Traditional practitioners in an acute intensive setting, including physical therapists, nurses and physicians, have historically expected patients to remain on bed rest for the majority of the patient's stay in the intensive care unit (ICU). Treatment for hemodynamic instability along with organ and respiratory failure typically takes priority over declining neuromuscular or functional status. Recent research published in both physical therapy and critical care literature has linked early mobility with multiple health benefits and little risk of injury.
This research led a collaborative, multidisciplinary team at Aurora St. Luke's Medical Center in Milwaukee, WI, to initiate an activity protocol in a 24-bed medical respiratory unit. Led by Lisa West, DPT, Asif Anwar, MD, and Aaron Wolfgram, RN, the group used a previously established activity algorithm to increase mobility in critical care patients.
Consequently, the average ICU length of stay decreased by 17 percent despite a 12 percent increase in number of admissions to the ICU during the trial.
The established goal was to prove a relationship between early mobilization in critically ill patients with quality outcomes such as earlier extubation and to decrease the ICU length of stay for all patients. The target population included patients in a medical ICU setting with diagnoses such as respiratory failure, sepsis and shock, and post-surgical patients. The exclusion criteria included patients who were non-ambulatory prior to admission and those who were receiving neuromuscular blockades. The rationale for exclusion was to minimize the confounding variables and safety concerns for both the patient and caregiver.
Barriers to Mobility
There are multiple challenges to mobility in the ICU setting, including a patient's medical acuity, the use of sedation, communication with other caregivers and time limitations. These barriers required close examination to determine the causes and solutions to each, in order to facilitate an environment of increased activity.
Many of the patients admitted to the ICU have higher medical acuities compared to data from previous years. Some analysts believe that current economic conditions cause patients to delay treatment for illnesses, and as a result develop serious, life-threatening diseases. Traditionally, patients with low blood pressure, abnormal lab values or impaired cardiac function (such as arrhythmia) are on bed rest for fear of worsening an already unstable condition.
These patients relied on pharmacological or procedural intervention for treatment prior to increasing mobility. Part of the activity protocol was to determine if mobility, in addition to traditional treatment, would assist in correction of the hemodynamic instability. For example, while assisting a patient with hypotension to sit up at the edge of the bed, many times the blood pressure measurements would actually increase to a more normal range.
Use of sedation for patients in the ICU can be quite common. As part of our activity protocol, it was necessary to implement a daily interruption of sedation. These interruptions were previously difficult to execute due to a perceived safety risk for the patient and a lack of consistency between activity orders to successfully wean a patient from sedation and mechanical ventilation.
The ICU determined 8 a.m. as the time for "sedation vacation" for all patients. The early timeframe would allow nurses to communicate the results of the vacation with physicians later in the day. PT interventions were aimed for around this same time. Therapists would communicate with nurses the schedule for sedation vacation and for the physical therapy session to occur concurrently, when the patient was most alert.
Collaboration between respiratory therapists, nurses, multiple physicians, physical therapists, family members and patients requires significant communication and time commitment. In an acute-care setting it may not be feasible to spend extra time talking to other health care professionals, in addition to actual treatment time, about when and how to mobilize a patient.
Adding to this, physical therapists are becoming more and more independent within the health care realm. The DPT degree establishes an expectation for therapists to act more independently and with less direction from other health care professionals.
Despite these professional advances and especially in an intensive care setting, teamwork across multiple disciplines to progress a patient's medical, respiratory and physical status should be a priority. Therefore, a protocolized approach is mandated and used to minimize the time spent in communicating with other team members as well as perform the activities at established times.
A research article titled "Early Intensive Care Unit Mobility Therapy in the Treatment of Acute Respiratory Failure" by Morris, et al. (Critical Care Med. 2008. Vol. 36, No. 8) outlined a mobility protocol to facilitate "standard and frequent administration of physical therapy to acute respiratory failure patients." Broken into four phases, the algorithm started with passive range of motion and developed toward ambulation as the patient tolerated increase in activity.
The algorithm used in the research study was printed and placed in every patient's hospital room at Aurora St. Luke's upon admission. The algorithm served two purposes: To act as a visual reminder to progress mobility and as a communication source for caregivers to document the patient's current functional status. (See table on opposite page).
In addition to the algorithm, the team initiated a daily rounding on each patient in the ICU to begin practical application of the advanced activity guidelines.
Each morning, appropriateness of mobilization was discussed. If a patient was deemed appropriate for mobility, the nurse along with the patient's physical therapist and respiratory therapist would discuss a schedule for collaboration of care to maximize safe mobility.
For example, if the physical therapist would assist with mobilizing a ventilated patient to sit in the chair and perform core-stabilization exercises, the respiratory therapist could follow to record spontaneous volume measurements in efforts toward extubation. The team would then track the mobility on the printed algorithm, indicating to other caregivers a benchmark from which to build further mobility. This daily tracking facilitated communication and provided all staff members with the most recent and safest method to mobilize a patient.
An important part of changing the expectations for activity in the ICU was encouraging all practitioners to participate. The purpose of the algorithm and daily rounding was not to increase the number of physical therapy consults, but rather promote a change in behavior for all caregivers and therefore modify the culture of sedation and mobility.
Three months after initiating the activity protocol, data was collected on length of stay, which had decreased significantly from the previous quarter. Tracking other data points was cumbersome and hence, was not pooled in the analyzed measures and not the purpose of the activity initiative. Using a more subjective measure, walking around the ICU three months later one could observe more patients sitting in chairs and walking, versus lying in bed.
The activity protocol was successfully completed without increases in cost or personnel and one would extrapolate that it resulted in significant cost savings because of the reduced length of stay.
An unexpected result of the activity initiative was the empowerment staff felt and the revived sense of teamwork between practitioners. The activity protocol was a proactive measure that demonstrated quick, visible results.
Nurses, doctors, respiratory therapists and rehabilitation staff all contributed to positive outcomes for the patients and were able to see the enhanced quality of care as a direct consequence of their efforts.
Given the outcomes of the preliminary data, it would be safe to assume similar outcomes in future trials. Quantifying the connection between early mobility and number of ventilated days in critically ill patients is one area that has received relatively little research attention.
Determining the relationship of activity of mobile hospitalized patients with pedometers or a calorie-expenditure device and data such as length of stay or number of readmissions is predicted to result in similar conclusions. Conducting this research is significant to progress the role of evidence-based practice in place of traditional practice to advance the physical therapy profession.
Lisa West is a staff physical therapist specializing in ICU care at Aurora St. Luke's Medical Center in Milwaukee, WI. She also writes a weekly blog on the ADVANCE website called "PT and the City."