Welcome. Good morning, good afternoon, good evening, depending on when you're listening to this lecture. Very unfortunate that we can't get together in Chicago. I was really looking forward to that trip, but I hope that you find this presentation useful and feel free to reach out to me if you have any questions or want any tips regarding this really important topic for the care of the critically ill. My name is Michelle Ballas, and I'm an associate professor at The Ohio State University College of Nursing in their Center of Healthy Aging and Self-Management Complex Care. Here's my disclosures. So what I hope to do with you over this next hour is to emphasize what we know, what we're learning, and what we hope to know about early mobility in the critically ill. So I set up the presentation to give you a background about why this is such an important topic, the science behind early mobility as an intervention in the critical care, and also give a glimpse of the role early mobility plays in the ABCDF bundle. And if you're interested in that, I just recorded another lecture that discusses some really interesting findings regarding some of the challenges that we're having globally at delivering this safe and effective intervention. So the earliest descriptions of ICU-acquired weakness, years and years ago. Osler and Olson, 1915-1956, started discussing the problem of ICU-acquired weakness in conditions such as sepsis and coma. And as you can see on this slide, it's been developing over the course of those years in terms of the magnitude of disability that comes about from ICU-acquired weakness. But this has been a topic that we've been talking about for a long time. There's a lot of information, and as you see on this screen, you can find that a lot of the randomized control trials were published in really high impact journals. We're talking New England Journal of Medicine, Lancet Critical Care Medicine, Blue Journal. But this might be a handy reference for you when you're developing your protocols or starting to get the buy-in that's necessary to better facilitate early mobility in your intensive care unit. One of the biggest challenges we find when trying to get ICU patients up and moving, understanding early mobility, is the hesitancy that many have, and it's quite rational, over the concern of whether it's safe or not. And the evidence base surrounding early mobility as an intervention is profound, and the evidence showing that it is a safe intervention, really based in strong science. As you can see here, several systematic reviews looked at this particular topic. Is it safe to mobilize somebody who's critically ill? And as you can see here, very few adverse events are reported in the literature when early mobility is delivered. Most of the events, so pretty rare, right? So most of the events relate to drops in O2 sat, some BP or cardiac-related events, and it's pretty consistent. It's also outlined in the new Society of Critical Care Medicine's pain, agitation, delirium, immobility, and sleep guidelines as well. You know, those adverse events that stop us from delivering this intervention are rare, right? And this is over thousands of patients, thousands of sessions. But as you know, all it takes sometimes is for one bad event to happen, and then the amount of culture change that has to... the amount of education and culture change that has to accompany implementing early mobility, it's profound after one of those events, right? People don't forget the bad things. You know, they don't remember the good, and they often don't forget the bad. But it's a frequent question you'll face in your early mobility implementation efforts is, is this safe to do? So in general, what do we know about critical illness? We know that we're getting so much better in terms of reducing the mortality associated with critical illness. So as you can see, dropping over the years. And this is in both critically ill sepsis and critically ill non-septic patients. We're getting better. More critically ill patients are surviving. And fortunately, at the same time, we're also seeing of those survivors, they face a lot of challenges. The number of people that are being discharged to rehab and nursing homes after critical illness increasing. And again, we see that not just with sepsis patients, but also critically ill patients that have multiple diagnosis. So they're living longer, but they're getting... we're using much more resources in terms of that rehabilitation after critical illness. And those skilled nursing home and nursing home placement increasing over the years. We also know that disability following a critical illness is very common. So it's been estimated between 30 to 70% of patients will experience a disability in either their activities of daily living or with walking. And again, this is pretty consistent, that range of disability that we're seeing in physical impairments, pretty consistent, again, across multiple studies. So when we're thinking about the disability process in acute illness, I'd like to envision it because it is such a complex phenomenon, including those things as the original pathology that the patients admitted for, right? So the disease or the injury that is altering normal physiologic processes. That pathology can then lead to impairments, which really refer to dysfunction and structural abnormalities in the body systems. Those impairments then lead to functional limitations. And when we're talking about functional limitations, that's the restrictions and the basic physical and mental activities that consequently leads to disability. So disability, in this particular case, being defined as the inability to perform our normal socially defined roles and tasks. So that process. And you can pick basically any diagnosis and see how this happens, but common ICU admissions, sepsis and ARDS. You see that pathology that occurs and we know the pathology that's involved with sepsis and ARDS, leading to the impairment being the muscle wasting, the functional limitation being weakness and balance and fatigue, and then that further going on to the disability, right? So that the patient's not able to mobilize normally. They're not able to perform their activities of daily living or their instrumental activities of daily living, having a checking account, going to the store, things like that. So there's been several studies across the years that have documented the role hospitalization plays in terms of patients becoming disabled. In this example, this JAMA study by Gill, they did monthly phone assessments where they looked at specifically at ADL disability. And then also looked at some possibly intervening events, the biggest one being hospitalizations. Follow these patients over five years and what happened with them. And what they found was hospitalization was not only important, but it was the major risk factor for a disability, for developing a disability. And you can see here the other factors that are involved that aging, physical frailty, certain diagnoses, but hospitalization, that adjusted hazard ratio of 59.8, major cause, major risk factor for developing disability. Another study looked again over the years, and they were interested in looking what happens to a person's life space and the role that hospitalizations would play in life space. Where a person goes, how frequently and how independently they go. I like this picture because it illustrates kind of the inner and then how life space goes out, right? So when you're thinking of life space, you're thinking immediately what you're doing at home. Are you going to the bathroom? Are you walking the stairs? And then going to the next circle, going outside, going around the neighborhood, city, town, or outside the city or town. So expanding life space. And what they found was medical patients really do recover life space poorly, right? So again, they're following these patients over the years and looked at this adjusted life space composite score, but basically a measure of life space. And they found that in particular, those medical patients, we see it here with the surgical as well, they have that event that impacts them, but the medical patients in particular recover the ability to go further and further out in those circles much more slowly than the surgical patients. Another, the health and retirement study, they looked at adults over 50 years of age and they did every two year phone assessments and were looking at ADLs and IADLs. They also then linked CMS data. So they were looking at hospitalizations for sepsis in particular. And what they found is after severe sepsis, disability was very, very common, right? So you can see this trajectory over the years and the after sepsis in particular, having those severe limitations occur after sepsis. But that was pretty consistent and over the years. So before sepsis and after. I think the last one that kind of emphasizes the dramatic societal impact ICU acquired weakness has. Again, following this study, followed older adults who were over 65 in Seattle and looked at their ADLs, IADLs and physical performance over the years, and then looked at a health plan claims data to find out what happened to these patients. And again, you can see here after an acute illness, many developed dependency in at least one activity of daily living, meaning they couldn't perform that activity of daily living by themselves. They required assistance from others, right? Caregivers, a lot of caregiver burden in patients who survive a critical illness, because that caregiver often has to take over a lot of the tasks that the seriously ill person did before. But you can see after acute illness, you get that disability, but look at the magnitude, the extent of changes in ADLs and dependency in terms of the impact that critical illness has. So Dr. Harridge and colleagues looked at what happens after acute respiratory distress syndrome. So they were looking at this particular population, the one-year outcomes of patients who survived acute respiratory distress syndrome. And again, in terms of this discussion, the role that functional recovery and what happens to patients' functions after this. Another summary, again, so you've seen here illustrated over the years, did a six-minute walk test, one of the in-person follow-ups, looked at health-related quality of life. And we see, again, this rather dramatic changes in physical functioning that occurs, and that prolongation of problems in physical functioning extending over that five-year period. You see here in the blue, the percent predicted versus the actual distance walked. It's a huge difference, right, in physical functioning. Not too familiar how many, how familiar you are with the term frailty. Very big in geriatrics and gerontology, study of frailty. Moving along, thanks in great part to Nate Bremel, who's now at Ohio State as well, but frailty as an important outcome measure. Many societies and their guidelines and a lot of the core outcome sets that they're doing are including frailty scores. So what is frailty multi-component syndrome? And it varies, specifically how you can measure it and the instruments that are used to define how frail somebody is. But in this example, you can see that as you become more frail, the association between frailty and survival. The more frail you are, much less likely to survive over this long, long-term period. Similar association found with the frailty and the ability to do your instrumental activities of daily living, right? So the more frail you are, the more likely you are to have those impairments and activities of daily living over a year after critical illness. And when we look at the pathology behind ICU acquired weakness, here's a, I love this picture because I think it so nicely illustrates the changes, some of the changes that were, that the patients are experiencing. So this looked with changes in diaphragm fibers, mechanically ventilated humans. So 57% reduction in those areas of slow and fast twitch muscle fibers after 20 to 70 hours of diaphragmatic inactivity. So rather dramatic changes that you're seeing at that basic cellular structure. And one of the questions comes up with those muscle fiber changes due to brain death. And actually they also did biopsies of the pec muscles and in six cases and six controls, and there was no difference there. So these are, you know, really, these are real changes that were observed due to mechanical ventilation. We know even short periods of bed rest can lead to severe skeletal muscle wasting and critical illness. Another great picture to illustrate some of those changes that occur, but that muscle weight was muscle wasting even after very short episodes of bed rest, right? You get in that critical illness. Organ failures associated with muscle loss seems intuitive, right? Multi-organ failure compared to single organ failure. You can see the changes there. Percent change in rectus femoris changes days after an ICU admission. Also, in addition to that disability and the changes in function, many other physical complications associated with acute lung injury, right? So they did, this study was a two-year long children's prospective study, and what they found was over one in three patients developed ICU-acquired weakness. Daily bed rest increased weakness. And then at follow-up, there is that relationship again demonstrated with health-related quality of life. We touched upon in my previous lecture on the ABCDF bundle and its role in PICS, some of the disability that occurs through multiple things that happen during an ICU stay. But this brilliant study by Jackson found disability was found in one in four survivors in the ICU. And you can see, yes, obviously the older you are, the disability levels were higher, the disability levels were higher, but this was across groups, right? So across age ranges and across groups, we're seeing this disability. In addition, the BRAIN-ICU study found half of newly unemployed, half of the patients that were enrolled in the study were newly unemployed at one year. You can see the changes in that, right? The employment level over time, those that were employed full-time, unemployed part-time over those timeframes, and enrollment three months and 12 months. So not getting back to their jobs. Now, we're talking about the randomized control trials that actually looked at the effects of early mobility in the intensive care unit. There's some classics that are often cited in terms of does, and answering the question of, does mobilizing patients in the intensive care unit or during that acute phase of critical illness impact outcomes? Classic study by Dr. Stryker. This study had 104, and it was a single-center study. It randomized 49 to intervention, 52 to control. Both groups got that daily spontaneous awakening trial, and the treatment group got early PT and OT, and the control group got physical therapy and occupational therapy per usual care, all at the hospital discharge. And what they found was some rather interesting findings. It's actually early mobility is often, when I'm doing my delirium lectures, often cited as one of the most effective, probably non-pharmacologic interventions to reduce delirium. But you see that reduction delirium days illustrated with the patients that got the early PT and OT in this study. A percent of ICU acquired weakness, less in the treatment, not significant, but less, and duration of mechanical ventilation. So showing that, yes, this intervention has some important effects. And when you're looking at this, again, that early PT group, those 55 patients that got the early PT and OT, to me, really the take-home point of this study is that functional independence at hospital discharge. Right? It's a big difference there. You see that big gap between the people that got the PT and the usual care? So reducing that, I mean, increasing the amount of people that are able to, are functionally independent at the time of hospital discharge. Another study by Moss, another randomized control trial, intensive PT therapy program for patients with acute respiratory failure, Blue Journal. This study, single center again, 120 patients, 59 to the intervention group. You can see the interventions that they got there, daily PT. The other group got PT three times a week of PT. Intervention group, three times a week PT at home, and both groups were followed up at six months. So you can see the different interventions in this study from the prior one. Intensive PT did not alter the patient's ability to perform their instrumental activities of daily living, right? So you can see on this graph. So in that particular outcome, secondary outcomes didn't appear affected either, right? The number of ICU free days, length of stay, no difference. No difference in the days mechanical ventilation, length of stay, institution free days. So a lot of people say, well, there you go. So this is evidence suggesting that the reason to question the benefits of early immobilization than critically ill. Some important things to note with this particular study, controls were seven years younger. These patients were on benzos, average time on benzos and or opiates greater than six days. There were some differences in the awakening and randomization at one week. And the intervention started really late, right? So the intervention started a median eight days after the patient was admitted to the ICU. So that's a pretty late start to, it's common thinking now, that's a pretty late start to get people up and moving after they've been there for eight days in your ICU, right? And there was a lot of incomplete follow-up. Another trial by Dr. Morris, looking at standard rehab and hospital length of stay among patients with acute respiratory failure. Let's see here, the randomization scheme, no sedation protocol, it needed a group. The treatment group got physical therapy and resistance training, whereas the control group just got standard of care and both groups were followed up through that, those time points you see up to six months. 33% of days on continuous sedation drip, additional bolus dosing seven days not reported. PT started at three days versus seven days in the treatment versus control. Received physical therapy on 55% of the days versus 12% of study days. No change in length of stay, slight non-significant improvements in mobility and functional performance. I think finally, I think this is the last one that we'll just touch on, just building up what we know and what we don't know and the outcomes that have been affected so far. So this one's looking at focusing on surgical intensive care unit patients. Another randomized control trial, 200 patients randomized to A, B, C, and D. Facilitator goal in ICU and followed to ICU discharge, whereas the control group got the daily A, B, C, D, and usual care. We can see here that there were some important changes in terms of that mean CQ optimization mobilization score and the functional independence measure. So in the intervention group, 55 to 61% were independent and transferring, not disabled. Scores in the usual care group, 31%. Delirium pre-days, some difference there. And in the ICU and three-month mortality, no difference in the three-month mortality though, you can see that. So when we look at these globally, and this is, again, just a small sample. You can do hours and hours and hours of lectures about all these given topics. But when we look at the summary of the randomized control trials of early mobility, and you're trying to make comparisons to figure out exactly what works and what's affected and what is the dose of early mobility that you need, now some of the things that you do need to consider is when the intervention is starting, what the intervention entails. Is it physical therapy and occupational therapy? Is it physical therapy? Is it a specific type of physical therapy? Is it physical therapy in addition to something else? Many of the studies that you'll find will take into consideration whether or not patients undergo spontaneous awakening trials because, as you know, early mobility is impossible in somebody who is deeply sedated. So if you have a patient with a RAS score of minus four or minus five, they're not going to be getting up and moving, correct? So a factor influencing whether or not early mobility is delivered, particularly in clinical practice, is the amount of sedation that they're getting. How long? How intense was the physical therapy? And again, you see the differences here between when the intervention starts and all those factors that we talked about in terms of what got better, particularly that independence, the effect that it has on delirium, the effect that it has on ICU and hospital length of stay, those light blue highlights, the improvements that we see with physical therapy and all of these different randomized control trials that vary in terms of the dosing and intensity and things like that. So again, when we're thinking of that spectrum occurring with the frailty and the impaired physical function, ICU acquired, sarcopenia, that muscle loss, poor muscle quality, and how they interact with each other to produce the impairments that we're seeing. So in addition to the safety questions, another question that frequently arises is when is it safe, exactly, to mobilize somebody in the intensive care unit? And you'll find there is a ton of different... Many people refer to them as safety screen criteria, but there's a number of professional societies and organizations and even different hospitals have different criteria for answering that question of whether it's safe to get that patient up and mobilize or have them start participating in exercise therapy. A lot of it, this example that I'm showing you here is the MOVE criteria, very frequently used, but looking at that myocardial stability, so the patient's not having evidence of active myocardial ischemia, that their vital signs are relatively stable and don't have any cardiac arrhythmias. Is their oxygenation adequate? Less than 60%. Some institutions across the country have much higher, like they're getting people up and moving 80, 100%, they're not even looking at that oxygen level per se, the amount of oxygen they're on when deciding because they've been so experienced over the years and are now more comfortable moving these people with PEPA 10. Whether or not the patients are on vasopressors or if they're on vasopressors and you're getting them up and moving, that you're not actively titrating those vasopressors, and again, that the patient's responsive, right? Because it's impossible to get a patient engaged in any kind of physical or cognitive stimulation if they are deeply sedated. So different criteria. In terms of the ICU Liberation Campaign, the Society of Critical Care Medicine's ICU Liberation Campaign, we had some really tough discussions on how do you operationalize early mobility? So what is it? Do you consider, is someone in your ICU who's getting passive range of motion, do you consider that that patient has engaged in physical activity? So when you're looking at the studies that are coming out on the results of that ICU Liberation Collaborative, when we're talking about the E there, this is how it was decided. This is what we considered physical mobility. So the patient had to at least dangle at the side of the bed, right? Dangle at the edge of the bed or any of the things higher. So we did not consider active or passive range of motion early mobility. So again, different levels. And when we looked at the 68 centers that participated in the ICU Liberation Collaborative and followed these, we collected data. They were such an amazing, responsive group of really committed, motivated clinicians, just absolutely fantastic. But we looked at what evidence-based interventions the patients received in the intensive care units before the collaborative started and then over the course of the collaborative. And unfortunately, one of the things that we've seen that was demonstrated as one of the more challenging interventions was that early mobility. So you can see illustrated here. So if you look at the E, so the early mobility part of the ABCDF bundle, we started out really low, right? In that pre-collaborative period. So that's what I'm going to get 22%-ish of patients before they started, before their ICU started in the ICU Liberation Collaborative, met that definition of early mobility, meaning dangling at the side of the bed or higher. And you see, yes, it improved over that short course of the collaborative period because that was a really quick. It was only like 14 months. But you see that early mobility did get better, but it was very slow and nowhere near where we expected it to climb to. So again, signifying that it's one of the more challenging interventions to get into place. And you can see the same thing with the spontaneous awakening trials and the spontaneous breathing trials that by the end of the collaborative, less than 40% of the patients were receiving them. And again, because they are so interconnected, it's harder to mobilize someone who's on mechanical ventilation. It's harder to mobilize somebody who's deeply sedated. So again, it's getting those three aspects of those three evidence-based interventions into care that's so important to make all of them kind of come about. So connected again, right? We also noticed that in this group of highly motivated intensive care units, there were indeed some excellent performers. There were some ICUs that were excellent at getting their patients these evidence-based interventions. And you can even see that's demonstrated when you go down to element E there. There was one of these ICUs, and I can probably tell you who it is because I know the physical therapist who delivers a lot of that care, but you can see there was that one particular outlier on there. Almost everybody was minimally dangling at the edge of the bed per day. Crazy, right? So we really do have this great opportunity to learn from high and low early mobility performers. There's been tons of strategies to use to increase early mobility in the intensive care unit setting. Some hospitals, and I'm not sure we're convinced in exactly in getting to that dose response or how's the best to deliver it. Some intensive care units, the bedside nurses are primarily involved in getting their patients up and moving. Other units have dedicated physical therapists and occupational therapists who are actively involved in the care of every patient who's admitted to the intensive care unit. Other intensive care units take the strategy of using physical and OT therapy consults as needed based on certain criteria or what patients would benefit from the intervention the most. So a variety of strategies used to deliver different components of early mobility. Differences that we talked about in terms of what is it, is it just getting up and walking? No, there's ICUs that have bikes and they're doing their exercises with bikes in their bed while they're there. They're on mechanical ventilation, ET tubing, and they're cycling in their bikes. There's others that are doing active resistance training. So there's many different approaches as to how to implement it into everyday care. I think the challenge most people experience when delivering early mobility is there are a number, we know that there's a lot of barriers, right, to delivering early mobility. Do you have the expert physical therapist, occupational therapist there? Someone who has the expertise in what we're trying to do here, right? Maintain physical function, maintain cognitive engagement. Are they in your intensive care unit? Some great studies out there from Dr. Needham and his group that looked at the fiscal benefits of starting an early mobility program. And if you haven't been to the Hopkins website that they have for specifically focused on ICU mobility, tremendous, tremendous amount of resources out there that can answer almost any question you have regarding delivering this. But you know, staffing is always a challenge and having the amount of people to mobilize the critically ill, I mean, it could be a challenge. As we know, we're, as a society, we struggle with obesity. Not everybody is physically fit from the patient perspective and able to come in with that great muscle mass and independence already. We're struggling with the obesity levels. Sometimes it takes a lot of work, physical work by individuals to get those people engaged in the activity, right? Barrier the culture. We have to move past this culture where it's normal to be deeply sedated and in the bed while you're in the intensive care unit. That culture change is exceptionally hard, right? You need to have the right individuals that are involved when implementing the early mobility aspect. You have to have those champions, those people that really believe in it, that really push and help other staff appreciate how important it is in terms of the patient's long-term physical and functional recovery afterwards. You have to have that C-suite support to have the time necessary to make these changes in your electronic health record about how you're going to document the patient was out of bed. Where is it going to be documented? You know, we have to have that IT support for the EHR. You need the C-suite support to have the money in your ICU budget to hire the experts that are required in delivering it. So a lot of complex factors come into play about whether or not this will be successful. We mentioned briefly overcoming that barrier regarding the fear, the injury. We always suggest to people, I mean, you start slow and move forward, right? You're not going to get your most acutely ill patient who's on 100% oxygen, 15 a peep. That's not the person you're going to start practicing early mobility with, with your intensive care unit, right? Maybe it's a person who is just young, not deeply sedated, minimal vent settings, probably going to extubate them a day or two. That might be the best person to start getting up and walking to build staff confidence in their ability to mobilize, right? You're not going to get 100% of your patients out of bed the first day. You start with one, then maybe next week move to two. It's progress. We can't expect change to occur overnight since we've been all so deeply conditioned to believe that patients need sedation, patients need rest while they're in an ICU, so a lot of changes. In terms of the intervention itself, we talked about some of the things that you really want to be clear with in terms of adapting for safety. When you're developing safety screens at your particular institution to determine whether it's safe to get the patient dangling at the side of the bed or higher or whatever you choose as your goal, to make sure those safety screen criteria are evidence-based because I've seen a number of institutions fail in their early mobility efforts because they set those safety screen criteria so tight that there's nobody that would ever be eligible for to even try to possibly be mobilized. Going back to the evidence of what's safe, what's not safe, talking to other people that have been engaged in these efforts, getting the professional resources that are already developed that you don't have to do again. For example, with SCCM, you can go and get the early mobility PowerPoint so you don't have to develop it yourself, that has all the great evidence and the how and the why and talks like that so that you don't have to reinvent the wheel since there are so many super excited people and such great minds working on this, again, complex issue. Here's in closing, here's some additional resources that weren't included in the previous slide that talked about the randomized control trials supporting early mobility, but some that are more related to the ABCDF bundle, IC liberation bundle, and the older versions of the ABCDE about how, because again, really important to consider how all of those factors in terms of cetacean mechanical ventilation and early mobility interact. But the last 16 and 17 specifically speak to some of the challenges that we had with early mobility during the ICU liberation collaborative from the provider's perspective and give some suggestions on how to overcome some of the barriers and facilitators that we experienced when we were trying to implement that.

early mobility

critically ill patients

ICU-acquired weakness

intervention

randomized control trials

patient outcomes

interdisciplinary collaboration

patient safety