1. The Campaign for McMaster University
KT Canada National Seminar Series: Interdisciplinary Knowledge Translation in Critical Care Rehabilitation Michelle Kho, PT, PhD Canada Research Chair in Critical Care Rehabilitation and Knowledge Translation Assistant Professor, School of Rehabilitation Science, McMaster University Clinician Scientist, St. Joseph’s Healthcare Adjunct Assistant Professor, Department of Physical Medicine and Rehabilitation, Johns Hopkins University December 12, 2013

2. Acknowledgements Canada Research Chairs Program
Canadian Institutes of Health Research
I have no other competing interests

3. Learning Objectives
Understand the state of current best evidence for interdisciplinary rehabilitation in the ICU
Understand barriers and facilitators to providing rehabilitation in the ICU
Identify opportunities for interdisciplinary ICU KT activities

4. What is the best evidence for rehab in the ICU?
Learning Objective 1:
What is the best evidence for rehab in the ICU?

5. What happens to patients after the ICU?

6. Long-term outcomes in survivors of critical illness

7. In an ICU survivor’s words…
“It is hard to convey just how debilitated one is after an insult of intensive care magnitude.
When I was finally weaned (from mechanical ventilation), sitting in a chair was impossible….
There was a remarkably persistent and overwhelming generalized weakness and fatigue.”
Misak. Am J Respir Crit Care Med 2011;183:845-6.

8. Prospective 1 and 5-year follow-up study of 109 ICU survivors: Impact on function
Setting: 4 Canadian ICUs
Population: Adult patients with ARDS
ICU Admission
ICU Discharge
Outcomes:
Primary – 6 minute walk test
Pulmonary function tests
Health-related quality of life
Clinical Course
3 months
6 months
12 months
60 months
N=83
281 m
49% predicted
422 m
66% predicted
6 minute walk distance
N=82
396 m
64% predicted
N=64
436 m
76% predicted
Herridge et al, NEJM :683-93;Herridge et al., NEJM : 8

9. Prospective 1 year study of 545 ICU survivors
Setting: 41 US ICUs
Population: Adult pts with ARDS in NHLBI EDEN RCT
ICU Admission
ICU Discharge
Outcomes:
Primary – SF-36 (V2) Physical function domain
Secondary – Physical, psychological, & cognitive function; quality of life; employment status
Clinical Course
Mean (SD) ICU LOS: 14(12); Hospital LOS: 22(16)
6 months
12 months
Outcomes
Norms
SF-36 Physical Function
82(9)
51(32)
55(32)
SF-36 Mental Health
76(3)
64(26)
65(25)
“Substantial” PTSD
26% (122/514)
23% (107/487)
Employed
52% (116/223)
Needham et al., BMJ :f1532. 9

10. Cognitive function 3 and 12 months post-ICU Median ICU length of stay = 5 days
Normal
Mild cognitive impairment
Traumatic brain injury
Alzheimer’s disease
Pandharipande et al. N Engl J Med 2013;369:

11. Potential KT Target: Effects of Bed Rest

12. Bed rest is bad for many body systems
Musculoskeletal
↓ Muscle mass/ volume
↓ Muscle strength
↓ Bone density
Joint contractures
Impaired balance/ kinesthesis
Cardiovascular
↓ VO2 max
↑ Heart rate
↓ Stroke volume
↑ risk VTE
Microvascular dysfunction
Systemic inflammation
Metabolic/ endocrine
Glucose intolerance
Pulmonary
Atelectasis
Dermatological
Pressure ulcers
Gastrointestinal
↓ Appetite
Constipation
Psychological / Behavioral
Sensory deprivation
Disorientation/ confusion/ delirium
Depression/ anxiety
Genitourinary
Urinary stasis, stones, infection
Am J Phys Med Rehabil :66-77; Crit Care Med (Suppl.): S422-S428. Med Sci Sports Exerc (2):

13. Muscle changes >10% in the 1st 7 days of bed rest in the ICU
Puthucheary et al., JAMA. Published online October 9, 2013.

14. For every day of bed rest in the ICU, patients are 11% weaker 2 years later
Fan et al., Crit Care Med
Published online November 15, 2013.

15. Potential KT Target: Effects of Delirium

16. Delirium is NOT “normal” for ICU patients
Signs & symptoms:
Change in level of consciousness
Abrupt onset & fluctuation during the day
Inattention
Change in cognition &/or perception:
Impaired short-term memory, word finding, orientation
Illusions
Hallucinations – often visual, but may be auditory or tactile
May have delusions, disorganized speech, emotional lability, sleep-wake disturbance
All in the absence of a psychiatric condition
Adapted from DSM IV-TR, American Psychological Association 2000

17. Epidemiology of ICU Delirium
Hypoactive delirium
Mixed delirium
Hyperactive delirium
44%
55% 1%
Sleepy, inattentive
Decreased motor activity
Agitated
Increased motor activity
% of ICU patients develop delirium at any point
Frequently unrecognized or misdiagnosed by clinicians
Typical onset in ICU patients: Day 2 ± 2 days
Typical duration in ICU patients: 4 ± 2 days
50% and 10% of ARDS patients ICU and Hospital d/c
Ely et al. JAMA : ; Ely et al. CCM :
Paterson et al. JAGS : ; McNicoll et al. JAGS :
Fan et al. CCM

18. Consequences of ICU Delirium
Higher mortality1
Longer duration of mechanical ventilation1
Longer ICU & hospital length of stay1
Higher ICU costs2
Poorer physical function 1 year post-ICU3
1Ely et al. JAMA :
2Millbrandt et al. Crit Care Med :955–962.
3Brummel et al., Crit Care Med epub ahead of print Oct 23.

19. Summary: Why is rehab in the ICU important?
After ICU, patients are at risk for:
Physical impairments
Cognitive impairments
Potential rehabilitation targets:
Bed rest:
The 1st 10 days of bed rest are crucial
Muscle volume and strength losses
Delirium

20. What is the evidence for rehab in the ICU?

21. Outcome # Active Mobilization Safety 10
No serious adverse events requiring life-saving measures
Muscle strength 6
Inconsistent results, but not worse
Walking 3
 6 minute walk test or walking distance
ADLs* 4
Improved
Mechanical ventilation 9
6 no difference, but not worse
3 shorter duration
Length of stay 7
No difference in RCTs
Non-RCTs, reduced ICU and hospital LOS
*ADLs = Activities of Daily Living
Li et al., Archives of Physical Medicine and Rehabilitation :

22. RCT of early PT/OT in the ICU
Primary Outcome:
Independent functional hospital discharge (composite)
(6 ADLs + independent walking)
Medical ICU R
Daily interruption of sedation + Early OT/PT 7d/wk
N=49
Daily interruption of sedation + Standard care OT/PT
N=55
59% (29/49)
p=0.02
N=104
35% (19/55)
Schweickert et al., Lancet :

23. It’s about receiving therapy while on mechanical ventilation
Intervention
PROM -> AAROM -> AROM -> Bed Mobility -> Transfers (sitting) -> Sitting balance -> ADLs -> Transfers (standing) -> Ambulation
Intervention
N=49
Control
N=55
Median time to start therapy (d)
1.5 [1.0 to 2.1]*
7.4 [6.0 to 10.9]
Median duration of therapy (h/d)
During MV
0.32 [0.17 to 0.48]*
0 [0 to 0]
During no MV
0.21 [0.08 to 0.33]
0.19 [0 to 0.38]
*= p<0.01
0.32 h/d = 19.2 minutes
Schweickert et al., Lancet :

24. Patients receiving early rehab had less ICU and hospital delirium
Intervention
N=49
Control
N=55
p value
ICU delirium (days)
2.0 [0.0 to 6.0]
4.0 [2.0 to 7.0]
0.03
Time in ICU with delirium (%)
33% [0 to 58]
57% [33 to 69]
0.02
Hospital delirium (days)
4.0 [2.0 to 8.0]
Hospital days with delirium (%)
28% (26)
41% (27)
0.01
Schweickert et al., Lancet :

25. RCT of cycling in the ICU
Primary outcome
6 minute walk hospital discharge (∆=50 m)
Treatment (5d/wk)
Cycling OD 20 min; passive/ active
Respiratory PT
A/PROM U+L/E
Ambulation as appropriate
N=45; median time to Rx: 14d
Control (5d/wk)
N=45; median time to Rx: 10d R
N=90
196 m [ m]
N=26
p<0.05
Single center
Medical (n=19)
Surgical (n=71)
143 m [37-226m]
N=32
Burtin et al., Crit Care Med (9):

26. Pilot RCT of early physical and cognitive therapy
Primary outcome
Tower 3 months post-ICU
Group 1
Cognitive Therapy + Early PT
N=43
10.0 [ ]
N=18 R
N=87
Group 2
Early PT
N=22
11.0 [ ]
N=14
p=0.20
Control
Usual Care
N=22
10.0 [ ]
N=12
Single center
Medical (n=53)
Surgical (n=34)
Normal = 7 to 13
Higher scores = better
Brummel et al., Intensive Care Med published online November 21.

27. What are barriers and facilitators to ICU rehab?
Learning Objective 2:
What are barriers and facilitators to ICU rehab?

28. Potential KT Challenges to implementing ICU rehab
Patient population
Medical vs. Medical-surgical ICU
Patient stability
Intervention
Active ingredients?
Dose?
By whom?
Outcomes

29. Pre-Johns Hopkins Hospital MICU QI
Setting: Academic MICU; N=32
Population: Adult patients mechanically ventilated ≥4 d
Objectives:
Describe frequency, physiologic effects, safety
Longitudinal changes over hospitalization – muscle strength, ROM, physical function
ICU Admission
ICU Discharge
Hospital Discharge
Awake
4 Days MV
Clinical Course
Results:
72% rec’d referrals (n=23)
Median 10 days to Ax
72% days pts deeply or moderately sedated
Rx on 12% ICU days/ pt
Minimal physiologic effects, no safety events
38% pts ICU d/c
Measures:
Muscle strength
Contracture index
Unsupported sitting
Ambulation
Functional status
Zanni et al., J Crit Care Jun;25(2):

30. Barriers to implementing ICU rehab: understanding the process and context of work
Staffing:
Time requirements and adequate staffing
Need for staff training
Need for team work and coordination
Safety:
Dislodgement of devices (CVC, ETT, feeding tubes)
Worsening gas exchange
Unstable hemodynamics
Sedation:
Over-sedation of ICU patients
Inadequate patient comfort, pain control
Zanni et al., J Crit Care Jun;25(2):

31. Facilitators to implementing rehab in the ICU
Execute: design an intervention “toolkit” targeted at barriers
- Tips: standardization, checks/reminders, & convenience
Dedicated PT and OT in the MICU
MICU tech assists PT & OT with patient mobilization
Simple guidelines for PT & OT MICU consult
Coordinator screens patients & prompts MD for PT referral
Patients screened daily by PT/OT for mobilization activity
Arch Phys Med Rehabil 2010;91:

32. Early ICU Rehab in Canada
Canadian survey of ICU mobilization practices
Rigorous survey of academic ICUs
311 respondents (117 PTs, 194 MDs), 71% response
Knowledge gap:
69% of ICU clinicians underestimated the incidence of ICU-acquired weakness
39% of PTs reported inadequate education for ICU mobility
Koo, KY Open Access Dissertations and Theses. Paper 7499.

33. Barriers to Early ICU Rehab
Institutional
Lack of guidelines/ protocols – 58%
Insufficient equipment – 51%
MD orders required – 41%
Provider
Limited staffing – PTs – 78%; RNs - 59%
Safety concerns – 64%
Delayed ID to start rehab by MDs – 63%; RNs – 58%
Patient
Medical stability – 83%
Excessive sedation – 60%
Risk of device / line dislodgement – 42%
Koo, KY Open Access Dissertations and Theses. Paper 7499.

34. What are opportunities for interdisciplinary ICU rehab kt activities?
Learning Objective 3:
What are opportunities for interdisciplinary ICU rehab kt activities?

35. Projected incidence of non-cardiac surgery, mechanically ventilated adults
More ICU survivors at risk for post-ICU impairments
40%
Needham et al., Crit Care Med (3):574-9.

36. Interdisciplinary Quality Improvement Projects

37. Barriers/Facilitators to
Monitor
Knowledge
Use
Sustain
Evaluate
Outcomes
Adapt
to Local Context
Assess
Barriers/Facilitators to
Knowledge Use
Select, Tailor,
Implement
Interventions
Identify Problem
Identify, Review,
Select Knowledge
Products/
Tools
Synthesis
Knowledge Inquiry
Tailoring Knowledge
J Cont Ed Hlth Prof :13-24.

38. Barriers/Facilitators to
Monitor
Knowledge
Use
Sustain
Evaluate
Outcomes
Adapt
to Local Context
Assess
Barriers/Facilitators to
Knowledge Use
Select, Tailor,
Implement
Interventions
Identify Problem
Identify, Review,
Select Knowledge
Products/
Tools
Synthesis
Knowledge Inquiry
Tailoring Knowledge

40. Quality improvement exemplar:
Top Stroke Rehabil 2010;17(4):271–281.
Quality improvement exemplar:
Arch Phys Med Rehabil 2010;91:
Additional information:

41. Structured KT and early ICU rehab implementation
Results of Johns Hopkins MICU Rehab QI Project:
Staffing: ↑ PT consults: 59% vs. 93% of pts (p=0.04)
Staffing: ↓ ICU days with no PT/OT: 41% vs. 7% (p=0.004)
Sedation: Significant ↓ in sedative drug use & deep sedation
Median Narc: 71 v. 24 mg/day (p=0.01), Benzo: 47 v. 15 mg/day (p=0.09)
MICU days alert: 30 v. 67% (p<0.001)
No difference in pain scale (0-10): 0.6 v. 0.6 (p=0.79)
Benefits: More ICU days without delirium
No delirium: 21% vs 53% (p=0.003)
Benefits: ↓ MICU & hosp LOS by 30% and 18%, respectively (p<0.03)
Arch Phys Med Rehabil 2010;91:

42. 4. Ensure all patients receive the interventions: Evaluate – ICU LOS
Lord et al. Critical Care Medicine (3):

43. 4. Ensure all patients receive the interventions: Evaluate – Hospital LOS
Projected Net Cost savings for 900 admissions/ yr: $817,836
22% reduction in ICU LOS
19% reduction in floor LOS
Lord et al. Critical Care Medicine (3):

44. Strengths and Limitations of QI approach
Interdisciplinary team approach
Rigorous data collection
Complements Knowledge to Action Model with specific implementation steps
Before-after study design
Specific identification of “active ingredients”

45. Interdisciplinary Primary Research in Critical Care Rehabilitation

46. Slide courtesy of Dr. Margaret Herridge

47. Interprofessional Collaborations with RECOVER PROGRAM
Slide courtesy of Dr. Margaret Herridge

48. Intensive Care Rehabilitation Study Barriers to Early Rehab in the ICU: A Delphi Study
Develop theory-based “library” of barriers and facilitators to early rehabilitation in mechanically ventilated patients
Study of nurses, physical therapists, physicians and respiratory therapists
Mixed methods
Semi-structured, theory guided interviews
Iterative quantitative survey to establish stability of responses (Delphi)
Slide courtesy of Drs. S. Goddard and B. Cuthbertson,
Sunnybrook Health Sciences

49. CIHR Knowledge Synthesis Grant: Neuromuscular Electrical Stimulation in the ICU
To conduct a systematic review of the benefits and risks of NMES for adults receiving mechanical ventilation in the ICU
To summarize the strengths and weaknesses of studies included in the systematic review in terms of research methodology and research conduct
To engage knowledge users:
To identify and rank clinically important outcomes for the systematic review a-priori
Using the results of the systematic review:
To assess the suitability of NMES for clinical practice
To identify future research opportunities for NMES in the ICU

50. Biking towards the future: the CYCLE Program of Research

51. CYCLE: Critical Care Cycling to Improve Lower Extremity Strength
TryCYCLE:
Phase II
open label study
1 center, 33 pt prospective cohort
Design the intervention; select outcomes; assess fidelity, safety, satisfaction, and acceptability
CYCLE
Preparation phase
Survey development: pt, family, clinician satisfaction with rehabilitation
CYCLE pilot:
Phase II randomized pilot
6 center, 50 pt pilot RCT
Feasibility, mechanisms
CYCLE RCT:
Phase III randomized trial
Multicenter RCT
BICYCLE
Behavioural Intervention for Knowledge Translation
CYCLE$
Economic evaluation
Retrospective chart audit
CYCLE-R
Systematic Review
Uni-CYCLE
ICAN Rehab

52. CYCLE: Critical Care Cycling to Improve Lower Extremity Strength
TryCYCLE:
Phase II
open label study
1 center, 33 pt prospective cohort
Design the intervention; select outcomes; assess fidelity, safety, satisfaction, and acceptability
CYCLE
Preparation phase
Survey development: pt, family, clinician satisfaction with rehabilitation
CYCLE pilot:
Phase II randomized pilot
6 center, 50 pt pilot RCT
Feasibility, mechanisms
CYCLE RCT:
Phase III randomized trial
Multicenter RCT
BICYCLE
Behavioural Intervention for Knowledge Translation
CYCLE$
Economic evaluation
Retrospective chart audit
CYCLE-R
Systematic Review
Uni-CYCLE
ICAN Rehab

53. Safety Outcomes
Cycling session termination: The a priori safety event rate is low (0 to 4%).
Adverse events: The intravascular catheter or indwelling tube dislodgement rate is low (<4%).
Stability: Patients will tolerate in-bed cycling while critically ill.

54. Feasibility Outcomes Consent: The consent rate is high (70%).
Intervention delivery: The daily research session delivery rate is high (>80%).
Outcome measures: Physical outcome measures are successfully performed in a high proportion of assessable patients

55. Additional Interdisciplinary KT activities
Occupational therapy examples
Activities of daily living
Cognitive interventions
Communication
Improve coping / locus of control
Psychology examples
Anxiety management
Psychiatry, Speech Language Pathology, Recreation Therapy, and many others

56. Learning Objectives
Understand the state of current best evidence for interdisciplinary rehabilitation in the ICU
Understand barriers and facilitators to providing rehabilitation in the ICU
Identify opportunities for interdisciplinary ICU KT activities