Early Mobility in the Intensive Care Unit

KATIE ANDERSON, M/OTS

GRAND VALLEY STATE UNIVERSITY

MARCH 2015

Objectives

Define early mobility in the ICU

Discuss current evidence-based research supporting the use of early mobility in the ICU

Early Mobility Program

Rehabilitation focus in ICU

OT treatment in ICU

Ideas to Implement

Outcomes

Wrap up & Questions

Why Early Mobility?

Traditional ICU Care

ICU literature pushed bedrest- believed to be “conservation of energy” beneficial for recovery

Effects of Mechanical Ventilation

Muscle weakness

Skin breakdown

Ventilator-associated pneumonia(VAP)

Delirium ~80%

Long term effects/disability

(Vollman, 2010)

The Progressive Mobility Movement

New Standard of Care in ICU

Promoting progressive activity within 24- 48 hours of mechanical ventilation

Promoting activity as tolerated

Improves functional recovery

Feasible, safe, treats neuromuscular complications

Decreases LOS, Delirium, and hospital readmission

Long-term quality of life

(Kleinpell, 2011)

(Lipshutz, Engel, Thomton & Gropper, 2012)

Schweickert WD, Pohlman MC, Pohlman AS, et al (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet;373:1874-1882.

Research question: # of patients returning to independent functional status at discharge with early mobility intervention

104 ICU patients ( control n=55, intervention n=49)

Intervention received OT/PT early mobilization ( therapeutic exercise/activity, 6 ADLs)

Control: daily interruption of sedation with therapy as ordered by primary care team

Duration: variable depending on ICU stay, 28 day follow-up

Outcomes: shorter duration of delirium, more ventilator-free days, return to hospital function occurred in 29 (59%) of patients in intervention group

Control group: 19(35%) of patients in control group returned to independent function at discharge

Evidence Based Practice:Importance of Early Mobility in the ICU

Evidence Based Practice

(Schweickert et. al, 2009)

Evidence Based Practice:ADL Independence/Discharge Planning

(Schweickert et. al, 2009)

Barriers to OT in ICU Mobility

“OT services are highly underutilized in most acute care settings”

Prospective cohort study: 514 patients with acute lung injury from 11 ICU’s in three hospitals in Baltimore, MD

Only 30% of patients received OT during their ICU length of stay

OT treatment began 1.5 days after admission, outcomes show significant improvement of physical/mental function at discharge

Patient outcomes without OT:

Increased days in coma

Increased mean oxygen requirements

Increased Delirium

Decreased ADL independence at d/c

(Dingals et al, 2013)

Advocating for OT in ICU Mobility

Barriers/Myths to OT in ICU

Pt is “too sick “ to engage in therapy

Doctors/Nurses have decreased understanding of OT’s role in the ICU

Lack of knowledge regarding medical lines/equipment

Patient is unable to participate in ADLs in the ICU

Solutions

Therapy team in ICU attend interdisciplinary rounds each week

Providing in-service on early mobility to ICU staff

Start small, begin with BADLs, ROM, and grade activities up as tolerated

Educate other disciplines on equipment, positioning, participation in BADLs, and importance of mobility

Change ICU culture with recent research for early mobilization programs

Early Mobility Program in the ICU

Research and Program Ideas developed by:Vanderbilt University, Beaumont Health System

ICU Delirium and Cognitive Impairment Study Group, 2013Beaumont Hospital Early Mobilization Program, 2013

Determining Appropriate Treatment in ICU

• Assessment by RN used to measure agitation -sedation levels

• Quick screen to determine if patient is appropriate for therapy

• Location of RASS-CAM-ICU score in Epic under “flowsheets”

PT/OT Focus in ICU

Initiating activities within 24-48 hours after ICU admission: Promote activity

Determine patients RASS score, develop treatment based off sedation levels

Turning/positioning & AROM/PROM

Bed Mobility (rolling, sit to supine, EOB sitting)

Chair Positioning: Light exercise & ADLs

( t/f, toileting, eating, bathing, dressing, grooming, walking)

Standing( pre-gait exercises)-Ambulation

Why Should OT’s be Involved?

Look at impairments and deficits

Muscle weakness, progressive loss of musculoskeletal functions

Impaired performance of ADLs/IADLs

Inability to return to work, habits, routines

Impaired cognition

Decreased mental status due to delirium

Joint contractures from immobility

Impaired sleep and rest

(Beaumont Health System, 2013)

(Kleinpell, 2011)

OT Intervention in the ICU Stress Pattern

• ADLs• Positioning• Splinting• Bed Mobility• Bed Exercise• Transfers• Vision• Cognition• Discharge rec’s• Equipment rec’s • Family education

Ideas to Implement

RASS Score: Collaborate with RN

Mobility Signs (implemented at Beaumont)

Go: Walk in hallway

Caution: Up in chair

Slow: Dangle EOB

Stop: Bed exercises or PROM

Mobility Carts

Thera band

Weights

Hand Bike for UE strengthening

Exercise programs posted in rooms: Involve Family!

Ankle pumps

Quad sets

Heel slides

Hand pumps

Arm Curls

Wrist Flexion/Extension

Note: ICU exercise programs & mobility sign information located on handout

Patient Outcomes

Delirium

Length of mechanical ventilation

Readmission & frequent flyers

Independence in ADLs at discharge

Shorter LOS in the hospital

Promotes importance of therapy in ICU/CCU

Take Away Message

By promoting early mobility in the ICU, it expands the ICU team to include physical/occupational therapists. In return, it changes the ICU culture to focus not just on treatment of critical illness, but also on promoting recovery after the ICU stay

(Hopkins & Spuhler, 2009)

Questions?

Questions, comments, concerns

Thank you for allowing me to be apart of the rehab team at Sparrow

References

Anne T. Affleck, Sheri Lieberman, Jan Polon, Kerry Rohrkemper.,Providing occupational therapy in an intensive care unity, AJOT, p323-332.

Bailey P, Thomsen GE, Spuhler VJ, et al (2007). Early activity is feasible and safe in respiratory failure patients. Crit Care Med ;35:139-145.

Beaumont Health System (September, 2013). Early mobility in the ICU- A multidisciplinary approach.

Burtin C, Clerckx B, Robbeets C, et al (2009). Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med.;37:2499-2505.

Dingals, V., Colantuoni, E., Ciesla, N., Mendez-Tellez, P., & Shanholtz, C. (2013, June). Occupational therapy for patients with acute lung injury: Factors associated with time to first intervention in the ICU. American Journal of Occupational Therapy,3(67), 355-362.

Hopkins RO, Spuhler VJ (2009). Strategies for promoting early activity in critically ill mechanically ventilated patients. AACN Adv Crit Care. 20:277-289.

Kleinpell, R. (2011, September 30). How early should we mobilize ICU patients? Medscape. Retrieved from: http://www.medscape.com/viewarticle/7504582

Lipshutz, A., Engel, H., Thomton, K., & Gropper, M. (2012, January). Early mobilization in the intensive care unit. ICU Director, 3(1), 10-16.

Vollman, 2010. Introduction to Progressive Mobility, In Critical Care Nurse (30), 2. S3-S5. Retrieved from: http://ccn.aacnjournals.org/content/30/2/S3

VUMC center for health services research. (2013). Family engagement and empowerment . In ICU delirium and cognitive impairment study group. Retrieved from: http://www.icudelirium.org/family.html