Early Mobilization in the Acute Care Setting

1. EarlyMobilization in the Acute Care Setting How can we better assist our patients? TIRR Memorial Hermann Neurologic Physical Therapy Residency Ann Valentine, PT, DPT

2. Objectives • Discuss current practice and investigate why current interventions/limitations with activity exist. • Explore common impairments that occur with prolonged bedrest and prolonged Intensive Care Unit (ICU) stays. • Define Early Mobilization. • Discuss the benefits of Early Mobilization. • Review an Early Mobilization Protocol. • Discuss Further Considerations with Early Mobilization in the ICU.

3. Current practice in many hospitals • We’ve come a long way but more improvements can be made.1 • Delayed initiation of physical therapy 1 • Infrequent treatments in the ICU • Once PT is initiated bed therapeutic exercise is usually the first intervention6,7

4. Barriers to Early Mobilization 2,3,7 • Psychosocial barriers • Comorbidities • Advanced age • Physiologic instability • ICU environment • Limited Evidence

5. Impairments seen with prolonged bedrest2-6 • Increased respiratory dysfunction • Impaired strength • Physiologic impairments • Increased risk for skin breakdown • Decreased quality of life

6. Prolonged hospital stays with mechanical ventilation  DECREASED FUNCTION! 3, 6-7 • Increased morbidity/mortality • Increased cost of care • Increased length of stay • Respiratory muscle weakness and increased duration of ventilation • Sleep deprivation • Lack of social interaction • Prolonged sedation • Delirium

7. Inactive & Alone: Physical Activity Within the First 14 days of Acute Stroke Unit Care 1

8. Inactive & Alone: Physical Activity Within the First 14 days of Acute Stroke Unit Care 1

9. Inactive & Alone: Physical Activity Within the First 14 days of Acute Stroke Unit Care 1

10. What is Early Mobilization? 6 The initiation of mobility when a patient is minimally able to participle, presents with hemodynamic stability and the patient receives acceptable levels of oxygen.

11. Benefits of Early Mobilization 2, 4-8 • Improved respiratory function • Maintains strength and joint range of motion • Fewer physiologic impairments • Repositioning allows for other interventions • Improved quality of life

12. Initiating an Early Mobilization Protocol What is needed to start an Early Mobilization Protocol? • Multidisciplinary involvement is crucial! • A thorough initial physical therapy evaluation • An individualized plan of care • Appropriate goals that meet patient’s values are needed • Determine what phase of the Early Mobilization Program the patient is starting in.

13. Initiating an early mobilization protocol for mechanically ventilated patients 6,7 • Heart rate <130 beats per minute • Mean arterial pressure: 60-100 mm Hg, • FiO2:<60% • PEEP ≤10 cm H2O • SpO2 > 88%

14. Phase 1 • Patient presentation: considerable weakness, limited activity tolerance, occasional altered mental status, minimally participate in therapy and are unable to ambulate. • 15-30 minute treatments • Goal: to start mobilization as soon as the patient is medically stable. • Progression: bed ther ex  rolling  sitting balance  standing with a walker and assistance

15. Further Treatment Options for Phase 1 2 • Tilt table with arms supported for 10-30 minutes • Standing Frame • Chair sitting

16. Phase 2 • Includes patients that have the strength to perform standing activities with a walker and assistance. • Goal: to start walking re-education and functional training • Progression: weight shift  steps in place  side steps along the EOB  chair transfer using a walker and assistance

17. Phase 3 • Includes patients that can tolerate ambulation with a walker and assistance for a short distance. • Goal: Master transfer training and increase endurance.

18. Phase 4 6 • Includes patients that are no longer on a ventilator and/or have been transferred out of the ICU. • Goal: functional training • Ultimate goal: Promote maximum independence by discharge.

19. Further Considerations with Early Mobilization 2,3,7 ALWAYS USE YOUR CLINICAL JUDGEMENT • Other Interventions: e-stim, UE exercise, inspiratory muscle training • Transitions back and forth between phases • Perform during “sedation vacations” • Need assistance to manage multiple lines • Monitor vital signs • Involvement of a multidisciplinary team is crucial!

20. When should an Early Mobilization Intervention be deferred/stopped? 1,2,7 • HR <40 or >130 bpm • RR <5 or >35 bpm • SpO2 <88% for <1 minute • SBP <90 mm Hg or >180 mm Hg • Elevated ICPs • Changes in patient presentation occur • New medical findings occur

21. Adverse Effects with Early Mobilization 2,7 Adverse events are rare. • Fall to knees • Hypoxemia <88% SpO2 for >1 minute • Unscheduled extubation • Orthostatic Hypotension < 80 mm Hg SBP

22. Bottom line 1,2, 6-8 • No medical status decline occurred with an early physical therapy intervention. • This is a safe and feasible intervention. • Early mobilization has the potential to prevent/treat neuromuscular complications of critical illness. • Early Mobilization Requires a Culture Change

23. Questions

24. References • Bernhardt J, Dewey H, Thrift A, and Donnan G. Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care. Stroke 2004;35:1005-1009. • Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):400-407. • Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing 2008;10(1):21-33. • Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy. (4th ed). St. Louis: Mosby. 2006. • Kisner C, Colby LA. Therapeutic Exercise. (5th ed.). Philadelphia: F.A. Davis Company. 2007. • Perme C, Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:212-221. • Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:1874-82. • West L. Early Mobilization: How one multidisciplinary team initiated an activity protocol to decrease ICU lengths of stay. Advance for Physical Therapy and Rehab Medicine May 30, 2011:12-14. *References for images available upon request.