When Bed Rest Causes Harm: Early Mobilization for the Mechanically Ventilated Patient

Editor’s note: This text-based course is an edited transcript of the webinar, When Bed Rest Causes Harm: Early Mobilization for the Mechanically Ventilated Patient, presented by Nancy Nathenson, BS, RRT.

Learning Outcomes

After this course, participants will be able to:

• Identify the harmful, multisystem effects of prolonged bed rest in the mechanically ventilated patient.
• Describe the potential benefits resulting from the early mobilization of the mechanically ventilated patient.
• Recognize the contraindications and barriers to early mobility in mechanically the ventilated patient.
• Explain the key components of an early mobilization program.

Our healthcare system is quite complex there is no doubt. That being said there are steps that we can take together to address those challenges that we face.

Historical Background

Intensive care medicine was created as a consequence of the poliomyelitis epidemic, the peak of which occurred in the 1940s and 50s when widespread mechanical ventilation was required. This crisis was similar to COVID-19 because at that time there were ventilator shortages, understaffed facilities, and many wards of iron lungs being used to ventilate our patients. The iron lung uses a vacuum to evacuate the air from the iron lung to lift the chest and ribs and expand the lungs. Then that stops and the lungs go back to resting and exhalation then occurs. That was quite a challenge back then similar to our COVID challenge right now.

Thomas L. Petty, who lived from 1932 to 2009, was a renowned pulmonologist who was a pioneer and a visionary. He went into medicine because he suffered pneumonia as a young boy and sadly lost his brother to the same infection. He was considered a renegade or rogue physician at the time. He drew an arterial blood gas and got fired for it because it was only supposed to be the cardiologists that were able to do that. He was reinstated after a few days, so all was well. He also wrote multiple articles on the use of PEEP in ARDS and was shunned by the most prestigious journal stating that it was inappropriate and dangerous, yet now PEEP is now an integral part of ARDS management. He was also the first to promote the benefit of using oxygen for COPD patients when the medical community thought that it was very dangerous and possibly fatal to use oxygen in that population.

It used to be said that Dr. Petty had his entourage with him. He believed that the nurse, the respiratory therapist, and the physician were a team and they should discuss the plans of care together, even though that was not really the culture at that time. Kudos to Dr. Petty for envisioning this and putting it into practice back then, because we all know that in the ICU, rehab, and across hospital systems, we have those types of interdisciplinary teams.

Dr. Petty said that in the ICU in 1964, “Patients who required mechanical ventilation were awake and alert and often sitting in a chair and they could interact and they could feel human.” He also said about the ICU in the eighties, “What I see these days are paralyzed, sedated patients lying without motion, appearing to be dead, except for the monitors that tell me otherwise.” He knew then that this was a problem and attributed it to technology and pharmaceuticals.

He also understood that there was a very delicate machine/patient interface that seemed to be lost and that was what required the sedation and the paralysis at that time. Those anxious and depressed patients required a great amount of interaction from the health care team, which they were not getting at that time. He also said that the technology of keeping patients alive and pharmacology played a role in patients’ recovery.

Aging Population

We have an aging population. According to the National Institute for Aging, approximately 10,000 baby boomers are going to turn 65 today, and about 10,000 more will cross that threshold every day. By 2030, all the baby boomers will have turned 65. The other important thing that has impacted healthcare and the ICU is people age 85 or older are the fastest-growing segment of the US population. Patients are living longer because of our technology and that has put a burden on us.

According to the Society of Critical Care Medicine, nearly 6 million patients are admitted annually to the ICUs in the United States. Between 80% and 90% of them survive their ICU stay, because of our advancements in technology. The five primary reasons patients get admitted to the ICU are respiratory insufficiency/failure, post-operative management, ischemic heart disorder, sepsis, and heart failure.

Chronic Critical Illness Syndrome (CCIS)

There is a syndrome called the Chronic Critical Illness Syndrome (CCIS). This term was first coined in 2002 in the Critical Care Nursing Clinics of North America journal. The syndrome is considered consistent symptoms linked to common underlying pathophysiology. Within the syndrome, there is a prolonged inflammatory response to an acute illness that leads to multi-organ dysfunction. Bed rest exacerbates this.

Patients at risk for CCIS are ICU patients that are on mechanical ventilation for more than 72 hours or have a length of stay of more than three to five days. If they have three or more pre-existing conditions, such as obesity, diabetes, and hypertension, or they are older than 65 years, they are more at risk for CCIS. In addition, having reduced physical function prior to the ICU admission puts them at greater risk.

Often a patient with CCIS comes in acutely ill and their status turns to chronic status during their ICU stay. That is because of the inability to resolve what underlying problem the patient has and they have a development of new issues which result in continued organ damage. This is an unintended consequence of advances in life-sustaining technology which has led to poor outcomes. Our patients are surviving without thriving.

Technology has an impact on the long-term survival of critically ill patients. Prolonged stays in the ICU lead to a functional decline, increased morbidity, increased mortality, increased cost of care, more complications, and an increased length of stay. Technology has not been our friend in this particular regard.

Early Mobility

Although early mobilization was considered important in the late 19th century, it was not made a top priority until WWII. Early mobilization was introduced late during World War II (1939-1945) in an effort to expedite the return of soldiers to the battlefield.

In 1944, the first conference on bed rest was released and an article was published in The Journal of the American Medical Association (JAMA) called The Evil Sequelae of Complete Bed Rest. There was a statement in this article about the benefits of early mobility. It said, "First morale is greatly improved... general health and strength are better maintained and convalescent more rapid."

Bed Rest

Bed rest is a common intervention for the critically ill, but there is increased scrutiny for using it as a therapeutic intervention. This is because outcomes are poor, costs are going up, and the length of stays are going up. There are benefits of bed rest though. It helps maintain patency when you have multiple lines and tubes, such as chest tubes, Swan-Ganz, and arterial lines. It can help if you need to keep the spine and bone alignment stable. It will reduce falls if we are not getting patients out of bed and it will prevent injury to care providers, especially if patients are obese and unable to move properly. In addition, bed rest reduces oxygen consumption and slows metabolism. However, bed rest causes negative effects on the body on the molecular level and systemic levels, so we have to balance bed rest and mobility.

Multi-Factorial Impact of Bed Rest

Here is a list of the multi-factorial impacts of bed rest. Every system is affected negatively by bed rest. The one system that is not on here is reproductive, but it does have complications with bed rest.

• Muscle Wasting/Atrophy
• Ventilator-Induced Diaphragmatic Dysfunction (VIDD)
• Bone Loss
• Integumentary
• Cardiopulmonary
• Hematologic
• Gastrointestinal
• Endocrine
• Urinary
• Immune Response
• Hormonal
• Inflammation
• Allostatic Response
• Neurological

Disuse Atrophy: Muscle Wasting

When muscles are not used it leads to atrophy and a loss of muscle strength at a rate of about 12% per week. If you think about that, after three to five weeks of bed rest, almost half of the normal strength of a muscle is lost. The first muscles to become weak are those in our lower limbs. Those skeletal muscles lose tone when they no longer bear weight. Weakened muscles generate an increase in oxygen demand. When this is happening, muscles will stiffen and shrivel up, which leads to a dramatic reduction in muscle mass. This and the loss of fat may be responsible for the weight loss that sometimes accompanies bedrest. There are some exercises that can be done even in the bed, such as cycle ergometers for the legs and arms. However, even high-intensity exercises like that in bed do not reverse the adverse effects of muscle wasting in bed rest.

Disuse Atrophy of the Diaphragm

The diaphragm is a very important part of our respiratory system. Ventilator Induced Diaphragm Dysfunction (VIDD) is when you have decreased neurostimulation and muscle loading occurs. Your brain automatically tells your diaphragm to load up and function but that is not needed when we are on mechanical ventilation.

Myosin isoforms convert Slow Twitch fibers that are fatigue resistant into Fast Twitch fibers. Slow Twitch fibers efficiently use oxygen and provide endurance for patients when we are asking them to wean from the ventilator and do more breathing on their own. Fast Twitch fibers do not burn oxygen to create energy so they are spent right away and are very short-lived and not fatigue resistant.

With the atrophy of the diaphragm, there is a decrease in muscle length. The diaphragm actually shrinks and the blood flow decreases as well. In addition, there is an increase in the functional residual capacity of the lungs.

Bone Loss

Bone loss is another significant negative effect of bed rest. Weight-bearing activities are what helps us maintain bone mass. Weightlessness and immobility result in bone loss. NASA does studies on weightlessness and immobility and the effect on the astronauts in space. It results from a loss of phosphorus and calcium in the bone. Weight-bearing is the best treatment to keep phosphorus and calcium inside the bone. Vitamin D and magnesium supplements help to redirect phosphorus reabsorption and bone mineralization.

Integumentary System

The integumentary system is your skin. Only the feet are designed to bear weight and immobility is the most likely factor to put an individual at risk of altered skin integrity.  Impaired lymph and blood flow causes ischemic lesions like pressure ulcers. About 70% of lesions occur in older adults within two weeks. The highest risks are over the bony prominences. I worked in rehab and our referral hospitals would send us patients with terrible wounds. They would have occipital wounds, elbow wounds, sacral wounds, and even heel wounds. In addition, they would have orthostatic hypotension because they were rarely or never gotten out of bed. When we would sit them up they would not be able to function. The prolonged pressure on the skin, the friction of repositioning patients, and moist bed sheets can cause bacterial reproduction in the skin. Early mobility is the best prevention for pressure ulcers and all of these issues we are talking about.

Cardiopulmonary Complications

When you are in bed you have fluid losses which contribute to postural hypotension. Heart rate will increase, stroke volumes will go down, and cardiac output goes down. The peak oxygen uptake also plummets. All of these have been shown to occur in healthy subjects undergoing bed rest with an extended recovery. This could be a person that is snowboarding or biking that has an accident. They break their leg or pelvis and are in bed and all of these cardiopulmonary complications can happen to them.

Hematological Effects

When we are sitting around on bed rest we have water loss. This leads to increased blood viscosity or thickening, decreased oxygen demand, and decreased hemoglobin. Venous stasis occurs when there is a pooling of the venous blood while you are in bed and due to positioning.

There is a risk of embolism, which we fight against regularly. We use TED hose and inflatable stockings to help reduce the risk of deep vein thrombosis, or DVT. Stroke, myocardial infarction (MI), and pulmonary embolism are also risks of bed rest. Pulmonary embolism is the most common cause of sudden, unexpected death in hospitals.

Gastrointestinal

Effects of bed rest on the gastrointestinal system include a decrease in taste, smell, and appetite. There will be decreased food intake which will cause atrophy of the mucosal lining and shrinking of the glandular structures within our intestinal surfaces. Due to the lack of calories, vitamins, and nutrients, patients will have less strength. Constipation will occur. Patients are 16 times more likely to have constipation with bed rest.

Gut motility, or movement within the intestines, is reduced. This causes transit times to increase with any food that is taken in. There will be increases in water reabsorption causing hardening of the stools and a reduced urge to defecate. Another contributing factor for constipation is opioid-based medications which slow gut motility. In addition, food passage during swallowing is 66% slower in the upright position. Another effect on the gastrointestinal system from bed rest is gastroesophageal reflux (GERD) due to the acidity of the stomach.

In addition, patients with artificial airways are at risk for aspiration and pneumonia. We should institute VAP prevention protocols to ensure patients with artificial airways have the head of their bed up 35 to 40 degrees. We should also do vigorous and regular oral care for them. Also, even though we have proper trach cuff pressure on our endotracheal tubes secretions and bacteria can get down into the lungs and cause a problem.

Endocrine

In my time in the ICU, it seemed like the nurses struggled with managing patients’ hyperglycemia, including stress-induced hyperglycemia. It is estimated that 90% of all critically ill patients develop hyperglycemia due to lack of sleep and bed rest (stress) with serum glucose above 126 mg/dL.

Studies have shown that individuals that sleep less than five to six hours a night were twice as likely to develop diabetes. The ICU is not the perfect place or the perfect environment to get sleep. Patients that are at increased risk are those that have heart failure, CVA, myocardial infarction, and multiple traumas. Those seem to have the highest risk of hyperglycemia with uncontrolled blood sugars. Hyperglycemia can also increase the risk of renal failure due to advanced glycation end products (AGE) that are produced in the body. Early mobilization, including just standing and moving, can decrease serum blood glucose levels to normal.

Urinary System

Thinking about the urinary system, there is a negative effect of gravity when you are in the supine position, and like not experiencing an urge to defecate, the urge to urinate is reduced. An overfull bladder leads to the stretching of the muscles. Over a prolonged period of time, the stretch receptors lose the ability to be stimulated to say it is time to pee. That loss of sensation of urinary urgency and the absence of gravity hinders complete emptying, which predisposes the growth of bacteria. That can lead to UTIs which can set patients back in their recovery.

Sleep Deprivation and the Immune Response

Sleep deprivation impacts many things, but there is a severe effect on the immune system. During early sleep, specific immune cells peak in concentration. They prep our entire body to be ready to face any pathogen, bacteria, or virus that we might face the next day. It enhances our bodies’ ability to form an initial response to invaders. Lack of sleep depresses this response to invading organisms, which plummets the immune system and makes us more vulnerable to those pathogens and bacteria, et cetera.

Sleep Deprivation and Hormonal Regulation

Sleep deprivation also affects the hormonal system. During sleep, there is a balancing of three key hormones. There is an increase in ghrelin, which is an appetite stimulant excreted by the stomach. There is a decrease in leptin, an appetite suppressant produced by fat cells. If you have too much ghrelin you are going to have too much appetite stimulation going on and not an appetite suppressant. There is an increase in cortisol, the stress hormone that comes from the adrenal gland. During sleep, our stress hormone equilibrates and our bodies are always trying to get to homeostasis. We want a proper balancing of the appetite suppressant and appetite stimulant hormones, ghrelin, and leptin, as well as cortisol. Too many are going to throw us into a stress response and we can become ill and be slower in recovering from illness.

Inflammatory Response

Inflammation is the root cause of all diseases. We have chemicals in our bodies including prostaglandins, histamine, and bradykinins that initiate that inflammatory response. That sometimes leads to swelling of an area, or inflammation, heat, and pain. This inflammatory response causes tissue damage. It also causes a breakdown in the blood-brain barrier, which helps us to keep certain chemicals and amino acids from getting into the brain. It helps us control serotonin, our feel-good hormone. Also, there is the recruitment of other circulatory and immune cells such as histamine and bradykinins. All of this is causing inflammation trying to go to the site and trying to heal it as best it can. Increased inflammation, however, is associated with paid. Just from being immobile, patients can have this inflammatory response and experience pain. Early mobilization decreases the risk for immobilization-associated pain.

Allostatic Response

I previously mentioned that our bodies are constantly trying to stay in homeostasis. The homeostatic function of our bodies includes things like regulating our vital signs, temperature, oxygen levels, glucose, and water and ion content in our bodies. When homeostasis cannot be achieved, allostasis or an allostatic response occurs. Then we have chemicals that persist in the body without a return to stability. There is a persistent inflammatory response going on systemically. There is persistent protein tissue breakdown which can lead to organ dysfunction and muscle wasting. In addition, we have high blood sugars that are difficult to control in this response and an increased risk of renal failure.

Neurological

The ICU can be a hostile environment. It is very difficult to get any rest at night in the ICU. This can cause delirium, which is when a patient is disoriented. They are unable to remember basic information and are not fully aware of what is going on around them. That is why we consistently ask our patients questions such as:

• What is your name?
• What is the date?
• Who is the president?
• What month is it?

We want to reorient our patients and make sure that they are aware and not slipping into delirium.

One of the causes of delirium in patients is noise, such as ventilator alarms, IV pump alarms, oximeter alarms, and call lights going off across the unit. There may be ECG machines alarming or EKG monitors going off. Ambient lighting is also a contributing cause of delirium. Restriction of mobility and social isolation lead to delirium. Negative effects on the body from delirium include peripheral vasoconstriction, increased arterial pressure, an increase in epinephrine release, and an increase in muscle tension.

Delirium contributes to an increase in length of stay and an increase in mortality. Disorganized and inattentive thinking has been seen in 75% of ICU patients with delirium. In addition to delirium, studies have shown that sleep deprivation negatively impacts attention, concentration, language, memory, psychomotor, and executive function.

Perception of ‘Self’

I think it is always important to come back to the patient and their perception of themself, or their self-concept. Patients come into the hospital with their self-concept, a stable set of beliefs about their own qualities and attributes. They have a degree of self-esteem, the feeling of self-worth that you have. Having good self-esteem is a central component of our psychological well-being. These make up an individual’s image, achievement, self-identification, and social functioning. Prolonged bed rest results in a decrease in body function and altered appearance, leading your body image to plummet during illness.

Disabling Effects of ICU Stay

An ICU stay can have disabling effects. Post-traumatic stress disorder (PTSD) occurred in 44% of ICU survivors at discharge. There is a long-term disruption in our short-term memory and executive functioning. In addition, 49% of patients are unable to return to their work-life roles. Weakness occurred in 50% of patients with sepsis, those on mechanical ventilation, or those that experienced multiple organ failure. Delirium and disorganized thinking occurred in up to 75% of ICU patients. Any of these things can happen when you have an ICU stay. I am suggesting that having early mobility is going to help prevent and improve these outcomes.

Many ICU patients experience emotional problems as well. Emotional problems are a common symptom in the ICU patient’s recovery. About 25% of ICU survivors experience negative emotional outcomes during the months and years after their ICU stay. They often experience struggles with daily activities such as working and interacting with friends and family. They may even struggle with their activities of daily living, such as cleaning themselves up. Predictors of adverse emotional outcomes have been linked to ICU length of stay, prolonged mechanical ventilation, female gender, alcohol use, and smoking.

Rehabilitation: A Philosophy of Care

I spent 10 years in ICU and about 25 years in rehabilitation. I submit to you that rehabilitation is not a particular place or setting, but it is a philosophy of care. It should be occurring in the ICU, step-down units, LTACH, acute rehab, sub-acute, skilled nursing, nursing home, assisted living, and at home. Rehabilitation, including mobility, walking, strengthening exercises, and breathing exercises should be occurring in all of these places and should begin at the get-go.

Goal of Rehabilitation

The goal of rehabilitation is for patients to return to their life roles and the activities that they enjoy, in whatever setting they are in. Interdisciplinary teams were created to help patients achieve physical function and cognitive function. Rehabilitation early in the continuum of care helps to prevent the impairments that lead to poor outcomes. With early mobility, the incidence and severity of impairment can be reduced in mechanically ventilated patients. When we intervene early, patients have the ability to improve their outcome, whether it is short-term or long-term, and a patient outcome or hospital outcome.

Pre-Habilitation

Pre-habilitation is when you have multidisciplinary interventions for patients that are going to be having elective surgeries, such as a total knee replacement, hernia repair, or heart surgery. The interventions are done with the intention of diminishing the side effects of a medical or surgical procedure. The goal is to increase their baseline fitness before surgery to make recovery easier.

Examples include teaching a patient active and passive range of motion exercises or strengthening exercises such as with a TheraBand. It also includes breathing exercises they might need such as an incentive spirometer, blow bottles, or expiratory maneuvers. Another example is to add high protein supplements or drinks to their diet.

When patients are taught these things before the surgery, then they are better prepared and know what to expect after surgery. They will be familiar with the exercises and can initiate them and not struggle with them right after their intervention. The protein supplements will help prevent muscle wasting and rebuild, strengthen, and tone muscles. Pre-habilitation, in some cases, is done before the patient even gets into the hospital.

Levine’s Conservation Principles

Myra Estrine Levine was a nurse and a theorist who lived from 1920 to 1996. According to Levine, each individual has a unique range of responses when they are faced with the challenge of illness. This could be due to heredity, gender, or age. She believed the timing and manifestations of the responses are unique as well. She said that the role of the nurse is to defend and seek the realization of their wellness through integrities, or conservation principles. I believe that as healthcare providers it is our role to do the same. Levine identifies these conservation principles as the conservation of personal integrity, the conservation of a patient's social integrity, the conservation of structural integrity, and the conservation of energy.

Application of Levine’s Four Conservation Principles

Let’s start with the conservation of a person's personal integrity. Recognize the patient, no matter who they are or where they come from, as a person needing respect, self-awareness, and self-determination. We want them to be able to understand their character, their feelings, their motives, and their desires while they are in the hospital. We want to have them be self-determined in their actions. We want them to use their personality and psychological presence to overcome what is happening and be able to deal with it.

The conservation of social integrity is to reconnect patients with their loved ones. This has been a huge struggle in hospitals during COVID. There has been a profound lack of connection with patients and their families, but when we can we must do our best to connect them with their loved ones. That is a key component of their wellness. We are looking at this holistic view of how we take care of the patient, not just their medical issues that are happening.

The conservation of structural integrity is where we are working on restoring and maintaining the structure of their body. We need to make sure their skin, brain, muscles, and nerves all stay healthy. We want to prevent any physical breakdown in those areas.

The conservation of energy is important so patients are able to do the things that they enjoy and get better. We want them to save energy for the healing process. It is important to balance energy input and output to avoid excessive fatigue. This is important when we are weaning patients, not just when they may be up walking. We want to make sure that they have adequate nutrition with calories to burn, as well as adequate sleep and rest. Those are the facets of conservation of energy for our patients in this holistic view of care.

Benefits of Early Mobility

There are several benefits of early mobility. One of those is that we will minimize the laundry list of complications that occur due to bed rest. It is going to help the promotion of improved physical and cognitive function for patients. It will also help promote weaning from ventilator support. As a patient’s strength and endurance improve, we will see the effects of that such as a decreased length of stay and decreased cost. Also, early mobility will lead to an improved quality of life.

Review of the Literature

One study by Needham et al. (2010) discussed providing early physical medicine and rehabilitation for patients with acute respiratory failure. It involved providing physical and occupational therapy in the ICU setting with the goal of decreasing the risk of delirium and loss of physical function. Participants included 57 patients that were mechanically ventilated four days or longer. They received daily PT and OT sessions consisting of 30 minutes twice daily for PT and 30 minutes daily of OT. They found that benzodiazepine use was decreased by 50%. It also resulted in improvements in ICU delirium and patients’ functional mobility and a decrease in hospital and ICU length of stays.

Another study by Balas et al. (2014), evaluated the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle (ABCDE bundle) into everyday practice. They implemented this bundle in a diverse group of critically ill patients and found that it resulted in reduced time on the ventilator, less delirium, and more time spent out of bed compared with patients not treated with the bundle. These improvements were achieved despite little difference in medication exposure and incomplete bundle adherence. The ABCDE bundle appears to be a valuable tool in the management of critically ill patients.

As I reviewed the literature, I found that there are few randomized control trials published that examine the effects of establishing an ICU early mobility program. There is more happening but at that time, the design of most of the studies were prospective cohort studies or before and after studies following implementation of an ICU early mobility QI initiative. Findings included:

• Improved outcomes
• Out of bed earlier (5 days versus 11 days)
• Decreased incidence of ICU psychosis
• Shorter ICU length of stay (5.5 days versus 6.9 days)
• Shorter hospital length of stay (11.2 days versus 14.5 days)
• Greater incidence to return to independent functional status after discharge
• Improved quality of life

In addition to these improved outcomes, costs will be reduced for the facility when you have a shorter ICU or hospital length of stay.

Barriers to Early Mobility in the ICU

Although early mobility in the ICU has many positive outcomes, there are barriers to achieving this. As you can see in figure 1, the patient is hooked up to multiple lines including IVs, life equipment, and monitoring equipment. It is no easy task for sure.

Figure 1. Image of a patient in ICU.

Major Contraindications of Early Mobility

The major contraindications of early mobility are cardiovascular, pulmonary, or musculoskeletal instability. If you have instability in any one of these areas, then you are not going to be able to proceed with early mobility.

Patient Barriers

Further barriers to immobility on the patient's side are if they have instability, multiple lines, or are on a mechanical ventilator. In addition, if they have a profound neuromuscular weakness they are not going to be able to mobilize very well. Another patient barrier is if they have a neurologic impairment that is going to affect their mobility.

Provider Barriers

On the provider side, we need to look at the culture of immobility. Not every hospital works the same and has a culture of mobility. It is seen more and more but it is still not the top priority in many facilities. Staffing levels can be a barrier to immobility as well. When I worked in rehab, I was deployed to some of our referral facilities to do presentations on early mobility and to help the staff, respiratory therapists, and nurses understand what kind of services we provided at the rehab hospital. What I heard from them was that they all knew how important it was. They even admitted that in those hospitals that they had patients that had not been out of bed for two weeks or even 32 days, or they had an admission a week ago and the patient still had not been out of bed. They did not think that there was any reason why that patient could not get out of bed, but it was not part of their hospital’s policy to provide early mobility. Another provider barrier is if the patient is over-sedated.

Lack of Training, Expertise, and Confidence

The lack of training, expertise, and confidence is a barrier to getting our patients up. Sometimes nurses might not want RTs messing with their patients and RTs do not want nurses messing with the ventilator. Everyone is afraid. The physical therapists may also be worried and unsure about doing mobility with a patient on a ventilator.

Multi-Disciplinary Mobility Team

A multi-disciplinary mobility team is led by the physician. We have to have their buy-in. Also included on the team are the nurse, respiratory therapist, physical therapist, occupational therapist, speech therapist, neuropsychologist, and pastoral care. All of these disciplines need to be involved as we talk about the wellbeing of the patient and the idea of getting the patient to move. It is critical to have a well-rounded multidisciplinary team.

Multi-Disciplinary Education

Multi-disciplinary education is important as well. In my rehab facility, we had a unique situation where the PTs, OTs, and the speech therapist learned RT competencies on how to make ventilators portable, understanding a ventilator, and tracheostomy management and troubleshooting. They had classes on ventilator modes, the levels of support, and endotracheal tube management. They all learned about airway emergencies, such as mucus plugging or dislodgement or partial dislodgement of the trach. We also taught safe patient handling. Everyone in the rehab facility learned how to safely move a patient from point A to point V. Patient monitoring, such as how to monitor the oxygenation levels or heart monitor was covered as well.

Speaking valve use was a key component of our weaning strategy for our patients. Our patients could very well be mobilizing with the speaking valve in place. Speaking valve use and trach cap use when we were weaning a patient from a trach was also part of our multidisciplinary education for nurses, PTs, OTs, speech, et cetera. Most of the therapies understand the work of breathing and how to identify it, but we spent quite a bit of time making sure that nurses understood and were able to observe and identify the key components of the work of breathing. We had competencies that we would provide for all the different disciplines.

Early Intervention Strategies

One early intervention strategy is to identify patients that are at risk and intervene early. It is important to establish good communication with the patient and their family. We should assist with goal-setting prior to a decline in cognition, which might occur in patients in the ICU. We should schedule a patient/family meeting within 24 to 48 hours of ICU admission. We want to be proactive with patient and family communication on days three through five. I always feel like if you can get the family on board then the patient is going to succeed. Families want to understand what is going on and how they can help.

Another strategy is to implement early activity and mobility. This includes minimizing unnecessary bed rest and utilizing various positioning strategies, which will aid in wound prevention. Mary Massery is a physical therapist who said, "If you cannot breathe you cannot function." We can utilize her techniques when positioning patients. She has courses that train nurses, RTs, and physical therapists on how to position patients for the most effective ventilation and breathing while performing various activities. Sometimes if a patient is slumping over in their chair it is just a matter of putting a little bolster behind them to help open up their trunk a little bit and spread their shoulders back to help them get air in better.

In regards to mobility, we will start with the range of motion and passive active sitting. Create a sitting schedule to have them sit either at the edge of the bed or in a chair. We want them to bear weight as soon as possible and move into early ambulation. We may need a portable ventilator that can be pushed along with the patient as they mobilize. We also want to have an ongoing assessment of symptoms of multiple organ failure or dysfunction.

Technology as a Solution

We have talked about technology and how it helps us extend the lives of patients for multiple years. They are surviving their ICU stays and technology got us there, but we are behind the eight ball in their functional mobility and other things that would improve their outcomes.

How can technology actually help us? There is wireless monitoring for cardiac monitors, SpO2, and blood pressure if we are ambulating someone. You do not necessarily need a portable ventilator for the mobility of your patient. Most critical care vents can be made portable by disconnecting the high-pressure oxygen and hooking it up to a portable. We can unplug the power, use the battery, and off we go with our patients.

There are things like custom transport carts that can be helpful. In our rehab, the maintenance guys came up with some really great makeshift transport carts. You can buy some that are a little more sophisticated and have room on them for a portable ventilator to be mounted on it. There are some that are a walker style where the ventilator is actually on the walker and the patient is moving it. There are holders for oxygen on IV poles and multiple line holders where you can prop up the urinary catheter line or the chest tube line.

There are mobile high-flow oxygen devices that you can move with the patients. This is good for spontaneously breathing patients that may be on a nasal cannula or a trach mask with high flow. Neuromuscular electrical stimulation (NES) is a tool we used in rehab a lot for stimulating muscles for patients to mobilize their legs. Diaphragmatic pacing is also an electrical stimulation device.

Cycle ergometers for arms and legs are helpful as well as specialty beds that can configure themselves into a chair. Specialty beds seem to be a part of early mobility quality improvement projects in ICU because of this.

Mobility in the ICU

Before doing any early mobility determine the patient’s medical stability. The vitals may vary a little bit because every patient is different, but basically, they should have a heart rate of less than 110 at rest, mean arterial blood pressure between 60 and 110 mmHg, and FiO2 of less than 0.6. If you are trying to mobilize someone and their FiO2 is 60, you know they are going to need a little bit more oxygen when they mobilize.

Phases of Mobility

There are three phases of mobility in the ICU. During phase one, physical therapists will come in and do range of motion activities with patients. They will start with passive exercises so the patient is not doing anything and the PT does it for them. When it is appropriate, they will do active range of motion exercises, stretching exercises, resistance exercises, and breathing exercises.

In phase two, they will progress to standing activities. These may be in a standing frame where the patient can stand up and have a place to put their elbows or their forearms. They can be on a mechanical ventilator and the standing frame can help support them. This also may be done with a walker or with assistance. Next will be weight shifting where patients just stand, moving their weight from foot to foot. Then they will progress to stepping in place, sidestepping, and then walking re-education as tolerated as they begin to move.

In phase three patients might use a cane or a walker or walk with assistance. They will increase their transfers and endurance. We want to make sure they can get from point A to point B. Any time patients are doing these activities, we want to make sure they are ventilating properly and have oxygenation support for increased exertion.

Standardization of Practices

There is a standardization of practices that we can employ in hospitals. When a patient admits to ICU there should be activity as tolerated, right off the bat. A PT eval should be included in standard admission orders. We should strive for a goal of 60 to 80% of patients to receive consistent PT daily. Of course, there are going to be days where it is not going to work out, but have that consistent goal. Patients should be kept wakeful as much as possible and mobile as soon as possible. We want to minimize delirium, so have protocols and standardization of how you handle sedation vacations, making sure patients are getting proper sleep. It is also important to minimize the work of breathing during activities.

Components of Early Mobility Programs

Having an early mobility program is a big project with many components. First of all, you need to recognize and understand the problem, and the impact within your healthcare system. You need administrative and stakeholder support. You may need to start at grassroots and go to mid-level and have mid-level take to admin, but we have to get their support. It is important to provide a business plan, as they are going to want to see how this will financially help them.

There should be a structured quality improvement project with a multidisciplinary team. Collect preliminary data, including how your outcomes have been without early intervention. Your quality assurance person can help identify what data should you gather. There should be the adoption of changes in the current culture to establish permanent changes. If you have a culture that is not focusing on early mobility, we want to try to change that culture and have it become a permanent change in this effort.

The early mobility program should engage leadership and frontline staff to identify barriers to change and appropriate solutions. It is helpful to understand the problem and look at different solutions. Educate, collaborate with each other and other facilities, execute your plan, and then evaluate it. The current research presents safe and effective strategies for early mobilization to improve patient and hospital outcomes.

Strategies for Success

Strategies for success include educating and promoting this effort. Start small. Do not try to bite off more than you can chew and evolve your plan over time. Make sure to have a forward motion with your advancements. Treat the patient's pain, but make sure that they have sedation vacations. Find your champions. Find the people that are in support of this initiative. We all should be, but it is very important to find your champions throughout the levels of care.

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