STANDARDIZE ICU MOBILITY.COORDINATE YOUR TEAM.IMPROVE OUTCOMES.Mobility protocol for critical care

Early mobility protocols help nurses keep the ICU safe and stable — even as patients’ conditions fluctuate quickly and dramatically.1

Caregivers follow two sets of criteria to correctly implement these guidelines:

∙ Exclusion — if contraindications ever appear in a mobilized patient, caregivers should consult a physician before resuming therapeutic activity.2

∙ Movement — if a patient ever fails to attain the movement criteria to advance to the next level of activity, caregivers should consult a physical therapist.3

Communication matters

From shift to shift and unit to unit, a patient’s mobility status should always be shared among nurses. So that caregivers can meet their patient’s physical goals and achieve standardized care together.4

1. Sommers J, Engelbert RH, Dettling-Ihnenfeldt D, et al. Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations. Clin Rehabil. 2015;29(11):1051–1063.

2. Engel HJ, Needham DM, Morris PE, Gropper MA. ICU early mobilization: from recommendation to implementation at three medical centers. Crit Care Med. 2013;41(9 Suppl 1):S69–80.

3. Agency for Healthcare Research and Quality. ICU Early Mobility Protocol. In: AHRQ safety program for mechanically ventilated patients. 2017;16(17)-0018-S2-EF.

4. Balas MC, Vasilevskis EE, Burke WJ, et al. Critical care nurses’ role in implementing the “ABCDE bundle” into practice. Crit Care Nurse. 2012;32(2):35–48.

5. Agency for Healthcare Research and Quality. ICU Early Mobility Screening Algorithm. In: AHRQ safety program for mechanically ventilated patients. 2017;16(17)-0018-S2-EF.

† AHQR recommends that a patient should not ambulate on the same day he is extubated.3

Legend

RASS: Richmond Agitation-Sedation Scale

CNS: Clinical nurse specialist

ICP: Intracranial pressure

DATs: Daily awakening trials

ROM: Risk of mortality

AHRQ: Agency for Healthcare Research and Quality

ADL: Activities of daily living

Is lack of response rooted in either CNS etiology or unstable ICP?

Change sedation measures so the patient is only mildly sedated at most. John Hopkins Medicine recommends decreasing sedation by:

∙ Ceasing continuous infusion

∙ Administering medication as needed instead of continuously

∙ Treating hyperactive delirium with antipsychotics instead of sedatives

Caregivers should then perform DATs every 12 hours.

Initiate early mobility assessment.

Reassess in 24 hours.

Begin Level 2 mobility protocol — active ROM exercises, sitting on edge of bed, active leg/arm cycling, stretching.

Proceed to Level 4 mobility — walking,† gait training, building strength by increasing exercises through:

∙ Duration

∙ Number of sets

Proceed to Level 3 mobility — transfer from bed to chair, sit to stand, static standing, ADL training, active ROM exercises.

Advance to standing.

Confine physiotherapy to the bedside.

Continue with Level 3.

Initiate Level 1 mobility.

Confine physiotherapy and orthostatic training to the bed.

START

Does patient respond adequately to verbal stimulation (RASS > -3)?

NO

YES

YES

YES

YES

NO

NO

NO

NO

PASSES

YES

FAILS

Can patient sit unassisted? AHRQ notes that if patients can tolerate chair activity, they should always sit upright in a chair at mealtimes.3

Can patient stand with assistance?

Can patient stand unaided?

∙ Intensity

∙ Frequency

SAMPLE ICU EARLY MOBILITY SCREENING ALGORITHM

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