ICU Early Mobilization: From Recommendation to Implementation at Three Medical Centers

Heidi J. Engel, PT, DPT1; Dale M. Needham, MD, PhD2; Peter E. Morris, MD3; Michael A. Gropper, MD, PhD4

Objective: To compare and contrast the process used to implement an early mobility program in ICUs at three different medical centers and to assess their impact on clinical outcomes in critically ill patients. Design: Three ICU early mobilization quality improvement projects are summarized utilizing the Institute for Healthcare Improvement framework of Plan-Do-Study-Act. Intervention: Each of the three ICU early mobilization programs required an interprofessional team-based approach to plan, educate, and implement the ICU early mobility program. Champions from each professionnursing, physical therapy, physician, and respiratory carewere identied to facilitate changes in ICU culture and clinical practice and to identify and address barriers to early mobility program implementation at each institution. Setting: The medical ICU at Wake Forest University, the medical ICU at Johns Hopkins Hospital, and the mixed medical-surgical ICU at the University of California San Francisco Medical Center. Results: Establishing an ICU early mobilization quality improvement program resulted in a reduced ICU and hospital length of stay at all three institutions and decreased rates of delirium and the need for sedation for the patients enrolled in the Johns Hopkins ICU early mobility program. Conclusion: Instituting a planned, structured ICU early mobility quality improvement project can result in improved outcomes and reduced costs for ICU patients across healthcare systems. (Crit Care Med 2013; 41:S69S80)
Department of Rehabilitative Services, University of California San Francisco Medical Center, San Francisco, CA. 2 Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD. 3 Pulmonary and Critical Care Medicine, Wake Forest University School of Medicine, Winston Salem, NC. 4 Critical Care Medicine, University of California San Francisco Medical Center, San Francisco, CA. Dr. Engel holds a consultancy with the Institute for Healthcare Improvement. Dr. Morris has received travel support from Hill-Rom and Covidien. The remaining authors have disclosed that they do not have any potential conicts of interest. For information regarding this article, E-mail: Heidi.Engel@ucsfmedctr.org
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Key Words: barriers; critical care; early mobility; early mobilization; ICU-acquired weakness; interprofessional; outcomes; physical rehabilitation; quality improvement

Copyright 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e3182a240d5

ore than 4 million patients are admitted to ICUs in the United States each year, with 8090% of these patients surviving their ICU stay (1). A high proportion of these ICU survivors experience signicant cognitive, psychological, and physically disabling side effects of their critical illness, regardless of their admitting diagnosis, with nearly half of these individuals being unable to return to their previous work more than 1 year after hospital discharge (25). Delirium, a temporary alteration of cognition characterized by inattention and disorganized thinking, occurs in up to 75% of ICU patients (6). Long-term neurocognitive disability also occurs commonly in critically ill patients, especially those with acute respiratory distress syndrome (ARDS) and delirium, and can persist for months to years after hospital discharge (7). In patients with ARDS, Hopkins and Jackson (810) reported cognitive impairments in 78% of ICU survivors at the time of hospital discharge, and in 46% of these individuals 1 year later. Girard and colleagues (11) found that increasing duration of delirium in ICU patients was an independent predictor of worse cognitive performance at 3 and 12 months after ICU discharge. In a systematic review of psychiatric morbidity in ICU survivors, Davydow and colleagues (12) reported a prevalence of psychiatrist-diagnosed posttraumatic stress disorder at hospital discharge, 5 years, and 8 years to be 44%, 25%, and 24%, respectively. Disabling weakness and associated impairments in physical function in ICU survivors also occur commonly (13, 14). The frequency of these impairments is approximately 50% in ICU patients with sepsis, multiple organ failure, or prolonged mechanical ventilation (15, 16). Recent retrospective studies from separate medical, trauma, and surgical ICUs reveal that at least half of patients discharged, regardless of age, are unable to return to premorbid levels of activity due primarily to weakness and lack of endurance (3, 4, 17, 18). It has been theorized that the weakness experienced by survivors of critical illness arises in part from an interaction of inammatory and metabolic changes due to critical illness and is exacerbated by the
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detrimental effects of prolonged bed rest commonly imposed on ICU patient care (1922). Recognizing the need to address the diminished quality of life (23) experienced by ICU survivors because of cognitive (24), psychological (25), and functional (26) impairment, a Society of Critical Care Medicine (SCCM) stakeholders conference convened in 2010 created the acronym postintensive care syndrome (PICS) (27, 28). The stakeholders conference met to develop collaborative interprofessional improvements in care to reduce PICS through increasing education about PICS, identifying areas of needed research, and identifying barriers to quality improvement (QI) initiatives aimed at reducing PICS (27). Similarly, several expert panel recommendations for reducing ICU survivor impairments have been proposed, including wide spread implementation of: 1) the awakening and breathing, coordination of delirium screening, and early mobility bundle (29, 30); 2) the ICU Pain, Agitation, and Delirium (PAD) care bundle, as part of the SCCMs 2013 ICU PAD guidelines (31); 3) the World Health Organizations International Classication of Functioning, Disability and Health model of assessment and care (32); and 4) recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients (33). All of these include recommendations for implementing treatment programs to improve ICU patients physical, cognitive, and mental health impairments, with structured rehabilitative patient physical activity timed closer to ICU admission rather than ICU discharge (34, 35). The health benets of physical activity for improving longevity, physical functioning and cognitive vitality in nonICU patients are well established (36), even for people with chronic ailments such as cancer (37) or heart disease (38, 39). Historically, critically ill patients have not been considered appropriate for early physical activity because they were deemed to be too medically unstable or were tethered to lifesustaining equipment. More recent evidence contradicts these assumptions and has demonstrated that early mobility of ICU patients is both safe and feasible (34, 4044). Furthermore, early physical therapy and mobility of ICU patients is emerging as an evidence-based strategy for preventing long-term neurocognitive and physical disability in these patients (7, 4548) Despite the safety, feasibility, and efcacy of early mobility of ICU patients, many ICUs struggle to create the culture change and protocols needed to provide ICU patients with early physical activity (4951). The purpose of this article is to present the experience of three academic medical centers in their establishment of ICU early mobility programs. These experiences may help other institutions in their creation of an ICU early mobility program.

intervention in the ICU. As a result, the design of most studies looking at the effects of implementing an ICU early mobility program are either prospective cohort studies or before-after studies following implementation of an ICU early mobility QI initiative (34, 35, 43, 5355). The ICU early mobility programs described in this article are from three separate institutions that established such a program. Investigations at Wake Forest University Medical Center in Winston Salem, NC (35), and at LDS Medical Center Intermountain Health in Salt Lake City, UT (34), were among the rst descriptions of ICU early mobility projects. Both projects served as models for a comprehensive structured QI initiative at Johns Hopkins Hospital (JHH) in Baltimore, MD (55), which in turn inspired a physical therapist-driven initiative at University of California San Francisco (UCSF) Medical Center in San Francisco, CA (54). The Wake Forest (35), JHH, and UCSF ICU early mobility programs were all QI projects (54, 55) created through a local and individualized approach, with similar interprofessional collaboration toward a synonymous goal. As a means of retrospectively organizing the information provided from the three programs at Wake Forest, JHH, and UCSF, the plan-do-study-act (PDSA) (56, 57) QI framework has been applied to their description. The PDSA cycle is part of the Institute for Healthcare Improvement Model for Improvement (58). Each of the three ICU early mobility programs followed steps similar to the PDSA model of QI initiatives, although on a different time line and without utilizing this specic format in the process. The PDSA process is described in more detail in Table 1 (56). Planning Phase All three ICU Early Mobility QI initiatives began with the formation of a group of critical care and rehabilitation clinicians from each discipline that would be responsible for providing early mobility interventions in the ICU. Wake Forest established a mobility team consisting of critical care nurses, physical therapists, nursing assistants, and intensivist physicians to create a mobility protocol designed to standardize early physical therapy in mechanically ventilated ICU patients. The purpose of the project was to determine if early physical therapy provided to patients within 72 hours of admission to the ICU and 48 hours of intubation via an endotracheal tube was both safe and feasible. The Wake Forest team hypothesized that the previously published evidence of inconsistent and infrequent physical therapy in the ICU (59) might be due in part to a lack of protocol-driven practice for mobility. Because protocols for other new practice patterns in the ICU such as weaning from mechanical ventilation and daily sedation interruption had led to previous improvements in patient care in their ICUs (60, 61), they believed that the same approach could be effectively applied to implementing a physical therapy/mobility program for mechanically ventilated ICU patients. In the planning phase of the program, the interprofessional mobility team developed a protocol for early delivery of activity and physical therapy in ICU patients consistent with the existing nursing and physical therapy department policies. Eligibility
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METHODS
Few randomized control trials (RCTs) investigating the effects of establishing an ICU early mobility program have been published (48, 52), most likely because of the complexity and expense of conducting an RCT of a physical activity
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TABLE 1.
Plan:

Plan-Do-Study-Act Implementation Strategies

 Critically appraise the literature to select an evidence-based initiative.  Ensure QI team is interdisciplinary and represents key stakeholdersincluding frontline staff, quality champions, and key executives.  Evaluate resources within institution to provide support.  Anticipate changes in resource and personnel needs associated with process change; consider the opportunity costs of the initiative.  Utilize QI tools to identify opportunities for improvement, including root cause analysis, shbone diagrams, run charts, Pareto charts, and prioritization matrices.  Identify SMART (specic, measurable, achievable, relevant, timely) goals/targets.  Identify a champion of the QI effort in each department or stakeholder group; create a backup plan in the event of unexpected loss of a champion.  Perform work-ow analyses to assess how the initiative will affect the work environment.  Consider pilot testing and stepwise implementation.  Design an easy-to-use measurement tool that is integrated into the workow and provide incentives for its use. Do:  Market the practice change with sound evidence provided in a concise format distributed to all stakeholders.  Remind clinicians of the process change using signage and compliance monitoring.  Communicate goals/targets and the time line for achievement.  Consider creating competition among various units to increase motivation and participation.  Ensure protocol or process change is effectively incorporated into practice through tools such as order sets: Create standard work.  Verify validity of data collection. Study: Reevaluate protocol.  Obtain clinician feedback.
QI = quality improvement.

criteria for ICU patients to receive physical therapy and early mobility were strictly set. An ICU mobility team nurse with no direct patient care duties screened all patients for eligibility. The ICU mobility team rotated through various ICUs and when ICU patients met criteria, they received protocolized care from the mobility team. Simultaneously, in ICUs at Wake Forest without the mobility team according to the team rotation schedule, ICU patients received usual care. Patients were enrolled in the ICU mobility program at Wake Forest over a 2-year period (20042006). Of the 1,427 patients who received mechanical ventilation during this period, 330 patients met eligibility criteria (35). Johns Hopkins cited the safety and feasibility of early mobilization of mechanically ventilated patients previously demonstrated by Wake Forest and Intermountain Health (34, 35) as evidence to support the Johns Hopkins QI project for creating an early physical medicine and rehabilitation for patients with acute respiratory failure (55). Johns Hopkins collected and analyzed baseline data to establish their low rate of patients receiving physical therapy (PT) in the medical Critical Care Medicine

ICU (MICU) before initiation of the QI project. They found that only 24% of patients received PT consultations and that 58% of these patients were treated with deep sedation that would make participation in early mobility impossible (62, 63). Similar to Wake Forest, Johns Hopkins established an interprofessional team to guide their ICU early mobility QI project. This project was funded through JHH and included a broader patient population than Wake Forest because specic study design criteria were not needed for this QI project. All ICU patients who were mechanically ventilated 4 days or longer and cognitively intact without neuromuscular disease were included in the Johns Hopkins project. All eligible MICU patients were enrolled in the ICU early mobility QI project at Johns Hopkins over a 4-month period (May to August 2007), resulting in 30 patients receiving the intervention, and later compared with 27 eligible patients receiving usual care before the QI study period. Johns Hopkins adopted a structured QI approach (64) incorporating the following components: 1) understanding the problem of immobility within the larger healthcare system; 2)
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creating an interprofessional improvement team; 3) enlisting all stakeholders to identify barriers to change and appropriate solutions; and 4) creating a change in practice through a 4Es approach: engage, educate, execute, and evaluate. The interprofessional team consisting of a physical therapist, an occupational therapist, a part-time mobility technician, physician coordinator and a part-time coordinator, as well as representatives from nursing, the Director of the Department of Physical Medicine and Rehabilitation, and physicians from critical care, physical medicine and rehabilitation, and neurology departments met weekly for 1 year during the planning phase of the project, in order to strategize and evaluate the issues and barriers to implementing an ICU early mobility program. Education of all clinical ICU staff as to the potential benets of increasing early physical medicine for the ventilated ICU patients and lightening sedation was provided through the use of staff newsletters, posters, ICU patient testimonials to the staff, and presenting educational research summaries at staff meetings and conferences. Outside experts with rsthand experience in implementing ICU early mobility programs were brought in to meet with members of the interprofessional mobility team. Mobility team members were also sent to other institutions with existing ICU early mobility programs. All MICU nurses were exposed to educational sessions describing the benets and feasibility of maintaining light levels of sedation for patients in their clinical practice in order to enable patients to actively participate in physical therapy (PT) and rehabilitation activities. The JHH added one full-time PT and one full-time occupational therapist (OT) and a part-time rehabilitation assistant to the clinical staff to help facilitate implementation of their early mobility program. In contrast to the Wake Forest experience, Johns Hopkins did not have standing orders for screening all ICU patients, but instead they assigned a clinical coordinator to screen all ICU patients at admission for appropriateness for early rehabilitation. Johns Hopkins also did not employ a protocol for implementing their ICU rehabilitation program. Rather, they changed the admitting activity order set from the default of bed rest to as tolerated, plus they established and disseminated simple guidelines for ordering PT and OT consults. Utilizing the existing literature at the time (34), the Johns Hopkins group also established safety exclusion criteria for all patients being evaluated for early mobility and rehabilitation. This planning phase of engaging and educating staff before executing the QI project lasted approximately 12 months, which was followed by a 4-month QI period with the ICU rehabilitation team continuing to meet weekly during this period to assess progress and barriers to wide spread implementation. Data collected during this 4-month QI period were then compared with data prospectively gathered on the same qualifying MICU patient population for 3 months before the QI start. The approach to planning an ICU early mobility QI project at UCSF was modeled after the experience of Johns Hopkins and was similar in many ways. As with both the Wake Forest and Johns Hopkins projects, an interprofessional early mobility committee was created at UCSF, consisting of representatives
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from PT, nursing, ICU nurse practitioner, critical care physicians, respiratory therapy, and medical center administration. The UCSF QI project leaders were responsible for establishing guidelines for ICU patient eligibility, promoting the evidence base for early mobility, educating across and within clinical disciplines, and making a case for adding additional clinical staff in the ICU to help facilitate an ICU early mobility program. Rather than limit the intervention to only mechanically ventilated patients, the UCSF project sought to include all medical-surgical ICU patients in order to assess the feasibility and benets to providing early mobility to medically complex surgical patients, a population which was not included in previous published studies of ICU early mobility programs in the United States. The UCSF Executive Director for Service Lines served as the administrative representative on the QI project and was instrumental in helping to create the program. Utilizing the nancial model developed at Johns Hopkins, which demonstrated signicant nancial savings associated with an ICU early mobility program, despite additional stafng costs (55, 65), she demonstrated the potential nancial benet of implementing an ICU early mobility program at UCSF to medical center administrators, convincing them to allocate 1 full-time PT to this ICU QI project for a 9-month period. Similar to Johns Hopkins, preparation at UCSF (66) included a site visit to a hospital with an established ICU early mobility program, and experts from outside institutions were invited to share their experiences with UCSF staff. A promotional campaign including educational presentations made to all UCSF staff, newsletters, and posters was utilized to engage everyone in the process of promoting widespread early mobility of ICU patients. ICU mobility guidelines, which included inclusion and exclusion criteria for mobility, were created in order to help staff to readily identify eligible ICU patients. The UCSF mobility QI group felt that it was important not to implement a strict ICU mobility protocol because this might result in some patients not receiving mobility who would otherwise safely benet from this treatment. During the 9-month ICU early mobility QI study period (March to December 2010), 294 ICU patients received early PT. At initiation of the QI period, the UCSF physical therapists created a ow sheet to guide individual patient treatments with the goal of providing an optimal intensity of mobility tailored to each patients ability during their early mobility sessions. The UCSF ow sheet and exclusion criteria are included in the Figure1 (54). Doing Phase Ongoing data collection and analysis of both process and outcome measures is a critical aspect of any QI project (67). The group at Wake Forest collected data on patient demographics including all medications, central lines, rates of ventilator associated pneumonia, deep vein thrombosis, reintubation, and pulmonary embolism. Outcome measures included the number of patient ventilator days, days until rst episode out of bed, ICU and hospital length of stay (LOS). Patients who met eligibility criteria in the intervention group triggered an automatic referral for PT even if they were not awake and alert
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Figure 1. Daily mobility assessment and treatment. MD = physician, NP = nurse practitioner, RASS = Richmond Agitation-Sedation Scale, PT = physical therapy, CAM-ICU = the Confusion Assessment Method for the ICU, PEEP = positive end-expiratory pressure, MAP = mean arterial pressure, CVA = cerebrovascular accident, SAH = subarachnoid hemorrhage, ICH = intracerebral hemorrhage.

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at the time. Patients who were unable to actively participate received passive range of motion exercises three times per day from mobility technicians until they were able to actively participate. At which point, they began working with the physical therapist, progressing along a four-stage mobility treatment protocol. Researchers at Wake Forest hypothesized that the perceived dangers of lightening patients sedation (i.e., dislodging endotracheal tubes or catheters, stressing and destabilizing critically ill patients in respiratory failure, etc.) prevented most mechanically ventilated patients from being awake and mobile in the ICU (6870). However, in the Wake Forest study, there were no adverse events associated with patient participation in mobility activities (i.e., death or near death, need for reintubation, or accidental removal of a device), demonstrating that active physical therapy by ICU patients during their ICU stay was both safe and feasible. The most frequent reasons for terminating a mobility session was patient fatigue without a signicant change in the patients vital signs. Data collection for the ICU mobility QI project at Johns Hopkins was used to evaluate the projects performance and impact on patient care and for providing ongoing incentives for continued staff buy-in and support of early mobility in ICU patients. The JHH team had two primary objectives that complimented and reinforced each other. The rst objective was to encourage a change in nursing sedation practice in the ICU to reduce the doses of sedative medications patients received without causing any added discomfort. This was accomplished by changing their routine sedation practice of administering continuous IV infusions of benzodiazepines and narcotics, to as-needed IV bolus doses of these medications (71, 72). The second objective was to increase the number of ICU patients receiving physical medicine and rehabilitation, ideally within 48 hours of their admission to the ICU. The referral for physical therapy and the progression of patient mobility was not automatically driven by either protocols or order sets; rather, initiation of early mobility for patients relied upon a QI project coordinator to assess each patients readiness for rehabilitation therapy, based upon mobility screening guidelines developed by the mobility QI team. Implementation of the Johns Hopkins program was systematically phased in, starting with a small number of ICU patients, and then sharing these early patient success stories with staff to build staff buy-in and support for the program before implementing the early mobility program more broadly in the ICU. Part of the success of this approach was demonstrating the safety of each ICU patient mobility session to ICU staff and family members and being transparent and proactive about preventing and dealing with adverse events. Johns Hopkins recorded only four unexpected events during PT sessions, which involved dislodging either rectal tubes or feeding tubes without any signicant medical consequence for these patients. They consulted a physiatrist for all MICU patients receiving rehabilitation therapy, increased the number of neurology consultations obtained for these patients, and actively collaborated with other clinical services at Johns Hopkins.
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In addition to recording data for patient demographics, critical lines, and adverse events as Wake Forest had, the Johns Hopkins QI project collected data on delirium screening, medication dosing, the number of PT consultations obtained, and the frequency and type of mobility activity used for each patient. Baseline data for the 3-month period before the start of the QI project were compared with similar data collected during the 4-month QI intervention period. The short time line for this before and after comparison enabled the QI team to establish a sense of urgency with concrete goals and deadlines in order to avoid dilution of the intervention and keep the momentum going to establish new practice patterns. The early mobility QI project at UCSF was modeled after the Johns Hopkins program, but did not have a project manager or a reliable system for data collection. The UCSF project was facilitated and organized by the treating PT in the ICU who established an interprofessional group to help implement this program. The UCSF project relied heavily on critical care nurse practitioners (NPs) working in the ICU to determine patient readiness for PT based on exclusion guidelines developed by the ICU physical therapist together with other members of the interprofessional critical care group. Critical care NPs were granted the authority by the UCSF Medical Executive Board to write referrals for PT for patients, as a means of increasing the frequency of PT consults, and timing them closer to patients admission to the ICU, rather than having all PT consults be physician driven. During the 9-month pilot intervention phase, physical therapists and rehabilitation department aides recorded the number of days from ICU admission to initiation of PT, daily functional mobility performed with a physical therapist, and their distance walked. ICU and hospital LOS and disposition upon patient hospital discharge were extracted from medical records and retrospectively analyzed by staff from the Department of Rehabilitation Services at UCSF. This data collection process was perceived by the UCSF team to be lengthy and cumbersome and led to signicant delays in communicating the impact of this program on ICU patient care, making it difcult to build widespread buy-in and support from ICU staff and hospital administrators. Studying Phase Once established, the early mobility programs were assessed for barriers encountered, effectiveness of the protocols and referral systems, and cost effectiveness. At Wake Forest, the percentage of MICU patients who underwent at least one physical therapy session at any time during their hospital stay in the usual care group was 47.4%, versus 80.0% in the protocol group. Of the usual care group who received PT, 12.5% initiated it in the ICU compared with 91.4% of patients in the protocol group. The Wake Forest team attributed this difference to having clinical staff dedicated strictly to facilitating patient mobility in the ICU, an interprofessional ICU mobility team, and protocols for initiating and delivering PT. The barriers highlighted by the structure of this QI project are apparent for the usual care group, but are not mentioned for the protocol group. Wake Forest also found a signicant difference between the usual
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care group and the protocol group in terms of ICU and hospital LOS. The adjusted ICU LOS was 6.9 days for usual care group versus 5.5 days for the protocol group. The hospital LOS was 14.5 days for the usual care group versus 11.2 days for the protocol group. When analyzing the nancial impact of their early mobility program, Wake Forest found the total direct inpatient costs for the protocol group, inclusive of the mobility team salaries, were $6,805,082 versus $7,309,871 in direct inpatient costs for the usual care group. This represents a net savings of over a half a million dollars in direct patient care costs following implementation of the ICU mobility program at Wake Forest. Johns Hopkins reported similar results when analyzing their QI project and has since published detailed accounts of both clinical and nancial impacts of implementing an ICU early mobility program (63, 65, 66, 73, 74). The percentage of patients receiving either PT or OT in their MICU increased from 70% to 93%, and the median number of PT/OT treatments per patient increased from 1 in the pre-QI period to 7 during the QI period. The average ICU LOS across all MICU patients decreased during the QI period by 2.1 days, and hospital LOS for the QI period MICU patients decreased by 3.1 days (55). Johns Hopkins published a detailed assessment of barriers to developing and implementing their early mobility QI project (63, 66), which included: a need for both institutional and project leadership; additional stafng and equipment; increasing physician referrals for PT closer to patient ICU admission; and management of patients pain, delirium, and tolerance for activity and safety. Strategies used to overcome these barriers are summarized in Table 2. Johns Hopkins nancial assessment of their early mobility QI project demonstrated a net nancial savings for the institution despite the investment costs of added stafng salaries. Combining their cost data with similar data from other institutions with successful ICU early rehabilitation programs, Johns Hopkins created a nancial model for estimating the net cost savings of implementing an ICU early mobility program. Based on a variety of scenarios ranging from conservative to best case, they estimated a projected net cost of $87,611 in the most conservative scenario and a projected net savings $3,763,149 in the best-case scenario, with the model predicting a significant net cost savings for most early mobility program cost scenarios (65). The design of the UCSF project benetted from the demonstrated savings recorded from the Johns Hopkins QI project. Although this information was unpublished at the time, Johns Hopkins agreed to collaborate and share their nancial data with UCSF. This allowed the UCSF ICU early mobility administrative champion to take UCSF medical/surgical ICU demographics and to create a UCSF-specic nancial model based upon a relatively conservative cost-benet scenario. UCSF estimated a net savings following implementation of their ICU early mobility program, including the costs of adding an additional physical therapist in the ICU. As a result, they were able to get approval and funding for this PT position from the chief operating ofcer for the 9-month QI Critical Care Medicine

pilot period. Financial analysis at the end of the pilot period demonstrated that sufcient net savings were generated, so that the full-time ICU PT staff position was kept indenitely, and additional staff were added to allow the program to be expanded. Despite the addition of a full-time physical therapist in the ICU, there was still a signicant lack of nursing and other ICU staff to help facilitate the labor intensive process of helping critically ill patients transfer out of bed and become more mobile. This labor shortage was addressed in part through the creation of an accredited ICU PT elective for physical therapy students from the San Francisco State University/UCSF Graduate Program in Physical Therapy. These students were assigned to the ICU in order to gain rsthand experience in helping to facilitate PT activities in critically ill patients, while providing aide/mobility technician support for academic credit. The interprofessional early mobility group at UCSF met every 2 weeks during the QI period and assessed the project for barriers (54), strategized solutions, and searched the literature or consulted experts at professional meetings to resolve program barriers (Table2). Regular updates summarizing program progress and clinical improvements associated with early mobility in the ICU were made available to ICU staff and all staff through posters, e-mails, and presentations at medical center-wide rounds. After implementation of the ICU early mobility program at UCSF, the median number of days from ICU admission to initial PT evaluation decreased from 3 days to 1 day, and the median distances that patients walked in the ICU increased from 40 to 140 ft. Similar to the experiences at Wake Forest and Johns Hopkins, median ICU LOS at UCSF decreased by 2 days, and median hospital LOS decreased by 2 days (54). Acting Phase Success of any QI project requires action well beyond the initial recorded achievements to sustain the new practice patterns through a process of renement, communication via internal announcements as well as external publishing, and standardizing the new systems. In 2008, Wake Forest published their QI project and demonstrated that early physical therapy compared with a group receiving usual care was associated with signicant improvements in clinical outcomes for ICU patients (35). Other institutions such as Johns Hopkins and UCSF were able to subsequently cite this evidence as a rationale for developing and implementing ICU early mobility and rehabilitation programs at their facilities in order to improve ICU patient outcomes. In 2011, Wake Forest published a 1-year follow-up report that looked at the long-term outcomes of ICU survivors managed under the ICU early mobility project (48). This report demonstrated that ICU patients who had not received treatment as part of the ICU early mobility program were at higher risk of death or hospital readmission within 1 year of hospital discharge, as compared with patients who received early ICU PT (75). The initial QI project at Wake Forest also provided the preliminary data needed to continue an ongoing randomized controlled study for ICU early mobility.
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TABLE 2.
Barriers

Barriers to Early Mobility Encountered and Solution Strategies

Wake Forest Johns Hopkins University of California San Francisco

Lack of leadership

Recruited interdisciplinary team QI program funded addition of mobility team Literature review Protocol

Recruited interdisciplinary team with an overall physician leader for the project Conducted as QI pilot program Staff added conditional to outcome Education from champions to staff Education across disciplines Interprofessional consensus policy written Site visit to established ICU early mobilization program

Recruited interdisciplinary team with a PT leader and physician head of critical care support Conducted as QI pilot program Staff added conditional to outcome PT students taking ICU elective Education from champions to staff Education across disciplines Interprofessional consensus policy physical therapist/written Site visit to established ICU early mobilization program PT and ICU nurse practitioner rounds Inquiry at professional meetings Staff meeting education

Lack of stafng and equipment

Lack of knowledge and training

Lack of physician referrals for PT Over-sedation

Automatic physicians order

Project coordinator screening Continuous education and reinforcement from champion physician for use of bolus rather than infusion sedation Screening Minimize sedation Mobilize

Delirium

Screening Minimize sedation Mobilize Created exclusion guidelines PT daily screening Retrospective analysis of incident reports

Patient hemodynamic tolerance of activity Safety

Specic protocol Prospectively set adverse events recorded

Created exclusion guidelines PT daily screening PT and occupational therapy emphasis on untangling lines before therapy

QI = quality improvement, PT = physical therapy.

Johns Hopkins has since expanded their program and have published several articles on their clinical experiences and the economic impacts of their ICU early mobility program (7, 18, 76, 77). Johns Hopkins has also developed an interprofessional continuing education course on early mobility of ICU patients, which to date has been attended by critical care practitioners from several countries (78). The ICU early mobility program at Johns Hopkins continues to innovate and improve their ICU early physical medicine and rehabilitation program by trialing new rehabilitation equipment (79, 80) and treatment strategies (73, 81, 82). The ICU early mobility program at UCSF is also expanding and sustaining its momentum. An additional full-time PT position has been added to the second mixed medical-surgical ICU at UCSF, and a full-time mobility technician has now been added to the program. Continuing education courses are offered to the interprofessional critical care community from UCSF. Funding sources are expanding to include research grants that assist in providing data collectors and research coordinators to help to assess the impacts of early mobility in
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ICU patients. Publishing efforts by UCSF critical care personnel (46) further motivate the staff to continue the their early PT efforts in the ICU.

DISCUSSION
The long-term disabling impacts to patients caused by critical illness are becoming clearer (5, 8385). Providing early physical medicine and rehabilitation to critically ill patients as a way of improving their quality of life both functionally and cognitively after they leave the hospital is in keeping with the expressed goals of patients themselves (86, 87). Despite the many barriers to developing and implementing the delivery of this new practice pattern (50), it is imperative to the growing numbers of ICU survivors that we address these issues (88). Asystematic approach of collaborative QI, implemented by an interprofessional team of early physical rehabilitation in the ICU as outlined by the experiences of three institutions here, is a reproducible treatment strategy. Hopefully, it will encourage widespread adoption of ICU early mobility programs, while
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encouraging a more rigorous approach to clinical research on this issue with larger, multicenter studies looking at both the effects on outcomes and costs, and identifying best clinical practices, in order to improve the quality of life for ICU survivors. Although signicant differences in ICU cultures, personnel, institutional knowledge about early ICU rehabilitation, and funding resulted in varying approaches to the development and implementation of an ICU early physical rehabilitation program across these three institutions (89, 90), some common themes emerge here which may serve as a guiding set of principles for other hospitals and healthcare systems looking to establish ICU early mobility and rehabilitation programs. A detailed initial planning phase by an interdisciplinary team is essential. The Johns Hopkins program makes a compelling case for developing and implementing a structured QI project that was applied to all mechanically ventilated MICU patients with respiratory failure, in order to keep the implementation TABLE 3.

of the intervention on track and to keep ICU staff motivated to change their practice patterns. On the other hand, the Wake Forest approach of starting on a small scale with a select population of ICU patients and demonstrating success before expanding the program more broadly may also help to facilitate implementation. It is also important to identify a clinical champion to lead an ICU early mobility effort, someone who works in the ICU and understands its culture and workow. But as the UCSF program demonstrates, a clinical champion does not necessarily need to be an ICU physician, although support from ICU physician leadership is essential. Both process and outcome measures must be identied at the beginning of the project and tracked over time to evaluate the effectiveness of the project. The interprofessional mobility team needs to assess data and then work collaboratively to overcome programmatic barriers identied during the QI process. Information about the progress and successes of the project need to be communicated frequently and consistently

Comparison of Three ICU Early Mobility Quality Improvement Projects

Wake Forest Johns Hopkins University of California San Francisco

Quality Improvement for Early Mobility

Objective

Reduce immobility and weakness with early PT for MICU patients

Optimize patient sedation Provide early PM&R in the ICU for MICU patients 1 yr n = 27 retrospective comparison n = 30 on MV 2007 6 days/week mobility 1 physical therapist, 1 occupational therapist, 1 technician, 1 coordinator, 1 part-time assistant coordinator 2 wheelchairs Percentage of ICU patients receiving PT ICU/hospital LOS Pain/delirium scores Adverse events Yes Yes Same results as shown in Wake Forest plus: Decreased dosages of sedating  medications Decreased patient delirium rates  No change in patient reported  pain scores

Provide earlier and more frequent PT in the ICU for MICU and surgical ICU patients 1.5 yr n = 179 retrospective comparison n = 294 all ICU patients 2010 5 days/week mobility 1 physical therapist, 1 part-time aide

Planning time frame Comparison group Intervention group and time frame Number of added personnel and titles n = 165 control group n = 165 patients on MV 20042006 7 days/week mobility 1 registered nurse, 1 certied nursing assistant, 1 physical therapist, 1 project manager None Days until out of bed Frequency of therapy ICU/hospital LOS Adverse events Yes Yes Safe and feasible earlier mobility Increased number of patients receive ICU PM&R Patients receive increased number of treatments Decreased ICU and hospital LOS Net cost savings

Equipment added Outcome measures

ICU platform walker Number of days to initiating PT ICU/hospital LOS Distance walked in ICU Discharge disposition Incident reports No Yes Same results as shown in Wake Forest plus: Applied to medical and surgical all  ICU patients Increased distance patients walked  in ICU Increased percentage of patients  able to discharge to home rather than rehabilitation facility

Financial analysis performed? Expanded to other ICUs? Results

PT = physical therapy, MICU = medical ICU, PM&R = physical medicine and rehabilitation, MV = mechanical ventilation, LOS = length of stay.

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to both internal and external stakeholder groups, including ICU staff, administrators, and patients and their families, in order to gain widespread buy-in and ongoing support for change, and to directly engage these individuals in improving the program over time. Finally, development of a business model that includes a nancial analysis of the local-associated costs and savings of an ICU early mobility and rehabilitation program will facilitate approval for additional resources from hospital administrators. Table 3 provides a summary of the full QI projects described in this article.

CONCLUSIONS
Early mobility and rehabilitation of critically ill patients is associated with signicant improvements in both short- and longterm physical and neurocognitive outcomes in ICU survivors. This article summarizes the development, implementation, and clinical and economic impacts of ICU early mobility programs at three different institutions. The examples provided here may help facilitate the development and implementation of similar ICU early mobility and rehabilitation programs at other facilities.

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