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Improving Outcome with Early Mobilization

February 5th, 2019




Your presenter today:

Carl Hinkson, MS, RRT-ACCS, NPS, FAARC

- Respiratory therapist with over 20 years of critical care experience.

- Director of the Pulmonary Service Line at Providence Regional medical Center in Everett, Washington.

- Involved in implementing programs including early mobility, patient driven protocols, and advanced mechanical ventilation.

Compassion | Dignity | Justice | Excellence | Integrity

Carl Hinkson, MSc, RRT, RRT-ACCS, RRT-NPS, FAARC

Director, Pulmonary Service Line

Providence Regional Medical Center Everett

Early ICU Mobility


Objectives

List the challenges for patients presented by Post Intensive Care Syndrome

Discuss potential problems with immobility in the ICU & describe diagnostic approach to ICU-acquired weakness

Review safety data for Early mobility program

Review outcomes based research for Early Mobility

Describe implementing a early mobility program


Post Intensive Care Syndrome

Post Intensive Care Syndrome• Constellation of worsening impairments from

having survived a critical illness treated in an ICU environmentoPhysical

oMental

oCognitive abilities

• Many of these impairments can persist for years beyond hospitalization

Source: Ohtake P et al. Physical therapy 2018


Impairments Following Critical Illness

PFT values reduced by 65-88% of predictive values• Majority consistent with restrictive patterns

Reduction in inspiratory muscle strength

Reduction in handgrip strength

Reduction in 6 minute walk test

Limitations to returning to previous activities• Driving & working

Source: Ohtake P et al. Physical therapy 2018


• Cognitive impairment is common• 100% of ALI survivors impaired at d/c

• ~ 50% with persisting impairment at 1 year

• Anxiety, depression and post-traumatic stressseen in many survivors• 25-50% of survivors may be affected

Long-term outcomes after critical illness

7

Hopkins RO. AJRCCM 1999Herridge MS. NEJM 2003


Weaker patients have poorer outcomes

Increased duration of mechanical ventilation

o Time of ventilation increases by 1-3 weeks

Most significant predictor of prolonged MV

Longer ICU and hospital stay

More likely to need re-intubation

Less likely to go home at hospital discharge

More likely to die in the hospital

Experience delays in rehabilitation

• Take longer to regain strength, walk, work

Leijten JAMA 1995 ;De Jonghe JAMA 2002; Hough ICM 2009; Ali AJRCCM 2008


Objectives







• De-conditioning causes changes in organ system physiology brought on by inactivity & is reversed by activity

• Acute de-conditioning• Changes seen days to weeks

• Chronic de-conditioning• Changes seen weeks to years

• De-conditioning creates changes in:• Mood• Coordination• Muscle Strength• Balance Work Tolerance

Perils of immobility

10


Perils of Immobility

Muscle atrophy• Inactivity may cause skeletal muscle strength

to decline by 1-1.5% per day with strict bed rest

• Casting a limb can cause skeletal muscle strength to decline 5-6% per dayoProminent in muscles used to oppose gravity

Morris, PE Crit Care Clin, 2007


Critical Illness Polyneuropathy & Myopathy

Critical illness polyneuropathy (CIP)• Impaired oxygen & nutrient delivery to nerves• Sepsis / hyperglycemia• Direct / indirect nerve damage by cytokines

Critical illness myopathy (CIM)• Increase upregulation of protein catabolism by

pro-inflammatory cytokines

CIM & CIP collectively together are called: Critical Illness Neuromyopathy or ICU Acquired Weakness

Fan E, Resp Care 2012


ICU Acquired Weakness Risk Factors

SIRS/ Sepsis Multi-organ failure Hyperglycemia Renal replacement therapy Catecholamine administration Female sex Duration of mechanical ventilation Corticosteriods Neuromuscular blocking agents

Lipshutz Anesthesiology, 2012


Diagnosing ICU Acquired Weakness

Physical exam• Requires awake and cooperative patient

Electrophysiological testing• Can detect changes 24-48 hours after onset

of critical illness

• Test quality impacted by several factors including limb edema and local temperature

Muscle biposy• Definitive diagnosis for myopathies

Fan E, Resp Care 2012

Source:

LipshutzAnesthesiology, 2012


Practical Approach to Diagnosis for ICU-AW

Source: Jolley SE et al. Chest 2016


Objectives







Observational Study: Mobilizing RICU patients

Prospective cohort study• 8 bed RICU• Included all patients with > 4 days MV• 3 criteria to begin activity (guidelines)

o Neurologic (response to verbal stimulus)o Respiratory (FIO2< 0.6 and PEEP < 10)o Circulatory (no orthostasis or vasopressors)

Intervention: progressive increase in activity• Sit on bed, sit in chair, ambulate (twice daily)

Team: PT, RT, RN and critical care technician Outcome: Ambulation > 100 ft at ICU d/c

Source; Bailey P. CCM 2007


Early ICU Mobility Safety

14 adverse events out of 1449 activity events

• Fall to knees (5)

• SBP < 90 (4– all orthostatic)

• SBP > 200 (1)

• O2 desaturation to <80% (3– all rapidly resolved)

• Removal of nasal feeding tube (1)

Source; Bailey P. CCM 2007


QI Study of Early Mobilization of MICU Patients

Prospective cohort study• Block allocation design

Study question: • Does a mobility protocol and team increase the proportion

of ICU patients receiving PT?

Population: MICU patients requiring MV on admission

Intervention: Mobility Team (RN, PT, NA) initiating progressive protocol within 48 hours of MV• Control: RN-PROM, positioning

Outcome: proportion of hospital survivors receiving PT

Source: Morris PE. CCM 2008

Protocol


Safety criteria*

•Hypoxia: desats < 88%•Hypotension: MAP <65 mmHg•New vasopressor•New myocardial infarction•Dysrhythmia requiring new agent•Increase in PEEP•Return to AC when in weaning mode

*Mobility withheld for 1 day, then reassessed


More Physical Therapy and Early Outcomes

Mobility protocol increased PT• More patients seen in hospital (80% vs. 47%)

• More sessions (5.5 vs. 4.1 sessions)

• Patients out of bed sooner (day 8.5 vs. 13.7)

Mobility protocol improved outcomes• Shortened ICU and hospital LOS (1.5, 3.3 days less)

• Duration of MV not significantly different

No increase in costs

No adverse events



Reporting on Adverse Events & Early Mobility

Source: Nydahl et al. AnnalsATS 2017


Objectives







Physiotherapy Following Cardiac Surgery

Patman et al:

Goal to start physiotherapy while intubated following surgery• Total n = 236, 108 / 109 in treatment, control

respectively. 26 withdrew

Source: Patman S et al. Australian Journal of Physiotherapy 2001

• Randomized controlled study

• Population:

– Previously independent MICU patients requiring < 72 hours mechanical ventilation

• Intervention: Early exercise and mobilization

– Control: Daily interruption of sedation with “usual PT/OT”

• Primary outcome: Independent functional status at hospital discharge

– Independent performance of 6 ADLs and ambulation

• Additional outcomes: delirium, duration of MVSchweickert WD. Lancet 2009


Schweickert outcomes

Source: Schweickert et al. Lancet 2009


Schweickert et al Outcomes

Source: Schweickert et al. Lancet 2009


Early Physical Therapy in ICU with Sepsis

Randomized controlled trial• N = 50, 26 / 24 intervention / control

respectively

• Primary outcome was physical function using SF-36 telephone 6 month post discharge

• Secondary outcomes included MRC score and measured cytokines

Source: Kayambu et al. Intensive Care Med. 2015


Source: Kayambuet al. Intensive Care Med. 2015


Standard Rehab Therapy vs Usual Care

Randomized Controlled Trial• Large: n = 300; 150 control & intervention

• Standard Rehab Therapy was progressive physical therapy with increasing intensity

• Primary Outcome was Hospital Length of Stay (HLOS)

• Secondary Outcomes included ventilator length of stay, SF-36, Mini-Mental State Examiniation

Source: Morris PE, JAMA 2016


Source: Morris PE, JAMA 2016


Meta-Analysis

Included Six (6) RCTs

Physical therapy vs. usual care


Source: Fuke et al. BMJ 2018

Costs of Early Mobility

• Morris et al– $41,142 early mobility vs

$44,302 usual care

• Ronnenbaum et al– $22,000 per patient

Source: Hunter, A., Johnson, L., & Coustasse, A. (2014). Reduction of intensive care unit length of stay: The case of early mobilization. The Health Care Manager, 33(2), 128-135.


Objectives







How To Implement a Early Mobility Program

Administrative buy-in

Physician champion

Multi-disciplinary approach

Re-educate to overcome misconceptions about mobility


Overcoming Barriers to Implementation

Safety Concerns• Accidental dislodgement of medical devices:

oEndotracheal tubes

ovascular devices

• Potential complications of increased activityoHypoxemia

oHemodynamic

• Patient discomfort

Morris, PE Crit Care Clin, 2007


Overcoming Barriers to Implementation

Sedation / Delirium• Over-sedated patients cannot participate in an active

mobility program

• Use CAM tool to assess for delirium

• Minimize benzodiapines

Cost• Need to increase staffing w/ appropriate personnel

• Early ICU mobility current not considered “skilled therapy” for PT


Progression

Step 1: Sit up

Step 2: Dangle patient on edge of bed

Step 3: Stand up & bear weight. If unable to bear weight move patient to cardiac chair and assess for reasons unable to bear weight

Step 4: Transfer from bed to chair or commode

Step 5: Ambulate with walker / portable vent

Step 6: Increase frequency of mobility


Role of Every Clinician in Supporting Program

Help screen patients & encourage mobilization

Ensure SAT’s and SBT’s are done daily

While mobilizing• manage mobile vent

• protect ETT

• assess cardio-pulmonary status for stopping criteria

Document patient progression

Participate in rounds

Hand-off to next shift


Pre-mobilization Checklist

Suction / give bronchodilators if indicated

Check and secure• Artificial airway

• Ventilator circuit

Double check O2 supply and fittings

Discuss change of vent mode with MD• Consider change to PS

• Goal: matching VT to assisted settings

• If ordered: trial for 10-15 minutes before mobilization

Consider increasing FIO2 10-20%

Equipment check: vent, suction, O2, sensor…


Summary

Post-intensive Care Syndrome is a constellation of negative consequences that impact long term outcomes for patients who survive a critical illness

Early Mobility is a potential mitigation to PICS

Early Mobility is safe for patients receiving mechanical ventilation

Outcomes data is mixed for Early Mobility programs

Clinician buy-in is essential for establishing a successful program


Questions?

Contact: Carl HinksonE-mail: [email protected]




Find more information:

www.draeger.com/Early-Mobilization

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