wells-pittas.acutecaresection csm handout early mobility ... · 12/1/15 2 objectives •...

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No Harm No Foul: Effective Early Treatment of Patients Who are Critically

Ill in the ICU Julie Pi,as, PT, DPT

Chris L. Wells, PhD, PT, CCS, ATC Combined Sec@ons Mee@ng 2016

Anaheim, California, February 17 -‐20, 2016

Speaker Disclosure Julie Pi,as and Chris Wells have no financial rela@onships to disclose.

Property of UMMC, J Pi,as, CL Wells

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Objectives •  1. Understand the pathophysiology of CCI and PICS. •  2. Appreciate the components of the ABCDEF bundle and the interdisciplinary collabora@on to implement the evidence based prac@ce guidelines.

•  3. Understand the basic components of implemen@ng a hospital wide Early Mobility Program.

•  4. Iden@fy key clinical educa@on and competencies that need to exist to promote safe and effec@ve rehabilita@on in the ICU seXng.

•  5. Discuss the benefits of interdisciplinary collabora@on in the ICU environment.


Exciting Times •  1954 Olser/ 1956 Olsen: ICU tetraplegia published case reports •  1984, Bolten: Coined “Cri@cal Illness Polyneuropathy” •  2000’s: Focus has moved from mortality alone to quality outcomes

•  Physical Therapists are key to the understanding, the mi@ga@on, and the management of cri@cally ill pa@ents


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Critical Illness •  5 million annual ICU admissions

•  Respiratory Failure •  Post Opera@ve Management •  Ischemic Heart Disease •  Sepsis •  Heart Failure

•  1.4 million older adults ICU admissions

SCCM.org; 2015 Property of UMMC, J Pi,as, CL Wells

Critical Illness

•  200,000 ALI annually with 25 -‐ 40% mortality rates • Average return to work: 1 year • Many cannot return to prior employment or func@on

•  500,000 elder adults adm with cri@cal illness •  26% mortality rate in 1st year post discharge •  54% morbidity rate in 1st year post discharge


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ICU Experience •  Seda@on •  Sleep Disturbance •  Malnutri@on •  Adverse Medica@ons Effects

•  Poor Pain Management •  Immobility •  Loss of Self Control & Dignity


Chronic Critical Illness

• 14 days post ICU admissions •  50% treated for sepsis

•  25 – 30% mortality rate

•  15 -‐20% will have new cogni@ve deficits •  40% will have at least 1 new ADL limita@on •  80-‐100% will have persistent skeletal muscle impairments

SCCM.org; 2015 Property of UMMC, J Pi,as, CL Wells

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Delirium •  Cluster of symptoms of decreased cogni@ve func@on

•  A,en@on and memory •  Arousal •  Execu@ve func@on

•  Associated with prolonged ICU & ven@lator days •  > 40% of ICU pa@ents •  22-‐72% mortality rate

Dose effect: ↑ 10% /day of delirium linked to mortality 1 year


Delirium

• A#en&onal deficits •  Fluctua@ons in consciousness •  Illusions & hallucina@ons • Dysphasia & dysarthria • Changes in tone / motor control


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PICS or PSS

• Describes a collec@on of health disorders •  Sufferers of cri@cal illness and ICU Environment •  Range of Signs and Symptoms

•  Physical Dysfunc@on •  Cogni@ve Dysfunc@on •  Mental Health Issues

SCCM.org 2015; Kress, 2013; Needham 2013


PICS or PSS

•  Persistent Cogni@ve Impairments •  Modeling mild to moderate TBI or Alzheimer's Syndrome •  Impairments in execu@ve func@on skills

Jackson, 2003 Property of UMMC, J Pi,as, CL Wells

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PICS

•  Persistent Psychological Problems •  35% PTSD at 2 years •  60% Anxiety •  40% Depression

•  25-‐ 40% s@ll out of work at 1 year

Puthucheary, 2013; Needham, 2010; Morris, 2008


PICS •  Persistent Muscle Impairment / Func@onal

Limita@ons •  50% will develop ICU Acquired Weakness in 1 week

•  Prolonged mechanical ven@la@on •  35 – 45% Func@onal limita@ons


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PICS

• Mechanisms •  Mitochondrial dysfunc@on •  Neuromuscular decoupling •  Protein catabolism •  ↓ Protein synthesis •  Muscle fiber necrosis •  Microvascular damage •  Altera@on in fast sodium channels

Apostolakis, 2015; Wollersheim, 2014


PICS: Muscle Dysfunction

•  Early phase •  Mitochondrial edema •  Sarcomere widening

•  Later phase •  Sarcomere disrup@on with myosin loss

• Atrophy of Type II fibers > type I •  ↓ myosin heavy chain •  Glycogen dysfunc@on

•  Loss of cross-‐sec@onal area of all fibers post 5 days

Apostolakis, 2015; Wollersheim, 2014 Property of UMMC, J Pi,as, CL Wells

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Who are at Risk

•  Sepsis •  Systemic inflammatory response syndrome • Comorbidi@es

•  Age •  Mechanical Ven@la@on •  Cor@costeroid Use •  ? NM Blockages

Apostolakis, 2015; Wollersheim, 2014; Hooijman, 2015; Kress, 2014


Critical Illness MUSCLE DYSFUNCTION What do we call it?

ICUAW CIP

CIM CINM

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ICU acquired weakness

•  CIP: Cri@cal Illness Polyneuropathy •  Normal to minimal reduc@on in nerve conduc@on velocity •  Abnormal EMG (muscle ac@on poten@al: CMAP) •  Diminished NCS (sensory ac@on poten@al: SNAP) •  46% incidence •  100% in pa@ents with systemic inflammatory response syndrome and MSOF

Schorl, 2013; Kukre@, 2014; Kress, 2014


ICU Acquired Weakness

•  CIM: Cri@cal Illness Myopathy •  Normal to minimal slowing in nerve conduc@on velocity •  Abnormal EMG (muscle ac@on poten@al) •  Increase CMAP dura@on •  Decrease in excitability with direct s@mula@on •  Normal NCS (sensory) •  24% incidence

Kukre@, 2014; Kress, 2014


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ICU Acquired weakness

•  ICUAW •  Clinical Presenta@on

•  Profound weakness (<48 /60 on MRC MMT) •  Difficult to wean from ven@lator •  Decrease in pain, temperature and vibra@on percep@on


ICU Acquired weakness

•  MRC weakness •  MMT: 0-‐5 scale •  UE: Shoulder abduc@on, elbow flexion and wrist extension •  LE: Hip flexion, knee extension, dorsi flexion

•  ICUAW Dx: < 48 /60


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ICU Acquired Weakness

• MRC ≥ 48 associated with •  More likely to be discharged home •  Less likely to avoid prolonged acute care stay •  Less likely to be readmi,ed to acute care facility •  Lower 28 day and 12 month mortality

Denehy, 2013; Schweickert, 2009


Dilemma

Early Rehabilita@on Model

Rehabilita@on became a consult service

More Survivors


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ICU Trends

• Commonly literature shows PT is of low frequency, low intensity and limited u@liza@on. OT and SLP is commonly only consulted at end of hospital stay and with limited consulta@on.

•  Falvey 2015: sugges@ng an under prescrip@on of exercises in the elderly leading to further hospital acquired disability

Ramsey, 2014


Adverse Effects

•  Post ICU studies: •  3 – 60 months: 58% motor – sensory deficits •  Poor endurance •  Poor ac@vity tolerance •  Easy fa@gability •  Persistent weakness / muscle atrophy

Schorl, 2013

Post ICU Syndrome (PICS)


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Adverse Effects

•  Psychiatric Impairments •  Anxiety: (62%) •  Depression: (36%) •  PTSD: (39%)

•  55-‐60% Cogni@ve impairment •  57% execu@ve func@on

Mikkelsen, 2012; Pandharipandle, 2013

Impairments consistent with TBI

and Alzheimer’s


Role of PT in ICU

•  Leader of Early Mobility •  PT mobilizes at a higher level •  Establishing procedures for mobiliza@on with ICU equipment •  Addressing various barriers

•  Research: most effec@ve exercise prescrip@on

Garzon-‐Serrano, 2011; Jolley, 2014


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Hospital trends

•  Form interdisciplinary commi,ee: •  Minimizing adverse effects of hospitaliza@on • What does each profession bring to the table to reach goals •  Promote effec@ve communica@on •  Interdisciplinary training and sustainability •  Process evalua@on and re-‐evalua@on


ICU trends •  Early rehabilita@on program

•  ROM •  Strengthening •  Func@onal mobility •  NMES

•  Seda@on Holiday •  Decrease delirium

•  Address pain •  Spontaneous breathing trials

•  Decrease respiratory weakness •  Mechanical ven@la@on weaning

•  Proper nutri@on •  Adequate sleep •  ICU diary


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ICU trends

ABCDEF Bundle

Pa@ent

A Spontaneous Awakening

Trials

B Spontaneous Breathing Trials

C A & B

Coordina@on ; Choice of Seda@on

D Delirium

Assessment and Monitoring

E Exercise / Early

Mobility

F Follow up, referral

Family

H: Handouts to educa@on about PICS

G: Good communica@on

Property of UMMC, J Pi,as, CL Wells www.aacr.org, 2015

Rise & Shine Initiative UMMC

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Rise & Shine •  Interdisciplinary Commi,ee

•  Nursing, Physician, Respiratory Therapy, Pharmacy, Informa@on Technology, Rehabilita@on

•  Planning began 2012 •  Implementa@on of components Fall 2013

•  Ini@al Focus included all adult ICUs

•  Standardized ICU prac@ce when appropriate

  Cardiac surgery   Cardiology   Medical   Surgical

  Neurology/Neurosurgery   Mul@-‐trauma   Neuro-‐trauma


Rise & Shine •  Interdisciplinary Training Components •  RN

•  Use of Richmond Agita@on and Seda@on Scale (RASS) and Confusion Assessment Method for the ICU (CAM ICU)

•  RT •  Performance and @ming of spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT)

•  MD/Pharmacy •  New order set •  Pharmacological selec@on •  Guidelines for administra@on

•  Rehab/RN •  Early Mobility Program

•  Team communication during rounds (daily goals sheet)


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Spontaneous Awakening Trial

•  Lighten seda@on •  Calm & Alert

• RASS •  Goal: +1 – 0 -‐ -‐ 1 -‐ -‐ 2

• Goal: •  Allow pa@ents to ac@vely par@cipate •  Ven@lator libera@on •  Mi@gate / avoid iatrogenic effects •  Prepare for life post ICU stay

Key: Control pain


Screening: Spontaneous Breathing trial

•  Medical stability

•  Ven@lator parameters: •  PEEP < 8 cm H2O; FiO2 < .5; Ve < 15 L/min; Pressure < 25 cm H2O

•  Unstable airway •  ICP < 15 mmHg

•  Significant hemoptysis


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Communication / Coordination

• Pa@ent Rounds •  Medical assessment •  Coordina@on SAT / SBT •  Delirium screening •  Daily plan


Delirium

• RASS < -‐2 to assess • CAM ICU

•  Confusion Assessment Method – ICU

•  ICDSC •  Intensive Care Delirium Screening Checklist

•  Issue: When present, what do you do to treat

• Acute changes in mental status •  Ina,en@on • Altered level of consciousness • Disorganized thoughts


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Delirium Management

•  Repeated reorienta@on •  Repeated cogni@ve s@mula@on •  Sleep Protocols •  Early Mobiliza@on •  Timely removal of lines and tubes •  Minimalize noise •  Pain management

•  Seda@on management

PREVENTION


ABCDE: Early Mobilization

•  Feasibility, efficacy and safety •  ↓ Mechanical ven@la@on supported days •  ↓ ICU LOS, ? Hospital LOS •  ↓ Delirium •  ↓ Func@onal loss

•  Interdisciplinary collabora@on

Morris, 2008; Schweickert, 2009; Needham, 2011 – 2013; Hough, 2010


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Early Mobility Guidelines

•  Formulated by an interdisciplinary team • Create a framework for:

•  LIPs to determine if a pa@ent is appropriate for OOB •  Nursing to determine by what means a pa@ent is most appropriate to get OOB and/or ambulate

•  Dependent technique •  Standing transfer

•  Rehabilita@on to focus on higher facilita@ve training •  Assignment of a Mobility Level to communicate the pa@ent’s mobility status to the interdisciplinary team


Early Mobility Goals

• Provide Advance Rehabilita@on •  ↑ Pa@ent ac@vity level •  ↓ Hospital associated complica@ons •  Minimize muscle atrophy/weakness •  ↓ LOS •  Improve level of discharge •  Increase awareness about mobility and discharge outcomes


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Early Mobility Guidelines Step 1: Mobility Orders

Evalua@on minimal pre shix • Non-‐prescrip@ve: case by case review • Criteria:

•  Cardiac: myocardial or hemodynamic instability •  Pulmonary: severe respiratory instability, unstable airway •  Neurological: cerebra-‐dynamic instability •  Orthopedic: unstable Fx, unstable spine •  Integumentary: some open cavity wounds, severe sacral wounds


UMMC Mobility Screen

Purpose: •  Nursing tool to assess func@onal ability and readiness

Goals for use: •  ↑ Safe pa@ent handling •  ↑ Ac@vity engagement •  Standardize assessment of pa@ent ability •  ↑ Communica@on •  ↓ Pa@ent handling associated injuries


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Utilization of Mobility Screen

Pa@ent safety: • Determine safety for transfers and walking

Staff safety: • ↓ Risk of employee injuries

Referrals: • Determine if a PT or OT consult should be obtained


Mobility Screen Part 1: Strength Screen & Sitting Balance

Strength Screen: 3 Func@onal Muscle Groups

1.  Elbow extension 2.  Hip & knee extension 3.  Seated knee extension

SiXng Balance: 60 Seconds


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Mobility Screen Part 2: Modified Dionne’s Egress Test

1.  Sit to stand 2.  Marching in place 3.  Stepping forward and back


Early Mobility Guidelines Level 1 Level 2 Level 3 Level 4 Level 5

RASS -‐2 -‐ -‐3 RASS > -‐1 RASS > -‐1 RASS > -‐1 RASS >1

Mobility Screen: fail Mobility Screen: fail Mobility Screen: pass

OOB: dependently OOB: dependently OOB: ac@ve

OOB: ac@ve Ambulatory

Baseline Mobility as tolerated

Rehab focus: Bed mobility, EOB, standing ADLs

Rehab Focus: Transfers, pre gait/ gait ac@vi@es ADLs

Rehab Focus: Transfers, gait, steps, higher level ac@vi@es ADLs


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Mobility Level Signs

RN and rehab shared responsibility for signage


Implementation

•  Electronic Educa@onal Modules • Return Demonstra@on •  Train the Trainer: Early Mobility Champions

•  Classroom training •  Laboratory experience •  Competence

• Bedside training • Built into the EMR documenta@on

• Unit audits on performance


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Common Barriers: Implementation and Sustainability •  Inconsistent mobility dialog during patient rounds •  Inconsistent rehabilitation presence •  Inconsistent completion of mobility screen •  Staff turn over •  Documentation •  Inconsistent placement of OOB orders •  Equipment availability, training, and use


Moving Forward

•  Implement F – G – H •  Assess protocol implementation

•  Educa@onal model for training of:   Rehabilita@on staff   Nursing staff

•  Compliance with program components •  Crea@on of sustainability model

•  Examining outcomes •  Iatrogenic rates •  LOS •  Pa@ent’s func@onal levels & sa@sfac@on •  Falls & injuries


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National Survey of PTs Practicing in ICU in the US

•  Experience: •  13 years in acute care hospital •  7.8 years in ICU •  PTs in academic seXngs had more acute care and ICU years of experience than PTs in community hospitals


Malone, 2015

National Survey •  Training:

•  31.8% formal ICU training (APTA creden@aled CC fellowships)

•  55.9% hospital based informal training (mentorship and competency programs)

•  12.3% no training •  Reports of both formal and “no” training higher in community hospital seXngs

•  PTs in academic seXngs more likely to have established competency requirements (52% in academic vs 28% in community)

Malone, 2015


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Implications of National Survey • Need for internal and external competent mentorship

• “Competent mentorship”-‐ the mentor is truly competent in the knowledge, skills, and abili@es that will enable safe and successful PT prac@ce in the ICU

• Mentorship oxen delegated to senior level staff with other administra@ve responsibili@es

• Hospital PT staff turn over rate of 12% -‐ so more @me devoted to direct pt care vs having resources to provide one-‐on-‐one mentorship of junior staff

Malone, 2015


Implications of Survey

• Recommenda@ons: •  Entry level PT curricula and clin ed include ICU based objec@ves and student exposure (1)

•  Development of peer reviewed hospital based competency requirements and prac@ce guidelines

•  Cont. ed courses based on current prac@ce guidelines and assessed by content experts

•  Expansion of residency and fellowship programs


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APTA Credentialed CC Residency & Fellowship Programs • CC Fellowship Programs

•  Johns Hopkins •  Houston Methodist Hospital •  University of Chicago

• Residency Programs •  Johns Hopkins (Complex Medicine)


What makes an effec@ve ICU PT?

Training

Experience Mentorship

Drive

Accountability

Ongoing educa@on

Teaching opportuni@es


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A strong ICU training, mentorship, and accountability program :

Enhances the ability of the therapists to provide the most advanced therapeu@c interven@ons with the

most cri@cally ill pa@ents &

Fosters inter-‐professional trust and respect for the benefit of therapy services


UMMC CC Orientation and Training Program

•  PT, OT, and SLP

•  2 weeks (80 hrs) one-‐on-‐one mentorship by therapist who is validated to prac@ce in CC units per UMMC guidelines and has done so for at least one year

•  8 hrs of CC orienta@on @me delegated to CC Clinical Specialist for higher level integra@on of trained material across service lines and pa@ent popula@ons


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UMMC Orientation and Training Program •  Primarily performed by same discipline, supplemented by other disciplines (OT, SLP) to increase awareness of other prac@@oner’s services and importance of interdisciplinary collabora@on

•  Primarily in one service line: •  Neurology/Neurosurgery •  Cardiology/Cardiac surgery, Medicine •  Surgery, Mul@-‐trauma, Neuro-‐trauma


Training Resources •  Training modules developed for each system including lines & tubes, braces,

devices relevant to that system (cardiac, pulmonary, neuro, GI GU, musculoskeletal, sox @ssue)

•  Ven@lator training modules •  Hands on examples of all lines/tubes •  Annual departmental lecture series •  CC orienta@on documents outlining general expecta@ons •  CC competency rubrics outlining advanced clinical problem solving •  UMMC Clinical prac@ce guidelines for specific popula@ons


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UMMC CC Orientation   Diagnoses   Factors that impact outcomes (comorbidi@es, hospital course, medica@ons, etc. )   Equipment   Lines/tubes   Techniques for mobilizing cri@cally ill pa@ents   Ven@lator seXngs and basic management   Evalua@on and treatment techniques appropriate for cri@cally ill pa@ents   Ar@ficial airway suc@oning procedure   Communica@on with mul@disciplinary medical team   Documenta@on


Competency Process Structure •  Post orienta+on wri-en test

•  ~2 weeks following close of formal orienta@on •  Covers material in educa@onal modules •  Spans all service lines in general fashion •  Must receive >80% to progress to prac@cal competency

•  Observed evalua+on or treatment session •  One cri@cal line (IVC, CRRT/CVVHD, ECMO, temporary VAD, PA Catheter, ETT, Trach on ven@lator)

•  3 other lines/tubes •  Session must include mobiliza@on of the pa@ent (supine to sit edge of bed, sit to stand, stand pivot, ambula@on) with appropriate management of line/tubes

*Exam ques@ons and grading rubrics wri,en using educa@onal model by content expert


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UMMC Rehab Critical Care Profile

68% (63/93 total rehab staff ) currently CC competent per UMMC guidelines

•  68% (34/50) of PTs •  55% (16/29) of OTs •  100% (13/13) of SLPs

11 CC Validators from the three disciplines manage the annual competency process.


CC Validator Requirements •  Advanced Therapist (2nd @er in UMMC organiza@on) •  Recommenda@on by supervisor •  Successful comple@on of validator competency by content expert •  Successful comple@on CC competency for at least 2 years prior to validator status •  Consistently prac@cing in CC environment incorpora@ng 2 or more service line popula@ons

•  Demonstrates self awareness of personal limita@ons and seeks assistance for interpreta@on of complex scenarios and decision making if necessary


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UMMS CC Competency Grading Rubric •  Scoring Criteria:

•  Knowledge and integra@on of pa@ent diagnosis, past medical history, current hospital course and current presenta@on

•  Understanding of pa@ent tolerance to treatment •  Interpreta@on of vital signs •  Assessment of environment •  Assessment of pa@ent (discipline specific, pain, visual signs) •  U@liza@on and knowledge of CC equipment and response to alarms •  Management of mechanical ven@lator


UMMC CC Competency Grading Rubric

•  Performance of appropriate evalua@on or treatment techniques based on pt’s needs and POC

•  Comple@on of session in logical sequence •  Iden@fica@on of one cri@cal line and three other lines/tubes present with the pa@ent, their purpose and precau@ons

•  No red flag safety concerns (as listed in the rubric) •  Demonstrate ability to respond to emergency situa@on scenario •  Documenta@on of session in medical record reviewed to ensure complete, well wri,en, and accurate representa@on of session


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Continuing Competence

• Competency renewed one year axer ini@al, then every 3 years if con@nues to pass

• May be placed on one year renewal cycle axer the first year if exposure in CC units is minimal or if further training is required to maintain competency

• Annual renewal educa@on sessions provided with clinical updates relevant to CC topics, new lines/tubes, new procedures


Suctioning of an Artificial Airway

Skill required for all therapists prac@cing in CC environment, and those prac@cing with chronic

pulmonary pa@ents with ar@ficial airways


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Rationale for Suctioning by Rehabilitation Therapists

• Performing airway clearance techniques (percussion, postural drainage, cough and deep breathing techniques, physical mobiliza@on) results in the mobiliza@on of airway secre@ons that require immediate removal for airway safety and to allow pa@ents to con@nue to par@cipate in their therapy session

• Airway clearance is within the PT scope of prac@ce and should not be delayed to call for RN or RT during PT treatment as it could impact the safety of the pt


Suctioning of Artificial Airway •  Ar@ficial Airways

•  Tracheostomy •  Endotracheal tube • Nasotracheal tube

•  Open and Closed (in-‐line) technique •  UMMS Suc@oning Guidelines

•  Adapted from AARC Clinical Prac@ce Guidelines •  Formal training performed during CC orienta@on process

• Mannequin simula@on • Hands on pa@ent training •  Training videos

• Wri,en test precedes prac@cal competency •  Skill observa@on performed (open and closed technique) – must receive at least 80% per grading rubric


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So, what’s the point?

Aim of the process = to iden@fy whether a clinician possesses and can apply their knowledge and skills to

prac@ce safely and effec@vely in the CC seXng


In other words… Can the therapist:

1.  Iden@fy and integrate all per@nent informa@on related to the pa@ent’s care

2.  Accurately assess for a pa@ent’s discipline specific impairments

3.  Perform meaningful and therapeu@c interven@ons to address those deficits


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Who runs the mobility show in your ICU?

Does this scenario sound familiar…


Therapy Lead Model vs Team Model Therapy Lead Approach

•  PT or OT requests ac@vity orders from provider

•  Therapist constantly jus@fies services

•  Therapist sets schedule around pt’s other daily ac@vi@es

•  Nurses call therapy to see “when you’re going to get my pt OOB”

•  Pa@ent’s mobility documented only in PT/OT notes

Team Approach

•  Ac@vity orders determined by standardized criteria and expected for most pa@ents

•  Providers aware of need for and support therapy services

•  Therapy is made priority like any other test/procedure

•  Nurse gets the pa@ent OOB even if therapy not present on a given day

•  Therapy able to use tx @me to provide skilled interven@ons

•  Pt’s ac@vity/mobility level present in mul@disciplinary documenta@on


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Multidisciplinary Model of ICU Mobility

•  Everyone manages their piece of the puzzle

•  Expecta@ons are clear • Pa@ent/family sa@sfac@on with process improves

• Communica@on is more succinct •  Improved efficiency

•  Improved outcomes


Contributing Factors…

• Historical culture of the unit – differs between hospital and within hospitals

• Cri@cal care a,ending vs individual service a,ending managing ICU pt care

• Consistent Rehab staff coverage with dedicated PT, OT, and SLP • Mul@disciplinary rounding process • Mul@disciplinary CC staff mee@ngs


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The Far Reaching Multi-D Mobility Program

•  Falls ini@a@ves

• Hospital evacua@on plan

•  Exercise protocols


The PT’s Piece of the Puzzle…

Dazzle them with your skills!


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Mobilization of Critically Ill Patients

• Before you go in the room… •  Comprehensive understanding of pt’s diagnosis and hospital course •  New informa@on RN may have per@nent to your plan •  Current pulmonary status (vent requirements, weaning plan) •  Cogni@ve status (pt alert, par@cipatory, following commands)


Mobilization of Critically Ill Patients

• Once you’re there… •  Comprehensive assessment of environment (surroundings and pa@ent)

•  Accurate con@nuous vital monitoring system •  Equipment (what and where) •  Lines/tubes •  Extraneous s@mula@on (ex: TV, visitors) •  Secure wound dressings and briefs

•  Have the assist that you need before you start •  Don’t fear the lines!


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Dispelling ICU Myths…

Be careful, and the lines will be just fine.


Femoral Catheters

• Poten@al complica@ons •  Uninten@onal catheter removal •  Local trauma •  Bleeding •  Infec@on

•  239 Femoral catheters (81% venous, 29% arterial, 6% HD) •  101 pts received PT while catheter in place •  Performed combina@on of ac@vi@es: standing, walking, siXng, supine cycle ergometry, in bed exercises

•  253 total PT sessions – NO adverse events

Damluji, 2013 Property of UMMC, J Pi,as, CL Wells

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Pulmonary Artery Catheters


•  Poten&al complica@ons from posi@onal changes of PA Cath: •  Catheter fracture •  Accidental dislodgement into the R ventricle •  dysrhythmias •  infarc@on or rupture of PA

Of the 2097 days with a PAC in place for 366 pts – 15 occurrences of PAC complica+ons, NONE of which associated with PT, OT, or nursing mobility ac+vi+es.

Included BM, transfers, ambula+on and stairs.

Fields, 2015

ECMO •  Increased u@liza@on as technology and cannula@on techniques improve •  Bridge to transplant and bridge to recovery both benefit •  Mul@-‐D approach needed to mobilize pt

•  CCRN, PT, perfusionist •  RT or CCNP/intensivist if situa@on required •  Discon@nue nonessen@al therapies during mobility •  Stabilize cannula if necessary •  May need to increase support for gas exchange (ECMO sweep gas flow rates, ECMO blood flow rates, and supplemental O2)

•  Interrupt or terminate session per clinical judgement in presence of hemodynamic instability, hypoxemia, dizziness, weakness, chest pain, dyspnea

•  No pt related or circuit related complica@ons as a result of PT tx reported •  Femoral cannula@on not absolute contraindica@on for ambula@on and transfers but upper body configura@on recommended to decrease cannula related complica@ons

Abrams, 2014


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Femoral ECMO Cannulation & Mobility

• UMMC Cardiac Surgery ICU (Jan 2013-‐may 2014) • Bed mobility, sta@c and dynamic standing, SPT •  Inclusion Criteria:

•  Surgical stabiliza@on of cannula@on site •  Stable blood flow through femoral cannulas with hip flexion •  Alert

Forrester, 2014


Results

•  12 of 93 pts on VV ECMO with femoral cannula@on mobilized •  48 of 73 total therapy sessions included mobility • No adverse events noted •  10/12 successfully weaned from ECMO (2 expired) •  7 d/c’d to rehabilita@on facility, 2 d/c’d home

Forrester, 2014


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Intracranial Pressure Monitoring

•  Elevated ICP = ICP ≥ 20 mm Hg for > 5 min • Maintain during ac@vity:

•  Intracranial pressure (ICP) <20 mm Hg •  Cerebral perfusion pressure (CPP) >70 mm Hg

•  External ventricular drain (EVD) or intraventricular catheter (IVC) •  Must be clamped during mobility to prevent excess CSF drainage •  Changes in body posi@on, increased internal pressure, and agita@on cause increases in ICP


Don’t forget who you are!

Unique Skills and Perspec@ve • Con@nuous assessment of vital signs

•  Monitoring ac@vity tolerance •  Ranges for common VS’s

•  Titra@on of ac@vity level in response to change in physiological status

•  Secre@on clearance when necessary •  Therapeu@c handling techniques

•  Key points of control • Building blocks • Use of specialized equipment to progress mobility


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Exercise prescription in the critically ill •  2013 Summary of RCTs inves@ga@ng ICU physical therapy in the cri@cally ill:

•  Exercise interven@on arms consisted of… •  PROM, AROM, “limb strengthening” •  Transfers, bed mobility, siXng edge of bed •  ADLs •  Gait training/ambula@on, stair training •  “Early mobiliza@on” •  Diaphragma@c exercises and respiratory muscle training, chest PT, incen@ve spirometry

•  Arm and leg ergometer •  Dura@on/frequency/intensity

•  Ranged from “daily”, 10 reps PROM 1-‐2 sets, 20 min ergometer, 30 min lower limb exercise…

•  Suggests that PT as a “program package” is beneficial in many areas •  More studies needed to determine the effects of specific prescrip@ve exercise and ac@vity intensity

Kayambu, 2013 Property of UMMC, J Pi,as, CL Wells

Strength Training Exercise Prescription for Acute Respiratory Failure

Intensity for frail individuals (ACSM recommenda@ons): •  60% of muscle’s max force to increase strength • Use of typical 1 Rep max technique to determine the amount of weight is very difficult in ICU seXng.

• Alternate approach – have pt perform 8-‐12 reps of given exercise, if fa@gued and unable to perform more reps they are working at appropriate intensity

• Resistance applied by hand, strap on weights, resistance bands

Berry, 2013 Property of UMMC, J Pi,as, CL Wells

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Strength Training Exercise Prescription for ARF

Volume of strength training exercise – •  Func@on of the # of reps and sets of and exercise that are completed

•  Strength gains for normal individuals come with 2-‐4 sets of strength exercises per muscle group

•  Frail pts – ACSM recommends that at least one set of each exercise (8-‐12 reps) be performed

•  Number of sets increases as pt demonstrates gain •  Exercises should target the major muscle groups:

•  Chest, shoulders, arms, upper and lower back, abdomen, hips and legs

Berry, 2013 Property of UMMC, J Pi,as, CL Wells

Strength Training Exercise Prescription for ARF

Frequency – number of @mes per week •  Yet to be determined for ARF pts but may be more frequent than outpa@ent recs of 2-‐3 x wk with 48 hr rest between bouts

• ACSM Recs for ini@a@ng strength training program – as soon as pt can perform 8-‐10 reps of ac@ve ROM

Berry, 2013


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Functional Outcome Measures for Critically Ill Patients

• Physical Func@on ICU Test (PFIT) •  Acute Care Index of Func@ons • Hand grip dynamometry


References Chris L Wells, PhD, PT, CCS, ATC •  Schorl M, Valerisu-‐Kukula SJ, Kemmer TP. (2013) Cri@cal illness polyneuropathy as sequelae of sever neurological illness: Incidence and impact on ven@lator therapy and rehabilita@on. Neurorehabilita@on 32:149-‐156.

•  Ramsey P, Salisbury LG, Huby G, et al. (2014) A rehabilita@on interven@on to promote physical recovery following intensive care: A detailed descrip@on of construct development, ra@onale and content together with prosed taxonomy to capture processes in a randomized controlled trial. Trials 15:38-‐56.

•  Mikkelsen M, Chris@e JD, Lanken PA, et al. (2012) The adults respiratory distress syndrome cogni@ve outcomes study: Long term neuropsychological func@on in survivors of acute lung injury. American Journal of Cri@cal Care Medicine 185(12) 1307-‐1315.

•  Lone NL, Walsh TS. (2012) Impact of intensive care unit organ failures on mortality during the five years axer a cri@cal illness. American Journal of Cri@cal Care Medicine 186(7) 640-‐647.

•  Kukre@ V, Shamim M, Khilnani P. (2014) Intensive care unit acquired weakness in children: Cri@cal illness polyneuropathy and myopathy. Indian Journal of Cri@cal Care Medicine 18(2):95-‐103.

•  Jones C, Backman C, Griffiths RD. (2013) Intensive care diaries and rela@ves’ symptoms of pos,rauma@c stress disorder axer cri@cal illness: A pilot study. American Journal of Cri@cal Care 21(3): 172-‐176.

•  Davidson JE, Harvey MA, Bemis-‐Dougherty AR, et al. (2013) Implementa@on of the pain, agita@on and delirium clinical prac@ce guidelines and promo@ng pa@ent mobility to prevent post intensive care syndrome. Cri@cal Care Medicine 41:S136-‐S145.

•  Davidson JE, Jones C, Bienenu OJ. (2012) family response to cri@cal illness: Post-‐intensive care syndrome: Family. Cri@cal Care Medicine 40:618-‐624.


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References

•  Craik R. (2013) Rehabilita@on for people with cri@cal illness: Taking the next steps. Physical Therapy 92(12): 1484-‐1490. •  Cox CE, Docherty SL, Brandon DH, et al. (2009) Surviving cri@cal illness: Acute respiratory distress as experienced by

pa@ents and their caregivers. Cri@cal Care Medicine 37(10):2702-‐2709.

•  Brummel NE, Jackson JC, Girand TD, et al. (2012) A combined early cogni@ve and physical rehabilita@on program for people who are cri@cally ill: The ac@vity and cogni@ve therapy in the intensive care units (ACT-‐ICU) Trial. Physical therapy 92(12): 1580-‐1594.

•  Bienvenu OJ, Gellar, J, Althouse BM, et al. Post-‐trauma@c stress disorder symptoms axer acute lung injury: A 2 year prospec@ve longitudinal study. Psychological Medicine 43: 2657-‐2671.

•  Bemis-‐Dougherty, AR. (2014) What follows survival of cri@cal illness? Physical Therapists’ management of pa@ents with post-‐intensive care syndrome. Physical Therapy 93(2): 179-‐188.

•  Bellar A, Kunkler K, Burke, M. (2009) Understanding, recognizing, and managing chronic cri@cal illness syndrome. Journal of American Academy of Nurse Prac@@oners 21:571-‐578.

•  Fritz S, Lusardi, M. (2009). White paper: "walking speed: the sixth vital sign". Journal of Geriatric Physical Therapy, 32(2): 2-‐5.

•  Denehy L, de Morton NA, Skinner EH, et al. (2013) A physical func@on test for use in the intensive care unit: Validity, responsiveness, and predic@ve u@lity of the physical func@on in intensive care test (scored). Physical Therapy Journal 16(2): 1636-‐1645.

•  Pandharipande PP, Girard TD, Jackson JC, et al. (2013) Long-‐term cogni@ve impairment axer cri@cal illness. New England Journal Medicine 369:1306–1316.


References

•  Garzon-‐Serrano J, Ryan C, Waak K, et al. (2011) Early mobility in cri@cally ill pa@ents: Pa@ents’ mobiliza@on level depends on health care provider’s profession. Journal of Physical Medicine and Rehabilita@on. 3; 307-‐313.

•  Jolley SE, Regan-‐Baggs J, Dickson R, et al. (2014) Medical intensive care unit clinician aXtudes and perceived barriers towards early mobility of cri@cally ill pa@ents: A cross \-‐sec@onal survey study. Biomedical Anesthesiology. 14; 84-‐93.

•  Nordon-‐Crax A, Schenkman M, Edbrooke L, et al. (2014). The physical func@on intensive care test: Implementa@on in survivors of cri@cal illness. Physical Therapy Journal. 94 (10); 1499-‐1509.

•  SCCM.org

•  Perme, C; LeXvin, C; Throckmorton, T; Mitchell, K; Masud, F. (2011) Early mobility and walking for pa@ents with femoral arterial catheters in intensive care unit: a case series. Journal of Acute Care Physical Therapy: 2(1): 32-‐36.

•  Winkelman, C. Ambula@ng with pulmonary artery or femoral catheters in place. (2011) Cri@cal Care Nurse 31(5).

•  Fields, C; Trotsky, A; Fernandez, N; Smith, B. (2015). Mobility and ambula@on for pa@ents with pulmonary artery cathters: A retrospec@ve descrip@on study. Journal of Acute Care Physical Therapy. 6(2); 64-‐70.

•  Wang, Y; Hines, T; Ritchie, P; walker, C; et al. (2014). Early mobiliza@on on con@nuous renal replacement therapy is safe and may improve filter life. Cri@cal Care: 18: 161-‐171.

•  De Jonghe, B; sharshar, T; Lefaucheur, J; Anthier, F; et al. (2002) Paresis acquired in the intensive care unit. Journal of American Medical Associa@on. 288; 2859-‐2867.

•  Falveym JR; Mangione, KK; Stevens-‐Lapsley, JE. (2015) Rethinking hospital associated decondi@oning: Proposed paradign shix. Physical Therapy Journal. 95:1307-‐1315.

•  Kress, JP; Hall, JB. (2014). ICU Acquired weakness and recovery from cri@cal illness. New England Journal of Medicine. 370: 1626-‐1635.

•  Wollersheim, T; Woehlecke, J; Krebs, M; et al. (2014). Dynamics of myosin degrada@on in intensive care unit acquired weakness during severe cri@cal illness. Intensive Care Medicine. 40; 528-‐538.

•  Apostolakis E; Papakonstan@nou, NA; Baikoussis, NG; Papadopoulos G. (2015). Journal of Anesthesiology. 29; 112-‐121.


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References Julie Pittas, PT, DPT

•  Hooijman, PE; Beishuizen A; Wi,, CC; et al. (2015). Diaphragm muscle fiber weakness and Ubiqui@n-‐proteasome ac@va@on in cri@cally ill pa@ents. American Journal of respiratory and Cri@cal Care Medicine. 191(10) 1126-‐ 1138.

•  Berry, M. J., & Morris, P. E. (2013). Early Exercise Rehabilita@on of Muscle Weakness in Acute Respiratory Failure Pa@ents. Exercise and Sport Sciences Reviews, 41(4), 208–215. h,p://doi.org/10.1097/JES.0b013e3182a4e67c

•  Camp, P. G., Reid, W. D., Yamabayashi, C., Brooks, D., Goodridge, D., Chung, F., … Hoens, A. (2013). Safe and effec@ve prescrip@on of exercise in acute exacerba@ons of chronic obstruc@ve pulmonary disease: Ra@onale and methods for an integrated knowledge transla@on study. Canadian Respiratory Journal : Journal of the Canadian Thoracic Society, 20(4), 281–284.

•  Berney, S., Haines, K., Skinner, E., Denehy, L. (2015). Safety and Feasibility of an Exercise Prescrip@on approach to rehabilita@on across the con@nuum of care for survivors of cri@cal illness. PT Journal, 92 (12), 1524-‐1535.

•  Malone, D., Ridgeway, K., Nordon-‐Crax, A., Moss, P., Schenkman, M., Moss, M. (2015). Physical Therapist Prac@ce in the Intensive Care Unit: Results of a Na@onal Survey. PT Journal, 95 (10), 1335-‐1344.

•  Damluji, A., Zanni, J., Mantheiy, E., Colantuoni, E., Kho, M., Needham, D. (2013). Safety and Feasibility of Femoral Catheters during physical rehabilita@on in the intensive care unit. Cri+cal Care Medicine. 28, 535.39-‐535.e15.

•  Perme, C., Nalty, T., Winkelman, C., Kenji Nawa, R., Masud, F. (2013). Safety and Efficacy of Mobility Interven@ons in Pa@ents with Femoral Catheters in the ICU: A Prospec@ve Observa@onal Study. Cardiopulmonary Physical Therapy Journal, 24(2), 12-‐17.


References

•  Abrams, D., Javidfar, J., Farrand, E., Mongero, L., Agerstrand, C.L., Ryan, P., Zemmel, D., Galuskin, K., Morrone, T.M., Boerem, P., Bacche,a, M., Brodie, D. (2014). Early Mobiliza@on of Pa@ents Receiving Extracorporeal Membrane Oxygena@on: a Retrospec@ve Cohort Study. Cri+cal Care, 18(1).

•  h,p://www.ncbi.nlm.nih.gov/pmc/ar@cles/PMC4056162/

•  Vincent, J., Hall, J., Slutsky, A. (2015). Ten Big Mistakes in Intensive Care Medicine. Intensive Care Medicine, 41, 505-‐507.

•  Kayambu, G., Boots, R., Paratz, J.(2013). Physical Therapy for the Cri@cally Ill in the ICU: A systema@c Review and Meta-‐Analysis. Cri+cal Care Medicine, 41 (6), 1543-‐1554.

•  Berry, M., Morris, P., (2013). Early Exercise Rehabilita@on of Muscle Weakness in Acute Respiratory Failure Pa@ents. Exercise Sport Science Review, 41(4), 208-‐215.

•  Fields, C., Trotsky, A., Fernandez, N., Smith, B., (2015) Mobility and Ambula@on for Pa@ents with Pulmonary Artery Catheters: A Retrospec@ve Descrip@ve Study. Journal of Acute Care Physical Therapy, 6(2), 64-‐70.

•  Abrams, D., Javidfar, J., Farrand, E., et. al (2014). Early Mobiliza@on of pa@ents receiving extracorporeal membrane oxygenta@on: a retrospec@ve cohort study. Cri+cal Care, 18(1).

•  h,p://ccforum.com/content/18/1/R38

•  Nordon-‐Crax, A., Schenkman, M., Edbrooke, L., Malone, D., Moss, M., Denehy, L., (2014). The Physical Func@on Intensive Care Test: Implementa@on in Survivors of Cri@cal Illness. Physical Therapy Journal, 94(10), 1499-‐1507.

•  Forrester, J., Vogel, J., Rector, R., Wells, CL. Pa@ents with femoral extracorporeal membrane oxygena@on (ECMO) cannula@on can be safely mobilized. Journal of Acute Care Physical Therapy 2014, 4(3), 110.


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