Critical Illness

Special Series

Move to Improve: The Feasibility of

Using an Early Mobility Protocol to
Increase Ambulation in the Intensive
and Intermediate Care Settings

Downloaded from https://academic.oup.com/ptj/article-abstract/93/2/197/2735513 by guest on 11 August 2019

Anne Drolet, Patti DeJuilio, Sherri Harkless, Sherry Henricks, Elizabeth Kamin,
Elizabeth A. Leddy, Joanna M. Lloyd, Carissa Waters, Sarah Williams A. Drolet, MS, ANP-BC, CCRN,
Central DuPage Physician Group,
25 N Winfield Rd, Winfield, IL
Background. Prolonged bed rest in hospitalized patients leads to deconditioning, 60190 (USA). Address all corre-
impaired mobility, and the potential for longer hospital stays. spondence to Ms Drolet at:
anne.drolet@cadencehealth.org.
Objective. The purpose of this study was to determine the effectiveness of a P. DeJuilio, MS, RRT-NPS, Respira-
nurse-driven mobility protocol to increase the percentage of patients ambulating tory Therapy, Central DuPage
during the first 72 hours of their hospital stay. Hospital, Winfield, Illinois.

S. Harkless, MSN, APRN/CNS,

Design. A quasi-experimental design was used before and after intervention in a CCNS, CCRN, Central DuPage
16-bed adult medical/surgical intensive care unit (ICU) and a 26-bed adult interme- Hospital.
diate care unit (IMCU) at a large community hospital. S. Henricks, MSN, ACNP-BC,
CCRN, Central DuPage Physician
Method. A multidisciplinary team developed and implemented a mobility order Group.
set with an embedded algorithm to guide nursing assessment of mobility potential. E. Kamin, RN, BSN, MSCRN, Cen-
Based on the assessments, the protocol empowers the nurse to consult physical tral DuPage Hospital.
therapists or occupational therapists when appropriate. Daily ambulation status
E.A. Leddy, PharmD, Central
reports were reviewed each morning to determine each patient’s activity level. DuPage Hospital.
Retrospective and prospective chart reviews were performed to evaluate the effec-
tiveness of the protocol for patients 18 years of age and older who were hospitalized J.M. Lloyd, MS, Central DuPage
Hospital.
72 hours or longer.
C. Waters, RN, BSN, CCRN, 2ICU–
Results. In the 3 months prior to implementation of the Move to Improve project, Intensive Care Unit, Central
DuPage Hospital.
6.2% (12 of 193) of the ICU patients and 15.5% (54 of 349) of the IMCU patients
ambulated during the first 72 hours of their hospitalization. During the 6 months S. Williams, PT, MPT, Central
following implementation, those rates rose to 20.2% (86 of 426) and 71.8% (257 of DuPage Hospital.
358), respectively. [Drolet A, DeJuilio P, Harkless S,
et al. Move to Improve: the feasi-
Limitations. The study was carried out at only one center. bility of using an early mobility
protocol to increase ambulation in
the intensive and intermediate
Conclusion. The initial experience with a nurse-driven mobility protocol sug- care settings. Phys Ther.
gests that the rate of patient ambulation in an adult ICU and IMCU during the first 72 2013;93:197–207.]
hours of a hospital stay can be increased.
© 2013 American Physical Therapy
Association

Published Ahead of Print:

September 13, 2012
Accepted: September 4, 2012
Submitted: November 14, 2011

Post a Rapid Response to

this article at:
ptjournal.apta.org

February 2013 Volume 93 Number 2 Physical Therapy f 197

An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings
P
hysical inactivity associated
with hospital care for a range of
medical conditions can have
many unfavorable consequences.
They include neuromuscular dys-
function, metabolic disturbances,
and other organ system abnormali-
ties that add to the disease burden.1
Prolonged bed rest is associated with
extended hospital stays and persis-
tent physical and neuropsychiatric
disabilities in intensive care unit
(ICU) settings.1 A meta-analysis of
39 randomized controlled trials
revealed bed rest was not beneficial
and may be harmful.2 Studies also
have demonstrated that reducing
the use of sedation and introduc-
ing physical activity as soon as clini-
cally feasible can decrease the fre-
quency and severity of these
complications.3,4
Although these problems have been
carefully studied in ICU settings, few
studies are available about the com-
plications of inactivity outside the
ICU. Studies of the consequences of
prolonged bed rest have been con-
ducted in volunteers without ill-
ness.5 Skeletal muscle changes can
be documented within 72 hours of
physical inactivity.6 In addition,
physiologic dysfunction has been
found across a range of organ sys-
tems and metabolic processes. When
non-ICU patients are subjected to
bed rest, it is reasonable to assume
Available With
This Article at
ptjournal.apta.org
• Listen to a special Craikcast
on the Special Series on
Rehabilitation in Critical Care
with editors Patricia Ohtake, Dale
Strasser, and Dale Needham.
• Audio Podcast: “Rehabilitation of
Patients With Critical Illness”
symposium recorded at CSM
2013, San Diego, California.
198 f Physical Therapy Volume 93
they will experience similar degrees
of dysfunction.7
The application of bed rest in
hospital-based medical care is wide-
spread and enduring. There exists a
time-honored impression that bed
rest is therapeutic and physical activ-
ity harmful in the presence of illness.
There are practical barriers to mobi-
lizing some patients due to monitor-
ing or life support equipment, frailty,
and weakness. In such circum-
stances, considerable resources may
be needed for safe mobilization.8
At our 313-bed acute care commu-
nity hospital, we were concerned
about the adverse effects of inactiv-
ity in both our adult ICU and inter-
mediate care populations. Increasing
patient activity through mobilization
is associated with improved respira-
tory function, reducing adverse
effects of immobility, increased lev-
els of consciousness, increased
functional independence, improved
cardiovascular fitness, and psycho-
logical well-being.9
Prior to the early mobility protocol
initiative, common practice was a
slower approach to mobilizing
patients who are critically ill. Often
the physical therapist was the first
member of the health care team to
begin mobilizing the patient. The
physical therapist is only with the
patient for approximately 30 min-
utes per day in our setting. As the
nurses are the primary caregivers for
8 to 12 hours at a time, we hypoth-
esized that a nurse-driven mobility
protocol could provide important
benefits. Little is known about how
nurses make decisions about
whether to ambulate, how they
ambulate, and when they ambulate
older patients. In a recent qualitative
study, factors that seemed to have a
greater impact on nurses’ decisions
regarding patient ambulation were
the risk/opportunity assessment,
preventing complications, and the
Number 2
presence of unit expectation to
ambulate patients.10 Furthermore,
Kalisch11 found that ambulation was
regularly missed in the provision of
nursing care. Reasons given by
nurses were related to time required
to carry out ambulation, ease of omit-
ting ambulation, and believing that
ambulation was the job of a physical
therapist. Barriers to ambulation
most frequently cited by nurses were
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related to patients’ physical symp-
toms such as weakness, pain, and
fatigue; presence of devices such as
intravenous line and urinary cathe-
ters; concerns about falls; and lack of
staff to assist with out-of-bed activ-
ity.12 A recent study showed that
83% of patient time is spent lying in
bed,13 and during one observational
study, 73% of patients considered
able to walk did not walk.14 Ambula-
tion should be viewed as a priority
and as a vital component of quality
nursing care.15
Considering the deleterious effects
of bed rest, the emerging literature
on ambulation of patients with acute
illness, and the potential for nursing
staff to engage in ambulation activi-
ties with their patients, the Move to
Improve team decided to develop a
quality improvement study. We
hypothesized that implementation of
a mobility program would increase
the likelihood of early mobilization
in our ICU and intermediate care
unit (IMCU) patients.
Method
Three months of data (January–
March 2010) were collected before
implementation of the mobility pro-
gram to confirm consistency of base-
line information. Postimplementa-
tion data were collected for 6
months (March–August 2011). To
evaluate the impact of this initiative,
we compared the frequency of
ambulation for patients admitted to
the ICU and IMCU, or who were
transferred from the ICU to the
IMCU, during these time periods.
February 2013
 An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings
In February 2010, nursing manage-
ment gave approval to begin the
quality improvement project. A mul-
tidisciplinary team consisting of
advanced practice nurses, registered
nurses, physical therapists, a critical
care pharmacist, a respiratory thera-
pist, and a critical care physician was
assembled in April 2010. The team
adopted the Plan-Do-Check-Act
framework for the development and
implementation of the Move to
Improve mobility program; the
“Plan” stage ran from January 2010
to April 2010 (see Appendix 1 for
complete time line).
Two units were selected for the pilot
study. The first unit was the IMCU, a
26-bed unit with an average daily
census of 21.6 patients and a nurse-
to-patient ratio of 1:4. The patient
population included patients with
complex medical and surgical condi-
tions as well as patients who were
hemodynamically stable with a tra-
cheostomy on a ventilator and had
potential for respiratory insuffi-
ciency. These patients often
required frequent vital sign monitor-
ing and respiratory therapy manage-
ment. The second pilot unit was an
adult ICU, a 16-bed unit designed to
provide intensive medical/surgical
care to patients with acute and
chronic medical diagnoses. Its aver-
age daily census was 11.3 patients
and a 1:2 nurse-to-patient ratio. Dur-
ing the study, from March through
August 2011, this ICU had a standard
mortality ratio of 0.726 (observed
deaths/expected deaths) utilizing
the APACHE IV scoring system.16
The average length of stay was 3.2
days. For patients admitted directly
to the IMCU, the average length of
stay was 4.95 days.
In April 2010, the Move to Improve
team reviewed current evidence and
exemplary protocols to determine
whether the adult ICUs were utiliz-
ing best practices for mobilizing
patients. The literature review was
February 2013
expanded to include ambulating
patients in the non-ICU areas, wean-
ing patients from ventilators safely
and efficiently, and sedation and pain
management guidelines.17–19 The
team divided into small groups to
focus on the multiple facets of the
program.
The “Do” stage of the project ran
from April through November of
2010. Multiple order sets and proto-
cols were developed for the pilot
study. A mobility order set was cre-
ated that included a screening tool
based on the exclusion criteria from
the Critical Care Physical Medicine
and Rehabilitation Program at Johns
Hopkins Medical Center.20 The
exclusion criteria were modified to
address the needs of our patient pop-
ulation based on recommendations
from the intensivists and medical
staff chairpersons. The mobility algo-
rithm developed by the physical
therapist on the planning team was
embedded in the order set to guide
the assessment and allowed the
nurse to consult physical therapists
and occupational therapists when
appropriate (Appendix 2). The ven-
tilator weaning order set was devel-
oped by ICU respiratory therapists.
This order set included a protocol
for pain management with appropri-
ate sedation determined by clinical
pharmacists and implemented by
bedside nurses, use of the Richmond
Agitation Sedation Scale,21,22 and
more frequent readiness trials to
determine whether patients were
capable of ventilator discontinua-
tion.23–28 A primary objective was to
remove mechanical ventilation as
soon as possible, as it is easier and
safer to mobilize patients without
the burden of an artificial airway.
Pain that could worsen with move-
ment was addressed to avoid patient
resistance, and sedation was modi-
fied so that patients were alert
enough to mobilize. The sedation
protocol for ICU patients was modi-
fied from a practice of continuous
Volume 93
infusions to a preferred practice of
using intermittent dosing of sedation
medications when possible to main-
tain goal sedation.
After careful review of the multiple
order sets, approval for the 4-week
pilot study was granted by the hos-
pital’s Medical Executive Committee
in September 2010. The team
received approval from the hospi-
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tal’s institutional review board in
November 2010. Data would be col-
lected on patients 18 years of age or
older who were hospitalized for 72
hours or longer.
During November 2010, in prepara-
tion for the pilot study, nurses and
patient care technicians completed
an education program developed by
the Move to Improve team. The edu-
cation included verbal presentations
by the advanced practice nurses and
physical therapists at unit staff meet-
ings. The staff was instructed on the
exclusion criteria, the mobility algo-
rithm, and the use of gait belts when
transferring and ambulating patients.
The nurses and patient care techni-
cians also received self-learning
packets, and posters were placed on
the 2 units as reminders of the study.
The nurses and patient care techni-
cians had 1 month to complete the
education. Respiratory therapists
received mandatory education in
both written and classroom formats
on the use of the portable ventilator,
ventilator weaning, sedation, and the
mobility protocols. Physical thera-
pists were educated on use of a
custom-designed walker with fold-
down seat, funded by the hospital
foundation, and intravenous pole
that supported the portable ventila-
tor (Fig. 1). They also received spe-
cific instructions on handling
patients who are critically ill and ven-
tilated for safety during ambulation.
Beginning the first week of Decem-
ber 2010, education was provided to
the medical staff at their quarterly
Number 2 Physical Therapy f 199
An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings
Figure 1.
Custom-designed walker and intravenous
pole (purchased from Spectrum Surgical
Instruments Co, Stow, Ohio, www.
spectrumsurgical.com) with ventilator
(Versamed Ivent 201, GE Healthcare,
www.gehealthcare.com).
meeting along with posters outlining
the program and pilot study. The
physicians were made aware that the
mobility protocol would be manda-
tory for all patients in the adult ICU
and IMCU during the pilot project,
which was to run from December
14, 2010, through January 11, 2011.
The physicians were informed that
the nurse would have the ability to
order physical therapy or occupa-
tional therapy when appropriate.
Decisions about ability or appropri-
ateness of activity were made by the
nurse based on the mobility algo-
rithm coupled with the assessment
of exclusion criteria. All patients in
both the ICU and the IMCU were
screened using the same process.
Upon completion of the pilot proj-
ect, the team returned to the Medical
Executive Committee in February
2011 to complete the “Check” pro-
cess. Approval was granted to pro-
ceed with the program in the ICU
and the IMCU with the understand-
ing that the mobility protocol would
200 f Physical Therapy Volume 93
no longer be mandatory but would
now need a physician’s order to
implement. The Medical Executive
Committee also approved hospital-
wide implementation to begin in July
2011.
The “Act” process began in March
2011 at the beginning of the post-
implementation period with the
objective of increasing the number
of adult patients ambulating during
the first 72 hours of their hospital
stay. For the purpose of this study,
we defined ambulation as the act of
walking with or without an assistive
device, moving self from point A to
point B. Distance was measured for
each patient’s ambulation efforts.
Multiple assessments were per-
formed daily by the nurse to deter-
mine activity readiness.3
Ambulation was recorded before and
after implementation of the mobility
protocol for patients admitted to the
ICU and the IMCU, or transferred
from the ICU to the IMCU. Patients
who were discharged in less than 72
hours or transferred to another unit
(other than the IMCU) during that
time frame were excluded. Due to
these exclusions, the patient census
during the study period appears to
be less than that seen during the pre-
implementation period. Nurses and
patient care technicians were
encouraged to ambulate all patients
regardless of their length of stay in
the ICU or IMCU. Collected data cap-
tured only nurse or patient care tech-
nician documentation of ambulation
and did not include activity per-
formed by the physical therapist.
Aggregated and de-identified data
were reviewed. Monthly collection
and analysis of data were reported to
the nurse managers and staff at unit
meetings. The retrospective chart
reviews revealed little improvement
in ambulation compared with pre-
implementation data. For this rea-
son, an ambulation status report
(Appendix 3) was developed that
Number 2
would provide real-time data for the
nurses. This report was distributed
to the units daily, noting each
patient’s length of stay and the dis-
tance the patient had ambulated on a
given day. The ambulation status
report was embraced by the IMCU
staff and reviewed at multidisci-
plinary rounds each morning. With
the creation and use of this daily
report, there was an immediate
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increase in the number of patients
ambulating in the IMCU. However,
we did not see regular use of the
ambulation status report in the ICU
until several months into the study.
Patient demographics such as age
and sex were tracked across both
departments studied. Data are pre-
sented as means (standard deviation)
for descriptive variables. Compari-
sons of preimplementation and post-
implementation data were per-
formed using an unpaired, 2-tailed
t test. Significance was set at P⬍.05.
Analyses were performed with
Microsoft Excel 2007 software
(Microsoft Corporation, Redmond,
Washington).
Results
Data were collected for 193 ICU
patients and 349 IMCU patients dur-
ing the 3-month preimplementation
period and for 426 ICU patients and
358 IMCU patients during the
6-month postimplementation period
(Table). During the preimplementa-
tion period, patients in the ICU had
an average (SD) age of 67.0 (15.7)
years; 42% were female. In the
IMCU, the average (SD) patient age
was 65.7 (17.5) years; 55% were
female. Patients followed in the ICU
during the postimplementation
period had an average (SD) age of
64.4 (17.0) years of age; 48% were
female. In the IMCU, the average
(SD) patient age was 68.0 (16.1)
years; 51% were female. There were
no differences in average patient age
or sex distribution between the 2
data collection periods.
February 2013
 An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings

Table.
Summary of Patient Demographicsa

ICU IMCU

Variable Preimplementation Postimplementation P Preimplementation Postimplementation P

Total population 193 426 349 358

Age (y), X (SD) 67.0 (15.7) 64.4 (17.0) .07 65.7 (17.5) 68.0 (16.1) .07

Female, n (%) 81 (42) 204 (48) .17 193 (55) 184 (51) .30
a
ICU⫽intensive care unit, IMCU⫽intermediate care unit. Preimplementation of Move to Improve early mobility program: January–March 2010;
postimplementation of Move to Improve early mobility program: March–August 2011.

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During the preimplementation The Move to Improve committee them, or that it was the role of the
period, only 6.2% (12 of 193) of the met biweekly from April through physical therapist to do the required
ICU patients and 15.5% (54 of 349) November 2010 to develop order exercises. During the pilot study in
of the IMCU patients ambulated sets and algorithms to formulate a the adult ICU, there was a change in
within 72 hours of hospital admis- mobility pathway to be used across the leadership structure and a higher
sion. In contrast, following imple- the continuum of care. A major les- than normal staff turnover rate.
mentation of the Move to Improve son learned was that in order to These factors posed additional chal-
program, 20.2% (86 of 426) of the implement practice changes, the lenges to the implementation of
ICU patients (P⬍.001) and 71.8% leadership and staff needed an envi- change.
(257 of 358) of the IMCU patients ronment and culture that supported
(P⬍.001) ambulated within 72 hours learning and a commitment to best Despite the challenges, after focus-
of admission (Fig. 2). practice.30 Initially, the ICU staff and ing on the topic in staff meetings and
physicians felt the patients with crit- through education, nurses realized
Discussion ical illness were too sick to move, the importance of the mobility pro-
This quality improvement study was that it was too risky to mobilize gram, and it became a priority. The
undertaken to determine whether
routine patient care could be modi-
fied to include mobility. The project
utilized current evidence that a sig-
nificant change in clinical practice
could be effected, as demonstrated
in a quality research study by Need-
ham et al.29 The Move to Improve
project was a vision of health care
professionals who knew more
needed to be done to improve
patients’ ability to overcome illness.
The mobility initiative has enabled
nurses to drive the care for the
patient through an evidence-based
protocol. Within our institution,
patient activity levels were fre-
quently not addressed until many
days into their hospital stay. Some
patients became deconditioned,
which led to the cancellation of
discharges or transfer to a rehabilita-
tion facility. Upon realization of Figure 2.
this hospital-wide problem, it was Patient ambulation in the intensive care unit (ICU) and the intermediate care unit
(IMCU) before and after implementation of the Move to Improve early mobility pro-
brought to the attention of the ICU gram. Preimplementation of Move to Improve early mobility program: January–March
leadership and the quality commit- 2010; postimplementation of Move to Improve early mobility program: March–August
tee in the IMCU. 2011.

February 2013 Volume 93 Number 2 Physical Therapy f 201

An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings
staff of the IMCU and ICU gathered
to discuss the successes and obsta-
cles of the program. During the open
discussion, the nurses stressed the
importance of teamwork and making
ambulation a priority as they pro-
vided care to patients. It is now a
daily expectation to discuss the
mobility plan for patients who are
critically ill.
Upon completion of the pilot study,
the data were presented to the hos-
pital’s Medical Executive Committee
to obtain approval for a house-wide
Move to Improve initiative, which
began in July 2011. After receiving
approval, the committee focused on
implementation to all remaining
adult patient care units. The market-
ing department facilitated communi-
cation and organizational support for
this project through posters and
Intranet communications. The Move
to Improve team encouraged physi-
cians to order the mobility protocol
on admission orders so that nurses
would become familiar with the
exclusion criteria and begin to think
of mobility as part of the daily clini-
cal routine. The physicians sup-
ported this change, as it streamlined
care for their patients and reduced
the number of telephone calls for the
nurses and medical staff.
The outcomes of our initial data col-
lection were as expected. We pre-
dicted that with nurses assessing the
patient’s ability to ambulate, more
patients will be walking during their
hospital stay. Our data support Bai-
ley and colleagues’ findings in
patients with respiratory failure that
early activity is feasible and can be
used to prevent or treat neuromus-
cular complications of critical ill-
ness.31 We have determined that
modifications to our protocol are not
needed at this time; however, it is
critical to maintain protocol use in
daily routine patient care.
202 f Physical Therapy Volume 93
In our study, we showed that imple-
menting a practice and culture
change led to an improvement in the
number of patients ambulating
within 72 hours of their admission in
both the ICU and the IMCU. Our data
indicate that it is feasible to ambulate
these patients.
Limitations
One limitation of this study is that it
was carried out at only one center.
There is a lack of detailed data on
patient demographics and illness
severity. However, all patients were
screened for appropriateness of
mobility using the criteria presented
in Appendix 2; therefore, all patients
in this study met these physiologic
parameters. Applicability of our
results may be limited by changes
made to the practice of sedation
management in the ICU to support
the mobility initiative, which posed a
challenge to nursing and physician
staff. Inconsistent practice patterns
as well as variations in levels of seda-
tion may have affected the patients’
ability to participate in mobility and
subsequent ambulation trials.
Conclusion
A nurse-driven protocol significantly
increased the number of patients
who ambulated in the adult ICU and
IMCU during the first 72 hours of
their hospital stay. The health care
team consisting of nurses, physi-
cians, physical therapists, respiratory
therapists, and pharmacists
approached this project with enthu-
siasm and a commitment to provide
outstanding care. When this project
was introduced to hospital leader-
ship 2 years previously, there was
little thought given to patients’ activ-
ity level. Today it has become a pri-
ority throughout the hospital.
Although this study was conducted
in a single community hospital set-
ting without additional staffing, we
feel strongly that it could be repli-
cated in other settings. The ancillary
staff utilized at our hospital for this
Number 2
program is present at other hospi-
tals, and the biases our staff had
regarding mobility of patients are
likely to be common at other institu-
tions. As only initial ambulation was
investigated in this study, future
studies may be useful in determining
overall distance improvements,
impact on length of stay, the number
of inappropriate physical therapist
evaluation orders, incidence of falls,
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and the number of patients dis-
charged to rehabilitation facilities.
Ms Drolet, Ms Harkless, Ms Henricks, Ms
Kamin, Dr Leddy, Ms Waters, and Ms Wil-
liams provided concept/idea/research
design. Ms Drolet, Ms DeJuilio, Ms Harkless,
Ms Henricks, Dr Leddy, Ms Waters, and Ms
Williams provided writing. Ms Drolet, Ms
Harkless, Ms Henricks, and Ms Waters pro-
vided data collection. Ms Drolet, Ms Hen-
ricks, and Ms Lloyd provided data analysis.
Ms Drolet provided project management
and facilities/equipment. Ms Drolet, Ms Har-
kless, and Dr Leddy provided consultation
(including review of manuscript before
submission).
The authors thank the following individuals
for their expertise, guidance, and assistance
in the design and performance of the study
and in preparation and editing of the man-
uscript: Jeffrey Huml, MD; David Cooke, MD;
Jeffrey Hinchman, BS, MS; Patricia Raetz,
APN, CNRN; Alice Siehoff, RN, MSN, DNP;
and Julie Stielstra, MLS.
The project was presented at the Interna-
tional ICU Physical Medicine & Rehabilita-
tion meeting, May 14, 2011; Denver,
Colorado.
DOI: 10.2522/ptj.20110400
References
1 Dean E. Mobilizing patients in the ICU:
evidence and principles of practice. Acute
Care Perspectives. 2008;17:3–9.
2 Allen C, Glasziou P, Del Mar C. Bed rest: a
potentially harmful treatment needing
more careful evaluation. Lancet. 1999;
354:1229 –1233.
3 Timmerman R. A mobility protocol for
critically ill adults. Dimens Crit Care Nurs.
2007;26:175–179.
4 Schweikart W, Pohlman M, Pohlman A,
et al. Early physical and occupational ther-
apy in mechanically ventilated, critically ill
patients: a randomised controlled trial.
Lancet. 2009;373:1874 –1882.
February 2013
 An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings
5 Needham D. Mobilizing patients in the
intensive care unit: improving neuromus-
cular weakness and physical function.
JAMA. 2008;300:1685–1690.
6 Convertino VA, Bloomfield SA, Greenleaf
JE. An overview of the issues: physiologi-
cal effects of bed rest and restricted phys-
ical activity. Med Sci Sports Exerc. 1997;
29:187–190.
7 Kleinpell R, Fletcher K, Jennings B. Reduc-
ing functional decline in hospitalized
elderly. In: Hughes RG, ed. Patient Safety
and Quality: An Evidence-Based Hand-
book for Nurses. Rockville, MD: Agency
for Healthcare Research and Quality;
2008. Available at: http://www.ncbi.nlm.
nih.gov/books/NBK2629/. Accessed No-
vember 7, 2011.
8 Flanders S, Harrington L, Fowler R. Falls
and patient mobility in critical care. AACN
Adv Crit Care. 2009;20:267–276.
9 Stiller K. Safety issues that should be con-
sidered when mobilizing critically ill
patients. Crit Care Clin. 2007;23:35–53.
10 Doherty-King B, Bowers B. How nurses
decide to ambulate hospitalized older
adults: development of a conceptual mod-
el. Gerontologist. 2011;51:786 –797.
11 Kalisch BJ. Missed nursing care: a qualita-
tive study. J Nurs Care Qual. 2006;21:
306 –313.
12 Brown C, Williams B, Woodby L, et al. Bar-
riers to mobility during hospitalization
from the perspectives of older patients
and their nurses and physicians. J Hosp
Med. 2007;2:305–313.
13 Brown C, Redden D, Flood K, et al. The
underrecognized epidemic of low mobil-
ity during hospitalization of older adults.
J Am Geriatr Soc. 2009;57:1660 –1665.
14 Callen B, Mahoney J, Grieves C, et al. Fre-
quency of hallway ambulation by hospital-
ized older adults on medical units of an
academic hospital. Geriatr Nurs. 2004;25:
212–217.
February 2013
15 Padula C, Hughes C, Baumhover L. Impact
of a nurse-driven mobility protocol on
functional decline in hospitalized older
adults. J Nurs Care Qual. 2009;24:325–
331.
16 Zimmerman JE, Kramer AA, McNair DS,
et al. Acute Physiology and Chronic Health
Evaluation (APACHE) IV: hospital mortal-
ity assessment for today’s critically ill
patients. Crit Care Med. 2006;34:1297–
1310.
17 Perme C, Chandrashekar R. Early mobility
and walking program for patients in inten-
sive care units: creating a standard of care.
Am J Crit Care. 2009;18:212–221.
18 Fisher S, Kuo Y, Graham J, et al. Early
ambulation and length of stay in older
adults hospitalized for acute illness. Arch
Intern Med. 2010;170:1942–1943.
19 Jacobi J, Fraser G, Coursin DB, et al. Clin-
ical practice guidelines for the sustained
use of sedatives and analgesics in the crit-
ically ill adult. Crit Care Med. 2002;30:
119 –141.
20 Korupolu R, Gifford J, Needham D. Early
mobilization of critically ill patients: reduc-
ing neuromuscular complications after
intensive care. Contemporary Critical
Care. 2009;6:1–11.
21 Ely EW, Truman B, Shintani A, et al. Mon-
itoring sedation status over time in ICU
patients: the reliability and validity of the
Richmond Agitation Sedation Scale
(RASS). JAMA. 2003;289:2983–2991.
22 Stawicki S. Sedation scales: very useful,
very underused. OPUS 12 Scientist. 2007;
1:10 –12.
23 Chittawatanarat K, Thongchai C. Sponta-
neous breathing trial with low pressure
support protocol for weaning respirator in
surgical ICU. J Med Assoc Thai. 2009;92:
1306 –1312.
Volume 93
24 Cook D, Meade M, Guyatt G, et al. Evi-
dence report on criteria for weaning from
mechanical ventilation. In: AHRQ Evi-
dence Report Summaries. Rockville, MD:
Agency for Healthcare Research and Qual-
ity; 1999. Available at: http://www.ncbi.
nlm.nih.gov/books/NBK11921/. Accessed
November 7, 2011.
25 Girault C, Daudenthun I, Chevron V, et al.
Noninvasive ventilation as a systematic
extubation and weaning technique in
acute-on-chronic respiratory failure: a pro-
spective, randomized controlled study.
Am J Resp Crit Care Med. 1999;160:86 –
92.
Downloaded from https://academic.oup.com/ptj/article-abstract/93/2/197/2735513 by guest on 11 August 2019
26 Jubran A, Tobin MJ. Pathophysiological
basis of acute respiratory distress in
patients who fail a trial of weaning from
mechanical ventilation. Am J Respir Crit
Care Med. 1997;155:906 –915.
27 MacIntyre N, Cook D, Ely E, et al.
Evidence-based guidelines for weaning
and discontinuing ventilatory support.
Chest. 2001;120:375S–395S.
28 Cohen CA, Zagelbaum G, Gross D, et al.
Clinical manifestations of inspiratory mus-
cle fatigue. Am J Med. 1982;73:308 –316.
29 Needham D, Korupolu R, Zanni J, et al.
Early physical medicine and rehabilitation
for patients with acute respiratory failure:
a quality improvement project. Arch Phys
Med Rehabil. 2010;91:536 –542.
30 Hopkins R, Spuhler V, Thomsen G. Trans-
forming ICU culture to facilitate early
mobility. Crit Care Clin. 2007;23:81–96.
31 Bailey P, Thomsen G, Spuhler V, et al.
Early activity is feasible and safe in respi-
ratory failure patients. Crit Care Med.
2007;35:139 –145.
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 Appendix 1.

204
Move to Improve Early Mobility Protocol Time Linea

f
Physical Therapy
Volume 93
a
ICU⫽intensive care unit, IMCU⫽intermediate care unit, IRB⫽institutional review board.

Number 2
An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings

February 2013
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 An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings

Appendix 2.
Non–Intensive Care Unit Mobililty Order and Mobility Protocola

Non–ICU Mobility Order

1. Evaluate patient for presence of any exclusion criteria (see #2). If exclusion criteria are present, do not initiate
mobility protocol until cleared by physician.
2. Exclusion Criteria
a. Respiratory Criteria
i. FIO2 greater than 0.6

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ii. PEEP greater than 5 cm H2O
iii. Hypoxemia: pulse oximeter less than 88%
iv. Tachypnea: respiratory rate greater than 35
v. Acidosis: Arterial pH less than 7.25
b. Circulatory Criteria
i. Continuous infusion of a vasodilator medication
ii. Addition of a new anti-arrhythmic agent within previous 24 hours
iii. Unstable arrhythmia within previous 24 hours
iv. New cardiac ischemia within 24 hours
v. MAP greater than 140 mm Hg or less than 65 mm Hg
vi. New DVT/pulmonary emboli (first 24 hours)
vii. Compartment syndrome
c. Neurologic Criteria
i. Acute stroke (first 24 hours)
ii. CSF leak
d. Orthopedic Criteria
i. Acute fracture
e. Hematologic Criteria
i. Hemoglobin less than 7 g/dL
ii. Platelet count less than 20,000
iii. INR greater than 5.0
3. Prevent Excessive Work of Breathing–Desaturation
a. Increase baseline FIO2 up to 20% as needed to keep SaO2 greater than 90% with maximum FIO2 80%
b. If trached and not on ventilator during activity, have BVM with 100% oxygen available
c. If newly extubated: NO AMBULATION ON DAY OF EXTUBATION
4. Document patient’s previous level of mobility and exercise capacity (prior to admission).
5. If patient does not progress through the activity algorithm, consult PT and OT for evaluation and treatment.
6. If PT/OT are consulted, the nursing staff/PCTs are to mobilize the patient 1–2 times daily in addition to physical
therapy/occupational therapy as tolerated.
7. If patient tolerates chair activity, then patient should be up in chair for all meals as tolerated.
8. Patients requiring airborne or AFB precautions may not participate in physical activity outside their room.
9. Patients in isolation, please refer to isolation policy for preparation of patients prior to ambulating outside their
room.

Signature: Provider Number: Date: Time:

[PLACE PATIENT LABEL HERE]

(Continued)

February 2013 Volume 93 Number 2 Physical Therapy f 205

An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings

Appendix 2.
Continued

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a
ICU⫽intensive care unit, FIO2⫽fraction of inspired oxygen, PEEP⫽positive end-expiratory pressure (cm H2O), MAP⫽mean arterial pressure, DVT⫽deep vein
thrombosis, CSF⫽cerebrospinal fluid, INR⫽international normalized ratio, SaO2⫽arterial oxygen saturation, BVM⫽bag value mark, PT⫽physical therapist,
OT⫽occupational therapist, PCT⫽patient care technician, AFB⫽acid fast bacilli, WOB⫽work of breathing. 1 ft⫽0.3048 m.

206 f Physical Therapy Volume 93 Number 2 February 2013

 An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings

Appendix 3.
Intermediate Care Unit (IMCU) Ambulation Status Reporta

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a
LOS⫽length of stay. 1 ft⫽0.3048 m.

February 2013 Volume 93 Number 2 Physical Therapy f 207