Accepted Manuscript

Safety and feasibility of a neuroscience critical care program to mobilize patients with
primary intracerebral hemorrhage

Mona N. Bahouth, MD, Melinda C. Power, ScD, Elizabeth K. Zink, MS, Kate
Kozeniewski, RN, BS, Sowmya Kumble, PT, NCS, Sandra Deluzio, MS, Victor C.
Urrutia, MD, Robert D. Stevens, MD
PII: S0003-9993(18)30175-8
DOI: 10.1016/j.apmr.2018.01.034
Reference: YAPMR 57181

To appear in: ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Received Date: 1 June 2017

Revised Date: 23 January 2018
Accepted Date: 29 January 2018

Please cite this article as: Bahouth MN, Power MC, Zink EK, Kozeniewski K, Kumble S, Deluzio S,
Urrutia VC, Stevens RD, Safety and feasibility of a neuroscience critical care program to mobilize
patients with primary intracerebral hemorrhage, ARCHIVES OF PHYSICAL MEDICINE AND
REHABILITATION (2018), doi: 10.1016/j.apmr.2018.01.034.

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 ACCEPTED MANUSCRIPT

Safety and feasibility of a neuroscience critical care program to mobilize patients with
primary intracerebral hemorrhage

Mona N. Bahouth, MD1, Melinda C. Power, ScD2, Elizabeth K. Zink, MS3, Kate Kozeniewski,
RN, BS3, Sowmya Kumble, PT, NCS3, Sandra Deluzio, MS3, Victor C. Urrutia, MD1, Robert D.
Stevens, MD1,4.

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1-Department of Neurology; Cerebrovascular Division, Johns Hopkins University School of
Medicine; Baltimore, MD, USA
2-Department of Epidemiology and Biostatistics, George Washington University Milken Institute

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School of Public Health, Washington, DC, USA
3-Johns Hopkins Hospital, Baltimore, MD, USA
4-Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of

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Medicine; Baltimore, MD, USA

Running head: Early mobilization neurocritical care

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Search terms: Stroke – Intracerebral hemorrhage – Early mobilization – Patient Safety
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Word count:
Title (character count include spaces) 106
Abstract: 243
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Brief report Manuscript: 1262

Number of references: 10
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Number of tables: 2
Supplemental figure: 1
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Supplemental data: Stroke checklist

Corresponding author:
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Mona Bahouth, MD
Department of Neurology;
600 N Wolfe Street; Phipps Suite 486
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Johns Hopkins University School of Medicine;

Baltimore, Maryland 21287
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Email: mbahout1@jhmi.edu
Phone: 410-955-2228 (o); 410-614-9807 (f)

Statistical analysis conducted by Melinda Power, ScD, George Washington University Milken
Institute School of Public Health
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Author contributions:

Mona Bahouth, MD conceptualized the study, designed, collected data, interpreted

data, drafted and revised the manuscript

Melinda Power, ScD assisted with study design, data analysis, interpretation, and
revision of the manuscript

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Elizabeth Zink, MSN assisted with study design, collected data, and revised the
manuscript

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Kate Kozeniewski, BS assisted with data collection and revised the manuscript

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Sowmya Kumble, PT, NCS reviewed the manuscript

Sandra Deluzio, MS, OTR/L reviewed the manuscript

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Victor Urrutia, MD – reviewed manuscript
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Robert D Stevens, MD – study design, data analysis, review of the manuscript
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Acknowledgement: The authors would like to acknowledge the enthusiastic work of

the Johns Hopkins Hospital Neuroscience Critical Care Unit staff for their participation in
the early mobility project.
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Author Disclosures:

Mona Bahouth, MD, Melinda C. Power, ScD, Elizabeth Zink, MSN, Sowmya Kumble,
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PT, NCS and Sandra Deluzio, MS, OTR/L have no conflicts of interest to report.

Robert Stevens, MD - advisory boards and received honoraria from Portola

Pharmaceuticals and Lundbeck.
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Victor Urrutia, MD – Genentech, Inc. Investigator sponsored trial SAIL ON.

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Study funding: Helene Fuld Leadership Program for the Advancement of Patient
Safety and Quality
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2 Safety and feasibility of a neuroscience critical care program to mobilize patients with
3 primary intracerebral hemorrhage

4 Abstract:

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5 OBJECTIVE: To measure the impact of a progressive mobility program on patients admitted to

6 a neuroscience critical care unit (NCCU) with intracerebral hemorrhage (ICH). The early

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7 mobilization of critically ill patients with spontaneous ICH is a challenge due to the potential for

8 neurologic deterioration and hemodynamic lability in the acute phase of injury. Patients admitted

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9 to the ICU have been excluded from randomized trials of early mobilization after stroke.

10 DESIGN: An interdisciplinary working group developed a formalized NCCU Mobility Algorithm

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11 which allocates patients to incremental passive or active mobilization pathways on the basis of
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12 level of consciousness and motor function. In a quasi-experimental consecutive group

13 comparison, patients with ICH admitted to the NCCU were analyzed in two six-month epochs,
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14 before and after roll-out of the algorithm. Mobilization and safety endpoints were compared

15 between epochs.
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16 SETTING: Neuro Critical Care Unit (NCCU) in an urban, academic hospital

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17 PARTICIPANTS: Adult patients admitted to the NCCU with primary intracerebral hemorrhage

18 RESULTS: The two groups of ICH patients (pre-, n=28; post algorithm roll-out, n=29) were
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19 similar on baseline characteristics. Patients in the post-intervention group were significantly

20 more likely to undergo mobilization within the first 7 days after admission (OR: 8.7, 95% CI:
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21 2.1,36.6; p=0.003). No neurologic deterioration, hypotension, falls or line dislodgements were

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22 reported in association with mobilization. A non- significant difference in mortality was noted pre

23 and post roll-out (4% versus 24% respectively, p=0.12).

24 CONCLUSIONS: The implementation of a progressive mobility algorithm was safe and

25 associated with a higher likelihood of mobilization in the first week after spontaneous ICH.
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26 Research is needed to investigate methods and timing for first mobilization in critically ill stroke

27 patients.

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29 Key Words: Early mobilization; Stroke; Intracerebral hemorrhage; Neurocritical care; Patient
30 Safety

31

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32 List of abbreviations:

33 CT = computed tomography (CT scan brain)

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34 GCS = Glasgow coma score

35 HOB = Head of bed

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36 ICH = intracerebral hemorrhage

37 Letto = cycle ergometer

38 NCCU = Neuro Critical Care Unit

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39 ROM = Range of motion
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40 While early mobility programs have been widely deployed in general intensive

41 care units, it has only recently been suggested that such programs are feasible, safe,

42 and potentially beneficial in critically ill neurological patients.1,2 This concept was

43 challenged by results from a recent large-scale, randomized trial which indicated that

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44 patients who underwent mobilization less than 24 hours after stroke onset had less

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45 benefit, some with worse outcomes.3,4 Notably, critically ill stroke patients were

46 excluded from this trial. Thus, there is clinical equipoise regarding the feasibility, efficacy

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47 and safety of mobility practices in the acute phase of stroke care in the Neurocritical

48 Care Unit (NCCU).

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49 Spontaneous intracerebral hemorrhage (ICH) is associated with high morbidity

50 and mortality, prolonged hospital stays, and significant health care resource allocation.
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51 A high proportion of patients in the acute phase of ICH are admitted to the intensive

52 care unit where they undergo invasive therapy such as ventriculostomy drain placement
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53 or mechanical ventilation. These patients experience prolonged periods of bedrest,

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54 possibly due to safety concerns such as physiologic instability (hemodynamic or

55 intracranial pressure) or invasive device integrity.5 Here, we examine mobility practices

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56 and adverse events in ICH patients before and after the implementation of a structured
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57 progressive mobility algorithm. We hypothesized that implementation of the algorithm

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58 would be safe and associated with a higher likelihood of earlier mobilization in this

59 population.

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61 Methods:
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62 Study Design and Population

63 This work was approved by the academic Institutional Review Board. The study

64 was designed as a pragmatic, quasi-experimental, consecutive group comparison

65 study. Patients were included if they were adults admitted to the NCCU for management

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66 of primary ICH. Patients were excluded if they had secondary ICH due to trauma,

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67 surgery, vascular anomaly, hemorrhagic transformation of stroke, or underlying mass.

68 Patients were grouped in two 6-month epochs defined with respect to implementation of

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69 the progressive mobility algorithm: November 2014-March 2015 (pre-implementation)

70 and November 2015-March 2016 (post-implementation).

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71 Progressive Mobility Algorithm:

72 An interdisciplinary early mobility working group comprised of nurses,

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73 neurologists, neurointensivists, administrators, physical therapists, occupational

74 therapists, and respiratory therapists was created to design and implement a

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75 progressive mobility algorithm designed to decrease prolonged bedrest specifically for

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76 patients admitted to the NCCU (Figure 1).6 In this algorithm, all patients admitted to the

77 NCCU are assigned to either an active or a passive mobility pathway depending on

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78 mental status and motor function. The algorithm is designed to provide the care team
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79 with objective goals for efficiently progressing the patient’s mobility status. The
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80 algorithm stipulates ‘Stopping Criteria’ which require immediate cessation of the mobility

81 activity if there is neurologic deterioration, physiologic instability, pain, or device

82 dislodgment. We hypothesized that the implementation of the algorithm would increase

83 the percentage of hemorrhagic stroke patients mobilized out of bed.

84 Data Abstraction:
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85 Data abstracted (KK) from the electronic medical record included patient

86 demographics, reported baseline functional status, and physiologic parameters,

87 Glasgow-Coma Score (GCS), ICH score,7 and Activity Measure for Post-Acute Care

88 (AMPAC) scores8 collected at the time of admission to the NCCU. ICH volumes were

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89 computed by a stroke neurologist (MB) using the ABC/2 method on the first non-

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90 contrast cranial computed tomography (CT) image, with the assessor blinded to the

91 epoch and mobility status of the patient. Hospital discharge locations were collected as

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92 an exploratory indicator of discharge status. Quality of data was checked by a second

93 reviewer (EZ). All data collected for this study were documented at the time of patient

94
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care. Data abstractors used a single case report form and standard definitions using a
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95 pre-specified codebook to ensure consistency.
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96 Study Endpoints

97 The primary endpoint was time to achieve first mobilization, with mobilization
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98 defined as time elapsed from admission to achieving an out of bed seated or standing
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99 position for at least 5 minutes even if mechanical lift was required. This broad definition

100 was intended to capture the varying levels of function in this patient population. As the
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101 timing and frequency of mobilization are potentially important, we determined when
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102 patients achieved mobilization during their NCCU stay (ever, or within 1, 3, 5, or 7
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103 days), time to first mobilization (ever or within 7 days of admission among those

104 mobilized), and the number of times mobilization occurred (ever). Other endpoints

105 included the frequency of therapy sessions, discharge location, and any adverse events

106 occurring during the mobility session including falls, device dislodgements, change in

107 neurologic exam, and any increase in intracranial pressure or change in systolic blood
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108 pressure of > 10 mmHg.

109 Statistical Analysis:

110 We tabulated baseline characteristics and outcome variables by pre/post-

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111 intervention group. Means of continuous variables were compared using F-tests and

112 distributions of categorical variables using Fisher’s exact test. A logistic regression

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113 model adjusting for initial GCS score and a dichotomized ICH score (≤ 2 versus ≥ 3),

was used to determine strength of the associations between epoch and the

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115 achievement of mobilization within 1 day, 7 days, or the NCCU stay. Analyses were

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116 conducted using STATA version 14 (Statacorp, College Station, Texas).
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117 Results:

118 A total of 57 patients met inclusion criteria (28 pre-implementation and 29 post-
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119 implementation). Pre- and post-intervention groups had similar characteristics with the
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120 exception of higher mean weight in the pre-intervention group (Table 1). Of note,
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121 anatomical location, volumes of ICH and ICH scores were not statistically different

122 between groups though a larger proportion of post-intervention patients had more
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123 severe ICH scores of 3 or 4 compared with pre-intervention patients (34% post- versus

124 8% pre-intervention.
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125 In univariable analyses, patients in the post-implementation group were more

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126 likely to be mobilized at any time during their stay in the NCCU and during the first 7

127 days (Table 2). Of the 26 patients mobilized in this cohort, 22 were intubated at the time

128 of first mobilization (7 in the pre-intervention group and 15 in the post-intervention

129 group). Of those mobilized, there was no difference between groups in terms of time to
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130 first mobilization. Patients in the pre-intervention group were mobilized a mean of 0.4

131 versus 1.5 times in the post-intervention group. In adjusted multivariable analyses,

132 patients in the post-intervention group were not more likely to be mobilized within their

133 first day of their NCCU stay (OR: 1.5; 95% CI: 0.2, 11.7; p= 0.67) but were more likely

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134 to be mobilized within 7 days (OR: 8.7, 95% CI: 2.1, 36.6; p= 0.003). No episodes of

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135 hypotension, change in neurologic status, falls or line dislodgements were reported in

136 association with mobility interventions. Mortality rates pre and post intervention were

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137 rates 4% and 24% respectively (p=0.12). Of the seven patients who died post-

138 intervention, 6/7 (86%) had baseline ICH scores of 3 or 4. There was no difference in

139
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mean length of stay (LOS) in the NCCU and in the hospital (pre and post intervention,
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140 4.5 versus 6.1 days [NCCU LOS] and 11.0 versus 11.3 days [hospital LOS]). There was

no difference in discharge location between groups (p=0.12) (Table 3).

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141

142 Discussion:
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143 Implementation of a standardized mobility program based on an interdisciplinary

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144 algorithm was feasible and did not result in additional adverse events in patients

145 admitted to the NCCU with ICH. Following implementation of the algorithm, the
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146 likelihood and number of times that ICH patients were mobilized increased despite the
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147 fact that this group had more severe ICH. Additionally, the emphasis on a nurse-driven
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148 interventions increased the frequency of mobilization without increasing the workload of

149 physical and occupational therapists (in fact the number of sessions provided by the

150 therapists were nearly identical pre and post intervention). This is critical as we attempt

151 to reduce prolonged periods of bedrest and increase mobility for critically ill patients

152 within the staffing time constraints of rehabilitation specialists in the hospital setting.
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153 In critically ill patients, early mobility has been linked to improved functional

154 status.9,10 Early rehabilitation programs have been found to improve levels of mobility

155 and reduce complications in patients admitted to a NCCU10, although results of a recent

156 large trial of very early mobilization in non-ICU stroke patients demonstrated no benefit

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157 and suggested worse outcomes in those patients who were mobilized within 24 hours

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158 from stroke onset compared to those randomized to ‘usual care’.4 Studies specific to

159 critically ill stroke patients are limited since this population has traditionally been

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160 excluded from recent mobility trials, and thus the best timing for first mobilization after

161 stroke in the ICU setting remains uncertain.4,10 Our study suggests that a larger

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percentage of patients can be mobilized without additional adverse events within the
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163 first week after hemorrhagic stroke, though additional work is needed to truly

understand the safety of reducing the time to first mobilization in this clinically complex
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165 population with issues related to reduced mental status, raised intracranial pressures,
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166 and rigid blood pressure parameters in the very early period of care. Timing of
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167 interventions specific to the early mobilization of critically ill patients with ICH, as

168 described in this paper, has not been previously reported.

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169 The definition of “mobilization” endpoints varies considerably across studies.

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170 While previous work on early mobility in the critical care setting have emphasized
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171 walking as an endpoint, we focused on achieving an out of bed seated or standing

172 position which may represent an equally important goal in the acute period, particularly

173 in stroke patients with cognitive or motor deficits.4, We found that use of a formalized

174 mobility algorithm expedited time to out of bed positioning.

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175 Several interesting results are notable in this cohort. First, the increase in

176 frequency of mobilization between the groups was statistically significant though of

177 unclear clinical significance. Our mobility team continues to work to increase the

178 number of times out of bed within the parameters of clinical safety, though the efficacy

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179 of that practice requires additional study. Next, though not powered to do so, we do not

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180 see a meaningful difference in NCCU or hospital length of stay in this group of patients.

181 This will be an important outcome to measure in future studies. Finally, while not

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182 statistically significant, the difference in rates of mortality between the pre- and post-

183 intervention groups (4% versus 24% respectively, p=0.12) warrants consideration. In

184
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this cohort, the difference might relate to the disparity in severity of the ICH patients
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185 between the two groups. Specifically, 8% of the pre-intervention group had ICH scores

of 3 or 4 compared with 34% of the post-intervention group. Of the seven patients who
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187 died in the postintervention group, 6/7 (86%) had baseline ICH scores of 3 or 4. Thirty-
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188 day mortality rates for patients with ICH score of 3 and 4 are reported at 72% and 97%
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189 respectively.7

190 This relationship between early mobilization and both morbidity and mortality
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191 deserves additional scrutiny, especially in light of the results of the AVERT trial
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192 demonstrating less favorable outcomes 3 months after stroke in those patients who had
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193 been randomized to very early mobilization (less than 24 hours from stroke onset).4

194 AVERT was a single-blind, randomized controlled trial of non-ICU admitted stroke

195 patients (both ischemic ad hemorrhagic) who received very early mobilization (less than

196 24 hours after stroke) versus usual care. The median mobilization times for the

197 intervention and control groups were 18.5 and 22.4 hours respectively. The intervention
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198 group demonstrated less favorable outcomes as measured with the modified Rankin

199 scores at 3 months. Mortality rates did not differ between groups.4 Our study population

200 differs in that we only included patients with intracerebral hemorrhage admitted the

201 NCCU, a population that was excluded from AVERT. In the post-intervention group, our

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202 mean time to first mobilization was 2.6 days with only 10% of the cohort being mobilized

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203 within the first day. With all of those differences, safety is a primary concern as we

204 consider the best timing for first mobilization after stroke especially in critically ill ICH

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205 patients. Additional study in a larger cohort of patients is needed in order to clarify the

206 true significance of this finding.

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207 Standardization of mobilizing practices in stroke patients admitted to the ICU is

208 an important first step towards establishing a new clinical paradigm. This study
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209 demonstrated that implementation of a standardized algorithm is feasible, yields

210 increases in the number of times that a patient is mobilized within the first week after
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211 stroke, and was not directly associated with any adverse effects. In addition, the
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212 algorithm was implemented by our interdisciplinary team without the need to increase

213 staffing levels, suggesting a potentially cost effective approach.

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214 Limitations: Though this study meets the STROBE reporting guidelines for a
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215 research study (see attached checklist), this study has several limitations. The sample
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216 size was relatively small, and we used retrospective chart abstraction to gather data.

217 There is limited information about the duration of each mobilization intervention.

218 Additionally, longer-term post-hospital discharge functional outcomes were not available

219 in this population. Future studies will need to explore the impact of mobility timing,

220 dosage, duration and frequency in the stroke population.

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221 Conclusions: Implementation of a progressive mobility algorithm was feasible, did not

222 increase the number of adverse events, and was associated with a higher likelihood of

223 mobilization in the first week after spontaneous ICH for patients admitted to the ICU.

224 Research is needed to confirm the value and efficacy of very early mobilization on

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225 functional outcome and quality of life in critically ill stroke patients.

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226

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227 References

228 1. Klein, K, Mulkey, M, Bena, JF, & Albert, NM. Clinical and psychological effects of

229 early mobilization in patients treated in neurologic ICU: A comparative study. Critical

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230 Care Medicine 2015; 43: 865-873.

231 2. Olkowski, BF, Devine, M, Slotnick, et al. Safety and feasibility of an early

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232 mobilization program for patients with aneurysmal subarachnoid hemorrhage.

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233 Physical Therapy 2013; 93: 208-215.

234 3. Bernhardt, J, Churilov, L, Ellery, F, et al. Prespecified dose-response analysis for A

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235 Very early rehabilitation trial (AVERT). Neurology 2016; 86:1-8.
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236 4. AVERT Collaboration Group. Efficacy and safety of very early mobilization within 24

237 hours of stroke onset (AVERT): a randomized controlled trial. Lancet 2015; 386: 46-
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238 55.

239 5. Mendez-Tellez. PA, Nusr, R, Feldman, D, Needham, DM. Early physical

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240 rehabilitation in the ICU: a review for the neurohospitalist. Neurohospitalist 2012
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241 6. Titsworth, WL, Hester, J, Correia, T, et al. The effect of increased mobility on
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242 morbidity in the neurointensive care unit. J Neurosurg 2012; 16(6): 1379-1388.

243 7. Hemphill, JC, Bonovich, DC, Besmertis, L, Manley, GT, Johnston, C. The ICH score:
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244 A simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001; 32: 891-
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245 897.

246 8. Jette, DU, Stilphen, M, Ranganathan, VK, et al. AM-PAC “6 clicks” functional

247 assessment scores predict acute hospital discharge destination. Physical Therapy

248 2014, 94(9): 1252-1261.

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249 9. Needham, DM. Mobilizing patients in the intensive care unit: improving

250 neuromuscular weakness and physical function. JAMA 2008; 300:1685-1690.

251 10. Rand, ML, Darbinian, JA. Effect of an evidence-based mobility intervention on the

252 level of function in acute intracerebral and subarachnoid hemorrhagic stroke patients

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253 on a neurointensive care unit. Archives of Physical Medicine and Rehabilitation

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254 2015; 96: 1191-1199.

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Legend of figure and tables:

Figure 1: The XXX Neurocritical Care (NCCU) Mobility Algorithm

Table 1: Characteristics of ICH patients admitted to the NCCU before and after

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implementation of a standardized mobility intervention

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Table 2: Timing, dose and frequency of mobilizations before and after rollout of

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standardized mobilization algorithm

Table 3: Hospital discharge location before and after rollout of standardized mobility

algorithm
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Table 1: Characteristics of ICH patients admitted to the NCCU before and after implementation of a standardized
mobility intervention

Variable Pre-intervention Post Intervention

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(n=28) (n=29)
Mean (SD) or N (%) Mean (SD) or N (%) p-value
Age (years) 62.1 (13.9) 67.2 (14.1) 0.17

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Weight (kg) 90.3 (28.7) 74.7 (17.1) 0.02
Race White 14 (50%) 11 (38%) 0.18
Black 13 (46%) 12 (41%)

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Other 1 (4%) 6 (20%)
Female 11 (39%) 17 (59%) 0.19
Initial AMPAC 13.8 (5.6) 13.3 (6.1) 0.71

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Known to be functionally dependent 3 (11%) 1 (3%) 0.52
at baseline
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Initial Glasgow Coma Score 12.1 (3.2) 10.3 (4.4) 0.08
Intracerebral hemorrhage Score 0 7 (26%) 6 (21%) 0.07
1 7 (26%) 9 (31%)
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2 11 (41%) 4 (14%)
3 1 (4%) 5 (17%)
4 1 (4%) 5 (17%)
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Intracerebral hemorrhage location Supratentorial 22 (79%) 23 (79%) 1

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Infratentorial 6 (21%) 6 (21%)

Intracerebral hemorrhage volume 19.8 (25.1) 28 (27.1) 0.24
(cc)
Intraventricular hemorrhage present 8 (29%) 10 (34%) 0.78
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Intraventricular catheter on 26 (96%) 23 (82%) 0.11

admission
Initial ICP (dichotomized) Normal 27 (96%) 25 (86%) 0.35
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Elevated 1 (4%) 4 (14%)

Emergent Surgical Evacuation 4 (14%) 5 (17%) 1
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Intubated on admission 15 (56%) 16 (55%) 1

Restraints on admission 16 (62%) 18 (64%) 1
Initial Activity Order: OOB 19 (68%) 23 (79%)
Abbreviations: ICH= Intracerebral hemorrhage; NCCU = Neurocritical care unit; AMPAC
=Activity Measure for Post Acute Care (Basic Mobility); ICP = intracerebral pressure; OOB = out
of bed order
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Table 2. Mobility characteristics before and after rollout of standardized mobilization algorithm
Pre-intervention Post Intervention
(n=28) (n=29)
N(%) or Mean % or Mean
Variable (SD) (SD) p-value
Ever mobilized in the Neurocritical care unit 9 (32%) 17 (59%) 0.045

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Mobilized by:
day 1 2 (8%) 3 (10%) 0.68
day 3 6 (21%) 12 (41%) 0.11

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day 5 8 (29%) 14 (48%) 0.13
day 7 8 (29%) 16 (55%) 0.04
Time to first Mobilization (days)

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(among patients mobilized) 2.6 (3.0) 2.6 (3.3) 0.98
Time to first Mobilization (days)
(among mobilized within 7 days) 1.6 (1.2) 1.9 (1.6) 0.7
Number of times mobilized (ever) 0.4 (0.7) 1.5 (1.7) 0.002

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Number Physical Therapy/Occupational Therapy
session (ever) 2.7 (2.2) 1.8 (2) 0.11
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Table 3. Hospital discharge location before and after rollout of standardized mobility algorithm

Pre-intervention Post Intervention

(n=28) (n=29)
Discharge location N % N % p-value
Home 12 0.43 11 0.38

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Acute Rehabilitation 13 0.46 8 0.28
Subacute Rehabilitation 2 0.07 3 0.10
Died 1 0.04 7 0.24 0.12

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Figure 1: The XXX Neurocritical Care Mobility Algorithm

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Figure legend: NCCU = neurocritical care unit; GCS = Glasgow coma scale; HOB = head of bed; Letto=
cycle ergometer; ROM = range of motion
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ICH/Early Mobility Highlights

• A formalized early mobility program in the neurocritical care unit is feasible for stroke patients
• Use of a defined algorithm yielded more frequent mobilizations
• No additional adverse events with early mobilization of patients with intracerebral hemorrhage

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