Lindee Strizich Tull, MD MScC. Terri Hough, MD MSc11/20/2013EARLY MOBILITY IN

CRITICAL ILLNESS

Critical illness survival rates are increasing, however there are many long term consequences of ICU admission

Decreased QOL, increased mortality post-discharge, decreased functional status

ICU acquired weakness – profound neuromuscular dysfunction after critical illness Critically ill patients lose

significant muscle mass and strength

BACKGROUND

Schefold, JC, et al. “ICUAW and muscle wasting in critically ill patients.” J cachexia, sarcopenia and muscle. Oct 14 2010

Neuromuscular dysfunction and loss of muscle mass secondary to a complex host of factors: Prolonged immobility Increased caloric

requirements Paralytics Corticosteroids Increased inflammatory

mediators Altered membrane and

protein channel functioning

(Chambers 2009, Cherry-Bukowiec 2013, Derde 2012, Hough 2009, Latronico 2011, Wever-Carstens 2010)

PATHOPHYSIOLOGY

Schefold, JC, et al. “ICUAW and muscle wasting in critically ill patients.” J cachexia, sarcopenia and muscle. Oct 14 2010

Greater number of days on a ventilatorDelirium Increased total hospital length of stayDecreased quality of life post dischargeGreater length of time to be independent in ADL’s Increased mortality post-hospital discharge (Cox 2007, Herr idge 2003, Heyland 2005, Kel ly 2010, Semmler 2013).

CONSEQUENCES OF CRITICAL ILLNESS MYOPATHY

MOBILIZE CRITICALL

Y ILL PATIENTS!

SOLUTION?

Early mobility improves muscle strength (Llano-Diez 2012) decreases ICU and hospital LOS increases the likelihood of and decreases the length of time

until regaining functional independence increases QOL post-discharge Decreases length of time of delirium (Davis 2013, Hough 2012,

Morris 2008, Naeem 2008) associated with a decreased odds of hospital readmission or

death in the year following ICU admission (Morris 2011, Schweickert 2009)

BENEFITS OF MOBILIZATION

Minimum activity =“dangling”

WHAT IS MOBILITY IN CRITICAL ILLNESS?

All the way up to walking!

Estimated that only 30% of patients are mobilized at any point during their ICU admission (Dinglas 2013)

Rates vary both between and within institutions (Hodgkin 2009, Thomsen 2010, Dinglas 2013)

Factors that may affect rates of mobilization Patient factors: illness severity, sedation requirements,

need for continuous hemodialysis, gender (Dinglas 2013, Garzon 2011, Thomsen 2010)

Institution factors: profession of practitioner providing exercise, academic vs. community hospital, surgical vs. medical vs. other specialty ICU, presence of an ICU culture promoting early mobility (Bailey 2009, Dinglas 2013, Garzon 2011, Hodgkin 2009, Hopkins 2007, Morris 2008, Thomsen 2010).

WHY ISN’T EVERYONE MOBILIZED?

Hypothesis – ICU patients are mobilized infrequently, & this is based on multiple patient & institution specific factors

Study Goals: To assess rates of mobilization

of patients admitted to the MICU service at HMC

Determine which factors, both patient and institution related, were associated negatively or positively with mobilization.

WHAT ARE THE BARRIERS AT HMC?

Retrospective cohort studyComparing factors associated with critically ill MICU

patients who are mobilized to those who are not patients’ baseline factors (e.g., age, gender, weight,

language) aspects of critical illness (diagnosis, severity of illness,

cardiopulmonary instability, delirium/coma) medical treatments (e.g., use of BZD’s, paralytics, RRT) external factors (e.g., day of the week, location of ICU bed,

PT/OT consult).

STUDY METHODS

Admission to the MICU service between January 1, 2008 and December 31, 2012

A diagnosis of acute respiratory failure, requiring mechanical ventilation for at least 24 hours

ICU bed status for at least 96 hours

INCLUSION CRITERIA

jama.jamanetwork.com

Criteria indicating unstable patient conditions:

MAP < 65 mm Hg or > 110 mm Hg, or SBP > 200 mm Hg; HR < 40 BMP or > 130 BPM; RR< 5 or > 40; and pulse oximetry < 88%.

Other contraindications to mobilization: Raised ICP; active GIB; active MI; continuous procedures including haemodialysis

HMC Nursing Criteria for mobility –absolute contraindications Full spine precautions, IABP, Prone positioning, Sheath Precautions,

Critical hypoxemia on rescue therapy, persistent vegetative state Patients also ineligible for mobilization if:

paralyzed, known neurologic disease like myasthenia gravis precluding ability to mobilize, or baseline functional status less than “dangle.”

EXCLUSION CRITERIA

pharmacologyandpt.com

Compiling and cleaning data….

Analysis in Jan 2013

CURRENT STATUS

QI work!!! Goals –

how do we chart mobility in our EMR? How many patients are eligible for mobility How easy is it to figure out if someone meets eligibility criteria? What proportion are mobilized?

Methods: Data collected retrospectively from the EMR of a random sampling of patients admitted to the MICU for at least 24 h over a one month period

Only the first 120 hours of admission were analyzed Admission diagnoses, contraindications to mobilization,

highest level of activity charted each day, PT/OT consults and sessions, mention of mobility in daily progress notes and nursing notes, and daily activity orders were recorded

WHILE WAITING FOR THE IRB APPROVAL…

34 patients admitted to

MICU

• intubated >/= 24h, admitted to MICU >/=

48h & no contraindication

s to mobility

56% (19) of patients eligible

42% (8/19) achieved dangle or greater

FREQUENCY OF MOBILIZATION

• Mobilization event charted?

116 physican progress notes

54% mention mobility

20% of these are the same as

the charted mobility event

DOCUMENTATION OF MOBILITY

116 nursing progress

notes

20% mention mobility

19 pts. eligible for mobility

5 PT/OT consults

0 pts. Seen over first 120 hours in

ICU

PT/OT UTILIZATION

Cannot abstract mobilization events from physician or nursing progress notes We do not document this in our notes very well Nursing has a specific place to chart this, but even this can

be inconsistentWe do not chart reasons for not mobilizing seemingly

eligible patientsWe may not be utilizing PT/OT enough in our MICU,

and a PT/OT consult does not necessarily = mobilization

LESSONS FROM QI WORK?

Terri Hough, MD, MSc – research mentor, Associate Professor, Division of Pulmonary and Critical Care Medicine, HMC

Ellen Caldwell – Statistician, UWMC Division of Pulmonary and Critical Care Medicine

Colin Johnston – Research Coordinator, UWMC Division of Pulmonary and Critical Care Medicine

Scott Weigle, MD, Professor of Medicine and Associate Program Director for medical subspecialties and research, UWMC IM Residency Program

Kelly King, RN, MN, CCRN, Assistant Nurse Manager, MCICU, HMC

ACKNOWLEDGEMENTS

REFERENCES