ICU Liberation: The Role of Rehabilitation Professionals

A stay in the ICU can be a traumatizing experience for patients and families. The vulnerability and dependence patients experience when tethered to life-sustaining equipment in the disorienting ICU environment disconnects them from their known identity. Patients can have weakness, reduced aerobic capacity, pain, fatigue, and disorganized thinking within days of an ICU admission. This new debilitated reality can linger for years after the patient leaves the ICU,¹ sometimes in the form of post-intensive care syndrome (PICS). The mission of rehabilitation practitioners and RCPs for any patient is to optimize strength, cognitive capability, and autonomy. The end goal is functional independence. Clinical researchers, patients, and families can have different perspectives when it comes to outcomes goals.

A 2018 study of survivors of acute respiratory distress syndrome (ARDS), their family members, and clinical researchers found that patients and families rated cognitive, pulmonary, and physical functions the most important outcomes for researchers to measure.²

Clinical researchers, on the other hand, rated survival as the top priority to measure. ARDS survivors rated survival as the lowest priority.³ No doubt disease elimination and survival are crucial focuses for clinicians. But addressing our patients’ goals in a comprehensive way requires the full coordination of rehabilitative efforts early and consistently.

The Society of Critical Care Medicine and the American Thoracic Society both recommend early mobilization for ICU patients to reduce iatrogenic ICU trauma and disability. However, no shared or standardized definitions for ICU early mobility intervention choices, dosing, and intensity exist.⁴ While protocols for identifying and eliminating diseases such as sepsis and ARDS are effective, facilitating functional recovery for both mind and body is a progressive, collaborative process among clinicians, patients, and caregivers.

Published descriptive and randomized controlled studies of patient mobility interventions have attempted to create generalizable protocols for mobility that rely primarily on bed and low-level activity. When taken together in the form of systematic reviews or meta-analyses, they appear to have little influence on improving long-term patient outcomes.⁵ The heterogeneity of ICU patients, combined with the complexity of addressing the whole patient in a meaningful way to restore functional independence, requires an individualized treatment strategy that rehabilitation practitioners and RCPs are uniquely qualified to deliver. Perhaps the ideal way to demonstrate this is with a complex ICU patient example.

Consider a 56-year-old patient in the ICU recovering from severe ARDS due to influenza with sepsis. The patient requires mechanical ventilation and had required paralytics with deep sedation. On ICU admission day 6, the patient wakes up to a Richmond Agitation-Sedation Scale score of –1 when all sedation has been turned off. Using the ICU Liberation Bundle A-F elements as our guide, how should the team of rehabilitation practitioners and RCPs formulate patient care toward meaningful recovery?

When treating each patient, the patient’s needs and capabilities can be assessed as follows:
 
Examples of admitting events include elective surgeries, hypoxemic respiratory failure, cardiac arrest, septic shock, pulseless electrical activity, altered mental status, seizure, diabetic ketoacidosis, trauma, injury, and gastrointestinal bleeding.

Shifting Focus From the Admitting Event

After one to two weeks of hospitalization the admitting event is less relevant to the patient’s recovery and outcome than comorbid conditions and level of premorbid capability.⁶ At this point, the qualities at the base and middle of the pyramid are more pertinent and become the medical team’s primary focus. Sarcopenia and integrity of skeletal muscle are an evidence-based indicator of this patient’s resiliency.⁷ For some patients, providing the best care involves helping to prevent the normal skeletal muscle sacrificing the body engages in when illness or injury occur. Skeletal muscle is endocrine tissue and integral to bone health. When assessing the disease burden, it is important to note the number of organ systems involved or compromised chronically. For example, is there an underlying cancer diagnosis, diabetes, end-stage renal failure, liver disease, substance abuse history, or heart disease in a patient with an admitting event of hypoxemic respiratory failure?

When assessing the foundation of the person and his/her physiologic reserve, note activities of daily living, level of assistance needed in the home, support system, employment, stair-climbing capability, driving capability, hearing, vision, and falling history. Ask whether the patient appears to feel purpose and meaning in life and assess psychiatric history.

Returning to the example, in the initial phase of the 56-year-old ARDS survivor’s recovery, optimizing this patient’s cognitive, psychological, and pulmonary systems will be the first priority. During separate sessions each day, the PT and OT—through active listening and motivational interviewing with caregivers—will perform cognitive assessments, communication enhancement, and pulmonary optimization with the SLP and RCP. A treatment plan is developed to address how to:

• Control distress
• Prevent and reduce dyspnea
• Treat pain
• Orient the patient to reality
• Reacquaint the patient with sense of self and identity
• Improve neuromuscular capability

The rehabilitation team must collaborate to craft an individualized program that addresses:

• Physical inputs, such as bed exercises, sitting up on the edge of the bed, transferring to a chair
• Symptom management, such as supporting the work of breathing with adjustments to ventilator settings
• Pulmonary hygiene, including medication for pain and adequate blood pressure
• Talking the patient through anxiety reduction
• Facilitating a sense of working toward a meaningful return to self

A PT working alone focused on restoring skeletal muscle function alone will not provide the comprehensive restoration this patient needs. The following is a reasonable initial treatment sequence at this point:

The OT checks in with the patient, family, assigned nurse, and RCP in the morning. The patient is minimally responsive, displays profound attention deficit, and grimaces with movement. Using the ICU Liberation Bundle, the nurse provides no sedation but treats the patient for pain and administers vasopressor medication. The nurse explains to the family the rehabilitation treatment plan for today. Together, the OT and RCP work with the patient to optimize pulmonary hygiene, explain the ventilator and weaning strategies, and support the work of breathing. Patients on a mechanical ventilator cope with sleep deprivation, anxiety, pain, difficulty communicating, lack of control, thirst, and dyspnea. Ventilated patients often experience air hunger or an excessive work of breathing that is profoundly distressing. Clinicians should assess all ventilated patients for dyspnea by asking directly, Are you getting enough air? Are you working hard to try to breathe?^8,9 Together, the OT and RCP can assess for dyspnea and the RCP can adjust the ventilator to reduce asynchrony as much as possible.

In this initial session, the OT and RCP can sit the patient upright to facilitate orthostatic tolerance, patient autonomy, and neuromuscular control. The OT can facilitate an ICU diary for the patient and family, create a get-to-know-me board on the wall with family input of who this patient is as a person, facilitate communication for the patient despite the endotracheal tube, and facilitate cognition in a way that is meaningful to the patient. Together, the OT, nurse, and RCP will monitor the patient for fatigue. Later in the day (at a time that had been scheduled with the patient and family), the PT arrives with a mobility technician and RCP to orient the patient, recruit the family to encourage the patient, and challenge the patient with bed exercises as a warm-up activity and cognitive demand, while the RCP adjusts the ventilator, manages the equipment, and teaches the patient how to synchronize breathing with the ventilator. All help the patient to actively move out of bed.

Each day will follow a similar pattern in a progressive rehabilitative process, building on the patient’s resilience, improvement, daily medical condition, and cognitive recovery. Comprehensive and individualized care required to achieve patient-centered outcomes requires the ICU Liberation Bundle delivered by nursing and rehabilitation staff working together.

References

1. Herridge MS, Moss M, Hough CL, et al. Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers. Intensive Care Med. 2016 May;42(5):725-738.
2. Dinglas VD, Chessare CM, Davis WE, et al. Perspectives of survivors, families and researchers on key outcomes for research in acute respiratory failure. Thorax. 2018 Jan;73(1):7-12.
3. Dinglas VD, Faraone LN, Needham DM: Understanding patient-important outcomes after critical illness: a synthesis of recent qualitative, empirical, and consensus-related studies. Curr Opin Crit Care. 2018 Oct;24(5):401-409.
4. Clarissa C, Salisbury L, Rodgers S, Kean S. Early mobilisation in mechanically ventilated patients: a systematic integrative review of definitions and activities. J Intensive Care. 2019 Jan 17;7:3.
5. Geense WW, van den Boogaard M, van der Hoeven JG, Vermeulen H, Hannink G, Zegers M. Nonpharmacologic interventions to prevent or mitigate adverse long-term outcomes among ICU survivors: a systematic review and meta-analysis. Crit Care Med. 2019 Nov;47(11):1607-1618.
6. Iwashyna TJ, Viglianti EM. Patient and population-level approaches to persistent critical illness and prolonged intensive care unit stays. Crit Care Clin. 2018 Oct;34(4):493-500.
7. Toptas M, Yalcin M, Akkoc I, et al. The relation between sarcopenia and mortality in patients at intensive care unit. Biomed Res Int. 2018 Feb 12;2018:5263208.
8. Schmidt M, Banzett RB, Raux M, et al. Unrecognized suffering in the ICU: addressing dyspnea in mechanically ventilated patients. Intensive Care Med. 2014 Jan;40(1):1-10.
9. Gentzler ER, Derry H, Ouyang DJ, et al. Underdetection and undertreatment of dyspnea in critically ill patients. Am J Respir Crit Care Med. 2019 Jun 1;199(11):1377-1384.