ICU Adult Early Mobilization Program

1
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 Force
2
Objectives

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

3
Concept of Early Mobility

• Phys Therap 1972 Foss et al, Technique for
  augmenting ventilation during ambulation
• CHEST1975 Burns et al, use of special walker

4
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

5
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
6
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
7
Benefits of Early Mobility

• Improved outcome at 1yr 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
8
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
  4.853.3 hr

Krishnagopalan S, Crit Care Med 2002 Goldhill
DR, Anaesthesia 2008
9
(No Transcript)
10
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

11
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

12
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)

13
Our Interdisciplinary Team
14
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)

15
EMP Algorithm

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

16
(No Transcript)
17
EMP Contraindications

• ICP 15
• RASS 4
• Acute or Uncontrolled Intracranial Event
• Fio2 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

18
(No Transcript)
19
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

20
EMP Signs of Intolerance

• RR gt 40
• Sp02 lt 88
• MAP lt 50 or gt 130
• HR lt 50 or gt 130
• Development of any contraindications

21
Initial 5-Level EMP
22
5-Level Progressive EMP
23
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)

24
Data Collection Tool
25
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

26
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)

27
Data for Pilot Program

• Total mobilization activities
• Average mobilization activities/pt. day
• OT/PT activity

28
Total and Average ICU Mobilization Activities
Average Mobilization Activities per Patient Day
Total Mobilization Activities
Activities included ROM, positioning, bed in
chair position, splinting, dangle at the edge of
bed, out of bed, ADL, and ambulation.
29
Data Summary PT/OT Consults
Total number of visits in Pods C D (Sep. 10
Dec. 10)
30
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
31
Pilot Data Summary

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

32
Potential Cost Savings

• Based on reduction in ICU-LOS by 1 day
• Non-ventilated patients 3,872/day x
  136 pts/month 526,592/month
• Ventilated patients 7105/day x
  83 pts/month 589,715/month

33
EMP Beyond the Pilot Program
34
Simplified 3-Level EMP

• Highlight of Changes
• Condensed to 3 Levels
• Reduced contents of levels
• Incorporation of visual cues

35
Simplified 3-Level EMP
36
Sustainability and Expansion of EMP

• Feb 1, 2011 - Expanded program to 34/54 ICU beds
• May 1, 2011 - Expanded program to 54/54 ICU beds

Number of visits
37
Staffing and Education

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

38
Visual Cues - Door Signs Communication Signs
39
Visual Cues - Room Signs
40
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

41
(No Transcript)
42
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)
43
Thank you
44
(No Transcript)
45
Richmond Agitation Sedation Scale
46
Future Trend
47
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
48
(No Transcript)
49
Safety of EMP in Critically Ill

• Schweikert WD, Lancet 20093731874
• Morris PE, Crit Care Med 2008362238
• Bailey P, Crit Care Med 200735139
• Burtin C, Crit Care Med 2009372499
• Thomsen GE, Crit Care Med 2008361119
• Stiller K, Physiother Theory Pract 200319239

50
EMP Initial Process
Orders are written Early Mobilization Protocol
PT/OT consult treat

• RN
• Assess patient upon admission
• Begin nursing interventions based on level
• 4. Delegate activities to nursing assistant

• PT/OT
• Examine patient within 48 hours
• Reinforce teaching and nursing interventions
• Develop and implement PT/OT plan based on
  examination and Mobility Level
• 5. Update mobility levels motivational tokens
  in room