Transcript Early Mobilization in Acute Care

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
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Objectives

Discuss current practice and investigate why current
interventions/limitations with activity exist.
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Explore common impairments that occur with prolonged
bedrest and prolonged Intensive Care Unit (ICU) stays.
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Define Early Mobilization.
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Discuss the benefits of Early Mobilization.
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Review an Early Mobilization Protocol.
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Discuss Further Considerations with Early Mobilization in the
ICU.
Current practice in many hospitals
 We’ve come a long way but more improvements
can be made.1
 Delayed initiation of physical therapy 1
 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  DECREASED FUNCTION! 3, 6-7
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Increased morbidity/mortality
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Increased cost of care
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Increased length of stay
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Respiratory muscle weakness and increased duration of
ventilation
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Sleep deprivation
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Lack of social interaction
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Prolonged sedation
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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? 6
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 patient’s values are needed
Determine what phase of the Early Mobilization Program
the patient is starting in.
Initiating an early mobilization protocol
for mechanically ventilated patients 6,7
 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? 1,2,7
 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
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.