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Facilitators & Barriers to Acute Rehabilitation in the the Critically Ill
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  • Needham group undertook systematic review of 24 studies  evaluate the prevalence of ICU AW46% ICUAW>25% paresis
  • Persistent physical impairment is also common in patients recovering from critical illness. Patients stated that their functional impairment was due to loss of muscle bulk, proximal muscle weakness, and fatigue. Entrapment neuropathies, foot drop, joint immobility, persistent pain at chest tube insertion sites and dyspnea were also described by patients.
  • On average, patients had severe muscle atrophy and lost lost 18% of their base line body weight in the ICU.
  • At one year, over half of the patients could not return to work because they still experienced persistent fatigue and weakness and poor functional status.
  • -possible therapeutic intervention to minimize ICUAW may be EM-EM: acute rehabilitation immediately after physiological stabilization
  • EM: acute rehabilitation immediately after physiological stabilization EM: may include ambulating patients on vents but also includes…
  • A number of prosepctivestudyes had show EM is safe and feasible.
  • Morris showed that a proactive mobility team (PT, MD, & health aid) in combination with automated orders for physiotherapy reduced ICU and hospital LOS.
  • Early ambulation had significant improvement in composite independent neuromuscular function at hospital discharge (RRR 24%, p=0.02) compared to usual care. -Independent neuromuscular function at hospital discharge* (29 vs. 19, OR 2.7, CI 1.2-6.1, p=0.02). Delirium (median 2.0 days, IQR 0.0-6.0 vs. 4.0 days, 2.0-8.0, p=0.02) -Mechanical ventilation duration (23.5 days, 7.4-25.6 vs. 21.1 days, 0.0-23.8; p=0.05)
  • The strongest evidence in support of EM stems from a single center RCT in a medical ICU where previously functionally independent patients in the intervention group began physiotherapy at a median of 1.5 days (1.0-2.1) after intubation compared to those in the control group who began physiotherapy at 7.4 days (6.0-10.9) after intubation (p<0.0001) (6). Critically ill patients with diminished functional reserve and/or muscle wasting from chronic comorbidities may have limited rehabilitation potential, even in the hands of a very skilled team. The role for early activity in patients recovering from surgery, or those with spinal cord injury, renal failure requiring dialysis, delirium, deep vein thrombosis and pulmonary embolism also remains to be elucidated.
  • Survey administered to PTs in ICU/CCU & Step downs; convenience sample 25 ICUs MD & RNs also surveyed42% PT felt lack of MD orders was a major barrier 35% Most MD felt patient instability was a major barrier
  • 25% did not have PTVariable coverage: 79% coverage UK, non Germany & Sweden
  • 21% ICUs did not have an on call PT 55% patients referred for PT assessment Kumar JA et al. Indian J Crit Care Med 2007:11
  • < 10% hospitals have established initiation mobility criteria PT automatic assessment in only 1% hospitals Hodgin et al. CCM 2009: 37
  • French translations of the survey were sent to French-speaking clinicians
  • ICU-acquired weakness: polyneuropathy, polyneuromyopathy or neuropathy acquired during critical illness.

Transcript

  • 1. Facilitators & Barriers to AcuteRehabilitation in the the Critically IllKaren Koo MD, FRCPC, MScAdjunct Professor, Division Critical Care MedicineDepartment of Medicine, Western UniversityMedical Director, Acute Rehabilitation ProgrammeSwedish Health Medical Centre, Seattle WABC Critical Care Quality DayJune 4, 2013
  • 2. Disclosures• No Industry relationships.• Salary support from Academic Medical Organization ofSouth-western Ontario & Lawson Health ResearchInstitute• Grants from Physicians’ Services IncorporatedFoundation & Academic Health Sciences Centres AFPInnovation Fund
  • 3. Overview• Overview of ICU-Acquired Weakness• Evidence for Acute Rehabilitation in ICUs• National Surveys – Barriers• Facilitators to Acute Rehabilitation in ICUs• Limitations
  • 4. Case – Lori• 46F re-current ICU admission foracute on chronic respiratory failure• Cystic fibrosis with end stage lung disease& bronchiolitis obliterans syndrome (BOS)• In bed for 3 weeks• Awaiting assessment for lung transplant• Very depressed, unable to play her children and worriedabout her future
  • 5. Intensive Care Unit-Acquired WeaknessIdentifying a Syndrome:ICUAW = polyneuropathy, polymyopathy orpolyneuromyopathy acquired in the intensive care unit(aka critical illness acquired weaknesscritical illness polyneuropathycritical illness myopathyintensive care unit acquired paresis)
  • 6. - Systematic review: 24 studies using both clinical andelectrophysiological testing- 655 of 1421 (46%) critically ill patients had neuromuscularcomplications- Increased duration of mechanical ventilation and length ofICU and hospital stay.Stevens RD et al. Intensive Care Med 2007, 33: 1876-1891.• D_);0- . 7#;)R%)k)C_DCT)– _ah ). 7+K% ;#. )I 70: )%#- " 1 - ;8- ,+")+A% "1 +,7&#;)R1 #. 7+%)dh T)– 3#I );0- . 7#;)Ra);0- . 7#;T)8,+;;7H#. )=+&#%0;)I 70: )6J! )+%. M ")6J4 )R1 #. 7+%)="#$+,#%8#T)• DEh )REZBEh T)6J4 )• CBh )RBZFDh T)6J! )• ^h )RZBh T)A 0: )6J! )+%. )6J4 )
  • 7. Incidence of ICUAWMech ventilated at least 7 days (MS-ICU pop):- Multicentre prospective cohort: 25%(clinically defined)- Single centre prospective cohort: 58%(electrophysiological testing)Critically ill patients with Sepsis:- ICUAW observational studies: 50-100%De Jonghe B et al. JAMA 2002: 288; 2859-2867.Leijten FS et al. Intensive Care Med 1996; 22: 856-861.Berek Ket al. Intensive Care Med 1996; 22:849-855.De Jonghe B et al. Intensive Care Med 1998; 24:1242-1250
  • 8. - Prospective cohort study 109 ARDS pts, evaluation at 3, 6, 12m- Survivors were young (45y), high severity of illness (APACHEII score 23), prolonged ICU stay (25 days)-Persistent Functional Disability at 1 year – loss of muscle bulk,weakness, fatigueHerridge MS at al N Engl J Med. 2003; 348(8):683-693
  • 9. Herridge MS at al N Engl J Med. 2003; 348(8):683-693G>77&D%95002"I 5$) Q$5>$&-($? $! I -$6$) 5"$XTTV]VY^_W^VCWUV$
  • 10. Herridge MS at al N Engl J Med. 2003; 348(8):683-693L/, 9=>, #2&. /+9>M%7&W) G *$2. : 0/=5"$/=50$S$#5&0($L, >$83--$&L /0. &-$", 5$>/_$. , 84-5$A&83 I $` $A5&; 588($J//>$"0/: ($O/2 >$2. . /L2-2>#$
  • 11. Adhihari NKJ et al. Lancet 2010; 10: 1-8
  • 12. Mrs. L
  • 13. 1. Early Mobilization is safe and feasible
  • 14. 5#=%, +&D8+6&@. 5AB( , %/M>, 8#_&RB@)&` T&Yab99)&L8. c&XbJ )&5005&HX$$b&2-5#$+$5>$&-($102>$1&05$) 5"$XTTd]VZ_SVUCSYZ$ Bailey P et al. Crit Care Med 2007; 35: 139-145.
  • 15. - Prospective cohort study- 103 pts activated within the first 24h ICU admission- 2 daily sessions of PT lasting at least 30m- 69% of pts were able to ambulate over 100 feet prior to ICUdischarge- Adverse events were rareBailey P et al. Crit Care Med 2007; 35: 139-145.
  • 16. - 80 COPD pts in resp ICU randomized to stepwise pulm rehab vsstandard tx- Protocol 30 minutes, twice a day, of early ambulation combined withpassive ROM to extremities and use of a treadmill even duringmechanical ventilation- EM had longer 6MWD by ICU discharge (p<0.001);shorter LOS (33.2d vs 38.1, NS)Nava, S. Arch of Physical Medicine and Rehabilitation 1998: 79: 849-854.
  • 17. Morris PE et al. Crit Care Med 2008; 36: 2238-2243
  • 18. 2. Does Early Mobilization improvefunctional outcomes?
  • 19. • RCT: 104 Adult ICU patients mech vent > 24 hours, baseline forfunctional independence• Randomized to EM (7d/wk) by PT & OT during IS vs IS (usualcare)• Blinding of outcome assessment• Primary endpoint: functional independence at hospitaldischarge (ability to perform 6 ADLs and walk independently)
  • 20. Schweickert WD et al. Lancet 2009; 373:1874-82.
  • 21. Limitations of Randomized Controlled TrialsStudy Design Intervention / Control Main Findings LimitationsRCTMedical ICUsN = 104(Schweickert et al.Lancet 2009; 373)Early Mobilization duringinterrupted sedation vs.Standard RehabilitationImproved Independentneuromuscular function athospital dischargeLess DeliriumShorter Mechanicalventilation durationPatients withbaselinefunctionalimpairmentexcludedMedical ICUonlyRCTMedical &Surgical ICUsN = 90(Burtin et al. - CCM2009; 37)Bedside Cycle Ergometervs. Standard RehabilitationGreater 6MWD at hospitaldischargeNo difference inWeaning time,1 year mortality,ICU or hospital stayTime tointervention 14dWard rehab notcontrolledBlinding ofoutcomeassessors notreported
  • 22. 3. What are the Barriers to EarlyMobilization in ICUs?
  • 23. International Research on Barriers• Many national surveys!• Limited observational research• Focus mostly on Institutional & Patient level Barriers• Variable rigor & methodological approaches
  • 24. King & Crowe, Physiotherapy 1998; 210• Postal survey, convenience sample: PT, RN, MD• PT & RNs – perceived MD restricting ambulation• MD – perceived patient instability & lines
  • 25. Norrenberg et al. Intensive Care Med 2000; 26• Postal survey to head PT102/460 (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]
  • 26. 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
  • 27. 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
  • 28. Skinner ZH et al. Physiotherapy 2008; 223
  • 29. Hodgin et al. Crit Care Med 2009; 37• Postal survey to PT482/984 (49%) Response Rate• < 10% ICU - initiation criteria for mobilization• 1% ICU – automatic PT assessments
  • 30. 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
  • 31. International Surveys show…• Major Institutional BarriersLack of protocols/guidelines Insufficient Equipment Insufficient Staffing No physician requests for physiotherapy consult• Major Patient BarriersMedical instabilityExcessive sedation Lines
  • 32. 3. What are Current Barriers in Canada?
  • 33. Survey of Mobilization in Critically Adults:Knowledge, Perspectives & Stated Practices in Canadian ICUsKoo 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 methodsKoo et al. Am J Respir Crit Care Med 2011; 183
  • 34. 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 100Med-SurgCV SurgNeuroTraumaBurn86.5%43.2%39.3%40.7%19.4%Type of ICU Respondents Worked inType of ICU
  • 35. Results% CliniciansTop 3 Institutional§BarriersNo Written Guidelines or Protocols 57%Insufficient Equipment 52%Physician Orders required 41%Top 3 Patient BarriersMedical Instability 83%Excessive Sedation 60%Risk of Device/Line Dislodgement 42%§Institutional barriers defined as “customs and behavior patterns in your work environment”
  • 36. Results% CliniciansTop 3 Institutional§BarriersNo Written Guidelines or Protocols 57%Insufficient Equipment 52%Physician Orders required 41%Top 3 Patient BarriersMedical Instability 83%Excessive Sedation 60%Risk of Device/Line Dislodgement 42%§Institutional barriers defined as “customs and behavior patterns in your work environment”
  • 37. ResultsQ. What is (are) the most important Provider level barrier(s) toEM in YOUR ICU? If you believe that the listed barrier isimportant, please select ALL provider(s) who contribute to theexistence of that barrier.
  • 38. ResultsTop 3 Provider Barriers to Early Mobilization in ICUContributing ProvidersMD PT RN RT CSLimited 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) toEM in YOUR ICU? If you believe that the listed barrier isimportant, please select ALL provider(s) who contribute to theexistence of that barrier.
  • 39. Figure 1. Knowledge of ICU Acquired Weakness & Early Mobilization AmongCanadian Physiotherapists & PhysiciansKnowledge of intensive care unit (ICU) acquired weakness was based on prospectiveobservational studies (17,18,19,20,21) in medical-surgical intensive care units. ** Knowledge ofclinical trials (2,4,5,6) on early mobilization was evaluated using 5 true-false questions.0 20 40 60 80Knowledge of Clinical Trials on EarlyMobilization in ICUs** (% correct)Self-Reported Familiarity of EarlyMobilization Literature (% agree)Knowledge of ICU acquiredweakness* (% correct)586731646930586533PhysiotherapistsPhysiciansAll Respondents
  • 40. Canadian Survey shows…• Major Institutional BarriersLack of protocols/guidelines Insufficient Equipment Insufficient Staffing No physician requests for physiotherapy consult• Major Patient BarriersMedical instabilityExcessive sedation Lines
  • 41. Canadian Survey also identifies...• Major Health Care Provider BarriersKnowledgeSkills setSafety concernsDelays in Recognition of suitable patientsLack of PrioritizationPoor CommunicationInadequate Co-ordination
  • 42. 4. What are the Facilitators ofEarly Mobilization in ICUs?
  • 43. Winkelman & Peereboom. Crit Care Nurse 2010; 30(2)• Semi-structured interviews: Pre & post mobility protocolimplementation in 49 patients• Single US center: 33 RNs• Major perceived facilitators of “out of bed activity”Patient co-operationAdequate oxygen reserveMD orders• No outcome/performance measures
  • 44. Hopkins et al. Crit Care Clin 2007; 23• QI - Intermountain Health Respiratory ICU Model (UT, USA)• Introduced numerous interventions to promote rehabilitationOutcome Measures 2000 2005Length of ICU stay (Mean) 13 d 10 dLength of hospital stay (Mean) 28 d 24 dSatisfaction safety culture HighSatisfaction ICU team work culture High
  • 45. Hopkins et al. Crit Care Clin 2007; 23Steps1. 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)
  • 46. 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=0.002Days alert 30% 67% p<0.001Rehabilitation Treatments (#/patient) 1 7 p<0.001MICU Stay 7 d 5 d p=0.02Hospital Stay 17 d 14 d p=0.03Mortality 23% 21% p=0.55
  • 47. Needham et al. Arch Phys Med Rehabil 2010; 91
  • 48. Summary Important Facilitators• Institutional Facilitators Leadership/Champions Administrative support Protocols/guidelines Sufficient Resources (Staff & Equipment)• Patient Facilitators Sedation Interruption: Scales, Audit & feedback Delirium Screening Patient co-operation• Health Care Provider Facilitators Education: seminars, bedside Cross-training
  • 49. Take Home points• Most Barriers are modifiable• Facilitators for rehabilitation requireeducated, dedicated, & strategic interdisciplinaryTeam• Early Mobilization improves functional outcomes inpreviously healthy, medical patients…
  • 50. References1. King J, Crowe J. Mobilization practices in Canadian critical care units. Physiotherapy Canada 1998; 50:206–2112. Limperopoulos C, Majnemer A. The role of rehabilitation specialists in Canadian NICUs: A national survey. Physical & OccupationalTherapy in Pediatrics 2002; 22:57-723. Norrenberg M, Vincent JL. A Profile of European Intensive Care Physiotherapists. Int Care Med 2000; 26:988-9944. Kumar JA, Maiya AG, Pereira D. Role of physiotherapists in intensive care units of India: A multicenter survey. Indian J Crit Care Med2007; 11:198-2035. Hodgin KE, Nordon-Craft A, McFann KK, Mealer ML, Moss M. Physical therapy utilization in intensive care units: Results from a nationalsurvey. Crit Care Med 2009; 37:561-5686. Appleton RTD, MacKinnon M, Booth MG, Wells J, Quasim T. Rehabilitation within Scottish intensive care units: a national survey. TheJournal of the Intensive Care Society 2011; 12:221-227Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, Veale K, RodriquezL, Hopkins RO. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007; 35:139-1457. Koo KKY, K Choong, DJ Cook, M Herridge, A Newman, V Lo, K Burns, V Schulz, MO Meade for the Canadian Critical Care Trials Group.Development of a Canadian Survey of Mobilization of Critically Ill Patients in Intensive Care Units: Current Knowledge, Perspectives andPractices. Am J Respir Crit Care Med 2011; 183: A31458. Thompson GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive careunit where early activity is a priority. Crit Care Med 2008; 36:1119-11249. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M, Penley L, Howard A, DixonL, Leach S, Small R, Hite RD, Haponik E. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit CareMed 2008; 36:2238-224310. Nava S. Rehabilitation of patients admitted to a respiratory intensive care unit. Arch Phys Med Rehabil 1998; 79:849-85411. Schweickert WD, Pohlman MC, Polman AS, Nigos C, Pawlik A, Esbrook CL, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallisterKE, Hall J, Kress JP. Early physical and occupational therapy in mechanically ventilated critically ill patients: a randomized controlled trial.Lancet 2009; 373:1874-8212. Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, Hermans G, Decramer M, Gosselink R. Early Exercise in critically illpatients enhances short-term functional recovery. Crit Care Med 2009; 37:2499-2505Karen.koo@lhsc.on.ca