ICU Adult Early Mobilization Program Egbert Pravinkumar MD

ICU Adult Early Mobilization Program Egbert Pravinkumar, MD, FRCP Associate Professor Department of Critical Care UT MD Anderson Cancer Center Houston, Texas Presented on behalf of the ICU- EMP Task

Objectives • • • Overview Effects of immobility Benefits of early mobility Components of MDACC adult ICU-EMP Outcomes of our pilot program Future expansion of program

Concept of Early Mobility • Phys Therap 1972 – Foss et al, Technique for augmenting ventilation during ambulation • CHEST 1975 – Burns et al, use of special walker

Early and Progressive Mobility • Early Mobility - Mobility program commenced even when patient participation is minimal or none • Progressive Mobility - Series of planned movement in a sequential manner

Adverse Outcomes of Immobility Short-term • Ventilator associated pneumonia • Delayed weaning • Muscle de-conditioning/ weakness • Pressure ulcers Allen C, Lancet 1999 Morris PE, Crit Care Clin 2007

Adverse Outcomes of Immobility Long-term • Increased morbidity/ mortality • Decreased functional capacity • Dependency for ADL • Increased cost of care • Markedly impaired quality of life Herridge MS, NEJM 2003 Hopkins RO, Amer J Resp Crit Care Med 2005

Benefits of Early Mobility • • • Improved outcome at 1 yr post ICU Reduced delirium (ABCDE approach) Improved functional outcomes Decreased IMV days Decreased hospital days Decreased cost of care Morris PE, Am J Med Sci, 2011 Morandi A, Curr Opin Crit Care 2011 Schweickert WD, Lancet 2009

Established Standards vs. Practice • Only 3% of ICU patients were turned as per required standards • Only 50% had some change in body position • The average time between manual turns were 4. 85± 3. 3 hr Krishnagopalan S, Crit Care Med 2002 Goldhill DR, Anaesthesia 2008

Barriers for Early Mobility • • Need for a culture change Perceived harm of mobilization Subjective variations in decisions Disagreement between care givers Lack of structured algorithm Excessive sedation Lack of knowledge of the benefits Lack of tools and trained staff

Early Mobilization Program in Oncological ICU • Purpose: To develop, implement and evaluate an early mobilization program for adult ICU patients in a mixed medical and surgical oncology ICU. • Aim: To increase the average number of mobilization activities per patient day by 40% within an 8 week pilot period

MDACC-Adult ICU EMP • Interdisciplinary team • Design of evidence based EMP algorithm • Pre-implementation – Data collection – Survey on knowledge and perceptions related to mobilization – Education • 8 week trial period from October 2010 through December 2010 - Medical & surgical patients (16/54 ICU beds)

Our Interdisciplinary Team

MDACC-Adult ICU EMP • Interdisciplinary team • Design of an evidence based EMP algorithm • Pre-implementation – Data collection – Survey on knowledge and perceptions related to mobilization – Education • 8 week trial period from October 2010 through December 2010 - Medical & surgical patients (16/54 ICU beds)

EMP Algorithm Highlights • Contraindications • Precautions • Signs of intolerance • PT/OT consult within 24 hours of admission • 5 Levels based on RASS and functional status

EMP: Contraindications § ICP ≥ 15 § RASS +4 § Acute or Uncontrolled Intracranial Event § Fio 2 ≥ 0. 85 on invasive mechanical ventilation § PEEP ≥ 15 / VDR or HFOV § Unsecured airway § § Active cardiac ischemia Uncontrolled arrhythmias Blood pressure instability despite vasopressors Unstable fracture

EMP: Precautions § § § § Continuous dialysis VTE Lumbar drain External ventricular drain Plastic surgery Orthopedic surgery RASS +3 If precautions are present – discuss with team prior to initiating mobilization activity

EMP: Signs of Intolerance § § § RR > 40 Sp 02 < 88% MAP < 50 or > 130 HR < 50 or > 130 Development of any contraindications

Initial 5 -Level EMP

5 -Level Progressive EMP

MDACC-Adult ICU EMP • Interdisciplinary team • Design of evidence based EMP algorithm • Pre-implementation – Data collection – Survey on knowledge and perceptions related to mobilization – Education • 8 week trial period from October 2010 through December 2010 - Medical & surgical patients (16/54 ICU beds)

Data Collection Tool

Survey: Pre-Implementation of EMP • Need for a standardized process • Need for facilitator and mobility team • Variations in MD practices • Concern over tube and line integrity • Head/Neck & Plastic surgery patients • Lack of personnel/equipment • Lack of knowledge and skill

MDACC-Adult ICU EMP • Interdisciplinary team • Design of evidence based EMP algorithm • Pre-implementation – Data collection – Survey on knowledge and perceptions related to mobilization – Education • 8 week trial period from October 2010 through December 2010 - Medical & surgical patients (16/54 ICU beds)

Data for Pilot Program • Total mobilization activities • Average mobilization activities/pt. day • OT/PT activity

Total and Average ICU Mobilization Activities Average Mobilization Activities per Patient Day Total Mobilization Activities 18 650 16 550 14 450 12 350 Pre-Protocol 10 Pre-Protocol 2 -week 4 -week 250 4 -week 8 8 -week 6 150 4 2 50 -50 Nursing PT OT 0 Nursing PT Activities included: ROM, positioning, bed in chair position, splinting, dangle at the edge of bed, out of bed, ADL, and ambulation. OT

Data Summary: PT/OT Consults Total number of visits in Pods C & D (Sep. ’ 10 & Dec. ‘ 10)

Mobilization Activities Pre and Post EMP Mobilization activities* per patient day during pre-protocol period and at 8 weeks: • Nursing: increased by 31% • Occupational Therapy: increased by 86% • Physical Therapy: increased by 78% *Mobilization activities include: bed in chair position, dangle EOB, OOB, ADL and ambulation

Pilot Data Summary • Aim: To increase the average number of mobilization activities per patient day by 40% within an 8 week pilot period 47%

Potential Cost Savings • Based on reduction in ICU-LOS by 1 day Ø Non-ventilated patients [$3, 872/day x 136 pts/month] = $526, 592/month Ø Ventilated patients [$7105/day x 83 pts/month] = $589, 715/month

EMP: Beyond the Pilot Program

Simplified 3 -Level EMP Highlight of Changes • Condensed to 3 Levels • Reduced contents of levels • Incorporation of visual cues

Simplified 3 -Level EMP

Sustainability and Expansion of EMP Number of visits • Feb 1, 2011 - Expanded program to 34/54 ICU beds • May 1, 2011 - Expanded program to 54/54 ICU beds

Staffing and Education • Addition of 2 FT physiotherapist • Addition of 1 FT occupational therapist • On-going targeted education strategies

Visual Cues - Door Signs & Communication Signs

Visual Cues - Room Signs

EMP Research and Publication • Abstract accepted in 2012 SCCM congress • Abstract submitted to 2012 Canadian Respiratory Congress • Oral and poster presentation in Texas and American OT Association • Oral presentation in Texas PT Association • IRB proposal for prospective outcome trial

Special Thanks • Mary Lou Warren, RN, CNS-CC • Shari Frankel, PT, MBA, ATC • Stacy Ryan, PT, DPT, APC • Vi Nguyen, MOT, OTR, RRT • Becky Garcia, RN, BSN • Mini Thomas, RN, CCN • Laura Withers, MBA, RRT • Quan Nguyen, RRT • Ninotchka Brydges, MSN, ACNP-BC Thanks to Leadership of Nursing, Critical Care and Rehabilitation Services Funding provided by Volunteer Endowment for Patient Support (VEPS)

Thank you

Richmond Agitation Sedation Scale

Future Trend

System-Specific Effects of Immobility • • Psychosocial impairment VAP/HCAP, Atelectasis, FVC Reduced CO, autonomic dysfunction Decubitus ulcers, wound healing Critical illness myopathy/ Mm. atrophy Deep vein thrombosis Insulin resistance Greenleaf JE, Exerc Sport Sci Rev 1982 Steven RD, Int Care Med 2007 Hamburg NM, Arterioscler Thromb Vasc Biol 2007, Truong AD, Crit Care 2009

Safety of EMP in Critically Ill • • • Schweikert WD, Lancet 2009; 373: 1874 Morris PE, Crit Care Med 2008; 36: 2238 Bailey P, Crit Care Med 2007; 35: 139 Burtin C, Crit Care Med 2009; 37: 2499 Thomsen GE, Crit Care Med 2008; 36: 1119 • Stiller K, Physiother Theory Pract 2003; 19: 239

EMP: Initial Process Orders are written: Early Mobilization Protocol: PT/OT consult & treat RN 1. Assess patient upon admission 2. Begin nursing interventions based on level 4. Delegate activities to nursing assistant PT/OT 1. Examine patient within 48 hours 2. Reinforce teaching and nursing interventions 3. Develop and implement PT/OT plan based on examination and Mobility Level 5. Update mobility levels & motivational tokens in room