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ICU Liberation: How Physical Therapy Is Part of Reducing the Harms of

Critical Illness

Presented by Heidi Engel, PT, DPTUCSF Department of Rehabilitative Services

University of California San Francisco Medical Centerheidi.engel@ucsf.edu

February 2015

Disclosures

Academic work in the ICU setting for Heidi Engel, PT, DPT is funded by a grant from the Gordon and Betty Moore Foundation

Objectives

• Explain the importance of providing early physical rehabilitation to patients in the ICU

• Reinforce and define the role of Physical Therapists in providing care to critically ill patients as part of an inter-professional collaborative care ICU team

• Define the barriers to ICU early physical rehabilitation and suggest solutions to overcome those barriers

• Cite patient case studies that illustrate Physical Therapy clinical decision making in the ICU setting

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Course Outline

• Complex ICU case presentation emphasizing unique psycho-social aspects of ICU early physical rehabilitation

• Consequential harms to patients as a result of an ICU stay- weakness, immobility, delirium, long term functional and cognitive impairments

• Recommendations from Society of Critical Care Medicine outlined• Example ICU early rehabilitation programs• Assessing how we are doing• Barriers- looking at 3 issues at the bedside keeping patients immobile-

immobility is safety, timing and priorities, staffing and equipment• ICU case presentation illustrating unique role of Physical Therapists

Society of Critical Care Medicine ICU Liberation-Free Your Patients from Potential Harms

ICU Acquired Weakness (ICUAW)

Immobility

Delirium

Long term cognitive impairments

Functional decline

Inability to return to previous employment or activities of daily living

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).

Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM: (2012).

Rectus Femoris protein breakdown begins within 24 hours of ICU admission, cross sectional area declining rapidly during first weekPuthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS et al (2013).

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ICU Acquired Weakness

Change in architecture of muscle fibers within 18 to 69 hours

Loss of bone mineral density, bone adapts to the load placed on it, ALI patients have 19% greater risk of fracturing, 10 day study with average patient age of 55

Frailty: Fried Frailty Index, hallmark is neuromuscular weakness, every 1 pt increase equal to 3X increased risk of 6 month mortality, 82% of older Icu survivors qualify as frail

Kress JP, Hall JB (2014).Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS et al (2013)Baldwin MR, Reid MC, Westlake AA, Rowe JW, Granieri EC, Wunsch H, Dam TT, Rabinowitz D, Goldstein NE, Maurer MS et al: (2014).

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 (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 (2013).

Interpretation of PAD Guidelines

Quality of evidence: statements and recommendations –High (A)

–Moderate (B)

–Low/Very Low (C)

Strength of recommendations: recommendations only–Either strong (1) , weak (2), or none (0)

–Either in favor of an intervention (+) or against an intervention (-)

Society of Critical Care Medicine Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium

(PAD) Guidelines Barr J, et al., Critical Care Medicine 2013

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Outcomes Associated with Delirium

in ICU Patients

i. Delirium is associated with increased mortality in adult ICU patients (A).

ii. Delirium is associated with prolonged ICU and hospital lengths of stay in adult ICU patients (A).

iii.Delirium is associated with the development of post-ICU cognitive impairment in adult ICU patients (B).

Depth of Sedation in ICU Patients

i. Light levels of sedation associated with improved clinical outcomes (e.g., shorter duration of mechanical ventilation and a shorter ICU length of stay) (B).

ii. Light levels increase physiologic stress response, but is not associated with an increased incidence of myocardial ischemia (B).

iii. The association between depth of sedation and psychological stress in these patients remains unclear (C).

Depth of Sedation in ICU Patients (cont.)

iv. Recommend that sedative medications be titrated to maintain a light rather than a deep level of sedation, unless contraindicated (+1B).

v. Recommend routinely using either daily sedation interruption or targeting light level of sedation in MV patients (+1B).

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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, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al (2013)

Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D et al: (2009)

Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E (2010).

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 (2009).

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).

ICU Liberation Project of SCCM

SYMPTOMSPAD GUIDELINES

MONITORINGTOOLS

CAREABCDEF BUNDLE

PAIN BPS

NPS

CPOT

Assess / Treat Pain

Awakening Trials - SATs

Breathing Trials - SBTsCoordination of Care Choice of Sedatives

Delirium Reduction

Diseases, Drug Removal, Environment e.g., sleep, noise, eye glasses, hearing aids

Early mobility and ExerciseFamily - Communication and Involvement

AGITATION RASSSAS

DELIRIUM CAM-ICUICDSC

www.iculiberation.org & www.icudelirium.org

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Neurocognitive and Functional Benefits to ICU Patients

Schweickert WD, Pohlman MC, Pohlman AS, et al. (2009).

RCT- 104 patients on mechanical ventilation intervention group- PT median of 1.5 days intubationcontrol 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

.

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.

UCSF ICU Early Mobilization Started March 1st, 2010 9 ICU

• Physical Therapy coverage 8 hours/day

5 or 6 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

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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).

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 with RASS less than -3 or greater than +2

Patients with unstable spine or extremity fractures

Patients with a grave prognosis- transferring to comfort care

Patients with open abdomen, at risk for dehiscence

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: (2014)

In this 1-day point-prevalence study conducted across Germany

only 24% of all mechanically ventilated patients OOB

only 8% of patients with an endotracheal tube were mobilized out of bed as part of routine care.

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How Are We Doing?Point Prevalence Studies:

Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas PJ, Denehy L (2013).

45% were mechanically ventilated140 patients (28%) completed an in-bed exercise regimen 93 (19%) sat over the side of the bed182 (37%) sat out of bed 124 (25%) stood 89 (18%) walkedPredefined 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

How Are We Doing? ICU Early Mobility Protocols

Critical Care Medicine February 2014

Survey of 69 ICUs across the United States looking at structure, process, and outcomes

97-99% have protocols for ventilator management, infection control, nutrition, and VTEs

36% have an Early Mobility protocol, all requiring a MD Order to initiate (A Process Barrier)

Checkley W, Martin GS, Brown SM, Chang SY, Dabbagh O, Fremont RD, Girard TD, Rice TW, Howell MD, Johnson SB et al :(2014).

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Resulting Harm to Patients

“ Tracheostomy, female gender, higher Charlson Comorbidity Index and lack of early ICU mobility were associated with readmissions or death during the first year.

Although the mechanisms of increased hospital readmission are unclear, these findings may provide further support for early ICU mobility for patients with acute respiratory failure.”

Morris PE, Griffin L, Berry M, Thompson C, Hite RD, Winkelman C, Hopkins RO, Ross A, Dixon L, Leach S et al (2011).

How are we doing in the hospital overall?

32 % of older patients not engaged by an RN in ANY mobility event during an 8-hour period.Mean duration of ambulation was less than 2 minutes.

Mean age 74.6, 55.3% using an assistive device, 95.6% had an MD order for out of bed activity, none met criteria for dependent patient.Average length of stay 6.7 days

Doherty-King B, Yoon JY, Pecanac K, Brown R, Mahoney J (2014)

After Patients Leave the ICU?

Of the 72 patients who participated in the study 65 had either a physical therapy consultation or a request for nursing assistance with ambulation at ward transfer (90%)Activity level decreased in 40 participants (55%) on the first day Of the 61 participants who ambulated 100 ft or more on the last RICU day (85%) 14 did not ambulate, 22 ambulated less than 100 ft (59%)25 ambulated 100 ft or more on the first ward day (41%)

Hopkins RO, Miller RR, 3rd, Rodriguez L, Spuhler V, Thomsen GE: (2012).

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Mobility is Medicine

Health Benefits of Physical Activity

Improves blood sugar homeostasis Enhances cardiovascular function Enhances endothelial function Decreases chronic inflammation Regulates hormone levelsPreserves musculoskeletal and neuromuscular integrityDecreases depression and improves cognition

Warburton DE, Nicol CW, Bredin SS. (2006).

Barriers to Implementation

• Nervous or skeptical clinicians• Minimal resources allocated• Awkward equipment• PT referrals still too late• Unclear protocol• Mobility prior to extubation is difficult concept• Rotating and changing personnel• Variations in sedation practices• New hospital and discharge course predictions required for

ICU and floor personnel

Pawlik AJ, Kress JP. (2012).

3 Common Issues Keeping an ICU Patient Immobile

Are we patient centered or screen centered in our practices?

Immobility is Safety

Timing and Priorities

Staffing and Equipment

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Issue # 1. Immobility is Safety:

The patient is too sick, or too bigTRUE: 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. Awake and Mobile is Safer

Collaborate with RN,RT, MD

Use Clinical judgment

Every diagnosis in context

Delay increases risk later

Essential Information to Share

• Medical History- impact of the chronic, plus current level of acuity

• Physiologic Reserve• Motivation and Goals- what are patient expectations?• Cognition- anxiety, delirium, co-morbidity• Pain• Sedation- why is this patient being sedated?• Extubation- how is the patient tolerating breathing trials?• Procedures- dialysis, IR, CT scan?

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Context

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

Solution # 1. Awake and Mobile is Safer

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

Consider the Patient Physiologic Reserve, their Personal Fitness Account

Did this patient walk into your hospital?

What has the patient done in the past 2days, 2 weeks, 2 months, 2 years?

What are your assumptions?

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Issue # 1. Immobility is Safety

Excuse: The patient is too lethargic, tired?

RASS -2 to -4 Hypoactive delirious

Target RASS vs Actual RASSGoal targeted sedation?

Richmond Agitation Sedation Scale (RASS) icudelirium.org

+4 Combative Overtly combative, violent, immediate danger to staff

+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive

+2 Agitated Frequent non-purposeful movement, fights ventilator

+1 Restless Anxious but movements not aggressive vigorous

0 Alert and calm

-1 Drowsy Not fully alert, but has sustained awakening(eye-opening/eye contact) to voice (>10 seconds)

-2 Light sedation Briefly awakens with eye contact to voice (<10 seconds)

-3 Moderate sedation Movement or eye opening to voice (but no eye contact)

-4 Deep sedation No response to voice, but movement or eye openingto physical stimulation

-5 Unarousable No response to voice or physical stimulation

Solution to when the patient is too lethargic

Collaborate with RN,RT, MD

Use Clinical judgment

Every level of delirium

in context

Consider the environment, disease, medications

Delirium is treated with mobility

• Target RASS Zero

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ICU Sleep Promotion Programs

Consider the Noise level

Lighting

Night time routines

Circadian Rhythms

Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG et al (2013).

Kamdar BB, Needham DM, Collop NA: (2012).

Solution# 2. Mobility will re-orient and decrease lethargy

The patient may respond well to being up and communicating

Include the family in patient care activities

Solution # 3. The patient is too agitated, awake and re-oriented helps

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, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al (2013).

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What About All Those Critical Lines?

Patient lines and drains can be accommodated

Including Femoral Lines

Mechanical ventilation and CVVH linesDamluji, A., et al. (2013).Winkelman, C. (2011).

Issue #2 Timing and Priorities: The patient is leaving

The patient is going for:

A procedure

A CT scan

Transferring to the floor

Will be extubated soon

Solution: Mobility Is High PriorityActivity 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: (2007).

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Issue #2Timing and Priorities: 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 (2012).

Solution for Timing and Priorities: The Patient Needs a Short Rest

Schedule a time

Create a sleep hygiene program in your ICU

Address night staff as well as day

Set circadian rhythms

Issue #3 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

Where are family members?

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Solution for 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

Make a Financial case

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.

Kress JP: Sedation and mobility: changing the paradigm. Crit Care Clin 2013, 29(1):67-75.

Solution: Consider Patients Expectations and Patient Centered Goals

Returning to life as they knew it

Not a new life of disability or perpetual patient

Include Family in patient care activities

Misak C. (2005).

Muller M, Strobl R, Grill E. (20110>

Solution to StaffingEquipment : the PT is not here

• Seeing is believing• Create learning opportunities• Build the case for a full time dedicated ICU

PT• Collect Data!

• Plan ahead and coordinate care• Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB,

Needham DM (2013).

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Sitting on the Edge of the Bed

Trunk control

Vestibular training

Joint compression

Joint/muscle stretching

Lung expansion

Airway clearance

Aerobic exercise? (Yes!)

GI motility

Orientation, mental status

Endurance

Walking in the ICU

Allowing our patients to communicate their needs

Assessing and treating pain first

Preventing PTSD

Journaling the experience

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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 (mostly walking) 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

References• 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.

• 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.

• Kress JP, Hall JB: ICU-acquired weakness and recovery from critical illness. N Engl J Med 2014, 370(17):1626-1635.

• 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.

• Baldwin MR, Reid MC, Westlake AA, Rowe JW, Granieri EC, Wunsch H, Dam TT, Rabinowitz D, Goldstein NE, Maurer MS et al: The feasibility of measuring frailty to predict disability and mortality in older medical intensive care unit survivors. J Crit Care 2014, 29(3):401-408.

References

• 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): 147-157

• 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. CritCare Med 2013.

• 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.

• 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.

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References• Barr J, Fraser GL, Puntillo 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.

• 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): 341-348; discussion 348-349

• Timmers, T. K., M. H. Verhofstad, et al. (2011). "Long-term quality of life after surgical intensive care admission." Arch Surg 146 (4): 412-418

References• Sacanella E, Perez-Castejon JM, Nicolas JM, Masanes F, Navarro M, Castro P, et

al. Functional status and quality of life 12 months after discharge from a medical ICU in healthy elderly patients: a prospective observational study. Crit Care. 2011;15 (2): R105

• 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 13 2009

• 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): 307-313

• 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.

• 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.

References• Checkley W, Martin GS, Brown SM, Chang SY, Dabbagh O, Fremont RD, Girard TD,

Rice TW, Howell MD, Johnson SB et al: Structure, process, and annual ICU mortality across 69 centers: United States critical illness and injury trials group critical illness outcomes study*. Crit Care Med 2014, 42(2):344-356.

• Morris PE, Griffin L, Berry M, Thompson C, Hite RD, Winkelman C, Hopkins RO, Ross A, Dixon L, Leach S et al: Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci 2011, 341(5):373-377.

• Doherty-King B, Yoon JY, Pecanac K, Brown R, Mahoney J: Frequency and duration of nursing care related to older patient mobility. Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing / Sigma Theta Tau 2014, 46(1):20-27.

• Hopkins RO, Miller RR, 3rd, Rodriguez L, Spuhler V, Thomsen GE: Physical therapy on the wards after early physical activity and mobility in the intensive care unit. Physical therapy 2012, 92(12):1518-1523.

• Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. Cmaj. Mar 14 2006;174(6):801-809.

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References• Pawlik AJ, Kress JP. Issues Affecting the Delivery of Physical

Therapy Services for Individuals With Critical Illness. Phys Ther. 2012.

• Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG et al: The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med 2013, 41(3):800-809.

• 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.

• 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.

References• 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.

• 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.

• Kress JP: Sedation and mobility: changing the paradigm. Crit Care Clin 2013, 29(1):67-75.

• 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.

• 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.