early mobility in critical illness
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DESCRIPTIONEarly mobility in critical illness. Lindee Strizich Tull , MD MSc C. Terri Hough, MD MSc 11/20/2013. Background. Critical illness survival rates are increasing, however there are many long term consequences of ICU admission - PowerPoint PPT Presentation
Early mobility in critical illness
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 admissionDecreased QOL, increased mortality post-discharge, decreased functional statusICU acquired weakness profound neuromuscular dysfunction after critical illnessCritically ill patients lose significant muscle mass and strength
Schefold, JC, et al. ICUAW and muscle wasting in critically ill patients. J cachexia, sarcopenia and muscle. Oct 14 2010Neuromuscular dysfunction and loss of muscle mass secondary to a complex host of factors:Prolonged immobilityIncreased caloric requirementsParalyticsCorticosteroidsIncreased inflammatory mediatorsAltered 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 2010Greater number of days on a ventilatorDeliriumIncreased total hospital length of stayDecreased quality of life post dischargeGreater length of time to be independent in ADLsIncreased mortality post-hospital discharge (Cox 2007, Herridge 2003, Heyland 2005, Kelly 2010, Semmler 2013). Consequences of Critical Illness MyopathyMOBILIZE CRITICALLY ILL PATIENTS!Solution?
Early mobility improves muscle strength (Llano-Diez 2012) decreases ICU and hospital LOSincreases the likelihood of and decreases the length of time until regaining functional independenceincreases QOL post-dischargeDecreases 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 =danglingWhat 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 mobilizationPatient 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 isnt everyone mobilized?Hypothesis ICU patients are mobilized infrequently, & this is based on multiple patient & institution specific factorsStudy 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 notpatients 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 BZDs, paralytics, RRT)external factors (e.g., day of the week, location of ICU bed, PT/OT consult).
Study MethodsAdmission to the MICU service between January 1, 2008 and December 31, 2012A diagnosis of acute respiratory failure, requiring mechanical ventilation for at least 24 hoursICU bed status for at least 96 hoursInclusion Criteria
jama.jamanetwork.comCriteria 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 haemodialysisHMC Nursing Criteria for mobility absolute contraindicationsFull spine precautions, IABP, Prone positioning, Sheath Precautions, Critical hypoxemia on rescue therapy, persistent vegetative statePatients also ineligible for mobilization if:paralyzed, known neurologic disease like myasthenia gravis precluding ability to mobilize, or baseline functional status less than dangle.
pharmacologyandpt.comCompiling and cleaning data.Analysis in Jan 2013
QI work!!!Goals how do we chart mobility in our EMR? How many patients are eligible for mobilityHow 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 periodOnly 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 recordedWhile waiting for the IRB approvalFrequency of mobilizationMobilization event charted?Documentation of MobilityPT/OT UtilizationCannot abstract mobilization events from physician or nursing progress notesWe do not document this in our notes very wellNursing 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, HMCEllen Caldwell Statistician, UWMC Division of Pulmonary and Critical Care MedicineColin Johnston Research Coordinator, UWMC Division of Pulmonary and Critical Care MedicineScott Weigle, MD, Professor of Medicine and Associate Program Director for medical subspecialties and research, UWMC IM Residency ProgramKelly King, RN, MN, CCRN, Assistant Nurse Manager, MCICU, HMCAcknowledgementsReferences