AECOPD-Mob developed by Dr. P. Camp, Dr. D. Reid, F. Chung, Dr. D. Brooks, Dr. D. Goodridge, Dr. D. Marciniuk, and A. Hoens. The project was supported by the Canadian Institutes of Health Research, the UBC Faculty ofMedicine Department of Physical Therapy, the Physiotherapy Association of British Columbia, Vancouver Coastal Health Research Institute, Providence Health Research Institute and the COPD Canada Patient Network.Contact: Dr. Pat Camp pat@hli.ubc June 2015 1/
Clinical Decision-Making Tool for Safe and Effective Mobilization of Hospitalized Patients with AECOPD
####### Purpose, Scope & Disclaimer. The purpose of this document is to provide recently graduated or returning clinicians working in acute care settings with guidance on safe and effective mobilization of the
####### hospitalized patient with an acute exacerbation of COPD. This decision-making tool is evidence- and expert-informed. It is not intended to replace the clinician’s clinical reasoning skills and
####### interprofessional collaboration.
####### _________________________________________________________________________________________________________________________________________________________________
####### Prior to any patient mobilization, ensure there is enough qualified staff available, the patient has consented to the treatment plan, and the patient’s goals have been identified and effectively communicated
####### between patient, staff and family.
WHAT TO ASSESS PRIOR TO MOBILIZATION
####### Equipment
####### Mechanical lifts, poles, transfer belts etc. available
####### Portable oximeter; portable oxygen tank and tubing, blood pressure unit
####### Lines organized (i. cap feeding tubes, lines secure or capped as appropriate)
####### Mobility aids in reach, used appropriately and maintained
####### Glasses, footwear or hearing aids available
####### Review the chart:
####### Comorbidities, medications, medical status, etc.
####### Review the patient:
####### Not: combative, severely confused or agitated, or heavily sedated
####### Medically stable and without significant pain, fatigue, or diaphoresis
####### Cardiovascular signs and symptoms assessed – no angina at rest, untreated arrhythmia, decompensated
####### left or right heart failure, severe postural hypotension
####### Mobility assessment
- Standing/balance assessed to determine fall risk (eyes open, eyes closed, tandem, reaching /
####### Berg)
- Adequate body strength and energy required to perform specific exercise, transfer, or ambulation
####### Medications accessible and appropriate staff available to administer them if needed during activity
####### Note: SpO 2 < 88% at rest or during exercise requires supplemental oxygen
WHEN TO CONSIDER NOT MOBILIZING OR TO DISCONTINUE MOBILIZATION
(For patients in critical care settings, see SAFEMOB*)
####### Cardiovascular status
####### BP - A drop in systolic pressure (20 mm Hg) or below pre-exercise level OR a
####### disproportionate rise i. 200 mm Hg for systolic or 110 mm Hg for diastolic. 1
####### HR - < 40 2 or > 130 2 , 3 ; requiring temporary pacer
####### Pulmonary embolus – discussion with physician required to determine suitability.
####### Deep venous thrombosis – May mobilize as tolerated immediately after low
####### molecular weight heparin is given. If patient is on any other form of
####### anticoagulation, check mobility orders with the physician. Monitor patient for
####### changes in pain, swelling, colour and sudden shortness of breath. 4
####### Angina before, during or after activity
####### Untreated arrhythmia or decompensated left or right heart failure
####### Respiratory status
####### SpO 2 <88% 2 , 5 at rest or during exercise
####### RR - <5 or >40 2
####### FiO 2 - >60% 3 or high flow oxygen > 6 lpm
####### Uncontrolled asthma
####### Other
####### Intermittent hemodialysis 2
####### Unstable fracture
####### Excessive muscle soreness or fatigue that is residual from last exercise or activity session
####### Other contraindications specific to a given setting/unit
WHAT TO MONITOR DURING MOBILIZATION FOR PATIENT SAFETY
####### Staff should be available to monitor patient signs and symptoms, and the need for O 2
Ensure supplemental oxygen and tubing are nearby to administer if SpO 2 drops below 88%
Patient -- Subjective:
####### Dizziness, vertigo,
####### Dyspnea, fatigue
####### Nausea, pain
####### Consider use of scales e., Borg Dyspnea Scale or Rating of Perceived Exertion
Patient -- Objective
####### Cognition, balance
####### Perspiration, cyanosis, heart rate, oxygen saturation, respiratory rate and blood pressure
####### Other factors relevant to patient and mobility task, for example, cardiac rhythm in those patients when ECG
####### is essential during mobilization or blood pressure monitoring in patient that is prone to postural hypotension.
WHAT TO MONITOR AND HOW TO PROGRESS MOBILIZATION TO ENHANCE EFFECTIVENESS
####### Written communication regarding daily targets for exercise activities and a record of exercise activities accomplished should be posted at bedside and documented
####### Type of exercise activities match patient’s functional needs upon discharge i. walk distance, stairs, balance, strength sufficient to carry and unpack groceries.
####### Targets for progression are determined daily i. increase walk distance and/or increase number of walks, stair climbing, standing balance, U/E exercises.
####### Pertinent exercise parameters i. heart rate and breathlessness, increase proportionately with incremental activity and recover to baseline within 5 minutes post activity
####### *SAFEMOB available at physicaltherapy.med.ubc/physical-therapy-knowledge-broker/safemob-project/
AECOPD-Mob developed by Dr. P. Camp, Dr. D. Reid, F. Chung, Dr. D. Brooks, Dr. D. Goodridge, Dr. D. Marciniuk, and A. Hoens. The project was supported by the Canadian Institutes of Health Research, the UBC Faculty ofMedicine Department of Physical Therapy, the Physiotherapy Association of British Columbia, Vancouver Coastal Health Research Institute, Providence Health Research Institute and the COPD Canada Patient Network.Contact: Dr. Pat Camp pat@hli.ubc June 2015 2/
HOW TO PROGRESS
For mobilization prior to Level V see SAFEMOB*
LEVEL V LEVEL VI LEVEL VII LEVEL VIII
####### Mobility Criteria
####### for Entering this
####### Level 6 , 7
####### Patient is unable to transfer out of bed
####### without moderate to maximum assistance
####### and unable to sit independently.
####### Patient can transfer out of bed with
####### minimal assistance, has independent
####### sitting balance but unable to stand
####### independently or walk without assistance.
####### Patient has independent standing balance.
####### Patient can transfer/walk independently or
####### with supervision, but has poor endurance.
####### Unable to ascend/descend flight of stairs
####### Patient is independent with transfers and
####### gait and has high level balance skills.
####### Patient can do stairs with minimal
####### assistance/supervision
####### TURNING AND
####### BED MOBILITY
####### Q2H: Encourage patient to reposition self. Q2H; Same as level V, plus encourage
####### patient to sit up in bed for meals.
####### Q2H: Same as level VI, plus encourage
####### patient to sit up in chair for meals.
####### Q2H: Same as level VII, plus encourage
####### patient mobilize as tolerated.
####### EXERCISE
####### PROGRAM 6 , 7
####### Bed exercise program should include
####### targeted lower limb, upper limb and
####### abdominal strengthening exercises in
####### supine as well as sitting balance
####### exercises. (See Appendix I&II)
####### Sitting exercise program should include
####### targeted lower limb, upper limb and
####### abdominal strengthening exercises in
####### sitting position, sit to stand exercises,
####### marching on the spot and standing
####### balance exercises. (See Appendix I&II)
####### Standing exercise program should include
####### targeted lower limb, upper limb exercises
####### as per level VI and ambulation. (See
####### Appendix I&II)
####### Stairs exercise program should include
####### targeted lower limb and upper limb
####### exercises as per level VII (See Appendix
####### I&II)
####### Consider inclusion of:
- Airway clearance techniques.
####### Additional exercise / mobilization as
####### indicated by PT assessment.
####### Consider inclusion of:
- Cycle ergometry
- Wheelchair mobility for wheelchair user.
####### Consider inclusion of:
- Closed kinetic chain or functional
####### strengthening exercises
####### Consider inclusion of:
- Treadmill training
####### Progress exercise duration/rep or train at
####### a target rate e. percentage of the
####### maximum load.
####### As per level V As per level V As per level V
####### MOBILIZATION Sitting balance exercises with physio as
####### appropriate, 5 to 10 minutes initially OD,
####### then progress to BID and increased
####### duration as tolerated.
####### Physio assesses ability to weight shift, and
####### walk. Initial duration in chair 30 minutes,
####### progress as indicated by OT/PT
####### assessment.
####### Physio assesses walking and outlines
####### walking program with appropriate aids.
####### Patient able to manage O2 tanks, tubes,
####### flow
####### Progress walking program with incline or
####### stairs.
####### Increasing time and/or frequency as
####### patient tolerates.
####### Ensure safe use of oxygen tank and
####### tubing.
####### Same as level V.
####### Patients with neuro/ortho status precluding
####### WB require individualized mobilization
####### prescription.
####### Progress walking time/distance or training
####### at a target rate e. Borg scale,
####### As per level VII
WHAT TO CONFIRM PRIOR TO DISCHARGE
Patient status, Home Services
####### D/C planning involves the patient/ friends/family/other caregivers where appropriate
####### General health status, nutrition, mental health, sleep hygiene, bodyweight, and need for
####### smoking cessation counselling has been assessed and deemed appropriate for D/C
####### Able to feed independently while sitting without undue fatigue
####### SpO2 > 88% during ambulation, with or without supplemental O
####### Assessed for home oxygen, under different conditions, and/or night-time mechanical
####### ventilation completed
####### Assessed for and set up with home health (PT, OT, SW, RN) and community supports if
####### indicated, and/or has been provided with info on this
####### Referred to pulmonary rehabilitation and physician follow-up appointment
Mobility
####### Update mobility/balance assessment to determine if patient is safe for D/C.
####### Prescribe mobility aids and/or hip protector if there is a fall risk.
####### Patient should be able to ambulate a distance in accordance with home and community needs
Education -- consistent information, in understandable terms, to patient and family
####### Written home activity/exercise plan provided
####### Inhaler technique, use of oral medications, use of supplemental O2 (including connections, flow
####### rates, use with gait aids, potential side effects
####### Action plan for management of future AECOPD
####### Patient has received education on self monitoring and self management of COPD (i. pacing,
####### airway clearance, breathing techniques, smoking cessation etc.
####### *SAFEMOB available at physicaltherapy.med.ubc/physical-therapy-knowledge-broker/safemob-project/
AECOPD-Mob developed by Dr. P. Camp, Dr. D. Reid, F. Chung, Dr. D. Brooks, Dr. D. Goodridge, Dr. D. Marciniuk, and A. Hoens. The project was supported by the Canadian Institutes of Health Research, the UBC Faculty ofMedicine Department of Physical Therapy, the Physiotherapy Association of British Columbia, Vancouver Coastal Health Research Institute, Providence Health Research Institute and the COPD Canada Patient Network.Contact: Dr. Pat Camp pat@hli.ubc June 2015 4/
