conducted across Germany, only 24% of all mechanically ventilated patients and only 8% of patients with an endotracheal tube were mobilized out of bed as part of routine care.

5/30/2014

3

How Are We Doing? Point Prevalence Studies:

Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas PJ, Denehy L: Intensive care unit mobility practices in Australia and New Zealand: a point prevalence study. Crit Care Resusc 2013, 15(4):260-265.

45% were mechanically ventilated. Mobilisation activities were classified into five categories that were not mutually exclusive: 140 patients (28%) completed an in-bed exercise regimen, 93 (19%) sat over the side of the bed, 182 (37%) sat out of bed, 124 (25%) stood and 89 (18%) walked. Predefined adverse events occurred on 24 occasions (5%). No patient requiring mechanical ventilation sat out of bed or walked.

How Are We Doing? Point Prevalence Studies:

Terri Hough University of Washington Medical Center, Presenting at The 7th International Physical Medicine and Rehabilitation of Critically Ill Patients Meeting 5/17/2014, Across the US:

64% of ICU patients experienced any activity, 50% of those were bed level activity, 20% of those were transfers to a chair, 10% of those were walking

Profoundly variable practice patterns

Moving From Information to Practice: How Exercise Can Help You Live Longer By GRETCHEN REYNOLDS, April 2, 2014, New York Times

Having unhealthy cholesterol numbers, elevated blood pressure or an expanding waistline substantially increases your chances of developing heart disease. But an encouraging new study finds that exercise may slash that risk, even if your other risk factors stay high.

Top 10 Excuses for Keeping An ICU Patient Immobile

5/30/2014

4

SAFETY:

Excuse: The Patient is too…,

Excuse # 1. SAFETY: The patient is too sick, or too big

TRUE: New onset sepsis or respiratory distress (think of hours NOT days)

Unstable bleeding or surgical site

Terminal disease (comfort care measures),

Comatose

Acute unstable cardiovascular event

Solution # 1. SAFETY: The patient is too sick, or too big

Collaborate with RN,RT, MD

Use Clinical judgment

Every diagnosis in context

Context

Is it a beautiful sunny day after so much rain, or are we in the middle of a drought?

5/30/2014

5

Excuse # 1. SAFETY: The patient is too sick, or too big

FALSE: The patient has a DVT (reference the American College of Chest Physicians 2012 guidelines: people with acute DVT do not need a period of bed rest)

FALSE: The obese patient was admitted able to walk at home (think of how crucial prevention can be)

FALSE: The patient is on ARDS Net Protocol

FALSE: The patient is a new admit to the ICU

Excuse # 2. SAFETY: The patient is too sleepy RASS -1 to -4 Hypoactive delirious Goal targeted sedation?

True: Delirium is Brain Failure Brain Failure Looks Like This

Solution# 2. SAFETY: The patient is too sleepy

Collaborate with RN,RT, MD

Use Clinical judgment

Every level of delirium

in context

Consider the environment

5/30/2014

6

Solution# 2. SAFETY: The patient is too sleepy and may respond well to being up

Excuse # 3. SAFETY: The patient is too agitated

Solution # 3. SAFETY: The patient is too agitated Society of Critical Care Medicine Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium

“We recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium” (+1B)

• Barr J, Fraser GL, Punti l lo K, Ely EW, Gel inas C, Dasta JF, Davidson JE, Devl in JW, Kress JP, Joffe AM et al: Clinical practice guidelines for the

management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013, 41(1):263-306.

• Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawl ik AJ, Esbrook CL, Spears L, Mi l ler M, Franczyk M, Deprizio D et al: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009, 373(9678):1874-1882.

• Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Pa lmer JB, Brower RG, Fan E: Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010, 91(4):536-542.

Excuse # 4. SAFETY: the patient has challenging lines or endotracheal tube

5/30/2014

7

What About All Those Critical Lines?

Patient lines and drains can be accommodated

Including Femoral Lines

Mechanical ventilation and CVVH lines

Damluji, A., et al. (2013). "Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit." J Crit Care.

Winkelman, C. (2011). "Ambulating with pulmonary artery or femoral catheters in place." Crit Care Nurse 31(5): 70-73.

What About All Those Critical Lines?

Lines, catheters and drains can be accommodated, secured

EVD line stationary bike

Excuse #5 Timing: The patient is leaving

The patient is going for:

A procedure

A CT scan

Transferring to the floor

Will be extubated soon

Solution #5 Timing: Soon to be Extubated

Activity trumps extubation:

A pre- and post-activity rest period with assist-control ventilation for 30 min was employed as needed to support early activity.

If the patient was intubated and able to participate in activity, the FIO2 was increased by 0.2 before initiation of activity. We deferred ventilator weaning in support of activity, as necessary.

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(1):139-145.

5/30/2014

8

Excuse #6 Timing: The patient needs a nap

The patient

Had a bad night

Feels tired

Didn’t sleep last night

Wants to sleep now to make up for it

Kamdar BB, Needham DM, Collop NA: Sleep deprivation in critical illness: its role in physical and psychological recovery. Journal of intensive care medicine 2012, 27(2):97-111.

Solution #6 Timing: The patient needs a nap

Schedule a time

Create a sleep hygiene program in your ICU

Address night staff as well as day

Set circadian rhythms

Excuse #7 Staffing/Equipment : No one is available to manage the lines

No portable ventilator

No high back chairs

No minimal lift equipment

No full time PT

Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM: ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care Med 2013, 41(3):717-724.

Solution # 7. Staffing/Equipment Overcome the Barriers

Establish the program for your local culture

Begin with the easier smaller success stories

Collect data to evaluate and re-evaluate

• Kress JP: Sedation and mobility: changing the paradigm. Crit

Care Clin 2013, 29(1):67-75.

5/30/2014

9

Excuse#8 Staffing/Equipment : My other patient is too sick, I can’t help or watch this patient

Solution #8. Patients Expectations and Patient Centered Goals

Returning to life as they knew it

Not a new life of disability or perpetual patient

Misak C: ICU psychosis and patient autonomy: some thoughts from the inside. The Journal of medicine and philosophy 2005, 30(4):411-430.

Muller M, Strobl R, Grill E: Goals of patients with rehabilitation needs in acute hospitals: goal achivement is an indicator for improved functioning. J Rehabil Med 2011, 43(2):145-150.

What Are the Expectations? Excuse #9. Staffing/Equipment : the attending MD doesn’t think it’s a going to work for this patient

5/30/2014

10

Solution # 9. Learning opportunities

Engel HJ, Needham DM, Morris PE, Gropper MA: ICU early mobilization: from recommendation to implementation at three medical centers. Crit Care Med 2013, 41(9 Suppl 1):S69-80.

Excuse #10. Staffing/Equipment : The physical therapist is not here

The PT has higher priority patients outside the ICU

The PT leaves the difficult

to transfer patient in the chair

Solution #10. Staffing Equipment : the PT is not here

Build the case for a full time dedicated ICU PT

Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM: ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care Med 2013, 41(3):717-724.

Plan ahead and coordinate care

In Summary

Critical illness is catabolic and depleting, rapidly and potentially lasting for years

A prolonged ICU stay can cause delirium and cognitive changes for most patients

Mobility combined with minimal or no sedation started at the beginning of an ICU stay is protective and preventative

Approach the task with structured QI project, collaboration, barrier identification

5/30/2014

11

Mobility is Life

Early mobility is profoundly beneficial to your patients

Don’t be afraid, they do better than you expect

It is a MULTIDISCIPLINE task