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Early Mobilization on a neurological ICU

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Nydahl – Nursing Research

Slides are online: www.nydahl.de > Vortrag

Early Mobilization on a neurological ICU

09.0

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Nydahl – Nursing Research

Early mobilization on a neurological ICU

09.0

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Nydahl – Nursing Research

12,000 employees 2,500 beds 16 ICUs 230 beds

NICU & SU 6 & 11 beds

Does bed rest support healing?

Immobility increases risks for … •  Pressure sores, contractures, thrombosis •  Atelectasis, pneumonia •  Insulin resistance, loss of Ca+ •  Loss of muscle strength (1-1.5%/d) •  Loss of body weight (20%/2w) •  ICU acquired weakness (50% sepsis, ARDS) •  80% Delirium, 28% PTSD, 28% depression, 24% anxiety •  Rehabilitation after 48h mech. ventilation: up to 9-12 months (Boles et al. 2007, Brower 2009, Vollman 2010, NICE 2010, Desai, 2011)

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Nydahl – Nursing Research

Modified abcdef-approach

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Nydahl – Nursing Research

Mobilization

Wakefulness & Partizipation

Assisted Ventilation mode

Management of pain, anxiety,

stress

Management of delirium

Family presence

Balas et al., 2013; Pic: Strøm, Spuhler

Early Mobilization

Review incl. 52 studies (Nava, 1998 … Wang, 2014) •  Early mobilisation is feasible and safe •  Better strength, endurance, balance •  More independence in ADL, QoL •  Reduced length of MV, ICU, hospital •  Reduced incidence of delirium •  Reduced incidence of complications •  Reduced readmissions •  More admissions, more money •  But: effects multifaceted & incongruent Nydahl, 2016; Pic: Spuhler, 2008

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Early Mobilization with neurological pts

n.r. not reported; ns non significant; * significant; ** highly significant, ns non significant

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Author Pts (after/before)

MV (d) ICU (d) Hosp (d) ADL

Titsworth 2012

170 (93/77)

n.r. 3 vs 4* 9 vs 12* !*

Klein 2015

637 (377/260)

n.r. 4 vs 8** 10 vs 15** !*

Witcher 2015

68 (37/31)

7 vs 5 13 vs 10ns 23 vs 22ns n.r.

Early Mobilization with neurological pts

n.r. not reported; ns non significant; * significant; ** highly significant, ns non significant

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Nydahl – Nursing Research

Author Pts (after/before)

MV (d) ICU (d) Hosp (d) ADL

Titsworth 2012

170 (93/77)

n.r. 3 vs 4* 9 vs 12* !*

Klein 2015

637 (377/260)

n.r. 4 vs 8** 10 vs 15** !*

Witcher 2015

68 (37/31)

7 vs 5 13 vs 10ns 23 vs 22ns n.r.

Early Mobilization with neurological pts

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Author Pts % on MV

Inclusion Out of bed

Titsworth 2012

SAH, tumor, stroke, ICH, other

31% 94% n.r.

Klein 2015 Stroke (isch, hem, SAH), epilepsia, nm disorders

37% 73% 21% ->43%

Witcher 2015 ICH; SAH, Stroke, epilepsia, other

n.r. 37% 65% -> 72%

In- and exclusion criteria

Hodgson 2014

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•  Interprofessional discussion: inclusion & exclusion criteria

•  Traffic-Light-System •  Red: risks outweigh benefits •  Yellow: benefits may outweigh risk,

individual decision •  Green: clear benefit

•  Neuro: brain pressure, ongoing seizures, large bleeding, palliative

Checklist

Talley, 2013, Berry 2014, Nydahl 2016

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"  Hygienic working, e.g. hands, disconnection of lines & tubes "  Experienced physician nearby "  Portable ventilator, monitor, suction, manual resuscitator bag "  Security clips for lines, loops "  Press ventilator circuit on ETT with soft/moderate pressure "  Foreseeing thinking: what risks may appear with this patient and

what strategies prevent and solve events? "  Check risks for clinicians, e.g. BMI > 30, hyperactive delirium "  Check length of lines according to targeted mobilization level "  Wheelchair behind patient in case of sudden weakness (Family?)

ICU Mobility Scale

Hodgson 2014

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0 Nothing (lying in bed) 1 Sitting in bed, exercises in bed 2 Passively moved to a chair 3 Sitting over edge of bed 4 Standing 5 Transferring bed to chair 6 Marching on spot 7 Walking, assistance ≥ 2 persons 8 Walking, assistance 1 person 9 Walking independently (gait aid) 10 Walking independently

Safety ≤ 20% variation HF, BP ≤ 5% variation sO2

Dyspnoea (Borg Scale 3-6): FiO2 + 0.2 & PEEP + 2 mbar Pressure support + 2-4 mbar

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Walking

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Documentation & Evaluation

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!Nydahl, 2013, Schreiter, 2013

Whole concept

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Approach: abcdef concept

Traffic-Light-System: daily screen for mobility

Checklist before mobilization

Stepwise mobilization incl. safety screen

Documentation & evaluation

Take home message

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Early mobilization •  Is feasible for neurological pts •  Is a team approach & requires

good cooperation •  Reduces complications, leads

to more independency, shorter duration of MV, ICU, hospital

•  More research is needed for neurological patients on ICU

•  Peter.Nydahl@uksh.de

Networks for early mobilization •  www.mobilization-network.org •  MedConcert: ICU Recovery

Network, incl. >900 clinicians, monthly newsletter etc.

Conference •  4. European conference on

Weaning & Rehabilitation: Nov,12.-13. 2016 Hamburg

•  info@mobilization-network.org

Barriers to EM and how to convince them

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Dubb, Nydahl, 2016

Patient-related barriers: Safety guidelines, ampel-system, stepwise

mobilization, safety screen, feasibility studies, evaluation

Process related barriers: interprofessional rounds, sharing responsibilities, automatic order,

promoters/champions

Structural barriers: protocol & algorithm, daily goals, regular interprofessional staff

training & meetings, documentation, additional staff

Cultural barriers: training & education (Evidence), changed decision making

(RN/PT), champions, feedback

Barriers & Solutions

Dubb, Nydahl, 2016

ETT tolerance: only a very few patients want to be sedated because of the ETT

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Checklist ETT tolerance Based on syst. Review (Nydahl, 2015) Available on ICU Recovery Network or www.nydahl.de