Progressive Mobility in the ICU
Move to Improve Progressive Mobility in the Intensive Care Unit Jordan R. Atkins, BSN, RN; Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC
Bed rest has detrimental consequences, and therefore in the ICU, progressive early mobility should be the goal for every patient expected to survive. This article examines the consequences of immobility, barriers experienced when attempting to increase patients’ mobility, and ways in which dedicated mobility teams can overcome these barriers. Keywords: Barriers to mobility, Bed rest, Intensive care units, Mobility teams, Progressive mobility [DIMENS CRIT CARE NURS. 2014;33(5):275/277]
The intensive care unit (ICU) is a complicated place, full of critically ill patients, life-supportive monitoring, and emotional peaks and valleys for patients, family members, and staff. Deconditioning is a major problem in ICUs. For every day on bed rest, a person loses 1% to 2% of muscle mass; an average 1-week stay on bed rest can mean a loss of up to 14% of muscle mass or more.1 Unfortunately, in critically ill patients, deconditioning may also set into motion a cascade of complications. These patients are at increased risk for ventilator-associated pneumonia, atelectasis, muscle mass loss, and hemodynamic instability, in addition to other problems. Mobility is a way to combat those complications, but it must start early. Thus, even though patients are debilitated, it is important to remember the level of functioning they had before admission and think about the level they need to get back to by discharge. The goal for every patient is to return to a level of functioning that is meaningful. The best way to achieve that goal is progressively. This article uses case studies to show the importance of a progressive mobility protocol, discusses barriers in trying to implement it, and concludes with the evidence suggesting mobility teams as an excellent way to ensure that mobility protocols are implemented. PROGRESSIVE MOBILITY In progressive mobility, start with a series of planned movements and build up to the goal of returning the patient to the previous level of functioning. Assess the patient’s tolDOI: 10.1097/DCC.0000000000000063
erance to an activity while escalating to more physically challenging activities, such as getting out of bed and ambulating. Active and passive range-of-motion exercises can be done in the bed to begin an activity session. Most ICU beds will place the patient into the ‘‘chair’’ and ‘‘chair egress’’ positions. The ‘‘chair’’ position places the patient upright at 90 degrees with feet hanging down, as if sitting in a chair. The ‘‘chair egress’’ position is for patients who have the ability to move their legs against gravity and have trunk control. This position is like the chair position, but the footboard is removed from the bed, and the patient is allowed to bear weight on the floor. Both are excellent weight-bearing exercises for patients that the nurse can do without the help of another staff member. Just putting a patient in the chair position in the bed forces the patient’s body to use muscles that the patient would not use if lying supine, while at the same time challenging the body to remain hemodynamically stable with fluid shifts. From this beginning, the patient can move to more mobility.
CASE STUDIES Jordan (one of the authors) works in an ICU at High Point Regional, a satellite facility of The University of North Carolina at Chapel Hill Hospital, a major research institution. She has seen the importance of progressive mobility firsthand. ‘‘Carol’’ was a ‘‘typical COPD (chronic obstructive pulmonary disease) failure to wean,’’ intubated patient. She was transferred from a nearby hospital as a respiratory September/October 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
275
Progressive Mobility in the ICU
arrest and was intubated before arriving at our facility. She was in the ICU for a few weeks, and based on the unit protocol’s criteria, she was to be mobilized by using the chair position in the bed and then being slid over to the stretcher chair as tolerated. If she was lying in semi-Fowler’s or even on continuous lateral rotation, she was able to remain hemodynamically stable with systolic blood pressures in the 130s to 140s mm Hg. Jordan assisted Carol’s primary nurse to get her out of the bed and into the stretcher chair for the first time. It was an easy transfer, and the patient was sitting upright at almost 90 degrees. Then, after almost an hour, the staff noticed a change in her blood pressure: it was dropping. And it continued to do so over the course of the next 2 hours. The patient became so hemodynamically unstable that she had to be placed on vasopressors in order to help her body compensate for the fluid shifts from being upright. Her inability to maintain her blood pressure is an example of the importance of mobility. Lying still in the bed, her body was not challenged with the fluid shifts that occur when a person is upright with legs hanging down. If we had had a dedicated mobility team following a progressive mobility protocol, the move to the stretcher chair would not have been such a shock to her, because she would have been mobilized sooner, consistently, and with fewer complications. Carol ended up needing a tracheostomy and was sent to a long-term acute care facility. As a result of Carol’s experiences and those of other, similar patients, the facility implemented a progressive mobility team. ‘‘Rex’’ was one of our first success stories once our progressive mobility team was in place. He was a cardiac arrest patient who was nearing death. He was in multisystem organ failure, was unconscious, and for several days did not respond to staff or family. He ended up on daily dialysis, but not much improvement was being made. Talk of withdrawing care was beginning to come up, but the night before the withdrawal date, Rex woke up. He began responding to staff and opening his eyes. We had already been using the bed for continuous lateral rotation while he was unresponsive, but now that he could participate, we began more meaningful therapy. We used the ceiling lift to get him out of the bed and into a recliner. He was soon extubated without any respiratory complications, although the physical deconditioning had taken a toll on him. Physical therapists helped the nursing staff work on mobilizing him, starting with leg exercises. It was a slow start, but it was something. Soon Rex was using the sit-to-stand lift where he was weight bearing, moving from sitting in the chair to standing! After a few days of using the lift, Rex was able to sit on the side of the bed, stand, and pivot to the recliner without the use of a lift. His liver and kidneys regained function, and he was able to come off of dialysis. Rex was moved to our step-down unit, 276
Dimensions of Critical Care Nursing
where we continued to work with him daily. After about 2 weeks there, he was discharged to home, walking. Those are 2 very different stories, and the difference was the use of a mobility team. In the first case, we used only nursing staff to mobilize Carol. When Rex came along, we had developed a mobility team consisting of physical therapists, respiratory therapists, and staff nurses. Also, our intensive care physician is passionate about mobility and helped to spearhead the movement.
DECONDITIONING Physical deconditioning in critically ill patients is a problem. Just being in ICU compromises patients, never mind adding other complications such as ventilator-associated pneumonia, atelectasis, plasma volume loss, and muscle mass loss. These complications are commonly seen but can be prevented with progressive mobility. The sooner a patient is mobilized, his/her body begins to adjust to fluid shifts preventing orthostatic hypotension. Also, lung complications previously mentioned are less likely to occur, because as the patient is mobilized, he/she tends to take bigger breaths, increasing his/her tidal volume preventing atelectasis and ventilator-associated pneumonia, which leads to shorter ventilator days. Muscle mass is lost quickly and poses threats of skin breakdown along with it. When pressure ulcers begin to form because of bed rest, the patient is at increased risk for infection, which could lead to sepsis and in turn a longer ICU stay.
DEVELOPING MOBILITY PROTOCOLS AND A TEAM Developing a progressive mobility protocol is essential. Mobility levels 1 to 5 are assigned to the patient based on ability to participate in activity sessions. Each level has a set of activities that the patient should be doing that day, for example, getting out of bed to a chair or doing standing exercises with the sit-to-stand lift and, eventually, walking. Defining criteria include hemodynamic stability; arm, trunk, and leg control; and level of consciousness and the Richmond Agitation Sedation Scale score. Given the complexity of the patients and equipment in intensive care, these units need a dedicated mobility team staffed with a physical therapist and assistant, occupational therapist, respiratory therapist, and a registered nurse, whether the patient’s primary nurse or not. Having a mobility team allows for safe transfer of patients and more productive activity sessions. Developing a team is crucial for success of a progressive mobility protocol. Staff nurses cannot do it all alone, and with budget cuts, many hospitals are not hiring extra staff. We used our managers when building our team. We noticed that our respiratory therapists often had multiple units to care for and could not always be at our call for ICU mobility, so their manager became our
Vol. 33 / No. 5
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Progressive Mobility in the ICU
mobility representative for the respiratory department. Now the physical therapists assigned to our unit attend rounds every morning with the nurses, our physician, nutritionists, pharmacists, social workers, the chaplain, and the unit coordinator to ensure they know the patient’s condition and can help plan mobility for the day. The physical therapist does specialized exercises with the patient, and the respiratory therapist is there to ensure that the patient’s endotracheal tube and ventilator are stable and to protect the patient’s airway. A registered nurse should always be present during activity sessions to ensure patient stability and monitor heart rate, blood pressure, and any central catheters the patient might have.
BARRIERS Jordan asked the nurses on her unit about barriers to early mobility. Common answers were lack of staff and equipment. It takes a number of people to assist a critically ill patient to get out of bed; that is why many times it does not get done. Lack of staff is a common answer when ICU staff are asked why patients are not being mobilized as early as they should be. However, when a mobility team is in place, this issue is solved. A lack of lifts and equipment was considered to be a barrier on the unit because not all of the rooms had lift tracks built into the ceiling. When these exist in each room, it is easier for nurses and other staff to mobilize and navigate patients to the chair, and this eliminates the need for other equipment in the already small rooms. Advanced ICU beds are an important tool in mobilizing patients. Many will assist with turning the patient, as well as sitting them in a chair position. Beds with built-in percussion and vibration help to decrease ventilator days by increasing pulmonary function, thus improving mobility. Still another barrier was nurses’ attitudes toward mobility. Nurses will say that they cannot get their patient out of bed because the patient will not cooperate or is too delirious, but that is not an acceptable answer. Intensive care unitYinduced delirium can be an issue, but with adequate agitation assessments, and proper sedation, delirium can be managed. Once sedation and delirium are balanced, it is easier to mobilize the patient. With a team and protocol in place, nurses have the assistance they need to get these patients up and moving.2 Many nurses think it is easier to leave the person in the bed, although in reality this creates more complications. Prolonged bed rest leads to increased ventilator time, which means a longer ICU stay, a longer hospital stay, and increased costs to the patient and organization. Studies have shown that ICUs with a mobility intervention group have reached milestones much sooner than those without a
dedicated mobility group, and ICUs with a mobility group also see a decrease in delirium and ventilator days.3 These are the positive patient outcomes we should be striving for, and the best way to reach those outcomes is with a properly trained, dedicated mobility intervention team. Education on the proper use of sedation and on the equipment and resources available to staff and the importance of getting patients out of the bed is imperative. For example, the unit’s mobility protocol along with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) assessment could be made a competency checkoff. Everyone should receive refresher training on all of the functions of the beds and lifts as well as ensuring staff understand how to accurately assess the patient’s CAM-ICU and Richmond Agitation Sedation Scale. In addition, progressive mobility may need to become an explicit unit goal or core measure. Then the unit’s governance team can monitor how the unit is doing, and report the results to everyone. Once a mobility team becomes the standard of care, everyone will see the results, including fewer complications, shorter stays, more satisfied nurses, and happier patients and families.
Acknowledgment The authors thank Ms Elizabeth Tornquist, MA, FAAN, for her the vision, inspiration, and editorial assistance with this article.
References 1. Brower RG. Consequences of bed rest. Crit Care Med. 2009; 37(suppl 10):S422-S428. 2. Schweickert W, Pohlman M, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373: 1874-1882. 3. Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012;23(1): 5-13.
ABOUT THE AUTHORS Jordan R. Atkins, BSN, RN, is a staff nurse at High Point RegionalYUNC Health Care. Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC, is an associate professor of nursing at the University of North Carolina at Greensboro. The authors did not receive funding for this work. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Address correspondence and reprint requests to: Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC, UNC Greensboro, PO Box 26170, Greensboro, NC 27402 ([email protected]).
September/October 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
277
Move to Improve Progressive Mobility in the Intensive Care Unit Jordan R. Atkins, BSN, RN; Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC
Bed rest has detrimental consequences, and therefore in the ICU, progressive early mobility should be the goal for every patient expected to survive. This article examines the consequences of immobility, barriers experienced when attempting to increase patients’ mobility, and ways in which dedicated mobility teams can overcome these barriers. Keywords: Barriers to mobility, Bed rest, Intensive care units, Mobility teams, Progressive mobility [DIMENS CRIT CARE NURS. 2014;33(5):275/277]
The intensive care unit (ICU) is a complicated place, full of critically ill patients, life-supportive monitoring, and emotional peaks and valleys for patients, family members, and staff. Deconditioning is a major problem in ICUs. For every day on bed rest, a person loses 1% to 2% of muscle mass; an average 1-week stay on bed rest can mean a loss of up to 14% of muscle mass or more.1 Unfortunately, in critically ill patients, deconditioning may also set into motion a cascade of complications. These patients are at increased risk for ventilator-associated pneumonia, atelectasis, muscle mass loss, and hemodynamic instability, in addition to other problems. Mobility is a way to combat those complications, but it must start early. Thus, even though patients are debilitated, it is important to remember the level of functioning they had before admission and think about the level they need to get back to by discharge. The goal for every patient is to return to a level of functioning that is meaningful. The best way to achieve that goal is progressively. This article uses case studies to show the importance of a progressive mobility protocol, discusses barriers in trying to implement it, and concludes with the evidence suggesting mobility teams as an excellent way to ensure that mobility protocols are implemented. PROGRESSIVE MOBILITY In progressive mobility, start with a series of planned movements and build up to the goal of returning the patient to the previous level of functioning. Assess the patient’s tolDOI: 10.1097/DCC.0000000000000063
erance to an activity while escalating to more physically challenging activities, such as getting out of bed and ambulating. Active and passive range-of-motion exercises can be done in the bed to begin an activity session. Most ICU beds will place the patient into the ‘‘chair’’ and ‘‘chair egress’’ positions. The ‘‘chair’’ position places the patient upright at 90 degrees with feet hanging down, as if sitting in a chair. The ‘‘chair egress’’ position is for patients who have the ability to move their legs against gravity and have trunk control. This position is like the chair position, but the footboard is removed from the bed, and the patient is allowed to bear weight on the floor. Both are excellent weight-bearing exercises for patients that the nurse can do without the help of another staff member. Just putting a patient in the chair position in the bed forces the patient’s body to use muscles that the patient would not use if lying supine, while at the same time challenging the body to remain hemodynamically stable with fluid shifts. From this beginning, the patient can move to more mobility.
CASE STUDIES Jordan (one of the authors) works in an ICU at High Point Regional, a satellite facility of The University of North Carolina at Chapel Hill Hospital, a major research institution. She has seen the importance of progressive mobility firsthand. ‘‘Carol’’ was a ‘‘typical COPD (chronic obstructive pulmonary disease) failure to wean,’’ intubated patient. She was transferred from a nearby hospital as a respiratory September/October 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
275
Progressive Mobility in the ICU
arrest and was intubated before arriving at our facility. She was in the ICU for a few weeks, and based on the unit protocol’s criteria, she was to be mobilized by using the chair position in the bed and then being slid over to the stretcher chair as tolerated. If she was lying in semi-Fowler’s or even on continuous lateral rotation, she was able to remain hemodynamically stable with systolic blood pressures in the 130s to 140s mm Hg. Jordan assisted Carol’s primary nurse to get her out of the bed and into the stretcher chair for the first time. It was an easy transfer, and the patient was sitting upright at almost 90 degrees. Then, after almost an hour, the staff noticed a change in her blood pressure: it was dropping. And it continued to do so over the course of the next 2 hours. The patient became so hemodynamically unstable that she had to be placed on vasopressors in order to help her body compensate for the fluid shifts from being upright. Her inability to maintain her blood pressure is an example of the importance of mobility. Lying still in the bed, her body was not challenged with the fluid shifts that occur when a person is upright with legs hanging down. If we had had a dedicated mobility team following a progressive mobility protocol, the move to the stretcher chair would not have been such a shock to her, because she would have been mobilized sooner, consistently, and with fewer complications. Carol ended up needing a tracheostomy and was sent to a long-term acute care facility. As a result of Carol’s experiences and those of other, similar patients, the facility implemented a progressive mobility team. ‘‘Rex’’ was one of our first success stories once our progressive mobility team was in place. He was a cardiac arrest patient who was nearing death. He was in multisystem organ failure, was unconscious, and for several days did not respond to staff or family. He ended up on daily dialysis, but not much improvement was being made. Talk of withdrawing care was beginning to come up, but the night before the withdrawal date, Rex woke up. He began responding to staff and opening his eyes. We had already been using the bed for continuous lateral rotation while he was unresponsive, but now that he could participate, we began more meaningful therapy. We used the ceiling lift to get him out of the bed and into a recliner. He was soon extubated without any respiratory complications, although the physical deconditioning had taken a toll on him. Physical therapists helped the nursing staff work on mobilizing him, starting with leg exercises. It was a slow start, but it was something. Soon Rex was using the sit-to-stand lift where he was weight bearing, moving from sitting in the chair to standing! After a few days of using the lift, Rex was able to sit on the side of the bed, stand, and pivot to the recliner without the use of a lift. His liver and kidneys regained function, and he was able to come off of dialysis. Rex was moved to our step-down unit, 276
Dimensions of Critical Care Nursing
where we continued to work with him daily. After about 2 weeks there, he was discharged to home, walking. Those are 2 very different stories, and the difference was the use of a mobility team. In the first case, we used only nursing staff to mobilize Carol. When Rex came along, we had developed a mobility team consisting of physical therapists, respiratory therapists, and staff nurses. Also, our intensive care physician is passionate about mobility and helped to spearhead the movement.
DECONDITIONING Physical deconditioning in critically ill patients is a problem. Just being in ICU compromises patients, never mind adding other complications such as ventilator-associated pneumonia, atelectasis, plasma volume loss, and muscle mass loss. These complications are commonly seen but can be prevented with progressive mobility. The sooner a patient is mobilized, his/her body begins to adjust to fluid shifts preventing orthostatic hypotension. Also, lung complications previously mentioned are less likely to occur, because as the patient is mobilized, he/she tends to take bigger breaths, increasing his/her tidal volume preventing atelectasis and ventilator-associated pneumonia, which leads to shorter ventilator days. Muscle mass is lost quickly and poses threats of skin breakdown along with it. When pressure ulcers begin to form because of bed rest, the patient is at increased risk for infection, which could lead to sepsis and in turn a longer ICU stay.
DEVELOPING MOBILITY PROTOCOLS AND A TEAM Developing a progressive mobility protocol is essential. Mobility levels 1 to 5 are assigned to the patient based on ability to participate in activity sessions. Each level has a set of activities that the patient should be doing that day, for example, getting out of bed to a chair or doing standing exercises with the sit-to-stand lift and, eventually, walking. Defining criteria include hemodynamic stability; arm, trunk, and leg control; and level of consciousness and the Richmond Agitation Sedation Scale score. Given the complexity of the patients and equipment in intensive care, these units need a dedicated mobility team staffed with a physical therapist and assistant, occupational therapist, respiratory therapist, and a registered nurse, whether the patient’s primary nurse or not. Having a mobility team allows for safe transfer of patients and more productive activity sessions. Developing a team is crucial for success of a progressive mobility protocol. Staff nurses cannot do it all alone, and with budget cuts, many hospitals are not hiring extra staff. We used our managers when building our team. We noticed that our respiratory therapists often had multiple units to care for and could not always be at our call for ICU mobility, so their manager became our
Vol. 33 / No. 5
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Progressive Mobility in the ICU
mobility representative for the respiratory department. Now the physical therapists assigned to our unit attend rounds every morning with the nurses, our physician, nutritionists, pharmacists, social workers, the chaplain, and the unit coordinator to ensure they know the patient’s condition and can help plan mobility for the day. The physical therapist does specialized exercises with the patient, and the respiratory therapist is there to ensure that the patient’s endotracheal tube and ventilator are stable and to protect the patient’s airway. A registered nurse should always be present during activity sessions to ensure patient stability and monitor heart rate, blood pressure, and any central catheters the patient might have.
BARRIERS Jordan asked the nurses on her unit about barriers to early mobility. Common answers were lack of staff and equipment. It takes a number of people to assist a critically ill patient to get out of bed; that is why many times it does not get done. Lack of staff is a common answer when ICU staff are asked why patients are not being mobilized as early as they should be. However, when a mobility team is in place, this issue is solved. A lack of lifts and equipment was considered to be a barrier on the unit because not all of the rooms had lift tracks built into the ceiling. When these exist in each room, it is easier for nurses and other staff to mobilize and navigate patients to the chair, and this eliminates the need for other equipment in the already small rooms. Advanced ICU beds are an important tool in mobilizing patients. Many will assist with turning the patient, as well as sitting them in a chair position. Beds with built-in percussion and vibration help to decrease ventilator days by increasing pulmonary function, thus improving mobility. Still another barrier was nurses’ attitudes toward mobility. Nurses will say that they cannot get their patient out of bed because the patient will not cooperate or is too delirious, but that is not an acceptable answer. Intensive care unitYinduced delirium can be an issue, but with adequate agitation assessments, and proper sedation, delirium can be managed. Once sedation and delirium are balanced, it is easier to mobilize the patient. With a team and protocol in place, nurses have the assistance they need to get these patients up and moving.2 Many nurses think it is easier to leave the person in the bed, although in reality this creates more complications. Prolonged bed rest leads to increased ventilator time, which means a longer ICU stay, a longer hospital stay, and increased costs to the patient and organization. Studies have shown that ICUs with a mobility intervention group have reached milestones much sooner than those without a
dedicated mobility group, and ICUs with a mobility group also see a decrease in delirium and ventilator days.3 These are the positive patient outcomes we should be striving for, and the best way to reach those outcomes is with a properly trained, dedicated mobility intervention team. Education on the proper use of sedation and on the equipment and resources available to staff and the importance of getting patients out of the bed is imperative. For example, the unit’s mobility protocol along with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) assessment could be made a competency checkoff. Everyone should receive refresher training on all of the functions of the beds and lifts as well as ensuring staff understand how to accurately assess the patient’s CAM-ICU and Richmond Agitation Sedation Scale. In addition, progressive mobility may need to become an explicit unit goal or core measure. Then the unit’s governance team can monitor how the unit is doing, and report the results to everyone. Once a mobility team becomes the standard of care, everyone will see the results, including fewer complications, shorter stays, more satisfied nurses, and happier patients and families.
Acknowledgment The authors thank Ms Elizabeth Tornquist, MA, FAAN, for her the vision, inspiration, and editorial assistance with this article.
References 1. Brower RG. Consequences of bed rest. Crit Care Med. 2009; 37(suppl 10):S422-S428. 2. Schweickert W, Pohlman M, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373: 1874-1882. 3. Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012;23(1): 5-13.
ABOUT THE AUTHORS Jordan R. Atkins, BSN, RN, is a staff nurse at High Point RegionalYUNC Health Care. Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC, is an associate professor of nursing at the University of North Carolina at Greensboro. The authors did not receive funding for this work. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Address correspondence and reprint requests to: Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC, UNC Greensboro, PO Box 26170, Greensboro, NC 27402 ([email protected]).
September/October 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
277
