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1. Mobility in the Icu Why we should, why we don’t and how we can

2. Objectives Review the negative effects of bed rest Understand the physiological, psychological and financial advantages to ICU mobilization Examine barriers to ICU mobility Understand these barriers from a multidisciplinary approach Present protocols for ICU mobilization Increase awareness of the need to ICU mobility and strategies to accomplish it

3. Why should we mobilize in the ICU?

4. Effects of Immobilization 1,2 MSK: decreased muscle strength and atrophy, decreased endurance, contracture, osteoporosis CV: increased HR, decreased cardiac reserve, orthostatic hypotension, venous thromboembolism Respiratory: decreased ventilation, atelectasis, pneumonia Endocrine and renal: decreased metabolism, increased diuresis, glucose intolerance, hypercalcemia , renal stones GI: anorexia, constipation Skin: pressure sores

5. The ICU is particularly harmful After discharge from ICU, pts have impaired exercise capacity, persistent weakness, suboptimal quality of life, enduring neurophysiological impairments and high costs of healthcare utilization. 3 Pts requiring sedations, long-term ventilation and bed rest have significant long-term deficits in muscle weakness, functional impairments and loss of quality of life. 4

6. ICU mobility can improve pt outcomes Functional mobility improved in most studies although it can be difficult to quantify 3-8 Barthel index scores improved by 59% compared to 35% in pts with mobilization 5 FIM scores also improved 6

7. ICU mobility can improve pt outcomes Activity and mobility in the ICU can lead to significant improvements in ambulation independence, reduced duration of mechanical ventilation, better ability to perform self care activities, and improved respiratory function. 3 Muscle force production was increased at discharge. 7 Early mobilization reduces risk of death and hospital readmission within 12 months of discharge 8 Early mobilization in ICU can reduce length of stay and save money, despite cost of implementation 9

8. ICU mobility is safe Adverse events occur very infrequently <1% of the time. 5-7,12-14 Line dislodgement and/or accidental extubation were extremely rare despite being frequently cited as reasons to avoid mobility 5

9. Bottom line for why we should mobilize ICU stay and immobilization results in a wide variety of deficits for pts ICU mobility improves pt outcomes ICU mobility is safe

10. Why don’t we mobilize?

11. What Are the Barriers to Mobilizing Intensive Care Patients ? 10 106 pts in a single ICU with a total of 327 pt days Mobilization did not occurred on 151 of these days (46%) 47% of these considered “avoidable” Why?

12. Barriers to Mobilization for PTs 10 Avoidable (71 sessions) Femoral catheters - 32/ 71 Timing of procedures - 18 / 71 Sedation management - 12/ 71 Early transfer in 9/ 71 Unavoidable (80 sessions) Respiratory instability - 20 / 80 Hemodynamic instability 17/ 80 Intracranial hypertension 15/ 80 Medical orders for bed rest 15/ 80 Other 13/80

13. Avoidable Reasons for Missed Mobilization 10

14. Unavoidable Reasons for Missed Mobilization 10

15. Staff-Perceived Barriers and Facilitators 11 Interview of 33 ICU nurses on 49 activity sessions 41/49 (84%) involved in-bed activity as opposed to out-of-bed activity Why?

16. Barriers to Mobilization for Nursing 11 Barriers (41 sessions) Unstable vitals – 59% Poor respiratory status – 46% Safety concerns – 34% Sedation – 27% Low level of consciousness or agitation – 7% Facilitators (8 sessions) “ Pt is cooperative today” – 100% Good O2 reserve – 50% Physician orders – 50%

17. PT attitudes and barriers 15 Nursing attitudes and barriers 15 Mobilized about twice as often Main barrier: neurologic impairment Mobilized about half as often Main barriers: renal replacement therapies and hemodynamic instability Conclusion: Different professions identify different barriers to mobilization, interdisciplinary communication is key to overcoming these barriers.

18. Bottom line for why we don’t mobilize Different barriers amongst medical professionals make a unifying solution difficult Misconceptions about safety of mobilization in ICU Communication/coordination amongst health care professionals

19. Lets make a plan

20. Stiller et al 17 31 pts with 69 treatments Established a screening criteria that predicted which pts were appropriate Showed significant increase in HR and BP and drop in SpO 2 but not clinically important 3 adverse event requiring temporary increase in O 2 requirement

21. Major vitals checklist Cardiovascular Resting HR <50% age predicted max BP less than 20% variability ECG normal ------------------- Respiratory PaO 2 >300, SpO 2 >90% AND no major recent decrease -------------------- Other factors Hemoglobin stable and >7 grams/ dL No fever Blood glucose 3.5-20 mmol /L Stable, conscious state

22. Morris et al 6 Prospective cohort study of 330 pts receiving either usual care or protocol Protocol administered by “Mobility Team”: critical care nurse, nursing assistant and PT

23. Results 6 Protocol pts had PT more frequently, were out of bed earlier, and had similarly low complication rates Protocol pts had shorter length of stays in ICU and hospital No statistical difference in cost

24. Bottom line to implementation of ICU mobility Chart review/screening is crucial Have a plan for treatment progression that challenges pt appropriately Don’t forget EDUCATION and COMMUNICATION

25. Summary ICU stay has significant impact on pt impairments both at a body structure/function level and a broader activity/participation level ICU mobility is safe and proven to address these impairments Perceived barriers to mobility differ across medical professions Interdisciplinary communication is key to addressing these barriers Screening and treatment progression is vital to providing the highest quality care to ICU pts

26. Thank you

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28. Sources Winkelman  C,  Peereboom  K. Staff-perceived barriers and facilitators.  Crit Care Nurse 2010;30:S13–S16 . Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients.  Crit Care Med. 2007;35(1):139–145. Pohlman MC, Schweickert WD, Pohlman AS, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation.  Crit Care Med. 2010;38:2089–2094 . Zeppos L, Patman S, Berney S, Adsett JA, Bridson JM, Paratz JD. Physiotherapy in intensive care is safe: an observational study.  Aust J Physiother . 2007;53:279–283 GarzonSerrano  J, Ryan C,  Waak  K, Hirschberg R, Tully S, Bittner EA,  Chipman  DW, Schmidt U,  Kasotakis  G, Benjamin J,  et al . Early mobilization in critically ill patients: patients’ mobilization level depends on health care provider’s profession.  PM R  2011;3:307–313 . Goodson CM, Friedman LA, Mantheiy E, et al. Perceived Barriers to Mobility in a Medical ICU: The Patient Mobilization Attitudes & Beliefs Survey for the ICU.  Journal of Intensive Care Medicine . 2018:088506661880712. doi:10.1177/0885066618807120 . Stiller K, Phillips AC, Lambert P. The safety of mobilisation and its effects on haemodynamic and respiratory status of intensive care patients.  Physio Theory Pract . 2004;20:175–185.