36C26119Q0345-0003002.pdf

Early Mobility: Rehabilitation

Kahlila Fowler, OTR/L, Marcella McGee, OTR/L, Susan Wyatt, BSN, RN

**36C26119Q0345 Reference Information**

Presenter Presentation Notes Introduce ourselves

OBJECTIVES

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Participants will be able to:

1.Describe the scope of how immobility impacts client factors, body functions, structures and performance skills

2. Describe how early mobility programs improve outcomes

3. Describe importance of the interdisciplinary team, communication, and roles

4. Identify 2-3 precautions to be aware of when moving the critical care patient

5. Identify 2-3 specific assessments, and equipment a clinician can use to enhance early mobility

Presenter Presentation Notes Questions:

Do you have an early mobility program at your facility How long has it been in place How many of you want to have one? are you apprehensive?

DEFINITION OF EARLY MOBILITY

• “Early mobility is a term used to describe mobilization activities that begin immediately upon stabilization of hemodynamic and respiratory physiology, generally within 24-48 hours after ICU admission”

• Vollman, K.M. (2010). Progressive mobility in the critically ill. Critical Care Nurse, 30(2), Supplement, S3-S5.

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HISTORY OF EARLY MOBILITY

• Before WWII it was thought that “rest was the most powerful aid which the surgeon could bring to disordered tissue” Ghormley, Ralph, JAMA 1944

• Early ambulation first introduced during WW II to Speed up recovery for return to war • Rheum Dis Clinic NA 1990;16:791-

• “Early Rising After Operation” Benefits of early mobility were clear: “First, morale is greatly improved…General health and strength are better maintained & convalescence is more rapid.” NEJM 1942;14:576-577 BMJ 1948;2(4588):102 6-7 –

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• Provider Barriers

• Knowledge • Lack of Staffing • Fearful attitude • Patient Sedation • Culture of immobility • Unfamiliar professions

• Solutions

• Education, promotion • Start small, evolution • Treat pain, target sedation • Find your champions • Learn to speak their language

• Needham, D. M. and R. Korupolu (2010). "Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model." Top Stroke Rehabil 17(4):

271-281 Pawlik, A. J. and J. P. Kress (2013). "Issues affecting the delivery of physical therapy services for individuals with critical illness." Phys Ther 93(2): 256-265.

BARRIERS TO ICU EARLY MOBILIZATION

WHAT DOES EARLY MOBILITY LOOKS LIKE TODAY

• PROM

• Bed mobility, rolling side to side

• Rising HOB gradually to progressing to sitting at EOB

• Working on sitting tolerance, balance, posture, trunk control

• Working on sit to stand

• Standing tolerance

• Transfers to chair, wc, bed side commode

• Sitting up to complete simple

ADL’s/grooming

• Exercise in bed and progressing to exercise sitting in chair

• ambulation

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• Early Mobility

• Return to Independence

59%

• Shorter duration of delirium 2 days

• Ventilator free days 21.1

• Improved physiological and psychological

• Improved return to independent functional status (59% vs. 35%)

• Bed Rest

• Return to Independence

35%

• Longer duration of

Delirium 4 days

• Ventilator 23.6 days

• Discontinuation of therapy due to pt instability 4%

• Longer rehabilitation

EARLY MOBILITY VS BED REST

ICU AND COGNITION AND DELIRIUM

• Definition of Delirium: a disturbance of consciousness with inattention accompanied by a change in cognition or perceptual disturbance that develops over a short period of time (hours to days) and fluctuates over time.

• There are three main types of delirium: hyperactive (ICU psychosis), hypoactive (quiet delirium) and mixed (fluctuation between hyper and hypoactive)

• Symptoms that may manifest during OT treatment include: Confusion, Agitation, Difficulty concentrating or following directions, Rambling speech, Jumbled thought processes

• Hallucinations/paranoia

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WHO IS AT RISK

• Symptoms are more likely to occur in individuals whom already have a history of depression, anxiety, PTSD, younger/female, history of alcoholism, use opioids, have pre-existing dementia, history of hypertension, and a high severity of illness at admission

• How many are affected?

• ~10-60% of patients will develop postoperative delirium

• ~60-75% of patients receiving mechanical ventilation can experience delirium

• Patients overall in the ICU setting are 10X more likely to have delirium

• Potential causes of delirium include: infection, Dehydration, Lack of proper sleep, Prior co-morbidities, Hypoxemia, Electrolyte imbalances, Sensory deficits

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ROLE OF OT IN COGNITION

• Assist with sleep hygiene cycle

• Reality orientation

• Relaxation techniques

• Pain reduction techniques/positioning

• Education to caregivers/staff on cognitive levels and overall expectations

• Educate patients on ICU surroundings/POC

• Sensory integration

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LONG TERM EFFECTS

• ~20-30% of patients will have cognitive challenges up to a year post ICU stay.

• 1 in 10 patients could have PTSD up to one year related to the ICU experience (6 to 12% of patients - Iraq Veteran rates are ~8%

• ICU induced delirium/PTSD can manifest itself in nightmare-like experiences, safety restrains, creating communication barriers, fears of imminent death, fears of breathlessness, confusion, anxiousness, aggressive behaviors, and physical outbursts.

• Higher incidence of SNF placement

• Loss of job/continued disability

• Increase stress on caregivers

• Decreased survival rate

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Nursing Responsibility and Interventions for Delirium Management:

• Documenting Accurate and appropriate delirium assessments for all veterans.

• Utilize CAM-ICU assessment tool (follow the algorithm) during sedation vacations to assess for delirium in our intubated veterans.

• Consider reasons for positive results in delirium assessment (external v internal)

• Manage symptoms with mobilization if applicable, reality orientation, and medication if deemed necessary.

CAM-ICU DELIRIUM ASSESSMENT ALGORITHM

RAZZ ASSESSMENT STEP 1 LEVEL OF CONSCIOUSNESS

ASSESSMENT

SESSLER, ET AL., AM J REPIR CRIT CARE MED 2002, 166: 1338-1344 ELY, ET AL., JAMA 2003; 286, 2983-2991

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RASS AND EARLY MOBILITY CREATED BY VANDERBILT

UNIVERSITY

HTTP://WWW.ICUDELIRIUM.ORG/EARLYMOBILITY.HTML

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RASS AND BMAT

• https://www.youtube.com/watch?v=jAS3v pupqmQ RASS

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https://www.youtube.com/watch?v=jAS3vpupqmQ

COGNITIVE ASSESSMENTS

• Confusion Assessment Method (CAM-ICU)- evaluative tool used for assessment of delirium. It is validated and has shown reliability in an ICU setting. Nursing is primarily using this assessment, but can be used by other health professionals.

• Mini-Mental State Exam or Folstein Test- Can be used in the ICU setting for cognitive assessment, but is not sensitive for delirium. This test is copyrighted.

• Chelsea (CPAx)-Developed for physical mobility in critical care settings. It measures 10 areas of physical performance and is a good indicator for hospital discharge location

• Physical Function ICU Test (PFITS)- It is a valid measure of function for individuals who require medical ventilation for four days or longer and are critically ill. It addresses 7 aspects of functioning and is a good indicator for discharge location.

• Cognitive Test for Delirium (CTD)- Assesses 5 aspects of cognition and is considered a reliable test to assess delirium, but costs money to acquire.

• St. Louis University Mental Status (SLUMS)- Administered to identify persons whom have dementia or mild neurocognitive impairment. It takes approximately seven minutes to complete.

• Allen Cognitive Levels- (ACLS)- Assess problem solving abilities and assists with caregiver education. Not ICU/critical care validated.

• Cognitive Performance Test (CPT)- Utilizes six common activities of daily living tasks to assess for functional capabilities. This test has been used in the acute care setting, but not ICU validated.

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MOBILITY ASSESSMENTS TO SUPPORT OUTCOMES

• FIM Functional Independence measure

• TUG Timed Up and Go

• FTSST Five time Sit to Stand

• 2MWT 2-Minute Walk Test

• MMT

Journal of Neurologic Physical Therapy: September 2011 - Volume 35 - Issue 3 - p 133–140

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FINANCIAL OUTCOMES

• 30% reduction in MICU LOS

• 18% reduction in hospital LOS

• 10% reduction in hospital mortality

• Based on 900 patient admissions with the LOS reduced by 22% and ICU LOS by 19% there can be an average cost savings of $817,836

• Critical Care med 2013 Mar;4(3):171-24

• J Am Coll Surg 2106 Mar: 222(3):219-225

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EARLY MOBILIZATION

TECHNOLOGY AND ADAPTIVE

EQUIPMENT

Presenter Presentation Notes Question Do you have all the equipment you need?

Beds

Presentation Notes Know the functions and special features of your beds Lateral Ability to weight bear Chair position Be apart of the team when purchasing of beds is occurring

Air Assistive Devices

• Lateral transfers

• Repositioning

Friction Reducing devices

• Lateral transfers

• Repositioning

• Therapeutic exercises

• ROM

Chairs

• Do you have chairs for each of your rooms?

• Do you know the weight capacity?

Overhead lifts

• Do you have overhead ceiling mounted lifts in your rooms?

• Slings

– Repositioning

– Turning

– Limb lifting

– Transferring

Patient slings

Mobile floor based lifts

Presentation Notes Powered sit to stands Non-powered sit to stands Floor based lift Some have the option for gait training with walking harness

Specialty Walkers

Presentation Notes -Accommodate lines/tubing

THE EVIDENCE

• Vanderbilt University web page on OT and PT in the ICU http://www.icudelirium.org/earlymobility.html

• Critical Care Magazine http://www.sccm.org/Communications/Critical-Connections/Archives/Pages/Importance-Early-Rehabilitation-Mobility-ICU.aspx

• How Early Should We Mobilize ICU Patients http://www.medscape.com/viewarticle/750458

• Get Moving: Johns Hopkins Research Shows Early Mobility Better than Bed Rest for ICU Patients http://www.hopkinsmedicine.org/news/media/releases/get_moving_johns_hopkins_research_shows_early_mobility_better_than_bed_rest_for_icu_patie nts

• Davydow DS, Desai SV, Needham DM, Bienvenu OJ. Psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review.

Psychosom Med 2008; 70(4): 512-9.

• van der Schaaf M, Beelen A, Dongelmans DA, Vroom MB, Nollet F. Poor functional recovery after a critical illness: a longitudinal study. J Rehabil Med 2009;

41(13): 1041-8.

• Timmers TK, Verhofstad MH, Moons KG, van Beeck EF, Leenen LP. Long-term quality of life after surgical intensive care admission. Arch Surg 2011; 146(4):

412-8.

• Albert T, et al. Early Ambulation After Hip Fracture, Effects on Function and Mortality: 2006 American Medical Association

• Livingston DH, Tripp T, Biggs C, Lavery RF. A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit. J

Trauma 2009; 67(2): 341-8; discussion 8-9.

• Deitrick J, Whedon G, Shorr E. Effects of immobilization upon Various metabolic and physiologic functions of normal men. Amjmed Jan 1948, 4, 1, 3-36

• Herridge MS, Tansey CM, Matte A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364(14): 1293-304.

• Morandi A, Jackson JC, Ely EW. Delirium in the intensive care unit. International review of psychiatry (Abingdon, England) 2009; 21(1): 43-58.

• Hopkins RO, Jackson JC. Long-term neurocognitive function after critical illness. Chest 2006; 130(3): 869-78

• Lipshutz AK, Gropper MA. Acquired Neuromuscular Weakness and Early Mobilization in the Intensive Care Unit. Anesthesiology 2012.

• Kortebein P, Ferrando A, Lombeida J; Effect of 10 Days of Bed Rest on Sketal Muscle in Healthy Older Adults: JAMA. 2007;297(16)1769-1774

• Occupational therapists’ roles in intensive care, http://www.caot.ca/otnow/March05/OTNowMarch05_Roles.pdf

• Occupational Therapy in Acute Care http://www.aota.org/About-Occupational-Therapy/Professionals/RDP/AcuteCare.aspx

Presenter Presentation Notes The evidence is there for both patient outcomes and financial for the hospital http://www.icudelirium.org/earlymobility.html http://www.sccm.org/Communications/Critical-Connections/Archives/Pages/Importance-Early-Rehabilitation-Mobility-ICU.aspx http://www.medscape.com/viewarticle/750458 http://www.caot.ca/otnow/March05/OTNowMarch05_Roles.pdf

THE EVIDENCE CONTINUED

• Adamis, D., Sharma, N., Whelan, P. J., & Macdonald, A. J. (2010). Delirium scales: a review of current evidence. Aging & mental health, 14(5), 543-555.

• American Thoracic Society. (2016, January 7). Veterans, civilian patients at risk of ICU-related PTSD up to a year post discharge. ScienceDaily. Retrieved January 10, 2017 from www.sciencedaily.com/releases/2016/01/160107094420.htm

• Foreman, J. (2005). Occupational therapists' roles in intensive care. Occupational Therapy Now, 7(2), 15. Retrieved January 10, 2017 from http://www.caot.ca/otnow/March05/OTNowMarch05_Roles.pdf

• Girard, T. D., Pandharipande, P. P., & Ely, E. W. (2008). Delirium in the intensive care unit. Critical Care, 12(Suppl 3), S3.

• ICU Delirium and Cognitive Impairment Study Group. Vanderbilt University Medical Center and the Department of Veterans Affairs. (2013). Retreived January 10, 2017 from: http://www.icudelirium.org/

• Nordon-Craft, Amy PT, DSc; Schenkman, Margaret PT, PhD, FAPTA; Ridgeway, Kyle DPT; Benson, Alexander MD; Moss, Marc MD (2011), Physical Therapy Management and Patient Outcomes Following ICU–Acquired Weakness: A Case Series, 35 (3) 133-140.

• Pandharipande, P. P., Girard, T. D., Jackson, J. C., Morandi, A., Thompson, J. L., Pun, B. T., ... & Moons, K. G. (2013). Long-term cognitive impairment after critical illness. New England Journal of Medicine, 369(14), 1306-1316.

• RASS and Early mobility, Created by Vanderbilt University http://www.icudelirium.org/earlymobility.html

• Sakuramoto, H., Subrina, J., Unoki, T., Mizutani, T., & Komatsu, H. (2015). Severity of delirium in the ICU is associated with short term cognitive impairment. A prospective cohort study. Intensive and Critical Care Nursing, 31(4), 250-257.

• Wergin, R., & Modrykamien, A. (2012). Cognitive impairment in ICU survivors: assessment and therapy. Cleveland Clinic journal of medicine, 79(10), 705-712.

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http://www.icudelirium.org/

• Marcella J Mcgee; Marcella.Mcgee2@va.gov

• Kahlila M. Fowler; Kahlila.Fowler@va.gov

• Katherine Grasham; Clinical Nurse Leader in ICU Katherine.Grasham@va.gov,

• Ricky Harps; Respiratory Therapy Chief Ricky.Harps@va.gov

• Judy Kuhn; Safe Patient Handling Coordinator Judy.Kuhn@va.gov

• Sandra Bertke; Sandra.Bertke@va.gov

• Sarah Reineck; Sarah.Reineck@va.gov

• Cynthia Huey; Cynthia.Huey@va.gov

• This power point was adapted from a previous online learning for the OT monthly education call. All above authors contributed to this presentation.

mailto:Marcella.Mcgee2@va.gov mailto:Kahlila.Fowler@va.gov mailto:Katherine.Grasham@va.gov mailto:Ricky.Harps@va.gov mailto:Judy.Kuhn@va.gov mailto:Sandra.Bertke@va.gov mailto:Sarah.Reineck@va.gov mailto:Cynthia.Huey@va.gov

Questions