Non-Medical Barriers to Early Mobilization in the

Intensive Care Unit

Michael Azzopardi - PT Student

Introduction The benefits of early mobilization in the ICU Barriers to early mobilization Delirium Safety Concerns – PTs and RNs Staffing/Time Moving Forward Take home message

Overview

Why this topic interested me:

Variety of PT styles

Conservative Aggressive - Where do I want to be?

Motivate change – work smarter not harder

Introduction

1. Increase the efficiency and effectiveness of physiotherapy

interventions

2. Generate more of an interdisciplinary team approach to early mobilization in the ICU

3. Increase the number of early mobilization interventions in the ICU

Improve the quality of care to patients in the ICU

Goals of This Presentation

Standard forms of early mobilization:

EOB dangle Transfers: sitstand, bedchair Ambulation

Alternate forms of early mobilization1:

Semi-recumbent positioning (bed chair) Frequent changes in postures Daily joint passive range of movement AROM Bed cycling Electrical stimulation

What is Early Mobilization (EM)?

Improvement in respiratory function8

Decrease in muscle wasting and deconditioning8

Reduced length of stay in the ICU8

Decreased delirium2

Reduced ventilator days2

Improved neuropsychochological function4

Increased quality of life4

Reduced readmission and mortality 12 months post discharge8

Benefits of Early Mobilization in the ICU

Leditschke et al.

Avoidable barriers were recorded in 47% of the days surveyed8: vascular access catheters in a femoral position timing of procedures sedation management (agitation and low Glasgow Coma Score) early ward transfer

Unavoidable barriers to mobility8 Respiratory instability Hemodynamic instability Neurologic instability (intracranial hypertension control difficulties) Medical orders for bed rest

Jolley (2014) – RNs and PT’s responses to EM barriers7

Staffing and time Risk of self-injury Excess work stress

Research on Barriers to Early Mobilization

Clinical Presentation:

Disorientation, impaired attention and awareness, disordered thinking, cognitive impairment, reduced LOC, hallucinations or illusions, inappropriate behaviour5

Hypoactive Delirium over-sedation prolongs ICU length of stay, leads to more complications,

increases costs and mortality3

Hyperactive Delirium under-sedation increases anxiety, pain, self-extubation, hypercoagulation

and post-traumatic stress disorder3

Delirium

Patient factors

Communication about care, cognitively stimulating activities, promotion of good sleep patterns, exercise and early mobilization5

Exercise associated with lower risk for developing delirium (Level 2 evidence)5

Environmental factors Lighting, visible clock & calendar5

Prevention

Encourage mobilization

Check in with nursing in the AM and ask if the patient can be weaned off sedation in time for your intervention5

Measures to re-orient and engage patient Provide sensory aides – e.g. glasses, hearing aids etc.5

Normalize sleep-wake cycle Open the blinds in the morning Get patients to a chair during the day5

Treatment

PT safety concerns: adverse effects d/t mobilization

In a prospective cohort study involving patients with respiratory failure in the ICU:4

1449 activity events including EOB dangle, sitting in a chair, and ambulation were recorded

Adverse events – fewer than 1% Included extubation, catheter/tube removal, systolic blood pressure > 200 mmHg or <90

mmHg, and SpO2 <80%)4

Leditschke et al (2012) reported an adverse effect in 2/176 (1.1%) mobilizations8 both involving hypotension requiring return to bed8

Solution: Come up with a safe plan and mobilize anyway

PT/RN Safety Concerns

Risk of self-injury7

71% indicated that EM puts staff at risk for MSK injury

Excessive work stress7

65%

Nursing time7 88% estimated 16-45 min of time for mobilization

Solution: Defining care roles and expectations between nursing and PT staff may enhance overall access to EM7

RN Safety Concerns

Communication with Nursing/RTs

Enable nursing to help mobilize whenever possible Drolet et al (2013) – a QI initiative to get nursing to help with

mobilizations by increasing knowledge re: EM increased ambulation in the ICU from 6% to 20%6

Solution: More diligent use of whiteboards in patient rooms as reminders for mobilization schedules if appropriate

Two lines for PT Name and pager number Mobilization status

Lack of Helping Hands

Solution: Mobility Teams

2PTs, 2PTs, 1PT + 1TA Combine caseloads and tackle them together

Benefits of collaboration9:1. Fewer and shorter delays2. Improved morale 3. Greater job satisfaction 4. Increased efficiency 5. Lower staff stress 6. Improved patient satisfaction 7. Enhanced clinical effectiveness 8. Fewer errors 9. Better outcomes after transfer or discharge from ICU

Lack of Helping Hands

1. Collaboration with Nursing and Respiratory Therapy

Checking in with nurses in the AM Use of white boards more effectively

2. Collaboration within physiotherapy - Mobility teams Extra hands, collaboration with care plans, less load on the

body

Moving Forward

3. Accountability – Introducing: The Mobilization Board

Mobilization can be defined any type of movement – e.g. PROM for sedated patients, bed chair, EOB dangle, sit to stand, marching on spot, ambulation

% of patients mobilized/total caseload Record each team’s mobilization score each day – e.g. 8/10 End of week/month – get the ICU team total: % of patients mobilized.

Use it as a goal setting tool for the next month Any help from nursing/RT counts as a mobilization in your favour

4. Investigate further into quality improvement studies regarding more specific implementation strategies of early mobilization.

Moving Forward

1. Early Mobilization is safe and effective!

2. Collaboration is the key to implementation

Take Home Message

Change Starts With YOU!

1 Ambrosino et al. (2014). Physiotherapy in the ICU. The Journal for Respiratory Care Practitioners.

Aug; 27 (8): 16-9.

2 Atkins, J. & Kauts, D. (2014) Move to Improve. Progressive Mobility in the Intensive Care Unit. Dimens Crit Care Nurs. 33(5) 275-277

3 Beck L; Johnson C; (2008) Nurse-Driven Sedation Protocol in the ICU. Dynamics, Winter; 19 (4): 25-8

4 Castro et al. (2015) Early mobilization: Changing the mindset. Critical Care Nurse 35 (4): 1-6.

5Delirium in hospitalized patients. In DynaMed [database online.] EBSCO Information Services. Htttp://www.dynamed.com. Updated Aug 06 2015. Accessed Oct 3rd, 2015.

6 Drolet, A. et al (2013) Move to Improve: The Feasibility of Using an Early Mobility Protocol to Increase Ambulation in the Intensive and Intermediate Care Settings, Physical Therapy Feb; Vol. 93 (2), pp. 197-207

References

7 Jolley SE (2014). Medical intensive care unit clinician attitudes and perceived barriers towards

early mobilization of critically ill patients: a cross-sectional survey study. BMC anesthesiology. Vol 14 pg: 84.

8 Leditschke, A. et al. (2012) What are the barriers to mobilizing intensive care patients? Cardiopulmonary Physical Therapy Journal. 23 (1): 26-29

9 Yeager, S. (2005) Interdisciplinary collaboration: the heart and soul of health care. Critical Care Nursing Clinics of North America. Jun: Vol 17 (2), pp. 143-148

References

Questions/Comments?