Abstract & Commentary
Strategies for Implementing an ICU Early Mobility Program: Lessons From Leaders in the Field
By Linda L. Chlan, RN, PhD, FAAN
Dean's Distinguished Professor of Symptom Management Research, The Ohio State University, College of Nursing
SYNOPSIS: Leaders in progressive mobility programs for ICU patients offer their lessons learned and strategies to overcome barriers to help establish these programs on any ICU, including an interdisciplinary team with staff champions to maintain these important programs.
- SOURCE: Engel HJ, et al. ICU early mobilization: From recommendation to implementation at three medical centers. Crit Care Med 2013;41: S69-S80.
A majority of ICU survivors experience weakness and impairments in cognitive,
psychological, and physical functioning. A number of research studies have been published over the past years documenting the positive benefits of early, progressive mobility interventions for ICU patients, including those receiving mechanical ventilatory support. These benefits include less overall weakness, shorter ICU stays, less incidence of delirium, and improved cognitive and functional outcomes. The challenge for many ICUs has been how to implement an early, progressive mobility program. This abstract will summarize the key points emphasized in this article.
The article authors are leaders in the field of progressive mobility in the ICU from Johns Hopkins Hospital, Wake Forest University, and the University of California, San Francisco. The Plan-Do-Study-Act Quality Improvement (QI) framework was used to describe each medical center’s progressive mobility programs.
• The Planning Phase is critical to get any QI project off the ground. All of the centers speak to the importance of an interdisciplinary team to begin planning the early mobility program. The inclusion of physical therapy is essential to establishing any progressive mobility program, as these professionals have the knowledge and skills needed for the interdisciplinary team. The minimum planning time reported by these programs was at least 1 year.
• The Doing Phase consists of data collection and analysis of both processes and outcomes that the unit desires as important QI indicators. Typical outcome measures include ventilator patient days, days until first out-of-bed experience, and ICU and hospital length of stay. It is imperative to gain widespread buy-in from all team and staff members, with support needed from administrators.
• Aspects of the Studying Phase need to allow for the consideration of barriers to the mobility program, as well as indicators of effectiveness, referrals to physical therapy, and cost effectiveness. Additional staff positions will be needed to safely and effectively establish and maintain any progressive mobility program. Regular meetings of the core interdisciplinary mobility team as well as regular updates for all staff are important aspects of this phase.
• The Acting Phase includes those strategies needed to sustain any new practice. This can be accomplished in a number of ways, including any necessary refinements to the protocol, frequent communication with staff, and standardization of the mobility program.
The authors include a daily mobility assessment and treatment algorithm that ICU clinicians may find useful to design and implement their own progressive mobility programs. Overall, the early mobility QI programs were found to be safe, with decreased ICU and hospital lengths of stay for a net cost savings.
Ever since the first evidence has emerged documenting the many benefits of progressive mobility for critically ill patients, ICU clinicians have been challenged to implement programs with their own patients. For many ICU clinicians, establishing and maintaining these programs can be daunting. The article by Engel and colleagues details how three leading medical centers established their progressive mobility QI programs. There is much for the reader to learn from these leaders, including what has worked in their respective ICUs and how those looking to establish a progressive mobility program can do so to meet the needs of their patients and staff members.
Common concerns of progressive mobility programs are patient safety and the risk for accidental extubation or removal of any invasive lines. Other concerns include enough manpower to implement progressive mobility, including ambulation of mechanically ventilated patients.
One of the most important contributions of this article is a presentation of barriers experienced and solutions surrounding their respective mobility QI projects. Identified barriers included a lack of leadership, staffing and equipment, knowledge and training, and physician referral for PT; over-sedation; delirium; patient hemodynamic intolerance of activity; and safety. Solutions presented included an interdisciplinary team, funding for additional staff, education and staff champions, alerts to physicians to order PT, education surrounding sedation practices, minimizing medications that promote delirium, protocols to promote patient tolerance for mobility, and interventions to promote safety such as close oversight of any IV and monitoring lines. These barriers and their solutions can be used by ICUs looking to establish their own progressive mobility programs to improve patient outcomes.