Implementing an Early Mobility Programme for Critically Ill Patients

Original Editor - Jess Bell Top Contributors - Jess Bell and Kim Jackson

Introduction

As discussed here, early mobility (EM) programmes for patients in intensive care units (ICU) are safe and achievable and have been found to improve outcomes in critically unwell patients. It is key that the patients are carefully assessed in order to ensure safety. This page explores the logistics of implementing EM for patients in ICU, particularly in terms of identifying and addressing barriers to commencing EM programmes.

Impact of Immobility and Delayed Mobility

Understanding the negative multi-systemic impact of immobility reinforces the benefits of implementing EM programmes, both for clinicians and patients.[1][2][3] In general, bed rest causes increased morbidity and mortality, decreased functional capacity, increased care costs and reduced quality of life.[4]

Cardiovascular system

Inactivity and prolonged bed rest lead to cardiac deconditioning, which affects both the central and peripheral cardiovascular systems.[5] Water loss and cardiac deconditioning can occur as fluids are redistributed when a patient is in a supine position. Prolonged bed rest causes a reduction in blood volume and decreases blood return - this causes a gradual decrease in diastolic volume and stroke volume drops.[6] Stroke volume has been found to decrease by 30% after one month of bed rest.[5] This causes an increase in heart rate in order to try to maintain cardiac output.[6] As stroke volume drops, the workload of the myocardium decreases, so it begins to atrophy.[6] Orthostatic intolerance begins to develop within three days of inactivity.[5] There is also increased blood stasis, which increases the risk of deep vein thrombosis and associated conditions like embolus.[4][5][6]

Respiratory System

Bed rest results in atelectasis and increases the risk of complications such as pneumonia.[5] Bed rest often also results in delayed weaning from ventilators and decreased respiratory muscle strength.[4] There may be increased airway resistance, decreased mucus clearance with increased mucus pooling, altered ventilation/perfusion ratio and decreased minute ventilation.[4][6]

Other Complications

Bed rest also causes pressure ulcers, insulin resistance, and can lead to delirium and other impairments related to cognitive processing and changes in sleep patterns.[5] There are also issues associated with pain - these may be due to musculoskeletal dysfunctions or compression neuropathies.[4]

Intensive Care Unit-Acquired Weakness

Most of the changes discussed above improve once mobilisation is commenced and sedation is reduced.[5] Bed rest does, however, result in long term changes in skeletal muscle strength, which is referred to as Intensive Care Unit-Acquired Weakness (ICU-AW).[5] In healthy individuals, immobility is said to cause muscle strength to decrease by 1.3% to 3% per day.[2] Strength decreases by as much as 20 percent after one week of bed rest. Each subsequent week of bed rest causes a further 20 percent decrease in the remaining strength.[1] ICU-AW has been linked to prolonged hospitalisation, delayed weaning and increased mortality.[5] The aetiology of ICU-AW is complex, but risk factors for this condition include:[5]

  • Sepsis
  • Organ failure involving two or more organs and severity of illness
  • Length of time of mechanical ventilation
  • Length of ICU stay
  • Being female
  • Hyperglycemia
  • Immobility

It is believed that the combination of immobility and local / systemic inflammation promote muscle loss in critically ill patients.[5] Other alterations to the musculoskeletal system that occur with bed rest include:[4]

  • Diaphragmatic thinning, which impacts respiratory status
  • Loss of bone mineral density
  • Contracture / stiffness
[7]

Benefits of Early Mobility

An EM programme may essentially mitigate the effect of long term immobilisation.[3] These programmes are associated with improved functional capacity, increased muscle strength, decreased time on mechanical ventilation, increased walking distance and improved health related quality of life.[8] EM may help to improve muscle strength, which has a positive effect on patient-centred outcomes post discharge. It can also have a positive effect on delirium and[3] cognitive function, as well as reducing depression.[4]

EM programmes can also have a positive impact on the respiratory system as mobility helps to improve ventilation-perfusion matching, increases the efficiency of the respiratory mechanism, enhances lung volumes, tidal volumes and minute ventilation and improves airway clearance.[4]

Positive cardiovascular effects include:[4]

  • Increased venous return
  • Increased myocardial contractility
  • Increased stroke volume, heart rate and cardiac output
  • Increased coronary perfusion
  • Reduced blood stasis and, thus, decreased risk of developing DVT and thromboembolism

Other benefits are improved blood sugar homeostasis, gastrointestinal motility, endothelial function, decreased chronic inflammation and better regulation of hormone levels.[4]

Please click here for more information on early mobilisation in the intensive care setting.

Barriers to Early Mobility

Despite the numerous evidence-based benefits of EM, implementing these programmes within the critical care setting remains a challenge.[9] More so, although several guidelines and safe protocols for EM have been developed for different critical care centers, implementation remains problematic.[4]

Barriers vary across ICUs depending on the patient population, setting and ICU culture.[9][10][11][12] But a recent qualitative study by Anekwe and colleagues across three teaching hospitals in Canada found that there were 36 unique complex barriers to implementing EM programmes.[10] These barriers ranged from a lack of time, equipment, poor staffing, as well as poor communication across the team and the unpredictable nature of ICU. Survey respondents also noted a lack of conviction or limited knowledge about the benefits of EM and a lack of ability to remember and focus on care pathways that could result in gain for the patient.[10] These findings reiterated previously confirmed barriers, as well as identifying new barriers associated with fear, expectation of poor outcomes and lack of evidence for EM.[10] Ultimately, the research has found that barriers to EM programmes exist at different levels:[4]

  • Patient Level[11][4]
    • Physical barriers, including lack of devices and equipment[12]
    • Respiratory instability / distress or ventilator asynchrony[11]
    • Pain
    • Poor nutritional status
    • Baseline or new immobility / weakness
    • Deep sedation
    • Delirium or agitation
    • Lack of motivation or lack of consent
    • Anxiety
    • Fatigue and sleepiness
    • Palliative care
  • Institutional level[11]
    • Limited staff
    • Time constraints[10][12]
    • Lack of EM protocol and mobility culture
    • Limited equipment[10]
  • Provider level[11]
    • Lack of knowledge of the benefits and the expertise to effectively implement EM[10]
    • Nervous or skeptical clinicians
    • Concerns about unpredictable nature of ICU[10]
    • Limited or lack of staff support
    • Lack of planning and coordination amongst mobility team
    • Lack of communication[10]
  • Family / care giver level[4]
    • Unclear expectations and roles
    • Lack of knowledge on benefits of EM
    • Lack of motivation to actively participate in mobility exercises

Key Considerations Before Implementing an EM Programme

In order to effectively implement EM programmes, these barriers need to be considered. This requires a coordinated effort between different members of the mobility team, clinicians and the patient.[13]

An interdisciplinary mobility team should be created to champion mobility programmes for the patient.[13] This team will need to identify and, where possible, address barriers to the EM programme. These teams have been shown to improve patient outcomes, staff satisfaction and reduce costs related to employee injuries.[14]

A key component of creating such a team will involve education of team members.[15][13] It is important that every team member understand the patient’s goals and the aim of the EM programme. Education may be specific to the mobility programme - such as how to use a hoist, how to mobilise or lift / move a specific patient. These factors need to be considered before the EM programme commences.[13] Staff education may also cover the deleterious effects of bed rest and the benefits of EM, as well as the safety of these programmes to enhance provider confidence.[15]

Communication is key when implementing an EM programme. It is important to communicate with the entire team as well as with the patient and their family - the family will likely become a key part of the mobility team on discharge. Thus, it’s important they understand the aim of the EM programme as well.[13] The chosen intervention will depend on the patient’s level of consciousness, sedation level and delirium status.[13]

Facilitators to Implementing Early Mobility

Specific facilitators have been identified that may help to improve up-take of EM programmes.[10] In particular, systematic efforts to change ICU culture to prioritise early mobilisation using an interprofessional approach and multiple targeted strategies are important components of successfully implementing early mobility in clinical practice.[16][17] The general consensus on the ABCDE Bundle[18] of caring for critically ill patient includes early mobility as a key component.[4]

Efficiency in carrying out EM involves coordinated efforts between the mobility team and the patient. The table below contains approaches which are proposed to ensure efficiency and effectiveness.[4][19][5]

Mobility Team Patient
Identify and address barriers
  • Establish an inter-professional mobility team
  • Identify local barriers to mobility and devise strategies to address them
  • Constantly evaluate progress

Engage mobility team

  • Identify and engage members of the team

Educate the team

  • Mobility / Rehabilitation skills training
  • Bed side teaching

Communicate and coordinate

  • Mobility should be coordinated with patient’s pain level, sedation / agitation and delirium status
  • Inter-professional collaborations in the form of rounds and discussions to facilitate efficient goal setting and task accomplishment
  • Evaluate pre-ICU and current functional status
  • Assess current physiological status using measures that would still be relevant post-ICU
  • Evaluate feasibility and safety of mobility
  • Identify specific areas to target for mobility programme / intervention to address unique patient problems / limitations
  • Constantly communicate with the patient and family concerning mobility goals
  • Prepare patient for mobility and implement the actual mobility intervention
  • Re-evaluate patient’s attainment of goals and make necessary adjustments
  • Communicate goals with patient and family to boost motivation and promote cooperation

Summary

  • Critical illness is catabolic, rapidly depleting and its effect is long-lasting
  • Mobility combined with minimal or no sedation started early is protective and preventative
  • When implementing an EM programme, it is essential to have a structured plan, which includes barrier identification and collaboration with the whole team and patient / patient's family or caregivers[4]

References

  1. 1.0 1.1 Perme C, Chandrashekar R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care. 2009;18(3):212-221.
  2. 2.0 2.1 Morris PE, Griffin L, Berry M, 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(5):373-377.
  3. 3.0 3.1 3.2 Denehy L, Lanphere J, Needham DM. Ten reasons why ICU patients should be mobilized early. Intensive Care Med. 2017;43(1):86-90. 
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 Okeke C. Implementing an Early Mobility Programme for Critically Ill Patients Course. Physioplus. 2020.
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 Parry SM, Puthucheary ZA. The impact of extended bed rest on the musculoskeletal system in the critical care environment. Extrem Physiol Med. 2015;4:16.
  6. 6.0 6.1 6.2 6.3 6.4 Knight J, Nigam Y, Jones A. Effects of bedrest 1: cardiovascular, respiratory and haematological systems. Nurs Times. 2009;105(21):16-20.
  7. Dräger Global. Early Mobilization – A first step toward returning to normal life. Available from https://www.youtube.com/watch?v=_CCSwOWilR8 [last accessed 18/09/2020]
  8. Arias-Fernández P, Romero-Martin M, Gómez-Salgado J, Fernández-García D. Rehabilitation and early mobilization in the critical patient: systematic review. J Phys Ther Sci. 2018;30(9):1193-1201.
  9. 9.0 9.1 Anekwe DE, Koo KK, de Marchie M, Goldberg P, Jayaraman D, Spahija J. Interprofessional Survey of Perceived Barriers and Facilitators to Early Mobilization of Critically Ill Patients in Montreal, Canada. J Intensive Care Med. 2019;34(3):218-226. 
  10. 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 10.9 Anekwe DE, Milner SC, Bussières A, de Marchie M, Spahija J. Intensive care unit clinicians identify many barriers to, and facilitators of, early mobilisation: a qualitative study using the Theoretical Domains Framework. J Physiother. 2020;66(2):120-127. 
  11. 11.0 11.1 11.2 11.3 11.4 Dubb R, Nydahl P, Hermes C, et al. Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units. Ann Am Thorac Soc. 2016;13(5):724-730. 
  12. 12.0 12.1 12.2 Bakhru RN, McWilliams DJ, Wiebe DJ, Spuhler VJ, Schweickert WD. Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices. An International Survey. Ann Am Thorac Soc. 2016;13(9):1527-1537.
  13. 13.0 13.1 13.2 13.3 13.4 13.5 Okeke C. Early Mobility Assessment for Critically Ill Patients Course. Physioplus. 2020.
  14. Ratcliffe J, Williams B. Impact of a Mobility Team on Intensive Care Unit Patient Outcomes. Crit Care Nurs Clin North Am. 2019;31(2):141-151.
  15. 15.0 15.1 Linke CA, Chapman LB, Berger LJ, Kelly TL, Korpela CA, Petty MG. Early Mobilization in the ICU: A Collaborative, Integrated Approach. Crit Care Explor. 2020;2(4):e0090. 
  16. Iwashyna TJ, Hodgson CL. Early mobilization in ICU is far more than just exercise. The Lancet. 2016; 388(10052): 1351‐1352.
  17. Gosselink R, Bott J, Johnson M, et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med. 2008;34(7):1188-1199. 
  18. Balas MC, Burke WJ, Gannon D, et al. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines. Crit Care Med. 2013;41(9 Suppl 1):S116-S127.
  19. Hodgson CL, Stiller K, Needham DM, et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care. 2014;18(6):658.