Early p ro g ressive m o b iliz a tio n in th e in te n s iv e

care u n it w ith o u t d e d ic a te d p erso n n el

By A lessan dra N eg ro , RN, Luca C a b r in i , MD, R osalba L em bo , M S c , G ia co m o M o n t i , MD, M auro D o s si , RN, CNS,
A ria n n a P e r d u c a , RN, Ser g io C o l o m b o , MD, M o n ic a M a r a z z i , RN, HNIC, G iu lia V illa , M S c N, RN, D u il io M a n a r a ,
M S c N , RN, G iov ann i L a n d o n i , MD, a n d A lberto Z a n g r il lo , MD

A b s tra c t
Background: Immobility in intensive care unit (ICU) patients is
associated with relevant short-term and long-term adverse con­
sequences such as delirium and ICU-acquired weakness. Early
and progressive mobilization protocols have shown to be feasible,
safe, and effective in improving outcomes. A dedicated mobili­
zation team has been proposed as a necessity in the ICU, but in
times of resource limitations it could be unavailable.
Objectives: To assess the feasibility and safety o f an early pro­
gressive mobilization protocol implemented without dedicated
personnel, as part of the ABCDE bundle.
Methods: This observational study took place in the general ICU
of a teaching hospital in Italy. All of the staff, composed of nurses,
aides and doctors, took part in a preliminary educational course.
The protocol was nurse-led; mobilization was performed only
with patients passing a safety checklist. Data collection lasted one
year and included patients’ demographics, duration and number
of every advanced mobilization session, where “advanced” was
defined as dangling, out-of-bed and walking, and any adverse
event related to mobilization.
Results: During the study period, 482 patients were admitted in
the ICU and 94(19.5%) were mobilized. Non-mobilized patients
were more frequently surgical patients. We conducted 356 mobi­
lization sessions. We found that there was a significant increase
over time of patients being mobilized while receiving mechani­
cal ventilation. Four minor adverse events occurred in the first
three months, and no adverse events thereafter; all events were
resolved immediately after stopping mobilization without any
consequences.
Conclusion: The implementation of an early and progres­
sive mobilization protocol is both feasible and safe, even in the
absence o f dedicated personnel, but the number of mobilized
patients was low.

Negro, A., Cabrini, L„ Lembo, R., Monti, G., Dossi, M„ Perduca, A., Colombo, S„ Marazzi, M., Villa, G., Manara, D„ Landoni, G„ & Zangrillo, A. (2018).
Early progressive mobilization in the intensive care unit without dedicated personnel. Canadian Journal of Critical Care Nursing, 29(3), 26-31.

mmobility is common in intensive care unit (ICU) patients. life (Farhan, Moreno-Duarte, Latronico, Zafonte, & Eikermann,

I Complete bed rest was, until recently, considered part of

the treatment of severe illness (Lipshutz & Gropper, 2013).
Mechanical ventilation and the adm inistration of sedatives
and analgesics are typically associated with immtableobil-
2016; Fraser, Spiva, Forman, & Hallen, 2015; Kayambu, Boots,
& Paratz, 2013; Klein, Mulkey, Bena, & Albert, 2015; Lipshutz
& Gropper, 2013; Schweickert et al., 2009).

Shared definitions of what constitutes mobilization are lacking

ity (Cameron et a l, 2015). Immobility was recently found to
be associated with adverse consequences such as delirium
and ICU-acquired weakness (ICUAW) (Cameron et al., 2015;
Hermans & Van den Berghe, 2015; Lipshutz & Gropper, 2013).
Short- and long-term outcomes are affected, with high mortal­
ity rates, long ICU and hospital stay, poor functional ability and
quality of life in these patients (Cameron et al., 2015; Desai, Law,
& Needham, 2011; Lipshutz & Gropper, 2013; Needham et al.,
2012). Disability and weakness were reported as the most com­
mon challenges faced by ICU survivors (Govindan, Iwashyna,
Watson, Hyzy, & Miller, 2014). Immobility is of particular con­
cern in elderly patients, who are the majority of ICU patients
and their number is expected to increase further due to changes
in population demographics, comorbid illness prevalence and
improvements in medical care (Brummel et al., 2015).
Unfortunately, rehabilitation interventions performed after ICU
discharge are not effective (Connolly et al., 2016; Mehlhorn et
al., 2014). On the contrary, early and progressive mobilization
protocols in medical and surgical ICU settings have demon­
strated to be feasible, safe, and effective in improving short- and
long-term patient outcomes, including survival and quality of
in the literature. Further, there is an inconsistency about when
it should be done, who should perform it, and to what extent it
should be applied (Amidei, 2012). Early progressive mobiliza­
tion is commonly defined as a spectrum of interventions with
the aim of reducing muscle weakness and wasting, in a stepwise
approach that includes activities such as changing position in
the bed with or without help, sitting, standing and ambulation.
Early mobilization can be implemented as a “stand-alone”
intervention or as part of a bundle, aiming at improving patient
outcomes. The ABCDE bundle (Awakening and Breathing,
Coordination, Delirium management and Early mobility) is
an effective multicomponent strategy aimed at minimizing
sedation, reducing the duration of mechanical ventilation and
managing/preventing delirium, weakness, and physical dys­
function (Balas et al., 2014).
The im plementation of early mobilization protocols must
coexist and conform with several organizational and cultural
barriers (Balas et al., 2013; Cameron et al., 2015; Lipshutz &
Gropper, 2013). Due to workload concerns, additional person­
nel in the form of a dedicated exercise team has been proposed

26 The C anadian Journal of C ritical C are N ursing • C anadian Association op C ritical C are N urses
(Cameron et al., 2015). Furthermore, physical therapists can
achieve a higher level of mobilization compared to nurses,
because of their training (Garzon-Serrano et al., 2011).
The purpose of this study was to assess the feasibility (meaning
the capability of performing advanced mobilization) and safety
(meaning the capability of avoiding adverse events during
mobilization) of an early progressive mobilization protocol,
focusing on the three most advanced steps (dangling, out-of­
bed and walking) implemented without additional dedicated
personnel, as part of the ABCDE bundle.
Materials and methods
The study was approved by the local ethics committee, and took
place in the eight-bed general ICU of a teaching hospital. The
unit admits more than 500 medical and surgical patients per
year; the staff includes 11 intensivists (three in the morning shift,
two in the afternoon, one during the night and the weekend), 20
nurses (four in the morning shift, four in the afternoon and three
in the night with the same staffing every day of the week), and
four nurse-assistants (two in the morning, one in afternoon).
Physical therapists are not part of the staff.
The protocol of early mobilization was implemented in March
2015, as the last part of the ABCDE protocol to be adopted. In
February 2015, all of the staff tookpart in a five-hour educational
course consisting of mobilization risks and benefits and work­
shops on the subsequent phases of progressive mobilization:
dangling (i.e., sitting on edge of bed), out of bed (i.e., standing at
bedside and sitting in an armchair), and walking a short distance
with the help of the staff (Table 1). Posters with the flowchart of
the early mobilization were positioned in every patient’s room
(Table 2). The protocol was entirely nurse-led and mobilization
was performed only with patients passing the safety checklist
derived from the original ABCDE protocol (Nydal et al., 2014)
and performed daily for every patient (with the only exception

Table 1. Mobility Levels of the Early Mobilization Protocol

Level 1 Level 2 Level 3 Level 4 Level 5 Level 6

HOB 30°- 45° HOB 60° HOB 80° Dangling Out of bed Walking
+ 30 minutes 30 minutes twice a day twice a day
Lateral decubitus at at least once a shift at least once a shift
least once a shift

Walking!!

Out of bed Out of bed

twice a day twice a day

Dangling Dangling Dangling

twice a day twice a day twice a day

HOB 80 °x 3 0 HOB 8 0 °x 30 HOB 80°x 30 HOB 80°x 3 0

min. A t least min. A t least min. A t least min. A t least
once a shift once a shift once a shift once a shift

HOB 60 °x 30 HOB 6 0 *x 3 0 HOB 60°x 30 HOB 60°x 30 HOB 60*x 3 0

min. min. min. min. min.

£? A t least once
a shift
A t least once
a shift
A t least once
a shift
At least once
a shift
At least once
a shift
HO B 3 0 *- 4 5 ’ HOB 3 0 °- 4 5 “ HOB 3 0 ’ - 4 5 ’ HOB 3 0 * - 4 5 * HOB 3 0 “- 4 5 * HOB 3 0 * - 4 5 *
+ + + + + +
L a t e r a l d e c u b it u s Lateral decubitus Lateral decubitus Lateral decu bitus L ateral decubitus Lateral decu bitus

m in o n c e a s h ift m in o nce a shift m in once a shift m in once a shift m in once a shift m in once a shift

Level 4 Level 5 Level 6

Table 2. Flowchart of the Early Mobilization Protocol

Volume 29, N umber 3, Fall 2018 • www.caccn .ca 27

of dying patients and patients to be discharged in the next few
hours). Patients not passing the check-list were not mobilized.
Safety criteria were alertness, hemodynamic stability (no cardiac
ischemia, no increase in vasopressor dose in the past two hours,
no arrhythmia onset in the last 24 hours) and respiratory stability
( Fi02 < 0.65, PEEP < 12 cmH20).
M obilization only occurred if no medical emergency was
occurring in the ICU. At least one nurse (but more commonly
two) remained available for other patients’ needs during the
mobilization sessions. The mobilizations were considered
“early” only when the patient was mobilized for the first time
within 48 hours of admission. For every patient, nurses kept
a “mobilization diary” in which the achieved mobilization
stages were recorded. All of the mobilization to armchair was
performed with the help of a patient lift; only the few patients
who could walk were mobilized out of bed without the patient
lift. Episodes of mobilization including earlier stages, like pas­
sive movements and range of motions, were performed, but not
standardized and not recorded.
The following data were collected in the period from March
2015 to March 2016: patient characteristics, type, duration (not
including the preparation) and number of every advanced mobi­
lization session (i.e., dangling, out-of-bed and walking), and any
adverse event related to mobilization. We considered the follow­
ing as adverse events: dislodgement of lines, tubes, drains and any
devices; falls; mean arterial pressure < 55 mmHg or > 140 mmHg;
new arrhythmia; cardiac arrest and oxygen saturation < 85%.
S ta t is t ic a l a n a ly s is
Categorical data are presented as absolute numbers and per­
centages and compared by two tailed yltest or Fisher’s exact
test when appropriate. Numerical data are presented as median
(25th and 75th percentiles) or as mean (standard deviation -
SD), as appropriate. Continuous measurements were compared
Table 3. Characteristics o f the m obilized and non-mobilized patients
Characteristics Non-m obilized patients (n.=388)
(number and interquartile range or
percentage)
Sex (male) 261 (67%)
Age, years 65(13.9)
Body Mass Index 24.8 (22.5-27.7)
Trauma patients 24 (6.6%)
Surgical patients 217 (59%)
Intensive care patients* 201 (52%)
SOFA score 5(3-9)
Vasoactive drugs 147 (41%)
Days of mechanical ventilation 1(0-3)
Intensive care unit length of stay, days 2(1-4)
Hospital length of stay, days 11(6-19)
Intensive care unit mortality 68(18%)
*(as opposed to postoperative monitoring)
28 The C anadian Journal of C ritical C are N ursing • C anadian Association of C ritical C are Nurses
using the Mann-Whitney U test or T test if data were normally
distributed. Two-sided significance tests were used throughout.
A P-value less than 0.05 was considered statistically significant.
All statistical analyses were performed with the STATA soft­
ware (ver. 13; Texas USA).
To evaluate a potential increase of mobilization during the tri­
mesters, simple linear regression models were fitted using the row
percentages as response variables and the quarters as covariates.
R e s u lts
D uring the study period 482 patients were adm itted in
the ICU with a mean age of 79.5 years, a mean Simplified
Acute Physiology Score (SAPS) II score of 31.33 and a mean
Sequential Organ Failure Assessment (SOFA) score of 5.25. Of
the sample, 94 patients (19.5%) were mobilized. The character­
istics of the mobilized and non-mobilized patients are reported
in Table 3. Non-mobilized patients were more frequently sur­
gical patients being admitted for postoperative monitoring and
with lower clinical status severity when compared to mobilized
patients. Mobilized patients had longer ICU and hospital length
of stay and a better ICU survival rate. Thirty-four patients
were mobilized while mechanically ventilated (seven with an
orotracheal tube and 27 with a tracheostomy in place), while
no patients were mobilized during non-invasive ventilation.
Sixteen patients were mobilized while on vasopressors, such as
dopamine, noradrenaline and adrenalin.
The number of mobilization sessions was 356. Table 4 reports
the number and type of advanced mobilization sessions in each
three-month period. Some significant differences were found
among the different periods, but without consistent time trends,
with the exception of the number of patients being mobilized
while mechanically ventilated, that increased progressively
over time (linear regression p=0.03). The mean length of mobi­
lization sessions was 86.8 ± 65.1 minutes, largely due to the
Mobilized patients (n.=94) p-value
(number and (interquartile
range or percentage)
62 (66%) 0.8
64(16.1) 0.75
24.5(22.9-28.1) 0.5
3 (3.7%) 0.4
35 (41%) 0.006
69 (73%) <0.001
6.5 (4-9) 0.015
42 (51%) 0.09
4(0-10.5) <0.001
8(4-16) <0.001
25 (11-47) <0.001
6 (6%) 0.007
 Table 4. Number and type of advanced mobilization sessions, three-month periods
Type of advanced Number (%) of Number (%) of
mobilization, and mobilizations in the mobilizations in the
number of mobilized period March-May period June-August
patients
Dangling, 153 patients 38 (45%) 34 (34%)
Out of bed, 198 patients 42 (50%) 64 (65%)
Walking, 5 patients 4 (5%) 1(1%)
Total 84 99
out-of-bed sessions with the patients sitting in armchairs. A
temporary shortage of armchairs dedicated to mobilization
caused a reduction of mobilization, during the September-
November period.
All the sessions took place during the morning or afternoon
shifts. In all of the periods the median number of personnel
required for every mobilization was two (interquartile range
2-3) and did not change over time.
We observed four m inor adverse events in the first three
months after protocol implementation (decrease in blood pres­
sure, atrial fibrillation, decrease of oxygen saturation, panic),
and no adverse events in the following trimesters. These four
events could have been due to our lack of adequately preparing
the patients. These events took place while the patients were
dangling or out of bed, and all resolved immediately without
consequences by stopping the mobilization.
D iscussion
In the present study, the implementation of an early and pro­
gressive mobilization program in a mixed ICU proved feasible
and safe even in its more advanced steps despite the lack of
additional personnel dedicated to mobilization, but the num ­
ber of mobilized patients was low.
The anatomical, physiological and psychological negative
sequelae of immobility and its absence of benefits have been
clearly demonstrated (Allen, Glasziou, & Del Mar, 1999). ICU
patients are particularly subjected to immobility and at a higher
risk of developing immobility-related complications, such as
delirium, ICUAW, muscle wasting, longer ICU and hospital
stay, and poorer long-term outcomes (Cameron et a l, 2015;
Desai et al., 2011; Lipshutz & Gropper, 2013; Needham et al.,
2012). Weakness and decreased exercise capacity are reported
by ICU survivors as the main concerns even years after ICU
discharge. It is present in almost all survivors and associated
with relevant social and financial negative effects (Desai et al.,
2011; Govindan et al., 2014; Lipshutz & Gropper, 2013). Elderly
patients are at increased risk of both immobility and immobili­
ty-related sequelae (Baldwin, 2015; Brummel et al., 2015).
Physical function rehabilitation programs initiated after ICU
discharge have shown to be largely ineffective (Mehlhorn et al.,
2014). Even if innovative recovery programs are appealing and
promising (Denehy & Elliott, 2012) so far early active and pas­
sive mobilization, started in the first days after ICU admission,
Number (%) of Number (%) of
mobilizations mobilizations
in the period in the period
September-November December-February
44 (66%) 37 (35%)
23 (34%) 69 (65%)
0 (0%) 0 (0%)
67 106
appears to be the most effective strategy (Farhan et al., 2016;
Fraser et al., 2015; Kayambu et al., 2013; Klein et al., 2015;
Lipshutz & Gropper, 2013; Schweickert et al., 2009). Recent
findings also suggest the anti-inflammatory effects of mobiliza­
tion in septic patients (Kayambu, Boots, & Paratz, 2015).
It is important to consider the potential adverse events asso­
ciated with early progressive mobilization (Cameron et al.,
2015; Hodgson et al., 2014). Adverse events that can happen
during mobilization include falls, catheter removal, extubation,
hypotension and decrease in oxygen saturation (Lipshutz &
Gropper, 2013), and the adoption of early mobilization proto­
cols is still lagging despite being recommended by societies like
the European Respiratory Society and the European Society of
Intensive Care Medicine (Gosselink et al., 2008). Major orga­
nizational and cultural barriers such as healthcare worker
resource limitations, perceived risks for the mobilized patients
and the perception that the potential risks outweigh the benefit
of early progressive mobilization must be addressed, commonly
by educational initiatives and by additional dedicated person­
nel (Cameron et al., 2015; Lipshutz & Gropper, 2013).
The introduction of a mobilization team was reported as the
optimal solution, with the potential to be cost effective thanks
to the cost-saving related to a shorter ICU and hospital stay
(Cameron et al., 2015; Lipshutz & Gropper, 2013; Mendez-
Tellez & Needham, 2012). The presence of a physiotherapist
was proposed by some writers as fundamental to allow early,
effective mobilization in the ICU (Hough, 2013; Stiller, 2013).
Physiotherapists achieve a higher level of mobilization than
nurses: sitting, standing and walking were more frequently
performed by physiotherapists, while nurses more commonly
mobilized patients in bed (Garzon-Serrano et al., 2011).
The overall percentage of mobilized patients in our study was
19.5% (but higher when excluding postoperative monitoring
admissions). Mobilization rates ranging from 40% to 100%
were previously reported (Harrold, Salisbury, Webb, & Allison,
2015; Pires-Neto, Lima, Cardim , Park, & Denehy, 2015;
Schweickert et al., 2009). Without a dedicated team, we were
unable to mobilize a higher percentage of patients.
Absolute or relative contraindications to early mobilization can
be present in up to 89% of mobilization sessions (Lipshutz &
Gropper, 2013), but our safety criteria does not match those
originally adopted by Balas et al. (2013) and those stated by
Hodgson et al. (2014), as we set more permissive criteria to
Volume 29, N umber 3, Fall 2018 • www.caccn .ca 29
include more patients and mobilize them more frequently. patient. The lack of a historical control group weakens our
Recently, Nydahl, Ewers, and Brodda (2014) stated that “there finding. However, before the implementation of the protocol,
is no convincing evidence for general cut-off values according advanced mobilization sessions were performed very rarely.
to hemodynamic or pulmonary safety limits, which could be
Finally, we did not collect data on the number of sessions that
applied to every population” (p. 9). We found an incidence of
were not performed due to organizational barriers (i.e., nurses
adverse events in the mobilization sessions of 1.1%, without
unavailable to mobilize a patient) or to patient contraindica­
major complications. Most studies reported no adverse events
tions (safety checklist not passed), or to the occurrence of an
related to mobilization (Cameron et al„ 2015). Schweickert et
emergency with another ICU patient.
al. (2009) reported a 4% incidence of events causing interrup­
tion of the session, with a 0.2% incidence of severe complication
Conclusion
(oxygen desaturation < 80%). In our study, no adverse event
The implementation of an early and progressive mobilization
took place after the first three months, despite a growing num­
protocol, as part of the ABCDE bundle, was feasible and safe
ber of patients who were mobilized even while ventilated.
even in the absence of dedicated personnel, but the number
Due to resource limitations and the current lack of a phys­ of mobilized patients were few. Further research is required to
iotherapist in the ICU, we decided to implement a nurse-led evaluate the efficacy and generalizability of our strategy and the
mobilization protocol. Our experience was based on the bed­ additional nurse-workload. *
side ICU nurse and is different from other experiences in
which the nurse-led mobilization was performed by a dedi­ About the authors
cated nurse mobility team (Fraser et al., 2015). A preliminary Alessandra Negro, RN, ICU, IRCCS San Raffaele Scientific
physician consultation was not required, in contrast to other Institute, Milan, Italy
protocols (Hodgin, Nordon-Craft, McFann, Mealer, & Moss,
Luca Cabrini, MD, ICU, IRCCS San Raffaele Scientific Institute,
2009), but in accordance with some authors (Jolley, Regan-
Milan, Italy
Baggs, Dickson, & Hough, 2014) considered as an “automatic”
standard of care. Rosalba Lembo, MSc, Statistician, IRCCS San Raffaele Scientific
Institute, Milan, Italy
The present study does not intend to support the notion that
physiotherapists or dedicated mobilization teams are redun­ Giacomo Monti, MD, ICU, IRCCS San Raffaele Scientific
dant and not required for early mobilization programs. On the Institute, Milan, Italy
contrary, in accordance with the literature and on the basis of
Mauro Dossi, RN, CNS, ICU, IRCCS San Raffaele Scientific
our experience, we believe they have a key role. Without phys­
Institute, Milan, Italy
ical therapists and a without a dedicated team we were unable
to mobilize more than 20% of patients. Physiotherapists could Arianna Perduca, RN, Niguarda General Hospital, Milan, Italy
achieve better, longer and personalized mobilization, and
Sergio Colombo, MD, ICU, IRCCS San Raffaele Scientific
could have a crucial role also as educators of the rest of the
Institute, Milan, Italy
staff. Moreover, we are aware that mobilization adds significant
workload to the already busy ICU staff, above all to the nurses. Monica Marazzi, RN, HNIC, ICU, IRCCS San Raffaele
Nevertheless, we agree early mobilization is a necessary part Scientific Institute, Milan, Italy
of the treatment for ICU patients (Cabrini et al., 2015), but we
Giulia Villa, MScN, RN, Tutor Nurse, School o f Nursing, Vita-
lacked the possibility to obtain dedicated personnel and started
Salute San Raffaele University, Milan, Italy
the program with the already existing ICU staff. We hypothe­
size that this situation is common in other teaching hospitals, Duilio Manara, MScN, RN, Associate Professor, School o f Nursing
especially in times of resource limitations. In a recent review of Director, Vita-Salute San Raffaele University, Milan, Italy
barriers and strategies for early mobilization of ICU patients,
Giovanni Landoni, MD, Associate Professor, ICU, IRCCS San
28 unique patients, structural, process-related, and ICU cul­
Raffaele Scientific Institute, Vita-Salute San Raffaele University,
tural barriers were identified, with patient-related barriers
Milan, Italy
being the most common category. More than 70 strategies to
overcome these barriers were identified and synthesized (Dubb Alberto Zangrillo, MD, Professor, ICU, IRCCS San Raffaele
et al., 2016). Scientific Institute, Vita-Salute San Raffaele University, Milan,
Italy.
Limitations Address for correspondence: Alessandra Negro, IRCCS San
The present work is a descriptive study that shows the expe­
Raffaele Hospital and Vita-Salute San Raffaele University, Via
rience in a single ICU. Therefore, these results cannot be
Olgettina 60, 20132 Milan, Italy
generalized. However, our experience can reflect the reality of
many ICUs. We did not collect data of adverse events in the Phone: +39 02 2643 2222
ICU potentially related to the increased nurse workload. We do
E-mail: negro.alessandral@gmail.com
not know if some patients suffered from adverse events while
nurses were perform ing a mobilization session on another

30 The C anadian Journal of C ritical C are N ursing • C anadian Association of C ritical C are N urses
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Volume 29, N umber 3, Fall 2018 • www.caccn .ca 31
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