PICU Up: Teaming Up And Transforming To A Culture Of Mobility . - LLUCH

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PICU Up: Teaming up andTransforming to a Culture of Mobilityfor the Critically Ill ChildSapna R. Kudchadkar, MD, FAAPAssistant Professor, Anesthesiology and Critical Care Medicine &PediatricsSeptember 12th, 2017#PedsICU#ICURehab

Disclosures/Research Support FAER Research in Fellowship Grant Institutional K12 (CTSA) Society for Anesthesia & Sleep Medicine(SASM) JHSPH Sommer Scholar ATS Early Career Award JHU Clinical Research Scholars Sleep Services of America PICU Up! TrademarkTM

Objectives Describe characteristics of sleep across the agespectrum in healthy & critically ill children Discuss the effects of sedatives and analgesics onsleep in the developing brain Define early mobilization and discuss the adult andpediatric literature Describe the interplay of sleep, sedation anddelirium in team-based implementation of earlymobilization initiatives

The Patient Experience

Post-intensive care syndrome PICS“THRIVE takes the proverbial baton, leverages the principles espoused in theABCDEF bundle championed within the ICU Liberation Initiative to mitigate longterm impairment, and focuses on life after critical d-toCare-about-Post-Intensive-Care-Syndrome.aspx

“The synthesis revealed that, similarto adult ICU patients, a wide rangeof physical, neurocognitive andpsychological morbidities occur inPICU patients after discharge.”

SCCM ICU Liberation Initiativewww.iculiberation.orgSeptember 18, 20177

ICU Liberation Model: ABCDEFBundle*iculiberation.org

Adult Evidence for the ABCDEFABDCEF

“Critically ill patients managed with the Awakening and Breathing Coordination,Delirium monitoring/management, and Early exercise/mobility bundle spent threemore days breathing without assistance, experienced less delirium, and weremore likely to be mobilized during their ICU stay than patients treated with usualcare” – Crit Care Med 2014

What about the ilyinvolvementDeliriumEarlymobilization

Challenges in caring forcritically ill children Heterogeneity in ages and development Children unable to understand orcommunicate basis and need forinterventions– Danger of inadvertently removing life-savingmodalities (endotracheal tube, vascular access)– Fear and anxiety contribute to physiologicchanges and stress

Creating a healing environment for childrenin the hospital: It just makes sense! Optimizing pain and sedation mgmt. Optimizing sleep Optimizing a child’s ability tocommunicate Minimizing risk factors for delirium Early mobilization


@SapnaKmdReality: A complex interplay wecan tackle

The Cost: Multiprofessional Collaboration toPromote Culture Change--It just makes sense!NursesChild LifePhysiciansPatient &FamilyRespiratoryCareDieticianPT/OTPharmacist

Fall 2013: Our PICU Culture Mechanically ventilated children oversedated High prevalence of benzodiazepine use andescalation PT/OT consultation often ordered by medicalteam 4 days into PICU admission Restraints Not screening for, diagnosing or treatingdelirium Benzos, diphenhydramine and narcotic beingused to improve sleep

Goals Challenge the PICU paradigm that children must receive large doses ofsedatives to tolerate PICU interventions Change the standard of care and confront an unmet and unrecognizedneed for sleep promotion Encourage hospital teams/staff to “buy in” to the risk factors for deliriumand interventions to prevent it TRANSITION FROM A CULTURE OF IMMOBILITY TO MOBILITY

Why should we care about sleep in thehospital? Natural sleep is integral to une defensesEndocrine

Sleep and the Developing Brain“Broadly speaking, it might be argued that the mostfundamental requirements for healthy growth anddevelopment in young children include:a) Loving support and protection byparents/caretakersb) Adequate nutrition, andc) Adequate sleep”-Ronald Dahl, SLEEP 2007

Are they sleeping?

Sleep StagesAverage adult: 25% REMInfants: Up to 80% REM

Principle ConceptsSleep is necessary for: Neurosensory development Preservation of brain plasticity Learning and long term memory Evolution of sleep reflects the complexbrain maturational process duringinfancy, childhood and adolescence

Sleep and the Developing Brain:Neurosensory, plasticity, long-term memory

Hospital Sleep DisturbancesNoiseLightPainMedicationsPICU Sleep DisturbanceImmobilityCircadian rhythm disturbanceSleep LossSleep FragmentationCares/InterventionsStress

A vicious circle?

Hospital sleep is not a priority– Multitude of studies of sleep in the NICU– Nine publications about sleep in the PICU Four publications from same RCT Two studies using subjective assessment(PSBOT)Kudchadkar et al., Sleep Med Rev 2014

341 pediatric intensivists 15% aware of efforts to optimize sleep ofcritically ill children in their unit includingany of following:– Noise reduction– Lighting– Earplugs/eyemasksCrit Care Med 2014.

Pediatric Intensive Care andSleep: Is it a priority? 85% use a combination ofbenzodiazepine and opioid for sedationin mechanically ventilated children 10% use dexmedetomidine 10% utilize dexmedetomidine as aprimary sedative agentKudchadkar et al. 2014, Crit Care Med.

What’s wrong with opioids andbenzodiazepines?Benzodiazepines are the only independent risk factor for thedevelopment of deliriumKudchadkar et al. Contemporary Critical Care 2009Pandaripande, et al. J Trauma 2008

Dexmedetomidine 10% of all respondents usedexmedetomidine as a primary agent Dexmedetomidine most closely inducesan EEG pattern consistent with naturalsleep

Synaptic density, CMRO2 and deltawave amplitude: parallelsGamma distribution modelof growth in childhood anddecline in adolescence. synaptic density---- delta wave amplitudecerebral metabolic rateChanges in delta power are a reflection of synaptic pruning, brain maturation and reorganizationFeinberg et al, 1990. Journal of Theoretical Biology

Preliminary data 8 subjects from Pediatric ICU at Johns Hopkins All healthy, developmentally appropriate childrenprior to admission to hospital All receiving opioid and benzodiazepine forsedation during mechanical ventilation due toprimary respiratory failureJCSM Dec. 2015

Delta Activity

Critical illness and the CircadianRhythm: Melatonin Produced by the pineal gland Under control of circadian pacemaker ofsuprachiasmatic nuclei Peaks at 2 a.m., decreases to daylight levels by 8a.m. Nocturnal melatonin suppression noted in ICU andpost-operative patients

Ongoing work What is the longitudinal evolution ofsleep-wake patterns in children in thePICU and during recovery from criticalillness?

Methods Prospective, observational study– All children 0-18 s/p major surgeryadmitted to the PICU Actigraphy initiated POD #1 anddiscontinued at hospital discharge

Actigraphy plot demonstratesnormal sleep-wake cycles39

What we’ve learned Evolution of sleep is a marker of braindevelopment in childhood Sleep is severely fragmented in childrenadmitted to the hospital Sleep disturbances during infancy andchildhood may have negative effects onneurocognitive outcomes

Sleep: On the causal pathway fordelirium?

What is Delirium?- Key Features– Disturbance in attention and awareness– Disturbance in cognition, e.g. memory, disorientation,language, perception– Develops over a short period of time and fluctuatesthroughout the day– Disturbances are not better explained by a preexisting,established or evolving neurocognitive disorder and don’toccur in the context of severely reduced level of arousal(coma)–American Psychiatric Association: DSM V, Washington, DC: p. 2013

Incidence in the Adult ICU 60%-80% of mechanically ventilatedpatients 50%-70% of non-ventilated patients Hypoactive delirium 44% Hyperactive delirium 2% Mixed delirium 54%(Girard, 2008)

Outcomes 3 fold increase in 6-month mortality– 1 in 3 delirium survivors develop permanentcognitive impairmentAssociated with . New nursing home placement– Increased length of stay 8.0 days– Increased mortality– Increased number of days on the ventilator

Insight from half a century ago ‘Theproblem of delirium is far from anacademic one. Not only does thepresence of delirium often complicateand render more difficult thetreatment of a serious illness, but alsoit carries the serious possibility ofpermanent irreversible brain damage’-Engel & Romano, 1959J Chronic Dis 1959Trogrlic et al, Crit Care 2015

Why should we focus on sleep promotion andsedation optimization to prevent delirium? Low cost, non-invasive, and low risk: CULTURECHANGE and INTERDISCIPLINARYCOLLABORATION Lack of proven prophylactic agents to reducedelirium It just makes sense– especially for thedeveloping brain!

What do we know about the interactionbetween sleep and delirium? Definitive relationship has not beenestablished but Sleep disturbance can independently causeall features of delirium Metabolic waste is primarily removed fromCNS during sleep (“glymphatic system”) Loss of rapid-eye movement sleep isassociated with delirium Sleep-deprived patients are more likely todevelop delirium than those who are notsleep-deprived

What do we know about the interactionbetween sleep and delirium? 10 studiesincluded 6 demonstratedsignificantreduction indeliriumincidence Most studiesused subjectivetoolsCrit Care MedDec. 2016

Sleep promotion interventions(bundled)1. Minimize nighttimeinterventions2. Noise reduction3. Earplugs4. Soothing music5. Dim lights6. Eye masks7. Increased lightexposure duringdaytime8. Artificial light duringdaytime9. Avoidance ofdeliriogenic meds10. Minimize napping11. Pharmacologictherapy (zolpidem,melatonin,antipsychotic)

What about the kids?FamilyinvolvementChoice ofSedationSpontaneousbreathing trialsDeliriumEarlymobilization

State of delirium screening in PICUsinternationally: 2013 Only 2% of respondents reporteddelirium screening is performed for allmechanically ventilated patients onceper shift When asked which tools were being usedfor delirium, several listed withdrawalscales– Sophia Observation ScaleCrit Care Med 2014– Withdrawal Assessment Tool-1 (WAT-1)

But why? We have our own tools!icudelirium.orgCrit Care Med 2014Crit Care Med 2011Crit Care Med 2016

Journal of Pediatric Nursing 2015

Barriers to diagnosis Pathophysiology– Confusion with agitation, withdrawal, pain Absence of screening Tolerance of hypoactive state Sedation and pain management– Protocols? Consistent language? Focus on other organ systems Busy work flow If screening is positive– what’s the next step?

Why should we consistently screenfor delirium? Not just to diagnose delirium and treat it! “A positive delirium screen after severalnegative screens is a warning sign forimpending badness” - Wes Ely, MD

Odds ratioVariable25% Delirium PrevalenceN 835, Traube et al, Crit Care Med 2017(95% CI)Age 2 years0.7 (0.5, 1.0)Physical restraints4.0 (2.0, 7.7)Mechanical ventilation1.7 (1.1, 2.7)Narcotics2.3 (1.5, 3.5)Benzodiazepines2.2 (1.5, 3.3)Antiepileptics2.9 (1.8, 4.8)General anesthesia0.4 (0.3, 0.8)Vasopressors2.4 (1.5, 3.8)

Smith HA et al. Crit Care Med September 2017

Noise pollution in the PICU: Canwe make a difference?

Where do we go from here?

Goals Challenge the PICU paradigm that childrenmust receive large doses of sedatives totolerate PICU interventions Change the standard of care and confront anunmet and unrecognized need for sleeppromotion Encourage hospital teams/staff to “buy in” tothe risk factors for delirium and interventionsto prevent it

Creating a healing environment forchildren in the hospital Optimizing pain and sedation mgmt. Optimizing sleep Optimizing a child’s ability tocommunicate Minimizing risk factors for delirium Early mobilization

Benefits of mobility Blood sugar homeostatsisCardiovascular functionPulmonary functionDecreases chronic inflammationHormonal regulationMusculoskeletal & neuromuscularintegrity Sleep/wake pattern Cognition Decreases depression9/18/201762

Consequences of IMMOBILITYK Koo, K Choong, E Fan, Crit Care Rds 2011

What is Early Mobilization?

ICU Liberation Model: ABCDEFBundle*iculiberation.org

“Critically ill patients managed with the Awakening and Breathing Coordination,Delirium monitoring/management, and Early exercise/mobility bundle spent threemore days breathing without assistance, experienced less delirium, and weremore likely to be mobilized during their ICU stay than patients treated with usualcare” – Crit Care Med 2014

Early Mobilization in AdultsSCCM 2016:www.iculiberation.org67

Weak patients have worseoutcomesCredit: Jolley & Hough 201568

Muscle wasting occurs quickly inthe ICU

Standardized rehabilitationtherapy did not decrease hospitallength of stay among patientswith acute respiratory failure Limitation: No sedation protocolpatients were unarousable on15% of ventilator days.JAMA 2016

Crit Care Med 2016

32% of patient-days with any therapistprovided mobility intervention 16% of patient days with out-of-bedmobility 4% of patient days with ambulation Predictor of mobility progression: PT/OTinvolvement Negative predictors: ETT, deliriumCrit Care Med 2016


Early Mobilization in AdultsSCCM 2016:www.iculiberation.org76

Pediatric Literature review Methods– All prospective and retrospective studies investigatingearly mobilization in the PICU– PubMed, CINAHL, Embase, no limiters– 1928 abstracts reviewed by 2 independent reviewers– 168 articles identified for full-text review– 59 included for data extraction with double data entry– 6 included in review» JPIC 2015

Included Studies Melchers et al 1999: 30 severe TBIJacobs et al 2001: 133 LTRsAndelic et al 2012: 61 severe TBIAbdulsatar et al 2013: 8 Wii boxingHollander et al 2014: 14 VADSSchweitz & Van Aswegan 2013: Pectus

State of Practice Choong et al. (PCCM 2014 & CCM 2013)– Reported the therapy practices in Canadian PICUs Retrospective Rehab practices largely included chest physiotherapy Barriers» MD and PTs reporting - 66.7% reported having adequate knowledge» MDs and PTs – 76.1% reported therapy/mobility important– Institutional barriers» No practice guidelines» Lack of champions/advocates» Lack of MD order for therapy– Provider barriers» Safety concerns» Medical stability, risk of device dislodgement, presence of ETT» Conflicting views regarding stability» Slow to recognize when child was ready» Limited staffing» Poor communication re: readiness and goals

PCCM 2015

Recommendations from LiteratureReview Safe, feasible, positive outcomes when – Unit culture– Barriers and facilitators– Protocols– Knowledge– Resources– Interdisciplinary collaboration 2 or more individuals, differentdisciplines, working together, sharedgoals, patient outcomes

Fall 2013: Our PICU Culture Mechanically ventilated children oversedated High prevalence of benzodiazepine use andescalation PT/OT consultation often ordered by medicalteam 4 days into PICU admission Restraints Not screening for, diagnosing or treating delirium Benzos, diphenhydramine and narcotic beingused to improve sleep

PICU Up! : Early Rehabilitation andProgressive MobilityTM Structured and interdisciplinary program Integrated into the routine care of the critically illchild Outcomes– Provide a standardized mechanism to increaseactivity level– Improve patient outcomes Lower rates of mobility associatedcomplications Decrease length of mechanical ventilation Decrease length of stay– PICU– Hospital

PICU Up! Task Force: Champions metweekly for one year PhysiciansNursesNurse practitionersChild Life SpecialistsKennedy KriegerRespiratory TherapistsPhysical therapistsOccupational therapistsSpeech and Language

One year process. Identify barriersDiscuss solutionsCreate draft guidelinesPilot the processCreate the learning moduleImplement!

Program Development:PICU Up! Activity Levels Stratified: 3 levels– Objective clinical data Severity of illness Behavioral state Premorbid historyLevel 2Level 1 ROM Positioning Each level associated with activities Criteria to pause activity and reassess– Changes in vital signs– Changes in LOC– Concern for device integrity– Behavioral issues OOB tochair Play in bed ConsiderambulationLevel 3 Mat play Ambulate

Development of Unit-wide myLearningModulePatient scenario compatible with delirium module

Shift-based patient scenario

PICU Up! Levels

PICU Up! Activity Progression

Rest and Reassess

Exclusions but no longer

Program Evaluation Sample– Non-probability, convenience– Before/After implementation July/August 2014 and July/August 2015– Inclusion criteria– Ages 1 day to 17 years– PICU LOS 3 daysPCCM 2016

Patient Characteristics

Outcomes Patient Characteristics: Pre/post implementationsample similar in age, weight, reason for admission,premorbid processes, physiologic status as measured byPRISM scores and PICU LOS. No adverse events including tube dislodgments andvascular device compromise Barriers Procedures Change in patient condition EquipmentPCCM 2016

Results 59% of children with OT consultation andsession by PICU Day 3 after PICU Up! (44%pre; p 0.04) 66% with PT consultation vs. 54% (p 0.08) 82% of PICU patients had a PT session priorto discharge from PICU vs. 53% (p 0.02) Median number of mobilization activities perpatient by day 3 doubled from 3 to 6 No adverse events

PICU Up! Outcomes

Barriers to Mobilization

Daily Safety Timeout:Accountability!

Breaking down the silosEarly Mobilization

Take home points Consistency creates culture change! Cluster non-emergent interventions and optimizerehab and communication to promote wakefulnessduring the day! Minimize benzodiazepines and deliriogenic drugs–analgesia first, and start low, go slow! Critically ill children CAN tolerate an endotrachealtube and communicate with us! Focus on non-pharmacologic therapy Push the envelope safely!

Celebrate all successes, big andsmall!

Additional free resources www.johnshopkinssolutions.com/solution/amp/ www.icudelirium.org

Thank [email protected]@[email protected] Up

Delirium monitoring/management, and Early exercise/mobility bundle spent three more days breathing without assistance, experienced less delirium, and were . Not screening for, diagnosing or treating delirium Benzos, diphenhydramine and narcotic being used to improve sleep . Goals