Jeff Maglin: It’s now my pleasure to introduce our speaker Nan Nathenson. Nan is a respiratory therapist and educator. She has worked in nearly every level care including critical care and rehabilitation settings. In her experience, she has narrowed the gaps between levels of care. Bridging those gaps with an early mobility module can bring about a more enriching experience for clinicians and enhance experience for patients and families, while improving patient and financial outcomes. I will now hand the controls over to Nan.
Nan Nathenson: Thank you, Jeff. I am very happy to be with you. For the RTs out there I want to wish you a happy respiratory care week and thanks for all that you do for our patients and their families. I think it’s … Anyone in healthcare, I think, we could all agree that early mobilization benefits our patients, whether they’re on a mechanically ventilated or whether they’re mechanically ventilated or not. Dr. Petty, Tom Petty and Stouffer and Olson in 1981 stated that the increased acuity of the ICU patient over the years and the development of pharmaceuticals for sedation and technological advancements in life-support have played a role in the challenge of providing early mobility for this patient population. To us, what is the extent of the dangers of neglecting early mobility? How can we as healthcare providers come full circle and integrate both technology and back to basics approach that offers a more holistic humane care?
Even though we all know that early mobility is very important, it’s not lost on me the barriers to providing an early mobility program no matter what level of care you are in but specifically in the ICU. we’ll get to all that. Thanks again and let’s get moving. Jeff already covered this slides so we’re going to move on. Our objectives, we’re going to be looking at the profound impact of bed rest in a mechanically-ventilated patient, and, of course, even if their patient is not mechanically-ventilated, these effects are going to be as profound in those patients as well.
We’re going to look at strategies for early mobilization. To improve patient outcomes we’ll explain the potential benefits resulting from early mobilization of the mechanically-ventilated patient in the ICU, but again, this is certainly going to apply to any patient and even a healthy specimen, maybe a 24-year-old ski bum that broken leg and is busted up and needs to be laying around in bed and is immobile. Even in healthy subjects, the effects of bedrest are very profound.
I’m in rehab and I’ll be the first one to tell you that rehabilitation is not a particular setting. It should be a philosophy of care and that’s where we’re coming from today. The ICU, whether it’s a step down unit, long-term acute care hospital, acute rehab, subacute nursing home, assisted living and home, across the continuum of care, we have got to look at rehabilitation as a key component of the road to recovery.
Interdisciplinary teams, no matter what level of care, what we’re looking at is helping patients achieve their physical and cognitive function. We want to maximize their independence so that they can return to their life roles. Rehabilitation early in the continuum of care can help prevent impairments that lead to barriers to recovery. There’s such a thing is prehabilitation and we’ll talk about that found in a later slide. In mechanically-ventilated patients, the incidence and severity of the impairment can be reduced in proving both short-term and long-term patient outcomes and also hospital outcomes.
The ICU, interestingly, was developed the specialty of intensive care, was developed as a consequence of the poliomyelitis epidemic, of which my great-grandfather died, my grandfather rather died during the 40s and 50s when widespread mechanical ventilation was required. You can see we have the old iron lungs and there’s an entire word of this type of patients in this type of mechanical ventilator. Obviously, these patients are not going to be getting up and moving. According to the Society of Critical Care Medicine closer now to 5.7 million patients are admitted annually to the ICUs and it’s great, 80% to 90% of the patients survived their ICU stay but really to what end and to what quality of life? We’ll be looking at that. The five primary ICU admission diagnosis are, top of the list, respiratory insufficiency and failure, in addition to postoperative management, heart disorders, sepsis, and also heart failure.
Early mobilization was introduced late during World War II, but it was identified as being important as early as 1889. The reason that early mobilization was introduced during World War II was in an effort to get our soldiers back on the battlefield. The first conference on bedrest was published in 1944, and there is an international journal with the title, “The Evil Sequelae of Complete Bed Rest.” Long ago, we knew that mobility was very important and that bed rest was going to be impacting our patients.
In this journal, one quote, first, morale is greatly improved, general health and strength are better maintained, and convalescence more rapid. I think that’s just a great quote. Thomas L. Petty, who is a famous pulmonologist and worked at the University of Colorado, in 1964, he stated, “Patients who require mechanical ventilation were awake and alert and often sitting in the chair. They could interact and feel human. The ICU present”, what he sees and this is in the early 2000’s and the 80s, and I can speak from my experience in the ICU in 1980s, that the patients were essentially paralyzed, sedated lying without motion, appearing to be dead except for the monitors that tell us otherwise.
In my experience, every day we worked really hard to keep our patients alive and make sure that they were not awake, they were tucked in bed with clean bed sheets for the oncoming shift, and that there was very rarely a time when we had our patients up to the cardiac chair, we called it the pink chair. They may still have pink chairs out there. We really didn’t have mobility going on in my ICU back in the day.
Thomas Petty noted that the high acuity care in the pharmacologic therapy led to the present situation. He also recognized that respiratory patients are anxious and they are depressed and they require a great amount of interaction from the healthcare team, which they weren’t getting. He also felt like there needed to be a better understanding of the delicate machine-patient interface that seems to be lost these days and requiring sedation and paralysis. I think we all realize that respiratory patients are anxious, and they’re worried, and they’re waiting to get their next breath, and they’re worried about being off the ventilator. They have a lot of anxiety, and that is something that we need to be more cognizant of and certainly to address. We need our patients awake and alert to do that.
The effects of bed rest really impacts every system in the body, reproductive, gastrointestinal, hematologic, just every system. After one week of bedrest, as far as muscle strength goes, it can decrease as much is 20%, with an additional 20% loss each subsequent week. This also I might add is for healthy subjects. The weakened muscles generate increased oxygen demand and even, as you see pictured there, high intensity exercises in bed don’t counteract the adverse effects of rest, so you see a cycle ergometer at the top and an arm ergometer at the bottom. These can be put in bed, they can be set to move for patients or for patients to work them themselves.
The allostatic response to critical illness is essentially your stress response. What happens in this situation is we have chemicals in our body that persist without restoration of stability. We have all these chemicals that are being triggered and produced where, and they have really nowhere to go and no way to help the body to heal. You have persistent protein tissue breakdown, organ and tissue deterioration, and this persistent inflammatory response going on and in addition, the patients will have high blood sugars even if they’ve never had hyperglycemia or never been diabetic. If anyone has experience in the ICU, it always is a struggle to manage blood sugars. They’re very difficult to control. Muscle wasting. Disuse of our muscles leads to atrophy and a loss of muscle strength now at the rate of about 12% per week. If you figure 3 to 5 weeks of bed rest almost half of the normal strength of the muscle is lost. The first muscles become weak are the ones that resist gravitational forces in our lower limbs. It’s our skeletal muscles that lose tone when the no longer bear weight. This is the first muscles to become weak and notice how that could certainly impact on mobility, having the most weakened muscles being our skeletal muscles in our legs.
Then we have the stiffening and shriveling of muscles that causes reduction in the mass of the muscle and along with the loss of fat that is possibly what is responsible for weight loss that sometimes accompanies bed rest. Just laying around, you think you wouldn’t burn a lot of calories, but with this stiffening and shriveling of muscles and the loss of body fat, that contributes to weight loss in that situation.
Disuse atrophy of the diaphragm. VIDD or ventilator-induced diaphragm dysfunction occurs with the mechanically-ventilated patient, and this is because you do not have that neural stimulation or muscle loading of the diaphragm. We have … Our brains tell us to breathe. We don’t have to tell our brains to breathe and that neural stimulation of the diaphragm is something that is lost during mechanical ventilation. In addition, there is isoforms that convert our slow twitch muscle fibers into fast twitch fibers. If you’re familiar with that, if we’ve got runners out there, we know that slow twitch fibers are the fatigue resistant fibers. When you make that switch from slow twisted to fast twitch, you have the muscle fibers in the body including the diaphragm that is not fatigue resistant, and it’s getting less fatigue-resistant as time goes on.
In addition, you have decreased muscles length and blood flow. Also in the lungs, we have a decrease in the residual volume and lung collapse. When we’re on a mechanical ventilator, certainly we can prevent lung collapse and atelectasis and so forth by having the patient on peep and such. But still, this is the impact of the disuse of the diaphragm during mechanical ventilation.
The inflammatory response. Most … Johns Hopkins, I believe, has stated that really all disease is a result of inflammation. When you have inactivity that triggers the prostaglandins in the body that initiate the inflammatory response. When you have inflammatory response going on in the body, this is associated with pain. Early mobilization including pre-rehab decreases the risk for immobilization associated with pain. Let’s talk about prehabilitation that includes active and passive range of motion. This would be for the patient going in for an elective surgery. Maybe they’re having a total knee or a total hip or some other type of surgery, so they go in and they are trained and given exercises for active and passive range of motion. They have other strengthening exercises and they boost the patient’s protein with supplements and drinks to prepare them for what comes after their surgery. What they found is that helps to decrease their risk of immobilization associated pain.
We talk about blood sugars and it is estimated that there’s about 90% of critically ill patients that develop hyperglycemia, which with blood sugar is about 126 mg/dL and studies have shown that sleep less than 5 to 6 hours a night, those patients were twice as likely develop diabetes. We’re going to talk about sleep deprivation in the moment, but who gets 5 to 6 hours of straight sleep if you’re in the ICU and that could be true for patients in other levels of care as well.
There are patients that are at increased risk for hyperglycemia, and those include the heart failure patients, CVA, myocardial infarction, and multiple traumas. Hyperglycemia also increases the risk of renal failure due to the advanced glycation end product, which decreases the functioning of the kidneys. Early mobilization can decrease serum glucose to normal levels. Standing, just standing, helps to lower blood sugars.
We also have cardiac complications. In our facility, we’re a rehabilitation hospital, Madonna Rehab in Lincoln and we also have a site in Omaha, but we receive patients from across the country. From those facilities, we know the patients that come to us who have not had early mobility protocols, and in some of the training that I have done across our state there have been admittedly staff that say, “We have a vent patient that hasn’t been out of bed for 15 days”, or “They haven’t been out of bed 32 days”, or “We did get them up to the chair after a couple weeks for a little bit”. What happens is certainly and what we have seen is that our patients come and they have terrible postural hypotension. They have not been up, sitting up. They haven’t been erect, standing, and we have fluid losses that are associated with that.
We have patients that come that had increased heart rate. We’ve got to get them on medication to just deal with their heart rate so that we can let them up and begin their rehab. Also, the impact on the cardiac system decreased stroke volume, decreased cardiac output because of these fluid losses and decreased peak oxygen uptake. Just to mention again that all of this occurs in healthy volunteers undergoing bed rest with a long recovery period. Think of our patients that we see in the hospital. Think of the age of the patient and also of the co-morbidities that they have in those cases.
Bone loss is very profound, and it’s the weight-bearing activities that actually help develop and maintain bone mass, and when you have weightlessness and immobility, results in bone loss. Decreased bone mass is a result of the phosphorus and calcium in the bone. The phosphorus leaks out of the bone and calcium and so weight-bearing is really the best treatment. That’s why it’s so important when we get older and we have the risk of osteopenia, which is the precursor of osteoporosis that we need to do strength training, weight-bearing and exercise. There are some supplements that help to redirect phosphorus reabsorption and bone mineralization. You may think it’s calcium but more than that, it’s vitamin D, which is a hormone and magnesium help redirect phosphorus reabsorption and the bone mineralization back into the bones. It turns out that our feet and the skin on our feet are the only areas of the body that are designed to bear weight. When we have immobility, that is most likely to put individuals at risk, of course, of altered skin integrity. When we look at some of the patients that have come to us that have not been mobile, we have these terrible occipital wounds on the back of patients heads. We’ve got on their elbows and their bottoms ulcerations and pressure ulcers that come. It happens very quickly. The lymph and the blood flow also causes the pressure ulcer so it’s not just immobility, but when you have immobility you have the impaired outflow of the lymph system and then blood flow also. We have these ischemic lesions and it turns out that about 70% occur in older patients within a couple of weeks. Sometimes by the time our patients reach us they have been in the ICU for multiple weeks.
Of course, the boney prominences that are on the bed and the pressure there are at highest risk. We have, with the prolonged pressure then you have the friction of repositioning. You have the moistness of the bed sheets from sweat or any kind of bad accidents, which causes bacterial reproduction and then infection. Sometimes patients come with wounds that set them back, way back from their rehabilitation because we are nursing their wounds. Anyway, it really takes its toll, of course. Again, what is the best prevention for pressure ulcers? Early mobility.
The G.I. tract. With the mechanical ventilation, patients on mechanical ventilation, they have their trach cuff up and they’re being ventilated solely by that mechanical ventilator. Their upper airway is bypassed so their sense of taste and smell and appetite are going to be decreased. Now in rehab we have ways that we … our patients can eat even if they’re on mechanical ventilators, which is good, but that doesn’t always happen in the ICU. We utilize speaking valves which we’ll talk about a little bit later in the program. You have the decrease in taste, smell and appetite. You have decrease food intake. Probably they’re getting some type of NG tube feeding or some type of feeding of that nature.
With decrease food intake, we have atrophy of the mucosal lining and the shrinking of the glandular structures in the body. There’s a risk of a leaky gut syndrome to occur when you have micro openings in the intestinal system where we have the … excuse me, I’m blank. The gastric juices and so forth like leaking into our body systems right out of our intestines. In addition, constipation can cause a lot of problems with patients. The pain relieving medication, of course, slows gut motility so if we have patients on pain meds they’re going to slow their gut motility and cause constipation, which can be very serious. The acidity in the stomach and cause gastroesophageal reflux. We try to prevent that, of course, making sure that we have our trach cuffs inflated well that we don’t have micro aspiration which still can occur even if you have your trach cuff Inflated properly, so we have that.
We also keep the heads of our beds up on our trach in our vent patients to help reduce that chance of that acidity of the stomach being aspirated into the lungs. We have the acidity of the stomach causing GERD, and then patients with artificial airways, of course, are at risk for aspiration and pneumonia, micro aspiration and things if their head of the bed is down, if their trach is not patent. What happens to the blood? We have water loss with bed rest and that increases to the thickening or increase blood viscosity. The oxygen demand is decreased. Hemoglobin is decreased. Hemoglobin, our carrying capacity for oxygen. We have a decreased hemoglobin. we have venous stasis because our bodies are sedentary. Venous blood pools cause stasis. The risk of embolism is very high, which can cause a stroke, ischemic strokes, where you can have a myocardial infarction, DVT, deep vein thrombosis. Turns out that pulmonary embolism is one of the most common causes of sudden death, sudden unexpected death in hospitals. Even the blood is affected, and is very risky for that immobile patient.
The intensive care as a hostile environment. I worked in the ICU and our patients never got any sleep, but the cartoon says, “Try to get some rest. I’ll be in every few minutes to make sure you don’t.” I think we’re probably a few chuckles going on right now. In the ICU, you have delirium is a real issue, and it’s caused from noise, ambient light, restriction of mobility, social isolations, all of those play a part. Constant sounds of IV pumps going, alarms going off, telephones ringing, pagers, just conversations, things like that. The negative effects of the ICU as a hostile environment are peripheral vasoconstriction. We’ve got increased arterial pressure. We have got increased epinephrine release in the body, increased muscle tension and delirium also contributes to increased LOS, length of stay, and increase mortality. Just delirium in itself has an impact on our length of stay and mortality.
Everybody should be getting a lot of sleep. The person that says, “Oh, I only need five hours of sleep.” Even a healthy body needs much more sleep than that. There have been studies that have shown that sleep deprivation negatively impacts attention, awareness, reaction time, memory, reasoning skills, creative thinking, all of that. I think any of us that have been sleep deprived or maybe taken a global trip or something like that have felt that by not getting adequate sleep ourselves, brain fog and so forth. Imagine the patient being ill and the compounding effects of everything that’s going on in their body and then not to get enough sleep.
When we are sleeping we have very important hormones in our body that need to come to homeostasis, they need to equilibrate at night, and it is only during sleep that we can equilibrate these hormones. You have your appetite stimulant hormone which is Ghrelin and that increases with sleep deprivation. Also, you have Leptin, which is your appetite suppressant hormone that’s produced by the fat cells, and this decreases with sleep deprivation. Then, of course, cortisol we’re most familiar with, which is our stress hormone. With sleep deprivation, your cortisol increases. Cortisol is something that we struggle with on a day-to- day basis with stress just of our own. We have a stressful day, it may start with waking up late, getting stuck in traffic, being late for a meeting with our boss, then we get home and we realize we don’t have eggs and we’re planning to make keesh for dinner. We constantly have this elevated stress, it never really does go down. This also happens with patients that are in the ICU, the stress of being medically ill and all of these things cause the patient had increased cortisol.
When you have all that stress in your body, none of your bodily systems can function properly and the body can’t heal, because the body naturally heals itself. You cut yourself and you don’t have to tell your body to heal, it naturally heals itself and that’s constantly going on in our bodies. No matter what is our ailment, our bodies are really trying to heal themselves. With all of this increased stress, we’ve got to have enough sleep to normalize these hormones and especially cortisol, to respond to stress and not to become ill.
The immune response. During the early stages of sleep we have certain immune cells that peak in concentration. What happens is, this is our initial response to invaders. During sleep, that’s when we have this boost of these immune cells that help prevent us from being attacked by invading organisms of which there are a multitude of course in the hospital.
Even the perception of self, our self-awareness concept, self-esteem, all of that is subject to a really severe impact. Just to mention self-concept, our self-concept of ourselves is the stable set of beliefs about one’s qualities and one’s attributes, so each and every one of your qualities and attributes that you see in yourself. Your self-esteem is feeling self-worth, which is also a central component of psychological well-being. These self-concepts, self-esteem make up a person’s also body image, their achievement, their social functioning and their self identification. During bed rest, there is a decrease, of course, in body function, the appearance is altered, of course. You have multiple bad hair days in the ICU. Probably if you’re woman you’re not going to be able to be putting on your makeup, you’re going to lose weight, you’re going to just look sick and so your body image is going to plummet during illness.
The other aspects of self are, that are negatively affected are the achieving self. What is he achieving self? The achieving self is when bed rest threatens your aspects of your achievement that you have through your work or your hobby. Many of us draw satisfaction from our jobs and our interests, and this sense of satisfaction can be threatened if they’re unable to do them. Your social self is the interactions you have with your friends, with your family. It can be a vital source of our self-esteem and emotional support. When you have a breakdown in this support system, it can have very unhelpful consequences for the patient’s sense of identity within the family or social network. In the ICU, for example, there’s not a lot of visiting going on so there’s not a lot of opportunities to connect socially with your families. Then your private self. When you’re on bed rest you’re dependent on others aren’t you? There’s a resulting loss of that independence and the strain of imposing on others to care for you and just so many different ways can be a major threat to your private self.
Adverse emotional problems are a common symptom in ICU patients recovery. It turns out about 25% of ICU survivors experience adverse emotional outcomes during months and years after the ICU. These patients struggle with their everyday activities just with working and with interacting with their friends and families. It turns out that the predictors of adverse emotional outcomes have been linked to increased length of stay, prolonged mechanical ventilation, female gender, alcohol use, and smoking it turns out. Many patients in the aftermath of an ICU stay experience emotional problems, depression, anxiety and such.
The impact of aging in healthcare. Admittedly, I’m a baby boomer. Roughly 10,000 of us will turn 65 today in 10,000 more will cross that person everyday for the next 19 years. We’re going to have a lot of baby boomers to take care of. Also, you might be interested to know that people aged 85 or older are the fastest growing segment of the US population. We’re living way longer than expected, and so what we want right and the goal of this presentation and the goal of early mobility in healthcare is to make sure that we’re just a happy healthy bunch like the ones you see on the slide.
Technology. Technology really got us into this mess and the impact of that has been we have long-term survival. We got people surviving and what’s happened to those people is they’ve had dysfunctional decline without early mobility. They have increased morbidity, more complications, increased mortality, increased cost of care, increased length of stay, all of those things have occurred from prolonged ICU stays. How do we get our patients out of the ICU sooner? We get them up and out of bed.
The chronic critical illness syndrome was first termed in 2002 in the critical care nursing clinics of North America. A syndrome is where you have a consistent symptoms linked to underlying pathophysiology. What happens with this prolonged inflammatory response to acute illness, this leads to multiorgan dysfunction, and what’s really happening in the chronic critical illness syndrome is patients that have an acute status move to a chronic status during their ICU stay, so they have an acute issue and it becomes chronic. That is because we have failure to resolve the underlying problem, there’s the development of new issues like we talked about, hyperglycemia, all different types of impact that we’ve mentioned previously, and also continued organ damage. That’s the unintended consequence that we have had with having such advances in life-sustaining technology, whether it’s machinery or pharmaceuticals or just the culture that we’ve had with immobility. Not only that, outcomes are poor. We have surviving without thriving, and that’s what we want to turn around.
Who is at risk? ICU patients, patients on mechanical ventilator greater than 72 hours, patients that are there more greater than 3 to 5 days, greater or equal to three pre-existing conditions, and we know our patients, a lot of patients have pre-existing conditions. They come in with obesity, they come in with hypertension, they come in with diabetes and COPD and so forth, and definitely, patients that are older, greater than 65 years of age. Not only that, those patients that come in with reduced function prior to the ICU, they are also at risk for developing this critical chronic illness syndrome.
Myra Estrin Levine. She was a nurse and the theorist. Of all the things that we need to be doing in the ICU and a lot of times I know that we’re doing our best just to keep our patients alive, but there’s many things that we need to do as healthcare professionals. The principles of Mrs. Levine was to conserve personal integrity, our social integrity of our patient, the structural integrity of a patient, and also conserving energy.
How do we do this? How do we apply the conservation principles in this way? The patient’s personal integrity. This is that interface with patient and healthcare provider, recognizing that the patient has an individual needing of respect, we want to honor their self-awareness and their self-determination, their social integrity. We want to do our best to get their loved ones at the bedside, and that is huge. If there’s an ICU that’ll let a puppy or a kitty cat in the room that would be good too because we do have that at our facility. We have the angel dog program and there’s been a lot of studies about just the happiness quotient that skyrockets with a visit from a pet. Certainly, we want to get our loved ones at the bedside to reconnect with our patient.
The structural integrity. We want to maintain the structure of the body to prevent the physical breakdown. Then, saving energy, conserving energy, how we do that? We need to save energy for the healing process. We can overtax our patients. We want to balance that energy input and output to avoid excessive fatigue. We do that with ventilator weaning. We may have our patients sprint off the ventilator for a while. We make with a speaking valve in for them, for their weaning, but we always get them to add time, adequate time to rest and to rebuild. If you’re on a person that goes to the gym, really going to the gym every day, never gives your body and your muscles time to rebuild. Adequate rest and sleep, of course, and adequate nutrition is important.
How do we intervene early and identified the at risk patients? We have good communication. Back in the day, in the ICU, we never had team meetings in the ICU, when I worked in the ICU. In rehab, we always have team meetings. The whole team is involved from RT to nurse to doctor to physical therapist, case management, OT, everybody’s there. We want to establish good communication. There are more team meetings now in the ICU. That’s part of the ICU model now, is to really have these meetings.
We want to assist the patient with setting their goals prior to any kind of possible decline in cognition. The patient’s goals are what we want to identify. We want to get a family meeting with the patient within 24 to 48 hours and be proactive with the patient and family communication. What I found in rehab, and many of you probably also have found this to be true, is on connecting with the family is really a good way to keep your patients motivated and going in the right direction for their recovery.
We want to early implement activity and mobility, wound prevention, positioning strategies. Positioning strategies is really very important. If anyone has ever taken Mary Massery course, Mary Massery states that you can’t breathe, you can’t function. She’s identified many different positioning strategies for different neuromuscular diseases and different elements that help to maximize ventilation and oxygenation in patients. Positioning strategies are key, mobility just range of motion, sitting, weight-bearing and early ambulation for definitely the mechanically-ventilated patient often requires portable ventilators, or at least a ventilator you can unplug and roll around.
We want to get our patients in and out of bed. We want to get PT and OT going. Some ICUs don’t have the standard for PT and OT. Some physicians don’t give us the order to get our patients out of bed, so we need that support. We want to preserve their functional capacity and make sure they’re not in bed too much, balance the rest again, and then also get the patient and family involved. We want the patient to be able to help orally suction themselves and help sit themselves up and so forth, always the patient participation as best as possible.
Who’s the team? It begins with the physician. Even above that, it begins with admin, it begins with the administration, buy-in. We need to get their buy-in and if we have a development of the business model that demonstrates that, financial investments and additional staff reap the rewards and cost savings. Then by decreasing our critical care patient days, we can decrease the overall hospital stay and fewer complications. But we’ve got to have the doctor on board, the nurse, the RT, PT, OT, speech, neuropsych pastoral care, always include and always honor the spirituality of a patient and have pastoral care involved.
Medical stability. Before we’re getting in moving, this is just a general rule. We all know that our patients have individually this medical stability could be tweaked a little bit for this patient or that patient but heart rate less than 110 or so at rest mean arterial blood pressure about between 60 and 110, and FIO2 of less than 60. We find that having such high oxygen needs are … it’s very difficult to get our patients mobile and so that’s were cut off point from doing too much mobility with patients that requires such high oxygen needs.
The contraindications of early mobility. Certainly, if we have instability in the cardiovascular, pulmonary or musculoskeletal system. We’ve got broken bones, we’ve got that type of thing. We certainly aren’t going to start early mobility then.
early mobility phases, in the ICU begin just with basic in-bed passive range emotion. In other words, we have a therapist that’s helping the patient to move and do range of motion exercises and then active having the patient participate, just with stretching, just opening up the chest, getting the shoulders back, positioning them, getting them doing some resistance exercises and then breathing exercises too, especially if there on off the ventilator.
Standing activities. I had one physical therapist say, “I’m the only physical therapist and we can’t our patients up and I wish we had a standing frame. We don’t have the money for that. It’s the ground troops really that know the importance of early mobility and sometimes the barrier which we’ll get to also in a minute are too great.
Just getting patients vertical, feet on the ground, using a walker, using a little bit of assistance, just doing some wait shifts from right to left but right to left foot, doing steps in place and then sidestepping and then walking reeducation as tolerated. Walking with a walker, walking with assistance, there you’ve got a LTV Ventilator that’s in tow for that in-patient. The increase … there are transfer and endurance so patient being able to move from point A to point B and their endurance in doing so. Then also, we got to meet the ventilation and oxygenation needs for this increased exertion for the patient.
Yeah, this is an ICU, and this a patient that has multiple lines and tubes and on a ventilator and everything. Yeah, there’s barriers to early mobility for sure. We’ve got the instable, unstable patient. we’ve got the lines, mechanical ventilator, we’ve got profound muscular weakness. I mentioned the lack of standard of PT and the ICU. Staffing levels also are a barrier. Lack of training expertise and confidence. In the facilities that I’ve presented to, there’s nurses, they don’t respiratory touching their patient and the respiratory therapist don’t want the nurses in some cases messing with their ventilator.
It’s important to have multi-disciplinary education strategies. That’s something that in rehabilitation we do. The PTs, the OTs, they all have competencies on ventilator troubleshooting, ventilator modes, the levels of support, how that’s different. Work of breathing, we don’t have endo-tracheal tubes at our facility, only tracheostomy tubes, but just really the management of those tubes, the speaking valve use. Speaking valve use is not used as much in the ICU. We use the speaking valve from weaning from mechanical ventilation and we do that very early on in the patient’s stay and what it has happened in multiple studies that, I believe are at the end of the presentation are that they found that the use of a speaking valve with the mechanically-ventilated patient, has helped to decrease anxiety.
There is an earlier advancement in a diet. Improved patient’s satisfaction, increased management of heavy secretion loads. They tolerate weaning better with a speaking valve. The patient’s breathing is made easier and feels more normal to have air going or pressure into their lungs and then as they exhale, they exhale through their mouth and nose, and then in that case they can verbalize.
There’s barriers to that because some of the critical care ventilators, they aren’t set up to use the speaking valve very well. You may have to put them in a non-invasive mode of ventilation where you might have less alarms to alert you that there’s something going on with the patient. But that is something hopefully with technology we’ll be able to have more of the speaking valve use in the ICU. Airway emergencies, understanding work of breathing, understanding how to safely move the patient and patient monitoring. All of the team, the entire interdisciplinary team that I mentioned needs to have this type of training.
Technology as a solution. Let’s use it as the solution. We have more portable ventilators that are available. We have wireless monitoring devices. There is mobile high velocity nasal insufflation systems. On the right, you see, this is the Vapotherm Transfer Unit that helps with those patients that have high oxygen needs and work of breathing issues so that they can become mobile. There is neuromuscular, electrical stimulation devices that use like a low-voltage electrical impulse to create passive contraction of the skeletal muscles through electrodes on the skin, and that helps to mimic a mild exercise.
we have … there’s also the cycle ergometers that I mentioned earlier that can help preserve the muscular architecture. There’s custom transport carts that maintenance folks develop that have shelves for the ventilator. They have IV poles on them, they got a seat for the patient to sit on when they need it. They’ve got hooks for IV poles, or rather our for chest tubes and urinary bags etc. There’s also specialty beds that go, can transform into a chair type of situation for patients.
The benefits of early mobilization are certainly minimizing the effect of bed rest that we have been over. The multi-system impact, minimizing that, promotion of improved function for patients, promotion of weaning from mechanical ventilator support, and by doing this, as the patient’s strength and endurance improve, we have our decreased length of stay, we have a decrease cost, and we have improved quality of life for sure.
There was a study by Needham and colleagues. Dale Needham, many of the respiratory therapists out there are probably familiar with Dale Needham. He did a memorial lecture for Thomas L. Petty, the professor of pulmonary and critical care medicine Needham is, and medical director of critical care, physical medicine and rehab at Johns Hopkins. He explained about how ICU acquired weakness can devastate patients both in the short and long-term. What happens he states that we have a focus on the immediate problems of what’s going on, we’ve got sedation still going on, and nearly half of the patients in one trial had neuromuscular abnormalities a year later and another half of those of working age returned to work, only a half of them returned to work.
There were … He states that in his study, feeding patients better doesn’t work. Just by giving them the nutrition, it doesn’t help. Long-term muscle weakness and the factors that contributed to long-term muscle weakness are age and bed rest. He stated in the study, “Early mobility works”, and after two and half years, narcotics were cut two thirds without an increase in pain, days without delirium doubled, ICU mortality dropped by 10%, ICU length of stay by 30%, and hospital length of stay by 18%. This is from Dale Needham from Johns Hopkins.
He also did the study with patients with acute respiratory failure. This involved PT and OT visits for the patients. Their goal was to decrease risk of delirium and loss of physical function. The patients then received daily sessions of PT and OT, about 30 minutes twice for PT and 30 minutes a day for OT. The participants included 57 patients mechanically-ventilated for four days or longer. Benzodiazepine use was decreased by 50% and this study resulted in improvements in ICU delirium, functional mobility, decrease in hospital and ICU length of stay.
What we’re finding is is that early mobility improves patient function and supports quality of life, promotes patient’s weaning from ventilator support, decreased length of stay, decreased cost, and of course, as I mentioned, improved quality of life, and that’s what we want so much for our patients. There is strong evidence now that there is an improvement in clinical and economic outcomes. With the patient’s quality of life, a patient’s experience within healthcare and their sense of self, that can enable them to transmute a serious trial and hospitalization into experience of growth and of healing.
By just embracing the technology or the technological advancements in our medical equipment, that gives us the opportunity to make mobility happen early and safely for our patients. Let’s see, didn’t we already do that? okay. In an analysis of the literature and there has been very few randomized controlled trials published that examine the effects of establishing and early ICU mobility programs, the design of most studies were prospective cohort studies on or before or after the studies following implementation of an early mobility, a QI initiative, but the findings in general and you’ll find this in the literature references is, there are improved outcomes. Patients were gotten out of bed in five days versus 11 days. They had a decrease in the incidence of ICU’s psychosis or a.k.a. delirium. Shorter ICU length of stay from 6.9 days to 5.5 days. Shorter hospital length of stay from 14.5 to 11.2.
Greater incidence of return to independent functional status after discharge, and that’s what where our goal is. No matter if it’s saving our patients or cardiac patients and making sure they get to the hospital in time, and we’re on the chest if they need CPR most of the time. We can make sure that they returned to their independent functional status after discharge or whether it’s a patient from the ICU that was on the ventilator. Then of course improved quality of life is the absolute goal for our patients.
The takeaways. We need to have recognition and understanding that there is a problem and that we’re not doing early mobility, and what impact that it’s having within the healthcare system, within your healthcare system. Administrative and stakeholder support is key. You have to talk to them and make sure that they have buy-in. You can’t just go to the doctors a lot of times. Go to admin, admin will often do what doctors I think is best. Creation of that multidisciplinary team so the PT, OT, speech, RT, nurse, doctor, everybody needs to be on the same team and have the same goal. Identify those barriers to change that are within your facility and what are the appropriate solutions? Yeah, there’s barriers, there’s problems but pick a solution.
Get a team together and see if you can change your clinic culture. Not sure what your cultures are like in your ICU. I’m not sure what they’re like if you’re working in a rehab facility or if you’re working in a step down unit or what it is. But again, across the continuum of care, no matter if the patients are at home or in the ICU, mobility is very important. Mobility is important if you have a parent at home. They need to get up and move and that’s going to help their quality of life and their longevity.
Research, as I mentioned, already has present safe and effective strategies for early mobilization and we can improve our patient and our hospital outcomes. Let’s see, here is some pictures of early mobility. This is one of our patients on the arm ergometer with of VTU card providing flow and oxygen for her so she can tolerate that.
Here’s a portable ventilator. This when we can just pop off and throw on the back of … we didn’t get the shelf built on the back of her little standing frame there but it could certainly get thrown on the back. Then here’s another picture of the Vapotherm. There are other high flow heated humidification devices that are out there. Not all of them are portable. Anyway, that’s one way that we can meet the needs of our patients that are, our respiratory patients that have oxygenation and a work of breathing issues.
Jeff Maglin: Well, we run out of time. Again, I want to thank you for leading this presentation Nan. Thank you to all the attendees. We’re going to have another two webinars, so the next two days, that’s 1PM Eastern time. If you’re interested, I’ll be on the lookout. We have a couple more CEU opportunities for this week. Happy Respiratory Care week and we’ll talk to you again tomorrow. Thanks Nan!
Nan Nathenson: Yes. Thanks, Jeff. Happy Respiratory Care week guys.