J Neurosurg 116:1379–1388, 2012

The effect of increased mobility on morbidity in the

neurointensive care unit

Clinical article
W. Lee Titsworth, M.D., Ph.D.,1 Jeannette Hester, M.S.N., R.N., C.C.R.N., 2
Tom Correia, B.S.N., 2 Richard Reed, B.S.N., 2
Peggy Guin, Ph.D., A.R.N.P., C.N.S.-B.C., C.N.R.N., 2 Lennox Archibald, M.D., 3
A. Joseph Layon, M.D., 4 and J Mocco, M.D., M.S.1
Departments of 1Neurosurgery, 2Nursing and Patient Services, and 3Infection Prevention and Control, Shands
Hospital at the University of Florida, Gainesville, Florida; and 4System Director, Critical Care Medicine,
Geisinger Health System, Danville, Pennsylvania

Object. The detrimental effects of immobility on intensive care unit (ICU) patients are well established. Limited
studies involving medical ICUs have demonstrated the safety and benefit of mobility protocols. Currently no study
has investigated the role of increased mobility in the neurointensive care unit population. This study was a single-
institution prospective intervention trial to investigate the effectiveness of increased mobility among neurointensive
care unit patients.
Methods. All patients admitted to the neurointensive care unit of a tertiary care center over a 16-month period
(April 2010 through July 2011) were evaluated. The study consisted of a 10-month (8025 patient days) preinterven-
tion observation period followed by a 6-month (4455 patient days) postintervention period. The intervention was a
comprehensive mobility initiative utilizing the Progressive Upright Mobility Protocol (PUMP) Plus.
Results. Implementation of the PUMP Plus increased mobility among neurointensive care unit patients by 300%
(p < 0.0001). Initiation of this protocol also correlated with a reduction in neurointensive care unit length of stay
(LOS; p < 0.004), hospital LOS (p < 0.004), hospital-acquired infections (p < 0.05), and ventilator-associated pneu-
monias (p < 0.001), and decreased the number of patient days in restraints (p < 0.05). Additionally, increased mobility
did not lead to increases in adverse events as measured by falls or inadvertent line disconnections.
Conclusions. Among neurointensive care unit patients, increased mobility can be achieved quickly and safely
with associated reductions in LOS and hospital-acquired infections using the PUMP Plus program.
(http://thejns.org/doi/abs/10.3171/2012.2.JNS111881)

Key Words      •      neurointensive care unit      •      mobility      •      restraints      •

hospital-acquired infection      •      length of stay      •      ventilator-associated pneumonia      •
pressure ulcer

P
ressure has been placed on all health care provid-
ers to decrease complications and improve quality
broadly defined across the spectrum of patient care.
The creation of the National Neurosurgery Quality and
Outcomes Database (N2QOD) by the AANS is evidence
of this movement within neurosurgery. However, there
remains a shortage of evidence-based quality improve-
ment initiatives that have shown positive outcomes in the
neurosurgical patient population.
Decreased mobility in critically ill patients has been a
recurrent historical problem with far-reaching physiologi-
cal consequences. A meta-analysis of 39 randomized tri-
Abbreviations used in this paper: ICU = intensive care unit;
I-MOVE = Independent Mobility Validation Examination; LOS =
length of stay; NHSN = National Health Safety Network; PUMP
= Progressive Upright Mobility Protocol; SUF = Shands Hospital
at the University of Florida; UTI = urinary tract infection; VAP =
ventilator-associated pneumonia.
als2 examining the effect of bed rest on 15 different medi-
cal conditions or procedures showed that bed rest resulted
in no improvement in 22 trials and worsened outcomes
in 17 trials. Short-term adverse outcomes for critically ill
patients include VAP and hospital-acquired pneumonia,
delayed weaning off of mechanical ventilation, muscle
weakness, and the development of pressure ulcers;24 a
major long-term complication is diminished quality of
life after discharge due to the physical deconditioning
that occurs during the patient’s stay in the ICU.12,13
Prolonged ICU care appears to have a particularly
detrimental effect on muscle strength. A landmark study
by Herridge et al.18 investigated outcomes among survi-
vors of acute respiratory distress syndrome and found
that they lost 18% of their body weight at discharge from
This article contains some figures that are displayed in color
on­line but in black-and-white in the print edition.

J Neurosurg / Volume 116 / June 2012 1379


the ICU and had significant functional limitations 1 year
later because of muscle wasting and fatigue. The median
6-minute walk distance in survivors was only 66% of that
predicted at 1 year after ICU discharge, with limitations
attributed to ICU-acquired morbidities, such as global
muscle wasting and weakness, foot drop, joint immobil-
ity, and dyspnea. Only 49% of survivors in this study had
returned to work at 1 year after discharge. In a systematic
review of ICU patients with sepsis, multiorgan failure, or
prolonged mechanical ventilation, neuromuscular dys-
function was identified in 46% of patients and was as-
sociated with prolonged duration of mechanical ventila-
tion and length of ICU and hospital stay.31 After 7 days
of mechanical ventilation, 25–33% of patients experience
clinically visible weakness.11 In a recent study, clinicians
found that more than one third of patients with stays in
the ICU greater than 2 weeks had at least 2 functionally
significant joint contractures.10
Low patient mobility is rampant in current ICU prac-
tice. A multicenter study of patients with acute lung injury
found that only 27% of patients received physical therapy
in the ICU, with therapy occurring on only 6% of all ICU
days;26 another single-center study found that only 6% of
mechanically ventilated patients received physical thera-
py in the ICU.25 Krishnagopalan et al.21 demonstrated that
during an 8-hour time frame, fewer than 3% of critically
ill patients were turned, even though ICU policy man-
dated turning patients every 2 hours, and that approxi-
mately 50% of patients had no change in body position
at all. Finally, Goldhill et al.14 found that the average time
between manual turns was 4.85 ± 3.3 hours among 40
different ICUs.
With more than 5 million persons experiencing an
ICU stay each year, the short- and long-term complica-
tions of immobility and bed rest significantly affect pa-
tient morbidity, mortality, cost, and quality of life.17 No
study has investigated the feasibility or benefit of in-
creased mobility on outcome in the neurointensive care
unit population. Furthermore, the neurointensive care
unit, given its high rate of immobility due to neurological
dysfunction, may be an ideal setting for such an interven-
tion. In this paper we present the results of a prospective
trial of a comprehensive mobility program among neuro-
intensive care unit patients at a single center.
Methods
Shands Hospital at the University of Florida is an
852-bed, tertiary-care medical center with 142 intensive
care beds, 30 of which constitute the neurointensive care
unit. The neurointensive care unit is overseen by an in-
terdisciplinary team composed of vested members from
neurosurgery, neurology, critical care medicine, nursing,
and social work. Its membership includes neuroscience
critical care staff nurses, nurse leaders, social workers,
pharmacists, physician extenders, and physicians.
Patients and Study Design
The study population consisted of all consecutive pa-
tients admitted to the neurointensive care unit from April
1, 2010, through July 31, 2011 (n = 3291). Patients were
1380
W. L. Titsworth et al.
excluded for age < 18 years, hemodynamic instability, or
end of life care. The study consisted of a 10-month pre-
intervention surveillance period (April 1, 2010, through
January 31, 2011) followed by a 6-month prospective in-
tervention phase (February 1–July 31, 2011). Study ap-
proval was granted by the Institutional Review Board at
the University of Florida and Shands Hospital.
Mobility Intervention
The Comprehensive Mobility Guidelines were devel-
oped by the SUF Mobility Task Force, a hospital-wide
interdisciplinary team that includes representatives from
hospital administration, departmental physicians, rehabil-
itation, physical therapy, clinical nurse leaders, and qual-
ity management. A literature review was performed and
evidence-based best practices were reviewed in detail.
Mobility protocols were developed for critical care units
and general hospital floors based on evidence review. In
addition, a mobility bundle toolkit was developed that
included recommendations for equipment purchasing,
staff education plans, validation checklists, and practical
implementation advice for medical and nursing leaders.
The Neuroscience Center inpatient units (neurointensive
care unit and two medical/surgical floors) were the pilot
units for testing the new mobility protocol. The mobility
bundle toolkit was then distributed to each unit’s nursing
leadership team for duplication.
The keystone of the critical care component of the
Comprehensive Mobility Guideline is the PUMP Plus al-
gorithm. Progressive mobility is a series of planned move-
ments in a sequential manner beginning at a patient’s
current mobility status with a goal of returning to his or
her baseline level.33 The PUMP Plus algorithm was devel-
oped and modified using existing evidence and guidelines
including “Progressive Mobility Guidelines for Critically
Ill Patients”1 and “Progressive Upright Mobility (PUM)
in the ICU: The How-to-Guide”22 at the University of
Kansas. The “plus” part of this protocol was the addition
of 6 levels for rehabilitation of patients beyond previous
protocols (Fig. 1). Steps 6–11 provide clear expectations
for patients beyond being “out-of-bed to chair,” which was
previously the ultimate mobility “goal” in ICU patients.
A neurocritical care subgroup of the SUF Mobility
Task Force added these 6 advanced levels to prevent ma-
jor deconditioning among able patients without requiring
the consultation of the physical therapy team. The stages
of PUMP Plus consist of elevating the head of the bed,
tilting the bed, sitting in an upright position, sitting on the
edge of the bed, standing, sitting in a chair, ambulating in
the room, ambulating outside of the room, and exercises
as determined by physical therapy/occupational therapy.
As patients completed each stage they were automatically
encouraged to progress to the next step rather than await
a physician’s orders; however, a patient’s maximum activ-
ity level could still be determined by physicians. It was
believed that this component was critical for the neuroin-
tensive care unit population because there are significant
numbers of patients who are maintained in the neuro-
intensive care unit for detailed monitoring and/or blood
pressure and fluid management despite good neurologi-
cal function (such as patients with subarachnoid hemor-
rhage).
J Neurosurg / Volume 116 / June 2012
Increased mobility in neurointensive care unit patients

Fig. 1.  The PUMP Plus algorithm. BP = blood pressure; CRRT = continuous renal replacement therapy; cont. = continuous;
CXR = chest x-ray (radiograph); HOB = head of bed; HR = heart rate; HTN = hypertension; mgmt = management; O2Sat = oxygen
saturation; PRN = as needed; pt = patient; q2hours = every 2 hours; Q shift = every 8 hour nursing shift; TBerg = Trendelenburg
bed position; TID = three times/day; tPA = tissue plasminogen activator.

Importantly, a neurointensive care unit policy, initi-
ated by the medical directors and agreed upon by all at-
tending physicians in the unit, stated that enrollment in
the PUMP Plus program was automatic unless clinically
contraindicated and documented by the attending physi-
cian. This was an important factor because it communi-
cated to the nursing staff that PUMP Plus and mobility
were the standard of care and to not mobilize the patient
was the exception. This is an important factor in changing
the culture of ICU patients who traditionally have been
placed on bed rest because of the perception that they are
too sick to be out of bed. A physician’s order was required
to discontinue PUMP Plus in neurointensive care unit pa-
tients. Clinical contraindications for PUMP Plus included
unstable spine, active stroke alerts, and/or up to 24 hours
after tissue plasminogen activator and endovascular in-
tervention, increased intracranial pressure, active resus-
citation for life-threatening hemodynamic instability,
femoral sheaths, traction, continuous renal replacement
therapy, or aggressive modes of ventilation and palliative
care. However, ventriculostomies (in the off position) are
not a contraindication to PUMP Plus.
Additional aspects of the Comprehensive Mobility
Guidelines included criteria for use of skilled physical
therapy and occupational therapy services, purchasing
additional assistive equipment, funding for additional
mobility aides, blocked time scheduling for rehabilitation
services, and requiring all patients without specific clini-
cal contraindications to be out of bed for meals, shower-
ing, and toilet use.
Data Collection
Demographic information, including morbidity, neu-
rointensive care unit LOS, and diagnosis, was obtained
from Decision Support Services and chart review. The
neurointensive care unit LOS was calculated as a month-
ly average for the neurointensive care unit. Hospital LOS
was determined for each patient in the 2-week pre- and
postintervention observation period by chart review.
Mobility was assessed by the I-MOVE tool.23 The
I-MOVE tool (Appendix A) records the highest level of
mobility obtained by a patient within the previous hour.
The stages included sitting upright in bed (1 point), sit-
ting on the edge of the bed (10 points), getting out of bed
(20 points), walking to the bathroom (30 points), walking
outside the room (40 points), or exercising (50 points). All
information was recorded by bedside nurses hourly and
analyzed during a 2-week collection period immediately
preceding the initiative (January 18–31, 2011) and for an-
other 2-week period (May 31–June 14, 2011) 4 months
after initiation of the mobility initiative.
Pressure ulcer data were collected by an Ostomy and
Wound Liaison nurse during weekly “Skin Rounds” ev-

J Neurosurg / Volume 116 / June 2012 1381


ery Wednesday using the National Pressure Ulcer Advi-
sory Panel rating scale.7 All patients were assessed for
the presence of pressure ulcers. The pressure ulcers were
categorized according to the National Pressure Ulcer Ad-
visory Panel scale and ranged from “Stage I” to “Deep
Tissue Injury.” The results presented are Stage II and
higher “unit acquired” pressure ulcer prevalence.
Patient falls and inadvertent tracheal extubations, as
well as unplanned central venous catheter and external
ventricular drain removals, were used as indicators of
protocol safety. These events were recorded as incident
reports within a preexisting adverse event monitoring
system.
Hospital-acquired infection data were regularly col-
lected as part of the quality improvement measures and
were reported to the Agency for Healthcare and Research
Quality. Hospital-acquired infections were defined by the
NHSN criteria.
Ventilator-Associated Pneumonia. Ventilator-associ-
ated pneumonia requires that the patient has an artificial
airway (endotracheal tube or tracheostomy) and is me-
chanically ventilated for more than 48 hours at the time
of culture, or within the 48 hours prior to the onset of
the event. Ventilator-associated pneumonia criteria can be
met by radiographic, clinical, and/or laboratory criteria as
follows.
Radiographic criteria require 2 or more serial chest
radiographs with at least 1 of the following: new or pro-
gressive and persistent infiltrate, consolidation, cavita-
tion, or pneumatoceles. Clinical criteria require at least
1 of the following: fever (> 38°C), leukopenia (< 4000
white blood cells/mm3) or leukocytosis (> 12,000 white
blood cells/mm3), or for adults more than 70 years old, al-
tered mental status. In addition, at least 1 of the following
is present: new onset of purulent sputum, increased re-
spiratory secretions, increased suctioning requirements,
new onset or worsening cough, dyspnea, tachypnea, rales,
bronchial breath sounds, and worsening gas exchange (O2
desaturations [PaO2/FiO2 < 240], increased O2 require-
ments, or increased ventilator demand). Laboratory crite-
ria require at least 1 of the following: positive growth in
blood culture not related to another source of infection,
positive growth in pleural fluid culture, positive quantita-
tive culture from minimally contaminated lower respira-
tory tract specimen (bronchoalveolar lavage or protected
specimen brushing), and ≥ 5% bronchoalveolar lavage–
obtained cells containing intracellular bacteria on direct
microscopic examination (Gram stain) or by histopatho-
logical examination. Ventilator-associated pneumonia
was excluded if the patient was within 48 hours of trans-
fer from another facility. The VAP rate per 1000 ventila-
tor days was calculated by dividing the number of VAPs
by the number of ventilator days and multiplying the re-
sult by 1000. The Infection Control Practitioner gathered
data on the patient (signs/symptoms, chest radiographs,
treatment, and other data) and referred any positive finds
to physicians in the Infectious Disease department who
reviewed the case and determined whether a VAP met the
NHSN definitions.
Catheter-Associated UTI. A catheter-associated UTI
was an infection that occurred while the patient had a uri-
1382
W. L. Titsworth et al.
nary catheter in place, or had a catheter in place within 48
hours prior to culture.19 Two possible definitions of UTI
were accepted. The first definition included a patient who
had at least 1 sign or symptom of UTI and a positive urine
culture growing > 105 cfu/ml with no more than 2 mi-
croorganisms. Signs and symptoms include temperature
> 38°C, urinary urgency, urinary frequency, dysuria, and
suprapubic tenderness. The second definition required
that a patient have at least 2 signs or symptoms but a less
compelling laboratory finding such as a positive dipstick
for leukocyte esterase or nitrite, pyuria with ≥ 3 white
blood cells/hpf, positive Gram stain, or 2 urine cultures
> 102 cfu/ml of a single pathogen in a patient undergo-
ing treatment with antimicrobial agents. Asymptomatic
catheter-associated bacteriuria or candiduria was defined
as a positive urine culture (> 105 cfu/ml) in a patient who
had had a urinary catheter within the previous 2 days and
who had no signs or symptoms of catheter-associated
UTI. Asymptomatic catheter-associated bacteriuria or
candiduria were not counted as catheter-associated UTIs
in this study. Patients were not routinely monitored for
asymptomatic bacteriuria. Urinalysis as well as urine and
blood cultures was performed whenever the patients de-
veloped systemic or local signs of infection; these includ-
ed fever (temperature > 38.5°C), urinary urgency, urinary
frequency, dysuria, and suprapubic tenderness.
The infection control investigation of possible cathe-
ter-associated UTI was triggered by a positive urine cul-
ture. An infection control nurse practitioner would then
perform a chart review to gather data. These data were
presented to the hospital epidemiologist to decide wheth-
er an infection based on NHSN definitions had occurred.
Catheter-associated UTI rate was defined as the number
of patients with catheter-associated UTI divided by the
number of indwelling urinary catheter days multiplied
by 1000. Catheter utilization was defined by the NHSN
definition, which was the total number of catheter days
divided by the total number of patient days multiplied by
100.
Education
The SUF Mobility Task Force developed and execut-
ed a comprehensive education and implementation plan.
This plan included policy and guideline development;
equipment inventory and purchasing; interdisciplinary
education; skills validation checklists for physicians,
nurses, and therapists; data collection tools; and shift-
to-shift monitoring via a newly designed support tech-
nician role. Interdisciplinary educational modules were
written and videos were developed to assist learners with
practical implementation of the Comprehensive Mobility
Guidelines. This education was electronically distributed
to all frontline care providers as a mandatory require-
ment. In addition, the hospital-wide preoperative surgery
and unit admission patient education brochures were re-
vised to include the Comprehensive Mobility Guidelines.
This education plan was so successful in changing the
culture on the neurointensive care unit that the SUF Mo-
bility Task Force “bundled” it into a toolkit for unit man-
agers throughout the hospital. Elements of the Mobility
Checklist are listed in Table 1.
J Neurosurg / Volume 116 / June 2012
Increased mobility in neurointensive care unit patients
Slogan promotion was also used to increase aware-
ness on the unit. Best practices were built into order sets
as defaults. Each department was provided a monthly up-
date of their current infections and targets, as well as the
percentage compliance of each physician with the PUMP
Plus.
Statistical Analysis
A mixed linear model was used to estimate the effects
of the variables of interest on mobility score (SAS PROC
MIXED, version 9.1). Independent variables were sex, di-
agnosis group, treatment, day of stay (considered as an or-
dered, continuous variable), age, and the diagnosis-group
× day interaction. We used an unstructured covariance
matrix. We used log(mobility + 1) to meet linear model as-
sumptions (the data were highly nonnormally distributed).
We added 1 to each mobility score before taking the log
because some mobility observations were 0.
Pre- and postintervention LOS and mortality infor-
mation were compared using 2-sample t-tests, and diag-
nosis group was compared using the chi-square test. A
probability value < 0.05 was considered statistically sig-
nificant. Sample size predictions were made with an a
error of 5% and a b error of 50% and were determined
prior to study initiation.
Results
Comprehensive Mobility Initiative and Patient Mobility
The PUMP Plus program compliance was assessed
during a 1-month period prior to the second mobility data
collection period. The neurointensive care unit Clinical
Leader reviewed each neurointensive care unit patient
daily to determine whether PUMP Plus was being per-
formed and found that 93.8% ± 4% of patients who had
no contraindication to the protocol were participating. On
average only 10.6% ± 4.7% of patients had to discontinue
the PUMP plus program for clinical contraindications.
Additionally, 2.2% ± 0.2% of patients per day refused
to participate and only 1.4% ± 0.2% of patients had the
protocol discontinued for inappropriate or indiscernible
reasons.
Mobility data were collected during two separate
2-week periods on a total of 166 patients. The first data
were collected immediately prior to implementation of
the mobility initiative and the second data collection oc-
curred 4 months into the initiative. The late date of the
second collection period allowed for complete adoption
of all mobility initiatives. There was no difference in the
age (p = 0.46), sex (p = 0.81), or diagnosis of the patient
population (p = 0.33) before and after intervention (Table
2). The estimated true means of the global mobility score,
as assessed by the I-MOVE tool, increased by 300% from
14.5 before the intervention to 44.7 following the inter-
vention after controlling for age, diagnosis, neurointen-
sive care unit LOS, and sex (p < 0.0001; Table 2). More
importantly, the number of patient days on which a score
of zero was recorded on the I-MOVE tool decreased from
92 patients (47.3%) to 27 patients (8.3%) after the interven-
tion. Further analysis of the mobility steps as recorded by
J Neurosurg / Volume 116 / June 2012
TABLE 1: Mobility elements used by unit managers*
Mobility Checklist for Unit Managers
select a mobility protocol for your unit (general vs PUMP Plus)
review care delivery roles, incorporate support/mobility technician into
  unit care
form unit-specific goals
review your current equipment inventory, purchase new equipment as
 needed
determine and measure unit endpoint outcomes (such as mobility
  compliance, LOS), measure before and after roll-out data collection
educate nursing staff on mobility guidelines/protocol/equipment
educate physician staff to mobility guidelines/protocol
educate other disciplinary staff (RT/PT/OT) to mobility initiative
update whiteboards in patient rooms with mobility education/goals
 template
set up patient/family education board in unit-specific waiting room
determine a go-live date, communicate it and implement
recommend daily unit-level surveillance to enforce compliance approx-
  imately 2–4 weeks after go-live, consider support technician role or
  something similar
incorporate endpoint measurements into unit-level dashboards and
  quality plan
*  OT = occupational therapist; PT = physical therapist; RT = respiratory
therapist.
the I-MOVE tool show that after initiation of the PUMP
Plus program the average patient more frequently sat up
in bed (p < 0.05), got out of bed (p < 0.001), and walked to
the bathroom (p < 0.001), but no patient exercised before
or after the intervention (Fig. 2). Our mixed linear model
indicated that treatment, diagnosis group, and the day of
neurointensive care unit stay were highly significant pre-
dictors of mobility score (c2 = 174.6, degrees of freedom
= 1, p < 0.0001). Not surprisingly, sex was not a signifi-
cant predictor of mobility (p = 0.36), and unexpectedly
neither was age (p = 0.26). Mobility generally increased
as a patient’s time in the neurointensive care unit passed.
Finally, when comparing the sample groups, hospi-
tal LOS decreased significantly from 12 days before the
mobility protocol to 8.6 days after implementation after
controlling for diagnosis group (p < 0.01; Table 2). Not
surprisingly, mobility score was a significant predictor of
hospital LOS (p < 0.004), with LOS tending to decrease
with increasing mobility score. It is estimated that LOS
decreases by 0.2% for each unit increase in mobility score
(95% CI 0.9969–0.9994).
Increased Mobility, Decreased Neurointensive Care Unit
LOS, and Hospital-Acquired Infections
Outcome measures were tracked throughout the 10-
month preintervention (8025 patient days) and 6-month
postintervention periods (4455 patient days) and com-
pared. The monthly average neurointensive care unit LOS
significantly decreased by 13% from 4.0 days prior to the
intervention to 3.46 after the intervention (p < 0.004). No
significant difference was observed in the secondary out-
1383
 W. L. Titsworth et al.

TABLE 2: Mobility data*

Variable Before the Initiative After the Initiative p Value

dates Jan 18–Jan 31, 2011 May 31–June 14, 2011
no. of patients 77 93
males (%) 37 (48.1) 43 (46.2) 0.81
mean age (yrs) ± SD 60.40 ± 2.2 58.40 ± 1.7 0.46
diagnosis (%) 0.33
 SAH 16 (20.8) 19 (20.4)
 ICH 9 (11.7) 7 (7.5)
 stroke 10 (13) 18 (19.4)
 tumor 11 (14.3) 19 (20.4)
 spine 6 (7.8) 7 (7.5)
 seizure 4 (5.2) 1 (1.1)
 other 10 (13) 11 (11.8)
 SDH 8 (10.4) 7 (7.5)
 TBI 3 (3.9) 0 (0)
mean corrected I-MOVE mobility score (95% CI) 14.5 (9.1–22.9) 44.7 (27.9–71.3) <0.0001
mean hospital LOS in days (95% CI) 12.0 (9.87–14.7) 8.6 (6.93–10.8) <0.01

* ICH = intracerebral hemorrhage; SAH = subarachnoid hemorrhage; SDH = subdural hematoma; TBI = traumatic brain injury.

comes of unit-acquired pressure ulcers (p = 0.22). Howev-
er, a significant 18.3% drop in the number of patient days
in restraints was observed (p < 0.05).
Increased mobility appeared to have the most pro-
nounced inverse correlation with hospital-acquired infec-
tions (Table 3). The average number of hospital-acquired
infections decreased by 60% when comparing the pre-
and postintervention periods (from 5.5 ± 0.9 to 2.2 ± 1.0,
respectively; p < 0.05; Fig. 3). Hospital-acquired infec-
tions in this study consisted of VAPs, central venous line
infections, and catheter-associated UTIs. Of these infec-
tions, the greatest effect was noted on the VAP rate. Be-
fore the intervention there were 2.14 ± 0.95 VAP cases
per 1000 ventilator days and after the intervention none
were observed during the 6-month follow-up period (p <
0.001). This is underscored by the fact that no significant
differences in number of ventilator days (p = 0.39), per-
centage of patients ventilated (p = 0.66), or compliance
with the VAP bundle (p = 0.23) were observed during the
same time period. While statistically insignificant, there
was a clinically significant reduction in the unit catheter-
associated UTI rate of 61% (2.72 ± 1.17 before vs. 1.07 ±
1.67 after; p = 0.11). This was likely related to the reduc-
tion in average number of catheter days per month, which
was decreased by 20.4%. Not surprisingly, urinary cath-
eter duration was the factor most strongly correlated with
the likelihood of catheter-associated UTI.9 There was no
significant change in central venous line infections be-
tween the pre- and postintervention period (p = 0.24). It
is important to note that review of the LOS, VAP, or days
in restraints from the opening of the neurointensive care
unit in 2008 revealed no major declines prior to the onset
of the PUMP Plus program, indicating that this change
was not a coincidence but more likely a significant inter-
action.

Increased Mobility and Adverse Events

Fig. 2.  Graph showing the change in the average number of record-
ed activities per day before and after implementation of the PUMP Plus
program. *p < 0.05; ***p < 0.001; OOB = out of bed.
Every intervention has associated risks and benefits.
To assess the risks associated with increased mobility
in the neurointensive care unit, patient falls, critical line
pulls, and total line pulls were monitored (Table 3). Both
the total number of falls per month (mean 1.00 vs 1.00,
respectively) and the fall rate per 1000 patient days (1.39
vs 1.31, respectively) were essentially identical before and
after the intervention. Similarly there was no significant
difference in the total line pull rate (p = 0.766) or the rate
of critical line pulls (p = 0.63). A critical line pull was

1384 J Neurosurg / Volume 116 / June 2012

Increased mobility in neurointensive care unit patients

TABLE 3: Comparison of outcome measure data before and after introduction of mobility protocol*

Outcome Measure Before Mobility After Mobility p Value

dates April 1, 2010–Jan 31, 2011 Feb 11–June 31, 2011
patient days 802 ± 71 742 ± 75 0.12
neurointensive care unit LOS (days) 4.00 ± 0.31 3.46 ± 0.31 <0.004
acquired pressure ulcer prevalence 2.6% ± 0.03 4.6% ± 0.02 0.22
days in restraints 368.57 ± 46.8 301.2 ± 55.3 <0.05
hospital-acquired infections 5.5 ± 0.9 2.2 ± 1.0 <0.05
VAP rate† 2.14 ± 0.95 0±0 <0.001
% of patients ventilated 32.0 ± 0.03 30.6 ± 0.07 0.66
ventilator days 255 ± 27.9 231 ± 70.7 0.39
VAP bundle compliance (%) 98.5 ± 0.02 95.6 ± 0.07 0.23
UTI rate† 2.72 ± 1.17 1.07 ± 1.67 0.11
urinary catheter days 581.6 ± 30 463 ± 145 <0.05
central venous line infections 0.35 ± 0.78 1.0 ± 0.93 0.24
total falls† 1.00 ± 0.35 1.0 ± 0.63 1.00
fall rate per 1000 patient days 1.39 ± 0.57 1.31 ± 0.85 0.867
critical line pulls 0.90 ± 0.53 0.67 ± 0.81 0.63
line pull rate† 1.10 ± 0.67 0.91 ± 1.12 0.766

*  All data represented as mean ± SD unless otherwise noted.

†  Rates are per 1000 days.

defined as the total number of self-extubations, pulled
arterial lines, and inadvertent external ventricular drain
removals. The lack of increase in adverse events demon-
strates the safety of this protocol in the neurointensive
care unit patient population.
Discussion
This study provides evidence that a hospital-wide
Comprehensive Mobility Campaign can result in in-
creased mobility in neurointensive care unit patients. It
must be noted that the mobility assessment used in this
study, the iMOVE tool, while previously reported as a
validated instrument, is composed of the same elements
as the PUMP Plus itself. Therefore, it is not surprising
that this tool was a sensitive measure of the PUMP Plus
program. We additionally found that these increases in
mobility occurred without increased falls or critical line
pulls, and that increased mobility correlated with an ob-
served decrease in neurointensive care unit LOS, hospi-
tal LOS, hospital-acquired infections in the neurointen-
sive care unit, and decreased days in restraints. A 13%
decrease in neurointensive care unit LOS was observed
without a significant difference in mortality rate. A 28%

Fig. 3.  Total number of culture-confirmed hospital-acquired infections over time. The dashed line indicates the start of the
Mobility Initiative.

J Neurosurg / Volume 116 / June 2012 1385


decrease was observed in the total hospital LOS, from 12
days before the intervention to 8.6 days after the inter-
vention, when adjusted for diagnosis, age, and sex. This
result is in agreement with those from previous mobil-
ity studies. One study,25 in a medical ICU that utilized a
similar Mobility Team and protocol model, showed that
ICU LOS decreased by 20% and hospital LOS decreased
by 23% when adjusted for body mass index and vasopres-
sor use. The similarity in these results is encouraging
and suggests the reproducibility among differing types of
ICU environments.
Early mobility of patients is not a new concept. The
early ambulation of hospitalized patients was first intro-
duced late in World War II in an effort to expedite the
recovery of soldiers for return to the battlefield.6 In 1972,
the University of Colorado published a photo-illustrated
report describing ambulation of a mechanically ventilat-
ed patient recovering from respiratory failure.29 Another
publication in 19758 from Geisinger Medical Center, in
Danville, Pennsylvania, provides similar historical evi-
dence of early ambulation for ICU patients.
Even minor increases in activity have shown benefi-
cial effects in ventilated ICU patients. Twenty prospec-
tive randomized controlled trials on rotational therapy
in ventilated patients were published between 1987 and
2004, and showed decreases in the incidence of pneu-
monia.15 However, studies supporting the early onset of
rehabilitation and, more importantly, ambulation in the
acute ICU setting are relatively new. The first published
report was an uncontrolled study of routine multidisci-
plinary, twice-daily rehabilitation therapy in the ICU pro-
vided to 103 mechanically ventilated patients. This study
demonstrated that activity, including sitting and ambula-
tion, was feasible and safe in mechanically ventilated pa-
tients.4 Moreover, this study demonstrated benefit, with
69% of these ICU patients ambulating more than 100 feet
(30 m) by ICU discharge with a mean distance walked
of 212 feet (65 m). Thus far, only 1 study25 has used a
Mobility Team and Mobility Protocol to initiate earlier
physical therapy in ICU patients. Morris et al. found that
protocol patients were out of bed 6 days earlier (5 vs 11)
and had therapy initiated more frequently (91% vs 13%,
respectively) and that ICU LOS was 5.5 vs. 6.9 days (p =
0.025). Finally, hospital LOS decreased from 14.5 to 11.2
days (p = 0.006) when adjusted for body mass index and
vasopressor usage.
The correlation between increased mobility and de-
creasing VAP rate was the least surprising finding in this
study. Even minor increases in activity have shown ben-
eficial effects in ventilated ICU patients. Rotational ther-
apy alone, without ambulation, decreases the incidence of
pneumonia but has no effect on duration of mechanical
ventilation, number of days in intensive care, or hospital
mortality.15 Accordingly, the European Society of Inten-
sive Care Medicine Task Force on Physiotherapy for Crit-
ically Ill Patients recently endorsed evidence-based tar-
gets for physiotherapy in the ICU. These targets included
deconditioning, impaired airway clearance, atelectasis,
intubation avoidance, and weaning failure.16 It is believed
that the mucocilliary escalator performs suboptimally
when prone and therefore increased upright mobility may
allow for increased clearance of secretions.
1386
W. L. Titsworth et al.
Changes in the catheter-associated UTI rate after in-
creased mobility is currently unreported. It is well estab-
lished that the duration of catheterization is directly relat-
ed to the risk of developing a UTI, with a risk of 3%–10%
per day of catheterization. At 1 month, this risk is nearly
100%.9 A retrospective cohort study of 400,000 nursing
home patients showed that the ability to walk was associ-
ated with a 69% lower rate of hospitalization for UTI and
that maintaining or improving mobility reduced the risk
of hospitalization for UTI by 38% to 80%.28 One possible
explanation is that increased mobility either required the
discontinuation of catheters or at least prompted physi-
cians to discontinue the use of these catheters more fre-
quently. In 1 study by Saint et al.,30 almost 40% of at-
tending physicians of patients with unnecessary urinary
catheters were unaware that the patient had a urinary
catheter in place. This idea is reinforced by the signifi-
cantly reduced number of catheter days after initiation of
the mobility protocol in this study.
It bears mentioning that prior to this mobility project
a VAP and UTI initiative had been enacted in our neuro-
intensive care unit. However, these interventions predated
this initiative by more than 6 months. More importantly,
the VAP rate had stabilized prior to beginning the PUMP
Plus program. Finally, there were no changes in either the
VAP or UTI protocols during this trial in an attempt to
control confounding variables.
It was our hypothesis that increased mobility would
correlate with a decreased incidence of pressure ulcer
prevalence, but this was not supported by the data. De-
creased mobility has been shown by multiple authors to
be an independent risk factor for the creation of pressure
ulcers. Keller et al.,20 in a systematic review of the litera-
ture, found that decreased mobility was 1 of the 11 likely
risk factors for pressure ulcer formation. Allman et al., 3
in a prospective inception cohort study of 286 patients,
found that immobility had a relative risk increase of 2.36
for pressure ulcer development. Batson et al., 5 in develop-
ment of their pressure ulcer scoring system, found that a
patient’s ability to turn was the single highest predictor of
ulcer formation. Unfortunately in this study no decrease
in pressure ulcer prevalence was observed. This may be
secondary to an overall low pressure-ulcer occurrence
rate, as both the pre- (2.6%) and postinitiative prevalence
rate (4.6%) were far below the NHSN 25th percentile of
7.89%. Therefore, detecting a decrease in pressure ulcer
formation may have been made more difficult given the
already comparatively low prevalence on this unit.
These data suggest that increased mobility is fea-
sible and safe for neurointensive care unit patients. A
prospective cohort study of early ambulation by Bailey et
al.4 showed that in 103 ventilated patients, 1449 activity
events were associated with less than 1% of activity-relat-
ed adverse events during a 6-month study. However, there
are considerable safety concerns that must be addressed
prior to initiating such a program, which have been dis-
cussed elsewhere.32
There is a strong body of literature suggesting that
venous thromboembolism should be affected by the in-
creasing of mobility. Weill-Engerer et al.34 showed that
the rate of deep venous thrombosis was strongly correlat-
ed with restriction of mobility. Deep venous thrombosis
J Neurosurg / Volume 116 / June 2012
Increased mobility in neurointensive care unit patients
formation was progressively more likely with decreasing
mobility, from limited mobility without immobilization
(OR = 1.73) to bedridden during the previous 15 days (OR
= 5.64). Unfortunately, these data could not be reliably
evaluated in our institution. Our neurointensive care unit
does not routinely screen for venous thromboembolism
and therefore any observed changes are not based on sys-
tematic observation.
Significant challenges were encountered during the
implementation of this initiative. Namely, acquiring new
equipment and support technician positions was not an
easy task in such a fiscally difficult time. Acquiring hos-
pital administration support for this initiative was impera-
tive. Once identified as a patient care priority for improving
quality outcomes, the financial resources were ultimately
allocated. The Mobility Task Force was concerned that
duplication of pilot unit efforts was paramount to achiev-
ing consistent success in every unit. For this reason, task
force members believed strongly that all unit leadership
should be given the Mobility Bundle Toolkit and Mobility
Checklist for Managers. Lastly, changing unit and inter-
disciplinary culture proved to be the most difficult chal-
lenge in this endeavor. Extensive education about current
evidence-based guidelines and mandatory enforcement of
its completion by interdisciplinary leaders were pivotal in
changing the status quo into a culture of early patient mo-
bility and complication prevention.
Our study has several limitations. First, while mobil-
ity data were collected for the entire study period, inten-
sive analysis and interpretation were only performed on
two 2-week periods (pre- and postinitiative). In our opin-
ion, further analysis would have been unduly cumber-
some and would have added little to the overall weight of
the results. Second, as with any nonrandomized study, the
interpretation of results should be conducted with care
and causality cannot be determined by the current results.
While every attempt was made to control for extraneous
factors, the role of unaccounted for variables cannot be
determined in a correlational study such as this. These
data suggest that further study is necessary and a ran-
domized control trial should be instituted to investigate
the influence of increased mobility in the ICU setting.
Conclusions
Current neurointensive care unit practice, with in-
creasingly aggressive and continuous monitoring tech-
niques, has demonstrated a shift toward sedation and in-
activity. The lack of mobility in ICU patients has been
well established in previous nonneurological work, as
has its detrimental outcomes. Recent literature has be-
gun to recognize the physiological benefits of increased
mobility in ICU patients, focusing mostly on ventilated
medical ICU wards. However, in this paper we present
only the second study to investigate the implementation
of a comprehensive mobility program (PUMP Plus) and
the first reported such initiative in a neurointensive care
unit population and the first in a predominantly surgical
population. We believe that the significant effect on hos-
pital-acquired infections and limitation of restraint merit
further randomized control trials as a means to broader
implementation.
J Neurosurg / Volume 116 / June 2012
When we first started our unit in 1964, patients who
required mechanical ventilation were awake and alert and often
sitting in a chair . . . these individuals could interact . . . they
could feel human. . . .The requirement of high acuity care and
available pharmacologic therapy has led to the present situation
. . . the awake and alert patient who is anxious or depressed
requires a great amount of interaction with the health care team.
. . . Understanding of the delicate machine/patient interface
seems to be lost these days; thus, the requirement of sedation
and paralysis.
Thomas L. Petty, M.D.27
Appendix
This article contains an appendix that is available only in the
online version of the article.
Disclosure
Dr. Mocco serves as a consultant to Actelion, has received sup-
port for nonstudy-related clinical or research effort from ev3, and
serves on the advisory boards of Lazarus Effect, Inc., Edge Thera­
peutics, NFocus, and Codman Neurovascular.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Mocco, Titsworth,
Hes­ter, Correia, Reed, Guin, Layon. Acquisition of data: Titsworth,
Hes­ter, Correia, Reed, Guin. Analysis and interpretation of data:
Moc­co, Titsworth, Hester. Drafting the article: Mocco, Titsworth.
Crit­ically revising the article: all authors. Reviewed submitted ver-
sion of manuscript: all authors. Approved the final version of the
man­uscript on behalf of all authors: Mocco. Statistical analysis: Tits­
worth. Administrative/technical/material support: Titsworth.
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Manuscript submitted October 21, 2011.
Accepted February 8, 2012.
Please include this information when citing this paper: pub-
lished online March 30, 2012; DOI: 10.3171/2012.2.JNS111881.
Address correspondence to: J Mocco, M.D., M.S., University of
Florida, P.O. Box 100265, Gainesville, Florida 32610. email: jmocco
@neurosurgery.ufl.edu.
J Neurosurg / Volume 116 / June 2012
Increased mobility in neurointensive care unit patients
Appendix

Shands UF Neuroscience Center

Patient Mobility Encounters Flowsheet

Place patient sticker here Date:___________________

TTiim
mee SSaatt EEd dg gee GGoott WWaallkkeedd WWaallkkeed d EExxeerrcciisseed
d TTh heerraap pyy//P Prroob blleem
mN Nootteess::
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dee ((ffuunnccttiioon naall lleevveell;; aassssiisstt
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nb beed d ssiittttiin
ngg bbeedd bbaatth
hrroooom
m rroooomm nneeeed deed d,, tthheerraap pyy d dcc’’dd,,
cclliin
niiccaall ttoolleerraannccee,, eettcc..))
0
077--0
0880
000
0
088--0
0990
000
0
099--1
1000
000
1
100--1
1110
000
1
111--1
1220
000
1
122--1
1330
000
1
133--1
1440
000
1
144--1
1550
000
1
155--1
1660
000
1
166--1
1770
000
1
177--1
1880
000
1
188--1
1990
000
1
199--2
2000
000
2
200--2
2110
000
2
211--2
2220
000
2
222--2
2330
000
2
233--2
2440
000
2
244--0
0110
000
0
011--0
0220
000
0
022--0
0330
000
0
033--0
0440
000
0
044--0
0550
000
0
055--00660000
0 6 - 0 7 0
0 6 -0 7 0 00
S
Siig
gnnaattu
urree:: S
Shhiifftt:: D
Diisscciip
plliin
nee::
S
Siig
gnnaattu
urree:: S
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plliin
nee::
S
Siig
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plliin
nee::
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Shhiifftt:: D
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plliin
nee::

*Please enter all mobility encounters for this patient in 24 hours by indicating a “√” or
initials in the box provided. Flowsheet will be collected and new flowsheet will be
redistributed at 0700, daily. If found, please return this flowsheet nursing mgt team.

J Neurosurg / Volume 116 / June 2012 A