No Harm No Foul: Effective Early Treatment of Patients Who are Critically Ill in the ICU

Transcription

1 No Harm No Foul: Effective Early Treatment of Patients Who are Critically Ill in the ICU Julie Pi,as, PT, DPT Chris L. Wells, PhD, PT, CCS, ATC Combined Anaheim, California, February 17-20, 2016 Speaker Disclosure Julie Pi,as and Chris Wells have no financial to disclose. 1

2 Objectives 1. Understand the pathophysiology of CCI and PICS. 2. Appreciate the components of the ABCDEF bundle and the interdisciplinary to implement the evidence based guidelines. 3. Understand the basic components of a hospital wide Early Mobility Program. 4. key clinical and competencies that need to exist to promote safe and rehabilita@on in the ICU sexng. 5. Discuss the benefits of interdisciplinary in the ICU environment. Exciting Times 1954 Olser/ 1956 Olsen: ICU tetraplegia published case reports 1984, Bolten: Coined Illness Polyneuropathy 2000 s: Focus has moved from mortality alone to quality outcomes Physical Therapists are key to the understanding, the and the management of ill 2

3 Critical Illness 5 million annual ICU admissions Respiratory Failure Post Opera@ve Management Ischemic Heart Disease Sepsis Heart Failure 1.4 million older adults ICU admissions SCCM.org; 2015 Critical Illness 200,000 ALI annually with 25-40% mortality rates Average return to work: 1 year Many cannot return to prior employment or func@on 500,000 elder adults adm with cri@cal illness 26% mortality rate in 1 st year post discharge 54% morbidity rate in 1 st year post discharge 3

4 ICU Experience Sleep Disturbance Adverse Effects Poor Pain Management Immobility Loss of Self Control & Dignity Chronic Critical Illness 14 days post ICU admissions 50% treated for sepsis 25 30% mortality rate 15-20% will have new deficits 40% will have at least 1 new ADL limita@on % will have persistent skeletal muscle impairments SCCM.org;

5 Delirium Cluster of symptoms of decreased and memory Arousal Associated with prolonged ICU & days > 40% of ICU 22-72% mortality rate Dose effect: 10% /day of delirium linked to mortality 1 year Delirium A#en&onal deficits Fluctua@ons in consciousness Illusions & hallucina@ons Dysphasia & dysarthria Changes in tone / motor control 5

6 PICS or PSS Describes a collec@on of health disorders Sufferers of cri@cal illness and ICU Environment Range of Signs and Symptoms Physical Dysfunc@on Cogni@ve Dysfunc@on Mental Health Issues SCCM.org 2015; Kress, 2013; Needham 2013 PICS or PSS Persistent Cogni@ve Impairments Modeling mild to moderate TBI or Alzheimer's Syndrome Impairments in execu@ve func@on skills Jackson,

7 PICS Persistent Psychological Problems 35% PTSD at 2 years 60% Anxiety 40% Depression 25-40% s@ll out of work at 1 year Puthucheary, 2013; Needham, 2010; Morris, 2008 PICS Persistent Muscle Impairment / Func@onal Limita@ons 50% will develop ICU Acquired Weakness in 1 week Prolonged mechanical ven@la@on 35 45% Func@onal limita@ons 7

8 PICS Mechanisms Mitochondrial Neuromuscular decoupling Protein catabolism Protein synthesis Muscle fiber necrosis Microvascular damage in fast sodium channels Apostolakis, 2015; Wollersheim, 2014 PICS: Muscle Dysfunction Early phase Mitochondrial edema Sarcomere widening Later phase Sarcomere with myosin loss Atrophy of Type II fibers > type I myosin heavy chain Glycogen dysfunc@on Loss of cross- sec@onal area of all fibers post 5 days Apostolakis, 2015; Wollersheim,

9 Who are at Risk Sepsis Systemic inflammatory response syndrome Age Mechanical Use? NM Blockages Apostolakis, 2015; Wollersheim, 2014; Hooijman, 2015; Kress, 2014 ICUAW CIP CIM Critical Illness MUSCLE DYSFUNCTION What do we call it? CINM 9

10 ICU acquired weakness CIP: Illness Polyneuropathy Normal to minimal in nerve velocity Abnormal EMG (muscle CMAP) Diminished NCS (sensory SNAP) 46% incidence 100% in with systemic inflammatory response syndrome and MSOF Schorl, 2013; 2014; Kress, 2014 ICU Acquired Weakness CIM: Illness Myopathy Normal to minimal slowing in nerve velocity Abnormal EMG (muscle Increase CMAP Decrease in excitability with direct Normal NCS (sensory) 24% incidence 2014; Kress,

11 ICU Acquired weakness ICUAW Clinical Profound weakness (<48 /60 on MRC MMT) Difficult to wean from Decrease in pain, temperature and ICU Acquired weakness MRC weakness MMT: 0-5 scale UE: Shoulder elbow flexion and wrist extension LE: Hip flexion, knee extension, dorsi flexion ICUAW Dx: < 48 /60 11

12 ICU Acquired Weakness MRC 48 associated with More likely to be discharged home Less likely to avoid prolonged acute care stay Less likely to be readmi,ed to acute care facility Lower 28 day and 12 month mortality Denehy, 2013; Schweickert, 2009 Dilemma More Survivors Early Model became a consult service 12

13 ICU Trends Commonly literature shows PT is of low frequency, low intensity and limited OT and SLP is commonly only consulted at end of hospital stay and with limited Falvey 2015: an under of exercises in the elderly leading to further hospital acquired disability Ramsey, 2014 Adverse Effects Post ICU studies: 3 60 months: 58% motor sensory deficits Poor endurance Poor ac@vity tolerance Easy fa@gability Persistent weakness / muscle atrophy Post ICU Syndrome (PICS) Schorl,

14 Adverse Effects Psychiatric Impairments Anxiety: (62%) Depression: (36%) PTSD: (39%) 55-60% impairment 57% Impairments consistent with TBI and Alzheimer s Mikkelsen, 2012; Pandharipandle, 2013 Role of PT in ICU Leader of Early Mobility PT mobilizes at a higher level Establishing procedures for mobiliza@on with ICU equipment Addressing various barriers Research: most effec@ve exercise prescrip@on Garzon- Serrano, 2011; Jolley,

15 Hospital trends Form interdisciplinary commi,ee: Minimizing adverse effects of What does each profession bring to the table to reach goals Promote Interdisciplinary training and sustainability Process and re- ICU trends Early program ROM Strengthening mobility NMES Holiday Decrease delirium Address pain Spontaneous breathing trials Decrease respiratory weakness Mechanical weaning Proper Adequate sleep ICU diary 15

16 F Follow up, referral Family A Spontaneous Awakening Trials B Spontaneous Breathing Trials ICU trends ABCDEF Bundle Pa@ent G: Good communica@on E C Exercise / Early Mobility D Delirium Assessment and Monitoring A & B Coordina@on ; Choice of Seda@on H: Handouts to educa@on about PICS Rise & Shine Initiative UMMC 16

17 Rise & Shine Interdisciplinary Commi,ee Nursing, Physician, Respiratory Therapy, Pharmacy, Technology, Planning began 2012 of components Fall 2013 Focus included all adult ICUs Cardiac surgery Cardiology Medical Surgical Neurology/Neurosurgery trauma Neuro- trauma Standardized ICU when appropriate Rise & Shine Interdisciplinary Training Components RN Use of Richmond and Scale (RASS) and Confusion Assessment Method for the ICU (CAM ICU) RT Performance of spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT) MD/Pharmacy New order set Pharmacological Guidelines for Rehab/RN Early Mobility Program Team communication during rounds (daily goals sheet) 17

18 Spontaneous Awakening Trial Lighten Calm & Alert RASS Goal: Goal: Allow pa@ents to ac@vely par@cipate Ven@lator libera@on Mi@gate / avoid iatrogenic effects Prepare for life post ICU stay Key: Control pain Screening: Spontaneous Breathing trial Medical stability Ven@lator parameters: PEEP < 8 cm H 2 O; FiO 2 <.5; Ve < 15 L/min; Pressure < 25 cm H 2 O Unstable airway ICP < 15 mmhg Significant hemoptysis 18

19 Communication / Coordination Pa@ent Rounds Medical assessment Coordina@on SAT / SBT Delirium screening Daily plan Delirium RASS < - 2 to assess CAM ICU Confusion Assessment Method ICU ICDSC Intensive Care Delirium Screening Checklist Issue: When present, what do you do to treat Acute changes in mental status Ina,en@on Altered level of consciousness Disorganized thoughts 19

20 Delirium Management Repeated Repeated Sleep Protocols Early Timely removal of lines and tubes Minimalize noise Pain management management PREVENTION ABCDE: Early Mobilization Feasibility, efficacy and safety Mechanical supported days ICU LOS,? Hospital LOS Delirium loss Interdisciplinary Morris, 2008; Schweickert, 2009; Needham, ; Hough,

21 Early Mobility Guidelines Formulated by an interdisciplinary team Create a framework for: LIPs to determine if a pa@ent is appropriate for OOB Nursing to determine by what means a pa@ent is most appropriate to get OOB and/or ambulate Dependent technique Standing transfer Rehabilita@on to focus on higher facilita@ve training Assignment of a Mobility Level to communicate the pa@ent s mobility status to the interdisciplinary team Early Mobility Goals Provide Advance Rehabilita@on Pa@ent ac@vity level Hospital associated complica@ons Minimize muscle atrophy/weakness LOS Improve level of discharge Increase awareness about mobility and discharge outcomes 21

22 Early Mobility Guidelines Step 1: Mobility Orders minimal pre shix Non- case by case review Criteria: Cardiac: myocardial or hemodynamic instability Pulmonary: severe respiratory instability, unstable airway Neurological: cerebra- dynamic instability Orthopedic: unstable Fx, unstable spine Integumentary: some open cavity wounds, severe sacral wounds UMMC Mobility Screen Purpose: Nursing tool to assess ability and readiness Goals for use: Safe handling engagement Standardize assessment of ability handling associated injuries 22

23 Utilization of Mobility Screen safety: Determine safety for transfers and walking Staff safety: Risk of employee injuries Referrals: Determine if a PT or OT consult should be obtained Mobility Screen Part 1: Strength Screen & Sitting Balance Strength Screen: 3 Func@onal Muscle Groups 1. Elbow extension 2. Hip & knee extension 3. Seated knee extension SiXng Balance: 60 Seconds 23

24 Mobility Screen Part 2: Modified Dionne s Egress Test 1. Sit to stand 2. Marching in place 3. Stepping forward and back Early Mobility Guidelines Level 1 Level 2 Level 3 Level 4 Level 5 RASS RASS > - 1 RASS > - 1 RASS > - 1 RASS >1 Mobility Screen: fail Mobility Screen: fail Mobility Screen: pass OOB: dependently OOB: dependently OOB: ac@ve Rehab focus: Bed mobility, EOB, standing ADLs Rehab Focus: Transfers, pre gait/ gait ac@vi@es ADLs OOB: ac@ve Ambulatory Rehab Focus: Transfers, gait, steps, higher level ac@vi@es ADLs Baseline Mobility as tolerated 24

25 Mobility Level Signs RN and rehab shared responsibility for signage Property of UMMC, J Pi,as, CL Wells Implementation Electronic Educa@onal Modules Return Demonstra@on Train the Trainer: Early Mobility Champions Classroom training Laboratory experience Competence Bedside training Built into the EMR documenta@on Unit audits on performance Property of UMMC, J Pi,as, CL Wells 25

26 Common Barriers: Implementation and Sustainability Inconsistent mobility dialog during patient rounds Inconsistent rehabilitation presence Inconsistent completion of mobility screen Staff turn over Documentation Inconsistent placement of OOB orders Equipment availability, training, and use Moving Forward Implement F G H Assess protocol implementation Educa@onal model for training of: Rehabilita@on staff Nursing staff Compliance with program components Crea@on of sustainability model Examining outcomes Iatrogenic rates LOS Pa@ent s func@onal levels & sa@sfac@on Falls & injuries 26

27 National Survey of PTs Practicing in ICU in the US Experience: 13 years in acute care hospital 7.8 years in ICU PTs in academic sexngs had more acute care and ICU years of experience than PTs in community hospitals Malone, 2015 National Survey Training: 31.8% formal ICU training (APTA CC fellowships) 55.9% hospital based informal training (mentorship and competency programs) 12.3% no training Reports of both formal and no training higher in community hospital sexngs PTs in academic sexngs more likely to have established competency requirements (52% in academic vs 28% in community) Malone,

28 Implications of National Survey Need for internal and external competent mentorship Competent mentorship - the mentor is truly competent in the knowledge, skills, and abili@es that will enable safe and successful PT prac@ce in the ICU Mentorship oxen delegated to senior level staff with other administra@ve responsibili@es Hospital PT staff turn over rate of 12% - so devoted to direct pt care vs having resources to provide one- on- one mentorship of junior staff Malone, 2015 Implications of Survey Recommenda@ons: Entry level PT curricula and clin ed include ICU based objec@ves and student exposure (1) Development of peer reviewed hospital based competency requirements and prac@ce guidelines Cont. ed courses based on current prac@ce guidelines and assessed by content experts Expansion of residency and fellowship programs 28

29 APTA Credentialed CC Residency & Fellowship Programs CC Fellowship Programs Johns Hopkins Houston Methodist Hospital University of Chicago Residency Programs Johns Hopkins (Complex Medicine) Ongoing Training Accountability What makes an ICU PT? Teaching Drive Mentorship Experience 29

30 A strong ICU training, mentorship, and accountability program : Enhances the ability of the therapists to provide the most advanced therapeu@c interven@ons with the most cri@cally ill pa@ents & Fosters inter- professional trust and respect for the benefit of therapy services UMMC CC Orientation and Training Program PT, OT, and SLP 2 weeks (80 hrs) one- on- one mentorship by therapist who is validated to prac@ce in CC units per UMMC guidelines and has done so for at least one year 8 hrs of CC delegated to CC Clinical Specialist for higher level integra@on of trained material across service lines and pa@ent popula@ons 30

31 UMMC Orientation and Training Program Primarily performed by same discipline, supplemented by other disciplines (OT, SLP) to increase awareness of other s services and importance of interdisciplinary Primarily in one service line: Neurology/Neurosurgery Cardiology/Cardiac surgery, Medicine Surgery, trauma, Neuro- trauma Training Resources Training modules developed for each system including lines & tubes, braces, devices relevant to that system (cardiac, pulmonary, neuro, GI GU, musculoskeletal, training modules Hands on examples of all lines/tubes Annual departmental lecture series CC documents outlining general CC competency rubrics outlining advanced clinical problem solving UMMC Clinical guidelines for specific 31

32 UMMC CC Orientation Diagnoses Factors that impact outcomes hospital course, etc. ) Equipment Lines/tubes Techniques for mobilizing cri@cally ill pa@ents Ven@lator sexngs and basic management Evalua@on and treatment techniques appropriate for cri@cally ill pa@ents Ar@ficial airway suc@oning procedure Communica@on with mul@disciplinary medical team Documenta@on Competency Process Structure Post orienta+on wri-en test ~2 weeks following close of formal orienta@on Covers material in educa@onal modules Spans all service lines in general fashion Must receive >80% to progress to prac@cal competency Observed evalua+on or treatment session One cri@cal line (IVC, CRRT/CVVHD, ECMO, temporary VAD, PA Catheter, ETT, Trach on ven@lator) 3 other lines/tubes Session must include mobiliza@on of the pa@ent (supine to sit edge of bed, sit to stand, stand pivot, ambula@on) with appropriate management of line/tubes *Exam ques@ons and grading rubrics wri,en using educa@onal model by content expert 32

33 UMMC Rehab Critical Care Profile 68% (63/93 total rehab staff ) currently CC competent per UMMC guidelines 68% (34/50) of PTs 55% (16/29) of OTs 100% (13/13) of SLPs 11 CC Validators from the three disciplines manage the annual competency process. CC Validator Requirements Advanced Therapist in UMMC organiza@on) Recommenda@on by supervisor Successful comple@on of validator competency by content expert Successful comple@on CC competency for at least 2 years prior to validator status Consistently prac@cing in CC environment incorpora@ng 2 or more service line popula@ons Demonstrates self awareness of personal limita@ons and seeks assistance for interpreta@on of complex scenarios and decision making if necessary 33

34 UMMS CC Competency Grading Rubric Scoring Criteria: Knowledge and of diagnosis, past medical history, current hospital course and current Understanding of tolerance to treatment of vital signs Assessment of environment Assessment of (discipline specific, pain, visual signs) and knowledge of CC equipment and response to alarms Management of mechanical UMMC CC Competency Grading Rubric Performance of appropriate or treatment techniques based on pt s needs and POC Comple@on of session in logical sequence Iden@fica@on of one cri@cal line and three other lines/tubes present with the pa@ent, their purpose and precau@ons No red flag safety concerns (as listed in the rubric) Demonstrate ability to respond to emergency situa@on scenario Documenta@on of session in medical record reviewed to ensure complete, well wri,en, and accurate representa@on of session 34

35 Continuing Competence Competency renewed one year axer then every 3 years if con@nues to pass May be placed on one year renewal cycle axer the first year if exposure in CC units is minimal or if further training is required to maintain competency Annual renewal educa@on sessions provided with clinical updates relevant to CC topics, new lines/tubes, new procedures Suctioning of an Artificial Airway Skill required for all therapists prac@cing in CC environment, and those prac@cing with chronic pulmonary pa@ents with ar@ficial airways 35

36 Rationale for Suctioning by Rehabilitation Therapists Performing airway clearance techniques (percussion, postural drainage, cough and deep breathing techniques, physical results in the of airway that require immediate removal for airway safety and to allow to to in their therapy session Airway clearance is within the PT scope of and should not be delayed to call for RN or RT during PT treatment as it could impact the safety of the pt Suctioning of Artificial Airway Airways Tracheostomy Endotracheal tube Nasotracheal tube Open and Closed (in- line) technique UMMS Guidelines Adapted from AARC Clinical Guidelines Formal training performed during CC process Mannequin Hands on training Training videos Wri,en test precedes competency Skill performed (open and closed technique) must receive at least 80% per grading rubric 36

37 So, what s the point? Aim of the process = to iden@fy whether a clinician possesses and can apply their knowledge and skills to prac@ce safely and effec@vely in the CC sexng In other words Can the therapist: 1. Iden@fy and integrate all per@nent informa@on related to the pa@ent s care 2. Accurately assess for a pa@ent s discipline specific impairments 3. Perform meaningful and therapeu@c interven@ons to address those deficits 37

38 Who runs the mobility show in your ICU? Does this scenario sound familiar Therapy Lead Model vs Team Model Therapy Lead Approach PT or OT requests orders from provider Therapist constantly services Therapist sets schedule around pt s other daily ac@vi@es Nurses call therapy to see when you re going to get my pt OOB Pa@ent s mobility documented only in PT/OT notes Team Approach Ac@vity orders determined by standardized criteria and expected for most pa@ents Providers aware of need for and support therapy services Therapy is made priority like any other test/procedure Nurse gets the pa@ent OOB even if therapy not present on a given day Therapy able to use to provide skilled interven@ons Pt s ac@vity/mobility level present in mul@disciplinary documenta@on 38

39 Multidisciplinary Model of ICU Mobility Everyone manages their piece of the puzzle are clear with process improves is more succinct Improved efficiency Improved outcomes Contributing Factors Historical culture of the unit differs between hospital and within hospitals care a,ending vs individual service a,ending managing ICU pt care Consistent Rehab staff coverage with dedicated PT, OT, and SLP rounding process CC staff 39

40 The Far Reaching Multi-D Mobility Program Falls Hospital plan Exercise protocols The PT s Piece of the Puzzle Dazzle them with your skills! 40

41 Mobilization of Critically Ill Patients Before you go in the room Comprehensive understanding of pt s diagnosis and hospital course New informa@on RN may have per@nent to your plan Current pulmonary status (vent requirements, weaning plan) Cogni@ve status (pt alert, par@cipatory, following commands) Mobilization of Critically Ill Patients Once you re there Comprehensive assessment of environment (surroundings and pa@ent) Accurate con@nuous vital monitoring system Equipment (what and where) Lines/tubes Extraneous s@mula@on (ex: TV, visitors) Secure wound dressings and briefs Have the assist that you need before you start Don t fear the lines! 41

42 Dispelling ICU Myths Be careful, and the lines will be just fine. Femoral Catheters catheter removal Local trauma Bleeding 239 Femoral catheters (81% venous, 29% arterial, 6% HD) 101 pts received PT while catheter in place Performed of standing, walking, sixng, supine cycle ergometry, in bed exercises 253 total PT sessions NO adverse events Damluji,

43 Pulmonary Artery Catheters Poten&al from changes of PA Cath: Catheter fracture Accidental dislodgement into the R ventricle dysrhythmias infarc@on or rupture of PA Of the 2097 days with a PAC in place for 366 pts 15 occurrences of PAC complica+ons, NONE of which associated with PT, OT, or nursing mobility ac+vi+es. Included BM, transfers, ambula+on and stairs. Fields, 2015 ECMO Increased u@liza@on as technology and cannula@on techniques improve Bridge to transplant and bridge to recovery both benefit Mul@- D approach needed to mobilize pt CCRN, PT, perfusionist RT or CCNP/intensivist if situa@on required Discon@nue nonessen@al therapies during mobility Stabilize cannula if necessary May need to increase support for gas exchange (ECMO sweep gas flow rates, ECMO blood flow rates, and supplemental O2) Interrupt or terminate session per clinical judgement in presence of hemodynamic instability, hypoxemia, dizziness, weakness, chest pain, dyspnea No pt related or circuit related complica@ons as a result of PT tx reported Femoral cannula@on not absolute contraindica@on for ambula@on and transfers but upper body configura@on recommended to decrease cannula related complica@ons Abrams,

44 Femoral ECMO Cannulation & Mobility UMMC Cardiac Surgery ICU (Jan may 2014) Bed mobility, and dynamic standing, SPT Inclusion Criteria: Surgical of site Stable blood flow through femoral cannulas with hip flexion Alert Forrester, 2014 Results 12 of 93 pts on VV ECMO with femoral mobilized 48 of 73 total therapy sessions included mobility No adverse events noted 10/12 successfully weaned from ECMO (2 expired) 7 d/c d to rehabilita@on facility, 2 d/c d home Forrester,

45 Intracranial Pressure Monitoring Elevated ICP = ICP 20 mm Hg for > 5 min Maintain during ac@vity: Intracranial pressure (ICP) <20 mm Hg Cerebral perfusion pressure (CPP) >70 mm Hg External ventricular drain (EVD) or intraventricular catheter (IVC) Must be clamped during mobility to prevent excess CSF drainage Changes in body posi@on, increased internal pressure, and agita@on cause increases in ICP Don t forget who you are! Unique Skills and Perspec@ve Con@nuous assessment of vital signs Monitoring ac@vity tolerance Ranges for common VS s Titra@on of ac@vity level in response to change in physiological status Secre@on clearance when necessary Therapeu@c handling techniques Key points of control Building blocks Use of specialized equipment to progress mobility 45

46 Exercise prescription in the critically ill 2013 Summary of RCTs ICU physical therapy in the ill: Exercise arms consisted of PROM, AROM, limb strengthening Transfers, bed mobility, sixng edge of bed ADLs Gait stair training Early exercises and respiratory muscle training, chest PT, spirometry Arm and leg ergometer Ranged from daily, 10 reps PROM 1-2 sets, 20 min ergometer, 30 min lower limb exercise Suggests that PT as a program package is beneficial in many areas More studies needed to determine the effects of specific prescrip@ve exercise and ac@vity intensity Kayambu, 2013 Strength Training Exercise Prescription for Acute Respiratory Failure Intensity for frail individuals (ACSM recommenda@ons): 60% of muscle s max force to increase strength Use of typical 1 Rep max technique to determine the amount of weight is very difficult in ICU sexng. Alternate approach have pt perform 8-12 reps of given exercise, if fa@gued and unable to perform more reps they are working at appropriate intensity Resistance applied by hand, strap on weights, resistance bands Berry,

47 Strength Training Exercise Prescription for ARF Volume of strength training exercise of the # of reps and sets of and exercise that are completed Strength gains for normal individuals come with 2-4 sets of strength exercises per muscle group Frail pts ACSM recommends that at least one set of each exercise (8-12 reps) be performed Number of sets increases as pt demonstrates gain Exercises should target the major muscle groups: Chest, shoulders, arms, upper and lower back, abdomen, hips and legs Berry, 2013 Strength Training Exercise Prescription for ARF Frequency number per week Yet to be determined for ARF pts but may be more frequent than outpa@ent recs of 2-3 x wk with 48 hr rest between bouts ACSM Recs for ini@a@ng strength training program as soon as pt can perform 8-10 reps of ac@ve ROM Berry,

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