Guttormson, Jill L.

McAndrew, Natalie S.

English

epublications@Marquette

Marquette University e-Publications@Marquette College of Nursing Faculty Research and Publications Nursing, College of 11-2019 Time to Move: Shifting the ICU Paradigm to Improve Outcomes for Survivors of Critical Illness Jill L. Guttormson Natalie S. McAndrew Follow this and additional works at: https://epublications.marquette.edu/nursing_fac  Part of the Nursing Commons  Marquette University e-Publications@Marquette  Nursing Faculty Research and Publications/College of Nursing  This paper is NOT THE PUBLISHED VERSION; but the author’s final, peer-reviewed manuscript. The published version may be accessed by following the link in the citation below.  Heart & Lung, Vol. 48, No. 6 (November/December 2019): 530-531. DOI. This article is © Elsevier and permission has been granted for this version to appear in e-Publications@Marquette. Elsevier does not grant permission for this article to be further copied/distributed or hosted elsewhere without the express permission from Elsevier.   Time to Move: Shifting the ICU Paradigm to Improve Outcomes for Survivors of Critical Illness  Jill L. Guttormson Marquette University College of Nursing, Milwaukee, WI Natalie S. McAndrew University of Wisconsin Milwaukee College of Nursing, Milwaukee, WI  Intensive care unit acquired weakness (ICUAW) affects up to 65% of patients in the intensive care unit (ICU) and is associated with increased mortality, as well as a longer duration of mechanical ventilation and ICU stay.1 Importantly, ICUAW also contributes to post intensive care syndrome (PICS), with ICU survivors experiencing long term negative effects on cognitive and physical functioning and mental health.2 In a recent study of medical and surgical critical care patients, 26% of ICU survivors had physical disability at three months post discharge and 19% experienced problems in at least two domains of PICS (cognitive, physical, or mental health).3 Early identification of ICUAW in our critically ill patients is an important strategy to address the problem. In this issue, Braganca and colleagues offer further validation of handgrip dynamometry for the diagnosis of ICUAW when compared to the gold standard Medical Research Council (MRC) muscle strength score criteria.4 Handgrip certainly provides a simple and fast method for clinical recognition of patients with ICUAW. However, similar to MRC testing, handgrip assessment is not possible with many of our at risk patients. Only 44% of screened mechanically ventilated patients could be included in Braganca and colleagues study.4 Similarly, in a study evaluating muscle strength, 46% of the patients could not be evaluated using MRC criteria due to inattention.5 Although the underlying specific cause of patient inattention or exclusion from testing cannot be explicitly determined from either study report, certainly sedation and delirium are significant barriers to MRC muscle strength testing and handgrip dynamometry, as both require an awake and cooperative patient. Despite guidelines calling for decreasing sedation since 2002,6,7 these guidelines are not consistently integrated into intensive care unit practice.8,9 This minimizes our ability to diagnose ICUAW with either of these two measures. The challenge of addressing ICUAW goes beyond identification and measurement. Early mobility interventions are safe and effective, improve functional outcomes, minimize time on the ventilator, and decrease delirium.10,11 However, estimates of patients receiving out of bed early mobility in the ICU are as low as 10%.12 Even within the context of a prospective research study over 60% of patients were never mobilized, with sedation as the most commonly reported modifiable barrier.13 Awakening and Breathing Coordination, Delirium Monitoring, and Early Exercise/Mobility (ABCDE) bundle adoption into practice is equally low with only 12% of survey respondents reporting routine integration of all the bundle components.9 Many of the identified modifiable risk factors for development of ICUAW and PICS12 are the same factors that preclude our ability to measure or intervene. Critical care practitioners and researchers are stuck in a vicious cycle with sedation as both a risk factor for negative outcomes and a barrier to evaluation and intervention for ICUAW and delirium. However, we are not doomed to measure complications after discharge nor to insufficiently address them during critical illness. Numerous resources are available to support practice change around sedation and mobility.14 There is an urgent need to create a paradigm shift in the ICU to support a new normal where the interactive patient on the ventilator is expected and the sedated immobile patient is uncommon. With this shift we move away from measuring the impact of complications and move to proactively decreasing the number of ICU survivors suffering long term negative outcomes. However, this paradigm shift will not be simple nor easy. It will take collaboration amongst interprofessional ICU team members15,16 as well as organizational support and investment. This sustained change to practice is possible through commitment and passion for the effort. It is time to move to improve quality of life for our ICU survivors. References 1. G. Hermans, G. Ven den Berghe. Clinical review: Intensive care unit acquired weakness. Crit Care, 19 (2015), pp. 274-282, 10.1016/s13054-015-0993-7 2. D.M. Needham, J. Davidson, H. Cohen, et al. 2012. Improving long-term outcomes after discharge form intensive care unit: report form a stakeholders’ conference. Crit Care Med, 40 (2012), pp. 502-509, 10.1097/CCM.0b013e318232da75 3. A. Marra, P.P. Pandharipande, T.D. Girard. Co-occurrence of post-intensive care syndrome problems amongst 406 survivors of critical illness. Crit Care Med, 46 (2018), pp. 1393-1401, 10.1097/CCM.0000000000003218 4. R.D. Braganca, C.G. Ravetti, L. Baretto, et al. Use of handgrip dyananometry for diagnosis and prognosis assessment of intensive care unit acquired weakness: a prospective study. Heart Lung, 48 (2019), pp. 532-537 5. C.L. Hough, B.K. Lieu, E.S. Caldwell. Manual muscle strength testing of critically ill patients: feasibility and interobserver agreement. Crit Care, 15 (2011), p. R43 6. J. Jacobi, G.L. Fraser, D.B. Coursin, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med, 30 (2002), pp. 119-141 7. J.W. Devlin, Y. Skrobik, C. Gélinas, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med, 46 (2018), pp. e825-e873 8. L.D. Burry, D.R. Williamson, M.M. Perreault, et al. Analgesic, sedative, antipsychotic, and neuromuscular blocker use in Canadian intensive care units: a prospective, multicentre, observational study. Can J Anaesth, 61 (2014), pp. 619-630 9. Miller MA, Govindan S, Watson SR, Hyzyl RC, Iwashy TJ. ABCDE, but in that order? A cross-sectional survey of Michigan intensive care unit sedation, delirium, and early mobility practices. Ann Am Thorac Soc 2015 11:1066–1071. https://0-doi-org.libus.csd.mu.edu/10.1513/AnnalsATS.201501-066OC. 10. D.M. Needham, R. Korupolu, J.M. Zanni, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: A quality improvement project. Arch Phys Med Rehabil, 91 (2010), pp. 536-542, 10.1016/j.apmr.2010.01.002 11. W.D. Schweikert, M.C. Pohlman, A.S. Pohlman, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet, 373 (2009), pp. 1874-1882, 10.1016/S0140-6736(09)60658-9 12. S.E. Jolley, A.E. Bunnett, C.L. Hough. ICU-acquired weakness. Chest, 150 (2016), pp. 1129-1140, 10.1016/j.chest.2016.03.045 13. C. Hodgson, R. Bellomo, S. Berney, M. Bailey, et al. Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care, 19 (2015), p. 81, 10.1186/s13054-015-0765-4 14. Society of Critical Care Medicine. ICU liberation bundle. www.sccm.org/ICULiberation/ABCDEF-Bundles accessed 15 September, 2019. 15. D.K. Costa, F.K. Barg, D.A. Asch, J.M. Kahn. Facilitators of an interprofessional approach to care in medical and mixed medical/surgical ICUs: a multicenter qualitative study. Res Nurs Health, 37 (2014), pp. 326-335, 10.1002/nur.21607 16. K.D. Costa. The team, the team, the team: What critical care research can learn from football teams. Ann Am Thorac Soc (2019), 10.1513/AnnalsATS.201903-202VP (epub ahead of print)  

Time to Move: Shifting the ICU Paradigm to Improve Outcomes for Survivors of Critical Illness

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Time to Move: Shifting the ICU Paradigm to Improve Outcomes for Survivors of Critical Illness

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