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IHI ExpeditionMobility in the Intensive Care Unit

Thursday, January 10, 2013

These presenters have nothing to disclose

Heidi Engel, PT, DPT

Kelly McCutcheon Adams,

LICSW

Expedition Coordinator

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Kayla DeVincentis, CHES, Project Coordinator,

has worked at IHI since 2009, starting as an intern

in the Event Planning department. Since then,

Kayla has contributed to the STAAR Initiative, the

IHI Summer Immersion Program, and the

Expeditions. Kayla obtained her Bachelor’s in

Health Science from Northeastern University and

brings her interest in health education and

wellness to IHI’s Work-Life Wellness Team.

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Expedition Director

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Kelly McCutcheon Adams, LICSW has been a

Director at the Institute for Healthcare Improvement

since 2004. Her primary areas of work with IHI have

been in Critical Care and End of Life Care. She is an

experienced medical social worker with experience in

emergency department, ICU, nursing home, sub-

acute rehabilitation, and hospice settings. Ms.

McCutcheon Adams served on the faculty of the U.S.

Department of Health and Human Services Organ

Donation and Transplantation Collaboratives and

serves on the faculty of the Gift of Life Institute in

Philadelphia. She has a B.A. in Political Science from

Wellesley College and an MSW from Boston College.

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Expedition Faculty

Heidi Engel, PT, DPT, has been a physical therapist for 25 years, working at University of California San Francisco Medical Center for the past 24 years, while also working in private practice and home health settings. She earned her doctorate in Physical Therapy in 2007 from Boston University, with an emphasis in Oncology and Integrative Medicine. Heidi started her focus on patients in the ICU at UCSF in October 2008, with formation of the ICU Early Mobility Multi-disciplinary Group, and initiated full time physical therapy in the Medical Surgical ICU there in March 2010. She received the UCSF Colleague of Nursing Award in 2012. Currently, she works full time in the intensive care units and teaches at the School of Physical Therapy at UCSF.

Today’s Agenda

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Review of homework – Kelly

The Role of Physical Therapy - Heidi

Homework for Next Session –Kelly & Heidi

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Expedition Objectives

At the conclusion of the Expedition, participants will be able to:

Describe the impact of immobility on the long term outcomes of critically ill patients.

Define the elements necessary for the development of a mobility protocol.

Create process measures and outcome measures for a successful early mobility program.

Identify strategies for overcoming cultural barriers to early mobility.

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Schedule of Calls

Session 4: The Role of Physical Therapy

Date: Thursday, Jan 10, 3:00-4:00 PM ET

Session 5: Case Examples of Improved Mobility in the ICU

Date: Thursday, Jan 24, 3:00-4:00 PM ET

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Homework for Today’s Call

Use the Protocol Development Worksheet

Identify how many steps in the protocol development

process you are able to complete before the next call

Review of User Group Responses

How many steps in the in the protocol development process were you able to complete? What did you learn or decide?

Arlene Boudreaux: Our protocol is in draft form, and will be presented to staff for feedback in early January. Once we have their input we hope to start rapid cycle testing by the end of the month.

Melody Campbell: Our protocol is completed. We are going to do our first small test of change using the Sim-Man lab so that our group can work through the protocol and adapt to changing patient conditions. We wrote three scenarios that involve assessing the patient to see if the patient meets criteria for early mobility, initiation of early mobility with deterioration during activity, and lastly inadvertent extubation during ambulation. Our Sim-Man Lab STOC will take place the last week of January.

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ICU EARLY MOBILIZATION

AT UCSF AND THE ROLE

OF PHYSICAL THERAPY

Presented by Heidi Engel, PT, DPT

Heidi.Engel@ucsfmedctr.org

Early Physical and Occupational Therapy

Randomized Control Trial: 104 patients on mechanical ventilation

• Intervention Group: PT median of 1.5 days intubation

• Control Group: PT median of 7.4 days

• Results• Intervention Group: less days of delirium and MV and 59% return to

independent function at hospital discharge versus 35% in control group

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

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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 levels• Preserves musculoskeletal

and neuromuscular integrity• Decreases depression and

improves cognition

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

Definition of Early ICU Mobilization

“Early” defined as initial physiologic stabilization, continuing through out ICU stay

Initiating patient mobilization within 48 hours of patient admission to the ICU through:

• ICU cultural shift, mobility as necessity• Practice patterns of ICU personnel across disciplines• Optimizing the ICU environment

• Equipment

• Sleep

• Sedation

Bailey PPR, ACNP; Miller, Russell R. MD, MPH; Clemmer, Terry P. Culture of Early mobility in mechanically ventilated patients. Critical Care Medicine. 2009; 37 (10): S429-S435

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ICU Early Mobilization Requires

• Admit to ICU with activity as tolerated orders

• Physical Therapy referrals are included in MD orders

• 60-80% of ICU patients receive consistent Physical Therapy daily

• Patients are awake and as mobile as possible

• Delirium minimized- sleep facilitated, sedatives targeted

• Work of breathing is minimized during activity

Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the 'ABCDE' approach. Curr Opin Crit Care. 2011; 17(1): 43-9

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). "Early Mobilization in Critically Ill Patients: Patients' Mobilization Level Depends on Health Care Provider's Profession." PM R 3 (4): 307-313

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Barriers to ICU Early Mobilization

Provider Barriers

• Knowledge

• Fearful attitude

• Patient Sedation

• Culture of immobility

• Unfamiliar professions

Solutions

• Education, promotion

• Start small, evolution

• Treat pain, target sedation

• Find your champions

• Learn to speak their

language

Needham, D. M. and R. Korupolu (2010). "Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model." Top Stroke Rehabil 17(4): 271-281

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 unresponsive to verbal stimuli

• Patients with unstable spine or extremity fractures

• Patients with a grave prognosis- transferring to comfort care

• Patients with a femoral dialysis catheter

• Patients with open abdomen, at risk for dehiscence

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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

UCSF ICU: Step 1-Untangling

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UCSF ICU: Step 2-Bed Exercise

UCSF ICU: Step 3-Sitting on EOB

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UCSF ICU: Step 4-Assisted Sit to Stand

UCSF ICU: Step 5-Walking

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UCSF ICU: Step 6-Sit and Rest as Needed

What About All Those Critical Lines?

• Lines, catheters and drains

can be accommodated,

secured

• EVD line stationary bike

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What About All Those Critical Lines?

• Patient lines and drains can

be accommodated

• Mechanical ventilation and

CVVH lines

What About All Those Critical Lines?

Adult Extra Corporeal Life Support (ECLS)

VV Cannulation via the Double Lumen Cannula

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Family Participation in Early Mobility

Family Participation in Early Mobility

• Positive feedback from family

members

• Less stress to family members

• Less patient delirium

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UCSF ICU Early Mobilization

Improvements in discharge outcome correlate to:

• Earlier mobility

• More intense intervention

• Greater distance walked

UCSF ICU Early Mobilization

• Improves patient satisfaction and

outcomes

• Higher percentage discharge to

home: 55% of ICU PT patients

versus 71%

• Decreased length of stay: 2 ICU

days and 5 hospital days

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The Ounce of Prevention Reward

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

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Thank You

• UCSF Critical Care- Michael Gropper, MD, Michael Matthay, MD, Kevin Thornton, MD

• UCSF Executive Director for Service Lines- Karen Rago, RN, MPA, FAAMA, FACCA

• UCSF Nursing- Steve Koster, RN, Charlotte Garwood, RN, Sarah Irvine, RN, Hildy Schell-Chaple, CNS, Cathy Schuster, RN

• UCSF Critical Care Nurse Practitioners- Geoffrey Latham, NP, Maureen Mary Arriola, NP, Tom Farley, NP

• UCSF Respiratory Therapy- Brian Daniel, RT

• UCSF Rehabilitative Services- Joy Devins, PT, Rebecca Mustille, PT, Shin Tatebe, PT, Sherri Heft, PT, Phil Alonzo,

• Johns Hopkins Hospital ICU PM&R- Dale Needham, MD, Eddy Fan, MD

• LDS Medical Center- Polly Bailey, NP, Louise Bezdjian, NP

• Photo Credits- Jim Jocoy, PTA

Questions?

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Raise your hand

Use the Chat

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Homework for Next Call

Repeat audit exercise from first session:

Respond to the discussion question on the user group

Expedition Communications

Listserv for session communications:

MobilityExpedition@ls.ihi.org

To add colleagues, email us at info@ihi.org

Pose questions, share resources, discuss barriers or

successes

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Next Session

Thursday, January 24, 3:00-4:00 PM ET

Session 5 – Case Examples of Improved Mobility in the ICU

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