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Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units
Rolf Dubb1*
, Peter Nydahl2*
, Carsten Hermes3, Norbert Schwabbauer
4, Amy Toonstra
5, Ann
M. Parker6, Arnold Kaltwasser
1, Dale M. Needham
7
1Department of Continuing Education of Critical Care Nursing, District Hospital of
Reutlingen, Reutlingen, Germany; 2Neurological ICU and Stroke Unit, University Hospital of
Schleswig-Holstein, Kiel, Germany; 3Intensive Care Unit, Helios Klinikum Siegburg, Siegburg,
Germany; 4Department of Medicine, University Hospital Tubingen, Tubingen, Germany;
5Physical Medicine and Rehabilitation, Johns Hopkins Hospital,
6Division of Pulmonary and
Critical Care Medicine, Johns Hopkins University School of Medicine, 7Pulmonary and Critical
Care Medicine, Johns Hopkins University, Baltimore, MD
*These authors contributed equally to the work and should be considered co-first authors
Corresponding Author:
Peter Nydahl
University Hospital of Schlweswig-Holstein - Nursing Research
Brunswiker Str. 10 Kiel 24105
Germany
Key Words: Critical Care; Intensive Care; Quality; Rehabilitation; Physical Therapy; Review
Word Count: 2135
Page 1 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
Abstract
Early mobilization of patients in the intensive care unit (ICU) is safe, feasible, and beneficial.
However, implementation of early mobility as part of routine clinical care can be
challenging. The objective of this review is to identify barriers to early mobilization and
discuss strategies to overcome such barriers. Based on a literature search, we synthesize
data from 40 studies reporting 28 unique barriers to early mobility, of which 14 (50%) were
patient-related, 5 (18%) structural, 5 (18%) ICU cultural and 4 (14%) process-related
barriers. These barriers varied across ICUs and within disciplines, depending on the ICU
patient population, setting, attitude, and ICU culture. To overcome the identified barriers,
>70 strategies were reported and are synthesized in this review, including: implementation
of safety guidelines; use of mobility protocols; interprofessional training, education, and
rounds; and involvement of physician champions. Systematic efforts to change ICU culture
to prioritize early mobilization using an interprofessional approach and multiple targeted
strategies are important components of successfully implementing early mobility in clinical
practice.
Abstract Word Count: 165
Page 2 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
For patients in intensive care units (ICUs), bed rest and prolonged immobility commonly
occur and increase the risk of ICU-acquired weakness and other complications (1,2). Early
mobilization of ICU patients has been associated with improved muscle strength and
functional independence, as well as a shorter duration of delirium, mechanical ventilation,
and ICU length of stay (3-7). Despite the safety and feasibility of early mobilization (8-13),
most ICU patients remain immobilized for long periods of time (14-18). Several prior
publications have reported modifiable and non-modifiable barriers to early mobilization
(10,19-21). Understanding such barriers, and associated strategies to overcome them, is
helpful for clinicians wanting to implement early mobility as part of routine clinical practice.
Hence, the objective of this literature review is to synthesize published data on
barriers to early mobilization of ICU patients and associated strategies used to address these
barriers. The information presented in this review here is based on a structured search of
the literature using PubMed, Cumulative Index to Nursing and Allied Health Literature
(CINAHL), Physiotherapy Evidence Database (PEDro), and Cochrane Central Register of
Controlled Trials, along with a review of the reference list from relevant studies.
Included studies were analyzed for descriptions of barriers and associated strategies
to overcome those barriers. Two authors independently categorized each barrier and
strategy. In the event of uncertainty in categorization, consensus among all authors was
used. To facilitate future quality improvement projects, reported barriers were organized
into 1 of 4 categories: 1) patient-related barriers, including patient symptoms and
conditions (e.g., hemodynamic instability); 2) structural barriers, including human and
technical resources (e.g., staffing, equipment or protocols); 3) barriers related to ICU
culture, including habits, attitudes, and context within ICUs and institutions (e.g. staff
Page 3 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
morale); and 4) process-related barriers, including how services are delivered and clinician
functioning (e.g. unclear roles and responsibilities).
ICU patients may have absolute contraindications (e.g. unstable fracture) that limit
mobilization and thus do not represent a modifiable barrier. If no strategy was reported to
address such a condition, it was classified as a contraindication, rather than a barrier.
Barriers were categorized into a) prospectively defined and empirically evaluated, using
specific criteria (e.g. high oxygen fraction), and b) perceived barriers (defined as those
without defined criteria determined based on perceptions arising from team meetings, staff
interviews or personal reflection), or c) a mix of both.
Strategies described within studies reporting barriers were abstracted, synthesized,
and categorized according the type of barrier(s) it addressed. When a strategy was reported
to address >1 category of barrier, it was listed with each category and designated, in the
tables, as a strategy used for multiple barriers. The success of these strategies at
overcoming barriers was classified as follows: (1) objective measurement (defined as having
at least one of the included studies demonstrating that the strategy was successful in
improving mobility rates); (2) subjective opinion (defined as having at least one of the
included studies in which the authors concluded, based on their opinions, the strategy was
important in addressing barriers to mobility); and (3) clinician survey (defined as clinicians
being surveyed/interviewed for their opinion about success).
Barriers and Strategies
From 40 studies identified via the structured literature search (9-16,19-50), a total of 28
unique barriers were identified: 14 (50%) patient-related, 5 (18%) structural, 5 (18%) related
Page 4 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
to ICU culture, 4 (14%) process-related (Tables 1-4). We identified 3 contraindications to
mobility, as previously defined: orthopedic or surgical issues, active hemorrhage or
coagulation issues, and cognitive impairment (e.g. coma).
Prospectively defined and empirically evaluated barriers, as previously defined, were
found in 17 studies (9,11,13-16,19,23-25,27-29,34,35,41,50), perceived barriers in 19
studies (12,20-22,26,31-33,36-39,43-49) and a mix of both in 4 studies (10,30,40,42) (Table
E1). Only 1 study used a validated instrument for the assessment of barriers (37), while
other studies identified barriers using a variety of techniques, including interdisciplinary
meetings (10,12,21,30,42) and interviews or custom-made surveys with clinicians
(19,28,38,44,45,47,48,49).
In summary, 68 (93%) of 73 strategies addressed more than one barrier. For
example, a protocol for early mobilization addressed barriers that included hemodynamic
instability, respiratory instability, and physician order for bed rest.
Patient-Related Barriers and Strategies
Patient-related barriers were reported by 31 (77%) of the relevant studies and included 14
unique barriers and included physical, neuropsychological, and ICU devices and equipment
barriers. The most common patient-related barrier was hemodynamic instability (n=20,
50% of studies) followed by vascular access devices, tubes and drains (n=18, 45%). Other
patient-related barriers included sedation or decreased level of consciousness, and patient
illness- and treatment-related factors (Table 1).
Strategies to address patient-related barriers were reported in 27 (67%) of the
studies. These strategies included: using an interdisciplinary approach to enhance early
mobilization in 20 (50%) studies, development and implementation of protocols in 18 (45%)
Page 5 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
studies, and defining inclusion and exclusion criteria for mobility in 7 (17%) studies, while 14
(42%) studies used others strategies. Notably, some authors performed their own studies or
quality improvement evaluations to address specific barriers, such as conducting surveys
(41,44,45,48) or systematically evaluating the safety and feasibility of early mobilization in
special circumstances, such as presence of femoral lines (29,39), renal replacement therapy
(12,43), or extracorporeal membrane oxygenation (13).
Structural Barriers and Strategies
Structural barriers were reported by 28 (70%) studies and included limited staff in 18 (45%)
of studies, lack of an organized program for early mobility in 14 (35%), and inadequate staff
training in 10 (25%) studies (Table 2).
Strategies to overcome structural barriers were identified in 25 (62%) studies and
included: development and implementation of protocols in 20 (50%) studies, increased
staffing in 18 (45%), and purchase of equipment in 12 (30%) studies. In particular,
interprofessional protocols were created to help with identifying appropriate patients for
early mobility and coordinating patient mobilization. Other strategies included staff training,
regular interprofessional staff meetings, and changes in clinical documentation to permit
better evaluation of early mobilization of patients.
ICU Culture-Related Barriers and Strategies
Barriers related to ICU culture were reported in 24 (60%) of studies. Such barriers included
14 (35%) studies reporting an attitude that does not view early mobility as a priority;
inadequate staff knowledge regarding the benefits, safety, and techniques of mobility in 12
(30%) studies; and low staff morale in 10 (25%) studies (Table 4).
Page 6 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
Strategies to overcome ICU cultural barriers were identified in 24 (60%) of included
studies. These strategies included education (e.g., training, sharing literature, videos, etc.)
and training (hands-on, bedside teaching, etc.) in 18 (45%) of studies. In 8 (20%) studies,
decision-making processes were changed and included improved coordination between
professions to allow for collaborative goal-making, as well as increased nurse and physical
therapist involvement. Timely feedback about successes with patient mobilization was also
important (30,31).
Process-Related Barriers and Strategies
Process-related barriers were identified in 24 (56%) studies. The most common such
barriers were lack of coordination (e.g., lack of consistent interprofessional rounds or
coordination of patient procedures with mobilization) in 16 (40%) studies, and missing or
delayed screening to identify patients appropriate for mobility in 15 (37%) studies. Unclear
job expectations, roles, and responsibilities were reported by 10 (25%) studies (Table 3).
Differences between physical therapists and nurses in their assessments of patient
appropriateness for mobilization, and lack of communication between these professions,
led to different levels of patient mobilization (28).
Strategies to overcome process-related barriers were identified in 25 (62%) of
studies. Such strategies included implementing interprofessional meetings and rounds in 18
(45%) studies, sharing clinical responsibilities in 15 (37%) studies, and collaboration with
champions to promote early mobilization in 12 (30%) studies. Methods to reduce the time
to a physician order for mobilization, such as use of an automatic order or removal of
default order for bed-rest, shortened the time to first mobilization (10,26).
Page 7 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
Discussion
In this focused review of barriers and strategies for early mobilization of ICU patients, 28
unique patient, structural, process-related, and ICU cultural barriers were identified, with
patient-related barriers being the most common category. More than 70 strategies to
overcome these barriers were identified and synthesized.
Existing literature on the safety of early mobilization provides evidence to address
some perceived patient-related barriers, such as safety concerns regarding presence of an
endotracheal tube, modest doses of vasopressors or hemodynamic instability (9,10,27).
Since the definition of hemodynamic “instability“ is subjective (51), without any clear
consensus for thresholds of vasopressor doses that are safe for mobilization (52), use of
unit-specific protocols developed based on local consensus may be helpful in systematically
addressing this potential barrier.
Some factors identified as “contraindications” (as defined above), such as unstable
spinal fracture and active bleeding may appropriately limit mobilization of ICU patients.
Nevertheless, other factors identified as “contraindications” in this review (e.g., coma) may
not be absolute contraindications, with some arguing, for instance, that mobilization of
patients with coma would stimulate increased awareness (53). In general, mobilization and
identification of barriers may depend on which profession was surveyed (28,38,44-47).
Therefore, a multiprofessional approach that utilizes both qualitative and quantitative data
may be optimal for identifying barriers and potential strategies to overcome them (54).
Common structural barriers included limited staffing and lack of protocols and staff
training. Physical therapists identified lack of physical therapists as a barrier (22,44) and
nurses also reported the same barrier for their own profession (36,44). Recruiting additional
Page 8 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
staff may assist with this specific barrier (55). Morris et al (23) reported that the financial
benefits to a hospital, via a reduced length of stay, compensated for the additional costs
required for staffing a mobility team. Needham et al (10) demonstrated a financial benefit
for the hospital through reduced length of stay and increased admissions to the ICU.
The potential financial benefit of implementing early mobilization has been
evaluated through a financial model (55) that may assist clinicians and hospital
administrators who are considering creating an ICU-based mobilization program. Such
financial modeling and associated business cases have facilitated expansion of staff for early
mobility programs in other institutions (20). However, additional staff may not always be
required if other strategies are used to address the staffing barrier.
Bailey et al. reported mobility activities on 88% of their ICU days without a higher
patient-staff ratio, given that they established an ICU culture that prioritized early mobility
(9). Other studies found no relationship between staffing and mobility level (16,20). The
ideal staff to patient ratio for a successful early mobilization program remains unclear.
Other issues (e.g. safety concerns, staff expertise, division of responsibilities) may be as
important as staff to patient ratio (44,46). For instance, there are significant differences in
barriers between ICUs with and without mobility practice; hence, barriers may change with
experience (47,48). Even with expanded staffing, early mobility protocols and staff training
may be important additional strategies necessary for overcoming barriers (47,56).
Barriers related to ICU culture are a systematic issue that can be time-consuming and
challenging (24, 57) to overcome. However, successful change of ICU culture may result in
changes that are sustained for several years (58). The most common strategies to address
these cultural barriers included multiprofessional education, mobility champions, mobility
protocols, daily interprofessional rounds, and documentation that allows evaluation of
Page 9 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
mobility efforts (59). In addition, the development and documentation of daily
interprofessional goals (10,25, 59) and sharing of improved patient outcomes (59) may be
beneficial. However, sustainability of early mobility programs may be hampered by
organizational changes such as staff turnover or change in leadership (37). At a minimum,
identifying barriers is an important first step for implementing change
(10,14,20,44,45,48,49).
Common process-related barriers included a lack of communication and unclear
delineation of staff roles for patient mobilization (9,10,19,21,23,27,30-32,34-
38,42,44,45,47). Interprofessional rounds, checklists and protocols, along with leadership
from an identified champion with available time may improve early mobilization. Timely
feedback about the frequency of early mobility that is actually occurring, potential safety
events, and sharing success stories may improve motivation and prioritization of early
mobilization (47,60). Concerns regarding staff safety emphasize the importance of
appropriate training, equipment, and planning (44).
Early mobilization in the ICU is associated with improved patient outcomes.
Successful implementation of early mobility depends on patient status, and ICU-related
processes, structures, and culture. This review identifies potential barriers to early mobility
as well as strategies to address those barriers, which may be helpful to future clinicians as
they implement early mobility programs in the ICU. A multiprofessional approach to early
mobility implementation and a change in ICU culture, making early mobility a high priority,
are especially important. Barriers and strategies may change during the implementation
process, indicating a need for ongoing, interprofessional reflection and evaluation.
Page 10 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
Conclusions
Barriers to early mobilization of ICU patients are multi-faceted, with patient-related barriers
being most commonly cited. Studies have identified numerous practical strategies that have
been successful in addressing most perceived barriers to early mobilization. Systematic
efforts to change ICU culture to prioritize early mobilization using an interprofessional
approach and multiple targeted strategies are important components of successfully
implementing early mobility in clinical practice.
Page 11 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
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49. Malone D, Ridgeway K, Nordon-Craft A, Moss P, Schenkman M, Moss M. Physical
Therapist Practice in the Intensive Care Unit: Results of a National Survey. Phys Ther.
2015 Oct;95(10):1335-44.
50. Harrold ME, Salisbury LG, Webb SA, Allison GT; Australia and Scotland ICU Physiotherapy
Collaboration. Early mobilisation in intensive care units in Australia and Scotland: a
prospective, observational cohort study examining mobilisation practises and barriers.
Crit Care. 2015 Sep 14;19:336.
51. Amidei C. Measurement of physiologic responses to mobilisation in critically ill adults.
Intensive Crit Care Nurs. 2012;28(2):58-72.
52. Hodgson CL, Stiller K, Needham DM, Tipping CJ, Harrold M, Baldwin CE, Bradley S,
Berney S, Caruana LR, Elliott D, Green M, Haines K, Higgins AM, Kaukonen KM,
Leditschke IA, Nickels MR, Paratz J, Patman S, Skinner EH, Young PJ, Zanni JM, Denehy L,
Page 15 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
Webb SA. Expert consensus and recommendations on safety criteria for active
mobilization of mechanically ventilated critically ill adults. Crit Care. 2014 4;18(6):658.
53. Seel RT, Douglas J, Dennison AC, Heaner S, Farris K, Rogers C. Specialized early treatment
for persons with disorders of consciousness: program components and outcomes. Arch
Phys Med Rehabil. 2013 Oct;94(10):1908-23.
54. Taylor N, Clay-Williams R, Hogden E, Braithwaite J, Groene O. High performing hospitals:
a qualitative systematic review of associated factors and practical strategies for
improvement. BMC Health Services Research (2015) 15:244.
55. Lord RK, Mayhew CR, Korupolu R, Mantheiy EC, Friedman MA, Palmer JB, Needham DM.
ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care
Med. 2013;41(3):717-24.
56. Jolley SE, Dale CR, Hough CL. Hospital-level factors associated with report of physical
activity in patients on mechanical ventilation across Washington State. Ann Am Thorac
Soc. 2015;12(2):209-15.
57. Hopkins RO, Spuhler VJ, Thomsen GE. (2007). Transforming ICU culture to facilitate early
mobility. Crit Care Clin.: 23(1):81-96.
58. Dinglas VD, Parker AM, Reddy DR, Colantuoni E, Zanni JM, Turnbull AE, Nelliot A, Ciesla
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active physical therapy intervention in patients with acute lung injury. Ann Am Thorac
Soc. 2014 Oct;11(8):1230-8.
59. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving
communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-5.
60. Eakin MN, Ugbah L, Arnautovic T, Parker AM, Needham DM. Implementing and
sustaining an early rehabilitation program in a medical intensive care unit: A qualitative
analysis. J Crit Care. 2015;30(4):698-704.
Page 16 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
Table 1. Patient-related barriers to early mobilization and related strategies to overcome
barriers
Barriers Strategy
Physical barriers
High severity of illness, patients “too sick”
or “too well”
Interprofessional meetings†*; PT screening of ICU
patients†*
32,41,42,46
Hemodynamic instability, arrhythmias
Stepwise approach†‡
*; protocols†‡
*; safety criteria†‡
*; avoid
mobilization until 2 hours after increase in vasopressor
dose†*, valid assessment
†‡*
9,10,19,23,24,26,31,44,46,48,50
Respiratory instability/distress, ventilator
asynchrony
Stepwise approach to mobility including a safety check after
each step†‡
*; protocol for standardized mobilization
including safety criteria†‡
*; adjust FiO2, PEEP, or other
ventilators settings for mobilization†*
9,10,19,24,26,31
Pain Screen for pain†*; provide pain medication prior to
mobilization†*
10,48
Poor nutritional status Perform nutritional screening‡*
38
Obesity (e.g. BMI ≥30) Use protocol for standardized mobilization†‡
* 33,47,48
Baseline or new immobility/weakness Initiate mobility within 24 hours of admission†*; re-evaluate
daily†*; Consult neurology
†*
10,24
Neuropsychological barriers
Deep sedation and/or paralysis Perform routine assessments of sedation and pain†*; target
lighter sedation goals†*; avoid medications with long half-
lives†‡
*, interprofessional approach‡*
10,19,44,46-48,50
Delirium, agitation Delirium screening†*; use of antipsychotics
†*; reduce
benzodiazepine use†*
10,25,36,44
Patient refusal, lack of motivation, anxiety Adjust treatment plan with patient input†*; provide patient
education and encouragement†*
9,19,25
Fatigue, need for rest, sleepiness
Safety criteria†*; sleep protocols to improve sleep quality
†*
10,25,27,36
Palliative care
Focus treatment on patient goals for quality of life ‡ 25
ICU devices and equipment
Page 17 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
Hemodynamic monitoring equipment
Use portable monitors†*; secure application of equipment
and lines†*
10,12
ICU-related devices Stepwise approach to mobility†*; secure
lines/tubes/drains†; perform pre-mobility planning
†*;
interdisciplinary teamwork†‡
*; define responsibilities for
each discipline†‡
*; strategic choice of catheter insertion
location‡ 9-13,19,27,29,39,43,44,46-48
Abbreviations: BMI: Body Mass Index, PEEP: Positive End Expiratory Pressure, PT: Physical
Therapy
Notes: Some strategies are repeated for more than one barrier because they were reported
as strategies for several barriers.
* Strategy can be used for more than one barrier
† At least one study empirically demonstrated the strategy was successful in improving
mobility rates.
‡ At least one study proposed that the strategy was important in addressing barriers to
mobility based on authors’ opinions
Page 18 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
Table 2. Structural barriers to early mobilization and related strategies to overcome barriers
Structural Barriers Strategy (reporting author)
Limited staff, time constraints Additional PT†‡
, OT†, and technician staffing
†*; financial
modeling of economic benefits to increase funds for
staffing†*; independent mobility team
†‡*
10,20,22,23,25,34,42,44-
46,48,49
Lack of early mobility program/protocol (e.g.
no routine delivery of PT), too many existing
protocols, limited guidelines, no eligibility
criteria
Development of protocols†*; evaluation and feedback to
medical team†*; review of safety criteria
†*
10,12,15,19,20,23,26,30,31,34,36,37,40,44,47-49
Inadequate staff training Development of protocols†‡
*; full time therapists
dedicated to ICU†‡
*; stable leadership‡; education
†*;
interprofessional champion†*
10,20,32,37,44-49
Limited equipment Training on appropriate use of equipment†*; cost analysis
and financial modeling of economic benefit†‡
* 10,12,13,19,20,31,44-49
Early discharge (before mobilization)
Planning and coordination of discharge‡ 19
Abbreviations: OT: Occupational Therapy, PT: Physical therapy
* Strategy can be used for more than one barrier
† At least one study empirically demonstrated the strategy was successful in improving
mobility rates.
‡ At least one study proposed that the strategy was important in addressing barriers to
mobility based on authors’ opinions
Page 19 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
Table 3. ICU cultural barriers to early mobilization and related strategies to overcome
barriers
Cultural barriers Strategies (reporting author)
Lack of mobility culture (e.g.
inadequate staff buy-in, lack of
multidisciplinary culture)
Interprofessional champions†*; promotion of mobility
programs†*; multimedia education
†*; assessment and orders by
RNs‡*; goal sharing
†*; unit-based services
†*; identifying
barriers†‡
* 9,10, 14,19,23,24,30-32,34,36,41,42,44-48
Lack of staff knowledge and expertise
about risks/benefits of mobility
Multiprofessional education and training†‡
* 10,20,30,36,44-48
Early mobility not a priority Assessments and decisions by bedside RNs
†‡*; interprofessional
champions†‡
*; screening for appropriate patients†*; experience
sharing†‡
* 10,15,19,20,23,30,34,44-47
Lack of support or staff buy-in Education†*; regular team meetings
†*; physician support
†*;
culture promoting quality improvement†‡
* 15, 19,30,36-38,44-48
Lack of patient/family knowledge
Media engagement and education†‡
30,35
Abbreviations: RN: Registered Nurse, RT: Respiratory Therapist
* Strategy can be used for more than one barrier
† At least one study empirically demonstrated the strategy was successful in improving
mobility rates.
‡ At least one study proposed that the strategy was important in addressing barriers to
mobility based on authors’ opinions
Page 20 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
Table 4. Process-related barriers to early mobilization and related strategies to overcome
barriers
Process-related barriers Strategy (reporting author)
Lack of planning and coordination
Regular screening for appropriate patients†*;
interprofessional planning and coordination of
procedures†‡
*; interprofessional rounds†‡
*; daily goal
sheets with reminder about mobility†‡
*; mobility
champion†‡
*; interprofessional task force or mobility
team†*
10,19,20,23,27,30-32,34-38,42,44-49
Unclear expectations, roles, and responsibility
Central champion and champion for each profession†*;
nurse-driven protocol†‡
*; interprofessional
communication and cooperation†‡
* 10,19,20, 24,28,32,36,37,42,
44-48
Missing/delayed daily screening for eligibility,
and standing bedrest order
Mobility team†*; automatic therapy order
†*; daily
screening for eligibility†*; implementation of
protocol†‡
*; coordinators for in-/exclusion†‡
*;
education†*
10,20,23,26, 30,31,37,44-48
Risks for mobility providers (stress, injuries) Training†*, defining roles and responsibilities
†*, re-
prioritizing‡*, screening staff risks
‡, appropriate
equipment‡*, Mobility team
†*, champions
†*
36,44
* Strategy can be used for more than one barrier
† At least one study empirically demonstrated the strategy was successful in improving
mobility rates.
‡ At least one study proposed that the strategy was important in addressing barriers to
mobility based on authors’ opinions
Page 21 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
Online Data Supplement
Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units
Rolf Dubb, Peter Nydahl, Carsten Hermes, Norbert Schwabbauer, Amy Toonstra, Ann M. Parker,
Arnold Kaltwasser, Dale M. Needham
Page 22 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
Table E1. Study design
Author &
year
Design Number,
type of ICU,
hospital1
Population, n,
main inclusion
criteria
Assessment of
barriers &
strategies/ type of
survey
Potential
participant
s
Response
rate
Type of
clinician
(%)
Method evaluating
effectiveness of
strategies2
Studies reporting prospectively defined and empirically evaluated barriers 3
Bailey
2007 (9)
Pros.
cohort
study
1 RICU,
community
hospital
Mixed, n=103,
>4d MV
Anecdotal report
of authors/data
evaluation
Multiprof.
Team - -
Objective
measurement
Morris
2008 (23)
Pros.
cohort
study
7 ICUs,
academic
hospital
Medical (I: 165,
K: 165), >48h
MV
Predefined
medical
contraindications
& data evaluation/
data collection
RN, PT - - Objective
measurement
Thomsen
2008 (24)
Cohort
study3
n.r.
Respiratory
failure, n=103
>4d MV
Data evaluation by
authors/evaluatio
n
Multiprof.
Team - -
Objective
measurement
Schweick
ert 2009
(25)
RCT
2 ICUs, 2
academic
hospitals
Medical, (I: 49,
E: 53), expected
duration of MV >
72h
Predefined
medical
contraindications
& data
evaluation/data
collection
OT, PT - - Objective
measurement
Pohlmann
2010 (27)
Cohort
study4
2 ICUs, 2
academic
hospitals
Medical, n=49,
OT & PT during
daily SBT & SAT
Data evaluation by
authors/evaluatio
n
OT, PT - - Objective
measurement
Zanni
2010 (14)
Cohort
study
1 ICU,
academic
hospital
Medical, n=32,
MV ≥4d
Predefined
medical
contraindications
& data
evaluation/data
collection
PT - - Subjective opinion
Garzon-
Serrano
2011 (28)
Obs.
study
1 ICU,
academic
hospital
Surgical, n=63,
all consecutive
patients
Predefined
medical
contraindications
& data
evaluation/data
collection
PT, RN n.r. n.r. Subjective opinion
Perme
2011 (29)
Retr.
Cohort
study
1 ICU,
academic
hospital
cardiovascular
and thoracic, n=
30, femoral
arterial catheter
Predefined
medical
contraindications
& data
evaluation/data
collection
PT - - Objective
measurement
Leditschk
e 2012
(19)
Obs.
study
1 ICU,
academic
hospital
Mixed, n=106,
all patients
Predefined clinical
contraindications
& data
evaluation/data
collection
PT - - Subjective opinion
Titsworth
2012 (34)
Pros.
cohort
study
1 ICU,
academic
hospital
Neurological,
Pre: 77, post: 93,
all consecutive
patients
Predefined clinical
contraindications
& data
evaluation/data
collection
Multiprof.
Team n.r n.r.
Objective
measurement
Winkelma
nn 2012
(35)
Pros.
cohort
study
2 ICUs,
academic
hospital
Medical and
surgical, pre: 20,
post 55, >48h
MV expected
Predefined clinical
contraindications
& data
evaluation/data
Research
assistants - -
Objective
measurement
Page 23 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
collection
Berney
2013 (15)
Preval
ence
study
Aust.,
NZ
38 ICUs in
Aust. & NZ
Mixed, n=514,
all consecutive
patients
Predefined clinical
contraindications
& data
evaluation/data
collection
PT,
research
nurse
- - Subjective opinion
Nydahl
2013 (16)
Preval
ence
study
Ger.
116 ICUs,
different
hospitals
116 mixed ICUs,
n=783, all on MV
Literature based
questionnaire /
electronically
survey
Multiprof.
Team n.r.
61% RN,
28% PT,
8%
physicia
n, 2%
other
Subjective opinion
Perme
2013 (11)
Obs.
study
1 ICU,
academic
hospital
cardiovascular
and thoracic,
n=77, femoral
lines
Predefined
medical
contraindications
& data
evaluation/data
collection
PT - - Objective
measurement
Abrams
2014 (13)
Retr.
Cohort
study
1 ICU,
academic
hospital
Medical, n=100,
ECMO
Predefined
medical
contraindications
& data
evaluation/data
collection
PT - - Objective
measurement
Choong
2014 (41)
Retr.,
multic
enter
obs.
study
6 pediatric
ICUs,
different
hospitals
Mixed on 6
PICUs, n=600,
>24h
Predefined
medical
contraindications
& data
evaluation/data
collection
Research
coordinato
rs
- - Subjective opinion
Harold
2015 (50)
Cohort
study
10 ICUs in
Australia, 9
ICUs in
Scotland,
n.r.
514 patients
Predefined
medical
contraindications
& data
evaluation/data
collection
PT - - Subjective opinion
Studies reporting a mix of clinician-perceived barriers and prospectively defined and empirically evaluated barriers
Needham
2010 (10) QIP
1 ICU,
academic
hospital
Medical (pre: 27,
post: 30), MV
≥4d
Predefined
medical
contraindications
& group meetings
Multiprof.
Team - -
Objective
measurement
Bassett
2012 (30) QIP
13 ICUs, 8
academic
hospitals
13 ICUs in US
Predefined
medical
contraindications
& group meetings
Multiprof.
Team n.r. n.r.
Objective
measurement &
clinician survey
Balas
2014 (40)
Prosp.
cohort
study
5 ICUs, 1
step down, 1
oncology
care unit,
academic
hospital
Mixed,
(pre=146, post:
150), MV
Predefined
medical
contraindications
& data
evaluation/data
collection
Multiprof.
Team - -
Objective
measurement
Harris
2014 (42) QIP
2 ICUs, type
of hospital
n.r.
Medical/surgical
and cardiac ICU,
21 patients, 32
RT and RN
Predefined
medical
contraindications
& staff meetings /
survey &
evaluation of
experiences
Multiprof.
Team n.r. n.r. Clinician survey
Studies reporting clinician-perceived barriers only
Page 24 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
McWillia
ms 2008
(22)
Obs.
study
1 ICU,
academic
hospital
Usual PT, n=65,
>24h on ICU
Data evaluation by
authors/evaluatio
n documentation
PT - - Subjective opinion
Hildreth
2010 (26)
Cohort
study
1 ICU,
academic
hospital
Surgical (pre: 50,
post: 50), all
patients
Anecdotal report
of barriers/data
evaluation
- - - Objective
measurement
Winkelma
nn 2010
(20)
Qual.
study
2 ICUs,
academic
hospital
33 RNs Interviews/intervi
ews
RN
(number
n.r.)
- 33 RN
(100%) Clinician survey
Butcher
2012 (31) QIP
1 ICU,
academic
hospital
Surgical, (pre:
50, post: 50), all
post operative
patients
medical
contraindications
& group meetings
Multiprof.
Team - -
Objective
measurement
Drolet
2012 (32) QIP
2 ICUs,
community
hospital
Medical, surgical
and IMCU, (pre:
542, post: 784),
hospitalization
>72h
medical
contraindications
& group meetings
Multiprof.
Team - -
Objective
measurement
Engel
2012 (21) QIP
1 ICU,
academic
hospital
Mixed, (pre:
179, post: 294),
all patients
medical
contraindications
& group meetings
Multiprof.
Team - -
Objective
measurement
Genc
2012 (33)
Retr.
cohort
study
1 ICU,
academic
hospital
Mixed, n=31,
obese patients
(BMI >30)
medical
contraindications,
obesity
PT - - Objective
measurement
Balas
2013 (36)
Prosp
mixed
metho
d study
5 ICUs, 1
step down, 1
special care
unit,
academic
hospital
5 ICUs, 1 step
down, 1 special
care unit, 328
clinicians,
voluntary
3 focus sessions, 3
online surveys, 1
educational
evaluation
Multiprof.
Team n.r. n.r. Subjective opinion
Carrother
s 2013
(37)
QIP
4 ICUs, 2
academic, 2
community
hospitals
4 ICUs of San
Francisco Bay
Area
RAND Success
Factors Survey,
AHRQ Hospital
Survey on Patient
Safety Culture /
Survey
Multiprof.
Team
76% RN,
7%
physicia
ns, 18%
other
Objective
measurement
Choong
2013 (38)
Multic
enter
survey,
differe
nt
hospit
als
17 pediatric
ICUs, type of
hospital n-r-
PICUs in Canada,
61 physicians, 27
PT’s
Literature based
questionnaire /
hard copy &
electronically
survey
102
physicians,
35 PTs
64.2%
59.8%
physicia
ns,
77.1%
PTs
Subjective opinion
Damluji
2013 (39)
Prosp.
Cohort
study
1 ICU,
academic
hospital
Medical, n=239,
femoral lines
(venous, arterial,
dialysis)
medical
contraindications,
femoral lines
PT - - Objective
measurement
Talley
2013 (12) QIP
5 ICUs,
academic
hospital
Mixed, n=109,
>48h CRRT
Literature based &
staff meetings /
evaluation of
experiences
Multiprof.
Team - -
Objective
measurement
Jolley
2014 (44) Survey
1 ICU,
academic
hospital
RN, PT,
physicians,
n=203
Questionnaire /
survey
RN, PT,
physicians -
82%
physicia
n, 22%
RN, 86%
PT
Clinician survey
Wang
2014 (43)
Prosp.
cohort
study
2 ICUs, 2
academic
hospitals
Mixed, n=33,
CRRT
medical
contraindications,
CCRT / data
evaluation/data
PT - - Objective
measurement
Page 25 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society
collection
Barber
2014 (45)
Qualita
tive
Study
1 ICU,
academic
hospital
RN, PT,
physicians, n=25
Interviews /
Interviews
RN, PT,
physicians -
Physician
s (48%),
PT
(28%),
RN (24%)
Subjective opinion
Eakin
2015 (46)
Qualita
tive
Study
1 ICU,
academic
hospital
Clinicians, n=20 Interviews /
Interviews Clinicians - - Clinician survey
Bakhru,
2015 (47)
Teleph
one
Survey
687 ICUs Clinicians, n=687 Interview /
telephone survey Clinicians 73%
RN
leader Subjective opinion
Castro
2015 (48) QIP
1 ICU,
academic
hospital
RN, n=56 Questionnaire RN 63%
a. 66%,
b. 61% c.
64%
Clinician survey
Malone
2015 (49) Survey
554 ICUs,
academic,
community
hospitals
PT, n=2320 Questionnaire /
survey PT 29% PT Clinician survey
Abbreviations: Aust: Australia; CRRT: continuous renal replacement therapy; ECMO: Extra corporal membrane
oxygenation; Ger: Germany; IMCU: adult intermediate care unit; Multiprof: Multiprofessional; MV: mechanically
ventilation; n.r.: not reported; NZ: New Zealand; Obs: observational, OT: Occupational Therapy; PICU: pediatric
Intensive Care Unit; PT: Physiotherapy; Pros: prospective; Qual.: qualitative; QIP: quality improvement project; Retr:
retrospective; RN: Registered Nurse; RT: Respiratory Therapist; SAT: Spontaneous awakening trial; SBT: Spontaneous
breathing trial
1. Academic hospitals include university hospitals, academic affiliated hospitals, teaching hospitals
2. Categories within this column were defined as follows: objective measurement (defined as having at least one of
the included studies demonstrating that the strategy was successful in improving mobility rates); subjective
opinion (defined as having at least one of the included studies in which the authors concluded, based on their
opinions, the strategy was important in addressing barriers to mobility); and clinician survey (defined as clinicians
being surveyed/interviewed for their opinion about success).
3. The study included patients of Bailey, 2007.
4. The study included intervention arm of Schweickert, 2009
Page 26 of 26 ANNALSATS Articles in Press. Published on 01-February-2016 as 10.1513/AnnalsATS.201509-586FR
Copyright © 2016 by the American Thoracic Society