Patient Mobility in the ICU
Barry Evans, RN, MSN
Adult Critical Care Quality Improvement Leader
Normal Mobility
• “On average, a healthy individual will alter his or her
posture during sleep every 11.6 minutes” (Hawkins,S.,
Stone,K., & Plummer, I., 1999)
Hawkins,S., Stone, K., & Plummer, I. (1999). An holistic approach to turning
patients. Nursing Standard, 14,(3), 52-56.
History of Bed Rest
• Before 1940 normal duration of bed rest
– 2 weeks strict bed rest for childbirth
– 3 weeks bed rest for hernia repair surgery
– >4 weeks for MI
• Post WWII
– Shortage of hospital beds and personnel shortened length of bed
rest
– Early mobilization improved outcomes and reduced
complications
– Outcomes from VA Rehab programs found that bed rest was
more disabling than the original injury
• 1980’s
– Early discharges result from DRG payment system
• No evidence of harm
Corcoran, P. (1991)
Bed Rest
“Look at a patient lying in bed.
What a pathetic picture he makes.
The blood clotting in his veins,
the lime draining from his bones,
the scybala stacking up in his colon,
the flesh rotting from his sweat,
the urine leaking from his distended bladder,
and the spirit evaporating from his soul”
Richard Asher, MD 1947
Corcoran, P (1991)
Immobility
• Every organ and body system
progressively deteriorates when
inactivated.
• There is a remarkable similarity
between physiological effects of
aging and the adverse systemic
effects from prolonged
immobility.
Bortz, W., (1982). Disuse and aging. JAMA, 248, 1203-1208
Creditor, M (1993)
Cardiac
• Tachycardia
• Hypotension
– Orthostatic hypotension occurs after 15-24 days of immobility
– Avg. loss of 600ml plasma volume when on bed rest-contributes to
hypotension.
– After 12 hrs of bed-rest an upward fluid shift stimulates the baroreceptors
in the aortic arch and carotid artery to have an opposite
depressor effect. Must allow for hemodynamic equilibration when
moving patient.
• Inc. risk DVT
• Decreased maximal oxygen uptake
• Dec. total blood volume
• Heart Muscle atrophy and decreased stroke volume
Physiological System Changes from Immobility
Metzler, et al. (1996), Positioning your patient properly. American Journal of Nursing, 96 (3), 33-37
Sciaky, A., (1994). Mobilizing the intensive care unit patient: pathophysiology and treatment. Physical Therapy Practice, 3(2), 69-80
Physiological System Changes from Immobility
cont’d
Pulmonary Complications
• Dec. vital capacity
• Dec. residual volume
• Less functional reserve
• Inc. secretions
• Inability to clear secretions (inc. aspiration risk)
• Increases risk for aspiration, pneumonia, pulmonary embolism and
development of ARDS
• Increases risk for atelectasis even in the absence of preexisting
respiratory disease
• Mucous film lining of smaller airways tends to pool
Sciaky, A., (1994).
Physiological System Changes from Immobility cont’d
Musculoskeletal
• Skeletal muscle atrophy has rapid onset
- Begins 4 hours after start of hospitalization if pt is immobile
- Dec. muscle mass, muscle cell diameter and # of fibers per muscle
• 1 week of bed rest = 20% decrease in muscle strength
• Loss of muscle strength is ongoing and progressive
-Additional 20% muscle strength loss for each week of bed rest
• Use of weakened muscles generates an increased oxygen
demand at the cellular level. Critically ill patients cannot meet this
demand!
• Loss of Bone Mass Density
• > 50% acceleration after 10 days bed-rest
• Calcium clearance 4-6 x normal after 3 weeks of total immobilization
• Contractures
• Can begin forming after 8 hours of bed rest
• Pressure Ulcers
• Develops within hours of immobilization if progressive turning schedule is not
implemented
Sciaky, A. (1994). Mobilizing the intensive care unit patient: pathophysiology and treatment. Physical Therapy Practice, 3
(2), 69-80.
Creditor, M., (1993). Hazards of hospitalization of the elderly. Annual of Internal Medicine, 118 (3), 219-223
Physiological System Changes from Immobility
cont’d
Gastrointestinal/Genitourinary Systems
• Constipation
– Decreased peristalsis
– Risk of Ileus
• Urinary stasis
– Inc. risk for UTI
– Calculus formation
– Increased calcium in urine is detected within a few
days after bed rest
• Fluid retention
Sciaky, A., (1994).
Physiological System Changes from
Immobility cont’d
Metabolic
• Inc. excretion of calcium nitrogen,
phosphorus
– Renal Calculi
• Inc. risk of osteoporosis
– Increased risk of bone fracture
Sciaky, A., (1994).
Physiological System Changes from Immobility
cont’d
Central Nervous System (CNS)
• Emotional & behavioral changes
• Anxiety, emotionally labile
• Decreased attention span
• Depression
• Altered Sleep Pattern (sleep deprivation)
• Perceptual /coordination deficits
• Diminished intellectual performance
• Learned helplessness syndrome
Sciaky, A., (1994).
Burden of Complications
Impact of
Decreased Mobility
Ventilator-associated Pneumonia
• Increases need for vent support
• Increases ICU LOS by 4.3 days
• Increases Hospital LOS by 9 days
• I case VAP costs $27,900 to treat
• National Cost of VAP > $1.2 Billion
• Mortality from VAP 50-70%
Heyland et al. Am J Respir Crit Care Med 1999;159:1249
Craven, D. Chest 2000, 117.,186-187S
Rello, et al, Chest 2002; 122, 2115
Pressure Ulcers
• Pain and Suffering
• Venous thrombus
• Sepsis
• Pneumonia
• Potential for Health Care Expenditures
• Mean cost of 1 pressure ulcer = $1,877
• Increases LOS 4-7 days
• Cost of healing 1 pressure ulcer = $5,000-
$40,000
Agency for Healthcare Policy and Research. Prevention of pressure ulcers,
(2003). Retrieved January 26, 2004, from www.guideline.gov/summary.
I
n
Quality
Improvement
Health Care
Resource Utilization
Product
Utilization
Cost
Care
Delivery
Information
Services
Customer
Satisfaction
Staff
Satisfaction
Current Patient Mobility Practices
found in Literature
• Q 2 hour turning
• AROM/PROM
• OOB
• Cardiac Chair
• Progressive Pivot/Stand
• Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen? Is it enough?
C
Corcoran, P., (1991). Use it or lose it –the hazards of bed rest and inactivity- adding life to years. Western Journal of Medicine,
154, 536-538
Literature Findings
Q 2 Hr. Turns
Krishnagdopalan et al. (2002)
Study: Prospective longitudinal observation study conducted to
determine compliance with Q 2 hr turning practices and how physicians
and nurses perceived the practice was carried out in their critical care
units
Setting: 3 separate ICU’s, 74 patients, with a total of 566 patient hour
observations.
Findings:
• 49.3% of observation time – No body position changes were noted
• 2.7% of Patients observed had Q 2 Hr. body position changes
• 80%-90% of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complications
• 57% of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICU’s
Krishnagdopalan, S., Johnson, W., Low, L,, & Kaufman, L., (2002. Body positioning of intensive care patients: clinical practice
versus standards. Critical Care Medicine, 30 (11) 2588-2592
Literature Findings, cont’d
Bailey, et al. (2007)
• Study: 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients.
• Goal: Ambulate patients 100 ft before discharge from RICU
– **Pt movement to upright position in bed, cardiac chair and passive ROM were not
considered activity
• Definitions:
– Activity period: From time of hemodynamic stability throughout ICU stay
– Adverse Events: Fall to knees, tube removal, SB/P < 90mmHg >200 mmHg, Desat <
80% and extubation
• Criteria: Pt.’s on MV >4 days, Fio2 < 60%, Peep < 10 cm H20, no orthostatic B/P, no
vasopressor qtts.
• Interventions:
– Progressive increase in activity level from sit in chair to ambulate BID
– Pre & Post 30min rest period with AC ventilation prn to support activity
– Increase FI02 by 20% prior to activity & administer 02 during activity to prevent desaturation
– VS measurement pre & post activity
– Activity assisted with RN, RT, PT or CC Tech
Mobility
Literature Findings
Bailey, et al. (2007)
• Results:
– 103 patients participated
– 89% patients on MV
– 42 % of pt’s with ETT tubes
ambulated
– 69% of patients ambulated
> 100ft.
– Median distance ambulated
• 400 ft.for pt.’s d/c home after
admission
• 270 ft for pt.’s d/c to SNF after
admission
• 230 ft for pt.s d/c to rehab after
admission
– Nurse to patient ratio 1:2
– No increase in nursing hours required
• Adverse Events:
– 9 patients had 14 adverse events
(14/1449 activity events =0.009%)
– 5 Falls to knees without injury
– 4 SBP< 90 mmHg
– 3 O2 desats < 80%
– 1 small bowel feeding tube removal
– 1 SBP > 200 mmHg
• No extubations, complications,
extended LOS, additional costs or
therapy required
• Clinical Significance:
Early activity is safe, feasible and beneficial
to ICU patients. It requires a
multidisciplinary team approach and is a
valuable therapy to reduce complications
associated with prolonged immobility.
Mobility
Mobility Expectations
Range of Activity
(Intensive Care Mobility Guidelines)
• Position Change Q 2 hrs
• AROM/PROM upper & lower extremities Q 8 hrs
– Incorporated into routine daily care
• HOB elevation 30o while in bed
– Progressive activity as tolerated following mobility algorithm
• Cardiac Chair
• Dangle legs
– While sitting on side of the bed
• Stand
– Any amount of time patient can stand will be beneficial for expanding lung
capacity, enhance weight bearing and restores normal fluid balance
• Pivot -> Out of Bed to Chair
– Patient should not be OOB to chair for > 1- 2 hours at a time
• Levels of ADL
– Encourage participation in hygiene and feeding as appropriate
• Progress to steps->ambulation
Mobility Expectations
Documentation
• Appropriate documentation adhering to unit standards.
• Do not use:
– Checkmarks
– Q 2 o Turn
– Side to Side
– Lines drawn through boxes
• Use specific position change Q2:
– Right (R), Left (L), Supine, Prone
• Time Specific
– Number of steps taken or distance if pt. is ambulatory
– Amount of time if OOB to chair
Mobility Expectations
• Utilize OT/PT to reduce risks associated with health
co-morbidities, provide early intervention for
rehabilitation and contribute to the patients well
being and quality of life (Madill, Cardwell, Robinson & Brintnell, (1986).
• Occupational Therapy:
– Ask physician to order consult on admission
– OT will follow up weekly to evaluate patient for OT intervention
• Physical Therapy:
– Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials
(SBT)