Presentatie Wenen final 3nov2013 - Mobilization- · PDF...
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Transcript of Presentatie Wenen final 3nov2013 - Mobilization- · PDF...
05.11.13
1
‘Start to move ASAP’ in the ICU: Proposi7on of the UZ LEUVEN protocol
Beatrix Clerckx
Department of Rehabilita6on Sciences, Department of Intensive Care Medicine, University Hospitals Leuven, Catholic University of Leuven
Prolonged ICU stay is devasta6ng and oEen results in long-‐term func6onal and cogni6ve impairment
Recent studies confirmed that early mobilisa6on of mechanically ven6lated pa6ents is feasible and safe and shortens ICU and hospital length of stay.
Purpose protocol
Establishing an early mobility and physical ac6vity protocol:
-‐ requires a mul,disciplinary team approach; -‐ facilitates a culture in the ICU to reduce immobility of cri,cally ill pa,ents;
Purpose protocol
encourages teamwork
change in mentality
-‐ requires a mul+disciplinary team approach; -‐ facilitates a culture in the ICU to reduce immobility of cri+cally ill pa+ents; -‐ offers a variety of interven,ons to start body posi,oning and
physiotherapy shortly a>er ICU admission.
Purpose protocol
Establishing an early mobility and physical ac6vity protocol:
05.11.13
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UZ LEUVEN ‘start to move asap’
6-‐level program deliver daily mobility or physical ac7vity from day 2 aHer admission to the ICU
each level is determined by assessment using objec7ve measurements
each level consists of a variety of body posi7ons and modali7es for physical training and early mobility
VARIABLE COOPERATION
S5Q1 0-5
VARIABLE COOPERATION
S5Q1 0-5
CLOSE TO FULL COOPERATION
S5Q1 ≥ 4/5
FULL COOPERATION
S5Q1 = 5
PHYSIOTHERAPY4
Passive/Active range of motion
Passive/active bed cycling
NMES
BODY POSITIONING4
2hr turning
Fowler’s position
Splinting
PHYSIOTHERAPY4
Passive/Active range of motion
Resistance training arms and legs
Passive/Active leg and/or cycling in bed or chair
NMES
BODY POSITIONING4
2hr turning
Splinting
Upright sitting position in bed
Passive transfer bed to chair
PASSES BASIC ASSESSMENT3 +
PASSES BASIC ASSESSMENT3 +
PHYSIOTHERAPY4
Passive/Active range of motion
Resistance training arms and legs
Active leg and/or arm cycling in bed or chair
NMES
ADL
BODY POSITIONING4
2hr turning
Passive transfer bed to chair
Sitting out of bed
Standing with assist (2 ≥ pers)
PASSES BASIC ASSESSMENT3 +
PHYSIOTHERAPY4
Passive/Active range of motion
Resistance training arms and legs
Active leg and/or arm cycling in chair or bed
Walking (with assistance/frame)
NMES
ADL
BODY POSITIONING4
Active transfer bed to chair
Sitting out of bed
Standing with assist (≥1 pers)
PASSES BASIC ASSESSMENT3 +
LEVEL 0 LEVEL 5
NO COOPERATION
S5Q1 = 0
FULL COOPERATION
S5Q1 = 5
PHYSIOTHERAPY4
Passive/Active range of motion
Resistance training arms and legs
Active leg and arm cycling in chair
Walking (with assistance)
NMES
ADL
BODY POSITIONING4
Active transfer bed to chair
Sitting out of bed
Standing
PASSES BASIC ASSESSMENT3 +
FAILS BASIC ASSESSMENT2
PHYSIOTHERAPY:
No treatment
LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4
BODY POSITIONING4
2hr turning
1 : score 5 questions: adequate response to 5 standardized orders
2 : FAILS = at least 1 risk factor present / 3 : if basic assessment failed, decrease to level 0 4 : safety: each activity should be deferred if severe adverse events (cv., resp. and subject. intolerance) occur during the intervention
UZLEUVEN ‘START TO MOVE' ASAP
Neurological or surgical or trauma condition does not allow transfer to chair
Obesity or neurological or surgical or trauma condition does not allow active transfer to chair (even if MRCsum ≥ 36)
MRCsum ≥ 36 +
BBS² Sit to stand = 0 +
BBS² Standing = 0 + BBS² Sitting ≥ 1
MRCsum ≥ 48 +
BBS² Sit to stand ≥ 0 +
BBS² Standing ≥ 0 + BBS² Sitting ≥ 2
MRCsum ≥ 48 +
BBS² Sit to stand ≥ 1 +
BBS² Standing ≥ 2 +
BBS² Sitting ≥ 3
BASIC ASSESSMENT =
- Cardiorespiratory unstable:
MAP < 60mmHg or
FiO2 > 60% or PaO2/FiO2 < 200 or
RR > 30 bpm
- Neurologically unstable
- Acute surgery
-Temp > 40°C
assessment?
assessment?
LEVEL 0 LEVEL ?
assessment?
Adequacy score
SCORE 5 QUESTIONS2
A. Open and close your eyes □
B. Look at me □
C. Open your mouth and put out your tongue □
D. Nod your head □
E. Raise your eyebrows when I have counted up to five □
De Jonghe B., et al. Crit Care Med 2007; 35(9): 2007-‐14.
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Basic assessment
-‐ Cardiorespiratory unstable
* MAP < 60mmHg or * FiO2 > 60% or * PaO2/Fi02 < 200 or * RR > 30 bpm -‐ Neurologically unstable -‐ Acute surgery -‐ Temp > 40°C
Func7onal assessment
0 = No visible contrac7on 1 = Visible contrac7on without movements of the limbs 2 = Movements of the limbs but not against the gravity 3 = Movement against gravity over (almost) the full range 4 = Movement against gravity and resistance 5 = Normal
Kleyweg R.P., et al. Muscle Nerve 1991; 14(II): 1003-‐09.
MRC-‐scale: 0-‐5 score
MRC TOTAL SUMSCORE
Total score = 60/60 (max)
(De Jonghe B, JAMA 2002)
Score < 48/60: ‘significant muscle weakness’
Berg Balance score
Berg Balance score SITTING TO STANDING 4 able to stand without using hands and stabilize independently 3 able to stand independently using hands 2 able to stand using hands aEer several tries 1 needs minimal aid to stand or stabilize 0 needs moderate or maximal assist to stand STANDING UNSUPPORTED 4 able to stand safely for 2 minutes 3 able to stand 2 minutes with supervision 2 able to stand 30 seconds unsupported 1 needs several tries to stand 30 seconds unsupported 0 unable to stand 30 seconds unsupported SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL 4 able to sit safely and securely for 2 minutes 3 able to sit 2 minutes under supervision 2 able to able to sit 30 seconds 1 able to sit 10 seconds 0 unable to sit without support 10 seconds
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4
ASSESSMENT of AMBULATION =
Through use of
‘RELIABLE’
MEASUREMENTS
CLOSE TO FULL COOPERATION
S5Q1 ≥ 4/5
NO COOPERATION
S5Q1 = 0
LEVEL 0 LEVEL ?
PASSES BASIC ASSESSMENT3 +
FAILS BASIC ASSESSMENT2
BASIC ASSESSMENT =
- Cardiorespiratory unstable:
MAP < 60mmHg or
FiO2 > 60% or PaO2/FiO2 < 200 or
RR > 30 bpm
- Neurologically unstable
- Acute surgery
-Temp > 40°C
ASSESSMENT OF ‘AMBULATION’
Berg Balance score SITTING TO STANDING 4 able to stand without using hands and stabilize independently 3 able to stand independently using hands 2 able to stand using hands after several tries 1 needs minimal aid to stand or stabilize 0 needs moderate or maximal assist to stand STANDING UNSUPPORTED 4 able to stand safely for 2 minutes 3 able to stand 2 minutes with supervision 2 able to stand 30 seconds unsupported 1 needs several tries to stand 30 seconds unsupported 0 unable to stand 30 seconds unsupported SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL 4 able to sit safely and securely for 2 minutes 3 able to sit 2 minutes under supervision 2 able to able to sit 30 seconds 1 able to sit 10 seconds 0 unable to sit without support 10 seconds
0 = No visible contrac7on 1 = Visible contrac7on without movements of the limbs 2= Movements of the limbs but not against the gravity 3 = Movement against gravity over (almost) the full range 4 = Movement against gravity and resistance 5 = Normal
MRC-scale: 36/60
LEVEL 3
LEVEL 0 LEVEL 5 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4
UZLEUVEN ‘START TO MOVE' ASAP
CLOSE TO FULL COOPERATION
S5Q1 ≥ 4/5
PASSES BASIC ASSESSMENT3 +
MRCsum ≥ 36 +
BBS² Sit to stand = 0 +
BBS² Standing = 0 + BBS² Sitting ≥ 1
Each level = Body Posi7oning
BODY POSITIONING
2hr turning
Passive transfer bed to chair
Signg out of bed
Standing with assist (2 ≥ pers)
Jointly with nursing staff
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LEVEL 0 LEVEL 5 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4
UZLEUVEN ‘START TO MOVE' ASAP
CLOSE TO FULL COOPERATION
S5Q1 ≥ 4/5
PASSES BASIC ASSESSMENT3 +
MRCsum ≥ 36 +
BBS² Sit to stand = 0 +
BBS² Standing = 0 + BBS² Sitting ≥ 1
BODY POSITIONING4
2hr turning
Passive transfer bed to chair
Sitting out of bed
Standing with assist (2 ≥ pers)
PHYSIOTHERAPY:
Passive/Ac6ve range of mo6on
Resistance training arms and legs
Ac6ve leg and/or arm cycling in chair or bed
Walking (with assistance/frame)
NMES
ADL
Each level = physiotherapy
LEVEL 0 LEVEL 5 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4
UZLEUVEN ‘START TO MOVE' ASAP
CLOSE TO FULL COOPERATION
S5Q1 ≥ 4/5
PASSES BASIC ASSESSMENT3 +
MRCsum ≥ 36 +
BBS² Sit to stand = 0 +
BBS² Standing = 0 + BBS² Sitting ≥ 1
BODY POSITIONING4
2hr turning
Passive transfer bed to chair
Sitting out of bed
Standing with assist (2 ≥ pers)
PHYSIOTHERAPY4
Passive/Active range of motion
Resistance training arms and legs
Active leg and/or arm cycling in bed or chair
NMES
ADL
Case: level?
05.11.13
6
VARIABLE COOPERATION
S5Q1 0-5
VARIABLE COOPERATION
S5Q1 0-5
CLOSE TO FULL COOPERATION
S5Q1 ≥ 4/5
FULL COOPERATION
S5Q1 = 5
PHYSIOTHERAPY4
Passive/Active range of motion
Passive/active bed cycling
NMES
BODY POSITIONING4
2hr turning
Fowler’s position
Splinting
PHYSIOTHERAPY4
Passive/Active range of motion
Resistance training arms and legs
Passive/Active leg and/or cycling in bed or chair
NMES
BODY POSITIONING4
2hr turning
Splinting
Upright sitting position in bed
Passive transfer bed to chair
PASSES BASIC ASSESSMENT3 +
PASSES BASIC ASSESSMENT3 +
PHYSIOTHERAPY4
Passive/Active range of motion
Resistance training arms and legs
Active leg and/or arm cycling in bed or chair
NMES
ADL
BODY POSITIONING4
2hr turning
Passive transfer bed to chair
Sitting out of bed
Standing with assist (2 ≥ pers)
PASSES BASIC ASSESSMENT3 +
PHYSIOTHERAPY4
Passive/Active range of motion
Resistance training arms and legs
Active leg and/or arm cycling in chair or bed
Walking (with assistance/frame)
NMES
ADL
BODY POSITIONING4
Active transfer bed to chair
Sitting out of bed
Standing with assist (≥1 pers)
PASSES BASIC ASSESSMENT3 +
LEVEL 0 LEVEL 5
NO COOPERATION
S5Q1 = 0
FULL COOPERATION
S5Q1 = 5
PHYSIOTHERAPY4
Passive/Active range of motion
Resistance training arms and legs
Active leg and arm cycling in chair
Walking (with assistance)
NMES
ADL
BODY POSITIONING4
Active transfer bed to chair
Sitting out of bed
Standing
PASSES BASIC ASSESSMENT3 +
FAILS BASIC ASSESSMENT2
PHYSIOTHERAPY:
No treatment
LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4
BODY POSITIONING4
2hr turning
1 : score 5 questions: adequate response to 5 standardized orders
2 : FAILS = at least 1 risk factor present / 3 : if basic assessment failed, decrease to level 0 4 : safety: each activity should be deferred if severe adverse events (cv., resp. and subject. intolerance) occur during the intervention
UZLEUVEN ‘START TO MOVE' ASAP
Neurological or surgical or trauma condition does not allow transfer to chair
Obesity or neurological or surgical or trauma condition does not allow active transfer to chair (even if MRCsum ≥ 36)
MRCsum ≥ 36 +
BBS² Sit to stand = 0 +
BBS² Standing = 0 + BBS² Sitting ≥ 1
MRCsum ≥ 48 +
BBS² Sit to stand ≥ 0 +
BBS² Standing ≥ 0 + BBS² Sitting ≥ 2
MRCsum ≥ 48 +
BBS² Sit to stand ≥ 1 +
BBS² Standing ≥ 2 +
BBS² Sitting ≥ 3
BASIC ASSESSMENT =
- Cardiorespiratory unstable:
MAP < 60mmHg or
FiO2 > 60% or PaO2/FiO2 < 200 or
RR > 30 bpm
- Neurologically unstable
- Acute surgery
-Temp > 40°C
The proposi6on of the protocol is discussed, adapted and evaluated by mul6disciplinary team members.
For 4 months the different levels for each ICU pa6ent were weekly saved in a database:
Level 0: 14%
Level 1: 29%
Level 2: 24%
Level 3: 16%
Level 4: 10%
Level 5: 7%
The inter-‐observer agreement of the levels was inves6gated by two observers independently. Good inter-‐observer agreement was reached (Kappa coefficient was 0.895 with p < 0.0001).
Evalua7on
Discussion
In the decision making of the levels, most of the pa6ents (2011) were subdivided in level 1. Those results appeared 4 months aEer the implementa6on of the protocol. Where are those pa6ents located aEer 2 years of implemen6ng the protocol, in other words; is there a culture change, are we moving the pa6ents faster out of the bed?
levels 2011-‐2013
2011: during 16 weeks, medical and surgical ICU pa6ents from day 2 2013: during 10 weeks, medical and surgical ICU pa6ents from day 2 with an expected stay of 5 days
0
5
10
15
20
25
30
35
40
level 0 level 1 level 2 level 3 level 4 level 5
14
29
24
16
10 7 8
38
27
10 11
6
%
2011
2013
05.11.13
7
levels 2011-‐2013
Level 0: < pat. in 2013: ≠ mul6disciplinary approach of the basic assessment: before contra-‐indica6on and now risk factor Level 1: > pat. in 2013: coming from level 0? Level 2: > pat. in 2013: culture change? Level 3, 4, 5: > pat.in 2011: inclusion from day 2, before day 7 to the ward?
0
5
10
15
20
25
30
35
40
level 0 level 1 level 2 level 3 level 4 level 5
14
29 24
16 10 7 8
38
27
10 11 6
2011
2013
%
Conclusion: Culture change? ≠ 2011-‐2013: a slight tendency to perceive ?
We struggle s6ll with perceived ‘barriers’ to facilitate rehabilita6on on the ICU: too sick, too sedated, too delirious, limited staffing, priori6za6on of rehab. pa6ents, limited knowledge of ICU staff, equipment limitations, .... Despite of presenta6ons especially for the nursing group, the most important and effec6ve method to make the culture change seems the bedside individual coaching.
Conclusions
Through the use of a protocol more pa6ents can probably be ac6vated and ambulated faster. Sensi6za6on and instruc6on of the mul6disciplinary team members is very important to implement safe and feasible early physical ac6vity and mobilisa6on.
Objec6ve measurements to facilitate the iden6fica6on of the levels are needed.
Further research to evaluate the early ac6vity and mobility protocol is warranted.
Thanks for your ajen7on !