Early Mobilization in the Acute Care Setting

How can we better assist our patients?

TIRR Memorial Hermann Neurologic Physical Therapy Residency

Ann Valentine, PT, DPT

Objectives

Discuss current practice and investigate why current interventions/limitations with activity exist.

Explore common impairments that occur with prolonged bedrest and prolonged Intensive Care Unit (ICU) stays.

Define Early Mobilization.

Discuss the benefits of Early Mobilization.

Review an Early Mobilization Protocol.

Discuss Further Considerations with Early Mobilization in the ICU.

Current practice in many hospitals

We’ve come a long way but more improvements can be made.1

Delayed initiation of physical therapy 1

Infrequent treatments in the ICU

Once PT is initiated bed therapeutic exercise is usually the first intervention6,7

Barriers to Early Mobilization 2,3,7

Psychosocial barriers

Comorbidities

Advanced age

Physiologic instability

ICU environment

Limited Evidence

Impairments seen with prolonged bedrest 2-6

Increased respiratory dysfunction

Impaired strength

Physiologic impairments

Increased risk for skin breakdown

Decreased quality of life

Prolonged hospital stays with mechanical ventilation

DECREASED FUNCTION! 3, 6-7

Increased morbidity/mortality

Increased cost of care

Increased length of stay

Respiratory muscle weakness and increased duration of ventilation

Sleep deprivation

Lack of social interaction

Prolonged sedation

Delirium

Inactive & Alone: Physical Activity Within the First 14 days of Acute

Stroke Unit Care 1

Inactive & Alone: Physical Activity Within the First 14 days of Acute

Stroke Unit Care 1

Inactive & Alone: Physical Activity Within the First 14 days of Acute

Stroke Unit Care 1

What is Early Mobilization? 6

The initiation of mobility when a patient is minimally able to participle, presents with hemodynamic stability and the patient receives acceptable levels of oxygen.

Benefits of Early Mobilization 2,

4-8

Improved respiratory function

Maintains strength and joint range of motion

Fewer physiologic impairments

Repositioning allows for other interventions

Improved quality of life

Initiating an Early Mobilization Protocol

What is needed to start an Early Mobilization Protocol?

Multidisciplinary involvement is crucial!

A thorough initial physical therapy evaluation

An individualized plan of care

Appropriate goals that meet patient’s values are needed

Determine what phase of the Early Mobilization Program the patient is starting in.

Initiating an early mobilization protocol for mechanically

ventilated patients 6,7

Heart rate <130 beats per minute

Mean arterial pressure: 60-100 mm Hg,

FiO2:<60%

PEEP ≤10 cm H2O

SpO2 > 88%

Phase 1

Patient presentation: considerable weakness, limited activity tolerance, occasional altered mental status, minimally participate in therapy and are unable to ambulate.

15-30 minute treatments

Goal: to start mobilization as soon as the patient is medically stable.

Progression: bed ther ex rolling sitting balance standing with a walker and assistance

Further Treatment Options for Phase 1 2

Tilt table with arms supported for 10-30 minutes

Standing Frame

Chair sitting

Phase 2

Includes patients that have the strength to perform standing activities with a walker and assistance.

Goal: to start walking re-education and functional training

Progression: weight shift steps in place side steps along the EOB chair transfer using a walker and assistance

Phase 3

Includes patients that can tolerate ambulation with a walker and assistance for a short distance.

Goal: Master transfer training and increase endurance.

Phase 4 6

Includes patients that are no longer on a ventilator and/or have been transferred out of the ICU.

Goal: functional training

Ultimate goal: Promote maximum independence by discharge.

Further Considerations with Early Mobilization 2,3,7

ALWAYS USE YOUR CLINICAL JUDGEMENT

Other Interventions: e-stim, UE exercise, inspiratory muscle training

Transitions back and forth between phases

Perform during “sedation vacations”

Need assistance to manage multiple lines

Monitor vital signs

Involvement of a multidisciplinary team is crucial!

When should an Early Mobilization Intervention be deferred/stopped?

1,2,7

HR <40 or >130 bpm

RR <5 or >35 bpm

SpO2 <88% for <1 minute

SBP <90 mm Hg or >180 mm Hg

Elevated ICPs

Changes in patient presentation occur

New medical findings occur

Adverse Effects with Early Mobilization 2,7

Adverse events are rare.Fall to knees

Hypoxemia <88% SpO2 for >1 minute

Unscheduled extubation

Orthostatic Hypotension < 80 mm Hg SBP

Bottom line 1,2, 6-8

No medical status decline occurred with an early physical therapy intervention.

This is a safe and feasible intervention.

Early mobilization has the potential to prevent/treat neuromuscular complications of critical illness.

Early Mobilization Requires a Culture Change

Questions

References

1. Bernhardt J, Dewey H, Thrift A, and Donnan G. Inactive and Alone: Physical Activity Within the First 14 Days of Acute Stroke Unit Care. Stroke 2004;35:1005-1009.

2. Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):400-407.

3. Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing 2008;10(1):21-33.

4. Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy. (4th ed). St. Louis: Mosby. 2006.

5. Kisner C, Colby LA. Therapeutic Exercise. (5th ed.). Philadelphia: F.A. Davis Company. 2007.

6. Perme C, Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units: Creating a Standard of Care. Am J Crit Care. 2009;18:212-221.

7. Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:1874-82.

8. West L. Early Mobilization: How one multidisciplinary team initiated an activity protocol to decrease ICU lengths of stay. Advance for Physical Therapy and Rehab Medicine May 30, 2011:12-14.

*References for images available upon request.