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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