Mock Template and Algorithm for DPT Students Prior to Acute Care Clinical

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 VO_{2 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 literature^9-11
• Mobilizing mechanically ventilated patients has been deemed safe^9-11
• 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 bpm^9-11
  • Systolic blood pressure >90 mmHg and <200 mmHg^9-11
  • No increase in vasopressor dose in past 2 hours^9-11
  • Respiratory rate >5 bpm and <40 bpm^9-11
  • Oxygen saturation >88%^9-11
  • Mechanical ventilation parameters FiO2<60% and/or PEEP <10 cmH₂0^9-11
  • No unstable fracture or bony instability^9-11
  • No active bleeding^9-11

 

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 ventilator^12-13
• Decreased risk of atelectasis and pleural effusion⁴
• Preserve cognitive function¹³
• Preserve muscle mass¹³
• Reduce ICU acquired weakness¹³
• Reduced length of stay^12-13
• Improved functional recovery^12-13
• Decrease mortality rate¹²

 

Financial Benefits of Early Mobility in the ICU

• Decreased re-admission rates which decreases the amount spent on hospital re-admission penalties^12-14
• 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 cost^12-14

 

ICU-Acquired Weakness and ICU Delirium

• Both are associated with longer length of stay, higher costs, and worse outcomes^15-17
• ABCDE bundle for optimal pain, sedation, and delirium management^16,17
  • Awakening and Breathing Trials, Choice of appropriate sedation, Delirium monitoring, and Early mobility and Exercise^16,17
• 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 stay^15-17
  • 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
  • Link To Family Infographic

 

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
  • Capstone Evaluation

 

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
  • https://qfreeaccountssjc1.az1.qualtrics.com/jfe/form/SV_b7TPQ8tK3ddIiuG

 

Resources

1. 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
2. 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
3. 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.
4. 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.
5. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/bedsores. Published August 8, 2021. Accessed February 10, 2023.
6. 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
7. 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.
8. 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
9. 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
10. Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012;23(1):5-13.
11. 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
12. 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.
13. 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
14. 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
15. 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
16. 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
17. 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
18. 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
19. 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