SCCM Resource Library-Happy, Sleepy, and Dopey

Happy, Sleepy, and Dopey

Video Transcription

Great. Good morning, everyone. Thank you so much for joining us at this session, which we titled Happy, Sleepy, and Dopey in light of the fact that we're in Orlando right now.  My name is Lauren Ferrante. I'm from Yale, and I will be moderating this session along with Dr. Nathan Rummel from The Ohio State University. Before we begin, I'm supposed  to state a few housekeeping remarks. Please silence your cell phones, and apparently there's another session coming in here when this one ends, so there are continue  to conversation areas outside the session rooms if you'd like to continue speaking after the session is over. Information about continuing education credit is available  on the Congress app. All speakers will disclose any conflicts, and we do encourage tweeting. Please use the hashtag CCC49. We're also going to use the hashtag Jerrycritcare  for the geriatric-specific topics in this session, and please be mindful that while social media provides an open air forum for the presenters,  there may be slides displaying the no social media icon, and so please do not tweet those. So our first speaker is Dr. Nathan Rummel from The Ohio State University.  He is an associate professor there, and Dr. Rummel is interested in reducing disability for older ICU patients. He's currently a recipient of a Paul Beeson Award  from the National Institute on Aging, and he'll be speaking  to us about frailty across the continuum of critical illness and survivorship. So frailty is the eighth dwarf that didn't make the cut,  but so I'm going to talk about frailty across the continuum of critical illness and survivorship, as Lauren mentioned. I've got NIH funding, but otherwise no conflicts  of interest, and before I begin, I want to have two plugs here. First is for our newly formed aging and critical care knowledge education group.  We just received word on Friday afternoon that council approved this group, and our first meeting is today from 2.30 to 3.30 in W103,  and as Lauren mentioned, if you're going to tweet, please do so responsibly and use the hashtag JerryCritCare. So in the next 10 minutes or so, I'm going to talk  about three topics here, talk about the common conceptual definitions of frailty, and then talk about patients who have frailty who come to see us in the ICU  and some outcomes associated with that, and then kind of flip the script because we are now learning that patients who survive critical illness may actually  develop frailty as a result of critical illness and being in the ICU. So why do we care about frailty? As the notion of PICS and the impairments and disabilities  that have been described over the last 10 to 12 years have come about, we started to try to understand how do these develop, and one way  that we can understand better how these develop is by using a hypothesis first developed in geriatrics but now applied to critical care called the vulnerability hypothesis.  And what the vulnerability hypothesis states is that these impairments and disabilities develop as a function of a patient's critical illness,  the intensity of their critical illness, in relation to their underlying vulnerability. And I think we're all very well versed in measures of intensity of critical illness, right?  We know about severity of illness scores, number of organ dysfunctions, how long somebody is sick, how many episodes of critical illness they've had.  But what we're less familiar with is the underlying vulnerability that we are coming to understand is equally important, if not more important, to this.  And how do we measure vulnerability? And that's talking about frailty. And frailty is a multidimensional syndrome that is characterized by the loss of physiologic reserve  that results in a reduced ability to maintain or to restore homeostasis in the setting of an acute stressor like a critical illness.  And so here we have two hypothetical patients, one in blue that is fit, that's on one end of the spectrum, and one that is frail in red there on the other end of the spectrum.  And on the y-axis there shows functional abilities over time. So if we look first at the patient in blue, the fit patient, both these patients  develop the same intensity of critical illness. But the fit patient, who suffers a drop in his or her functional abilities, recovers relatively quickly and back  to his or her baseline. In contrast, the frail patient starts out with worse functional abilities, suffers a much larger drop,  has a more prolonged recovery, and doesn't recover back to his or her baseline. So critical illness is a much bigger deal for patients with frailty.  And there are two schools of thought about how frailty develops. The first is that frailty there in yellow is a biologic syndrome that then clinically manifests  as unintentional weight loss, low physical activity, slow walking speed, decreased muscle strength, and low energy level. And so there's this integral process  that occurs in a patient that then is manifest through those clinical syndromes. The other in red is the deficit-driven approach, which basically is that your system gets assaulted  by a bunch of different things, such as poor nutrition, social vulnerability, comorbid medical conditions, functional decline, mental health impairment,  cognitive impairment, that all add up to stress your system. And so eventually these things add up to a point that you can't withstand additional things before things  begin to fall apart. And so that's called deficit-driven frailty. And both have been used in studies of critical illness. The deficit-driven approach has been used most commonly  because no one plans on getting critically ill, right? So you can assess these factors using questionnaires or talking to their surrogates about how patients were doing  beforehand, whereas the biologic-driven frailty requires physical performance measures, like getting a walking speed and a grip strength,  that at least in the initial phases of ICU admission are difficult or confounded by the acute critical illness. And so now let's talk a little bit  about outcomes in patients who are frail and come to see us in the ICU. So frailty has been on the radar in critical care for about the better part of five or six years.  There's been enough studies now that there was a meta-analysis published just a couple of years ago led by the Canadian Frailty Group.  And in this study they looked at about a dozen or so studies of patients with frailty who came to the ICU. And the first thing we can learn from this meta-analysis  is that frailty is actually present in about one out of three patients who come to see us. Now this study used both methods of measuring frailty,  the phenotype and the deficit-driven approach. And both studies came in about 30%, or both measures about a pool prevalence of about 30%.  So one out of three of the patients in your ICU this morning or when you go back will have frailty. And why do we care? Well frailty is associated in the short term  with greater mortality. In fact, patients in this meta-analysis had a 70% higher risk of dying in the hospital as compared with patients who weren't frail.  And over the long term, over the six to 12 months afterwards, that risk of mortality was still present. In fact, about 50% greater risk of dying  independent of other factors in those who were frail compared with those who weren't.  In our own work we've used the deficit-driven frailty approach using a tool called the Clinical Frailty Scale, which is a judgment-based tool that rates patients  from a score of one, which is very fit, to seven, which is severely frail, in a cohort of 1,000 patients with respiratory failure or shock that we published in the Blue Journal  now just over two years ago. And the interesting thing that we found is that patients of all ages have frailty. So here on the y-axis I'm showing you  the Clinical Frailty Scale score. Remember one is the most fit, and seven is the most severely frail. And we've divided this up by age.  Now if I just showed you that right-hand column, the older adults, those age 65 and older, you wouldn't be surprised. Older adults have a range of frailty scores.  But when we looked at the 50 and 60-year-olds and even the 30 and 40-year-olds, we found that not only were there a range of frailty scores but even younger adults had frailty  when they came to see us in the ICU. And in addition to the mortality outcomes that we had described earlier and we saw in our own cohort,  we identified that these patients are at greater risk for developing new or worsened disabilities and activities of daily living. Here we have now the Clinical Frailty Scale score  on the x-axis and the probability of having a higher IADL score, which is indicative of new or worsened disability. And you can see that as the frailty score increases,  so does the probability that these patients will have new or worsened disabilities.  Now my co-moderator Lauren Ferrante has also studied frailty, but she has used the biologic-driven frailty. And as I said, that's very tough to do,  but Lauren did an interesting thing in this study. She took advantage of a longitudinal study of aging of over 750 older adults who were enrolled  and followed serially with disability assessments and also serial frailty assessments. So these patients had undergone gait speed testing, grip strength, and so on  every 18 months over the course of about a decade with which this cohort was followed. And she found a very similar thing  that while frail patients before their critical illness had a greater number of disabilities than those who were pre-frail or not frail,  and that all patients, regardless of their frailty status, developed new disabilities in the months after their critical illness, that those who were not frail  were actually able to recover their functional status, their pre-critical illness functional status, whereas those who were frail or those who were pre-frail  recovered but never reached their baseline status. So again, frailty, in addition to being associated with greater risk of mortality,  is associated with new and prolonged disabilities and activities of daily living. These are the basic things that people need to do to live independently.  So now I'm going to talk about some of our new data on frailty in survivors. So kind of flipping the thing here, all these previous data looked at patients  who were frail and developed critical illness. This is going to now look at patients who were critically ill and some of them  developed new or worsening frailty. And so here, using data that I ask that you don't tweet because it's under review at the current time,  but we looked at clinical frailty scale scores at baseline and at three in 12 months. So we followed these patients for a year and assessed frailty in survivors.  And what you can see is that it's a pretty dynamic state, and there's a lot of spaghetti in between there, so we're going to walk through this a little bit slower,  but the general picture is that patients are developing new or worsened frailty after critical illness. And so we have here, we've lumped them into fit patients  with a score of one to three, vulnerable patients with a score of four, and frail patients with a score of five to seven. And what you can see is that these vulnerable  and fit patients are either developing new vulnerability or new frailty. And in fact, 46% of patients in this cohort had a higher clinical frailty scale score  at follow-up as compared with their baseline score. Now, looking between three and 12 months, there's a sizable proportion, about 20%,  but not near as many developed a worsening frailty between three and 12 months.  The second transition was no transition. The most common one was no transition, so about 40% of patients didn't change their frailty state afterwards.  But I think the interesting point of these data with no transition is that half of patients who were frail at three months didn't change their frailty status at 12 months.  So we have this proportion of patients who are developing new frailty and they're staying there over the course of the first year.  And there were some patients, about one out of eight, who actually were less frail after their critical illness. And we're not exactly sure who these people are,  but you could imagine if someone had a surgical condition that got improved and they were able to improve their function, or they got better control of a comorbid  medical condition afterwards, that those would be the ones who improved.  And then again, between three and 12 months, there's some people who improve, but not many. So most people are developing frailty as a result of critical illness,  and they're maintaining that frailty state, that increased risk of vulnerability in the three to 12 months afterwards.  And then we asked ourselves, because we used the deficit-driven approach that a bunch of different things can contribute to frailty, was this clinical frailty scale score  simply subsuming lots of things that we are already measuring, disability and cognitive impairment, the sort of PICS paradigm here. And so we looked at, in this cohort,  276 patients who either had disability, cognitive impairment, or frailty. And what we found was that one out of eight patients who had one of those three syndromes  had frailty in and of itself, without also these other syndromes that we've been talking about being important to measure in the post-ICU space, disability or cognitive impairment.  These data also show us that there's sort of multiple different flavors of frailty. You could have frailty characterized by disability,  frailty characterized by cognitive impairment. And so I think these data need, or these patients need a little bit more in-depth phenotyping in terms of  who are these patients that are developing both these syndromes,  and looking a little closer at who are these that are developing frailty without other problems as well. And what are the long-term outcomes associated with this?  I think they also tell us that frailty should probably take its place in the sort of PICS paradigm, with disability and cognitive impairment,  because patients with frailty, as we saw, are at increased risk for bad outcomes. In older adults, falls, re-hospitalizations, in the ICU space, mortality and disability.  So I think we need to study these patients a little bit more, but probably frailty should move into a space there where we look at it in the post-ICU space.  So we've talked about the two conceptual definitions of frailty, the frailty phenotype and the deficit accumulation model. We know that about a third of patients  who come to see us in the ICU will have clinical frailty, and that frailty present in ICU admission is associated with greater mortality  and greater disability in activities of daily living, and that it affects patients of all ages. And we've talked about now, probably that critical illness is resulting  in newly acquired frailty for our survivors, and there's still a lot of questions to be asked about frailty in this survivorship space. And so thank you,  and we'll have time for probably a few questions, I think, now, right? Yeah. Thank you. All right. Great. All right, so we'll open the floor to questions.  Sure. So there are two questions. The first was, are there standardized measures of frailty  that we can use in our critically ill patients? And the answer to that is yes. The most widely  used and easiest to use is the clinical frailty scale, which is a judgment-based tool. There are pictures, and you sort of gauge how a patient is, what category they fall into based  off your own assessment, their medical history, talking with their surrogates. So that's the  most commonly used. There are some other tools that are available that are a little bit more  difficult to apply into the acute ICU setting. And then the second question was, how do these  patients die, or where do they die? And we saw most patients, or that frailty is associated with an increase in hospital mortality. So there's a number of patients who die there.  I don't believe that people have looked at whether frailty is, whether people go to hospice care or whether ICU admission is actually beneficial to those patients. I would caution  us, though, from using these global scores for an individual patient. These are all population-based  data saying, on average, you have a 50% greater mortality. But as far as any specific patient,  it's very problematic, I think, to apply that and go down that road of, you're very frail, so we're not going to bring you to our ICU. I think that's an area of further research  that we need to get better at.  Yeah, no, that's a good question. So the question has to do with designing randomized trials and how we should treat frailty assessments in that setting.  And I think that we should measure it, because you may run into heterogeneity of treatment effect and those sorts of things in terms of a physical function intervention  or a physical therapy intervention. So some patients may actually benefit more because the critical illness is a much bigger deal. I think we need to study also more  about what happens to these patients before we can say this is a trial where we exclude these patients. Or I think more appropriately, these are the most vulnerable patients.  So they're potentially the ones who would benefit the most from intervention. So flip that even. Those should be the ones that we should focus on enrolling into a study.  So thank you. All right. Thank you.  So we're going to Lauren Ferrante is our next speaker. And Lauren is an assistant professor of medicine and pulmonary and critical care at Yale. And she also focuses on the study  of risk factors for disability and improving physical function in older adults. She too is funded with a Paul Beeson award from the NIH. Thanks, Nate.  So yes, Nate did a great job setting the stage for this session. And now you'll see from the program that the next five talks, we'll be  talking about how we can maximize recovery for our ICU patients. And so although I do have a research program focused in the area that Nate just described,  I'm going to be talking to you today about a program that we've implemented at Yale with some very practical recommendations for tracking mobility interventions in the hospital.  I have no conflicts of interest to disclose. I'm funded by a Beeson award from the NIH. And I do want to disclose that the STEPS ICU program is funded as a QI initiative from Yale.  So briefly, my first objective is to review why early mobilization in the ICU is important. I'm reviewing this briefly because I assume that this whole audience knows this already.  Second, to discuss how to propose, implement, and maintain a high-performing early mobilization program in your ICU. And third, to learn ways to leverage your EMR  to track mobility outcomes in the ICU and on the floor. So I think most of us remember the old paradigm, where patients would be sedated and lying in bed  and not mobilizing until we all felt that they were better. And at this point, we would wake them up and start trying to get them to sit up.  And we found that they were profoundly weak. And I always love to include this slide by Zudin Puthachiri from JAMA in 2013, where we can see  how acute skeletal muscle wasting happens in the ICU within the first week. But it wasn't always this way. And Margaret Pisani and I were talking about this this past week.  Because I was not around in 1964. But this editorial from, well, I know you weren't either. This editorial from Dr. Petty and Chest in 1998 was really impactful when I read it.  He writes, when we first started our unit in 1964, patients who required mechanical ventilation were awake and alert and often sitting in a chair eating food.  By being awake and alert, these individuals could interact with their family, friends, and the environment. And they could feel human.  And this picture was in a publication in Critical Care Medicine in 2017 and was provided to that article, courtesy of Heidi Engel and Michael  Gropper, and apparently is a picture of a patient mobilizing in the ICU in the 70s. And so we've clearly swung in the complete opposite direction.  And now we're all working to get back to this. And we know what the consequences of not mobilizing our patients are.  We know that, among other insults that patients are experiencing in the ICU, that not mobilizing can result in deficits, particularly in physical impairment,  that result in disability and decreased quality of life. And we also know the benefits now of early mobilization. So although there have been some mixed data on certain outcomes,  overall, and I particularly like the systematic review by Claire Tipping and Carol Hudson, we know that early mobilization in the ICU  reduces muscle strength, reduces activity limitations at hospital discharge, reduces participation restrictions at six months, and improves quality of life at six months.  And we know that early mobilization is an important part of the ABCDEF bundle. But how? How do we execute this new paradigm?  I can't tell you how many times I've been asked by trainees, well, can't I just order PT? No, you can't just order PT. Who are the key stakeholders?  How do I know the program has been implemented? How do I maintain a high-functioning program? And so I'm going to just walk you through briefly how we did this at Yale.  And so the first thing I would say is that when you're going to propose funding, to ask and see if this can be proposed as a quality improvement program and not a research study.  The issue with research, and although I am a researcher, is that research is generally funded by, quote unquote, soft money, which you then have to renew and reapply for.  Whereas a QI program, if you demonstrate efficacy, improved outcomes, and cost savings, the funding will generally continue. And this is something where we know  that efficacy-improving outcomes has been demonstrated, and it is a standard of care and recommended practice by all of the PCCM societies.  And one thing that worked with our hospital was they didn't want to be the one hospital not doing this. Second, you want to identify and recruit  key stakeholders, including hospital leadership, nursing and physician leadership, skilled rehabilitation services, and respiratory therapy leadership.  And finally, you want to present a business plan when thinking about launching your program. And I'm just going to plug Dale Needham's website here, where if you go to his website,  he has a free ICU mobility toolkit that you can download, and you'll see where the red arrow is, that's actually an Excel sheet. So many of you probably know that Dr. Needham  was an accountant before he became a physician scientist, and there's a very nice Excel sheet with a business plan there that you can then apply for your own hospital.  So another step in pre-launch planning, once you've secured funding and resources for the program, is you want to name your program, put up signs,  make sure you have a method of identifying patients who are appropriate for early mobilization. So in our case, we reviewed the literature  and came up with an evidence-based screening tool that would make it easy for any trainee, any physician, any nurse to screen and identify patients who are ready to be mobilized.  And in general, this just means that they're not bed-bound at baseline, they're not comfort measures only or hospice, and that they're not actively decompensating.  Just about everybody else should be eligible for early mobility.  Training and buy-in, which I will come back to, but basically training has to occur for everybody in the ICU.  Okay, so this is really the crux of my talk, will be all of these slides on leveraging the EMR. So as one of the first steps, you want to put the mobility screening tool in the EMR  so it's easy to find and can be inserted into notes. This is a screenshot of ours from Epic.  And another step before the launch that you want to take is to change any defaults that don't make sense for an early mobility program. So we were surprised and disheartened to find  that our default activity order in our ICU was bed rest for all patients in the ICU admission order set. And so we changed the activity order default to activity as tolerated.  And many of you can probably guess when our program launched right there. And so you can see that after the default activity order was changed, that we went up to nearly 100%  activity as tolerated.  So achieving sustainable culture change. I'm just gonna touch on this briefly before coming back to the EMR and dashboard piece. So this is not easy.  For the faculty, this require gentle and frequent harassment  which Margaret probably remembers fondly. Eventually this turned into emailed reminders and I would say by year three and a half or so, it's now part of practice.  For the residents and trainees, it's part of their core lecture series now. They have a checklist on rounds that includes mobility. Nursing undergoes online module training annually  and when hired as well as targeted education as needed. And it was really important to us that the skilled rehabilitation team felt that they were part of our MICU team  and not consultants so they have their own space in the unit and we've incorporated them into the MICU core lecture series so that they're working directly  with our resident trainees.  I just wanna pause and say that changing culture takes time and persistence. So this will not all happen immediately. It takes work, it takes revisiting  and it takes working together.  And I just wanna highlight the importance of a multidisciplinary partnership to make sure that this happens. This really has been an equal partnership  between nursing, skilled rehab and the physician lead and our leadership team reflects this. We meet every two to three months and as needed for troubleshooting or new issues.  So some examples include, we realized that they were having a hard time mobilizing patients on CVVH. It turned out that the long tubing was on back order  and there were safety concerns and so we all came together and came up with a CVVH mobility algorithm and then everyone received education on it. But this is just one example  where even once the program is up and running, you have to still continue meeting and actively troubleshooting issues.  So this is the title of my talk again is leveraging the EMR to monitor the program success. Once it's been implemented, you can't be sure that it's going to be implemented  in the way that you want or that it's being successful. And so these are the four areas that I recommend leveraging your EMR to track outcomes. The first one is process outcomes.  The second one is real time delivery of the intervention. Who is mobilized today and if they haven't, why not? Third, to retrospectively track mobility by day, week or month.  You can change the report so that it helps what you're looking for. And finally, the big picture outcomes that we're all usually interested in.  So ventilator hours for the hospital cost savings.  So I've showed you one example of a process outcome. These are some of the other ones that we have at the bottom. So we look to see among the patients in the ICU,  who has an activity order, what percent? And then for those who have the order, what's the average length of time between the order being placed and the consult occurring?  And so we track these metrics on everyone. So this ensures that our intervention is being delivered the way that we want.  Second, and I should mention that we've rolled out this program across all of the floors in the hospital, not just in the ICU. You can see that this is actually  one of the medicine floors I've chosen here. You can actually use your EMR to retrospectively track what is happening on each floor. And I should mention that we're on Epic,  so anybody who's on Epic should be able to do this, and I'm sure the other EMRs can too. So you can see here that we have every level of mobility from therapeutic exercise  all the way up to ambulating five times. These are the totals for all of the patients, and this is by day. And so we can see what's happening on each day.  And when I say we, I should mention that on every floor, there's a nursing clinical outcomes leader who takes ownership of this dashboard, and they review their own data  and then work with their floor to ensure that the target metrics are being met. So this is not coming down from the program leadership, but rather by floor.  And then there's also real-time daily tracking of our nurse clinical outcomes leader. So you can see that I ran this on Friday. Usually this report is run at 3 p.m.  I ran it a little bit early. But what we do is we look at the list of patients in the MICU. If they've already mobilized, it's tracked here,  and if they have not yet, there's a yellow highlight so that our nurse clinical outcomes leader can go back and follow up with that individual nurse,  and they can work together to come up with a plan for mobilizing the patient.  And finally, we did look at the big-picture outcomes. So just this past year, we ran a pre-post-intervention analysis with about 6,000 patients in the pre-intervention group  and about a little over 7,000 in the post-intervention group. And we were thrilled to find that we had decreased the ICU length of stay,  decreased ventilator hours, increased discharges home, and of course, increased the number of rehabilitation sessions. And the hospital was thrilled too  because this means cost savings  and if this means cost savings, this means ongoing funding for our program.  So in terms of take-home points and what I hope that all of you can take away from this talk, I would say first, make this a partnership  and remember what is important to key stakeholders. Second, you can leverage your EMR to track outcomes. So process outcomes, real-time mobility, which is actionable that day,  retrospective mobility outcomes, which is actionable that week or month, and the big-picture outcomes that we're all interested in.  And finally, changing culture takes time and persistence, but it is possible and we can all do it.  And I just wanna acknowledge our STEPS ICU team, which includes our physical therapy, nursing leadership, our EMR analysts, and of course,  the hospital that's funded this QI initiative. So thank you. Thank you.  We have time for a couple questions. I just ask that you come to a microphone just so the room can hear your question.  Lauren, Phil, Schweikert, your research just resonates. I love it. I have one question for you. Sometimes mobility activities can happen without the watchful observation  or in the moment of the nurse or therapist. How do you track that in your records so that you can reflect those activities? And is it consistent across disciplines, therapists,  nurses, et cetera? Yeah, thank you for that great question. So I'll just say, so in two pieces, when we initially started tracking, oh, everyone heard the question.  When we initially started tracking this, we realized that at first we were only tracking physical and occupational therapy. But a lot of mobility was happening with nursing.  In fact, when we look at the screening tool, it does say whether the patient can mobilize with nursing. So now that's all been incorporated into the dashboards.  The one thing I will say is it has to be tracked on the flow sheet or it didn't happen, and not as a free text field, because otherwise we can't pull it from the EMR.  In terms of the patient mobilizing independently of a nurse or a physical therapist, in the ICU, they're supposed to tell the nurse if they're going to get up.  And then the nurse would be the one to track that. If the patient chooses to get up on their own without notifying the nurse, we would have, unfortunately, no way to track that.  In terms of mobility on the floor, I suspect that that would probably not be in the flow sheet, unfortunately. It still is a flow sheet dependent issue.  I know that there is a lot of research happening in terms of movement in the room and trackers. But right now, we don't have a way to track that.  I like the picture that you had on with the whole staff behind that patient. But you have to try and think of small-town USA where I work.  Where are we going to get all the staff to help patient mobilize? Because that's not practical in small-town USA. And when JACO comes, or any of these crazy people come around,  and they come and start saying, oh, you should be doing this this way, you are talking about the teaching hospital that has residents that can intubate the patient when the ET tube  falls out. How do you? Yeah. Thank you. That's a great question. I will say that I know there were a lot of people in the picture. I think a lot of people probably just  wanted to be in the picture. You don't actually need that many people to mobilize a patient. In general, if someone's on the vent,  you want to make sure the respiratory therapist has to be a part of it for the reason that you mentioned. There are actually good data showing  that accidental extubations are very, very low with mobility programs. And so I think usually if you're going to mobilize an intubated patient,  you want the respiratory therapist and a nurse, sometimes two. If a person's not intubated, then usually just two people is fine. And it can be a nurse who has training, and then  one other person. In fact, usually that second person is not a nurse. It's a PCA who's just helping if the patient's not strong enough to ambulate with an assistive one.  Some patients will be strong enough to ambulate with an assistive one, and then they would just need that one person. But yeah, the picture is early on,  and everyone was excited to be in the picture, I think. OK. We have time for one more.  Thank you for the great talk. I've got two questions. We've been on this journey at our hospital for years now. I feel like I'm aging as opposed to patients mobilizing.  But one question I have is passive range of motion. Do you have your nurses do it, or do you have the family do it, or do you not think it's important at all?  And then when you took money from the hospital for a QI project, what exactly was the money used for? Was it investment in human capital,  or was it investment in informatics for the EMR? Thank you. Those are two great questions. So I should mention that our early mobilization program  is a program of progressive active mobility. So we do not consider passive range of motion to fall under the purview of this early mobilization program.  Nursing can do passive range of motion, or we'll train families to do passive range of motion. But none of that is included in this,  because we do want to focus on progressive active mobility. In terms of the QI funding, initially, this program was funded for two years with a couple of million dollars  from the hospital. But a lot of that went towards personnel and equipment. Our program has two full-time physical therapists, a full-time occupational therapist,  and a full-time rehab assistant just for the MICU. And then there was equipment that had to be purchased. I realize that is a heavy investment of personnel and money.  You don't need that much money or personnel. It depends on your bed census, the acuity of the patients, what the hospital is willing to do.  And in rolling this out to other campuses, our ask has not been that large. So you can basically use that business plan that I showed you on Needham's website,  work with your skilled rehabilitation leadership and your nursing leadership, and come up with a plan that works for your hospital. Thank you, everyone. Thank you.  So our next speaker is Margaret Pisani, who is an Associate Professor of Medicine in Pulmonary Critical Care and Sleep Medicine at Yale and also one of my mentors.  And she will be talking to us about sleep in the ICU, an elusive goal. Thank you and welcome. So I have no disclosures today.  And so what I'm going to talk about is sleep and its importance. And so most of us that are trained in critical care aren't also trained in sleep.  So just to remind everybody, we all know what sleep is. But it is defined as a periodic, reversible state of cognitive and sensory disengagement from the external environment.  It's essential to survival. We know that because studies of sleep deprivation in animal models show that after a certain period of time with sleep deprivation, the animals will die.  Although we do know that it's important, its total purpose is still not fully understood.  So if you look in the basic science literature, on a daily basis, new articles come out describing  the different mechanisms of sleep and what their pathogenesis and why it's important. One thing I do want to mention for us in critical care is that sedation is not sleep.  So that while we may sedate patients and they look like they're sleeping, if you do studies or EEG studies on these patients, they are not getting normal sleep.  And there's many reasons for that. Medications, their critical illness. But just so we recognize that sedation is not the same as sleep.  So what are the effects of sleep deprivation? Probably everybody in this room is aware of it, working in healthcare. And we all know what it feels like to be sleep deprived.  The things that are important for us in the ICU and things that also tie sleep deprivation to delirium are things like irritability, cognitive impairment.  Patients can have hallucinations with sleep deprivation. Sleep is important for immune function.  And so impaired sleep impacts immune function, which is important for our critically ill patients. And then things like heart disease, which happens over time.  But with sleep deprivation, you can get changes in hormones that actually will impact heart rate and heart rate variability.  And those things all are important for our critically ill patients. What I'm going to do today is kind of give you a little background.  So in my 12 minutes of time, I'm going to talk you through quickly circadian rhythm, sleep deprivation, what happens to it in the ICU, and treatments, or what can we do to  improve this in the ICU. So I'm going to start with circadian rhythm. And so just for everyone to know, everybody has the circadian rhythm is tied to the 24-hour  clock of day and night. And all mammals are controlled by a circadian rhythm. And the master clock sits in the suprachiasmatic nucleus in the hypothalamus.  And so what happens is there are things called zeitgeibers. And zeitgeiber is a German word for time giver.  And so these zeitgeibers are important to help maintain our circadian rhythm. And the most important zeitgeiber is light, or what we call a photzeitgeiber.  And you'll see when we talk about light in the ICU why this becomes important. But so light is the most important one. And this controls the master clock.  And then there's all peripheral clocks that are controlled by the master clock. And all of the organs have peripheral clocks.  The heart, the liver, the kidneys, and even blood cells have peripheral circadian clocks.  And so while light is our most important zeitgeiber, there's other what we call non-photic zeitgeibers that are important.  And when we think about these, the sleep-wake cycle is one. But physical activity, and you'll see as the story unfolds why these all become important in the ICU.  Physical activity is another. Social time and meal time. And so if we think about how we do things in the ICU, these will become important when  we think about maintaining sleep or improving sleep. So when you think about sleep, sleep is controlled by a two-process model.  And again, there's still lots of data being done to understand this. Lots of the circadian rhythm has been worked out again in animal models, less so this other process of sleep.  So there's two processes of sleep. One is called process S, and one is called process C, or the circadian process.  And so if you look up here on the top, this is process S. And what happens is the longer you're awake, the stronger your drive to sleep becomes.  And so you'll reach a threshold here, and you'll fall asleep. And then as you get more sleep, you move towards awakening.  What happens with the circadian process here is that you reach a threshold and move towards sleep as your alertness will decline, as melatonin will go up.  And you see around 9 p.m. here is when melatonin starts to go up, and then melatonin will peak. And then as melatonin comes down, you move towards wake.  And so these two processes work together to promote sleep. Sleep occurs best when it occurs, biological sleep occurs best when it occurs at night.  And there's lots of data to support this in shift workers, which we won't really talk about today. So what about sleep architecture in the ICU?  So there's been lots of studies dating back all the way to the early 90s that have documented that sleep is disruptive in critically ill patients.  These patients have increased difficulty falling asleep, they have increased numbers of arousal,  they don't progress through normal sleep stages, and they have a predominance of what we call  light sleep, or stage N1 and N2 sleep, and a lack or absence of what we call restorative stage sleep, or N3, or rapid eye movement, or REM sleep.  And those stages are felt to be the ones that are important for cognitive and processing for maintaining immune function.  And we also know that sleep is fragmented, and so while certain studies will report while patients in the ICU have a normal number of hours of sleep, half of that occurs during  the wrong time. So half of it is occurring during the daytime. And you'll see here, these are polysomnograms from a normal patient, and then four critically ill patients.  And the white is wake, and the gray, you actually can't see the white and the gray up there, can you? I can see it on the screen here, but I don't think it's projecting up there.  Anyway, white is, which you can't, I don't think you guys can see, wake and gray is sleep.  And so in a normal patient, over the course of the night, they'll go from wake and progress through the stages of sleep down to N3 and then to REM.  And this will occur in 90 to 120-minute cycles over the course of the night. If you look at critically ill patients, and these are four different ones, so this red here is all wake.  Is that better? Oh, sorry. The red here is wake, and you can see patients have a long latency until they fall asleep.  And then they also have much light stage sleep, so N1, N2, and very little of, or none of the restorative or REM sleep.  And this becomes important as we think about patients and healing in critical illness.  Again, if you look at sleep stage durations, patients have very little time-wise. Only 10% of their time was spent in REM, and only 3% of their time was spent in N3.  Again, these are the important restorative stages of sleep. Although if you look at total sleep time, you think it's not horrific. They had about five hours of total sleep time.  Again, half of this is occurring at the wrong time, and it's occurring during the daytime. This was a qualitative study that looked at patient and staff perceptions of sleep  in the ICU, and this actually pointed out some important things to us, I think. One of the things that we'll talk about a little bit in more detail is that the environment  is disruptive and that there's an unpredictable workflow that disrupts sleep. But patients reported that this disruptive environment was expected because they knew  they were in the ICU, and it was somewhat reassuring to have somebody in the room. And so while we're thinking that we need to really get people out of the rooms to let  people sleep, we also need to think about reassuring the patient if we're not going to be in the room, and that's what's important to patients.  Other things that were important in this qualitative study were the emotional factors.  Patients were scared and anxious, not unexpected, and so we need to think about that when we're  thinking about developing sleep promotion activities that we're going to actually, again, reassure patients that everything's okay if we're not going to be in the room.  And then the perceptions of sleep were variable, but interestingly, although there isn't any data to support that these medicines actually improve sleep in the ICU, the respondents  in this study, patients and staff, felt that the sleep medications actually improved sleep. So what contributes to sleep disruption? I don't think I really need to tell anybody.  If you work in the ICU, noise is a big problem, and at all times of day, our decibels are way too high.  So noise is a factor, and then again, the fact that the patients are critically ill and somebody needs to be in the room doing stuff.  So this is data from the Society for Critical Care Medicine PADIS guidelines, and they looked at what the risk factors were for poor sleep.  There were 12 observational studies, and then 9 studies with sleep measures, and you can  see none of these things are things that are unexpected, noise, pain, discomfort, immobility, patient care, and patients being worried or anxious.  And then the other things that were important were deliria, hypoxemia, certain medication use, ventilator asynchrony.  And all of these things on this slide, if you look at them except for the illness severity are things that we can potentially modify, and so these are the things you want to think  about when you're trying to improve sleep in your critically ill patients. This is just some data that looks over time, and then some data from our ICU, and ICU sleep  opportunity is really limited by high sound. So studies dating back as far as the early 70s have demonstrated that sound in ICUs is  way too high, and this sound comes from all things you can imagine, things that are within the ICU itself.  One of the things that patients report as the most disturbing is staff conversations and staff conversations outside the rooms, but things that you also can't control like  where your ICU is in relation to noise outside where the helipad is in your ICU, those kinds of things.  And if you look, this was our ICU, we looked to see, well, does the sound go down during the night?  And if you look even here in the night, overnight hours, the sound is just as high in those hours as it is during the day.  This was a systematic review that actually came out to try to understand, well, okay, we know it's noisy, but is it the noise that's really disrupting the sleep of patients?  And it looked at 20 publications, and what they found was in these studies there was a lot of potential for bias, and there was a lot of heterogeneity between the studies.  But healthy subjects are exposed to a lot of ICU noise, but it was difficult to quantify how much of that noise was contributing to sleep disruption.  If you look at things that disrupt patient sleep depending on the time of day, this green is the nighttime hours right here, and things that were important were bright lights  being on, the television being on, and whether or not the window shades were closed. Another thing that's important, again, we talk about is nighttime entrances into rooms.  And what happens at night, oftentimes patients are getting bathed at night, trash is getting emptied, things that potentially could be moved to other times.  And so when we looked at this in our ICU, in the midnight to 4 a.m., patients only had a total of 28 minutes of quiet time in that four-hour period where somebody wasn't in  their room to get to sleep. And if you remember, the time it takes to get through a full sleep cycle is 90 to 120 minutes.  So these patients didn't have enough time without somebody in the room to even get through one full sleep cycle.  And so these are all the things that impact poor sleep in the ICU, and you can see here sound, bedside care, critical illness, things that we can't impact on, but things that we  can, such as how the ventilator is set, are they in pain, are they anxious? And then other things that are important, such as circadian cues.  So when we feed people, are they ambulating or being upright? And so I'm going to quickly run through what the PATIS guidelines talk about in this iteration in 2018.  They added in sleep disruption. And so they looked at the three drugs for potential for sleep. And melatonin is one that they looked at.  This is based on only three small randomized trials. And the studies were very small, and they were not controlled for a lot of the things  that are probably important for sleep, such as light exposure. And how sleep was measured wasn't the same across these studies.  And so the guidelines make no recommendation regarding the use of melatonin. And the other caveat I would put in about using melatonin in critically ill patients  is oftentimes, and we didn't talk about this, their circadian rhythm is disrupted or shifted.  And so if you give melatonin to somebody who's already shifted, you have the potential to worsen their circadian disruption. As far as using propofol to improve sleep, the recommendation is to not use propofol  as a sleep aid in the ICU. Propofol is associated with REM suppression, so you get less REM sleep when you give propofol.  And then as far as dexmedetomidine, there's no recommendation to use dex either, again, because the trials aren't there that show that dex actually improves sleep.  The data just doesn't exist, although I want to just point out this one study that came out after the guidelines were published that looked at dex for ICU delirium and showed  that if you gave dex overnight to patients, so dex was given in the overnight hours, that patients had less delirium.  And while we're not talking about the interrelationship between delirium and sleep in this today, there is probably a relationship.  And so the mechanism for the less delirium may be through a sleep mechanism, although this study didn't demonstrate that. So what can you do?  The thing to really think about for sleep is non-pharmacologic interventions.  And so this was a pre- and post-study that looked at implementing a overnight sleep bundle  that occurred from midnight to 4 and demonstrated a 32% reduction in in-room entrances. And so this was proof of concept.  If you implemented this, you could improve having the lights off and reduce in-room entrances.  The key thing, though, and that wasn't that we need to think about is that we also need to think about circadian rhythm and its impact on sleep.  And in this study, if you look at the morning time, which is this top here in yellow, we really have a very low level of high light early in the day.  And that may be important for circadian maintenance.  Early mobilization has already been talked about, but we know it reduces delirium incidence. And again, being upright is a circadian cue.  So mobilizing patients should hopefully help maintain normal circadian rhythm, improve sleep.  So I'm just going to end here to say that sleep is severely impaired in the ICU. It occurs, people aren't getting enough of it. It occurs at the wrong time.  It's frequently interrupted.  And so what can you do for sleep promotion? Propofol, if you're using it for sleep, it's not to be used, shouldn't be used for sleep.  Other drugs may have a role in improving sleep, but the data isn't there yet. And then the key thing that we know will work is non-pharmacologic measures.  So improving light during the day, decreasing noise at night, reducing in-room interruptions, mobilizing patients, and considering bolus feeding.  So I just, all of these people here have contributed to any of the work that was from Yale. So I want to say thank you to them. And I don't know if we have time for questions.  Any questions? I have a question for you. Yes. I know. I was like, no questions yet. I noticed that you recommended increasing light levels early in the day, but what time,  for those of us who are not sleep medicine trained, what time should that happen? Well, so, I mean, early, I mean, if you look at the way circadian biology works, actually  it's probably around sunrise time is that when you should get those light levels up. So I usually go around if I'm seeing patients early in the day and try to open their curtains,  you know, at like 7, 8 in the morning. And so earlier in the day, it's probably better. You have to also take into account, which I didn't talk about, is what someone's normal  sleep pattern is at home. So you want to try to maintain that as much as possible when they're in the ICU.  So sometimes you'll have people who are like night owls or early birds and trying to get that history and maintain that.  And I know that's what happens in a lot of the geriatric wards. But trying to also do that in the ICU if you have that data.  Oftentimes the nurses don't want to open them up because they're like, well, they were up all night.  But then we get into this vicious cycle of then they're up all night and sleeping all day. So trying to break that if you can. Thanks for your talk.  You mentioned some pharmacological interventions like melatonin and propofol. What about other things like Seroquel, quetiapine for patients who may be agitated and that  might be contributing to their lack of sleep? Well, so they're sedatives. And so they will make people not agitated. But they don't promote sleep.  So you won't get normal sleep from them. And they actually probably, depending on the agent you use, alter the normal sleep pattern. So again, you won't get that REM sleep.  It will do kind of the same thing. They are sedatives. So they will make the patient not agitated. But you're treating the agitation. You're not actually promoting sleep.  And so you have to think about if the patient's agitated, I need to treat the agitation. But recognizing it's not really giving you a normal sleep cycle. Thank you. Well, thank you.  I just want to know, as a critical care nurse, what method can I use to assess patient's sleep? Right.  Well, so there's questionnaires or something called the Richards-Campbell Sleep Questionnaire, which can be filled out by a nurse.  You know, it's a visual analog scale and nurses can fill them out. If the patients, a lot of the patients can't interact. If they can interact, you can assess it.  And so those are really the only two, that's really the only way. I mean, oftentimes when just observing the patient, thinking they're asleep, they're not really asleep.  So unless you're going to do a polysomnogram or use an ActiWatch as a rest, it doesn't give you sleep, but it gives you wake rest. Those are more invasive methods.  But there are questionnaires out there that you can use that can be filled out by the nurse like an observation. Okay. Thank you. All right.  Our next speaker is Adrian Austin from University of North Carolina, where he is a clinical instructor.  And he's kind of a unique breed that's actually growing in the aging and critical care community.  And that is folks who are board certified in geriatrics and also in pulmonary and critical care.  So in addition to the ABIM loving you for supporting them, yes, supporting them almost single-handedly, he's going to talk about acute care for elders in the ICU.  So sort of applying things that we know work outside of the ICU and what they might look like for our critically ill patients. Thank you, Nathan.  First, I've got nothing to disclose. So what are we going to do this morning? First thing we're going to do is define what an ACE unit or acute care of the elderly unit is.  We're going to review some of the data about the impact of ACE approach on outcomes in the non-ICU environment.  We'll review the core components of this program and then talk about some practical ways we can incorporate it into the ICU.  And I love the fact I'm following up Dr. Bassani because sleep was one of the big things about it. So what is it? It's not CARDS and it's not ACE inhibitors.  It is acute care of the elderly, so we will not talk about these things today. However, if you want to later, I'll happily talk CARDS with you.  So it's an interdisciplinary approach. It's been around for 25 years. The original RCT was published in New England Journal in 1995, and it focused on four elements,  a specially designed environment for older adults, patient-centered care, discharge planning, and careful review of medical care.  All of these don't sound that difficult, but in practice they can be. But I'm going to argue later that most of our units probably aren't that far off of this model.  What are the goals? So really we want to keep our people as close to baseline as what they are during their acute illness.  We want to maintain the ADLs and IADLs they currently have and to help them recover the  ones that they are lacking that they previously had at baseline, and with that their function.  We also want to prevent new geriatric syndromes such as delirium, falls, pressure ulcers, frailty. So what's the impact?  What's some of the data behind the acute care of the elderly approach in the nine ICU settings? So I'm just going to highlight a few things here. But first some epidemiology.  So as a geriatrician I appreciate, as many of you do, that the population is aging. We'll have over 70 million adults over age 65 within the next 10 years.  Currently the oldest old, 85 and older, make up 20% of our ICU admissions, and this population is growing much faster than we can train geriatricians. So it's not going to go away.  So as ICU providers we need to get comfortable with some of these geriatric principles.  Assessing on the ACE unit in particular, it does lead to numerous favorable outcomes. It reduces hospital length of stay.  Patients are more likely to go home and conversely less likely to go to a skilled nursing facility. I put this in here because I thought it was funny.  Reduces cost of hospitalization by $245 per patient. This is 2012 data. I would argue it's probably significantly higher than that, and certainly if we enacted  in the ICU it would probably be much higher than that. Then as a geriatrician with an interest in delirium, this is something near and dear to my heart.  It does reduce the incidence of delirium in our non-critically ill patients. Reduced falls, and it was a trend towards reduced pressure ulcers in this meta-analysis  that pulled Hunt Studies. So overall good for the patients. It gets them out of the hospital sooner, it maintains their function, and less bad things happen to them.  What are the core concepts? Again, there's four core concepts, and I'll go through those four. So first is a repaired environment.  Some things that would give an example of a repaired environment, well-lit rooms, ideally natural light.  Now realizing that you can't go tearing down your hospital and redesigning it, but ideally natural light if you're building a new one.  Carpets, that's for acute care of the elderly, non-ICU, perhaps not the best in the ICU due to infection control, but you don't know.  Large clocks and single-day calendars to help promote orientation. Then patient-centered care, and I think as medical providers we should be doing this  anyway, and I think in the ICU we do a pretty good job of this particular element. That's daily assessments of physical, cognitive, and psychosocial function, and with that daily  rounds by a multidisciplinary team. Moving on to the third tenet, discharge planning. Early emphasis on returning home, ideally to their prior environment and involving social  worker and home health nurses and outpatient therapists, if applicable. And then daily careful review of medical care, reviewing medications and having protocols  in place to minimize the adverse effects of procedures and medications. So that's it.  Doesn't sound too difficult, but again we all know practically it can be. How can we incorporate this into the ICU? So let's talk about prepared environment.  I would say some of this is low-hanging fruit. We can put large clocks on the wall and single-day calendars and help our patients with orientation,  keeping them grounded in time and reality as possible. Providing their assistive devices, glasses go a long way towards delirium prevention  and helping people interact with their environment. Hearing aids do as well, but if you don't ask, if the patients don't have them, then you'll never know.  Something else that is a big part of infection prevention that we should be doing is getting lines out of people, getting devices off of people.  So getting your catheters out as soon as possible, lines out as soon as possible, and I would  argue for your patient awaiting the floor, removing their telemetry too unless they really need it.  Then you want to, as Dr. Bassani was discussing, minimize daylight disturbances. Lights on during the day.  I too, when I'm going around in the morning, open up the blinds and try to get more natural light into the room, turn the lights on.  And then something that we've done is moving bath time at night, which also really helps. So if you look over a 24-hour cycle, at least at our institution, the big admission periods  was from about noon to 10 p.m. So that was when everybody was busy. And the lowest amount of time, the lowest acuity, lowest admission discharge timing  was between midnight and 4 a.m. So that created this incentive to do things to patients between midnight and 4 a.m.  You take them off the floor for that CT chest where maybe the physician has to go with them.  You change out that arterial line that's maybe not doing too well, and consequently the patients do not get an uninterrupted time at night, which may be detrimental to their sleep.  Patient-centered care. This is something I think in the ICU environment we actually excel at.  So getting our team members together, physicians, therapists, nurses, pharmacists, social workers, nutritionists, and discussing a daily plan for the patient.  I think this is the one that's the most immediately actionable because it doesn't require a lot of resources beyond what we currently have.  Then discharge planning, and I want to spend a minute on this. So I think we've become adept at discharge planning for patients to go home because a  big push to get them as soon as possible. But the transition from the ICU to the floor or step-down environment really is a vulnerable  time for a patient, and it's something we should be more focused on. It would be a great time to do a thorough medication review, think about things such  as do they still need their antiarrhythmic for that atrial fibrillation with RVR they had 48 hours ago? Do they need antipsychotics on their MR anymore, or can we stop them?  And I would encourage you to pursue warm handoffs as well to discuss the intricacies of the management of this patient. And finally, careful review of medical care.  We want to review our patients' medications daily. I would focus on minimizing deliriogenic medications as you can, minimizing anticholinergics such  as diphenhydramine, hopefully we're not using too much of that anyway, minimizing benzodiazepines, all things that we know are good care for our patients.  And again, getting those catheters and lines out as soon as possible, and thinking about  whether your patient really does need to leave the unit, and if so, can they not do it during the day? Do they really need a TTE, CT, etc.? So that's it. That's the ACE model.  It's something we've been using. We use it at UNC in our geriatric environment, and I wish we could say that we use it 100%  in the ICU environment, but we have some components of it. It's low harm to the patients. It improves outcomes.  And I think with a relatively low ask, many of the tenants can be integrated into your ICUs quickly. And so, thank you, and congrats. Again, we have time for questions.  I want to lead off. So we're trying to get a similar thing going in our ICU, and the feedback we get is similar to sort of what you're saying, that we do a lot of this.  But my sense is that we still have older adults with bad outcomes. So what is the sort of next step, or where is the focus?  I mean, you sort of focused on the, you know, you mentioned this with the resources, that we do a good job with a multidisciplinary team.  How can we shift, or what areas do you think are the shift in focus that we should have when we have that interdisciplinary team together to kind of focus on the older adult?  So first off, I would say that this model shouldn't only apply to older adults. I think it could apply to any critically ill patient, because I think it's a good sort  of care model in general.  The big thing to focus on, I think, is for one, sleep, and allowing our patients some uninterrupted time at night, and tied in with what you were saying, early mobilization during  the day. These are all intimately related, and they help each other. One thing that we found that's big is just getting all the therapists and the team members  in a room together daily goes a long way towards making a plan.  So coordinating better, yeah. I mean, that's the feedback as we get as well. We already do this, but are there additional things that we need to do?  I mean, like I said, the transition out of the ICU, too, is something we found, at least  in internal data that we have, that that could be improved upon, and I'm willing to bet we're not the only ones that have that issue, because we think, hey, they're better.  They're a lot better. See you later. Go to the floor. But perhaps don't think about that transition in as much detail as we should.  So a careful medication review at time of discharge, I think, is low-hanging fruit as well.  Well, good. That's a good segue, then, to our next speaker. Let's first of all give Dr. Austin a round of applause.  So our next speaker is Joanna Stollings, who's the medical ICU pharmacist at Vanderbilt University  Medical Center, and she also plays a prominent role in the Vanderbilt ICU Recovery Center, and she's going to talk.  Her topic is on medication reconciliation at critical transitions. Thank you, Nate, for that kind introduction, and thank all of you for allowing me to speak to you today.  So I have nothing to disclose. The objectives today are going to be discuss the prevalence of medications not being restarted  at transitions of care, to describe the prevalence of inappropriate medications being continued  at transitions of care, and finally to evaluate strategies to manage medications at transitions of care. So what is a transition of care?  Really, it's like any time that a patient has a change in a provider. So if you came and worked with me in the Vanderbilt MICU, this could be every one week I might  have a new attending. There might be new residents every three days. It can be quite often. Patients are at substantial risk for adverse drug events.  They're at higher risk if they have some degree of cognitive impairment or if they're on more than five medications.  Many hospital readmissions and emergency department visits are medication-related. There was a study specifically looking at patients through the Joint Commission, and  it showed that 20% of patients were readmitted within 30 days and 30% of patients were readmitted within 90 days, and this was secondary to not understanding their medications.  Fifty-four percent of errors occur when medications are ordered at hospital admission. So let's start with looking at medications that need to be started.  So this was a study that was published in JAMA a few years ago evaluating that. So this is a cohort study in Canadian patients, almost 400,000 Canadian patients, and it looked  at three different subgroups, so patients that weren't in the hospital, those that were in the hospital but not the ICU, and then those that were in the hospital but in the ICU.  And patients had to be receiving one of five different medication groups, so either statins,  anticoagulants or antiplatelets, levothyroxine, respiratory inhalers, or gastric acid suppressants.  So as you can see here, patients were more likely to not have the medication classes we just talked about restarted if they were hospitalized as compared to not being hospitalized.  They also were more likely to not have these medications restarted if they were hospitalized and in the ICU as compared to not being hospitalized.  Additionally, they specifically looked at patients that were hospitalized on the floor as compared to those that were hospitalized in the ICU.  And they found that being in the ICU, it was more likely that all these medications would not be restarted with the exception of respiratory inhalers.  And I don't think that really surprises anybody, especially when we think about the medical ICU because we use a lot of respiratory inhalers.  That might be a reason a patient's admitted, but it shows we really have a lot of work to do. Additionally, it showed the composite outcome of death, emergency department visit,  or emergent hospitalization was more likely to happen if someone did not have their statin restarted or their antiplatelet and anticoagulant restarted.  So I think this really highlights, I think the next thing I'm going to talk about is discontinuing meds that are not appropriate, but I think we also really need to focus on  restarting patients' home meds that are indicated when patients are in the hospital. So now we're going to move on and look at medications that need to be discontinued or stopped.  So deprescribing is a strategy that was published in JAMA a few years ago, and essentially it just provides steps to cleaning up medication lists for patients.  So the first step is to determine that each medication has an indication. Then to consider the overall potential harm of each of the different medications.  Determine if each individual drug needs to be discontinued. Then you need to prioritize the order of stopping the medications.  It's smart to stop five medications in a patient because then if there was a problem, such as maybe withdrawal, you wouldn't know which medication was the problem.  And then lastly, to initiate and monitor a drug discontinuation plan. So this was a study that was published by our research group at Vanderbilt a few years ago  that looked at inappropriate medication prescribing patients in elderly patients. So this study was in 120 elderly patients, and essentially medication lists were evaluated  when patients were admitted, when they were admitted to the floor, when they were admitted to the ICU,  when they were discharged from the ICU, and when they were discharged from the hospital. And it specifically looked at two different things.  So potentially inappropriate meds are meds that might be helpful but might be harmful, and the other are AIMs, which are actually inappropriate meds.  So these are meds that really have not demonstrated to be helpful to patients. So as you can see here, the meds that had the highest positive predictive value for being a PIM  were non-benzodiazepine hypnotics, atypical antipsychotics, and muscle relaxants. Moving on, looking at what predisposed patients to be discharged on a higher number of PIMs.  As you can see, it was the number of pre-admission, potentially inappropriate meds, if they were discharged from a surgical service versus a medical service.  And finally, their discharge disposition. If they were discharged to a facility, then they were more likely to be discharged on more potentially inappropriate meds.  There was a more recent study that was published by Rachel Krueger and colleagues looking at medication errors at the transition of care from the ICU to a non-ICU location.  So this study was a multicenter retrospective seven-day point prevalence study in 48 different ICUs in 34 different institutions.  So it included 985 patients that were transferred from an ICU to a non-ICU location. So unfortunately, 450 or 45% of patients had a medication error.  And also, patients that were on renal replacement therapy or the number of meds that were ordered post-transfer were factors that were associated with the occurrence of an error.  Anti-infective agents, hematologic agents, IV fluids, electrolytes, or diuretics are all associated with the increased incidence of an error.  Also, 75% of patients, the error reached the patient, but they did not have harm secondary to it. So I think, once again, this shows how important it is that we as pharmacists,  physicians, nurses, et cetera, need to evaluate patients' medication list and to be considering what medications that we stop when patients are admitted to the hospital  and as they transition through care throughout the hospital and are discharged. I'm sure this doesn't surprise any of you in the room.  There are a number of studies that have shown that we do a poor job of stopping stress ulcer prophylaxis once people have been started on this.  So we as clinicians need to be very cognizant that even if patients are still in the ICU, if they do not have an indication for stress ulcer prophylaxis,  if they are not mechanically ventilated, if they do not have a coagulopathy, we need to ensure this is discontinued. I don't think it's going to surprise anyone in the room either.  There's also a problem with continuing antipsychotics following an ICU admission. I'd like to think that after the publication of the MindUSA study,  which showed us that antipsychotics were not beneficial in patients  with high delirium that we have a decreased use of this, but still it is not infrequent to hear that people still use a number of these.  So this is also a problem that we need to be cognizant that if these are ordered in patients for whatever reason that we stop these if they are not appropriate  when patients are transitioned or even if they're still in the ICU and they have not transitioned care. So what can we do?  So one thing to think about is there's a number of different seemingly small things that we can do as individuals to help with all these medication errors.  So daily patient rounds in the ICU is one. Orders being discontinued and rewritten at the time of transfer. So at our institution, we specifically use Epic.  And if a patient is transferred to the floor from the ICU, then the physician has to approve that medication list. They don't have to rewrite it, but they do have to approve it.  At the VA, which is right across the street, then they actually have to rewrite all the different medication lists. But whatever your institution does,  then we need to be very cognizant to evaluate every medication on that list to make sure it still has an appropriate indication. Admission medication reconciliation.  So when patients are admitted, making sure that all their appropriate home medications get restarted. Pharmacists are the best at conducting medication reconciliation.  Discharge medication reconciliation as well. So this can be quite time consuming, so we need to do things like setting a time to make sure that we do this.  So we need to know when the patient is going to be discharged so we can set time aside to do this. And also, if possible, make sure their family members are there  so they can help with this process as well. So involving the family in the medication reconciliation process. Using adherence aids and education materials.  So using maybe a pillbox if a patient's on a number of medications. And providing adherence aids, such as maybe sometimes we will provide patients with pamphlets.  It's essentially a printout of each of the patient's different medications so they don't forget what each of the different medications look like.  Scheduling a time for discharge counseling. Using an in-hospital filling system. We have a system at Vanderbilt called Meds to Beds where we can actually call the pharmacy  and they will bring the patient a 30-day supply of their medications. It's actually great because the patient leaves, they don't have to go to another pharmacy,  and they can go home without having to stop. You can potentially provide the patient with a wallet-sized medication guide. And then also, as I said before,  just communicating about the discharge time so that we can set up this time to thoroughly go over their patient's medications.  So I work in the post-ICU recovery center at Vanderbilt. So essentially we see patients that have either had acute respiratory distress syndrome or sepsis that were in the ICU.  We see them in a clinic after they have been discharged to home. And my role as the pharmacist is I go see each of these different patients  and I interview them very comprehensively about their medications. And sometimes we have to make recommendations to start new medications.  As you can see here, this is the data that I published two years ago, specifically looking at our first 62 patients that we saw in our post-ICU recovery center.  And as you can see here, we started a number of different agents, including anti-constipation meds and people that were on opiates,  even some H2 blockers, non-steroidal agents as well. But more importantly, we stopped a lot of medications as well. I don't think it's going to surprise anybody in the room  that we stopped a lot of proton pump inhibitors and H2 blockers that were continued in people following their hospitalizations, bronchodilators that maybe didn't have an indication,  and even some antibiotics that did not have a clear plan. Moving on, as you can see here, we implemented preventive measures to prevent adverse drug events in several cases  and also actually stopped some adverse events in people that we noted that these had happened in. So, for example, in patients that were on inhaled steroids  that were not washing out their mouth, then we educated about this to prevent the development of thrush.  Moving on, as you can see, we did some dose increasing, some dose decreasing. We supplied some pill boxes.  But one of the most notable things that I was actually quite surprised about was how many influenza vaccines that we administered.  As you can see, we administered 13 of these or in 23% of our patients. So a lot of these patients, unfortunately, were actually admitted with the flu.  And as many of you, I'm sure, in the room know, it's not the best to really give a patient a vaccine in the ICU because they might not respond to the vaccine.  We actually have within our specific system at Vanderbilt reminders to vaccinate patients before they leave the hospital.  But this many people were discharged without receiving their influenza vaccine. So I think this really shows an area that we can improve upon. And then lastly, as you can see,  we also administered some pneumococcal vaccines as well. So in conclusion, critical home medications are often not restarted in the ICU. Many medications are started in the ICU  and continued at transistence of care when they're not indicated.  And lastly, post-ICU recovery centers, medication reconcilia at admission and discharge, and interprofessional daily ICU rounds help prevent medication errors.  Thank you, and I'm happy to take any questions at this time. Do I have time? Thank you. Hello.  So we have found that one of our biggest barriers is just the admission med history list.  We did a little bit of data and found that 80% of our high acuity level one critically ill patients, 70% have an inaccurate med history.  Ours are primarily taken by the nursing staff. And 17% of those inaccuracies are ISMP high alert medications. So how does the med history process kind of look at your facility?  And obviously the pharmacist, we try our best to go through and do thorough reviews on all of the patients that are admitted.  Our staffing poses challenges sometimes. So how does that look at your institution? That's an excellent question.  For anyone that couldn't hear, the question that was asked was how the medication reconciliation process looks at my institution. So you're correct.  There is only a certain number of pharmacists. I cover a unit that has 35 beds, and I'm only one person.  So we do know pharmacists are the best at performing medication reconciliation, but I think this is where you would want to consider a layered learning model.  So in other words, I have a lot of students and a lot of residents, and I have them help me tremendously with a lot of different medication reconciliations  just because I don't have the ability to do them all myself, and it's a great way for them to be involved. I just had a question for you about in your post-ICU recovery clinic,  since you're the one who's speaking to the patient and you tell them to stop, my question is twofold.  So first, how do you close the loop to ensure that the patient has actually stopped the medication and also that their physicians are aware?  And then second, do the patients ever have anxiety over stopping a medication that maybe they've been on for a long time or feel, I don't want to say emotionally attached to,  but there can be patient anxiety around medication discontinuation. Absolutely, two great questions. So the first was, if we stopped a medication,  how do we essentially close the loop with regards to that? So if we were going to stop a medication, then I would tell the patient to stop the medication,  but my attending that works in the clinic, Carla Steven, she's the loop closer. So she makes sure that every time we see a patient at our post-ICU recovery center,  she actually sends a letter to the patient's primary care provider, which would indicate that in there, so they would be aware that that would be stopped.  And the second part of the question was, if the patient would potentially develop anxiety secondary to stopping medication. So if somebody's been on a medication  for a very long period of time, such as maybe like a PIM, that we think they should stop, but we're maybe a little nervous to stop, we would put that in the letter  specifically to the primary care provider and suggest that they stop it, but we might not actually stop it just because that wouldn't really be our role,  especially if they've been on it that long.  Thank you.  Oh, sorry. Hi, I'm a surgical intensivist. I work here in Florida. We have a really nice system where the big commercial pharmacies feed in the outpatient medicines  that the patients are taking. We also, the hospital hires bilingual pharmacy techs that interview everybody, and we're really quite happy with the way that we get our intake done.  And we have a PharmD round with us every day, and because surgical patients are frequently NPO, we change a lot of the medicines around, and we usually do real well with that too.  I was wondering if you could give us some pointers. When the patient leaves the hospital, we give them a letter with their discharge summary that says this is what we stopped,  this is what we started, but that never gets to CVS or Walgreens, and it might get to the patient's PCP, but the patients are usually so much going on and so many changes,  and they've got casts and splints and walkers, and what have you done to try and get back to the PCPs saying, okay, we stopped this ACE inhibitor,  and we converted the Metformin to insulin, and they're gonna be on this pen, and narcotics are a huge problem in Florida because they basically outlawed us  to give outpatient narcotics more than three days.  Well, how do you, other than calling the PCPs, which would be time prohibitive, what do you do to try and get that back link back to the outpatient? That's an excellent question.  So the question that was asked was that how essentially we communicate what new medications or what medications that are gonna be stopped to the patient's primary care provider.  So first, I think that this really highlights what I was talking about, how it's important for the pharmacist to do the discharge medication reconciliation,  so to not only hand them that piece of paper like you're talking about with the walker and everything else they have going on, but to really actually go through that  and make them understand that now they're on Carvedilol maybe, and they're not taking Metoprolol, so they don't double up on those things, and making sure that the family is there  so that they can also help to make sure that that is understood. Something I've seen done as well is, much like my physician Carla Stevens  sends a letter from the post-ICU recovery center, once again, you could do that as well versus having to take the time to make a phone call to communicate that information  to their primary care provider.  Thank you.  Oh, one more question. We do have one more question. Hi, excellent talk. I'm Rita Gayed, I'm a pharmacist at the Grady Burn Center. I had a question for you.  We have a lot of patients who will leave the ICU and go to rehab, but we don't have our own rehab. So how are you guys going about communication?  Do you bring these patients back from rehab to your clinic? And if so, how are you going about meds? We've seen some really bad situations, and I'm curious how you handle that.  Thank you. That's a great question. The question that was asked was how we handle patients that went to rehab with regards to their medication list.  So really, you're specifically asking if they go to a facility, correct? Okay, so really, we would not wanna see the patient until they were out of the facility  because it wouldn't be helpful for us to assess compliance, et cetera, if the patient's actually having someone else give their medications to them.  So we would wait till they're out of the facility. We would follow them to determine when that would be, and then we would see them.  I'm wondering, Joanne, on that note, sorry, we have a little time. There was a recent paper in Annals ATS where they started to move some of these  post-ICU recovery center clinic interventions into the hospital, and I'm thinking, what would be the role or potential role of a pharmacist at the time of discharge  to sort of do that re-reconciliation? You talked about starting medicines, stopping medicines. I'm wondering if you could comment on the potential feasibility of that  or what that could look like, or? That's a great question. So the question was what the potential role of the pharmacist would be, essentially,  with regards to the discharge process. So we don't discharge a whole lot of patients from the ICU, but I work with a lot of patients, or pharmacists, I should say,  that work in the different floor areas, and they do a really good job of, essentially, when patients are being discharged to make sure they go over the medication list  with not only the patients, but also the family members to make sure they understand specifically what they're supposed to be taking. Okay, thank you. Thanks. Thank you.  So this great discussion about transitions of care  is a perfect segue to our last talk, and after this talk is over, I just wanna mention we will have a panel at the front where you'll have the chance to ask questions  of any of the speakers.  So our last talk is going to be given by Jason Falvey,  who is a physical therapist, PhD, and one of our postdoctoral research fellows at Yale,  and who has also just accepted a faculty position at the University of Maryland. And so he'll be speaking to us about muscle memory,  maximizing post-acute rehabilitation and recovery for critical illness survivors.  Thanks for that great introduction, Dr. Ferrante. I'm excited to come talk to you about this topic, mostly because it's often a black box for many of us in the room  of what happens in post-acute care. It's a nebulous web of settings that I hope I can help you untangle a little bit. I do have some teaching disclosures.  I do teach for a for-profit education company, but I'm not gonna try to sell you anything, so I wouldn't worry too much about that.  So I think the speakers that spoke before me kind of outlined really well this problem of persistent functional limitation following critical illness.  You've probably seen the classic papers where there are substantial declines in physical function that perseverate months or years after an ICU discharge.  Six-minute walk test distance in younger ICU survivors is only 76% of normal, and that's five years after they discharge.  Importantly, this happens in the absence of any pulmonary dysfunction, so it suggests that there's a lot of skeletal muscle and incomplete rehabilitation  that's occurring within this patient population.  This is associated with decreases in quality of life and increased activities of daily living dependence as well. For older adults, this is even more striking.  Older adults, as pointed out in a really nice editorial by two of the people sitting up here at this table, are substantially more susceptible to functional decline  during an ICU stay based on pre-hospitalization vulnerabilities and just the physiological vulnerability that comes with age and immobility and critical illness.  Half of older adults fail to return to their baseline basic activities of daily living and mobility six months after an ICU discharge,  so it suggests that despite our heroic efforts in the ICU with these early mobilization programs and our attention to care transitions,  there's still a lot to be done in this post-ICU period to promote optimal recovery.  Now, we've considered typically in the last decade that the critical window for intervention for patients is within the ICU, and early mobilization does have substantial benefits  and helps promote better recovery of function, and it also reduces risk of delirium and other cognitive impairments.  When you promote better ADL function in the ICU, you actually have survival benefits.  So this graph here, this black line, these are functionally dependent patients, and you can see that even marginal improvements in function at the time of hospital discharge  confer survival benefits out to five years. So promoting mobility in the hospital clearly is one place where we can create gains.  However, a perhaps more understudied window of opportunity is this first 30 days when patients leave the hospital. So care transitions and that early recovery window  are perhaps a place where we could have a lot more impact.  Failure to recover physical function in those first 30 days is associated with increased disability at six and 12 months, and higher rates of nursing home admission and mortality.  I think that says to us that we should really be paying attention to the trajectories of functional recovery, not just in the ICU, and how patients transition into these settings.  Most patients are receiving care in this early window in post-acute care. Older adults, 50 to 60% of them, are using post-acute care of some sort along the continuum,  immediately following an ICU stay, which is a high amount, considering that the average Medicare population is about half of that. Post-acute care is traditionally thought of  as these settings, these long-term acute care hospitals, inpatient rehab, skilled nursing facilities, or skilled home care, and the average length of time people are spending  is about right here. So you have 30 to 60 days with most of these patients, depending on how many they use, to really promote gains. The most common,  skilled nursing facility and home health agencies are the ones we'll kind of focus on today, because those settings really are where most patients go, and many use both.  Many use skilled nursing facilities and then home care,  and about 25% of those who go home receive skilled home care.  It's important to remember that there is some evidence suggesting that rehabilitation participation after the ICU confers survival benefits.  This is a large study conducted outside the United States, but suggests that even touching a rehabilitation therapist one time or more in the one year following hospitalization  is associated with a small, but significant survival benefit, and this is a dose-dependent relationship. So there is higher benefits that you get  from a larger dose of rehabilitation. And these patients were getting 18 plus visits at the max dose, and those were associated with a 29% lower likelihood of death.  And this was all ages, this wasn't just older adults, but I think it's important to kind of think about in the back of our minds as we design these programs for older adults.  In the United States, we don't necessarily know how much rehabilitation people are getting after critical illness. And I think it's important that we don't conflate  discharge to a rehabilitation setting with actually receiving rehabilitation. You can be discharged to a skilled nursing facility and be reimbursed by Medicare  and never touch a physical, occupational, or speech therapist, and that can still be a billable skilled nursing facility stay. Similarly, home health care,  you can be referred to home health care and be homebound and physically unable to leave your home and not touch physical, occupational, or speech therapy  and still be covered under Medicare. So just discharge to rehabilitation is not adequate to know if patients are actually participating. And even if they do participate,  we don't know the dose, frequency, or content of rehabilitation that actually promotes maximal recovery.  So really, I think that there is a couple strategies that I'm gonna outline that I think we can do to improve post-acute care rehabilitation.  And one is just get people to participate and know if they're participating and help patients overcome barriers to participation.  And you'll see in some of the data I'm gonna show you that that is perhaps a more daunting challenge than we might realize. And when patients do participate in rehab,  we have to make sure it's not garbage. Encourage appropriate intensity of rehabilitation. And too many times I see patients doing very low intensity or very low level activities  that are unlikely to reverse the serious deficits that they acquire during an ICU stay.  Using data from the longitudinal study at Yale, a 20-year longitudinal study that's linked with Medicare data. And this is some preliminary data,  so maybe don't photograph this slide. We found that 26% of patients who had a new ADL disability after an ICU stay did not receive any rehabilitation settings  across post-acute or outpatient. I think that's pretty striking. One in four patients never touch a physical therapist despite having a new disability  and activities of daily living.  And if they did receive rehab, 83% of the minutes of rehab were all in institutional settings and mostly skilled nursing facilities. Only 8% of patients  touched an outpatient physical therapist. So this is saying that these older, frailer adults have serious access issues to getting to outpatient clinic-based therapy.  It's pretty interesting that of this 8%, 4% of them were receiving care inside of a long-term care facility under Medicare Part B. So only 4% of these were actually leaving the home  to go to the clinic. And that is particularly striking.  In home care, this paper was just accepted in the Journal of the American Geriatric Society two days ago, so no link for you yet. We found that people who went to home care  and were all homebound, only one in three received any rehabilitation visits. And you can see that most were receiving very low doses of rehabilitation over a 30-day stay.  And these are patients discharged directly home after a 24-hour or more ICU stay. So it's suggesting that we're really under-dosing or under-recognizing the physical limitations  that these patients have.  And there's a lot of factors that influence rehabilitation use. Our study that we just showed found that rural environments, people who lived in rural settings  received substantially less rehab than those who lived in urban environments. And across our study and others, these other factors of mobility limitations, fatigue, living alone,  and having a high comorbidity burden all limit access to and participation in skilled rehabilitation.  And even if we get patients to rehab, what do we do with them when they're there? And I think that's particularly daunting because these patients are really medically complex.  They're challenging to work with. And they don't just have a knee problem or a shoulder problem that there's a specific protocol for. Every muscle's weak. Everything is tired.  They're cognitively impaired. They are delirious. They are very challenging to dose exercise for. And despite that, we do a really terrible job doing it.  So I have a couple of pragmatic approaches that I'm gonna go into exercise physiology.  Your step exams are now pass-fail, so you probably don't need to know this really well. But VO2 max, your measure of aerobic capacity, has all of these components.  Heart rate max, stroke volume max, and AVO2 difference max. Heart rate and stroke volume are your cardiac parameters. Now, patients early after an ICU discharge  are generally unable to participate in aerobic training long enough and intense enough to actually create cardiac muscle changes.  They create muscle fatigue far before they get to aerobic, you know, 60 to 80% of an aerobic max. So AVO2 difference is the other component of VO2 max.  And that's really a measure of how well your skeletal muscle extracts oxygen from your blood while you're working. Strength training improves mitochondrial density  and capillary density in working skeletal muscle, essentially making your muscles more fuel efficient, and increases aerobic endurance, and it's a lot more tolerable for patients.  So lifting weights at, you know, what I would consider 60 to 80% of a one repetition max, you know, eight to 12 repetitions to fatigue, appropriately dose-supervised exercise,  is probably a way to get more bang for your buck in this early post-hospitalization period. It's more tolerable for patients, especially those with respiratory or cardiac issues,  and probably promotes more reversal of frailty-related deficits than aerobic training alone.  The other strategies I suggest is make exercises functional. The sit-to-stand exercise seen here works quadriceps, and glutes, and ankle muscles, and promotes balance and power,  versus this exercise, which works quadriceps to some extent when you're lifting with a ankle weight. It is certainly not functional  and promotes very little activity besides the quadriceps. This, patients generally don't do. I usually encourage my home care patients, while they're watching Price is Right  during the commercials, they can sit-to-stand 10 times out of a chair during commercial breaks, and that's a really simple strategy to start promoting muscle strength and carryover.  So making these home exercises functional also makes patients a lot more likely to do them.  Account for home environment. So when we're in post-acute care settings and delivering care and suggesting what patients can do when they go home,  we assume they're exercising on these beautiful track facilities and they've got walking buddies. Most of the time our patients might live in settings like this,  where there is piles of stuff or crowded apartments. As a home care therapist, I've walked into many of these apartments where they've been told to do a walking program  and they have four feet of uninterrupted space. And to walk the amount that we tell them, they would have to do 400 laps around a 10-foot space.  And that's just not practical, it's very boring. Some patients live in very rundown home environments. Older adults tend to live in poor quality neighborhoods.  They're usually less financially able to live in better neighborhoods. And I think it's really important that we consider the home and neighborhood environment factors  when we're delivering rehabilitation.  And I think perhaps the most maybe controversial thing I'm going to say is that rehabilitation's not just for people who can get better.  Rehabilitation can be a palliative intervention. Rehabilitation is part of the Medicare Hospice Benefit, as well as recommended in a lot of palliative care guidelines.  So rehabilitation can be used to manage troubling symptoms like pain, dyspnea, and it can also help reduce caregiver burden by teaching transfer strategies  or fall prevention strategies in the home so patients can age in place. So even for your very frail or cognitively impaired patients  who might not have a ton of improvement potential, there's still a role for rehabilitation, so that shouldn't be a barrier to ordering it.  So these guidelines are somewhat codified in consensus recommendations from stakeholder groups in that patients should be doing aerobic training at moderate to high intensities  over the course of post-acute care, and circuit training, intensity resistance training, and pulmonary muscle training. I usually suggest starting with this intensity,  moderate intensity resistance training, and then working to the other things. But in terms of how we work with really sick, older, frail patients in the post-ICU settings,  I think there's still a lot to be learned about the dose and content of those interventions.  So those goals that we really should be focusing on, get patients home and improve functional capacity, and that's typically what clinical rehab trials focus on,  but I think perhaps understudied are these goals of preventing decline and decreasing symptom burden, and I think those are also important goals  for patients that we could consider a use for rehabilitation.  So some final thoughts is rehab is a critical part of what these patients need after an ICU stay, when they leave the hospital, and that first 30 to 60, 90 days afterwards,  but many don't get it.  And those that do, there's a lot of heterogeneity in what's provided, and most of it isn't provided in home and community settings, so it makes it very difficult for patients  to use that knowledge to actually improve their own individual situations. And the quality of rehab is generally poor, and I'm speaking from a physical therapist  in these settings, and I've watched other therapists, it's not good, so I think we can do a lot more to improve delivery of care to these patients  and up the bar and up the intensity, and I think as physicians and nurses, I think we all have a role in doing that as well. This is modifiable, right?  So among many other things that you can't change that increase people's risk in the ICU, age, gender, critical illness, you can modify the quality of rehabilitation  you deliver in the first 30 days after an ICU stay and potentially change the trajectory of recovery.  So with that, I'm gonna acknowledge my mentorship team, including Dr. Ferrante here at the table and the rest of my colleagues at Yale  and my funding sources from my physical therapy foundation and the National Institute on Aging,  and I'm happy to take any questions, comments, diatribes, or statements. Thank you. I don't know which one of those it's gonna fall into,  probably not a diatribe, I save those for later, but I guess my question is, you have this scenario where you have, you said rural patients are less likely to have access to care,  you have patients who are in small settings and can't really do a lot of rehab, so I'm just thinking of other modalities that can help improve physical function,  things that don't take much space like yoga or some cognitive behavioral things that can help with symptoms of dyspnea that would help people. What is the role of those sort of,  I don't know if they're alternative modes of rehab or complementary, I guess is probably the better term there, in this population? That's a great question.  For those of you who may not have heard that, Dr. Brummel was asking about the role of yoga or some other alternative strategies to manage pain, symptom management, dyspnea,  in this population, and I think those things are all helpful. Yoga, tai chi, those kind of interventions, patients like doing them in groups.  I'm kind of a fan of whatever patients will do and whatever's motivating to them. I don't think that there's necessarily a wrong way to be physically active.  In these post-acute care settings, there's all, generally the handcuffs are time, energy, and facility regulations for adding those kinds of things,  but I think we could do a lot more. Even things like music therapy and moving or walking to music have been tried in these settings for different patient populations,  so I think if you can be creative and get people active and moving more than they already are, I don't think that's a harmful thing at all.  I also had a question. I was really struck by the picture of the home environment in disarray that you showed,  and I think even, I mean, you're a home-based physical therapist,  so that's gotta be really challenging to even work with someone in that environment. And if you think about our most disabled patients, whether they're older or not,  they may have some difficulty cleaning up and organizing that area, so whose responsibility is it to conduct a home evaluation? Is that something we can order?  What can we do about that? That's a great question, and I see a lot of people discharged from the hospital with recommendations for a home safety evaluation,  which doesn't really exist in isolation,  but if you order skilled home care, that is part of our mission, to make sure that the home environment we're delivering care in is safe and appropriate, and there are resources.  The Veterans Administration actually has resources for helping people clean up cluttered environments if they're impacting medical care,  and you have to dig around in the social work resources at some VAs, but in Denver, we certainly did have that available. And then I think the challenge with any hoarding  or cluttered home environment is sometimes you have to be creative. So a walking program might not work, but a circuit exercise program where they do 20 sit-to-stands  and then stand at the counter and do 20 different exercises and move through without a whole lot of breaks is aerobically challenging  and a lot more conducive to a cluttered environment.  Thank you.  All right, great. So that concludes the speaking portion. We're gonna ask all of the speakers to just come up for a brief panel in case there are any outstanding questions  from the audience or any questions that might apply to more than one speaker since we've arranged these talks to all complement each other  on how we can maximize recovery for our patients. And I will stand up so all of you can sit.  Thank you.  Thank you. I especially want to congratulate the last speaker on that data and presentation. I feel it's very important as a trauma surgeon. They're out the door  and I assume people are being taken care of. And I think that's very eye-opening if not alarming. And I hope that that information goes to the right places  to show that there's a real deficit. My question for the panel in keeping with the theme of the conference, partly delving into AI,  is to what extent can we envision some type of mechanism where we can track the trajectory of patients who've been through the ICU so that for long-term planning,  we can engage them perhaps looking electronically or in other ways and see when they're falling off the curve and when they need help  or what their expected trajectory for recovery would be?  Am I answering this? Okay.  So I think, so right now I think we're a little bit limited in what we can do. We can use, I think with some of the data that I showed, we have a good way of leveraging the EMR  to track what's happening in the hospital. There are activity trackers that have been tested in terms of following people long-term after discharge,  but they come with some of their own issues in terms of patients taking a shower and then forgetting to put them back on or things like that.  But I think ultimately it's going to be a device like that that's going to allow us to track our patients and that's probably the best chance that we'll have  of tracking these outcomes, whether it comes in the form of an Apple Watch or something close to that or since everyone's tied to their phones, something tied into the phone  that maybe syncs with an activity tracker. And my hope is that over time, these trackers will become more advanced. So as an example, I'm part of a multi-center grant  that will be going in soon where we're hoping to work with engineering that will actually not just look at activity trackers, but all sorts of different components  by collaborating with our bioengineering colleagues. And hopefully that's the wave of the future, but obviously it will be many years before that's available to patients.  And we're starting to use in the context of research anyway, actigraphy to measure activity during hospitalization for critical illness. Right now we sort of have crude measures  of what was the maximum milestone that somebody reached, but it doesn't tell you kind of all the other things that they were doing in between. So I think those things are coming,  but not yet ready for primetime, but you could also see some machine learning and AI approaches to what are those signatures of mobility that people do during a hospitalization  or in the 30, 60, 90 days afterwards.  Adrian and I were talking a little bit earlier about some of the how to measure outcomes in older adults and sort of the, at least my bias was that, you gave an iPhone to my grandma  and she's not gonna know what to do with it, but he actually has some experience with measuring outcomes in older adults using some tablets.  And so I'll let him maybe talk a little bit about that. We're doing work with using telemedicine to measure delirium in the post ICU and post discharge setting,  working on validating a tool there.  Before we did that, we did a pilot study to see if older adults could use these devices. And I was actually shocked to find that 80 to 85% of our octogenarians  could facilely use an iPhone to do basic tasks and also own them.  So I think we may underestimate how adept the population is at using these devices and how prevalent they are. And that's another way we can sort of leverage technology  for research and for eventual patient care. And you can even see now, there's some rehab programs that you could get, exercise programs or whatever. What's the mirror thing, right?  You can envision something like that for rehab of older adults in confined spaces that may potentially allow dissemination of rehabilitation  that's hard to potentially have access to. So yeah, good question.  No one ever gets mad when you get out early. No. We have more questions, I think. Thank you all. My question is, what have you all personally done to reach out to administration  or look at your ICU budget and lobby for some of the tools that are helpful in this regard or staff to help get people moving, create a better environment?  So we were very,  in launching the STEPS ICU program really took a lot of effort in terms of working with hospital administration. And initially there was resistance.  They wanted to initially fund the STEPS ICU program as a three-month research project. And we pushed back and said, no, there are strong data supporting early mobilization.  And we basically said no.  And that took some negotiation, but they ultimately agreed to fund it as a two-year QI program.  And it's been so successful that they've just continued funding. We're in five years now.  One issue we've had recently had to do with staffing. We need more physical therapists and occupational therapists, not just for the ICU program, but basically what's happened  is because the MICU is a priority area and neurology is a priority area that the floors have become understaffed. So we've noticed that patients  are getting a lot of therapy in the ICU and then they go to the floor and they're getting less. And so recently we again,  met with the director of rehabilitation services and she and I and our MICU director, we all went back to the administration demonstrating how the program improved outcomes,  but how if patients then go to the floor and don't get rehab, then that will sort of take away the gains that they've made. And so again, worked with them  and came up with a clinical redesign initiative to secure more staffing. So we've actually had to partner with hospital administration quite a lot, but we're very deliberate  and we plan for those meetings.  For our sleep promotion protocol, we actually didn't have funding for that. And what we did was we recruited nurse champions and then we actually also recruited students  who were interested in doing some kind of project. And so they actually were really good because they developed like flyers for us, but they also developed things with QR readers  so people could use their phone. And so they kind of brought this technological thing, piece to it that we hadn't thought about when we were thinking about ways to improve sleep.  And so we kind of used volunteers to do that piece of it.  Two questions, number one, did you use missed visits as an outcome measure in the STEPS quality initiative, PT missed visits or OT missed visits?  And then the second question, is there a role for exercise physiologists in the critical care setting to supplement and support OT and PT and the nurse and unlicensed staff  and everybody else?  So by missed visits, do you mean that the therapist attempted to work with the patient  but that they were unable to because the patient, is that what you mean, that like they weren't able to work with the patient in that moment? Yeah, yeah, so we do look at that.  And actually, so in addition to the program that I presented, I have a project where we actually go in and manually abstract a lot of data about the program.  And that's one of the areas where we can capture it through the EMR, but we looked more closely to see what was happening.  And we wanted to know whether the patients were medically unstable or whether they were just off the floor.  Most of the times that there was a missed visit where the therapist attempted to work with the patient but was unable to do so is actually due to medical instability where  something had, you know, the patient started to decompensate and they weren't, they were no longer eligible that day. But then they're reassessed the next day.  With them being off the floor, that was not as much of a problem. And I think that's just because part of our protocol is that they go back again later to work with the patient.  In terms of your second question, I would love for an exercise physiologist to join our team. I think that would be fantastic.  That has not been an opportunity for us, but if anybody wants to come work with us, that would be great.  I really think that would be actually not just instrumental in the ICU, but maybe as a point of, you know, a person of continuity who follows the patient through the post-discharge  period and some of the other transitions of care that we've talked about today. I don't know if you want to add to that, Jason. Yeah, I think that last point is a great point.  Functional information often doesn't move with patients very often. Information about ADL disability and trajectories of recovery and response and tolerance to exercise.  So therapists in each setting are often starting with not much baseline knowledge about that. So having somebody that was exercise-trained that kind of followed patients through in  a care transition would really help make sure that these exercise intensities and goals kind of stayed kind of consistent and kept progressing through the continuum, because  you're thinking about a patient going to event weaning at LTAC and then going to inpatient rehab and then maybe a skilled nursing facility, then home care, then outpatient.  There's a lot of transitions and a lot of hands in the pot, so one common person for functional information would be invaluable, I think. All right.  So that actually closes our session. I want to thank you all for coming, and I'd like to thank the panel for a lot of great talks. Thanks, everyone.

Video Summary

Acute care for the elderly units (ACE units) are interdisciplinary hospital units that focus on providing specialized care for older adults, with the goal of maintaining or improving their functional abilities and preventing geriatric syndromes. These units have been shown to reduce hospital length of stay, increase the likelihood of patients going home instead of to a skilled nursing facility, and reduce the cost of hospitalization.<br /><br />The panel discussion emphasized the importance of post-acute care in the recovery of patients following critical illness. They highlighted the challenges in providing rehabilitation in these settings, such as limited access to services and lack of intensity. The panel suggested several strategies to improve post-acute care rehabilitation, including increasing patient participation, tailoring exercises to the patient's home environment, and considering rehabilitation as a palliative intervention for symptom management and caregiver support. They also discussed the use of technology to track patient progress and deliver rehabilitation in home settings.<br /><br />Overall, the panel emphasized the need for better access and quality of rehabilitation in post-acute care to promote optimal recovery for patients following critical illness. By incorporating ACE principles into the ICU, healthcare providers can improve outcomes for older adults and ensure that their unique needs are met.

Asset Subtitle

Quality and Patient Safety, Patient and Family Support, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Identify ways to increase mobility throughout hospitalization for critical illness
Describe the current state of post-ICU rehabilitation for survivors of critical illness and strategies to maximize function during care transitions
Review frailty measurements and potential interventions during acute critical illness and afterward
Recognize the principles of the Acute Care for Elders model and apply them to patients with critical illness
Identify common medications started in the ICU that are often inappropriately continued after hospital discharge

Frailty Across the Continuum of Critical Illness and Survivorship

Nathan E. Brummel

STEPS Toward Recovery: Tracking Mobility in the ICU and on the Floors

Lauren E. Ferrante

Sleep in the ICU: An Elusive Goal?

Margaret A. Pisani

The ACE Up Your Sleeve: Acute Care for Elders in the ICU

C. Adrian Austin

Medication Reconciliation at Critical Transitions

Joanna L. Stollings

Muscle Memory: Maximizing Post-Acute Rehabilitation and Recovery for Critical Illness Survivors

Jason Falvey

Meta Tag

Content Type Presentation

Knowledge Area Quality and Patient Safety

Knowledge Area Patient and Family Support

Knowledge Level Foundational

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Guidelines

Tag Rehabilitation Medicine

Year 2020

Keywords

Acute care for the elderly units

ACE units

specialized care for older adults

functional abilities

geriatric syndromes

hospital length of stay

skilled nursing facility

cost of hospitalization

post-acute care

recovery of patients

critical illness

rehabilitation

patient participation

tailoring exercises

palliative intervention

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.