Prioritizing Rehabilitation Strategies in the Care of the …...Facilitators & Barriers to Acute...
Transcript of Prioritizing Rehabilitation Strategies in the Care of the …...Facilitators & Barriers to Acute...
Facilitators & Barriers to Acute
Rehabilitation in the the Critically Ill
Karen K.Y. Koo MD, FRCPC, MSc Assistant Professor, Division Critical Care Medicine
Department of Medicine, Western University
Critical Care Canada Forum Oct 29, 2012
Disclosures
• I have no Industry relationships.
• I receive grant support from Academic Medical Organization of South-western Ontario & Lawson Health Research Institute, Physicians’ Services Incorporated Foundation & Academic Health Sciences Centres AFP Innovation Fund
Overview
• What & Whys of Early Mobilization in ICUs
• National Surveys – Barriers
• Facilitators for Early Mobilization
Early Mobilization = progressive series of activities - as early
as possible in ICU - from active ROM ambulation
Early Mobilization is Safe & Feasible
Study Design
Intervention
Main Findings
Limitations
Prospective cohort
N = 103 (Bailey et al. CCM 2007)
EM protocol
24h after RICU admission
69% patients
ambulate > 100” prior ICU discharge
Adverse events rare
Selection bias
94% from another ICU
(mean 10.5 +/- 9.9 days)
Prospective cohort N = 104
(Thomson et al. CCM 2008)
EM protocol 24h after RICU
admission
88% patients ambulate > 200” prior
ICU discharge
Selection bias
Prospective controlled trial
N = 330 (Morris et al. CCM 2008))
EM protocol 48h after ICU
admission by a mobility team
Shortens ICU & hospital length of
stay
Quasi-randomization
No concealment of randomization
Randomized study N = 80
(Nava, S. APMR 1998, 79)
Step-wise pulmonary
rehabilitation vs. standard
Most (52/60; 87%) regained
independent ambulation & ADLs
Baseline characteristics not reported
Early Mobilization improves functional outcomes
Study Design
Intervention / Control
Main Findings
Limitations
RCT Medical ICUs
N = 104
(Schweickert et al. Lancet 2009; 373)
Early Mobilization during interrupted sedation vs.
Standard Rehabilitation
Improved Independent neuromuscular function at
hospital discharge
Less Delirium
Shorter Mechanical ventilation duration
Patients with baseline
functional impairment
excluded
Medical ICU only
RCT Medical &
Surgical ICUs
N = 90
(Burtin et al. - CCM
2009; 37)
Bedside Cycle Ergometer vs. Standard Rehabilitation
Greater 6MWD at hospital discharge
No difference in
Weaning time, 1 year mortality,
ICU or hospital stay
Time to intervention 14d
Ward rehab not
controlled
Blinding of outcome
assessors not reported
Barriers to Early Mobilization
in ICUs
International Research on Barriers
• Many national surveys!
• Limited observational research
• Focus mostly on Institutional & Patient level Barriers
• Variable rigor & methodological approaches
King & Crowe, Physiotherapy 1998; 210
• Postal survey, convenience sample: PT, RN, MD
• PT & RNs – perceived MD restricting ambulation
• MD – perceived patient instability & lines
Norrenberg et al. Intensive Care Med 2000; 26
• European Postal survey to head PT
102/460 (22%) ICUs in 17 countries
• 25% No designated PT
• 33/102 (33%) – evening coverage but variable
[range: 0% Sweden & Germany - 79% UK]
• Variable role for PT: 25% managed vents
[range: 0% Sweden – 57% Portugal]
Kumar JA et al. Indian J Crit Care Med 2007:11
• Postal survey to PT (2 yrs critical care experience)
89/260 (35%) ICUs - India
• 21% ICU – no on call PT
• 55% ICU required MD order for rehab
Skinner ZH et al. Physiotherapy 2008; 223
• Postal survey to PT in 126/167 (75%) ICUs
• Evaluated subjective & objective factors used to prescribe exercise
• Major perceived barrier: medical instability
Skinner ZH et al. Physiotherapy 2008; 223
Hodgin et al. Crit Care Med 2009; 37
• Postal survey to PT
482/984 (49%) Response Rate
• < 10% ICU - initiation criteria for mobilization
• 1% ICU – automatic PT assessments
Appleton et al. Intensive Care Society 2012; 223
• Telephone survey in 23 ICU
(96% lead MD & 100% lead PT)
• Top 3 barriers:
– Patient severity of illness
– Insufficient $ for rehab
– Sedation
International Surveys show…
• Major Institutional Barriers Lack of protocols/guidelines Insufficient Equipment Insufficient Staffing No physician requests for physiotherapy consult
• Major Patient Barriers Medical instabilityExcessive sedation Lines
Survey of Mobilization in Critically Adults:Knowledge, Perspectives & Stated Practices in Canadian ICUs
Koo KKY, Choong K, Cook DJ, Herridge M, Newman A, Lo V, Priestap F, Campbell E, Guyatt G, Burns K, Lamontagne F, Meade MO for the Canadian Critical Care Trials Group
• A self administered, postal survey to PT & MD
• Developed a reliable & valid survey instrument
• Used incentive & evidence based methods
Koo et al. Am J Respir Crit Care Med 2011; 183
ResultsResponse Rates• Response Rate: 71% Clinicians (311/436)
• Respondents: 87% PT (117/134) & 64% MD (194/302)
Demographics
• 46 ICUs in 40 Canadian Teaching hospitals
• 18 beds/ICU (Range 10-36)
0 20 40 60 80 100
Med-Surg
CV Surg
Neuro
Trauma
Burn
86.5%
43.2%
39.3%
40.7%
19.4%
Type of ICU Respondents Worked in
Type of ICU
Results
% Clinicians
Top 3 Institutional§ Barriers
No Written Guidelines or Protocols 57%
Insufficient Equipment 52%
Physician Orders required 41%
Top 3 Patient Barriers
Medical Instability 83%
Excessive Sedation 60%
Risk of Device/Line Dislodgement 42% § Institutional barriers defined as “customs and behavior patterns in your work environment”
Results
% Clinicians
Top 3 Institutional§ Barriers
No Written Guidelines or Protocols 57%
Insufficient Equipment 52%
Physician Orders required 41%
Top 3 Patient Barriers
Medical Instability 83%
Excessive Sedation 60%
Risk of Device/Line Dislodgement 42% § Institutional barriers defined as “customs and behavior patterns in your work environment”
Results
Q. What is (are) the most important Provider level barrier(s) to EM in YOUR ICU? If you believe that the listed barrier is important, please select ALL provider(s) who contribute to the existence of that barrier.
Results
Top 3 Provider Barriers to Early Mobilization in ICU
Contributing Providers
MD PT RN RT CS
Limited Staffing 2% 78% 59% 30% 2%
Slow to Recognize 63% 17% 59% 19% 15%
Safety Concerns 31% 29% 64% 28% 12%
Q. What is (are) the most important Provider level barrier(s) to EM in YOUR ICU? If you believe that the listed barrier is important, please select ALL provider(s) who contribute to the existence of that barrier.
Figure 1. Knowledge of ICU Acquired Weakness & Early Mobilization Among Canadian Physiotherapists & Physicians
Knowledge of intensive care unit (ICU) acquired weakness was based on prospective observational studies (17,18,19,20,21) in medical-surgical intensive care units. ** Knowledge of
clinical trials (2,4,5,6) on early mobilization was evaluated using 5 true-false questions.
0 20 40 60 80
Knowledge of Clinical Trials on Early
Mobilization in ICUs** (% correct)
Self-Reported Familiarity of Early
Mobilization Literature (% agree)
Knowledge of ICU acquired
weakness* (% correct)
58
67
31
64
69
30
58
65
33
Physiotherapists
Physicians
AllRespondents
Canadian Survey shows…
• Major Institutional Barriers Lack of protocols/guidelines Insufficient Equipment Insufficient Staffing No physician requests for physiotherapy consult
• Major Patient Barriers Medical instabilityExcessive sedation Lines
Canadian Survey also identifies...
• Major Health Care Provider Barriers
KnowledgeSkills setSafety concernsDelays in Recognition of suitable patients
Facilitators of
Early Mobilization in ICUs?
Winkelman & Peereboom. Crit Care Nurse 2010; 30(2)
• Semi-structured interviews: Pre & post mobility protocol implementation in 49 patients
• Single US center: 33 RNs
• Major perceived facilitators of “out of bed activity”
Patient co-operation
Adequate oxygen reserve
MD orders
• No outcome/performance measures
Hopkins et al. Crit Care Clin 2007; 23
• QI - Intermountain Health Respiratory ICU Model (UT, USA)• Introduced numerous interventions to promote rehabilitation
Outcome Measures 2000 2005 Length of ICU stay (Mean) 13 d 10 dLength of hospital stay (Mean) 28 d 24 dSatisfaction safety culture HighSatisfaction ICU team work culture High
Hopkins et al. Crit Care Clin 2007; 23
Steps1. Review of Barriers established “state of urgency”2. Created powerful guiding coalition (Teamwork)
3. Created vision (Reduce sedation, prioritize activity, encourage sleep)
4. Communication of vision (Education, Mobility protocol)
5. Empowerment to act out vision (Cross-training, hiring new RNs)
6. Planning for “short term wins”7. Audit & feedback8. Institutional change (Transforming culture)
Needham et al. Arch Phys Med Rehabil 2010; 91
• QI: John Hopkins MICU – 2006, 2007
• Detailed data collection (pre/baseline, post/outcome)
Main Outcome Measures Pre-QI Post-QI____________
Benzodiazepine use (% of days used) 50% 25% p=0.002
Days alert 30% 67% p<0.001
Rehabilitation Treatments (#/patient) 1 7 p<0.001
MICU Stay 7 d 5 d p=0.02
Hospital Stay 17 d 14 d p=0.03
Mortality 23% 21% p=0.55
Needham et al. Arch Phys Med Rehabil 2010; 91
Summary Important Facilitators
• Institutional Facilitators Leadership/ChampionsAdministrative supportProtocols/guidelines Sufficient Resources (Staff & Equipment)
• Patient Facilitators Sedation Interruption: Scales, Audit & feedbackDelirium Screening Patient co-operation
• Health Care Provider Facilitators Education: seminars, bedside Cross-training
Take Home points
• Most Barriers are modifiable
• Facilitators for rehabilitation require educated, dedicated, & strategic interdisciplinary Team
• Early Mobilization improves functional outcomes in previously healthy, medical patients…
References
1. King J, Crowe J. Mobilization practices in Canadian critical care units. Physiotherapy Canada 1998; 50:206–2112. Limperopoulos C, Majnemer A. The role of rehabilitation specialists in Canadian NICUs: A national survey. Physical & Occupational
Therapy in Pediatrics 2002; 22:57-723. Norrenberg M, Vincent JL. A Profile of European Intensive Care Physiotherapists. Int Care Med 2000; 26:988-9944. Kumar JA, Maiya AG, Pereira D. Role of physiotherapists in intensive care units of India: A multicenter survey. Indian J Crit Care Med
2007; 11:198-2035. Hodgin KE, Nordon-Craft A, McFann KK, Mealer ML, Moss M. Physical therapy utilization in intensive care units: Results from a national
survey. Crit Care Med 2009; 37:561-5686. Appleton RTD, MacKinnon M, Booth MG, Wells J, Quasim T. Rehabilitation within Scottish intensive care units: a national survey. The
Journal of the Intensive Care Society 2011; 12:221-227Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, Rodriquez L, Hopkins RO. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007; 35:139-145
7. Koo KKY, K Choong, DJ Cook, M Herridge, A Newman, V Lo, K Burns, V Schulz, MO Meade for the Canadian Critical Care Trials Group. Development of a Canadian Survey of Mobilization of Critically Ill Patients in Intensive Care Units: Current Knowledge, Perspectives and Practices. Am J Respir Crit Care Med 2011; 183: A3145
8. Thompson GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med 2008; 36:1119-1124
9. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M, Penley L, Howard A, Dixon L, Leach S, Small R, Hite RD, Haponik E. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med2008; 36:2238-2243
10. Nava S. Rehabilitation of patients admitted to a respiratory intensive care unit. Arch Phys Med Rehabil 1998; 79:849-85411. Schweickert WD, Pohlman MC, Polman AS, Nigos C, Pawlik A, Esbrook CL, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE,
Hall J, Kress JP. Early physical and occupational therapy in mechanically ventilated critically ill patients: a randomized controlled trial. Lancet 2009; 373:1874-82
12. Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, Hermans G, Decramer M, Gosselink R. Early Exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009; 37:2499-2505