Mobilizing in the ICU: A Roadmap (for the rest of us)

Jeffrey M Singh, MD FRCPC MSc

Critical Care and Neurocritical Care

Toronto Western Hospital

and

Interdepartmental Division of Critical Care

University of Toronto

Disclosures

• I am the recipient of:

– unrestricted quality improvement

grants from Hospira

– honoraria from Snell Medical

Spot Quiz!

• How many PDSA cycle(s) are required

to implement an early mobility program

in the ICU with 75% compliance?

1. One cycle

2. Two cycles

3. Three cycles

4. Four cycles

Answer: TRICK QUESTION!

I don’t know… but it is ≥4!

Objectives

• Share a story of:

– Quality Improvement

– What we did

– Humility in acknowledging our

mistakes

– What worked and didn’t work

Toronto Western Hospital

• Part of UHN

• 236 beds

• 25 bed MSNICU – 40% neuroscience

• Specialty Programs – Neurosurgery / Spine

– Neurology / Stroke

– Ortho / Hand

– Bariatric

– Ophthalmology

ABCDE

Awake targeted sedation

and daily awakening

Breathing spontaneous

breathing trials

Coordination of SAT & SBT

Delirium Screening

Early Mobility

• 104 patients randomized to early

exercise and mobilization or mobility as

ordered by the care team

• Intervention group

– Dramatic improvement

in functional status

at discharge

Schweickert et al. Lancet. 2009.

E: Early Mobilization

Outcome

Intervention

(n=49)

Control

(n=50)

P

Functionally independent at

discharge

29 (59%) 19 (35%) 0.02

ICU delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-7.0) 0.03

Time in ICU with delirium (%) 33 (0-58) 57 (33-69) 0.02

Hospital delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-8.0) 0.02

Hospital days with delirium (%) 28 (26) 41 (27) 0.01

Barthel index score at discharge 75 (7.5-95) 55 (0-85) 0.05

ICU-acquired paresis at discharge 15 (31%) 27 (49%) 0.09

Ventilator-free days 23.5 (7.4-25.6) 21.1 (0.0-23.8) 0.05

Length of stay in ICU (days) 5.9 (4.5-13.2) 7.9 (6.1-12.9) 0.08

Length of stay in hospital (days) 13.5 (8.0-23.1) 12.9 (8.9-19.8) 0.93

Hospital mortality 9 (18%) 14 (25%) 0.53

Schweickert WD, et al. Lancet.

The QI Plan

• Understand the local context

• Identify champions – get a team

• Identify barriers

• Develop a multifaceted intervention:

– Structure

– Process

– Outcomes

• Plan, Do, Study, Act cycles

(Perceived) Barriers to Mobilization

• Clinical instability

• Clinical inertia

• Lack of resources

• Lack of time / workload issues

• Safety

– Line / tubes / drain removal or

displacement

• Lack of physician orders / bedrest

Barriers to Mobilization

Leditschke IA et al. Cardiopulm Phys Ther J. 2012

Other Barriers at TWH

Structure

• 1.5 Physiotherapy FTE

• 2 Personal Care Assistants

• Equipment

– Purchase of 2 new chairs

– Lifts & slings

– Walkers

• Medical directives

– Development of PT self-referral directive

• AAT orders

Process

• What do we want the team to do?

• Daily expectation for each eligible

patient to be mobilized

• Mobility target set by ICU

physiotherapist

Safety: Contraindications

• Receiving neuromuscular blockade

• SaO2 < 88% on FiO2 < 0.5

• Significant pressor/inotrope use

• Myocardial ischemia in last 24 hrs

• Raised ICP

• Unstable C-spine

• No arrhythmia requiring administration of new

antiarrhythmic agent in last 24 hrs

Safety: Screening

• Patients that require a PT consult prior

to mobilization:

– All SCI

– New neurological deficits

• Any new hemiparetic/hemiplegic patients

• Neurovascular disease

• Seizures

• All other patients receive safety screen

then mobilize

Active ROM (in bed)

Sit/ Dangle

March/ Walk

Transfer

No Exercises, but Passive

Range of Motion allowed

Pro

gre

ss a

s to

lera

ted

IC

U D

isch

arg

e

Ex

erc

ise

scre

en

SAS ≥ 3 SAS 2/3

Early Mobilization

Graphic courtesy of ME Wilcox, 2013

Courtesy of ME

Wilcox, 2013

Outcomes

• How are we going to measure our

progress?

• How do we measure mobility?

– Valid

– Responsive to changing behaviour

• ICU Mobility Scale

Hodgson CL. Am J Respir Crit Care Med 187;2013:A3123

Classification Definition

0 Nothing (lying in bed) Passively rolled or passively exercised by staff, but not actively moving

1 Sitting in bed, exercises in bed Any activity in bed, including rolling, bridging, active exercises, cycle ergometry and

active assisted exercises; not moving out of bed or over the edge of the bed

2 Passively moved to chair (no standing) Hoist, passive lift or slide transfer to the chair, with no standing or sitting on the edge

of the bed

3 Sitting over edge of bed May be assisted by staff, but involves actively sitting over the side of the bed with

some trunk control

4 Standing Weight bearing through the feet in the standing position, with or without assistance.

This may include use of a standing lifter device or tilt table.

5 Transferring bed to chair

Able to step or shuffle through standing to the chair. This involves actively

transferring weight from one leg to another to move to the chair. If the patient has

been stood with the assistance of a medical device, they must step to the chair (not

included if the patient is wheeled in a standing lifter device.)

6 Marching on spot (at bedside) Able to walk on the spot by lifting alternate feet (must be able to step at least 4 times,

twice on each foot), with or without assistance

7 Walking with assistance of 2 or more

people Walking away from the bed/chair by at least 5 metres (5 yards) assisted by 2 or more

people

8 Walking with assistance of 1 person Walking away from the bed/chair by at least 5 metres (5 yards) assisted by 1 person

9 Walking independently with a gait aid Walking away from the bed/chair by at least 5 metres (5 yards) with a gait aid, but no

assistance from another person. In a wheelchair bound person, this activity level

includes wheeling the chair independently 5 metres (5 years) away from the bed/chair

10 Walking independently without a gait aid Walking away from the bed/chair by at least 5 metres (5 yards) without a gait aid or

assistance from another person.

Outcomes

• PT recorded target mobility level for

each patient

• Actual activity level achieved was

recorded at end of day for each patient

• If activity done in evenings then data

revised the next morning.

False Start

• Educational Blitz:

– Inservices & Education

– Posters

– Daily Reminders

• But:

– Lacked total physician buy-in

– Nurses still not clear on what we expected

them to do

No Impact

Results

Pre-

Intervention

Post-

Intervention

3-month

Follow Up

% Patient-days with

ANY Mobility 52% 74% 100%

% Patient-days

meeting / exceeding

target

37% 57% 43%

Target Mean IMS

level 2.57 2.61 2.2

Actual Mean IMS

level 1.6 2.1 1.2

Results

Results - Safety

• Consistent with published evidence –

very safe

– One NG tube displaced

– One patient fell to their knees from a chair

• Returned to chair actively with assistance

– External Ventricular Drains

Olkowski B et al.Physical Therapy. 2013

Hale et al. Physiotherapy Canada. 2013.

Comparisons

• Practice Audit

– 54% of patients received any mobilization

– 43% active

– 23% active transfer

– 34% passive

Leditschke IA et al. Cardiopulm Phys Ther J. 2012

Myths To Debunk

• All of this has to happen in the day shift

• You can’t mobilize neuro patients

• Every patient needs a PT assessment

before I start mobilizing

• Passive transfer into a chair is enough

Key Tips I Have Learned

• You must engage everyone

– Spend equal time on your biggest

supporter and biggest sceptic

• You must measure your progress

– It doesn’t have to be extensive /

complicated

• Feedback results to the team

– Seeing is believing!

• Not everyone is on a treadmill

Acknowledgements

• Lisa Muc PT

• Christopher Iacob PT

• Elizabeth Wilcox MD

• Emma Mew

• Mandy Ettinger

…and ALL of the interprofessional team

Questions?

jeff.singh@uhn.ca