Early Mobilization in Acute Care
Every year in the U.S., millions of people are admitted to the hospital in the acute care setting. In 2015 alone, there were over 35 million hospital admissions. With each admission, many complications can present themselves. Patients may be at higher risk for hospital acquired infections, pressure ulcers, joint contractures, and complications related to decreased mobility.
Just some of these complications include higher fall risk, decreased muscle strength and function, and decreased respiratory endurance and function. Occupational and physical therapists play a crucial role in preventing these issues or minimizing their effects. In recent years, there has also been an increased focus on decreasing length of hospital stays.
Acute care occupational therapists can also improve these outcomes by providing early mobilization on the acute unit. However, not every patient is a good candidate for early mobilization, and not every patient will be able to return home. This article will discuss the expected outcomes from early mobilization as well as contraindications to early mobilization.
Overcoming the Initial Intimidation of Mobilizing
In the ICU or step-down unit, your patients will likely be attached to IV poles, catheters, telemetry, pulse oximeters, blood pressure cuffs, SCD’s, oxygen tubes and possibly ventilators. Often therapists are concerned about mobilizing patients who are attached to multiple devices as accidental removal of catheters and IVs can cause pain to the patient and reinsertion can increase the risk of infection.
However, research suggests that the risk of these complications is very low (less than 1%). Therefore, patients being hooked up to multiple devices is not a contraindication to early mobilization. There are, however, several other considerations and contraindications to early mobilization.
While keeping this list in mind, also be sure to always check with your nurse and do a thorough chart review before mobilizing.
Contraindications to Keep in Mind
If any of the following conditions are present, mobilization is not appropriate:
- Resting heart rate drops more than 20%.
- Heart rate is less than 40 beats per minute or greater than 130 beats per minute.
- New onset of dysrhythmia
- New anti-arrhythmia medication
- New MI by EKG or cardiac enzymes
- Pulse oximetry drop of 4% or more or drops below 88-90%
- Systolic blood pressure greater than 180
- 20% drop in blood pressure as evidenced by orthostatic hypotension
- Mean arterial blood pressure less than 65 or greater than 110 mgHg
- Presence of vasopressure, new vasopressure or escalating vasopressure medication
- Mechanical ventilation F1O2 of .60 or less, PEEP of 10 or greater, patient-ventilator asynchrony, MV mode change to assist-control, or a tenuous airway.
- Respiratory rate of less than 5 or greater than 40 breaths per minute.
- Patient sedated or in a coma
- Patient agitation requiring increase in sedative medication
- Patient complaining of intolerable dyspnea on exertion (DOE)
- Patient refusal
The most common condition that interferes with therapy treatment is a pulse oximetry drop. In many cases, therapy can be continued after a short break to allow the oxygen levels to return to normal. Be sure to keep your own pulse oximeter on hand to be able to monitor O2 levels at any time.
The Major Benefits of Early Mobilization
In ICUs where occupational therapy and physical therapy are emphasized, time to mobility goals and advanced mobilization milestones were reached more quickly, ultimately reducing length of stay in the hospital or post acute setting. Multiple studies have examined what specific effects early mobilization has on a patient, and they are as follows.
There is a small amount of evidence that proves strength gains are made on the ICU or on the acute units. However, patients who participate in early mobilization programs, will have greater strength gains when they discharge from a sub-acute unit. This outcome would be expected, as strength typically takes a few weeks to improve. Respiratory strength made gains in two studies as well.
In one study, the control group received standard therapy care versus the intervention group where early mobilization in the ICU was encouraged. At discharge, 59% of the intervention group had achieved independence as measured by FIM scores as compared to 35% in the control group. Other studies found a reduced time to reach mobility milestones, and increased participation by patients in advanced mobility activities.
Quality of life
There have not been many studies examining the effect of early mobilization on quality of life measures, such as decreased depression. However, it has been well documented that prolonged mechanical ventilation and ICU duration can negatively impact depression, anxiety and post-traumatic stress disorder. Therefore, a reasonable assumption could be made that decreasing the time spent in the ICU with early mobilization emphasized by physical and occupational therapy would decrease depression, anxiety and post-traumatic stress disorder.
These studies show the value in early mobilization by physical and occupational therapy to decrease time of hospital stay and improve ability to reach functional independence. This allows patients to return to home more often, and to have a higher level of function once they return home.
Early Mobilization Interventions
Patients who are more critically ill will benefit from lower level interventions, depending on what they can tolerate. This may range from transitioning from supine to chair position, or even completing simple grooming tasks sitting edge of bed. The interventions you choose should be based on the patient’s tolerance and should be client centered.
Patients may be able to tolerate ADL retraining transferring to a bedside commode or even walking to the bathroom and completing ADL tasks in standing. If a patient can tolerate this, it is a great way to get them mobilized while focusing on function as well.
Some patients, especially in the ICU, may have very low endurance, or very low strength. In these instances, it can be beneficial to co-treat with physical therapy. This can allow patients who require the assist of two people to participate in early mobilization activities, helping them to obtain the benefits of decreased length of stay and improved functional outcomes as well.
In conclusion, you may see some patients who are not appropriate for early mobilization. These patients are not medically stable, or are having medical issues that diminish their ability to participate in therapy- such as being in a coma.
However, many patients are appropriate for early mobilization, and there are few negative side effects to early mobilization in the ICU and in the acute care units. Therefore, it is of high priority to see these patients as soon as possible to work to reduce the risk of decline and increase their functional status.
How do you incorporate early mobilization in your treatments? Please share in the comments below.