EFFECTIVENESS OF AN EARLY MOBILITIZATION PROTOCOL TOWARDS

INTENSIVE CARE UNIT PATIENTS.

Maricel B. Bayucca

Isabela State University

Introduction

Intensive Care Unit has been known as an assigned area and a second setting for where critically

ill patients admitted from hospitals and from the care and treatment they received from ICU

health worker, leads them to survive but there are often factors that may affect or worsen their

situation such due to immobility, and one of the factor that impact the considered one of frequent

part of treatment of ICU patient treatment. Hippocrates may have implied that pain is relieved by

bed rest, but modern day researcher’s have been systematically found out that bed rest can

potentially harmful with complication of muscle wasting, vasomotor instability, constipation,

back pain, pressure ulcer, contraction and blood clots, pulmonary edema, bone demineralization.

Length of stay (LOS) of ICU patient can be a measure of resource in utilizing the effectiveness

of an early mobilization protocol among critical patient because of it surprisingly consistent

among most diagnosis. LOS has been documented as short as 24 hours and as long as 132 days

(Arabi, et al., 2002).

Literature Review

This chapter contains the current review of literature for evidence support in the effectiveness of

an early mobilization protocols towards ICU patients. Effectiveness of an early mobilization

protocol effect LOS of critically ill patient in ICU was also investigated. The literature support

the effectiveness of an early mobilization protocol was investigated in order to validate the

development of an evidence-based progressive mobility protocol. This chapter will review the

current literature on effectiveness of an early mobilization protocol towards ICU patient.

Early mobility protocols (EMPs) have been shown to be effective in decreasing total ventilator

days, healthcare acquired complications, hospital length of stay (LOS), and overall cost of care;

these protocols also increase functionality, quality of life, and patient outcomes (Adler &

Malone, 2012; Morris et al., 2008; Olkowski et al., 2015; Schweickert et al., 2009).

Research and expert consensus have established that mobility screening protocols are feasible,

safe, and easily replicable (Bailey, et al., 2007; Hashem),

Parker, & Needham, 2016; Moyer et al., 2017; Sottile et al., 2015)In 2015, Bognar et al. used

literature based clinical outcome estimates of EMPs for ICU patients to develop a financial

impact model and simulate the impact of introducing an EMP in an ICU on costs to hospitals,

third-party payers, and capitated healthcare delivery systems. Results from this study concluded

that “the total net present value over a seven-year time horizon of an EMP for a US hospital with

1000 yearly ICU admissions exceeds $2.3m” (p. 1). In addition, the yearly cost of care savings

generated by reducing ICU LOS and numbers of days on the ventilator was approximately

$927,000. Finally, the impact of EMPs on hospital readmission rates saves an additional $93,000

annually by reducing hospital readmission penalties.

Schweikert et al., studied 104 medical ICU patients who were sedated and ventilated for less

than 72 h and were expected to remain on mechanical ventilation for at least24 more hours.

Patients were randomized to early exercise/mobilization (progression of activity from range of

motion to full ambulation) versus daily sedation interruption with physical therapy at the

discretion of the primary team. Early mobilization was associated with an increased percentage

of patients returning to independent functional status at hospital discharge (59 vs. 35 %, p =

0.02), less delirium, increased ventilator free days and a trend toward increased likelihood of

being discharged home versus the need for further rehabilitation.

(Doiron KA et., al 2018)There is low quality evidence that early mobilization may have little or

no effect on physical function measured by the Short Physical Performance Battery score at ICU

discharge from one study of 184 participants (mean 1.6 in the intervention group versus 1.9 in

usual care, MD -0.30, 95% CI -1.10 to 0.50), or at hospital discharge (MD 0, 95% CI -1.00 to

0.90). The fourth study, which examined postoperative cardiac surgery patients did not measure

physical function as an outcome. Adverse effects were reported across the four studies but could

not combine the data. Our certainty in the risk of adverse events with either mobilization strategy

is low due to the low rate of events.

Chiarici A et., (August 2019) An early, interdisciplinary team approach, providing a customized

dynamic planning of physiotherapy programs, increases ventilator-free time and reduces total

hospital stay, especially in patients admitted to the ICU after general surgery. This rehabilitation

care pathway can be generalized to different geopolitical scenarios, being feasible, safe and cost

effective.

Cameron S. et al.,(2015). Early mobilization of critically ill patients is beneficial, suggesting that

it should be incorporated into daily clinical practice. Early passive, active, and combined

progressive mobilizations can be safely initiated in intensive care units (ICUs). Adult patients

receiving early mobilization have fewer ventilator-dependent days, shorter ICU and hospital

stays, and better functional outcomes. Pediatric ICU data are limited, but recent studies also

suggest that early mobilization is achievable without increasing patient risk. In this review, we

provide a current and comprehensive appraisal of ICU mobilization techniques in both adult and

pediatric critically ill patients. Contraindications and perceived barriers to early mobilization,

including cost and health care provider views, are identified. Methods of overcoming barriers to

early mobilization and enhancing sustainability of mobilization programs are discussed.

Optimization of patient outcomes will require further studies on mobilization timing and

intensity, particularly within specific ICU populations.

Hoffman TC et al., (2018). There is insufficient evidence on the effect of early mobilization of

critically ill people in the ICU on physical function or performance, adverse events, muscle

strength and health-related quality of life at this time. The four studies awaiting classification,

and the three ongoing studies may alter the conclusions of the review once these results are

available. We assessed that there is currently low-quality evidence for the effect of early

mobilization of critically ill adults in the ICU due to small sample sizes, lack of blinding of

participants and personnel, variation in the interventions and outcomes used to measure their

effect and inadequate descriptions of the interventions delivered as usual care in the studies

included in this Cochrane Review.

Zhang el et al., (2019). Physical therapy can prevent functional impairments and improve the

quality of life of patients after hospital discharge. However, the effect of early mobilization on

patients with a critical illness remains unclear. This study was performed to assess the evidence

available regarding the effect of early mobilization on critically ill patients in the intensive care

unit (ICU).

Methodology

The primary hypothesis of this study state, critically ill patient from ICU who participates in an

early mobilization protocols or activities can have a shorter LOS and a decreased cost of care.

While secondary hypothesis includes patient in ICU had fewer medical complication with early

mobilization.

The methodology of this study focuses on articles review. The name of website and articles was

used for full text articles. Google also has been used in searching in order to find and locate the
articles to be used in collecting and synthesizing data analysis. Key terms used in the search

include ICU and early mobilization, and critical patient, length of stay. The three article entitled

(1. Early intervention (mobilization or active exercise) for critically ill adults in Intensive Care

unit, 2. An early tailored intervention is the key to effective rehabilitation in the Intensive Care

Unit, 3. Patient early mobilization: A Malaysia's study of nursing practices) was explored and

from these original articles, primary and secondary data were included and relevant data among

those three articles were selected after review of abstract was performed to measure and prove

the effectiveness of an early mobilization protocols toward ICU patient. These articles were

chosen for basis for this knowledge synthesis.

Discussion:

This chapter aimed to discuss the method used in conceptualizing the analysis based on the three

reviewed article were data was collected. This study hypothesized that applying early

mobilization protocol to critically ill patient would be correlated with decreased pressure sore

incidence with affecting the decreased length of patient stay in ICU. In addition, when

implementing an early mobilization protocol in intensive care unit, total costs where shown to

decrease as well as fewer medical related complications were noted. There is quite evidence that

shows the effectiveness of an early mobilization protocol towards ICU patient. Early

mobilization should become a standard of care for critically ill and unstable patient in the

Intensive Care Unit setting.

Result

Critically ill Intensive Care Unit Patient length of stay was reduced with statistical significance

in examining effectiveness of an early mobilization protocol. Limited research on cost of

intensive care unit stay indicated savings potential with early mobilization. Applying an early

mobilization protocol to a critically ill patient was shown to decreased patient situation such risk

of infection such delirium by 2 days, reduce risk of re admission or death result.

Conclusion:

Early mobilization protocols has been potentially proven effectively and safe to used in

providing health care to a critically ill patient from Intensive Care Unit as evidence by reducing

length of stay and medical complication. In addition, early mobilization towards critically ill

patient would likely benefit in improving the continuous development of patient health status,

hospitals and insurance companies. Because of its benefits, early mobilization protocol should

become a considered one of effective standard of care for patient health workers particularly in

ICU setting to help in the potential reduction of patient medical complication.

References

Doiron KA, et al., (2018) Early intervention (mobilization or active exercise) for critically ill

adults in the intensive care unit. https://www.ncbi.nlm.nih.gov/m/pubmed/29582429/#fft

Chiarici A, et al. 2019. An Early Tailored Approach Is the Key to Effective Rehabilitation in the

Intensive Care Unit.https://www.ncbi.nlm.nih.gov/m/pubmed/30796918/

Leong YL, et al (June 21, 2017) .Patient early mobilization: A Malaysia's study of nursing

practices. http://criticalcare.imedpub.com/patient-early-mobilization-a-malaysias-study-of-

nursing-practices.php?aid=193
 Literature Matrix

Litterateur Definition Purpose Method Participants Instrument Data analysis Results

Reference Design used
Title Survivors of To asses the They search They include They include Two There is
Early critical effects of CENTRAL, four RCTs all researchers insufficient
intervention
illness often early MEDLINE, (total of 690 randomized independently evidence on
(mobilization
experience a intervention Embase and participants). trials (RCTs) screened the effect of
or active
multitude of (mobilization CINAHL. Participants or quasi - titles and early
RCTs that
exercise) for
problems that or active They were adults abstract and mobilization
compared
critically ill
begin in the exercise), searched who were early assessed full of critically
adults in the
intensive care commenced conference mechanically intervention text articles ill people in
Intensive unit (ICU) or in the ICU, proceedings ventilated at (mobilization against the the ICU on
Care Unit. present and provided to reference age ranging or active inclusion physical
continue after critically ill list of 56 - 62 years exercise or criteria of this function or
Author discharge. adults either retrieved old. both) review. performance,
Doiron KA, These can during or articles, delivered in adverse
et al., include after the data bases the ICU, events,
(2018) muscle mechanical of trial with delayed muscle
weakness, ventilation registries exercise or strength and
usual care
cognitive period, and health-
delivered to
impairments, compared contacted critically ill related
psychological with delayed experts in adults either quality of
difficulties, exercise or the field on during or life at this
reduced usual care, 31 August after the time.
physical on 2017. mechanical
function such improving ventilator
as in physical period in the
activities of function or ICU.
daily living performance,
(ADLs), and muscle
decreased strength and
quality of health-
life. Early related
interventions quality of
such as life.
mobilizations
or active
exercise, or
both, may
diminish the
impact of the
sequelae of
critical
illness.
Litterateur Definition Purpose Method Participants Instrument Data analysis Results
Reference Design used
An early To Observation Patients The The novel An early,
Title tailored investigate al admitted prospective rehabilitation interdiscipl
An early interventio the prospective between cohort care pathway inary team
tailored n is defined effectiveness, cohort April 1, benefited of a led to (1) an approach,
intervention as an early feasibility, study, with 2015, and rehabilitation increased providing a
care pathway
is the key to approach and safety of retrospectiv June 30, proportion of customized
based on (1)
effectiveness to an an evidence- e controls. 2015, was interdisciplin patients dynamic
rehabilitation Intensive based compared to ary receiving planning of
in the Care unit rehabilitation a teamwork; rehabilitative physiothera
Intensive care patient care pathway retrospectiv (2) early assessment py
unit. considering in the e cohort customized (P<.0001); programs,
the intensive admitted to and goal- (2) a increases
Author implement care unit the same oriented decreased ventilator-
Chiarici A, et ation of (ICU) in ICUs during rehabilitation latency from free time
al. Arch Phys safety and different the same 3- ; (3) daily ICU and
Med Rehabil. feasible patient month functional admission to reduces
monitoring
2019. active populations. period in both total
and treatment
exercises 2014. The revision; (4) rehabilitation hospital
and number of agreed team stay,
practice in patients discharge assessment especially
helping studied policy; and and in patients
them boost (N=285) (5) continuity rehabilitation admitted to
and restore included of care. The start the ICU
sufficient 152 in the retrospective (P<.0001); after
energy in prospective cohort (3) an general
addition to group and underwent increased surgery.
usual care.
their 133 in the proportion of This
received retrospectiv patients rehabilitati
treatment. e group. undergoing on care
rehabilitation pathway
shorter can be
mechanical feasible,
ventilation safe and
duration cost
Length of effective.
stay was
observed.
Litterateur Definition Purpose Method Participants Instrument Data Results
Reference Design used analysis
Title .Mobilization has The purpose Descriptive The study Research One Majority
Patient Earlybeen defined as of this study cross- was instrument in hundred of the ICU
Mobilization:“physical activity is to assess sectional conducted this study thirty two nurses had
A Malaysia’s sufficient to elicit nurses’ survey was among a comprised of survey met the
Study of
acute practices used to group of 3 checklist minimal
Nursing physiological regarding assess nurses components was practice of
Practices effects that early current working in which were distributed mobilizing
enhance mobilization nurses’ adult glossary of and 132 patient at
Author ventilation, central among practices critical care the study nurses least 3
Leong YL, et and peripheral mechanical and barriers units in a terms, completed times or
al,. perfusion, ventilated on patient teaching demographic mobilization more per
( June 21, circulation, patient early hospital. data, and practice and shift work.
2017) muscle mobilization The chosen participant barriers
metabolism and among in one was observational survey
alertness and are intensive University checklist (n=132, a
countermeasures care unit of Malaya response
for venous stasis a teaching Medical rate of
and deep vein hospital in Centre 100%). It
thrombosis” [1]. A Malaysia. A (UMMC), comprised
current definition convenient a 1200-bed ICU (n=71),
of early sampling referral CICU
mobilization refers approach center. (n=25), and
to the application was used. A Neuro ICU
of physical participant (n=36).
activity within the self- Data
first 2 to 5 days of administer analysis was
critical illness or checklist using SPSS
injury. was version 22.
distributed The results
to assess the were scored
practices. and
analysed.
Descriptive
statistics
and
normality
test were
used.
Twenty six
of the target
participants
did not met
the
inclusion
criteria.
Hence, they
were not
recruited
into the
study.