Across the country, nurses working in interdisciplinary teams recognize the dangers of immobility in critically ill patients and the benefits of getting these patients up and moving, improving outcomes.
“The literature is rich with the benefits of why it’s important to get patients out of bed,” said Cosme F. Taipe, BSN, RN, CCRN, clinical program coordinator at NewYork-Presbyterian Weill Cornell Medical Center in New York. “It’s the right thing to do for our patients,” said Taipe, who works on the medical center’s early mobility program.
Benefits include decreased time on mechanical ventilation, less delirium, less skin breakdown, greater lung expansion and less risk of pneumonia. Other advantages include improved circulation, less chance of deep vein thrombosis, less constipation and reduced debilitation. All of these positive points lead to fewer complications, shorter ICU and hospital stays and improved patient satisfaction.
Anne Pohlman, MSN, APN-CNS, CCRN, FCCM, at the University of Chicago Medicine Critical Care Clinical Research program, was involved in one of the early studies, “Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial,” published May 2009 in The Lancet. That study found 59% of patients in the early mobility cohort were functional at discharge compared with 35% in the control group.
“Doing this from the beginning is the difference between going home and going to acute rehab at discharge,” Pohlman said.
Progressive movement — from passive and active range of motion to sitting on the side of the bed to walking — keeps the muscles moving and avoids the loss of muscle mass resulting from immobility, said Cynthia Fine, MSN, RN, CRRN, clinical coordinator for early mobilization in the ICU at NewYork-Presbyterian/Columbia University Medical Center in New York.
“Our goal is to get them as mobile as we can, looking at their baseline,” Fine said. If patients walked prior to admission, the team aims to ensure they are walking again before they leave.
Patient and family response
Nurses must educate family members about the benefits. Taipe said once they understand, the families start to look forward to the mobilization and find it gives them hope.
Some patients, Taipe said, have called the mobility effort the best part of their stay, reporting that it helped them feel better as they are able to do a little more each day. A few of these patients have encouraged other patients, even returning after discharge to share how beneficial early mobility was to their lives.
“It’s beyond important and something the team is passionate about,” Taipe said.
A team commitment
For successful early mobility, every discipline — rehabilitation therapists, respiratory therapists, pharmacists, physicians and nurses — must take part, because early mobility requires coordination and flexibility. They discuss the plan and set the schedule on rounds or during a huddle.
The“Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit,” published in Critical Care Medicine, recommend a team approach and the use of checklists.
“It requires the buy-in of all disciplines that this is a priority,” Pohlman said.
Nurses take several steps before getting the patient up.
Nurses turn off the sedation prior to a spontaneous breathing trial and getting the patient up. They administer pain medication prior to mobilization.
Then nurses monitor the patient’s condition, lines and breathing tubes as the activity progresses.
“We couldn’t do this if it wasn’t for everybody [working together],” Taipe said.
Even so, early mobility represents a huge culture change in the ICU and not one that happens overnight, Fine said. “Nurses are able to talk more with patients. We get speech-language pathologists involved early when we suspect the patient may have dysphagia, so we can determine the proper type of diet and liquids.” While early mobility of patients represents a change from the past, she indicated that it’s one worth making in every ICU across the country.
“It should be everywhere; we should be getting people up and moving,” Fine said. “There are many good reasons to do it and not many not to do it.”