Early Mobilization in the ICU: Improving Patient Outcomes

Early Mobilization in the ICU: Improving Patient Outcomes

Patients in the ICU are frequently exposed to deep sedation and prolonged immobility, with limited access to rehabilitation services (Needham. JAMA. 2008;300[14]: 1685). This patient care paradigm was developed out of concern for physiologic instability, potential dislodgement of medical equipment, and patient discomfort.

However, the detrimental effects of bed rest are well-described, including insulin resistance, thromboembolic disease, disuse atrophy of muscles, and joint contractures (Brower. Crit Care Med. 2009;37[suppl 1]:S422). Survivors of critical illness may experience severe and prolonged muscle weakness and impairment in physical function (Herridge et al. N Engl J Med. 2003;348[8]:683). As ICU mortality rates continue to decline, the paradigm for ICU care must shift to reducing survivors’ long-term morbidities.

Early mobilization in the ICU seeks to reduce post-ICU physical morbidities through focused interventions that begin as soon as hemodynamic and respiratory problems have stabilized, frequently within the first 48 h after ICU admission. Growing numbers of studies demonstrate that early mobilization in the ICU is safe, feasible, and beneficial in improving patients’ short-term physical function (Schweickert et al. Lancet 2009;373[9678]:1874; Korupolu et al. Contemp Crit Care. 2009;[9]:1). Consequently, many ICUs are becoming interested in adopting early mobility programs and changing the culture of their ICU to include a model of care focused on improving patients’ long-term outcomes after ICU discharge.

Establishing a Multidisciplinary Team
Development of a successful ICU early mobility program requires a strong multidisciplinary team with a shared vision and common goals. While the ICU typically functions as a multidisciplinary environment, the ICU team must expand to include rehabilitation clinicians. This extended group includes physical and occupational therapists, sleep language pathologists, and physical medicine and rehabilitation physicians.

Learning to effectively work together requires designation of team representatives for each of the involved specialties, followed by interdisciplinary education and training, understanding each other’s roles, and clarification of the appropriate indications for early mobilization in the ICU. Regular communication and team meetings are key to understanding and addressing barriers to early mobilization of patients in the ICU.

Finally, we recommend developing a screening algorithm for early mobilization (Fig 1) to assist ICU staff in identifying eligible patients and highlighting safety issues.

Equipment and Devices
Specific equipment and devices help ensure the safety and efficiency of early mobility activities, especially for patients supported by mechanical ventilation.

At minimum, a portable cardiac monitor and pulse oximeter, wheeled IV pole, walker, and wheelchair are necessary (Fig 2). Mechanical ventilation can be provided through a number of methods, including the use of (1) the patient’s own ventilator under battery power; (2) a portable ventilator commonly used for intrahospital patient transport; or (3) a bag-valve mask with supplemental oxygen. Custom-designed biomedical devices have been created to easily and safely carry all required equipment and devices on a single wheeled pole and decrease the number of personnel required to provide mobility for a patient (Needham. Crit Care Med. 2009;37[10 suppD]: S436). Videos demonstrating one such device, along with early mobilization of mechanically ventilated patients and patient interviews, can be found at www.hopkinsmedicine.org/OACIS.

Additional rehabilitationspecific equipment and technology may play an important role for patients in the ICU. Neuromuscular electrical stimulation (NMES) therapy causes repeated muscle contractions and can be used even when patients are deeply sedated or comatose. NMES may help reduce muscle atrophy and improve weakness and physical function (Zanotti et al. Chest. 2003; 124[1];292).

In addition, specialized bedside cycle ergometers (with or without NMES) allow passive leg movement in sedated or comatose patients and active muscle training in awake patients while lying supine in bed. This cycling technology can serve as an adjunct to physical therapy and improve physical function by hospital discharge (Burtin et al. Crit Care Med. 2009; 37[9]:2499). Interactive participation with video game systems may also allow progression of activity from a seated position to a standing position, where dynamic balance, coordination, and weight-bearing activities can be initiated.

Challenges
Despite the many benefits of early mobility, challenges both within and outside the ICU must be overcome to create a successful program. First, ICU culture must change to promote patients being awake and moving. Second, an adequate, dedicated rehabilitation staff is required, which frequently requires negotiations with hospital leaders and administrators, including a cost-benefit analysis (eg, cost of early mobilization program vs savings achieved in decreasing hospital length of stay) (Korupolu et al. Contemp Crit Care. 2009;6[9]:1). Third, during daily ICU functioning, team leaders must regularly communicate to identify suitable patients for mobilization, and to coordinate, schedule and prioritize rehabilitation in conjunction with other ICU activities. Moreover, the complexity of patient problems in the ICU, including physiologic instability, delirium, and the presence of multiple medical devices, requires appropriate training, skills, and collaboration of a full multidisciplinary ICU and rehabilitation team.

Conclusion
ICU survivors frequently experience weakness and impairment in physical function, which can be severe and long-lasting after hospital discharge. Immobility is an important contributing factor to these morbidities. Early mobilization in the ICU plays a crucial role in helping improve patients’ physical health after critical illness. Expanding the ICU multidisciplinary team to include physical medicine and rehabilitation clinicians, and changing ICU culture and teamwork to embrace early mobilization can make important contributions to patients’ recovery after critical illness.

Jennifer M. Zanni, PT, MSPT; Dr. Radha
Korupolu; and Dr. Dale M. Needham, PhD.
From the Department of Physical Medicine
and Rehabilitation (JMZ) and Critical Care
Physical Medicine and Rehabilitation
Program (JMZ, RK, DMN), Johns Hopkins
Hospital; OACIS Group, Division of
Pulmonary and Critical Care Medicine,
Johns Hopkins University (RK, DMN); and
Department of Physical Medicine and
Rehabilitation (JMZ, DMN), Johns Hopkins
University, Baltimore, MD.