patient mobility in the icu - the healthcare - hanys · pdf filepatient mobility in the icu...
TRANSCRIPT
Patient Mobility in the ICU
Barry Evans RN MSN Adult Critical Care Quality Improvement Leader
Normal Mobilitybull ldquoOn average a healthy individual will alter his or her
posture during sleep every 116 minutesrdquo (HawkinsS StoneK amp Plummer I 1999)
HawkinsS Stone K amp Plummer I (1999) An holistic approach to turningpatients Nursing Standard 14(3) 52-56
History of Bed Rest
bull Before 1940 normal duration of bed restndash 2 weeks strict bed rest for childbirthndash 3 weeks bed rest for hernia repair surgeryndash gt 4 weeks for MI
bull Post WWIIndash Shortage of hospital beds and personnel shortened length of bed
restndash Early mobilization improved outcomes and reduced
complicationsndash Outcomes from VA Rehab programs found that bed rest was
more disabling than the original injurybull 1980rsquos
ndash Early discharges result from DRG payment systembull No evidence of harm
Corcoran P (1991)
Bed Rest
ldquoLook at a patient lying in bedWhat a pathetic picture he makes
The blood clotting in his veinsthe lime draining from his bones
the scybala stacking up in his colonthe flesh rotting from his sweat
the urine leaking from his distended bladderand the spirit evaporating from his soulrdquo
Richard Asher MD 1947
Corcoran P (1991)
Immobilitybull Every organ and body system
progressively deteriorates when inactivated
bull 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)
Cardiacbull Tachycardiabull Hypotension
ndash Orthostatic hypotension occurs after 15-24 days of immobilityndash Avg loss of 600ml plasma volume when on bed rest-contributes to
hypotension ndash After 12 hrs of bed-rest an upward fluid shift stimulates the baro-
receptors in the aortic arch and carotid artery to have an opposite depressor effect Must allow for hemodynamic equilibration whenmoving patient
bull Inc risk DVTbull Decreased maximal oxygen uptakebull Dec total blood volume bull 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) 33-37Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3(2) 69-80
Physiological System Changes from Immobilitycontrsquod
Pulmonary Complicationsbull Dec vital capacitybull Dec residual volumebull Less functional reservebull Inc secretions bull Inability to clear secretions (inc aspiration risk)bull Increases risk for aspiration pneumonia pulmonary embolism and
development of ARDSbull Increases risk for atelectasis even in the absence of preexisting
respiratory diseasebull Mucous film lining of smaller airways tends to pool
Sciaky A (1994)
Physiological System Changes from Immobility contrsquodMusculoskeletalbull 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
bull 1 week of bed rest = 20 decrease in muscle strengthbull Loss of muscle strength is ongoing and progressive
-Additional 20 muscle strength loss for each week of bed restbull Use of weakened muscles generates an increased oxygen demand at the cellular level Critically ill patients cannot meet thisdemand
bull Loss of Bone Mass Density bull gt 50 acceleration after 10 days bed-restbull Calcium clearance 4-6 x normal after 3 weeks of total immobilization
bull Contracturesbull Can begin forming after 8 hours of bed rest
bull Pressure Ulcersbull Develops within hours of immobilization if progressive turning schedule is not
implementedSciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3
(2) 69-80Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-223
Physiological System Changes from Immobility contrsquod
GastrointestinalGenitourinary Systemsbull Constipation
ndash Decreased peristalsisndash Risk of Ileus
bull Urinary stasisndash Inc risk for UTIndash Calculus formationndash Increased calcium in urine is detected within a few
days after bed restbull Fluid retention
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Metabolicbull Inc excretion of calcium nitrogen
phosphorusndash Renal Calculi
bull Inc risk of osteoporosisndash Increased risk of bone fracture
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Central Nervous System (CNS)bull Emotional amp behavioral changesbull Anxiety emotionally labilebull Decreased attention spanbull Depressionbull Altered Sleep Pattern (sleep deprivation)bull Perceptual coordination deficitsbull Diminished intellectual performancebull Learned helplessness syndrome
Sciaky A (1994)
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Normal Mobilitybull ldquoOn average a healthy individual will alter his or her
posture during sleep every 116 minutesrdquo (HawkinsS StoneK amp Plummer I 1999)
HawkinsS Stone K amp Plummer I (1999) An holistic approach to turningpatients Nursing Standard 14(3) 52-56
History of Bed Rest
bull Before 1940 normal duration of bed restndash 2 weeks strict bed rest for childbirthndash 3 weeks bed rest for hernia repair surgeryndash gt 4 weeks for MI
bull Post WWIIndash Shortage of hospital beds and personnel shortened length of bed
restndash Early mobilization improved outcomes and reduced
complicationsndash Outcomes from VA Rehab programs found that bed rest was
more disabling than the original injurybull 1980rsquos
ndash Early discharges result from DRG payment systembull No evidence of harm
Corcoran P (1991)
Bed Rest
ldquoLook at a patient lying in bedWhat a pathetic picture he makes
The blood clotting in his veinsthe lime draining from his bones
the scybala stacking up in his colonthe flesh rotting from his sweat
the urine leaking from his distended bladderand the spirit evaporating from his soulrdquo
Richard Asher MD 1947
Corcoran P (1991)
Immobilitybull Every organ and body system
progressively deteriorates when inactivated
bull 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)
Cardiacbull Tachycardiabull Hypotension
ndash Orthostatic hypotension occurs after 15-24 days of immobilityndash Avg loss of 600ml plasma volume when on bed rest-contributes to
hypotension ndash After 12 hrs of bed-rest an upward fluid shift stimulates the baro-
receptors in the aortic arch and carotid artery to have an opposite depressor effect Must allow for hemodynamic equilibration whenmoving patient
bull Inc risk DVTbull Decreased maximal oxygen uptakebull Dec total blood volume bull 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) 33-37Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3(2) 69-80
Physiological System Changes from Immobilitycontrsquod
Pulmonary Complicationsbull Dec vital capacitybull Dec residual volumebull Less functional reservebull Inc secretions bull Inability to clear secretions (inc aspiration risk)bull Increases risk for aspiration pneumonia pulmonary embolism and
development of ARDSbull Increases risk for atelectasis even in the absence of preexisting
respiratory diseasebull Mucous film lining of smaller airways tends to pool
Sciaky A (1994)
Physiological System Changes from Immobility contrsquodMusculoskeletalbull 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
bull 1 week of bed rest = 20 decrease in muscle strengthbull Loss of muscle strength is ongoing and progressive
-Additional 20 muscle strength loss for each week of bed restbull Use of weakened muscles generates an increased oxygen demand at the cellular level Critically ill patients cannot meet thisdemand
bull Loss of Bone Mass Density bull gt 50 acceleration after 10 days bed-restbull Calcium clearance 4-6 x normal after 3 weeks of total immobilization
bull Contracturesbull Can begin forming after 8 hours of bed rest
bull Pressure Ulcersbull Develops within hours of immobilization if progressive turning schedule is not
implementedSciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3
(2) 69-80Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-223
Physiological System Changes from Immobility contrsquod
GastrointestinalGenitourinary Systemsbull Constipation
ndash Decreased peristalsisndash Risk of Ileus
bull Urinary stasisndash Inc risk for UTIndash Calculus formationndash Increased calcium in urine is detected within a few
days after bed restbull Fluid retention
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Metabolicbull Inc excretion of calcium nitrogen
phosphorusndash Renal Calculi
bull Inc risk of osteoporosisndash Increased risk of bone fracture
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Central Nervous System (CNS)bull Emotional amp behavioral changesbull Anxiety emotionally labilebull Decreased attention spanbull Depressionbull Altered Sleep Pattern (sleep deprivation)bull Perceptual coordination deficitsbull Diminished intellectual performancebull Learned helplessness syndrome
Sciaky A (1994)
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
History of Bed Rest
bull Before 1940 normal duration of bed restndash 2 weeks strict bed rest for childbirthndash 3 weeks bed rest for hernia repair surgeryndash gt 4 weeks for MI
bull Post WWIIndash Shortage of hospital beds and personnel shortened length of bed
restndash Early mobilization improved outcomes and reduced
complicationsndash Outcomes from VA Rehab programs found that bed rest was
more disabling than the original injurybull 1980rsquos
ndash Early discharges result from DRG payment systembull No evidence of harm
Corcoran P (1991)
Bed Rest
ldquoLook at a patient lying in bedWhat a pathetic picture he makes
The blood clotting in his veinsthe lime draining from his bones
the scybala stacking up in his colonthe flesh rotting from his sweat
the urine leaking from his distended bladderand the spirit evaporating from his soulrdquo
Richard Asher MD 1947
Corcoran P (1991)
Immobilitybull Every organ and body system
progressively deteriorates when inactivated
bull 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)
Cardiacbull Tachycardiabull Hypotension
ndash Orthostatic hypotension occurs after 15-24 days of immobilityndash Avg loss of 600ml plasma volume when on bed rest-contributes to
hypotension ndash After 12 hrs of bed-rest an upward fluid shift stimulates the baro-
receptors in the aortic arch and carotid artery to have an opposite depressor effect Must allow for hemodynamic equilibration whenmoving patient
bull Inc risk DVTbull Decreased maximal oxygen uptakebull Dec total blood volume bull 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) 33-37Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3(2) 69-80
Physiological System Changes from Immobilitycontrsquod
Pulmonary Complicationsbull Dec vital capacitybull Dec residual volumebull Less functional reservebull Inc secretions bull Inability to clear secretions (inc aspiration risk)bull Increases risk for aspiration pneumonia pulmonary embolism and
development of ARDSbull Increases risk for atelectasis even in the absence of preexisting
respiratory diseasebull Mucous film lining of smaller airways tends to pool
Sciaky A (1994)
Physiological System Changes from Immobility contrsquodMusculoskeletalbull 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
bull 1 week of bed rest = 20 decrease in muscle strengthbull Loss of muscle strength is ongoing and progressive
-Additional 20 muscle strength loss for each week of bed restbull Use of weakened muscles generates an increased oxygen demand at the cellular level Critically ill patients cannot meet thisdemand
bull Loss of Bone Mass Density bull gt 50 acceleration after 10 days bed-restbull Calcium clearance 4-6 x normal after 3 weeks of total immobilization
bull Contracturesbull Can begin forming after 8 hours of bed rest
bull Pressure Ulcersbull Develops within hours of immobilization if progressive turning schedule is not
implementedSciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3
(2) 69-80Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-223
Physiological System Changes from Immobility contrsquod
GastrointestinalGenitourinary Systemsbull Constipation
ndash Decreased peristalsisndash Risk of Ileus
bull Urinary stasisndash Inc risk for UTIndash Calculus formationndash Increased calcium in urine is detected within a few
days after bed restbull Fluid retention
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Metabolicbull Inc excretion of calcium nitrogen
phosphorusndash Renal Calculi
bull Inc risk of osteoporosisndash Increased risk of bone fracture
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Central Nervous System (CNS)bull Emotional amp behavioral changesbull Anxiety emotionally labilebull Decreased attention spanbull Depressionbull Altered Sleep Pattern (sleep deprivation)bull Perceptual coordination deficitsbull Diminished intellectual performancebull Learned helplessness syndrome
Sciaky A (1994)
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Bed Rest
ldquoLook at a patient lying in bedWhat a pathetic picture he makes
The blood clotting in his veinsthe lime draining from his bones
the scybala stacking up in his colonthe flesh rotting from his sweat
the urine leaking from his distended bladderand the spirit evaporating from his soulrdquo
Richard Asher MD 1947
Corcoran P (1991)
Immobilitybull Every organ and body system
progressively deteriorates when inactivated
bull 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)
Cardiacbull Tachycardiabull Hypotension
ndash Orthostatic hypotension occurs after 15-24 days of immobilityndash Avg loss of 600ml plasma volume when on bed rest-contributes to
hypotension ndash After 12 hrs of bed-rest an upward fluid shift stimulates the baro-
receptors in the aortic arch and carotid artery to have an opposite depressor effect Must allow for hemodynamic equilibration whenmoving patient
bull Inc risk DVTbull Decreased maximal oxygen uptakebull Dec total blood volume bull 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) 33-37Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3(2) 69-80
Physiological System Changes from Immobilitycontrsquod
Pulmonary Complicationsbull Dec vital capacitybull Dec residual volumebull Less functional reservebull Inc secretions bull Inability to clear secretions (inc aspiration risk)bull Increases risk for aspiration pneumonia pulmonary embolism and
development of ARDSbull Increases risk for atelectasis even in the absence of preexisting
respiratory diseasebull Mucous film lining of smaller airways tends to pool
Sciaky A (1994)
Physiological System Changes from Immobility contrsquodMusculoskeletalbull 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
bull 1 week of bed rest = 20 decrease in muscle strengthbull Loss of muscle strength is ongoing and progressive
-Additional 20 muscle strength loss for each week of bed restbull Use of weakened muscles generates an increased oxygen demand at the cellular level Critically ill patients cannot meet thisdemand
bull Loss of Bone Mass Density bull gt 50 acceleration after 10 days bed-restbull Calcium clearance 4-6 x normal after 3 weeks of total immobilization
bull Contracturesbull Can begin forming after 8 hours of bed rest
bull Pressure Ulcersbull Develops within hours of immobilization if progressive turning schedule is not
implementedSciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3
(2) 69-80Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-223
Physiological System Changes from Immobility contrsquod
GastrointestinalGenitourinary Systemsbull Constipation
ndash Decreased peristalsisndash Risk of Ileus
bull Urinary stasisndash Inc risk for UTIndash Calculus formationndash Increased calcium in urine is detected within a few
days after bed restbull Fluid retention
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Metabolicbull Inc excretion of calcium nitrogen
phosphorusndash Renal Calculi
bull Inc risk of osteoporosisndash Increased risk of bone fracture
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Central Nervous System (CNS)bull Emotional amp behavioral changesbull Anxiety emotionally labilebull Decreased attention spanbull Depressionbull Altered Sleep Pattern (sleep deprivation)bull Perceptual coordination deficitsbull Diminished intellectual performancebull Learned helplessness syndrome
Sciaky A (1994)
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Immobilitybull Every organ and body system
progressively deteriorates when inactivated
bull 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)
Cardiacbull Tachycardiabull Hypotension
ndash Orthostatic hypotension occurs after 15-24 days of immobilityndash Avg loss of 600ml plasma volume when on bed rest-contributes to
hypotension ndash After 12 hrs of bed-rest an upward fluid shift stimulates the baro-
receptors in the aortic arch and carotid artery to have an opposite depressor effect Must allow for hemodynamic equilibration whenmoving patient
bull Inc risk DVTbull Decreased maximal oxygen uptakebull Dec total blood volume bull 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) 33-37Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3(2) 69-80
Physiological System Changes from Immobilitycontrsquod
Pulmonary Complicationsbull Dec vital capacitybull Dec residual volumebull Less functional reservebull Inc secretions bull Inability to clear secretions (inc aspiration risk)bull Increases risk for aspiration pneumonia pulmonary embolism and
development of ARDSbull Increases risk for atelectasis even in the absence of preexisting
respiratory diseasebull Mucous film lining of smaller airways tends to pool
Sciaky A (1994)
Physiological System Changes from Immobility contrsquodMusculoskeletalbull 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
bull 1 week of bed rest = 20 decrease in muscle strengthbull Loss of muscle strength is ongoing and progressive
-Additional 20 muscle strength loss for each week of bed restbull Use of weakened muscles generates an increased oxygen demand at the cellular level Critically ill patients cannot meet thisdemand
bull Loss of Bone Mass Density bull gt 50 acceleration after 10 days bed-restbull Calcium clearance 4-6 x normal after 3 weeks of total immobilization
bull Contracturesbull Can begin forming after 8 hours of bed rest
bull Pressure Ulcersbull Develops within hours of immobilization if progressive turning schedule is not
implementedSciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3
(2) 69-80Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-223
Physiological System Changes from Immobility contrsquod
GastrointestinalGenitourinary Systemsbull Constipation
ndash Decreased peristalsisndash Risk of Ileus
bull Urinary stasisndash Inc risk for UTIndash Calculus formationndash Increased calcium in urine is detected within a few
days after bed restbull Fluid retention
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Metabolicbull Inc excretion of calcium nitrogen
phosphorusndash Renal Calculi
bull Inc risk of osteoporosisndash Increased risk of bone fracture
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Central Nervous System (CNS)bull Emotional amp behavioral changesbull Anxiety emotionally labilebull Decreased attention spanbull Depressionbull Altered Sleep Pattern (sleep deprivation)bull Perceptual coordination deficitsbull Diminished intellectual performancebull Learned helplessness syndrome
Sciaky A (1994)
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Creditor M (1993)
Cardiacbull Tachycardiabull Hypotension
ndash Orthostatic hypotension occurs after 15-24 days of immobilityndash Avg loss of 600ml plasma volume when on bed rest-contributes to
hypotension ndash After 12 hrs of bed-rest an upward fluid shift stimulates the baro-
receptors in the aortic arch and carotid artery to have an opposite depressor effect Must allow for hemodynamic equilibration whenmoving patient
bull Inc risk DVTbull Decreased maximal oxygen uptakebull Dec total blood volume bull 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) 33-37Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3(2) 69-80
Physiological System Changes from Immobilitycontrsquod
Pulmonary Complicationsbull Dec vital capacitybull Dec residual volumebull Less functional reservebull Inc secretions bull Inability to clear secretions (inc aspiration risk)bull Increases risk for aspiration pneumonia pulmonary embolism and
development of ARDSbull Increases risk for atelectasis even in the absence of preexisting
respiratory diseasebull Mucous film lining of smaller airways tends to pool
Sciaky A (1994)
Physiological System Changes from Immobility contrsquodMusculoskeletalbull 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
bull 1 week of bed rest = 20 decrease in muscle strengthbull Loss of muscle strength is ongoing and progressive
-Additional 20 muscle strength loss for each week of bed restbull Use of weakened muscles generates an increased oxygen demand at the cellular level Critically ill patients cannot meet thisdemand
bull Loss of Bone Mass Density bull gt 50 acceleration after 10 days bed-restbull Calcium clearance 4-6 x normal after 3 weeks of total immobilization
bull Contracturesbull Can begin forming after 8 hours of bed rest
bull Pressure Ulcersbull Develops within hours of immobilization if progressive turning schedule is not
implementedSciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3
(2) 69-80Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-223
Physiological System Changes from Immobility contrsquod
GastrointestinalGenitourinary Systemsbull Constipation
ndash Decreased peristalsisndash Risk of Ileus
bull Urinary stasisndash Inc risk for UTIndash Calculus formationndash Increased calcium in urine is detected within a few
days after bed restbull Fluid retention
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Metabolicbull Inc excretion of calcium nitrogen
phosphorusndash Renal Calculi
bull Inc risk of osteoporosisndash Increased risk of bone fracture
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Central Nervous System (CNS)bull Emotional amp behavioral changesbull Anxiety emotionally labilebull Decreased attention spanbull Depressionbull Altered Sleep Pattern (sleep deprivation)bull Perceptual coordination deficitsbull Diminished intellectual performancebull Learned helplessness syndrome
Sciaky A (1994)
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Cardiacbull Tachycardiabull Hypotension
ndash Orthostatic hypotension occurs after 15-24 days of immobilityndash Avg loss of 600ml plasma volume when on bed rest-contributes to
hypotension ndash After 12 hrs of bed-rest an upward fluid shift stimulates the baro-
receptors in the aortic arch and carotid artery to have an opposite depressor effect Must allow for hemodynamic equilibration whenmoving patient
bull Inc risk DVTbull Decreased maximal oxygen uptakebull Dec total blood volume bull 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) 33-37Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3(2) 69-80
Physiological System Changes from Immobilitycontrsquod
Pulmonary Complicationsbull Dec vital capacitybull Dec residual volumebull Less functional reservebull Inc secretions bull Inability to clear secretions (inc aspiration risk)bull Increases risk for aspiration pneumonia pulmonary embolism and
development of ARDSbull Increases risk for atelectasis even in the absence of preexisting
respiratory diseasebull Mucous film lining of smaller airways tends to pool
Sciaky A (1994)
Physiological System Changes from Immobility contrsquodMusculoskeletalbull 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
bull 1 week of bed rest = 20 decrease in muscle strengthbull Loss of muscle strength is ongoing and progressive
-Additional 20 muscle strength loss for each week of bed restbull Use of weakened muscles generates an increased oxygen demand at the cellular level Critically ill patients cannot meet thisdemand
bull Loss of Bone Mass Density bull gt 50 acceleration after 10 days bed-restbull Calcium clearance 4-6 x normal after 3 weeks of total immobilization
bull Contracturesbull Can begin forming after 8 hours of bed rest
bull Pressure Ulcersbull Develops within hours of immobilization if progressive turning schedule is not
implementedSciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3
(2) 69-80Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-223
Physiological System Changes from Immobility contrsquod
GastrointestinalGenitourinary Systemsbull Constipation
ndash Decreased peristalsisndash Risk of Ileus
bull Urinary stasisndash Inc risk for UTIndash Calculus formationndash Increased calcium in urine is detected within a few
days after bed restbull Fluid retention
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Metabolicbull Inc excretion of calcium nitrogen
phosphorusndash Renal Calculi
bull Inc risk of osteoporosisndash Increased risk of bone fracture
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Central Nervous System (CNS)bull Emotional amp behavioral changesbull Anxiety emotionally labilebull Decreased attention spanbull Depressionbull Altered Sleep Pattern (sleep deprivation)bull Perceptual coordination deficitsbull Diminished intellectual performancebull Learned helplessness syndrome
Sciaky A (1994)
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Physiological System Changes from Immobilitycontrsquod
Pulmonary Complicationsbull Dec vital capacitybull Dec residual volumebull Less functional reservebull Inc secretions bull Inability to clear secretions (inc aspiration risk)bull Increases risk for aspiration pneumonia pulmonary embolism and
development of ARDSbull Increases risk for atelectasis even in the absence of preexisting
respiratory diseasebull Mucous film lining of smaller airways tends to pool
Sciaky A (1994)
Physiological System Changes from Immobility contrsquodMusculoskeletalbull 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
bull 1 week of bed rest = 20 decrease in muscle strengthbull Loss of muscle strength is ongoing and progressive
-Additional 20 muscle strength loss for each week of bed restbull Use of weakened muscles generates an increased oxygen demand at the cellular level Critically ill patients cannot meet thisdemand
bull Loss of Bone Mass Density bull gt 50 acceleration after 10 days bed-restbull Calcium clearance 4-6 x normal after 3 weeks of total immobilization
bull Contracturesbull Can begin forming after 8 hours of bed rest
bull Pressure Ulcersbull Develops within hours of immobilization if progressive turning schedule is not
implementedSciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3
(2) 69-80Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-223
Physiological System Changes from Immobility contrsquod
GastrointestinalGenitourinary Systemsbull Constipation
ndash Decreased peristalsisndash Risk of Ileus
bull Urinary stasisndash Inc risk for UTIndash Calculus formationndash Increased calcium in urine is detected within a few
days after bed restbull Fluid retention
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Metabolicbull Inc excretion of calcium nitrogen
phosphorusndash Renal Calculi
bull Inc risk of osteoporosisndash Increased risk of bone fracture
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Central Nervous System (CNS)bull Emotional amp behavioral changesbull Anxiety emotionally labilebull Decreased attention spanbull Depressionbull Altered Sleep Pattern (sleep deprivation)bull Perceptual coordination deficitsbull Diminished intellectual performancebull Learned helplessness syndrome
Sciaky A (1994)
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Physiological System Changes from Immobility contrsquodMusculoskeletalbull 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
bull 1 week of bed rest = 20 decrease in muscle strengthbull Loss of muscle strength is ongoing and progressive
-Additional 20 muscle strength loss for each week of bed restbull Use of weakened muscles generates an increased oxygen demand at the cellular level Critically ill patients cannot meet thisdemand
bull Loss of Bone Mass Density bull gt 50 acceleration after 10 days bed-restbull Calcium clearance 4-6 x normal after 3 weeks of total immobilization
bull Contracturesbull Can begin forming after 8 hours of bed rest
bull Pressure Ulcersbull Develops within hours of immobilization if progressive turning schedule is not
implementedSciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical Therapy Practice 3
(2) 69-80Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-223
Physiological System Changes from Immobility contrsquod
GastrointestinalGenitourinary Systemsbull Constipation
ndash Decreased peristalsisndash Risk of Ileus
bull Urinary stasisndash Inc risk for UTIndash Calculus formationndash Increased calcium in urine is detected within a few
days after bed restbull Fluid retention
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Metabolicbull Inc excretion of calcium nitrogen
phosphorusndash Renal Calculi
bull Inc risk of osteoporosisndash Increased risk of bone fracture
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Central Nervous System (CNS)bull Emotional amp behavioral changesbull Anxiety emotionally labilebull Decreased attention spanbull Depressionbull Altered Sleep Pattern (sleep deprivation)bull Perceptual coordination deficitsbull Diminished intellectual performancebull Learned helplessness syndrome
Sciaky A (1994)
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Physiological System Changes from Immobility contrsquod
GastrointestinalGenitourinary Systemsbull Constipation
ndash Decreased peristalsisndash Risk of Ileus
bull Urinary stasisndash Inc risk for UTIndash Calculus formationndash Increased calcium in urine is detected within a few
days after bed restbull Fluid retention
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Metabolicbull Inc excretion of calcium nitrogen
phosphorusndash Renal Calculi
bull Inc risk of osteoporosisndash Increased risk of bone fracture
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Central Nervous System (CNS)bull Emotional amp behavioral changesbull Anxiety emotionally labilebull Decreased attention spanbull Depressionbull Altered Sleep Pattern (sleep deprivation)bull Perceptual coordination deficitsbull Diminished intellectual performancebull Learned helplessness syndrome
Sciaky A (1994)
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Physiological System Changes from Immobility contrsquod
Metabolicbull Inc excretion of calcium nitrogen
phosphorusndash Renal Calculi
bull Inc risk of osteoporosisndash Increased risk of bone fracture
Sciaky A (1994)
Physiological System Changes from Immobility contrsquod
Central Nervous System (CNS)bull Emotional amp behavioral changesbull Anxiety emotionally labilebull Decreased attention spanbull Depressionbull Altered Sleep Pattern (sleep deprivation)bull Perceptual coordination deficitsbull Diminished intellectual performancebull Learned helplessness syndrome
Sciaky A (1994)
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Physiological System Changes from Immobility contrsquod
Central Nervous System (CNS)bull Emotional amp behavioral changesbull Anxiety emotionally labilebull Decreased attention spanbull Depressionbull Altered Sleep Pattern (sleep deprivation)bull Perceptual coordination deficitsbull Diminished intellectual performancebull Learned helplessness syndrome
Sciaky A (1994)
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Burden of Complications
Impact ofDecreased Mobility
Ventilator-associated Pneumoniabull Increases need for vent supportbull Increases ICU LOS by 43 daysbull Increases Hospital LOS by 9 daysbull I case VAP costs $27900 to treatbull National Cost of VAP gt $12 Billionbull Mortality from VAP 50-70
Heyland et al Am J Respir Crit Care Med 19991591249Craven D Chest 2000 117186-187SRello et al Chest 2002 122 2115
Pressure Ulcersbull Pain and Sufferingbull Venous thrombusbull Sepsisbull Pneumoniabull Potential for Health Care Expenditures
bull Mean cost of 1 pressure ulcer = $1877bull Increases LOS 4-7 daysbull Cost of healing 1 pressure ulcer = $5000-$40000
Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved January 26 2004 from wwwguidelinegovsummary
In
Quality Improvement
Health Care Resource Utilization
ProductUtilization
Cost
Care Delivery
Information Services
Customer Satisfaction
Staff Satisfaction
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Current Patient Mobility Practices found in Literature
bull Q 2 hour turningbull AROMPROMbull OOBbull Cardiac Chairbull Progressive PivotStandbull Ambulate
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen Is it enough
CCorcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years Western Journal of Medicine
154 536-538
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Literature FindingsQ 2 Hr T
urns
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 unitsSetting 3 separate ICUrsquos 74 patients with a total of 566 patient hour observationsFindings bull 493 of observation time ndash No body position changes were notedbull 27 of Patients observed had Q 2 Hr body position changesbull 80-90 of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complicationsbull 57 of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICUrsquos
Krishnagdopalan S Johnson W Low L amp Kaufman L (2002 Body positioning of intensive care patients clinical practiceversus standards Critical Care Medicine 30 (11) 2588-2592
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Literature Findings contrsquodBailey et al (2007)
bull Study 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients bull Goal Ambulate patients 100 ft before discharge from RICU
ndash Pt movement to upright position in bed cardiac chair and passive ROM were not considered activity
bull Definitionsndash Activity period From time of hemodynamic stability throughout ICU stay
ndash Adverse Events Fall to knees tube removal SBP lt 90mmHg gt200 mmHg Desat lt 80 and extubation
bull Criteria Ptrsquos on MV gt4 days Fio2 lt 60 Peep lt 10 cm H20 no orthostatic BP no vasopressor qtts
bull Interventions ndash Progressive increase in activity level from sit in chair to ambulate BIDndash Pre amp Post 30min rest period with AC ventilation prn to support activityndash Increase FI02 by 20 prior to activity amp administer 02 during activity to prevent desaturationndash VS measurement pre amp post activityndash Activity assisted with RN RT PT or CC Tech
Mobility
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Literature FindingsBailey et al (2007)
bull Resultsndash 103 patients participatedndash 89 patients on MVndash 42 of ptrsquos with ETT tubes
ambulatedndash 69 of patients ambulated
gt 100ftndash Median distance ambulated
bull 400 ftfor ptrsquos dc home after admission
bull 270 ft for ptrsquos dc to SNF after admission
bull 230 ft for pts dc to rehab after admission
ndash Nurse to patient ratio 12ndash No increase in nursing hours required
bull Adverse Eventsndash 9 patients had 14 adverse events
(141449 activity events =0009)ndash 5 Falls to knees without injuryndash 4 SBPlt 90 mmHgndash 3 O2 desats lt 80ndash 1 small bowel feeding tube removalndash 1 SBP gt 200 mmHg
bull No extubations complications extended LOS additional costs or therapy required
bull Clinical SignificanceEarly 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 ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Mobility ExpectationsRange of Activity
(Intensive Care Mobility Guidelines)
bull Position Change Q 2 hrsbull AROMPROM upper amp lower extremities Q 8 hrs
ndash Incorporated into routine daily carebull HOB elevation 30o while in bed
ndash Progressive activity as tolerated following mobility algorithmbull Cardiac Chairbull Dangle legs
ndash While sitting on side of the bedbull Stand
ndash Any amount of time patient can stand will be beneficial for expanding lung capacity enhance weight bearing and restores normal fluid balance
bull Pivot -gt Out of Bed to Chairndash Patient should not be OOB to chair for gt 1- 2 hours at a time
bull Levels of ADL ndash Encourage participation in hygiene and feeding as appropriate
bull Progress to steps-gtambulation
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Mobility Expectations
Documentation
bull Appropriate documentation adhering to unit standards bull Do not use
ndash Checkmarksndash Q 2 o Turnndash Side to Sidendash Lines drawn through boxes
bull Use specific position change Q2 ndash Right (R) Left (L) Supine Prone
bull Time Specificndash Number of steps taken or distance if pt is ambulatoryndash Amount of time if OOB to chair
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Mobility Expectations
bull Utilize OTPT 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 amp Brintnell (1986)
bull Occupational Therapyndash Ask physician to order consult on admissionndash OT will follow up weekly to evaluate patient for OT intervention
bull Physical Therapyndash Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials (SBT)
Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st centuryCanadian Journal of Occupational Therapy 53 38-44
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Mobility Expectations
Mobility AssistDevicesbull Over Head Liftsbull Hover Mattressbull Wedges (foam)bull Slider Boardsbull Mobility Cart
Mobility Assistancebull Lift Teambull Patient Care Techsbull Peers
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Intensive Care Progressive Mobility GuidelinesGoal of Early MobilizationPromote mechanical ventilator weaning processReduce ICU and Hospital LOSPrevent physical deconditioningPrevent Ventilator-Associated Pneumonia (VAP)Prevent Pressure UlcersMaintainachieve preadmission activity levelEnhance Patient physical and psychological well being
Advance mobility using progressive Algorithm Level as Pt tolerates Reassess q 12 hoursExclusion criteria for advancing mobility levelbullLobar collapse or atelectasis excessive secretions andorbullFio2 gt 50 with Peep gt 10bullSaO2 lt 90 at rest or lt 88 with activitybullDecreased MS or severe neurological insultbullSevere orthopaedic problemsbullHemodynamic instability SaO2 BP HR
Level I Modified Mobility ProcessCriteria Admission to Intensive Care Unit or Progressive Care UnitbullReposition and Turn Q 2 HrsbullAROMPROMbullSplints and or boots (alternate) for contracture preventionbullHOB 30 degrees
Level II (Include Level I Interventions)bullHOB 450 to 650 if hemodynamically stablebullPlace legs in dependent positionbullAdvance to Cardiac ChairbullOOB to Chair with assistive device ( 2X Daily for 1 hr)bullTime frame for OOB in Chair positioning is lt1 hr
Level III (Include Level I amp II Interventions)bullSit on Side of BedbullAdvance to Standing PositionbullInitiate Pivot Stand to bedside chair least 2 X Daily
Level IV (Include Level I II amp III Interventions)bullIndependent OOB Sit in Chair Stand Ambulate
Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill patients 2005Advancing Nursing Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdf
Hemodynamic Tolerance5-10 minutes equilibration time is required with each position change to determine hemodynamic instability
Document all Mobility on Flow Sheet
Monitor for Physical Therapy Occupational Therapy ConsultOT consult on admission then weekly follow-up evaluationPT consult when patient is able to cooperate with activity of begins SBT (Spontaneous Breathing Trials)
If Pt has large abdomen try a lesser HOB angle when in sitting position
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
ldquoTeach us to live that we may dread unnecessary time in bed
Get people up and we may saveOur patients from an early graverdquo
Richard Asher MD 1947
Corcoran P (1991)
REPOSITIONICU PATIENTS
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Mobility Level AchievedMobility Bundle Algorithm
n=137 mobility events1st Measure 22207-33107 2nd Measure 4507-52207
802
8743
14 0 051
679
44
131
66 5815 07
0
10
20
30
40
50
60
70
80
90
BR Level 1 CC=Level 2 OOB to CHAIR(Slide)=Level 3
OOB to CHAIR(StandPivot)= Level 4
AMBULATE=Level 5 DANGLE=Level 6 NOT SPECIFIED=Level 7
Perc
ent
n
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Mobility Bundle Alogrithm ComplianceMobility Component Achieved
824
688
109
19
43
124
0
10
20
30
40
50
60
70
80
90
22207-33107 4507-52207
Perc
ent C
ompl
ianc
e
LEVEL 1 LEVEL 2 LEVEL 3Level 1= Modif ied Mobility Process (BR Turning AROMPROM)Level 2= Progressive Mobility Process( CC OOB Dangle)Level 3 = Active Mobility Process (Ambulate)
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
MICU Number of Patients Eligible for Mobility Number of Patients Mobilized and Compliance Rate
0
10
20
30
40
50
60
70
80
Jan-0 6Feb-06Mar-0
6Apr-0
6
May-06Jun-0 6
Jul-06Aug -06Sep -06
Oct-06
Nov-06Dec-06
Jan-0 7Feb-07Mar-0
7Apr-0
7
Dates
Num
ber o
f Pat
ient
s
0
10
20
30
40
50
60
70
80
Con
mpl
ianc
e R
ate
Pts Eligible for Mobility Pts Mobilized Mobility Compliance
Pts Eligible for Mobility 31 19 16 8 14 37 33 71 50 24 53 55 58 53 39 30
Pts Mobilized 0 1 5 6 5 2 4 12 14 4 4 14 9 4 7 2
Mobility Compliance 0 53 31 75 31 54 12 17 28 17 8 25 16 8 18 67
Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-
Referencesbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Agency for Healthcare Policy and Research Prevention of pressure ulcers (2003) Retrieved
January 26 2004 from wwwguidelinegovsummarybull Ahrens T Burns S Phillips J Vollman K amp Whitman J (2005) Progressive mobility guidelines for critically ill
patients 2005 Retrieved September 24 2006 from httpwwwtotalcaretvimagesstories138930_PMGpdfbull Advancing Nursing Retrieved September 24 2006 from
httpwwwtotalcaretvimagesstories138930_PMGpdfbull Bortz W (1982) Disuse and aging JAMA 248 1203-1208bull Corcoran P (1991) Use it or lose it ndashthe hazards of bed rest and inactivity- adding life to years
Western Journal of Medicine 154 536-538bull Craven D (2000) Epidemiology of ventilator-associated pneumonia Chest 117186-187Sbull Creditor M (1993) Hazards of hospitalization of the elderly Annual of Internal Medicine 118 (3) 219-
223bull HawkinsS Stone K amp Plummer I (1999) An holistic approach to turning patients Nursing
Standard 14(3) 52-56bull Heyland D Cook D Griffith L Keenan S amp Brun-Buisson C (1999) The attributable morbidity and
mortality of ventilator-associated pneumonia in the critically ill patients Am J Respir Crit Care Med1591249
bull Krishnagdopalan S Johnson W Low L amp Kaufman L (2002) Body positioning of intensive care patients clinical practice versus standards Critical Care Medicine 30 (11) 2588-2592
bull Madill H Cardwell T Robinson I amp Brintnell S (1986) Old themes new directions-occupational therapy in the 21st century
bull Canadian Journal of Occupational Therapy 53 38-44bull Rello J Ollendorf D Oster G Montserrat V BellmL Redman R amp Kollef M (2002) Chest 122
2115bull Sciaky A (1994) Mobilizing the intensive care unit patient pathophysiology and treatment Physical
Therapy Practice 3 (2) 69-80
- Patient Mobility in the ICU
- Normal Mobility
- History of Bed Rest
- Bed Rest
- Immobility
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Physiological System Changes from Immobility contrsquod
- Current Patient Mobility Practices found in Literature
- Literature Findings contrsquod Bailey et al (2007)
- Literature FindingsBailey et al (2007)
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- Mobility Expectations
- References
-