Early Mobilization: Changing the Mindset

Furthermore, safety is a concern when mobilizing patients who are critically ill, including concerns about dislodgement of breathing tubes, nasogastric tubes, and rectal tubes.^9,11  In 2 studies,^7,9  a primary mobility team consisting of a primary nurse, a physical therapist, and a respiratory therapist helped ensure the safety of ambulating patients who had invasive catheters. A recent systematic review⁸  of several studies^9,16  demonstrated that early mobility of critically ill patients is safe and effective. In a prospective cohort study,¹⁶  103 patients with respiratory failure who were receiving mechanical ventilation were mobilized by using a progressive mobility protocol. A total of 1449 activity events such as sitting on the bed, sitting in a chair, and ambulating were recorded, and adverse events (eg, extubation, falling to knees, catheter/tube removal, systolic blood pressure >200 mm Hg or <90 mm Hg, and oxygen saturation <80%) were reported. The results indicated that mobilizing patients receiving mechanical ventilation was safe, with fewer than 1% of patients experiencing adverse events, whereas 69% of patients had ambulated at the time of discharge from the respiratory ICU. Knowing the detrimental effects of prolonged immobility and the safety concerns when mobilizing patients, especially patients receiving mechanical ventilation support, a quality improvement project initiative was put in place in a postsurgical/trauma acute ICU.

The aim of the quality improvement project was to assess and change the mindset of the SICU staff toward early mobilization of patients receiving mechanical ventilation. The hospital is a quaternary-level academic teaching hospital with more than 900 beds, located in the northeastern United States. Under the leadership of an interdisciplinary team, the SICU has 18 beds for acute critically ill postsurgical patients, kidney transplant patients, and trauma level I patients. The team consisted of attending surgeons, intensivists, surgical fellows, surgical residents, registered nurses, respiratory therapists, patient care associates, support care associates, physical therapists, a dietitian, a social worker, and clerical support associates. This quality improvement project was qualified for exemption from the institutional review board. The SICU nurses were informed in writing that participation in this project was voluntary and that non-participation would not affect their performance evaluation. For this project, clear operational definitions of mindset and early progressive mobilization activity were developed. Mindset was defined as beliefs and concerns of the SICU staff nurses about mobilizing patients receiving mechanical ventilation. Early progressive mobilization activity was defined as a wide range of activities from getting patients out of bed and into a chair, dangling patients’ legs at the side of the bed, having patients stand at the bedside, and ambulating patients who met the eligibility criteria.⁷ 

The Plan, Do, Study, Act (PDSA) quality improvement model¹⁷  was used to guide the planning, interventions, evaluation, and reinterventions to assess and change the mindset of the SICU staff toward early mobilization of patients receiving mechanical ventilation. The PDSA model consisted of 4 stages: “Plan” identified an opportunity for improvement; “Do” tested the interventions; “Study” reviewed the results of data; and “Act” was implementing the reinterventions, which were based on the lessons learned from the initial interventions.

The SICU Collaborative Care Council, consisting of staff nurses, attending physicians, physician assistants, ancillary staff, and nursing leaders, put together survey questions that most effectively addressed nurses’ mindset toward mobilizing patients receiving mechanical ventilation. The mindset of the SICU staff was assessed by having them indicate the strength of their concerns and beliefs about mobilizing patients receiving mechanical ventilation 2 weeks before, 6 months after, and 1 year after the implementation of early mobilization. Staff nurses indicated their level of agreement with the following statements: (1) Most patients in the SICU are able to get out of bed. (2) It is safe to mobilize an orally intubated patient out of bed to a chair. (3) It is difficult to coordinate the personnel needed to complete a patient’s transfer to a chair. (4) The risk of self-extubation is increased when orally intubated patients are in a chair. (5) Early mobilization of intubated patients decreases length of stay and decreases incidents of ventilator-associated pneumonia, deep vein thrombosis, and skin breakdown. (6) The nurse is comfortable in mobilizing an orally intubated patient out of bed to a chair. (7) Nursing staff share the responsibility for providing daily exercises to patients when appropriate. Included in the planning stage was an assessment of the barriers and appropriate interventions to change the mindset of the SICU staff toward mobilizing patients receiving mechanical ventilation. Recent studies^4,9,18,19  on different barriers to mobilizing ICU patients validated the same barriers that the SICU staff encountered. Table 1 shows the barriers to early mobilization in the SICU and the appropriate interventions.

The SICU interdisciplinary team adopted the eligibility criteria for early mobilization from the study by Needham and Korupolu,²⁰  which guided the nurses in assessing patients’ eligibility for early mobilization. Eligibility for early mobilization was determined by assessing for neurological stability (patient responds to verbal stimulation and follows verbal commands), respiratory stability (fraction of inspired oxygen <0.6; with positive end-expiratory pressure <10 cm H₂O), and circulatory stability (absence of orthostatic hypotension with low-dose vasopressor). The SICU interdisciplinary team adopted the progressive early mobility activity protocol used by Morris et al⁷  because this protocol resulted in a significant reduction in the length of stay for the mobility protocol group (5.5 days) than for the usual-care group (6.9 days) in that study. The early mobility activity protocol included 4 levels of activity therapy. The first level was designed for unconscious patients where passive range-of-motion exercises were performed on patients’ upper and lower extremities 3 times a day. The second level was designed for patients who responded and followed commands where progressive active-assistive and active range-of-motion exercises were administered. The third and fourth levels were designed for patients who were alert and able to participate actively. A key feature of mobilization strategies in the critically ill for the fourth level was to have the patient get out of bed and into a chair, dangle legs at the side of the bed, stand at the bedside, and ambulate.⁷ 

Multimodal education that incorporated lecture, online education, just-in-time education, and discussion during unit briefs was designed to prepare each interdisciplinary team member to understand the adverse outcomes of immobility, the eligibility criteria for early mobilization including sedation practice, and the early mobilization activity protocol. The education of the SICU multidisciplinary team was conducted by the SICU nurse educator, physical therapist, respiratory therapist, and SICU attending physician at multiple times during the unit briefs, huddles, staff meetings, and meetings of the Collaborative Care Council. The SICU staff successfully completed the multimodal education by attendance at education sessions.

A survey questionnaire that used a 5-point Likert scale was used to assess the mindset of the SICU staff toward early mobilization of patients receiving mechanical ventilation, with a score of “1” being strongly agree and “5” being strongly disagree with the 7 statements. The questionnaire was pilot tested on 5 SICU nurses to ensure the clarity and reliability of interpretations of the statements. The survey was distributed to the SICU staff nurses 2 weeks before, 6 months after, and 1 year after implementation of early mobilization of patients receiving mechanical ventilation.

Of 56 staff nurses working in the SICU, 37 nurses responded to the survey 2 weeks before implementation, 34 nurses responded to the survey 6 months after implementation, and 36 nurses responded to the survey 1 year after implementation of early mobilization for patients receiving mechanical ventilation. The first, second, and third groups of SICU nurses who responded to the survey had very similar characteristics: 30 had a bachelor’s degree in nursing, 7 had an associate’s degree, they were from 24 to 55 years old (mean age, 35 years), they had a mean of 8 years of experience in critical care nursing, and all were full-time staff.

The results of the association between time (2 weeks before implementation, 6 months after implementation, and 1 year after implementation) and mindset of the SICU staff toward early mobilization are shown in Table 2. The median response to statement 1 changed significantly, with participants choosing to disagree before implementation and to agree after implementation of the early mobility protocol. From before to 1 year after implementation, the responses changed from disagree to agree/neutral, respectively. For statements 2, 3, and 4, the median change in response changed significantly from before to 6 months after implementation and 1 year after implementation, with responses moving from agree to disagree to neutral, respectively. Although the median response to statement 5 was agree across all 3 time periods, the distribution of the responses changed significantly from agree to neutral before implementation to strongly agree to neutral at 6 months after implementation to strongly agree to agree at 1 year after implementation. The median response to question 6 changed from disagree before implementation to neutral at 6 months and 1 year after implementation. The response to question 7 did not change significantly from before to after implementation.

Interventions to overcome the barriers (Table 1) to mobilizing patients receiving mechanical ventilation have improved the mindset of SICU staff toward early mobilization. These interventions are continually being implemented in the SICU. The early mobilization protocol has been added to the SICU’s daily goal sheet, which is the paper tool used during bedside multidisciplinary patient care rounds. Beginning at 5 am, the SICU attending/intensivist, primary nurse, and respiratory therapist assess patients for eligibility for mobilization. When patients are qualified for mobilization, the respiratory therapist initiates the ventilator weaning protocol, which expedites the first step in the early mobilization protocol. Nurses have realized the importance of mobilizing patients as they incorporate early mobilization in their plan of care.

To hardwire and sustain the early mobilization project, the early mobilization protocol has been added to the orientation curriculum of nurses, surgical residents, and fellows in the SICU. Every month, early mobilization statistics and practices are discussed in the SICU care improvement meetings. This quality improvement project has been presented to the Critical Care Service Improvement Coordinating Group and is currently being disseminated to other ICUs in this hospital.

Overall, the results for 6 of the 7 statements on the survey showed a change in the mindset of SICU staff toward early mobilization of patients receiving mechanical ventilation. The SICU staff agreed that most of the patients were able to get out of bed after identifying the barriers and appropriate interventions to mobilizing patients receiving mechanical ventilation. Creating an early mobilization protocol and educating the SICU staff on eligibility for the early mobilization protocol, sedation practice, and the progressive mobilization activity protocol have improved the attitude of staff toward mobilizing patients receiving mechanical ventilation. Multimodal staff education, which incorporates lecture, online education, just-in-time education, and discussion during unit briefs, has contributed to decreasing staff bias against early mobilization of SICU patients, and this result is consistent with the results reported by Morris et al,³  who used multimodal education to eliminate barriers to mobilization in ICUs. Involving the SICU mobilization team, consisting of physician, midlevel provider, respiratory therapist, physical therapist, staff nurses, and patients, in planning and implementing the early mobilization protocol may have helped in alleviating the challenge of coordinating the personnel needed to complete transfers of patients to chairs. The SICU staff agreed that it was safe to mobilize intubated patients, which was consistent with the results reported by Balas et al²¹  on mobilizing patients in ICUs. The risk of self-extubation was prevented by use of an endotracheal tube securement device and by having adequate staff assisting with the mobilization. The SICU staff agreed that early mobilization of patients receiving mechanical ventilation has decreased length of stay and the occurrence of ventilator-associated pneumonia, deep vein thrombosis, and skin breakdown. This change in the mindset may be related to the monthly meeting of the SICU service improvement coordinating group, where quality data such as length of stay and frequency of ventilator-associated pneumonia, deep vein thrombosis, and skin breakdown are presented and analyzed. In addition, monthly staff meetings and display of these quality data in the nurses’ lounge may have contributed to better dissemination of results to the SICU staff. Responses to statement 7 on the survey showed that the SICU nurses did not agree that they share responsibility for providing daily exercises to patients when appropriate. This result may be related to the priority focus of staff in the SICU on hemodynamic stability, managing sepsis, and preserving organ function. Another reason may be related to lack of knowledge on providing passive exercises to patients and absence of a physician’s order for nurses to provide daily exercises. A physical therapist covers the ICU, and nurses have been relying on the physical therapist to provide daily exercises for patients. Clearly, a daily mobilization goal for patients should be in place, and nurses and the physical therapist should be in partnership in coordinating the mobilization activities of these patients.

The SICU Collaborative Care Council has played a vital role in conceptualizing and implementing this quality improvement project. Interdisciplinary collaboration among the SICU team members makes it possible to tackle the important issue of early mobilization of critically ill patients in the SICU, as concluded by Bassett et al.⁶  Repetitive education and training of interdisciplinary staff is helpful in removing the barriers to implementing the early mobilization protocol, a finding validated by a recent study²¹  on an initiative for awakening and breathing coordination. Expertise from each discipline brings forth innovative ideas, such as the physical therapist’s recommendation of purchasing mobilization support devices and hiring additional physical therapists. Referrals of patients to the physical therapy department have increased from 15 patients per month to 30 patients per month. Recommendations for future quality improvement projects or research include studying the effects of early mobilization of patients receiving mechanical ventilation in other patients from different types of ICUs, focusing on measurable outcomes such as length of stay; frequency of ventilator-associated pneumonia, pressure ulcers, deep venous thrombosis, catheter-associated urinary tract infections, and central catheter–associated bloodstream infections; use of sedation infusion agents; and readmission rates.

The SICU management team and leaders ensure that each member of the SICU team complies with protocols. Most of all, great appreciation goes to the SICU staff nurses, physical therapists, respiratory therapists, patient care associates, support care associates, physicians, and physician assistants who have been implementing the protocol as a team.