Success with Early Mobility in Critical Care

February 10,2012

Property of Amy J. Pawlik, not to be copied without permission 1

SUCCESS WITH EARLY MOBILITY IN CRITICAL

CARE

Combined Sections Meeting 2012Chicago, IL

February 8-11, 2012

Amy J. Pawlik, PT, DPT, CCSUniversity of Chicago Medical Center

Course Description• The increasing body of literature published on the subject of early mobility in

critical care is securing this intervention as a necessary component to consider in the management of patients experiencing critical illness. Recent research describes improvements in patient outcomes when Physical and Occupational Therapy interventions are paired with daily interruption of sedation in patients who are mechanically ventilated. These outcomes include increased functional independence, decreased neurocognitive complications of critical illness including the presence of ICU-acquired delirium and decreased hospital and ICU length of stay. Despite the mounting evidence to support this intervention, the implementation of an early mobility program in many ICUs can be difficult. Barriers such as coordinating care to hold sedation, ensuring competency of intervening therapists, determining equipment needs and gaining support of nurses, physicians and hospital administration can challenge therapists who hope to change practice in their ICUs. This presentation aims to identify short and long-term complications encountered by survivors of critical illness, describe early mobility as an intervention to prevent and manage the negative sequelae of critical illness, identify the physical therapist's role in an early mobility team and address potential barriers to implementing an early mobility program in the ICU.

Objectives

• Understand the incidence of critical illness and the resultant functional and cognitive impairments

• Discuss recent interventions found to improve patient outcomes

• Describe essential components to consider when creating successful early intervention programs

• Address potential barriers that may arise when developing an early intervention program in the ICU including coordinating care to hold sedation, ensuring competency of intervening therapists, equipment needs and gaining support of nurses, physicians and hospital administration

Why is Therapy Important in the ICU?

• Advancements in medical care leading to increased survival – Approx. 5,000,000 survivors annually – 540,000 deaths

• Patients suffer from long-term complications– Neuromuscular weakness– Neuropsychiatric, cognitive dysfunction– Especially patients with respiratory failure/MV

Mechanical Ventilation in ICU

• Aggressive sedation/analgesia

• Driven by concerns about causing harm to the patient:– Patient-ventilator dyssynchrony– Self-extubation– Psychological burdens

• Fear, anxiety, pain

Success with Early Mobility in Critical Care

February 10,2012

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• VAP• Delirium• Bed sores• GI dysmotility• Malnutrition• Deconditioning• ICU-AW• Joint contractures

Immediate Risks Prevalence of Neuromuscular Weakness

Occurs in 25-100% of ICU survivors– Inflammation– Hyperglycemia– Drugs (corticosteroids, etc)– Immobility

Neuromuscular Weakness

• Difficulty weaning from ventilator• Prolonged ventilation

• Mortality

“Lets wait until tomorrow for therapy”…

• Muscle strength in a healthy individual can decrease 1.3-3% per everyday spent on bedrest

• Effects are more profound in older individuals and those suffering from critical illness

Rapid muscle deterioration

•18-69 hours of inactivityPLUS

•Mechanical ventilation

Marked atrophy of human diaphragm myofibers

Delirium in the ICU

• Acute, fluctuating change in mental status, with inattention and an altered level of consciousness.

• Occurs in the majority of ICU patients– 70–80% of pts undergoing MV– ~70% of ICU pts > 65 years old– Decreased risk in younger patients

• 57% of pts < 65yo become delirious in the ICU

Success with Early Mobility in Critical Care

February 10,2012

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Impact of delirium

• Can occur very early in hospitalization – Onset ICU day 2 (+/- 1.7 days)

• Proven to impact….– Length of hospital stay– Mortality

• Impairs a person’s ability to complete basic functions such as ADL’s and IADL’s

“For each day of delirium, 1-yr mortality increased by 10%”

Pisani MA et al., AJRCCM 180: 1092

Long-Term Cognitive and Mental Health Impairments

• 50% of ICU survivors have cognitive impairments 1-2 years post ICU d/c– Memory, attention, executive function, and

slowed processing

• 20-25% have symptoms of PTSD 1-year post ICU (some have symptoms 8+ yrs. )– Depression, anxiety, and impaired sleep

• Symptoms can be mild and can go undiagnosed

Post-Traumatic Stress Disorder

• PTSD associated with – Recall of delusional memories– Prolonged sedation– Physical restraint with no sedation

Recovery?Long-Term Effects of Neuromuscular Disease

Herridge, MS et al. NEJM 348: 8, 2003

Success with Early Mobility in Critical Care

February 10,2012

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Mobility Deficits LongMobility Deficits Long--TermTerm

Herridge, et al. NEJM 2011Herridge, et al. NEJM 2011Herridge, et al. NEJM 2011Herridge, et al. NEJM 2011

Long-Term Quality of Life Deficits

Herridge, et al. NEJM 2011Herridge, et al. NEJM 2011Herridge, et al. NEJM 2011Herridge, et al. NEJM 2011

Pulmonary Function after Pulmonary Function after ARDS….ARDS….

Herridge, MS et al. NEJM 348: 8, 2003

What to do?What to do?

Intervention (wake-up)

Control P

N 68 60

MV duration, d

4.9 (2.5-8.6) 7.3 (3.4-16.1)

0.004

ICU LOS, d 6.4 (3.9-12.0)

9.9 (4.7-17.9)

0.02

Hosp LOS, d

13.3 (7.3-20.0)

16.9 (8.5-26.6)

0.19

% ICU days “awake”, able to follow commands

Control 9%, Intervention 85.5%; P < 0.001

Discharge to homeControl 40%, Intervention 59%; P = 0.06

•• Symptoms of PTSD Symptoms of PTSD –– Impact of Events ScoreImpact of Events Score

•• 27.3 27.3 ±± 19.2 [Control] vs. 11.2 19.2 [Control] vs. 11.2 ±± 14.9 14.9 [DSI]; P = 0.02[DSI]; P = 0.02

•• PTSD by DSM IV criteriaPTSD by DSM IV criteria

–– 6/19 [C6/19 [Controlontrol] vs. 0/13 [DSI]; P = 0.06] vs. 0/13 [DSI]; P = 0.06

Success with Early Mobility in Critical Care

February 10,2012

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Algorithm Control p Value

Duration MV, d 4.4 (2.1 - 9.8) 10.3 (3.5 - 17.2) 0.014

ICU LOS, d 8.0 (4.0 - 18.1) 15.0 (6.4 - 24) 0.043

Time to Awakening, d 2 (2 - 5) 4 (2 – 9) 0.006

Pressure Sores 18.6% (n=9) 37.0% (n=20) 0.04

Unplanned extubation 2.1% (n=1) 7.4% (N=4) 0.4

De Jonghe B et al. Sedation Algorithm in Criticall y Ill Patients without Acute Brain Injury

Girard TD, et al. ABC Trial Results

I’m awake…I’m awake…

Now what?

Feasibility Study

• RICU• Mechanically ventilated >4 days prior to

enrollment• Time to activity from initial ICU

admission=6.6 + 5.5 days– 69% ambulated >100’ at ICU discharge– Few adverse events

Morris PE, et al. CCM 2008;36:2238

• RESULTS—Protocol patients– At least one PT session (80% vs. 47%, p < 0.001)– Out of bed earlier (5 vs. 11 days, p < 0.001)– Therapy in ICU (91% vs. 13%, p < 0.001)

• ICU LOS (5.5 vs. 6.9 days, p = .025)• Hosp LOS (11.2 vs. 14.5 days, p = .006)

�Both LOS’s adjusted for BMI, APACHE II, vasopressor use

– No untoward events during ICU Mobility session– Decreased cost in protocol group

Success with Early Mobility in Critical Care

February 10,2012

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Needham DM, et al. Arch Phys Med Rehabil 2010;91:536

• Quality improvement project– Reduced sedation

– Reduced delirium– More rehab treatments per patient (1 vs.

7)– Higher level of functional mobility

– Decreased Hospital/ICU LOS

UCMC Early Intervention Study

• Investigate if extremely early OT/PT was possible in patients with acute critical illness

• Can therapy be paired with DIS?

• If possible, would the early therapy improve a patient’s functional independence at hospital discharge?

UCMC Study Population

• Inclusion– Adult MICU patients – MV < 72 hrs, expected > 12 additional hrs– High level of premorbid function

• Barthel index score > 70– Mahoney et al. Md State Med J, 1965.

• Exclusion– Rapidly evolving neurological or neuromuscular disease – Admission after cardiopulmonary arrest– Irreversible conditions, 6 mo. mortality estimated > 50% – Elevated ICP – Absent limbs– Enrollment in another trial

Study Protocol• RCT of 104 sedated, MV patients

– Intervention (n=49), Control (n=55)

• Intervention Patients– If unresponsive, passive ROM to all

extremities – If any command following noted, PT/OT

coordinated with DIS– Daily PT/OT until return to independence or

hospital discharge

• Control Patients– PT and OT as ordered by the primary team

Study Protocol

• Both groups received protocol-directed…– Spontaneous breathing trials– Daily interruption of sedation– Early enteral nutrition– Tight glycemic control

• Daily assessments– CAM-ICU– RASS

• Blinded assessments by PT or OT– Functional independence– Muscle strength

Success with Early Mobility in Critical Care

February 10,2012

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Intervention• Bed mobility/ROM• Assisted breathing techniques/Energy

conservation• Sitting balance activities, participation in

ADL’s, cognitive ex• Transfers

• Pre-gait activities• Ambulation

• Family/Caretaker Education

Intervention

• Monitoring for adverse events– Vitals– Medical devices

• Intervention tailored to individual deficits – Progression of functional activities as

appropriate

Primary Endpoint

• Independent functional status at hosp d/c– Independent ADLs

• Eating, grooming, bathing, dressing, toileting

– Independent transfers and ambulation

• Independence– FIM > 5: “supervision without assistance”

• Keith et al. Adv Clin Rehabil, 1987.

Secondary Endpoints

1. Barthel Index score2. Functionally independent ADL’s3. Independent ambulation distance4. ICU-AP

5. Delirium days

6. Ventilator-free days7. ICU and hospital LOS

Hospital Discharge

Safety Assessments

• Encounters meeting criteria for instability • Fall to knees• ETT removal• SBP > 200, < 90• Desaturation to < 80%

– Bailey et al. Crit Care Med, 2007.

• Equipment removal

Baseline CharacteristicsCharacteristic

Intervention (n = 49)

Control (n = 55)

Age, years 58 [36,69] 54 [47,66]Female, % 59 41Black race, % 56 61Barthel index 100 [85,100] 100 [90,100]Body mass index 27 [25,32] 28.0 [24,34]APACHE II score 20 [16,24] 19 [13,23]Diabetes, % 37 33

ICU Primary Admission dx, %Acute Lung Injury 55 56COPD Exacerbation 8 11Status Asthmaticus 10 7Sepsis 14 16Hemorrhage 2 4Malignancy 4 2Other 6 4

Success with Early Mobility in Critical Care

February 10,2012

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Results

Characteristic Control n=55

InterventionN=49

P-value

Days from intubation to first PT/OT session

7.4 [6,10.9] 1.5 [1.0,2.1] <0.001

# Independent ADLs ( ICU d/c) 0 [0,5] 3 [0,5] 0.15

# Independent ADLs (hosp d/c) 4 [0,6] 6 [0,6] 0.06

Time from intubation to milestones, days

Control Intervention P-Value

Out of bed 6.6 [4.2,8.3] 1.7 [1.1,3.0] <0.001

Standing 6.0 [4.5,8.9] 3.2 [1.5,5.6] <0.001

Marching 6.2 [4.6,9.6] 3.3 [1.6,5.8] <0.001

Chair Transfer 6.2 [4.5,8.4] 3.1 [1.8,4.5] <0.001

Ambulating 7.3 [4.9,9.6] 3.8 [1.9,5.8] <0.001

Milestones achieved-Intervention group (% of patients)

Bed

Mobility

Sit-

stand

Bed-

chair

Eating Grooming Ambulation

ETT 78% 57% 36% 72% 69% 19%ICU-No MV 98% 98% 86% 98% 98% 70%Floor 94% 96% 91% 95% 94% 90%

Oxygenation on MV

58% ALI58% ALI58% ALI58% ALI 35% FiO2 35% FiO2 35% FiO2 35% FiO2 ≥ 60≥ 60≥ 60≥ 60

Overcoming Perceived Barriers

Renal Replacement% Total PT/OT sessions in

ICU

HD or CVVH 13.9 (50/361)

CVVH 7.2 (26/361)

HD 6.6 (24/361)

Vasoactive infusion during 22% of PT/OT sessions (81/361) in MICU

BMI = 30-39 in 25% (12/49)

BMI ≥ 40 in 14% (7/49)

Actual Barriers to Interventions

• Not awake despite sedative interruption• Unable to tolerate sedative interruption

• Medical tests/procedures

Success with Early Mobility in Critical Care

February 10,2012

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Functional Outcomes

OutcomeIntervention

(n = 49)Control (n = 55)

P value

Independent functional status at hospital discharge, %

59 35 0.02

Barthel index score at hospital discharge 75 [7.5,95] 55 [0,85] 0.05

Independent ADL total at hospital discharge, n

6 [0,6] 4 [0,6] 0.06

ICU-AP (MRC < 48) at hospital discharge, % 31 49 0.09

Greatest ambulation distance, feet 110 [0,300] 0 [0,1 00] 0.004

Hospital delirium, days 2.0 [0.0,6.0] 4.0 [2.0,8.0] 0. 02=> Phys/cognitive=> Phys/cognitive=> Phys/cognitive=> Phys/cognitiveInteraction!!!!Interaction!!!!Interaction!!!!Interaction!!!!

Outcomes

OutcomeIntervention

(n = 49)Control (n = 55) P value

Ventilator-free days 23.5 [7.4,25.6] 21.1 [0.0,23.8] 0.05

Duration of MV, days 3.4 [2.3,7.3] 6.1 [4.0,9.6] 0.02

ICU LOS, days 5.9 [4.5,13.2] 7.9 [6.1,12.9] 0.08

Hospital LOS, days 13.5 [8.0,23.1] 12.9 [8.9,19.8] 0.93

Hospital mortality, % 18 26 0.53

Protocol Adherence: PT+OT

• Intervention Patients (n=49)– 93% underwent PT/OT

– PT/OT: 87% of days on study

• Control Patients (n=55)– Died from critical illness: 26%– Survivors

• Full functional recovery: 35%

• Incomplete functional recovery: 39% – 95% with PT and OT services

Protocol Adherence

Variable*Intervention

(n=49)Control (n=55) P value

Daily interruption of sedation (DIS)

% Days of sedation with DIS 100 [100,100] 100 [100,100] 0.56

Duration DIS per pt (hrs/day) 2.7 [0.8,6.5] 3.3 [1.0,8.9] 0.35

% of goal calories while intubated 37 [11,58 ] 34 [15,58] 0.99

Blood glucose, AM value (mg/dL) 132 [119,148] 129 [120,146] 0.83

Pts receiving insulin gtt, % 82 76 0.68

Protocol Adherence

VariableIntervention

(n=49)Control (n=55) P value

Propofol

Patients receiving, % 98 96 1.0

Propofol dose (mg/hr) 99 [46,136] 96 [53,141] 0.98

Opiate

Patients receiving, % 98 98 1.0

Morphine equivalents (mg/hr) 2.6 [0.7,5.4] 3.1 [0.9,6.1] 0.83

Benzodiazepine

Patients receiving, % 80 87 0.43

Lorazepam equivalents (mg/hr) 0.02 [0.0,0.3] 0.02 [0.0,0.2] 0.89

Haloperidol

Patients receiving, % 16 16 0.8

Haloperidol dose (mg/day) 0 [0.0,0.0] 0 [0.0,0.0] 1.0

Adverse Events During Intervention

Adverse events % of total sessions (n=501)

Desaturation (> 5% or more) 6.2

HR increase 20% from baseline 4.2

Ventilator asynchrony/tachypnea 4.0

Agitation/discomfort 2.0

Hardware/device removal* 0.8

Hypotension† 0.2

* Arterial line† Orthostatic hypotension

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Discharge Disposition

Discharge Disposition

Intervention (n = 49)

Control (n = 55)

P value

Home 43% 24% 0.06

Acute Rehab 27% 31%

Sub acute Rehab ??? 0% 11%

LTAC 10% 5%

Hospice 0% 2%

Death 18% 25%

Nursing Home 2% 2%

0 7 14 21 280

20

40

60

80

50 100

ControlIntervention

Number at RiskControl 55 51 21 13 9 4 0Intervention 49 40 21 13 8 2 1

048.0=P

Hospital Days

% F

unct

iona

lly In

depe

nden

t

Probability of return to independent functional status

Cox proportional-hazards analysis variables assoc with functional independence: ••AgeAgeAgeAgeAgeAgeAgeAge [HR 0·97; 95% CI, 0·95-0·99; p=0·001]••Absence of sepsisAbsence of sepsisAbsence of sepsisAbsence of sepsisAbsence of sepsisAbsence of sepsisAbsence of sepsisAbsence of sepsis [HR 2·27; 95% CI, 1·02-5·03; p=0·04]••Early PT/OTEarly PT/OTEarly PT/OTEarly PT/OTEarly PT/OTEarly PT/OTEarly PT/OTEarly PT/OT [HR 1·05; 95% CI, 1·01-1·09; p=0·04]

Morris- 1 Year Outcomes….

• 47% of population had died or had a hospital readmission

• Tracheostomy, female gender, higher Charlston Comorbidity Index, and lack ofearly ICU mobility

Additional Options

• NMES• Cycle ergometry

• MOVEO• Wii

22 year old male with acute chest syndrome and ARDS

�CXR 38 hours after intubation�Assist Control�Tidal Volume 400�PEEP 10�FiO2 60%

Implementation…

How can early mobility programs be replicated at other institutions?

Success with Early Mobility in Critical Care

February 10,2012

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The pressing question...Culture

• Greatly impacts practices at institutions• Varies between facilities • Creates difficulty when trying to establish

starting point– Relationships– Education– Degree of involvement

• Hopkins, 2007

Collaboration

• Multidisciplinary Involvement/Backing:– Nurses– Physicians– Respiratory therapists– Physical therapists– Occupational therapists– Hospital administration

Common Topics to Address in YOUR ICU….

• Education• Sedation interruption• Staff

– Adequate/efficient number– Who?– competent

• Equipment/medical status• Coordination of care• Prioritization

Education

• Long-term impact for patients and families • Benefits of early mobility

• Role of all team members • Specific processes

Sedative Interruption

• Assess current practice• Success with therapy is highly dependent

on level of alertness• Who initiates??

Success with Early Mobility in Critical Care

February 10,2012

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Staff

• Current allocation• Mobility team

• Increased utilization?• Cost implications

Mobility Team

• Mobility Team Members-Wake Forest– PT, NSA, and RN

-LDS Hospital – PT, RT, RN, and critical care technician

-UCMC– PT, OT, and RN PRN

-Johns Hopkins University – PT, OT, and rehabilitation assistant

Cost and Volumes…..

• Cost– Decreased cost for protocol group

-$6,805,082 vs. $7,309,871-Attributed to decreased ICU and hospital

LOS

•• Volumes/StaffingVolumes/Staffing–– 95% at UCMC’s control group received PT 95% at UCMC’s control group received PT

and/or OT servicesand/or OT services

•• Increased research is neededIncreased research is needed

Are PTs Prepared?

• Complex patients in a complex environment!

• Increasing exposure in professional programs

• 2:1 • Human Simulation

Getting Therapists Up to Speed for Critical Care….

• Importance of mentoring relationships and collaboration– Clinically experienced therapists– Medical professionals (MD, RN, PA)– Facility to facility – Professional organizations

• Developing clinical competencies at each facility • Developing appropriate CE courses• Residency/fellowship/specialist certification

UCMC ICU Competency

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February 10,2012

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With Clinical Competency…..

• Therapy can be completed safely and effectively with critically ill patients

• Schweickert et al., 2009– No extubations, no falls, no marked

hemodynamic instability in 498 therapy encounters

Equipment is a Barrier?

• Femoral– A-line– Dialysis access

• CVVHD• Pulmonary artery catheter• IABP

• ECMO

Medical Status as a Barrier?

• Command following• Hemodynamically stable

• Ventilation/oxygenation needs• Risk vs. benefit

• Guidelines vs. Protocols – Less absolute contraindications – Importance of team discussion

Coordination of Care

• Timing • Communication

• Systems

Developing and Following Systems

• ABCDE Bundle at Vanderbilt• QI Program at Johns Hopkins

• UCMC Feasibility Paper– Guideline for enrolling patients– Protocols vs. Guidelines

Prioritization

• Potential shift in thought process• Front-loading

• Treatment vs. prevention• Which patients?

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February 10,2012

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Allocation of tasks

• Who is responsible for initiating:– Sedation interruption– PT/OT referrals– Coordination of DIS with PT/OT– Ventilator weaning

Common Questions….

• Equipment Needs– Improves safety and monitoring

• Portable patient monitors• Portable ventilators • Ambulation aids

Themes in Making Early Intervention Successful…..

•• Establish a teamEstablish a team–– Identify roles and leadersIdentify roles and leaders

•• Coordination and communicationCoordination and communication–– Interdisciplinary vs. multidisciplinaryInterdisciplinary vs. multidisciplinary

• Ensure competency • Understand current practices

– Make adjustments if needed

Themes in Making Early Intervention Successful…..

• Culture change?• Redefining how sick is too sick

• Establishing trust amongst team members• Create reasonable and attainable

goals/timelines • Frequently assess progress

Questions?

amy.pawlik@uchospitals.edu

Success with Early Mobility in Critical Care

February 10,2012

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