Influence of Mobility Therapy on Mechanically Ventilated Patient’s Outcomes in the ICU

1. Influence of Mobility Therapy on Mechanically VentilatedPatient’s Outcomes in the ICU http://www.hopkinsmedicine.org/pulmonary/research/outcomes_after_critical_illness_surgery/oacis_programs_qi_projects.html

2. P-I-C-O-T P – Mechanically ventilated adults in the ICU I – Early implementation of mobility protocol C – Usual care O – Decreased physical complications related to immobility T – ICU hospitalization

3. Critical illness neuromyopathy and muscle weakness in patients in the intensive care unit Fan, E., Zanni, J. M. , Dennison, C. R., Lepre, S. J., & Needham, D. M. (2009) AACN Advanced Critical Care, 20(3):243-53. ICU-acquired weakness Schweickert, W. D., Hall, J. (2007) Chest, 131(5):1541-9.

4. Negative Effects of ICU Hospitalization • Shift from short-term to long-term morbidities • Recently decreasing mortality of critically ill patients • Prolonged mechanical ventilation • Muscle atrophy within hours of immobility, even in healthy adults • Decreased protein synthesis & muscle mass • Reduced deep tendon reflexes, sensory loss hands/feet, foot drop • Postural hypotension & tachycardia • Generalized pain & changes in mood • Extensive physical reconditioning to return to baseline, even after recovery of other organ systems

5. Acquired Muscle Weakness in ICU Patients Purpose: Advocate a standard approach that identifies risk factors for neuromuscular weakness early to minimize their impact Background: Studies find neuromuscular weakness in 25-50% of ICU patients Prospective cohort studies of patients utilizing multivariate analyses to assess independent risk factors http://doreen.mkbmemorial.com/NF/icu.pdf

6. Acquired Muscle Weakness in ICU Patients Results: Limited specific approaches to reduce ICU-acquired weakness Large number of potential risk factors make it difficult to determine one best practice • Immobility • Severe systemic inflammation • Neuromuscular blocking agents • Poor glycemic control Clinicians are encouraged to recognize and modify risk factors early, and adjust care accordingly Using the Beach Chair Position in ICU Patients: http://ccn.aacnjournals.org/content/30/2/S9.full?sid=e5669fe7-f106-454d-8f7c-f58e05aa6398

7. Limitations of Studying Critically Ill Patients • Lack of standard terminology for Critical Illness Neuromyopathy • Denervation and decreased O2/nutrient delivery to muscles • Small sample sizes • Retrospective design • Single-center experiences • Lack of comparable patient populations Flickr photo by Craig Anderson.

8. The feasibility of early physical activity in intensive care unit patients: A prospective observational one-center study Bourdin, G., Barbier, J., Burle, J. F., Durante, G., Passant, S., Vincent, B., . . . Guerin, C. (2010) Respiratory Care, 55(4), 400-407.

9. How Feasible is Early Rehabilitation? Purpose: Examine the feasibility of early rehabilitation of mechanically ventilated patients. Sample: Cohort of 20 ICU patients from a hospital in Lyon, France. Participants were mechanically ventilated for more than two days, and had an ICU duration stay of at least seven days. Method: Establishment of a mobility protocol to provide mobilization out of bed on a daily basis. Regression analysis examined the changes in patient’s heart rate, respiratory rate, MAP, and pulse oximetry with each mobility intervention.

10. Interventions Tilting-up with arms supported Tilting-up with arms unsupported Chair-sitting Walking

11. Results and Discussion Results: Effects to early interventions on physiologic variables find that rehabilitation is feasible and safe for patients without certain contraindications. Adverse effects were rare and occurred in only 3% of 424 interventions. Discussion: Small sample size Mostly male (14 of 20 participants) Study determined the feasibility of implementing early mobility therapy, but need for further investigation to evaluate long-term effects of early mobilization.

12. Lack of a Standard Protocol • Currently, usual care mobility therapy in ICUs is extremely variable • 17% of acutely ill patients receive therapy during their stay in the hospital • In only 11% of ICU days did patients undergo any activity beyond bed rest • 10% of all hospitals in the US have an established protocol for mobility therapy (Hopkins & Spuhler, 2009)

13. Purpose of Establishing a Mobility Protocol • By creating a protocol, ICU staff will have a structured approach to evaluate and ensure patient therapy • Empowers nurses to proactively initiate therapeutic patient activity, resulting in better patient outcomes • Easily incorporated into multidisciplinary rounds (Hopkins & Spuhler, 2009)

14. Early Intensive Care Unit mobility therapy in the treatment of Acute Respiratory Failure Morris, P., Goad, A., Thompson, C., Taylor, K., Harry, B., Passmore, L., Ross, A., Anderson, L., Baker, S., Sanchez, M., Penley, L., Howard, A., Dixon, L., Leach, S., Small, R., Hite, D., Haponik, E. (2008). Critical Care Medicine, 36(8), 2238-2243.

15. Early Mobility Therapy Purpose: Immobilization and subsequent weakness are consequences of critical illness. Despite the theoretical advantages of physical therapy to address this problem, it has not been determined whether physical therapy has increased benefit when initiated early during ICU treatment. Sample: Cohort of 330 intensive care unit patients with acute respiratory failure requiring mechanical ventilation on admission. Mobility therapy protocol was initiated in 165 patients, and usual care occurred in 165 patients. Method: Cohort study assessed whether a mobility protocol increased the proportion of intensive care unit patients receiving physical therapy vs. usual care.

16. Interventions An intensive care unit Mobility Team (critical care nurse, nursing assistant, and physical therapist) initiated protocol within 48 hours of mechanical ventilation.

17. Results and Discussion: • More protocol patients received at least one physical therapy session than did Usual Care • - 80% vs. 47%, p<.001 • Protocol patients were out of bed earlier • - 5 vs. 11 days, p<.001 • Protocol patients had physical therapy initiated more frequently than Usual Care • - 91% vs. 13%, p<.001 • Protocol patients had shorter ICU length of stay • - 5.5 vs 6.9 days, p=.025 • Protocol patients had shorter hospital length of stay • - 11.2 vs 14.5 days, p=.006 • There were no untoward events during ICU mobility session • No cost difference between two groups (incl. Mobility Team costs)

18. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation Pohlman, M. C., Schweickert, W. D., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., . . . Kress, J. P. (2010). Critical Care Medicine, 38(11), 2089-2094. Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., . . . Kress, J. P. (2009). Lancet, 373(9678), 1874-1882.

19. Mobility Therapy – How Soon? Purpose: Examine how quickly a mobility protocol can safely be initiated Sample: 49 ICU patients started on PT/OT Protocol w/in 72Hrs of intubation. 55 Control patients received normal standard of care Method: PT/OT Team followed a Protocol Flow Chart to guide completion of therapy www.medgadget.com

20. Mobility Protocol - Contraindications • Mean arterial pressure <65 • Heart rate <40, >130 beats/min • Respiratory rate <5, >40 /min • Pulse oximetry <88% • Evidence of elevated ICP • Active GI blood loss • Active myocardial ischemia • Actively undergoing a medical procedure • Agitation requiring increased sedative in the last 30 mins • Insecure airway (device)

21. Protocol Flow Chart

22. Adverse events occurred in 16% of sessions (80 of 498) Desaturation>5% (6%) Heart rate rise >20% (4.2%) Ventilator asynchrony (4%) Agitation/discomfort (2%) Device removal in (0.8%) Therapy was stopped prematurely in only 4% (n 19 of 498) of all sessions Positive Results Negative Results Therapy occurred on 87% of total eligible days (n498 of 570) Able to perform upper/lower extremity exercises (85%) Actively move in bed (76%) Sit at the edge of the bed (69%) Groom themselves (64%) Simulate eating (67%) Moved from bed to chair (33%) Stood (33%) Ambulated (15%)

23. Need for Further Research

24. Overall Recommendations • Unless contraindicated all intubated patients should be started on a mobility protocol to reduce complications. • The hospital should have a mobility protocol team to execute and guide interventions. • Mobility protocols should be started immediately after intubation.

25. Acknowledgements • We would like to thank Dr. Pamela Minarik for fruitful discussions about organizing our research and interpreting results towards implementing new evidence based practice standards. • We would also like to thank Debbie Sommer MLS for assistance with searching electronic databases and organizing references.

26. References Bourdin, G., Barbier, J., Burle, J. F., Durante, G., Passant, S., Vincent, B., . . . Guerin, C. (2010). The feasibility of early physical activity in intensive care unit patients: A prospective observational one-center study. Respiratory Care, 55(4), 400-407. Fan, E., Zanni, J. M., Dennison, C. R., Lepre, S. J., & Needham, D. M. (2009). Critical illness neuromyopathy and muscle weakness in patients in the intensive care unit. AACN Advanced Critical Care, 20(3), 243-253. Hopkins, R., & Spuhler, V. (2009). Strategies for promoting activity in critically ill mechanically ventilated patients. AACN Advanced Critical Care, 20(3), 277-289. Morris, P. E., Goad, A., Thompson, C., Taylor, K., Harry, B., Passmore, L., . . . Haponik, E. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine, 36(8), 2238-2243. doi:10.1097/CCM.0b013e318180b90e Pohlman, M.C., Schweickert, W. D., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., . . . Kress, J. P. (2010). Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Critical Care Medicine, 38(11), 2089-2094. doi:10.1097/CCM.0b013e3181f270c3 Schweickert,W. D., & Hall J. (2007). ICU-acquired weakness. Chest, 131(5), 1541-1549. Schweickert,W.D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., . . . Kress, J. P. (2009). Lancet, 373(9678), 1874-1882.

27. Questions?