early mobility in the intensive care unit: evidence

Feature

Early Mobility in the Intensive Care Unit: Evidence, Barriers, and Future DirectionsSusan M. Dirkes, MS, RN, CCRNCharles Kozlowski, RN

Early mobility is an element of the ABCDEF bundle designed to improve outcomes such as ventilator-free days and decreased length of stay. Evidence indicates that adherence to an early mobility protocol can prevent delirium and reduce length of stay in the intensive care unit and the hospital and may decrease length of stay in a rehabilitation facility. Yet many barriers exist to implementing early mobility effec-tively, including patient acuity, uncertainty about when to start mobilizing the patient, staffing and equipment needs, increased costs, and limited nursing time. Implementation of early mobility requires interdisciplinary collaboration, commitment, and tools that facilitate mobility and prevent injury to nurses. This article focuses on aspects of care that can affect patient outcomes, such as preventing delirium, reduc-ing sedation, monitoring the patient’s ability to wean from the ventilator, and encouraging early mobility. It also addresses the effects of immobility as well as challenges in achieving mobility and how to overcome them. (Critical Care Nurse. 2019;39[3]:33-43)

©2019 American Association of Critical-Care Nurses doi:https://doi.org/10.4037/ccn2019654

As the population ages and new treatments emerge, with more people surviving their illnesses, increasing numbers of patients are being admitted to critical care units. Today’s critical care nurses are tasked with all aspects of patient care and implementation of practices to improve

outcomes. This article focuses on aspects of care that can affect patient outcomes, such as preventing delirium, reducing sedation, monitoring the patient’s ability to wean from the ventilator, and encourag-ing early mobility. It also addresses the effects of immobility, as well as challenges in achieving mobility and tools now available to help overcome them.

The Society of Critical Care Medicine’s recently released “Clinical Practice Guidelines for the Manage-ment of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit” brings together current evidence on optimal management of pain, agitation, sedation, and delirium.1 The framework to facilitate implementation of these guidelines is an extensive set of evidence-based recommendations addressing key elements of health care quality and safety and patient suffering during critical illness.2 The ABCDEF

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Improving mobility follows reducing sedation in a natural sequence: increasing patient activity requires patients to be alert and interactive rather than sedated.

Authors

Susan M. Dirkes and Charles Kozlowski are staff nurses at the Uni-versity of Michigan hospital, Ann Arbor, Michigan.

Corresponding author: Susan M. Dirkes, MS, RN, CCRN, 3443 Tallywood Circle, Sara-sota, FL 34237 (email: [email protected]).

To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, [email protected].

bundle represents Assess, prevent and manage pain; Both spontaneous awakening trials and spontaneous breathing trials; Choice of sedation and analgesia; Delir-ium: assess, prevent and manage; Early mobility and exercise; and Family engagement and empowerment.3 A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence- based practices—generally 3 to 5—that, when performed collectively and reliably, have been shown to improve patient outcomes.4

Health care organizations that implement the ABCDEF bundle have improved patient outcomes such as reduced intensive care unit (ICU) and hospital lengths of stay, shortened duration of mechanical ventilation, decreased prevalence and duration of delirium, and decreased health care costs.5,6 This bundle can be implemented in today’s ICUs by, for example, waking patients each day from sedation, monitoring their breathing and assessing for readiness to wean from the ventilator, assessing daily for delirium, and coordinating care between disciplines. The “early mobility” part of the bundle may not be so easily achieved, for many reasons. According to Balas et

al,7 there is little evidence that mobility inter-ventions are routinely used in critical care. They suggest

that this discrepancy between what is known and what is actually done is due to a knowledge translation gap. Jolley et al8 reported that only 8% of German patients receiv-ing mechanical ventilation received out-of-bed mobiliza-tion, and across Australian and New Zealand hospitals only 3% achieved sitting at the side of the bed, with none progressing to standing or walking. The studies that have been conducted have been hampered by a lack of data identifying at-risk groups, problems with identifying the “chronically critically ill,” and differing lengths of stay.9

Patients admitted to ICUs today are often older than in the past, and survival of illness has improved markedly in recent years.10-14 Improving mobility follows reducing sedation in a natural sequence: increasing patient activ-ity requires patients to be alert and interactive rather than sedated. Adherence to the ABCDEF bundle can be helpful in facilitating this transition. Barriers to mobility implementation include patients’ being deemed “too sick” to engage in physical activity and the presence of many tubes and catheters, as well as intervention-related issues, communication and care coordination challenges, knowledge deficits, workload concerns, and documenta-tion burdens.8,15-17 In one international survey, safety concerns were considered a significant barrier to early mobility.18 Improving mobility may be the most chal-lenging part of rethinking critical care, as it involves the greatest shift in culture and daily processes.19-21 In addition, implementing a mobility program requires continued commitment from all disciplines.

Bed rest, or acute inactivity associated with hospital-ization or disease state, poses a potent threat to muscle tissue and functional capacity. Immobility, even among patients who were ambulatory before their illness, is common during hospitalization. In older adults, physi-cal inactivity during hospitalization is almost an accepted part of the inpatient experience yet contributes to a host of negative outcomes, including a reduced ability to per-form activities of daily living, an increased incidence of readmission, and institutionalization.22 Early mobility is especially important for the successful transition from the hospital to home. Several trials have established the pos-itive effects of early mobilization in critically ill patients, including a significant reduction in the incidence of delirium and an increase in ventilator-free days.8,20,21,23-25

Effects of ImmobilityLack of physical activity and prolonged bed rest have

significant effects on musculoskeletal, cardiovascular, respiratory, integumentary, and cognitive systems.20,26-28 In addition, hospitalized patients are often older, and many are obese. These patient characteristics increase the challenges associated with mobilization.

Musculoskeletal ConsequencesStudies have shown that skeletal muscle strength

declines by 1% to 1.5% per day when strict bed rest begins.29,30 Over time, the loss of lean tissue contributes


Nurses must assess whether patients are alert and able to be mobilized, as well as any functional decline, especially if they have been bedridden for several days.

to a decrease in muscle strength and power, which can affect balance and increase the occurrence of falls while reducing aerobic capacity.21,28,31-33 Other effects of immo-bility include more bony resorption than formation, resulting in a net reduction in bone integrity and demin-eralization that may place an individual at higher risk of fractures.34 Neuromuscular abnormalities can be found in patients with ICU stays of as few as 10 days.34

Contributors to muscle loss include atrophy from lack of use, inflammation, nutritional deficiencies, and a reduction in muscle protein synthesis.35-39 In addition, older age, female sex, hyperglycemia, hypoalbuminemia, parenteral nutrition, corticosteroid administration, and use of neuromuscular blocking agents are considered pos-sible risk factors for ICU-acquired weakness.35,40-46

A catabolic state develops rapidly in critically ill patients, particularly those with sepsis.46,47 Immobility increases the production of proinflammatory cytokines and reactive oxygen species, with subsequent muscle proteolysis promoting overall muscle loss.36,38,48 Anti-gravity muscles such as leg extensors and trunk muscula-ture are preferentially affected by the loss of mechanical loading compared with upper-body musculature.30,36,44,49,50 As a result of loss of muscle mass, up to 40% of muscle strength can be lost within the first week of immobiliza-tion.40 In one study involving healthy volunteers, 28 days of bed rest resulted in a 0.4-kg loss of lean muscle leg mass and a 23% reduction in leg extension.37 Given that ICU patients are not healthy and are often older than those in that study, their rate of muscle mass loss may be greater. This muscle weakness and physical disability are commonly found in these patients at discharge and can persist for years after discharge, depending on a variety of factors.16,31

Aging itself also appears to exacerbate inactivity-mediated muscle loss.51-53 Elderly patients already have significantly diminished skeletal muscle mass and strength due to sarcopenia.52-56 Kortebein et al35 showed that older adults on bed rest had greater muscle losses than did their younger counterparts. If it is assumed that the rate of muscle loss is consistent during the period of bed rest, bedridden older adults would lose muscle mass at a higher rate.

Over the past 2 decades, improvements in survival after discharge from the ICU have probably led to increased awareness of ICU-acquired weakness. Patients who sur-vive may be transferred in a very deconditioned state to

general care. These and other studies indicate that it is essential to take measures to increase mobility in criti-cally ill patients (Table).

Cardiovascular ConsequencesIn addition to loss of muscle mass, immobility results

in significant changes in the cardiovascular system. The act of lying down shifts 11% of the total blood volume away from the legs, with most of it going to the chest.60 This shift leads to an increase in cardiac workload, ele-vation of resting heart rate, and a decrease in the heart’s ability to pump, resulting in a reduction of cardiac out-put.61,62 During bed rest, the pulse rate can speed up 1 beat every few days. Increased heart rate leads to decreased diastolic filling time and shortened systolic ejection time, making the heart less capable of responding to meta-bolic demands.63 Stroke volume has been shown to be reduced by 30% within the first month of bed rest, with an associated increase in heart rate.64,65 Also, orthostatic tolerance deteriorates rapidly with immobility owing to baroreceptor dysfunction.24

Respiratory ConsequencesMechanical ventilation affects the diaphragm and its

strength. Clinically important muscle weakness has been reported in 25% to 65% of patients receiving mechanical ventilation for at least 5 days, resulting in a longer dura-tion of mechanical ventilation and increased ICU length of stay.33,40,66 One study showed that patients with respi-ratory failure who underwent prolonged mechanical ventilation (mean duration, 21 days) had prolonged functional limitations after hospi-tal dis-charge.67,68 In another study, although lung volumes improved at 6 months, only 38% of patients had returned to work in their previ-ous role, and only 32% had returned in their previous role and hours.69

The diaphragmatic dysfunction itself originates at the level of the muscle cell membrane and/or its ability to contract.65,66 Demoule et al70 found that patients showed a rapid progression of diaphragm atrophy, with a signifi-cant decrease in thickness after just 1 day of receiving mechanical ventilation. Dinglas et al71 found that survivors


of acute respiratory distress syndrome who had received mechanical ventilation had a decreased 90-day survival when they had post-ICU weakness at discharge.

Challenges in Achieving Early MobilityIncreasing the activity of patients in the hospital set-

ting presents many challenges. However, these challenges

Table Summary of key studies on mobility and findings

Abbreviations: ICU, intensive care unit; LOS, length of stay; OT, occupational therapy; PT, physical therapy; ROM, range of motion.

Study

Schweickert et al16

Morris et al58

Engel et al59

Barnes-Daly et al3

Needham et al60

Design Randomized

controlled trial

Prospective cohort study

Prospective study at 3 institutions

Prospective quality improvement study

Prospective before/after study

Patients

104 sedated patients in the medical ICU; received mechanical ventilation for < 72 h and were expected to continue for at least another 24 h

330 medical ICU patients at a single center with acute respiratory failure requiring mechanical ventilation for less than 48 hours

Patients at 3 large centers, 2 medical ICUs and 1 mixed medical-surgical ICU

6064 medical/surgical ICU patients at 7 community hospitals, receiving and not receiving mechanical ventilation, enrolled within 1 year

57 medical ICU patients at a single center, receiving mechanical ventilation for 4 days or more

Intervention

Early exercise and mobilization starting with active assisted ROM exercises, progressing to bed mobility, transferring, ambulating during periods of daily sedation interruption

Mobilization by mobility team per mobility protocol, starting with passive ROM progressing to active ROM, resistance, sitting and transferring vs usual care

Used the Institute for Healthcare Improvement framework of Plan-Do-Study-Act. Each institution developed an interprofessional team-based approach to plan, educate, and implement the program. Champions from each profession were identified to facilitate changes in culture and clinical practice.

Total and partial ABCDEF bundle compliance were measured daily, accounting for total compliance or partial compliance of the bundle

Multifaceted intervention including creation of a multi-disciplinary team; hiring 1 full-time PT, 1 full-time OT, 1 part-time rehabilitation assistant; establishing guidelines for eligibility for early mobilization and PT/OT consultation, and using administration of sedatives on an as-needed basis instead of an infusion

Primary endpoint

6-min walk distance at hospital discharge

Proportion of patients receiving PT in patients surviving to hospital discharge

Incidence of delirium and ICU and hospital LOS

Outcomes of survival and delirium- and coma-free days after adjusting for age, severity of illness, and presence of mechanical ventilation

Rehabilitation treatments, functional mobility, sedation and delirium status

Findings

Bedside ergonomics was associated with a longer 6-min walk distance and a trend toward increased discharge to home. No difference in ICU LOS or hospital LOS.

The mobility protocol was associated with more patients receiving at least 1 PT session and getting out of bed earlier and shorter ICU and hospital LOS.

Establishing an early mobility program resulted in reduced ICU and hospital LOS and a decrease in delirium.

Higher bundle compliance was associated with improved survival and more days free of delirium and coma.

The median number of rehabilitation treatments per patient increased, the proportion of treatments involving sitting or greater mobility increased, sedation requirement decreased, incidence of delirium decreased, and ICU and hospital LOS decreased.


should not prevent attempts to implement a mobility program. Major questions about the use of physical therapy (PT) for these patients include when to start mobilization, who should deliver the therapy, and how long it should be performed and at what inten-sity. Schweickert et al15 found that the percentage of patients walking independently at hospital discharge doubled from 25% to 50% with early mobilization. The recommendations of Bassett et al72 were chal-lenging; some teams who attended the educational sessions on mobility wanted to make the suggested changes but were unable to take effective action on return to their organizations.

Mobilizing patient populations has potential hazards, one of which is fall risk. Assessing the risk for falls is part of The Joint Commission’s National Patient Safety Goals.73 Frequently, a conflict arises between considering the benefits of mobility and the harm posed by immobility versus the risks to the patient of mobilization. Patient safety is often cited as a barrier to implementing an early mobility program.73 The nursing assessment may be that mobilization of the patient is not a safe option because of the patient’s weakness, weight, illness severity, dis-comfort, and length of time in bed. Because critically ill patients have poor vascular tone and often are receiving pressors, nurses may be reluctant to move them.72,74

Reported barriers to mobilization include the pres-ence of an endotracheal tube, receiving mechanical ven-tilation, the dislodgment of tubes such as catheters in continuous renal replacement therapy and extracorpo-real membrane oxygenation, and hemodynamic instabil-ity.75,76 Sedation and hemodynamic changes are given special consideration in the decision of whether to mobilize the patient.24,76,77 Nurses must assess whether the patient is alert and able to be mobilized, as well as how much functional decline there may be, especially if the patient has been bedridden for several days or more. If the assessment is inaccurate, both the nurse and the patient are at risk for injury.

Protocols for making step-by-step assessments of the patient’s readiness for mobility have been published.78,79 More recently, an international multidisciplinary expert consensus group developed recommendations for con-sideration before mobilization of patients in the ICU during mechanical ventilation.79 This panel developed a traffic light–based grading system for each of the safety criteria to determine the risks and benefits of mobilization.

Tools like this may be helpful for patient assessment and may prevent patient harm.

The ICU or nursing unit may or may not have a dedi-cated PT. Even if it does, if the unit is large (more than 10 beds), the PT may not be able to spend enough time evaluating patients and trying to mobilize them. Another consideration is whether the unit has ancillary staff to help nurses mobilize patients. The optimal frequency of mobility for a patient has not yet been determined. Some institutions have successfully implemented mobilization assessments and procedures and incorporated them into routine activities. These centers have committed teams for mobilization, including dedicated PTs.78-80 In the United States, PTs are not frequently available in the ICU; in one international study, only 34% of ICUs reported having a dedicated PT, and only 40% had an early mobility pro-gram in place.17 It is debatable whether nurses should be considered qualified to judge a patient’s ability to safely stand or even sit upright without a PT assessment.

Studies have shown that it is important to identify barriers at the organizational level to implementing early mobility protocols. Such protocols require both institutional and project leadership; additional staffing and equipment; increased physi-cian referrals for PT closer to patient ICU admission; and management of patients’ pain, delirium, tolerance for activity, and safety.74,75 Very little documen-tation exists in the literature regarding these issues.

Even if the institution agrees to implement an early mobility protocol, additional barriers—both perceived and real—may affect change. Identification of barriers to early mobilization and strategies to overcome these problems should be included as part of an early mobili-zation plan. Some of the drivers of clinical decisions may be modifiable with better adherence to sedation and mobi-lization protocols, clinical leadership, and increased staff resources and training.

Costs of MobilityStarting a mobility protocol has financial implica-

tions. Nursing costs, in addition to the use of at least 1 ancillary staff member such as a nursing assistant,81 was an additional 1 hour per patient day of nursing care cost—estimated at an average nursing wage of $540 per

Moving the patient from the bed to a chair is considered mobility if he or she can stand and bear weight.


day for the average census of 18 patients. The average wage of the temporary nursing technician is $234 per day for the same census level.81 Justifying the costs of dedicated PT or specialty tools in the ICU is difficult in light of the small amount of data available.24 Having dedicated PTs or even occupational therapists (OTs) to evaluate the patient and work with staff toward mobility comes with costs.82 It is important that institutional leaders believe that the positive outcomes justify these costs. One study by Jolley et al8 showed that dedicated PT and OT involvement was strongly associated with mobility in the ICU. Schweickert et al15 found in a ran-domized, blinded clinical trial that implementation of PT and early OT resulted in improved physical function and a reduced duration of delirium for 104 critically ill patients who were functionally independent at baseline.

Other costs include those of tools to mobilize patients, such as lift chairs or mechanical lifts (Figure 1). These tools can help in mobilizing very weak or very large patients, but not all institutions have them available. Worker injuries can be costly. According to the most recent US Bureau of Labor Statistics data, hospital workers sustain injuries and illnesses at a rate of 6.8 times that of other workers.83 In a large national survey drawn from 53 health care systems with roughly 1000 hospitals in all 50 states, patient handling injuries accounted for 25% of all workers’ compensation claims. Patient handling costs of $15 600 and wage replacement accounted for the largest share of this cost.84

In a cost-benefit analysis, decreased length of stay, decreased rehabilitation needs, and improved func-tional recovery at discharge can offset the costs of mobility.82 The costs of rehabilitation care also pose potential barriers to survivors’ recovery. Because of severe deconditioning, ICU survivors may be unable to tolerate the requirements of rehabilitation. In one study, the median cost of follow-up for all inpatient care (eg, hospitalizations, skilled nursing facility, and rehabilitation facility) was $16 800, with 81% of that attributable to postdischarge hospitalization.85

Overcoming Barriers and Tools for MobilityNurses can lessen the consequences of immobility by

initiating conversations with hospital administrators, staff members, and representatives of ancillary disci-plines about the importance of early mobilization. Some simple everyday tools are already available to foster

mobility. For example, using the high Fowler upright position in bed can help the patient feel more “normal” and also improve ventilation. One recent study showed that patients sitting upright had significantly better oxygen saturation than those who were supine.86 Upright positioning has been associated with oxygen-ation improvement in patients with acute respiratory distress syndrome because of increased functional residual capacity of the lungs.87,88 Upright positions have also been associated with a decrease in ventilator-associated pneumonia.89 Most beds have the high Fowler option for providing a good upright position. Some nursing staff consider simply sitting upright to constitute mobility, and this position is definitely a start to mobilization. However, the definition of mobile is “capable of moving.”90 Simply positioning a patient upright does not seem to meet this definition. More-over, this position does not increase strength in the legs, where the most significant muscle mass loss occurs.36,50

Figure 1 Liko Ceiling Patient Lift with HighBack Sling (Hill-Rom Services Inc) used to lift patient from bed or chair.Courtesy Hill-Rom Services Inc; used with permission.


If the patient ends up sliding down in the bed and no longer is in the upright position, this slumped position is even more detrimental to lung function and effective gas exchange. Moreover, sitting upright involves the use of core muscles but not the antigravity muscles that are significantly affected by immobility.

Moving the patient from the bed to a chair is consid-ered mobility if he or she can stand and bear weight. Nurses engage in heavy lifting to move the patient from the bed to initiate mobilization. More and more hospi-tals are using mechanical lifts to move a patient into a chair. Patients simply sitting in a chair are generally not using extensor muscles unless they are using the pedal device or stretch bands, which can greatly improve overall mobility.

Inflatable hover mats are also good tools to move the patient from the bed to a chair if no lift is available. Again, however, the patient must perform some type of exercise to strengthen muscles while in the chair, such as pedaling or using elastic bands.

Tilt tables can be used to gradually move the patient into an upright standing position. This tool does improve mobility because it not only positions the patient upright but at the same time improves orthostatic stability. Some of these tables allow the patient to stand on a surface at the foot of the table, causing the patient to use the leg muscles to bear weight. This maneuver not only increases muscle strength but also improves ventilation.91 However,

these tables are not readily available or frequently used in most nursing units and generally require PT supervi-sion.17 In addition, the patient must be transferred to the table, which requires additional personnel, adding to the nursing workload.

Chairs that stand the patient are also available. They accomplish the same objectives as the tilt table, and are excellent at gradually increasing the patient’s weight-bearing, but they come with the same workload challenges mentioned above. These chairs may not be suitable for the obese patients frequently encountered in practice.

Newer Tools for MobilityNewer beds are being devised that can help increase

mobility for normal-weight patients, obese patients, and the critically ill. These include typical critical care beds such as the VitalGo Total Lift Bed (VitalGo Systems Ltd; Figure 2) and the Catalyst bed (Kreg Therapeutics; Figure 3). These beds are unique in that they can stand patients upright. The patient is strapped in at the legs and the chest and the bed is gradually moved into a more upright position. This type of bed accommodates obese patients, requires fewer staff members, and allows gradual and safe positioning of the patient, and thus can greatly improve patient mobilization. Much like the tilt table and stand-ing chair, this type of bed can also help reduce footdrop, increase leg muscle strength, and improve ventilation and weaning from supplemental oxygen or the ventilator.

Figure 2 VitalGo Total Lift Bed (VitalGo Systems Ltd). (A) 60-degree tilt. (B) Full stand position.Courtesy of VitalGo Systems Ltd.

A B


It may also reduce length of stay in a rehabilitation facil-ity after discharge because of the patient’s increased strength and mobility. Although these “standing” beds are very new, some institutions are beginning to use them and are evaluating the results.

ConclusionEarly mobility is a high priority to help patients recover

and reduce their length of stay. Current methods of pro-viding early mobility are time consuming, are potentially costly if therapists are used, and typically increase the nursing workload. In addition, mobilizing very large, elderly, or weak patients requires extra time and addi-tional staff and may result in nurse or patient injury. Having the proper tools can improve outcomes. Nurses play an important role in driving the change toward early mobilization of critical care patients. They are instrumental in working with the health care team and other disciplines to implement early mobility programs. Cooperation and commitment of administrators and hospital PT and OT departments are essential to the suc-cess of such programs. CCN

Financial Disclosures None reported.

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See alsoTo learn more about mobility in the critical care setting, read “Identi-fying Barriers to Nurse-Facilitated Patient Mobility in the Intensive Care Unit” by Young et al in the American Journal of Critical Care, May 2018;27:186-193. Available at www.ajcconline.org.

References1. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the

management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306.

2. Marra A, Ely EW, Pandharipande PP, Patel MB. The ABCDEF bundle in critical care. Crit Care Clin. 2017;33(2):225-243.

3. Barnes-Daly MA, Phillips G, Ely W. Improving hospital survival and reducing brain dysfunction at seven California community hospitals: implementing PAD guidelines via the ABCDEF bundle in 6064 patients. Crit Care Med. 2017;45(2):171-178.

4. Institute for Healthcare Improvement. What is a bundle? Institute for Healthcare Improvement website. http://www.ihi.org/resources/Pages /ImprovementStories/WhatIsaBundle.aspx. Accessed March 13, 2019.

5. Kram SL, DiBartolo MC, Hinderer K, Jones RA. Implementation of the ABCDE bundle to improve patient outcomes in the intensive care unit in a rural community hospital. Dimens Crit Care Nurs. 2015;34(5):250-258.

6. Kress JP, Hall JB. ICU-acquired weakness and recovery from critical ill-ness. N Engl J Med. 2014;370(17):1626-1635.

7. 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 delir-ium guidelines. Crit Care Med. 2013;41(9 suppl 1):S116-S127.

8. Jolley SE, Moss M, Needham DM, et al. Point prevalence study of mobi-lization practices for acute respiratory failure patients in the United States. Crit Care Med. 2017;45(2):205-215.

9. Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J Respir Crit Care. 2010;182(4):446-454.

10. Brummel NE, Balas MC, Morandi A, Ferrante LE, Gill TM, Ely EW. Understanding and reducing disability in older adults following critical illness. Crit Care Med. 2015;43(6):1265-1275.

11. Kahn JM, Benson NM, Appleby D, Carson SS, Iwashyna TJ. Long-term acute care hospitalization after critical illness. JAMA. 2010;303(22): 2253-2259.

12. Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762-2770.

13. Wunsch H, Guerra C, Barnato AE, Angus DC, Li G, Linde-Zwirble WT. Three-year outcomes for Medicare beneficiaries who survive intensive care. JAMA. 2010;303(9):849-856.

14. Iwashyna TJ, Cooke CR, Wunsch H, Kahn JM. Population burden of long-term survivorship after severe sepsis in older Americans. J Am Geriatr Soc. 2012;60(6):1070-1077.

15. 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(9678):1874-1882.

16. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35(1):139-145.

17. Pohlman MC, Schweickert WD, Pohlman AS, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical venti-lation. Crit Care Med. 2010;38(11):2089-2094.

18. Bakhru RN, McWilliams DJ, Wiebe DJ, Spuhler VJ, Schweickert WD. Intensive care unit structure variation and implications for early mobili-zation practices: an international survey. Ann Am Thorac Soc. 2016; 13(9):1527-1537.

19. Lipshutz A, Gropper MA. Acquired neuromuscular weakness and early mobilization in the intensive care unit. Anesthesiology. 2013;118(1):202-215.

20. Garzon-Serrano J, Ryan C, Waak K, et al. Early mobilization in critically ill patients: patients’ mobilization level depends on health care provider’s profession. PM R. 2011;3(4):307-313.

21. Menendez-Tellez PA, Needham DM. Early physical rehabilitation in the ICU and ventilator liberation. Respir Care. 2012;57(10):1663-1669.

22. English KL, Paddon-Jones D. Protecting muscle mass and function in older adults during bed rest. Curr Opin Clin Nutr Metab Care. 2010;13(1):34-39.

23. Schaller SJ, Anstey M, Blobner M, et al. Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial. Lancet. 2016;388(10052):1377-1387.

Figure 3 Catalyst bed for standing mobility (Kreg Therapeutics).Courtesy of Kreg Therapeutics.


24. 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.

25. TEAM Study Investigators, Hodgson C, Bellomo R, et al. Early mobili-zation and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study. Crit Care. 2015;19:81.

26. Chambers MA, Moylan JS, Reid MB. Physical inactivity and muscle weak-ness in the critically ill. Crit Care Med. 2009;37(10 suppl):S337-S346.

27. Puthucheary ZA, Rawal J, McPhail M, et al. Acute skeletal muscle wast-ing in critical illness. JAMA. 2013;310(15):1591-1600.

28. Siebens H, Aronow H, Edwards D, Ghasemi Z. A randomized controlled trial of exercise to improve outcomes of acute hospitalization in older adults. J Am Geriatr Soc. 2000;48(12):1545-1552.

29. 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.

30. Honkonen SE, Kannus P, Natri A, Latvala K, Jarvinen MJ. Isokinetic per-formance of the thigh muscles after tibial plateau fractures. Int Orthop. 1997;21(5):323-326.

31. Herridge MS, Batt J, Santos CD. ICU-acquired weakness, morbidity, and death. Am J Respir Crit Care Med. 2014;190(4):360-362.

32. Wolfson L, Judge J, Whipple R, King M. Strength is a major factor in balance, gait, and the occurrence of falls. J Gerontol A Biol Sci Med Sci. 1995;50(special No.):64-67.

33. Ali NA, O’Brien JM Jr, Hoffmann SP, et al. Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med. 2008;178(3):261-268.

34. National Institutes of Health Osteoporosis and Related Bone Diseases, National Resource Center. Bed Rest and Immobilization: Risk Factors for Bone Loss. https://www.bones.nih.gov/health-info/bone/osteoporosis /conditions-behaviors/bed-rest. Accessed March 18, 2019.

35. Kortebein P, Ferrando A, Lombeida J, Wolfe R, Evans JW. Effect of 10 days of bedrest on skeletal muscle in healthy older adults. JAMA. 2007; 297(16):1772-1774.

36. Bloomfield S. Changes in musculoskeletal structure and function with prolonged bedrest. Med Sci Sports Exerc. 1997;29(2):197-206.

37. Paddon-Jones D, Sheffield-Moore M, Urban RJ, et al. Essential amino acid and carbohydrate supplementation ameliorates muscle protein loss in humans during 28 days bedrest. J Clin Endocrinol Metab. 2004;89(9): 4351-4358.

38. Powers SK, Smuder AJ, Criswell DS. Mechanistic links between oxidative stress and disuse muscle atrophy. Antioxid Redox Signal. 2011;15(9): 2519-2528.

39. Vesali RF, Cibicek N, Jakobsson T, Klaude M, Wernerman J, Rooyackers O. Protein metabolism in leg muscle following an endotoxin injection in healthy volunteers. Clin Sci (Lond). 2009;118(6):421-427.

40. DeJonghe B, Sharshar T, Lefaucheur JP, et al. Paresis acquired in the inten-sive care unit: a prospective multicenter study. JAMA. 2002;288(22): 2859-2867.

41. Witt NJ, Zochodne DW, Bolton CF, et al. Peripheral nerve function in sepsis and multiple organ failure. Chest. 1991;99(1):176-184.

42. Nates JL, Cooper DJ, Day B, Tuxen DV. Acute weakness syndromes in critically ill patients—a reappraisal. Anaesth Intensive Care. 1997;25(5):502-513.

43. Owczarek J, Jasinska M, Orszulak-Michalak D. Drug-induced myopathies: an overview of the possible mechanisms. Pharmacol Rep. 2005;57(1):23-34.

44. Topp R, Ditmyer M, King K, Doherty K, Hornyak J 3rd. The effect of bed rest and potential of prehabilitation on patients in the intensive care unit. AACN Clin Issues. 2002;13(2):263-276.

45. Gooch JL, Suchyta MR, Balbierz JM, Petajan JH, Clemmer TP. Prolonged paralysis treatment with neuromuscular junction blocking agents. Crit Care Med. 1991;19(9):1125-1131.

46. Garnacho-Montero J, Madrazo-Osuna J, Garcia-Garmendia JL, et al. Critical illness polyneuropathy: risk factors and clinical consequences: a cohort study in septic patients. Intensive Care Med. 2001;27(8):1288-1296.

47. Marshall JC. Inflammation, coagulopathy, and the pathogenesis of mul-tiple organ dysfunction syndrome. Crit Care Med. 2001;29(7 suppl): S99-S106.

48. Witteveen E, Wieske L, van der Poll T, et al. Increased early systemic inflammation in ICU-acquired weakness; a prospective observational cohort study. Crit Care Med. 2017;45(6):972-979.

49. Griffiths RD. Muscle mass, survival and the elderly ICU patient. Nutri-tion. 1996;12(6):456-458.

50. LeBlanc AD, Schneider VS, Evans HJ, Pientok C, Rowe R, Spector E. Regional changes in muscle mass following 17 weeks of bedrest. J Appl Physiol (1985). 1992;73(5):2172-2178.

51. Baumgartner RN, Koehler KM, Gallagher D, et al. Epidemiology of sarco-penia among elderly in New Mexico. Am J Epidemiol. 1998;147(8): 755-763.

52. Kirkwood TB. Understanding the odd science of aging. Cell. 2005;120(4): 437-447.

53. López-Otín C, Blasco MA, Partridge L, Serrano M, Kroemer G. The hall-marks of aging. Cell. 2013;153(6):1194-1217.

54. Kizilarslanoglu MC, Kuyumcu M, Yesil Y, Halil M. Sarcopenia in critically ill patients. J Anesth. 2016;30(5):884-890.

55. Morley JE. Sarcopenia: diagnosis and treatment. J Nutr Health Aging. 2008;12(7):452-456.

56. Wang C, Bai L. Sarcopenia in the elderly: basic and clinical issues. Geriatr Gerontol Int. 2012;12(3):388-396.

57. Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobil-ity therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36:2238-2243.

58. Engel HJ, Needham DM, Morris PE, et al. ICU early mobilization: from recommendation to implementation at three centers. Crit Care Med. 2013;41(9 suppl 1):S69-S80.

59. Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patient with acute respiratory failure. Arch Phys Med Rehabil. 2010;91(4):536-542.

60. Allen C, Glasziou P, Del Marc C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet. 1999;354(9186):1229-1233.

61. Convertino V. Cardiovascular consequences of bed rest on maximal oxygen uptake. Med Sci Sports Exerc. 1997;29(2):191-196.

62. Convertino V, Bloomfield S, Greenleaf J. An overview of the issues: phys-iological effects of bed rest and restricted physical activity. Med Sci Sports Exerc. 1997;29(2):187-190.

63. Saltin B, Blomqvist G, Mitchell JH, Johnson RL Jr, Wildenthal K, Chap-man CB. Response to exercise after bed rest and after training. Circula-tion. 1968;38(5 suppl):VII1-VII78.

64. Taylor HL, Henschel A, et al. Effects of bed rest on cardiovascular func-tion and work performance. J Appl Physiol. 1949;2(5):223-239.

65. Convertino V, Hung J, Goldwater D, DeBusk RF. Cardiovascular responses to exercise in middle-aged men after 10 days of bed rest. Cir-culation. 1982;65(1):134-140.

66. Johnson EC, Hudson TL, Greene ER. Left ventricular hemodynamics during exercise recovery. J Appl Physiol (1985). 1990;69(1):104-111.

67. Jaber S, Petrof BJ, Jung B, et al. Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans. Am J Respir Crit Care Med. 2011;183(3):364-371.

68. Cox CE, Carson SS. Medical and economic implications of prolonged mechanical ventilation and expedited post-acute care. Semin Respir Crit Care Med. 2012;33(4):357-361.

69. Norman BC, Jackson JC, Graves JA, et al. Employment outcomes after critical illness: an analysis of the bringing to light the risk factors and incidence of neuropsychological dysfunction in ICU survivors cohort. Crit Care Med. 2016;44(11):2003-2010.

70. Demoule A, Molinari N, Jung B, Prodanovic H, Chanques G, Matecki S. Patterns of diaphragm function in critically ill patients receiving pro-longed mechanical ventilation: a prospective longitudinal study. Ann Intensive Care. 2016;6(1):75.

71. Dinglas VD, Aronson Friedman L, Colantuoni E, et al. Muscle weakness and 5-year survival in acute respiratory distress syndrome survivors. Crit Care Med. 2017;45(3):446-453.

72. Bassett R, Adams KM, Danesh V, et al. Rethinking critical care: decreas-ing sedation, increasing delirium monitoring, and increasing patient mobility. Jt Comm J Qual Patient Saf. 2015;41(2):62-74.

73. The Joint Commission. 2017 National Patient Safety Goals presentation. The Joint Commission website. https://www.jointcommission.org/npsg _presentation. 2016. Accessed March 13, 2019.

74. Stiller K. Safety issues that should be considered when mobilizing criti-cally ill patients. Crit Care Clin. 2007;23(1):35-53.

75. Dubb R, Nydahl P, Hermes C, et al. Barriers and strategies for early mobiliza-tion of patients in intensive care units. Ann Am Thorac Soc. 2016;13(5):724-730.

76. Stiller K, Phillips AC, Lambert P. The safety of mobilisation and its effect on haemodynamic and respiratory status of intensive care patients. Physiother Theory Pract. 2004;20:175-185.

77. Fless K, Modica T, Wong J, Yodice P, Resai F, Litinski M. Implementation of a formal mobility protocol screening tool in the intensive care unit (ICU). Crit Care Med. 2013;41(9):S69-S80.

78. Green M, Marzano V, Leditschke IA, Mitchell I, Bissett B. Mobilization of intensive care patients: a multidisciplinary practical guide for clinicians. J Multidiscip Healthc. 2016;9:247-256.

79. Hodgson CL, Stiller K, Needham DM, et al. Expert consensus and rec-ommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care. 2014;18(6):658.

80. Nydahl P, Sricharoenchai T, Chandra S, et al. Safety of patient mobiliza-tion and rehabilitation in the intensive care unit: systematic review with meta-analysis. Ann Am Thorac Soc. 2017;14(5):766-777.


81. Knoblauch DJ, Bettis MA, Lundy F, Meldrum C. Financial implications of starting a mobility protocol in a surgical intensive care unit. Crit Care Nurs Q. 2013;36(1):120-126.

82. Lord RK, Mayhew CR, Korupolu R, et al. ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care Med. 2013;41(3): 717-724.

83. US Department of Labor, Bureau of Labor Statistics. https://www.bls .gov/opub/mlr/2017/article/hospital-workers-an-assessment-of -occupational-injuries-and-illness.htm. Accessed March 18, 2019.

84. US Department of Labor, Occupational Safety and Health Administration. September 2013. Section 4, Why It Matters. https://www.osha.gov/dsg /hospitals/documents/1.2_Factbook_508.pdf. Accessed March 18, 2019.

85. Ruhl A, Huang M, Colantuoni E, et al. Healthcare utilization and costs in ARDS survivors: a 1-year longitudinal national US multicenter study. Intensive Care Med. 2017;43(7):980-991.

86. Richard JC, Maggiore SM, Mancebo J, Lemaire F, Jonson B, Brochard L. Effects of vertical positioning on gas exchange and lung volumes in acute respiratory distress syndrome. Intensive Care Med. 2006;32(10):1623-1626.

87. Richard JC, Lefebvre JC. Positioning of patients with acute respiratory distress syndrome: combining prone and upright makes sense. Crit Care. 2011;15(6):1019.

88. Niël-Weise BSL, Gastmeier P, Kola A, et al. An evidence-based recom-mendation on bed head elevation for mechanically ventilated patients. Crit Care. 2011;15(2):R111.

89. Alexiou VG, Ierodiakonou V, Dimopoulos G, Falagas ME. Impact of patient position on the incidence of ventilator-associated pneumonia: a meta-analysis of randomized controlled trials. J Crit Care. 2009;24(4): 515-522.

90. Dictionary.com, s.v. “mobile.” http://www.dictionary.com/browse /mobile. Accessed March 18, 2019.

91. Chang AT, Boots R, Hodges PW, Thomas PJ, Paratz JD. Standing with the assistance of a tilt table improves minute ventilation in chronic critically ill patients. Arch Phys Med Rehabil. 2004;85(12):1972-1976.


CCN Fast Facts CriticalCareNurseThe journal for high acuity, progressive, and critical care nursing

Early Mobility in the Intensive Care Unit: Evidence, Barriers, and Future Directions

Dirkes SM, Kozlowski C. Early mobility in the intensive care unit: evidence, barriers, and future directions. Critical Care Nurse. 2019;39(3):33-43.

Early mobility is a high priority to help patients recover and reduce their length of stay. Current methods of providing early mobility are time

consuming, are potentially costly if therapists are used, and typically increase the nursing workload. Having the proper tools can improve outcomes. Nurses play an important role in driving the change toward early mobilization of critical care patients.

• Bed rest poses a potent threat to muscle tissue and functional capacity. Studies have shown that skeletal muscle strength declines by 1% to 1.5% per day when strict bed rest begins. Over time, the loss of lean tis-sue contributes to a decrease in muscle strength and power, which can affect balance and increase the occurrence of falls while reducing aerobic capacity.

• Immobility also results in significant changes in the cardiovascular system. The act of lying down shifts 11% of the total blood volume away from the legs, with most of it going to the chest. This shift leads to an increase in cardiac workload, elevation of resting heart rate, and a decrease in the heart’s ability to pump, resulting in a reduction of cardiac output.

• Patient safety is often cited as a barrier to implement-ing an early mobility program. Nurses must assess whether the patient is alert and able to be mobilized, as well as how much functional decline there may be, especially if the patient has been bedridden for several days or more. If the assessment is inaccurate, both the nurse and the patient are at risk for injury.

• Some nursing staff consider simply sitting upright to constitute mobility, and this position is definitely a

start to mobilization. However, the definition of mobile is “capable of moving.” Simply positioning a patient upright does not seem to meet this definition. Moreover, this position does not increase strength in the legs, where the most significant muscle mass loss occurs.

• Moving the patient from the bed to a chair is considered mobility if he or she can stand and bear weight. More and more hospitals are using mechanical lifts to move a patient into a chair. Inflatable hover mats are also good tools to move the patient from the bed to a chair.

• Tilt tables can be used to gradually move the patient into an upright standing position. Chairs that stand the patient are also available. They are excellent at gradually increasing the patient’s weightbearing, but may not be suitable for the obese patients frequently encountered in practice.

• Newer beds can help increase mobility for normal-weight and obese critically ill patients. The patient is strapped in at the legs and the chest and the bed is gradually moved into a more upright position. This type of bed requires fewer staff members and allows gradual and safe positioning of the patient, and thus can greatly improve patient mobilization. Much like the tilt table and standing chair, this type of bed can also help reduce footdrop, increase leg muscle strength, and improve ventilation and weaning from supplemen-tal oxygen or the ventilator. CCN

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early mobility in the intensive care unit: evidence

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