Entering the ICU: How to do this from the Physiatrist’s Perspective

Julie Lanphere DOAssistant Professor

Department of Physical Medicine & RehabilitationMedical Director

UPMC Rehabilitation Institute at Montefiore

• I have no conflicts of interest to report.• I do not endorse any products that may be

pictured in any photos.

Objectives

• Understand key pearls on how to build an early mobility program in your local institution

• Understand how to become comfortable working with ICU patients

• Understand the basic concepts and clinical pearls required for critically ill patients using a therapy program in the ICU

Physiatry in the ICU• Multidisciplinary team management• Enhance and restore functional ability and quality of life• Critical illness population-vulnerable

Cognitive deficits- delirium, agitation, memory, attention

Physical deficits- weakness, debility, CIN, CIM

Emotional deficits- anxiety, depression, PTSD, paranoia

Medical complexity-Cardiopulmonary deconditioning-Respiratory failure, multiorgan system injury

• Functional deficits in mobility, endurance, self care/ADL’s, cognition

Early Mobility Implementation Program

• Engage physician leadership for support• Need a critical care physician and RN director champions• Engage therapy and hospital administration leadership to

discuss dedicated therapy/RN driven early mobility program• Staff education-sedation protocols, team concept, evidence

surrounding feasibility and strengths of ICU early mobility• CQI to assess mobility interactions, HLOS, ICU LOS, HAP/VAP,

DVT’s

Rehabilitation in the ICU• Current literature supports that early mobility in the critical care unit

has a positive effect on cardiopulmonary, neurological, musculoskeletal, and integumentary systems

• SAFE and FEASIBLE

• Literature supports that detrimental medical complications occur with bed rest and immobility

• “You can’t debate the evidence that demonstrates that there’s a benefit to early rehabilitation. It’s like debating the sky is blue.” Director of Rehabilitation Services

ICU Mobility & Immobility:Evidence Based Medicine Suggested Readings

Schweickert, W.D. et al. Implementing early mobilization interventions in mechanically ventilated patients in the ICU. Chest. December, 2011, Vol 6, 1612-1617.

Morris, Peter et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine, 2008, Vol 36, No 8.

Herridge et al. One Year Outcomes in Survivors of ARDS. 2003;348(8):683-693.

Herridge et al. Functional Disability 5 Years after Acute Respiratory Distress Syndrome. N Engl J Med. 2011; 364; 1293-304.

Needham et al. Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders’ conference. Crit Care Med 2012; 40:502-509.

Kress, J.P., Hall, J.B., ICU-Acquired Weakness and Recovery from Critical Illness. N Engl J Med. 2014: 1626-1635

Early Mobility Implementation Program

• Engage physician leadership for support• Need a critical care physician and RN director champions• Engage therapy and hospital administration leadership to

discuss dedicated therapy/RN driven early mobility program• Staff education-sedation protocols, team concept, evidence

surrounding feasibility and strengths of ICU early mobility• CQI to assess mobility interactions, HLOS, ICU LOS, HAP/VAP,

DVT’s

Needham et al. Early Physical Medicine and Rehabilitation for Patients with Acute Respiratory

Failure: A Quality Improvement Project. Arch Phys Med

Rehabil. 2010; 91:536-542.

GOALS:

• Reduce sedation and delirium to allow for mobility

• Enforce and increase rehabilitation presence in the Unit

• Decrease LOS

Needham et al. Early Physical Medicine and Rehabilitation for Patients with Acute Respiratory

Failure: A Quality Improvement Project. Arch Phys Med Rehabil. 2010; 91:536-542.

Before• PT when ordered by the primary

team

• Standard bed rest order

• Routine RN care

• No Screen for Delirium

After• Automatic PT/OT consult

• Created guidelines for initiation of PT/OT

• Standard Mobility as tolerated order

• Decreased continuous infusion of benzos and narcotics prn bolus infusions

• Screened for Delirium

Cost Savings/LOS Data

ICU Early Physical Rehabilitation Programs:Financial Modeling of Cost Savings

Needham, DM et al, Critical Care Medicine, 2013

• Net cost savings with 900 annual admissions – actual length of stay reductions of 22% and 19% for the ICU and floor

estimated $817,836.

– conservative- and best-case scenarios for LOS reductions and varied the per-day ICU and floor costs 200–2,000 annual admissions, yielded financial projections ranging from $87,611 (net cost) to $3,763,149 (net savings)

ICU Early Physical Rehabilitation Programs: Financial Modeling of Cost SavingsNeedham, DM et al, Critical Care Medicine, 2013

Early Mobility Implementation Program

• Engage physician leadership for support• Need a critical care physician and RN director champions• Engage therapy and hospital administration leadership to

discuss dedicated therapy/RN driven early mobility program• Staff education-sedation protocols, team concept, evidence

surrounding feasibility and strengths of ICU early mobility• CQI to assess mobility interactions, HLOS, ICU LOS, HAP/VAP,

DVT’s

Medical Intensive Care Unit:

MOBILITY

PROJECT

Medical Intensive Care Unit• Prior to July of 2010, patients in the MICU remained sedated and

on formal bed rest until extubation occurred • Opportunity:

Review the Evidence Formed a multidisciplinary mobility team (MD, RN, PT, RT, OT) Help to create a mobility protocol MICU Mobility Trial Pilot (CQI) on MICU (9F, 10F, 11F)

for 3 months with 1 Designated Physical Therapist

Baseline Data: UPMC MICU

MICU Mobility Goals

• Start with Mobility Protocol /order set

– All patients admitted to unit screened by Physical Therapy

– Define and redefine relative/absolute contraindications

– Sedation Protocol

– Delirium screening

• Education to nursing staff by therapy (mobility intervention, transfer techniques, body mechanics, safety)

• Education by MD champion to the RN’s, residents, and Fellows

(sedation protocols/delirium/pain)

• Serve as resource for other ICU’s who wish to implement mobility program

Implementation of New ProcessPhysical Therapist Driven Mobility:

Early PT Consult

Early Interruption of Sedation

Successful Team

Mobility Program

Mobilityon the Unit is Driven by the Physical Therapist:~Screeningof all patients admitted to Unit~Plans of care and intervention set by Physical Therapist

~PT and RN Rounds BID~Weekly Mobility Rounds led by Physical Therapist

~Early TeamMobility coupled with Daily Interruption of Sedation~Ongoing Education to RN, RT staff by the Physical Therapist (body mechanics, transfer techniques, mobility intervention)

Mobility RoundsGOAL: Identify barriers to for mobility •Pulmonary/Critical Care

– Attending Physician Champion– House staff (residents, fellows)

•Physiatrist•PT (+/- PT aide)•Nurse clinician•RN Research Team•Bedside nurses

– Presenter•Respiratory therapy

Baseline Data: Historically, patients in the MICU remained sedated and on bed rest until extubation, and sedation

interruption not consistent…

Early Mobility in the ICU with PM&R• 94 patients recruited into the mobility protocol Jan-Mar 2013• 63% received PT intervention!

MICU Mobility CQI reduced LOS

HCAHPS MICUUPMC Presbyterian

• ~10% of sessions interrupted for safety concern

– Majority sustained desaturation SpO2 <90%

– 1 syncope episode with spontaneous recovery– 1 AICD discharge – AF with aberrant conduction and RVR – 0 Falls / Assist to floor– 0 CVC, feeding tube dislodgement– 1 partial ETT dislodgement– <10% Rectal tube dislodgement

MICU Mobility Safety

26

A Typical Day in the MICUINFORMATION ~ COORDINATION ~ TIMING

• Daily bedside rounds by RN clinician, PT, and bedside nurse • Evaluate patient stability & level of functioning• Evaluation of new consults• Coordination of care with RN based on

– Procedures– Sedation interruption– Weaning trials

• Mobility protocol implemented based on patient specific needs• Documentation of progress in medical record

Getting Comfortable with Critically Ill Patients

• Know the evidence• Guidelines to modify

therapies• FiO2 greater than 60%• PEEP greater than 10 cm H2O• Consistent O2 Saturations less

than 92%• Hx of desaturations with positional

changes during nursing care• Unstable BP on pressors or

inotropes• Severe Acidosis with pH less than

7.30

Getting Comfortable with Critically Ill Patients

Absolute Contraindications TO Stop Therapy

1. Severe CP associated with EKG changes

2. HR above predicted MHR or pre-determined limits set by medical team

3. Hypotension associated with dizziness, lightheadedness, and diaphoresis

4. Intolerable dyspnea, nasal flaring, or cyanosis

5. Unable to recover from or maintain SpO2 of 85% or more despite supplemental oxygen

6. Severe pain despite analgesia

7. Extreme fatigue8. Patient or Therapist

Safety9. Patient wishes to stop

Sedation Protocols

• Understand Sedation ProtocolsAssess need for & treat pain prior to sedativesIdentify & treat deliriumExpect agitation as sedation decreased and emphasize non-

pharmacological methods to bridge to wakefulnessTarget cessation of continuous sedative infusion by 48 hours

after intubation

• Goal: Awake and Breathing at 48 hrs after intubation without using continuous infusions

ABCDE BundleImproving Outcomes for Ventilated PatientsAn Expert Interview With Chandra Alexander RN, CCRN, and Dena Putnam, RN, BA, MBA, Elizabeth McGann,

DNSc, RN, June 14, 2012

A: Awakening trials for ventilated patients.B: Spontaneous breathing trials.C: Coordinated effort between the registered nurse and respiratory therapist

to perform the spontaneous breathing trial when the patient is awakened by reducing or stopping the patient's sedation. The combination of sedation and analgesics being used are reviewed, and changes or reductions in the doses are considered.

D: A standardized delirium assessment program, including treatment and prevention options.

E: Early mobilization and ambulation of critical care patients.

Basic concepts and clinical pearls using therapy in the ICU

Basic concepts and clinical pearls using therapy in the ICU

• Remember the basics to mobility*Edge of bed sitting

(CORE/RESPIRATORY MUSCLES/CARDIOPULM)*Transfers/standing/sit in chair

(Likolift, power standers, wheeled walkers, hand held assist)(CORE/RESPIRATORY MUSCLES/CARDIOPULM + PERIPHERAL MUSCLE/NERVE STIMULATION, STRENGTHENING)

*Ambulation (speaks for itself)-Wheeled Walkers *Stationary Bikes, therabands, Nustep

*PT, OT, SLP, Neuro Psych, Inpatient rehab if indicated/Outpatient therapies at DC (don’t forget these!)

SLEEP/WAKE CYCLES

Family Presence

• Advocate/motivator/help mood• Less sedation• Hygiene care• Advocacy-prevents complications, med error

prevention, unnecessary procedures• Invested in the patient

Mobility-A Docs Perspective as a Patient

• Huge impact on delirium and when you get home (1700)• Issues after DC do not get addressed by PCP, other medical providers• “The four steps to get into my house are my biggest physical barriers when

I leave the ICU.”• “As a critical care doc, I didn’t get a lot of training about assistive devices

patients can use at discharge. I just don’t think about it in my daily practice, about how I can make it easier for my patient when they get home. Not a lot of my primary care physicians and specialists address this. Until I saw my rehab specialists at discharge, these issues did not get addressed.

Mobility-A Docs Perspective as a Patient

• Sleep issues-big problem! “IF YOU CAN’T SLEEP, YOU CAN’T COPE.” PTSD exaggerated, becomes a vicious cycle

• Fear of getting sick again (lack of resources, seeking care post ICU DC, who do you call??)

• Depression-family members and patients• Set expectations on how to get better

Educational and Tutorial Videos Dale Neeham MD-Into

• http://www.youtube.com/watch?v=D53gygWRhLM

Phyllis-ICU REHAB COURSE-Short version

• http://www.youtube.com/watch?v=woofpnw-u74

ICU Delirium

• http://www.youtube.com/watch?v=30sbefBcjEU&feature=youtu.be

• Recovering from the ICU: An MD Survivor's Story/Perspective: http://www.youtube.com/watch?v=bvm6_6vtGa4

• University of Chicago PT/OT mobilization Video of patient https://www.youtube.com/watch?v=6xeHvr9WaxQ&feature=youtu.be&a

• Hopkins Early Mobility Resource website http://www.hopkinsmedicine.org/pulmonary/research/outcomes_after_critical_illness_surgery/oacis_videos_news.html

ICU Mobility, is it in you?

THANK YOU!

Culture is “the beliefs and attitudes that are shared by the organization’s members”

Bailey P et al. (2009). Crit Care Med, 37(10):5429-5435

ReferencesHerridge et al. Functional Disability 5 Years after Acute Respiratory Distress Syndrome. N Engl J Med 2011; 364; 1293-304

Needham et al. Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders’ conference. Crit CareMed 2012; 40:502-509.

Morris et al. Early Intensive Care Unit Mobility Therapy in the treatment of Acute Respiratory Failure. Crit Care Med. 2008; 36(8):2238-2243

Schweickert WD et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet. 2009; 373:1874-82.

Needham et al. Early Physical Medicine and Rehabilitation for Patients with Acute Respiratory Failure: A Quality Improvement Project. Arch Phys Med Rehabil. 2010; 91:536-542.

An Expert Interview With Chandra Alexander RN, CCRN, and Dena Putnam, RN, BA, MBA, Elizabeth McGann, DNSc, RN, Improving Outcomes for Ventilated Patients. June 14, 2012

Pohlman M C, Schweickert W D, Pohlman A S, Nigos C, Pawlik A J, Esbrook C L, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt G A, Bowman A, Barr R, McCallister K, Hall J B, Kress J P. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Critical Care Medicine. 2010; Vol 38, Number 11: 2089-2094.

Kress, J.P., Hall, J.B., ICU-Acquired Weakness and Recovery from Critical Illness. NEJM 2014: 1626-1635

http://www.aacn.org/WD/practice/docs/practicealerts/delirium-practice-alert-2011.pdf

Motomed CQI Powerpoint Sept 2012 MICU Team

MICU Mobility Magnet Presentation 2014

UPMC MICU Mobility Pilot Data

UPMC MICU Mobility Patient Photos

UPMC MICU Mobility Patient Video