Download Goals of Care: A Multi-Disciplinary Approach — Progressive Mobility

Goals of Care:
A Multi-Disciplinary Approach
— Progressive Mobility
Kathryn Booth, R.N.
Sarah Cuthbertson, P.T.
Mahtab Foroozesh, M.D.
Kellen Smith, P.T.
Shannon Radmacher, O.T.
9/3/15
Objectives
• To discuss the need for and review the latest
guidelines for decreasing sedation and
progressive mobility in the ICU
• To identify some of the barriers to progressive
mobility in ICU
• To discuss the best approach to progressive
mobility in the ICU
We Have No Disclosures
Like Fashion
Medicine comes full cycle
What was OLD
is NEW again.
Oversedation and Immobility in ICU:
• Origin:
• To promote patient comfort, safety, and
respiratory synchrony
• Problem:
• Widespread use for all patients in ICU
• Emerging evidence:
• Significant potential for harm
• Some not remediable over time
PICS
• Health problems that remain after critical illness:
• ICU-acquired weakness
•
•
•
•
•
33% of all patients on ventilators
50% of all patients admitted with sepsis
Up to 50% of patients who stay in the ICU for at least one week
> 1 year to recover fully
Makes the activities of daily living difficult
• Cognitive or brain dysfunction
• Problems with memory, attention, problem solving, organization and
working on complex tasks
• 30% to 80% of patients
• Other mental health problems
• Problems with SLEEP, nightmares, unwanted memories and flash
backs.
• Depression and anxiety,
• posttraumatic stress disorder (PTSD).
PTSD
• Posttraumatic stress disorder in critical
illness survivors: a metaanalysis
• Crit Care Med 2015 May;43(5):1121-9.
• Included (40 articles):
•
•
•
1) adult general/nonspecialty ICU,
2) validated PTSD assessment instrument >1 month post-ICU,
3) sample size >10 patients.
Clinically important posttraumatic stress disorder symptoms
occurred in one fifth of critical illness survivors at 1-year follow-up,
with higher prevalence in those who had comorbid
psychopathology, received benzodiazepines, and had early
memories of frightening ICU experiences.
Clinical Practice Guidelines for
the Management of Pain,
Agitation, and Delirium in Adult
Patients in the Intensive Care
Unit (SCCM)
• Critical Care Medicine, January 2013; 41(1):
263-306
“Distress” in ICU
•
•
•
•
PAIN
AGITATION
DELIRIUM
DYSPNEA
Identify and Treat the Cause
Monitoring Pain in ICU
Monitoring Pain in ICU: CPOT
RASS:
Richmond agitation-sedation scale
Score
Term
Description
+4
Combative
Overtly combative or violent, immediate danger to staff
+3
Very agitated
Pulls on or removes tubes or catheters, aggressive behavior toward staff
+2
Agitated
Frequent non-purposeful movement or patient-ventilator dysynchrony
+1
Restless
Anxious or apprehensive but movements not aggressive or vigorous
0
Alert and calm
-1
Drowsy
Not fully alert, sustained (>10 seconds) awakening, eye contact to voice
-2
Light sedation
Briefly (<10 seconds) awakens with eye contact to voice
-3
Moderate sedation
Any movement (but no eye contact) to voice
-4
Deep sedation
No response to voice, any movement to physical stimulation
-5
Unarousable
No response to voice or physical stimulation
Am J Respir Crit Care Med 2002; 166:1338.
Delirium
• Outcome of delirium in critically ill patients:
systematic review and meta-analysis
• BMJ 2015 Jun 3;350:h2538
• Included:
• Validated delirium assessment tool
• No underlying neurologic issues, Not post surgical or Neuro-ICU
Nearly a third of patients admitted to an intensive care
unit develop delirium, and these patients are at
increased risk of dying during admission, longer stays in
hospital, and cognitive impairment after discharge.
CAM-ICU
Feature 1: Acute Onset or Fluctuating Course
Score
Is the pt different than his/her baseline mental status?
OR
Has the patient had any fluctuation in mental status in the past 24 hours as evidenced
by fluctuation on a sedation scale (i.e., RASS), GCS, or previous delirium assessment?
Either ? Yes

Check if +
Feature 2: Inattention
Letters Attention Test
Directions: Say to the patient, “I am going to read you a series of 10 letters. Whenever
you hear the letter „A,‟ indicate by squeezing my hand.” Read letters from the following
letter list in a normal tone 3 seconds apart. S A V E A H A A R T
Errors: fails to squeeze on the letter “A” or squeezes on any letter other than “A.”
Number of Errors >2

Feature 3: Altered Level of Consciousness
Present if the Actual RASS score is anything other than alert and calm (zero)
RASS not 0
Feature 4:Disorganized Thinking
Yes/No Questions
1. Will a stone float on water?
2. Are there fish in the sea?
3. Does one pound weigh more than two pounds?
4. Can you use a hammer to pound a nail?
Errors: Incorrectly answers a question.
Command
Say to patient: “Hold up this many fingers” (Hold 2 fingers in front of patient) “Now do
the same thing with the other hand” (Do not repeat number of fingers) OR “Add one
more finger”
Error: Unable to complete the entire command.
Overall CAM-ICU
Feature 1 plus 2 and either 3 or 4 present = CAM-ICU positive
Criteria Met 
Criteria not Met 
+ Delirium
- Delirium
Delirium: Management
• Identify and Modify Risk Factors
• Multi-faceted delirium protocol: Preventive strategies
• Early mobilization of patients
• Sedation
• Minimize excess benzodiazepines & narcotics
• GABA-sparing agents ( alpha 2 agonist: dexmedetomidine)
• Improve sleep
• Non-pharmacologic Management:
•
•
•
•
•
Reorientation
Communication,
Family
Music Tx
CBT
Soon To Come to ICUs Near You
Mobility in ICU
• Current? belief:
• Critically ill patients not considered appropriate for
early physical activity
• Too medically unstable
• Unsafe to move with life sustaining equipment
• Recent? evidence
• Early mobility of ICU patients is both safe and feasible
• Preventing long-term neurocognitive and physical disability
Struggle to create the culture change and protocols
Johns Hopkins Study (2007)
• 30 intubated patients >4 days on MV
• c/w 27 similar patients the prior year
• Changes:
•
•
•
•
MICU admit orders : "bed rest" "as tolerated."
PRN Sedation Protocol
Guidelines for PT & OT consults
Full-time PT/OT in ICU
Johns Hopkins: Results
•
•
•
•
•
•
Decreased Benzodiazepines use
Decreased Opiates
Decreased delirium: 21% vs. 53%
Functional mobility at D/C: 78% vs. 56%
Reduce ICU LOS by 2.1 days
Reduce hospital LOS by 3.1 days
Quality Improvement for Early
Mobility
Objective
Wake Forest
Johns Hopkins
University of California
San Francisco
Reduce immobility and weakness with
early PT for MICU patients
Optimize patient sedation
Provide early PM&R in the ICU for MICU
patients
Provide earlier and more frequent PT
in the ICU for MICU and SICU patients
1 year
1.5 years
n=27 retrospective comparison
n=179 retrospective comparison
Planning time frame
Comparison group
n=165
Control group
Intervention group and time
frame
n=165 patients on MV
2004 - 2006 7days/week mobility
n=30 on MV
2007 6 days/week mobility
n= 294 all ICU patients
2010 5 days/week mobility
Number of added personnel and
titles
1 registered nurse, 1 certified nursing
assistant, 1 physical therapist, 1 project
manager
1 physical therapist, 1 occupational
therapist, 1 technician, 1 coordinator,
1 part-time assistant coordinator
1 physical therapist, 1 part-time aide
Equipment added
none
2 wheelchairs
ICU platform walker
Outcome measures
Days to out of bed Frequency of therapy
ICU/hospital LOS
Adverse events
Percentage of ICU patients receiving PT
ICU/hospital LOS
Pain/delirium scores
Adverse events
Number of days to initiating PT
ICU/hospital LOS
Distance walked in ICU
Discharge disposition
Incident reports
Results
Safe and feasible earlier mobility
Increased number of patients receive ICU
PM&R
Patients receive increased number
treatments
Decreased ICU and hospital LOS
Net cost savings
Same Results as shown in Wake
Forest plus:
Decreased dosages of sedating
medications
Decreased patient delirium rates
No change in patient reported pain
scores
Same Results as shown in Wake
Forest plus:
Applied to medical and surgical all ICU
patients
Increased distance patients walked in
ICU
Increased percentage of patients able
to discharge to home rather than
rehabilitation facility
Crit Care Med. 2013;41(9);S69-S80.
Early Mobilization in the Intensive Care Unit:
A Systematic Review
Joseph Adler, PT, DPT, CCS1
Daniel Malone, PhD, MPT, CCS2
Cardiopulm Phys Ther J. Mar 2012; 23(1): 5–13.
Results
• Decreased time to mobility milestones
• Increase patient participation in advanced
mobility activities
• Improved Functional Mobility scores
• 59% vs. 35% functional independence at D/C
How Are We Doing?
ABCDE, but in That Order? A CrossSectional Survey of Michigan Intensive
Care Unit Sedation, Delirium, and Early
Mobility Practices
Ann Am Thorac Soc 2015 Jul;12(7):1066-71
Study Design / Results
• Written survey
• 2012 annual meeting of the Michigan Health and Hospital
Association's Keystone ICU collaborative
• 212 respondents: 76% response rate
• Only 12% with routine spontaneous awakening trials and
delirium assessments as well as early mobility
• 36% reported not having early mobility as an active goal in their
units (nonmovers)
• 52% reported attempts at early mobility without both routine
sedation interruption and delirium screening implementation.
Results
• Exercise + sedation interruption +delirium screening  3.5 times
more likely to achieve higher levels of exercise than exercise without
both sedation interruption &delirium screening.
• CONCLUSIONS:
• Incomplete penetrance of aspects of ABCDE across ICUs in this
highly motivated statewide quality improvement collaborative.
• Implementation of exercise in the context of both sedation
interruption and delirium screening was associated with
improved self-reported mobility outcomes
• Effective knowledge translation and implementation strategies
may offer substantial benefits to ICU patients
Progressive Mobility
DANGLE BID
WHAT?
DANGLE BID
•Trunk control
•Vestibular training
•Joint compression
•Joint/muscle stretching
•Lung expansion
•Airway clearance
•Aerobic exercise? (Yes!)
•GI motility
•Orientation, mental status
•Endurance
Barriers to Early Mobility
Major Institutional Barriers
Lack of protocols and guidelines
Insufficient Equipment
Insufficient Staffing
No physician requests for PT consults
Major Health Care Provider Barriers
Knowledge
Skills set
Safety concerns
Delays in recognition of suitable patients
Patient Barriers
Koo et al. Am J Respir Crit Care Med 2011; 183
Safety Concerns
• Multiple studies show early mobility of ICU
patients, including ambulation, to be safe
•
Stiller K: The safety of mobilization and its effect on haemodynamic and
respiratory status of intensive care patients.
•
•
•
Physiother Theory Pract 2004, 20:175-185.
31 patients, 61 interventions. 3 episodes of transient hypoxemia reported.
Bailey P: Early activity is feasible and safe in respiratory failure patients.
•
•
Crit Care Med 2007, 35: 139-145.
103 pts, 1449 interventions. 14 adverse events including transient reductions in blood
pressure and oxygenation, 1 feeding tube removal, 5 falls to the knees without injury
(ambulating patients)
Safety of Physical therapy in
Critically ill Patients
• Single center prospective evaluation from July 2009
through Dec 2011 in Johns Hopkins MICU
• Evaluated potential safety events associated with
physical therapy
• 62% ( of 1787 admissions) participated in PT ( 5267 PT
sessions) with 4580 patient days
• 0.6% ( 34) sessions had a physiologic abnormality or
potential safety event
• Only 4 occurrences ( 0.1%) required minimal additional
treatment or cost, without additional length of stay
• Evaluated consecutive Medical ICU
patients who received PT with femoral
lines
• 22% had femoral lines, of those 42% had
PT with 253 PT sessions
• There was no catheter related adverse
events
Cost
• Morris PE: Early intensive care unit mobility therapy in
the treatment of acute respiratory failure. Crit Care Med
2008, 36:2238-2243.
• No difference in overall hospital costs compared to control
patients. This was even with additional dedicated mobility staff
to perform these interventions
• Experienced centers with early mobility (Johns Hopkins,
UCSF) are reporting reductions in hospital costs. Mainly
related to reductions in hospital LOS.
ICU Early Physical
Rehabilitation
Programs: Financial
Modeling of Cost
Savings*.
Needham et. Al.
Critical Care
Medicine. 41(3):717724, March 2013.
© 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams
& Wilkins, Inc.
Multidisciplinary Approach to
Patient Mobilization in the ICU
Early Mobility:
Therapy and nursing
Perspectives & Barriers
It is bed rest, not early mobilization, that
appears to be unsafe to patients‟ health
and outcomes. (Needham)
Mobilization
(17,26,45,46,56,57)
• Umbrella term for functional movement
defined by a hierarchy of low level tasks to
upper level tasks
• Whole body rehab in chronic vent patientsincreased strength & independence
• Clinical decision making from therapist
perspective: “MOVE” criteria
Mobilization
(cont.)
• Early physical therapy has been shown to
reduce LOS by 3 days and incidence of delirium
• PT’s have been found to mobilize patients to a
higher functional level while in the ICU as
compared to RN’s
• Fewer days in bed=fewer days in hospital
• PT did not increase costs but did decrease LOS with
ARDS
• Upright position:
• Increase lung volume/gas exchange
• recruitment of alveoli, secretion clearance and gas
exchange
• Current research is moving towards mobility
teams/champions
Planning process
•
•
•
•
Engage key stakeholders
Review current literature
Identify barriers
Change processes to meet projected
goals
• Commit to the process
???????
“MOVE”
Inclusion Criteria
(25,34,46,53,66)
• Myocardial Stability
– No evidence of active myocardial ischemia
x 24 hours
– No symptomatic dysrhythmia
– HR >40 <130 at rest
• Oxygenation adequate
–
–
–
–
FiO2 ≤ 0.6*
PEEP ≤10 cm H20*
O2 Sat >88%*
RR >5 <40
“MOVE”
Inclusion Criteria
(25,34,46,53,66)
• Vasopressor(s) minimal
– No increase in any vasopressor x2 hours
• Elevated ICP
– ICP sustained < 20 mmHg without patient
stimulation and NOT actively treating
We like to move it, move it
LEVEL II
LEVEL III
LEVEL IV
LEVEL V
LEVEL VI
Unstable
Stable
Stable
Stable
Stable
Stable
*Passive
ROM 3x/d
*Passive ROM
3x/d
*Passive/Active
ROM 3x/d
*Active ROM 3x/d
q2Hr turning
q2Hr turning
W/ full assist
q2Hr turning
w/ mod. assist
q2Hr turning
w/ min. assist
Micro shifting
qHr
Consider
PT/OT consult
Obtain MD
order if no
order present
Consider
PT/OT consult
Obtain MD
order if no
order present
Consider
PT/OT consult
Obtain MD
order if no
order present
Active Transfer
to Chair
Min. 1 hr 3x/day
Sitting Position
Min.20 min. 3x/d
Sitting Position
Min.20 min. 3x/d
Ambulate 50 ft
3X/day
Trial Dangle:
Ensure Adequate
Support
Start Activity:
Supervised Sitting
on edge of bed
Active Transfer to
Chair
Min. 1 hr 3x/day
Progress to level
III if pt.
successfully
completes above
activities and
moves arm against
gravity
Progress to
level IV if pt.
successfully
completes above
activities and
moves leg
against gravity
Assess for
CLRT if
p/F ratio <
300;
pulmonary
status
worsening
with 
PEEP
Progress to level
V if pt. successfully
completes above
activities and can
stand with min. to
mod. assist
Perform Egress
Test
Up in chair
3X/day
Ambulates 100 ft
3X/day
Progress to level
VI if pt.
successfully
completes above
activities and can
move to chair and
ambulates with
min. assist.
•Communicate Mobility Level and weight-bearing restrictions and bracing requirements on Communication Board.
•Mobility is the responsibility of the RN, with assistance from the CAs, PT, and OT
•Passive ROM can be performed by an RN, CA, or a Family Member
•PT and OT will guide and direct the team on appropriate advancement to the higher levels. PT will document Level in note.
•Use Assist Devices if and when necessary for patient mobility
•Monitor for patient response: increased pain, dizzy, nausea, chest pain, short of breath, tachypnea, ST segment changes
•Immobile patients, such as brain injury, spinal cord injury or other paralysis should be in the chair for < 2 hours at a time & micro shifted every 30 minutes.
Discharge/Transfer
LEVEL I
“Hesitation on the part of the
intensive care unit physiotherapist
is unfortunate because these
patients experience greater loss of
function than any other patient in
any other level of care.”
Immobility
complications
• Respiratory: Decreased lung volume,
atelectasis, VAP and PE
• Cardiac: Decreased SV, muscle atrophy as
well as orthostatic intolerance
• Metabolic: Glucose intolerance and
inflammatory cytokines
• Neurological: Critical illness poly and delirium
• Musculoskeletal: Atrophy and contractures
• Psycho-emotional ramifications of critical
illness
Cardiovascular
• Lying down shifts approximately 11% of total
blood volume towards the chest
• Decreased stroke volume=decreased Q
• Baroreceptors decrease in sensitivity
resulting in orthostasis
• Changes in autonomic tone and
microvascular dysfunction have been seen
with prolonged bed rest
• Increased peripheral vascular resistance
Neuromuscular
• 1st week of bed rest=10% loss of postural
strength
• Muscle mass decreases by 5% per week
• Skeletal muscle strength declines 1-1.5%
daily
• Diaphragm begins thinning in the first 48hrs
of MV
• VIDD or VDI
• ICU-acquired weakness (ICU-AW)
ICU-AW
• ICU-acquired weakness: syndrome of
profound neuromuscular weakness
• Possible link to systemic inflammation and
prolonged immobility
• Can be described as neuropathy and
myopathy
• CIM-muscle may develop a “functional
denervation” correlated to decreased
frequency and intensity of nerve impulses
• CIP-linked to disruption of microcirculation
The walking ventilated
• Very limited patient population-tend
to be fully independent prior to
hospitalization
• Highly motivated
• Supportive family/friends
• Requires timing with procedures,
road trips, RT availability and
appropriate equipment
• RICU protocol established that
distance walked influenced
placement at discharge
• 337’, 293’, 138’
Barriers
to Mobility
• Physician Orders:
• Bedrest
• Nursing: comfort with early mobility
• Lack of understanding of what PT and OT can
and cannot do with ICU patients
• Therapist (RT, PT & OT): time constraints
• Hemodynamic Instability:
• Hypo/hypertension, vasopressors, new
arrhythmias
• Troponin levels:
Barriers
to Mobility
(cont.)
• RASS Level: Sedation/pain relief reducing
participation or agitated
• RASS <-1 or >1 can be difficult to safely move if
not impossible
• CRRT-hemodynamically stable for mobility?
• Research supports but can be a limiting factor
• Femoral lines: arterial or dialysis catheters
• Research does support this activity
• Swan-Ganz: can be mobilized safely with therapist
“…activity require(s) the
development of a coordinated
multidisciplinary team, whose
members share a cultural
expectation of early activity for all
patients.” (Hopkins 2007)
Occupational Therapy:
isn’t that just
PT for the arms?
• Overall focus of OT:
• What? Facilitate engagement in everyday
life activities (occupations)
• How? Address the physical, cognitive,
psychosocial, sensory-perceptual, and
contextual aspects of activity performance
• Why? Support participation in life roles for
optimal physical and mental health, wellbeing, and quality of life
OT Interventions
in the ICU
• Physical:
• UE ROM/strengthening if not stable for
mobilization of LEs
• Bed level mobility before ready for
EOB/OOB with PT (e.g. chair position
activities)
• Cognitive: following commands,
sequencing, motor planning, alertness for
activity
OT Interventions
in the ICU
• Sensory: visual tracking, sustained focus,
shifting of gaze; sensory stim
• Emotional/psychological: participation in
familiar or habitual tasks/routines,
accessing environment via call system,
methods for communicating wants/needs
Postintensive Care
Syndrome (PICS)
• Impairments experienced by former ICU
patients over the long term
• Physical (pulmonary, neuromuscular)
• Cognitive (executive function, memory, attention,
processing, visuospatial)
• Up to 50% of ICU survivors have cognitive deficits even
6 years post-discharge (Needham)
• Mental Health (PTSD, depression, anxiety)
• Can have significant impact on occupational
performance and return to life roles following
hospital discharge
Postintensive Care
Syndrome (PICS)
• Patients who participate in basic self-care activities
without assistance, or who are able to make choices
related to their daily routine in the hospital, report
less anxiety and depression than those who are fully
dependent on hospital staff (Howell).
• Clients who receive early PT and OT in the ICU are
more likely to be discharged to home, have less
incidence of delirium, and demonstrate improved
functional independence (Rochester; Schweickert et
al.).
OT/PT Teamwork
for Early Mobility
• Most ICU patients require 2-person assist
for initial EOB/OOB activity
• Can focus on multiple therapeutic areas at
once with two skilled therapists vs. PT and
rehab aide
• Example: PT focuses on trunk control for
dynamic balance at EOB while OT focuses on
visual tracking and motor planning to reach
for objects
• Time-efficient approach when assist from
nursing and/or respiratory staff are
required at time of therapy intervention
Coordination and collaboration between
all members of the medical team to pair
daily interruption of sedation with
therapy interventions has been shown to
positively impact the incidence of
delirium and allow patients to engage in
retraining related to cognition, ROM,
mobility, and functional tasks, resulting
in shorter ICU and hospital stays and
improved functional abilities. (Robinson)
References
available upon
request
*********************
THANK YOU FOR
YOUR TIME