The University of North Carolina at Chapel Hill
Doctor of Physical Therapy
Capstone Project
Carson Matthews
PHYT 854
Mock Template and Algorithm for DPT Students Prior to Acute Care Clinical
Capstone Narrative
Early mobility in the intensive care unit (ICU) is an important topic for clinicians because length of stay is something that healthcare systems are constantly concerned about. The amount of time a patient spends in the hospital ultimately affects the finances of the hospital. Early mobility is gaining traction at larger medical centers around the country and it’s something students will be immersed in while on their acute care clinical rotations. Physical therapists are experts on the importance of physical activity in reducing overall deconditioning, even for severely ill patient populations.
My second and third clinical rotations were at UNC Hillsborough Hospital in their acute inpatient rehab facility and at Duke Regional Hospital in their acute care physical therapy department. While at Duke Regional Hospital, I spent the majority of my time in the ICU evaluating and treating critically ill patients. The diagnoses that I commonly treated in the ICU were stroke, respiratory failure, myocardial infarction, and post coronary artery bypass surgery (CABG). During physical therapy school, we had classes and labs which discussed lines and leads, mobilizing critically ill patients, and taking quick action to mitigate adverse events during mobilization but it’s very difficult to replicate this environment in a classroom setting to prepare the student for the complexity of a real patient.
In this capstone, I will develop a case study and algorithm for faculty to use during mock clinicals in the third year of the Doctor of Physical Therapy (DPT) curriculum. This will help students become more aware of the challenges when evaluating and treating this patient population so they are not blindsided on their acute care clinical rotation.
NOTE: The main product of this project, a mock clinical scenario, could be utilized within the DPT program in the future. It may be viewed within the course site in Sakai.
Physiologic Consequences of Prolonged Bedrest
Musculoskeletal
- Anti-gravity muscles are most effected by bedrest including trunk muscles and leg extensors1
- Bedrest has been proven to cause muscle mass to decrease 30% in just 10 days1
- Up to 40% of muscle strength can be lost with one week of immobilization, also known as intensive care unit-acquired weakness (ICU-AW)1
- Greater bone resorption than formation, 1% reduction in bone mineral density of the vertebral column after one week of immobility1
- Type 2 fast twitch muscle fibers are lost more rapidly than type 1 slow twitch muscle fibers1
- Contractures can form due to an increase in collagen and decrease in sarcomeres1
Cardiac
- In a study done with young adult males, 21 days of bedrest caused a 26% decrease in VO2 max and maximal cardiac output2
- Decreased venous return and lower blood volume can lead to orthostatic hypotension2
- During bedrest, a 36% reduction in blood flow to lower extremity musculature has been shown2
- For every 2 days of bed rest, the resting heart rate increases one beat per minute2
- A higher resting heart rate results in a decreased diastolic time. This means less time for the myocardium to be perfused with blood via the coronary arteries2
- Bed rest increases the risk of DVT by 13% secondary to an increase in blood fibrinogen, which increases the risk of clots forming2
Pulmonary
- The supine position restricts the rib cage from adequately expanding due to the patient’s body weight hindering movement3
- Decreased residual volume and total lung volume3
- The decreased residual volume leads to alveoli closure which lowers blood oxygen levels3
- Gravity causes mucous to accumulate in the lungs which can lead to pneumonia3
- Mucous accumulation can be made worse by dehydration which causes the mucous to be more viscous and thicker3
- Increased risk of atelectasis and pleural effusion4
Genitourinary
- When standing, gravity plays a pivotal role in draining urine from the kidneys3
- Prolonged supine positioning also causes the bladder to not completely void all urine which increases bacteria accumulation3
- During bedrest, urinary stasis ensues in the kidneys and bladder and the risk of urinary tract infection (UTI) increases due to bacteria accumulating3
- Urinary stasis causes prolonged stretching of the bladder which subsequently causes the stretch receptors to lose their sensitivity to stretch resulting in decreased urinary urgency3
Integumentary
- 95% of pressure ulcers occur at the bony prominences of the sacrum, ischial tuberosity, greater trochanter, lateral malleolus, or heel5
- Pressure ulcers develop when blood flow is cut off from an area for 2-3 hours5
- It is suggested to turn and reposition every 2 hours in bed and every 20 minutes in a chair5
Cognitive
- Delirium occurs in up to 80% of ICU patients and can cause cognitive impairments years after discharge6
- Longer duration of delirium correlates with worse executive function and global cognition at one year post discharge6
- In a study of 821 ICU patients, 6% had cognitive deficits at baseline and almost 80% developed delirium in the ICU. At 3 months, 26% of patients had a global cognition score similar to patients with mild Alzheimer’s disease6
What is Early Mobility?
- Active range of motion7
- Passive range of motion7
- Bed mobility7
- Therapeutic exercises
- Sitting upright
- Out of bed transfers
- Ambulation
- Hoist therapy7
- Electrical stimulation7
- Tilt tables7
- Resistance exercises
- Moveo XP machine7
- Cycle ergometer7
- Functional electrical stimulation (FES) cycling7
Barriers to Early Mobility in the ICU
- Hemodynamic instability8
- Respiratory instability8
- Active bleeding8
- Pain8
- Obesity8
- Sedation8
- Fatigue8
- Paralysis8
- Delirium8
- Patient refusal8
- Orthopedic restrictions8
- Poor nutrition8
- Limited staff8
- Limited number of staff trained in early mobility8
- Limited equipment8
- Lack of multidisciplinary team8
- Lack of patient and family knowledge8
- Early mobility not being a priority in the hospital system8
- Time constraints8
Is Early Mobility Safe When Implemented in the Critically Ill Patient Population?
- Mobilizing ICU patients has been deemed to be safe per the literature9-11
- Mobilizing mechanically ventilated patients has been deemed safe9-11
- The most common adverse event was oxygen desaturation which was mitigated with rest or increasing the liters (L) of oxygen (O2) per minute the patient was receiving9
- Accidental extubating or line dislodgement was very rarely observed9
- 1,110 ICU patients were studied in a total of 5,267 sessions and early mobility caused an adverse event in 34 patients (0.6%)9
- Adverse events included arrythmias, mean arterial pressure (MAP) >140 mmHg or <55 mmHg, oxygen desaturation, fall, feeding tube extraction, radial artery catheter removal, or chest tube removal9
- Safety Criteria for Mobilization
- Heart rate >40 bpm and <130 bpm9-11
- Systolic blood pressure >90 mmHg and <200 mmHg9-11
- No increase in vasopressor dose in past 2 hours9-11
- Respiratory rate >5 bpm and <40 bpm9-11
- Oxygen saturation >88%9-11
- Mechanical ventilation parameters FiO2<60% and/or PEEP <10 cmH209-11
- No unstable fracture or bony instability9-11
- No active bleeding9-11
Physiological Benefits of Early Mobility in the ICU
- Increase blood flow13
- Increase heart rate13
- Increase stroke volume13
- Increase venous return13
- Increase arousal13
- Increase electrical activity of the cerebrum13
- Increase sympathetic stimulation13
- Shorten the period of delirium13
- Increase volume of urine voided13
- Increase motility of GI tract13
- Increase airway clearance13
- Decrease the number of days spent on a ventilator12-13
- Decreased risk of atelectasis and pleural effusion4
- Preserve cognitive function13
- Preserve muscle mass13
- Reduce ICU acquired weakness13
- Reduced length of stay12-13
- Improved functional recovery12-13
- Decrease mortality rate12
Financial Benefits of Early Mobility in the ICU
- Decreased re-admission rates which decreases the amount spent on hospital re-admission penalties12-14
- Wake Forest University Baptist Medical Center studied 330 patients in the ICU and found that early mobility reduced ICU stays by 1.4 days and reduced hospital stays by 3.3 days12
- Early mobility saved the hospital $504,78912
- Similarly, Johns Hopkins Hospital studied early mobility in the ICU and found that it reduced ICU stays by 2.1 days and reduced hospital stays by 3.1 days12
- Early mobility saved the hospital $1,172,31212
- Reduces the average direct variable cost by over $8,000 per patient12
- Reduces the time spent on mechanical ventilation which decreases hospital cost12-14
ICU-Acquired Weakness and ICU Delirium
- Both are associated with longer length of stay, higher costs, and worse outcomes15-17
- ABCDE bundle for optimal pain, sedation, and delirium management16,17
- Awakening and Breathing Trials, Choice of appropriate sedation, Delirium monitoring, and Early mobility and Exercise16,17
- 12% higher odds of survival in the hospital when this protocol is utilized17
- Early mobility in the ICU led to…
- Significant improvement in functional mobility at discharge. In one study, 34% more patients returned to walking16
- 50% decrease in delirium duration16
- Significant decrease in hospital length of stay15-17
- More ventilator free days at 28 days (23.5 days in experimental group and 21.1 days in the control group which was statistically significant)16
Technological Advancements and Equipment Utilized with Early Mobility in the ICU
- Bedside Cycle Ergometer
- 90 critically ill patients were studied. Control group received the usual care, and the treatment group used the bedside cycle ergometer 20 mins/day18
- Quadriceps force, subjective functional status measured by SF-36, and the 6-minute walk test were measured at hospital discharge18
- At hospital discharge, all items were significantly higher in the treatment group18
Exercise Parameters and Protocol for Early Mobility in the Critically Ill Patient Population
- 330 intubated ICU patients were assigned to the Usual Care group or Protocol Group19
- Protocol Group received mobility 7 days per week by the Mobility Team19
- Critical care nurse, Nursing assistant, Physical therapist19
- Patients were assigned to Level I of the protocol when they were unconscious19
- Nursing assistant performed PROM to all UE and LE joints, 3 times per day, at least 5 repetitions19
- Level II was initiated when the patient could follow simple commands19
- Progression to level III was based on patients’ ability to have at least 3/5 biceps strength19
- Patients would advance to level IV when their quadriceps strength was at least 3/519
- No significant adverse effects observed19
- Usual Care: 47.4% of patients had at least one PT session during their hospital stay19
- 5% of these patients had PT initiated in the ICU19
- Protocol: 80% of patients had at least one PT session during their hospital stay19
- 4% of these patients had PT initiated in the ICU19
- Usual care
- 1 sessions per patient19
- Patients first out of bed in 11.3 days19
- ICU length of stay was 6.9 days19
- Hospital length of stay was 14.5 days19
- Average cost per patient was $44,30219
- Protocol
- 5 sessions per patient19
- Patients first out of bed in 5.0 days19
- ICU length of stay was 5.5 days19
- Hospital length of stay was 11.2 days19
- Average cost per patient was $41,14219
Family Infographic
- Below is a link to an infographic that can be disseminated to the families of patients we are treating in the ICU. The hand-out provides basic education and information regarding the benefits of physical therapy in the critically-ill patient population, as well as what they can do to help the patient during their recovery
Evaluation
- After running through the mock clinical scenario with peers, the link below provides a summary of the constructive criticism that was provided, without eluding to details regarding the case
Acknowledgements
- To Dr. Sean Lowers PT, DPT, thank you so much for all of the assistance you provided throughout this project. You equipped me with the tools necessary to refine this capstone, and to ultimately aid future physical therapy students learning experience in preparation for their acute care clinical.
- To Dr. Jessica Cassidy PT, DPT, PhD, thank you for agreeing to be on my capstone committee and providing me with the logistical information needed to maintain the integrity of the capstone and deliver it to future students.
- To Karlyn Green PT, DPT, thank you for agreeing to serve on my capstone committee and all of the helpful information you provided based on your vast clinical experience.
- To The UNC DPT Class of 2023, what a ride it’s been. After spending three years of my life with you all, I know without a shadow of a doubt, each of you are destined to do amazing things in your respective careers.
Survey
- Please consider taking this short survey at the link below so I can get your feedback on the project
Resources
- Parry SM, Puthucheary ZA. The impact of extended bed rest on the musculoskeletal system in the critical care environment. Extrem Physiol Med. 2015;4:16. Published 2015 Oct 9. doi:10.1186/s13728-015-0036-7
- Convertino VA. Cardiovascular consequences of bed rest: effect on maximal oxygen uptake. Med Sci Sports Exerc. 1997;29(2):191-196. doi:10.1097/00005768-199702000-00005
- Petruccio, Luana & Oliveira, Maria & Carvalho, Gustavo. (2018). Deleterious effects of prolonged bed rest on the body systems of the elderly – a review. Revista Brasileira de Geriatria e Gerontologia. 21. 499-506. 10.1590/1981-22562018021.170167.
- Moradian ST, Najafloo M, Mahmoudi H, Ghiasi MS. Early mobilization reduces the atelectasis and pleural effusion in patients undergoing coronary artery bypass graft surgery: A randomized clinical trial. J Vasc Nurs. 2017 Sep;35(3):141-145. doi: 10.1016/j.jvn.2017.02.001. PMID: 28838589.
- Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/bedsores. Published August 8, 2021. Accessed February 10, 2023.
- Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306-1316. doi:10.1056/NEJMoa1301372
- Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M, Schönhofer B, Stiller K, van de Leur H, Vincent JL. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med. 2008 Jul;34(7):1188-99. doi: 10.1007/s00134-008-1026-7. Epub 2008 Feb 19. PMID: 18283429.
- Dubb R, Nydahl P, Hermes C, et al. Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units. Ann Am Thorac Soc. 2016;13(5):724-730. doi:10.1513/AnnalsATS.201509-586CME
- Sricharoenchai T, Parker AM, Zanni JM, Nelliot A, Dinglas VD, Needham DM. Safety of physical therapy interventions in critically ill patients: a single-center prospective evaluation of 1110 intensive care unit admissions. J Crit Care. 2014;29(3):395-400. doi:10.1016/j.jcrc.2013.12.012
- Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012;23(1):5-13.
- Conceição TMAD, Gonzáles AI, Figueiredo FCXS, Vieira DSR, Bündchen DC. Safety criteria to start early mobilization in intensive care units. Systematic review. Critérios de segurança para iniciar a mobilização precoce em unidades de terapia intensiva. Revisão sistemática. Rev Bras Ter Intensiva. 2017;29(4):509-519. doi:10.5935/0103-507X.20170076
- Invest in early mobility to invest in patients — and your bottom line. Standardizing the protocol. https://www.medtronic.com/content/dam/covidien/library/us/en/product/acute-care-ventilation/puritan-bennett-840-980-ventilators-early-mobility-economic-outcomes-brochure.pdf. Accessed May 11, 2022.
- Falkenstein BA, Skalkowski CK, Lodise KD, Moore M, Olkowski BF, Rojavin Y. The Economic and Clinical Impact of an Early Mobility Program in the Trauma Intensive Care Unit: A Quality Improvement Project. J Trauma Nurs. 2020;27(1):29-36. doi:10.1097/JTN.0000000000000479
- Bognar K, Chou JW, McCoy D, et al. Financial implications of a hospital early mobility program. Intensive Care Med Exp. 2015;3(Suppl 1):A758. Published 2015 Oct 1. doi:10.1186/2197-425X-3-S1-A758
- Cumming TB, Thrift AG, Collier JM, et al. Very early mobilization after stroke fast-tracks return to walking: further results from the phase II AVERT randomized controlled trial. Stroke. 2011;42(1):153-158. doi:10.1161/STROKEAHA.110.594598
- Banerjee A, Girard TD, Pandharipande P. The complex interplay between delirium, sedation, and early mobility during critical illness: applications in the trauma unit. Curr Opin Anaesthesiol. 2011;24(2):195-201. doi:10.1097/ACO.0b013e3283445382
- Barnes-Daly MA, Phillips G, Ely EW. Improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients. Crit Care Med. 2017;45(2):171-178. doi:10.1097/CCM.0000000000002149
- Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med. 2009;37(9):2499-2505. doi:10.1097/CCM.0b013e3181a38937
- Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-2243. doi:10.1097/CCM.0b013e318180b90e
4 Responses to “Mock Template and Algorithm for DPT Students Prior to Acute Care Clinical”
Ashlyn Warren
Carson,
This was an excellent project idea! I found your materials extremely beneficial and have actually read some of the cited research articles to inform my practice in my current acute neuro rotation. I have been working with delirium patients on the step-down unit and ICU and have found early mobilization to be very beneficial for these patients. This has been a great resource for me and I believe it will continue to serve as a resource for future students in the program. Great work!
Josh
Carson, this is a neat idea for a capstone project. I like how your clinical/professional experiences and interests combined to allow you to create such a unique project.
Particularly interesting to me was the information on the importance of early mobilization. It’s good to get this message out to current and future clinicians. I also found information like the contraindications to mobilization to be helpful. This project can serve as a resource to refer back to when practicing.
Hopefully, this project will adequately prepare current students for their future clinical rotations and careers. It’s nice of you to give back to the program! I’m excited to follow your career.
– Josh
krpatel8
Carson,
Wow, this was such a great capstone idea! Especially since I am about to go on my acute care clinical rotation, I can truly relate to your comments in the first paragraph about how the classroom setting can never completely replicate what the hospital will throw at you. One piece of your project that I really loved is the list of consequences of prolonged bedrest broken down by body system. Although any one reason alone should be enough to promote mobility, having all of these listed together is so powerful in displaying how detrimental bedrest is on every level. Although much of it is medical jargon, I think that many of these points can be used as motivators to push patients to be as active as they can in acute care. Additionally, although we have learned much of this before, I am so glad that you included the safety criteria for mobilization as it will be really helpful for me as well. Awesome job all around!
Jessica Cassidy
Carson- I really enjoyed reading your mock case study along with reviewing all of the important information and evidence you compiled. I’m glad that you had the opportunity to share your mock with other students to acquire feedback, and I’m sure that that experience provided you with the unique perspective on being on the “other side” of a mock. Excellent work this semester.