PfP NJ 2.0 Critical Care Webinar Series– Walk This Way ...

PfP NJ 2.0 Critical Care Webinar Series– Walk This Way:

Implementation of Progressive Mobility Program in our ICU

August 24, 2016

ATTENTION

If you are looking to receive CEUs for this program, you must attend the webinar open for at least 80% of the duration AND complete the

evaluation at the end

Hosted by New Jersey Hospital AssociationLauren Rava, MPP

Collaborative FacultyKathleen M. Vollman, MSN, RN, CCNS, FCCM, FAAN

Clinical Nurse Specialist/ Educator/Consultant Advanced Nursing LLC

Agenda

• Brief Partnership for Patients-NJ 2.0 updates• Critical Care Webinar Series – Post ICU

Syndrome: Impacting Long Term Cognitive & Physical Function through Evidence Based Care

• Q&A• Next steps

Goals• Reduce HACs 40% from 2010 baseline• Reduce preventable readmissions 20% from

2010 baseline

*It is important to note a data anomaly for the fall and falls with injury rates for first quarter 2015. The data shows a dramatic increase in rates. There are a couple of possibilities. One, 2015 was a particularly harsh winter and this could have possibly led to increase in falls due the effect with the elderly population. Or two, the data is misrepresented. We are currently investigating the issue and will update with our findings.

Early Mobilization: The Role of the Critical Care Nurse

Kathleen Vollman MSN, RN, CCNS, FCCM, FAANClinical Nurse Specialist/Educator/Consultant

ADVANCING NURSING [email protected]

www.vollman.com © ADVANCING NURSING LLC 2015

mailto:[email protected]

Disclosures

Sage Products LLC Hill-Rom Inc Eloquest Healthcare, Inc

Learning ObjectivesAt the completion of this activity, the participant will be able to:

• Build the will to understand the significance of early mobility

• Identify and discuss key in-bed and out of bed mobility techniques to successfully achieve your early mobility protocol to improve patient outcomes.

• Overcoming barriers and feeling empowered to own patient mobility within your unit.

10

• 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 Function

Knight J, et al. Nurs Times. 2009;105(21):16-20.Vollman KM. Crit Care Nurse. 2010;30:S3-S5.

Respiratory

– 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)1

– On average, ICU patients with VAP had an additional 10.5-day LOS2

– Per case: VAP $40,144. (95% CI, %36,286-$44,220)3

Ventilator-Associated Pneumonia (VAP) Rates

1.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.

2.Restrepo MI, et al. Infect Control Hosp Epidemiol. 2010;31(5):509-515.3.Zimlichman E. et al. JAMA Internal Med, 2013;173(22):2039-46

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 high

– Rate of 35% for HAPII in 1 South Africa Hospital Stage III or IV facility-acquired pressure injury are not reimburses & impact value based purchasing

• The average cost per hospital stay for a patient with a stage III or IV pressure ulcer in the acute care setting is $43,180

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;37:253-264.5. http://www.coloplast.co.za/Documents/South%20Africa/COLOPLAST%20PRESSURE%20ULCER%20SUMMIT%20PRESENTATIONS.pdf/ (Helen

Joseph Hospital)

Setting Facility –Acquired Rates

Critical Care 3.3% to 53.4%

Acute Care 0% to 12%

Siebens H, et al, J Am Geriatr Soc 2000;48:1545-52Topp R et al. Am J of Crit Care, 2002;13(2):263-76Wagenmakers AJM. Clin Nutr 2001;20(5):451-4

Skeletal Muscle Deconditioning

• Skeletal muscle strength reduces 4-5% every week of bed rest (1-1.5% per day)

• Without activity the muscle loses protein• Healthy individuals on 5 days of strict bed rest

develop insulin resistance and microvascular dysfunction

• 2 types of muscle atrophy– Primary: bed rest, space flight, limb casting– Secondary: pathology

Candow DG, Chilibick PD J Gerontol, 2005:60A:148-155Berg HE., et al. J of Appl Physiol, 1997;82(1):182-188Homburg NM,. Arterioscler Thrombo Vasc Biol, 2007;27(12):2650-2656

Siebens H, et al, J Am Geriatr Soc 2000;48:1545-52Topp R et al. Am J of Crit Care, 2002;13(2):263-76Wagenmakers AJM. Clin Nutr 2001;20(5):451-4

Skeletal Muscle Deconditioning• Muscle groups that lose strength most quickly related to

immobilization are those that maintain posture, transferring positions & ambulation.

• > 1/3 of patients with ICU stays greater than two weeks had at least two functionally significant joint contractures.

• Muscle atrophy in mechanically ventilated patients contribute to fatigue of the diaphragm and challenges with weaning.

• Degradation within 6-8 days; continues as long as bedrest occurs

• One day of bed rest requires two weeks of reconditioning to restore baseline muscle strength

Candow DG, Chilibick PD J Gerontol, 2005:60A:148-155Berg HE., et al. J of Appl Physiol, 1997;82(1):182-188Hamburg NM,. Arterioscler Thrombo Vasc Biol, 2007;27(12):2650-2656DeJonnge B, et al. Crit Care Med, 2007;39:2007-2015Zhang et al. 2008 GenomProtBioinf: 6Kortebien et al. 2008 JGerontolMedSci: 63)

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. Average Medical Research Council Scale (MRC) score <4 across all muscles tested.

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

develop ICUAW• Est 75,000 pts in US, 1 million worldwide

Caused By:– Critical illness polyneuropathy, myopathy &/or muscle atrophy– Combination

ICU-Acquired Weakness (ICUAW)

Fan E, et al. Am J Respir Crit Care Med. 2014 Dec 15;190(12):1437-46.Hermans G, et al. Crit Care. 2008;12:238.Jolley SE, et al Chest, 2016; published online

Risk factors:– Severe Sepsis1,6

– Duration of mechanical ventilation1,4

– ICU LOS5,7

– Systemic inflammatory response syndrome2

– Multiple organ failure2,4

– Immobility2,7

– Use of corticosteroids/neuromuscular blockers2,3,5,6,7

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):1214-12246. Penuelas O, et al. J of Intensive Care Medicine, 2016;1-137. Hashem MD, et al. Chest, 2016;doi:10.1016/j.chest2016.03.003

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

Outcomes of Early Mobility Programs

• incidence of VAP• time on the ventilator• days of sedation• incidence of skin injury• delirium• ambulatory distance• Improved function• in hospital readmissions

Staudinger t, et al. Crit Care Med, 2010;38.Abroung F, et al. Critical Care, 2011;15:R6Morris PE, et al. Crit Care Med, 2008;36:2238-2243 Pohlman MC, et al. Crit Care Med, 2010;38:2089-2094Schweickert WD, et al. Lancet, 373(9678):1874-82. Thomsen GE, et al. CCM 2008;36;1119-1124Winkelman C et al, CCN,2010;30:36-60Azuh O, et al. The American Journal of Medicine, 2016, doi:10.106/jmjmed.2016.03.032

Early Mobility Protocol: Impacting Outcomes

• Morris, et al, conducted a prospective cohort study to determine the impact of early mobility therapy using a team on patients who were mechanically ventilated with respiratory failure

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

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

– Therapy initiated within 48 hours of mechanical ventilation

– Therapy 7 days/week until ICU discharge

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

.Morris PE, et al. Crit Care Med. 2008;36:2238-2243.

Early ICU Mobility Therapy

• Baseline characteristic similar in both groups• Protocol group:

– Received as least 1 PT session vs. usual care (80% vs. 47%, p < .001)– Out of bed earlier (5 vs. 11 days, p < .001)– Reduced ICU LOS (5.5 days vs. 6.9 days, p=.025)– Reduced Hospital LOS ( 11.2 days vs. 14.5 days, p =.006)– No adverse outcomes;

• Most frequent reason for ending mobility session was patient fatigue

– Cost• Average cost per patient was $41,142 in the protocol group• Average cost per patient was $44,302 in the control group

Morris PE, et al. Crit Care Med, 2008;36:2238-2243

Results

Early Physical and Occupational Therapy in Mechanically Ventilated Patients

• Prospective randomized controlled trial from 2005-2007

• 1161 screen, 104 patients mechanically ventilated < 72hrs, functionally independent at baseline met criteria

• Randomized to:

– early exercise of mobilization during periods of daily interruption of sedation (49 pts)

– daily interruption of sedation with therapy as ordered by the primary care team (55 pts)

• Primary endpoint: number of patients returning to independent functional status at hospital discharge able to perform activities of daily living and walk (independently)

Schweickert WD, et al. Lancet, 373(9678):1874-82.


Schweickert WD, et al. Lancet, 373(9678):1874-82


Schweickert WD, et al. Lancet, 373(9678):1874-82

• Safe• Well tolerated• duration of

delirium• VFD• Functional

independence at discharge 59% protocol group vs. 35% in control arm

(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

http://www.aacn.org/wd/nti2009/nti_cd/data/papers/main31710.pdf

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%

Protocol Driven Mobility Program: Impacting Neurological 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 Neurological Outcomes

Multivariate analysis done to control for group differences:

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

Multi-Center Pilot Feasibility RCT of Early Goal-Directed Mobilization in the ICU• A pilot randomized controlled

trial.• Five ICUs in Australia and

New Zealand• Fifty critically ill adults

mechanically ventilated for > 24 hours

• EGDM: Early goal-directed mobilization comprised functional rehabilitation treatment conducted at the highest level of activity possible for that patient assessed by the ICU mobility scale while receiving mechanical ventilation. Hodgson CL, et al. Crit Care Med 2016; 44:1145–1152

Median time to randomization 3 daysMedian time ICU adm & EGDM 3 days

Multi-Center Pilot Feasibility RCT of Early Goal-Directed Mobilization in the ICU

• Results– Highest level of activity (IMS) 7.3 versus 5.9 when compared with

controls (p = 0.05)– Proportion of patients that walk was almost double in the EGDM

group (p=0.05)– No difference in hospital stay– Safe and feasible

Environmental Scan of EM Practices

• 687 randomly selected ICU’s stratified by regional density & size- 500 responded (73% response rate)

• Demographics:– 51% academic affiliation, mixed medical/surgical (58%) or

medical (22%) with a median of 16 beds (12–24)– 34% dedicated PT or OT for the ICU– Performed a median of 6 days, 52% began on admission

Bakhru RN, et al. Crit Care Med 2015; 43:2360–2369

Factors associated with EMP:• Dedicated

PT/OT • Written sedation

protocol• Daily MDR• Daily written

goals

ASESSMENT OF PAIN

BREATHE/SAT &SBT

CHOICE OF SEDATION

DELIRIUM

EARLY MOBILITY

FAMILY

A

DE

BC

Balas MC, et al. Crit Care Nurse. 2012 Apr;32(2):35-8, 40-7

F

ABCDE Bundle Reduces Ventilation, Delirium & OOB

• 18 month, prospective, cohort, before-after study• 5 adult ICU’s, 1 step down, 1 oncology unit• Compared 296 patients (146 pre-bundle) & 150

post bundle)• Intervention: ABCDE• Measured:

– For mechanical ventilation patients (187) examined ventilator free days

– All patients examined incidence of delirium, mortality, time to discharge and compliance with the bundle

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

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

Driving Change

Structure

Process

Outcomes

• Gap analysis• Build the Will• Protocol

Development

• Make it Prescriptive

• Overcoming barriers

• Daily Integration

The Goal: Patient & Caregiver Safety

Safe Patient

Handling

Prevention of Pressure Injuries

Patient Progressive

Mobility

Early Mobility

• Head elevation• Manual turning• Passive & Active ROM• 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

Progressive Mobility:Planned movement in a sequential manner beginning at a patients current mobility status and returning them to baseline & includes:

Vollman KM. Crit Care Nurse.2010 Apr;30(2):S3-5.

• Objective• To create a progressive mobility initiative that will help ICU

teams to address key cultural, process and resource opportunities in order to integrate early mobility into daily care practices.

• Methods• Multi-center implementation of key clinical interventions• An evidence-based, user-friendly progressive mobility

continuum was developed, lead by the Clinical Nurse Specialist faculty

• Implementation plan: process design, culture work & education

• 130 patients/3120 prospectively collected hourly observations

• Qualitative and quantitative data collected• 15 process and 5 outcome metrics

• Results reported as cohort and unit specific data

The Mobility Initiative

Bassett RD, et al.Intensive Crit Care Nurs (2012) 2012 Apr;28(2):88-97

Determining Readiness• Perform Initial mobility screen w/in 8 hours of ICU

admission & daily

• PaO2/FiO2 > 250• Peep <10• O2 Sat > 90%• RR 10-30• No new onset cardiac arrhythmias or

ischemia• HR >60 <120• MAP >55 <140• SBP >90 <180• No new or increasing vasopressor

infusion• RASS > -3

Patient Stable, Start at Level II & progress

Yes

Patient is unstable, start at Level I & progress

No

Bassett RD, et al.Intensive Crit Care Nurs (2012) 2012 Apr;28(2):88-97Needham DM, et al. Arch Phys Med Rehabil. 2010 Apr;91(4):536-42

Consensus on Safe Criteria for Active Mobilization

• Systematic review performed than 23 international experts gather to reach consensus

• Respiratory• Cardiovascular• Neurological• Other Considerations

Categories Consensus reach on all criteria. If no other contraindications; vasoactives, endotracheal tube, FIO2 < 60% with SaO2 90% & RR < 30/min were considered safe criteria

Hodgson CL, et. al Critical Care, 2014;18:658

Use of a ICU Mobility Scale (IMS) -Standardizing Language

• Construct and predictive validity were assessed by comparing IMS values at ICU discharge in 192 patients to other variables

• The IMS at ICU discharge demonstrated a moderate correlation with muscle strength(r = 0.64, P ,0.001).

• Significant difference between the IMS at ICU discharge in patients with ICU-acquired weakness vs those without P=0.001).

• Increasing IMS values at ICU discharge were associated with survival to 90 days and discharge home

Tipping CJ, et al. AnnalsATS, 2016;13(6):887-893

Green M, et al. J of Multidisciplinary Health Care, 2016;9:247-256

LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V

Progressive Mobility ContinuumIncludes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated

Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications

RASS -5 to - 3 RASS -3 & up RASS -1 & up

*Mobility is the responsibility of the RN, with the assistance from the RT’s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment.

RASS 0 & up

***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level***For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant

START HERE

RASS 0 & up

Tolerates Level IIActivities

ToleratesLevel IVActivities

Tolerates Level IIIActivities

Ambulate progressively longer distances with less

assistance x2 or x3/day with

RN/PT/RT/UAP

Tolerates Level I

Activities

Refer to the following criteria to assist in

determining mobility level

YESNO

Start at level II and progress*

Start at level I*

o PaO2/FiO2 > 250

o Peep <10

o O2 Sat > 90%

o RR 10-30

o No new onset cardiac arrythmias or ischemia

o HR >60 <120

o MAP >55 <140

o SBP >90 <180

o No new or increasing vasopressor infusion

o RASS > 3

Perform Initial mobility screen w/in 8 hours of ICU

admissionReassess mobility level at

least every 24 hours(Recommended at shift Δ)

Goal: upright sitting; increased strength and

moves arm against gravity

PT consultation prnOT consultation prn

Goal: Increased trunk strength, moves leg against gravity and

readiness to weight bear

PT: Active Resistance Once a day, strength

exercises

OT consultation prn

ACTIVITY:Self or assisted Q 2 hr turning

1.Sitting on edge of bed w/RN, PT, RT assist X 15 min.

2.Progressive bed sitting PositionMin.20 min. 3X/d

OrPivot to chair position 2X/d


1.Bed sitting PositionMin.20 min. 3X/d;

2.Sitting on edge of bed; stand w/ RN, PT, RT assist

3.Active Transfer toChair (OOB) w/ RN/PT/RT assist Min. 3X/d

PT x 2 daily & OT x1 daily


1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day

2.Meals consumed while dangling on edge of bed or in chair

Goal: stands w/ min. to mod. assist, able to

march in place, weight bear and transfer to chair

PT x 2 dailyOT consult for ADL’s

Goal: clinical stability; passive ROM

ACTIVITY:Q 2 hr turning

*Passive /Active ROM 3x/d

1. HOB 45º X 15 min.2. HOB 45º,Legs

in dependant position X 15 min.

3. HOB 65º,Legs in dependantposition X 15 min.

4. Step (3) & full chair mode X20 min. 3X/d

Or Full assist into cardiac

chair 2X/day

ACTIVITY:

HOB > 30º*Passive ROM 2X/d performed by RN, or

UAP_________________

CLRT/Pronation initiated if patient

meets criteria based on institutional

practiceOR

Q 2 hr turning

Goal: Increase distance in ambulation

& ability to perform some ADLs

Do We Even Achieve the Minimum Mobility Standard…

“Q2 Hours”?

• Body position: clinical practice vs standard1

– Study of 74 patients in which the change in body position was recorded every 15 minutes for an average observation time of 7.7 hours

– 49.3% of observed time showed no body position change for >2 hrs, and 2.7% had every-2-hour demonstrable body position change

• Positioning prevalence2

– Prospectively recorded, 2 days, 40 ICUs in the United Kingdom

– Average time between turns, 4.85 hours

How Well Are We Really Doing?

1. Krishnagopalan S, et al. Crit Care Med. 2002;30:2588-2592.2. Goldhill DR, et al. Anaesthesia. 2008;63:509-515.






RASS 0 & up


START HERE

RASS 0 & up






RN/PT/RT/UAP

Tolerates Level I

Activities



YESNO


Start at level I*

o PaO2/FiO2 > 250

o Peep <10

o O2 Sat > 90%

o RR 10-30


o HR >60 <120

o MAP >55 <140

o SBP >90 <180


o RASS > 3










exercises

OT consultation prn
























chair 2X/day

ACTIVITY:


UAP_________________



practiceOR

Q 2 hr turning



Level IRASS -5 to -3

Goal: Clinical Stability,Passive ROM

ACTIVITY:

HOB > 30º*Passive ROM 2X/d performed

by RN, or UAP_________________

CLRT/Pronation initiated if patient meets criteria based on

institutional practiceOR

Q 2 hr turning

ROM Active & Passive• When muscles are immobilize in shorten 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 & strength

Gosslink R, et al. Intensive Care Medicine 2008;34:1188-1199.Perme C, Chandrashekar R. Am J of Crit Care, 2009;18:212-221.Schweickert WD, et al. Lancet, published online May 14, 2009.Griffiths RD, et al. Nutrition, 1995;11:428-432.

Recommended 10 repetitions each extremity x2 daily

Manual Turning: Impact on Pneumonia

• Effect of Post Op Immobilization (Chulay MA et al, CCM, 1982)

– RCT: 35 post op CABG patient– Compared q 2 turning to supine in first 24 hrs post op– Results:

• no problems with Hemo or O2• Patient turned has less fever & 3 day in ICU LOS

• Freq of Turning on Pneumonia (Schallom et. al. 2005)

– Observation: 284 ICU pts for 16/hrs/day x3 days• Mean # of observed turns 9.64 vs. 23 possible

turns/48 hrs)– Results: day 4 patients with pneumonia turned average

8.6x vs. 10.62 without pneumonia

Use of Neuromuscular Stimulation• NMES utilizes skin electrodes

to deliver electrical stimuli to arm and leg muscles to produce visible contractions

• Studies have reported it to be safe, feasible and may have potential benefit in proving muscle mass, strength and function

• A meta-analysis of 35 randomized trials of NMES in healthy adults (n 1345) concluded that, during immobilization, NMES is effective at increasing quadriceps strength.

Bax L, Sports Med 2005; 35:191–212Kho ME, et al. Crit Care Med, 2015;30(1):32-39Parry Sm, et al. Crit Care Med, 2013;41(10):2406-2418Williams N, et al. Physiother Therory Pract, 2014;30(1):6-11

In-Bed Technology

Continuous Lateral Rotation Therapy

Goldhill DR et al. Amer J Crit Care, 2007;16:50-62

• 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

VentDays ICU Days Hospital

Days

Cost toTreat,

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.

CLRT to Prevent VAP

• Prospective randomized controlled trial, 3 medical ICUs at a single center

• Eligible if ventilated < 48 hours & free from pneumonia, ALI or in ARDS

• 150 patients with 75 in each group• 35 CLRT patients allocated to undergo percussion before

suctioning• Measures to prevent VAP were standardized for both groups

including HOB

Methodology

Results: CLRT vs. Control

• VAP: 11% vs. 23% p = .048• Ventilation duration: 8 + 5 days vs. 14 + 23 days, p = .02• LOS: 25 + 22 vs. 39 + 45 days, p = .01• Mortality: no difference

Staudinger t, et al. Crit Care Med, 2010;38.

Systematic Method of Approaching Placement &

Removal of Rotational Therapy

Prone Positioning: The New Evidence

• RCT 466 patients with severe ARDS– Severe ARDS P/F ratio < 150 mm Hg, with

Fio2 0.6, PEEP of at least 5 cm of water, and a Tv to 6 ml per kg of PBW

• Initiation 12-24hrs• Prone-positioning 16hrs/or supine

position• NMB used 5 days• Results:

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

– No differences in complications except > cardiac arrest in supine position

Guerin C. et al. N Engl J Med, 2013

Transition: Level I to Level II

The patient meets the criteria for physiological stability, including cardiovascular, respiratory and neurological






RASS 0 & up


START HERE

RASS 0 & up






RN/PT/RT/UAP

Tolerates Level I

Activities



YESNO


Start at level I*

o PaO2/FiO2 > 250

o Peep <10

o O2 Sat > 90%

o RR 10-30


o HR >60 <120

o MAP >55 <140

o SBP >90 <180


o RASS > 3










exercises

OT consultation prn
























chair 2X/day

ACTIVITY:


UAP_________________



practiceOR

Q 2 hr turning



Level IIRASS -3 & Up

Goal: Upright sitting; increase strength & moves arm against gravity



*Passive /Active ROM 3x/d1.HOB 45º X 15 min.2. HOB 45º,Legs



4. Step (3) & full chair mode X20 min

Or Full assist into cardiac chair

2X/day


Transition: Level II to Level III

The patient meets the mobility goals for level II and is able to move their arm bicep against gravity

An acceptable strength to advance is considered to be a 3/5 with zero being no movement observed against gravity and five being muscle contracts normally against full resistance

Grading Muscle Strength• Grade 5: Muscle contracts normally against full

resistance. • Grade 4: Muscle strength is reduced but muscle

contraction can still move joint against resistance. • Grade 3: Muscle strength is further reduced such that the

joint can be moved only against gravity with the examiner's resistance completely removed. As an example, the elbow can be moved from full extension to full flexion starting with the arm hanging down at the side.

• Grade 2: Muscle can move only if the resistance of gravity is removed. As an example, the elbow can be fully flexed only if the arm is maintained in a horizontal plane.

• Grade 1: Only a trace or flicker of movement is seen or felt in the muscle or fasciculations are observed in the muscle.

• Grade 0: No movement is observed. Medical Research Council. Aids to the examination of the peripheral nervous system, Memorandum no. 45, Her Majesty's Stationery Office, London, 1981






RASS 0 & up


START HERE

RASS 0 & up






RN/PT/RT/UAP

Tolerates Level I

Activities



YESNO


Start at level I*

o PaO2/FiO2 > 250

o Peep <10

o O2 Sat > 90%

o RR 10-30


o HR >60 <120

o MAP >55 <140

o SBP >90 <180


o RASS > 3










exercises

OT consultation prn
























chair 2X/day

ACTIVITY:


UAP_________________

CLRT/Pronationinitiated if patient


practiceOR

Q 2 hr turning



Level IIIRASS -1 to up

Goal: Increased trunk strength, moves leg against gravity and readiness to weight bear

PT x 2 dailyOT consult for ADLs

Tolerates Level III Activities





In-Bed Progressive Mobility

Journey to tolerating upright position, turning, tilt, sitting, standing and walking and out of bed chair sitting can occur quicker through the use of technology

Transition: Level III to Level IV

The patient meets the mobility goals for level III and is able to move their leg against gravity

An acceptable strength to advance is considered to be a 3/5 with zero being no movement observed against gravity and five being muscle contracts normally against full resistance






RASS 0 & up


START HERE

RASS 0 & up






RN/PT/RT/UAP

Tolerates Level I

Activities



YESNO


Start at level I*

o PaO2/FiO2 > 250

o Peep <10

o O2 Sat > 90%

o RR 10-30


o HR >60 <120

o MAP >55 <140

o SBP >90 <180


o RASS > 3










exercises

OT consultation prn
























chair 2X/day

ACTIVITY:


UAP_________________



practiceOR

Q 2 hr turning



Level IVRASS 0 & up

Goal: stands w/ min. to mod. assist, able to march in place, weight bear and transfer to chair

PT x 2 dailyOT consult for ADLs

Tolerates Level IV Activities





Out of Bed Technology






RASS 0 & up


START HERE

RASS 0 & up






RN/PT/RT/UAP

Tolerates Level I

Activities



YESNO


Start at level I*

o PaO2/FiO2 > 250

o Peep <10

o O2 Sat > 90%

o RR 10-30


o HR >60 <120

o MAP >55 <140

o SBP >90 <180


o RASS > 3










exercises

OT consultation prn
























chair 2X/day

ACTIVITY:


UAP_________________



practiceOR

Q 2 hr turning



Level VRASS 0 & up

Goal: Increase distance in ambulation & ability to perform some ADLs

PT x 2 dailyOT x 1 daily




Ambulate progressively longer distances with less assistance

x2 or x3/day with RN/PT/RT/UAP

Early Mobility:Can We Do It?Is it Safe?

Safety

• > 1 % adverse events during 1449 sitting, standing and walking sessions with patients on ventilators.

• Underwent daily sedation interruption followed by PT & OT daily until achieving physical function independence– Safety events occurred in 16% of all sessions

• Loss of 1 arterial line, 1 nasogastric tube, 1 rectal tube

– Therapy was stopped on 4% of all sessions for vent asynchrony, agitation, or both

– Delirium present 53% of the time during therapy sessions

Bailey P, et al. Crit care Med, 2007;35:139-145Pohlman MC, et al. Crit Care Med, 2010;38:2089-2094

Challenges to Mobilizing Critically Ill Patients

• Patient –related barriers (50%)– Hemodynamic instability, ICU

devices, physical & neuropysch• Structural (18%)

– Human or Technological Resources• ICU culture (18%)

– Knowledge/Priority/Habits• Process related (14%)

– Service delivery/lack of coordination– Clinician function

Potentially Modifiable Barriers

Dubb R, et al, Annual ATS, 2016 in press

Evidence Based Strategies to Overcome Barriers

• Patient –related barriers – Hemodynamic instability

• Structural– Human & technological resources

• ICU culture (18%)– Knowledge/Priority/Habits

• Process related (14%)– Service delivery– Clinician function


HemodynamicInstability

Is it a Barrier to Positioning?

???

50% reported in studies as the # 1 patient barrier

• 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

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.

Evidence Based Strategies to Overcome Barriers

• Patient –related– Inclusion, exclusion criteria, protocols, research on

specific equipment for safety (CCRT, etc.)• Structural

– Development and implementation of protocols, increase staffing & purchase of equipment

• ICU culture – Education, training, coaching, video’s, improve

coordination between professionals • Process related

– Interprofessional meetings and rounds, sharing clinical responsibility, collaboration with champions, remove default orders


It Takes a Village For Sustainability1. Necessary Components for

Early Rehab• Buy-in• Multiple disciplines• Team communication• Opinion leader• Individual discipline champion• Dedicated rehab personnel• Equipment• Sedation practice• Administrative funding

2. Implementation Strategies• Team center approach• Staff education• Strength & quality of evidence

3. Perceived Barriers• Increase workload• Safety concerns

4. Positive Outcomes • Improved patient outcomes• Staff satisfaction• Changed culture• Financial savings

Eakin MN, et al. J of Crit Care, 2015;30:698-704

Ensuring Safety & Success

• Mobility readiness assessment

• Determining absolute contraindications for any mobility protocol

• Criteria for stopping a mobility session

• Changing the culture• Sufficient resources and

equipment to make it easy & safe to do

Financial Model for Cost Effectiveness

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

The Goal: Patient & Caregiver Safety

Safe Patient

Handling

Prevention of Pressure Injuries

Patient Progressive

Mobility

↓ Hospital LOS↓ ICU LOS↓ Skin Injury↓ CAUTI↓ Delirium↓ Time on the vent

↓ Repetitive motion injury↓ Musculoskeletal injury↓ Days away from work↓ Staffing challengesLoss of experienced staffNursing shortage

↓ Skin Injury↓ Costs↓ Pain and suffering↓ Hospital LOS↓ ICU LOS

It is not enough to do your best, you have to know what to do and then do your best.

E Deming

Questions?

Next Steps

• Please complete survey to receive your attendance certificate and CEUs

• Continue to submit data – Next webinar: September 27, 1pm: One Is Too

Many: Going Beyond Guidelines to Prevent Catheter-Associated Urinary Tract Infections