Disclosures - Kathleen Vollman on Hospitals: 1859 “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

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Advancing Early Mobility in Critical Care: Evidence Based Strategies for Making it HappenCreated in Conjunction With Kathleen M. Vollman, MSN, RN, CCNS, FCCM, FAAN/[email protected]

Disclosures

• Sage Products Speaker Bureau & Consultant

• Eloquest Healthcare Speaker Bureau & Consultant

• Hill-Rom Speaker Bureau & Consultant

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• Create the link of patient advocacy to mobilizing critically ill patients

• Understand the importance of early patient mobility

• Recognize the traditional standards of care for patient mobility– Identify current practice patterns

• Understand institutional costs associated with immobility

• Recognize what evidence supports the use of early mobility

• Determine how to implement an early mobility protocol

• Strategies for creating sustainability

Learning Objectives

Notes on Hospitals: 1859

“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

Florence Nightingale

Advocacy = SafetyNightingale F. Notes on Hospitals. Third Edition [Online]. London: Longman; 1863.Available from: http://www.archive.org/stream/notesonhospital01nighgoog

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PROTECT THE PATIENT FROM BAD THINGS HAPPENING ON YOUR WATCH

Interventional Patient Hygiene

• Hygiene…the science and practice of the establishment and maintenance of health

• Interventional Patient Hygiene….nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies

Incontinence Associated Dermatitis Prevention

Program

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INTERVENTIONAL PATIENT HYGIENE(IPH)

Oral Care/ Mobility

VAP/HAP

Catheter Care

CA-UTICLA-BSI

Skin Care/ Bathing/Mobility

HASISSI

HAND

HYGIENE

Patient

Vollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154

Attitude &

Accountability

Factors Impacting theability to Achieve QualityNursing Outcomesat the Point of Care

Achieving the Use of the Evidence

ValueVollman KM. Intensive Crit Care Nurs, 2013;22(4): 152-154

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Why Is Early Patient

Mobility Important?

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“Teach us to live that we may dread,Unnecessary time in bed,Get people up and we may save,Our patients from an early graved”

RAJ Asher

RAJ. The dangers of going to bed. British Medical Journal,1947 December 13

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Respiratory: respiratory tract infections, atelectasis, and pulmonary embolism1

Cardiovascular: postural hypotension, cardiac muscle atrophy, orthostatic intolerance, and deep vein thrombosis1

Hematologic: anemia1

Metabolic: glucose intolerance2

Skin: pressure ulcers3

Neurological: depression, anxiety, forgetfulness, and confusion1

Musculoskeletal: osteoporosis, muscle atrophy and weakness, and contractures3

Renal: calculi2

Gastrointestinal: constipation and fecal impaction2

1. Knight J, et al. Nurs Times. 2009;105(21):16-20.2. Knight J, et al. Nurs Times. 2009;105(22):24-27.3. Nigam Y, et al. Nurs Times. 2009;105(23):18-22.

Potential Complications of Immobility

• Decreased movement of secretions

• Decreased respiratory motion

• Increased risk of pulmonary embolism

• Increased dependent edema

• Increased risk of atelectasis

• Increased risk of pneumonia

• Decreased arterial oxygen saturation

Effects of Immobility on Respiratory Function1,2

1. Knight J, et al. Nurs Times. 2009;105(21):16-20.2. Vollman KM. Crit Care Nurse. 2010;30:S3-S5.

Respiratory

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• In North America– In the United States, the Centers for Disease

Control (CDC), through the National Healthcare Safety Network, has reported critical care unit VAP rates, per 1,000 ventilator-days, ranging from 0.2 (pediatric cardiothoracic) to 4.4 (burn ICU)2

– On average, ICU patients with VAP had an additional 10.5-day LOS3

– Per case: VAP $40,144. (95% CI, %36,286-$44,220)4

Ventilator-Associated Pneumonia (VAP) Rates

1. Rosenthal VD, et al. Am J Infect Control. 2012;40(5):396-407.2. Dudeck MA, et al. National Healthcare Safety Network (NHSN) Report, Data Summary for 2012, Device-Associated Module. American Journal

of Infection Control. 2013,41:1148-66.3. Restrepo MI, et al. Infect Control Hosp Epidemiol. 2010;31(5):509-515.4. Zimlichman E. et al. JAMA Internal Med, 2013;173(22):2039-465. Accessed 10/2013 at http://www.phac-aspc.gc.ca

Respiratory

The CDC defines ventilator-associated events (VAE) as deterioration in respiratory status after a period of stability, possible infection/inflammation, and laboratory evidence of respiratory infection.

Ventilator-Associated Events-Not a New Definition for VAP

Device-associated module: ventilator-associated event protocol. NHSN website. http://www.cdc.gov/nhsn/PDFs/pscManual/10-VAE_FINAL.pdf. Accessed 2/22/13.

Before:

VAP was the only VAE that the National Healthcare Safety Network (NHSN) collected data on

Now:

NHSN has revised its policy to include surveillance of all VAE, including

• Ventilator-associated conditions (VAC)• Infection-related ventilator-associated complications (IVAC)• Possible and probable VAP

Patient criteria for VAE surveillance• Included patients: mechanically-ventilated patients ≥18 years

who have an event on or after calendar day 3 of mechanical ventilation

• Excluded patients: patients receiving rescue therapies)

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Cardiovascular

1. Winkelman C. AACN Adv Crit Care. 2009;20:254-266. 2. Knight J, et al. Nurs Times. 2009;105(21):16-20.3. Harms MP, et al. Exp Physiol. 2003;88:611-616.4. Sjostrand T. Physiol Rev. 1953;33:202-228.

• Fluid shift– Occurs when the body goes from upright to supine position1,2

– 10% of total blood volume is shifted from lower extremities to the rest of the body; 78% of this is taken up in the thorax3,4

– Decreased blood volume (~15% of plasma volume is lost after 4 weeks of bed rest)2

• Cardiac effects– Increased resting heart rate (an increase of

~10 beats/min is observed after 4 weeks of bed rest)1,2

– Cardiac deconditioning2

• Orthostatic intolerance– Increased in bedridden patients due to decreased baroreceptor

sensitivity, reduced blood volume, cardiac deconditioning, decreased venous return and stroke volume, and venous distensibility1,2

Effects of Immobility on Cardiovascular Function

The current facility acquired of pressure ulcers is high7

– Stage III or IV facility-acquired pressure ulcers are not reimburses & impact value based purchasing2

• The average cost per hospital stay for a patient with a stage III or IV pressure ulcer in the acute care setting is $43,1803

Effects of Immobility on Integumentary Function

Skin

1. National pressure ulcer Advisory panel, European pressure ulcer Advisory panel and Pan Pacific pressure injury alliance. Clinical practice guideline, 2014

2. Hospital-acquired conditions. Centers for Medicare & Medicaid Services website. http://www.cms.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp. Accessed 1/3/12.

3. CMS. Fed Regist. 2008;73:48433-49084.4. Jankowski IM, Nadzam DM. Jt Comm J Qual Patient Saf. 2011;37:253-264.

– Mobilization of patients is recommended to help prevent pressure ulcers and might coordinate with 2-hour repositioning schedules4

Setting Facility –Acquired Rates

Critical Care 3.3% to 53.4%

Acute Care 0% to 12%

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• Muscle wasting (almost half of the normal muscle strength is lost after 3-5 weeks of bed rest)1,2

• Change in type or density of muscle fibers (muscle protein synthesis decreases by 50% after 2 weeks of bed rest)2

• Muscle wasting occurs early & rapidly during first week of critically illness3

– protein synthesis & protein breakdown

– Severity increased with multiple organ failure

• Separate phenotypes of muscle atrophy1

– Primary: bed rest, space flight, limb casting, and denervation

– Secondary: pathology

Effects of Immobility on Skeletal Muscle

Musculoskeletal

1. Morris PE. Crit Care Clin. 2007;23:1-20.2. Nigam Y, et al. Nurs Times. 2009;105(23):18-223. Puthucheary ZA, et al. JAMA 2013;310(15):1591-1600

• During immobilization, the muscle groups involved with transferring and posture lose strength most quickly (shoulders, hip girdle)1,2,4

• After less than a day of immobility, contractures start to develop. After 2-3 weeks of immobility, firmer contractures develop, and after 2-3 months of immobility, surgical correction may be needed2

• Recovering from muscle atrophy caused by immobility takes ~4 weeks. With exercise, disuse weakness is reversed at a rate of ~6%/week2

• Respiratory muscle weakness may occur 4 & is a predictor for prolonged mechanical ventilation and delayed weaning3

Effects of Immobility on Skeletal Muscle (Cont.)

Musculoskeletal

1. Topp R, et al. AACN Clin Issues. 2002;13(2):263-276.2. Nigam Y, et al. Nurs Times. 2009;105(23):18-22.3. De Jonghe B, et al. Crit Care Med. 2007;35(9):2007-2015.4. Kress JP, Hall JB. N Engl J Med, 2014;370:1626-1635

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• Delirium1

– Acute, fluctuating change in consciousness and cognition

– Develops over a brief time period

– Hyperactive or hypoactive (most common)

– Associated with higher mortality3,4

• Depression2

• Anxiety2

• Forgetfulness2

• Confusion2

Effects of Immobility on Neurological Function

Neurological

1. Vasilevskis EE, et al. Chest. 2010;138:1224-1233.2. Knight, et al. Nurs Times. 2009;105(21):16-20.3. Ely EW, et al. JAMA 2004;291:1753-17624. Pisani MA, et al. AM J Resp Crit Care Med 2009;180:1092-1097

Neurological: depression, anxiety, forgetfulness, and confusion1

Brain-ICU Study

• Multicenter RCT- medical-surgical ICU’s

• 821 patients with ARF or Shock

• Evaluated in-hospital delirium and cognitive impact 3-12 months post d/c

Results

• 74% of patients developed delirium during hospital stay

• 3 months: 40% had global cognition scores 1.5 SD below population mean, 26% had scores 2 SD below pop mean

• 12 months: 34%(older) & 24%(younger) global cognition scores below the mean

Pandharipande, PP. et al. N Engl J Med;369:1306:1316

1 out of 4 cognitive

Impairment at 12

months

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Definition: • Syndrome of generalized limb weakness that develops while the

patient is critically ill and for which there is no alternative explanation other than the critical illness itself.1 Average Medical Research Council Scale (MRC) score <4 across all muscles tested.

Incidence:• 25% of patients with prolonged mechanical ventilation will develop

ICUAW1

• Est 75,000 pts in US, 1 million worldwideCaused By:1

– Critical illness polyneuropathy and myopathy

– Combination

ICU-Acquired Weakness (ICUAW)

1. Fan E, et al. Am J Respir Crit Care Med. 2014 Dec 15;190(12):1437-46.2. Hermans G, et al. Crit Care. 2008;12:238.

Risk factors:– Severe Sepsis1

– Duration of mechanical ventilation1,4

– ICU LOS5

– Systemic inflammatory response syndrome2

– Multiple organ failure2,4

– Immobility2

– Use of corticosteroids/neuromuscular blockers2,3,5

Negative impact:1,2

– Prolong mechanical ventilation

– Reoccurring respiratory failure & VAP

– Increased ICU and hospital length of stay

– Increase mortality

ICU-Acquired Weakness (ICUAW)

1. Fan E, et al. Am J Respir Crit Care Med. 2014 Dec 15;190(12):1437-46.2. Kress JP et al. N Engl of Med, 2014;370:1626-16353. Hermans G, et al. Crit Care. 2008;12:238.4. De Jonghe B, et al. Crit Care Med. 2007;35(9):2007-2015.5. Needham DM, et al. Am J of Respir and Crit Care Med. 2014;189(10):1214-1224

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• Society of Critical Care Medicine: Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU1

– “Recommend performing early mobilization of adult ICU patientswhenever feasible to reduce the incidence and duration of delirium

• AACN Practice Alert: Delirium Assessment and Management2

– Strategies to decrease delirium risk factors should be used, including early exercise

SCCM and ACCN Practice Guidelines to Address Delirium

1. Barr J, et al. Crit Care Med. 2013;41(1):263-306.2. AACN practice alert: delirium assessment and management.

http://www.aacn.org/WD/practice/docs/practicealerts/delirium-practice-alert-2011.pdf. Accessed 02/25/13.

Effects of Immobility: Conclusion

Because the consequences of immobility and bed rest

are so severe, mobilizingcritically ill patients early

appears to have merit.–K.M. Vollman

Vollman KM. Crit Care Nurse. 2010;30:S3-S5.

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• Early mobility/rehabilitation is associated with a decrease in the incidence and duration of delirium, as well as numerous adverse effects on the different body systems

• Benefits of early mobility appear to be associated with reduced time on the ventilator, shorter hospital LOS and lower mortality rates.

• In addition, early mobility can improve quality of life after the ICU stay

Summary: Importance of Early Patient Mobility

Early mobility in critically ill patients is essential to the prevention of complications associated with immobility

What Are Some Traditional

Standards of Care for

Patient Mobility?

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What Are Some Traditional Standards of Care for Patient Mobility?

The old standby physician order…The old standby physician order…

Traditional intervention• Every 2 hours*• Manual turning• Head of bed at 30°

Traditional intervention• Every 2 hours*• Manual turning• Head of bed at 30°

Pressure ulcers and pneumonia

Out of bedto chair

*Although 80%-90% of surveyed ICU physicians believe that every-2-hour turning should occur, only 57% of them believe that it is currently happening in their ICU.1

1. Krishnagopalan S. Crit Care Med. 2002;30:2588-2592.

How Well Are We Really Doing?Every-2-Hour Turning

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Methodology

• 74 patients/566 total hours of observation

• 3 tertiary hospitals

• Change in body position recorded every 15 minutes

• Average observation time 7.7 hours

• Online MD survey

Results

• 49.3% of observed time no body position change for > 2 hours

• 2.7% had an every-2-hour demonstrable body position change

• 80% to 90% believed every-2-hour position change should occur, but only 57% believed it happened in their ICU

Body Position: Clinical Practice vs Standard

Krishnagopalan S. Crit Care Med. 2002;30:2588-2592.

Positioning Prevalence

• Prospectively recorded, 2 days, 40 ICUs in the UK

• Analysis on 393 sets of observations

• Turn defined as supine position to a right or left side lying

• Five patients prone at any time, 3.8% (day 1) and 5% (day 2) rotating beds

• Patients on back 46% of observation

• Left 28.4%

• Right 25%

• Head up 97.4%

• Average time between turns 4.85 hours (3.3 SD)

• No significant association between time and age, weight, height, respiratorydiagnosis, intubation, sedation score, day of week, nurse/patient ratio, hospital

Goldhill DR, et al. Anaesthesia. 2008;63:509-515.

Results:

Methodology:

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• Heavier patients1*

• Patients receiving vasopressors*

• Patients receiving a paralytic agent at least once1

• Trauma patients with multiple fractures or high intracranial pressure1

• Fear of line dislodgement• Heavy sedation• Patient comfort• Human and technological resources• Fear of further decreases in oxygenation or

hemodynamic parameters

Potential Barriers to Early Mobilization

1. Schallom L, et al. Am J Crit Care. 2005;14:476-478.2. Morris PE. Crit Care Clin. 2007;23:1-20.* *not statistically significant

Patients noted to be turned less

Perceived patient and environmental barriers to mobilizing ICU patients2:

EBP Recommendations to Achieve Offloading & Reduce Pressure

• Turn & reposition (avoid positioning patients on a pressure ulcer)– Repositioning should be undertaken to reduce the duration &

magnitude of pressure over vulnerable areas– Cushioning devices to maintain alignment /30 ° side-lying &

prevent pressure on boney prominences– Use lifting device or other aids to reposition & make it easy to

achieve the turn• Do not leave moving and handling equip underneath the

patient– Assess whether actual offloading has occurred

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. And Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed,) Cambridge Media: Perth, Australia; 2014.American Nurses Association. Safe patient handling and mobility: Interprofessional national standards. Silver Spring, MD: author; 2013

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• Every-2-hour turning is considered the current practice to help offset the effects of immobility

• Keeping the head of bed at 30°-45° is an intervention to help prevent VAP

Summary: Traditional Standards of Care

What Are the Average Costs of

Immobility for Organizations?

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In the United States:• >6,000 ICU beds1

• >5 million patients admitted annually to the ICUs1

• ICU patients represent 10% of admissions but 30% of hospital costs2

• Average mortality in ICUs is 10%-29%1

• Average LOS in the ICU is 6.1-9.3 days1

ICU Statistics

1. Society of Critical Care Medicine. Critical care statistics in the United States. Mount Pleasant, IL: Society of Critical Care Medicine; 2012. http://www.sccm.org/SiteCollectionDocuments/StatisticsBroch_d4.pdf. Accessed 7/27/12.

2. Pendergraft TB, et al. Ann Allergy Asthma Immunol. 2004;93:29-35.3. Rhodes A, et al. Intensive Care Med. 2012;38:1647-1653. 4. Vincent J, et al. Crit Care Med. 2006;34:344-353.5. Edbrooke DL, et al. Crit Care. 2011;15:R56.

Unplanned ICU Readmissions

Reintubation is associated

with increased

risk of developing

VAP2,3

Average ICU readmission

rate of 7% and average

ICU daily costs of $3,1841,4

ICU readmissions

have twicethe average

hospital LOS1

Hospital death rates

are 1.5-10 times

higher1

1. Rosenberg AL, Watts C. Chest. 2000;118:492-502. 2. Torres A, et al. Am J Respir Crit Care Med. 1995;152:137-141. 3. Elward AM, et al. Pediatrics. 2002;109:758-764.4. Dasta JF, et al. Crit Care Med. 2005;33(6):1266-71.5. Emerson CB, et al. Infect Control Hosp Epiemiol, 2012:33:539-544

Respiratory complications are the major

reason1

Development of an HAI is associated

with readmission of 27days6

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• Single center retrospective cohort study of 9405 consecutive patients admitted from an acute care hospital to an inpatient rehab

• Functional status on admission to rehab was assessed (FIM score) and categorized into low, middle and high functional status

• Results– 13% readmission rate– Low and middle FIM score was significantly associated with readmission in

comparison to high FIM scores across diagnostic categories– Medical patients with the lowest functional status had the highest readmission rate

Functional Status at Discharge: Impact on Readmission

The Centers for Medicare and Medicaid Services will reduce payments to hospitals with excess readmissions

(admissions within 30 days of discharge)2

FIM= functional independent measure

1.Hoyer EH, et. al. Journal of Hospital medicine. 2014;9:277-2822. Readmissions reduction program. CMS website. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed.

In the United States:• Acute care facility-acquired pressure ulcer rate: 0-12%1

• 60,000 deaths from facility-acquired pressure ulcer complications per year2

• Average cost of facility-acquired stage III or IV pressure ulcers: $43,1803

• $11 billion per year in preventable costs4

Impact of Pressure Ulcers

1. National pressure ulcer Advisory panel, European pressure ulcer Advisory panel and Pan Pacific pressure injury alliance. Clinical practice guideline, 2014

2. Courtney BA, et al. Nurs Manage. 2006;37:36,38,40.3. CMS Office of Public Affairs. Fact sheet: CMS proposes additions to list of hospital-acquired conditions for fiscal year 2009.

Baltimore, MD: Centers for Medicare & Medicaid Services; 4/14/08. 4. Reddy M, et al. JAMA. 2006;296:974-984.5. Phillips L, Buttery J. Nurs Times. 2009;105:34-36.6. Bennett G, et al. Age Ageing. 2004;33:230-235.

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Quality Implications

1. 2014 clinical quality measures tipsheet. http://www.cms.gov/RegulationsandGuidance/Legislation/EHRIncentivePrograms/Downloads/ClinicalQualityMeasures Tipsheet.pdf. 2. FY2009 quality measure reporting for 2010 payment update. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/

HospitalQualityInits/Downloads/HospitalRHQDAPU200808.pdf. 3. CMS quality measurement programs characteristics. http://www.cms.gov/medicare/quality-initiatives-patient-assessmentinstruments/qualitymeasures/

downloads/cmsqualitymeasurementprogramscharacteristics.pdf. 4. Readmissions reduction program. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. 5. Hospital value-based purchasing program. CMS website. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/

Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf.6. 2015 Patient Safety Goals http://www.jointcommission.org/assets/1/6/2015_HAP_NPSG_ER.pdf

• Increasing number of quality measures1

• CMS financial pressures for quality reporting2,3

• Excessive readmission penalties begin in 20134

Centers for Medicare & Medicaid Services

(CMS)

• CMS-based program

• Started in October 2012

• Pay-for-performance

• CMS will withhold in 2015 1.5% of payments and redistribute the money based on how well hospitals meet quality measures compared to baseline measures

CMS Value-Based Purchasing5

• National patient safety goals for 2015:

– Patient identification– Infection prevention– Medication safety– Effective

communication– Surgical mistakes– Patient safety risks

The Joint Commission6

• ICU patients represent a disproportionate amount of hospital costs

• Respiratory complications are the major reason for unplanned ICU readmissions– ICU readmissions average longer hospital LOS and higher

mortality rates

• Facility-acquired pressure ulcers represent a large preventable cost

• There may be long-term financial implications associated with poor performance with regard to healthcare safety indicators through the CMS Value-Based Purchasing Program

Summary: Institutional Costs Associated With Immobility

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It is not enough to do your best; you must know what to do, and THEN do your best.

–W. Edwards Deming

Introduction to Early Mobility

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• Early mobility definition:– Planned movement in a sequential manner beginning at a patient’s

current mobility status and returning the patient to baseline

• Early mobility includes:– Head elevation– Manual turning– Passive and active range of motion– Continuous lateral rotation therapy/prone positioning– Movement against gravity– Physiologic adaptation to an upright/leg down position (Tilt Table,

bed egress)– Chair position– Dangling– Ambulation

Definition of Early Mobility1

1. Vollman KM. Crit Care Nurse. 2010;30:S3-S5.

What Does Clinical Evidence

Tell Us About Early Mobility?

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1

3

2

4

Start at the Top: Which Head of Bed Is at 30°?1

1. Garcia R. Presented at: APIC. 2004.

The Clinical Impact of 45° Head of Bed on Ventilator-Associated Pneumonia (VAP)1

1. Drakulovic MB, et al. Lancet. 1999;354:1851-1858.

Number of patients 86

Patient populationMonitored clinically suspected and microbiologically confirmed nosocomial pneumonias

InterventionRandomly assigned to:• Supine position (n=47)• Head of bed 45° (n=39)

Results

• Microbiologically confirmed nosocomial pneumonia lower in the semirecumbent group, 2/39 (5%) vs 11/47 (23%)

• Supine position and enteral nutrition were independent risk factors for VAP and had the greatest number of VAP cases 14/28 (50%)

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A Comparison of Two Measurements of Head of Bed on VAP1

Number of patients 221

Patient population Critically ill patients undergoing mechanical ventilation

Intervention

Randomly assigned to• Head of bed 10° (n=109)• Head of bed 45° (n=112)Head of bed elevation was measured continuously

Results

• Backrest elevation was measured continuously• Average elevation range in the first week

- 10° group: 9.8°-14.8°- 45° group: 29.3°-23.1° (intended elevation was not

achieved 85% of the time)• Microbiologically confirmed VAP occurred in 7.3% of patients in

the 10° group and in 11.6% of the 45° group

VAP=ventilator-associated pneumonia.1. Van Nieuwenhoven CA, et al. Crit Care Med. 2006;34:396-402.

• Evaluate frequency of bihourly turning (16 hours × 3 days)

• 284 ICU patients, tube fed and on mechanical ventilation

• Evaluate frequency of bihourly turning (16 hours × 3 days)

• 284 ICU patients, tube fed and on mechanical ventilation

Study

• 49% of patients developed VAP

• Patients with VAP were turned less frequently

• Mean number of turns was 9.64/patient vs 23 possible bihourly turns

• 49% of patients developed VAP

• Patients with VAP were turned less frequently

• Mean number of turns was 9.64/patient vs 23 possible bihourly turns

Results

The Clinical Impact of Manual Turning on VAP1

VAP=ventilator-associated pneumonia.1. Schallom L, et al. Am J Crit Care. 2005;14:476-478.

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• CLRT mechanism of action– A gentle side-to-side, full-body motion of the patient in which one

lung is placed above the other– This motion allows for gravitational flow and mobilization of

pulmonary secretions, as well as enhance gas exchange

• What impact does it have on gas exchange?– Increased oxygen– Decreased CO2

– Improved blood flow– Decreased atelectasis

• What happens inside the airways when patients are turned?

Continuous Lateral Rotation Therapy

Table-Based vs Cushion-Based Rotation

• Turning on the long axis

• Measured in degrees of angle/turn– 124° (62° per side) in 3.5 minutes

• Unstable spine patients

• Rotates patient by inflation/deflation of air cushions

• Longitudinal, full-body rotation

• Measured in percent of air bladder inflation

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Key Differences

Table-Based Rotation

• Ideally suited for patients with unstable heads, necks, and spines (neuro and trauma patients)1

• Uses a firm mattress essential for maintenance of spine alignment1– Can potentially put skin integrity

at risk

• Can be set by degree of angle desired– Requires 2 fixed planes to

accurately determine angle– Table-based products can

achieve this as both the surface and the frame are moving at the same angle

Cushion-Based Rotation

• Usually does not require transfer to a different surface, allowing it to be initiated more readily

• More user-friendly for clinicians1

• Beds may include additional features such as assist modes for patient positioning1

1. Basham KA, et al. Respir Care Clin N Am. 1997;3:109-134.

Cross Section of a Chest in the Supine Position

Rib

HeartLung

Bronchi

Spine

PulmonaryInfiltrates

Sternum

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Rotation of the Chest

90°

45°

30°

62°

• Pulmonary infiltrates are unable to drain into the bronchi

• Pulmonary infiltrates are unable to drain into the bronchi

Supine Position

• Pulmonary infiltrates are unable to drain into the bronchi

• Pulmonary infiltrates are unable to drain into the bronchi

Rotation of the Chest

90°

30°

30°

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• Pulmonary infiltrates are unable to drain into the bronchi

• Pulmonary infiltrates are unable to drain into the bronchi

Rotation of the Chest

90°

45°

45°

Rotation of the Chest

90° 62°

• Some amount of drainage of pulmonary infiltrates into the bronchi

• Some amount of drainage of pulmonary infiltrates into the bronchi

62°

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Rotation of the Chest

180°

90°

• Pulmonary infiltrates can successfully drain into the bronchi

• Pulmonary infiltrates can successfully drain into the bronchi

180°

Methods:

• Systematic review and meta-analysis of studies on prophylaxis and/or treatment

• Prospective, randomized controlled trials

• Various types of beds were studied– Table- and cushion-based therapies

• Kinetic (62°) and CLRT (40°, 30°, and 20°)

Systematic Review and Meta-Analysis of Rotational Bed Therapy to Prevent and Treat Respiratory Complications1

CLRT=continuous lateral rotation therapy.Goldhill DR, et al. Am J Crit Care. 2007;16:50-61.

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• Rotational therapy

provides a benefit with

respect to the incidence

of pneumonia

Review and Meta-Analysis of Rotational Bed Therapy to Prevent and Treat Respiratory Complications: Meta-Analysis of Pneumonia1

Goldhill DR, et al. Am J Crit Care. 2007;16:50-61.

Conclusions:

• Little evidence on which rotation parameter is most effective

• Effectiveness may not depend entirely on the angle of rotation, but also on– Frequency and duration of rotation– Pause time– Underlying disease– Size and weight of patient– Use of adjuncts such as vibration, percussion, or pulsation

• Some awake patients do not tolerate steep angle rotation

• May be best for patients with higher BMI, unconscious, or sedated

• Key recommendation: Rotational therapy may be useful for preventing and treating respiratory complications in selected critically ill patients receiving mechanical ventilation

Review and Meta-Analysis of Rotational Bed Therapy to Prevent and Treat Respiratory Complications1

Goldhill DR, et al. Am J Crit Care. 2007;16:50-61.

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• The Medical Center of Central Georgia evaluated the impact of CLRT

• A CLRT protocol was implemented in patients who were identified as at risk for pulmonary complications, and outcomes were compared with a historical comparison group

• When introduced early, CLRT may reduce critical care length of stay and cost to treat

• CLRT is an option for patient mobility

Rotational Therapy Using Cushion-Based Rotation

Vent Days ICU DaysHospital

Days

Cost to Treat, Thousands of

Dollars

ICU Readmission

Rates, %

Reintubation Rates, %

No CLRT 17.4 18.4 29.7 59.4 21 19

CLRT after 48 hours

16.6 18.9 28.8 62.1 17 13

CLRT within 48 hours

12.4 13.1 23.4 45.2 4 4

CLRT=continuous lateral rotation therapy.No CLRT: 75 patients; CLRT after 48 hours: 46 patients; CLRT within 48 hours: 50 patients.Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31:270-279.

• Methodology– Prospective randomized controlled trial, 3 medical ICUs at a single center– Eligible if ventilated <48 hours and free from pneumonia, ALI, or in ARDS– 150 patients with 75 in each group– 35 patients with CLRT allocated to undergo percussion before suctioning– Measures to prevent VAP were standardized for both groups including

head of bed

• Results: CLRT vs control– VAP: 11% vs 23% P=0.048– Ventilation duration: 8 ± 5 days vs 14 ± 23 days, P=0.02– LOS: 25 ± 22 vs 39 ± 45 days, P=0.01– Mortality: no difference

CLRT to Prevent VAP: Controlling the Variables1

ALI=acute lung injury; ARDS=acute respiratory distress syndrome; CLRT=continuous lateral rotation therapy; VAP=ventilator-associated pneumonia.Staudinger T, et al. Crit Care Med. 2010;38:486-490.

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• Introduction of CLRT into patient care can provide an efficient way of providing early mobility to those critically ill patients whose condition or instability prevents implementation of other forms of mobility1,2

Introducing CLRT Into Patient Care

Systematic method of approaching placement and removal of CLRT therapy… a protocol

CLRT=continuous lateral rotation therapy.1. Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31:270-279.2. Basham KA, et al. Respir Care Clin N Am. 1997;3:109-134.

• Target high-risk patient populations– Pulmonary-hemodynamic instability with manual turning– FiO2 50% or more– Positive end-expiratory pressure (PEEP) 8 or more– Existing pulmonary complications– FiO2 increases by 20% (20 points) or PEEP >3 cm H2O from baseline within 2

calendar days

• Which patients should NOT receive CLRT?– Those with unstable spines– Those with long bone fractures or patients requiring traction– Those with unstable intracranial pressure– Marked agitation without therapeutic management– Those with severe, uncontrolled diarrhea and patients that weigh more than 300lbs

Moving Those Who Cannot Move Themselves: Which Patients Should Receive CLRT?

CLRT=continuous lateral rotation therapy.Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31:270-279.Basham KA, et al. Respir Care Clin N Am. 1997;3:109-134.

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• Assess for potential complications frequently– Malposition of endotracheal tube– Positional transient desaturation– Positional hemodynamic instability

• Every 2 hours check to see if patient is in optimal position to promote effective turn

• Every 2 hours manually turn patient and evaluate skin and lungs, then resume rotational therapy

• Document in medical record: degree of rotation, pause time settings, hours of rotation, turn for skin check and lung evaluation every 2 hours

• Discontinue CLRT when the patient:– May be mobilized safely using other means (head of bed, chair position, out-of-bed chair,

and/or ambulation)– Shows improvement in respiratory status– Has agitation that is not therapeutically managed

Ongoing Monitoring/Evaluation and Documentation

CLRT=continuous lateral rotation therapy.

• Early CLRT intervention

• The therapy must be driven by a protocol and changes in settings are nursing orders

• Monitor initial rotation cycle to ensure one lung is above the other

• Automation of rotation requires insertion of usual assessment practices

• Minimum of 18 hours per day and 6 cycles per hour

• If done incorrectly, can cause skin injury– Shorter pause times– Assessment to ensure one lung above the other– Every two-hour assessment of the lungs and skin

• Yearly competency-based education to ensure proper use of the therapy

CLRT Strategies for Success

CLRT=continuous lateral rotation therapy.

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Prone Positioning: 2013 Evidence

• RCT 466 patients with severe ARDS (26 ICU’s in France/1 Spain)– Severe ARDS P/F ratio < 150 mm Hg, with Fio2 0.6, PEEP of at least

5 cm of water, & a Vt of 6 ml per kg of PBW– Initiation 12-24hrs

• Prone-positioning 16hrs/or supine position/ (proned within 1hr of randomization)

• NMB used 5 days

• Stopping prone treatment– After 4hrs in supine meeting oxygenation criteria– in PaO2/FiO2 ratio of 20% (after 2 consecutive prone positions)– Complications leading to immediate interruption

• Applied for 28 days, then clinician discretion

Guerin C. et al. N Engl J Med, 2013, 368(23): 2159-2168

Results: Guerin C, et. al. Prone Study

• Results:– Baseline characteristics similar

except for, vasopressors (S), sepsis related SOFA score (S) & use of NMB’s (P)

– Prone 16% mortality, supine 32.8% p< 0.0001

– Prone group ICU LOS (2 days, & VFD (4 days) (NS)

– No differences in complications except > cardiac arrest in supine position (31 S vs. 16 P)

Guerin C. et al. N Engl J Med, 2013, 368(23): 2159-2168

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• When muscles are immobilized in shortened positions, there is remodeling of muscle fibers

• Bed rest entails immobilization of limb extensor muscles in shortened positions

• Passive movement has been shown to enhance ventilation, prevent contractures in patients in high-dependency units

• Low-resistance multiple repetition muscle training can augment muscle mass and strength

Evidence for Active and Passive Range of Motion1-3

1. Gosselink R, et al. Intensive Care Med. 2008;34:1188-1199.2. Perme C, Chandrashekar R. Am J Crit Care. 2009;18:212-221.3. Schweickert WD, et al. Lancet. 2009;373:1874-1882.

Sets of repetitions to perform daily within patient tolerance recommended by ICU patient.

e.g. 3 sets of 8-10 repetitions at 50-70% of 1 rep max.

• Prospective cohort study to determine the impact of early mobility therapy on mechanically ventilated with respiratory failure

• The control group received standard passive ROM and turning (n=165)

• The study group received low-impact mobility (n=165)

– Assessment & therapy initiated within 48 hours of mechanical ventilation by a team

– Therapy 7 days/week until ICU discharge

– Mobility team included 1 ICU nurse, 1 physical therapist, and 2 nursing assistants

The Clinical Outcomes of an Early Mobility Protocol: Methods

ROM=range of motion.Morris PE, et al. Crit Care Med. 2008;36:2238-2243.

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• The early mobility protocol:– Shortened time to patient first out of bed (=6.3 days)– Hospital LOS (=3.3 days)– ICU LOS (=1.4 days)

The Clinical Outcomes of an Early Mobility Protocol: Results

LOS=length of stay.Morris PE, et al. Crit Care Med. 2008;36:2238-2243.

InterventionGroup

Control

PT session during hospital stay

80% 47.7%

Cost per patient including team

$41,142 $44,302

• 104 adults fully functional at baseline, sedated and on mechanical ventilation (for less than 72 hours) in the ICU Patients :

– Intervention group: planned daily activity during interruption of sedation (n=49)

– Control group: daily interruption of sedation with standard care (n=55)

• Patients assigned to the early mobilization had:– Fewer hospital days with delirium (28% as compared to 41% in the control group)

– More ventilator-free days (23.5 as compared to 21.1 in the control group)

– A higher probability of returning to independent functional status at hospital discharge (59% of patients as compared to 35% in the control group)

Early Physical and Occupational Therapy of Mechanically Ventilated Patients Impact Outcomes

PT/OT=physical/occupational therapy; ROM=range of motion.Schweickert WD, et al. Lancet. 2009;373:1874-1882.

Shorter Time from Intubationto

Intervention (days)

Control (days)

First PT/OT session 1.5 7.4

Out of bed 1.7 6.6

Standing 3.2 6.0

Transfer to chair 3.1 6.2

Walking 3.8 7.2

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• Manual turning, 30°-45° head of bed, continuous lateral rotation therapy, passive and active range of motion, as well as sitting in the chair and ambulating are part of early patient mobility

• Early activity is feasible and safe in patients with respiratory failure

Summary: Clinical Evidence for Early Patient Mobility

Overcoming Barriers to

Early Mobility

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• Patients noted to be turned less often1:– Heavier patients*

– Patients receiving vasopressors*

– Patients receiving a paralytic agent at least once– Trauma patients with multiple fractures or high intracranial pressure

• Perceived patient and environmental barriers to mobilizing ICU patients2,4:– Fear of line dislodgement– Heavy sedation– Patient comfort– Human and technological resources

• Weaning patients served as their own control.– Out of Bed chair 55-80° vs 40-60 ° : No difference in ABG’s, respiratory or

hemodynamic values3

– Fear of further decreases in oxygenation or hemodynamic parameters

Potential Barriers to Early Mobilization

1. Schallom L, et al. Am J Crit Care. 2005;14:476-478.2. Morris PE. Crit Care Clin. 2007;23:1-20.3. Thomas P, et al. Heart & Lung. 2014;43:105-1114. Jolley SE, et al. BMC Anesthesiology,. 2014;14:1-9* *not statistically significant

• 103 patients who are mechanically ventilated for >4 days

• Mobility team included registered nurse, physical therapist, respiratory therapist, and care technician

• Patients assessed upon admission and daily for readiness

• Activity begins when patient exhibits physiologic stability

• Sedation reduced and oxygen levels supported

• Measures of activity related adverse events Fall to knees, systolic blood pressure >200 or <90 mm Hg, oxygen desaturation <80% and/or extubation, and/or tube removal

Feasibility and Safety of Early Activity in Patients With Acute Respiratory Failure: Methods

Bailey P, et al. Crit Care Med. 2007;35:139-145.

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• Measured 1,449 activity events

• Sit on bed (16%), sit in chair (31%), and ambulate (53%)

• Patients with an endotracheal tube in place had 593 activity events– 249 (42%) were ambulated

• 69% survivors ambulated >100 feet at respiratory ICU discharge

• <1% activity-related adverse events

Feasibility and Safety of Early Activity in Patients With Acute Respiratory Failure: Results

Photo courtesy of Bailey P, et al. Crit Care Med. 2007;35:139-145.Bailey P, et al. Crit Care Med. 2007;35:139-145.

• Methods:– Study included 49 ICU patients who had been mechanically ventilated for <72 hours

43% of the patients had ARDS on ICU admission– Patients received daily sedative interruption and were screened for the safety of PT/OT

• PT/OT progressed from passive/active range of motion through bed mobility exercises followed by sitting at the edge of the bed, balance activities, ADLs, transfers, and finally ambulation

• Results:– Average time from intubation to initial therapy was 1.5 days– Therapy occurred on

• 87% of total eligible days on study• 90% of days on mechanical ventilation• 90% of days in the ICU while not on mechanical ventilation

– Patients had ICU delirium during 53% of sessions– Adverse events only occurred during 16% of all PT/OT sessions, including desaturation

≥5%, heart rate increase, ventilator asynchrony/tachypnea, agitation/discomfort, and device removal

Feasibility and Safety of Early Activity in Mechanically Ventilated Patients

ARDS=acute respiratory distress syndrome; PT/OT=physical/occupational therapy.Pohlman MC, et al. Crit Care Med. 2010;38:2089-2094.

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• Published literature on safe use of early mobilization with various patient populations

• Continuous renal replacement therapy1,2

• Extracorporeal membrane oxygenation3,4

• Burns5

• Abdominal surgery6

Yes…. They Can Be Mobilized

1. Wang YT, et al. Critical Care. 2014;18:R1612. Talley, et al. Critical Care Nursing Quarterly. 2013 36(1):89-1003. Abrams D, et al. Critical Care. 2014;18:R384. Freeman R, et al. Critical Care Nursing Quarterly. 2013 36(1):73-885. Taylor S, et al. Critical Care Nursing Quarterly. 2013 36(1):56-626. Havey R, et al. Critical Care Nursing Quarterly. 2013 36(1):63-72

• Lateral turn results in a 3%-9% decrease in SVO2, which takes 5-10 minutes to return to baseline

• Appears the act of turning has the greatest impact on any instability seen

• Minimize factors that contribute to imbalances in oxygen supply and demand

The Role of Hemodynamic Instability in Positioning1,2

1. Winslow EH, et al. Heart Lung. 1990;19:557-561.2. Price P. Dynamics. 2006;17:12-19.3. Vollman KM. Crit Care Nurs Q. 2013;36:17-27

• Factors that put patients at risk for intolerance to positioning:3

• Elderly• Diabetes with neuropathy• Prolonged bed rest• Low hemoglobin and cardiovascular reserve• Prolonged gravitational equilibrium

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Decision-Making Tree for Patients Who Are Hemodynamically Unstable With Movement1,2

Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible

Is the patient hemodynamically unstable with manual turning?• O2 saturation < 90%• New onset cardiac arrhythmias or ischemia• HR < 60 <120• MAP < 55 >140• SPB < 90 >180• New or increasing vasopressor infusion

Is the patient still hemodynamically unstable after allowing 5-10 minutes’ adaption post-position change before determining tolerance?

Has the manual position turn or HOB elevation been performed slowly?

Initiate continuous lateral rotation therapy via a protocol to train the patient to tolerate turning

Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates

Allow the patient a minimum of 10 minutes of rest between activities, then try again to determine tolerance

Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates

Try the position turn or HOB maneuver slowly to allow adaption of cardiovascular response to the inner ear position change

No

No

No

No

Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible

Yes

Yes

Yes

Yes

HOB=head of bed; HR=heart rate; MAP=mean arterial pressure; SPB=systolic blood pressure.Vollman KM. Crit Care Nurse. 2012;32:70-75.Vollman KM. Crit Care Nurs Q. 2013;36:17-27.

Mobility Initiative to Overcome Process/ Culture Barriers: Methods

• Multicenter implementation of key mobility related clinical interventions

• Development of an evidence-based, user-friendly early mobility continuum

• Implementation plan: process design, culture work, and education

• 130 patients/3,120 prospectively collected hourly observations

• Qualitative and quantitative data collected

Figure used with the permission of Rick D. Bassett.Bassett RD, et al. Intensive Crit Care Nurs. 2012;28:88-97.

Results• Qualitative reports suggest that the collaborative approach improved both

the culture and team focus on the process of mobility• A reduction in ventilator days (3.0 days pre vs 2.1 days post) approached

significance (P=0.06)

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Cultural Adaptation to Increase Sustainability

Vollman KM, Bassett R. Transforming the Culture: The Key to Hardwiring Early Mobility & Safe Patient Handling. Amer Nurse Today, 2014, September

Early mobility has the potential to help reduce ICU LOS for non-vented and vented patients, creating the potential for significant savings.

Average ICU Costs

Potential Cost Savings if 1 Day ReducedICU LOS (with mechanical ventilation) in

an ICU With an Average of 200 Vent Patients Annually

Reduced ventilator days 1 day

Vent cost/day $3,968

Vent savings/patient $3,968

Annual number of vent patients* 200

Annual ventilator savings $793,600

Potential Cost Savings if 1 Day Reduced ICU LOS (with no mechanical ventilation) in an ICU With an Average of 500 Patients

Annually

ICU reduced LOS 1 day

ICU cost/day $3,184

ICU savings/patient $3,184

Annual number of ICU patients 500

Annual ICU LOS savings $1,592,000

1. Dasta JF, et al. Crit Care Med. 2005;33(6):1266-71.

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Financial Model for Cost Effectiveness

Lord R. Crit Care Med, 2013;41:717

Care Bundles and Protocols

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• ABCDE bundle = Awakening and Breathing Coordination, Delirium monitoring, and Exercise/early mobility

• ABCDE is designed to:– Promote collaboration among clinical team members– Standardize care– Break the ICU ventilation-sedation-delirium-weakness cycle

ABCDE Bundle to Mitigate ICU-Acquired Delirium and Weakness

Vasilevskis EE, et al. Chest. 2010;138:1224-1233.

National resources materials available to help implement:

• ICU liberation SCCM collaborative at www.iculiberation.org

• AACN CSI Academy & Clinical toolkit: Implementing ABCDE at www.aacn.org

• The ABCDE bundle was evaluated in critically ill patients receiving mechanical ventilation in a prospective before-after study of 186 patients from 5 ICUs (93 patients pre-ABCDE bundle implementation and 94 patients post implementation)

– After ABCDE bundle implementation, patients experienced more days breathing without assistance (average of 24 days without vent assistance vs 21 days in the pre-bundle group) and were less likely to experience ICU delirium (66% vs 75.3% in the pre-bundle group)

• A prospective study evaluated nonventilated patients in the ICU both prior to (n=53) and after (n=56) the implementation of the ABCDE bundle

– ABCDE bundle implementation resulted in a reduction in the overall incidence (19.6% vs 39.6% in the pre-bundle group) and duration of delirium in nonventilated ICU patients

ABCDE Bundle Clinical Evidence

1. Balas M, et al. Crit Care Med. 2014 May;42(5):1024-36.

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(Appendix (Appendix A) NeuroIntensiveA) NeuroIntensive Care UnitCare UnitProgressive Upright Mobility Protocol (PUMP) Plus AlgorithmProgressive Upright Mobility Protocol (PUMP) Plus Algorithm

Assess patient (pt.) for the following:•Pt. at risk for/has deconditioning due to immobility? OR•Does pt. require orthostatic training to upright position?

CONTRAINDICATIONS?Include but are not limited to unstable spine, active stroke alerts and/or up to 24hours after receiving tPA or endovascular intervention, increased intracranial HTN, active resuscitation for life-threatening hemodynamicinstability, femoral sheaths, traction, CRRT, aggressivemodes of ventilation and palliative care.

Is the pt. immobile or have ineffective mobility plus one or more of:•Lobar collapse, atelectasis, excessive secretions?•P/F Ratio < 300?•Hemodynamic instability with manual turning (↓O2Sat; ↓BP, ↑HR)?

Assess skin q2hours. Temporarily offload Pressure areas for circulatory recovery. Do not use turning wedges during rotation.

Q shift: assess pt. progress towards expected outcomes; adherence to rotation goals; tolerance to therapy; clinical contra-indications (listed above)…Does the pt. meet CLRT discontinuation criteria:•CXR improved/resolving infiltrates; P/F ratio> 300; stable hemodynamically; improved secretion mgmt; pt. turns self?

PUMP STEPS: Progress each step from 30-60 minutes. Each step must be implemented at least three times/day and more frequently as tolerated. Repeat each step until patient demonstrates clinical tolerance to stated activity/position, then advance to next step, at the next activity period opportunity.* It is highly recommended to coordinate pt. mealtime with mobility steps whenever possible.STEP 1: HOB elevated at 45°STEP 2: HOB elevated at 45°plus legs in dependent position (partial chair mode or cardiac chair)STEP 3: HOB elevated at 45°plus legs in full dependent position (full bed chair mode/cardiac chair)STEP 4: HOB elevated at 65°plus legs in full dependent position & feet on floor & standing in place*If cardiopulmonary intolerance develops, use reverse T-Berg for orthostatic training TID, until resolved.STEP 5: Initiate stand position/pivot and into chairSTEP 6: (PLUS) Transfer standing from bed to chair for 2-3 meals with sitting time not to exceed 45min.STEP 7 (PLUS): Ambulate within room using assistive devices & extra personnel PRN (goal = 20 feet)STEP 8 (PLUS): Ambulate within hallway using assistive devices & extra personnel PRN (goal = 50 feet)STEP 9 (PLUS): Ambulate within hallway using assistive devices & extra personnel PRN (goal = 100 feet)STEP 10 (PLUS): Ambulates 150 ft with contact guard (hands on only for balance) or personnel supervision/assistance (coaching only).STEP 11: (PLUS): Ambulates without coaching or supervision, may use device if necessary.

Initiate/continueCont. Lateral

RotationTherapy (CLRT)

Initiate orcontinue

PUMP Steps

Pt. able toambulate at all?

START HERESTART HERE……

N Y

Y

Proceed to PUMP PLUS

Steps 6 through 11

N

N

Y

N

Y

N

Notify primary MDto prescribe appropriateactivity orders for pt.

Y

Use of a of a Mobility Bundle Toolkit and Technology in a Neurointensive Care Unit

• All patient admitted over 16 month period

• 10 month pre-obs- 6 month post

• 100% Nurse-driven protocol

• One protocol for nurses to follow; all patients

• Mobility goals for patients with or without deconditioning

• Defined steps beyond “chair” to better prepare patients for discharge, earlier

• End point mobility goals similar to outpatient PT goals

Modified from The University of Kansas Hospital Progressive Mobility Algorithm for Critically Ill Patients (http://www.aacn.org/wd/nti2009/nti_cd/data/papers/main31710.pdf© Shands at the University of Florida, 2010Courtesy of J Hester.

Titsworth WL. J Neurosurg, 2012 116:1379-1388

Use of a of a Mobility Bundle Toolkit and Technology in a Neurointensive Care Unit (NICU)

Titsworth WL. J Neurosurg, 2012 116:1379-1388

Mobility was increased among the NICU care patients by 300%

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Protocol Driven Mobility Program: Impacting NICU Outcomes

• Pre-post intervention study

• Large academic NICU

• 637 patients

– 260 pre

– 377 post

• Intervention: Early Progressive Mobility Protocol

– Exclusion criteria

– Readiness criteria

– Started on admission

– Encourage to use ICU bed features & lifts to assist

– Protocol place at bedside

Klein K, et al. Crit care Med, 2015, epub

Protocol Driven Mobility Program: Impacting NICU OutcomesMultivariate analysis done to control for group differences:

K, et al. Crit care Med, 2015, epub

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• One day point prevalence study on early mobilization of mechanically ventilated patients

• 116 ICUs in Germany (2011)

• 783 patients data

• Results– 24% mobilized out of the bed

• Endotracheal tube (8%)• Tracheostomy, (39%)• Noninvasive ventilation(53%)

– Common barriers• Cardiovascular instability (17%)• Deep sedation (15%)

– Out of bed mobilization was not associated with a higher frequency of complications

Where Do We Stand

Nydahl P, et al. Crit Care Med, 2014;42(5):1178-1186

• Surveyed directors of medical and mixed medical surgical ICUs in 4 countries

• Institutions selected a random• Results

• 833 ICUs (US 396; France 151, UK 138, Germany 148)• 27% reported having a formal EM protocol• 21% have adopted him practices without a protocol• 52% have not adopted EM practices• EM protocols applied to both ventilated and non-ventilated upon ICU

admission• Factors associated with EM protocol

– presence of multidisciplinary rounds (US)– written daily goals (US)– Sedation protocol (US)

International Survey of Early Mobilization Practices: Where Do We Stand

Bakhru RN, et al. Amer J of Respir & Critical Care Medicine. 2014;A3933

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How Can We Implement a

Program to Help Patients Achieve

Early Mobility and Potentially

Reduce Organizational Costs?

Utilizing bed systems combined with lifts and a early mobility protocol,caregivers can progress patients from the flat/supine position throughexiting the bed safely, easily, and more often.

This early mobility protocol is a simplified process of small,interventional activities that can be easily accomplished at the bed sidewith a minimum number of caregivers.

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Initial Patient Assessment

Mobility Level Criteria Start at Level 1 if:

PaO2/FiO2 <250

Positive end-expiratory pressure (PEEP) ≥10 cm H2O

O2 saturation <90%

Respiratory rate (RR) Not within 10-30 per min.

Cardiac arrhythmias or ischemia New onset

Heart rate (HR) <60 or >120 beats per min.

Mean arterial pressure (MAP) <55 or >140 mm Hg

Systolic blood pressure (SBP) <90 or >180 mm Hg

Vasopressor infusion New or increasing

Richmond agitation sedation scale (RASS) <–3

Riker sedation-agitation scale (SAS) <3

• Assess patients’ mobility levels within 8 hours of admission to the ICU and reassess at least every 24 hours

Adapted from Bassett RD, et al. Intensive Crit Care Nurs. 2012;28:88-97.

HOB angle – improve VAP protocol compliance• The Centers for Disease Control and

Prevention recommends an HOB angle of 30°-45°, unless contraindicated1

• Visually confirm the HOB is elevated ≥30°to comply with VAP prevention protocols

Activities• Every-2-hour turning• Passive range of motion• 20° Reverse Trendelenburg/Tilt Table with

lower extremity exercises/retracting footboard

Breathe

1. Tablan OC, et al. MMWR Recomm Rep. 2004;53:1-36.

RASS –5 to –3; SAS 1-2 (eg, cannot participate)Patient Assessment

Early Mobility Protocol Level 1: Breathe

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• Continuous lateral rotation therapy (CLRT) can be considered part of early mobility therapy in patients who are at high risk for pulmonary complications1

• CLRT provides side-to-side rotation to help facilitate gravitational effects on pulmonary secretions and blood flow

• Consult the CLRT Quick Reference Guide for additional information

– The CLRT QRG provides information regarding patient assessments and activities to be implemented in both hemodynamically stable and hemodynamically unstable patients

Early Mobility Protocol Level 1: Breathe (Cont.)

1. Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31:270-279.

Breathe

Where Does CLRT Fit Into a Early Mobility Program?

CLRT=continuous lateral rotation therapy; PEEP=positive end-expiratory pressure.

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Activities Activities Activities Activities

Where Does CLRT Fit Into a Early Mobility Program? (Cont.)

CLRT=continuous lateral rotation therapy; PEEP=positive end-expiratory pressure.

CLRT Protocol for HemodynamicallyStable Patients

CLRT Quick Reference Guide

CLRT=continuous lateral rotation therapy.* This tool is provided for education and discussion only. Each facility is responsibility for the development, adoption and implementation of its own protocols. Follow protocols and rules adoptedby your facility.

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CLRT Protocol for HemodynamicallyUnstable Patients

CLRT Quick Reference Guide

CLRT=continuous lateral rotation therapy.* This tool is provided for education and discussion only. Each facility is responsibility for the development, adoption and implementation of its own protocols. Follow protocols and rules adopted by your facility.

Early Mobility Program Protocol Level 1: Breathe (Cont.)

• Move to Level 2 when the patient…– Has acceptable

oxygenation/hemodynamics

– Tolerates every-2-hour turning

– Tolerates HOB>30° or Reverse Trendelenburg 20°

Breathe

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20° Reverse Trendelenburg/Tilt Table position• Tilt Table positioning allows for orthostatic

training in fragile patients1

• If available, use in conjunction with retracting foot section to allow for partial weight bearing prior to sitting up in bed or getting out of bed

Activities• Maintain head of bed ≥30°• Every-2-hour turning• Passive/active range of motion• Legs dependent (partial chair)• PT consultation

Early Mobility Program Protocol Level 2: Tilt

Tilt

1. Trees D, Coale N. Acute Care Perspect. 2007;16:6-9.

RASS >–3; SAS >3 (eg, opens eyes; may have profound weakness)Patient Assessment

Early Mobility Protocol Level 2: Tilt (Cont.)

• Move to Level 3 when the patient…– Tolerates active-assistance exercises 2 times a day

– Tolerates lower extremity exercises against footboard/20° Reverse Trendelenburg

– Tolerates partial chair position (legs dependent/HOB ≥30°)

– Can move arms against gravity

Tilt

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Chair mode (footboard on)• Full upright positioning allows for diaphragmatic

excursion and lung expansion• Sitting with legs in a dependent position

facilitates gas exchange

Activities• Maintain head of bed ≥30°• Every-2-hour turning (assisted)• Active range of motion• Encourage activities of daily living• Dangling• PT/Occupational therapist actively involved

Early Mobility Protocol Level 3: Sit

Sit

RASS >–1; SAS >3 (eg, weak but may move arms/legs independently)Patient Assessment

Early Mobility Protocol Level 3: Sit (Cont.)

• Move to Level 4 when the patient…– Tolerates increasing active exercise in bed

– Actively assists with every-2-hour turning or turns independently

– Tolerates chair position 3 times/day

– Can move leg against gravity

Sit

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Stand Attempts• Chair egress position (footboard off/feet on

the floor)• Consider using a sit-to-stand lift• If tolerates partial weight bearing,

pivot to chair

Activities • Maintain head of bed ≥30°• Every-2-hour turning (self/assisted)• Active range of motion• Encourage activities of daily living• PT/OT actively involved

Stand

Early Mobility Protocol Level 4: Stand

RASS >0; SAS >4 (eg, weak but may tolerate increased activity)Patient Assessment

Early Mobility Protocol Level 4: Stand (Cont.)

• Move to Level 5 when the patient…– Can successfully comply with all activities

– Tolerates trial periods of chair egress position (footboard off/feet on the floor) 3 times a day

– Tolerates partial weight-bearing stand and pivots to chair

Stand

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Early Mobility Protocol Level 5: Move

MoveAchieve “out-of-bed” orders• Utilize mobile floor lift (or ceiling lift) to

ambulate to bedside chair

Activities• Maintain head of bed ≥30°• Every-2-hour turning (self/assisted)• Active range of motion• Encourage activities of daily living• Patient stands/bears weight >1 minute• Patient marches in place• PT/ OT actively involved

RASS >0; SAS >4 (eg, weak but may tolerate increased activity)Patient Assessment

Patients continue to ambulate progressively longer distances as tolerated until they consistently participate and move independently

• Implementation of the early mobility protocol may result in better clinical outcomes and financial outcomes– Clinical outcomes may include patients getting off the ventilator sooner,

less VAP, less potential for skin injury, and a reduction in delirium– Financial outcomes may include decreased ICU LOS, decreased

ventilator days, and decreased hospital LOS

• Use of early mobility is safe– It can be used in patients with ARDS or delirium– It can increase the comfort of staff and patients

• Various tools and techniques can facilitate the implementation of a simple, 5-step early mobility protocol

Summary: Implementing the Early Mobility Protocol Using Technology

ARDS=acute respiratory distress syndrome; LOS=length of stay; VAP=ventilator-associated pneumonia.

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Questions?

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