ICU Early Mobilization at UCSF

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Jodie Cummings
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1 ICU Early Mobilization at UCSF Critical Care Medicine & Trauma Conference San Francisco, CA June 5, 2010 Presented by Heidi Engel, PT, DPT Can We Do Better? Herridge MS. Mobile, awake and critically ill. CMAJ. Mar ;178(6): There appears to be significant potential for harm arising from the current ICU culture of patient immobility and an often excessive or unnecessary use of sedation. This is a culture that began for all the right reasons: to promote patient comfort, safety and respiratory synchrony while allowing intubation and mechanical ventilatory support for severe respiratory failure. But this culture has persisted despite emerging evidence that these practices may, alone or in combination with acute illness that precipitated the ICU admission, have important adverse consequences that may not be remediable over time. 1

2 Presentation Objectives Define early ICU mobilization Review of patient functional decline related to an ICU stay Outline steps necessary to increase mobility of ICU patients Site evidence of benefits to patients, family members, and the medical center of early ICU mobilization. Definition of Early ICU Mobilization Early defined as initial physiologic stabilization, continuing through out ICU stay Initiating patient mobilization within 48 hours of patient admission to the ICU through: ICU cultural shift toward mobility as necessity, not optional Practice patterns of all ICU personnel emphasizing team work with mobilization Optimizing the ICU environment to allow for patient mobility Equipment Sleep Sedation Bailey PPR, ACNP; Miller, Russell R. MD, MPH; Clemmer,, Terry P. Culture of Early mobility in mechanically ventilated patients. Critical Care Medicine. 2009;37(10):S429-S435. S435. 2

3 Functional Decline Related to ICU Stay Joint contractures- 39% of patients at ICU d/c after 2 week stay Delirium- 1 in 3 survivors experience long term cognitive decline Global profound weakness due to Immobility, bed rest Metabolic changes, catabolic effects of illness Systemic inflammation Medication side effects Nutrition Neuropathic changes Functional Decline Related to ICU Stay Intensive care unit-acquired weakness (ICUAW) can occur early in an ICU stay and persist for years after. An independent predictor of mortality A common problem (25-100% of patients on MV > 7 days) Patients from the ICU fall 3 times as often as those who had not been in the ICU 1 year after discharge, walking capacity 66% of predicted norm on 6 minute walk test, 49% return to work 3

4 Evidence of ICU Acquired Weakness Occurs early: Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med. Mar ;358(13): Can persist for years: Herridge Herridge MS, Cheung AM, Tansey CM, et al. One- year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. Feb ;348(8): Is common: Schweickert Schweickert WD, Hall J. ICU-acquired weakness. Chest. May 2007;131(5): Stevens RD, Dowdy DW, Michaels RK, Mendez-Tellez PA, Pronovost PJ, Needham DM. Neuromuscular dysfunction acquired in critical illness: a systematic review. Intensive Care Med. Nov 2007;33(11): Evidence of ICU Acquired Weakness Short term complications Greater risk of falls: Flanders Flanders SAea.. Falls and Patient Mobility in Critical Care: Keeping Patients and Staff Safe. AACN Advanced Critical Care. July/September 2009;20(3): Longer time weaning from mechanical ventilation: Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med. Mar ;358(13): Independent predictor of mortality: Ali NA, O'Brien JM, Jr., Hoffmann SP, et al. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med. Aug ;178(3): Long term complications Livingston DH, Tripp T, Biggs C, Lavery RF. A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit. J Trauma. Aug 2009;67(2): ; 348; discussion

Mobility is Medicine Health Benefits of Physical Activity: Improves blood sugar homeostasis Enhances cardiovascular function Enhances endothelial function Decreases chronic

Health benefits of physical activity: the evidence. Cmaj. Mar 14 2006;174(6):801-809. 809.

5 Mobility is Medicine Health Benefits of Physical Activity: Improves blood sugar homeostasis Enhances cardiovascular function Enhances endothelial function Decreases chronic inflammation Regulates hormone levels Preserves musculoskeletal and neuromuscular integrity Decreases depression and improves cognition Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. Cmaj. Mar ;174(6): ICU Early Mobilization Requires Patients admit to ICU with activity as tolerated orders Easy prompts for initiating PT referrals are included in MD orders Majority of ICU patients receive consistent PT daily 80% currently at Johns Hopkins Hospital and LDS Medical Center 5

6 Steps Taken at UCSF: Gathering Information- One Year Research articles Conferences Presenting the proposal in written and power point forms to both research and clinical groups of: RT, MD, PT, NP, Administration, and RN Staff meetings, informal meetings, scheduled meetings, CEO and COO office hours support from JHH and LDS Attending monthly critical care meetings with updates LDS site visit Steps Taken at UCSF: Creating the Multi-discipline Team Clinical group and QI program chosen rather than research Director of Critical Care identified and proposed champions Executive Director of Service Lines Administration- fiscal project goal, our executive sponsor RT, PT, RN, NP Department Managers and Clinical Specialists 6

Steps Taken at UCSF: Location Choice 9 ICU chosen for presence of NPs, physical space medicine, liver transplant, hematologic oncology, orthopedic, cardiac, general surgery patients 10 ICC unit

7 Steps Taken at UCSF: Location Choice 9 ICU chosen for presence of NPs, physical space medicine, liver transplant, hematologic oncology, orthopedic, cardiac, general surgery patients 10 ICC unit serves as role model Administrative Message: Established Early ICU Mobilization Program Financial Savings The preliminary projected business case for this was modeled after the success at Johns Hopkins IF UCSF experiences moderate success against the JHH QI results, we can expect: >$500,000 direct cost savings a reduction in ICU days across 57 cases of 264 days a total hospital day reduction of 274 days An average Hospital LOS reduction from 53.4 to

Clinical Message: Established Early ICU Mobilization Programs Schweickert WD, Pohlman MC, Pohlman AS,

Early physical and occupational therapy in mechanically ventilated, critically ill patients: a

Randomised controlled trial of 104 patients on mechanical ventilation, intervention group received PT

8 Clinical Message: Established Early ICU Mobilization Programs Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. May Randomised controlled trial of 104 patients on mechanical ventilation, intervention group received PT median of 1.5 days after intubation vs 7.4 days for controls. Intervention group had: less days of delirium less days of MV 59% of intervention group return to independent function at hospital d/c vs 35% in control group Present a Compelling Case for the RN Groups 8

9 Barriers At this First Stage Sounds like a good idea, but: I cannot add staff at this time It s s too much work The evidence is not conclusive enough Verbal support without concrete follow up Skeptical managers and Medicine clinicians Practice patterns, protocols, communication, and documentation systems must be changed Endless meetings, no start date ICU Early Mobilization Started March 1st, 2010 UCSF 9 ICU Full time Physical Therapy coverage 8 hours/day 5 days/week in 9 ICU Objective: referrals for physical therapy to start within 48 hours of patient admission to the ICU Objective: most ICU patients ambulating during their ICU stay Goal: patients wean ventilators faster, sleep better, experience less delirium, and leave the ICU sooner. 9

10 Motivational Stage- Before and After Start Date Announcing change to all the disciplines and medical/surgical services Approval for NPs to write all referrals for PT regardless of patient service A prompt in the MD order set Articles in RN news letters Change barrier policies RN must accompany PT at all times Purchase new equipment updates weekly Monthly critical care meeting updates Post-start start Date Barriers- It s s Not a Strength Issue. Nervous or skeptical clinicians Minimal resources allocated Awkward equipment PT referrals still too late Unclear protocol PT in the ICU now a moderate priority rather than a last priority, but not a top priority Mobility prior to extubation is difficult concept for all Constantly rotating and changing personnel Variations in sedation practices New hospital and discharge course predictions required for ICU and floor personnel 10

11 Early Success Stories Two planned tracheotomies avoided Patients able to go to acute rehab and home rather than long term acute care facility Patients able to go home instead of to SNF Early Success Stories Tremendous positive feedback from family members Reduced patient and family stress as a result 11

Future for ICU Early Mobilization Looking at our ability to prevent deconditioning as important as our ability to prevent skin breakdown, VAP, line infections Considering functional mobility and

12 Future for ICU Early Mobilization Looking at our ability to prevent deconditioning as important as our ability to prevent skin breakdown, VAP, line infections Considering functional mobility and activity history as vital signs Thank You UCSF Critical Care- Michael Gropper, MD, Michael Matthay,, MD, Kevin Thorton,, MD UCSF Executive Director for Service Lines- Karen Rago,, RN, MPA, FAAMA, FACCA UCSF Nursing- Tereza De Paula, RN, Charlotte Garwood, RN, Sarah Irvine, RN, Hildy Schell-Chaple Chaple,, CNS, Cathy Schuster, RN UCSF Critical Care Nurse Practitioners- Geoffrey Latham, NP, Maureen Mary Arriola,, NP UCSF Respiratory Therapy- Brian Daniel, RT UCSF Rehabilitative Services- Joy Devins,, PT, Rebecca Mustille,, PT, Shin Tatebe,, PT, Sherri Heft, PT, Phil Alonzo Johns Hopkins Hospital ICU PM&R- Dale Needham, MD, Eddy Fan, MD LDH Medical Center- Polly Bailey, NP, Louise Bezdjian,, NP 12

ICU Early Mobilization at UCSF

ICU Early Mobilization at UCSF Presented by Heidi Engel, PT, DPT Heidi.Engel@ucsfmedctr.org Presentation Objectives Review of patient functional decline related to an ICU stay Define early ICU mobilization