Early Mobilization

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.

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.

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.

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.

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

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.

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.

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, versus standard care only. At the time of discharge from the hospital they compared the outcomes of 6-min walk tests. Here, the intervention patients covered a median of 196 metres in 6 minutes, versus median 143 metres 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.

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.

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.

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.

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