Early mobility in critical illness

1. Early mobility in critical illness LindeeStrizichTull, MD MSc C. Terri Hough, MD MSc 11/20/2013

2. Background • 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 Schefold, JC, et al. “ICUAW and muscle wasting in critically ill patients.” J cachexia, sarcopenia and muscle. Oct 14 2010

3. Pathophysiology • 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) Schefold, JC, et al. “ICUAW and muscle wasting in critically ill patients.” J cachexia, sarcopenia and muscle. Oct 14 2010

4. Consequences of Critical Illness Myopathy • Greater number of days on a ventilator • Delirium • Increased total hospital length of stay • Decreased quality of life post discharge • Greater length of time to be independent in ADL’s • Increased mortality post-hospital discharge (Cox 2007, Herridge 2003, Heyland 2005, Kelly 2010, Semmler 2013).

5. Solution? MOBILIZE CRITICALLY ILL PATIENTS!

6. Benefits of Mobilization • 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, Naeem2008) • associated with a decreased odds of hospital readmission or death in the year following ICU admission (Morris 2011, Schweickert 2009)

7. What is mobility in critical illness? Minimum activity = “dangling” All the way up to walking!

8. Why isn’t everyone mobilized? • 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, Dinglas2013) • 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).

9. What are the barriers at HMC? • 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.

10. Study Methods • Retrospective cohort study • Comparing 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).

11. Inclusion Criteria • Admission to the MICU service between January 1, 2008 and December 31, 2012 • Adiagnosis of acute respiratory failure, requiring mechanical ventilation for at least 24 hours • ICU bed status for at least 96 hours jama.jamanetwork.com

12. Exclusion Criteria • 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.” pharmacologyandpt.com

13. Current Status • Compiling and cleaning data…. • Analysis in Jan 2013

14. While waiting for the IRB approval… • 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

15. Mobilization event charted? Frequency of mobilization

16. Documentation of Mobility

17. PT/OT Utilization

18. Lessons from QI work? • 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 inconsistent • We do not chart reasons for not mobilizing seemingly eligible patients • We may not be utilizing PT/OT enough in our MICU, and a PT/OT consult does not necessarily = mobilization

19. Acknowledgements • 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

20. References