Early Mobilization In the Intensive Care Setting Lauren Wesson-Stout University of South Florida, College of Nursing

Objectives Define early mobilization within the intensive care setting Identify benefits of early mobilization Discuss current evidence-based research supporting the use of early mobilization in the ICU

What is early mobilization? Getting patients moving! Includes sitting, moving to a chair, ambulating, and AROM and PROM exercises based on patient status Evaluate patients individually to determine if they are stable for mobilization

Risks of Immobility Increased length of hospital stay Increased mortality Increased muscle atrophy Increased risk of aspiration Increased rate of return to ICU

Benefits of Early Mobilization Improved functional independence Reduced ICU delirium Reduced duration of mechanical ventilation Reduced ICU (and hospital) length of stay Improved walk distance Improved muscle strength

Goals of Mobility for TGH Reduce bounceback Patients should be out of bed before transfer to floor Patient should maintain pre-hospital mobility Prevent pressure ulcers

Patient Data Inconsistent over the months – some there are multiple pts out of bed, some very few. What are the reasons for noncompliance?

Perceived Barriers Lack of understanding of mobility benefits Patient status Resources

Early Progressive Mobility Protocol – Step One Evaluation of patient – if they meet these requirements, move to step 2.

Early Progressive Mobility Protocol – Step Two

Resource Solutions Interdisciplinary Involvement Physician Groups Respiratory Therapy Physical Therapy Lift Team Patient Care Technicians Physician – activity level ordered RT – vented pts PT – mobility people! Machinery/equipment Lift – help with sitting up PCT – help with ambulating/assistance

Mobility Technician (MT) Turn patients every two hours Responsible for PROM exercise Ambulate stable patients Tech is with lift team during rounds – available to help pts

Delegation Level 1 Level 2 Level 3 Level 4 Passive ROM – MT Turn every 2 hours – Lift Team/MT Level 2 Active resistance exercise – PT Sitting position for 20 minutes – Lift Team/MT Level 3 Active transfer to chair – PT/MT/RT Level 4 Stand at bedside – PT/MT/RT Ambulating in hallway – PT/MT/RT Nurse is involved in all levels – these represent the assistance available to the RN

Evaluation Audit – can be performed by mobility tech/RN on staff. Ask each room if OOB for the day (or if pt didn’t meet mobilization requirements)

References and Research Bourdin, G., Barbier, J., Burlem, J., Durante, G., Passant, S., Vincent, B., Badet, M., & Guerin, C. (2010). The feasibility of early physical activity in intensive care unit patients: a prospective observational one- center study. Respiratory Care, 55(4), 400-407. Retrieved from http://rc.rcjournal.com/content/55/4/400.short Clark, D., Lowman, J., Griffin, R., Matthews, H., & Reiff, D. (2013). Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study. American Physical Therapy Association, 93(2), 186-196. doi: 10.2522/​ptj.20110417 Engel, H., Needham, D., Morris, P., & Gropper, M. (2013). Icu early mobilization: from recommendation to implementation at three medical centers. Critical Care Medicine, 41. doi: 10.1097/CCM.0b013e3182a240d5 Hopkins, R. (2010). Early activity in the icu: beyond safety and feasibility. Respiratory Care, 55(4), 481-484. Retrieved from http://rc.rcjournal.com/content/55/4/481.short

Leditschke, I. , Green, M. , Irvine, J. , Bissett, B. , & Mitchell, I Leditschke, I., Green, M., Irvine, J., Bissett, B., & Mitchell, I. (2012). What are the barriers to mobilizing intensive care patients?. Cardiopulmonary Physical Therapy Journal, 23(1), 26-29. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3286497/ Mah, J., Staff, I., Fichandler, D., & Butler, K. (2012). Resource-efficient mobilization programs in the intensive care unit: who stands to win?. The American Journal of Surgery, 206(4), 488-493. doi: 10.1016/j.amjsurg.2013.03.001 Meyer, M., Stanislaus, A., Lee, J., Waak, K., Ryan, C., Saxena, R., Ball, S., & Eikermann, M. (2013). Surgical intensive care unit optimal mobilisation score (soms) trial: a protocol for an international, multicentre, randomised controlled trial focused on goal-directed early mobilisation of surgical icu patients. BMJ Open, 3(8). doi: 10.1136/bmjopen-2013- 003262 Morris, P., Goad, A., Thompson, C., Taylor, K., Harry, B., Passmore, L., Ross, A., & Haponik, E. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine, 36(8), 2238-43. doi: 10.1097/CCM.0b013e318180b90e Pires-Neto, R., Kawaguchi, Y., Hirota, A., Fu, C., Tanaka, C., Caruso, P., Park, M., & Carvalho, C. (2013). Very early passive cycling exercise in mechanically ventilated critically ill patients: physiological and safety aspects - a case series. PLoS One, 8(9). doi: 10.1371/journal.pone.0074182 Schweickert, W., & Kress, J. (2011). Implementing early mobilization interventions in mechanically ventilated patients in the icu. Chest, 140(6), 1612-17. doi: 10.1378/chest.10-2829

Schweickert, W. , Pohlman, M. , Pholman, A. , Nigos, C. , Pawlik, A Schweickert, W., Pohlman, M., Pholman, A., Nigos, C., Pawlik, A., Esbrook, C., Spears, L., & Kress, J. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. The Lancet, 373(9678), 1874-82. doi: 10.1016/S0140-6736(09)60658-9 Zomorodi, M., Topley, D., & McAnaw, M. (2012). Developing a mobility protocol for early mobilization of patients in a surgical/trauma icu. Critical Care Research and Practice. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3539434/