The Importance of Early Mobility in the ICU

Susanne Worden, PT, MS

Historically, ICU patients were thought to be in too much pain or too sick to be awakened while on mechanical ventilation. As a result, immobile patients were not moved by the healthcare team. It was common for patients to remain unconscious for days or weeks at a time with only sporadic intervention by Physical or Occupational Therapists (PT/OT).
Some neuromuscular complications are frequently overlooked or even misdiagnosed, which can cause impaired patient function due to respiratory distress even up to five years after an ICU stay. Changes occurring at the cellular level impact a patient’s neuromuscular function, causing difficulty with generalized weakness, independent breathing, movement, and higher level functions.1
As recently as 2003, critical care physicians and other ICU team members began looking at the long-term outcomes for patients who required an ICU stay.2 In a meta-analysis of multiple studies, it was noted that there was a decreased quality of life—especially in physical function.3
The terms Critical Illness Polyneuropathy and, more commonly, Intensive Care Unit-Acquired Weakness (ICUAW) were coined as early as 1986.4 This began the inclusion of rehabilitation therapists in the care of ICU patients, and their increased recognition meant they were included in identifying and managing the restoration of function and mitigating the deficits associated with an ICU stay.5

Current ICU Trends

A Society of Critical Care Medicine study noted that 5.7 million ICU admissions occur annually in the U.S.— mainly for respiratory failure, post-surgical care, heart disease, sepsis, and heart failure. Of those, 1.8 million are older adults, who are at higher risk for greater deficits upon discharge and who are predicted to suffer poorer outcomes.5
Many complications and conditions may occur in the ICU, including ICUAW, where neuromuscular recovery lags behind other organ system recovery.6 ICUAW can cause impaired cognition; difficulty dressing, eating, and rising from bed; shortness of breath; and fatigue.
Acute Respiratory Distress Syndrome (ARDS) is also common in the ICU, and the cause is frequently pulmonary sepsis. ARDS patients have fewer ventilation–free days and longer ICU stays with reduced long-term survival rates. ARDS occurs in 2.5 to 19 percent of the ICU population with a mortality rate of 23-72 percent (dependent on study population).7
Delirium occurs in up to 80 percent of ICU patients. The subtypes are: hyperactive (an agitated state); hypoactive (a sleepy state); and mixed hyper- and hypo-active delirium. It usually occurs by day two of an ICU stay, with a duration of at least four days. Up to 50 percent of ARDS patients are delirious in the ICU and 10 percent at discharge.8

Importance of Early Mobilization

In a five-center international research study, a randomized group of surgical ICU patients received early goal-directed mobilization, while the control group was given usual care. At discharge, 52 percent of those patients who received early goal-directed mobilization and PT were walking, versus 25 percent of patients who received usual care. Patients who received early mobilization and PT began therapy within 48 hours of intubation, while the control group waited 6-14 days.9
In the Johns Hopkins QI project (2010), patients received improved care in the ICU, including: PT/OT five times per week; sedation provided only as PRN bolus rather than infusion; and consults with Physical Medicine and Rehabilitation or Neurology as needed. As a result, patients involved were more alert, less delirious, had lower pain scores, and had decreased ICU and hospital stays.10 Across studies performed, there were some rare adverse events that caused rehabilitation to stop: endotracheal tube removal without replacement; a fall; blood pressure changes; and desaturation (decreased blood oxygen).11 Falls in the ICU are of great concern, especially when early mobilization is initiated. Despite the acknowledged negative effects of immobility and literature supporting early mobility, mobilizing ICU patients (especially on mechanical ventilation) remains uncommon.12 However, mobilization in the ICU is safe when performed by nurses, PT/OT, and even trained family members. In a systematic review of 48 publications of 5,972 critically ill adults, there were only 11 occurrences of falls during 16,342 mobility and/or rehab sessions.13

Bedside Moility Assesment Tool (BMAT)

Level 1
Max Assist
Task:
Get up to sit and shake while sitting
Equipment:
  • 2-person assist
  • Bedside lift and sling
  • Air Transfer Device
Level 2
Mod Assist
Task:
Stretch and point foot in sitting
Equipment:
  • Bedside lift and sling
  • Sit-to-stand device
Level 3
Mod Assist
Task:
Sit to stand and balance
Equipment:
  • Sit-to-stand device
  • Ambulation aid (i.e. walker, wheelchair)
Level 4
Min Assist to independent
Task:
Walk with or without device
Reassess as necessary
Equipment:
  • Walker/cane
  • No device

Updated Hospital and ICU Protocols

Many hospital ICU protocols have been updated to include the “sedation vacation.” Delirium is associated with prolonged ICU stays, especially with sedation. New sedation protocols include the daily stopping of PRN and infusion sedation medications. Reduction in sedation promotes improved awake time without delirium, allowing patient to follow directions for daily care and therapy and to interact with family and caregivers.14 The Confusion Assessment Method for the ICU (CAM-ICU) is a valid test for delirium that can be administered each shift to monitor changes in confusion occurring throughout the day and night.16
Utilization of the ABCDEF Bundle in ICU patient care is increasing across the country. This protocol is considered Best Practice and assists professional staff in managing their ICU patients while maximizing the patient outcomes.
ABCDEF stands for:

  • Assess, Prevent, and Manage Pain
  • Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
  • Choice of analgesia and sedation
  • Delirium: Assess, Prevent, and Manage
  • Early mobility and Exercise
  • Family engagement and empowerment15

Nursing and Rehab Therapy Methods for Early Mobilization

Assessment using a tool such as the Bedside Mobility Assessment Test (BMAT) will reveal the baseline and level of function at which to begin. Interventions for slowly increasing tolerance for upright positioning include tilt beds, tilt tables, tilt stretchers, bed mobility, elevation of the head of the bed, sitting at the edge of the bed, transfers to a chair, and standing and ambulation with and without aids (see above). Caregivers can combine regular treatments with activities, such as range of motion (ROM) of extremities while bathing.
PTs/OTs are trained to closely monitor clinical changes in the patient to ensure safety. Training for ICU therapists also includes ventilation modes and tubes and lines of concern. This allows even the most complicated ECMO patients to be safely mobilized.

Outcome measures
To assess an ICU Mobility Program

  • Physical function
  • Pulmonary function
  • Six minute walk test
  • Quality of life evaluation
  • Pain assessment
  • Mini-mental assessment

Language of the icu

ARDS: Acute Respiratory Distress Syndrome
CICU: Cardiac Intensive Care Unit
Critical Care: Multidisciplinary healthcare specialty for patients with acute, life-threatening illness or injury
Delirium: Abrupt onset of inattention and other cognitive signs experienced by patients on medications that cause unconsciousness or lack of awareness
ICU: Intensive Care Unit
ICUAW: ICU-acquired weakness Mechanical Ventilation: Breathing support for patients unable to breath easily on their own
NICU: Neurological Intensive Care Unit or Neonatal Intensive Care Unit
PICU: Pediatric Intensive Care Unit
Speaking Valve: Device placed in the trach tube to allow patient to use their voice while on mechanical ventilation
Tracheostomy: A hole and tube placed into the patient’s trachea for comfort and ease of breathing
Weaning: Act of gradually removing patient from mechanical ventilation

Conclusion

The overarching goal of early mobility in the ICU is to improve quality of life through higher levels of function and improved cognition throughout the hospital stay and onto discharge. With increased patient activity levels, there have been decreases in hospital-associated complications. Muscle atrophy/ weakness has been minimized resulting in earlier return to functional activities, decreases in length of stay, and improved care requirements at discharge.

Resources for implementation of early mobility programs

Search online for:

  • AHRQ Early Mobility Guide
  • Johns Hopkins OACIS Group
  • Johns Hopkins Improving Long-Term Outcomes
  • Helping ICUs Implement ABCDE Bundle

About the Author

Susanne Worden, PT, MS
Sue Worden is a Sizewise Clinical Liaison, a certified Physical Therapist, and has more than 30 years’ experience in patient care.

References:
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