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 Early Mobilization in the Acute Care Setting How can we better assist our patients? TIRR Memorial Hermann Neurologic Physical Therapy Residency Ann Valentine,

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Presentation on theme: " Early Mobilization in the Acute Care Setting How can we better assist our patients? TIRR Memorial Hermann Neurologic Physical Therapy Residency Ann Valentine,"— Presentation transcript:

1  Early Mobilization in the Acute Care Setting How can we better assist our patients? TIRR Memorial Hermann Neurologic Physical Therapy Residency Ann Valentine, PT, DPT

2 Objectives  Discuss current practice and investigate why current interventions/limitations with activity exist.  Explore common impairments that occur with prolonged bedrest and prolonged Intensive Care Unit (ICU) stays.  Define Early Mobilization.  Discuss the benefits of Early Mobilization.  Review an Early Mobilization Protocol.  Discuss Further Considerations with Early Mobilization in the ICU.

3 Current practice in many hospitals  We’ve come a long way but more improvements can be made. 1  Delayed initiation of physical therapy 1  Infrequent treatments in the ICU  Once PT is initiated bed therapeutic exercise is usually the first intervention 6,7

4 Barriers to Early Mobilization 2,3,7  Psychosocial barriers  Comorbidities  Advanced age  Physiologic instability  ICU environment  Limited Evidence

5 Impairments seen with prolonged bedrest 2-6  Increased respiratory dysfunction  Impaired strength  Physiologic impairments  Increased risk for skin breakdown  Decreased quality of life

6 Prolonged hospital stays with mechanical ventilation  DECREASED FUNCTION! 3, 6-7  Increased morbidity/mortality  Increased cost of care  Increased length of stay  Respiratory muscle weakness and increased duration of ventilation  Sleep deprivation  Lack of social interaction  Prolonged sedation  Delirium

7 Inactive & Alone: Physical Activity Within the First 14 days of Acute Stroke Unit Care 1



10 What is Early Mobilization? 6 The initiation of mobility when a patient is minimally able to participle, presents with hemodynamic stability and the patient receives acceptable levels of oxygen.

11 Benefits of Early Mobilization 2, 4-8  Improved respiratory function  Maintains strength and joint range of motion  Fewer physiologic impairments  Repositioning allows for other interventions  Improved quality of life

12 Initiating an Early Mobilization Protocol What is needed to start an Early Mobilization Protocol?  Multidisciplinary involvement is crucial!  A thorough initial physical therapy evaluation  An individualized plan of care  Appropriate goals that meet patient’s values are needed  Determine what phase of the Early Mobilization Program the patient is starting in.

13 Initiating an early mobilization protocol for mechanically ventilated patients 6,7  Heart rate <130 beats per minute  Mean arterial pressure: 60-100 mm Hg,  FiO2:<60%  PEEP ≤10 cm H2O  SpO2 > 88%

14 Phase 1  Patient presentation: considerable weakness, limited activity tolerance, occasional altered mental status, minimally participate in therapy and are unable to ambulate.  15-30 minute treatments  Goal: to start mobilization as soon as the patient is medically stable.  Progression: bed ther ex  rolling  sitting balance  standing with a walker and assistance

15 Further Treatment Options for Phase 1 2  Tilt table with arms supported for 10-30 minutes  Standing Frame  Chair sitting

16 Phase 2  Includes patients that have the strength to perform standing activities with a walker and assistance.  Goal: to start walking re-education and functional training  Progression: weight shift  steps in place  side steps along the EOB  chair transfer using a walker and assistance

17 Phase 3  Includes patients that can tolerate ambulation with a walker and assistance for a short distance.  Goal: Master transfer training and increase endurance.

18 Phase 4 6  Includes patients that are no longer on a ventilator and/or have been transferred out of the ICU.  Goal: functional training  Ultimate goal: Promote maximum independence by discharge.

19 Further Considerations with Early Mobilization 2,3,7 ALWAYS USE YOUR CLINICAL JUDGEMENT  Other Interventions: e-stim, UE exercise, inspiratory muscle training  Transitions back and forth between phases  Perform during “sedation vacations”  Need assistance to manage multiple lines  Monitor vital signs  Involvement of a multidisciplinary team is crucial!

20 When should an Early Mobilization Intervention be deferred/stopped? 1,2,7  HR 130 bpm  RR 35 bpm  SpO2 <88% for <1 minute  SBP 180 mm Hg  Elevated ICPs  Changes in patient presentation occur  New medical findings occur

21 Adverse Effects with Early Mobilization 2,7 Adverse events are rare.  Fall to knees  Hypoxemia 1 minute  Unscheduled extubation  Orthostatic Hypotension < 80 mm Hg SBP

22 Bottom line 1,2, 6-8  No medical status decline occurred with an early physical therapy intervention.  This is a safe and feasible intervention.  Early mobilization has the potential to prevent/treat neuromuscular complications of critical illness.  Early Mobilization Requires a Culture Change

23 Questions

24 References 1. Bernhardt J, Dewey H, Thrift A, and Donnan G. Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care. Stroke 2004;35:1005-1009. 2. Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):400-407. 3. Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing 2008;10(1):21-33. 4. Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy. (4 th ed). St. Louis: Mosby. 2006. 5. Kisner C, Colby LA. Therapeutic Exercise. (5 th ed.). Philadelphia: F.A. Davis Company. 2007. 6. Perme C, Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:212-221. 7. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:1874-82. 8. West L. Early Mobilization: How one multidisciplinary team initiated an activity protocol to decrease ICU lengths of stay. Advance for Physical Therapy and Rehab Medicine May 30, 2011:12-14. *References for images available upon request.

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