Lindee Strizich Tull, MD MScC. Terri Hough, MD MSc11/20/2013EARLY MOBILITY IN
CRITICAL ILLNESS
Critical illness survival rates are increasing, however there are many long term consequences of ICU admission
Decreased QOL, increased mortality post-discharge, decreased functional status
ICU acquired weakness – profound neuromuscular dysfunction after critical illness Critically ill patients lose
significant muscle mass and strength
BACKGROUND
Schefold, JC, et al. “ICUAW and muscle wasting in critically ill patients.” J cachexia, sarcopenia and muscle. Oct 14 2010
Neuromuscular dysfunction and loss of muscle mass secondary to a complex host of factors: Prolonged immobility Increased caloric
requirements Paralytics Corticosteroids Increased inflammatory
mediators Altered membrane and
protein channel functioning
(Chambers 2009, Cherry-Bukowiec 2013, Derde 2012, Hough 2009, Latronico 2011, Wever-Carstens 2010)
PATHOPHYSIOLOGY
Schefold, JC, et al. “ICUAW and muscle wasting in critically ill patients.” J cachexia, sarcopenia and muscle. Oct 14 2010
Greater number of days on a ventilatorDelirium Increased total hospital length of stayDecreased quality of life post dischargeGreater length of time to be independent in ADL’s Increased mortality post-hospital discharge (Cox 2007, Herr idge 2003, Heyland 2005, Kel ly 2010, Semmler 2013).
CONSEQUENCES OF CRITICAL ILLNESS MYOPATHY
MOBILIZE CRITICALL
Y ILL PATIENTS!
SOLUTION?
Early mobility improves muscle strength (Llano-Diez 2012) decreases ICU and hospital LOS increases the likelihood of and decreases the length of time
until regaining functional independence increases QOL post-discharge Decreases length of time of delirium (Davis 2013, Hough 2012,
Morris 2008, Naeem 2008) associated with a decreased odds of hospital readmission or
death in the year following ICU admission (Morris 2011, Schweickert 2009)
BENEFITS OF MOBILIZATION
Minimum activity =“dangling”
WHAT IS MOBILITY IN CRITICAL ILLNESS?
All the way up to walking!
Estimated that only 30% of patients are mobilized at any point during their ICU admission (Dinglas 2013)
Rates vary both between and within institutions (Hodgkin 2009, Thomsen 2010, Dinglas 2013)
Factors that may affect rates of mobilization Patient factors: illness severity, sedation requirements,
need for continuous hemodialysis, gender (Dinglas 2013, Garzon 2011, Thomsen 2010)
Institution factors: profession of practitioner providing exercise, academic vs. community hospital, surgical vs. medical vs. other specialty ICU, presence of an ICU culture promoting early mobility (Bailey 2009, Dinglas 2013, Garzon 2011, Hodgkin 2009, Hopkins 2007, Morris 2008, Thomsen 2010).
WHY ISN’T EVERYONE MOBILIZED?
Hypothesis – ICU patients are mobilized infrequently, & this is based on multiple patient & institution specific factors
Study Goals: To assess rates of mobilization
of patients admitted to the MICU service at HMC
Determine which factors, both patient and institution related, were associated negatively or positively with mobilization.
WHAT ARE THE BARRIERS AT HMC?
Retrospective cohort studyComparing factors associated with critically ill MICU
patients who are mobilized to those who are not patients’ baseline factors (e.g., age, gender, weight,
language) aspects of critical illness (diagnosis, severity of illness,
cardiopulmonary instability, delirium/coma) medical treatments (e.g., use of BZD’s, paralytics, RRT) external factors (e.g., day of the week, location of ICU bed,
PT/OT consult).
STUDY METHODS
Admission to the MICU service between January 1, 2008 and December 31, 2012
A diagnosis of acute respiratory failure, requiring mechanical ventilation for at least 24 hours
ICU bed status for at least 96 hours
INCLUSION CRITERIA
jama.jamanetwork.com
Criteria indicating unstable patient conditions:
MAP < 65 mm Hg or > 110 mm Hg, or SBP > 200 mm Hg; HR < 40 BMP or > 130 BPM; RR< 5 or > 40; and pulse oximetry < 88%.
Other contraindications to mobilization: Raised ICP; active GIB; active MI; continuous procedures including haemodialysis
HMC Nursing Criteria for mobility –absolute contraindications Full spine precautions, IABP, Prone positioning, Sheath Precautions,
Critical hypoxemia on rescue therapy, persistent vegetative state Patients also ineligible for mobilization if:
paralyzed, known neurologic disease like myasthenia gravis precluding ability to mobilize, or baseline functional status less than “dangle.”
EXCLUSION CRITERIA
pharmacologyandpt.com
Compiling and cleaning data….
Analysis in Jan 2013
CURRENT STATUS
QI work!!! Goals –
how do we chart mobility in our EMR? How many patients are eligible for mobility How easy is it to figure out if someone meets eligibility criteria? What proportion are mobilized?
Methods: Data collected retrospectively from the EMR of a random sampling of patients admitted to the MICU for at least 24 h over a one month period
Only the first 120 hours of admission were analyzed Admission diagnoses, contraindications to mobilization,
highest level of activity charted each day, PT/OT consults and sessions, mention of mobility in daily progress notes and nursing notes, and daily activity orders were recorded
WHILE WAITING FOR THE IRB APPROVAL…
34 patients admitted to
MICU
• intubated >/= 24h, admitted to MICU >/=
48h & no contraindication
s to mobility
56% (19) of patients eligible
42% (8/19) achieved dangle or greater
FREQUENCY OF MOBILIZATION
• Mobilization event charted?
116 physican progress notes
54% mention mobility
20% of these are the same as
the charted mobility event
DOCUMENTATION OF MOBILITY
116 nursing progress
notes
20% mention mobility
19 pts. eligible for mobility
5 PT/OT consults
0 pts. Seen over first 120 hours in
ICU
PT/OT UTILIZATION
Cannot abstract mobilization events from physician or nursing progress notes We do not document this in our notes very well Nursing has a specific place to chart this, but even this can
be inconsistentWe do not chart reasons for not mobilizing seemingly
eligible patientsWe may not be utilizing PT/OT enough in our MICU,
and a PT/OT consult does not necessarily = mobilization
LESSONS FROM QI WORK?
Terri Hough, MD, MSc – research mentor, Associate Professor, Division of Pulmonary and Critical Care Medicine, HMC
Ellen Caldwell – Statistician, UWMC Division of Pulmonary and Critical Care Medicine
Colin Johnston – Research Coordinator, UWMC Division of Pulmonary and Critical Care Medicine
Scott Weigle, MD, Professor of Medicine and Associate Program Director for medical subspecialties and research, UWMC IM Residency Program
Kelly King, RN, MN, CCRN, Assistant Nurse Manager, MCICU, HMC
ACKNOWLEDGEMENTS
REFERENCES
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