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.

A Physical Therapy Knowledge Broker project supported by: University of British Columbia Department of Physical Therapy (Faculty of Medicine), Physiotherapy Association of BC, Vancouver Coastal Research Institute and Providence Healthcare Research Institute.

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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[1][2][3][4][5][6]

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 agent[1]; 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 rhythm[5]; 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: Increased[3] 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[7]

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


How to Progress[1][3][8][9][10][11][12][13]

Continue to monitor vitals to guide progression

Level I[1]
Target Level of Consciousness (RASS)[14] Strength Criteria for Entering this Level
  • RASS -5 to -2
Turning & Bed Mobility Positioning & Devices
  • Q2H
  • Patient to assist as able
  • Keep HOB >30°
  • Apply splints, other positioning devices as per OT/PT instructions
  • Focusing on preventing pressure ulcers, especially on heels and sacrum
Exercise Program Mobilization
  • PROM exercises to incorporate into patient care (e.g. during washing, turns)
  • Additional exercise/mobilization as per physio assessment
  • HOB >45° x 30-60 minutes BID, support to achieve midline head and trunk position
Level II[1]
Target Level of Consciousness (RASS)[14] Strength Criteria for Entering this Level
  • RASS -2 to -1
Turning & Bed Mobility Positioning & Devices
  • Q2H
  • Same as Level I, plus:
    • Scooting/bridging
    • Supine ↔ Sitting
  • Same as Level I
Exercise Program Mobilization
  • Encourage patient assist with ROM during patient care (e.g. during washing, turns)
  • Consider inclusion of:
    • Breathing exercises
    • Stretching exercises
    • Balance/coordination exercises for head, neck, and trunk
  • Additional exercise/mobilization as per physio assessment
  • High fowlers or cardiac chair position x 30-60 minutes TID
  • Mobilization may include tilt table, dangle or to chair with mechanical lift prn (use caution for patients at risk of hypotension)
Level III[1]
Target Level of Consciousness (RASS)[14] Strength Criteria for Entering this Level
  • RASS -1 to +1
  • Able to move arm against gravity
Turning & Bed Mobility Positioning & Devices
  • Q2H
  • Gradual withdrawal of assistance
  • Initiation of training to promote patient’s independence
  • Same as Level I
  • Assess for seating needs
Exercise Program Mobilization
  • Encourage patient assist with ROM with more active involvement
  • Breathing, stretching, and balance/coordination exercises as prior with more active involvement
  • Consider inclusion of arm ergometry
  • Additional exercise/mobilization as per physio assessment
  • Assist physio with dangle on side of bed - may need ceiling lift if patient is heavy
  • Sitting balance exercises with physio as appropriate, 5 to 10 minutes to start
  • Initially OD, progress to BID as patient tolerates
  • As per physio assessment of patient strength, assist physio with sit to stand, walking in place; +/- walker
  • Patients with neuro/ortho status precluding weight-bearing require individualized mobilization prescription
Level IV[1]
Target Level of Consciousness (RASS)[14] Strength Criteria for Entering this Level
  • RASS -1 to +1
  • Able to move arm and leg against gravity
Turning & Bed Mobility Positioning & Devices
  • Q2H
  • Focus on training to promote patient's independence
  • Same as Level III
Exercise Program Mobilization
  • Encourage active ROM as per Level III
  • Breathing, stretching, and balance/coordination exercises as well as arm ergometry as per Level III
  • Consider inclusion of weight-bearing/weight-shifting exercises
  • Additional exercise/mobilization as per physio assessment
  • If dangle and stand at bedside successful, physio assesses ability to weight shift, ability to transfer to chair
  • Initial time in chair 30 minutes, progress per OT/PT assessment
  • Initially OD, progress to BID as patient tolerates
  • If patient able to transfer to chair, tolerates well, physio assesses ambulation, begins walking practice with appropriate aids, increasing distance and frequency as patient tolerates

Q2H = Every 2 Hours; HOB = Head of Bed; BID = Twice daily; TID = Three times daily; OD = Once daily


Richmond Agitation Sedation Scale (RASS)[14]

+4 Combative; violent, immediate danger to staff
+3 Very agitated; pulls or removes tubes/lines; aggressive
+2 Agitated; frequent non-purposeful movement, fights ventilator
+1 Restless; anxious but movement not aggressive or vigorous
0 Alert and calm
-1 Drowsy; not fully alert, sustained wakening (eye-opening/contact) to voice >10 sec
-2 Light sedation; briefly awakens with eye contact to voice <10 sec
-3 Moderate sedation; Movement or eye opening to voice but no eye contact
-4 Deep sedation; No response to voice but movement or eye opening to physical stimulation
-5 Unarousable; No response to voice or physical stimulation


References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 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,fckLR2008; 36:2238-43.
  2. 2.0 2.1 Stiller, K. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin 2007; 23, 35-53.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 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. 4.0 4.1 ACSM Guidelines for Exercise Testing and Prescription. 8th edition. Lippincott Williams & Wilkins. Philadelphia 2010 pp.209-10.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Timmerman, RA. A mobility protocol for critically ill adults. [DIMENS CRIT CARE NURS. 2007; 26(5):175-9.
  6. 6.0 6.1 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. 14.0 14.1 14.2 14.3 14.4 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.