Background

Delays in early patient mobility are common in critical care areas. Oral intubation with mechanical ventilation is negatively associated with out-of-bed activities.

Objectives

To explore nurses’ mobility practices for patients with oral intubation and mechanical ventilation and identify barriers related to patient, nurse, and environment-of-care factors specific to this population.

Methods

In this cross-sectional, descriptive study in a medical intensive care unit, mobility was defined as standing, sitting in a chair, or walking. A total of 105 patients who met predefined mobility criteria and their 48 nurses were enrolled. Nurses were interviewed about mobility practices at the ends of shifts. Descriptive statistics summarized nurse and patient characteristics and mobility barriers.

Results

Patients were deemed ready to begin mobility within a mean (SD) of 41.5 (34.8) hours after oral endotracheal intubation. Two-thirds of nurses reported that they never or rarely got these patients out of bed. Only 12.4% of patients had a clinician’s activity order. Common patient-related barriers were uncooperative behavior (21.9%) and active medical issues (15%), even in patients who met mobility criteria. Nurse-related barriers were concerns for patient safety, specifically falls (14.3% of patients) and harm (9.5%). The environment of care posed very few barriers; nurses rarely mentioned that lack of help (13.3% of patients) or lack of clinician’s activity order (5.7%) impeded mobility.

Conclusions

Mobility practices were nonexistent in these patients despite patients’ being deemed ready to begin out-of-bed activities. Nurses must be attentive to their unit’s mobility culture to overcome these barriers.

Notice to CE enrollees:

This article has been designated for CE contact hour(s). The evaluation demonstrates your knowledge of the following objectives:

  1. List consequences of prolonged bedrest in critically ill patients.

  2. Describe methods for examining patient/nurse/environmental barriers to mobilizing patients with oral intubation and mechanical ventilation.

  3. Discuss implications that the results of this study have on mobility practices of critical care nurses.

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Critically ill patients who remain on bed rest can experience acute physical deconditioning within a few days.1  The resulting immobility is often referred to as critical illness intensive care unit (ICU) polymyoneuropathy.2,3  Skeletal muscle strength decreases by 1% to 1.5% per day of bed rest. The loss of muscle strength is greatest during the first week of bed rest, with variable declines in different muscle groups over time.4  Muscle strength is lost in muscle groups that maintain posture and facilitate patient transfer and ambulation.5 

Prolonged bed rest also affects the cardiovascular system by increasing cardiac workload. Supine positioning shifts 11% of the total intravascular volume from the legs to the chest, with subsequent decreases as bed rest continues over time. In addition, the combined effects of baroreceptor dysfunction, fluid shifts, and changes in autonomic tone may lead to a progressive decrease in orthostatic tolerance.5 

Prolonged bed rest in critically ill adults is associated with negative outcomes,6,7  including ventilator-associated or hospital-acquired pneumonia, delayed ventilator weaning, pressure injuries, skeletal muscle weakness and atrophy, thromboembolic disease, insulin resistance, microvascular dysfunction, systemic inflammation, insulin resistance, and orthostasis.1,4,8  Prolonged bed rest also increases the patient’s risk of delirium that leads to long-term cognitive dysfunction.9,10 

Early mobilization of critically ill patients improves their functional outcomes and enhances their sense of well-being at the time of discharge.11  Numerous publications describe strategies for initiating early mobility in critically ill patients to minimize the adverse effects of prolonged bed rest.10,12-21  However, there are potential safety concerns with mobility practices in this population. Although their incidence is low, serious safety events during mobilization have been reported and include falls, endotracheal tube removal, intravascular catheter removal or dysfunction, other catheter or tube removal, hemodynamic changes, and desaturation.7 

Despite the benefits of early mobilization, clinicians’ safety concerns about mobilizing critically ill patients create barriers to implementing mobility practices.22,23  These barriers can be conceptualized as patient condition barriers, nurse and health care team barriers, and environment-of-care barriers. Prominent patient condition barriers are obesity,24  agitation,25  delirium,23  excessive sedation,26  distressing symptoms (pain, fatigue, and dyspnea),27  lack of motivation,23-25,27  and unstable vital signs.25,26  Use of invasive monitoring devices, endotracheal intubation, and use of vascular access devices23,24  have all been cited by clinicians as patient-related reasons for not mobilizing their patients.

The health care team has concerns about catheter and device safety5,23,24  and the risk of falls25,27  when mobilizing critically ill patients. The need for mechanical ventilation increases the complexity of mobilizing these patients. Clinicians are primarily concerned about patient safety related to inadvertent endotracheal extubation, physiologic instability, management of delirium, and the need for sedation during out-of-bed (OOB) activities.23 

Prolonged bed rest in critically ill adults is associated with negative outcomes.

Lack of teamwork is another barrier mentioned in numerous studies. Clinicians practicing in critical care may lack a shared vision for mobilizing patients.23  Some teams do not have coordinated workflows, and in some settings nurses often wait for assistance from physical and respiratory therapists.24  These issues increase nurses’ perception that they do not have adequate time to incorporate patient mobility into their practice.24,28 

Factors within the environment of care contribute to a lack of early mobility practices. Barriers occur when the unit does not have a mobility protocol,24,26  staffing is inadequate,6,27  physical therapists are not available,26  the unit lacks assistive devices and equipment,6,24,26,27  and clinicians fail to enter mobility orders.25 

Current evidence indicates that extensive barriers to mobilizing critically ill patients stem from several sources. However, mobility is described in various studies as 1 or more nurse-led or physical therapist– led activities including a gamut of interventions: passive or active range-of-motion exercises,5,6,19,25,29  manual turning and repositioning,5,25  continuous lateral rotation,5,19  positioning the patient in the bed in the beach chair position,5,6,16,19,25,29  dangling the patient’s legs at the bedside,5,14,19,25  and OOB activities including sitting in a chair or walking.5,14,18,19,25,27,29  Defined mobility barriers are generic in nature and are not specific to a particular mobility intervention. We currently do not know if these barriers also apply to patients who require endotracheal intubation and mechanical ventilation and are deemed stable enough for OOB activities. Therefore, the aims of this study were to (1) determine how soon after endotracheal intubation patients were ready to get out of bed; (2) explore the mobility practices of medical ICU (MICU) nurses caring for patients who were orally intubated, receiving mechanical ventilation, and deemed ready for early OOB activities; and (3) identify patient condition, nurse, and environment-of-care barriers to getting these patients out of bed.

We defined mobility practices as nurse-initiated interventions that helped patients get out of bed to stand, sit in a chair, or walk.

Methods

Design, Setting, and Sample

This cross-sectional, descriptive study was designed to explore the mobility practices of critical care nurses in a 56-bed MICU including a step-down unit in a large Magnet-accredited academic medical center that exclusively admits patients with medical diagnoses. This unit does not have a dedicated mobility team, which would typically include nurses and physical and respiratory therapists. We defined mobility practices as nurse-initiated interventions that helped patients get out of bed to stand, sit in a chair, or walk. We enrolled 48 nurses and their 105 patients over the age of 18 years who required an oral endotracheal tube and mechanical ventilation. We included patients who met predefined early mobility criteria aligned with criteria established by an international consensus panel of critical care experts30  (Table 1). We excluded patients who had unstable cervical spine or pelvic fractures, evolving stroke, titration of intravenous vasopressors within the previous 12 hours, active bleeding, orthostatic changes in vital signs, coagulopathies, platelet counts of less than 50 × 103/μL, or pressure injuries of stage 3 or above. We also excluded patients who had been intubated in other critical care units within the hospital or at referring hospitals and then admitted to our MICU. We invited MICU nurses to participate if they cared for patients meeting the inclusion criteria, with the exception of nurse members of the research team. The hospital’s institutional review board approved this study.

Procedures

We maintained a running study log of patients requiring oral intubation and mechanical ventilation. Each day a staff nurse member of the research team, usually a night shift nurse, updated the log with new patients and completed a patient data collection form. During the 7:00 AM to 3:30 PM shift, we reviewed the electronic health records of patients on the study log to determine if they met the mobility criteria (Table 1). At a convenient time near the end of the day shift, we obtained written informed consent from nurses of patients who met the MICU mobility criteria but had not yet started OOB activities. We interviewed nurses by using an interview schedule designed specifically for this study.

Measures

The 25-item interview schedule contained commonly cited patient, nurse, and environmental barriers25,27,31  and barriers experienced by staff nurse research team members. Items related to patient condition were patients’ demographic characteristics (age, sex, and race/ethnicity) and clinical characteristics, which included admitting diagnosis, number of intravascular devices, body mass index, presence of incontinence, and scores on the Richmond Agitation-Sedation Scale (RASS)32,33  and Rothman Index.34  The Rothman Index creates a score derived from 26 electronic medical record data points taken from nursing assessments, including vital signs and laboratory data. Clinicians use the Rothman Index to follow trends in a patient’s condition.

Items representing potential nurse-related barriers included nursing practice information (eg, comfort level with using mobility equipment, previous mobility training, and work schedule) and nurses’ perceived barriers to mobility (eg, safety concerns, lack of help, and competing demands of other patients).5,6,24,25,27,28  We also collected registered nurses’ demographic characteristics (eg, age, level of experience, education, and work experience).

The 3 environment-of-care barriers examined were availability of lifting equipment, orders for mobility, and the need to wait for others for assistance with OOB activities.6,13,23-25,27,28  A comment section after the patient, nurse, and environment-of-care barrier sections was used to record verbatim other barriers described by the nurse. A 5-member expert panel ascertained face and content validity of the interview schedule for clarity and relevance.35 

Analysis

We analyzed data with SPSS software, version 22 (IBM). We calculated measures of central tendency (means, SDs, and ranges) for interval/ratio variables and frequencies and percentages for nominal variables to describe the sample characteristics and responses to the questionnaire items. We conducted a thematic analysis of all barriers indicated on write-in responses.

Results

Forty-eight of the 130 nurses in our MICU (37%) participated in this study. Participants had been practicing in critical care a mean (SD) of 5 (6) years, and 67% reported that they never or rarely got patients with endotracheal tubes who were receiving mechanical ventilation out of bed. Most nurses (81%) received training on the portable lift equipment, yet only 58% reported feeling comfortable or very comfortable using this equipment. Six rooms in the unit have a ceiling lift, but only 17% of the nurses reported having training on its use and 12% felt comfortable or very comfortable using it (Table 2).

Of the 191 orally intubated patients receiving mechanical ventilation who were screened for eligibility for OOB activities, 105 (55%) met these criteria. This cohort of patients had a mean (SD) age of 62.6 (16.8) years; 68.6% were White and 52.4% were male. The most common MICU admitting diagnosis was respiratory failure. Patients had a mean (SD) of 6.2 (3.3) comorbid conditions, had a mean body mass index in the overweight range, required a mean (SD) of 2.4 (1.1) intravascular devices or other tubes, and had a mean RASS score indicating an alert/calm to slightly drowsy state. Most patients (61.0%) had a Rothman Index trend indicating an improving or stable clinical course, whereas 36.2% had a declining Rothman Index trend. More than half of the patients (68.6%) required restraints, and 12.4% had a clinician order for OOB activities. Patients remained intubated for a mean (SD) of 113 (80.5) hours during their MICU stay (Table 3).

Our first study aim was to determine how soon after intubation patients were ready to get out of bed. Patients meeting early mobility criteria (Table 1) were deemed ready to begin OOB activities within a mean (SD) of 41.5 (34.8) hours after oral endotracheal intubation. These data were positively skewed (+2.2) and leptokurtic (+4.5) (see Figure).

Our second aim was to explore OOB mobility practices of MICU nurses caring for this population. Although all 105 patients met the early mobility criteria within 8 to 173 hours after intubation, none were mobilized.

Our third aim was to identify barriers to OOB activities related to patient, nurse, and environment-of-care factors. Nurses reported that 21.9% of patients exhibited uncooperative behavior such as agitation, anxiousness, restlessness, or combativeness that prevented the nurses from mobilizing the patients. Nurses reported numerous patient situations, such as having active medical concerns (15.0% of patients), undergoing procedures (11.4%), and being weaned from mechanical ventilation or awaiting endotracheal extubation (8.6%), that prohibited them from getting patients out of bed. Very few nurses indicated that a patient’s large habitus (2.9% of patients), need for restraints (1.9%), or refusal to cooperate (1.0%) posed a barrier to OOB activities. None of the nurses reported that the presence of too many catheters or of urinary or stool incontinence created mobility barriers (Table 4).

With regard to nurse-related barriers, nurses indicated that they had patient safety concerns, specifically that the patient might fall (14.3% of patients) or would be harmed in some way (9.5%) during OOB activities. Some of the nurses reported being unable to get patients out of bed because of competing demands of their other patients (18.1% of patients). Only a few nurses mentioned that they did not think of getting the patient out of bed or asking the provider for an activity order (3.8% of patients).

The environment of care posed very few barriers to getting patients out of bed. Nurses mentioned a lack of help from other nursing staff for only 13.3% of patients and lack of an OOB activity order for only 5.7% of patients. None of the nurses cited lack of availability of physical or respiratory therapists to help get patients out of bed as a barrier (Table 4).

Discussion

Previous studies examining early mobility practices in critical care settings have included an array of interventions by nurses and other clinicians.5-7,13,16-19,28,29,36,37  However, use of the term early mobility has been inconsistent among researchers and could mean passive or active range-of-motion exercises or in-bed or OOB activities. The unique contributions of this study are the clear definition of early mobility as OOB activities, the well-defined inclusion criteria based on specific readiness parameters for patients who were intubated and receiving mechanical ventilation, and the prospective approach used to describe barriers related to patient, nurse, and environmental factors specific to this patient population from the nurses’ perspective.

To the best of our knowledge, our study is the first to report how soon after intubation patients were in stable enough condition to begin OOB activities within a defined set of early mobility parameters. After examining MICU nurses’ early mobility practices, we found that none of the patients in this study began OOB activities after meeting these criteria. This finding was not surprising because delays to early mobilization are a common problem in critical care settings.31  Authors of recent studies have reported that the presence of an endotracheal tube with mechanical ventilation was negatively associated with a patient being engaged in OOB activities.26,38-41  Results of 3 critical care unit 1-day point-prevalence studies showed that patients receiving mechanical ventilation never40  or very rarely were mobilized with OOB activities.26,38  Timenetsky et al26  reported that only 16% of 158 patients receiving mechanical ventilation in 26 ICUs had engaged in OOB activities. Similarly, Nydahl et al38  found that just 8% of 401 patients with endotracheal tubes in 116 ICUs had OOB activities performed.

In our study, patients requiring endotracheal intubation and mechanical ventilation had patient-related mobility barriers similar to those identified in studies of more inclusive samples of critically ill patients. Uncooperative behavior of patients is a major impediment to early mobility.6,25  Nurses in our study also identified these behaviors as deterrents to getting patients out of bed, even though we excluded patients who were very agitated or combative according to their RASS scores. The range of RASS scores for most of these patients indicated light sedation to restlessness, which was not consistent with the uncooperative behaviors that nurses reported.

Almost 70% of patients in our study required restraints, yet nurses identified restraints as a barrier to OOB activities in only 2 patients. We found no other studies that identified restraint use as a mobility barrier. Although the mean body mass index of patients in our study was in the overweight range, nurses indicated that large patient body size was a barrier to OOB activities in only a small proportion of patients, unlike in other studies.24,25  Events such as bedside procedures, transport off the unit for tests, and ventilator weaning trials have been reported to take precedence over efforts to mobilize patients.36  We also found that these situations created patient-related barriers to OOB activities.

It is not feasible to mobilize patients with unstable medical conditions or respiratory contraindications, which are considered mobility barriers.24,25,36  For this reason, we included in this study only patients who met the hemodynamic and respiratory early mobility criteria. Therefore, it was quite surprising to note that some of the nurses identified medical conditions and respiratory instability as barriers.

The predominant themes of nurse-related barriers to OOB activities in our MICU are consistent with those of other studies. The most common theme was nurses’ concern for patient safety or adverse events.5,22-25,27,36  These fears may be exaggerated because the incidence of adverse events during OOB activities is very low in patients who are intubated and receiving mechanical ventilation.7,17,36 

We believe our study is the first to report how soon after intubation patients were in stable enough condition to begin OOB activities within a defined set of early mobility parameters.

The most commonly cited environment-of-care barrier is the lack of a unit culture that sets the expectation that these patients will be mobilized.13,23,24,28,39  Our findings are aligned with this theme; very few nurses identified environment-of-care barriers to early mobility. Most nurses reported that they never or rarely got intubated patients receiving mechanical ventilation out of bed. Clinicians infrequently entered mobility orders for these patients.

Our study had some limitations. It was conducted in a single MICU in a large academic medical center. We used a convenience sample of nurses, which may have biased the results. Including an assessment of nurses’ mobility skills, knowledge, and beliefs would have provided us with a broader depth of knowledge about mobility practices. We assessed patients for mobility readiness in the morning and interviewed nurses at the end of the shift to determine if patients had performed OOB activities. The condition of some patients may have deteriorated during this time, making them ineligible to participate in mobility activities.

Future research should be focused on ways to minimize barriers to implementation of early mobility practices in patients who are intubated and receiving mechanical ventilation. It would be advisable to examine the effect of interventions designed to improve nurses’ early mobility knowledge and skills, minimize perceived barriers, and enhance OOB practices in this population. Primary outcomes of such research should focus on early mobility rates for all eligible patients, serious and minor safety events, ventilator days, and ICU cost and length of stay.

Conclusions

Mobility practices were nonexistent in these patients despite patients’ being deemed ready to begin out-of-bed activities. Therefore, results of this study have implications for the implementation of early mobilization practices for patients who are intubated and receiving mechanical ventilation. Critical care nurses need to collaborate with the interdisciplinary team to create a unit culture that embraces early mobility practices. The team’s initial step is to vet mobility criteria and protocols for patients with complicated medical conditions. Unit leaders are responsible for ensuring that nurses and support staff members have the knowledge and competencies to engage in this practice safely and that clinicians enter orders for all eligible patients. Together the team should take an inventory of barriers related to patient, nurse, and environment-of-care factors unique to their setting. Once this groundwork is laid, an interdisciplinary protocol-driven mobility program that is known to be safe and effective10,12,17,18,42-45  can be systematically applied to surmount the barriers to early mobilization.

ACKNOWLEDGMENTS

We acknowledge Dr Wei Teng, senior data analyst at Yale New Haven Health, for her statistical support. Special recognition goes to current and former Yale New Haven Hospital York Street Campus medical intensive care unit research team members, especially Kathy McKiernan, Evelyn Flaherty, Belen Hilario, Lynn Page, Victoria Ramik, and Ann Ryder, who helped design and implement the study. We appreciate the contributions of all of the York Street Campus medical intensive care unit nurses who participated in the study.

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Footnotes

 

FINANCIAL DISCLOSURES

Yale New Haven Hospital, Division of Nursing, provided grant/financial support for this study.

 

SEE ALSO

For more about early mobility, visit the Critical Care Nurse website, www.ccnonline.org, and read the article by Schallom et al, “Implementation of an Interdisciplinary AACN Early Mobility Protocol” (August 2020).

 

To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org.