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Early Mobilization in the

Acute Care Setting

How can we better assist our patients?

TIRR Memorial Hermann


Neurologic Physical Therapy
Residency
Ann Valentine, PT, DPT

Objectives
Discuss current practice and investigate why current

interventions/limitations with activity exist.

Explore common impairments that occur with

prolonged bedrest and prolonged Intensive Care Unit


(ICU) stays.

Define Early Mobilization.


Discuss the benefits of Early Mobilization.
Review an Early Mobilization Protocol.
Discuss Further Considerations with Early

Mobilization in the ICU.

Current practice in many


hospitals
Weve come a long way but more

improvements can be made.1


Delayed initiation of physical therapy

Infrequent treatments in the ICU


Once PT is initiated bed therapeutic

exercise is usually the first intervention6,7

Barriers to Early Mobilization


2,3,7
Psychosocial barriers
Comorbidities
Advanced age
Physiologic instability
ICU environment
Limited Evidence

Impairments seen with prolonged


bedrest 2-6
Increased respiratory

dysfunction
Impaired strength
Physiologic impairments
Increased risk for skin

breakdown
Decreased quality of life

Prolonged hospital stays with


mechanical ventilation
3, 6-7
DECREASED
FUNCTION!
Increased morbidity/mortality

Increased cost of care

Increased length of stay

Respiratory muscle weakness and increased duration


of ventilation

Sleep deprivation

Lack of social interaction

Prolonged sedation

Delirium

Inactive & Alone: Physical Activity


Within the First 14 days of Acute
Stroke Unit Care 1

Inactive & Alone: Physical Activity


Within the First 14 days of Acute
Stroke Unit Care 1

Inactive & Alone: Physical Activity


Within the First 14 days of Acute
Stroke Unit Care 1

What is Early Mobilization?

The initiation of mobility when a


patient is minimally able to
participle, presents with
hemodynamic stability and the
patient receives acceptable levels
of oxygen.

Benefits of Early Mobilization

2,

4-8
Improved respiratory function
Maintains strength and joint range of

motion
Fewer physiologic impairments
Repositioning allows for other

interventions
Improved quality of life

Initiating an Early Mobilization


Protocol
What is needed to start an Early Mobilization
Protocol?
Multidisciplinary involvement is crucial!
A thorough initial physical therapy evaluation
An individualized plan of care
Appropriate goals that meet patients values are

needed
Determine what phase of the Early Mobilization

Program the patient is starting in.

Initiating an early mobilization


protocol for mechanically
6,7
ventilated
patients
Heart rate <130 beats per minute
Mean arterial pressure: 60-100 mm Hg,
FiO2:<60%
PEEP 10 cm H2O
SpO2 > 88%

Phase 1
Patient presentation: considerable weakness,

limited activity tolerance, occasional altered


mental status, minimally participate in
therapy and are unable to ambulate.

15-30 minute treatments


Goal: to start mobilization as soon as the

patient is medically stable.

Progression: bed ther ex rolling sitting

balance standing with a walker and


assistance

Further Treatment Options for


Phase 1 2
Tilt table with arms supported for 10-30

minutes
Standing Frame
Chair sitting

Phase 2
Includes patients that have the strength

to perform standing activities with a


walker and assistance.
Goal: to start walking re-education and

functional training
Progression: weight shift steps in place

side steps along the EOB chair


transfer using a walker and assistance

Phase 3

Includes patients that can

tolerate ambulation with a


walker and assistance for a
short distance.
Goal: Master transfer training

and increase endurance.

Phase 4 6
Includes patients that are no

longer on a ventilator and/or


have been transferred out of
the ICU.
Goal: functional training
Ultimate goal: Promote

maximum independence by
discharge.

Further Considerations with Early


Mobilization 2,3,7
ALWAYS USE YOUR CLINICAL JUDGEMENT
Other Interventions: e-stim, UE exercise,

inspiratory muscle training

Transitions back and forth between phases


Perform during sedation vacations
Need assistance to manage multiple lines
Monitor vital signs
Involvement of a multidisciplinary team is

crucial!

When should an Early Mobilization


Intervention be deferred/stopped?
HR <40 or >130 bpm
RR <5 or >35 bpm
SpO2 <88% for <1 minute
SBP <90 mm Hg or >180 mm Hg
Elevated ICPs
Changes in patient presentation

occur

New medical findings occur

1,2,7

Adverse Effects with Early


Mobilization 2,7

Adverse events are


rare.
Fall to knees
Hypoxemia <88% SpO2 for >1 minute
Unscheduled extubation
Orthostatic Hypotension < 80 mm Hg SBP

Bottom line 1,2, 6-8


No medical status decline occurred with

an early physical therapy intervention.


This is a safe and feasible intervention.
Early mobilization has the potential to

prevent/treat neuromuscular
complications of critical illness.
Early Mobilization Requires a Culture

Change

Questions

References
1.

Bernhardt J, Dewey H, Thrift A, and Donnan G. Inactive and Alone: Physical Activity Within the First 14
Days of Acute Stroke Unit Care. Stroke 2004;35:1005-1009.

2.

Bourdin G, Barbier J, Burle JF, et al. The Feasibility of Early Physical Activity in Intensive Care Unit
Patients: A Prospective Observational One-Center Study. Respiratory Care 2010;55(4):400-407.

3.

Choi J, Tasota FJ, Hoffman LA. Mobility Interventions to Improve Outcomes in Patients Undergoing
Prolonged Mechanical Ventilation: A Review of the Literature. Biological Research for Nursing
2008;10(1):21-33.

4.

Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy. (4th ed). St. Louis: Mosby. 2006.

5.

Kisner C, Colby LA. Therapeutic Exercise. (5th ed.). Philadelphia: F.A. Davis Company. 2007.

6.

Perme C, Chandrashekar R. Early Mobility and Walking Program for Patients in the Intensive Care Units:
Creating a Standard of Care. Am J Crit Care. 2009;18:212-221.

7.

Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in
mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009;373:1874-82.

8.

West L. Early Mobilization: How one multidisciplinary team initiated an activity protocol to decrease ICU
lengths of stay. Advance for Physical Therapy and Rehab Medicine May 30, 2011:12-14.

*References for images available upon request.

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