Across the country, nurses have returned to basic principles of getting patients up and moving while embracing new evidence that such activity improves outcomes for critically ill, ventilated patients in the ICU. Gone are the days when bed rest for extended periods of time was considered the best plan for all critically ill patients. The effectiveness of early mobility plans, however, hinges on team implementation.
Nurses may feel patients on a ventilator have to be sedated, but we found thats not the case, said Patricia Rychcik, RN, MSN, patient care director for medical intensive care at NewYork-Presbyterian Hospital/Columbia University Medical Center in New York City. Patients can do very well with early mobilization in the ICU.
NewYork-Presbyterian began planning its early mobilization program last year, kicked it off with medical ICU patients in January and now is rolling it out to all five ICUs at the Milstein Hospital Building in Manhattan. Its the best thing to do for our patients, Rychcik said. ICU-acquired weaknesses can occur early in an ICU stay and have impacts that exist beyond discharge.
Nurses are sitting critically ill patients up, walking them in the hall and witnessing remarkable progress. Its all part of implementing the E portion of the awakening and breathing coordination, delirium monitoring, and exercise/early mobility (ABCDE) bundle, described in 2010 by clinicians at VA Tennessee Valley Healthcare System and Vanderbilt University Medical Center, both in Nashville, Tenn. The ABCDE bundle now is being implemented in many facilities.
Early mobility is fascinating, said Michele C. Balas, RN, PhD, APRN-NP, CCRN, assistant professor at the University of Nebraska Medical Center, College of Nursing in Omaha. Theres not much good that happens on bed rest.
Balas said within hours, muscles start to atrophy, patients are at greater risk for pneumonia and deep vein thrombosis and blood vessels lose tone. Its imperative that the early mobility piece be started on day one of admission, she said, adding that the goal is to keep patients from deteriorating to a point that jeopardizes mobility.
Early mobility also allows patients to be more actively involved in their care.
Not a walk in the park
Executing an early mobility program presents its own set of challenges. Its not going to be easy, and each institution will operationalize how it happens, Balas said. The whole ABCDE bundle is dependent on nurses.
Balas and colleagues have outlined minimum criteria for early mobility, including that the patient must respond to verbal stimulation and meet certain respiratory and cardiac benchmarks, such as no evidence of active myocardial ischemia and no unstable fractures. Patients are reassessed during daily rounds.
At McKenzie-Willamette Medical Center, Springfield, Ore., nurses and physicians might get the patient moving even if he or she falls outside the traditional criteria after an evaluation of the benefits and risks on a case-by-case basis, said Chandra Alexander, RN, CCRN, ICU charge nurse at the hospital.
McKenzie-Willamette began its multidisciplinary early mobilization program in May 2011. The hospital added a physical therapist to work exclusively in the ICU. It can be done, if its done comprehensively with the key people in place, said Dena Putnam, RN, MBA, manager of McKenzie-Willamettes ICU. Get the buy-in ahead of time, and push through the discomfort of something you have not done before because it does affect patient care.
Getting critically ill patients out of bed requires a group effort among multiple disciplines physicians, nurses, physical and occupational therapists and respiratory therapists and a plan, including how to deal with potential problems, according to Erin Mathews, RN, BSN, CCRN, a Vanderbilt University Medical Center ICU staff nurse. Even dangling will require at least three people, including an RT to monitor the ventilator. It takes a lot of coordination to walk someone on a breathing machine, typically requiring four or five people, said Juliane Jablonski, RN, MSN, CNS, a clinical nurse specialist at the Hospital at the University of Pennsylvania in Philadelphia, which is ambulating ventilated patients.
Lauren Yon, RN, MSN, CCRN, a critical care nurse at Lakeland (Fla.) Regional Medical Center, which is just beginning to implement early mobilization, suggested creating an evidence-based protocol and reaching out to nurses at other institutions that have begun early mobilization programs. She also emphasized the importance of education and using the appropriate assistive devices, such as walkers and gait belts, to protect you and the patient.
Early mobility programs usually begin with the patient sitting in bed with legs dependent, then dangling, sitting up in a chair, marching in place, walking around the room and finally ambulating in the hall.
Patients on a ventilator will need portable equipment when ambulating, or the team may ventilate with an Ambu bag.
Mathews said at first some family members resist, thinking patients must stay sedated when on a ventilator. Patients sometimes become angry with her, but, she said, in the long run, they are grateful.
Boons of early mobility
Early mobility can decrease the amount of time patients spend in the ICU and hospital, Mathews said, and it helps all body systems.
Six months after implementing early mobilization, McKenzie-Willamette reported a 32% reduction in ventilator days, a 10% death rate decline and a decrease in length of stay from 2.5 to 2.3 days, Alexander said.
A randomized, controlled trial reported in May 2009 in the Lancet involving 104 patients by University of Pennsylvania researchers found whole-body rehabilitation with PT and OT resulted in mechanically ventilated, critically ill patients having better functioning at discharge, a shorter duration of delirium and more days off the ventilator during a 28-day follow-up period than patients receiving standard care.
A Vanderbilt paper, Reducing iatrogenic risks: ICU-acquired delirium and weakness crossing the quality chasm, published in the journal Chest in November 2010, reported a reduction in cognitive and physical dysfunction among patients who receive early mobilization. In addition, it reported length of stay can decrease, patients are more likely to return to independent functioning at time of discharge and the incidence of delirium is reduced.
Balas reported that early mobility is the only nonpharmacological intervention that has been shown to decrease delirium. About 80% of ventilated patients and 40% to 50% of other patients develop delirium in the ICU, she said. Delirium is a huge problem for patients, Balas said. Bad things will happen to you. [By] developing delirium you are more likely to die, and a lot of the patients never go back home.
Balas said she suspects the benefits of early mobility derive from less sedation. You cannot heavily sedate someone if you expect them to get up and walk, Jablonski said.
Respiratory status improves because patients who are up can cough up secretions better and lung expansion increases. Mathews recalled a patient on ventilator support who required significant sedation to avoid agitation. The first day she cared for the patient, she reassured the woman, weaned her off the medication and got her up into a chair, where she sat for 30 minutes. By the third day, she was breathing on her own for two hours and up walking in the hall. The next day, the patient was extubated. Getting her up, she was able to ventilate more of the lung fields and cough up secretions, Mathews said.
Patients skin integrity also can improve. Not only are patients up, their muscle strength improves, and they are better able to reposition themselves, Mathews and Balas said. It redistributes weight on the bony prominences, and it allows for aeration of the skin and normal processes in the body to start to work, Mathews said.
Jablonski also reported fewer pressure ulcers in patients subjected to early mobility.
Mathews noted patients experience improved mood, are less depressed and feel less helpless when she gets them up. It makes them feel better, she said. Its a sense of empowerment.
Jablonski urges nurses not to fear getting people up. The results are worth the effort. The old culture was we were protecting our patients by sedating them and keeping them immobile if they had a breathing tube, but we now know what we thought was helping can actually be harming them, Jablonski said. Dont be afraid of change.