SAFEMOB

Developed by the SAFEMOB Task Force:
Dr. Elizabeth Dean, Dr. Darlene Reid, Frank Chung, Simone Gruenig, Rosalyn Jones, Jocelyn Ross, Maylinda Urbina, Alison Hoens.

SAFE PRESCRIPTION OF MOBILIZING PATIENTS IN ACUTE CARE SETTINGS

What to Assess, What to Monitor, When not to Mobilize, and How to Mobilize and Progress

Purpose, Scope, & Disclaimer

The purpose of this document is to provide physical therapists with guidance on safe mobilization of the patient in acute care settings. This decision-making guide is evidence informed and where there is insufficient evidence, expert informed. It is not intended to replace the clinician’s clinical reasoning skills and interprofessional collaboration. Mobilization, for the purposes of this document, has been defined as “To work towards the functional task of locomotion”.

What to Assess

The Chart

The Patient, Family, and Team Member

Medical history Premorbid level of function (e.g., mobility aids), activity and exercise response Primary diagnosis Medications Investigations, lab work (e.g., Hgb, RBC, Blood sugar, ECG, fluid/electrolytes) Risk factors and lifestyle conditions Physician orders re specific restrictions on mobilization

Multisystem review (e.g. cognition, respiratory, cardiac, musculoskeletal & neuro systems) Level of cooperation Ask patient what he/she currently feels about mobilization concerns and readiness. Consider the impact of the illness or medical procedures & medications on the patient’s mobility (e.g. weakness from disuse, incision, trauma, pain, equipment needs, e.g., walker) Coordinate with team members the timing of treatment with medication, availability of equipment and of personnel to optimize effectiveness

When to Consider Not Mobilizing

Cardiovascular Status	Respiratory Status
Mean arterial pressure: <65 1,3 or >110 3 BP: A drop in systolic pressure (>20 mm Hg) or below pre-exercise level OR a disproportionate rise i.e., >200 mm Hg for systolic or >110 mm Hg for diastolic 4 HR: <40 3 or >130 3,5; requiring temporary pacer. Hemodynamic: Administration of a new pressor e.g. inotropes agent1; two or more pressor or frequent increase 5; uncontrolled systemic hypertension; active bleeding 3,5 Acute or unstable cardiac status: New MI 1; dysrhythmia requiring new medications 1; active cardiac ischemia 3; unstable rhythm5; intra aortic balloon 5 Pulmonary embolus: Discussion with physician required to determine suitability Deep venous thrombosis: May mobilize as tolerated immediately after low molecular weight heparin (e.g, enoxaparin (lovenox®), dalteparin (fragmin®), tinzaparin (innohep®), nadroparin (fraxiparine®)) is given. If patient is on any other form of anticoagulation (e.g., IV heparin) please check mobility orders with the physician. Monitor patient for changes in pain, swelling, colour and sudden shortness of breath 6	SpO2: <88% 1,3 or undetermined cyanosis RR: <5 or >40 3 FiO2: >60% 5 Ventilator issues: Decreased ventilatory support that could precipitate fatigue or increased ventilatory support; ventilator asynchrony 3; unsecure airway 3; pressure control ventilation 5; uncontrolled airway irritability Uncontrolled asthma
Neurological Status	Other
Patient status: Severe agitation, distress, or combative 2,3; not able to understand instructions thus risking patient or therapist safety ICP: Increased3 i.e. >20 mm Hg, however, ICP needs to be considered in conjunction with cerebral compliance Uncleared, unstable/non fixated spinal cord injury 5 or head injury	Intermittent hemodialysis 3 Unstable fracture Excessive muscle soreness or fatigue that is residual from last exercise or activity session Other contraindications specific to a given setting/unit

• Please note: The cited values are not absolute criteria for withholding mobilization but are within the range of concern that could benefit from team discussion.

What to Consider During Mobilization

Subjective	Objective
Dizziness Vertigo Shortness of breath Fatigue Nausea Pain Consider use of scales (e.g. Borg scale of perceived exertion)	Cognition Balance Perspiration Cyanosis Heart rate Oxygen saturation Respiratory rate Blood pressure All other factors relevant to patient and mobility task (e.g. cardiac rhythm in those patients when ECG is essential during mobilization)

How to Mobilize and Progress

Step 1: Prepare	Step 2: Safety First
Note obstacles or challenges related to the patient and environment and plan appropriately (e.g. set up equipment – chairs, transfer belt, mobility aids, length of leads/lines) Determine whether the benefits outweigh the risk Ensure pre-medication as indicated (analgesia, bronchodilators, oxygen) Obtain baseline vital signs (heart rate, blood pressure, oxygen saturation) Have objective end-points such as limits of blood pressure, heart rate, oxygen saturation and level of exertion pre-determined before mobilization	Use proper body mechanics during transfer and allow gradual change from lying to upright position; Encourage circulation exercises i.e. foot and ankle, knee flexion/extension before commencing more demanding mobilization procedures If postural hypotension is suspected, monitor BP and ask patient about lightheadedness at each phase of the mobilization i.e. sitting on edge of bed, standing, walking a few paces
Step 3: When to Quite While You are Still Ahead	Step 4: Monitor and Progress
Monitor closely. Watch for signs of fatigue, pain, diaphoresis and intolerance during activity; Frequently ask patient how he/she feels Evaluate patient’s status at each progression to determine whether to continue or stop	Determine the limiting factor of the mobilization and any undesirable response(s) Use objective outcome measures to monitor progress e.g., ease of transfer, sitting duration, walking distance, HR, RR, oxygen saturation, Borg scales, and pain scales After mobilization, monitor patient until vital signs have returned to pre-activity level

References

1. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical Care Medicine, 2008; 36:2238-43. 2. Stiller, K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin 2007; 23, 35-53. 3. Schweickert WD, Pohlman MC, Pohlman NS Nigos C, Pawlik AJ, Esbrook CL et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: an RCT. Lancet. 2009; 373:1874-82. 4. ACSM Guidelines for Exercise Testing and Prescription. 8th edition. Lippincott Williams & Wilkins. Philadelphia 2010 pp.209-10. 5. Timmerman, RA. A mobility protocol for critically ill adults. [DIMENS CRIT CARE NURS. 2007; 26(5):175-9. 6. Singh C, Fletcher R, Cunningham K, and Szlivka M. Mobilization with a Deep Vein Thrombosis. Clinical Practice Guideline (DRAFT in process). Fraser Health Authority. 2009. 7. Reid WD, Chung F. Clinical management notes and case histories in cardiopulmonary physical therapy. New Jersey: Slack; 2004. 8. Chung F, Fletcher R, Lavoie K, Parrent L, Perret D, Roy L, Urbina,M. Members of the physiotherapy professional practice council critical care practice stream for the Fraser Health Authority. Canada. Forthcoming. 2009. 9. Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007; 35:139-45. 10. Collard HR, Saint S, Matthay MA. Prevention of ventilator-associated pneumonia: an evidence-based systematic review. Ann Intern Med. 2003;138:494-501. 11. Dodek P, Keenan S, Cook D, MD, Heyland D, Jacka M, Hand L et al. Evidence-based clinical practice guideline for the prevention of ventilator associated pneumonia. Ann Intern Med. 2004; 141:305-13. 12. Needham D. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008; 300:1685-90. 13. Perme C, Chandrashekar R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care. 2009; 18:212-21. 14. Sessler CN, Gosnell M, Grap MJ, Brophy GT, O'Neal PV, Keane KA et al. The Richmond Agitation-Sedation Scale: validity and reliability. Am J Respir Crit Care Med 2002; 166:1338-44.