EARLY MOBILITY 1

Shirley Van
12/12/13
NURS 611 Section 01
Dr. Fetzer and Professor Kallmerten

Does early mobility for mechanically ventilated patients in the ICU reduce hospitalization
time?

Background & Rationale
Mobility for patients in the hospital is one of the most important interventions. Although
it is standard for many patients to have sequential compression device, ted stockings, or heparin
shots while they are in the hospital to prevent issues like deep vein thrombosisactually getting
the patient up and walking if they tolerate it is better. A lot of patients in the ICU are usually
confined to their beds which do not help them at all. If the patient is able to do even just range of
motion on their beds it would help them recover faster. There are a lot of studies conducted on
how an early mobility protocol in the ICU could reduce mortality, days in the ICU, and costs for
the hospital (Lowry, 2011). There are a lot of mobility protocols out there that are even getting
the patients that are mechanically ventilated out of bed.
Patients in the ICU are usually neglected on getting them out of bed due to all the lines
that are connected to them. It makes it a harder challenge to get them walking or even into a
chair and their risk for fall is higher. With those challenges, patients are bedridden and so its
prolonging their stay in the hospital. With an early mobility protocol, even getting the patient out
of the ICU ward a day earlier is good for them. Evidence based practice is important because
with the results of those studies it helps show that the interventions could work and help patients
improve their progress. With evidence showing that a certain intervention helps, the hospital
staff would actually initiate those interventions.

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Search Methods
The information about this intervention was research through the CINAHL database. The
key terms that were typed into the search bar were ICU and early because the question is
dealing with ICU patients and an early mobility protocol. Previously, the term ventilator was
tried too, but very few results came up with full texts. With only those two terms in the search
bar, a lot more results came up on early mobility protocol and even articles about patients on
mechanical ventilators. The limits for this research were English, full text, and only articles from
2003 onwards. Google was also used to look up basic information on this intervention, and an
article came up from medscape about the early mobility protocol and there was a lot of research
on it but because there are no references to the studies that was completed, this article from
medscape could not be used as evidence. Some of the information from the article is used in the
background and rationale.
Critical Appraisal of Evidence
In the article Early Mobilization Improves Functional Outcomes in Critically Ill Patients,
the study is completed with an open label randomized clinical trial. This trial is to see the
functional outcomes of early mobility during their daily interruption of sedation on ICU patients
with mechanical ventilation. This study was completed at two university hospitals and there are
104 participants. The intervention group was early exercise and mobility with the physical or
occupational therapists or regular therapy as ordered by their primary care provider during their
daily interruption of sedation. The therapists were blinded to the treatment assignmentswhich
makes it a strength of the study. With the therapists being blinded, it prevents results from being
skewed. The results of this study is that 59% of the patients in the intervention group was able to
return to their independent functional status when they were discharged from the hospital
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compared to 35% of the patients in the control group. The patients in the intervention group also
had a shorter duration of delirium. They also had more ventilator free days when the study did a
28 day follow up period. The limitations of who could participate in the study strengthened the
study. All of the participants were functionally independent prior to hospitalization, all of them
has to be on the mechanical ventilation for at least 72 hours, and continue the ventilation for at
least 24 hours after the enrollment into the study. With these limitations in place, it reduces
outliers. Although it is strength, it is also a weakness. For this study, since it was completed on
patients that were functionally independent prior to hospitalization so it does not show how it
would affect patients that have a more severe illness if the results would be the same for them.
The results also did not provide enough information such as the scores of sedation and delirium.
Although the results for this study is limited to patients that were independent prior to
hospitalization, its still shows that early mobility for patients improve their status more than
patients that receive standard care. (Brahmbhatt, Murugan, Milbrandt, 2010)
In the study Examining the Positive Effects of Exercise in Intubated Adults in ICU is a
prospective repeated measures study. This study has four different research questions. They want
to know about if exercise associated with the changes in vital signs would cause unsafe events
for the patient, if mode or duration of exercise causes the changes in the IL-6 or IL-10, if there
are any changes in IL-6 or IL-10 that affects patient outcomes, and if there are any differences in
patient outcomes between mobility therapy and standard care. The main question that is mostly
related to this intervention is the last question. There were three different periods throughout this
study. There was the control period (standard care for the patients), run-in period (protocol is
introduce to the staff and the protocol is refined), and the intervention period (protocol is
implemented). This study was conducted from December 2007 to March 2009 at a large, urban,
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academic medical center. The limits for the participants is that they cant have any underlying
disease that could affect the progressive mobility, they need to already been on the mechanical
ventilator for at least 48 hours and continue to be on the ventilator for another 24 hours in order
to be a participant. The strengths and weakness between this study and the previous study is
very similar due to their limitations for participants. With this study though, it provides more
information like how the vital signs are affected and if its dangerous for the patient when are
completing the exercise. Results from this study showed that the early mobility protocol only
reduce their length of stay in the ICU. Other results such pressure ulcers, ventilator associated
pneumonia, or delirium did not change much. In this study it was also unknown whether or not
patients had to be readmitted in the future or what their outcome was after the ICU so thats
another weakness. (Daly, et al., 2012)
The third article, Physical Therapist-Established Intensive Care Unit Early Mobilization
Program: Quality Improvement Project for Critical Care at the University of California San
Francisco Medical Center, is a nine month retrospective analysis. Although this study is not
about patients have a mechanical ventilator, it is still relevant to the question because it is about
an early mobility protocol for ICU patients. This study was conducted from 2009 to 2010 with a
physical therapist working with them. The patients in the 2009 group were the control group
where they received standard care, and the patients in the 2010 group were the intervention
group. The goal of this program that is initiated is to reduce the length of stay in the ICU and to
reduce the time from ICU admission to physical therapy initiation. The patient has to be in the
ICU for at least 48 hours in order to qualify for the study. With these patients, if they were able
to tolerate the exercise they were included in the study. If they have some underlying disease that
may affect them, their situation is examined before they participate in the intervention. Since the
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limitation to participate in this study is more open, it might skew the results since not all patients
have similar situations. This is a good change compared to the other two studies though, so this
way it could be compared to how all kinds of patients could be affected. With this study, patients
would have physical therapy for at least 15 minutes each day if they tolerate it. One of the
weaknesses of this is that this is only from Monday to Friday, so on the weekends patients do not
receive this intervention. In the results, it showed that ICU patients had a shorter length of stay
when the intervention was implemented. Overall, their whole hospital stay was shorter than the
control group. With the new intervention in place, it also prevents weakness in the patients
muscles because bed rest could cause weakness. If patients are exercising, it prevents that from
happening and lessens the time for their physical therapy after hospitalization. Another weakness
of this study is since its not a randomized trial the level of evidence is lowered. The evidence is
not as strong. (Engel, Tatebe, Alonzo, Mustille, Rivera, 2013)
Evidence Synthesis
Throughout all three studies that were conducted on how the intervention of early
mobility would help the patient more it all showed that it definitely reduced their length of stay
in the ICU. Exercise did not have to be patients getting out of bed and walking, it could also be
in bed exercises such as range of motion. That prevented muscle weakness from bed rest and
helped them recover faster. Their length of stay in the hospital also reduced due to early physical
therapy. The only trouble with getting ICU patients up is that it usually requires a team of people
to work together because of all the lines and drains the patient may have. That is a challenge and
could cause back injury for the staff if theyre not careful. Getting patients out of bed to exercise
could be a safe procedure; as long as preparations are completed and the aides are making sure
that the patients are resting when they need to then the whole procedure would not have
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problems. With this evidence, it answers the question whether or not early mobility protocols
would reduce hospitalization times and it does.
Clinical and Research Recommendation
For future practice, this intervention should be included into a care plan. If patients are
able to tolerate exercise they should do it to prevent muscle weakness from all the bed rest.
Being on bed rest could cause more complications for the patient and could cause them to have
to stay in the ICU longer than needed. According to some of the studies found on this
intervention, it not only reduces a patients length of stay in the ICU, it also helps the hospital
and patient reduces cost. Though, more studies do need to be completed on this intervention.
There are a lot of articles on how it could improve a patients health, but there are not many
studies that are conducted. If this intervention is initiated, it does need a physical therapist,
registered nurse, and a nursing aide to work together to prevent injuries to the patient and the
staff.




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References

Brahmbhatt, N., Murugan, R., Milbrandt, E., (2010) Early Mobilization Improves Functional
Outcomes in Critically Ill Patients Retrieved from
http://www.biomedcentral.com/content/pdf/cc9262.pdf

Engel, H. J., Tatebe, S., Alonzo, P. B., Mustille, R. L., & Rivera, M. J. (2013). Physical
Therapist-Established Intensive Care Unit Early Mobilization Program: Quality
Improvement Project for Critical Care at the University of California San Francisco
Medical Center. Physical Therapy, 93(7), 975-985. doi:10.2522/ptj.20110420

Lowry, F., (2011) Mobility Protocol Gets Even Ventilated ICU Patients Up & Moving Retrieved
from http://www.medscape.com/viewarticle/736041

Daly, J., Gordon, N., Hejal, R., Johnson, K., Levine A., Peereboom, K., Rowbottom, J.,
Winkelman, C., (2012) Examining the positive effects of exercise in intubated adults in
ICU: A prospective repeated measures clinical study, Retrieved from
http://www.sciencedirect.com/science/article/pii/S0964339712000286