ObjectivesDiscuss current practice and investigate why current interventions/limitations with activity exist.Explore common impairments that occur with prolonged bedrest and prolonged Intensive Care Unit (ICU) stays.Define Early Mobilization.Discuss the benefits of Early Mobilization.Review an Early Mobilization Protocol.Discuss Further Considerations with Early Mobilization in the ICU.

Current practice in many hospitalsWeve come a long way but more improvements can be made.1Delayed initiation of physical therapy 1Infrequent treatments in the ICUOnce PT is initiated bed therapeutic exercise is usually the first intervention6,7

Barriers to Early Mobilization 2,3,7Psychosocial barriersComorbiditiesAdvanced agePhysiologic instabilityICU environmentLimited Evidence

Impairments seen with prolonged bedrest 2-6Increased respiratory dysfunctionImpaired strengthPhysiologic impairmentsIncreased risk for skin breakdownDecreased quality of life

Prolonged hospital stays with mechanical ventilation DECREASED FUNCTION! 3, 6-7Increased morbidity/mortalityIncreased cost of careIncreased length of stayRespiratory muscle weakness and increased duration of ventilationSleep deprivationLack of social interactionProlonged sedationDelirium

Inactive & Alone: Physical Activity Within the First 14 days of Acute Stroke Unit Care 1

Inactive & Alone: Physical Activity Within the First 14 days of Acute Stroke Unit Care 1

Inactive & Alone: Physical Activity Within the First 14 days of Acute Stroke Unit Care 1

What is Early Mobilization? 6The initiation of mobility when a patient is minimally able to participle, presents with hemodynamic stability and the patient receives acceptable levels of oxygen.

Benefits of Early Mobilization 2, 4-8Improved respiratory functionMaintains strength and joint range of motionFewer physiologic impairmentsRepositioning allows for other interventionsImproved quality of life

Initiating an Early Mobilization ProtocolWhat is needed to start an Early Mobilization Protocol?Multidisciplinary involvement is crucial!A thorough initial physical therapy evaluationAn individualized plan of careAppropriate goals that meet patients values are neededDetermine what phase of the Early Mobilization Program the patient is starting in.

Initiating an early mobilization protocol for mechanically ventilated patients 6,7Heart rate

Phase 1Patient presentation: considerable weakness, limited activity tolerance, occasional altered mental status, minimally participate in therapy and are unable to ambulate.15-30 minute treatmentsGoal: to start mobilization as soon as the patient is medically stable. Progression: bed ther ex rolling sitting balance standing with a walker and assistance

Further Treatment Options for Phase 1 2Tilt table with arms supported for 10-30 minutesStanding FrameChair sitting

Phase 2Includes patients that have the strength to perform standing activities with a walker and assistance. Goal: to start walking re-education and functional trainingProgression: weight shift steps in place side steps along the EOB chair transfer using a walker and assistance

Phase 3Includes patients that can tolerate ambulation with a walker and assistance for a short distance.Goal: Master transfer training and increase endurance.

Phase 4 6Includes patients that are no longer on a ventilator and/or have been transferred out of the ICU.Goal: functional trainingUltimate goal: Promote maximum independence by discharge.

Further Considerations with Early Mobilization 2,3,7ALWAYS USE YOUR CLINICAL JUDGEMENTOther Interventions: e-stim, UE exercise, inspiratory muscle trainingTransitions back and forth between phasesPerform during sedation vacationsNeed assistance to manage multiple linesMonitor vital signsInvolvement of a multidisciplinary team is crucial!

When should an Early Mobilization Intervention be deferred/stopped? 1,2,7HR 130 bpmRR 35 bpmSpO2

Adverse Effects with Early Mobilization 2,7Adverse events are rare.Fall to kneesHypoxemia 1 minuteUnscheduled extubationOrthostatic Hypotension < 80 mm Hg SBP

Bottom line 1,2, 6-8No medical status decline occurred with an early physical therapy intervention.This is a safe and feasible intervention.Early mobilization has the potential to prevent/treat neuromuscular complications of critical illness.Early Mobilization Requires a Culture Change

Questions

ReferencesBernhardt J, Dewey H, Thrift A, and Donnan G. Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care. Stroke 2004;35:1005-1009.Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):400-407.Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing 2008;10(1):21-33.Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy. (4th ed). St. Louis: Mosby. 2006.Kisner C, Colby LA. Therapeutic Exercise. (5th ed.). Philadelphia: F.A. Davis Company. 2007.Perme C, Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:212-221.Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:1874-82.West L. Early Mobilization: How one multidisciplinary team initiated an activity protocol to decrease ICU lengths of stay. Advance for Physical Therapy and Rehab Medicine May 30, 2011:12-14.*References for images available upon request.

Professional background*So basically what we are going to look at:How far we have come.What do we currently do for our patients in the acute care setting?Investigate why we have this current practice.Discuss the potential pitfalls with this current practice.Explain early mobilization and the potential benefits with this innovative interventionDiscuss how we can implement an early mobilization protocol.*Early mobilization after uncomplicated acute myocardial infarction was proposed in 1951. Before this , patients were prescribed 6-8 weeks of bedrest to allow time for myocardial healing and scar formation.Currently Guidelines now propose 12 hours bedrest after uncomplicated acute myocardial infarction, with early mobilization and early discharge considered the norm.Bernhardt J, Dewey H, Thrift A, and Donnan G. Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care. Stroke 2004;35:1005-1009.

High intensity bed ther ex doesn't necessarily counteract the negative affects of prolonged bedrest due to the patients position in supine allowing intravascular fluid to redistribute more into the chest because of lack of gravitational stress.

Perme C and Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:212-221.

Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:1874-82.

*Why do we have this current practice? Because getting our patients up early can be challenging due to a number of barriers to patient participation and endurance.Agitation, Confusion, impaired or no response to simple commandsComplex comorbidities, Advanced age with an increasing issue as the baby boom generation continues to ageShock = SBP < 90 mm Hg or need for ongoing vasopressors, Persistent respiratory failure = RR >35 bpmOngoing renal replacement therapy, Ongoing sedation, Out of the ICU for a procedure, Multiple lines and equipmentLimited Evidence to support this intervention

It is difficult to find good studies that are randomized control trials looking at the benefits of early mobilization. This may in part be due to ethical issues with comparing an intervention to a no-intervention group given all the impairments that can occur with immobilization. Also creating a study with a large enough sample size, homogenous sample group (no 2 patients are alike), specific outcome measures to monitor progress from a very low level of activity and consistent duration of intervention is difficult.

Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):400-407.Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing 2008;10(1):21-33.

Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:1874-82.

*But we know there are serious consequences to inactivity especially in the acute setting.

Increased energy requirements for the lung and heart, Increased oxygen demand, Difficult to wean a patient from the ventDecreased muscle strength/massDecreased orthostatic tolerance, Deep vein thrombosis, Vital organ dysfunction, Sepsis, Hypoxemia, AcidosisSkin breakdownNeuromuscular drug toxicityDecreased quality of life

Prolonged bedrest is also with increased risk for deep vein thrombosis, increased energy requirements for the lung and heart, decreased orthostatic tolerance and increased risk for skin breakdown. A 20% decline in muscle strength can occur within the first week of prolonged bedrest and a further decline of 20% every week afterwards with continued bedrest.1 These weakened muscles increase a patients oxygen demand and make it more difficult to wean a patient from the vent.1 Patients who experience more than 1 week of bedrest exhibit up to 40% loss of muscle strength in the antigravity muscles of the calf and back.

Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy. (4th ed). St. Louis: Mosby. 2006.

Kisner C, Colby LA. Therapeutic Exercise. (5th ed.). Philadelphia: F.A. Davis Company. 2007.

Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):400-407.

Perme C and Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:212-221.

Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):400-407.

Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing 2008;10(1):21-33.*

I believe early mobilization can be especially valuable when applying to patients that are mechanically ventilated for a long period of time.

Loss of upper limb motor strength impairs weaning outcome.Perme C and Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:212-221.

Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:1874-82.

Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing 2008;10(1):21-33.

*This open observational behavioral mapping study occurred in Melbourne, Australia between 2001-2002.Observed 58 patients,