ICU Liberation How Physical Therapy Is Part of

ICU Liberation: How Physical Therapy Is Part of Reducing the Harms of Critical Illness Presented by Heidi Engel, PT, DPT UCSF Department of Rehabilitative Services University of California San Francisco Medical Center heidi. engel@ucsf. edu February 2015

Disclosures Academic work in the ICU setting for Heidi Engel, PT, DPT is funded by a grant from the Gordon and Betty Moore Foundation

Objectives • Explain the importance of providing early physical rehabilitation to patients in the ICU • Reinforce and define the role of Physical Therapists in providing care to critically ill patients as part of an interprofessional collaborative care ICU team • Define the barriers to ICU early physical rehabilitation and suggest solutions to overcome those barriers • Cite patient case studies that illustrate Physical Therapy clinical decision making in the ICU setting

Course Outline • Complex ICU case presentation emphasizing unique psycho-social aspects of ICU early physical rehabilitation • Consequential harms to patients as a result of an ICU stay- weakness, immobility, delirium, long term functional and cognitive impairments • Recommendations from Society of Critical Care Medicine outlined • Example ICU early rehabilitation programs • Assessing how we are doing • Barriers- looking at 3 issues at the bedside keeping patients immobile- immobility is safety, timing and priorities, staffing and equipment • ICU case presentation illustrating unique role of Physical Therapists

Society of Critical Care Medicine ICU Liberation. Free Your Patients from Potential Harms ICU Acquired Weakness (ICUAW) Immobility Delirium Long term cognitive impairments Functional decline Inability to return to previous employment or activities of daily living

Why Early ICU Patient Mobility? Diaphragm muscle thinning and atrophy begins within 18 to 48 hours after intubation Levine, S. , T. Nguyen, et al. (2008). Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM: (2012). Rectus Femoris protein breakdown begins within 24 hours of ICU admission, cross sectional area declining rapidly during first week Puthucheary ZA, Rawal J, Mc. Phail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS et al (2013).

ICU Acquired Weakness Change in architecture of muscle fibers within 18 to 69 hours Loss of bone mineral density, bone adapts to the load placed on it, ALI patients have 19% greater risk of fracturing, 10 day study with average patient age of 55 Frailty: Fried Frailty Index, hallmark is neuromuscular weakness, every 1 pt increase equal to 3 X increased risk of 6 month mortality, 82% of older Icu survivors qualify as frail Kress JP, Hall JB (2014). Puthucheary ZA, Rawal J, Mc. Phail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS et al (2013) Baldwin MR, Reid MC, Westlake AA, Rowe JW, Granieri EC, Wunsch H, Dam TT, Rabinowitz D, Goldstein NE, Maurer MS et al: (2014).

Why Early ICU Patient Mobility? The duration of bed rest during critical illness was consistently associated with weakness throughout 24 -month follow-up. Fan E, Dowdy DW, Colantuoni E, Mendez-Tellez PA, Sevransky JE, Shanholtz C, Himmelfarb CR, Desai SV, Ciesla N, Herridge MS et al (2013). Based on available evidence, early exercise/PT seems to be the only treatment yet shown to improve long-term physical function of ICU survivors. Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA (2013).

Society of Critical Care Medicine Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium (PAD) Guidelines Barr J, et al. , Critical Care Medicine 2013 Interpretation of PAD Guidelines Quality of evidence: statements and recommendations – High (A) – Moderate (B) – Low/Very Low (C) Strength of recommendations: recommendations only – Either strong (1) , weak (2), or none (0) – Either in favor of an intervention (+) or against an intervention (-)

Outcomes Associated with Delirium in ICU Patients i. Delirium is associated with increased mortality in adult ICU patients (A). ii. Delirium is associated with prolonged ICU and hospital lengths of stay in adult ICU patients (A). iii. Delirium is associated with the development of post-ICU cognitive impairment in adult ICU patients (B).

Depth of Sedation in ICU Patients i. Light levels of sedation associated with improved clinical outcomes (e. g. , shorter duration of mechanical ventilation and a shorter ICU length of stay) (B). ii. Light levels increase physiologic stress response, but is not associated with an increased incidence of myocardial ischemia (B). iii. The association between depth of sedation and psychological stress in these patients remains unclear (C).

Depth of Sedation in ICU Patients (cont. ) iv. Recommend that sedative medications be titrated to maintain a light rather than a deep level of sedation, unless contraindicated (+1 B). v. Recommend routinely using either daily sedation interruption or targeting light level of sedation in MV patients (+1 B).

Delirium Prevention We recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium (+1 B) Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al (2013) Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D et al: (2009) Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E (2010).

Functional Decline Related to ICU Stay Long Term Problem – 3. 3 year median follow up after d/c from trauma ICU 100 patients • 70% consider themselves less active than pre-injury • 49% returned to work. Livingston DH, Tripp T, Biggs C, Lavery RF (2009). More than 6 years after a surgical ICU admission, HRQOL is largely reduced. Many patients still have a variety of health problems, including decreased cognitive functioning. Timmers, T. K. , M. H. Verhofstad, et al. (2011).

ICU Liberation Project of SCCM www. iculiberation. org & www. icudelirium. org SYMPTOMS PAD GUIDELINES MONITORING CARE TOOLS ABCDEF BUNDLE Assess / Treat Pain PAIN BPS Awakening Trials - SATs NPS Breathing Trials - SBTs Coordination of Care Choice of Sedatives CPOT AGITATION RASS SAS DELIRIUM CAM-ICU ICDSC Delirium Reduction Diseases, Drug Removal, Environment e. g. , sleep, noise, eye glasses, hearing aids Early mobility and Exercise Family - Communication and Involvement

Neurocognitive and Functional Benefits to ICU Patients Schweickert WD, Pohlman MC, Pohlman AS, et al. (2009). RCT- 104 patients on mechanical ventilation intervention group- PT median of 1. 5 days intubation control group- PT median of 7. 4 days Intervention groupless days of delirium and MV 59% return to independent function at hospital discharge 35% in control group.

Role Models- LDS Medical Center • LDS Medical Center Mobility Protocol • Walk 200’ prior to extubation • Walk 400’ prior to ICU discharge – When patients appear not to have strength to do both reconditioning and weaning, support reconditioning first, then weaning. – Support work of breathing during physical activity. – Advance activity aggressively NOT progressively, patients will do the most that they can do at any given time.

UCSF ICU Early Mobilization Started March 1 st, 2010 9 ICU • Physical Therapy coverage 8 hours/day 5 or 6 days/week in 9 ICU • Objective- referrals for physical therapy within 48 hours of patient admission to the ICU • Objective- most ICU patients ambulating during their ICU stay • Goals- – patients wean ventilators faster – sleep better/experience less delirium – leave the ICU sooner

Staffing and Equipment UCSF- one full time PT added No additional RN or RT staff ICU platform walker, ear plugs, eye masks, seating cushions PTs mobilize patients to higher level than RNs Garzon-Serrano, J. , C. Ryan, et al. (2011).

UCSF Exclusion Guidelines Patients with immediate plans to transfer to outside hospital Patients who require significant doses of vasopressors for hemodynamic stability (maintain MAP> 60) Mechanically ventilated patients who require Fi. O 2. 8 and/or PEEP >12, or have acutely worsening respiratory failure Patients maintained on neuromuscular paralytics Patients in an acute neurological event (CVA, SAH, ICH) with re-assessment for mobility every 24 hours Patients with RASS less than -3 or greater than +2 Patients with unstable spine or extremity fractures Patients with a grave prognosis- transferring to comfort care Patients with open abdomen, at risk for dehiscence

How Are We Doing? Point Prevalence Studies: Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, Kaltwasser A, Mende H, Rothaug O, Schuchhardt D et al: (2014) In this 1 -day point-prevalence study conducted across Germany only 24% of all mechanically ventilated patients OOB only 8% of patients with an endotracheal tube were mobilized out of bed as part of routine care.

How Are We Doing? Point Prevalence Studies: Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas PJ, Denehy L (2013). 45% were mechanically ventilated 140 patients (28%) completed an in-bed exercise regimen 93 (19%) sat over the side of the bed 182 (37%) sat out of bed 124 (25%) stood 89 (18%) walked Predefined adverse events occurred on 24 occasions (5%) No patient requiring mechanical ventilation sat out of bed or walked

How Are We Doing? Point Prevalence Studies: Terri Hough University of Washington Medical Center, Presenting at The 7 th International Physical Medicine and Rehabilitation of Critically Ill Patients Meeting 5/17/2014, Across the US: 64% of ICU patients experienced any activity 50% of those were bed level activity 20% of those were transfers to a chair 10% of those were walking Profoundly variable practice patterns

How Are We Doing? ICU Early Mobility Protocols Critical Care Medicine February 2014 Survey of 69 ICUs across the United States looking at structure, process, and outcomes 97 -99% have protocols for ventilator management, infection control, nutrition, and VTEs 36% have an Early Mobility protocol, all requiring a MD Order to initiate (A Process Barrier) Checkley W, Martin GS, Brown SM, Chang SY, Dabbagh O, Fremont RD, Girard TD, Rice TW, Howell MD, Johnson SB et al : (2014).

Resulting Harm to Patients “ Tracheostomy, female gender, higher Charlson Comorbidity Index and lack of early ICU mobility were associated with readmissions or death during the first year. Although the mechanisms of increased hospital readmission are unclear, these findings may provide further support for early ICU mobility for patients with acute respiratory failure. ” Morris PE, Griffin L, Berry M, Thompson C, Hite RD, Winkelman C, Hopkins RO, Ross A, Dixon L, Leach S et al (2011).

How are we doing in the hospital overall? 32 % of older patients not engaged by an RN in ANY mobility event during an 8 -hour period. Mean duration of ambulation was less than 2 minutes. Mean age 74. 6, 55. 3% using an assistive device, 95. 6% had an MD order for out of bed activity, none met criteria for dependent patient. Average length of stay 6. 7 days Doherty-King B, Yoon JY, Pecanac K, Brown R, Mahoney J (2014)

After Patients Leave the ICU? Of the 72 patients who participated in the study 65 had either a physical therapy consultation or a request for nursing assistance with ambulation at ward transfer (90%) Activity level decreased in 40 participants (55%) on the first day Of the 61 participants who ambulated 100 ft or more on the last RICU day (85%) 14 did not ambulate, 22 ambulated less than 100 ft (59%) 25 ambulated 100 ft or more on the first ward day (41%) Hopkins RO, Miller RR, 3 rd, Rodriguez L, Spuhler V, Thomsen GE: (2012).

Mobility is Medicine Health Benefits of Physical Activity Improves blood sugar homeostasis Enhances cardiovascular function Enhances endothelial function Decreases chronic inflammation Regulates hormone levels Preserves musculoskeletal and neuromuscular integrity Decreases depression and improves cognition Warburton DE, Nicol CW, Bredin SS. (2006).

Barriers to Implementation • • • Nervous or skeptical clinicians Minimal resources allocated Awkward equipment PT referrals still too late Unclear protocol Mobility prior to extubation is difficult concept Rotating and changing personnel Variations in sedation practices New hospital and discharge course predictions required for ICU and floor personnel Pawlik AJ, Kress JP. (2012).

3 Common Issues Keeping an ICU Patient Immobile Are we patient centered or screen centered in our practices? Immobility is Safety Timing and Priorities Staffing and Equipment

Issue # 1. Immobility is Safety: TRUE: The patient is too sick, or too big New onset sepsis or respiratory distress (think of hours NOT days) Unstable bleeding or surgical site Terminal disease (comfort care measures), Comatose Acute unstable cardiovascular event

Solution # 1. Awake and Mobile is Safer Collaborate with RN, RT, MD Use Clinical judgment Every diagnosis in context Delay increases risk later

Essential Information to Share • Medical History- impact of the chronic, plus current level of acuity • Physiologic Reserve • Motivation and Goals- what are patient expectations? • Cognition- anxiety, delirium, co-morbidity • Pain • Sedation- why is this patient being sedated? • Extubation- how is the patient tolerating breathing trials? • Procedures- dialysis, IR, CT scan?

Context Is it a beautiful sunny day after so much rain, or are we in the middle of a drought?

Solution # 1. Awake and Mobile is Safer The patient is too sick, or too big FALSE: The patient has a DVT (reference the American College of Chest Physicians 2012 guidelines: people with acute DVT do not need a period of bed rest) FALSE: The obese patient was admitted able to walk at home (think of how crucial prevention can be) FALSE: The patient is on ARDS Net Protocol FALSE: The patient is a new admit to the ICU

Consider the Patient Physiologic Reserve, their Personal Fitness Account Did this patient walk into your hospital? What has the patient done in the past 2 days, 2 weeks, 2 months, 2 years? What are your assumptions?

Issue # 1. Immobility is Safety Excuse: The patient is too lethargic, tired? RASS -2 to -4 Hypoactive delirious Target RASS vs Actual RASS Goal targeted sedation?

Richmond Agitation Sedation Scale (RASS) icudelirium. org +4 Combative Overtly combative, violent, immediate danger to staff +3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive +2 Agitated Frequent non-purposeful movement, fights ventilator +1 Restless Anxious but movements not aggressive vigorous 0 Alert and calm -1 Drowsy Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice (>10 seconds) -2 Light sedation Briefly awakens with eye contact to voice (<10 seconds) -3 Moderate sedation Movement or eye opening to voice (but no eye contact) -4 Deep sedation No response to voice, but movement or eye opening to physical stimulation -5 Unarousable No response to voice or physical stimulation

Solution to when the patient is too lethargic Collaborate with RN, RT, MD Use Clinical judgment Every level of delirium in context Consider the environment, disease, medications Delirium is treated with mobility • Target RASS Zero

ICU Sleep Promotion Programs Consider the Noise level Lighting Night time routines Circadian Rhythms Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG et al (2013). Kamdar BB, Needham DM, Collop NA: (2012).

Solution# 2. Mobility will re-orient and decrease lethargy The patient may respond well to being up and communicating Include the family in patient care activities

Solution # 3. The patient is too agitated, awake and re-oriented helps Society of Critical Care Medicine Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium “We recommend performing early mobilization of adult ICU patients whenever feasible to reduce the incidence and duration of delirium” (+1 B) Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al (2013).

What About All Those Critical Lines? Patient lines and drains can be accommodated Including Femoral Lines Mechanical ventilation and CVVH lines Damluji, A. , et al. (2013). Winkelman, C. (2011).

Issue #2 Timing and Priorities: The patient is leaving The patient is going for: A procedure A CT scan Transferring to the floor Will be extubated soon

Solution: Mobility Is High Priority Activity Trumps Extubation: A pre- and post-activity rest period with assist-control ventilation for 30 min was employed as needed to support early activity. If the patient was intubated and able to participate in activity, the FIO 2 was increased by 0. 2 before initiation of activity. We deferred ventilator weaning in support of activity, as necessary. Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriquez L, Hopkins RO: (2007).

Issue #2 Timing and Priorities: The patient needs a nap The patient Had a bad night Feels tired Didn’t sleep last night Wants to sleep now to make up for it Kamdar BB, Needham DM, Collop NA (2012).

Solution for Timing and Priorities: The Patient Needs a Short Rest Schedule a time Create a sleep hygiene program in your ICU Address night staff as well as day Set circadian rhythms

Issue #3 Staffing/Equipment : No one is available to manage the lines No portable ventilator No high back chairs No minimal lift equipment No full time PT Where are family members?

Solution for Staffing/Equipment: Overcome the Barriers Establish the program for your local culture Begin with the easier smaller success stories Collect data to evaluate and re-evaluate Make a Financial case Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM: ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care Med 2013, 41(3): 717 -724. Kress JP: Sedation and mobility: changing the paradigm. Crit Care Clin 2013, 29(1): 67 -75.

Solution: Consider Patients Expectations and Patient Centered Goals Returning to life as they knew it Not a new life of disability or perpetual patient Include Family in patient care activities Misak C. (2005). Muller M, Strobl R, Grill E. (20110>

Solution to Staffing Equipment : the PT is not here • Seeing is believing • Create learning opportunities • Build the case for a full time dedicated ICU PT • Collect Data! • Plan ahead and coordinate care • Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM (2013).

Sitting on the Edge of the Bed Trunk control Vestibular training Joint compression Joint/muscle stretching Lung expansion Airway clearance Aerobic exercise? (Yes!) GI motility Orientation, mental status Endurance

Walking in the ICU

Allowing our patients to communicate their needs Assessing and treating pain first Preventing PTSD Journaling the experience

In Summary Critical illness is catabolic and depleting, rapidly and potentially lasting for years A prolonged ICU stay can cause delirium and cognitive changes for most patients Mobility (mostly walking) combined with minimal or no sedation started at the beginning of an ICU stay is protective and preventative Approach the task with structured QI project, collaboration, barrier identification

References • Levine, S. , T. Nguyen, et al. (2008). "Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. " N Engl J Med 358 (13): 1327 -1335. • Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM: Diaphragm muscle thinning in patients who are mechanically ventilated. Chest 2012, 142(6): 14551460. • Puthucheary ZA, Rawal J, Mc. Phail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS et al: Acute Skeletal Muscle Wasting in Critical Illness. Jama 2013. • Kress JP, Hall JB: ICU-acquired weakness and recovery from critical illness. N Engl J Med 2014, 370(17): 1626 -1635. • Puthucheary ZA, Rawal J, Mc. Phail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS et al: Acute Skeletal Muscle Wasting in Critical Illness. Jama 2013. • Baldwin MR, Reid MC, Westlake AA, Rowe JW, Granieri EC, Wunsch H, Dam TT, Rabinowitz D, Goldstein NE, Maurer MS et al: The feasibility of measuring frailty to predict disability and mortality in older medical intensive care unit survivors. J Crit Care 2014, 29(3): 401 -408.

References • Schefold, J. C. , J. Bierbrauer, et al. (2010). "Intensive care unit-acquired weakness (ICUAW) and muscle wasting in critically ill patients with severe sepsis and septic shock. " J Cachex Sarcopenia Muscle 1 (2): 147 -157 • Fan E, Dowdy DW, Colantuoni E, Mendez-Tellez PA, Sevransky JE, Shanholtz C, Himmelfarb CR, Desai SV, Ciesla N, Herridge MS et al: Physical Complications in Acute Lung Injury Survivors: A 2 -Year Longitudinal Prospective Study. Crit Care Med 2013. • Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA: Interventions to improve the physical function of ICU survivors: a systematic review. Chest 2013, 144(5): 1469 -1480. • Gunther ML, Morandi A, Krauskopf E, Pandharipande P, Girard TD, Jackson JC, Thompson J, Shintani AK, Geevarghese S, Miller RR, 3 rd et al: The association between brain volumes, delirium duration, and cognitive outcomes in intensive care unit survivors: the VISIONS cohort magnetic resonance imaging study*. Crit Care Med 2012, 40(7): 2022 -2032.

References • Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013, 41(1): 263 -306. • Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D et al: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009, 373(9678): 1874 -1882. • Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E: Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010, 91(4): 536 -542. • Livingston DH, Tripp T, Biggs C, Lavery RF. A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit. J Trauma. Aug 2009; 67(2): 341 -348; discussion 348 -349 • Timmers, T. K. , M. H. Verhofstad, et al. (2011). "Long-term quality of life after surgical intensive care admission. " Arch Surg 146 (4): 412 -418

References • Sacanella E, Perez-Castejon JM, Nicolas JM, Masanes F, Navarro M, Castro P, et al. Functional status and quality of life 12 months after discharge from a medical ICU in healthy elderly patients: a prospective observational study. Crit Care. 2011; 15 (2): R 105 • Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. May 13 2009 • Garzon-Serrano, J. , C. Ryan, et al. (2011). "Early Mobilization in Critically Ill Patients: Patients' Mobilization Level Depends on Health Care Provider's Profession. " PM R 3(4): 307 -313 • Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, Kaltwasser A, Mende H, Rothaug O, Schuchhardt D et al: Early mobilization of mechanically ventilated patients: a 1 -day point-prevalence study in Germany*. Crit Care Med 2014, 42(5): 1178 -1186. • Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas PJ, Denehy L: Intensive care unit mobility practices in Australia and New Zealand: a point prevalence study. Crit Care Resusc 2013, 15(4): 260 -265.

References • Checkley W, Martin GS, Brown SM, Chang SY, Dabbagh O, Fremont RD, Girard TD, Rice TW, Howell MD, Johnson SB et al: Structure, process, and annual ICU mortality across 69 centers: United States critical illness and injury trials group critical illness outcomes study*. Crit Care Med 2014, 42(2): 344 -356. • Morris PE, Griffin L, Berry M, Thompson C, Hite RD, Winkelman C, Hopkins RO, Ross A, Dixon L, Leach S et al: Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci 2011, 341(5): 373 -377. • Doherty-King B, Yoon JY, Pecanac K, Brown R, Mahoney J: Frequency and duration of nursing care related to older patient mobility. Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing / Sigma Theta Tau 2014, 46(1): 20 -27. • Hopkins RO, Miller RR, 3 rd, Rodriguez L, Spuhler V, Thomsen GE: Physical therapy on the wards after early physical activity and mobility in the intensive care unit. Physical therapy 2012, 92(12): 1518 -1523. • Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. Cmaj. Mar 14 2006; 174(6): 801 -809.

References • Pawlik AJ, Kress JP. Issues Affecting the Delivery of Physical Therapy Services for Individuals With Critical Illness. Phys Ther. 2012. • Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG et al: The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Crit Care Med 2013, 41(3): 800 -809. • Kamdar BB, Needham DM, Collop NA: Sleep deprivation in critical illness: its role in physical and psychological recovery. Journal of intensive care medicine 2012, 27(2): 97 -111. • Damluji, A. , et al. (2013). "Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit. " J Crit Care. • Winkelman, C. (2011). "Ambulating with pulmonary artery or femoral catheters in place. " Crit Care Nurse 31(5): 70 -73.

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