EARLY MOBILIZATION IN THE ICURalph Carumba, MS, RN, CCRNJodi Herbsman, MS, PT, DPT

About NYU Langone Hospital (Tisch)• Academic Medical Center• 705-Bed Acute-Care Tertiary Facility

• 18 Medical ICU Beds

• 9 Surgical ICU Beds• Magnet® Recognized (3 times consecutively)

• Rusk Rehabilitation ranked #8 in US News and World Report (#1 in New York State)

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Objectives• Define the ABCDEF Bundle and how it was implemented and NYULHC• Describe how to initiate an early mobilization program

• Share the results of effective early mobilization programs in the adult and pediatric ICUs at NYULHC

• Review strategies for sustainability of a program• Discuss challenges and successes with implementing an early mobility program

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What is Early Mobilization?• The proactive provision of physical therapy to

critically ill patients on ICUs. Includes:– sitting on edge of the bed

– sitting on chair

– Ambulating(Fraser, Spiva, Forman, & Hallen, 2015)

• “Early” defined as “the interval starting with initial physiologic stabilization and continuing through the ICU stay” (Fraser, Spiva, Forman, & Hallen, 2015)

• In practice, early mobility programs can be difficult to implement given the complexity of safely mobilizing a patient while still on a ventilator. (Klompas, 2015)

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Early Mobilization and Ventilator Associated Events• Immobility is associated with atelectasis and pneumonia• Early physical and/or occupational therapy

– Can decrease time on the ventilator

– Reduce risk of acute delirium

– Has been associated with lower rates of complications and Ventilator Associated Pneumonia(Cocoros & Klompas, 2016)

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The “ABCDEF(+G)” Bundle

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ICU Checklist • Helps to ensure standard

ICU needs are addressed for each patient

• Designed to promote discussion on different matters of care

• Utilized with morning and evening rounds

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Safe Patient Handling • Each room in MICU & SICU equipped with

ceiling lift devices

• Utilized to assist patients with repositioning, transferring between chair/bed, and mobilization

• Used by RN, PT/OT

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Starting an Early Mobilization Program• Leadership support • Business plan

• Forming a team

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Interventions Summary• Increased staffing and intensity of service based on business proposal (Adult)

• Interdisciplinary team mobilized (Adult and Peds)

• PICU admission order set updated (Adult and Peds)

• Algorithm created (Peds)

• Patient scheduling (Adult and Peds)

• Therapy/Nursing education and training provided (Adult and Peds)

• Family advisor interviews conducted with patients and caregivers (Peds)

• Family advisor/nursing discussions conducted (Peds)

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Early Mobilization:Contraindications, Precautions, and Signs of Intolerance

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Start/End Points

Process

Decision Point Sub-process

Legend

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PICU Patients Mobilized Within Established Time Frame

Scheduling of patients for therapies initiated 4/11/16

Family advisor discussions with families initiated 6/2/16

Mobilization training initiatedfor nursing staff 6/6/16

PICU Admission Order Set Updated to include activity

orders 11/19/15

Algorithm Finalized 2/25/16

Initiated late shift for PT/OT 3 days a week to increase POD#0 coverage 11/1/16

0

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%%

of P

atie

nts

Mob

ilize

d w

ithin

Est

ablis

hed

Tim

e Fr

ame

Week Ending Date% of Patients Who Met the Desired Clinical Outcome Median Goal

Des

ired

Dire

ctio

n

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Time From PICU Admission to First Mobilization

0

5

10

15

20

25

30

35

40

45

50

55

60

Wee

kly

Aver

age

(in H

ours

)

Date

Daily Average Hours Centerline Control Limits

Desired

Direction

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Outcomes (PICU)

20%

82%76%

12%

60%

89% 91% 91%

52%

85%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Activity Orders PT Orders OT Orders SLP Orders % Patients Mobilizedwithin recommended time

frame

Perc

ent o

f Pat

ient

s

PRE (N=51) POST (N=46)

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Barriers to Mobilizing Non-Vented Patients (PICU)

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Barriers to Mobilizing Vented Patients (PICU)

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Greatest Concerns About Mobilizing Patients (PICU)

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Key Components of Sustainability• Supportive management structure• Change structure (to prevent “slip back”)

• Robust, transparent feedback system

• Shared sense of the system to be improved• Culture of improvement

• Engaged staff

• Formal capacity to build programs

(Institute for Healthcare Improvement, n.d.)

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Implementation/Sustain Plan

Activity Status

Identify process owner/create transition plan

PT Supervisor with assistance from project manager.

Monitor performance/data collection

Currently on paper, collected daily. Long-term goal to transition to using reports from EHR.

Standards and procedures Still in process of being hardwired. Education to continue.

Training On-going

Transition Plan Goal is unit/therapy leadership to integrate early mobility into daily care treatment. Transition near completion.

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Challenges• Coordination of the mobilization team in real-time

• Coordination of training

• Changing culture is gradual

• Time and resources

• Documentation consistency

• Sustainability

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Successes/Wins• Strong team collaboration (including family advisors)

• Positive feedback from patients and families

• Improved clinical care

• Cost saving

• No adverse events

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Questions?

References• Bailey, P., Thomsen, G.E., Spuhler, V.J., et al, Early activity is feasible and safe in respiratory failure patients. Crit Care Med

2007; 35:139-145.

• Balas M.C., Vasilevskis E.E., Olsen K.M., Schmid K.K., Shostrom V., Cohen M.Z., … Burke W.J. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014 May;42(5):1024-36.

• Brahmbhatt, N., Murugan, R., Milbrandt, E.B. Early mobilization improves functional outcomes in critically ill patients. Crit Care2010; 14:321.

• Choong K, Chanci F, Clark H, et al. Practice recommendations for early mobilization in critically ill children. J Pediatr Intensive Care 2017; Efirst.

• Cocoros, N., Klompas, M. Infect Dis Clin N Am 30 (2016) 887–908.

• Corcoran JR, Herbsman JM, Bushnik T, et al. Early rehabilitation in the medical and surgical intensive care units for patients with and without mechanical ventilation: An interprofessional performance improvement project. PM R 2016; 1-7.

• Dowdy, D.W., Eid, M.P., Sedrakyan, A. et al, Quality of life in adult survivors of critical illness: a systematic review of the literature. Intensive Care Med 2005; 31:611-620.

• Fraser, D., Spiva, L., Forman, W., Hallen, C. Original research: Implementation of an early mobility program in an ICU. AJN. 2015; 115(12)

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References (cont.)

• Herridge, M.S., Tansey, C.M., Matte, A., et al, Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364:1293-1304.

• Hodgson, C.L., Stiller, K., Needham, D.M., et al, Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care 2014; 18:658.

• Hopkins RO, Choong K, Zebuhr CA, et al. Transforming PICU culture to facilitate early rehabilitation. J Pediatr Intensive Care.2015;4: 204-211.

• Institute for Healthcare Improvement. How-to guide: Sustainability and spread. http://www.ihi.org/resources/Pages/Tools/HowtoGuideSustainabilitySpread.aspx. Accessed August 20, 2017.

• Kahn, J.M., Rubenfeld, G.D., Rohrbach, J., et al, Cost savings attributable to reductions in intensive care unit length of stay for mechanically ventilated patients. Med Care 2008; 46:1226-1233.

• Kayambu, G., Boots, R., Paratz, J. Physical Therapy for the Critically Ill in the ICU: A Systematic Review and Meta-Analysis. CritCare Med 2013; 41:1543-1554.

• Korupolu, R., Zanni, J.M., et al, Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010; 91:536-542.

• Kress, J.P., Hall, J.B. ICU-acquired weakness and recovery from critical illness. N Engl J Med 2014; 370:1626-1635.

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References (cont.)

• Lord, R.K., Mayhew, C.R., Korupolu, R., et al, ICU early physical rehabilitation programs: financial modeling of cost savings. CritCare Med 2013; 41:717-724.

• Morandi, A., Brummel, N.E., Ely, E.W. Sedation, delirium and mechanical ventilation: the 'ABCDE' approach. Curr Opin Crit Care2011; 17:43-49.

• Morris, P.E., Goad, A., Thompson, C., et al, Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36:2238-2243.

• Needham, DKayambu, G., Boots, R., Paratz, J. Physical Therapy for the Critically Ill in the ICU: A Systematic Review and Meta-Analysis. Crit Care Med 2013; 41:1543-1554.

• Oeyen, S.G., Vandijck, D.M., Benoit, D.D., et al, Quality of life after intensive care: a systematic review of the literature. Crit Care Med 2010; 38:2386-2400.

• Schweickert, W.D., Pohlman, M.C., Pohlman, A.S., et al, Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373;1874-1882Sukantarat, K., Greer, S., Brett, S., et al, Physical and psychological sequelae of critical illness. Br J Health Psychol 2007; 12:65-74.

• Thomsen, G.E., Snow, G.L., Rodriguez, L., et al, Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med 2008; 36:1119-1124.

• Truong, A.D., Fan, E., Brower, R.G., et al, Bench-to-bedside review: mobilizing patients in the intensive care unit--from pathophysiology to clinical trials. Crit Care 2009; 13:216.

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THANK YOU