How mobility can shorten stay, improve outcomes

Organization started by defining mobility

Every now and then at Sunnybrook Health Sciences in Toronto, Canada, there was talk about getting ventilated patients up and about even if they were still intubated. Some people thought that the patients should be weaned off the ventilator first, some thought after, says Linda Nusdorfer, RN, MSN, an advanced practice nurse for critical care and cardiovascular care at the facility. Still others wanted to work on weaning and mobility at the same time. But what did mobility mean? Is it passive range of motion exercises or walking?

"We would have these quality walkabouts every month, and once, we spent it asking nurses for the definition of mobility," she explains. "One of the answers was that it was using a lift to put a patient in the chair."

The idea of improving mobility — and the way caregivers thought of it — burbled along without resolution until 2011, when Nusdorfer and her colleague Angie Jeffs, RN, MSN, the patient care manager for critical and cardiac care, attended an Institute for Healthcare Improvement conference. "It was inspiring," Jeffs says. "When we were trained in the 1980s, we were taught to sedate ICU patients as much as possible. We were told they wouldn't want to remember they were here, and besides we should rest their lungs."

The IHI conference gave the women and the others from Sunnybrook added information and the confidence they needed to try to do something different — to get the patients up and moving as soon as possible. The potential benefits included less time being intubated, less delirium, reduced DVT risk, less potential for bed sores, and better patient and family satisfaction. "The families like to see the progress," Nusdorfer says. "The patients like to be up and around." Although there is not proof yet, she thinks they may even have a reduced rate of ventilator-associated pneumonia (VAP) because the patients spend less time horizontal, less time intubated, and have a greater degree of muscle strength that helps them clear their lungs.

Once they got back to Sunnybrook, Jeffs says they were a little overwhelmed with how to convince their peers that this was a good idea. "We chose our first candidates carefully, to make sure that they were stable," she says. "But we saw at the conference that this could be done, so we moved forward."

Two nurses, a physical therapist, a respiratory therapist, and Jeffs and Nusdorfer met regularly and started to go out as a team to identify likely candidates. "We talked to the physicians on rounds about getting people up, as well as other nurses and therapists." While the physicians were all for it, there was resistance from some nurses and therapists. "They wanted to take it slowly," Nusdorfer says.

For instance, there might be a patient in a collar who a physicians says can tolerate mobility, but somehow, it would never get done, Nusdorfer says. "PT would have to take the bull by the horns and just get that patient up." Or a patient would be up in a chair, and the nurses would argue that they were mobile, but they were being lifted into the chair mechanically. They were not using their own muscle power to do anything.

Leading by example

Having a nurse manager there to help with education was key in convincing recalcitrant people to take this chance. "We led by example," Nusdorfer says. "And then, once they saw it could be done, and the benefits that accrued to the patients, they were much more interested in getting on board." They also noted successes in a very public way — taking pictures of walking patients, celebrating the first walk down the hall, or even sitting up in a chair for the first time. They take videos of patients, and every couple months when a new batch of residents cycles through the ICU, they do an in-service education module to dismiss the myth that ventilated patients can't be mobilized.

Whenever anyone suggested that they were willing, if only there was a team that could put the idea into place, Nusdorfer informed those staff members that they were the team. "They had the best knowledge of the patient, not some group of outsiders. They were best placed to coordinate this."

Not just any patient is pulled out of bed for a saunter through the ward. Nusdorfer says they use a safe mobility tool to assess the level of consciousness in a patient, which helps determine the level of activity appropriate for the patient. It might be that one patient can dangle but isn't ready to sit in a chair, while another one, who is so soon out of surgery you don't think he or she would want to do anything but moan in bed, is raring to get up and move.

There is a database collecting pertinent information, including when is the patient medically stable, whether the patient was mobilized within 24 hours of admission or of being deemed medically stable (the definition of early mobilization), intubation data, mode of ventilation, how much oxygen the patient was on at the time of early mobility, progression of mobility from passive range of motion to walking. They look at the resources used when walking — one nurse, two nurses, PT, RT, aide, family member, any tube losses during mobilization (to date there have been none). They are looking at whether there were any pressure ulcers at admission and on discharge, delirium rates, sedation, and restraint use.

Jeffs says a year ago, a delirious patient would have been restrained. Now, the first thing they do is get them up and moving. "The staff really sees the benefits of that." She also says they note how much more alert patients get just from sitting up. "All of a sudden their eyes get wide. It's almost like there is this synapse [that] wasn't connecting, and now it's on by helping them move." They notice, too, that the patients who are moving more are sleeping better and move more easily back into a regular routine.

Nusdorfer says they are doing a chart review now of a period from before they implemented the early mobilization program about 15 months ago so that they can compare things like pressure ulcer rates.

"Our slogan is 'Time is Muscle,'" she says. "You hear it as a cardiac phrase, but we should remember it's true for all muscle in the hospital."

For more information on this topic, contact:

  • Linda Nusdorfer, RN, MSN, advanced practice nurse, critical and cardiac care, Sunnybrook Health Sciences Center, Toronto, Canada. Email: Linda.nusdorfer@sunnybrook.ca. Telephone: (416) 480-4040.
  • Angie Jeffs, RN, MSN, patient care manager, critical and cardiac care, Sunnybrook Health Sciences Center, Toronto, Canada. Email: Angie.jeffs@sunnybrook.ca