Early Mobility Assessment for Critically Ill Patients
- 1 Introduction
- 2 What is Early Mobility?
- 3 Levels of mobility
- 4 Evidence of Effectiveness for Early Mobility Programmes
- 5 Assessing a Patient for Early Mobility
- 6 Safety Guidelines for EM Programmes
- 7 Summary
- 8 References
As technology and science evolve in intensive care medicine, more patients are surviving critical illness episodes. However, prolonged stays in intensive care units (ICU) are linked with functional declines, increased morbidity and mortality and increased length of stay in hospital. Patients who survive a stay in ICU often go on to experience various long term challenges on discharge, some psychological (i.e. cognitive impairment, post-traumatic stress disorder, persistent anxiety), as well as social, financial and physical impairments, including ICU acquired weakness, decreased physical function and a decrease in quality of life. These long-lasting sequelae are referred to as post-intensive care syndrome.
It has been found that early mobility (EM) programmes can have a positive impact on these factors. Mobilisation is described as physical activity which results in certain physiological effects. It is energy consuming and includes various activities that produce movement (such as actively moving limbs, actively rolling in bed, sitting on the edge of the bed etc).
What is Early Mobility?
Early Mobility (EM) is defined as mobilisation started within 24-48 hours of admission into ICU. It is a safe and achievable practice that has the potential to mitigate the effects of critical illness on several body systems.
EM consists of a series of planned movements that are progressed in a sequential manner. It is commenced with minimal or no participation from the patient. It can also be safely implemented for mechanically ventilated patients and patients receiving continuous hemofiltration. A comprehensive assessment enables the physiotherapist and other members of the mobility team to make an informed decision on the individual mobility requirement of the patient.
Levels of mobility
Robust mobility protocols have been developed to guide critical care clinicians in EM. It is important to liaise with every member of the team to ensure a flow of communication when planning interventions. Goals should be set with the patient and these should always follow the SMART (Specific, Measureable, Achievable, Realistic and Time bound) and FITT (Frequency, Intensity, Time and Type) principles. It is important to note that goal setting is not always straightforward. The goal setting process should be undertaken in such a way that the clinician is able to gain an understanding of what is important to the patient.
For more information on Early Mobility in ICU, please click here.
Evidence of Effectiveness for Early Mobility Programmes
Evidence exists for the clinical effectiveness of EM in combating the negative effects associated with prolonged immobility during critical illness. Early progressive mobility programmes can be safely implemented for patients in ICU. These programmes can have a positive impact on many outcomes in critical illness survivors.
In particular, they can improve ventilation, circulation, perfusion, muscle metabolism and alertness, as well as decrease the incidence of delirium, reduce the number of days on a ventilator, decrease the length of hospital stay and improve function on discharge.
Evidence has also shown short-term improvements in physical-related outcomes such as muscle strength and a reduction in the incidence of Intensive Care Unit Acquired Weakness (ICU-AW). A review by Stiller provides specific evidence on the efficacy of EM on secondary outcomes such as ICU and hospital length of stay. Although some studies provide contrasting reports, this has been attributed to poor study quality and a delay in the initiation of early mobilization interventions.
Assessing a Patient for Early Mobility
An EM programme must be tailored to suit the patient’s condition. Various mobility protocols have been developed to guide clinical care clinicians (including intensivites, physiotherapists and occupational therapists) when implementing EM. A thorough assessment will enable the clinician to determine what level of mobility is achievable and safe for each patient. Strong communication with the MDT is essential when managing ICU patients. As for goal setting, when deciding on management, the SMART principle should be followed.
As discussed in detail below, in order for the therapist to consider the unique factors of every presenting case, the following features should be assessed prior to implementing an EM plan:
- Medical history
- Cardio-respiratory fitness / physiological reserve / functional capability
- Neuromuscular / musculoskeletal status
- Medications (which may affect mobilisation response)
- Cognitive function and level of consciousness
- Motivation and goals, as well as patient expectations
- Anxiety levels
- Other procedures required by the patient
- Existence of any contraindications
Prior to implementing any physiotherapy intervention, it is essential to find out the patient’s medical history. Much of this information will be obtained from the patient’s notes and communication with the patient’s family. Key points to consider include:
- Impact of this acute / chronic illness on the patient
- Current level of acuity
- Presence of comorbidities that may impact on the management plan
- Pre-morid fitness to ensure that EM programmes are realistic and safe
- Functional capability
Cardio-Respiratory Fitness and Physiological Reserve
Understanding cardio-respiratory fitness and physiological reserves, as well as functional capability, will help the therapist to determine what level of mobility will be sufficient and effective for a particular patient.
It is essential to assess the patient’s current physiological status (i.e heart rate, respiratory rate, blood pressure) and to remember that these readings can change rapidly in ICU. Continuously monitoring is, therefore, essential. Specific safety parameters are discussed below.
Neuromuscular and Musculoskeletal Status
It is important to assess musculoskeletal status, including strength, balance and coordination in order to plan an EM programme. Insufficient strength of the lower limbs or major balance deficits will impact on your treatment planning.
Using outcome measures early in a patient’s hospital stay (i.e. in ICU) can be beneficial as these measures can be monitored and compared over time. There are a number of outcome measures to assess physical function in ICU survivors, but one study by Parry and colleagues found that the Physical Function in Intensive Care Test and Functional Status Score for the ICU (see link here) appears to be promising measures when assessing physical function in ICU. See also ICU Mobility Scale
Certain types of medications, such as vasopressors, might hamper the introduction of a mobility programme.
Level of consciousness and cognitive function are also vital considerations. They will provide you with some insight as to how well the patient may be able to follow instructions.
Motivation and Goals
It is important to consider what the patient’s goals are and his or her level of motivation. Motivation levels will impact patient engagement. It is beneficial to also find out the patient’s expectations. This will help to ensure that the EM programme is patient-centred and enhance cooperation.
Once goals are determined, clinicians can identify target areas to direct the intervention (e.g. sitting on the edge of the bed, standing, walking, sitting balance).
Many patients in ICU have been found to be anxious. One study by McKinely and colleagues reported that some anxiety was reported by 85% of patients using the Faces Anxiety Scale. Good communication about the EM programme may help to alleviate some anxieties.
Any EM programme will have to fit around other procedures that the patient requires, such as dialysis, CT scans, wound dressings and blood transfusions. It is important to liaise with all members of the MDT, so that the EM programme can be timed effectively around other interventions.
The physiotherapist will need to consider if the patient is prepared generally for an EM intervention. Questions to consider include: does the patient need to eat? Will catheters need to be removed or changed? Will the patient need cleaning or covering?
It is important to rule out contraindications before implementing an EM programme (discussed in detail below). When assessing a patient’s ability to engage in an EM programme, various guidelines exist to highlight specific contraindications.
Physiotherapists will need to re-evaluate the patient throughout a treatment session and make adjustments as needed to ensure patient safety.
Safety Guidelines for EM Programmes
Key considerations are the heart rate - the patient should not be tachycardic (i.e. > 130 bpm) or bradycardic (i.e. < 40 bpm). It is also necessary to assess for signs of chronotropic incompetence. Chronotropic incompetence is defined as the inability of the heart to increase its rate in relation to increased activity / demand, which is a common problem for patients with cardiovascular disease. When mobilising an ICU patient, it would be expected that the patient’s heart rate increase due to exertion.
Most patients in ICU will have a target mean arterial pressure (MAP). MAP indicates the level of blood supply to the organs. According to the American College of Critical Care Medicine (ACCM) guidelines, a MAP of 60-65 mm HG is necessary for organ perfusion. Adler and Malone state that EM should be terminated if MAP is less than 65 mm Hg or more than 110 mm Hg. However, these figures may be individualised to each patient. When carrying out an EM programme, the patient’s BP must remain within the limits of their target MAP.
It is also important to check if a patient is on vasopressors as this will provide an indication of their level of stability / dependence. Vasopressors increase vasoconstriction, which results in increased systemic vascular resistance (SVR). This will increase the MAP and, in turn, improve perfusion to the organs. The ACCM guidelines state that if MAP does not increase to around 60 mm HG after fluid resuscitation, then vasopressors should be initiated. Adler and Malone note that the presence of vasopressor medication, new vasopressor and an escalating dose of vasopressor medication is a contraindication to EM.
You will need to check the patient’s respiratory status. Respiratory rate will be the first indication of respiratory distress. A respiratory rate of fewer than 5 breaths per minute or greater than 40 breaths per minute would require the EM programme to terminate. SpO2 should be more than 88-90% and a drop of more than 4% would require the session to terminate.
When the patient is on a mechanical ventilator, you will need to check the fraction of inspired oxygen (FiO2). Typically, an FiO2 of more than 60 would be unsafe for EM. Any mobility programme increases a patient’s oxygen demand. If the patient’s baseline oxygen demands are very high (i.e. an FiO2 of > 60) the EM programme could destabilise the patient. Positive End Expiratory Pressure (PEEP) levels higher than 10 are not considered safe for an EM programme.
Level of sedation is a key consideration before implementing any EM programme. If a patient is deeply sedated, it is not considered safe to mobilise him or her. A Richmond Agitation Sedation Scale (RASS) score of less than 3 is considered unsafe for EM, as are levels of agitation requiring additional sedative medication (i.e. an RASS of > 2).
It is also essential to consider what a patient tells you. EM should be terminated if a patient complains of intolerable dyspnoea on exertion. In such cases, it is important to determine if there are other challenges or factors that are causing these symptoms.
|Cardiovascular system||Heart rate
>70% age predicted maximum heart rate
>20% decrease in resting heart rate
<40 beats/minutes; >130 beats/minutes
New onset dysrhythmia
New anti-arrhythmia medication
New myocardial infarction
Systolic blood pressure >180mmHg
>20% decrease in systolic blood pressure / diastolic blood pressure
Mean Arterial Pressure < 65mmHg or > 110mmHg
Presence of vasopressor medication; new vasopressor or escalating dose of vasopressor medication
|Respiratory system||Respiratory rate
<5 breaths/minute; >40 breaths/minute
Pulse oximetry (SP02- i.e. saturation of peripheral oxygen)
<88 in COPD patients
|Mechanical ventilator parameters||Fraction of inspired oxygen (FiO2) >0.60
|Patient factors||Sedation level (measured using RASS) ≤ 3
Agitation requiring addition or escalation of sedative medication; RASS ≥ 2
Complaints of intolerable dyspnea on exertion
Refusal to participate in mobility session
EM programmes may be carried out safely in ICU and can confer many benefits to patients. However, every patient needs to be carefully and regularly assessed in order to ensure that the programme is safe. For more information on implementing EM programmes in ICU, click here.
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