Presentatie Wenen final 3nov2013 - Mobilization- · PDF...

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‘Start to move ASAP’ in the ICU: Proposi7on of the UZ LEUVEN protocol

Beatrix Clerckx

Department of Rehabilita6on Sciences, Department of Intensive Care Medicine, University Hospitals Leuven, Catholic University of Leuven

 Prolonged ICU stay is devasta6ng and oEen results in long-‐term func6onal and cogni6ve impairment

 Recent studies confirmed that early mobilisa6on of mechanically ven6lated pa6ents is feasible and safe and shortens ICU and hospital length of stay.

Purpose protocol

 Establishing an early mobility and physical ac6vity protocol:

-‐ requires a mul,disciplinary team approach; -‐ facilitates a culture in the ICU to reduce immobility of cri,cally ill pa,ents;

Purpose protocol

encourages teamwork

change in mentality

-‐ requires a mul+disciplinary team approach; -‐ facilitates a culture in the ICU to reduce immobility of cri+cally ill pa+ents; -‐ offers a variety of interven,ons to start body posi,oning and

physiotherapy shortly a>er ICU admission.

Purpose protocol

 Establishing an early mobility and physical ac6vity protocol:

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UZ LEUVEN ‘start to move asap’

  6-‐level program   deliver daily mobility or physical ac7vity from day 2 aHer admission to the ICU

  each level is determined by assessment using objec7ve measurements

  each level consists of a variety of body posi7ons and modali7es for physical training and early mobility

VARIABLE COOPERATION

S5Q1 0-5


S5Q1 0-5

CLOSE TO FULL COOPERATION

S5Q1 ≥ 4/5

FULL COOPERATION

S5Q1 = 5

PHYSIOTHERAPY4

Passive/Active range of motion

Passive/active bed cycling

NMES

BODY POSITIONING4

2hr turning

Fowler’s position

Splinting

PHYSIOTHERAPY4


Resistance training arms and legs

Passive/Active leg and/or cycling in bed or chair

NMES

BODY POSITIONING4

2hr turning

Splinting

Upright sitting position in bed

Passive transfer bed to chair

PASSES BASIC ASSESSMENT3 +


PHYSIOTHERAPY4



Active leg and/or arm cycling in bed or chair

NMES

ADL

BODY POSITIONING4

2hr turning


Sitting out of bed

Standing with assist (2 ≥ pers)


PHYSIOTHERAPY4



Active leg and/or arm cycling in chair or bed

Walking (with assistance/frame)

NMES

ADL

BODY POSITIONING4

Active transfer bed to chair

Sitting out of bed

Standing with assist (≥1 pers)


LEVEL 0 LEVEL 5

NO COOPERATION

S5Q1 = 0

FULL COOPERATION

S5Q1 = 5

PHYSIOTHERAPY4



Active leg and arm cycling in chair

Walking (with assistance)

NMES

ADL

BODY POSITIONING4


Sitting out of bed

Standing


FAILS BASIC ASSESSMENT2

PHYSIOTHERAPY:

No treatment

LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4

BODY POSITIONING4

2hr turning

1 : score 5 questions: adequate response to 5 standardized orders

2 : FAILS = at least 1 risk factor present / 3 : if basic assessment failed, decrease to level 0 4 : safety: each activity should be deferred if severe adverse events (cv., resp. and subject. intolerance) occur during the intervention

UZLEUVEN ‘START TO MOVE' ASAP

Neurological or surgical or trauma condition does not allow transfer to chair

Obesity or neurological or surgical or trauma condition does not allow active transfer to chair (even if MRCsum ≥ 36)

MRCsum ≥ 36 +

BBS² Sit to stand = 0 +

BBS² Standing = 0 + BBS² Sitting ≥ 1

MRCsum ≥ 48 +

BBS² Sit to stand ≥ 0 +

BBS² Standing ≥ 0 + BBS² Sitting ≥ 2

MRCsum ≥ 48 +


BBS² Standing ≥ 2 +

BBS² Sitting ≥ 3

BASIC ASSESSMENT =

- Cardiorespiratory unstable:

MAP < 60mmHg or

FiO2 > 60% or PaO2/FiO2 < 200 or

RR > 30 bpm

- Neurologically unstable

- Acute surgery

-Temp > 40°C

assessment?

assessment?

LEVEL 0 LEVEL ?

assessment?

Adequacy score

SCORE 5 QUESTIONS2

A. Open and close your eyes □

B. Look at me □

C. Open your mouth and put out your tongue □

D. Nod your head □

E. Raise your eyebrows when I have counted up to five □

De Jonghe B., et al. Crit Care Med 2007; 35(9): 2007-‐14.

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Basic assessment

-‐  Cardiorespiratory unstable

* MAP < 60mmHg or * FiO2 > 60% or * PaO2/Fi02 < 200 or * RR > 30 bpm -‐ Neurologically unstable -‐ Acute surgery -‐ Temp > 40°C

Func7onal assessment

0 = No visible contrac7on 1 = Visible contrac7on without movements of the limbs 2 = Movements of the limbs but not against the gravity 3 = Movement against gravity over (almost) the full range 4 = Movement against gravity and resistance 5 = Normal

Kleyweg R.P., et al. Muscle Nerve 1991; 14(II): 1003-‐09.

MRC-‐scale: 0-‐5 score

MRC TOTAL SUMSCORE

Total score = 60/60 (max)

(De Jonghe B, JAMA 2002)

Score < 48/60: ‘significant muscle weakness’

Berg Balance score

Berg Balance score SITTING TO STANDING 4 able to stand without using hands and stabilize independently 3 able to stand independently using hands 2 able to stand using hands aEer several tries 1 needs minimal aid to stand or stabilize 0 needs moderate or maximal assist to stand STANDING UNSUPPORTED 4 able to stand safely for 2 minutes 3 able to stand 2 minutes with supervision 2 able to stand 30 seconds unsupported 1 needs several tries to stand 30 seconds unsupported 0 unable to stand 30 seconds unsupported SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL 4 able to sit safely and securely for 2 minutes 3 able to sit 2 minutes under supervision 2 able to able to sit 30 seconds 1 able to sit 10 seconds 0 unable to sit without support 10 seconds

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ASSESSMENT of AMBULATION =

Through use of

‘RELIABLE’

MEASUREMENTS


S5Q1 ≥ 4/5

NO COOPERATION

S5Q1 = 0

LEVEL 0 LEVEL ?



BASIC ASSESSMENT =


MAP < 60mmHg or


RR > 30 bpm


- Acute surgery

-Temp > 40°C

ASSESSMENT OF ‘AMBULATION’

Berg Balance score SITTING TO STANDING 4 able to stand without using hands and stabilize independently 3 able to stand independently using hands 2 able to stand using hands after several tries 1 needs minimal aid to stand or stabilize 0 needs moderate or maximal assist to stand STANDING UNSUPPORTED 4 able to stand safely for 2 minutes 3 able to stand 2 minutes with supervision 2 able to stand 30 seconds unsupported 1 needs several tries to stand 30 seconds unsupported 0 unable to stand 30 seconds unsupported SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL 4 able to sit safely and securely for 2 minutes 3 able to sit 2 minutes under supervision 2 able to able to sit 30 seconds 1 able to sit 10 seconds 0 unable to sit without support 10 seconds

0 = No visible contrac7on 1 = Visible contrac7on without movements of the limbs 2= Movements of the limbs but not against the gravity 3 = Movement against gravity over (almost) the full range 4 = Movement against gravity and resistance 5 = Normal

MRC-scale: 36/60

LEVEL 3

LEVEL 0 LEVEL 5 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4



S5Q1 ≥ 4/5


MRCsum ≥ 36 +



Each level = Body Posi7oning

BODY POSITIONING

2hr turning


Signg out of bed


Jointly with nursing staff

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S5Q1 ≥ 4/5


MRCsum ≥ 36 +



BODY POSITIONING4

2hr turning


Sitting out of bed


PHYSIOTHERAPY:

Passive/Ac6ve range of mo6on


Ac6ve leg and/or arm cycling in chair or bed


NMES

ADL

Each level = physiotherapy




S5Q1 ≥ 4/5


MRCsum ≥ 36 +



BODY POSITIONING4

2hr turning


Sitting out of bed


PHYSIOTHERAPY4




NMES

ADL

Case: level?

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S5Q1 0-5


S5Q1 0-5


S5Q1 ≥ 4/5

FULL COOPERATION

S5Q1 = 5

PHYSIOTHERAPY4


Passive/active bed cycling

NMES

BODY POSITIONING4

2hr turning

Fowler’s position

Splinting

PHYSIOTHERAPY4



Passive/Active leg and/or cycling in bed or chair

NMES

BODY POSITIONING4

2hr turning

Splinting

Upright sitting position in bed




PHYSIOTHERAPY4




NMES

ADL

BODY POSITIONING4

2hr turning


Sitting out of bed



PHYSIOTHERAPY4



Active leg and/or arm cycling in chair or bed


NMES

ADL

BODY POSITIONING4


Sitting out of bed

Standing with assist (≥1 pers)


LEVEL 0 LEVEL 5

NO COOPERATION

S5Q1 = 0

FULL COOPERATION

S5Q1 = 5

PHYSIOTHERAPY4



Active leg and arm cycling in chair

Walking (with assistance)

NMES

ADL

BODY POSITIONING4


Sitting out of bed

Standing



PHYSIOTHERAPY:

No treatment

LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4

BODY POSITIONING4

2hr turning

1 : score 5 questions: adequate response to 5 standardized orders

2 : FAILS = at least 1 risk factor present / 3 : if basic assessment failed, decrease to level 0 4 : safety: each activity should be deferred if severe adverse events (cv., resp. and subject. intolerance) occur during the intervention


Neurological or surgical or trauma condition does not allow transfer to chair

Obesity or neurological or surgical or trauma condition does not allow active transfer to chair (even if MRCsum ≥ 36)

MRCsum ≥ 36 +



MRCsum ≥ 48 +


BBS² Standing ≥ 0 + BBS² Sitting ≥ 2

MRCsum ≥ 48 +


BBS² Standing ≥ 2 +

BBS² Sitting ≥ 3

BASIC ASSESSMENT =


MAP < 60mmHg or


RR > 30 bpm


- Acute surgery

-Temp > 40°C

 The proposi6on of the protocol is discussed, adapted and evaluated by mul6disciplinary team members.

 For 4 months the different levels for each ICU pa6ent were weekly saved in a database:

Level 0: 14%

Level 1: 29%

Level 2: 24%

Level 3: 16%

Level 4: 10%

Level 5: 7%

 The inter-‐observer agreement of the levels was inves6gated by two observers independently. Good inter-‐observer agreement was reached (Kappa coefficient was 0.895 with p < 0.0001).

Evalua7on

Discussion

  In the decision making of the levels, most of the pa6ents (2011) were subdivided in level 1. Those results appeared 4 months aEer the implementa6on of the protocol.   Where are those pa6ents located aEer 2 years of implemen6ng the protocol, in other words; is there a culture change, are we moving the pa6ents faster out of the bed?

levels 2011-‐2013

2011: during 16 weeks, medical and surgical ICU pa6ents from day 2 2013: during 10 weeks, medical and surgical ICU pa6ents from day 2 with an expected stay of 5 days

0

5

10

15

20

25

30

35

40

level 0 level 1 level 2 level 3 level 4 level 5

14

29

24

16

10 7 8

38

27

10 11

6

%

2011

2013

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levels 2011-‐2013

Level 0: < pat. in 2013: ≠ mul6disciplinary approach of the basic assessment: before contra-‐indica6on and now risk factor Level 1: > pat. in 2013: coming from level 0? Level 2: > pat. in 2013: culture change? Level 3, 4, 5: > pat.in 2011: inclusion from day 2, before day 7 to the ward?

0

5

10

15

20

25

30

35

40

level 0 level 1 level 2 level 3 level 4 level 5

14

29 24

16 10 7 8

38

27

10 11 6

2011

2013

%

Conclusion: Culture change?   ≠ 2011-‐2013: a slight tendency to perceive ?

  We struggle s6ll with perceived ‘barriers’ to facilitate rehabilita6on on the ICU: too sick, too sedated, too delirious, limited staffing, priori6za6on of rehab. pa6ents, limited knowledge of ICU staff, equipment limitations, ....   Despite of presenta6ons especially for the nursing group, the most important and effec6ve method to make the culture change seems the bedside individual coaching.

Conclusions

 Through the use of a protocol more pa6ents can probably be ac6vated and ambulated faster.   Sensi6za6on and instruc6on of the mul6disciplinary team members is very important to implement safe and feasible early physical ac6vity and mobilisa6on.

  Objec6ve measurements to facilitate the iden6fica6on of the levels are needed.

  Further research to evaluate the early ac6vity and mobility protocol is warranted.

Thanks for your ajen7on !

Presentatie Wenen final 3nov2013 - Mobilization- · PDF...

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