Early mobilization of ICU patients safe, effective with no additional staffing needed

Implementing an early mobilization (EM) protocol in the intensive care unit (ICU) is effective in increasing mobilization rate without requiring additional staffing and with a low rate of adverse events (AEs), a Singapore study has shown.

“[B]arriers to effective mobilization still exist, including administrative, logistical and personnel factors, and a lack of patient cooperation,” the researchers said. “These problems may be addressed by a systematic multidisciplinary approach involving intensivists, physiotherapists, and nursing staff, as well as changing both staff and patient mindsets regarding mobilization in the ICU through education.”

In this prospective nonblinded observational cohort study based on a quality improvement project, a protocol for EM was employed on suitable patients admitted to medical and surgical ICUs of a tertiary care hospital. Other aspects of patient care were managed as usual.

The researchers followed participants up to discharge and collected data from July to August 2016 preimplementation and from November 2016 to February 2017 following protocol implementation.

Mobilization rate, the primary outcome, was defined as the number of days mobilized divided by the number of days each patient met the mobilization criteria. Secondary outcome measures were AE rate, length of mechanical ventilation, ICU and hospital stay, ICU and in-hospital mortality, and discharge destination.

Three hundred twelve patients (mean age 63.4 years, 60 percent men) were included in the analysis. The mobilization rate increased from 39 percent to 65 percent following EM implementation (p=0.006), and the proportion of patients discharged home rose from 49.0 percent to 75.9 percent (p<0.001). [Proc Singapore Healthc 2021;30:193-199]

Mortality, length of mechanical ventilation, length of stay, and AE rate did not significantly differ. AE rates during mobilization were 8.5 percent and 4.7 percent in the pre- and postimplementation group. Of note, no instances of falls, line, or endotracheal tube dislodgement occurred during mobilization.

In subgroup analysis of patients who required ventilation during their ICU stay, the relative risk of home discharge was over 1.5 times post- vs preimplementation.

“Besides demonstrating an improved mobilization rate with our protocol implementation, our study also highlights areas that may be addressed for further improvement,” the researchers said. “Competing activities, patient refusal, and ongoing continuous renal replacement therapy account for over 70 percent of patients not mobilized despite meeting eligibility criteria.”

Such factors are modifiable and could be corrected with better planning of activities for the patients and by exploring means to address concerns of those who refuse treatment.

“There is an emerging body of evidence to support the feasibility of mobilizing selected patients on continuous renal replacement therapy, a point that should be mooted to healthcare providers who share concerns of safety,” the researchers said. [Crit Care 2015;19:205; Am J Crit Care 2014;23:348-351]

“Mobilizing such patients nonetheless presents unique challenges in terms of staffing and logistics and represents another area for special attention,” they added.