Implementing an Early Mobility Programme for Critically Ill Patients

Introduction[edit | edit source]

As discussed here, early mobility (EM) programmes for patients in intensive care units (ICU) are safe and achievable and have been found to improve outcomes in critically unwell patients. It is key that the patients are carefully assessed in order to ensure safety. This page explores the logistics of implementing EM for patients in ICU, particularly in terms of identifying and addressing barriers to commencing EM programmes.

Impact of Immobility and Delayed Mobility[edit | edit source]

Understanding the negative multi-systemic impact of immobility reinforces the benefits of implementing EM programmes, both for clinicians and patients.[1][2][3] In general, bed rest causes increased morbidity and mortality, decreased functional capacity, increased care costs and reduced quality of life.[4]

Cardiovascular system[edit | edit source]

Inactivity and prolonged bed rest lead to cardiac deconditioning, which affects both the central and peripheral cardiovascular systems.[5] Water loss and cardiac deconditioning can occur as fluids are redistributed when a patient is in a supine position. Prolonged bed rest causes a reduction in blood volume and decreases blood return - this causes a gradual decrease in diastolic volume and stroke volume drops.[6] Stroke volume has been found to decrease by 30% after one month of bed rest.[5] This causes an increase in heart rate in order to try to maintain cardiac output.[6] As stroke volume drops, the workload of the myocardium decreases, so it begins to atrophy.[6] Orthostatic intolerance begins to develop within three days of inactivity.[5] There is also increased blood stasis, which increases the risk of deep vein thrombosis and associated conditions like embolus.[4][5][6]

Respiratory System[edit | edit source]

Bed rest results in atelectasis and increases the risk of complications such as pneumonia.[5] Bed rest often also results in delayed weaning from ventilators and decreased respiratory muscle strength.[4] There may be increased airway resistance, decreased mucus clearance with increased mucus pooling, altered ventilation/perfusion ratio and decreased minute ventilation.[4][6]

Other Complications[edit | edit source]

Bed rest also causes pressure ulcers, insulin resistance, and can lead to delirium and other impairments related to cognitive processing and sleep patterns change.[5] There are also issues associated with pain, due to conditions such as musculoskeletal dysfunction and compression neuropathy.[4]

Intensive Care Unit-Acquired Weakness[edit | edit source]

Most of the changes discussed above, improve once mobilisation is commenced and sedation is reduced.[5] Bed rest does, however, result in long term changes in skeletal muscle strength, which is referred to as Intensive Care Unit-Acquired Weakness (ICU-AW).[5] In healthy individuals, immobility is said to cause muscle strength to decrease by 1.3% to 3% per day.[2] Strength decreases by as much as 20 percent after one week of bed rest. Each subsequent week of bed rest causes a further 20 percent decrease in the remaining strength.[1] ICU-AW has been linked to prolonged hospitalisation, delayed weaning and increased mortality.[5] The aetiology of ICU-AW is complex, but risk factors for this condition include:[5]

  • Sepsis
  • Organ failure involving two or more organs and severity of illness
  • Length of time of mechanical ventilation
  • Length of ICU stay
  • Being female
  • Hyperglycemia
  • Immobility

It is believed that the combination of immobility and local / systemic inflammation promote muscle loss in critically ill patients.[5] Other musculoskeletal deconditioning that occurs with bed rest are:[4]

  • Diaphragmatic thinning, which impact the respiratory status
  • Loss of bone mineral density
  • Contracture / stiffness

Benefits of Early Mobility[edit | edit source]

An EM programme may essentially mitigate the effect of long term immobilisation.[3] These programmes are associated with improved functional capacity, increased muscle strength, decreased time on mechanical ventilation, increased walking distance and improved health related quality of life.[7] EM may help to improve muscle strength, which has a positive effect on patient-centred outcomes post discharge, as well as improve problems associated with delirium,[3] cognitive function and reduce depression.[4]

EM programmes can also have a positive impact on the respiratory system as it optimises ventilation-perfusion matching, increases the efficiency of the respiratory mechanism, enhances lung volumes, tidal volumes and minute ventilation and improves airway clearance.[4]

Positive cardiovascular effects include:[4]

  • Increases in venous return
  • Increased myocardial contractility
  • Increased stroke volume, heart rate and cardiac output
  • Increased coronary perfusion
  • Reduced blood stasis and risk of developing DVT and consequently thromboembolism

Other benefits are improved blood sugar homeostasis, gastrointestinal motility, endothelial function, decreased chronic inflammation and better regulation of hormone levels.[4]

Please also click here for more information on early mobilisation in the intensive care setting.

Barriers to Early Mobility[edit | edit source]

Despite the numerous evidence-based benefits of EM, implementing these programmes within the critical care setting remains a challenge.[8] More so, although several guidelines and safe protocols for EM have been developed for different critical care centers, implementation remains problematic.[4]

These barriers vary across ICUs depending on the patient population, setting and ICU culture.[8][9][10][11] But a recent qualitative study by Anekwe and colleagues across three teaching hospitals in Canada found that there were 36 unique complex barriers to implementing EM programmes.[8] These barriers ranged from a lack of time, equipment, poor staffing, as well as poor communication across the team and the unpredictable nature of ICU. Survey respondents also noted a lack of conviction or limited knowledge about the benefits of EM and a lack of ability to remember and focus on care pathways that could result in gain for the patient.[8] These findings reiterated previously confirmed barriers, as well as identifying new barriers associated with fear, expectation of poor outcomes and lack of evidence for EM.[8] Ultimately, the research has found that barriers to EM programmes exist at different levels:[4]

  • Patient Level[10][4]
    • Physical barriers, including lack of devices and equipment[11]
    • Respiratory instability / distress or ventilator asynchrony[10]
    • Pain
    • Poor nutritional status
    • Baseline or new immobility / weakness
    • Deep sedation
    • Delirium or agitation
    • Lack of motivation or lack of consent
    • Anxiety
    • Fatigue and sleepiness
    • Palliative care
  • Institutional level[10]
    • Limited staff
    • Time constraints[8][11]
    • Lack of EM protocol and mobility culture
    • Limited equipment[8]
  • Provider level[10]
    • Lack of knowledge of the benefits and the expertise to effectively implement EM[8]
    • Nervous or skeptical clinicians
    • Concerns about unpredictable nature of ICU[8]
    • Limited or lack of staff support
    • Lack of planning and coordination amongst mobility team
    • Lack of communication[8]
  • Family / care giver level[4]
    • Unclear expectations and roles
    • Lack of knowledge on benefits of EM
    • Lack of motivation to actively participate in mobility exercises

Facilitators to Implementing Early Mobility[edit | edit source]

Efforts to address perceived and actual barriers would help to promote EM culture in critical care settings.[4] Systematic efforts to change ICU culture to prioritise early mobilization using an interprofessional approach and multiple targeted strategies are important components of successfully implementing early mobility in clinical practice.[12][13] The general consensus on the ABCDE model of caring for critically ill patient has moved early mobility as a significant component.[4]

Efficiency in carrying out EM involves coordinated efforts between the mobility team and the patient. Below are proposed approaches to ensure efficiency and effectiveness.[4][14][5]

References[edit | edit source]

  1. ↑ 1.0 1.1 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(3):212-221.
  2. ↑ 2.0 2.1 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.
  3. ↑ 3.0 3.1 3.2 Denehy L, Lanphere J, Needham DM. Ten reasons why ICU patients should be mobilized early. Intensive Care Med. 2017;43(1):86-90. 
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 Okeke C. Implementing an Early Mobility Programme for Critically Ill Patients Course. Physioplus. 2020.
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 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.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Knight J, Nigam Y, Jones A. Effects of bedrest 1: cardiovascular, respiratory and haematological systems. Nurs Times. 2009;105(21):16-20.
  7. ↑ Arias-Fernández P, Romero-Martin M, Gómez-Salgado J, Fernández-García D. Rehabilitation and early mobilization in the critical patient: systematic review. J Phys Ther Sci. 2018;30(9):1193-1201.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 Anekwe DE, Koo KK, de Marchie M, Goldberg P, Jayaraman D, Spahija J. Interprofessional Survey of Perceived Barriers and Facilitators to Early Mobilization of Critically Ill Patients in Montreal, Canada. J Intensive Care Med. 2019;34(3):218-226. 
  9. ↑ Anekwe DE, Milner SC, Bussières A, de Marchie M, Spahija J. Intensive care unit clinicians identify many barriers to, and facilitators of, early mobilisation: a qualitative study using the Theoretical Domains Framework. J Physiother. 2020;66(2):120-127. 
  10. ↑ 10.0 10.1 10.2 10.3 10.4 Dubb R, Nydahl P, Hermes C, et al. Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units. Ann Am Thorac Soc. 2016;13(5):724-730. 
  11. ↑ 11.0 11.1 11.2 Bakhru RN, McWilliams DJ, Wiebe DJ, Spuhler VJ, Schweickert WD. Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices. An International Survey. Ann Am Thorac Soc. 2016;13(9):1527-1537.
  12. ↑ Iwashyna TJ, Hodgson CL. Early mobilization in ICU is far more than just exercise. The Lancet. 2016; 388(10052): 1351‐1352.
  13. ↑ Gosselink R, Bott J, Johnson M, et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med. 2008;34(7):1188-1199. 
  14. ↑ Hodgson CL, Stiller K, Needham DM, et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care. 2014;18(6):658. 
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