Implementing an ICU Rehabilitation Program

Early Mobilization

• Safe and feasible• Improves functional outcomes• Decreases LOS• Decreases ventilator days

Barriers for PT/OT to implement early mobilization

• Lack of leadership• Lack of staffing and equipment• Lack of knowledge and training• Lack of appropriate referrals• Over-sedation• Delirium• Pain and discomfort• Physiological instability• Safety of the patient• Sleep deprivation

Factors impacting early rehabilitation • Team buy in

• “ If you’re a rehab team and you don’t have a buy-in by nurses, MD’s and Respiratory Therapists it’s not going happen”

• Multi disciplinary team

• Evidence based research• “You can’t debate the evidence that demonstrates the benefit to early mobilization. It’s like debating

the sky is blue”• Champion• Administrative support

• “It takes time and willingness to work hard to get what you need from the Executive leadership of the hospital…and that’s not just throwing resources out the window when you invest in these resources because you get them back”

• Culture change

Factors impacting early rehabilitation

• Champion• Administrative support

• “It takes time and willingness to work hard to get what you need from the Executive leadership of the hospital…and that’s not just throwing resources out the window when you invest in these resources because you get them back”

• Culture change

Processes to help implementation

• Staff education• Team communication• Integrate delirium and sedation protocols• Just do it• Use data to track progress• Set up weekly meetings

Engage

• Get clinicians interested-”Why is Rehab so important?”

– Invite patients– Guest speakers– Share data regarding performance versus peer

hospital

EducateEducate on evidence supporting interventions

• Newsletter, posters• PT/OT to educate RN’s on rehab intervention• RT to educate PT on vent settings for ambulation• Group discussions

Execute

Design a standardized toolkit• Dedicated PT/OT in ICU• Guidelines for PT/OT consults• Screening patients and prompt MD for

referral• Decrease over-sedation• Tech assisting with mobilization

Evaluate

Regularly asses performance and unintended problems

• Weekly meetings• Discuss problems that arise• Brain storm ways to resolve unintended

problems

Teaching An Old Dog New Tricks

Changing the Culture

• Culture Beliefs and attitudes that are shared by the organizations members. The older and more traditional an organization is, the stronger the culture, and more difficult to change.

• Culture Change requires agreement of a common vision and a shared desire to work toward mutual goals of better patient outcomes.

• The Desired Vision• Restoring the mobility of a critically ill patient

quickly, safely, and effectively in order to return them back to their prior way of life with as little physical and cognitive deficits as possible.

Doctor

OT

RT

RN

PT

RT

Doctor

RN

OT

PT

Evidence Supporting Culture Change

• Transfer of patients to an ICU that promoted mobility resulted in almost a 3-fold increase in ambulation.

• The improvement in ambulation was not explained by improvements in physiology.

• Thomsen SE et al. (2008). Critical Care Medicine 2008 Vol 36(4):1119-1124.

Evidence Continued

• 55% of patients (ventilated > 4 days) who transferred from an ICU that focussed on early mobility to the ward showed a decrease in activity from the last full day in the ICU to the 1st full day on the ward.

– Non-ICU staff may not be knowledgeable about long-term impairments in ICU survivors and the need for continued mobility and activity throughout the hospital stay.

– Hopkins, RO. Physical Therapy. 2012, 92(12), 1518-1523.

Challenges to Culture change

• Tendency to maintain the status quo– Older Institutions– Lack of knowledge

• Resistance to change• Lack of prioritization/urgency• Insufficient personnel• Fragmentation of health-care delivery

– Core group of ICU therapists

So What do we do?

Barriers To Overcome

• Lack of leadership

• Lack of staffing and equipment

• Lack of knowledge and training

• Lack of appropriate referrals• oversedation

• Delirium• Pain and discomfort• Physiological instability• Safety of the patient• Sleep deprivation

Gathering “Champions”

Need higher level management involvement for a culture change to take place.

Champions We Will need• Nurse managers (pushing for dedicated mobility nurses, additional mobility

equipment, establishing and instituting screening protocols for appropriate therapy referrals and ICU patients readiness for PT)

• Unit nurses (educating PCT’s and other nurses on the importance of mobilization and performing PROM and to follow up with mobility of their patients on a regular and consistent basis)

• Intensivists (sedation protocols) (sleep enhancement programs)• Respiratory Therapy Managers (wean screens during nightly rounds

and educating their staff on early mobility and be open to educate therapists on vent settings, alarms, and suctioning)

• Hospital administrators (Provide the necessary resources for early mobility, staffing, equipment)

• Rehab administrators (to facilitate the change in culture in the rehab department itself with dedicated staff, appropriate scheduling, and on-going education of staff members)

Get ICU survivors to return to the unit after discharge home to talk to the multi-disciplinary team regarding his stay in the ICU, his pre-morbid level of function, and his current level of function.

Weekly Meetings

• Weekly rounds in the therapy department itself.Regarding current barriers to rehab, consistency in the POC, current therapy treatments, coordinating treatments with OT and PT ,and any pertinent new medical issues for the patient that would influence there progress.

• Weekly meetings with ICU nurses.Regarding all ICU patients and how therapy is going this week, such as missed visits due to delirium and any other barriers to therapy.

In regard to Delirium and Oversedation

• Delirium screening• Sleep deprivation • Sedation assessment

Motivational Interviewing

• “We should listen…..They should talk”

Patients must also be engaged to participate in early mobility.

Motivational InterviewingThis is a person-centered counseling style where the professional does not do all the talking. Let the patient give the reasons for their motivation or goals. Try to recognize if there is any resistance by the patient toward mobilizing. Lecturing and warnings do not work. Step back and let them talk. Get to know who this patient was before getting sick.

The Rehab Department

• Dedicated therapists• Dedicated rehab aids• Weekly rounds• Scheduling appropriate caseloads• Continued education (courses, in-services,

etc)

Patient safety, unstable patients, and inappropriate referrals

• Continuous education of ICU Therapists• Competencies and/or education in line management• Nursing protocols for assessing stability of patients and their

readiness for mobilization• Nursing screening protocols for determining if PT or OT

consult is needed. “Early activity and or mobility does not always need a therapy consult.”

• Nurse managers to facilitate unit nurses to be pro-active in clamping lines that could be dislodged during therapy sessions.

The Nursing Department• MICU report sheets filled out by nurses at 7am on

each patient regarding what the patient’s plans are for the day. (Decreases missed visits)

• Nurse managers educating their staff that “Early activity and or mobility does not always need a PT or OT consult.”

• Can nurse managers make it a policy for their nurses to do PROM on patients who can not actively participate in therapy?

• Educate nursing leaders in deciding which patients can walk with nursing and family and do not need a PT necessarily.

Nursing continued • Obtain nursing grants for purchase of equipment (additional SARA’s or

Moveos)• Create guidelines for assessing physiological stability• Cross-train PT’s and OT’s to basic ECG, suctioning, and trouble shooting

alarms on vents.• Cross-train nurses for safe transfers from bed to chair.• Educate on appropriate referrals• Inter-disciplinary education on continuous versus bolus sedation• Standardized approach to sedation assessment (RASS)• Standardized approach to delirium screening (CAM-ICU)• Minimize use of Benzodiazepines for delirium• Encourage use of anti-psychotics to treat delirium• Initiate protocol to titrate pain meds• Get nursing staff pro-active for clamping any lines that could be

dislodged during PT /OT sessions.

Quotes From Prior Courses

Quotes

• In Regard to the Multi-Disciplinary Approach:“I think the wonderful way this project was implemented in our unit was that it was very multi-disciplinary. When we were having meetings to implement the program, every type of clinician was at the table. There were physicians, Occupational therapists, physical therapists, nurses, and respiratory therapists. So I think it takes the group collaboration to obviously implement this type of initiative.”- RN

More quotes

• In Regard to teamwork and Communication:“I think having weekly multi-disciplinary rounds are helpful to address barriers, especially barriers to a specific patient.”-PT

“On a more granular level , for example, every week I meet with all the MICU therapists where we review all of the patients and talk about the rehab plan every week.”-Physician

The Vision

“Just as important as it is for me to give a patient an antibiotic, I kind of prioritize mobilization in that same category so I know that I can not skip out on mobilization because I don’t have the time.”-RN

Sedation & Delirium

Delirium•Abrupt onset (hours to days) with fluctuation

during the day

•Inattention - inability to direct, sustain, & shift attention

•Decreased awareness of environment - disorientation

•Change in cognition &/or perception

•Short-term memory, language/speech abnormalities

•Hallucinations: auditory or tactile (not a requirement)

•Up to 80% of ICU patients develop delirium at any point

•Post-Intensive Care Syndrome (PICS)

•Family

•Mental Health: Anxiety, PTSD, Depression, Complicated Grief

•Survivor

•Mental Health: Anxiety, PTSD, Depression

•Cognition Impairments: Executive function, Memory, Attention, Visuo-spatial, Mental processing speed

•Physical Impairments: Pulmonary, Neuromuscular, Physical function

Patient Outcomes

Patient Outcomes

•Independently associated with 2-13x increased risk of death

•Duration associated with long term cognitive impairments

•Increased ICU stay (8 vs 5 days)

•Increased hospital stay (21 vs 11 days)

•Estimated national cost $4 - $16 Billion

Management•2013 SCCM - Clinical Practice Guidelines

•“Patients should be awake and follow commands!”

•Regular assessment of Pain, Agitation/Sedation, and Delirium

•Pain: self-report, other pain scales

•Agitation/Sedation: RASS

•Delirium: CAM-ICU

•Mobilize early

Management

•Multidisciplinary team approach

•Stop all continuous and PRN sedation at 0800

•Decrease use of drugs associated with delirium

•Benzodiazepines

•Antihistamines & sleep aids

•Narcotics

•Using antipsychotics to treat agitated delirium

Management•Sleep enhancements

•Eye masks/ear plugs or soft music

•Dim lights

•Bath by 10 pm

•Appropriate sleep medication

•TV off

•Day/Night cycle

•Lights on, shades up

•Avoid caffeine after 3 pm

Management•Early PT/OT reduced delirium by

50%