We're here today talking about resuscitating the ICU liberation bundle following the COVID-19, and it's my great honor to be here to talk about the letter E, that it's early mobility and exercise. I have no potential financial interest to report, and the learning objectives for this lecture is to list two consequences of bed rest and immobility, and also list two strategies to resuscitate the letter E of the ICU liberation bundle. Okay, so here we are talking about resuscitating the ICU liberation, and the letter E, which in my opinion, it's the most exciting letter of the A to F bundle. I know I'm biased, but I think it's the greatest one, and in my opinion, the most important one. So basically, let's just start talking about, is this a new concept? When we talk about early mobility and exercise, more than 70 years ago, in 1940s, Dr. Asher published the dangers of going to bed article, and in this article, there's a quote that is one of my favorites, where he says that it's my intention to justify putting beds and graves in the same category. And then in the 1970s, there were two publications that addressed patients who were on mechanical ventilation, and they were ambulatory, and both of these publications really talk about the incredible benefits that that provided to the patients. And moving on, in the late 2000s, where we had the first articles that started showing us the scientific evidence that early mobility and exercise in ICU is safe, feasible, improves physical function, it can reduce delirium, and also can reduce the length of hospital stay as well as costs. So after that, you know, later in the 2010s, actually in 2018, the Patti's recommendations were published, and at that time, the letter E was addressed when they addressed immobility for patients in the ICU. And then what happened? COVID-19 hit in 2020. And I'm sure that everybody is well aware that COVID-19 changed the landscape of healthcare. So basically, this article that I'm showing here, it really represents what happened with the COVID-19. So the results of this study are very powerful, in my opinion. So basically, it's a multi-center cohort study that was carried out in 69 adult ICUs in 14 different countries, and that study included more than 2,000 patients. So basically, the results demonstrated that because of COVID-19, and the way practice was changed, sedation was increased, as we have been able to, you know, learn recently here. Also, mobility was suspended, family visitation was suspended, the median RAS score for patients on mechanical ventilation was minus 4 in this study, and more than 81% of the patients were in a comatose state for about 10 days. When I look at this, I think this is devastating. And why is that devastating? Because of the consequences of bed rest and immobility. So why should we care about that? We should care because when patients stay on bed rest or immobility for too long, it's going to lead to deconditioning, not recovery. There are very few medical reasons why a patient should be in bed. And anyone who thinks that bed rest is going to solve any medical problem, it does not. It's the opposite. In addition to that, it will lead to profound muscle weakness. This is what I have been dealing with for the past 30 years of my career in ICU. Believe it or not, this is my patient who is 52 years old. I mean, it's basically the skin on top of the bone. And finally, it also leads to significant loss of functional independence. Here I have another young person that in order to take a few steps, it takes two staff members holding them up to barely take a few steps. So basically, again, when we talk about the letter E, why should we care? We should care because bed rest and immobility in ICU remain a major issue all over the world. And unfortunately, the practice of bed rest and immobility leads to substantial problems for patients, families, as well as the healthcare system. So now let's talk very briefly about understanding the letter E. I know that there are some, you know, definitions that have been published in multiple, you know, articles. But the reality is that when I ask different clinicians about what do you think it's early mobility, they have different opinions about it. Some may think that, you know, early mobility is PT and OT. Just consult PT and OT and that's early mobility. Others may think it's just, oh, you have to walk on the vent later. It doesn't matter what it is. You have to walk on the vent. And then sitting on the side of the bed, perhaps sitting in a chair, perhaps out of bed within 24 hours. What about any exercises? What about ICU rehab? So there's this kind of confusion about, I mean, early mobility is just an umbrella term. But in reality, early mobility means early physical activity. What kind of activity are we talking about? Basically, in bed could be turning side to side, sitting on the side of the bed, maybe doing some exercises in bed or out of bed activity. That could be sitting in a chair or in a stretcher chair, which means that the patient does not have the ability to stand up and take a few steps to the chair and then get back into the bed. Also, standing by the bedside and taking some steps and walking. So basically, when you look at all of those physical activities that I just listed in here, I want you to understand that you do not need to have a physical therapy license to provide any of those to the patients. And the reason for that, it's important to understand that for physical activity in ICU, it's basic nursing care. If the patients do not have any significant weakness or any kind of functional deficits, if they just need a little help to get up and move to the chair, this is basic nursing care. So you can't really wait until there's a consult for physical therapy and wait for the physical therapist to show up for those patients to be mobilized. In 19, I'm sorry, 2021, the Choosing Wisely for Critical Care, the next five article was published and the current recommendation number four was do not delay mobilizing ICU patients. And the recommendations were that mobility can be initiated and guided by the bedside nurses and mobility should not be solely dependent on PTs and OTs. And because the resources for PTs is very limited, as you all know, I mean, we are not, there's not a whole lot of physical therapists in the hospital to begin with, and much less physical therapists that are trained to take care of critically ill patients. So basically, these patients need to be mobilized before we get there. All right, so what kind of strategies should we have to resuscitate the letter E? The first thing we need to evaluate the current mobilization practice in your ICU. So there's no point in start hiring more physical therapists if patients are still sedated, right? So you really need to look and see what's going on. Also create specific mobilization guidelines. Obviously, if you work in a trauma ICU versus a cardiovascular ICU versus a medical ICU, those patients have different needs. So you have to have specific guidelines for each patient population. I think one of the most important strategies would be to eliminate bed rest orders altogether and just write them if there is a reason for and justify the need for bed rest so everybody will understand why the patients are in bed. Also including the E letter in daily ICU rounds, establish clear patient-centered mobility goals. We have to make sure that we are offering the patient what they are able to do. Now a lot of times, you know, they want everybody to walk, but not necessarily everybody has the ability to walk or their strength or the endurance to walk. So we have to be clear. We can't be telling the patient, oh, the physical therapist is going to be coming here later on to help you walk. And I go there, they cannot even move the legs. You know, so it has to be patient-centered. And finally, we must engage patients and families in the letter E. It's very important. We must give permission for these patients to move. Patients in ICU are scared to move. They are told over and over again when they are intubated that don't raise your arm, don't move your arm, because if you raise your arm, we are going to tie your arm down. Have you heard that before? Now do you think that after patients are intubated that anybody notifies them that now they can move their arm? I cannot even tell you how many times I will tell my patients to move the legs and lift the legs. They say, are you sure I can do that? I'm sure they're not going to tie my legs. So again, we must give them permission, you know, to move, because a lot of times they want to do that. They just don't do it because they don't know they can do it. All right, let's talk a little bit about letter E, equality. I believe that every patient, every day, in every single ICU in the entire world should have the opportunity to experience early mobility and early exercise. So obviously, when we talk about developed countries, there are, you know, technology, equipment and all that to help do this, but when you talk about underdeveloped countries, the resources are not there, but that doesn't mean the patient should be in bed. And I love to talk about this friend of mine from Brazil that for more than 20 years, he's been going to the hardware store, he buys the PVC pipes, and he builds those chairs so he can mobilize those patients because there are no chairs in the ICU. So we have to offer the patients, even in low resource areas, you know, the ability to be mobilized. So what are some simple strategies? Because in reality, early mobility in ICU is not about how are you going to get the funds to buy this $30,000 incredible technology with electrical stimulation and a computer to mobilize the patient. No, it's not about that. It's about the simple things that make a difference. So for early exercises, this is just like an idea. What about if we expect our patients to do 100 leg lifts or 100 arm raises every day? Not at once, throughout the day. Anybody that walks in, ask the patient to lift the arm or the leg, that would make a significant difference for those patients. As far as early out of bed activities, we don't need to be creating a mobility program about who's going to get out of bed. The rule is everybody gets out of bed except the patients who should not be out of bed, which are going to be very few patients. If they have like active bleeding requiring transfusion, escalating doses of vasopressors, maybe unstable fractures. But other than that, I mean, it's very unlikely that there's a reason for them to be in bed. All right, so what are the strategies? What about if we sit the patients on the side of the bed for vital signs? It doesn't take that long. Sitting in the chair for the meals. I mean, who eats in bed? Sometimes when I tell my patients, you need to get out of bed to eat, oh, I cannot do that. They won't let me do this. You know, those are simple things that can be done. Also, mobility tax in ICU. Five years ago, the facility that I work, we started having mobility tax in our ICU because there's not enough physical therapists. The nurses are busy. So the program has been incredibly successful. Now we are implementing mobility tax in the nursing floors also. They are hired to do mobility. That's all they do. Now, do you have the budget for that? Well, they did. They changed the nursing assistant positions to mobility tax. So they are hired to do that. So that's their job. Okay. Another simple strategy. This article was just published from a group from Brazil that they just created a UI improvement. They just put a clock on the wall and with two handles. One was the handle that is the goal for the mobility for the day, and the other one was what the patient achieved. So every person that walks into that room every day has a clear understanding that the patient needs to walk, however, it's 2 o'clock in the afternoon, he's still in bed. So it's visual. So with that, increased out-of-bed mobilization, increased the daily higher level of mobility, and also reduced the mobility protocol noncompliance and rate. Here are the takeaway messages that I want you to have. Bed rest and mobility are dangerous to patients in ICU. Please do not forget that. The letter E is applicable to adult and pediatric population. I know the pediatric patients are different, but we have to think about the same way and also mobilize those patients. Interprofessional collaboration is imperative for the success of early mobility. Patients must be awake for letter E. Letter E is not equal to physical therapy. And letter E is everyone's job. I'm not telling for anybody that you have to go and get patients out of bed, but just asking, you know, have you been out of bed today? Have you been doing your exercises? Everybody has to be involved. So finally, the time to resuscitate the letter E is now. Early mobility and exercise must be a priority for all patients in ICU. And I think that the theme for the Congress this year is better together. So I don't know that there's any better way to say that. Better together, we need to get our patients in ICU moving, please. Thank you very much.

early mobility

ICU

bed rest

deconditioning

patient care