Advocacy = Safety. Notes on Hospitals: Learning Objectives At the completion of this activity, the participant will be able to:

Transcription

1 Early Progressive Mobility is a Must: Evidence Based Strategies for Achieving Safe Mobility Practices Kathleen Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist/Educator/Consultant ADVANCING NURSING LLC kvollman@comcast.net ADVANCING NURSING LLC Disclosures for Kathleen Vollman Consultant-Michigan Hospital Association Keystone Center Consultant/Faculty for CUSP for MVP AHRQ funded national study Subject matter expert for CAUTI and CLABSI for CMS/HEN 1.0 & 2.0 Consultant and speaker bureau for Sage Products LLC Consultant and speaker bureau for Hill-Rom Inc Consultant and speaker bureau for Eloquest Healthcare Niveus medical Learning Objectives At the completion of this activity, the participant will be able to: Notes on Hospitals: 1859 Build the will to understand the significance of early mobility Identify and discuss key in-bed and out of bed mobility techniques to successfully achieve your early mobility protocol to improve patient outcomes. Overcoming barriers and feeling empowered to own patient mobility within your unit. It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm. Florence Nightingale Advocacy = Safety

2 Effects of Immobility on Respiratory Function Effects of Immobility on Cardiovascular Function Decreased movement of secretions Decreased respiratory motion Increased risk of pulmonary embolism Increased dependent edema Increased risk of atelectasis Increased risk of pneumonia Decreased arterial oxygen saturation Respiratory Fluid shift Occurs when the body goes from upright to supine position 1,2 10% of total blood volume is shifted from lower extremities to the rest of the body; 78% of this is taken up in the thorax 3,4 Decreased blood volume (~15% of plasma volume is lost after 4 weeks of bed rest) 2 Cardiac effects Increased resting heart rate (an increase of ~10 beats/min is observed after 4 weeks of bed rest) 1,2 Cardiac deconditioning 2 thostatic intolerance Increased in bedridden patients due to decreased baroreceptor sensitivity, reduced blood volume, cardiac deconditioning, decreased venous return and stroke volume, and venous distensibility 1,2 Knight J, et al. Nurs Times. 2009;105(21): Vollman KM. Crit Care Nurse. 2010;30:S3-S5. 1. Winkelman C. AACN Adv Crit Care. 2009;20: Knight J, et al. Nurs Times. 2009;105(21): Harms MP, et al. Exp Physiol. 2003;88: Sjostrand T. Physiol Rev. 1953;33: Effects of Immobility on Integumentary Function The current facility acquired of pressure ulcers is high Setting Facility Acquired Rates Critical Care 3.3% to 53.4% Acute Care 0% to 12% NDNQI data base: critical care: 7% med-surg: 1-3.3% Most severe pressure ulcer: sacrum (44.8%) or the heels (24.2%) Pressure ulcers cost $9.1-$11.6 billion per year in the US. Cost of individual patient care ranges from $20,900 to $151,700 per pressure ulcer 17,000 lawsuits are related to pressure ulcers annually 1. National pressure ulcer Advisory panel, European pressure ulcer Advisory panel and Pan Pacific pressure injury alliance. Clinical practice guideline, Hospital-acquired conditions. Centers for Medicare & Medicaid Services website. Acquired_Conditions.asp. Accessed 1/3/ CMS. Fed Regist. 2008;73: Jankowski IM, Nadzam DM. Jt Comm J Qual Patient Saf. 2011;37: Skin Skeletal Muscle Deconditioning Skeletal muscle strength reduces 4-5% every week of bed rest (1-1.5% per day) Without activity the muscle loses protein Healthy individuals on 5 days of strict bed rest develop insulin resistance and microvascular dysfunction 2 types of muscle atrophy Primary: bed rest, space flight, limb casting Secondary: pathology Siebens H, et al, J Am Geriatr Soc 2000;48: Topp R et al. Am J of Crit Care, 2002;13(2): Wagenmakers AJM. Clin Nutr 2001;20(5):451-4 Candow DG, Chilibick PD J Gerontol, 2005:60A: Berg HE., et al. J of Appl Physiol, 1997;82(1): Homburg NM,. Arterioscler Thrombo Vasc Biol, 2007;27(12): Deconditioning During Critical Care Deconditioning Can Occur Within 1 Week of Bed Rest MUSCLE MASS > 15% MUSCLE STRENGTH Up to 40% Puthucheary et al. Acute skeletal muscle wasting in critical illness. JAMA Oct 16;310(15): Hirose et al. The effect of electrical stimulation on the prevention of disuse atrophy in patients with consciousness disturbance in the intensive care unit. J Crit Care Topp et al. The Effect of Bed Rest and the potential for prehabilitation on patients in the intensive care unit. AACN Clin Issues. 2002;13(2): Skeletal Muscle Deconditioning Muscle groups that lose strength most quickly related to immobilization are those that maintain posture, transferring positions & ambulation. > 1/3 of patients with ICU stays greater than two weeks had at least two functionally significant joint contractures. Muscle atrophy in mechanically ventilated patients contribute to fatigue of the diaphragm and challenges with weaning. Degradation within 6-8 days; continues as long as bedrest occurs One day of bed rest requires two weeks of reconditioning to restore baseline muscle strength Siebens H, et al, J Am Geriatr Soc 2000;48: Topp R et al. Am J of Crit Care, 2002;13(2): Wagenmakers AJM. Clin Nutr 2001;20(5):451-4 Candow DG, Chilibick PD J Gerontol, 2005:60A: Berg HE., et al. J of Appl Physiol, 1997;82(1): Hamburg NM,. Arterioscler Thrombo Vasc Biol, 2007;27(12): DeJonnge B, et al. Crit Care Med, 2007;39: Zhang et al GenomProtBioinf: 6Kortebien et al JGerontolMedSci: 63)

3 ICU-Acquired Weakness (ICUAW) Definition: Syndrome of generalized limb weakness that develops while the patient is critically ill and for which there is no alternative explanation other than the critical illness itself. Average Medical Research Council Scale (MRC) score <4 across all muscles tested. Incidence: 25% of patients with prolonged mechanical ventilation will develop ICUAW Est 75,000 pts in US, 1 million worldwide Caused By: Critical illness polyneuropathy, myopathy &/or muscle atrophy Combination Fan E, et al. Am J Respir Crit Care Med Dec 15;190(12): Hermans G, et al. Crit Care. 2008;12:238. Jolley SE, et al Chest, 2016; published online ICU-Acquired Weakness (ICUAW) Risk factors: Severe Sepsis 1,6 Duration of mechanical ventilation 1,4 ICU LOS 5,7 Systemic inflammatory response syndrome 2 Multiple organ failure 2,4 Immobility 2,7 Use of corticosteroids/neuromuscular blockers 2,3,5,6,7 Negative impact: 1,2 Prolong mechanical ventilation Reoccurring respiratory failure & VAP Increased ICU and hospital length of stay Increase mortality 1. Fan E, et al. Am J Respir Crit Care Med Dec 15;190(12): Kress JP et al. N Engl of Med, 2014;370: Hermans G, et al. Crit Care. 2008;12: De Jonghe B, et al. Crit Care Med. 2007;35(9): Needham DM, et al. Am J of Respir and Crit Care Med. 2014;189(10): Penuelas O, et al. J of Intensive Care Medicine, 2016; Hashem MD, et al. Chest, 2016;doi: /j.chest Brain-ICU Study Multicenter RCT- medical-surgical ICU s 821 patients with ARF or Shock Evaluated in-hospital delirium and cognitive impact 3-12 months post d/c Results 74% of patients developed delirium during hospital stay 3 months: 40% had global cognition scores 1.5 SD below population mean, 26% had scores 2 SD below pop mean 12 months: 34%(older) & 24%(younger) global cognition scores below the mean 1 out of 4 cognitive Impairment at 12 months Pandharipande, PP. et al. N Engl J Med;369:1306: Post Intensive Care Syndrome Harvey M, Davidson J. Crit Care Med, 2016;44(2): Outcomes of Early Mobility Programs Early Mobility Protocol: Impacting Outcomes incidence of VAP time on the ventilator days of sedation incidence of skin injury delirium ambulatory distance Improved function in hospital readmissions ICU & Hospital LOS Staudinger t, et al. Crit Care Med, 2010;38. Abroung F, et al. Critical Care, 2011;15:R6 Morris PE, et al. Crit Care Med, 2008;36: Pohlman MC, et al. Crit Care Med, 2010;38: Schweickert WD, et al. Lancet, 373(9678): Thomsen GE, et al. CCM 2008;36; Winkelman C et al, CCN,2010;30:36-60 Azuh O, et al. The American Journal of Medicine, 2016, doi:10.106/jmjmed Corcoran JR, et al. PMR J, 2016 in press Morris, et al, conducted a prospective cohort study to determine the impact of early mobility therapy using a team on patients who were mechanically ventilated with respiratory failure The control group received standard passive ROM and turning (n=165) The study group received low-impact mobility by a team (n=165) Therapy initiated within 48 hours of mechanical ventilation Therapy 7 days/week until ICU discharge Mobility team included 1 ICU nurse, 1 physical therapist, and 2 nursing assistants. Morris PE, et al. Crit Care Med. 2008;36:

4 Early ICU Mobility Therapy Results Baseline characteristic similar in both groups Protocol group: Received as least 1 PT session vs. usual care (80% vs. 47%, p <.001) Out of bed earlier (5 vs. 11 days, p <.001) Reduced ICU LOS (5.5 days vs. 6.9 days, p=.025) Reduced Hospital LOS ( 11.2 days vs days, p =.006) No adverse outcomes; Most frequent reason for ending mobility session was patient fatigue Cost Average cost per patient was $41,142 in the protocol group Average cost per patient was $44,302 in the control group Early Physical and Occupational Therapy in Mechanically Ventilated Patients Prospective randomized controlled trial from screen, 104 patients mechanically ventilated < 72hrs, functionally independent at baseline met criteria Randomized to: early exercise of mobilization during periods of daily interruption of sedation (49 pts) daily interruption of sedation with therapy as ordered by the primary care team (55 pts) Primary endpoint: number of patients returning to independent functional status at hospital discharge able to perform activities of daily living and walk (independently) Morris PE, et al. Crit Care Med, 2008;36: Schweickert WD, et al. Lancet, 373(9678): Early Physical and Occupational Therapy in Mechanically Ventilated Patients Early Physical and Occupational Therapy in Mechanically Ventilated Patients Safe Well tolerated duration of delirium VFD Functional independence at discharge 59% protocol group vs. 35% in control arm Schweickert WD, et al. Lancet, 373(9678): Schweickert WD, et al. Lancet, 373(9678): Use of a of a Mobility Bundle Toolkit and Technology in a Neurointensive Care Unit Use of a of a Mobility Bundle Toolkit and Technology in a Neurointensive Care Unit (NICU) All patient admitted over 16 month period 10 month pre-obs- 6 month post 100% Nurse-driven protocol One protocol for nurses to follow; all patients Mobility goals for patients with or without deconditioning Defined steps beyond chair to better prepare patients for discharge, earlier End point mobility goals similar to outpatient PT goals Modified from The University of Kansas Hospital Progressive Mobility Algorithm for Critically Ill Patients ( Shands at the University of Florida, 2010 Courtesy of J Hester. Titsworth WL. J Neurosurg, : Mobility was increased among the NICU care patients by 300% Titsworth WL. J Neurosurg, :

5 Financial Impact of a PMP Retrospective analysis of economic and clinical outcomes over 2 year period Neuro ICU pts: 1,118 pts in the pre period, 731 pts in the post period, and 796 pts in the sustained period. Intervention: Implementation of Progressive Upright Mobility Protocol Plus Results: HLOS 11.3 ± 14.1 days to 8.6 ± 8.8 post days and 8.8 ± 9.3 days sustained p< % in HAI s 11.3 days 8.6 days 8.8 days 16% 11% 12 million dollar reduction in direct cost Protocol Driven Mobility Program: Impacting Neurological Outcomes Pre-post intervention study Large academic NICU 637 patients 260 pre 377 post Intervention: Early Progressive Mobility Protocol Exclusion criteria Readiness criteria Started on admission Encourage to use ICU bed features & lifts to assist Protocol place at bedside Klein K, et al. Crit care Med, 2015, epub Hester JM, et al. Crit Care Medicine, 2017;45: Protocol Driven Mobility Program: Impacting Neurological Outcomes Multivariate analysis done to control for group differences: Systematic Review of Early Rehabilitation in the ICU 14 studies/1753 patients 880 patients in intervention group 873 patient in control group Varying methodologies Results No difference in short or long term mortality Klien K, et al. Crit care Med, 2015, epub Tipping CJ, et al. ICM, 2017;43: Systematic Review of Early Rehabilitation in the ICU A ASESSMENT OF PAIN Results of Active Rehab muscle mass at ICU d/c probability of walking without assistance at hospital d/c more days alive and out of hospital 180 days Limitations Variation in dosage, small sample sizes of individual studies Tipping CJ, et al. ICM, 2017;43: B C D E F BREATHE/SAT &SBT CHOICE OF SEDATION DELIRIUM EARLY MOBILITY FAMILY Balas MC, et al. Crit Care Nurse Apr;32(2):35-8,

6 ABCDEF Bundle: Improving Survival & Reducing Brain Dysfunction ICU Liberation Collaborative Ventilated and non-ventilated medical and surgical ICU patients enrolled between January 1, 2014, and December 31, 2014 Determine association between ABCDEF bundle compliance/total & partial & outcomes of hospital survival and delirium-free and comafree days/ adjusting for age, severity of illness, and presence of mechanical ventilation Patients experienced more days alive and free of delirium and coma with both total bundle compliance (incident rate ratio, 1.02; 95% CI, ; p = 0.004) and partial bundle compliance (incident rate ratio, 1.15; 95% CI, ; p < 0.001). Barnes-Daly, CCM % in total bundle compliance, patients had a 7% higher odds of hospital survival Prospective, multicenter, cohort study of national collaborative 68 academic, community and federal ICU s collected data-20 months Measure complete and proportional bundle performance against 3 groups of outcomes, patient related, symptom related and system related Pun BT, et al. Crit Care Med Jan;47(1): ICU Liberation Collaborative Pun BT, et al. Crit Care Med Jan;47(1): Progressive Mobility + Care Giver Safety + Skin Safety & Fall Prevention The Goal: Patient & Caregiver Safety Black J, et al. Crit Care Nurs Q. 2018;41(3):

7 Early Mobility Progressive Mobility: Planned movement in a sequential manner beginning at a patients current mobility status and returning them to baseline & includes: Head elevation Manual turning Passive & Active ROM Continuous Lateral Rotation Therapy/Prone Positioning Movement against gravity Physiologic adaptation to an upright/leg down position (Tilt table, Bed Egress) Chair position Dangling Ambulation Vollman KM. Crit Care Nurse.2010 Apr;30(2):S The Mobility Initiative Objective To create a progressive mobility initiative that will help ICU teams to address key cultural, process and resource opportunities in order to integrate early mobility into daily care practices. Methods Multi-center implementation of key clinical interventions An evidence-based, user-friendly progressive mobility continuum was developed, lead by the Clinical Nurse Specialist faculty Implementation plan: process design, culture work & education 130 patients/3120 prospectively collected hourly observations Qualitative and quantitative data collected 15 process and 5 outcome metrics Results reported as cohort and unit specific data Bassett RD, et al.intensive Crit Care Nurs (2012) 2012 Apr;28(2):88-97 Patient Stable, Start at Level II & progress Determining Readiness Perform Initial mobility screen w/in 8 hours of ICU admission & daily Yes PaO2/FiO2 > 250 Peep <10 O2 Sat > 90% RR No new onset cardiac arrhythmias or ischemia HR >60 <120 MAP >55 <140 SBP >90 <180 No new or increasing vasopressor infusion RASS > -3 Bassett RD, et al.intensive Crit Care Nurs (2012) 2012 Apr;28(2):88-97 Needham DM, et al. Arch Phys Med Rehabil Apr;91(4): No Patient is unstable, start at Level I & progress Consensus on Safe Criteria for Active Mobilization Systematic review performed than 23 international experts gather to reach consensus Categories Respiratory Cardiovascular Neurological Other Considerations Consensus reach on all criteria. If no other contraindications; vasoactives, endotracheal tube, FIO2 < 60% with SaO2 90% & RR < 30/min were considered safe criteria Hodgson CL, et. al Critical Care, 2014;18:658 Use of a ICU Mobility Scale (IMS) - Standardizing Language Construct and predictive validity were assessed by comparing IMS values at ICU discharge in 192 patients to other variables The IMS at ICU discharge demonstrated a moderate correlation with muscle strength(r = 0.64, P,0.001). Significant difference between the IMS at ICU discharge in patients with ICU-acquired weakness vs those without P=0.001). Increasing IMS values at ICU discharge were associated with survival to 90 days and discharge home Tipping CJ, et al. AnnalsATS, 2016;13(6): START HERE Progressive Mobility Continuum Includes complex, intubated, hemodynamically unstable Includes intubated, non intubated hemodynamically stable/stabilizing, no and stable intubated patients; may include non-intubated contraindications LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V Perform Initial mobility RASS -5 to - 3 RASS -3 & up RASS -1 & up RASS 0 & up RASS 0 & up screen w/in 8 hours of ICU Goal: clinical stability; Goal: upright sitting; Goal: Increased trunk Goal: stands w/ min. Goal: Increase admission passive ROM increased strength and strength, moves leg to mod. assist, able to distance in ambulation Reassess mobility level at moves arm against gravity against gravity and march in place, & ability to perform least every 24 hours readiness to weight bear weight bear and some ADLs (Recommended at shift Δ) transfer to chair PT consultation prn PT: Active Resistance & OT x1 Refer to the following OT consultation prn Once a day, strength daily OT consult for ADL s criteria to assist in exercises determining mobility level OT consultation prn o PaO2/FiO2 > 250 *Passive /Active ROM 3x/d o Peep <10 HOB > 30º 1. HOB 45º X 15 min. o O2 Sat > 90% *Passive ROM 2X/d 2. HOB 45º,Legs o RR performed by RN, or in dependant Self or assisted Self or assisted Self or assisted UAP position X 15 min. o No new onset cardiac 3. HOB 65º,Legs 1.Sitting on edge of 1.Bed sitting Position arrythmias or ischemia in dependant bed w/rn, PT, RT Min.20 min. 3X/d; 1.Chair (OOB) w/ o HR >60 <120 CLRT/Pronation position X 15 min. assist X 15 min. 2.Sitting on edge of RN/PT/RT assist initiated if patient 4. Step (3) & full 2.Progressive bed bed; stand w/ RN, Min. 3X/day o MAP >55 <140 meets criteria based chair mode sitting Position PT, RT assist 2.Meals consumed Min.20 min. 3X/d o SBP >90 <180 on institutional X20 min. 3X/d 3.Active Transfer to while dangling on practice Chair (OOB) w/ edge of bed or in o No new or increasing Full assist into cardiac Pivot to chair RN/PT/RT assist chair vasopressor infusion chair 2X/day position 2X/d Min. 3X/d o RASS > 3 Ambulate NO YES progressively longer distances with less Level I Level II Level III Level IV assistance x2 or x3/day with Start at Start at RN/PT/RT/UAP level I* level II and progress* For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant ***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level*** *Mobility is the responsibility of the RN, with the assistance from the RT s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment.

8 Do We Even Achieve the Minimum Mobility Standard Q2 Hours? How Well Are We Really Doing? Body position: clinical practice vs standard 1 Study of 74 patients in which the change in body position was recorded every 15 minutes for an average observation time of 7.7 hours 49.3% of observed time showed no body position change for >2 hrs, and 2.7% had every-2-hour demonstrable body position change Positioning prevalence 2 Prospectively recorded, 2 days, 40 ICUs in the United Kingdom Average time between turns, 4.85 hours 1. Krishnagopalan S, et al. Crit Care Med. 2002;30: Goldhill DR, et al. Anaesthesia. 2008;63: START HERE Progressive Mobility Continuum Includes complex, intubated, hemodynamically unstable Includes intubated, non intubated hemodynamically stable/stabilizing, no and stable intubated patients; Level may include I non-intubated contraindications LEVEL I RASS -5 LEVEL to -3II LEVEL III LEVEL IV LEVEL V Perform Initial mobility RASS -5 to - 3 RASS -3 & up RASS -1 & up RASS 0 & up RASS 0 & up screen w/in 8 hours of ICU Goal: Goal: clinical Clinical stability; Stability, Goal: upright sitting; Goal: Increased trunk Goal: stands w/ min. Goal: Increase admission passive ROM increased strength and strength, moves leg to mod. assist, able to distance in ambulation Reassess mobility level at Passive ROMmoves arm against gravity against gravity and march in place, & ability to perform least every 24 hours readiness to weight bear weight bear and some ADLs (Recommended at shift Δ) transfer to chair PT consultation prn PT: Active Resistance & OT x1 Refer to the following OT consultation prn Once a day, strength daily OT consult for ADL s criteria to assist in exercises determining mobility level HOB > Q 30º 2 hr turning OT consultation prn o PaO2/FiO2 > 250 *Passive /Active ROM o Peep <10 *Passive ROM 2X/d 3x/dperformed HOB > 30º 1. HOB 45º X 15 min. o O2 Sat > 90% *Passive ROM 2X/d by RN, 2. HOB or 45º,Legs UAP o RR performed by RN, or in dependant Self or assisted Self or assisted Self or assisted UAP NMES 30 position min X 15 x2 min. o No new onset cardiac 3. HOB 65º,Legs 1.Sitting on edge of 1.Bed sitting Position 1.Chair (OOB) w/ arrythmias or ischemia in dependant bed w/rn, PT, RT Min.20 min. 3X/d; RN/PT/RT assist assist X 15 min. o HR >60 <120 CLRT/Pronation position X 15 min. 2.Sitting on edge of Min. 3X/day initiated if patient 4. Step (3) & full 2.Progressive bed bed; stand w/ RN, 2.Meals consumed o MAP >55 <140 meets CLRT/Pronation criteria based chair mode initiated if sitting Position PT, RT assist while dangling on Min.20 min. 3X/d 3.Active Transfer to o SBP >90 <180 on institutional X20 min. 3X/d edge of bed or in patient practicemeets criteria based on Chair (OOB) w/ chair o No new or increasing Full assist into cardiac Pivot to chair RN/PT/RT assist vasopressor infusion institutional chair practice 2X/day position 2X/d Min. 3X/d o RASS > 3 Ambulate NO YES progressively longer distances with less Level I Level II Level III Level IV assistance x2 or x3/day with Start at Start at RN/PT/RT/UAP level I* level II and progress* For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant ***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level*** *Mobility is the responsibility of the RN, with the assistance from the RT s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment ROM Active & Passive When muscles are immobilize in shorten positions there is remodeling of muscle fibers Bed rest entails immobilization of limb extensor muscles in shortened positions Passive movement has been shown to enhance ventilation, prevent contractures in patients in high dependency units Low resistance multiple repetition muscle training can augment muscle mass & strength Recommended 10 repetitions each extremity x2 daily Gosslink R, et al. Intensive Care Medicine 2008;34: Perme C, Chandrashekar R. Am J of Crit Care, 2009;18: Schweickert WD, et al. Lancet, published online May 14, Griffiths RD, et al. Nutrition, 1995;11:

9 Use of Neuromuscular Stimulation In-Bed Technology NMES utilizes skin electrodes to deliver electrical stimuli to muscles to produce visible contractions Studies have reported it to be safe, feasible, well-tolerated, and beneficial for preserving muscle mass, strength, and function Review of studies of NMES in ICU pts (n > 350): NMES has an impact on muscle strength, length of mechanical ventilation and intensive care stay. These are important findings identifying that NMES can have an impact on clinically important outcomes in critically ill patients Bax L, Sports Med 2005; 35 Kho ME, et al. Crit Care Med, 2015;30(1) Parry Sm, et al. Crit Care Med, 2013;41(10) Williams N, et al. Physiother Therory Pract, 2014;30(1) Cycle Trail in Ontario Ca Continuous Lateral Rotation Therapy Rotational Therapy Using Cushion-Based Rotation The Medical Center of Central Georgia evaluated the impact of CLRT A CLRT protocol was implemented in patients who were identified as at risk for pulmonary complications, and outcomes were compared with a historical comparison group Vent Days ICU Days Hospital Days Cost to Treat, Thousands of Dollars ICU Readmission Rates, % Reintubation Rates, % No CLRT CLRT after 48 hours CLRT within 48 hours When introduced early, CLRT may reduce critical care length of stay and cost to treat CLRT is an option for patient mobility Goldhill DR et al. Amer J Crit Care, 2007;16: CLRT=continuous lateral rotation therapy. No CLRT: 75 patients; CLRT after 48 hours: 46 patients; CLRT within 48 hours: 50 patients. Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31: Transition: Level I to Level II Systematic Method of Approaching Placement & Removal of Rotational Therapy The patient meets the criteria for physiological stability, including cardiovascular, respiratory and neurological

10 Progressive Mobility Continuum Includes complex, intubated, hemodynamically Level unstable II Includes intubated, non intubated hemodynamically stable/stabilizing, no START HERE and stable intubated patients; may include non-intubated contraindications RASS -3 & Up LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V Goal: Upright sitting; increase strength Perform Initial mobility RASS -5 to &- 3 moves arm RASS against -3 & up gravityrass -1 & up RASS 0 & up RASS 0 & up screen w/in 8 hours of ICU Goal: clinical stability; Goal: PT upright consultation sitting; Goal: prn Increased trunk Goal: stands w/ min. Goal: Increase admission passive ROM increased strength and strength, moves leg to mod. assist, able to distance in ambulation Reassess mobility level at moves OT arm consultation against gravity prn against gravity and march in place, & ability to perform least every 24 hours readiness to weight bear weight bear and some ADLs (Recommended at shift Δ) transfer to chair PT consultation prn PT: Active Resistance & OT x1 Refer to the following Q 2 hr OT consultation turning/nmes prn Once 30min a day, strength daily OT consult for ADL s criteria to assist in exercises determining mobility level x2 OT consultation prn o PaO2/FiO2 > 250 *Passive /Active ROM ROM 3x/d 3x/d o Peep <10 1.HOB 45º X 15 min. HOB > 30º 1. HOB 45º X 15 min. o O2 Sat > 90% *Passive ROM 2X/d HOB 45º,Legs o RR performed by RN, or Self or assisted Self or assisted in in dependant Self or assisted UAP position X 15 min. o No new onset cardiac 3. position HOB 65º,Legs X 15 min. 1.Sitting on edge of 1.Bed sitting Position 1.Chair (OOB) w/ arrythmias or ischemia 3. HOB in dependant 65º,Legs bed w/rn, PT, RT Min.20 min. 3X/d; RN/PT/RT assist assist X 15 min. 2.Sitting on edge of o HR >60 <120 CLRT/Pronation position X 15 min. Min. 3X/day in dependant initiated if patient 4. Step (3) & full 2.Progressive bed bed; stand w/ RN, 2.Meals consumed o MAP >55 <140 meets criteria based position chair mode X 15 min. sitting Position PT, RT assist while dangling on Min.20 min. 3X/d 3.Active Transfer to edge of bed or in o SBP >90 <180 on institutional 4. Step X20 min. (3) 3X/d & full practice Chair (OOB) w/ chair o No new or increasing chair Full assist mode into cardiac Pivot to chair RN/PT/RT assist vasopressor infusion X20 chair min2x/day position 2X/d Min. 3X/d o RASS > 3 Ambulate NO YES Full assist into cardiac chair progressively longer distances with less 2X/day Level I Level II Level III Level IV assistance x2 or x3/day with Start at Start at RN/PT/RT/UAP level I* level II and progress* For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant ***If the patient is intolerant of Level current II mobility level activities, reassess and place in appropriate mobility level*** *Mobility is the responsibility of the RN, with the assistance from the RT s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment Transition: Level II to Level III An acceptable strength to advance is considered to be a 3/5 with zero being no movement observed against gravity and five being muscle contracts normally against full resistance The patient meets the mobility goals for level II and is able to move their arm bicep against gravity Grading Muscle Strength START HERE Progressive Mobility Continuum Includes complex, intubated, hemodynamically unstable Includes intubated, non intubated hemodynamically stable/stabilizing, no and stable intubated patients; may include non-intubated Level III contraindications LEVEL I LEVEL RASS II -1 to LEVEL up III LEVEL IV LEVEL V Grade 5: Muscle contracts normally against full resistance. Grade 4: Muscle strength is reduced but muscle contraction can still move joint against resistance. Grade 3: Muscle strength is further reduced such that the joint can be moved only against gravity with the examiner's resistance completely removed. As an example, the elbow can be moved from full extension to full flexion starting with the arm hanging down at the side. Grade 2: Muscle can move only if the resistance of gravity is removed. As an example, the elbow can be fully flexed only if the arm is maintained in a horizontal plane. Grade 1: Only a trace or flicker of movement is seen or felt in the muscle or fasciculations are observed in the muscle. Grade 0: No movement is observed. Medical Research Council. Aids to the examination of the peripheral nervous system, Memorandum no. 45, Her Majesty's Stationery Office, London, Perform Initial mobility RASS -5 to - 3 RASS -3 & up RASS -1 & up RASS 0 & up RASS 0 & up screen w/in 8 hours of ICU Goal: Goal: Increased upright sitting; trunk Goal: strength, Goal: clinical stability; Increased trunk Goal: stands w/ min. Goal: Increase admission passive ROM moves increased leg strength against and gravity strength, and moves leg to mod. assist, able to distance in ambulation Reassess mobility level at moves arm against gravity against gravity and march in place, & ability to perform least every 24 hours readiness to weight readiness bear to weight bear weight bear and some ADLs (Recommended at shift Δ) transfer to chair PT consultation prn PT: Active Resistance & OT x1 Refer to the following OT consultation prn Once a day, strength daily OT consult for ADL s criteria to assist in exercises determining mobility level Q 2 OT hr turning consult for OT consultation ADLs prn o PaO2/FiO2 > 250 *Passive /Active ROM 3x/d o Peep <10 HOB > 30º 1. HOB 45º X 15 min. o O2 Sat > 90% *Passive ROM 2X/d 2. HOB 45º,Legs Self or assisted o RR performed by RN, or in dependant Self or assisted Self or assisted /Possible Self or assisted UAP position X 15 min. o No new onset cardiac 3. HOB 65º,Legs NMES therapy 1.Sitting on edge of 1.Bed sitting Position 1.Chair (OOB) w/ arrythmias or ischemia in bed w/rn, PT, RT Min.20 min. 3X/d; 1.Sitting dependant on edge of RN/PT/RT assist assist X 15 min. o HR >60 <120 CLRT/Pronation position X 15 min. 2.Sitting on edge of Min. 3X/day initiated if patient 4. Step bed (3) & full w/rn, PT, RT 2.Progressive bed bed; stand w/ RN, 2.Meals consumed o MAP >55 <140 meets criteria based chair assist mode X 15 min. sitting Position PT, RT assist while dangling on Min.20 min. 3X/d 3.Active Transfer to edge of bed or in o SBP >90 <180 on institutional X20 min. 3X/d 2.Progressive bed practice Chair (OOB) w/ chair o No new or increasing Full assist sitting into cardiac Position Pivot to chair RN/PT/RT assist vasopressor infusion chair position 2X/d Min. 3X/d Min.20 2X/daymin. 3X/d o RASS > 3 Ambulate NO YES progressively longer Pivot to chair distances with less Level I Level II position 2X/d Level III Level IV assistance x2 or x3/day with Start at Start at RN/PT/RT/UAP level I* level II and progress* For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant ***If the patient is intolerant of current mobility Level III level activities, reassess and place in appropriate mobility level*** *Mobility is the responsibility of the RN, with the assistance from the RT s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment. In-Bed Progressive Mobility Transition: Level III to Level IV An acceptable strength to advance is considered to be a 3/5 with zero being no movement observed against gravity and five being muscle contracts normally against full resistance Journey to tolerating upright position, turning, tilt, sitting, standing and walking and out of bed chair sitting can occur quicker through the use of technology The patient meets the mobility goals for level III and is able to move their leg against gravity

11 START HERE Progressive Mobility Continuum Includes complex, intubated, hemodynamically unstable Includes intubated, non intubated hemodynamically stable/stabilizing, no and stable intubated patients; may include non-intubated Level contraindications IV LEVEL I LEVEL II LEVEL III RASS 0 LEVEL & upiv LEVEL V Out of Bed Technology Perform Initial mobility RASS -5 to - 3 RASS -3 & up RASS -1 & up RASS 0 & up RASS 0 & up screen w/in 8 hours of ICU Goal: upright sitting; Goal: Increased stands trunk w/ min. Goal: to stands mod. w/ min. assist, Goal: clinical stability; Goal: Increase admission passive ROM increased strength and able strength, to march moves leg in place, to mod. assist, weight able to bear distance in ambulation Reassess mobility level at moves arm against gravity against gravity and march in place, & ability to perform least every 24 hours and readiness transfer to weight to bear chair weight bear and some ADLs (Recommended at shift Δ) transfer to chair PT consultation prn PT: Active Resistance & OT x1 Refer to the following OT consultation prn Once a day, strength daily OT consult OT consult for ADLs for ADL s criteria to assist in exercises determining mobility level OT consultation prn o PaO2/FiO2 > 250 *Passive /Active ROM 3x/d o Peep <10 HOB > 30º 1. HOB 45º X 15 min. Self or assisted o O2 Sat > 90% *Passive ROM 2X/d 2. HOB 45º,Legs o RR performed by RN, or in dependant Self or assisted Self or assisted Self or assisted UAP position X 15 min. Q 2 hr 1.Bed turning sitting Q Position 2 hr turning o No new onset cardiac 3. HOB 65º,Legs 1.Sitting on edge of 1.Bed sitting Position 1.Chair (OOB) w/ arrythmias or ischemia in dependant bed w/rn, Min.20 PT, RT min. Min.20 3X/d; min. 3X/d; RN/PT/RT assist assist X 15 min. o HR >60 <120 CLRT/Pronation position X 15 min. 2.Sitting on edge of 2.Sitting on edge of Min. 3X/day initiated if patient 4. Step (3) & full 2.Progressive bed bed; stand w/ RN, 2.Meals consumed o MAP >55 <140 meets criteria based chair mode sitting Position bed; stand PT, w/ RT RN, assist while dangling on Min.20 min. 3X/d 3.Active Transfer to edge of bed or in o SBP >90 <180 on institutional X20 min. 3X/d PT, RT assist practice Chair (OOB) w/ chair o No new or increasing Full assist into cardiac Pivot 3.Active to chair Transfer RN/PT/RT to assist vasopressor infusion chair 2X/day position 2X/d Min. 3X/d Chair (OOB) w/ o RASS > 3 Ambulate NO YES RN/PT/RT assist progressively longer Min. 3X/d distances with less Level I Level II Level III Level IV assistance x2 or x3/day with Start at Start at RN/PT/RT/UAP level I* level II and progress* For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant ***If the patient is intolerant of current mobility level activities, reassess Level and IV place in appropriate mobility level*** *Mobility is the responsibility of the RN, with the assistance from the RT s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment START HERE Progressive Mobility Continuum Includes complex, intubated, hemodynamically unstable Includes intubated, non intubated hemodynamically stable/stabilizing, no and stable intubated patients; may include non-intubated contraindications Level V LEVEL I LEVEL II LEVEL III LEVEL RASS IV 0 & uplevel V Ambulation Assist Devices Perform Initial mobility RASS -5 to - 3 RASS -3 & up RASS -1 & up RASS 0 & up RASS 0 & up screen w/in 8 hours of ICU Goal: upright sitting; Goal: Increased Goal: trunk Increase Goal: stands distance w/ min. in Goal: clinical stability; Goal: Increase admission passive ROM increased strength and strength, moves ambulation leg to mod. & assist, ability able to to distance perform in ambulation some Reassess mobility level at moves arm against gravity against gravity and march in place, & ability to perform least every 24 hours readiness to weight ADLs bear weight bear and some ADLs (Recommended at shift Δ) transfer to chair PT consultation prn PT: Active Resistance & OT x1 Refer to the following OT consultation prn Once a day, strength daily OT consult OT for ADL s x 1 daily criteria to assist in exercises determining mobility level OT consultation prn o PaO2/FiO2 > 250 *Passive /Active ROM 3x/d o Peep <10 Self or assisted HOB > 30º 1. HOB 45º X 15 min. o O2 Sat > 90% *Passive ROM 2X/d 2. HOB 45º,Legs Q 2 hr turning o RR performed by RN, or in dependant Self or assisted Self or assisted Self or assisted position X 15 min. 1.Chair (OOB) w/ UAP o No new onset cardiac 3. HOB 65º,Legs 1.Sitting on edge of 1.Bed RN/PT/RT sitting Positionassist 1.Chair (OOB) w/ arrythmias or ischemia in dependant bed w/rn, PT, RT Min.20 min. 3X/d; RN/PT/RT assist assist X 15 min. o HR >60 <120 CLRT/Pronation position X 15 min. 2.Sitting Min. on 3X/day edge of Min. 3X/day initiated if patient 4. Step (3) & full 2.Progressive bed bed; stand w/ RN, 2.Meals consumed 2.Meals consumed o MAP >55 <140 meets criteria based chair mode sitting Position PT, RT assist while dangling on Min.20 min. 3X/d 3.Active Transfer to o SBP >90 <180 on institutional X20 min. 3X/d while dangling edge on of bed or in practice Chair (OOB) w/ chair o No new or increasing Full assist into cardiac Pivot to chair RN/PT/RT edge of assist bed or in vasopressor infusion chair 2X/day position 2X/d Min. chair 3X/d o RASS > 3 Ambulate NO YES progressively longer distances with less Level I Level II Level III Ambulate Level IVprogressively assistance longer x2 or x3/day with Start at Start at distances with less assistance RN/PT/RT/UAP level I* level II and x2 or x3/day with progress* For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant ***If the patient is intolerant of current mobility level activities, reassess and place RN/PT/RT/UAP in appropriate mobility level*** *Mobility is the responsibility of the RN, with the assistance from the RT s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment Early Mobility: Can We Do It? Is it Safe? Safety of patient mobilization & rehab in ICU: systematic review & meta-analysis 7,546 patients with 583 potential safety events occurring in 22,351 mobilization/rehabilitation sessions (2.6%) Meta-analysis: hemodynamic changes, 3.8 ( ) and desaturation 1.9 ( ) per 1000 mobilization sessions Events that could not be meta-analyzedo 11 falls, 2 removals of ETT, 35 removal or dysfunctions of intravascular catheters, 15 removals of other tube/catheter, 4 cardiac arrest in a single study (not during mobilization). o Consequences of Potential Safety Events Were reported in23 publications, with 3,329 patients & 13,974 mobilization sessions, 308 potential safety events, for incidence of 2% with consequences 0.6% (78 events) Nydahl P, et al. Annals ATS, 2017;14(5):

12 Challenges to Mobilizing Critically Ill Patients Potentially Modifiable Barriers Patient related barriers (50%) Hemodynamic instability, ICU devices, physical & neuropysch Structural (18%) Human or Technological Resources ICU culture (18%) Knowledge/Priority/Habits Process related (14%) Service delivery/lack of coordination Clinician function Dubb R, et al, Annual ATS, 2016 in press Hemodynamic Instability??? Is it a Barrier to Positioning? 50% reported in studies as the # 1 patient barrier The Role of Hemodynamic Instability in Positioning 1,2 Lateral turn results in a 3%-9% decrease in SVO 2, which takes 5-10 minutes to return to baseline Appears the act of turning has the greatest impact on any instability seen Minimize factors that contribute to imbalances in oxygen supply and demand Factors that put patients at risk for intolerance to positioning: 3 Elderly Diabetes with neuropathy Prolonged bed rest Low hemoglobin and cardiovascular reserve Prolonged gravitational equilibrium 1.Winslow EH, et al. Heart Lung. 1990;19: Price P. Dynamics. 2006;17: Vollman KM. Crit Care Nurs Q. 2013;36:17-27 Decision-Making Tree for Patients Who Are Hemodynamically Unstable With Movement 1,2 Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible Is the patient hemodynamically unstable with manual turning? O 2 saturation < 90% New onset cardiac arrhythmias or ischemia HR < 60 <120 MAP < 55 >140 SPB < 90 >180 New or increasing vasopressor infusion Yes Is the patient still hemodynamically unstable after allowing 5-10 minutes adaption post-position change before determining tolerance? Yes Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate inbed mobility strategies as soon as possible Yes Has the manual position turn or HOB elevation been performed slowly? Yes Initiate continuous lateral rotation therapy via a protocol to train the patient to tolerate turning HOB=head of bed; HR=heart rate; MAP=mean arterial pressure; SPB=systolic blood pressure. Vollman KM. Crit Care Nurse. 2012;32: Vollman KM. Crit Care Nurs Q. 2013;36: No No No No Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates Allow the patient a minimum of 10 minutes of rest between activities, then try again to determine tolerance Try the position turn or HOB maneuver slowly to allow adaption of cardiovascular response to the inner ear position change It Takes a Village For Sustainability 1. Necessary Components for Early Rehab Buy-in Multiple disciplines Team communication Opinion leader Individual discipline champion Dedicated rehab personnel Equipment Sedation practice Administrative funding 2. Implementation Strategies Team center approach Staff education Strength & quality of evidence 3. Perceived Barriers Increase workload Safety concerns 4. Positive Outcomes Improved patient outcomes Staff satisfaction Changed culture Financial savings A B C D E F ASSESS, PREVENT & MANAGE PAIN BOTH SAT & SBT CHOICE OF SEDATION DELIRIUM EARLY MOBILITY FAMILY ENGAGEMENT & EMPOWERMENT CODINATION & COMPREHENSIVE AL CARE Eakin MN, et al. J of Crit Care, 2015;30:

13 The Goal: Patient & Caregiver Safety Repetitive motion injury Musculoskeletal injury Days away from work Staffing challenges Retain experienced staff Skin Injury Costs Pain and suffering Hospital LOS ICU LOS Hospital LOS ICU LOS Skin Injury CAUTI Delirium Time on the vent Black J, et al. Crit Care Nurs Q. 2018;41(3): Falls Falls with injury Hospital LOS It is not enough to do your best, you have to know what to do and then do your best. E Deming 75 13