June 23, 2017
Historically, success in critical care medicine was gauged using patient survival rates, with significant focus placed on early identification and stabilization of the patient's primary diagnosis. Underlying this approach was a long-standing belief that patients could wait to receive physical and occupational therapy until recovery, usually after being discharged from the intensive care unit (ICU). However, although patient survival rates following ICU admission have improved, it's become apparent that many of these patients have profound weakness along with new challenges to their brains and emotional states.
Physical consequences include ICU-acquired weakness that occurs in 25 to 80 percent of patients on mechanical ventilation for more than four days and in 50 to 75 percent of patients with sepsis. Cognitive impairment occurs in 30 to 80 percent of ICU patients and includes problems with memory, processing, planning, problem-solving and visual-spatial awareness. From 10 to 50 percent of ICU patients have symptoms of post-traumatic stress disorder (PTSD), which can persist for eight years. Experts who gathered at a 2010 meeting of the Society of Critical Care Medicine named the combination of difficulties that survivors experience post-intensive care syndrome (PICS).
The idea that many ICU patients would benefit from rehabilitation services as early as 24 to 48 hours after admission, even while they are very ill, is gaining acceptance. Multiple studies have confirmed that early therapy interventions are both safe and feasible. Early mobility programs have been shown to reduce ICU and hospital lengths of stay and thus decrease the cost of care. Access to rehabilitation services also can help increase strength, improve functional status, and decrease delirium, depression and anxiety.
Recognizing these benefits, staff from Physical Medicine and Rehabilitation (PM&R), in partnership with staff from Critical Care Integrated Medical Practice (CC-IMP), at Mayo Clinic's campus in Minnesota, sought to develop a new care model to guide practitioners in determining how and when to integrate rehabilitation services into care plans for ICU patients.
Before this care model was revised, assessment of Mayo Clinic Hospital — Rochester ICU patients' need for rehabilitation services was performed by providers (including M.D.s, P.A.s, C.N.P.s, R.N.s) who were not involved in providing that physical medicine and rehabilitation care. These providers screened patients for the appropriateness of therapy (right time, right patient, right provider) and placed an electronic consultation request for review by physical therapists (PTs) and occupational therapists (OTs) who were located in a different area of the hospital.
The goal of the staff charged with updating the ICU care model for rehabilitation services was to optimize timing of PT and OT consultations. The team also sought to reduce the time that elapsed between the provider screening and PT-OT consultation.
2017 care plan goals and implementation
Defining the process for embedded therapy in a combined medical-surgical ICU
The new model of care is being used at a 21-bed mixed medical/surgical/transplant ICU at Mayo Clinic Hospital — Rochester, Methodist Campus. The plan embeds three PTs, two OTs and one rehabilitation technician to provide coverage seven days a week. The therapists attend the charge nurse handoff meeting at 7 a.m. each day and screen every patient for appropriateness of therapy.
"This model greatly improves communication between care team members, reduces the time required to obtain consultation from rehabilitation staff, and facilitates nurse-driven patient mobilization and self-care," says Patrick J. Cornelius, P.T., D.P.T., CCS, acute hospitalist clinical lead in physical therapy and team leader for the care model update.
Beyond adding rehabilitation staff on-site within the ICU, the plan also includes:
- A new orientation process for the embedded therapy staff
- Updates to the therapy ICU manual
- OT dysphagia training
The embedded therapy staff also attended a national continuing education conference in preparation, and a newly developed ICU PT-OT training course was offered to all PM&R staff across the Mayo Clinic enterprise.
Implementation of the revised care plan began on Jan. 3, 2017, and data collection will continue through June 30, 2017. Thus far, the overall response from ICU staff members has been favorable.
"I cannot overstate the value of the PM&R group to our critical care practice!" says anesthesiologist and critical care specialist Jeffrey B. Jensen, M.D., medical director of the Thoracic/Vascular Intensive Care Unit at Mayo Clinic Hospital — Rochester, Saint Marys Campus. "I have witnessed significant progress in many chronically critically ill patients, including increased strength, faster mechanical weaning, decreased delirium and increased sleep without adding additional medications to mimic sleep. In years past, many of these patients would have languished far longer."
"Despite the progress made in blood transfusion restrictions, new ventilation strategies and expensive medication regimens, I believe this practice of integrating physical therapy in a structured format will demonstrate more significant returns moving forward," adds Dr. Jensen.
Clinical resource nurse Andrea Y. Lehnertz, M.S.N., R.N., offers these observations about the care model's impact: "Any day walking through the 10-3 ICU is a testament to the success of this project. Vented patients are in chairs and ambulating, and patients deemed too cognitively impaired to get out of bed do so with the help of PT-OT. As our patients' cognition clears, they become interactive in their care."
Beyond the ICU
A multidisciplinary group is currently working to improve awareness about PICS while also testing multiple prevention and treatment strategies. The project team has made various education tools about PICS available to patients, family members and Mayo providers. A survivor support group also has formed with assistance from the Society of Critical Care Medicine Thrive Initiative.