Early Mobility in the Intensive Care Unit
Transcript of Early Mobility in the Intensive Care Unit
Early Mobility in the Intensive Care Unit
KATIE ANDERSON, M/OTS
GRAND VALLEY STATE UNIVERSITY
MARCH 2015
Objectives
Define early mobility in the ICU
Discuss current evidence-based research supporting the use of early mobility in the ICU
Early Mobility Program
Rehabilitation focus in ICU
OT treatment in ICU
Ideas to Implement
Outcomes
Wrap up & Questions
Why Early Mobility?
Traditional ICU Care
ICU literature pushed bedrest- believed to be “conservation of energy” beneficial for recovery
Effects of Mechanical Ventilation
Muscle weakness
Skin breakdown
Ventilator-associated pneumonia(VAP)
Delirium ~80%
Long term effects/disability
(Vollman, 2010)
The Progressive Mobility Movement
New Standard of Care in ICU
Promoting progressive activity within 24- 48 hours of mechanical ventilation
Promoting activity as tolerated
Improves functional recovery
Feasible, safe, treats neuromuscular complications
Decreases LOS, Delirium, and hospital readmission
Long-term quality of life
(Kleinpell, 2011)
(Lipshutz, Engel, Thomton & Gropper, 2012)
Schweickert WD, Pohlman MC, Pohlman AS, et al (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet;373:1874-1882.
Research question: # of patients returning to independent functional status at discharge with early mobility intervention
104 ICU patients ( control n=55, intervention n=49)
Intervention received OT/PT early mobilization ( therapeutic exercise/activity, 6 ADLs)
Control: daily interruption of sedation with therapy as ordered by primary care team
Duration: variable depending on ICU stay, 28 day follow-up
Outcomes: shorter duration of delirium, more ventilator-free days, return to hospital function occurred in 29 (59%) of patients in intervention group
Control group: 19(35%) of patients in control group returned to independent function at discharge
Evidence Based Practice:Importance of Early Mobility in the ICU
Evidence Based Practice
(Schweickert et. al, 2009)
Evidence Based Practice:ADL Independence/Discharge Planning
(Schweickert et. al, 2009)
Barriers to OT in ICU Mobility
“OT services are highly underutilized in most acute care settings”
Prospective cohort study: 514 patients with acute lung injury from 11 ICU’s in three hospitals in Baltimore, MD
Only 30% of patients received OT during their ICU length of stay
OT treatment began 1.5 days after admission, outcomes show significant improvement of physical/mental function at discharge
Patient outcomes without OT:
Increased days in coma
Increased mean oxygen requirements
Increased Delirium
Decreased ADL independence at d/c
(Dingals et al, 2013)
Advocating for OT in ICU Mobility
Barriers/Myths to OT in ICU
Pt is “too sick “ to engage in therapy
Doctors/Nurses have decreased understanding of OT’s role in the ICU
Lack of knowledge regarding medical lines/equipment
Patient is unable to participate in ADLs in the ICU
Solutions
Therapy team in ICU attend interdisciplinary rounds each week
Providing in-service on early mobility to ICU staff
Start small, begin with BADLs, ROM, and grade activities up as tolerated
Educate other disciplines on equipment, positioning, participation in BADLs, and importance of mobility
Change ICU culture with recent research for early mobilization programs
Early Mobility Program in the ICU
Research and Program Ideas developed by:Vanderbilt University, Beaumont Health System
ICU Delirium and Cognitive Impairment Study Group, 2013Beaumont Hospital Early Mobilization Program, 2013
Determining Appropriate Treatment in ICU
• Assessment by RN used to measure agitation -sedation levels
• Quick screen to determine if patient is appropriate for therapy
• Location of RASS-CAM-ICU score in Epic under “flowsheets”
PT/OT Focus in ICU
Initiating activities within 24-48 hours after ICU admission: Promote activity
Determine patients RASS score, develop treatment based off sedation levels
Turning/positioning & AROM/PROM
Bed Mobility (rolling, sit to supine, EOB sitting)
Chair Positioning: Light exercise & ADLs
( t/f, toileting, eating, bathing, dressing, grooming, walking)
Standing( pre-gait exercises)-Ambulation
Why Should OT’s be Involved?
Look at impairments and deficits
Muscle weakness, progressive loss of musculoskeletal functions
Impaired performance of ADLs/IADLs
Inability to return to work, habits, routines
Impaired cognition
Decreased mental status due to delirium
Joint contractures from immobility
Impaired sleep and rest
(Beaumont Health System, 2013)
(Kleinpell, 2011)
OT Intervention in the ICU Stress Pattern
• ADLs• Positioning• Splinting• Bed Mobility• Bed Exercise• Transfers• Vision• Cognition• Discharge rec’s• Equipment rec’s • Family education
Ideas to Implement
RASS Score: Collaborate with RN
Mobility Signs (implemented at Beaumont)
Go: Walk in hallway
Caution: Up in chair
Slow: Dangle EOB
Stop: Bed exercises or PROM
Mobility Carts
Thera band
Weights
Hand Bike for UE strengthening
Exercise programs posted in rooms: Involve Family!
Ankle pumps
Quad sets
Heel slides
Hand pumps
Arm Curls
Wrist Flexion/Extension
Note: ICU exercise programs & mobility sign information located on handout
Patient Outcomes
Delirium
Length of mechanical ventilation
Readmission & frequent flyers
Independence in ADLs at discharge
Shorter LOS in the hospital
Promotes importance of therapy in ICU/CCU
Take Away Message
By promoting early mobility in the ICU, it expands the ICU team to include physical/occupational therapists. In return, it changes the ICU culture to focus not just on treatment of critical illness, but also on promoting recovery after the ICU stay
(Hopkins & Spuhler, 2009)
Questions?
Questions, comments, concerns
Thank you for allowing me to be apart of the rehab team at Sparrow
References
Anne T. Affleck, Sheri Lieberman, Jan Polon, Kerry Rohrkemper.,Providing occupational therapy in an intensive care unity, AJOT, p323-332.
Bailey P, Thomsen GE, Spuhler VJ, et al (2007). Early activity is feasible and safe in respiratory failure patients. Crit Care Med ;35:139-145.
Beaumont Health System (September, 2013). Early mobility in the ICU- A multidisciplinary approach.
Burtin C, Clerckx B, Robbeets C, et al (2009). Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med.;37:2499-2505.
Dingals, V., Colantuoni, E., Ciesla, N., Mendez-Tellez, P., & Shanholtz, C. (2013, June). Occupational therapy for patients with acute lung injury: Factors associated with time to first intervention in the ICU. American Journal of Occupational Therapy,3(67), 355-362.
Hopkins RO, Spuhler VJ (2009). Strategies for promoting early activity in critically ill mechanically ventilated patients. AACN Adv Crit Care. 20:277-289.
Kleinpell, R. (2011, September 30). How early should we mobilize ICU patients? Medscape. Retrieved from: http://www.medscape.com/viewarticle/7504582
Lipshutz, A., Engel, H., Thomton, K., & Gropper, M. (2012, January). Early mobilization in the intensive care unit. ICU Director, 3(1), 10-16.
Vollman, 2010. Introduction to Progressive Mobility, In Critical Care Nurse (30), 2. S3-S5. Retrieved from: http://ccn.aacnjournals.org/content/30/2/S3
VUMC center for health services research. (2013). Family engagement and empowerment . In ICU delirium and cognitive impairment study group. Retrieved from: http://www.icudelirium.org/family.html