special feature

Successful Implementation of an Early Mobility Protocol in Critical Care

By James E. McFeely, MD, Medical Director Critical Care Units, Alta Bates Summit Medical Center, Berkeley, CA, is Associate Editor for Critical Care Alert.

Dr. McFeely reports no financial relationships relevant to this field of study.

Things done well and with a care, exempt themselves from fear.

— Henry VIII, Act 1, Scene 2

Patients who survive admission to the ICU often are left with long-term disabilities resulting both from their presenting illness and from the care they receive while there. For example, patients with acute respiratory distress syndrome (ARDS) have persistent exercise limitations and a reduced physical quality of life 5 years after their critical illness, despite having near normal pulmonary function.1 Up to 50% of patients with prolonged ventilation, sepsis, or multiple organ systems failure develop neuromuscular dysfunction.2 This weakness is independently associated with hospital mortality.3 Severe sepsis in older patients is independently associated with substantial and persistent new cognitive impairment and functional disability among survivors.4 The ICU cultural preference for immobility, coupled with excessive use of sedation, is leaving patients with long-term disabilities.

Successful implementation of an early mobility protocol, with its associated improvement in sedation and delirium management practices, can improve these outcomes. In a retrospective study of 280 patients with respiratory failure, lack of early mobilization was independently associated with higher rates of readmission and death.5 In one well-executed, randomized trial of 100 mechanically ventilated patients, those who received early mobilization — physical therapy (PT) started on average 1.4 days after intubation vs 7.4 days — had fewer days of delirium and fewer days on mechanical ventilation.6 At the time of hospital discharge, 59% of the early mobility group were back to independent function as opposed to 35% of the control group.6

Successful implementation of a mobility protocol requires a cultural shift in ICU care.7 Mobility has to be considered as important a therapeutic modality as ventilation bundles, nutritional support, skin care, and all the other outcome variables with which we now concern ourselves. Early mobility needs to be the rule rather than the exception. This cultural shift will be difficult. The preference of many senior staff for immobility and sedation, based on reasons of "safety," needs to evolve to a preference for mobility and alertness. We need to educate staff to understand that it is unsafe to oversedate patients, and that immobility harms them and leaves long-lasting disability.

Such cultural change requires a team of believers. ICU mobility is a multidisciplinary process and needs a champion from each involved discipline. At a minimum a physician, nurse, PT, and respiratory therapist (RT) champion are needed. These individuals will hopefully have enough gravitas to influence the behavior of others. In addition, some low-tech hardware — including a platform walker, seat cushions, eye shades, and ear plugs to facilitate sleep — is needed. Initially, the incremental additional PT and RT time can be absorbed by existing staff; but an early mobility protocol may require an additional full-time PT, especially if successful in a large unit. The goal should be to have 60-80% of ICU patients receiving PT daily.

There are patients for whom mobility is contraindicated (see Table 1). For all others, early mobility should be the default. The early mobility process goes through stages (see Table 2). Other than the PT time, no additional resources are needed until the point of sitting at the edge of the bed.

Table 1. Contraindications to Early Mobility

• Significant vasopressor requirement

• FIO2 > 0.8; PEEP > 12 cm H2O; worsening respiratory failure

• Use of paralytics

• Acute neurologic event (reassess daily)

• Unstable spine or extremities

• Comfort care status

• Femoral dialysis catheter

• Open abdominal wounds

• Unresponsiveness (reassess sedation orders)


Table 2. Stages of Mobilization

• Detangle all lines and tubes

• Range of motion in bed

• Sitting at the edge of the bed

• Assisted sit to stand (more RT time needed from here)

• Walking in place

• Walking in unit

The major barrier to early mobility is excess sedation.8 Commonly, patients are sedated excessively at night, and then are unable to participate in activities during the day. To avoid this, an ICU committed to early mobility will make use of daily sedation vacations, lightened goals of sedation, and real-time feedback to staff when patients are unable to participate due to sedation. Facilitating sleep through environmental modifications, medication optimization, and minimization of patient care interruptions can help avoid delirium. Treating delirium with appropriate medications, rather than silencing delirium through sedation, will also help.

Other barriers to successful implementation exist (see Table 3). These barriers can be overcome in a variety of ways. The default activity level for ICU patients must become "as tolerated" rather than bed rest. Sedation goals need to default to alert, with Richmond Agitation Sedation Scale (RASS) = 0 rather than moderately sedated (RASS = -2). Physical therapy orders need to go in at the time of admission, not as an afterthought on week 2 of the ICU stay.

Table 3. Barriers to Early Mobilization

Provider Barriers Solutions
Knowledge Education; promotion
Fearful attitude Start small; evolution
Patient sedation Treat pain and delirium; minimize sedation
Culture of immobility Find your champions
Unfamiliar professions Learn to speak their language

Administrators who balk at requests for additional resources will respond to decreased length-of-stay data and decreases in mechanical ventilation days. Management can facilitate having consistent staff in the ICU for improved continuity and team building. Fearful staff can be won over by education from peers who speak their clinical language and by early "wins" by the team of believers.

For example, a common fear is that tubes will fall out during the mobilization process. This has been studied repeatedly and simply does not happen with any significant frequency (≤ 1%).9 Having a previously critically ill ventilated patient walk through the ICU under her own power on the way home sends a powerful message of positive feedback to resistant staff. Linking improved outcomes to changes in culture is the fastest way to change behavior.

Early mobility for ICU patients is the right thing to do. While there are formidable barriers to successful implementation, the improved patient outcomes that result make it well worth the challenge.

References

  1. Herridge MS, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011;364:1293-1304.
  2. Stevens RD, et al. Neuromuscular dysfunction acquired in critical illness: A systematic review. Intensive Care Med 2007;33:1876-1891.
  3. Ali NA, et al. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med 2008; 178:261-268.
  4. Iwashyna TJ, et al. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010; 304:1787-1794.
  5. Morris PE, et al. Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci 2011;341:373-377.
  6. Schweickert WD, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet 2009;373:1874-1882.
  7. Bailey PP, et al. Culture of early mobility in mechanically ventilated patients. Crit Care Med 2009;37(10 Suppl):S429-S435.
  8. Needham DM, Korupolu R. Rehabilitation quality improvement in an intensive care unit setting: Implementation of a quality improvement model. Top Stroke Rehabil 2010;17:271-281.
  9. Pohlman MC, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med 2010;38:2089-2094.