Mobilizing Patients in the ICU Is Safe and Cost-effective
Abstract & Commentary
By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.
Dr. Hoffman reports no financial relationship to this field of study.
Synopsis: Earlier physical therapy in the ICU led to a shorter ICU and hospital length-of-stay with no untoward events and no cost difference, inclusive of mobility team costs.
Source: Morris PE, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008;36:2238-2243.
This study compared outcomes in 330 patients who were managed with mobility therapy (n = 165) vs usual care (n = 165) in a medical ICU. Patients were prospectively enrolled within 48 hours of intubation and 72 hours of ICU admission. Exclusion criteria included inability to speak (nonverbal) or walk prior to ICU admission (use of a cane or walker was not an exclusion), neuromuscular disease that could impair weaning, acute stroke, body mass index > 45 kg/m2, unstable fractures, cardiopulmonary resuscitation or do-not resuscitate status at ICU admission, and preadmission steroid administration (prednisone > 20 mg/day for 2 weeks). The mobility team rotated in a set order among 7 ICUs that admitted MICU patients, recruiting patients over 24 consecutive months. Usual care patients were recruited from units where the team was not currently assigned. The mobility protocol was administered 7 days a week and included four levels of activity: Level 1 = passive range of motion and turning every 2 hours; Level 2 = those activities plus active resistance physical therapy and moving to a sitting position; Level 3 = the prior activities plus sitting on the edge of the bed; and Level 4 = prior activities plus active transfer to a chair, weight shifting in place, and ambulation.
At baseline, intervention patients did not differ from usual care patients with respect to any measured variable. APACHE II scores were 21.6 ± 8.0 for usual care patients and 23.5 ± 8.8 for intervention patients (P = 0.092). Intervention patients were out of bed earlier (5 vs 11 days; P < 0.001), had therapy more frequently (91% vs 13%; P < 0.001), and experienced a shorter length-of-stay (LOS) in the ICU (5.5 vs 6.9 days; P = 0.025) and hospital (11.2 vs 14.5 days; P = 0.006). There was a trend toward a lower incidence of ventilator-associated pneumonia (P = 0.087) and deep vein thrombosis (P = 0.078) in intervention patients. There were no adverse events. Costs, inclusive of the mobility team, averaged $41,142 for intervention patients and $44,302 for usual care patients (P = 0.262).
Commentary
An increasing body of recent literature has reported positive benefits from early mobilization of ICU patients, accompanied by few or no adverse events. Early mobilization of patients in the ICU is not new. In the 1970s, several centers reported their experience with ambulation of mechanically ventilated patients, including excellent patient acceptance, improved strength, and earlier weaning from mechanical ventilation. More recently, Needham reported a conversation with a 56-year-old man who experienced a complicated 2-month medical ICU stay that included aspiration, sepsis, and nutritional depletion.1 His rehabilitation included walking laps around the medical ICU while still ventilator-dependent. When interviewed after discharge, he described bed rest as "unbearable" and walking while ventilator-dependent as "wonderful" and "not uncomfortable."
The present study found that implementation of a step-wise early mobility protocol resulted in more physical therapy sessions, shorter ICU and hospital stays, and, importantly, no adverse events. Although there was no significant difference in costs, the absolute difference was less for the mobility group. The authors attribute the benefits they describe to several factors, including the step-wise protocol and delivery by an independent multidisciplinary team (physical therapist, critical care nurse, nursing assistant). The team began passive range of motion when the patient was unconscious and, freed from other responsibilities, was able to insure that sessions were delivered as prescribed.
Bed rest has known detrimental effects that include changes in muscle fibers, inflammatory markers, and metabolic parameters. Laboratory studies have demonstrated insulin resistance and microvascular dysfunction after 5 days of bed rest in healthy volunteers.1 Findings of this and other studies suggest the need for a protocol-driven focus in ICU patient care that includes target sedation levels, daily sedation interruption, daily assessment of weaning readiness, and mobility therapy with the latter directed by an evidence-based protocol that identifies who to enroll, when to begin, and when to progress through various levels culminating in ambulation, if possible.
Reference
- Needham DM. Mobilizing patients in the intensive care unit: Improving neuromuscular weakness and physical function. JAMA 2008;300:1685-1690.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content