This website uses cookies. By using the website you agree to our cookie policy. You can change your cookie settings in your browser.Find out more

Early Mobilization - Early mobilization ICU

Early Mobilization

Ask your specialist

Mobilize your patients, improve your outcomes

Traditionally, every patient admitted to an ICU is immediately put on enforced bed rest. Research now shows that bed rest can have adverse effects on muscles and organs, which can impair neuropsychological functions and reduce movement capacity. As a result, the concept of 'early mobilization' (EM) in the ICU is attracting considerable attention. Early mobilization can lead to the following patient benefits:

  • Decrease in delirium1
  • More ventilator-free days
  • Reduced length of ICU stay and care costs2,3
  • Improved independent functional status at hospital discharge1

Proven facts: Benefits of early mobilization

Early Mobilization - Dräger

Early Mobilization - Dräger

Early mobilization is an intervention which has shown to prevent ICU acquired weakness.

A breath ahead

Improving Outcome with Early Mobilization

Earn 1 free CRCE contact hour by watching our presentation on Early mobilization and ICU acquired weakness. Carl Hinkson explores early mobilization as an intervention to prevent extreme muscle weakness from prolonged hospital bed rest.

Feature presentation

Hurdles to overcome

Patient-related barriers

The physical conditions of patients in the ICU – especially hemodynamic instability, a reduced level of consciousness, and respiratory instability – frequently prevent caregivers from mobilizing their patients. Staff education has proven to be an effective strategy to address these barriers, which are sometimes only perceived.

That's why understanding exclusion criteria, guidelines, and screening is crucial.


* Dafoe S et al., Inter. 2015;13:2.

* Dubb R et al., Ann Am Thorac Soc. 2016;13:724-30.

* Engel HJ et al., Crit Care Med. 2013 Sep;41(9 Suppl 1):S69-80.

Limited staff/time contraints

Early mobilization requires time with the patient and a dedicated, well-trained staff. If either of these is in scarce supply, EM will be much harder to implement. By reducing length of ICU and hospital stays, EM reduces costs of care.

Pilot quality improvement projects are a good start to prove the benefits of EM to your organization.
 

* Appleton RTD et al., J Intensive Care Soc. 2011;12:221-7.

* Koo KK et al., CMAJ. Open 2016;4:E448-54.

* Engel HJ et al., Crit Care Med. 2013 Sep;41(9 Suppl 1):S69-80.

Cultural and structural barriers

According to a 2015 study, the most important barriers include the lack of a 'mobility culture' - which means that early mobility is not seen as a priority. There is inadequate staff buy-in to shoulder the workload, as well as a lack of a multidisciplinary culture, staff knowledge and support, and expertise about the benefits of mobility.

Start with a pilot project that would include, for example, an interdisciplinary team with an overall physician leader to get the 'mobility' mindset going.

 

* Dubb R et al., Ann Am Thorac Soc. 2016;13:724-30.

* Engel HJ et al., Crit Care Med. 2013 Sep;41(9 Suppl 1):S69-80.

Patient safety

A key barrier in the delivery of early mobilization seems to be the concern about patient safety. ICU patients are attached to a variety of devices via a multitude of connections, vascular lines, nasogastric tubes, urinary catheters and ventilator airways. Health care professionals report fears of accidentally loosening or severing these connections when mobilizing their patients.

Start with a step-by-step mobility plan that includes defining responsibilities, with an emphasis on untangling lines before therapy and use of portable monitors.

 

* Hodgson CL et al., Crit Care. 2013;17:207.

* Engel HJ et al., Crit Care Med. 2013 Sep;41(9 Suppl 1):S69-80.

Obesity

Some obese patients may require additional resources during early mobilization activities, such as additional staff and extra devices for support and balance. These patients might feel more discouraged or reluctant to participate in mobilization activities. Additionally, concerns have been voiced regarding the possible effects of EM on their respiratory and hemodynamic parameters.

Protocols, guidelines and screening strategies can help you overcome these hurdles.

 

* ICU Management & Practice 2009/2010, ICU Volume 9; 4

Respiratory distress/ventilator asynchrony

Patient ventilator asynchrony leads to agitation, discomfort, prolonged ventilation – and prevents the process of early mobilization.

Synchronous ventilation is a precondition for patient comfort. It improves sleep quality and enables mobilization activities.

 

* Thille, A. et al., Patient-Ventilator Asynchrony during Assisted Mechanical Ventilation. Intensive Care Medicine 32, Nr. 10 (29. September 2006):1515–22. doi:10.1007/s00134-006-0301-8.

Early mobilization: development, opportunities and challenges

Clinicians assisting with early mobilization

'Early mobilization should be a quality indicator all over the world'

An interview with Carsten Hermes, health care consultant, specialized nurse for anesthesia and intensive care and health business graduate.

Download interview

Clinical evidence on early mobilization

Read the following studies and reviews to learn how the concept of early mobilization improves various clinical and economic outcomes.

Improved independent functional status at hospital discharge

A randomized controlled trial published in the Lancet in 2009 included 104 ICU patients on mechanical ventilation. The trial assessed the efficiency of combining daily interruption of sedation with physical and occupational therapy on various outcomes. 59 percent of the intervention patients returned to independent functional status at hospital discharge. During the 28-day follow-up, patients in the intervention group also experienced half as many days of delirium (median 2.0 vs. 4.0 days), and more ventilator-free days (23.5 vs. 21.1 days) than did controls. The authors conclude that this strategy was "safe and well-tolerated and resulted in overall better functional outcomes at discharge."

 

* Schweickert WD et al., Lancet. 2009;3731874-82.

Significantly better physical function and increased muscle strength

A more recent review by Taito et al quoting the Lancet article as a “landmark study” points to another investigation. 90 mechanically ventilated patients underwent either a 20-minute session of bicycle ergometer exercise daily, 5 days per week, in addition to standard care, or standard care only. Here, the intervention patients covered a median of 196 miles in 6 minutes, versus median 143 miles of the controls. They also had a significantly better physical function as well as significantly increased quadriceps and femoral strength.

 

* Taito S et al., Intensive Care. 2016;4:50.

* Burtin C et al., Crit Care Med. 2009;37:2499-2505.

Improved sedation and delirium status

Researchers at Johns Hopkins University report on a “quality improvement project” which included hiring physical and occupational therapists to treat 57 patients (ventilated ≥4 days) in an ‘early intervention’ scheme. The intervention patients showed a markedly decreased use of benzodiazepines and an improved sedation and delirium status. In addition, administrative data demonstrated a decrease in length of hospital stay (LOS) on the ICU and in the hospital by 2.1 and 3.1 days, respectively.

 

* Needham DM et al., Arch Phys Med Rehabil. 2010;91:536-42.

Reduced risk of readmission or death, and a fewer cases of ventilator-assisted pneumonia as well as central line and catheter infections

This research study analyzed five electronic databases with 26 articles focused on the effects of EM on the LOS, cost of care, and medical complications. In this paper, EM suggested a decrease in delirium by 2 days, a reduced risk of readmission or death, and a fewer cases of ventilator-assisted pneumonia as well as central line and catheter infections. LOS in the ICU was reduced “with statistical significance”, and total costs were decreased. The authors call for EM to become a “standard of care for critically ill but stable patients in the ICU.”

 

* Hunter A et al., Health Care Manag (Frederick). 2014;33:128-35.

Mobility study shows nearly 20% reduced length of stay and decreased average cost per day in ICU

A study investigating early mobility in ventilated and non-ventilated ICU patients found that early mobility reduced LOS by almost 20%, increased the percentage of patients discharged home without further services, and decreased the average cost per day in the ICU – resulting in annualized net cost savings of $1.5 million.

According to a prospective trial of 330 ICU patients, early rehabilitation vs. usual care is associated with a shorter adjusted ICU and hospital LOS, translating to lower mean costs per patient: $41,142 versus $44,302. The authors also showed that total costs were reduced even after accounting for the additional cost associated with implementing the mobility team for the intervention group2.
 

* Corcoran JR et al., PM R. 2017;9:113-9.

* Morris PE et al., Crit Care Med. 2008;36:2238-43.

Earlier participation in early mobilization through automated weaning

A Cochrane Review of 10 trials compared automated weaning and SBT systems (the machine automatically performs ‘spontaneous breathing trials’) with non-automated weaning strategies. They found that automated weaning and SBT systems significantly decreased weaning time, time to successful extubation, ICU stay and proportions of patients receiving ventilation for longer than 7 / 21 days.

 

* Burns KEA et al., Cochrane Database Syst Rev. 2014 Sep 9; (9):CD008638. doi: 10.1002/14651858.CD008638.pub2

early mobilization literatures

Literature list

Clinical studies, cases and reviews

Download list

Our solutions for early mobilization

At Dräger, we recognize that early mobilization is about interdisciplinary teamwork and that no single voice or solution will completely remove all barriers. With our efforts and enabling technology, we join this common aspiration and are optimistic to be on the right path in the journey towards improving acute care.

Get in Touch With Dräger

Contact-us Hospital

Draeger Medical Canada Inc.

2425 Skymark Ave, Unit 1
Mississauga, ON L4W 4Y6

+1 866-343-2273

Call us from 8 am - 5 pm (ET), Monday - Friday

Sources

Schweickert, W.D. et al., Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial.

Lord, R.K. et al., ICU early physical rehabilitation programs: financial modeling of cost savings.

Morris, P.E. et al., Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure.