Rehabilitation within critical care

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Earl Pearson
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1 Rehabilitation within critical care

2 Why consider Rehab on ITU? 110,000 people admitted to critical care units in England and Wales each year (ICNARC) 75% survive and are discharged home

3 Long Term Effects Griffiths et al (May 2013) study 22 hospitals across UK (n293): 73% reported moderate/severe pain 1 year after discharge 44% were significantly anxious or depressed. Two-thirds still had problems walking, 6months after leaving hospital. Patients who said a job was their main source of income went from 19% before hospital admission to 11%. 1/3 reported negative impact on family income 6 months after discharge (only declining slightly at 12 months after discharge).

4 Long Term Effects Only 55% ITU survivors return to previous work (Linko et al 2010, Van der Shaaf et al 2009) Persistent functional disability over 1 year following discharge in ARDS patients (Herridge et al 2003) HRQL slowly improved up to one year following ITU D/C, but remained below controls (Cuthbertson et al 2010) Prolonged ventilation in critical care - impaired health related quality of life up to 3 years after discharge, even when patients are living independently at home (Combes et al 2003)

demineralisation = Approx 2% bone mass/month (Up to 2 years to recover) - mitochondria in Type 1 (slow twitch) fibres - Change in fibre

5 Physiological Adaptations to Bed Rest - VO2 Max ( 0.9% per day) - HR (required to maintain resting VO2) - SV (Approx 28% after 10 days bed rest) (Compensated by Ejection Fraction) - Bone demineralisation = Approx 2% bone mass/month (Up to 2 years to recover) - mitochondria in Type 1 (slow twitch) fibres - Change in fibre type of Type II fibres from A to B - Muscle atrophy (1-1.5% loss per day) * Note all these results involve healthy individuals. Disease, malnutrition, sedatives, paralytics and sepsis all have the potential to increase these responses

6 Evidence for Rehab - Physiotherapy has a positive effect on LOS, function and HRQL. - significant positive effect favoring physical therapy for the critically ill to improve the quality of life, physical function, peripheral muscle strength, and respiratory muscle strength. Length of hospital and ICU stay significantly decreased and ventilator-free days increased following physical therapy in the ICU. Paratz et al (June 2013)

7 Study investigating intensive therapy and daily sedation holds. Scweickert et al 2009 >18 years Ventilated <72hrs but expected to cont >24hrs Randomly assigned to: - Intervention (PT & OT with daily sedation holds) n=49 - Control (Physician ordered sedation holds and therapy sessions) n=55

8 Scweickert et al 2009

9 Study into Physio exercise programme. Chiang et al (2006) Treatment group (n20) Physical training 5 days per week for 6/52 with a senior physiotherapist UL and LL ex s using weights and breathing ex s for resp muscles practiced functional activities (e.g. rolling, sitting, standing and walking as strength progressed) Control group (n19) not seen by the Physio Both received standard medical + nursing care and no rehab prior to commencement of study

10 Inclusion/exclusion Ventilated >14days Mentally alert ** Haemodynamically stable Not on any sedatives or paralytic agents Pts with pre existing neurological conditions **

11 Does mobility protocol increase proportion of patients receiving physical therapy Morris et al (2008) Protocol (n165) vs Normal care (n165) An ICU Mobility team initiated protocol within 48 hours of mechanical ventilation Consisted of Critical care nurse Nursing assistant Physical Therapist

12 Figure 2. Morris et al - Early Therapeutic Mobility Protocol. LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 Unconscious Conscious Conscious Conscious Turn every 2hr Turn every 2hr Turn every 2hr Turn every 2hr Passive ROM exercises Sitting position min 20 minutes 3x daily Sitting position min 20 minutes 3x day. Sitting position min 20 minutes 3x day. Sitting on edge of bed with Physical therapist Active resistance range of motion (ROM) with physical therapy or RN daily Sitting on edge of bed with Physical therapist Active Transfer to Chair (OOB) with Physical Therapist Minimum 20 minutes Can move arms against gravity Can move legs against gravity

13 Results Outcome Proportion of patients receiving physical therapy Protocol Control P Value 80% 47% p< st Day out of bed 5 11 p<0.001 Ventilator days p=0.163 Therapy initiated on ICU 91% 13% p<0.001 ICU LOS (days) p=0.025 Hospital LOS (days) p=0.006

Rehab protocol aiming at sit out by Day 5 McWilliams & Pantelides (2008) To identify whether sitting patients on the edge of the bed or out in a chair within the first 5 days of admission decreases

14 Rehab protocol aiming at sit out by Day 5 McWilliams & Pantelides (2008) To identify whether sitting patients on the edge of the bed or out in a chair within the first 5 days of admission decreases length of stay on ITU To identify limiting factors to early mobilisation & facilitate methods to decrease these 65 Patients admitted to ICU from 20th Jun - 20th Sept 2005 (Exclusions: Patients on ITU for < 24 hours) Data collected from: rehab monitoring form & patient notes

15 Results Mobilisation took place Met standard By the 5 th day Met Standard Not by 5 th day Did not meet standard Not by the 5 th day No. of cases 17/65 (26%) 14/65 (22%) 34/65 (52%) Mean LOS 5.7 days 12.9 days 21.1 days Range (LOS) 2-18 days 3-29 days 5-86 days

16 Results Reason for not sitting out Number of cases (n=48): Percent age: Poorly/ Sedated/ paralysed 22 46% Decreased staffing* 8 17% Fractures 4 8.5% Weekend* 4 8.5% Reason not stated 2 4% Decreased GCS 2 4% On Noradrenaline 2 4% CVS unstable 2 4% Agitated % Deranged Clotting 1 2% *Approx 30% reversible

17 Mobility On Leaving ICU (Hospital LOS in days) A B C A = Mobile 10m or more B = SOEOB/ out in chair C = Not sat up/out yet

18 Conclusion to Audit Small numbers Numerous variables BUT Significant difference for those patients mobilised (approx 7 days) 7 days = 10, pts = 140,000 over 3 months = 560,000 p/a potentially avoidable with staff/ resources

19 Study investigating post ITU rehab. McWilliams et al patients admitted to ICU 5 days 6 week out patient exercise based rehabilitation programme, commenced within 2 weeks of hospital d/c Outcomes 6MWT, ISWT and HADS No control group for analysis

20 McWilliams et al 2009

21 Why Rehab early? Facilitate weaning from mechanical ventilation Decrease negative effects Impact on costs Approx 1700 per day on ITU 1-2% of UK hospital budget per year Comprehensive Critical Care Nice Guidelines CG83

22 NICE CG83 Published in 2009 with an evidence review in Provides a framework for inclusion of rehabilitation in the Critical Care environment and following discharge. Not a specific How to guide to rehab.

23 Table 1: Examples from the short clinical assessment that may indicate the patient is at risk of developing physical and nonphysical morbidity Note: This list is not exhaustive and healthcare professionals should use their clinical judgment. Physical Unable to get out of bed independently. Anticipated long duration of critical care stay. Obvious significant physical or neurological injury. Lack of cognitive functioning to continue exercise independently. Unable to self ventilate on 35% of oxygen or less. Presence of pre-morbid respiratory or mobility problems. Unable to mobilise independently over short distances. Non-physical Recurrent nightmares, particularly where patients report trying to stay awake to avoid nightmares. Intrusive memories of traumatic events which have occurred prior to admission (for example, road traffic accidents) or during their critical care stay (for example, delusion experiences or flashbacks). New and recurrent anxiety or panic attacks. Expressing the wish not to talk about their illness or changing the subject quickly off the topic.

24 Admitted To Critical Care - Physio Ax within 24 hours - History/ Baseline Mobility Whilst in acute phase/ Sedated +/- Paralysed - Daily Passive Movements - Positioning Programme Once Patient Wakes/ Stable - Commence active exercise programme - Sit on edge of bed - Chair Position if unable to sit out Seating Plan Documented Daily & weekly rehab goals Ongoing active exercise Long Term Patients > 14 Days Weekly MDT Meetings Joint Goal setting Weaning / Rehab Plan? To include: - Medical Staff - Nursing Staff - Physiotherapist - Pharmacist - Dietician - Occup. Therapist - SALT (As approp.) On Discharge from Critical Care - Discharge summary completed with established rehab plan & Exercise programme (Within 24 hours) Ongoing Rehab on ward as per rehab plan until discharge (Review/ Monitor by Follow up team as required) Post Hospital Discharge < 5 days on ITU discharge info/ booklet > 5 Days on ICU Structured Post ITU Rehab programme (Within 2 weeks) ICU Follow up Clinic Approx 3 months post d/c

25 Importance of MDT Collaborative Weaning Plans (medics & Physio) Seating Plans, exercises, positioning (Physio & N/S) Adequate Nutrition and calories (dietician) Anxiety Management & PADL s (OT) Pain relief, night sedation (Pharmacist) Appropriate equipment

26 The Challenges of Mobilisation

28 Critical Care Rehab at Royal Cornwall Hospital

29 How do we use the MMS? Electronic records (since March 2012) Physiotherapy ward book Nursing Protocol folder in each bedspace Rehab teaching sessions and rehab focus for all patients Rehabilitation physiotherapy technical instructor 4 days/week Each patient should have their rehab recorded every day

30 RCHT Rehab Scale 1 Passive movts 6 Indep sitting on edge of bed 2A Active assisted movts 7A Sit to stand with 2+ / encore 2B Active movts 7B Sit to stand with 1/2 3 Chair position in bed 7C Sit to stand with min asst 4 Hoisted out into chair 8 Standing step transfer 5A Tilt table 9 Mob to end of bed 5B Sit on edge of bed with Mob 10m R Pt refused U Pt too unwell for rehab S Unable to rehab due to staffing levels

31 How has it helped? Demonstrates the level of rehab we are reaching individually and on average March 12 average Level 3 Oct 12 average Level 6 May 13 average Level 8 Identifies both nursing and Physiotherapy input

32 How has it helped? Highlights the effects of vacancies and understaffing Prompts consideration of rehab for all patients by the MDT as a whole.

33 Where next at RCH? Audit to evaluate impact of rehab Tech III & static Specialist Physiotherapist. Audit of discharge mobility status. MDT approach with rehab protocol? seating plans, rehab targets and standards.

34 Where next at RCH? ITU Rehab funding bid Challenge ourselves to rehab earlier more pts with ETT s out of bed, filtered pts, those on ionotropes. Group rehab sessions Follow-up rehab sessions or ESD

35 Acknowledgements With thanks to David McWilliams ACPRC Critical Care Champion RCH critical care nursing staff and physio team for embracing the rehab culture and making the improvements happen.

36 Any Questions?????

Early and Structured Rehabilitation Team Collaboration. David McWilliams Clinical Specialist Physiotherapist - UHB

Early and Structured Rehabilitation Team Collaboration David McWilliams Clinical Specialist Physiotherapist - UHB Start early Moving through milestones Schweikert et al (2009) Increase frequency of higher