Early Rehabilitation: An Overview Jim Smith, PT, DPT, MA President, Acute Care Section- APTA Anita Bemis-Dougherty, PT, DPT, MAS Director, Department of Clinical Practice American Physical Therapy Association

APTA The American Physical Therapy Association (APTA) is a professional organization representing more than 88,000 member physical therapists (PTs), physical therapist assistants (PTAs), and students of physical therapy. APTA seeks to improve the health and quality of life of individuals in society by advancing physical therapist practice, education, and research, and by increasing the awareness and understanding of physical therapy's role in the nation's health care system. For more information go to: www.apta.org The Acute Care Section- APTA has a mission to foster excellence in acute care practice, in all settings, in order to enhance the health and functioning of patients and clients. www.acutept.org

Polling question: Patients on a ventilator are critically ill and the documented risks from early rehabilitation and mobilization include: Delirium and increased agitation Increased occurrence of falls Inadvertent extubation or disconnection of lines All of the above None of the above

Overview What is early rehab? Interprofessional teamwork Demonstration Interprofessional teamwork Problems associated with critical illness Benefits from early rehabilitation Which patients are appropriate? Screening algorithm What interventions are appropriate? Getting started Overcome barriers CUSP 4 MVP-VAP roll-out Value Questions

What is it? “ICU early mobility… is a preventative form of physical and cognitive rehabilitation, engaging the critically ill person in activity that assists with recovery of the cardiopulmonary system, prevents muscle deterioration and joint contractures, and begins restoration of autonomy. This engagement can be a labor-intensive process, but the early initiation of daily activity – preferably at the beginning of a patient’s ICU stay – pays off for the patient with greater physical independence, greater chance of discharge to home rather than to a skilled nursing facility, and lower rates of delirium.” http://www.iculiberation.org/Mobility/Pages/default.aspx

Video http://www.youtube.com/watch?v=JXBbaR1PQu0

Interprofessional Teamwork Collaboration is essential Physical & occupational therapists need to engage in building relationships in the ICU Common interest in meaningful outcomes Decrease length of stay Decrease readmissions Improve patient outcomes & satisfaction

Polling question: The problems that accompany several days in an ICU are due to deconditioning and will resolve with rest and routine rehabilitation after discharge from the ICU. True False

Problems Associated with Critical Illness When deconditioning and muscle weakness occur the course becomes complicated, the stay in the ICU is prolonged, and mortality increases Risk developing ICU-associated weakness due to polyneuropathy, myopathy, or a combination of both The cumulative effect of the complications are functional limitations that might or might not resolve.

Potential body/structure effects of critical illness Nordon-Craft A, Moss M, Quan D, Schenkman M: Intensive care unit-acquired weakness: Implication for physical therapist management. Phys Ther. 2012; 92:1494-1506.

“The complications experienced by ICU survivors include deterioration of strength, physical abilities, and psychological abilities. The persistence of symptoms such as reduced ability to perform activities of daily living, reduced capacity for ambulation, depression, posttraumatic stress syndrome, and anxiety contributes to an adverse effect on the individual’s quality of life and long-term survival. ‘Post–intensive care syndrome’ (PICS) is the preferred designation for this constellation of complications that endure well past the stay in the ICU.” Bemis-Dougherty AR, Smith JM. What follows survival of critical illness? Physical therapists’ management of patients with post–intensive care syndrome. Phys Ther. 2013;93:179–185.

Benefits of Early Rehabilitation in the ICU Benefits to patients Financial benefits Feasible and safe

Benefits to patients Preserve muscle strength Improve functioning Promote weaning from ventilator Decrease length of stay in ICU Decrease length of stay in hospital Improve quality of life

Financial Benefits Due to decrease in the length of stay in ICU and hospital For elegant modeling and analysis refer to Lord RK, Mayhew CR, Korupolu R, et al. ICU early physical rehabilitation programs: Financial modeling of cost savings. Crit Care Med. 2013;41:717-724. Example net savings > $800,000 / year

Feasible and Safe There is low risk for harm from early rehab There is risk of harm without early rehab Recommended resources Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306. Li Z, Peng X, Zhu B, Zhang Y, Xi X. Active mobilization for mechanically ventilated patients: A systematic review. Arch Phys Med Rehabil. 2013;94:551-561. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility in the treatment of acute respiratory failure. Crit Care Med. 2008;36:2238-2243.

Which Patients are Appropriate? ICU patients who demonstrate: Mental alertness and ability to follow simple commands Hemodynamic stability Adequate respiratory status with acceptable levels of oxygen saturation Risk of complications that could be prevented with exercise or activity

Medical screening algorithm to evaluate patient appropriateness for rehabilitation

Can this patient engage and participate in early rehabilitation?

Does my patient have the physiologic capacity to participate in early rehabilitation?

What Interventions are Appropriate? Planning interventions for a heterogeneous population requires rigorous clinical decision-making

What Interventions are Appropriate? Rehabilitation interventions should be directed at improving impairments (eg, insufficient aerobic capacity, weakness) and activity limitations (eg, inability to transfer out of bed or to ambulate) Exercise principles to guide interventions SAID Overload

What Interventions are Appropriate? Strategies for Exercising and Mobilizing Patients: The intensity, duration, and frequency of interventions are individually determined for each patient and titrated based on the response to an activity Safety is elevated by access to data about the patient's response and use of thresholds for exercise termination Decision-making is integral to dosing exercise intensity Garzon-Serrano J, Ryan C, Waak K, et al. Early mobilization in critically ill patients: Patients’ mobilization level depends on health care provider’s profession. PM&R. 2011;3(4):307-313.

Getting Started Cultures differ among ICUs Even within a hospital Recommendation – identify a rehabilitation contact person for each ICU Recognition improves collaboration and trust between the ICU team and the rehab provider Examples for participating as a part of the ICU team: increased presence in unit, attendance at meetings, rounds and training sessions Zanni JM, Needham DM. Promoting Early Mobility and Rehabilitation in the Intensive Care Unit. PT in Motion. 2010;2(4):32-38.

Getting Started Successful teams develop shared goals, measure their effectiveness, and have shared accountability for desired patient outcomes Interprofessional collaboration and engagement with the patient / family are essential

Polling question: What are the barriers to the implementation of early rehabilitation and mobilization of patients in the ICU: Insufficient evidence to justify the interventions Deep sedation of patients High cost of implementation All of the above None of the above

Potential Barriers Lack of leadership Lack of resources Over-sedation and delirium Staff concerns about the safety of early mobilization Lack of clinical training to mobilize critically ill patients

CUSP for MVP-VAP Key Mobility Interventions Multi-disciplinary and coordinated approach Daily sedation  interruption and minimizing sedative use Structured assessments  of sedation level and delirium using sedation and delirium scales. Screening for eligibility for mobilization Employing a nurse-driven  protocol to achieve highest level of mobility  

CUSP for MVP-VAP Mobility Reports Distribution of highest level of mobility % of RASS/SAS actual as being {-1, 0, 1} or {4, 5} % of achieving RASS/SAS target Delirium assessment compliance rate % of CAM-ICU negative or ASE <=2 (no delirium) % of patient days mobilized out of bed Distribution of perceived barriers Adverse event incidence rate Adverse event rate (patient-day level)

In the Pipeline CUSP for MVP-VAP Early Mobility Toolkit Data facilitator call: Daily Early Mobility Data Collection Training on May 14th 2014 Content call: Early Mobility: A Practical Approach on Aug 5th 2014 Any teams willing to share? Homework: identify 3 barriers to mobilizing patients and use action plan template to address these

Value “Potential benefits for patients participating in early rehabilitation in the ICU include improved muscle strength, physical function, and quality of life. In addition, early rehabilitation programs may be associated with reduced hospital and ICU length of stay (LOS), duration of mechanical ventilation, and hospital costs.” Parker AM, Sricharoenchai T, Needham DM. Early Rehabilitation in the Intensive Care Unit: Preventing Impairment of Physical and Mental Health. 2013. Curr Phys Med Rehabil Rep. Dec;1(4):307-314.

“A patient on a ventilator riding a stationary bike or ambulating in the ICU is perhaps the most powerful image in the shifting paradigm of increased mobility in this setting. A culture that expects this level of activity - in contrast to a tradition that encourages bedrest and sedation - is the greatest challenge to improving outcomes.” Smith J. Mobility lost in the ICU [Spotlight]. AHRQ WebM&M [serial online]. October 2011. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=251.

Questions? Recommended Resources SCCM’s ICU Liberation project (http://www.iculiberation.org) Early Mobility resources include documents, suggested readings and videos APTA’s PTNow (http://www.ptnow.org) clinical summary on “Critical Illness: Managing Patients in the Intensive Care Unit” Includes recommendations for examination & intervention and contains resources (eg, video)