et al (2013). - Acute Care Section-APTA

Report
ICU Liberation: How Physical Therapy
Is Part of Reducing the Harms of
Critical Illness
Presented by Heidi Engel, PT, DPT
UCSF Department of Rehabilitative Services
University of California San Francisco Medical Center
[email protected]
February 2015
Disclosures
Academic work in the ICU setting for Heidi Engel, PT, DPT
is funded by a grant from the Gordon and Betty Moore
Foundation
Objectives
• Explain the importance of providing early physical
rehabilitation to patients in the ICU
• Reinforce and define the role of Physical Therapists in
providing care to critically ill patients as part of an interprofessional collaborative care ICU team
• Define the barriers to ICU early physical rehabilitation and
suggest solutions to overcome those barriers
• Cite patient case studies that illustrate Physical Therapy clinical
decision making in the ICU setting
Course Outline
• Complex ICU case presentation emphasizing unique psycho-social
aspects of ICU early physical rehabilitation
• Consequential harms to patients as a result of an ICU stay- weakness,
immobility, delirium, long term functional and cognitive impairments
• Recommendations from Society of Critical Care Medicine outlined
• Example ICU early rehabilitation programs
• Assessing how we are doing
• Barriers- looking at 3 issues at the bedside keeping patients immobileimmobility is safety, timing and priorities, staffing and equipment
• ICU case presentation illustrating unique role of Physical Therapists
Society of Critical Care Medicine ICU LiberationFree Your Patients from Potential Harms
ICU Acquired Weakness (ICUAW)
Immobility
Delirium
Long term cognitive impairments
Functional decline
Inability to return to previous
employment or activities of daily living
Why Early ICU Patient Mobility?
Diaphragm muscle thinning and atrophy begins within 18 to
48 hours after intubation
Levine, S., T. Nguyen, et al. (2008).
Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM: (2012).
Rectus Femoris protein breakdown begins within 24 hours
of ICU admission, cross sectional area declining rapidly
during first week
Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T,
Sidhu PS et al (2013).
ICU Acquired Weakness
Change in architecture of muscle fibers within 18 to 69 hours
Loss of bone mineral density, bone adapts to the load placed on it, ALI
patients have 19% greater risk of fracturing, 10 day study with average
patient age of 55
Frailty: Fried Frailty Index, hallmark is neuromuscular weakness, every 1
pt increase equal to 3X increased risk of 6 month mortality, 82% of older
Icu survivors qualify as frail
Kress JP, Hall JB (2014).
Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, Hopkinson NS, Padhke R, Dew T, Sidhu PS et al (2013)
Baldwin MR, Reid MC, Westlake AA, Rowe JW, Granieri EC, Wunsch H, Dam TT, Rabinowitz D, Goldstein NE, Maurer MS et al:
(2014).
Why Early ICU Patient Mobility?
The duration of bed rest during critical illness was consistently
associated with weakness throughout 24-month follow-up.
Fan E, Dowdy DW, Colantuoni E, Mendez-Tellez PA, Sevransky JE, Shanholtz C, Himmelfarb CR, Desai SV, Ciesla N,
Herridge MS et al (2013).
Based on available evidence, early exercise/PT seems to be the
only treatment yet shown to improve long-term physical
function of ICU survivors.
Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA (2013).
Society of Critical Care Medicine Clinical Practice Guidelines for
the Management of Pain, Agitation, and Delirium
(PAD) Guidelines
Barr J, et al., Critical Care Medicine 2013
Interpretation of PAD Guidelines
Quality of evidence: statements and recommendations
– High (A)
– Moderate (B)
– Low/Very Low (C)
Strength of recommendations: recommendations only
– Either strong (1) , weak (2), or none (0)
– Either in favor of an intervention (+) or against an intervention (-)
Outcomes Associated with
Delirium
in ICU Patients
i. Delirium is associated with increased mortality
in adult ICU patients (A).
ii. Delirium is associated with prolonged ICU and
hospital lengths of stay in adult ICU patients
(A).
iii.Delirium is associated with the development of
post-ICU cognitive impairment in adult ICU
patients (B).
Depth of Sedation in ICU Patients
i. Light levels of sedation associated with improved
clinical outcomes (e.g., shorter duration of
mechanical ventilation and a shorter ICU length of
stay) (B).
ii. Light levels increase physiologic stress response, but
is not associated with an increased incidence of
myocardial ischemia (B).
iii. The association between depth of sedation and
psychological stress in these patients remains
unclear (C).
Depth of Sedation in ICU Patients
(cont.)
iv. Recommend that sedative medications be
titrated to maintain a light rather than a deep
level of sedation, unless contraindicated (+1B).
v. Recommend routinely using either daily
sedation interruption or targeting light level of
sedation in MV patients (+1B).
Delirium Prevention
We recommend performing early mobilization of
adult ICU patients whenever feasible to reduce the
incidence and duration of delirium (+1B)
Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM et al (2013)
Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D et al: (2009)
Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E (2010).
Functional Decline Related to ICU Stay
Long Term Problem
–3.3 year median follow up after d/c from trauma ICU 100 patients
• 70% consider themselves less active than pre-injury
• 49% returned to work.
Livingston DH, Tripp T, Biggs C, Lavery RF (2009).
More than 6 years after a surgical ICU admission, HRQOL is
largely reduced. Many patients still have a variety of health
problems, including decreased cognitive functioning
.
Timmers, T. K., M. H. Verhofstad, et al. (2011).
ICU Liberation Project of SCCM
www.iculiberation.org & www.icudelirium.org
SYMPTOMS
MONITORING
CARE
PAD GUIDELINES
TOOLS
ABCDEF BUNDLE
Assess / Treat Pain
PAIN
BPS
Awakening Trials - SATs
NPS
Breathing Trials - SBTs
Coordination of Care
Choice of Sedatives
CPOT
AGITATION RASS
SAS
DELIRIUM CAM-ICU
ICDSC
Delirium Reduction
Diseases, Drug Removal,
Environment
e.g., sleep, noise, eye glasses,
hearing aids
Early mobility and Exercise
Family - Communication and
Involvement
Neurocognitive and Functional Benefits to
ICU Patients
Schweickert WD, Pohlman MC, Pohlman AS, et al. (2009).
RCT- 104 patients on mechanical ventilation
intervention group- PT median of 1.5 days intubation
control groupPT median of 7.4 days
Intervention groupless days of delirium and MV
59% return to independent function at hospital discharge 35% in control group
.
Role Models- LDS Medical Center
• LDS Medical Center Mobility Protocol
• Walk 200’ prior to extubation
• Walk 400’ prior to ICU discharge
– When patients appear not to have strength to do both reconditioning
and weaning, support reconditioning first, then weaning.
– Support work of breathing during physical activity.
– Advance activity aggressively NOT progressively, patients will do
the most that they can do at any given time.
UCSF ICU Early Mobilization Started
March 1st, 2010 9 ICU
• Physical Therapy coverage 8 hours/day
5 or 6 days/week in 9 ICU
• Objective- referrals for physical therapy within 48 hours of
patient admission to the ICU
• Objective- most ICU patients ambulating during their ICU stay
• Goals– patients wean ventilators faster
– sleep better/experience less delirium
– leave the ICU sooner
Staffing and Equipment
UCSF- one full time PT added
No additional RN or RT staff
ICU platform walker, ear plugs, eye masks, seating cushions
PTs mobilize patients to higher level than RNs
Garzon-Serrano, J., C. Ryan, et al. (2011).
UCSF Exclusion Guidelines
Patients with immediate plans to transfer to outside hospital
Patients who require significant doses of vasopressors for hemodynamic stability
(maintain MAP> 60)
Mechanically ventilated patients who require FiO2 .8 and/or PEEP >12, or have
acutely worsening respiratory failure
Patients maintained on neuromuscular paralytics
Patients in an acute neurological event (CVA,SAH, ICH) with re-assessment for
mobility every 24 hours
Patients with RASS less than -3 or greater than +2
Patients with unstable spine or extremity fractures
Patients with a grave prognosis- transferring to comfort care
Patients with open abdomen, at risk for dehiscence
How Are We Doing?
Point Prevalence Studies:
Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, Kaltwasser A, Mende H, Rothaug O,
Schuchhardt D et al: (2014)
In this 1-day point-prevalence study conducted across Germany
only 24% of all mechanically ventilated patients OOB
only 8% of patients with an endotracheal tube were mobilized out
of bed as part of routine care.
How Are We Doing?
Point Prevalence Studies:
Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas PJ, Denehy L (2013).
45% were mechanically ventilated
140 patients (28%) completed an in-bed exercise regimen
93 (19%) sat over the side of the bed
182 (37%) sat out of bed
124 (25%) stood
89 (18%) walked
Predefined adverse events occurred on 24 occasions (5%)
No patient requiring mechanical ventilation sat out of bed or
walked
How Are We Doing?
Point Prevalence Studies:
Terri Hough University of Washington Medical Center, Presenting at The 7th International Physical
Medicine and Rehabilitation of Critically Ill Patients Meeting 5/17/2014, Across the US:
64% of ICU patients experienced any activity
50% of those were bed level activity
20% of those were transfers to a chair
10% of those were walking
Profoundly variable practice patterns
How Are We Doing?
ICU Early Mobility Protocols
Critical Care Medicine February 2014
Survey of 69 ICUs across the United States looking at structure,
process, and outcomes
97-99% have protocols for ventilator management, infection control,
nutrition, and VTEs
36% have an Early Mobility protocol, all requiring a MD Order to
initiate (A Process Barrier)
Checkley W, Martin GS, Brown SM, Chang SY, Dabbagh O, Fremont RD, Girard TD, Rice TW, Howell MD, Johnson SB et al
:(2014).
Resulting Harm to Patients
“ Tracheostomy, female gender, higher Charlson Comorbidity
Index and lack of early ICU mobility were associated with
readmissions or death during the first year.
Although the mechanisms of increased hospital readmission are
unclear, these findings may provide further support for early ICU
mobility for patients with acute respiratory failure.”
Morris PE, Griffin L, Berry M, Thompson C, Hite RD, Winkelman C, Hopkins RO, Ross A, Dixon L, Leach S et al (2011).
How are we doing in the hospital overall?
32 % of older patients not engaged by an RN in ANY
mobility event during an 8-hour period.
Mean duration of ambulation was less than 2 minutes.
Mean age 74.6, 55.3% using an assistive device, 95.6% had
an MD order for out of bed activity, none met criteria for
dependent patient.
Average length of stay 6.7 days
Doherty-King B, Yoon JY, Pecanac K, Brown R, Mahoney J (2014)
After Patients Leave the ICU?
Of the 72 patients who participated in the study
65 had either a physical therapy consultation or a request for
nursing assistance with ambulation at ward transfer (90%)
Activity level decreased in 40 participants (55%) on the first day
Of the 61 participants who ambulated 100 ft or more on the last
RICU day (85%)
14 did not ambulate, 22 ambulated less than 100 ft (59%)
25 ambulated 100 ft or more on the first ward day (41%)
Hopkins RO, Miller RR, 3rd, Rodriguez L, Spuhler V, Thomsen GE: (2012).
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. (2006).
Barriers to Implementation
•
•
•
•
•
•
•
•
•
Nervous or skeptical clinicians
Minimal resources allocated
Awkward equipment
PT referrals still too late
Unclear protocol
Mobility prior to extubation is difficult concept
Rotating and changing personnel
Variations in sedation practices
New hospital and discharge course predictions required for
ICU and floor personnel
Pawlik AJ, Kress JP. (2012).
3 Common Issues Keeping an ICU Patient
Immobile
Are we patient centered or screen centered in our practices?
Immobility is Safety
Timing and Priorities
Staffing and Equipment
Issue # 1. Immobility is Safety:
TRUE: The patient is too sick, or too big
New onset sepsis or respiratory distress (think of hours
days)
Unstable bleeding or surgical site
Terminal disease (comfort care measures),
Comatose
Acute unstable cardiovascular event
NOT
Solution # 1. Awake and Mobile is Safer
Collaborate with RN,RT, MD
Use Clinical judgment
Every diagnosis in context
Delay increases risk later
Essential Information to Share
• Medical History- impact of the chronic, plus current level of
acuity
• Physiologic Reserve
• Motivation and Goals- what are patient expectations?
• Cognition- anxiety, delirium, co-morbidity
• Pain
• Sedation- why is this patient being sedated?
• Extubation- how is the patient tolerating breathing trials?
• Procedures- dialysis, IR, CT scan?
Context
Is it a beautiful sunny
day after so much rain,
or are we in the middle
of a drought?
Solution # 1. Awake and Mobile is Safer
The patient is too sick, or too big
FALSE: The patient has a DVT (reference the American
College of Chest Physicians 2012 guidelines: people with
acute DVT do not need a period of bed rest)
FALSE: The obese patient was admitted able to walk at home
(think of how crucial prevention can be)
FALSE: The patient is on ARDS Net Protocol
FALSE: The patient is a new admit to the ICU
Consider the Patient Physiologic Reserve,
their Personal Fitness Account
Did this patient walk into your
hospital?
What has the patient done in
the past 2days, 2 weeks, 2
months, 2 years?
What are your assumptions?
Issue # 1. Immobility is Safety
Excuse: The patient is too lethargic, tired?
RASS -2 to -4
Hypoactive delirious
Target RASS vs Actual RASS
Goal targeted sedation?
Richmond Agitation Sedation Scale (RASS) icudelirium.org
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive
+2 Agitated Frequent non-purposeful movement, fights ventilator
+1 Restless Anxious but movements not aggressive vigorous
0 Alert and calm
-1 Drowsy Not fully alert, but has sustained awakening
(eye-opening/eye contact) to voice (>10 seconds)
-2 Light sedation Briefly awakens with eye contact to voice (<10 seconds)
-3 Moderate sedation Movement or eye opening to voice (but no eye contact)
-4 Deep sedation No response to voice, but movement or eye opening
to physical stimulation
-5 Unarousable No response to voice or physical stimulation
Solution to when the patient is too lethargic
Collaborate with RN,RT, MD
Use Clinical judgment
Every level of delirium
in context
Consider the environment, disease, medications
Delirium is treated with mobility
• Target RASS Zero
ICU Sleep Promotion Programs
Consider the Noise level
Lighting
Night time routines
Circadian Rhythms
Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E,
Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG et
al (2013).
Kamdar BB, Needham DM, Collop NA: (2012).
Solution# 2. Mobility will re-orient and decrease lethargy
The patient may respond well to being up and communicating
Include the family in patient care activities
Solution # 3. The patient is too agitated,
awake and re-oriented helps
Society of Critical Care Medicine Clinical Practice
Guidelines for the Management of Pain, Agitation, and
Delirium
“We
recommend performing early
mobilization of adult ICU patients whenever
feasible to reduce the incidence and
duration of delirium” (+1B)
Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress
JP, Joffe AM et al (2013).
What About All Those Critical Lines?
Patient lines and drains can be
accommodated
Including Femoral Lines
Mechanical ventilation and CVVH lines
Damluji, A., et al. (2013).
Winkelman, C. (2011).
Issue #2 Timing and Priorities: The patient is
leaving
The patient is going for:
A procedure
A CT scan
Transferring to the floor
Will be extubated soon
Solution: Mobility Is High Priority
Activity Trumps Extubation:
A pre- and post-activity rest period with assist-control ventilation
for 30 min was employed as needed to support early activity.
If the patient was intubated and able to participate in activity,
the FIO2 was increased by 0.2 before initiation of activity. We
deferred ventilator weaning in support of activity, as necessary.
Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriquez L, Hopkins
RO: (2007).
Issue #2Timing and Priorities: The patient
needs a nap
The patient
Had a bad night
Feels tired
Didn’t sleep last night
Wants to sleep now to make
up for it
Kamdar BB, Needham DM, Collop NA (2012).
Solution for Timing and Priorities: The
Patient Needs a Short Rest
Schedule a time
Create a sleep hygiene
program in your ICU
Address night staff as well as
day
Set circadian rhythms
Issue #3 Staffing/Equipment : No one is
available to manage the lines
No portable ventilator
No high back chairs
No minimal lift equipment
No full time PT
Where are family members?
Solution for Staffing/Equipment: Overcome the
Barriers
Establish the program for your local culture
Begin with the easier smaller success stories
Collect data to evaluate and re-evaluate
Make a Financial case
Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM: ICU early physical rehabilitation
programs: financial modeling of cost savings. Crit Care Med 2013, 41(3):717-724.
Kress JP: Sedation and mobility: changing the paradigm. Crit Care Clin 2013, 29(1):67-75.
Solution: Consider Patients Expectations
and Patient Centered Goals
Returning to life as they knew it
Not a new life of disability or perpetual patient
Include Family in patient care activities
Misak C. (2005).
Muller M, Strobl R, Grill E. (20110>
Solution to Staffing
Equipment : the PT is not here
• Seeing is believing
• Create learning opportunities
• Build the case for a full time dedicated ICU
PT
• Collect Data!
• Plan ahead and coordinate care
• Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB,
Needham DM (2013).
Sitting on the Edge of the Bed
Trunk control
Vestibular training
Joint compression
Joint/muscle stretching
Lung expansion
Airway clearance
Aerobic exercise? (Yes!)
GI motility
Orientation, mental status
Endurance
Walking in the ICU
Allowing our patients to communicate their needs
Assessing and treating pain first
Preventing PTSD
Journaling the experience
In Summary
Critical illness is catabolic and depleting,
rapidly and potentially lasting for years
A prolonged ICU stay can cause delirium and
cognitive changes for most patients
Mobility (mostly walking) combined with
minimal or no sedation started at the
beginning of an ICU stay is protective and
preventative
Approach the task with structured QI project,
collaboration, barrier identification
References
• Levine, S., T. Nguyen, et al. (2008). "Rapid disuse atrophy of diaphragm fibers in
mechanically ventilated humans." N Engl J Med 358 (13): 1327-1335.
• Grosu HB, Lee YI, Lee J, Eden E, Eikermann M, Rose KM: Diaphragm muscle
thinning in patients who are mechanically ventilated. Chest 2012, 142(6):14551460.
• Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P,
Hopkinson NS, Padhke R, Dew T, Sidhu PS et al: Acute Skeletal Muscle Wasting in
Critical Illness. Jama 2013.
• Kress JP, Hall JB: ICU-acquired weakness and recovery from critical illness. N
Engl J Med 2014, 370(17):1626-1635.
• Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P,
Hopkinson NS, Padhke R, Dew T, Sidhu PS et al: Acute Skeletal Muscle Wasting in
Critical Illness. Jama 2013.
• Baldwin MR, Reid MC, Westlake AA, Rowe JW, Granieri EC, Wunsch H, Dam TT,
Rabinowitz D, Goldstein NE, Maurer MS et al: The feasibility of measuring frailty
to predict disability and mortality in older medical intensive care unit survivors. J
Crit Care 2014, 29(3):401-408.
References
• Schefold, J. C., J. Bierbrauer, et al. (2010). "Intensive care unit-acquired weakness
(ICUAW) and muscle wasting in critically ill patients with severe sepsis and septic
shock." J Cachex Sarcopenia Muscle 1 (2): 147-157
• Fan E, Dowdy DW, Colantuoni E, Mendez-Tellez PA, Sevransky JE, Shanholtz C,
Himmelfarb CR, Desai SV, Ciesla N, Herridge MS et al: Physical Complications
in Acute Lung Injury Survivors: A 2-Year Longitudinal Prospective Study. Crit
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References
• Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW,
Kress JP, Joffe AM et al: Clinical practice guidelines for the management of pain,
agitation, and delirium in adult patients in the intensive care unit. Crit Care Med
2013, 41(1):263-306.
• Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears
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• Sacanella E, Perez-Castejon JM, Nicolas JM, Masanes F, Navarro M, Castro P, et
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• Checkley W, Martin GS, Brown SM, Chang SY, Dabbagh O, Fremont RD, Girard TD,
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• Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld
KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG et al: The effect
of a quality improvement intervention on perceived sleep quality and
cognition in a medical ICU. Crit Care Med 2013, 41(3):800-809.
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illness: its role in physical and psychological recovery. Journal of
intensive care medicine 2012, 27(2):97-111.
• Damluji, A., et al. (2013). "Safety and feasibility of femoral catheters
during physical rehabilitation in the intensive care unit." J Crit Care.
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catheters in place." Crit Care Nurse 31(5): 70-73.
References
• Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriquez
L, Hopkins RO: Early activity is feasible and safe in respiratory failure patients.
Crit Care Med 2007, 35(1):139-145.
• Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB,
Needham DM: ICU early physical rehabilitation programs: financial modeling of
cost savings. Crit Care Med 2013, 41(3):717-724.
• Kress JP: Sedation and mobility: changing the paradigm. Crit Care Clin 2013,
29(1):67-75.
• Misak C: ICU psychosis and patient autonomy: some thoughts from the inside. The
Journal of medicine and philosophy 2005, 30(4):411-430.
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hospitals: goal achivement is an indicator for improved functioning. J Rehabil Med
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recommendation to implementation at three medical centers. Crit Care Med
2013, 41(9 Suppl 1):S69-80.

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