1 Early Progressive Mobility is a MustKathleen Vollman MSN, RN, CCNS, FCCM, FAAN Clinical Nurse Specialist/Educator/Consultant ADVANCING NURSING LLC © ADVANCING NURSING LLC 2017 1

2 Disclosures for Kathleen VollmanConsultant-Michigan Hospital Association Keystone Center Consultant/Faculty for CUSP for MVP—AHRQ funded national study Subject matter expert for CAUTI and CLABSI for CMS/HEN 1.0 & 2.0 Consultant and speaker bureau for Sage Products LLC Consultant and speaker bureau for Hill-Rom Inc Consultant and speaker bureau for Eloquest Healthcare Niveus medical

3 Learning Objectives At the completion of this activity, the participant will be able to:Build the will to understand the significance of early mobility Identify and discuss key in-bed and out of bed mobility techniques to successfully achieve your early mobility protocol to improve patient outcomes. Overcoming barriers and feeling empowered to own patient mobility within your unit.

4 Advocacy = Safety Notes on Hospitals: 1859 Florence Nightingale“It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.” Florence Nightingale When I am able to successfully advocate for my patient or my family I feel greater confidence in a deeper sense of reward. Advocacy = Safety

5 Protect The Patient From Bad Things Happening on Your WatchImplement Interventional Patient Hygiene

6 Interventional Patient HygieneHygiene…the science and practice of the establishment and maintenance of health Interventional Patient Hygiene….nursing action plan directly focused on fortifying the patients host defense through proactive use of evidence based hygiene care strategies Catheter Care Hand Hygiene Bathing & Assessment Comprehensive Oral Care Plan Pressure Ulcer Prevention Incontinence Associated Dermatitis Prevention Program

7 INTERVENTIONAL PATIENT HYGIENE(IPH)VAP/HAP Oral Care/ Mobility HAND Patient HYGIENE Skin Care/ Bathing/Mobility Catheter Care CA-UTI SSI CA-BSI Falls HASI Vollman KM. Intensive Crit Care Nurs, 2013;22(4):

8 Achieving the Use of the EvidenceSkills & Knowledge Factors Impacting the ability to Achieve Quality Nursing Outcomes at the Point of Care Resources & System Attitude & Accountability Vollman KM. Intensive Crit Care Nurs, 2013;22(4): Value

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10 Implementation ScienceBuild The Will Implementation Science

11 Effects of Immobility on Respiratory FunctionEdited JA Effects of Immobility on Respiratory Function Decreased movement of secretions Decreased respiratory motion Increased risk of pulmonary embolism Increased dependent edema Increased risk of atelectasis Increased risk of pneumonia Decreased arterial oxygen saturation I’d first like to talk about the effect of immobility on respiratory function. When we need to cough, our body naturally sits up. When we are in a supine position, even with the head of the bed elevated, our lungs don’t work the same way; it is difficult to get the secretions out. We also have a decrease in respiratory motion, based on what happens with our diaphragm, so our lungs don’t expand the way they should when we’re lying down. In addition, lack of movement makes are blood thicker, placing the patient at an increased risk for pulmonary embolism. When we lay flat, fluid is heavier than air, so if we have any fluid from secretions or proteinous fluid from ARDS, it is going to be heavier and may cause compression atelectasis resulting in closed alveoli. Gravity-dependent perfusion is matched to non working alveoli worsening ventilation-perfusion relationship, creating atelectasis and decreased gas exchange. Whenever there is stationary fluid or collapsed alveoli, there is a higher risk for pneumonia, and overall, arterial oxygen saturation can be reduced. Respiratory Knight J, et al. Nurs Times. 2009;105(21):16-20. Vollman KM. Crit Care Nurse. 2010;30:S3-S5.

12 Ventilator-Associated Pneumonia (VAP) RatesEdited JA Ventilator-Associated Pneumonia (VAP) Rates In North America In the United States, the Centers for Disease Control (CDC), through the National Healthcare Safety Network, has reported critical care unit VAP rates, per 1,000 ventilator-days, ranging from 0.2 (pediatric cardiothoracic) to 4.4 (burn ICU) On average, ICU patients with VAP had an additional 10.5-day LOS3 Per case: VAP $40,144. (95% CI, %36,286-$44,220)4 In Ireland: 17.2% of total HAI’s ( pneumonia) INNIS: VAP rate 15.8 per 1000/vent days, 12 extra days,15% higher mortality If we look at VAP rates internationally, the average rate is roughly around 15.8 per 1000 ventilator-days. The ICU patient with VAP, internationally, had roughly about 12 extra days’ LOS and had about a 15% higher average crude excess in mortality rate. In North America, we use the National Healthcare Safety Network, and the data have shown VAP rates ranging from 0.7 in pediatric cardiothoracic to 5.8 in burn ICU. On average, the ICU patients with VAP had roughly almost 11 extra days in LOS. Rosenthal VD, et al. Am J Infect Control. 2012;40(5): Dudeck MA, et al. National Healthcare Safety Network (NHSN) Report, Data Summary for 2012, Device-Associated Module. American Journal of Infection Control. 2013,41: Restrepo MI, et al. Infect Control Hosp Epidemiol. 2010;31(5): Zimlichman E. et al. JAMA Internal Med, 2013;173(22):

13 Effects of Immobility on Cardiovascular FunctionEdited JA Effects of Immobility on Cardiovascular Function Fluid shift Occurs when the body goes from upright to supine position1,2 10% of total blood volume is shifted from lower extremities to the rest of the body; 78% of this is taken up in the thorax3,4 Decreased blood volume (~15% of plasma volume is lost after 4 weeks of bed rest)2 Cardiac effects Increased resting heart rate (an increase of ~10 beats/min is observed after 4 weeks of bed rest)1,2 Cardiac deconditioning2 Orthostatic intolerance Increased in bedridden patients due to decreased baroreceptor sensitivity, reduced blood volume, cardiac deconditioning, decreased venous return and stroke volume, and venous distensibility1,2 Now that we’ve got an idea of the impact of immobility on the pulmonary system, let’s take a look at it in the cardiovascular system. When I lay down, I have a fluid shift up toward my thoracic cage—about 500 ccs; most of us can handle it. One of the more significant challenge a bed rest patient faces is that in the first couple of days we start to third space. Volume is removed from the intravascular space into the interstitium, resulting in a maximum loss of about 15%-20% of our plasma volume that occurs after about 4 weeks of bed rest. Initially we lose about 10% with the first few days. In the clinical area, we tend to lean more toward fluid restriction, therefore this normal effect decreases an already reduced blood volume. When we don’t have enough fluid in the vessel, the heart has to work harder in order to compensate to try to sustain cardiac output. We also frequently forget that the heart is a muscle itself, and it deconditions with bed rest and may not work effectively. However, the immobility complication we focus on the most in relation to cardiovascular function is orthostatic intolerance. When I lay down and I need to get up, how does my body prevent me from passing out? The baroreceptors read the plasma volume shift, send a message up to the autonomic nervous system, and a message is sent to constrict the vessels moving everything from the periphery to the center so that I don’t pass out. Have you ever been sick with the flu for 1 or 2 days and attempted to get out of bed, only to be dizzy? Consider that you were relatively healthy and you had that effect. These patients are critically ill, so they have reduced baroreceptor sensitivity (that’s the autonomic tone challenge), reduced blood volume, and cardiac deconditioning. All of this impacts their orthostatic tolerance. Winkelman C. AACN Adv Crit Care. 2009;20: Knight J, et al. Nurs Times. 2009;105(21):16-20. Harms MP, et al. Exp Physiol. 2003;88: Sjostrand T. Physiol Rev. 1953;33:

14 Effects of Immobility on Integumentary FunctionEdited JA Effects of Immobility on Integumentary Function The current facility acquired of pressure ulcers is high Prevalence rates in Ireland are 16%-range of 4%- 37%5 Incidence rates in Ireland are 11%-range of 8%- 14.4%5 €119,000 to successfully treat one patient with a grade 4 pressure ulcer €250,000,000 per annum to manage pressure ulcers across all care settings in Ireland Setting Facility –Acquired Rates Critical Care 3.3% to 53.4% Acute Care 0% to 12% What about the skin? We know the risk for pressure ulcers of patients when they’re immobile. The current prevalence for pressure ulcers is 1 in 10 patients in acute care will experience the development of one. That should never happen. We’ve had improvements in our pressure ulcer rates since the change in Medicare and Medicaid that resulted in nonpayment or no reimbursement for facility-acquired pressure ulcers stage III or stage IV. We used to be able to get a $43,000 reimbursement for those. That’s helping to create and use of resources to eliminate the harm. Now the rate of facility-acquired pressure ulcers has gone down to about 4.5%, which is exciting because that’s the first time in over 20 years we have seen a sustained decrease in acute care. Mobilizing patients help prevent pressure ulcers and following practices of schedule q 2 hour turning is likely to reduce the risk. Skin National pressure ulcer Advisory panel, European pressure ulcer Advisory panel and Pan Pacific pressure injury alliance. Clinical practice guideline, 2014 Hospital-acquired conditions. Centers for Medicare & Medicaid Services website. http://www.cms.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp. Accessed 1/3/12. CMS. Fed Regist. 2008;73: Jankowski IM, Nadzam DM. Jt Comm J Qual Patient Saf. 2011;37:

15 Skeletal Muscle DeconditioningSkeletal muscle strength reduces 4-5% every week of bed rest (1-1.5% per day) Without activity the muscle loses protein Healthy individuals on 5 days of strict bed rest develop insulin resistance and microvascular dysfunction 2 types of muscle atrophy Primary: bed rest, space flight, limb casting Secondary: pathology Siebens H, et al, J Am Geriatr Soc 2000;48: Topp R et al. Am J of Crit Care, 2002;13(2):263-76 Wagenmakers AJM. Clin Nutr 2001;20(5):451-4 Candow DG, Chilibick PD J Gerontol, 2005:60A: Berg HE., et al. J of Appl Physiol, 1997;82(1): Homburg NM,. Arterioscler Thrombo Vasc Biol, 2007;27(12): 15

16 Deconditioning During Critical CareMUSCLE MASS Deconditioning Can Occur Within 1 Week of Bed Rest > 15% MUSCLE STRENGTH Up to 40% Puthucheary et al. Acute skeletal muscle wasting in critical illness. JAMA Oct 16;310(15): Hirose et al. The effect of electrical stimulation on the prevention of disuse atrophy in patients with consciousness disturbance in the intensive care unit. J Crit Care. 2013 Topp et al. The Effect of Bed Rest and the potential for prehabilitation on patients in the intensive care unit. AACN Clin Issues. 2002;13(2):

17 Skeletal Muscle DeconditioningMuscle groups that lose strength most quickly related to immobilization are those that maintain posture, transferring positions & ambulation. > 1/3 of patients with ICU stays greater than two weeks had at least two functionally significant joint contractures. Muscle atrophy in mechanically ventilated patients contribute to fatigue of the diaphragm and challenges with weaning. Degradation within 6-8 days; continues as long as bedrest occurs One day of bed rest requires two weeks of reconditioning to restore baseline muscle strength Siebens H, et al, J Am Geriatr Soc 2000;48: Topp R et al. Am J of Crit Care, 2002;13(2):263-76 Wagenmakers AJM. Clin Nutr 2001;20(5):451-4 Candow DG, Chilibick PD J Gerontol, 2005:60A: Berg HE., et al. J of Appl Physiol, 1997;82(1): Hamburg NM,. Arterioscler Thrombo Vasc Biol, 2007;27(12): DeJonnge B, et al. Crit Care Med, 2007;39: Zhang et al GenomProtBioinf: 6Kortebien et al JGerontolMedSci: 63) 17

18 ICU-Acquired Weakness (ICUAW)Edited JA ICU-Acquired Weakness (ICUAW) Definition: Syndrome of generalized limb weakness that develops while the patient is critically ill and for which there is no alternative explanation other than the critical illness itself. Average Medical Research Council Scale (MRC) score <4 across all muscles tested. Incidence: 25% of patients with prolonged mechanical ventilation will develop ICUAW Est 75,000 pts in US, 1 million worldwide Caused By: Critical illness polyneuropathy, myopathy &/or muscle atrophy Combination When we look at the pathological side of ICU-acquired weakness, it’s usually phrased as critical illness polyneuropathy or myopathy. It occurs in patients with severe acute illness requiring an ICU stay and involves the nerves and muscles. It clearly delays weaning and compromises the ability to rehabilitate the patient. It’s associated with significant increases in ICU and hospital length of stay and has an impact on mortality. Risk factors include sepsis, inflammatory responses, multiple organ failure, higher levels of blood glucose, and—the one you’re probably most familiar with—the use of steroids or neuromuscular blockades, which contribute to the pathological ICU-acquired weakness. Fan E, et al. Am J Respir Crit Care Med Dec 15;190(12): Hermans G, et al. Crit Care. 2008;12:238. Jolley SE, et al Chest, 2016; published online

19 ICU-Acquired Weakness (ICUAW)Risk factors: Severe Sepsis1,6 Duration of mechanical ventilation1,4 ICU LOS5,7 Systemic inflammatory response syndrome2 Multiple organ failure2,4 Immobility2,7 Use of corticosteroids/neuromuscular blockers2,3,5,6,7 Negative impact:1,2 Prolong mechanical ventilation Reoccurring respiratory failure & VAP Increased ICU and hospital length of stay Increase mortality 1. Fan E, et al. Am J Respir Crit Care Med Dec 15;190(12): 2. Kress JP et al. N Engl of Med, 2014;370: 3. Hermans G, et al. Crit Care. 2008;12:238. 4. De Jonghe B, et al. Crit Care Med. 2007;35(9): 5. Needham DM, et al. Am J of Respir and Crit Care Med. 2014;189(10): 6. Penuelas O, et al. J of Intensive Care Medicine, 2016;1-13 7. Hashem MD, et al. Chest, 2016;doi: /j.chest

20 1 out of 4 cognitive Impairment at 12 monthsBrain-ICU Study 1 out of 4 cognitive Impairment at 12 months Multicenter RCT- medical-surgical ICU’s 821 patients with ARF or Shock Evaluated in-hospital delirium and cognitive impact months post d/c Results 74% of patients developed delirium during hospital stay 3 months: 40% had global cognition scores 1.5 SD below population mean, 26% had scores 2 SD below pop mean 12 months: 34%(older) & 24%(younger) global cognition scores below the mean Mild traumatic brain injury Mild Alzheimer's Pandharipande, PP. et al. N Engl J Med;369:1306:1316

21 Post Intensive Care SyndromeHarvey M, Davidson J. Crit Care Med, 2016;44(2):

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23 Outcomes of Early Mobility Programs incidence of VAP  time on the ventilator  days of sedation  incidence of skin injury  delirium  ambulatory distance Improved function  in hospital readmissions  ICU & Hospital LOS Staudinger t, et al. Crit Care Med, 2010;38. Abroung F, et al. Critical Care, 2011;15:R6 Morris PE, et al. Crit Care Med, 2008;36: Pohlman MC, et al. Crit Care Med, 2010;38: Schweickert WD, et al. Lancet, 373(9678): Thomsen GE, et al. CCM 2008;36; Winkelman C et al, CCN,2010;30:36-60 Azuh O, et al. The American Journal of Medicine, 2016, doi:10.106/jmjmed Corcoran JR, et al. PMR J, 2016 in press

24 Early Mobility Protocol: Impacting OutcomesMorris, et al, conducted a prospective cohort study to determine the impact of early mobility therapy using a team on patients who were mechanically ventilated with respiratory failure The control group received standard passive ROM and turning (n=165) The study group received low-impact mobility by a team (n=165) Therapy initiated within 48 hours of mechanical ventilation Therapy 7 days/week until ICU discharge Mobility team included 1 ICU nurse, 1 physical therapist, and 2 nursing assistants Now, we’ll move on to introduction of early mobility protocols within the ICU. The first protocol that I’d like to talk to you about was done by Dr Morris group. It was the seminal study that made the implementation of early mobility seem feasible. This was a prospective cohort study of about 330 patients who were randomized either to control, which was passive ROM and turning, or to the study group, which were evaluated within 48 hours of mechanical ventilation by a mobility team that comprised a critical care nurse, a physical therapist, and 2 nursing assistants. They received therapy 7 days a week until ICU discharge. . Morris PE, et al. Crit Care Med. 2008;36:

25 Early ICU Mobility TherapyResults Baseline characteristic similar in both groups Protocol group: Received as least 1 PT session vs. usual care (80% vs. 47%, p < .001) Out of bed earlier (5 vs. 11 days, p < .001) Reduced ICU LOS (5.5 days vs. 6.9 days, p=.025) Reduced Hospital LOS ( 11.2 days vs days, p =.006) No adverse outcomes; Most frequent reason for ending mobility session was patient fatigue Cost Average cost per patient was $41,142 in the protocol group Average cost per patient was $44,302 in the control group Morris PE, et al. Crit Care Med, 2008;36:

26 Early Physical and Occupational Therapy in Mechanically Ventilated PatientsProspective randomized controlled trial from 1161 screen, 104 patients mechanically ventilated < 72hrs, functionally independent at baseline met criteria Randomized to: early exercise of mobilization during periods of daily interruption of sedation (49 pts) daily interruption of sedation with therapy as ordered by the primary care team (55 pts) Primary endpoint: number of patients returning to independent functional status at hospital discharge able to perform activities of daily living and walk (independently) Schweickert WD, et al. Lancet, 373(9678):

27 Early Physical and Occupational Therapy in Mechanically Ventilated PatientsSchweickert WD, et al. Lancet, 373(9678):

28 Early Physical and Occupational Therapy in Mechanically Ventilated PatientsSafe Well tolerated  duration of delirium  VFD Functional independence at discharge 59% protocol group vs. 35% in control arm Schweickert WD, et al. Lancet, 373(9678):

29 Protocol Driven Mobility Program: Impacting Neurological OutcomesPre-post intervention study Large academic NICU 637 patients 260 pre 377 post Intervention: Early Progressive Mobility Protocol Exclusion criteria Readiness criteria Started on admission Encourage to use ICU bed features & lifts to assist Protocol place at bedside Klein K, et al. Crit care Med, 2015, epub

30 Protocol Driven Mobility Program: Impacting Neurological OutcomesMultivariate analysis done to control for group differences: Klien K, et al. Crit care Med, 2015, epub

31 Multi-Center Pilot Feasibility RCT of Early Goal-Directed Mobilization in the ICUA pilot randomized controlled trial. Five ICUs: Australia/New Zealand Fifty critically ill adults mechanically ventilated for > 24 hours EGDM: functional rehabilitation tx conducted at the highest level of activity possible for that patient assessed by the ICU mobility scale while on a vent. Results Highest level of activity (IMS) 7.3 versus 5.9 when compared with controls (p = 0.05) Proportion of patients that walk was almost double in the EGDM group (p=0.05) No difference in hospital stay Safe and feasible Median time to randomization 3 days Median time ICU adm & EGDM 3 days Hodgson CL, et al. Crit Care Med 2016; 44:1145–1152

32 Standard Rehab & Hospital LOS in ARF Morris PE, et alStandard Rehab & Hospital LOS in ARF Morris PE, et al. JAMA, 2016;315(24): Single center RCT from 10/ /2014 Randomized to SRT or usual care SRT: passive ROM, physical therapy & progressive resistance 3x per day for every day of hospitalization Measured hospital LOS (primary) Physical function and health quality of life Measurements performed at hospital d/c, 2, 4 and 6 months. Physical function also performed at ICU d/c Results: 4804 screened/ 618 eligible/No ABC protocol SRT: 1 day PRM, 3 days to PT, 4 days for resistance ex SRT received tx: PRM-87%, PT-54.6%, Resistance-35.7% Usual care: PT-11.7% (1 day-0 to 8) Hospital LOS no difference Secondary outcomes all significantly better in SRT at 6 months

33 Systematic Review of Early Rehabilitation in the ICU14 studies/1753 patients 880 patients in intervention group 873 patient in control group Varying methodologies Results No difference in short or long term mortality Tipping CJ, et al. ICM, 2017;43:

34 Systematic Review of Early Rehabilitation in the ICUResults of Active Rehab ↑ muscle mass at ICU d/c ↑ probability of walking without assistance at hospital d/c ↑ more days alive and out of hospital 180 days Limitations Variation in dosage, small sample sizes of individual studies Tipping CJ, et al. ICM, 2017;43:

35 International Survey of Early Mobilization Practices: Where Do We StandSurveyed directors of medical and mixed medical surgical ICUs in 4 countries Institutions selected a random Results 951 ICUs (US 500; France 151, UK 150, Germany 150)/response rate 64% Staffing models of RN/patient and Physiotherapist differ by country France Germany UK US % EM practice 40% 59% 52% 45% % EM protocol 24% 30% 20% Factors associated with EM practice presence of multidisciplinary rounds setting daily goals Presence of a dedicated physiotherapist Nurse patient ratio Sedation protocol Bakhru RN, et al. Ann Am Thorac Sur, 2016 Sep;13(9):

36 A B C D E F ASESSMENT OF PAIN BREATHE/SAT &SBT CHOICE OF SEDATIONDELIRIUM EARLY MOBILITY FAMILY A B C D E F Balas MC, et al. Crit Care Nurse Apr;32(2):35-8, 40-7

37 ABCDE Bundle Reduces Ventilation, Delirium & OOB18 month, prospective, cohort, before-after study 5 adult ICU’s, 1 step down, 1 oncology unit Compared 296 patients (146 pre-bundle) & 150 post bundle) Intervention: ABCDE Measured: For mechanical ventilation patients (187) examined ventilator free days All patients examined incidence of delirium, mortality, time to discharge and compliance with the bundle Balas MC, et al. Crit Care Med,  2014;42(5):

38 Delirium risk ↓from 62.3% to 48.7% & 17% less time spent deliriousBalas M, et al. Crit Care Med May;42(5):

39 ABCDEF Bundle: Improving Survival & Reducing Brain DysfunctionVentilated and non-ventilated medical and surgical ICU patients enrolled between January 1, 2014, and December 31, 2014 Determine association between ABCDEF bundle compliance/total & partial & outcomes of hospital survival and delirium-free and coma-free days/ adjusting for age, severity of illness, and presence of mechanical ventilation Patients experienced more days alive and free of delirium and coma with both total bundle compliance (incident rate ratio, 1.02; 95% CI, 1.01–1.04; p = 0.004) and partial bundle compliance (incident rate ratio, 1.15; 95% CI, 1.09–1.22; p < 0.001). 10% ↑ in total bundle compliance, patients had a 7% higher odds of hospital survival Barnes-Daly, MA, et. al. Crit Care Med, 2017;45:

40 How do I make this happen

41 Progressive Mobility + Care Giver Safety + Skin Safety & Fall Prevention

42 Driving Change Gap analysis Build the Will Protocol DevelopmentStructure Process Outcomes Gap analysis Build the Will Protocol Development Make it Prescriptive Overcoming barriers Daily Integration

43 The Goal: Patient & Caregiver SafetySafe Patient Handling Falls Prevention of Pressure Injuries Patient Progressive Mobility Leadership Leadership Leadership Leadership

44 Early Mobility Progressive Mobility:Planned movement in a sequential manner beginning at a patients current mobility status and returning them to baseline & includes: Head elevation Manual turning Passive & Active ROM Continuous Lateral Rotation Therapy/Prone Positioning Movement against gravity Physiologic adaptation to an upright/leg down position (Tilt table, Bed Egress) Chair position Dangling Ambulation  Vollman KM. Crit Care Nurse.2010 Apr;30(2):S3-5. 44

45 The Mobility InitiativeObjective To create a progressive mobility initiative that will help ICU teams to address key cultural, process and resource opportunities in order to integrate early mobility into daily care practices. Methods Multi-center implementation of key clinical interventions An evidence-based, user-friendly progressive mobility continuum was developed, lead by the Clinical Nurse Specialist faculty Implementation plan: process design, culture work & education 130 patients/3120 prospectively collected hourly observations Qualitative and quantitative data collected 15 process and 5 outcome metrics Results reported as cohort and unit specific data Bassett RD, et al.Intensive Crit Care Nurs (2012) 2012 Apr;28(2):88-97

46 Determining ReadinessPerform Initial mobility screen w/in 8 hours of ICU admission & daily PaO2/FiO2 > 250 Peep <10 O2 Sat > 90% RR 10-30 No new onset cardiac arrhythmias or ischemia HR >60 <120 MAP >55 <140 SBP >90 <180 No new or increasing vasopressor infusion RASS > -3 No Yes Patient Stable, Start at Level II & progress Patient is unstable, start at Level I & progress Bassett RD, et al.Intensive Crit Care Nurs (2012) 2012 Apr;28(2):88-97 Needham DM, et al. Arch Phys Med Rehabil Apr;91(4):536-42

47 Consensus on Safe Criteria for Active MobilizationSystematic review performed than 23 international experts gather to reach consensus Categories Consensus reach on all criteria. If no other contraindications; vasoactives, endotracheal tube, FIO2 < 60% with SaO2 90% & RR < 30/min were considered safe criteria Respiratory Cardiovascular Neurological Other Considerations Hodgson CL, et. al Critical Care, 2014;18:658

48 Use of a ICU Mobility Scale (IMS) -Standardizing LanguageConstruct and predictive validity were assessed by comparing IMS values at ICU discharge in 192 patients to other variables The IMS at ICU discharge demonstrated a moderate correlation with muscle strength(r = 0.64, P ,0.001). Significant difference between the IMS at ICU discharge in patients with ICU-acquired weakness vs those without P=0.001). Increasing IMS values at ICU discharge were associated with survival to 90 days and discharge home Tipping CJ, et al. AnnalsATS, 2016;13(6):

49 START HERE LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL VProgressive Mobility Continuum START HERE Includes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V Perform Initial mobility screen w/in 8 hours of ICU admission Reassess mobility level at least every 24 hours (Recommended at shift Δ) RASS -5 to - 3 RASS -3 & up RASS -1 & up RASS 0 & up RASS 0 & up Goal: clinical stability; passive ROM Goal: upright sitting; increased strength and moves arm against gravity Goal: Increased trunk strength, moves leg against gravity and readiness to weight bear Goal: stands w/ min. to mod. assist, able to march in place, weight bear and transfer to chair Goal: Increase distance in ambulation & ability to perform some ADLs PT consultation prn OT consultation prn PT: Active Resistance Once a day, strength exercises OT consultation prn PT x 2 daily & OT x1 daily Refer to the following criteria to assist in determining mobility level *Mobility is the responsibility of the RN, with the assistance from the RT’s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment. PT x 2 daily OT consult for ADL’s ACTIVITY: Q 2 hr turning *Passive /Active ROM 3x/d 1. HOB 45º X 15 min. 2. HOB 45º,Legs in dependant position X 15 min. 3. HOB 65º,Legs 4. Step (3) & full chair mode X20 min. 3X/d Or Full assist into cardiac chair 2X/day For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant PaO2/FiO2 > 250 Peep <10 O2 Sat > 90% RR 10-30 No new onset cardiac arrythmias or ischemia HR >60 <120 MAP >55 <140 SBP >90 <180 No new or increasing vasopressor infusion RASS > 3 ***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level*** ACTIVITY: HOB > 30º *Passive ROM 2X/d performed by RN, or UAP _________________ CLRT/Pronation initiated if patient meets criteria based on institutional practice OR Q 2 hr turning ACTIVITY: Self or assisted Q 2 hr turning 1.Bed sitting Position Min.20 min. 3X/d; 2.Sitting on edge of bed; stand w/ RN, PT, RT assist 3.Active Transfer to Chair (OOB) w/ RN/PT/RT assist Min. 3X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Sitting on edge of bed w/RN, PT, RT assist X 15 min. 2.Progressive bed sitting Position Min.20 min. 3X/d Or Pivot to chair position 2X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day 2.Meals consumed while dangling on edge of bed or in chair Ambulate progressively longer distances with less assistance x2 or x3/day with RN/PT/RT/UAP Tolerates Level III Activities Tolerates Level IV Activities Tolerates Level I Activities Tolerates Level II Activities NO YES Start at level I* Start at level II and progress*

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51 Do We Even Achieve the Minimum Mobility Standard… “Q2 Hours”?51

52 How Well Are We Really Doing?Body position: clinical practice vs standard1 Study of 74 patients in which the change in body position was recorded every 15 minutes for an average observation time of 7.7 hours 49.3% of observed time showed no body position change for >2 hrs, and 2.7% had every-2-hour demonstrable body position change Positioning prevalence2 Prospectively recorded, 2 days, 40 ICUs in the United Kingdom Average time between turns, 4.85 hours How well are we doing? There was a study that looked at 556 hours of observation over an 8-hour period every 15 minutes to determine the frequency at which patients were turned. What percentage of patients got turned every 2 hours? Only 2.7%. What percentage of patients never moved over a 6-8-hour period? Almost 50%. Clearly, we’re not doing very well. I know that you’re thinking “that’s not my unit.” The only way you can be sure of that is not by a checkmark on the chart but by direct observation. Sometimes we say we don’t have enough resources and that is the reason for turning not to take place. In the UK, they did a 40-ICU positioning prevalence study over a 2-day period. The UK has 1:1 ratio of nursing and additional support staff. The average time between turns was approximately 5 hours. So it’s not just about the resources there is a value component associated with mobility. Krishnagopalan S, et al. Crit Care Med. 2002;30: Goldhill DR, et al. Anaesthesia. 2008;63:

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54 Goal: Clinical Stability, Passive ROM ACTIVITY: HOB > 30º Progressive Mobility Continuum START HERE Includes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated Level I RASS -5 to -3 Goal: Clinical Stability, Passive ROM ACTIVITY: HOB > 30º *Passive ROM 2X/d performed by RN, or UAP NMES 30 min x2 _________________ CLRT/Pronation initiated if patient meets criteria based on institutional practice OR Q 2 hr turning Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V Perform Initial mobility screen w/in 8 hours of ICU admission Reassess mobility level at least every 24 hours (Recommended at shift Δ) RASS -5 to - 3 RASS -3 & up RASS -1 & up RASS 0 & up RASS 0 & up Goal: clinical stability; passive ROM Goal: upright sitting; increased strength and moves arm against gravity Goal: Increased trunk strength, moves leg against gravity and readiness to weight bear Goal: stands w/ min. to mod. assist, able to march in place, weight bear and transfer to chair Goal: Increase distance in ambulation & ability to perform some ADLs PT consultation prn OT consultation prn PT: Active Resistance Once a day, strength exercises OT consultation prn PT x 2 daily & OT x1 daily Refer to the following criteria to assist in determining mobility level *Mobility is the responsibility of the RN, with the assistance from the RT’s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment. PT x 2 daily OT consult for ADL’s ACTIVITY: Q 2 hr turning *Passive /Active ROM 3x/d 1. HOB 45º X 15 min. 2. HOB 45º,Legs in dependant position X 15 min. 3. HOB 65º,Legs 4. Step (3) & full chair mode X20 min. 3X/d Or Full assist into cardiac chair 2X/day For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant PaO2/FiO2 > 250 Peep <10 O2 Sat > 90% RR 10-30 No new onset cardiac arrythmias or ischemia HR >60 <120 MAP >55 <140 SBP >90 <180 No new or increasing vasopressor infusion RASS > 3 ***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level*** ACTIVITY: HOB > 30º *Passive ROM 2X/d performed by RN, or UAP _________________ CLRT/Pronation initiated if patient meets criteria based on institutional practice OR Q 2 hr turning ACTIVITY: Self or assisted Q 2 hr turning 1.Bed sitting Position Min.20 min. 3X/d; 2.Sitting on edge of bed; stand w/ RN, PT, RT assist 3.Active Transfer to Chair (OOB) w/ RN/PT/RT assist Min. 3X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Sitting on edge of bed w/RN, PT, RT assist X 15 min. 2.Progressive bed sitting Position Min.20 min. 3X/d Or Pivot to chair position 2X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day 2.Meals consumed while dangling on edge of bed or in chair Ambulate progressively longer distances with less assistance x2 or x3/day with RN/PT/RT/UAP Tolerates Level III Activities Tolerates Level IV Activities Tolerates Level I Activities Tolerates Level II Activities NO YES Start at level I* Start at level II and progress*

55 Recommended 10 repetitions each extremity x2 dailyROM Active & Passive When muscles are immobilize in shorten positions there is remodeling of muscle fibers Bed rest entails immobilization of limb extensor muscles in shortened positions Passive movement has been shown to enhance ventilation, prevent contractures in patients in high dependency units Low resistance multiple repetition muscle training can augment muscle mass & strength Recommended 10 repetitions each extremity x2 daily Gosslink R, et al. Intensive Care Medicine 2008;34: Perme C, Chandrashekar R. Am J of Crit Care, 2009;18: Schweickert WD, et al. Lancet, published online May 14, 2009. Griffiths RD, et al. Nutrition, 1995;11:

56 Use of Neuromuscular StimulationNMES utilizes skin electrodes to deliver electrical stimuli to muscles to produce visible contractions Studies have reported it to be safe, feasible, well-tolerated, and beneficial for preserving muscle mass, strength, and function Review of studies of NMES in ICU pts (n > 350): “NMES has an impact on muscle strength, length of mechanical ventilation and intensive care stay. These are important findings identifying that NMES can have an impact on clinically important outcomes in critically ill patients” Bax L, Sports Med 2005; 35 Kho ME, et al. Crit Care Med, 2015;30(1) Parry Sm, et al. Crit Care Med, 2013;41(10) Williams N, et al. Physiother Therory Pract, 2014;30(1)

57 In-Bed Technology Cycle Trail in Ontario Ca

58 Reducing HAPI & Patient Handling InjuriesCompared pre-implementation turning practice: pillows/draw sheet vs turn and position system (breathable glide sheet/foam wedges/wick away pad) Baseline: November 2011-August 2012 Implementation period: November 2012 to August 2015 3660 patients Compared HAPI rates, patent handling injuries and cost 74% reduction Way H, Am JSPHM, 2016;6(4):

59 Continuous Lateral Rotation TherapyGoldhill DR et al. Amer J Crit Care, 2007;16:50-62 59

60 Rotational Therapy Using Cushion-Based RotationThe Medical Center of Central Georgia evaluated the impact of CLRT A CLRT protocol was implemented in patients who were identified as at risk for pulmonary complications, and outcomes were compared with a historical comparison group When introduced early, CLRT may reduce critical care length of stay and cost to treat CLRT is an option for patient mobility Vent Days ICU Days Hospital Days Cost to Treat, Thousands of Dollars ICU Readmission Rates, % Reintubation Rates, % No CLRT 17.4 18.4 29.7 59.4 21 19 CLRT after 48 hours 16.6 18.9 28.8 62.1 17 13 CLRT within 48 hours 12.4 13.1 23.4 45.2 4 Breaking down the evidence, here’s a study where the Medical Center of Central Georgia introduced a continuous lateral rotation therapy (CLRT) protocol in patients who were identified as being at high risk for pulmonary complications and compared the results against historical controls. The data showed that when CLRT was introduced early, the length of stay (LOS) was reduced and the cost of treatment was less. Let’s look at this chart. Compared to historical controls of no CLRT, there were patients who received CLRT after 48 hours and those that received it before. The patients who received CLRT later, after 48 hours, reacted very similar to the patients who never received CLRT in the historical controls. When patients did receive CLRT within 48 hours of intubation, they had 5 fewer days on the vent, had 5 fewer days in the ICU (which was carried out to 6 fewer days in hospital stay), required significantly less dollars to treat, had significantly lower readmission rates to the ICU, and had lower reintubation rates. When CLRT is introduced early, the data show that it can reduce LOS and cost of treatment, which makes it a valuable option for our patients. CLRT=continuous lateral rotation therapy. No CLRT: 75 patients; CLRT after 48 hours: 46 patients; CLRT within 48 hours: 50 patients. Swadener-Culpepper L, et al. Crit Care Nurs Q. 2008;31:

61 Systematic Method of Approaching Placement & Removal of Rotational Therapy61

62 Prone Positioning: The New EvidenceRCT 466 patients with severe ARDS Severe ARDS P/F ratio < 150 mm Hg, with Fio2 0.6, PEEP of at least 5 cm of water, and a Tv to 6 ml per kg of PBW Initiation 12-24hrs Prone-positioning 16hrs/or supine position NMB used 5 days Results: Prone 16% mortality, supine 32.8% p< No differences in complications except > cardiac arrest in supine position N=6 Guerin C. et al. N Engl J Med, 2013

63 Transition: Level I to Level IIThe patient meets the criteria for physiological stability, including cardiovascular, respiratory and neurological

64 Level II RASS -3 & Up START HEREProgressive Mobility Continuum Level II RASS -3 & Up Goal: Upright sitting; increase strength & moves arm against gravity PT consultation prn OT consultation prn START HERE Includes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V Perform Initial mobility screen w/in 8 hours of ICU admission Reassess mobility level at least every 24 hours (Recommended at shift Δ) RASS -5 to - 3 RASS -3 & up RASS -1 & up RASS 0 & up RASS 0 & up Goal: clinical stability; passive ROM Goal: upright sitting; increased strength and moves arm against gravity Goal: Increased trunk strength, moves leg against gravity and readiness to weight bear Goal: stands w/ min. to mod. assist, able to march in place, weight bear and transfer to chair Goal: Increase distance in ambulation & ability to perform some ADLs ACTIVITY: Q 2 hr turning/NMES 30min x2 *Passive /Active ROM 3x/d 1.HOB 45º X 15 min. 2. HOB 45º,Legs in dependant position X 15 min. 3. HOB 65º,Legs 4. Step (3) & full chair mode X20 min Or Full assist into cardiac chair 2X/day PT consultation prn OT consultation prn PT: Active Resistance Once a day, strength exercises OT consultation prn PT x 2 daily & OT x1 daily Refer to the following criteria to assist in determining mobility level *Mobility is the responsibility of the RN, with the assistance from the RT’s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment. PT x 2 daily OT consult for ADL’s ACTIVITY: Q 2 hr turning *Passive /Active ROM 3x/d 1. HOB 45º X 15 min. 2. HOB 45º,Legs in dependant position X 15 min. 3. HOB 65º,Legs 4. Step (3) & full chair mode X20 min. 3X/d Or Full assist into cardiac chair 2X/day For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant PaO2/FiO2 > 250 Peep <10 O2 Sat > 90% RR 10-30 No new onset cardiac arrythmias or ischemia HR >60 <120 MAP >55 <140 SBP >90 <180 No new or increasing vasopressor infusion RASS > 3 ***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level*** ACTIVITY: HOB > 30º *Passive ROM 2X/d performed by RN, or UAP _________________ CLRT/Pronation initiated if patient meets criteria based on institutional practice OR Q 2 hr turning ACTIVITY: Self or assisted Q 2 hr turning 1.Bed sitting Position Min.20 min. 3X/d; 2.Sitting on edge of bed; stand w/ RN, PT, RT assist 3.Active Transfer to Chair (OOB) w/ RN/PT/RT assist Min. 3X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Sitting on edge of bed w/RN, PT, RT assist X 15 min. 2.Progressive bed sitting Position Min.20 min. 3X/d Or Pivot to chair position 2X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day 2.Meals consumed while dangling on edge of bed or in chair Ambulate progressively longer distances with less assistance x2 or x3/day with RN/PT/RT/UAP Tolerates Level III Activities Tolerates Level IV Activities NO YES Tolerates Level I Activities Tolerates Level II Activities Start at level I* Start at level II and progress* Tolerates Level II Activities

65 Transition: Level II to Level IIIAn acceptable strength to advance is considered to be a 3/5 with zero being no movement observed against gravity and five being muscle contracts normally against full resistance The patient meets the mobility goals for level II and is able to move their arm bicep against gravity

66 Grading Muscle StrengthGrade 5: Muscle contracts normally against full resistance. Grade 4: Muscle strength is reduced but muscle contraction can still move joint against resistance. Grade 3: Muscle strength is further reduced such that the joint can be moved only against gravity with the examiner's resistance completely removed. As an example, the elbow can be moved from full extension to full flexion starting with the arm hanging down at the side. Grade 2: Muscle can move only if the resistance of gravity is removed. As an example, the elbow can be fully flexed only if the arm is maintained in a horizontal plane. Grade 1: Only a trace or flicker of movement is seen or felt in the muscle or fasciculations are observed in the muscle. Grade 0: No movement is observed. Medical Research Council. Aids to the examination of the peripheral nervous system, Memorandum no. 45, Her Majesty's Stationery Office, London, 1981

67 Level III RASS -1 to up PT x 2 daily OT consult for ADLs START HEREProgressive Mobility Continuum START HERE Includes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated Level III RASS -1 to up Goal: Increased trunk strength, moves leg against gravity and readiness to weight bear PT x 2 daily OT consult for ADLs Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V Perform Initial mobility screen w/in 8 hours of ICU admission Reassess mobility level at least every 24 hours (Recommended at shift Δ) RASS -5 to - 3 RASS -3 & up RASS -1 & up RASS 0 & up RASS 0 & up Goal: clinical stability; passive ROM Goal: upright sitting; increased strength and moves arm against gravity Goal: Increased trunk strength, moves leg against gravity and readiness to weight bear Goal: stands w/ min. to mod. assist, able to march in place, weight bear and transfer to chair Goal: Increase distance in ambulation & ability to perform some ADLs PT consultation prn OT consultation prn PT: Active Resistance Once a day, strength exercises OT consultation prn PT x 2 daily & OT x1 daily Refer to the following criteria to assist in determining mobility level *Mobility is the responsibility of the RN, with the assistance from the RT’s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment. PT x 2 daily OT consult for ADL’s ACTIVITY: Q 2 hr turning *Passive /Active ROM 3x/d 1. HOB 45º X 15 min. 2. HOB 45º,Legs in dependant position X 15 min. 3. HOB 65º,Legs 4. Step (3) & full chair mode X20 min. 3X/d Or Full assist into cardiac chair 2X/day For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant PaO2/FiO2 > 250 Peep <10 O2 Sat > 90% RR 10-30 No new onset cardiac arrythmias or ischemia HR >60 <120 MAP >55 <140 SBP >90 <180 No new or increasing vasopressor infusion RASS > 3 ***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level*** ACTIVITY: HOB > 30º *Passive ROM 2X/d performed by RN, or UAP _________________ CLRT/Pronation initiated if patient meets criteria based on institutional practice OR Q 2 hr turning ACTIVITY: Self or assisted Q 2 hr turning/Possible NMES therapy 1.Sitting on edge of bed w/RN, PT, RT assist X 15 min. 2.Progressive bed sitting Position Min.20 min. 3X/d Or Pivot to chair position 2X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Bed sitting Position Min.20 min. 3X/d; 2.Sitting on edge of bed; stand w/ RN, PT, RT assist 3.Active Transfer to Chair (OOB) w/ RN/PT/RT assist Min. 3X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Sitting on edge of bed w/RN, PT, RT assist X 15 min. 2.Progressive bed sitting Position Min.20 min. 3X/d Or Pivot to chair position 2X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day 2.Meals consumed while dangling on edge of bed or in chair Ambulate progressively longer distances with less assistance x2 or x3/day with RN/PT/RT/UAP Tolerates Level III Activities Tolerates Level IV Activities NO YES Tolerates Level I Activities Tolerates Level II Activities Start at level I* Start at level II and progress* Tolerates Level III Activities

68 In-Bed Progressive MobilityJourney to tolerating upright position, turning, tilt, sitting, standing and walking and out of bed chair sitting can occur quicker through the use of technology

69 Transition: Level III to Level IVAn acceptable strength to advance is considered to be a 3/5 with zero being no movement observed against gravity and five being muscle contracts normally against full resistance The patient meets the mobility goals for level III and is able to move their leg against gravity

70 Level IV RASS 0 & up PT x 2 daily OT consult for ADLs START HEREProgressive Mobility Continuum START HERE Includes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated Level IV RASS 0 & up Goal: stands w/ min. to mod. assist, able to march in place, weight bear and transfer to chair PT x 2 daily OT consult for ADLs Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V Perform Initial mobility screen w/in 8 hours of ICU admission Reassess mobility level at least every 24 hours (Recommended at shift Δ) RASS -5 to - 3 RASS -3 & up RASS -1 & up RASS 0 & up RASS 0 & up Goal: clinical stability; passive ROM Goal: upright sitting; increased strength and moves arm against gravity Goal: Increased trunk strength, moves leg against gravity and readiness to weight bear Goal: stands w/ min. to mod. assist, able to march in place, weight bear and transfer to chair Goal: Increase distance in ambulation & ability to perform some ADLs PT consultation prn OT consultation prn PT: Active Resistance Once a day, strength exercises OT consultation prn PT x 2 daily & OT x1 daily Refer to the following criteria to assist in determining mobility level *Mobility is the responsibility of the RN, with the assistance from the RT’s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment. PT x 2 daily OT consult for ADL’s ACTIVITY: Q 2 hr turning *Passive /Active ROM 3x/d 1. HOB 45º X 15 min. 2. HOB 45º,Legs in dependant position X 15 min. 3. HOB 65º,Legs 4. Step (3) & full chair mode X20 min. 3X/d Or Full assist into cardiac chair 2X/day For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant ACTIVITY: Self or assisted Q 2 hr turning 1.Bed sitting Position Min.20 min. 3X/d; 2.Sitting on edge of bed; stand w/ RN, PT, RT assist 3.Active Transfer to Chair (OOB) w/ RN/PT/RT assist Min. 3X/d PaO2/FiO2 > 250 Peep <10 O2 Sat > 90% RR 10-30 No new onset cardiac arrythmias or ischemia HR >60 <120 MAP >55 <140 SBP >90 <180 No new or increasing vasopressor infusion RASS > 3 ***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level*** ACTIVITY: HOB > 30º *Passive ROM 2X/d performed by RN, or UAP _________________ CLRT/Pronation initiated if patient meets criteria based on institutional practice OR Q 2 hr turning ACTIVITY: Self or assisted Q 2 hr turning 1.Bed sitting Position Min.20 min. 3X/d; 2.Sitting on edge of bed; stand w/ RN, PT, RT assist 3.Active Transfer to Chair (OOB) w/ RN/PT/RT assist Min. 3X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Sitting on edge of bed w/RN, PT, RT assist X 15 min. 2.Progressive bed sitting Position Min.20 min. 3X/d Or Pivot to chair position 2X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day 2.Meals consumed while dangling on edge of bed or in chair Ambulate progressively longer distances with less assistance x2 or x3/day with RN/PT/RT/UAP Tolerates Level III Activities Tolerates Level IV Activities NO YES Tolerates Level I Activities Tolerates Level II Activities Tolerates Level IV Activities Start at level I* Start at level II and progress*

71 Out of Bed Technology

72 Level V RASS 0 & up PT x 2 daily OT x 1 daily START HEREProgressive Mobility Continuum START HERE Includes complex, intubated, hemodynamically unstable and stable intubated patients; may include non-intubated Includes intubated, non intubated hemodynamically stable/stabilizing, no contraindications Level V RASS 0 & up Goal: Increase distance in ambulation & ability to perform some ADLs PT x 2 daily OT x 1 daily LEVEL I LEVEL II LEVEL III LEVEL IV LEVEL V Perform Initial mobility screen w/in 8 hours of ICU admission Reassess mobility level at least every 24 hours (Recommended at shift Δ) RASS -5 to - 3 RASS -3 & up RASS -1 & up RASS 0 & up RASS 0 & up Goal: clinical stability; passive ROM Goal: upright sitting; increased strength and moves arm against gravity Goal: Increased trunk strength, moves leg against gravity and readiness to weight bear Goal: stands w/ min. to mod. assist, able to march in place, weight bear and transfer to chair Goal: Increase distance in ambulation & ability to perform some ADLs PT consultation prn OT consultation prn PT: Active Resistance Once a day, strength exercises OT consultation prn PT x 2 daily & OT x1 daily Refer to the following criteria to assist in determining mobility level *Mobility is the responsibility of the RN, with the assistance from the RT’s Unlicensed Assistive Personnel and PT/ OT. PT and OT may assist the team with placement to the appropriate mobility level of activity, always prioritizing patient and provider safety. Placement is based on clinical judgment. PT x 2 daily OT consult for ADL’s ACTIVITY: Q 2 hr turning *Passive /Active ROM 3x/d 1. HOB 45º X 15 min. 2. HOB 45º,Legs in dependant position X 15 min. 3. HOB 65º,Legs 4. Step (3) & full chair mode X20 min. 3X/d Or Full assist into cardiac chair 2X/day For each position/activity change allow 5-10 minutes for equilibration before determining the patient is intolerant ACTIVITY: Self or assisted Q 2 hr turning 1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day 2.Meals consumed while dangling on edge of bed or in chair PaO2/FiO2 > 250 Peep <10 O2 Sat > 90% RR 10-30 No new onset cardiac arrythmias or ischemia HR >60 <120 MAP >55 <140 SBP >90 <180 No new or increasing vasopressor infusion RASS > 3 ***If the patient is intolerant of current mobility level activities, reassess and place in appropriate mobility level*** ACTIVITY: HOB > 30º *Passive ROM 2X/d performed by RN, or UAP _________________ CLRT/Pronation initiated if patient meets criteria based on institutional practice OR Q 2 hr turning ACTIVITY: Self or assisted Q 2 hr turning 1.Bed sitting Position Min.20 min. 3X/d; 2.Sitting on edge of bed; stand w/ RN, PT, RT assist 3.Active Transfer to Chair (OOB) w/ RN/PT/RT assist Min. 3X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Sitting on edge of bed w/RN, PT, RT assist X 15 min. 2.Progressive bed sitting Position Min.20 min. 3X/d Or Pivot to chair position 2X/d ACTIVITY: Self or assisted Q 2 hr turning 1.Chair (OOB) w/ RN/PT/RT assist Min. 3X/day 2.Meals consumed while dangling on edge of bed or in chair Ambulate progressively longer distances with less assistance x2 or x3/day with RN/PT/RT/UAP Tolerates Level III Activities Tolerates Level IV Activities NO YES Tolerates Level I Activities Tolerates Level II Activities Ambulate progressively longer distances with less assistance x2 or x3/day with RN/PT/RT/UAP Start at level I* Start at level II and progress*

73 Ambulation Assist Devices

74

75 Early Mobility: Can We Do It? Is it Safe?

76 Safety > 1 % adverse events during 1449 sitting, standing and walking sessions with patients on ventilators. Impact of safety of therapy intervention in a single center (routine care) between 1787 admission of at least 24hrs 1110 participated in 5267 PT sessions (1-3 days from admission) 10 different therapist on 4580 days Results: Physiological abnormalities: 34 session (0.6%) Arrhythmias: 10 occurrences (0.2%) MAP > 140: 8 occurrences (0.2%) MAP < 55: 5 occurrences (0.1%) Oxygen desaturation: 4 occurrences (0.8%) Falls: 3 occurrences (0.6%) 1 chest tube, feeding tube and arterial line Bailey P, et al. Crit care Med, 2007;35: Sricharoenchai T, et al. J of Crit Care, 2104;29:

77 Challenges to Mobilizing Critically Ill PatientsPotentially Modifiable Barriers Patient –related barriers (50%) Hemodynamic instability, ICU devices, physical & neuropysch Structural (18%) Human or Technological Resources ICU culture (18%) Knowledge/Priority/Habits Process related (14%) Service delivery/lack of coordination Clinician function Dubb R, et al, Annual ATS, 2016 in press 77

78 Hemodynamic Instability??? Is it a Barrier to Positioning? 50% reported in studies as the # 1 patient barrier 78

79 The Role of Hemodynamic Instability in Positioning1,2Lateral turn results in a 3%-9% decrease in SVO2, which takes 5-10 minutes to return to baseline Appears the act of turning has the greatest impact on any instability seen Minimize factors that contribute to imbalances in oxygen supply and demand One of the big concerns that we have is when a hemodynamically unstable patient is turned or early mobilization is used. A couple of practices that we routinely do that are not supported by science. One of them is that when we turn patients, we’re looking at all of the data on the monitor (the saturation and the blood pressure) and if we see that change, we immediately return the patient to the supine position. That isn’t supported by science. When we are laterally turning these patients, their hemodynamic variables do drop; it is expected. These patients require about 5 to 10 minutes of equilibration before they return to baseline. We shouldn’t be making our assessment until 5 to 10 minutes into the position turn or sitting up (because this also applies to dangling patients). We’re preventing progression to mobility because we’re not allowing this adaptation to occur. The other intervention that we can do to help is to minimize the factors that contribute to the oxygen supply-and-demand imbalance, because turning takes a fair amount of demand for the patient and that patient may not have the supply. By breaking up our care practices so the pateints have rest period in between they are more likely to tolerate activity. Factors that put patients at risk for intolerance to positioning:3 Elderly Diabetes with neuropathy Prolonged bed rest Low hemoglobin and cardiovascular reserve Prolonged gravitational equilibrium Winslow EH, et al. Heart Lung. 1990;19: Price P. Dynamics. 2006;17:12-19. Vollman KM. Crit Care Nurs Q. 2013;36:17-27

80 Has the manual position turn or HOB elevation been performed slowly?Decision-Making Tree for Patients Who Are Hemodynamically Unstable With Movement1,2 Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible Is the patient hemodynamically unstable with manual turning? O2 saturation < 90% New onset cardiac arrhythmias or ischemia HR < 60 <120 MAP < 55 >140 SPB < 90 >180 New or increasing vasopressor infusion No Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates Here’s an algorithm that was recently published. If a patient is hemodynamically unstable with manual turning, this algorithm can help you determine what to do. You can start by waiting 5 to 10 minutes for the patient to equilibrate. If the patient is still experiencing issues, you can look at the mobility readiness. You can try manually turning, slowly, to see if the patient tolerates it. If not, the patient can be moved to rotational therapy. This algorithm is designed to ensure that no patient will remain hemodynamically unstable with manual turning or remain in a supine position for extended periods of time. Yes No Is the patient still hemodynamically unstable after allowing minutes’ adaption post-position change before determining tolerance? Begin in-bed mobility techniques and progress out-of-bed mobility as the patient tolerates Yes No Screen for mobility readiness within 8 hrs of admission to ICU & daily initiate in-bed mobility strategies as soon as possible Allow the patient a minimum of 10 minutes of rest between activities, then try again to determine tolerance Yes No Try the position turn or HOB maneuver slowly to allow adaption of cardiovascular response to the inner ear position change Has the manual position turn or HOB elevation been performed slowly? Yes Initiate continuous lateral rotation therapy via a protocol to train the patient to tolerate turning HOB=head of bed; HR=heart rate; MAP=mean arterial pressure; SPB=systolic blood pressure. Vollman KM. Crit Care Nurse. 2012;32:70-75. Vollman KM. Crit Care Nurs Q. 2013;36:17-27.

81 Evidence Based Strategies to Overcome BarriersPatient –related Inclusion, exclusion criteria, protocols, research on specific equipment for safety (CCRT, etc.) Structural Development and implementation of protocols, increase staffing & purchase of equipment ICU culture Education, training, coaching, video’s, improve coordination between professionals Process related Interprofessional meetings and rounds, sharing clinical responsibility, collaboration with champions, remove default orders Dubb R, et al, Annual ATS, 2016 in press 81

82 It Takes a Village For SustainabilityNecessary Components for Early Rehab Buy-in Multiple disciplines Team communication Opinion leader Individual discipline champion Dedicated rehab personnel Equipment Sedation practice Administrative funding 2. Implementation Strategies Team center approach Staff education Strength & quality of evidence 3. Perceived Barriers Increase workload Safety concerns 4. Positive Outcomes Improved patient outcomes Staff satisfaction Changed culture Financial savings Eakin MN, et al. J of Crit Care, 2015;30:

83 Ensuring Safety & SuccessMobility readiness assessment Determining absolute contraindications for any mobility protocol Criteria for stopping a mobility session Changing the culture Sufficient resources and equipment to make it easy & safe to do

84 Financial Model for Cost EffectivenessLord R. Crit Care Med, 2013;41:717

85 Progressive Mobility + Care Giver Safety + Skin Safety & Fall Prevention

86 The Goal: Patient & Caregiver Safety↓ Repetitive motion injury ↓ Musculoskeletal injury ↓ Days away from work ↓ Staffing challenges Loss of experienced staff Nursing shortage ↓ Hospital LOS ↓ ICU LOS ↓ Skin Injury ↓ CAUTI ↓ Delirium ↓ Time on the vent Safe Patient Handling Falls Prevention of Pressure Injuries Patient Progressive Mobility Leadership Leadership Leadership ↓ Skin Injury ↓ Costs ↓ Pain and suffering ↓ Hospital LOS ↓ ICU LOS Leadership ↓ Falls ↓ Falls with injury ↓ Hospital LOS

87 It is not enough to do your best, you have to know what to do and then do your best.E Deming

88 Questions