1. Thoracic Surgery Tina Fields, PT, MPT, CCS Laura Pink-Baker, PT, DPT

2. Implementation • Started >30 years ago • Physician driven • Space driven

3. Consult Process • Paper Process. • Changes with computerized orders. • Now with standing consult via order sets.

4. Components of our Program • Standing activity orders POD#1 • Ambulate 4x/day • Up to chair 3x/day • IS 10 breaths/hour • Charting for accountability • Fast Track vs White Board

5. Accountability

6. Common diagnoses • Valve repair/replacement • CABG • Aneurysm repair – (open vs. endovascular) • Heart transplant • Lung transplant • Ventricular Assist Devices • Total Artificial Heart • VA ECMO/VV ECMO • Various other lung and heart surgeries

7. Triage Process • Chart Review • Activity Orders • Lab Values – see next slide • Visually assess patient and environment • Consult nurse regarding present status • Consult MD for assist with risk vs benefit prn • New arrhythmia with hemodynamic stability.

8. Lab Values • Trends • Possible Limits • HgB of <7 or Hct <20 • K+ <3.2 or >5.5 • Na+ <120 or >150 • Ca+ <7 or >12

9. Possible Exclusions: • CRRT with groin or unstable access • New onset of arrhythmia. • Unclamped Lumbar drain. • Acute DVT/PE if not anti-coagulated per protocol. • VA ECMO • Hemodynamic instability

10. Barriers to Mobility • High FiO2 >70% or PEEP of >15 • New arrhythmia w/hemodynamic instability • Femoral Lines • MAP <55 • Maintain with or without pressors • Heavy Sedation/Nitric Oxide • PA Catheters • Open Chest • Tranvenous Pacemaker – if PM dependent • Precautions w/SCI or M.D.

11. Risks with Mobility • Hypotension • Arrhythmia • Accidental removal of tubes/lines • Fall risk

12. Risks versus Benefits of early mobility • Surgical vs Medical ICU populations • Medically managed Aortic Aneursym • Surgical Risks • Risk of death from rupture • Parameters

13. Treatment • Consult Received • Hemodynamic Stability • Education regarding precautions: • No ROM restrictions (except if painful) • Lift/Push/Pull <5-10 lbs • Exercises • Mobility Progression • Airway Clearance

14. Exercise Program s/p Sternotomy • Exercises Included in our program: • Shoulder Shrugs • Shoulder Circles • Trunk Twists • Trunk Sidebending • Chest Stretch • Shoulder Flexion • Shoulder Abduction

15. Equipment Barriers due to precautions Heart Hugger Hoyer Lift MOVEO®

16. Safeguards • Line Management • Gait Belt • Constant monitoring of vital signs • Careful planning for contingencies • Ability to increase FiO2 • Portable Telemetry • Nurse aware of treatment plan

17. Recent Interdisciplinary Programs • nursing aide involvement • Pressure relief documentation • Hourly rounds • pressure ulcer prevention: • Mepilex ® Border Sacrum¹ 1. Pressure Ulcer Prevention in High Risk Cardiovascular Surgery Patients. R. Freeman, J. Stieve-Swarup, A. Czernik, L. Silveus, L Portice, J. Kilpatrick, D. Totzkay, C. Nault, J. Mowry, K. McKenney

18. Contact Information • Tina Fields = chrifiel@med.umich.edu • Laura Pink-Baker = laubaker@med.umich.edu