Introduction and Evidence for Early Mobility: A Protocol To Get Patients Out of Bed Faster: Slide Presentation

Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients

Introduction and Evidence for Early Mobility: A Protocol To Get Patients Out of Bed Faster

Slide 2: Learning Objectives

After this session, you will be able to—

• Recognize the importance of implementing an early mobility (EM) protocol.
• Identify the key interventions of an EM program.
• Apply evidence from current literature to support the use of an EM protocol.

Slide 3: Importance of Early Mobility

• There is strong evidence that mobilizing critically ill patients—
  • Is safe and feasible.¹
  • Is cost effective.¹
  • Decreases duration of mechanical ventilation.²
  • Decreases hospital and intensive care unit (ICU) length of stay.^1,2
  • Mitigates the short-term complications of critical illness: delirium and muscular weakness.³
  • Mitigates the long-term disabilities of critical illness: physical, cognitive, and psychological.⁴

^1. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008 Aug;36(8):2238-43. PMID: 18596631.

^2. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009 May 30;373(9678):1874-82. PMID: 19446324.

^3. Ferrante L, Pisani M, Murphy T, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015 Apr;175(4):523-9. PMID: 25665067.

^4. Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 2015 Feb 26;19:81. PMID: 25715872.

Slide 4: Daily EM: Summary of Key Interventions

• Use a multidisciplinary and coordinated approach:
  • Include nurses; physical, occupational, and respiratory therapists;  physicians; and administrators.
• Interrupt daily sedation and minimize sedative use:
  • Daily sedative interruptions and targeting light sedation will help patients remain alert and cooperative.
• Assess sedation and delirium with structured scales:
  • Routinely assessing the patient’s cognitive function helps target lighter sedation levels and treat delirium.
• Screen for highest level of mobilization:
  • Use a standard screening algorithm to determine which patients may safely participate in a mobilization program.
• Employ a nurse-driven protocol to achieve highest level of mobility:
  • Shifting the focus of nurse-driven mobilization to the time of acute illness promotes recovery.

Slide 5: Evidence From Two Studies

• Ferrante L et al.³
  • Functional trajectories among older persons before and after critical illness.
• Hodgson C et al.⁴
  • Early mobilization and recovery in mechanically ventilated patients in the ICU.

^3. Ferrante L, Pisani M, Murphy T, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015 Apr;175(4):523-9. PMID: 25665067.

^4. Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 2015 Feb 26;19:81. PMID: 25715872.

Slide 6: Functional Trajectories Among Older Persons Before and After critical Illness³

• Data from longitudinal prospective study, pre-baseline information collected by self-report and confirmed by medical record review:
  • 291 patients ≥ 70 years old.
  • Participants were drawn from a separate ongoing longitudinal study on restricted activity among community-living older persons.
• Number of disabilities in 13 activities collected:
  • Basic Activities of Daily Living (ADL) (score: 0–4).
  • Instrumental ADLs (score: 0–5).
  • Mobility (score: 0–4).
• Functional trajectories analyzed before and after ICU.

^3. Ferrante L, Pisani M, Murphy T, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015 Apr;175(4):523-9. PMID: 25665067.

Slide 7: Functional Trajectories Pre and Post ICU³

• 54% of patients with critical illness had significant functional decline post ICU.
• 45% experienced early death (within 30 days of admission).

Image: Graph of functional trajectories of older patients before and after ICU.

^3. Ferrante L, Pisani M, Murphy T, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015 Apr;175(4):523-9. PMID: 25665067.

Slide 8: Functional Trajectories Pre and Post ICU³

• 25% of minimally disabled patients became severely disabled or experienced early death.
• 40% of mild to moderately disabled patients became severely disabled; 25% experienced early death.

Image: Graph of functional trajectories of older patients before and after ICU.

^3. Ferrante L, Pisani M, Murphy T, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015 Apr;175(4):523-9. PMID: 25665067.

Slide 9: Mortality Associated With Worsening Pre-ICU Functional Trajectory³

• Within 1 year, risk of death more than doubled for patients considered  mild to moderately disabled upon admission.
• Adjusted Hazard Ratio (95% CI) = 2.41 (1.29 to 4.50).

Image: Table showing mortality associated with worsening pre-ICU functional trajectory.

^3. Ferrante L, Pisani M, Murphy T, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015 Apr;175(4):523-9. PMID: 25665067.

Slide 10: Mortality Associated With Worsening Pre-ICU Functional Trajectory³

• Within 1 year, risk of death more than tripled for those patients considered severely disabled upon admission.
• Adjusted Hazard Ratio (95% CI) = 3.84 (1.84 to 8.03).

Image: Table showing mortality associated with worsening pre-ICU functional trajectory.

^3. Ferrante L, Pisani M, Murphy T, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015 Apr;175(4):523-9. PMID: 25665067.

Slide 11: Summary³

• In this study of older patients—
  • Decline from pre-ICU functional status was noted in 53% of patients.
  • Early death occurred in 25% of patients.
  • Functional decline prior to ICU showed higher post-ICU risks for—
    • Death.
    • Further functional declines.

^3. Ferrante L, Pisani M, Murphy T, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015 Apr;175(4):523-9. PMID: 25665067.

Slide 12: Early Mobilization and Recovery of Mechanically Ventilated Patients in the ICU⁴

• Prospective cohort study of 192 mechanically ventilated patients in Australia and New Zealand:
  • 12 ICUs participating:
    • Median ratio of physical therapists (PT) to patient = 1 to 9.
    • PT provides respiratory therapy (including mechanical ventilation).
  • All patients were capable of independent mobilization prior to hospital.
  • Data collection for up to 14 days in ICU.

^4. Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 2015 Feb 26;19:81. PMID: 25715872.

Slide 13: Objectives⁴

• Observe practices related to active early mobilization exercises during mechanical ventilation.
• Assess relationship of early mobilization to ICU-acquired weakness.

^4. Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 2015 Feb 26;19:81. PMID: 25715872.

Slide 14: Findings⁴

• 122 (64%) of patients did not receive any EM.
• In ventilated patients who received EM:
  • Median (interquartile range [IQR]) time to EM: 5 (3-8) days.
  • Median (IQR) number of EM sessions: 2 (1-4).
• For 209 PT sessions:
  • 45 percent involved exercises in bed.
  • 25 percent involved passive transfer to sitting.
  • 11 percent involved sitting over the edge of the bed.
  • 11 percent involved standing at the bedside.
  • 4 percent of all sessions involved transfer from bed to chair through standing.
  • 12 percent involved walking (no patients walked before day 7).

^4. Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 2015 Feb 26;19:81. PMID: 25715872.

Slide 15: PT Reported Barriers to Early Mobilization⁴

• Intubation and sedation were main barriers.

Image: Table showing the main barriers for early mobilization.

^4. Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 2015 Feb 26;19:81. PMID: 25715872.

Slide 16: Time to Activity⁴

Image: Table showing the time to activity for patients in the ICU.

^4. Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 2015 Feb 26;19:81. PMID: 25715872.

Slide 17: Other Outcomes⁴

• Strength assessed for 94/156 survivors at ICU discharge:
  • Mean (± SD) Medical Research Council Dyspnea Scale (MRC) score (range 0-60) = 43 ± 12.5.
• 49 (52%) had ICU-acquired weakness:
  • (MRC < 48) at ICU discharge.
• Higher MRC score at ICU discharge associated with—
  • Early mobilization (p=0.003).
  • Discharge to home versus facility (p<0.0001).
  • Increased survival at day 90 (p<0.0001).

^4. Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 2015 Feb 26;19:81. PMID: 25715872.

Slide 18: Summary⁴

• EM was uncommon in mechanically ventilated ICU patients:
  • Despite long history of dedicated PTs in units.
  • Sedation is the most common barrier.
• Over 50% of ICU survivors may develop ICU-acquired weakness.
• Lower muscle strength associated with—
  • Less ICU mobilization.
  • Institutionalization at hospital discharge.
  • Worse 90-day survival.

Additional findings specific to EM in the ICU setting can be found in the educational slide set Early Mobility in the Intensive Care Unit.

^4. Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 2015 Feb 26;19:81. PMID: 25715872.

Slide 19: Evidence of Early Mobility—Recap

An early mobility protocol for mechanically ventilated patients in the ICU…

• Is safe, feasible, and cost effective.¹
• Decreases duration of mechanical ventilation and ICU and hospital length of stay.^1,2
• Mitigates both short- and long-term complications of critical illness such as delirium, muscular weakness, and physical, cognitive, and psychological disabilities.^3,4
• Is not contraindicated by the presence of intubation.

^1. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008 Aug;36(8):2238-43. PMID: 18596631.

^2. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009 May 30;373(9678):1874-82. PMID: 19446324.

^3. Ferrante L, Pisani M, Murphy T, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015 Apr;175(4):523-9. PMID: 25665067.

^4. Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 2015 Feb 26;19:81. PMID: 25715872.

Slide 20: Questions?

Image: Multicolored hanging question marks on tags.

Slide 21: References

^1. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008 Aug;36(8):2238-43. PMID: 18596631.

^2. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009 May 30;373(9678):1874-82. PMID: 19446324.

^3. Ferrante L, Pisani M, Murphy T, et al. Functional trajectories among older persons before and after critical illness. JAMA Intern Med 2015 Apr;175(4):523-9. PMID: 25665067.

^4. Hodgson C, Bellomo R, Berney S, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care 2015 Feb 26;19:81. PMID: 25715872.