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Jill Wing, PT, DPTJune 14, 2018

¨ Participants will:¨ Recognize the importance of interdisciplinary

mobility strategies for patient care¨ Understand the importance of a written

interdisciplinary protocol for compliance¨ Describe the role each discipline could play in a

mobility encounter

¨ Repositioning¡ HOB elevated or decreased¡ Side to side positioning¡ Chair position of bed

¨ ACTIVE Range of motion¨ Bed mobility and functional activities in bed or

dangling at edge of bed¨ Transfers including standing and positioning OOB¨ Walking¨ Climbing stairs¨ Sitting or standing endurance activities¨ Exercises including cycling, marching in place

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¨ Bedrest negatively affects musculoskeletal, cardiovascular, respiratory and immune function which slows recovery overall.¡ Muscle loss is rapid and early

¨ To prevent immobility related complications such as pressure ulcers, DVT/PE

¨ To prevent ICU acquired weakness and general deconditioning¡ ICU acquired weakness has been shown to persist after

hospital discharge and disrupt quality of life¡ Weakness is associated with decreased post-ICU survival

¨ Mobilization within 24 hours of intubation and/or ICU admission

¨ Identification of appropriate patient ¨ Clarification of orders (protocol to assist)¨ No limitations with regard to intubation

and/or lines and tubes¨ Planning sedation vacation if needed

¨ Controversy regarding in-hospital cost and burden of ICU early mobility program VS. benefit¡ Staffing resources

¨ Shorter duration of mechanical ventilation¨ Increased function at time of discharge¨ Low rate of adverse events

¡ Falls¡ Removal of ETT¡ Removal of catheters or tubes¡ Arrhythmias¡ Desaturation¡ Hemodynamic changes including cardiac arrest

¨ Barriers: waiting until extubation, waiting for a consult order, staffing limitations, financial limitations (budget neutral)

¨ SBMC Results: Decreased hospital LOS by 2 days, Decreased cost per case by $7K ($5.4m per year); Trends-Decreased vent days, Decreased ICU LOS

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¨ Mobility is a shared responsibility!!

¨ Increased opportunity for multiple encounters throughout the day

¨ Collaborative effort toward patient goals (functional independence, wean from vent or O2, increased strength, decreased delirium)

From left to right: Alicia Stafford, PT; patient; Emily Beffa, PT; Ashley Bruner, RN; Steve Spratlen, RT. Photo courtesy of Parkland Health and Hospitals System.

¨ Nursing: Disconnect lines if possible, pre-medicate if necessary, line management during mobility

¨ Respiratory Therapist: Prepare patient for mobility (adjust oxygen or vent settings, connect/disconnect supportive equipment, monitor airway and oxygen tubing

¨ Physical Therapist: Adjust assistive devices, plan and direct movement, physically support/guard patient during activity

¨ All: Monitor status of the patient

¨ Automated ordering?¨ Makes it clear to all parties which patients are

stable enough to tolerate mobility¨ Prevents staff from deferring because patient is

“too sick”¨ Clear communication toward patient goals¨ Simplification of process

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¨ Dedicated staff in a closed ICU ¨ Multidisciplinary rounding¨ Education of all staff including rotating

medical residents or other providers¨ Quality improvement reporting

¡ Program adjustment¨ Objective data on the number of consults for

justification of staffing resources

#112: Implementation of a Formal Mobility Protocol Screening Tool in the Intensive Care Unit (ICU)

Jill Wing, PT, DPT; Kristin Fless MD; Lauren Grimes RN, BSN, CCRN; Mikhail Litinski MD; Tom Modica PT, DPT, OTR, CHT; Fariborz Rezai MD, Paul Yodice MD

Objective: Patients with critical illness are at risk for developing weakness and impaired physical mobility which may lead to decreased activity tolerance and decreased function in the home and community. Patients may even demonstrate an inability to return to work or recreational activities well past hospital discharge. Although critically ill, patients in the ICU can benefit from a structured, progressive physical therapy program which can contribute to improved short term and long term physical outcomes. The goals of this project were to identify strategies to increase the number of patients in the ICU who are receiving physical therapy, to establish a formal standardized criteria by which patients would be screened and referred for physical therapy intervention, and to establish and promote an interdisciplinary culture of mobility.

Methods: An informal screening process (ISP) was completed by the ICU nurse manager and lead PT daily for 2 weeks. Data was collected to estimate the volume of patients expected from a formalized mobility program. The interdisciplinary team (MD, RN, RT, PT) developed formalized mobility program (FMP) referral criteria, from which a screening tool was developed and approved. The FMP algorithm was implemented by the lead PT as a daily screening tool for all ICU patients within 48 hours of admission and data was collected for 14 weeks. The lead PT used screening results to request a PT order from the medical team for initiation of therapy.

Figure 1

Results: Nurse/PT assessment by ISP suggested the potential rate of patients who could tolerate therapy was 56.6%. The FMP algorithm was developed and approved so that a patient would receive an order for PT when they met the criteria as described in Table 1. After implementing the FMP, patients who were identified to have mobility potential increased to 80.21%. The actual number of PT orders on ICU patients increased from 27.9% to 57.2% after implementation of FMP. Table 2 presents a description of patient encounters as defined by mobility program criteria.

Table 1

Conclusion: Development and use of a standardized tool (FMP) improved the identification of patients in the ICU who are appropriate for PT intervention. ISP performed by experienced clinicians did not accurately identify patients who were ready for mobility assessment. Implementation of a formal screening criteria identified patients who were stable enough for mobility intervention. In addition, FMP criteria provided a framework by which to determine timing of the physical therapy order. Further education of the entire team will help to hardwire the criteria, thus improving the rate of placement of PT orders. Higher patient enrollment in a mobility program will hopefully lead to improved outcomes such as decreased ICU length of stay, decreased number of ventilator days, decreased hospital length of stay and improved functional mobility for patients, as reflected in the current literature.

References:1 Nordon-Craft A, Moss M, Quan D, Schenkman M. Intensive Care Unit-Acquired Weakness: Implications for Physical Therapist Management. PhysTher. 2012;92(12):1494-1505. 2 Needham DM, Korupolu R. Rehabilitation Quality Improvement in an Intensive Care Unit Setting: Implementation of a Quality Improvement Model. Top Stroke Rehabil. 2010;17(4):271-281.3 Engel HJ, Tatebe S, Alonzo PB, Mustille RL, Rivera MJ. A Physical Therapist-Established Intensive Care Unit Early Mobilization Program: A Quality Improvement Project for Critical Care at the University of California San Francisco Medical Center. Phys Ther. 2013; 93(7):975-85.

Total Pt Encounters 874

Pt Independent 13Medical Hold 42Neuro Hold 33Resp Hold 5Too Sedated 63Palliative/End of Life 15CCU boarder 2Pt Not Appropriate 173

Actual 50057.21%

Potential 70180.21%

May 20-Aug 23, 2013 (14 weeks)Table 2

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¨ Partnering for mobility sessions¡ Co-treatment¡ Coordination of patient schedule

¨ Weaning protocols¡ Coordination of patient schedule

¨ Overall conditioning and strengthening supports weaning¡ Inspiratory muscle training

¨ Rehabilitation After Critical Illness in Adults¨ An Official American Thoracic Society/American College of

Chest Physicians Clinical Practice Guideline-Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests.*

¨ Guideline for Family Centered Care in the Neonatal, Pediatric and Adult ICU

¨ Liberation from Mechanical Ventilation: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation and Non-Invasive Ventilation Immediately After Extubation

¨ An Official American Thoracic Society Clinical Practice Guideline-The Diagnosis of ICU Acquired Weakness in Adults

¨ Others regarding asthma, COPD, OSA, CF, lung CA, pulmonary fibrosis and pulmonary rehab

¨ Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support¡ Considerations for trach placement to support

mobility¨ An Official American Thoracic Society Clinical

Practice Guideline: The Diagnosis of Intensive Care Unit–acquired Weakness in Adults

¨ Pulmonary Rehabilitation Executive Summary

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¨ 1. Girard TD, Alhazzani W, Kress JP, et al. An Official American Thoracic Society/American College of Chest Physicians Clinical Practice Guideline-Liberation from Mechanical Ventilation in Critically Ill Adults. Rehabilitation Protocols, Ventilator Liberation Protocols, and Cuff Leak Tests. Am J of Respir Crit Care Med. 2017;195(1):120-133.

¨ 2. Turton P, Hay R, Taylor J, et al. Human limb skeletal muscle wasting and architectural remodeling during five to ten days intubation and ventilation in critical care-an observational study using ultrasound. BMC Anesthesiology. 2016;16(1):119.

¨ 3. Mah JW, Staff I, Fichandler D, Butler KL. Resource-efficient mobilization programs in the intensive care unit: who stands to win? Am J Surg. 2013;206(4):488-93.

¨ 4. Hester JM, Guin PR, Danek GD, et al. The Economic and Clinical Impact of Sustained use of a Progressive Mobility Program in a Neuro-ICU. Crit Care Med. 2017;45(6):1037-43.

¨ 5. Iwashyna TJ, Netzer G. The burdens of survivorship: an approach to thinking about long-term outcomes after critical illness. Semin Respir Crit Care Med. 2012;33(4):327-38.

¨ 6. Hodgson CL, Capell E, Tipping CJ. Early mobilization of patient in intensive care: organization, communication and safety factors that influence translation into clinical practice. Crit Care. 2018;22(1):77.

¨ 7. Walsh CJ, Batt J, Herridge MS. Muscle Wasting and Early Mobilization in Acute Respiratory Distress Syndrome. ClinChest Med. 2014;35(4):811-26.

¨ 8. Nordon-Craft A, Moss M, Quan D, Schenkman M. Intensive Care Unit-Acquired Weakness: Implications for Physical Therapist Management. PhysTher. 2012;92(12):1494-1505.

¨ 9. Needham DM, Korupolu R. Rehabilitation Quality Improvement in an Intensive Care Unit Setting: Implementation of a Quality Improvement Model. Top Stroke Rehabil. 2010;17(4):271-281.

¨ 10. Engel HJ, Tatebe S, Alonzo PB, Mustille RL, Rivera MJ. A Physical Therapist-Established Intensive Care Unit Early Mobilization Program: A Quality Improvement Project for Critical Care at the University of California San Francisco Medical Center. Phys Ther. 2013; 93(7):975-85.

¨ 11. Dammeyer JA, Baldwin N, Packard D, et al. Mobilizing Outcomes: Implementation of a Nurse-Leg Multidisciplinary Mobility Program. Crit Care Nurs Q. 2013;36(1):109-19.

¨ 12. Titsworth WL, Hester J, Correia T, et al. The effect of increased mobility on morbidity in the neurointensive care unit. J Neurosurg. 2012;116:1379-88.

¨ 13. Elkins M, Dentice R. Inspiratory muscle training facilitates weaning from mechanical ventilation among patients in the intensive care unit: a systematic review. J Physiother. 2015;61(3):125-34.

¨ 14. Advance Healthcare Network. ICU Liberation: With help from portable ventilators, ICU patients are getting up and walking sooner than ever before. Available at http://respiratory-care-sleep-medicine.advanceweb.com/Features/Articles/ICU-Liberation.aspx. Accessed June 12, 2018.

¨ 15. American Association of Respiratory Care Clinical Practice Guidelines. Available at http://www.aarc.org/resources/clinical-resources/clinical-practice-guidelines/. Accessed on June 12, 2018.