Move to Improve Progressive Mobility in ICU

8/10/2019 Move to Improve Progressive Mobility in ICU

1/3

Move to ImproveProgressive Mobility in the Intensive Care Unit

Jordan R. Atkins, BSN, RN;

Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC

Bed rest has detrimental consequences, and therefore in the ICU,

progressive early mobility should be the goal for every patient expected

to survive. This article examines the consequences of immobility, barriersexperienced when attempting to increase patients mobility, and ways

in which dedicated mobility teams can overcome these barriers.

Keywords: Barriers to mobility, Bed rest, Intensive care units, Mobility

teams, Progressive mobility

[DIMENSCRITCARENURS. 2014;33(5):275/277]

The intensive care unit (ICU) is a complicated place, full

of critically ill patients, life-supportive monitoring, and

emotional peaks and valleys for patients, family mem-

bers, and staff. Deconditioning is a major problem in ICUs.For every day on bed rest, a personloses 1% to 2%of mus-

cle mass; an average 1-week stay on bed rest can mean a

loss of up to 14% of muscle mass or more.1 Unfortunately,

in critically ill patients, deconditioning may also set into

motion a cascade of complications. These patients are at

increased risk for ventilator-associated pneumonia, atelec-

tasis, muscle mass loss, and hemodynamic instability, in ad-

dition to other problems. Mobility is a way to combat those

complications, but it must start early. Thus, even though

patients are debilitated, it is important to remember the

level of functioning they had before admission and thinkabout the level they need to get back to by discharge. The

goal for every patient is to return to a level of functioning

that is meaningful. The best way to achieve that goal is

progressively. This article uses case studies to show the

importance of a progressive mobility protocol, discusses

barriers in trying to implement it, and concludes with the

evidence suggesting mobility teams as an excellent way to

ensure that mobility protocols are implemented.

PROGRESSIVE MOBILITY

In progressive mobility, start with a series of planned move-

ments and build up to the goal of returning the patient tothe previous level of functioning. Assess the patients tol-

erance to an activity while escalating to more physically

challenging activities, such as getting out of bed and am-

bulating. Active and passive range-of-motion exercises can

be done in the bed to begin an activity session. Most ICUbeds will place the patient into the chair and chair egress

positions. The chair position places the patient upright at

90 degrees with feet hanging down, as if sitting in a chair.

The chair egress position is for patients who have the

ability to move their legs against gravity and have trunk

control. This position is like the chair position, but the

footboard is removed from the bed, and the patient is allowed

to bear weight on the floor. Both are excellent weight-bearing

exercises for patients that the nurse can do without the

help of another staff member. Just putting a patient in the

chair position in the bed forces the patients body to usemuscles that the patient would not use if lying supine, while

at the same time challenging the body to remain hemody-

namically stable with fluid shifts. From this beginning, the

patient can move to more mobility.

CASE STUDIES

Jordan (one of the authors) works in an ICU at High Point

Regional, a satellite facility of The University of North

Carolina at Chapel Hill Hospital, a major research insti-

tution. She has seen the importance of progressive mobility

firsthand. Carol was a typical COPD (chronic obstruc-

tive pulmonary disease) failure to wean, intubated patient.She was transferred from a nearby hospital as a respiratory

DOI: 10.1097/DCC.0000000000000063 September/October 2014 275

Progressive Mobility in the ICU

Copyright 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.


2/3

arrest and was intubated before arriving at our facility. She

was in the ICU for a few weeks, and based on the unit

protocols criteria, she was to be mobilized by using the

chair position in the bed and then being slid over to the

stretcher chair as tolerated. If she was lying in semi-Fowlersor even on continuous lateral rotation, she was able to

remain hemodynamically stable with systolic blood pres-

sures in the 130s to 140s mm Hg.

Jordan assisted Carols primary nurse to get her out

of the bed and into the stretcher chair for the first time. It

was an easy transfer, and the patient was sitting upright at

almost 90 degrees. Then, after almost an hour, the staff

noticed a change in her blood pressure: it was dropping. And

it continued to do so over the course of the next 2 hours.

The patient became so hemodynamically unstable that

she had to be placed on vasopressors in order to help her

body compensate for the fluid shifts from being upright.Her inability to maintain her blood pressure is an

example of the importance of mobility. Lying still in the

bed, her body was not challenged with the fluid shifts that

occur when a person is upright with legs hanging down. If

we had had a dedicated mobility team following a progressive

mobility protocol, the move to the stretcher chair would not

have been such a shock to her, because she would have been

mobilized sooner, consistently, and with fewer complications.

Carol ended up needing a tracheostomy and was sent to a

long-term acute care facility.

As a result of Carols experiences and those of other,

similar patients, the facility implemented a progressive mo-

bility team. Rex was one of our first success stories once

our progressive mobility team was in place. He was a car-

diac arrest patient who was nearing death. He was in

multisystem organ failure, was unconscious, and for sev-

eral days did not respond to staff or family. He ended up

on daily dialysis, but not much improvement was being

made. Talk of withdrawing care was beginning to come

up, but the night before the withdrawal date, Rex woke

up. He began responding to staff and opening his eyes. We

had already been using the bed for continuous lateral rota-

tion while he was unresponsive, but now that he couldparticipate, we began more meaningful therapy. We used

the ceiling lift to get him out of the bed and into a recliner.

He was soon extubated without any respiratory compli-

cations, although the physical deconditioning had taken a

toll on him. Physical therapists helped the nursing staff

work on mobilizing him, starting with leg exercises. It was

a slow start, but it was something. Soon Rex was using the

sit-to-stand lift where he was weight bearing, moving from

sitting in the chair to standing! After a few days of using

the lift, Rex was able to sit on the side of the bed, stand,

and pivot to the recliner without the use of a lift. His liver

and kidneys regained function, and he was able to comeoff of dialysis. Rex was moved to our step-down unit,

where we continued to work with him daily. After about

2 weeks there, he was discharged to home, walking.

Those are 2 very different stories, and the difference

was the use of a mobility team. In the first case, we used

only nursing staff to mobilize Carol. When Rex came along,we had developed a mobility team consisting of physical

therapists, respiratory therapists, and staff nurses. Also,

our intensive care physician is passionate about mobility

and helped to spearhead the movement.

DECONDITIONING

Physical deconditioning in critically ill patients is a prob-

lem. Just being in ICU compromises patients, never mind

adding other complications such as ventilator-associated

pneumonia, atelectasis, plasma volume loss, and muscle

mass loss. These complications are commonly seen but can

be prevented with progressive mobility. The sooner a pa-tient is mobilized, his/her body begins to adjust to fluid shifts

preventing orthostatic hypotension. Also, lung complications

previously mentioned are less likely to occur, because as

the patient is mobilized, he/she tends to take bigger breaths,

increasing his/her tidal volume preventing atelectasis and

ventilator-associated pneumonia, which leads to shorter

ventilator days. Muscle mass is lost quickly and poses

threats of skin breakdown along with it. When pressure

ulcers begin to form because of bed rest, the patient is at

increased risk for infection, which could lead to sepsis

and in turn a longer ICU stay.

DEVELOPING MOBILITY PROTOCOLS

AND A TEAM

Developing a progressive mobility protocol is essential.

Mobility levels 1 to 5 are assigned to the patient based

on ability to participate in activity sessions. Each level has

a set of activities that the patient should be doing that day,

for example, getting out of bed to a chair or doing standing

exercises with the sit-to-stand lift and, eventually, walking.

Defining criteria include hemodynamic stability; arm,

trunk, and leg control; and level of consciousness and the

Richmond Agitation Sedation Scale score.Given the complexity of the patients and equipment in

intensive care, these units need a dedicated mobility team

staffed with a physical therapist and assistant, occupational

therapist, respiratorytherapist, and a registered nurse, whether

the patients primary nurse or not. Having a mobility team

allows for safe transfer of patients and more productive

activity sessions. Developing a team is crucial for success

of a progressive mobility protocol. Staff nurses cannot do

it all alone, and with budget cuts, many hospitals are not

hiring extra staff. We used our managers when building

our team. We noticed that our respiratory therapists often

had multiple units to care for and could not always be atour call for ICU mobility, so their manager became our

276 Dimensions of Critical Care Nursing Vol. 33 / No. 5




3/3

mobility representative for the respiratory department. Now

the physical therapists assigned to our unit attend rounds

every morning with the nurses, our physician, nutritionists,

pharmacists, social workers, the chaplain, and the unit

coordinator to ensure they know the patients conditionand can help plan mobility for the day. The physical ther-

apist does specialized exercises with the patient, and the

respiratory therapist is there to ensure that the patients

endotracheal tube and ventilator are stable and to protect

the patients airway. A registered nurse should always be

present during activity sessions to ensure patient stability

and monitor heart rate, blood pressure, and any central

catheters the patient might have.

BARRIERS

Jordan asked the nurses on her unit about barriers to early

mobility. Common answers were lack of staff and equip-ment. It takes a number of people to assist a critically ill

patient to get out of bed; that is why many times it does not

get done. Lack of staff is a common answer when ICU staff

are asked why patients are not being mobilized as early as

they should be. However, when a mobility team is in place,

this issue is solved. A lack of lifts and equipment was con-

sidered to be a barrier on the unit because not all of the

rooms had lift tracks built into the ceiling. When these

exist in each room, it is easier for nurses and other staff to

mobilize and navigate patients to the chair, and this elim-

inates the need for other equipment in the already small

rooms. Advanced ICU beds are an important tool in mobi-

lizing patients. Many will assist with turning the patient, as

well as sitting them in a chair position. Beds with built-in

percussion and vibration help to decrease ventilator days by

increasing pulmonary function, thus improving mobility.

Still another barrier was nurses attitudes toward mo-

bility. Nurses will say that they cannot get their patient out

of bed because the patient will not cooperate or is too

delirious, but that is not an acceptable answer. Intensive

care unitYinduced delirium can be an issue, but with ade-

quateagitation assessments, and proper sedation, delirium

can be managed. Once sedation and delirium are balanced,it is easier to mobilize the patient. With a team and protocol

in place, nurses have the assistance they need to get these

patients up and moving.2

Many nurses think it is easier to leave the person in the

bed, although in reality this creates more complications.

Prolonged bed rest leads to increased ventilator time, which

means a longer ICU stay, a longer hospital stay, and in-

creased costs to the patient and organization. Studies have

shown that ICUs with a mobility intervention group have

reached milestones much sooner than those without a

dedicated mobility group, and ICUs with a mobility group

also see a decrease in delirium and ventilator days.3 These

are the positive patient outcomes we should be striving

for, and the best way to reach those outcomes is with a

properly trained, dedicated mobility intervention team.Education on the proper use of sedation and on the

equipment and resources available to staff and the im-

portance of getting patients out of the bed is imperative.

For example, the units mobility protocol along with the

Confusion Assessment Method for the Intensive Care Unit

(CAM-ICU) assessment could be made a competency check-

off. Everyone should receive refresher training on all of the

functions of the beds and lifts as well as ensuring staff un-

derstand how to accurately assess the patients CAM-ICU

and Richmond Agitation Sedation Scale. In addition, pro-

gressive mobility may need to become an explicit unit goal

or core measure. Then the units governance team can moni-tor how the unit is doing, and report the results to everyone.

Once a mobility team becomes the standard of care, ev-

eryone will see the results, including fewer complications,

shorter stays, more satisfied nurses, and happier patients

and families.

AcknowledgmentThe authors thank Ms Elizabeth Tornquist, MA, FAAN,for her the vision, inspiration, and editorial assistancewith this article.

References1. Brower RG. Consequences of bed rest. Crit Care Med. 2009;

37(suppl 10):S422-S428.2. Schweickert W, Pohlman M, Pohlman AS, et al. Early physical

and occupational therapy in mechanically ventilated, criticallyill patients: a randomised controlled trial. Lancet. 2009;373:1874-1882.

3. Adler J, Malone D. Early mobilization in the intensive careunit: a systematic review.Cardiopulm Phys Ther J. 2012;23(1):5-13.

ABOUT THE AUTHORS

Jordan R. Atkins, BSN, RN, is a staff nurse at High PointRegionalYUNC Health Care.

Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC, is an associate

professor of nursing at the University of North Carolina at Greensboro.

The authors did not receive funding for this work.

The authors have disclosed that they have no significant relationship

with, or financial interest in, any commercial companies pertaining

to this article.

Address correspondence and reprint requests to: Donald D. Kautz,

PhD, RN, CRRN, CNE, ACNS-BC, UNC Greensboro, PO Box 26170,

Greensboro, NC 27402 ([email protected]).

September/October 2014 277



Documents

Move to Improve Progressive Mobility in ICU