Cardiopulmonary Physical Therapy Journal Vol 23 Y No 1 YMarch 2012 26

What Are the Barriers to Mobilizing

Intensive Care Patients?
I Anne Leditschke, FRACP, FCIC, MMgt;
1
Margot Green, Bachelor of Applied Science (Physiotherapy);
2
Joelie Irvine,
BPhysio;
3
Bernie Bissett, Bachelor of Applied Science (Physiotherapy) (Hons);
4
Imogen A. Mitchell, FRCP FRACP FCICM
5
1
Senior Specialist, Intensive Care Unit, Canberra Hospital; & Senior Lecturer, Australian National University, Canberra,
Australia,
2
Senior Physiotherapist, Intensive Care Unit, Canberra Hospital; & Physiotherapy Department, Canberra Hospital,
Canberra, Australia,
3
Cardiorespiratory Physiotherapist, Physiotherapy Department, Canberra Hospital, Canberra, Australia
4
Clinical Educator, Physiotherapy Department, Canberra Hospital; & University of Queensland, Australia,
5
Director, Intensive
Care Unit, Canberra Hospital; and Associate Professor, Australian National University, Canberra Australia
Address correspondence to: I Anne Leditschke, FRACP,
FCICM, MMgt, Intensive Care Unit, Canberra Hospital,
Canberra, ACT Australia 2605, Ph: +61 2 6244 3103,
Fax: +61 2 6244 3507 (Anne.Leditschke@act.gov.au).
ABSTRACT
Purpose: Recently there has been increased interest in early
mobilization of critically ill patients.

Proposed benets in-
clude improvements in respiratory function, muscle wast-
ing, intensive care unit (ICU), and hospital length of stay.
We studied the frequency of early mobilization in our inten-
sive care unit in order to identify barriers to early mobiliza-
tion. Methods: A 4-week prospective audit of 106 patients
admitted to a mixed medical-surgical tertiary ICU (mean
age 60 20 years, mean APACHE II score 14.7 7.8) was
performed. Outcome measures included number of patient
days mobilized, type of mobilization, adverse events, and
reasons for inability to mobilize. Results: Patients were mo-
bilized on 176 (54%) of 327 patient days. Adverse events
occurred in 2 of 176 mobilization episodes (1.1%). In 71
(47%) of the 151 patient days where mobilization did not
occur, potentially avoidable factors were identied, includ-
ing vascular access devices sited in the femoral region, tim-
ing of procedures and agitation or reduced level of con-
sciousness. Conclusions: Critically ill patients can be safe-
ly mobilized for much of their ICU stay. Interventions that
may allow more patients to mobilize include: changing the
site of vascular catheters, careful scheduling of procedures,
and improved sedation management.
Key Words: intensive care units, mobility, physical therapy
INTRODUCTION AND PURPOSE
In many intensive care units, it has been usual practice
to manage critically ill patients with deep sedation and bed
rest.
1
However, an increasing body of literature has docu-
mented the complications associated with bed rest, which
affect virtually every body system.
2-5
Much recent attention
has focused on intensive care unit (ICU)-acquired weakness
and the long-term adverse functional sequelae for ICU sur-
vivors, particularly in the physical domain
6,7
and this has led
to an increased interest in early mobilization in the ICU as
a potential means of prevention. Proposed potential ben-
ets of early mobilization of critically ill patients include
improvements in respiratory function, reduced muscle wast-
ing, decreased ICU and hospital length of stay, and reduced
readmission and mortality for 12 months postdischarge.
8-11
We have been pursuing a strategy of reduced sedation
and active mobilization in our ICU for approximately 10
years.
12
Unless deep sedation is required for a clear medi-
cal indication, such as the management of intracranial
hypertension following traumatic brain injury, sedation in
our ICU is managed with a nurse-controlled sedation al-
gorithm, titrated to a goal Riker Sedation Agitation Scale
13

of 4, which is a calm, alert, and cooperative patient. Anal-
gesia is managed with patient-controlled analgesia where
possible, and nurse controlled analgesia when this is not
possible. In order to assess the frequency of early mobiliza-
tion in our ICU and to identify barriers to early mobiliza-
tion, we performed a quality audit.
METHODS
Participants
A 4 week prospective audit of usual practice was con-
ducted on all 106 patients present in a mixed medical-surgi-
cal tertiary ICU during a 4 week period in October-November
2008. Mean age was 60 (SD 20) years, and mean APACHE
II score
14
was14.7 (SD 7.8). Of the 106 patients admitted,
70 (66%) were male, with surgical postoperative admissions
in 47 patients (44%) and trauma admissions in 14 patients
(13%). Median ICU length of stay was one (range 1-198) day,
and median hospital length of stay was 12.5 (range 1-454)
days. The study was approved by the relevant Canberra Hos-
pital Executive as a quality audit and has been approved by
the Australian Capital Territory Human Research Ethics Com-
mittee as a Low Risk Study (ETHLR.11.225).
Mobilization techniques
The mobilization techniques used were classied into
3 groups:
Cardiopulmonary Physical Therapy Journal Vol 23 YNo 1 YMarch 2012 27
1. Active mobilization was dened as marching on the
spot for > 30 seconds or mobilizing away from the bed-
space (Figure 1A).
2. Active transfer was dened as active transfer from bed
to chair where the patient assists with transfer against
gravity (Figure 1B).
3. Passive transfer, where a lifter, sling, or other device
is used to transfer a patient out of bed, with minimal
patient assistance with the transfer (Figure 1C).
Data collection
De-identied data were collected on the number of pa-
tient days mobilized, type of mobilization, adverse events,
and reasons for inability to mobilize as follows. For each day
during the audit period, the physiotherapist assigned to the
ICU on that day recorded the number of patients in the ICU
on that day. For each patient for that day, whether they were
mobilized and the type of mobilization, any adverse events
and reasons for inability to mobilize was also recorded. If
there were multiple reasons for inability to mobilize in a sin-
gle patient, a judgement was made about the most important
reason for not mobilizing. For example, a patient who was
hemodynamically unstable and was medically required to
rest in bed because of a fractured pelvis would be classied
as unable to mobilize due to medical orders.
Additional data collected by the physiotherapist pro-
spectively included demographic data (age and gender)
and admission diagnosis. This was compared for accuracy
with the de-identied data routinely collected for quality
purposes as part of our contribution to the Australian and
New Zealand Intensive Care Society (ANZICS) Adult Pa-
tient Database
15
. Severity of illness (APACHE II
14
) scoring
for the audit period was obtained from the de-identied
data routinely collected for quality purposes as part of our
contribution to the database, and was calculated using AN-
ZICS AORTIC software, version 7.0.
16
Outcome Measures
A patient day was counted for each day that a patient
was in the ICU during the audit. For each patient day, type
of mobilization, adverse events, and reasons for inability to
mobilize were recorded.
RESULTS
Frequency of mobilization
There were 327 patient days during the audit period.
Ventilated patient days accounted for 155 (47%) of these.
Although 47 (44%) of the 106 patients present in the ICU
unit during the audit period were postoperative surgical pa-
tients, only 54 (17%) of the 327 patient days audited were
postoperative patient days, presumably because these pa-
tients had shorter ICU length of stay.
Patients were mobilized on 176 (54%) of the 327
patient days audited. Figure 2 demonstrates the propor-
tions of different types of mobilization that occurred,
and the impact of mechanical ventilation on mobiliza-
tion overall and mobilization techniques used. Active
mobilization occurred in 76 patient days (23%) and
active transfer in 40 patient days (12%). Of these 116
patient days, 20 (17%) involved patients who were me-
chanically ventilated. Passive transfer was the mobiliza-
tion method used for 60 patient days and 40 (67%) of
these passive transfer days involved mechanically venti-
lated patients. Of the 106 patients in the audited period,
11 (10%) underwent passive transfer, 28 (26%) active
transfer, 36 (34%) active mobilization, and 31 (29%) re-
mained resting in bed.
Adverse events
There were two adverse events recorded in 176 mo-
bilization episodes (1.1%). Both episodes involved hypo-
tension requiring intervention (return to bed, uid loading,
and transient increase in vasopressor requirements).
Figure 1. Mobilization methods. A. Active mobilization (left frame). B. Active transfer (middle frame). C. Passive transfer (right frame).
A B C
Cardiopulmonary Physical Therapy Journal Vol 23 Y No 1 YMarch 2012 28
Barriers to mobilization
Figure 3 is a frequency histogram of the reasons that
patients were not mobilized, for both ventilated and non-
ventilated patient days. Reasons for inability to mobilize in-
cluded potentially avoidable factors in 47% of the patient
days surveyed. These included vascular access catheters in
a femoral position in 32 patient days, timing of procedures
in 18 patient days, sedation management in 12 patient days
(agitation in 9 patient days and low Glasgow Coma Score in
3 patient days) and early ward transfer in 9 patient days. Of
the unavoidable factors preventing mobilization, respiratory
instability was the most frequent, accounting for 20 patient
days, followed by hemodynamic instability for 17 patient
days, neurologic instability (difcult to control intracranial
hypertension) for 15 patient days, and medical orders to rest
in bed (for pelvic fractures or similar indication)15 patient
days. Other unavoidable factors occurred in13 patient days.
DISCUSSION
We undertook this audit to assess our performance in
mobilizing patients and to record reasons patients were
not mobilized in an attempt to identify modiable factors.
We were surprised that only 54% of patient days involved
mobilization, as we expected the proportion of mobilized
patient days to be higher than this, but these results are
consistent with the critical care nutrition literature, where
underfeeding, despite a perception of adequate feeding, is
common.
17
This is also consistent with physiotherapy evi-
dence regarding mobilization of postoperative abdominal
surgery patients, where amount of time out of bed was
found to be low
18
despite evidence that early physiotherapy
reduces postoperative pulmonary complications.
19
Howev-
er our mobilization rate compares favorably to the two re-
cent prospective randomized controlled trials of early mo-
bilization in critically ill patients, in which fewer than 10%
of screened patients were enrolled.
8,9
Although both stud-
ies suggested that mobilization therapy was benecial, the
low enrollment to screening ratio casts some doubt on the
generalizability of these results to the critical care patient
population. The very low occurrence of adverse events in
our study is consistent with other published studies, which
have reported no adverse events or adverse event rates of
less than 1%.
8-10,20-22
Specically, we were able to mobilize
ventilated patients with both passive and active mobiliza-
tion techniques, and nd it surprising that anecdotally some
ICUs are still reluctant to mobilize these patient groups de-
spite the low risks
20,21
and potential benets.
It is of note that in almost half of the patient days where
mobilization did not occur, mobilization would have been
possible with relatively simple changes in management,
such as selection of site for vascular access devices, timing
of procedures and improved sedation management. As early
mobilization has been shown to be the key component of
physiotherapy intervention for reducing postoperative pul-
monary complications in high risk patients
23
and recent evi-
dence suggests that a critical care early mobilization program
reduces the risk of death or hospital readmission within 12
Figure 2. Mobilization methods and ventilation status.
Top: Relative frequencies of each mobilization method.
Patients were mobilized out of bed via passive transfer,
active transfer, or active mobilization. Patients not
mobilized remained in bed.
Figure 3. Frequency of barriers to mobilization
The number of patient days that patients were not
mobilized is shown for each categeory of reason for non-
mobilization both ventilated and nonventilated patient
days with the frequency of each reason recorded. GCS:
Glasgow Coma Score.
Cardiopulmonary Physical Therapy Journal Vol 23 YNo 1 YMarch 2012 29
months of discharge,
11
it would seem imperative that all re-
versible obstacles to early mobilization should be addressed.
While the most effective method of implementing an early
mobilization program in the ICU is yet to be determined, we
believe that a multidisciplinary team approach including ac-
tive collaboration between physiotherapy, nursing and medi-
cal staff is likely to be the most effective. Whatever model
is used, active identication of barriers to mobilization and
active planning to avoid these issues should be included as
part of the mobilization strategy.
CONCLUSIONS
In summary, we have demonstrated that in our intensive
care unit patients are mobilized more than 50% of patient
days, and that this high frequency of mobilization is safe. In
addition, we have identied a number of relatively simple
interventions that may allow more patients to mobilize, in-
clude changing the site of vascular access devices, careful
scheduling of procedures, and improved sedation manage-
ment. Further studies investigating the impact of strategies
to address these issues are recommended.
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