Facilitators & Barriers to Acute

Rehabilitation in the the Critically Ill

Karen K.Y. Koo MD, FRCPC, MSc Assistant Professor, Division Critical Care Medicine

Department of Medicine, Western University

Critical Care Canada Forum Oct 29, 2012

Disclosures

• I have no Industry relationships.

• I receive grant support from Academic Medical Organization of South-western Ontario & Lawson Health Research Institute, Physicians’ Services Incorporated Foundation & Academic Health Sciences Centres AFP Innovation Fund

Overview

• What & Whys of Early Mobilization in ICUs

• National Surveys – Barriers

• Facilitators for Early Mobilization

Early Mobilization = progressive series of activities - as early

as possible in ICU - from active ROM ambulation

Early Mobilization is Safe & Feasible

Study Design

Intervention

Main Findings

Limitations

Prospective cohort

N = 103 (Bailey et al. CCM 2007)

EM protocol

24h after RICU admission

69% patients

ambulate > 100” prior ICU discharge

Adverse events rare

Selection bias

94% from another ICU

(mean 10.5 +/- 9.9 days)

Prospective cohort N = 104

(Thomson et al. CCM 2008)

EM protocol 24h after RICU

admission

88% patients ambulate > 200” prior

ICU discharge

Selection bias

Prospective controlled trial

N = 330 (Morris et al. CCM 2008))

EM protocol 48h after ICU

admission by a mobility team

Shortens ICU & hospital length of

stay

Quasi-randomization

No concealment of randomization

Randomized study N = 80

(Nava, S. APMR 1998, 79)

Step-wise pulmonary

rehabilitation vs. standard

Most (52/60; 87%) regained

independent ambulation & ADLs

Baseline characteristics not reported

Early Mobilization improves functional outcomes

Study Design

Intervention / Control

Main Findings

Limitations

RCT Medical ICUs

N = 104

(Schweickert et al. Lancet 2009; 373)

Early Mobilization during interrupted sedation vs.

Standard Rehabilitation

Improved Independent neuromuscular function at

hospital discharge

Less Delirium

Shorter Mechanical ventilation duration

Patients with baseline

functional impairment

excluded

Medical ICU only

RCT Medical &

Surgical ICUs

N = 90

(Burtin et al. - CCM

2009; 37)

Bedside Cycle Ergometer vs. Standard Rehabilitation

Greater 6MWD at hospital discharge

No difference in

Weaning time, 1 year mortality,

ICU or hospital stay

Time to intervention 14d

Ward rehab not

controlled

Blinding of outcome

assessors not reported

Barriers to Early Mobilization

in ICUs

International Research on Barriers

• Many national surveys!

• Limited observational research

• Focus mostly on Institutional & Patient level Barriers

• Variable rigor & methodological approaches

King & Crowe, Physiotherapy 1998; 210

• Postal survey, convenience sample: PT, RN, MD

• PT & RNs – perceived MD restricting ambulation

• MD – perceived patient instability & lines

Norrenberg et al. Intensive Care Med 2000; 26

• European Postal survey to head PT

102/460 (22%) ICUs in 17 countries

• 25% No designated PT

• 33/102 (33%) – evening coverage but variable

[range: 0% Sweden & Germany - 79% UK]

• Variable role for PT: 25% managed vents

[range: 0% Sweden – 57% Portugal]

Kumar JA et al. Indian J Crit Care Med 2007:11

• Postal survey to PT (2 yrs critical care experience)

89/260 (35%) ICUs - India

• 21% ICU – no on call PT

• 55% ICU required MD order for rehab

Skinner ZH et al. Physiotherapy 2008; 223

• Postal survey to PT in 126/167 (75%) ICUs

• Evaluated subjective & objective factors used to prescribe exercise

• Major perceived barrier: medical instability

Skinner ZH et al. Physiotherapy 2008; 223

Hodgin et al. Crit Care Med 2009; 37

• Postal survey to PT

482/984 (49%) Response Rate

• < 10% ICU - initiation criteria for mobilization

• 1% ICU – automatic PT assessments

Appleton et al. Intensive Care Society 2012; 223

• Telephone survey in 23 ICU

(96% lead MD & 100% lead PT)

• Top 3 barriers:

– Patient severity of illness

– Insufficient $ for rehab

– Sedation

International Surveys show…

• Major Institutional Barriers Lack of protocols/guidelines Insufficient Equipment Insufficient Staffing No physician requests for physiotherapy consult

• Major Patient Barriers Medical instabilityExcessive sedation Lines

Current Barriers in Canada

Survey of Mobilization in Critically Adults:Knowledge, Perspectives & Stated Practices in Canadian ICUs

Koo KKY, Choong K, Cook DJ, Herridge M, Newman A, Lo V, Priestap F, Campbell E, Guyatt G, Burns K, Lamontagne F, Meade MO for the Canadian Critical Care Trials Group

• A self administered, postal survey to PT & MD

• Developed a reliable & valid survey instrument

• Used incentive & evidence based methods

Koo et al. Am J Respir Crit Care Med 2011; 183

ResultsResponse Rates• Response Rate: 71% Clinicians (311/436)

• Respondents: 87% PT (117/134) & 64% MD (194/302)

Demographics

• 46 ICUs in 40 Canadian Teaching hospitals

• 18 beds/ICU (Range 10-36)

0 20 40 60 80 100

Med-Surg

CV Surg

Neuro

Trauma

Burn

86.5%

43.2%

39.3%

40.7%

19.4%

Type of ICU Respondents Worked in

Type of ICU

Results

% Clinicians

Top 3 Institutional§ Barriers

No Written Guidelines or Protocols 57%

Insufficient Equipment 52%

Physician Orders required 41%

Top 3 Patient Barriers

Medical Instability 83%

Excessive Sedation 60%

Risk of Device/Line Dislodgement 42% § Institutional barriers defined as “customs and behavior patterns in your work environment”

Results

% Clinicians

Top 3 Institutional§ Barriers

No Written Guidelines or Protocols 57%

Insufficient Equipment 52%

Physician Orders required 41%

Top 3 Patient Barriers

Medical Instability 83%

Excessive Sedation 60%

Risk of Device/Line Dislodgement 42% § Institutional barriers defined as “customs and behavior patterns in your work environment”

Results

Q. What is (are) the most important Provider level barrier(s) to EM in YOUR ICU? If you believe that the listed barrier is important, please select ALL provider(s) who contribute to the existence of that barrier.

Results

Top 3 Provider Barriers to Early Mobilization in ICU

Contributing Providers

MD PT RN RT CS

Limited Staffing 2% 78% 59% 30% 2%

Slow to Recognize 63% 17% 59% 19% 15%

Safety Concerns 31% 29% 64% 28% 12%

Q. What is (are) the most important Provider level barrier(s) to EM in YOUR ICU? If you believe that the listed barrier is important, please select ALL provider(s) who contribute to the existence of that barrier.

Figure 1. Knowledge of ICU Acquired Weakness & Early Mobilization Among Canadian Physiotherapists & Physicians

Knowledge of intensive care unit (ICU) acquired weakness was based on prospective observational studies (17,18,19,20,21) in medical-surgical intensive care units. ** Knowledge of

clinical trials (2,4,5,6) on early mobilization was evaluated using 5 true-false questions.

0 20 40 60 80

Knowledge of Clinical Trials on Early

Mobilization in ICUs** (% correct)

Self-Reported Familiarity of Early

Mobilization Literature (% agree)

Knowledge of ICU acquired

weakness* (% correct)

58

67

31

64

69

30

58

65

33

Physiotherapists

Physicians

AllRespondents

Canadian Survey shows…

• Major Institutional Barriers Lack of protocols/guidelines Insufficient Equipment Insufficient Staffing No physician requests for physiotherapy consult

• Major Patient Barriers Medical instabilityExcessive sedation Lines

Canadian Survey also identifies...

• Major Health Care Provider Barriers

KnowledgeSkills setSafety concernsDelays in Recognition of suitable patients

Facilitators of

Early Mobilization in ICUs?

Winkelman & Peereboom. Crit Care Nurse 2010; 30(2)

• Semi-structured interviews: Pre & post mobility protocol implementation in 49 patients

• Single US center: 33 RNs

• Major perceived facilitators of “out of bed activity”

Patient co-operation

Adequate oxygen reserve

MD orders

• No outcome/performance measures

Hopkins et al. Crit Care Clin 2007; 23

• QI - Intermountain Health Respiratory ICU Model (UT, USA)• Introduced numerous interventions to promote rehabilitation

Outcome Measures 2000 2005 Length of ICU stay (Mean) 13 d 10 dLength of hospital stay (Mean) 28 d 24 dSatisfaction safety culture HighSatisfaction ICU team work culture High

Hopkins et al. Crit Care Clin 2007; 23

Steps1. Review of Barriers established “state of urgency”2. Created powerful guiding coalition (Teamwork)

3. Created vision (Reduce sedation, prioritize activity, encourage sleep)

4. Communication of vision (Education, Mobility protocol)

5. Empowerment to act out vision (Cross-training, hiring new RNs)

6. Planning for “short term wins”7. Audit & feedback8. Institutional change (Transforming culture)

Needham et al. Arch Phys Med Rehabil 2010; 91

• QI: John Hopkins MICU – 2006, 2007

• Detailed data collection (pre/baseline, post/outcome)

Main Outcome Measures Pre-QI Post-QI____________

Benzodiazepine use (% of days used) 50% 25% p=0.002

Days alert 30% 67% p<0.001

Rehabilitation Treatments (#/patient) 1 7 p<0.001

MICU Stay 7 d 5 d p=0.02

Hospital Stay 17 d 14 d p=0.03

Mortality 23% 21% p=0.55

Needham et al. Arch Phys Med Rehabil 2010; 91

Summary Important Facilitators

• Institutional Facilitators Leadership/ChampionsAdministrative supportProtocols/guidelines Sufficient Resources (Staff & Equipment)

• Patient Facilitators Sedation Interruption: Scales, Audit & feedbackDelirium Screening Patient co-operation

• Health Care Provider Facilitators Education: seminars, bedside Cross-training

Take Home points

• Most Barriers are modifiable

• Facilitators for rehabilitation require educated, dedicated, & strategic interdisciplinary Team

• Early Mobilization improves functional outcomes in previously healthy, medical patients…

References

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