The concept of Progressive Mobility

Breaking the paradigm of bed rest

“First, morale is greatly improved…. General health and strength are better maintained and convalescence is more rapid.”

Dock, W.The Evil Sequelae of Complete Bed Rest.

The benefits of early ambulation:

1944…

“There appears to be significant potential for harm arising from current ICU culture of patient immobility and often excessive or unnecessary use of sedation…. But this culture has persisted despite emerging evidence that these practises may, alone or in combination with acute illness that precipitated the ICU admission, have important adverse consequences that may not be remediable over time.”

21st Century …..

Herridge MS. Mobile, Awake and Critically Ill, 2008

The Impact of Immobility

Table taken from Critical Care Rounds Volume 8, Issue 4 ,2011

9. Convertino, VA et al, 1997

10. Davydow DS et al , 2008

11. Cox et al, 2009

Abbreviations: VO2 Oxygen delivery

MIB Maximal Inspiratory Volume

FVC Forced vital capacity

ICUAW ICU acquired weakness

PTSD Post traumatic stress disorder

QOL Quality of life

The Impact of Immobility

“Many of these patients experience physical disabilities one year after hospital discharge, with approximately half of the patients unable to return to work because of persistent fatigue, weakness and poor functional status due to immobility.”

Herridge MS. One-year outcomes in survivors in acute respiratory distress syndrome, 2003

“ Changing the focus from simply improving vital organ function and preventing death to helping the patient to achieve long-term independence modifies how we must take care for patients… We need to understand better the late effects of critical illness and their future impact on the patient.”

Bailey: Culture of Early mobility in mechanically ventilated patients, 2009

Targets of Early ICU Mobilization

•  Early defined as initial physiologic stabilization, continuing throughout ICU stay •  Initiating patient mobilization within 48 hours of patient admission to ICU through: •  ICU cultural shift toward mobility as a necessity, not optional, emphasizing team work

•  Optimizing ICU to allow for patient mobility - Equipment - Sleep - Sedation

Bailey PPR: “Culture of Early mobility in mechanically ventilated patients, 2009

Definition of Early ICU Mobilization

Effective mobilization of Critical Care patients starts on day one

What is Progressive MobilityTM?

Research indicates a correlation between positive outcomes and the following factors: •  Early implementation •  Frequency of rotation •  The pause time •  Head of bed elevation •  Duration of rotation (> 18 of 24 hrs) •  Use of adjuncts such as vibration, percussion •  Underlying disease •  Size and weight of patient •  Patients tolerance needs to be monitored

How to use CLRT?

Continuous Lateral Rotation Therapy

Head of Bed Elevation

Components of Progressive MobilityTM

Artificial ventilation in the semi recumbent position improves oxygenation and gas exchange (Ben Speelberg, MD, Frits van Beers)

•  Supine position vs. 30°and 45 HOB elevation in 32 interdisciplinary ICU patients

•  Measured outcomes: Gas exchange and lung mechanics

Research findings

End-tidal CO2 significantly lower:

45°< 30°< supine (p = 0,001)

Results

Chest/124/4/October, 2003 supplement

Lung mechanics improve with HOB elevation:

45° >30°> supine

Oxygen saturation significantly improved:

45°>30°> supine (p = 0,001)

Verticalisation

Components of Progressive MobilityTM

• Achieves up to 20° of Reverse Trendelenburg

•  Gradually and safely acclimatizes your patient to an upright position

•  Provides orthostatic training

Preliminary Tilt Table

• Enhances respiratory efficiency, pulmonary mechanics, oxygenation, and gas exchange

FullChair® Position

• Safe and easy position for patients to egress the bed

Chair Egress Position

Standing up with full support

•  Standing up strengthens the skeleton, stimulates the circulatory system and have a positive effect on several body functions

Mutch K et al. “Changing manual handling practice in a stroke rehabilitation unit”, Professional Nurse March 2004 Vol.19 No 7.

Standing up with partial body weight support

•  Using a lift and vest makes it possible to adjust the help given to the patient

Perme C. Early Mobility and Walking Program for patients in ICU. Creating a Standard of Care. Am J Crit Care, 2009, 18: 212-221

The first three hours… •  Starting walking training within the first three hours after admission is associated with better outcomes, especially for patients on a rather low level of function!

Walking training

Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008;36(8):2238-2243

Stepwise progressive rehabilitation

The graduated scheme used in Dr. Morris’ study:

Abbreviations : ROM Passive range of motion

OOB Out of bed

q2Hr Every 2 hours

3x/d Three times a day

MT Mobility team

PT Physical Therapy

•  78,6% ambulated independently •  4,7% sat on edge of bed •  Mean distance all 60 m •  Only 2,4% severely dependent

Results of Early Mobilisation

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

Is it safe for the patient?

•  Lower complication rate compared to ”usual care” group •  Adverse events like falls, extubation etc. occurred in <1% of all patients and were immediately corrected (no extubation).

Source: 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

Process improvement: Impact on Outcomes

1: „Comparison of Caregiver time necessary for Patient positioning using the TotalCare® Bed vs. a Standard Bed, Tampa General Hospital, Tampa, FL 2: Comparative study TotalCare® Bed vs. Standard Bed: Analysis of physiological parameters in patients after coronary bypass procedures; Emory Hospital, Atlanta, Georgia

•  Significant ergonomic improvement for caregivers 1, reduction in time needed by 84,7%1 •  Frequency of mobilisation increased by 48.5%1 •  Number of caregivers required per verticalisation reduced by 45% vs. standard mobilisation procedures

•  Time span between extubation and full mobilisation out of bed reduced by 38%2

TotalCare® Connect Foam

TotalCare® Connect Duo® 2

TotalCare® Connect P500

Progressive Mobility and safe Verticalisation for ICU- and High dependency patients at risk for complications due to immobility

Skin protection, length of stay - and pressure ulcer management for ICU patients at risk. Progressive Mobility and safe Verticalisation

Clinical outcomes, length of stay - and pulmonary complication management for ICU patients at risk . Progressive Mobility and safe Verticalisation

Clear Lungs, Safe Skin, No Falls:

TotalCare® Bariatric Plus

Enhancing outcomes in Critical Care

TotalCare ® Connect SpO2RT® 2

2012-01-18 24

Dr. Needham: “What did you think when we discussed getting you out of the bed while you were being ventilated and had a respiration tube in your mouth?” Mr. E.: “I thought it would be wonderful. Anything to get myself up, get out of bed. Anything to get off my back and onto my feet – that’s what I really wanted. I enjoyed it. I think it had a very positive effect on me.” Needham 2008

Vision quality of life!

What remains to be said…

Bailey P, et. al. Culture of early mobility in mechanically ventilated patients; Crit Care Med 2009 Vo. 37, No. 10 (Suppl): S429-S435 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 Burns JR, Jones FL. Early ambulation of patients requiring ventilatory assistance. Chest. 1975; 68(4): 608 Burns SM, et. al. Effect of body position on spontaneous respiratory rate and tidal volume in patients with obesity, abdominal distension and ascites. Am J Critical Care;1994 Mar;3(2):102-6 Clavet H, Herbert P, Fergusson D, Doucette S, Trudel G. Joint contractures following prolonged stay in the intensive care unit, CMAJ, March 11, 2008: 691-697 Convertino VA, Bloomfield SA. Greenleaf JE. An overview of issues: physiological effects of bed rest and restricted physical activity. Med Sci Sports Exerc. 1997;29:187-190 Cox CE, Docherty SL, Brandon DH,et al. Surviving critical illness: acute respiratory distress syndrome as experienced by patients and their caregivers. 2009;37:2702-2708 Davydow DS, et al. Psychiatric morbidity in survivors of acute respiratory distress syndrome: a systemic review. Psychosom Med. 2008;70:512-519 Delaney et al. Kinetic bed therapy to prevent nosocomial pneumonia in mechanically ventilated patients; a systematic review and meta-analysis. Crit Care, 2006, 10, E-pub. Dock, W. The evil sequelae of complete bed rest. JAMA. 1944;125: 1085 Drakulovic MB, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial; Lancet 1999; 354(9193):1851-1858 Engel H. ICU Early Mobilization at UCSF; Critical care & Trauma Conference San Francisco 2010 Grap, MJ, Cautley M, Munro, CL, Corley, MC. Use of backrest elevation in critical care: a pilot study. American Journal of Critical Care 1999; 8(1): 475-480 Herridge MS. Mobile, Awake and Critically Ill. Can. Med. Assoc. J. 2008 178: 725-726 Herridge MS. One-year outcomes in survivors in acute respiratory distress syndrome. N Engl J Med. 2003;348(8): 683-693 Hopkins RO, Spuhler VJ, Thomsen GE. Transforming ICU culture to facilitate early mobility. Crit Care Clin 2007;23(1):81-96 Hopkins Ramona O., Spuhler Vicki J.: Strategies for Promoting Early Activity in Critically Ill Mechanically Ventilated Patients; AACN,; 20(3): 277-289 Johannigman JA, et al. Effect of body positioning on pulmonary gas mechanics, gas exchange, and lung volumes in elderly and obese subjects without lung disease. American College of Chest Physicians, New Orleans, LA, 1997 Keane, F.X. The minimum physiological movement requirement (MPMR) for man supported on a soft surface; Paraplegia, 1978; 16:383-9 Korupolu Radha et. al. : Series on Early Mobilisation of Critically Ill Patients; Part One: Screening and Safety Issues; ICU Management 3-2009: 27-29 Korupolu Radha et. Al. : Early Mobilization of Critically Ill Patients: Reducing Neuromuscular Complications After Intensive Care; Contemporary Critical Care , February 2009: 1-12 Koo KY, et al. Prioritizing Rehabilitation Strategies in the Care of the Critically ill : Critical Care Rounds, 2011, vol 8,issue 4 Krishnagopalan S. Body positioning of intensive care patients: clinical practice versus standards. Crit Care Med 2002;30,2588-2592 Malbouisson et al. CT Scan ARDS Study Group. Role of the heart in the loss of aeration characterizing lower lobes in acute respiratory distress syndrome. Am J Respir Crit Care Med 2000;161:2005–12 Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008;36(8):2238-2243 Morris et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med, 2008, 36, 2238-2243 Needham Dale M. Mobilizing Patients in the Intensive Care Unit. JAMA, October 8, 2008 ; 300 (14): 1685-1690 Perme C. Early Mobility and Walking Program for patients in ICU. Creating a Standard of Care. Am J Crit Care, 2009, 18: 212-221 Swadener-Culpepper et al. The effect of continuous lateral rotation therapy in overall clinical and financial outcomes of critically ill patients. Crit Care Nurs , 2008, 31: 270-279. Schweickert, W.D. et. al: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial, Lancet, Vol. 373, No. 9678, 1874-1882 Seiler Prof. O. The dangers of bed rest; 1979 Skelton DA. Strength, power & related functional ability of healthy people aged 65–89 years. Age Ageing 23: 371–377, 1994. Speelberg B. Ventilation Practitioner; Artificial ventilation in the semi recumbent position improves oxygenation and gas exchange Teasell Robert, Dittmer Douglas: Complications of Immobilization and Bed Rest, Part2: Other Complications; Canadian Family Physician Vol 39: June 1993: 1440-1446 Thomsen George et. al. : Patients with respiratory failure increase ambulation after transfer to an intensive care unit were early activity is a priority; Crit Care Med 2008 ; 36(4): 1119-1124 Torres A, Serra-Batlles J, Ros E, et al; Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann. Intern Med 1992; 116 (7): 540-543 Truong Alex D et al.: Bench-to-bedside review: Mobilizing patients in the intensive care unit – from pathophysiology to clinical trials; ccforum.com/content/13/4/216 Van Nieuwenhoven CA, et. al. Feasibility and effects of the semi recumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med. 2006;34(2): 396-402. Vollman, K. The Right Position at the Right Time: Mobility makes the difference 2003 Winkelman Chris Bed Rest in Health and Critical Illness, AACN Advanced Critical Care; 20(3) 254-266 Winkelman Chris, Peereboom Karen: Staff-Perceived Barriers and Facilitators; Critical care Nurse; 30(4) 2010, Supplement S13-S17 Zanni Jennifer M., Needham Dale M. Promoting Early Mobility and Rehabilitation in the Intensive Care Unit. CEU, May 2010: 32-38

References and Resources

The reference of publications and studies in this presentation is for the purpose of medical - scientific background information only.

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