june 1 4pm weeks a and yi p (early mobility program in the ... · pdf fileearly mobility...

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© 2013 Memorial Sloan-Kettering Cancer Center, All Rights Reserved.

Objectives1. Discuss evidence proving the negative impacts of

prolonged immobility.

2. Review evidence supporting early physical rehabilitation in mechanically vented patients.

3 D fi E l M bili ti t MSKCC3. Define Early Mobilization at MSKCC.

4. Describe PT specific assessment and intervention strategies for patients who qualify for early mobility.

5. Describe OT specific assessment and intervention strategies for patients who qualify for early mobility.

Negative Effects of Prolonged Immobility in the Intensive Care Unit (ICU)


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Decreased Strength• ICU-acquired weakness:

• Critical illness polyneuropathy (CIP), critical illness myopathy (CIM) or combination of both

• Associated with a prolonged need for mechanical ventilation and increased ICU and hospital length of stay1,2

• Immobility may result in 1.3 – 3.0 % loss in muscle strength per day in healthy individuals3

• Patients who survived ARDS lost an average of 18% body weight in ICU and were only able to walk 66% of their predicted value at 1 year after hospital discharge4

Impaired Functional Performance• Significant delay in return to work with only 77% returned

to work at 5 year follow up– Those who returned to work often required gradual transition,

modified work schedule, or job retraining4

• At 3 month follow-up ARDS survivors describe profound disability that interfered with BADL

• Patient perspective: “to start with, when I tried to hold a cup, I spilled it in the bed. I could not brush my own teeth, I could not comb my own hair, and I wasn’t able to pick the covers up and move them.” 5

Delirium• Defined as a disturbance of consciousness with

inattention accompanied by a change in cognition that develops in a short period and fluctuates over time

• ICU delirium has been associated with prolonged hospital stays and increased mortality rates2, 4, 6, 7, 8

• Associated with higher incidence of short-term health problems independent from severity of illness 6,7,9


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Cognitive Dysfunction• ICU survivors report persistent difficulties with memory,

concentration and executive function (planning/organizing)7

– Negatively impacts QOL, IADL, decision making, managing finances, ability to function autonomously, ability to return to work

• 46% of ARDS survivors present with cognitive impairment 1 d 2 % 6 6year post and 25% 6 years post 6

• 1/3 of ARDS survivors at 2 year follow-up were unemployed or permanently left the work force largely due to cognitive impairment 7

• Higher incidence of depression, anxiety, & PTSD in ICU survivors compared to non-ICU patients (23-41% vs. 5-20%)10

Benefits of Early Mobility

Benefits of Participation in Early Mobilization:– Decreased duration of delirium – Reduced strength/ROM impairments – Improved ability to perform BADL – Reduced duration on mechanical ventilation – Decreased ICU and hospital LOS11, 12,13

A study performed in 2012 by Winkelman et al. demonstrates patients who received early mobility vs. those who did not had better hospital discharge outcomes with less long term rehab required.14


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Early Rehabilitation is the Key!

• By 2026, the anticipated need for MV will increase by 80%15

• Long term physical disability (6 Minute W lk) i ICUWalk) persists up to 5 years post ICU4

• Lower levels of physical fitness are directly associated with mortality and cardiovascular disease16

Early Mobility Program Development

• A need for consistent PT/OT involvement with ICU patients was recognized

• A multidisciplinary effort to change the ICU “culture” and improve quality of patient careculture and improve quality of patient care was initiated

• MSK EM definition: mobilization of a patient on mechanical ventilation once medically stable, often occurring within 24-48 hours of intubation

Early Mobility Program at MSKCC

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Patient Identification Process1. Day and Night RNs/RTs to identify patients on mechanical ventilation upon admission to ICU

2. Day RT staff will screen patients based on inclusion/exclusion criteria

and discuss with bedside RN BEFOREteam rounds

2. ICU TEAM identifies patient on rounds and

places an EM orderOR

places an EM order3. RT obtains approval from ICU

attending – wean sedation

4. EM is marked on daily grease board next to patients’ names to flag mobility candidates once appropriate

4. Order identifying “Early Mobility” must be placed for

PT/OT in CIS

** SEDATION MUST BE WEANED PRIOR TO EM ASSESSMENT TO COMMENCE

If “Yes” is chosen, “Early Mobility” auto-populatesMobility auto populates


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Early Mobility CriteriaAll patients admitted to ICU requiring mechanical ventilation are

considered to be a potential early mobility candidate.

EXCLUSION CRITERIA:– BP: MAP < 65mmHg or > 110mmHg or SBP > 200mmHg– HR: < 40 bpm or > 130 bpm– SpO2: < 88%– Active gastrointestinal blood lossg– Patient agitation requiring increase in sedation in past 30 minutes– Unsecure/difficult airway– Raised intracranial pressure– Active myocardial ischemia– Open abdomen

** These broad guidelines do not preclude sound clinical judgment to proceed with intervention

Team CollaborationCultural Change for Mobilization in the ICU• 4 Essential Elements for Effective Teams

– Shared goals: a reason for working together– Interdependence: recognition of the need for individual

experience, ability and judgment to arrive at mutual goals– Commitment: knowledge that working together leads to

more effective decisions than working in isolationmore effective decisions than working in isolation– Accountability: shared commitment as a functioning unit

within a larger organizational context

• The ICU team must work collaboratively to create a care process that supports a consistent approach to daily patient mobilization.17

Multidisciplinary EM Initial Assessment

Early Mobility Team

Physical Therapist

Occupational Therapist

Respiratory Therapist Nursep p p

• Decide extent of mobilization• Assess cognitive status • Assist with mobility activities

• Manage airway• Monitor vent & respiratory status

• Monitor vitals• Manage lines

1st Early Mobility Intervention: ALL TEAM MEMBERS MUST BE PRESENTEarly Mobility Team to discuss and coordinate time for intervention in AM


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Role of Respiratory Therapy: Support Oxygenation & Ventilation

Maximize Respiratory status prior to, during and post mobility as needed

• Increase FI02• Increase Pressure support• Alternate between modes• Patient’s airway is clear of secretionsPatient s airway is clear of secretions• Inner Cannula is patent – has been changed

according to schedule• Patient receives bronchodilator treatment prior to

ambulation• Keep 840 on “side” of the bed, not behind, to

minimize pulling of artificial airway

Role of Nursing: Monitoring Sedation, Lines & Vitals

• General care provided prior to mobilization

• Management of pain medication at needed

• Room setup management to allow for optimal mobilization

• Managing patient medication/limiting sedatives for increased arousal

• Telemetry monitoring

Role of RehabilitationAssess cognition

Assist the patient to sit EOB

Transfer patient to a chair with pivot transfer or taking

Stand patient from bed surface

1-2 steps

Complete ADL tasks sitting or standing

Ambulation within room or in hall


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Early Mobility Video

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Ambulation with Use of Portable Vent

Multi-disciplinary approach to facilitate Early Mobilization

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Rehabilitation Follow Up Plan

• After the initial Early Mobility session, PT and OT communicate and follow up with one of the following approaches:

• PT/OT co treat• PT/OT co-treat • Back to back PT/OT sessions • Coordinate specific times for PT and OT during

the day to provide the patient with a rest break


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Rehabilitation Follow Up Plan

• Determine if RT presence during follow up therapy sessions is needed– Increase FiO2– Decompensation– Decompensation– Securing airway– Mechanical ventilator monitoring and adjustments

Physical Therapy Early Mobility A t & T t tAssessment & Treatment

Physical Therapy Early Mobility Assessment

• Cognition• General pulmonary assessment

– Vitals– Vent settings– Breath sounds

• AROM/PROM, MMT• Sensation, coordination, muscle tone• Functional mobility

– Bed – EOB –Transfers – Ambulation• Balance• Gait • Endurance


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Impairments:– Mucociliary

clearance/inability to expectorate

– Impaired lung

Treatment Interventions:– Chest physical therapy

• Postural drainage• Percussion/vibration

C t h i

Physical Therapy Interventions

p gvolume

– V/Q mismatch– Dyspnea– Decreased

expansion of ribs

• Costophrenic assisted cough

– Deep breathing exercises

– Incentive spirometer– Manual therapy

Impairments:– Orthostatic

hypotension– Deconditioned state

I i d i l ti

Treatment Interventions:– Therapeutic activities

• Tilt table• Bed level ther-ex• Standing frame


– Impaired circulation• Blood• Lymphatics

g• SARA PLUS

In Room Mobility with Vented Patient

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Treatment Equipment

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• Impairments– Weakness

• General or specific

– Decreased

• Treatment Interventions– Therapeutic exercise

• PROM; A/AROM; Resisted ROM

• Weight bearing activitiesPNF di l


endurance• Fatigue

– Decreased bone density

• PNF diagonals– Functional training

• Bed mobility, transfers– Gait training

• Assistive device• Orthotics

– Stair negotiation

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• Impairments– Impaired motor

planning– Paresis/paralysis

B l

• Treatment Interventions– Balance/trunk control

• Static and dynamic

C di ti ti iti– Balance– Tone(Hyper or Hypo)– Coordination– Proprioception– Kinesthetic

awareness– Delirium

– Coordination activities– Neuromuscular

facilitation• NDT• PNF• Tapping/quick stretch

Physical Therapy 2 Week Goals1. Pt will maintain oxygen saturation >90% on room air

while participating in activities to promote functional mobility and endurance.

2. Pt will log roll into side lying positions with min assist to facilitate proper positioning for pressure relief.

3 Pt ill d t t i it ith d i t t3. Pt will demonstrate supine <-> sit with mod assist to increase sitting tolerance in preparation for transfers.

4. Pt will complete sit <-> stand utilizing a rolling walker with min assist to promote BLE strengthening and endurance.

5. Pt will ambulate 250’ with rolling walker with min assist to facilitate access to toilet and pantry.

Occupational Therapy Early Mobility Assessment & Treatment


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Occupational Therapy Early Mobility Assessment

• Delirium Assessment – CAM-ICU

• Cognition – Orientation attention direction followingOrientation, attention, direction following– Montreal Cognitive Assessment (MOCA)

• Communication• ADL Assessment• ROM/MMT• Sensation

Confusion Assessment Method for ICU (CAM-ICU)

4 Features:1. Acute onset/fluctuating course

• Use RASS or past CAM-ICU scores2. Inattention

• SAVEAHAARTSAVEAHAART3. Altered level of consciousness

• RASS

4. Disorganized thinking• 4 yes/no questions, direction following

Score = Feature 1 + 2 and either 3 or 4

Occupational Therapy ADL Intervention

Impairment:- Activity tolerance - Balance (seated or

standing)

Treatment Interventions:- Grade time spent in various

positions (EOB, OOB, standing)

Patients often have multiple physical impairments limiting BADL performance

g)- Impaired gross/fine

motor coordination- Decreased

ROM/strength- Neuropathy

- Neuro re-education- Therapeutic activities- Therapeutic exercises- Remedial and compensatory

strategies- Use of meaningful patient-

selected activities


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ADL Participation

Use of tilt-in-space wheel chair to accommodate for pressure relief

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Leisure Participation

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Occupational Therapy Cognitive & Mood Dysfunction Interventions

Impairment:- Orientation & arousal/

attention- Communication/expression

Concentration/processing

Treatment Interventions:- Establish routine for daily

activities, sleep-wake cycle- Orientation aides/devices- Communication devices, adaptive

t t i- Concentration/processing- Command following- Anxiety- Sensory tolerance

strategies- Environmental modification, task

simplification- Grade commands (1 step vs.

multi-step)- Relaxation strategies- Introduction to various stimuli


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Adaptive Communication

Communication Board

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Writing

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Occupational Therapy 2 Week Goals1. Patient will participate in grooming task seated EOB x 5 min

with min A demonstrating good sitting balance and tolerance with maintained attention to task 100% of time.

2. Patient will demonstrate A & O x 3 5/5 consecutive days with use of compensatory device without assist from caregiver.

3 Patient will demonstrate effective communication with3. Patient will demonstrate effective communication with caregiver/ medical team 100% time using adaptive communication device prn.

4. Patient/caregiver will be Independent with OT home program for increased BUE strength/coordination and activity tolerance in order to improve ADL performance.

5. Patient will complete all surface transfers (i.e. bed, chair, toilet) with moderate A demonstrating good safety awareness.

MSKCC Early Mobility Research

PURPOSE:

• To evaluate if pre ICU length of stay (LOS) influences outcomes in patients with cancer on MV receiving early PT/OT.

METHODS: • Retrospective review of 42 critically ill patients with respiratory

failure on MV who underwent early PT and OT (within 72 hours) from June 2010-July 2011.

• MSKCC Functional Assessment: (supine-sit, sit-stand, ambulation, bed-chair transfer, lower body dressing, grooming) .

• MSKCC Cognitive Assessment: (orientation, direction-following, communication).

• Composite Scores analyzed at baseline ICU assessment, ICU discharge, and hospital discharge for two groups.


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MSKCC Early Mobility ResearchRESULTS:

• 42 patients received early PT/OT and were divided into two groups based on pre-ICU LOS.

• Group 1 (n = 20) Pre-ICU LOS < 72 hours.• Group 2 (n = 22) Pre-ICU LOS > 72 hours.• Both groups demonstrated similar improvement in PT/OT scores from

baseline to ICU and hospital discharge.baseline to ICU and hospital discharge.• No significant difference between the two groups at each time studied.• Group 1 had significantly lower total hospital LOS and mortality.

CONCLUSIONS:

• Early PT/OT appears equally beneficial in improving the functional status of critically-ill patients on MV with short or long pre-ICU LOS.

In Summary

• EM is beneficial for patients in the ICU

• PT and OT have a vital role in reducing the impairments related to prolongedthe impairments related to prolonged immobility and MV in the ICU population

• A multidisciplinary approach is critical for a successful program

1 Year After Discharge from Hospital


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References1. Judemann K, Lunz D, Zausig YA, Graf BM, Zink W. Intensive care unit-acquired weakness in critically ill: Critical

illness polyneuropathy and critical illness myopathy. Anaesthesist. 2011;60(10):887-901. 2. Morris P, Griffin L, Berry M, et al. Receiving early mobility during an intensive care unit admission is a predictor of

improved outcomes in acute respiratory failure. The American Journal of Medical Sciences. 2011;341(5). 3. Stevens, R, et al. Neuromuscular dysfunction acquired in critical illness: a systematic review. Intensive Care Med.

2007;3(11):1876-1891. 4. Herridge, M. Tansey, C, Matte A, et al. Functional disability 5 years after acute respiratory distress syndrome. New

England Journal of Medicine. 2011; 364:1293-13048. 5. Cox, C, Docherty, S, Brandon, D, et al. Surviving critical illness: acute respiratory distress syndrome as experienced

by patients and their caregivers. Crit Care Med. 2009;37(10):2702-08. 6. Ely, E, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA.

2004;291 (14) 1753-17622004;291 (14), 1753 1762. 7. Hopkins R, Jackson J. Short - and long-term cognitive outcomes in intensive care unit survivors. Chest Med Clinic.

2009;30:143-153. 8. Jochum T, Bar K. Disease management in patients with delirium. Open Critical Care Medicine Journal. 2011;4:44-55. 9. McDaniel M, Brudney C. Postoperative delirium: Etiology and management. Current Opinion in Critical Care.

2012;18(4):372-376. 10. Jackson, J, Mitchell, N, Hopkins, R. Cognitive functioning, mental health, and quality of life in ICU survivors: an

overview. Anesthesiology Clin. 2011;(29):751-764. 11. Pawlik A. Early mobilization in the management of critical illness. Critical Care Nursing. 2012;24:481-490. 12. Needham, D. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical

function. JAMA. 2008;300(14):1685-1690.13. Schweickert, W D. et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a

randomized controlled trial. Lancet. 2009 May; 373(9678):1874-82.

References14. Winkelman, C., Johnson, D., Hejal, R. et al. Examining the positive effects of exercise in intubated adults in ICU:

A prospective repeated measures clinical study. Intensive Critical Care Nursing. 2012 Dec;28(6):307-18.15. Needham D, Bronskill S, Calinawan J, Sibbald W, Pronovost P, Laupacis A. Projected incidence of mechanical

ventilation in Ontario to 2026: preparing for the aging baby boomers. Crit Care Med. 2005; 33 (3): 574-579.16. Blair SN, Kohl HW, III, Paffenbarger RS, Jr, Clark DG, Cooper KH, Gibbons LW. Physical Fitness and All-Cause

Mortality: A Prospective Study of Healthy Men and Women. JAMA. 1989;262(17):2395-2401.17. Hopkins, R, Spuhler, V. Strategies for promoting early activity in critically ill mechanically ventilated patients.

Advanced Critical Care. 2009;20(30): 277-289.18. Affleck, A.T., et al. Providing occupational therapy in an ICU. American Journal of Occupational Therapy. 1986;

40, 323-332.19. Bailey, P., Thomsen, G., Spuhler, V., Blair, R., Jewkes, J., Bezdjian, L., Veale, K., Rodriquez, L., & Hopkins,

B. Early activity is feasibly and safe in respiratory failure patients. Crit Care Med. 2007; 35 (1), 139-145.20. Dean, E. Mobilizing patients in the ICU: evidence and principles of practice. Acute Care Section: APTA

Publication. 2008;17 (1), 1-9.Publication. 2008;17 (1), 1 9.21. Howell, D. Neuro-Occupation: linking sensory deprivation and self care in the ICU patient. Occupational Therapy

in Healthcare. 1999;11 (4), 75-85. 22. Needham D., Korupolu R., Zanni J., et al. Early physical medicine and rehabilitation for patients with acute

respiratory failure: a quality improvement project. Archives of Physical Medicine and Rehabilitation. 2010;91:536-542.

23. Perme, C., & Chandrashekar, R. Early mobility and walking program for patients in intensive care units: creating a standard of care. American Journal of Critical Care. 2009;18:212-221.

24. Topp R, Ditmyer M, King K, et al. The effects of bed rest and potential of prehabilitation on patients in the intensive care unit. AACN Clinical Issues. 2002;13:263-76.

25. van den Boogaard M, Schoonhoven L, van der Hoeven JG, van Achterberg T, Pickkers P. Incidence and short-term consequences of delirium in critically ill patients: A prospective observational cohort study. International Journal of Nursing Studies. 2012 July;49(7):775-83.

26. Zanni, J., & Needham, D. Promoting early mobility and rehabilitation in the intensive care unit. PT in Motion, May 2010; 32-38.


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