PTJ SYMPOSIUM: Rehabilitation of Patients with Critical ...€¦ · PTJ Symposium: Rehabilitation of Patients with Critical Illness CSM 2013 January 24, 2013 Special Series on the

PTJ Symposium: Rehabilitation of Patients with Critical Illness

CSM 2013 January 24, 2013

PTJ SYMPOSIUM:

Rehabilitation of Patients with Critical Illness (Handout – 18 pages)

Combined Sections Meeting 2013

San Diego, CA January 21 – 24, 2013

Patricia J Ohtake, PT, PhD

Editorial Board Member, PTJ

Associate Professor

Department of Rehabilitation Science

515 Kimball Tower

University at Buffalo

Buffalo, NY 14214

(716) 829-6732

[email protected]

Symposium Speakers

Michelle Kho, PT, PhD

Neuromuscular Electrical Stimulation for Intensive Care Unit-Acquired Weakness:

Protocol and Methodological Implications for a Randomized, Sham-Controlled,

Phase II Trial

Darin Trees, PT, DPT, CWS

The Innovative Mobility Strategies for the Patient with Intensive Care Unit-

Acquired Weakness: A Case Report

Diane Clark, PT, DScPT

Effectiveness of an Early Mobilization Protocol in a Trauma and Burn Intensive

Care Unit: A Retrospective Cohort Study

Amy Pawlik, PT, DPT, CCS

Issues Impacting the Delivery of Physical Therapy Services for Individuals with

Critical Illness



COURSE DESCRIPTION AND OBJECTIVES

PTJ SYMPOSIUM: Rehabilitation of Patients With Critical Illness

Date: Thursday, January 24, 2013

Time: 3:00 pm–5:00 pm

Speakers: Patricia J. Ohtake, PT, PhD; Michelle Kho, PT; PhD, Darin Trees, PT, DPT, CWS;

Diane Clarke, PT, DScPT; Amy Pawlik, PT, DPT, CCS; Jan Reynolds

Level: Multiple Level

Rehabilitation in the critical care setting is emerging as an important strategy in improving

functional outcomes in the acute care population. The latest research suggests that early

interventions aimed at restoring and maintaining physical function in patients with critical illness

are associated with improved physical function and well being. During this session, authors who

contributed the recent special issue of APTA's Physical Therapy journal (PTJ) will share their

insights on the role of rehabilitation in the management of critical illness; outcome measures;

new rehabilitative interventions; and issues related to optimal timing, intensity, and dosage.

Upon completion of this course, you'll be able to: • Discuss the roles of physical therapy, occupational therapy, and other disciplines in the critical

care setting.

• List underlying mechanisms of critical illness neuromyopathy.

• Describe the latest findings on efficacy and effectiveness of rehabilitation interventions on

activities of daily living, quality of life, physical function, activity, participation, and disability.

• Explain what is known about the use of rehabilitative services by patients following critical

illness.

Symposium Schedule:

3:00 – 3:20 Introduction to the Special Series Symposium

Patricia J Ohtake, PT, PhD

PTJ Editorial Board Member and Guest Co-Editor of this Special Series

3:20 – 3:45 Neuromuscular Electrical Stimulation for Intensive Care Unit-Acquired Weakness:

Protocol and Methodological Implications for a Randomized, Sham-Controlled,

Phase II Trial

Michelle Kho, PT, PhD

3:45 – 4:10 The Innovative Mobility Strategies for the Patient with Intensive Care Unit-

Acquired Weakness: A Case Report


4:10 – 4:35 Effectiveness of an Early Mobilization Protocol in a Trauma and Burn Intensive

Care Unit: A Retrospective Cohort Study


4:35 – 5:00 Issues Impacting the Delivery of Physical Therapy Services for Individuals with

Critical Illness




Special Series on the Rehabilitation of People with Critical Illness

Guest Co-editors: Patricia J Ohtake, PT, PhD, Dale C Strasser, MD, and Dale M Needham, MD, PhD

This Special Series on rehabilitation for people with critical illness is being published in two

issues, December 2012 and February 2013, and presents recent advances in managing critical

illness across the continuum of care, from the intensive care unit (ICU) to the community setting.

The Special Series also serves to raise awareness of the essential role physical therapists and

rehabilitation and critical care professionals play in providing strategies to improve health

outcomes of this growing patient population. Both established and new investigators in this field,

including physical therapists from across the United States and from Australia, have authored the

articles in these two issues.

As presented in our Editorial in the December 2012 issue of PTJ, the challenge for the

rehabilitation and critical care community is three-fold. First, we must continue developing

effective rehabilitation interventions for the management of patients with critical illness while

they are in the ICU and as they move to subsequent levels of care. Second, we must increase

awareness of “post–intensive care syndrome,” helping our colleagues in acute care, subacute

rehabilitation, skilled nursing, outpatient, and home care settings to recognize the clinical

presentation and understand the role of critical illness in the functional limitations that exist for

many ICU survivors. Third, we must endeavor to be committed members of interprofessional

health care teams and promote collaborative practice across all health care settings. We hope that

the articles in this Special Series will provide an enhanced understanding of, and new

management strategies for, the many physical and cognitive challenges facing survivors of

critical illness so that this unique and complex patient population achieves improved outcomes.

The manuscripts in this Special Series cover a wide range of topics important to this practice area

and I encourage you to read both the December 2012 and February 2013 issues of PTJ. At the

end of this handout is a complete listing of the articles.

Michelle Kho, PT, PhD 11/13/12

[email protected] / [email protected] Please do not copy or distribute without wriBen permission from the author 1

Neuromuscular Electrical Stimulation for ICU-Acquired Weakness: Protocol and Methodological Implications for a Phase II RCT

Michelle E. Kho, PT, PhD Assistant Professor, School of Rehabilitation Science, McMaster University, CANADA Adjunct Faculty, Department of Physical Medicine and Rehabilitation Johns Hopkins University, Baltimore, MD, USA

January 24, 2013

Acknowledgements •  Co-‐inves3gators

–  Alexander Truong, MD, MPH –  Dale Needham, MD, PhD

•  Study team –  Blinded outcomes assessments – Jen Zanni, MSPT, DSc;

Julie Skrzat, DPT; Nicole Yare, DPT; Amy Toonstra, DPT; Ladan Hakima, OT

–  Research sessions -‐ Nancy Ciesla, DPT, MS; Karen Oakjones Burgess, RN; Dorianne Feldman, MD, MSPT

•  Salary support (Kho) –  Canadian Ins3tutes of Health Research Fellowship and

Bisby Prize •  Grant # UL1 RR 025005 from the Na3onal Center for

Research Resources, Na3onal Ins3tutes of Health

•  CareRehab, McLean VA

Con3nuum of physical ac3vity

Bedrest Completely Passive

Completely Ac3ve

Increasing physical ac3vity and pa3ent engagement in rehab

What is NMES?

Pflugers Arch. 1983;398(2):139-‐141.

Neuromuscular Electrical SLmulaLon

Also known as: • Electrical S3mulaLon “E-‐sLm” • FuncLonal Electrical SLmulaLon “FES”

To-‐date, NMES in the published ICU literature is completely passive.

Selected contraindica3ons to NMES   Any pacemaker (e.g., cardiac, diaphragm) or implanted cardiac defibrillator

  Infected 3ssues, tuberculosis or wounds with underlying osteomyeli3s

  Over confirmed / suspected malignancy   Area of untreated DVT   Areas of uncontrolled bleeding   Damaged or at-‐risk skin  OK in intact skin overlying implants containing metal, plas3c, or cement

Full issue dedicated to Electrophysical Agents & ContraindicaLons (NMES ch 4): Physiotherapy Canada . 2010. 62(5).

R

NMES N=12

Control N=12

Chronic venLlaLon >30 d bedbound

5d/wk x4wk NMES Quadriceps femoris & vastus glutei 30 min/ session + acLve limb mobilizaLon

AcLve limb mobilizaLon

Interven3on Primary Outcome Peripheral muscle strength (muscles not specified; blinding not reported)

3.83 ± 0.57

3.08 ± 0.51

p=0.02 for change



R

NMES N=70

Control N=72

Day 2 ICU admission; APACHE II >=13

Daily NMES rectus femoris (RF) & vastus intermedius (VI) 55 min/ session

Not reported

Interven3on Primary Outcome ICU Acquired Weakness @ awakening MRC score <48/60 (unblinded)

Excluded (n=46) •  Died (28) •  Impaired cogniLve state (11) •  Neuromuscular blockers (3); no NMES (2); no consent (2)

Excluded (n=44) •  Died (22) •  Impaired cogniLve state (22)

NMES N=24

Control N=28

NMES N=3

Control N=11

p=0.004

Current evidence suppor3ng NMES in mechanically ven3lated pa3ents

•  7 unique randomized controlled trials – Total 160 evaluated / 263 enrolled – Sample size 8 min -‐ 140 max enrolled

•  Popula3ons – Chronic mechanical ven3la3on (n=1) – COPD, pneumonia, or sepsis (n=6)

•  Comparisons – Rou3ne care, sham, contralateral side

Kho et al. Phys Ther. 2012 Mar 15. [Epub ahead of print]

Current evidence: NMES parameters and Outcomes •  NMES interven3on parameters varied

– Visible contrac3on (n=6); max tolerable (n=1) – Daily dura3on: 30 min (n=1); ~60 min (n=5) – Number of days per week: 4 – 7

•  Outcomes – Body structure: microcircula3on, muscle circumference/ area/ volume/ thickness

– Body func3on: muscle strength – Ac3vity: 3me to transfer from bed to chair – None measured beyond ICU awakening


Current evidence: Selected results

1Zanoo et al., Chest. 2003. 124:292-‐296. 2Poulsen et al. CriLcal Care Medicine. 2011. 39: 456-‐461.

3Routsi et al., CriLcal Care. 2010. 14:R74. 4Karatzanos et al., CriLcal Care Research and PracLce. 2012. 1-‐8.

Outcome Pa3ents NMES No NMES Muscle strength1 Chronic 3.8/5.0 3.1/5.0

Transfer from bed to chair1

Chronic 11 days 14 days

Quadriceps muscle volume2

Acute -‐20% -‐16%

ICU-‐acquired weakness at awakening3

Acute 13% 39%

Leg muscle strength4 Acute 29/30 25/30

Ongoing research @ Johns Hopkins ICU

In mechanically ven3lated adult ICU pa3ents, does 60 minutes of daily NMES therapy applied bilaterally to lower extremity muscle groups compared to sham therapy reduce muscle weakness at hospital discharge?

Clinicaltrials.gov # NCT00709124

Quadriceps Tibialis Anterior Gastrocnemius

NMES Semngs

Frequency (Hertz)

Pulse duration (Microseconds)

Contraction duration

(Seconds)

Rest duration (Seconds) Wave form

Quadriceps* 50 400 5 10 Asymmetical biphasic

Tibialis anterior 50 250 5 5 Asymmetical biphasic

Gastrocnemius 50 250 5 5 Asymmetical biphasic

*Includes the vastus lateralis, vastus medialis, and rectus femoris muscles




Screening & Eligibility Inclusion criteria:

All paLents receiving 1 day of MV and expected to require >=2 days ICU stay

Exclusion Criteria: •  Unable to understand or speak English •  Unable to independently transfer at baseline •  Known primary neuromuscular disease •  Known intracranial process associated with localizing weakness •  Transferred from other ICU auer >4 consecuLve days of MV •  Moribund •  AnLcipated transfer to another ICU •  Any pacemaker or implanted cardiac defibrillator •  Pregnancy •  BMI ≥ 35 kg/m2

•  Any limitaLon in care other than a sole no-‐CPR order •  Declined to parLcipate

Randomiza3on Kho et al. Phys Ther. 2012 Mar 15. [Epub ahead of print]

Trial Schema

NMES 60 min N=41

Sham N=41

R

N=82

Primary outcome (blinded)

Strength @ hospital discharge •  MMT (Lbialis anterior, quadriceps, gastrocnemius)

Secondary outcomes (blinded where appropriate)

•  Lower extremity muscle strength (HHD) •  Overall body strength (MMT (composite MRC score), HGD, MIP) •  FuncLonal status (FSS-‐ICU) •  DuraLon of Mechanical VenLlaLon •  LOS (ICU, Hospital) •  Mortality (ICU, Hospital) •  Total hospital charges •  Hospital discharge desLnaLon


Clinical Course

Outcome Measurement Timing

ICU Discharge

Hospital Discharge

NMES/Sham Therapy RouLne PT

Test #2 Test #3

Study Outcome Assessments

Test #1

Awake

ICU Admission

Study Entry >24h MV

1 Day MV

N=54 maximum (27 per group)

Sample Size CalculaLon


Criteria NMES Pilot RCT

RandomizaLon AllocaLon concealment Blinding – caregivers Blinding – outcome assessors Analysis by paLents randomized Enrolled paLents contribuLng to primary outcome analysis

Only those with hospital discharge Ax

Methodological Cri3cal Appraisal

Strengths and Limita3ons of NMES pilot RCT

Strengths

•  Pilot RCT •  Randomized, concealed allocaLon

•  Sample size calculaLon •  Blinded outcomes assessors •  Outcome measures at hospital discharge

Limita3ons

• Muscle strength not paLent-‐centered outcome

•  ImplicaLons of results for clinical implementaLon unclear

Is NMES ready for clinical use? Strengths •  Can be iniLated in sedated paLents

•  Can occur in supine •  Single person implementaLon

•  Provides “something”

Limita3ons •  Completely passive modality

•  Impaired current delivery: obesity, edema

•  Opportunity cost of limited therapist Lme

•  No outcomes beyond ICU awakening (yet)




Title: Innovative Mobility Strategies for the Patient with ICU-Acquired Weakness: A Case Report

Presenter: Darin Trees, PT, DPT, CWS

Background and Purpose:

Although the benefits of early mobilization in the Intensive Care Unit (ICU) have been well-documented

in recent years, the decision making process and customization of treatment strategies for patients with

ICU-acquired weakness has not been well defined in the literature. This case report will describe a

patient with ICU-acquired weakness in the long term acute care hospital (LTACH) setting and

mobilization strategies that include novel devices for therapeutic exercise and gait training.

Case Description:

A 73-year-old active female underwent a routine cardioversion for atrial fibrillation but developed

multiple complications, including sepsis and respiratory failure. The patient spent three weeks of

limited activity in ICU and was transferred to our LTACH for continued medical intervention and

rehabilitation. A four-phase graded mobilization program was initiated in the LTACH ICU. Within that

program, the physical therapy interventions included partial weight-bearing antigravity strength training

with a mobile leg press and gait training with a hydraulic-assist platform walker.

Outcome:

Prior to interventions, the patient had severe weakness (Medical Research Council [MRC] sum score of

18/60) and displayed complete dependence for all functioning. She progressed to being able to

ambulate 150 feet using a rolling walker with accompanying strength increases to an MRC sum score of

52/60.

Discussion:

This report describes novel mobility strategies for managing a patient with ICU-acquired weakness. The

application of a graded mobilization program using a mobile leg press and a hydraulic-assist platform

walker was safe, feasible, and appeared to expedite the patient’s recovery process while decreasing the

amount of manual lifting for the therapists.

Timeline of Significant Events

Day Event

1 Routine cardioversion

2-20 Respiratory failure requiring mechanical ventilation, sepsis, and pneumonia.

21 Transfer to LTACH. Dependent for all mobility. MRC sum score 18. Vent- CPAP 45% FiO2.

22-31 Physical therapy consisting of AAROM, leg presses, and assisted sitting activities.

32 Emergent thoracentesis. Transfer back to STACH.

33-55 STACH ICU stay for medical stability. PROM by nursing.

56 Transfer to LTACH. Dependent for all mobility. MRC sum score 18. CPAP 45% FiO2.

57 3 sets of 10 inclined squats at 30-45% BW. Assisted sitting with maximal assist.

61 4 sets of 12 inclined squats at 55% BW. Static sitting 5 minutes without assist.

62 Stood 30 sec with HAPW and moderate assist. Weaned to tracheal collar 28% FiO2.

69 Walked 5 feet with HAPW and moderate assist. Weaned to room air.

70 Walked 12 feet with HAPW and moderate assist.

77 Walked 55 feet with HAPW and minimal assist.

78 Walked 8 feet in parallel bars with moderate assist.

79 Walked 15 feet with rolling walker and moderate assist.

89 Walked 150 feet with rolling walker and supervision. MRC sum score 52.

MRC- Medical Review Council. CPAP- Continuous positive airway pressure. BW- Body weight.

HAPW- Hydraulic-assist platform walker




Graded Mobilization Program

Phase 1 Phase 2 Phase 3 Phase 4

Description

Pt. unable to follow

simple commands.

Pt. able to follow

simple commands.

Severely weak and

requires maximal

assistance to stand

or unable to stand.

Patients is weak, but

only requires min-

mod assistance to

stand and can

support the majority

of body weight.

Patient is able to

transfer and

ambulate > 10 feet

with a walker and

minimal or no

assistance.

Treatment

Suggestions

Nursing:

- PROM to all

extremities

- Sitting in stretcher

chair or chair

position 3

times/day, 20 min. +

PT:

- AA/AROM of UEs

and LEs in all planes

-Bed mobility skills

- Assisted sitting

balance activities

- Mobile leg press

for graded PWB

exercise

- Progressive

standing with

hydraulic-assist

platform walker

- Transfer training to

chair

- Pre-ambulation

training with

hydraulic assist

platform walker or

rolling walker

- Gait training

- Progressive

walking and gait

training

- High-level balance

activities

-Endurance

activities

-Promote

independence with

home exercise and

walking program

Criteria for

Progressing to

Next Phase

Patient able to

follow simple

commands.

Hemodynamic

status and

oxygenation stable.

Patient requires

min-mod assistance

to stand and can

support the majority

of body weight.

Patient requires

minimal assistance

to ambulate >10

feet with a walker.




Effectiveness of an Early Mobilization Protocol in a Trauma and Burns

Intensive Care Unit: A Retrospective Cohort Study

Diane Clark, PT, MBA, DScPT

John Lowman, PT, PhD

Helen Matthews, PT

Page 2

UAB HOSPITAL LEVEL 1 TRAUMA CENTER

Page 3

THE PROBLEM

� Emergency department visits > 70,000 / year

�Diversion

�Require critical care

� High census in Trauma and Burns ICU

Page 4

QUALITY IMPROVEMENT PROCESS

Page 5

P D C A

� PLAN

�Identify and analyze the problem

� DO

�Develop and test a possible solution

� CHECK

�Measure effectiveness, look for improvement

� ACT

�Implement the improved solution fully

Page 6

S O L U T I O N ? E A R L Y M O B I L I Z A T I O N

� Strong evidence of reduced complication rate and LOS in respiratory and medical ICU

� Unknown effectiveness in trauma and burn population

� Acute physical therapy department proposes solution




Page 7

Partners in Crime at UAB Hospital

� Donald Reiff, MD Medical Director, TBICU� Helen Matthews, PT Acute Care Manager� John Lowman, PT, PhD Faculty� Russell Griffin, PhD Statistician/Epidemiologist� Kelly Shields, RN Nurse Educator

� Physician assistants, nurses and managers, PTs, RTs � Trauma Registry Staff� Trauma Care Coordinator� Hospital Administration� Hospital Finance

Page 8

Initiative – Early Mobilization in TBICU

January – April 2009Program developmentInterdisciplinary teamChampionsPilot evaluation

D = Do

Page 9

Planning the Intervention

� Early Mobility Protocol (EMP) tailored to the trauma and burns population

� Contraindications to the protocol

� Personnel and resources

� Staff education

� Sedation management

� Barriers

� Communication and coordination

TRAUMA AND BURN POPULATION

SYSTEM

Musculoskeletal

Neurological

Integument

Cardiovascular

Pulmonary

Visceral organs

INJURY

Multiple fractures, skeletal traction, surgical fixation, immobilization, amputation, contusion, hematoma

Spinal cord injury, peripheral nerve injury

Burns, abrasions, lacerations, degloving

Cardiac contusions, tamponade, shock, MI, aortic dissection, vascular trauma

Smoke inhalation, rib fractures, tension pneumothorax, contusion, lung collapse, diaphragmatic rupture

Contusions, laceration, organ dysfunction and failure, hemorrhage

Page 11

PROTOCOL

Initial Patient Management

�Physical therapy initial patient screening and assignment to mobility level

�Identification of passive range of motion (PROM) precautions†

�Physical therapy exam when appropriate

Page 12

4 M o b i l i t y L e v e l s

11• Patient least able to participate

22

• Able to follow motor commands

• Sitting back supported in bed

33• Sitting edge of bed

44• Standing, transfers, walking




Page 13


May 2009 – August 2009Pilot study: Safety and feasibilityData collectionAnalysis

VAP and DVTPressure ulcers

C = Check

Page 14


May 2009 – April 2010Data collection and analysis

Historical control group

Page 15

Demographic Characteristics

� Post EMP population

�Older than pre-EMP (46.6 vs. 44.1 yrs)

�Fewer males (70 vs. 75.1%)

�Mean ISS lower (23.6 vs. 22.2)*

�Higher incidence of comorbidities

� Arthritis, CVD, diabetes, neurologic disorder, OSA, pulmonary disorder

Page 16

RESULTS

Complications

Airway 0.52 (0.35-0.70)

Pulmonary 0.84 (0.74-0.95)

Pneumonia 0.79 (0.66-0.93)

Vascular 0.58 (0.45-0.75)

DVT 0.67 (0.50-0.90)

Cardiovascular 1.81 (1.16-2.83)*

* Pericardial effusion/tamponade: Not attributed to mobility

Page 17

R e s u l t s

LOS

�19.2 – 16.8 but not statistically significant when ISS

Adverse Events

�None

Page 18

S O W H A T ?

� Earlier mobilization in TBICU was safe and reduced complications resulting in cost savings to the hospital

� Culture where mobility is cornerstone of non-emergent interventions

� Collaboration rather than coordination

� Dosage




Page 19

Physical Therapy Roles

� Recognition as innovators� Recognition as collaborators � Working outside of silos� Implementation of new programs

Page 20

Take Home Message

� Be a leader at all levels� Be involved in solutions� Volunteer skills outside of your department� Identify non-traditional partners

Above All…

Don’t just ride a bike -

Don’t just climb out of bedIn the morning -

Dare to be the pace setter!

Climb a mountain!




Issues Impacting the Issues Impacting the Delivery of Physical Delivery of Physical Therapy Services for Therapy Services for

Individuals with Critical Individuals with Critical IllnessIllness

Amy Pawlik, PT, DPT, CCSAmy Pawlik, PT, DPT, CCSUniversity of Chicago MedicineUniversity of Chicago Medicine

Combined Sections MeetingCombined Sections MeetingJanuary 24, 2013January 24, 2013

Previously published reviewsPreviously published reviews

�� EffectivenessEffectiveness

�� FeasibilityFeasibility

�� CultureCulture

�� Multidisciplinary collaborationMultidisciplinary collaboration

�� Sedation interruptionSedation interruption

Issues Specific to Physical Issues Specific to Physical TherapistsTherapists

�� CompetencyCompetency

�� PersonnelPersonnel

�� PrioritizationPrioritization

�� Functional outcome measures Functional outcome measures

�� PostPost--acute care interventionsacute care interventions

CompetenceCompetence--why?why?

�� Rapid decision making due to change in Rapid decision making due to change in statusstatus

�� Maximize oxygen transport while Maximize oxygen transport while addressing impairmentsaddressing impairments

�� Understanding of impact of bedrest and Understanding of impact of bedrest and medical interventionsmedical interventions

�� Safely intervene in a complex environmentSafely intervene in a complex environment

Clinical CompetencyClinical Competency

�� Academic preparationAcademic preparation

�� Clinical competenceClinical competence

�� Specialist certificationSpecialist certification

�� Advanced clinical educationAdvanced clinical education

Academic PreparationAcademic Preparation

�� APTA Minimum Required Skills of APTA Minimum Required Skills of Physical Therapy Graduates at EntryPhysical Therapy Graduates at Entry--LevelLevel

�� Normative Model of Physical Therapist Normative Model of Physical Therapist Professional EducationProfessional Education

�� APTA Physical Therapists Clinical APTA Physical Therapists Clinical Education PrinciplesEducation Principles

�� 1010--12 weeks of clinical experience12 weeks of clinical experience




Clinical educationClinical education

�� Lack of available sitesLack of available sites

�� 2:1 model2:1 model

�� SimulationSimulation

Clinical CompetenceClinical Competence

�� Nursing, pharmacistsNursing, pharmacists

�� Few published examplesFew published examples

�� Harris KB. Acute Care Perspectives 2006.Harris KB. Acute Care Perspectives 2006.

UCMC ICU Competency

Advanced Clinical TrainingAdvanced Clinical Training

�� Specialist certificationSpecialist certification

�� Acute care residencyAcute care residency

Personnel ResourcesPersonnel Resources

�� Mobility teamsMobility teams

�� PT or other?PT or other?

�� Reallocation of resources?Reallocation of resources?

�� CostCost

Mobility TeamMobility Team

InstitutionInstitution Team membersTeam members

University of University of ChicagoChicago

Physical Therapist, Occupational Physical Therapist, Occupational TherapistTherapist

Wake ForestWake Forest Physical Therapist, Nursing Physical Therapist, Nursing Assistant, Critical Care NurseAssistant, Critical Care Nurse

Johns HopkinsJohns Hopkins Physical Therapist, Occupational Physical Therapist, Occupational Therapist, Rehabilitation AssistantTherapist, Rehabilitation Assistant

LDS HospitalLDS Hospital Physical Therapist, Respiratory Physical Therapist, Respiratory Therapist, Registered Nurse, Therapist, Registered Nurse, Critical Care TechnicianCritical Care Technician




Unique Skills of the PTUnique Skills of the PT

�� GarzonGarzon--Serrano, et al. PM R 2010.Serrano, et al. PM R 2010.

�� PT achieved higher level of mobilizationPT achieved higher level of mobilization

�� Different barriers identifiedDifferent barriers identified

�� Atrophy, deconditioning, cardiopulmonary Atrophy, deconditioning, cardiopulmonary compromisecompromise

Reallocation of ResourcesReallocation of Resources

�� Schweickert, et al. Lancet 2008.Schweickert, et al. Lancet 2008.

�� 95% of control group received physical 95% of control group received physical therapytherapy

�� Needham, et al. Arch Phys Med Rehabil Needham, et al. Arch Phys Med Rehabil 2010.2010.

�� More sessions during ICU stayMore sessions during ICU stay

�� Morris, et al. Crit Care Med 2008.Morris, et al. Crit Care Med 2008.

�� More sessions during hospitalizationMore sessions during hospitalization

CostCost

�� Morris PE et al. Crit Care Med 2008.Morris PE et al. Crit Care Med 2008.

�� Usual care Usual care –– intervention (mobility team) = intervention (mobility team) = $504, 000+$504, 000+

�� Mobility team salary/benefits= $250,000+Mobility team salary/benefits= $250,000+

�� Decreased hospital and ICU LOSDecreased hospital and ICU LOS

�� Increased ventilatorIncreased ventilator--free daysfree days

PrioritizationPrioritization

�� HospitalHospital--widewide

�� Within the ICUWithin the ICU

�� Treatment vs. preventionTreatment vs. prevention

�� Baseline functional level?Baseline functional level?

Outcome MeasuresOutcome Measures

�� Functional Independence Measure (FIM)Functional Independence Measure (FIM)

�� Univ. of Rochester Acute Care Evaluation Univ. of Rochester Acute Care Evaluation (URACE)(URACE)

�� Johns Hopkins Hospital Function Acute Johns Hopkins Hospital Function Acute Care Score (JHHCare Score (JHH--FACS)FACS)

�� Acute Care Index of FunctionAcute Care Index of Function

�� Physical Function ICU Test (PFIT)Physical Function ICU Test (PFIT)

Outcome MeasuresOutcome Measures

�� Strength testingStrength testing

�� Manual muscle testingManual muscle testing

�� DynamometryDynamometry




PostPost--acute care followacute care follow--upup

�� AwarenessAwareness

�� Interdisciplinary clinicsInterdisciplinary clinics

�� Outpatient group modelsOutpatient group models

�� HomeHome--based programsbased programs

Future DirectionsFuture Directions

�� CompetencyCompetency

�� PersonnelPersonnel

�� PrioritizationPrioritization

�� Functional outcome measures Functional outcome measures

�� PostPost--acute care interventionsacute care interventions

Questions?Questions?



COMPLETE LISTING OF THE ARTICLES IN THE SPECIAL SERIES: REHABILITATION

OF PEOPLE WITH CRITICAL ILLNESS

ProfessionWatch � How the National Heart, Lung, and Blood Institute (NHLBI) Develops Research Priorities and Supports

Critical Care Research Andrea L. Harabin and James P. Kiley (December 2012)

� What Follows Survival of Critical Illness? Physical Therapists' Management of Patients With Post-

Intensive Care Syndrome Anita R. Bemis-Dougherty and James M Smith (February 2013)

Perspectives � Intensive Care Unit–Acquired Weakness: Implications for Physical Therapist Management Amy Nordon-

Craft, Marc Moss, Dianna Quan, and Margaret Schenkman (December 2012)

� Physical Therapist Management of Patients with Ventricular Assist Devices: Key Considerations for the

Acute Care Physical Therapist Chris L. Wells (February 2013)

� Issues Affecting the Delivery of Physical Therapy Services for Individuals With Critical Illness Amy J.

Pawlik and John P. Kress (February 2013)

Research Reports

� Quantifying Physical Activity Levels of Survivors of Intensive Care: A Prospective Observational Study

Linda Denehy, Sue Berney, Laura Whitburn, and Lara Edbrooke (December 2012)

� Physical Therapy on the Wards After Early Physical Activity and Mobility in the Intensive Care Unit

Ramona O. Hopkins, Russell R. Miller III, Larissa Rodriguez, Vicki Spuhler, and George E. Thomsen (December

2012)

� Safety and Feasibility of an Exercise Prescription Approach to Rehabilitation Across the Continuum of

Care for Survivors of Critical Illness Sue Berney, Kimberley Haines, Elizabeth H. Skinner, and Linda Denehy

(December 2012)

� Simulation Experience Enhances Physical Therapy Student Confidence in Managing a Patient in the

Critical Care Environment Patricia J. Ohtake, Marcilene Lazarus, Rebecca Schillo, and Michael Rosen

(February 2013)

Research Reports – Outcome Measures � The Clinical Utility of the Functional Status Score for the Intensive Care Unit (FSS-ICU) at a Long-Term

Acute Care Hospital: A Prospective Cohort Study Aaron Thrush, Melanie Rozek, and Jennifer L. Dekerlegand

(December 2012)

� Global Muscle Strength But Not Grip Strength Predicts Mortality and Length of Stay in a General

Population in a Surgical Intensive Care Unit Jeanette J. Lee, Karen Waak, Martina Grosse-Sundrup, Feifei

Xue, Jarone Lee, Daniel Chipman, Cheryl Ryan, Edward A. Bittner, Ulrich Schmidt, and Matthias Eikermann

(December 2012)

� Repeatability of the Six-Minute Walk Test and Relation to Physical Function in Survivors of a Critical

Illness Jennifer A. Alison, Patricia Kenny, Madeleine T. King, Sharon McKinley, Leanne M. Aitken, Gavin D.

Leslie, and Doug Elliott (December 2012)

Study Protocols � Neuromuscular Electrical Stimulation for Intensive Care Unit–Acquired Weakness: Protocol and

Methodological Implications for a Randomized, Sham-Controlled, Phase II Trial Michelle E. Kho, Alexander

D. Truong, Roy G. Brower, Jeffrey B. Palmer, Eddy Fan, Jennifer M. Zanni, Nancy D. Ciesla, Dorianne R.

Feldman, Radha Korupolu, and Dale M. Needham (December 2012)



� A Combined Early Cognitive and Physical Rehabilitation Program for People Who Are Critically Ill: The

Activity and Cognitive Therapy in the Intensive Care Unit (ACT-ICU) Trial Nathan E. Brummel, James C.

Jackson, Timothy D. Girard, Pratik P. Pandharipande, Elena Schiro, Brittany Work, Brenda T. Pun, Leanne

Boehm, Thomas M. Gill, and E. Wesley Ely (December 2012)

Quality Improvement Articles � Effectiveness of an Early Mobilization Protocol in a Trauma and Burns Intensive Care Unit: A

Retrospective Cohort Study Diane E. Clark, John D. Lowman, Russell L. Griffin, Helen M. Matthews, and

Donald A. Reiff (February 2013)

� Safety and Feasibility of an Early Mobilization Program in Patients With Aneurysmal Subarachnoid

Hemorrhage Brian F. Olkowski, Mary Ann Devine, Laurie E. Slotnick, Erol Veznedaroglu, Kenneth M. Liebman,

Melissa I. Arcaro, and Mandy Jo Binning (February 2013)

� Move to Improve: The Feasibility of Using an Early Mobility Protocol to Increase Ambulation in the

Intensive and Intermediate Care Settings Anne Drolet, Patti DeJuilio, Sherri Harkless, Sherry Henricks,

Elizabeth Kamin, Elizabeth A. Leddy, Joanna M. Lloyd, Carissa Waters, and Sarah Williams (February 2013)

Case Reports � Innovative Mobility Strategies for the Patient With Intensive Care Unit–Acquired Weakness: A Case

Report Darin W. Trees, James M. Smith, and Steve Hockert (February 2013)

� Inspiratory Muscle Strength Training in Infants with Congenital Heart Disease and Prolonged Mechanical Ventilation: A Case Report Barbara K. Smith, Mark S. Bleiweis, Cimaron R. Neel, and A. Daniel Martin

(February 2013)

� Physical Rehabilitation of Patients in Intensive Care Units Requiring Extracorporeal Membrane

Oxygenation: A Small Case Series Rod A. Rahimi, Julie Skrzat, Dereddi Raja S. Reddy, Jennifer M. Zanni, Eddy

Fan, R. Scott Stephens, and Dale M. Needham (February 2013)

Documents

PTJ SYMPOSIUM: Rehabilitation of Patients with Critical ...€¦ · PTJ Symposium: Rehabilitation of Patients with Critical Illness CSM 2013 January 24, 2013 Special Series on the