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11/24/2015
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Nurse Driven Early Progressive Mobility Programs: Impacting Both Short and Long Term Outcomes
Kathleen Vollman MSN, RN, CCNS, FCCM, FAANClinical Nurse Specialist/Educator/Consultant
ADVANCING NURSING [email protected]
www.vollman.com© ADVANCING NURSING LLC 2015
Speaker Disclosures
• I disclose that I am a Consultant for Sage Products, Hill-Rom and Eloquest Healthcare and a member of all three companies speaker’s bureau.
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Learning ObjectivesAt the completion of this activity, the participant will be able to:
• Build the will to understand the significance of early mobility Identify and discuss key in-bed and out of bed mobility techniques to successfully achieve your early mobility protocol to improve patient outcomes.
• Overcoming barriers and feeling empowered to own patient mobility within your unit.
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• Decreased movement of secretions
• Decreased respiratory motion
• Increased risk of pulmonary embolism
• Increased dependent edema
• Increased risk of atelectasis
• Increased risk of pneumonia
• Decreased arterial oxygen saturation
Effects of Immobility on Respiratory Function1,2
1. Knight J, et al. Nurs Times. 2009;105(21):16-20.2. Vollman KM. Crit Care Nurse. 2010;30:S3-S5.
Respiratory
– In the United States, the Centers for Disease Control (CDC), through the National Healthcare Safety Network, has reported critical care unit VAP rates, per 1,000 ventilator-days, ranging from 0.2 (pediatric cardiothoracic) to 4.4 (burn ICU)2
– On average, ICU patients with VAP had an additional 10.5-day LOS3
– Per case: VAP $40,144. (95% CI, %36,286-$44,220)4
Ventilator-Associated Pneumonia (VAP) Rates
1.Rosenthal VD, et al. Am J Infect Control. 2012;40(5):396-407.2.Dudeck MA, et al. National Healthcare Safety Network (NHSN) Report, Data Summary for 2012,
Device-Associated Module. American Journal of Infection Control. 2013,41:1148-66.3.Restrepo MI, et al. Infect Control Hosp Epidemiol. 2010;31(5):509-515.4.Zimlichman E. et al. JAMA Internal Med, 2013;173(22):2039-465.Accessed 10/2013 at http://www.phac-aspc.gc.ca
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1. Winkelman C. AACN Adv Crit Care. 2009;20:254-266. 2. Knight J, et al. Nurs Times. 2009;105(21):16-20.3. Harms MP, et al. Exp Physiol. 2003;88:611-616.4. Sjostrand T. Physiol Rev. 1953;33:202-228.
• Fluid shift– Occurs when the body goes from upright to supine position1,2
– 10% of total blood volume is shifted from lower extremities to the rest of the body; 78% of this is taken up in the thorax3,4
– Decreased blood volume (~15% of plasma volume is lost after 4 weeks of bed rest)2
• Cardiac effects– Increased resting heart rate (an increase of
~10 beats/min is observed after 4 weeks of bed rest)1,2
– Cardiac deconditioning2
• Orthostatic intolerance– Increased in bedridden patients due to decreased baroreceptor
sensitivity, reduced blood volume, cardiac deconditioning, decreased venous return and stroke volume, and venous distensibility1,2
Effects of Immobility on Cardiovascular Function
The current facility acquired of pressure ulcers is high7
– Stage III or IV facility-acquired pressure ulcers are not reimburses & impact value based purchasing2
• The average cost per hospital stay for a patient with a stage III or IV pressure ulcer in the acute care setting is $43,1803
Effects of Immobility on Integumentary Function
Skin
1. National pressure ulcer Advisory panel, European pressure ulcer Advisory panel and Pan Pacific pressure injury alliance. Clinical practice guideline, 2014
2. Hospital-acquired conditions. Centers for Medicare & Medicaid Services website. http://www.cms.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp. Accessed 1/3/12.
3. CMS. Fed Regist. 2008;73:48433-49084.4. Jankowski IM, Nadzam DM. Jt Comm J Qual Patient Saf. 2011;37:253-264.
Setting Facility –Acquired Rates
Critical Care 3.3% to 53.4%
Acute Care 0% to 12%
Siebens H, et al, J Am Geriatr Soc 2000;48:1545-52Topp R et al. Am J of Crit Care, 2002;13(2):263-76Wagenmakers AJM. Clin Nutr 2001;20(5):451-4
Skeletal Muscle Deconditioning
• Skeletal muscle strength reduces 4-5% every week of bed rest (1-1.5% per day)
• Without activity the muscle loses protein• Healthy individuals on 5 days of strict bed rest
develop insulin resistance and microvascular dysfunction
• 2 types of muscle atrophy– Primary: bed rest, space flight, limb casting– Secondary: pathology
Candow DG, Chilibick PD J Gerontol, 2005:60A:148-155Berg HE., et al. J of Appl Physiol, 1997;82(1):182-188Homburg NM,. Arterioscler Thrombo Vasc Biol, 2007;27(12):2650-2656
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Siebens H, et al, J Am Geriatr Soc 2000;48:1545-52Topp R et al. Am J of Crit Care, 2002;13(2):263-76Wagenmakers AJM. Clin Nutr 2001;20(5):451-4
Skeletal Muscle Deconditioning• Muscle groups that lose strength most quickly related to
immobilization are those that maintain posture, transferring positions & ambulation.
• > 1/3 of patients with ICU stays greater than two weeks had at least two functionally significant joint contractures.
• Muscle atrophy in mechanically ventilated patients contribute to fatigue of the diaphragm and challenges with weaning.
• Degradation within 6-8 days; continues as long as bedrest occurs
• One day of bed rest requires two weeks of reconditioning to restore baseline muscle strength
Candow DG, Chilibick PD J Gerontol, 2005:60A:148-155Berg HE., et al. J of Appl Physiol, 1997;82(1):182-188Hamburg NM,. Arterioscler Thrombo Vasc Biol, 2007;27(12):2650-2656DeJonnge B, et al. Crit Care Med, 2007;39:2007-2015Zhang et al. 2008 GenomProtBioinf: 6Kortebien et al. 2008 JGerontolMedSci: 63)
Brain-ICU Study
• Multicenter RCT- medical-surgical ICU’s
• 821 patients with ARF or Shock
• Evaluated in-hospital delirium and cognitive impact 3-12 months post d/c
Results• 74% of patients developed
delirium during hospital stay
• 3 months: 40% had global cognition scores 1.5 SD below population mean, 26% had scores 2 SD below pop mean
• 12 months: 34%(older) & 24%(younger) global cognition scores below the mean
Pandharipande, PP. et al. N Engl J Med;369:1306:1316
1 out of 4 cognitive
Impairment at 12
months
Definition: • Syndrome of generalized limb weakness that develops while the
patient is critically ill and for which there is no alternative explanation other than the critical illness itself.1 Average Medical Research Council Scale (MRC) score <4 across all muscles tested.
Incidence:• 25% of patients with prolonged mechanical ventilation will
develop ICUAW1
• Est 75,000 pts in US, 1 million worldwideCaused By:1
– Critical illness polyneuropathy and myopathy
– Combination
ICU-Acquired Weakness (ICUAW)
1. Fan E, et al. Am J Respir Crit Care Med. 2014 Dec 15;190(12):1437-46.2. Hermans G, et al. Crit Care. 2008;12:238.
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Risk factors:– Severe Sepsis1
– Duration of mechanical ventilation1,4
– ICU LOS5
– Systemic inflammatory response syndrome2
– Multiple organ failure2,4
– Immobility2
– Use of corticosteroids/neuromuscular blockers2,3,5
Negative impact:1,2
– Prolong mechanical ventilation
– Reoccurring respiratory failure & VAP
– Increased ICU and hospital length of stay
– Increase mortality
ICU-Acquired Weakness (ICUAW)
1. Fan E, et al. Am J Respir Crit Care Med. 2014 Dec 15;190(12):1437-46.2. Kress JP et al. N Engl of Med, 2014;370:1626-16353. Hermans G, et al. Crit Care. 2008;12:238.4. De Jonghe B, et al. Crit Care Med. 2007;35(9):2007-2015.5. Needham DM, et al. Am J of Respir and Crit Care Med. 2014;189(10):1214-1224
Outcomes of Early Mobility Programs
• � incidence of VAP
• � time on the ventilator• � days of sedation
• � incidence of skin injury
• � delirium• � ambulatory distance
• Improved function
Staudinger t, et al. Crit Care Med, 2010;38.Abroung F, et al. Critical Care, 2011;15:R6Morris PE, et al. Crit Care Med, 2008;36:2238-2243 Pohlman MC, et al. Crit Care Med, 2010;38:2089-2094Schweickert WD, et al. Lancet, 373(9678):1874-82. Thomsen GE, et al. CCM 2008;36;1119-1124Winkelman C et al, CCN,2010;30:36-60
Early Mobility Protocol: Impacting Outcomes
• Morris, et al, conducted a prospective cohort study to determine the impact of early mobility therapy using a team on patients who were mechanically ventilated with respiratory failure
• The control group received standard passive ROM and turning (n=165)
• The study group received low-impact mobility by a team (n=165)
– Therapy initiated within 48 hours of mechanical ventilation
– Therapy 7 days/week until ICU discharge
– Mobility team included 1 ICU nurse, 1 physical therapist, and 2 nursing assistants
.Morris PE, et al. Crit Care Med. 2008;36:2238-2243.
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Early ICU Mobility Therapy
• Baseline characteristic similar in both groups
• Protocol group:– Received as least 1 PT session vs. usual care (80% vs. 47%, p < .001)
– Out of bed earlier (5 vs. 11 days, p < .001)
– Reduced ICU LOS (5.5 days vs. 6.9 days, p=.025)
– Reduced Hospital LOS ( 11.2 days vs. 14.5 days, p =.006)
– No adverse outcomes;
• Most frequent reason for ending mobility session was patient fatigue
– Cost
• Average cost per patient was $41,142 in the protocol group
• Average cost per patient was $44,302 in the control group
Morris PE, et al. Crit Care Med, 2008;36:2238-2243
Results
Early Physical and Occupational Therapy in Mechanically Ventilated Patients
• Prospective randomized controlled trial from 2005-2007
• 1161 screen, 104 patients mechanically ventilated < 72hrs, functionally independent at baseline met criteria
• Randomized to:
– early exercise of mobilization during periods of daily interruption of sedation (49 pts)
– daily interruption of sedation with therapy as ordered by the primary care team (55 pts)
• Primary endpoint: number of patients returning to independent functional status at hospital discharge able to perform activities of daily living and walk (independently)
Schweickert WD, et al. Lancet, 373(9678):1874-82.
Early Physical and Occupational Therapy in Mechanically Ventilated Patients
Schweickert WD, et al. Lancet, 373(9678):1874-82
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Early Physical and Occupational Therapy in Mechanically Ventilated Patients
Schweickert WD, et al. Lancet, 373(9678):1874-82
• Safe• Well tolerated• � duration of
delirium• � VFD• Functional
independence at discharge 59% protocol group vs. 35% in control arm
(Appendix (Appendix A) NeuroIntensiveA) NeuroIntensive Care UnitCare UnitProgressive Upright Mobility Protocol (PUMP) Plus A lgorithmProgressive Upright Mobility Protocol (PUMP) Plus A lgorithm
Assess patient (pt.) for the fol lowing:•Pt. at risk for/has deconditioning due to immobility? OR•Does pt. require orthostatic training to upright position?
CONTRAINDICATIONS?Include but are not limited to unstable spine, active stroke alerts and/or up to 24hours after receiving tPA or endovascular intervention, increased intracranial HTN, active resuscitation for life-threatening hemodynamicinstability, femoral sheaths, traction, CRRT, aggressivemodes of ventilation and palliative care.
Is the pt. immobile or have ineffective mobility plus one or more of:•Lobar collapse, atelectasis, excessive secretions?•P/F Ratio < 300?•Hemodynamic instability with manual turning (↓O2Sat; ↓BP, ↑HR)?
Assess skin q2hours. Temporarily offload Pressure areas for circulatory recovery. Do not use turning wedges during rotation.
Q shift: assess pt. progress towards expected outco mes; adherence to rotation goals; tolerance to therapy; clinical contra-indications (listed above)…Does the pt. meet CLRT d iscontinuation cr iter ia:•CXR improved/ resolving infiltrates; P/F ratio> 300; stable hemodynamically; improved secretion mgmt; pt. turns self?
PUMP STEPS: Progress each step from 30-60 minutes. Each step must be implemented at least three times/day and more frequently as tolerated. Repeat each step until patient demonstrates clinical tolerance to stated activity/position, then advance to next step, at the next activity period opportunity.* It is highly recommended to coordinate pt. mealtime with mobility steps whenever possible.STEP 1: HOB elevated at 45°STEP 2: HOB elevated at 45°plus legs in dependent position (partial chair mode or cardiac chair)STEP 3: HOB elevated at 45°plus legs in full dependent position (full bed chair mode/cardiac chair)STEP 4: HOB elevated at 65°plus legs in full dependent position & feet on floor & standing in place*If cardiopulmonary intolerance develops, use reverse T-Berg for orthostatic training TID, until resolved.STEP 5: Initiate stand position/pivot and into chairSTEP 6: (PLUS) Transfer standing from bed to chair for 2-3 meals with sitting time not to exceed 45min.STEP 7 (PLUS): Ambulate within room using assistive devices & extra personnel PRN (goal = 20 feet)STEP 8 (PLUS): Ambulate within hallway using assistive devices & extra personnel PRN (goal = 50 feet)STEP 9 (PLUS): Ambulate within hallway using assistive devices & extra personnel PRN (goal = 100 feet)STEP 10 (PLUS): Ambulates 150 ft with contact guard (hands on only for balance) or personnel supervision/assistance (coaching only).STEP 11: (PLUS): Ambulates without coaching or supervision, may use device if necessary.
Initiate/continueCont. Lateral
Rotat ionTherapy (CLRT)
Initiate orcontinue
PUMP Steps
Pt. able toambulate at all?
START HERESTART HERE……
N Y
Y
Proceed to PUMP PLUS
Steps 6 through 11
N
N
Y
N
Y
N
Notify primary MDto prescribe appropriateactivity orders for pt.
Y
Use of a of a Mobility Bundle Toolkit and Technology in a Neurointensive Care Unit
• All patient admitted over 16 month period
• 10 month pre-obs- 6 month post• 100% Nurse-driven protocol• One protocol for nurses to follow;
all patients• Mobility goals for patients with or
without deconditioning• Defined steps beyond “chair” to
better prepare patients for discharge, earlier
• End point mobility goals similar to outpatient PT goals
Modified from The University of Kansas Hospital Progressive Mobility Algorithm for Critically Ill Patients (http://www.aacn.org/wd/nti2009/nti_cd/data/papers/main31710.pdf© Shands at the University of Florida, 2010Courtesy of J Hester.Titsworth WL. J Neurosurg, 2012 116:1379-1388
Use of a of a Mobility Bundle Toolkit and Technology in a Neurointensive Care Unit (NICU)
Titsworth WL. J Neurosurg, 2012 116:1379-1388
Mobility was increased among the NICU care patients by 300%
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Protocol Driven Mobility Program: Impacting NICU Outcomes
• Pre-post intervention study
• Large academic NICU
• 637 patients– 260 pre
– 377 post
• Intervention: Early Progressive Mobility Protocol
– Exclusion criteria
– Readiness criteria
– Started on admission
– Encourage to use ICU bed features & lifts to assist
– Protocol place at bedside
Klein K, et al. Crit care Med, 2015, epub
Protocol Driven Mobility Program: Impacting NICU Outcomes
Multivariate analysis done to control for group differences:
Klien K, et al. Crit care Med, 2015, epub
ASESSMENT OF PAIN
BREATHE/SAT &SBT
CHOICE OF SEDATION
DELIRIUM
EARLY MOBILITY
FAMILY
A
D
E
B
C
Balas MC, et al. Crit Care Nurse. 2012 Apr;32(2):35-8, 40-7
F
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ABCDE Bundle Reduces Ventilation, Delirium & �OOB
• 18 month, prospective, cohort, before-after study• 5 adult ICU’s, 1 step down, 1 oncology unit• Compared 296 patients (146 pre-bundle) & 150
post bundle)• Intervention: ABCDE• Measured:
– For mechanical ventilation patients (187) examined ventilator free days
– All patients examined incidence of delirium, mortality, time to discharge and compliance with the bundle
Balas MC, et al. Crit Care Med, 2014;42(5):1024-36.
Balas M et al Crit Care Med, 2014; onlineBalas MC, et al. Crit Care Med, 2014;42(5):1024-36
Driving Change
Structure
Process
Outcomes
• Gap analysis• Build the Will• Protocol
Development
• Make it Prescriptive
• Overcoming barriers
• Daily Integration
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• Surveyed directors of medical and mixed medical surgical ICUs in 4 countries
• Institutions selected a random
• Results• 833 ICUs (US 396; France 151, UK 138, Germany 148)• 27% reported having a formal EM protocol
• 21% have adopted him practices without a protocol• 52% have not adopted EM practices
• EM protocols applied to both ventilated and non-ventilated upon ICU admission
• Factors associated with EM protocol– presence of multidisciplinary rounds (US)
– written daily goals (US)– Sedation protocol (US)
International Survey of Early Mobilization Practices: Where Do We Stand
Bakhru RN, et al. Amer J of Respir & Critical Care Medicine. 2014;A3933
Instituting a planned, structured ICU early mobility quality improvement project can
result in improved outcomes, and reduced costs across healthcare systems
Engel HJ, et al. Crit Care Med. 2013;41:S69-80
Early Mobility
• Head elevation• Manual turning• Passive & Active ROM• Continuous Lateral Rotation Therapy/Prone Positioning• Movement against gravity• Physiologic adaptation to an upright/leg down position (Tilt
table, Bed Egress)• Chair position• Dangling• Ambulation
Progressive Mobility:Planned movement in a sequential manner beginning at a patients current mobility status and returning them to baseline & includes:
Vollman KM. Crit Care Nurse.2010 Apr;30(2):S3-5.
• Objective• To create a progressive mobility initiative that will help ICU
teams to address key cultural, process and resource opportunities in order to integrate early mobility into daily care practices.
• Methods• Multi-center implementation of key clinical interventions
• An evidence-based, user-friendly progressive mobility continuum was developed, lead by the Clinical Nurse Specialist faculty
• Implementation plan: process design, culture work & education
• 130 patients/3120 prospectively collected hourly observations
• Qualitative and quantitative data collected
• 15 process and 5 outcome metrics
• Results reported as cohort and unit specific data
The Mobility Initiative
Bassett RD, et al.Intensive Crit Care Nurs (2012) 2012 Apr;28(2):88-97
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Determining Readiness
• Perform Initial mobility screen w/in 8 hours of ICU admission & daily
• PaO2/FiO2 > 250• Peep <10• O2 Sat > 90%• RR 10-30• No new onset cardiac arrhythmias or
ischemia• HR >60 <120• MAP >55 <140• SBP >90 <180• No new or increasing vasopressor
infusion• RASS > -3
Patient Stable, Start at Level II & progress
Yes
Patient is unstable, start at Level I & progress
No
Bassett RD, et al.Intensive Crit Care Nurs (2012) 2012 Apr;28(2):88-97Needham DM, et al. Arch Phys Med Rehabil. 2010 Apr;91(4):536-42
Consensus on Safe Criteria for Active Mobilization
• Systematic review performed than 23 international experts gather to reach consensus
• Respiratory• Cardiovascular• Neurological• Other Considerations
Categories Consensus reach on all criteria. If no other contraindications; vasoactives, endotracheal tube, FIO2 < 60% with SaO2 90% & RR < 30/min were considered safe criteria
Hodgson CL, et. al Critical Care, 2014;18:658
LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V
Progressive Mobility ContinuumIncludes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated
Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications
RASS -5 to - 3 RASS -3 & up RASS -1 & up
*Mobility is the responsibility of the RN, with the assistance from the RT’s Unlicensed Assistive Pers onnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment.
RASS 0 & up
***If the patient is intolerant of current mobility level activities, reassess and place in appropriat e mobility level***For each position/activity change allow 5-10 minute s for equilibration before determining the patient is intolerant
START HERE
RASS 0 & up
Tolerates Level IIActivities
ToleratesLevel IVActivities
Tolerates Level III
Activities
Ambulate progressively longer distances with less
assistance x2 or x3/day with
RN/PT/RT/UAP
Tolerates Level I
Activities
Refer to the following criteria to assist in
determining mobility level
YESNO
Start at level II and progress*
Start at level I*
o PaO2/FiO2 > 250
o Peep <10
o O2 Sat > 90%
o RR 10-30
o No new onset cardiac arrythmias or ischemia
o HR >60 <120
o MAP >55 <140
o SBP >90 <180
o No new or increasing vasopressor infusion
o RASS > 3
Perform Initial mobility screen w/in 8 hours of ICU
admissionReassess mobility level at
least every 24 hours(Recommended at shift ∆)
Goal : upright sitting; increased strength and
moves arm against gravity
PT consultation prnOT consultation prn
Goal : Increased trunk strength, moves leg against gravity and
readiness to weight bear
PT: Active Resistance Once a day, strength
exercises
OT consultation prn
ACTIVITY:Self or assisted Q 2 hr turning
1.Sitting on edge of bed w/RN, PT, RT assist X 15 min.
2.Progressive bed sitting PositionMin.20 min. 3X/d
OrPivot to chair position 2X/d
ACTIVITY:Self or assisted Q 2 hr turning
1.Bed sitting PositionMin.20 min. 3X/d;
2.Sitting on edge of bed; stand w/ RN, PT, RT assist
3.Active Transfer toChair (OOB) w/ RN/PT/RT assist Min. 3X/d
PT x 2 daily & OT x1 daily
ACTIVITY:Self or assisted Q 2 hr turning
1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day
2.Meals consumed while dangling on edge of bed or in chair
Goal: stands w/ min. to mod. assist, able to
march in place, weight bear and transfer to chair
PT x 2 dailyOT consult for ADL’s
Goal : clinical stability; passive ROM
ACTIVITY:Q 2 hr turning
*Passive /Active ROM 3x/d
1. HOB 45º X 15 min.2. HOB 45º,Legs
in dependant position X 15 min.
3. HOB 65º,Legs in dependantposition X 15 min.
4. Step (3) & full chair mode X20 min. 3X/d
Or Full assist into cardiac
chair 2X/day
ACTIVITY:
HOB > 30º*Passive ROM 2X/d performed by RN, or
UAP_________________
CLRT/Pronation initiated if patient
meets criteria based on institutional
practiceOR
Q 2 hr turning
Goal: Increase distance in ambulation
& ability to perform some ADLs
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ICU Mobility Score (IMS)
• Strong interrater reliability• Easy to use
Hodgson C, et al. Heart and Lung, 2014;43:19-24
Do We Even Achieve the Minimum Mobility Standard…
“Q2 Hours”?
• Body position: clinical practice vs standard1
– Study of 74 patients in which the change in body position was recorded every 15 minutes for an average observation time of 7.7 hours
– 49.3% of observed time showed no body position change for >2 hrs, and 2.7% had every-2-hour demonstrable body position change
• Positioning prevalence2
– Prospectively recorded, 2 days, 40 ICUs in the United Kingdom
– Average time between turns, 4.85 hours
How Well Are We Really Doing?
1. Krishnagopalan S, et al. Crit Care Med. 2002;30:2588-2592.2. Goldhill DR, et al. Anaesthesia. 2008;63:509-515.
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LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V
Progressive Mobility ContinuumIncludes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated
Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications
RASS -5 to - 3 RASS -3 & up RASS -1 & up
*Mobility is the responsibility of the RN, with the assistance from the RT’s Unlicensed Assistive Pers onnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment.
RASS 0 & up
***If the patient is intolerant of current mobility level activities, reassess and place in appropriat e mobility level***For each position/activity change allow 5-10 minute s for equilibration before determining the patient is intolerant
START HERE
RASS 0 & up
Tolerates Level IIActivities
ToleratesLevel IVActivities
Tolerates Level III
Activities
Ambulate progressively longer distances with less
assistance x2 or x3/day with
RN/PT/RT/UAP
Tolerates Level I
Activities
Refer to the following criteria to assist in
determining mobility level
YESNO
Start at level II and progress*
Start at level I*
o PaO2/FiO2 > 250
o Peep <10
o O2 Sat > 90%
o RR 10-30
o No new onset cardiac arrythmias or ischemia
o HR >60 <120
o MAP >55 <140
o SBP >90 <180
o No new or increasing vasopressor infusion
o RASS > 3
Perform Initial mobility screen w/in 8 hours of ICU
admissionReassess mobility level at
least every 24 hours(Recommended at shift ∆)
Goal : upright sitting; increased strength and
moves arm against gravity
PT consultation prnOT consultation prn
Goal : Increased trunk strength, moves leg against gravity and
readiness to weight bear
PT: Active Resistance Once a day, strength
exercises
OT consultation prn
ACTIVITY:Self or assisted Q 2 hr turning
1.Sitting on edge of bed w/RN, PT, RT assist X 15 min.
2.Progressive bed sitting PositionMin.20 min. 3X/d
OrPivot to chair position 2X/d
ACTIVITY:Self or assisted Q 2 hr turning
1.Bed sitting PositionMin.20 min. 3X/d;
2.Sitting on edge of bed; stand w/ RN, PT, RT assist
3.Active Transfer toChair (OOB) w/ RN/PT/RT assist Min. 3X/d
PT x 2 daily & OT x1 daily
ACTIVITY:Self or assisted Q 2 hr turning
1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day
2.Meals consumed while dangling on edge of bed or in chair
Goal: stands w/ min. to mod. assist, able to
march in place, weight bear and transfer to chair
PT x 2 dailyOT consult for ADL’s
Goal : clinical stability; passive ROM
ACTIVITY:Q 2 hr turning
*Passive /Active ROM 3x/d
1. HOB 45º X 15 min.2. HOB 45º,Legs
in dependant position X 15 min.
3. HOB 65º,Legs in dependantposition X 15 min.
4. Step (3) & full chair mode X20 min. 3X/d
Or Full assist into cardiac
chair 2X/day
ACTIVITY:
HOB > 30º*Passive ROM 2X/d performed by RN, or
UAP_________________
CLRT/Pronation initiated if patient
meets criteria based on institutional
practiceOR
Q 2 hr turning
Goal: Increase distance in ambulation
& ability to perform some ADLs
Level IRASS -5 to -3
Goal: Clinical Stability,Passive ROM
ACTIVITY:
HOB > 30º*Passive ROM 2X/d performed
by RN, or UAP_________________
CLRT/Pronation initiated if patient meets criteria based on
institutional practiceOR
Q 2 hr turning
ROM Active & Passive• When muscles are immobilize in shorten positions there
is remodeling of muscle fibers• Bed rest entails immobilization of limb extensor muscles
in shortened positions• Passive movement has been shown to enhance
ventilation, prevent contractures in patients in high dependency units
• Low resistance multiple repetition muscle training can augment muscle mass & strength
Gosslink R, et al. Intensive Care Medicine 2008;34:1188-1199.Perme C, Chandrashekar R. Am J of Crit Care, 2009;18:212-221.Schweickert WD, et al. Lancet, published online May 14, 2009.Griffiths RD, et al. Nutrition, 1995;11:428-432.
Recommended 10 repetitions each extremity x2 daily
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Goldhill DR et al. Amer J Crit Care, 2007;16:50-62
Prone Positioning: The New Evidence
• RCT 466 patients with severe ARDS– Severe ARDS P/F ratio < 150 mm Hg, with
Fio2 0.6, PEEP of at least 5 cm of water, and a Tv to 6 ml per kg of PBW
• Initiation 12-24hrs
• Prone-positioning 16hrs/or supine position
• NMB used 5 days
• Results:– Prone 16% mortality, supine 32.8% p<
0.0001
– No differences in complications except > cardiac arrest in supine position
Guerin C. et al. N Engl J Med, 2013
Manual Turning: Impact on Pneumonia
• Effect of Post Op Immobilization (Chulay MA et al, CCM, 1982)
– RCT: 35 post op CABG patient– Compared q 2 turning to supine in first 24 hrs post op– Results:
• no problems with Hemo or O2
• Patient turned has less fever & 3 day � in ICU LOS
• Freq of Turning on Pneumonia (Schallom et. al. 2005)
– Observation: 284 ICU pts for 16/hrs/day x3 days• Mean # of observed turns 9.64 vs. 23 possible turns/48
hrs)
– Results: day 4 patients with pneumonia turned average 8.6x vs. 10.62 without pneumonia
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In-Bed Technology
Out of Bed Technology
Progressive Mobility: Use of Technology to In-Bed & Out of Bed Mobility
Journey to tolerating
upright position, turning,
tilt, sitting, standing and
walking and out of bed
chair sitting can occur
quicker through the use of
technology
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Early Mobility:Can We Do It?Is it Safe?
Challenges to Mobilizing Critically Ill Patients
• Human or Technological Resources
• Knowledge/Priority
• Safety
• Hemodynamic instability
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Safety
• > 1 % adverse events during 1449 sitting, standing and walking sessions with patients on ventilators.
• Underwent daily sedation interruption followed by PT & OT daily until achieving physical function independence– Safety events occurred in 16% of all sessions
• Loss of 1 arterial line, 1 nasogastric tube, 1 rectal tube
– Therapy was stopped on 4% of all sessions for vent asynchrony, agitation, or both
– Delirium present 53% of the time during therapy sessions
Bailey P, et al. Crit care Med, 2007;35:139-145Pohlman MC, et al. Crit Care Med, 2010;38:2089-2094
HemodynamicInstability
Is it a Barrier to Positioning?
???
• Lateral turn results in a 3%-9% decrease in SVO2, which takes 5-10 minutes to return to baseline
• Appears the act of turning has the greatest impact on any instability seen
• Minimize factors that contribute to imbalances in oxygen supply and demand
The Role of Hemodynamic Instability in Positioning1,2
1.Winslow EH, et al. Heart Lung. 1990;19:557-561.2.Price P. Dynamics. 2006;17:12-19.3.Vollman KM. Crit Care Nurs Q. 2013;36:17-27
• Factors that put patients at risk for intolerance to positioning:3• Elderly• Diabetes with neuropathy• Prolonged bed rest• Low hemoglobin and cardiovascular reserve• Prolonged gravitational equilibrium
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Decision-Making Tree for Patients Who Are Hemodynamically Unstable With Movement1,2
Screen for mobility readiness within 8 hrs of admis sion to ICU & daily initiate in-bed mobility strategies as soon as possible
Is the patient hemodynamically unstable with manual turning?•O2 saturation < 90%•New onset cardiac arrhythmias or ischemia•HR < 60 <120•MAP < 55 >140•SPB < 90 >180•New or increasing vasopressor infusion
Is the patient still hemodynamically unstable after allowing 5-10 minutes’ adaption post-position change before determining tolerance?
Has the manual position turn or HOB elevation been performed slowly?
Initiate continuous lateral rotation therapy via a protocol to train the patient to tolerate turning
Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates
Allow the patient a minimum of 10 minutes of rest between activities, then try again to determine tolerance
Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates
Try the position turn or HOB maneuver slowly to allow adaption of cardiovascular response to the inner ear position change
No
No
No
No
Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible
Yes
Yes
Yes
Yes
HOB=head of bed; HR=heart rate; MAP=mean arterial pressure; SPB=systolic blood pressure.Vollman KM. Crit Care Nurse. 2012;32:70-75.Vollman KM. Crit Care Nurs Q. 2013;36:17-27.
It Takes a Village For Sustainability1. Necessary Components for
Early Rehab• Buy-in
• Multiple disciplines
• Team communication• Opinion leader
• Individual discipline champion• Dedicated rehab personnel
• Equipment
• Sedation practice• Administrative funding
2. Implementation Strategies• Team center approach• Staff education
• Strength & quality of evidence
3. Perceived Barriers• Increase workload• Safety concerns
4. Positive Outcomes • Improved patient outcomes• Staff satisfaction
• Changed culture
• Financial savings
Eakin MN, et al. J of Crit Care, 2015;30:698-704
Ensuring Safety & Success
• Mobility readiness assessment
• Determining absolute contraindications for any mobility protocol
• Criteria for stopping a mobility session
• Changing the culture• Sufficient resources and
equipment to make it easy & safe to do
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Financial Model for Cost Effectiveness
Lord R. Crit Care Med, 2013;41:717
It is not enough to do your best, you have to know what to do and then do your best.
E Deming
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