Treating the Critically Ill in Acute Care & the ICU Effective protocols for assessment, early mobility, treatment, discharge and documentation 1
Objectives Obj es & Ag Agenda enda Announcements Plan for the day: Resources!! Staying between the lines and labs Evaluations ‐ more than the FIM ICU & CCU Critically ill Acute Discharge prep and carry ‐ over 2
Get Getting in into a tr transdisciplinar ansdisciplinary fr fram ame of of mi mind… nd… 3
I. What is happening in Acute Care… • Nursing, Respiratory, Physicians, Pharmacy, and Therapy must communicate for safe early mobility and to minimize risks from immobility and delirium. • A graded collaborative approach focusing on one goal at a time • Choosing monthly goals was effective to get practitioners, patients, and families working on common goals (De La Fuente ‐ Martos et al, 2018). • Nursing presents with primary transfer role management (both passive and active) in contrast to therapy role for mobility outside of transfers (Brock et al, 2018). • https://www.youtube.com/watch?v=D53gygWRhLM • https://www.youtube.com/watch?v=W_FHZTGLWE8 4
Complexities & Barriers … weighing the risks • Complexities: (ICU ‐ AW) results in… • Delirium: occurs in more • PICS ‐ Post Intensive Care than a third of our ICU Syndrome patients (Petrucci, 2018). • Weakness • Mortality • Balance • Increased Mechanical • Anxiety, Ventilator Days: Post • Depression extubation dysphagia • Sleep disturbance • Quality Of Life decline • Memory Deficits • Can cause complications for months and years following • Attention Deficits hospitalization (Hashem et al, 2016). • Task Completion Deficits • Impaired protein synthesis • (Mayo Clinic, 2018) • ICU ‐ Acquired Weakness 5
What bedrest means to the human body. Results of 24 hours of rest (Tremain, 2016). 6
Barriers and considerations… • Arousal Level • Staff culture, • Orders • Hemodynamic referrals, resources instability (Castro et al, 2015). • Patient pain report • Tolerance is was not a reported determinate upon factor as a barrier 5 ‐ 10 minutes of positional tolerance with (Ahrens et al, 2005) implementation of • Respiratory Instability therapy services • PaO2/FiO2<100 or early in care (Hickmann et al, Respirations >35 2016). • Agitation • https://www.youtube.com/watch?v=OVi7WbbMkUY • Perceived Risk with line • https://www.youtube.com/watch?v=dyekODg0O2s management. • (Brock et al, 2018) 7
Respiratory Considerations in Critically Ill Patients Hashem, M, D., Nelliot, A., & Needham, D, M. (2016). Early mobilization and rehabilitation in the ICU: Moving back to the future. Respiratory Care, 61 (7), 971 ‐ 9. ASHA Wire reports: “Studies show that difficulty communicating is the most commonly distressing symptom of mechanically ventilated patients.” (Holden, 2017) 8
II. Line it up Check for SLA SLACK in your lines before you begin ANY intervention!! 9
Intercranial EKG Monitor Pressure Probe I.V Pump EEG Box Feeding Pump through Ventilator Nasogastric Tube Swan Line Compression Boots Pulse Ox. Electroencephal ography (EEG) 10 Foley Catheter
Catheter PICC Lines Tip • Peripheral inserted central catheter: goal anatomy is Vein superior vena cava PICC Line 11
NG Tubes ‐ Nutrition 12
• Common IV Lines: Fluids and medication delivery (see next slide) 13
Basillic Vein Cephalic Vein Cephalic Vein Median Cubital Vein Dorsal Venous Network Accessory Basillic Veins Cephalic Vein Dorsal Metacarpal Veins Cephalic Vein Digital Dorsal Basillic Veins Veins Median Antebrachial Vein 14
EKG Lines 15
Nephrostomy (Side View) Nephrostomy Catheter Drainage Bag Nephrostomy Kidney Ureter Bladder 16
17
”Swan Line” 18
Tracheostomy ‐ Airway Management 19
Guide from 2018 ICU Management and Practice 18(2) https://healthmanagement.org/c/icu/issuearticle/the ‐ role ‐ of ‐ speech ‐ and ‐ language ‐ therapy ‐ in ‐ critical ‐ care 20
Pleural Catheter 21
Removable Trocar Cannula Abdominal Wall Bladder Suprapubic Catheter Spine Suprapubic Catheter 22
Documentation Recommendations • Pre ‐ treatment, during treatment (minimally at the onset of each new task), and post ‐ treatment. • Patient presented with O2% of _(<90 ‐ 92%)_ indicating need for incorporation of pursed lip/diaphragmatic breathing pre activity/exercise to promote oxygenation and decreased CO2 retention for improved safety with ______. (p.63) • Due to patients lab value(s) of _______ treatment was modified/withheld/graded down due to __risk of/improvement of___ • https://www.nrsng.com/nursing ‐ lab ‐ values/ • https://cdn.ymaws.com/www.acutept.org/resource/resmgr/docs/2017 ‐ Lab ‐ Values ‐ Resource.pdf 23 • https://www.swallowstudy.com/quick ‐ link ‐ lab ‐ values ‐ dysphagia/
Lab: Walk the Line 24
III. Evaluations in the ICU, CCU, and Acute Care Setting • PTSD Checklist • FOUR Scale for Responsiveness (p.48) • RASS (Richmond Agitation Sedation Scale) • CAM (Confusion Assessment Method) • https://www.icudelirium.org/medical ‐ professionals/overview 25
Testing and evaluation options continued… • Borg *exertion and enjoyment *(p.34 ‐ 37) • Barthel Index (p.32) • FIST (p.47) • ICU Mobility Scale (p.25) • FAC ‐ Functional Ambulation Category (p.46) • CCI ‐ Charlson Comorbidity Index (p.40) • AM ‐ PAC (p.31) 26
Things to consider… • Cognition (p. 52 ICU memory tool) • Delirium • Orientation • Arousal Level • Behaviors • Vertigo • Weakness • Restrictions & Precautions 27
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IV. ICU & CCU Treatment Options • MOBILITY!!! Critical at all levels and imperative to minimize complications. • Positional Tolerances • Transfers • Exercises • ADLS • Simulations • Assistive Technologies • Functional Activities • Cognitive Therapy 29
• A ssess pain • P ain • B oth • A gitation breathing and • D elirium awakening The “PADIS” trials • I mmobility • C hoose & “ABCDEF” • S leep appropriate Disruption of ICU sedation Treatments • D elirium management • E arly mobilization • F amily inclusion (Medtronic, 2018) 30
Choosing Interventions • “In ‐ bed cycling increased thigh circumferences rectus femoris CSA. Adding FES did not show differences.” (Woo et al, p.16, 2018). • Mobility and exercises, even bed ‐ based interventions, decrease both LOS as well as inflammatory responses within patients leading to positive outcomes (Winkelman, 2012). • Even passive sling transfers have a positive impact on both respiratory and orthostatic patient stability (Brock et al, 2018). • Interventions do not have to be long in duration, hence the importance of a transdisciplinary approach especially as interventions grade up by day and with changes to med/surgical units. • What does this mean clinically and how does this change our approach to interventions 31
Saint ‐ Luc Hospital Early Mobilization Protocol 32
Delirium… • While this complexity initially presents in the cognitive realm there are profound ties to to mobility & mobility plays a significant role in the resolution of delirium. (p.68) • https://www.youtube.com/watch?v=roRQTf5F ‐ Aw 33
Access at www.icudelirium.org 34
Physiological and Cognitive Interventions Passive, Active, and Manual resistive interventions (Hickmann et al, 2017). Leg press and ergometry (3 ‐ 4 watts) ‐ how to modify, make it work for your patients Tilt tables and Standing Music: Triggers physiologic relaxation responses in patients (Pertucci, 2018). Family Involvement as a global initiative Delirium: Neurocognitive stimulation, virtual reality interventions 35
http://troymedia.com/2017/02/03/change ‐ the ‐ way ‐ we ‐ view ‐ exercise ‐ for ‐ frail ‐ and ‐ critically ‐ ill ‐ patients/ https://www.youtube.com/watch?v=GrxooU9WI9k https://www.youtube.com/watch?v=yLpe_DwsqFE https://www.youtube.com/watch?v=0C ‐ I9vhfO4o 36
ICU & CCU Treatment Trials 37
V. Treatment approaches for the critically ill acute care patient as they transition out of the ICU… • Mobility continues to be a primary focus ‐ • “…physical activity sufficient to elicit acute physiological effects that enhance ventilation, circulation and muscle metabolism.” (Cowan et al, 2017). • Nursing literature is increasing the focus on acute care culture. • “4 E’s" of Engage, Educate, Execute, and Evaluate will assist in creating a culture of mobility.” (Saunders, 2015). • John’s Hopkins reports 80% of critically ill patients suffer from delirium (2017). While there is increased focus in the ICU and CCU settings on cognition, as practitioners we need to continue this focus throughout our acute care interventions. 38
Patients begin to own components of care • Example ‐ EOB transfers: • Arm reach & trunk lift • Lateral and single leg movements • Bridging • Heel raises • Rolling and side ‐ lying • Trunk elevation • Upper Extremity Extension • Weight shifting, hips, and balance (Salzman, 2017) 39
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