ICU Adult
Early Mobilization
Program
Egbert Pravinkumar, MD, FRCP
Associate Professor
Department of Critical Care
UT MD Anderson Cancer Center
Houston, Texas
Presented on behalf of the ICU- EMP Task Force
Objectives
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Overview
Effects of immobility
Benefits of early mobility
Components of MDACC adult ICU-EMP
Outcomes of our pilot program
Future expansion of program
Concept of Early Mobility
• Phys Therap 1972 – Foss et al, Technique
for augmenting ventilation during
ambulation
• CHEST1975 – Burns et al, use of special
walker
Early and Progressive Mobility
• Early Mobility - Mobility program
commenced even when patient participation
is minimal or none
• Progressive Mobility - Series of planned
movement in a sequential manner
Adverse Outcomes of Immobility
Short-term
• Ventilator associated pneumonia
• Delayed weaning
• Muscle de-conditioning/ weakness
• Pressure ulcers
Allen C, Lancet 1999
Morris PE, Crit Care Clin 2007
Adverse Outcomes of Immobility
Long-term
• Increased morbidity/ mortality
• Decreased functional capacity
• Dependency for ADL
• Increased cost of care
• Markedly impaired quality of life
Herridge MS, NEJM 2003
Hopkins RO, Amer J Resp Crit Care Med 2005
Benefits of Early Mobility
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Improved outcome at 1yr post ICU
Reduced delirium (ABCDE approach)
Improved functional outcomes
Decreased IMV days
Decreased hospital days
Decreased cost of care
Morris PE, Am J Med Sci, 2011 Morandi A, Curr Opin Crit Care 2011
Schweickert WD, Lancet 2009
Established Standards vs. Practice
• Only 3% of ICU patients were turned as
per required standards
• Only 50% had some change in body
position
• The average time between manual turns
were 4.85±3.3 hr
Krishnagopalan S, Crit Care Med 2002 Goldhill DR, Anaesthesia 2008
Barriers for Early Mobility
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Need for a culture change
Perceived harm of mobilization
Subjective variations in decisions
Disagreement between care givers
Lack of structured algorithm
Excessive sedation
Lack of knowledge of the benefits
Lack of tools and trained staff
Early Mobilization Program in
Oncological ICU
• Purpose: To develop, implement and evaluate
an early mobilization program for adult ICU
patients in a mixed medical and surgical
oncology ICU.
• Aim: To increase the average number of
mobilization activities per patient day by 40%
within an 8 week pilot period
MDACC-Adult ICU EMP
• Interdisciplinary team
• Design of evidence based EMP algorithm
• Pre-implementation
– Data collection
– Survey on knowledge and perceptions related to
mobilization
– Education
• 8 week trial period from October 2010 through
December 2010
- Medical & surgical patients (16/54 ICU beds)
Our Interdisciplinary Team
MDACC-Adult ICU EMP
• Interdisciplinary team
• Design of an evidence based EMP algorithm
• Pre-implementation
– Data collection
– Survey on knowledge and perceptions related to
mobilization
– Education
• 8 week trial period from October 2010 through
December 2010
- Medical & surgical patients (16/54 ICU beds)
EMP Algorithm
Highlights
• Contraindications
• Precautions
• Signs of intolerance
• PT/OT consult within
24 hours of admission
• 5 Levels based on
RASS and functional
status
EMP: Contraindications
 ICP ≥ 15
 RASS +4
 Acute or Uncontrolled Intracranial Event
 Fio2 ≥ 0.85 on invasive mechanical ventilation
 PEEP ≥ 15 / VDR or HFOV
 Unsecured airway
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Active cardiac ischemia
Uncontrolled arrhythmias
Blood pressure instability despite vasopressors
Unstable fracture
EMP: Precautions
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Continuous dialysis
VTE
Lumbar drain
External ventricular drain
Plastic surgery
Orthopedic surgery
RASS +3
If precautions are present – discuss with team
prior to initiating mobilization activity
EMP: Signs of Intolerance
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RR > 40
Sp02 < 88%
MAP < 50 or > 130
HR < 50 or > 130
Development of any contraindications
Initial 5-Level EMP
5-Level Progressive EMP
MDACC-Adult ICU EMP
• Interdisciplinary team
• Design of evidence based EMP algorithm
• Pre-implementation
– Data collection
– Survey on knowledge and perceptions related
to mobilization
– Education
• 8 week trial period from October 2010 through
December 2010
- Medical & surgical patients (16/54 ICU beds)
Data Collection Tool
Survey: Pre-Implementation of EMP
• Need for a standardized process
• Need for facilitator and mobility team
• Variations in MD practices
• Concern over tube and line integrity
• Head/Neck & Plastic surgery patients
• Lack of personnel/equipment
• Lack of knowledge and skill
MDACC-Adult ICU EMP
• Interdisciplinary team
• Design of evidence based EMP algorithm
• Pre-implementation
– Data collection
– Survey on knowledge and perceptions related to
mobilization
– Education
• 8 week trial period from October 2010
through December 2010
- Medical & surgical patients (16/54 ICU beds)
Data for Pilot Program
• Total mobilization activities
• Average mobilization activities/pt. day
• OT/PT activity
Total and Average ICU Mobilization
Activities
Average Mobilization Activities per Patient Day
Total Mobilization Activities
18
650
16
550
14
450
12
350
Pre-Protocol 10
Pre-Protocol
2-week
2-week
4-week
250
4-week
8
8-week
8-week
6
150
4
2
50
Nursing
-50
PT
OT
0
Nursing
PT
OT
Activities included: ROM, positioning, bed in chair position, splinting,
dangle at the edge of bed, out of bed, ADL, and ambulation.
Data Summary: PT/OT Consults
Total number of visits
in Pods C & D
(Sep. ’10 & Dec. ‘10)
PT/OT Consults and Treatments
Number of Visits
250
200
150
Pod C & D
100
All Pods
50
0
Sep PT
Sep OT
Dec PT
PT/OT
Dec OT
Mobilization Activities
Pre and Post EMP
Mobilization activities* per patient day
during pre-protocol period and at 8 weeks:
• Nursing: increased by 31%
• Occupational Therapy: increased by
86%
• Physical Therapy: increased by 78%
*Mobilization activities include: bed in chair position, dangle EOB, OOB, ADL and ambulation
Pilot Data Summary
• Aim: To increase the
average number of
mobilization activities
per patient day by
40% within an 8 week
pilot period
47%
Potential Cost Savings
• Based on reduction in ICU-LOS by 1 day
 Non-ventilated patients
[$3,872/day x 136 pts/month] =
$526,592/month
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Ventilated patients
[$7105/day x 83 pts/month] =
$589,715/month
EMP:
Beyond the Pilot Program
Simplified 3-Level EMP
Highlight of Changes
• Condensed to 3 Levels
• Reduced contents of levels
• Incorporation of visual cues
Simplified 3-Level EMP
Sustainability and Expansion
of EMP
Number of visits
• Feb 1, 2011 - Expanded program to 34/54 ICU beds
• May 1, 2011 - Expanded program to 54/54 ICU beds
Staffing and Education
• Addition of 2 FT physiotherapist
• Addition of 1FT occupational therapist
• On-going targeted education strategies
Visual Cues - Door Signs &
Communication Signs
Visual Cues - Room Signs
EMP Research and Publication
• Abstract accepted in 2012 SCCM congress
• Abstract submitted to 2012 Canadian
Respiratory Congress
• Oral and poster presentation in Texas and
American OT Association
• Oral presentation in Texas PT Association
• IRB proposal for prospective outcome trial
Special Thanks
• Mary Lou Warren, RN, CNS-CC
• Shari Frankel, PT, MBA, ATC
• Stacy Ryan, PT, DPT, APC
• Vi Nguyen, MOT, OTR, RRT
• Becky Garcia, RN, BSN
• Mini Thomas, RN, CCN
• Laura Withers, MBA, RRT
• Quan Nguyen, RRT
• Ninotchka Brydges, MSN, ACNP-BC
Thanks to Leadership of Nursing, Critical Care and Rehabilitation Services
Funding provided by Volunteer Endowment for Patient Support (VEPS)
Thank you
Richmond Agitation Sedation Scale
Future Trend
System-Specific Effects of Immobility
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Psychosocial impairment
VAP/HCAP, Atelectasis, FVC
Reduced CO, autonomic dysfunction
Decubitus ulcers, wound healing
Critical illness myopathy/ Mm. atrophy
Deep vein thrombosis
Insulin resistance
Greenleaf JE, Exerc Sport Sci Rev 1982 Steven RD, Int Care Med 2007
Hamburg NM, Arterioscler Thromb Vasc Biol 2007, Truong AD, Crit Care 2009
Safety of EMP in Critically Ill
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Schweikert WD, Lancet 2009;373:1874
Morris PE, Crit Care Med 2008;36:2238
Bailey P, Crit Care Med 2007;35:139
Burtin C, Crit Care Med 2009;37:2499
Thomsen GE, Crit Care Med 2008;36:1119
Stiller K, Physiother Theory Pract
2003;19:239
EMP: Initial Process
Orders are written:
Early Mobilization Protocol:
PT/OT consult & treat
RN
1. Assess patient upon
admission
2. Begin nursing
interventions based on
level
4. Delegate activities to
nursing assistant
PT/OT
1. Examine patient within 48 hours
2. Reinforce teaching and nursing
interventions
3. Develop and implement PT/OT
plan based on examination and
Mobility Level
5. Update mobility levels &
motivational tokens in room