Team collabora+on: an impera+ve for early mobiliza+on Dr Louise Rose BN, ICU Cert, MN, PhD, FAAN TD Nursing Professor in Cri+cal Care Research
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1 Team collabora+on: an impera+ve for early mobiliza+on Dr Louise Rose BN, ICU Cert, MN, PhD, FAAN TD Nursing Professor in Cri+cal Care Research Sunnybrook Health Sciences Centre; Associate Professor, University of Toronto
2 No Disclosures
3 What I d like to cover. Defini+ons of early mobiliza-on and interprofessional collabora-on Why mobilize? Why collaborate? What do we know about barriers and facilitators to both? What strategies do we have to op+mize both?
4 Defini+ons: Early mobiliza+on Interprofessional collabora+on
5 Early mobiliza-on Early = Commenced while in the ICU as opposed to a/er ICU discharge OR later in the ICU stay May comprise of bed mobility ac-vi-es cycle ergometer ac-ve- assisted exercises transfer training pre- gait exercises ambula-on Also frequency (intensifica-on) Doiron (2013) Cochrane Lib Iss.10 Hodgson (2013) Crit Care 17:207
6 Mul-disciplinary vs Interprofessional vs Interdisciplinary Profession = voca-on requiring specialized knowledge/skills Mul-ple professions in healthcare Discipline = academic branch of knowledge Mul-ple disciplines are found within a healthcare profession.cri-cal care, cardiology, geriatrics
7 Mul-disciplinary vs Interprofessional vs Interdisciplinary Mul+disciplinary = Different disciplines working independently toward a common purpose Interdisciplinary = Different disciplines working collabora5vely toward a common purpose Interprofessional = Approach to work/ learning requiring integra-on/collabora5on to incorporate perspec5ves of more than one profession Zwarenstein et al (2009) Cochrane Lib.
8 Why?
9 WHY? Early mobiliza-on Neuromuscular weakness Neuropathies/ myopathies Dura+on of ven+la+on; ICU and hospital stay Muscle mass Joint contractures Prolonged immobiliza+on Insulin resistance Ac+va+on of inflammatory mediators REST DOES NOT = HEALING Psychological is BAD dysfunc+on Cogni+ve dysfunc+on HrQoL Atelectasis Pressure ulcers Prolonged rehab Delirium Healthcare costs
10 WHY? Early mobiliza-on The Evidence Multiple observational and nonrandomized studies Demonstrate feasibility, safety, physiological effects, and associations with improved outcomes Timed exercise/mobilization with sedation interruption Comparator: usual care (physician ordered PT) No routine PT for patients ventilated <14 days No dedicated PT Lancet (2009) 373:
11 WHY? Early mobiliza-on Primary outcome: return to independent functional status at hosp dx Able to complete 6 activities of daily living & walk independently The Evidence WHY DO WE NOT HAVE MORE RCTS??? 104 patients ALSO Delirium days Ventilator free days No effect on LOS or mortality
12 Who can we mobilize?
13 Interprofessional collabora-on The no-brainers! No discipline/profession can: Func-on in isola-on of others Address myriad & complex spectrum of pt/family problems No single individual can Manage all complex treatments while simultaneously responding to unpredictable physiologic instability Irwin et al (2012) Chest 142:1161-9
14 Why Collaborate? differences (in actual vs predicted death rates of ICUs) occurred within specific diagnos-c categories, for medical pa-ents alone and for medical and surgical pa-ents combined, and were related more to the interac-on and coordina-on of each hospital's intensive care unit staff than to the unit's administra-ve structure, amount of specialized treatment used, or the hospital's teaching status. Knaus et al. (1986) Arch Int Med 104:410-8
15 Arch Intern Med (2010) 170: Administrative database + hospital survey (Pennsylvania) Interprofessional care = daily IPC rounds 112 hospitals + 107,324 patients IPC rounds = odds of 30-day mortality OR 0.84 (95% CI ) Lowest odds of 30-day mortality High intensity intensivist staffing + IPC rounds OR 0.78 (95% CI ) Low intensity intensivist staffing + IPC rounds OR 0.88 (95% CI )
16 Barriers
17 Surveyed 500 ICUs in the US 52% began EM at admission 74% on both vent & non-vent Median 6 days/week; 2X daily 34% dedicated PT/OT team 77% interprofessional rounds CCM (2015) 43:2360-9
18 EM practice No practice CCM (2015) 43:2360-9
19 19 ICUs 514 patients over 4 weeks % mobilized 60% (Aus); 40% (Scot) CC (2015) 19:336
20 Aus Crit Care (2014) in press
21 ICARUS: Mixed Methods Study: 58 participants (22 PT, 19 RN, 16 RT, 15 MD, 2 OT US and Canada Lack of role clarity: It s my job to set goals I m making my own individualized goals for that pa/ent. I have the care plan in mind but I m thinking about what I think is realis/c for that person. ~PT Well, it s a collabora/on between the physician and the nurse taking care of the pa/ent ~RN
22 ICARUS: Team coordination and Team conflict the problem is that it s a mul/disciplinary process so it does involve, you know, all the RTs, all the nurses, all the physios, the die/cians. To get everybody to organize to do anything is always a challenge. ~RT We have to be collabora/ve in order to be successful, so it s just hard when people say, No, I don t like it. ~PT
23 Systemic Determinants of Collabora-on Social system Disparate social status and gender stereotypes Cultural system May foster autonomy over collaborative practice Professional system Perspective that may be in direct opposition to collaboration Educational system Socialization into a profession
24 Organiza-onal Determinants of Collabora-on Organizational structure Hierarchical vs horizontal structures Organizational philosophy Participation, interdependence, integrity, trust Administrative support Leaders role model collaborative practice Team resources Time, space sharing
25 Strategies for Improvement
26 Poten-al Strategies Communica-on interven-ons that promote interprofessional teamwork may be useful for early mobiliza-on Checklists Daily goals Interprofessional rounds Protocols/guidelines Bundles
27 Res Nurs Health (2014) 37: Interviewed 64 Interprofessional team members in 7 US hospitals Structural facilitators Checklists Daily rounds Clinical protocols Informa-on technology Cultural facilitators Accessibility Trust Value Leadership
28 GOALS, ROUNDS, PROTOCOLS 30% CCM (2015) 43:2360-9
29 PROTOCOL Survey responses from 216 Canadian ICUs 38% used mobilization protocols 31% had access to specialized mobility equipment JCC (2015) CCM 30:25-31
30 8% of pts. With ETT 39% of trach 53% of NIV Nydahl et al. (2014) CCM 42:
31 DAILY GOALS Mobility continuum User friendly, physiologically grounded, evidence-based Education/targeted messaging to engage stakeholders Coaching calls/change interventions Most effec-ve strategy: communica-on and collabora-on among all professions behaviour modification Data collection cultural/process issues Peer coaches/mobility champions Positive reinforcement of learning Feedback to stakeholders
32 GUIDELINE Hodgson(2014) Crit Care 18:658
33 GUIDELINE Significant potential risk or consequences of AE Active mobilization should not occur unless specifically authorized (intensivist, senior PT & RN) 23 For out-of bed active mobilization - examples MAP target & causing symptoms despite support (inotropic) Bradycardia requiring treatment/pacemaker Ventricular rate >150 bpm Femoral catheters for IABP/ECMO Cardiac ischemia (chest pain/dynamic ECG changes) Unrousable or deeply sedated Agitated or combative Active mx of intracranial hypertension Uncontrolled seizures Spinal precautions/unstable large bone fractures
34 BUNDLE Applied daily AWAKENING (RN) BREATHING (RT) DELIRIUM (RN) EARLY EXERCISE/ MOBILITY (PT/RN) (all pts) Safety screen Perform SAT, SBT, Measure CAM-ICU Exercise/mobility Coordination Awake perform SBT SBT tolerated extubate Discuss delirium mx Discuss mobility progression on daily rounds Balas et al. (2014) CCM 42:
35 BUNDLE Balas et al. (2014) CCM 42:
36 Checklists, daily goals, protocols, bundles Considera-ons and ques-ons Who should develop? Who polices/ is responsible? Tools only, need to consider complex What are the consequences for non- compliance? individual patient needs Poten-al for interprofessional conflict Poten-al for empowerment/power sharing Need to be contextualized
37 Cardiac arrest team Sepsis Response team Rapid Response team Do we need an early mobiliza-on team in every ICU? Weaning team Maybe..BUT.. Who is coordinating individual patient care? Infection control team
38 Thank you, Ques-ons?
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