24 February 2020
5 Minutes
Patient stays in the intensive care unit (ICU) can have long-term effects on patients even after stabilization.1 Many patients experience a decrease in quality of life for years after initial treatment.1 These problems often originate during the patient’s ICU stay where they are immobile for long periods of time.1
Immobility in the ICU is associated with muscular atrophy, delirium, pulmonary issues, skin breakdown, bacterial infections, and depressive moods.2 Overall, these complications hinder recovery in patients, increase cost of treatment, and in some cases, become life threatening.3–12
A range of complications that increase cost of care and length of stay can result when patients do not meet mobility goals:
Early mobility is a key part of the ICU Liberation Bundle, also known as the ABCDEFG Bundle. This is an evidence-based guide that is used to promote the assessment, prevention and integrated management of patients in the ICU.14 Together these components can decrease delirium, improve pain management and reduce long-term consequences for ICU patients.14 The early mobility element, in particular, is designed to improve patient outcomes such as ventilator-free days and length of stay.15
Many patient- and hospital-related barriers to early mobility can be overcome through technology, staff support and education, hospital protocols and communication.
Hemodynamic instability is the most common patient-related barrier to mobilization.16 Other barriers include respiratory instability, tubes, drains, and treatment related factors.16 Protocols with inclusion and exclusion criteria for mobility can help standardize mobility practices based on clinical evidence and respond to mobilization activities.16
Staff may not view early mobility as a priority in the daily care of the ICU patient. Sharing literature, videos and education may help.16 Collaborative goal making and interprofessional involvement can also lead to changes in mobility decision making.16
Mobility screening for appropriate activities may be delayed or missed. Differences in assessment for mobility readiness and lack of communication between care providers may also disrupt or delay mobility activities. Regular communication, such as interprofessional meetings, and improved clinical documentation can also aid in collaboration and be used to better evaluate patient progress.16, 17
Overhead and mobile lift systems, such as the Likorall® overhead lift, can enable care providers to safely move patients on their own, without strain and while keeping patients in the appropriate position.
Bed systems with continuous lateral rotation therapy of 90-degrees, or lung-over-lung, and percussive and vibration therapy can help prevent complications from immobility. The Progressa® bed system incorporates these key features and further supports early mobility through flexible angles and positions, including chair egress, to aid in physical therapy
Lung expansion therapy can also help reduce respiratory complications up to 50% post-surgery and decrease ICU and hospital length of stay (LOS).3, 18 The MetaNeb® System combines oscillation and lung expansion (OLE) therapy with aerosol delivery into a single, integrated therapy cycle. By reducing therapy time to as little as 10 minutes, the MetaNeb® System maximizes efficiency for clinicians and patients.
A comprehensive early mobility program can also significantly enhance patient outcomes. The Progressive Mobility® Program, integrated with ICU bed systems and patient lifts may lead to19, 20:
Early mobility can positively impact patient recovery in the ICU. Unfortunately, factors such as patient, structural, process-related, and cultural factors may delay mobility, impacting patient recovery. Early mobility and risk of complications can be improved by the implementation of safety standards, proper equipment, and monitoring systems.
References
1. Schujmann DS, Lunardi AC, Fu C. Progressive mobility program and technology to increase the level of physical activity and its benefits in respiratory, muscular system, and functionality of ICU patients: Study protocol for a randomized controlled trial. Trials. 2018;19(1):1-10.
2. Krupp A, Ehlenbach W, King B. Factors nurses in the intensive care unit consider when making decisions about patient mobility. Am J Crit Care. 2015;24(800):474-479.
3. Restrepo MI, Anzueto A, Arroliga AC, et al. Economic Burden of Ventilator‐Associated Pneumonia Based on Total Resource Utilization. Infect Control Hosp Epidemiol. 2010;31(5):509-515.
4. Graves N, Birrell F, Whitby M. Effect of Pressure Ulcers on Length of Hospital Stay. Infect Control Hosp Epidemiol. 2005;26(3):293-297.
5. Leslie WD, O’Donnell S, Jean S, et al. Trends in hip fracture rates in Canada. JAMA - J Am Med Assoc. 2009;302(8):883-889.
6. Bell L. AACN practice alert: Delerium assessment and managementt. 2011.
7. Pisani MA, Murphy TE, Van Ness PH, Araujo KLB, Inouye SK. Characteristics associated with delirium in older patients in a medical intensive care unit. Arch Intern Med. 2007;167(15):1629-1634.
8. Pandharipande P, Cotton BA, Shintani A, et al. Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients. Intensive Care Med. 2007;33(10):1726-1731.
9. Ely E, Siegel MD, Inouye M.D. SK. Delirium in the intensive care unit: An under-recognized syndrome of organ dysfunction. Semin Respir Crit Care Med. 2001;22(02):115-126. http://www.thieme-connect.de/DOI/DOI?10.1055/s-2001-13826. Accessed January 20, 2020.
10. Scott RD. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. enters Dis Control Prev. 2009;(March):13. http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf. Accessed January 20, 2020.
11. Nigam Y, Knight J, Jones A. Effects of bedrest 3: musculoskeletal and immune systems, skin and self-perception. Nurs Times. 2009;105(23):18-22.
12. Halar EM. (2001). Disuse Syndrome. 1994. Demos Publishing Med.
13. Medicare program: changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates. Fed Regist. 2008;73(161):48433-49084. http://www.ncbi.nlm.nih.gov/pubmed/18956499. Accessed January 20, 2020.
14. Marra A, Ely EW, Pandharipande P, Patel MB. The ABCDEF Bundle in Critical Care. 2018;33(2):225-243.
15. Dirkes SM, Kozlowski C. Early mobility in the intensive care unit: Evidence, barriers, and future directions. Crit Care Nurse. 2019;39(3):33-42.
16. Dubb R, Nydahl P, Hermes C, et al. Barriers and strategies for early mobilization of patients in intensive care units. Ann Am Thorac Soc. 2016;13(5):724-730.
17. Miller MA, Govindan S, Watson SR, Hyzy RC, Iwashyna TJ. ABCDE, but in that order? A cross-sectional survey of Michigan intensive care unit sedation, delirium, and early mobility practices. Ann Am Thorac Soc. 2015;12(7):1066-1071.
18. Rosenthal VD, Álvarez-Moreno C, Villamil-Gómez W, et al. Effectiveness of a multidimensional approach to reduce ventilator- associated pneumonia in pediatric intensive care units of 5 developing countries: International Nosocomial Infection Control Consortium findings. Am J Infect Control. 2012;40(6):497-501.
19. Klein K, Mulkey M, Bena JF, Albern NM. Clinical and Psychologic Effects of Early Mobilization in Patients Treated in a Neurologic ICU: A Comparative Study. Critical Care Medicine. 2015;43(4):865-873.
20. Klein K, Bena JF, Albert, NM. Impact of Early Mobilization on Mechanical Ventilation and Cost in Neurological ICU. Am J Respir Crit Care Med. 2015;191:A2293.
