Early Mobilization in the ICU: A Collaborative, Integrated Approach

Abstract

To develop and implement a protocol to increase patient mobility in three adult ICUs using an interdisciplinary approach and existing resources.

Design: The Iowa Model of Evidence-Based Practice was used for synthesis of literature and intervention planning. A retrospective pre- and post-intervention data collection design was used to compare outcomes of interest.

Setting: Three adult ICUs (64 total beds) in an urban, academic hospital. Physician, nursing, respiratory therapy, physical therapy, and occupational therapy representatives participated in planning and development. All adult ICU patients were included.

Interventions: Development and implementation of an inclusive early mobility protocol in three adult ICUs. Focus on interdisciplinary collaboration to restructure workflow, focusing on optimization and coordination of standard tasks. Multimodal education occurred in an interdisciplinary setting and on-site champions facilitated implementation.

Measurements and main results: Time from admission to ambulation, overall frequency of ambulation, and frequency of ambulation by age group were assessed across three time periods: no awareness (Time 1), awareness without protocol (Time 2), and protocolization (Time 3). Decrease in hours from admission to ambulation were seen in the cardiovascular ICU (62.3 vs 56.1; p = 0.10) and surgical ICU (64.9 vs 58.6; p = 0.022). Significant increase demonstrated in the proportion of patients who ambulated while in the ICU (24.6% vs 33.0%; p < 0.001). All age groups had increase in frequency of ambulation. The largest gains in patients over 65 years old (T1 = 19.7%, T2 = 26.6%, T3 = 30.9%; p < 0.001). No change found in ICU length of stay, hospital length of stay, or ventilator days.

Conclusions: This single-center evidenced-based practice project demonstrated increased mobility for ICU patients without addition of staff resources following implementation of an early mobility protocol using an interdisciplinary approach. Successful implementation led to creation of mobility protocol toolkit for use across all ICUs in the broader health system.

Keywords: early ambulation; early mobilization; evidence-based practice; intensive care; interdisciplinary health team; nursing.

Figure 1.

Minnesota Health ICU Early Mobility Protocol. Protocol developed for evaluating and completing early mobilization of critical care patients in the surgical, medical, and cardiovascular ICUs at the University of Minnesota. Protocol includes meta rules, evaluation criteria, progression algorithm, and tolerance assessment. CRRT = continuous renal replacement therapies, CVA = cerebrovascular accident, ECMO = extracorporeal membrane oxygenation, EZ stand = patient handling device, HR = heart rate, IABP = intra-aortic balloon pump, ICH = intracerebral hemorrhage, ICP = intracranial pressure, MAP = mean arterial pressure, PEEP = positive end-expiratory pressure, RR = respiratory rate, SAH = subarachnoid hemorrhage, SBP = systolic blood pressure.

Figure 2.

ICU ambulation (18 to 49). Percentages of patients 18 to 49 yr old mobilized to ambulation in the ICU across three timelines: “No Awareness” indicates staff did not have an awareness of an early mobility protocol, “Without Protocol” defines the timeframe staff was aware of value and importance of early mobilization of ICU patients but did not have a formal protocol, and “Formal Protocol” designates the timeframe staff had a protocol to direct early mobility in the ICU. CVICU = cardiovascular ICU, MICU = medical ICU, SICU = surgical ICU.

Figure 3.

ICU ambulation (50 to 64). Percentages of patients 50 to 64 yr old mobilized to ambulation in the ICU across three timelines: “No Awareness” indicates staff did not have an awareness of an early mobility protocol, “Without Protocol” defines the timeframe staff was aware of value and importance of early mobilization of ICU patients but did not have a formal protocol, and “Formal Protocol” designates the timeframe staff had a protocol to direct early mobility in the ICU. CVICU = cardiovascular ICU, MICU = medical ICU, SICU = surgical ICU.

Figure 4.

ICU ambulation (65 and older). Percentages of patients 65 yr old and older mobilized to ambulation in the ICU across three timelines: “No Awareness” indicates staff did not have an awareness of an early mobility protocol, “Without Protocol” defines the timeframe staff was aware of value and importance of early mobilization of ICU patients but did not have a formal protocol, and “Formal Protocol” designates the timeframe staff had a protocol to direct early mobility in the ICU. CVICU = cardiovascular ICU, MICU = medical ICU, SICU = surgical ICU.

Figure 5.

Average time to ambulation. Length of time required to initiate early mobilization of ICU patients in the cardiovascular ICU (CVICU), medical ICU (MICU), and surgical ICU (SICU) across three defined time periods. Time 1 is in which staff did not have an awareness of an early mobility protocol, Time 2 defines the timeframe staff was aware of value and importance of early mobilization of ICU patients but did not have a formal protocol, and Time 3 designates the timeframe staff had a protocol to direct early mobility in the ICU.