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Care Guideline

EARLY PROGRESSIVE MOBILIZATION FOR CRITICALLY ILL


PATIENTS (EPM)
Target Audience:

The target audience for this Care Guideline is all MultiCare employed
Physicians, nurses, CNA/ nurse tech, respiratory therapists, physical and
occupational therapists providing care for patients in intensive care units.

An additional audience includes providers and staff associated with our


Clinically Integrated Network.

Scope/Patient Population:
Adult patients undergoing treatment and or monitoring in medical and surgical
intensive care units across MultiCare Health System and meet
inclusion/exclusion criteria for Early Progressive Mobilization (EPM). The
application of this therapy in neurosurgical and cardiothoracic surgery patients
is beyond the scope of this guideline.

Rationale:
Cognitive, psychological and physical impairment is commonly seen in
survivors of critical illness including ARDS and hypotensive shock states.
Nearly 100% of survivors from Acute Lung Injury suffer from cognitive
impairment at discharge and this persists at 1 year in 50% of the cases. [1,2]

Anxiety, depression and post-traumatic stress disorder is encountered in 25-


50% of ICU survivors and prolonged disability is common. [1,2]

At least 25% of ICU patients develop muscle weakness and its development
correlates with increased time of mechanical ventilation, longer ICU and
hospital stay, increased reintubation rates and higher mortality rates. These
patients are also less likely to be discharged home and experience longer
rehabilitation needs [3,4,5]

A systematic mobility program during critical illness has beneficial effects on


the body by reducing muscle atrophy and weakness, improving respiratory
function (optimizing V/Q mismatch, increasing lung volumes, improving airway
clearance), increasing functional independence and improving cardiovascular
fitness. Mobility also has a positive psychological impact, increasing

EARLY PROGRESSIVE MOBILIZATION FOR CRITICALLY ILL PATIENTS (EPM)


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Care Guideline
physiological well being and improving level of consciousness [6]

Early mobility in the intensive care unit is a safe, feasible and effective
intervention as shown in prospective cohort and randomized clinical trials.
Early mobility improved outcomes (duration of mechanical ventilation,
delirium, length of hospital stay and functional independence at discharge),
increased the use of early physical therapy and did not increase cost of
hospitalization or result in increased adverse events. [7,8,9,10]

The current guideline provides an evidence based assessment algorithm and a


mobility protocol for critically ill patients on or off mechanical ventilator
support.

Objective
Describe current evidence based practice in the application of early progressive
mobilization of critically ill patients in medical and surgical intensive care units.

The ultimate goal of this intervention is to reduce disability among survivors of


critical illness, improve hospital outcomes, and reduce length of stay and
hospital utilization.
Recommendations:

Disclaimer: The below Care Guideline serves as a reference for health care professionals and
patients within the MultiCare Connected Care affiliated network. The guideline provides an
evidence-based* framework for evaluating, treating or preventing various health conditions.
The guideline is not meant to replace clinical judgment of individual providers and is not meant
for all circumstances.

* The process of determining evidence based criteria involves the review of peer-reviewed
literature and nationally published guidelines in the open literature where there is evidence
supporting these recommendations. When possible, along with the reference, the original
literature or links are provided to provide accurate assignment of original authorship.

With the exceptions outlined in section III, all ICU patients (including
mechanically ventilated) will be mobilized using this procedure.

I. Patient mobility is the responsibility of the RN, with the assistance of RT,
nurse tech, CNA, PT, and OT caregivers.
1. PT and OT may assist the team with placement in the appropriate
mobility level of activity, always prioritizing patient and caregiver
safety.
2. For each position/activity change, allow 5-10 minutes for
equilibration before determining that the patient is intolerant.
3. Physical therapy specialists will be involved in the therapy of
patients at stage II and above of mobility.
EARLY PROGRESSIVE MOBILIZATION FOR CRITICALLY ILL PATIENTS (EPM)
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4. Occupational therapy specialists will be involved in the therapy of
patients at stages III and above.

III. Contraindications for initiation of early progressive mobility:

A. Musculoskeletal injury: Unstable spinal cord injury, Orthopedic


fractures (weight bearing status must be specified by the
orthopedic or trauma MD), Balanced skeletal traction
B. Vascular access in femoral location
C. Traumatic Brain Injury (approval for progressive mobility must be
cleared with trauma MD)
D. Hypoxia: desaturations below 88%
E. Hypotension: MAP <65mmHg
F. New or increasing vasopressor use
G. Active cardiac ischemia
H. Arrhythmias requiring new pharmacological agent
I. Increasing PEEP

IV. Procedure:
A. Mobility screening:
1. Within 8 hours of ICU admission, assess the patient according to
the following criteria framework:
a. PaO2 / FiO2 > 250
b. PEEP < 10
c. O2 sat > 90%
d. RR 10 – 30/min
e. No new onset cardiac arrhythmias or ischemia
f. HR 60 - 120
g. MAP 55 – 140
h. SBP 90 – 180
i. No new or increasing vasopressor infusions
j. MAAS > 2
2. If the patient meets all of the above criteria, s/he is considered
to be ‘clinically stable’ for mobilization. Patient mobility should
start at level 2 and progress as able.
3. If the patient does not meet all of the above criteria, s/he is
considered ‘clinically unstable.’ Patient mobility should start at
level 1 and progress as able.
B. Advancing patient along mobility continuum:
1. Reassess patient at least every 24 hours (recommended at shift
change)
a. Consider contraindications listed in ‘special instructions’
EARLY PROGRESSIVE MOBILIZATION FOR CRITICALLY ILL PATIENTS (EPM)
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Care Guideline
b. Rescreen using criteria in A1
c. If the patient is ‘clinically stable’ and goals of current mobility
level are met, advance to next level.
d. If the patient is intolerant (as defined by criteria in A1) of
mobility activity:
1) rescreen as soon as possible using criteria in A1 above
2) place in appropriate mobility level
C. Mobility Levels:
1. Level 1:
a. Goal: clinical stability, passive ROM
b. Activity:
1) Q2h turning
2) HOB > 30°
3) Passive ROM 2x/day, performed by PT or RN
2. Level 2:
a. Goal: upright sitting, increase strength and activity tolerance
(i.e.: can move arm against gravity)
b. Activity:
1) Passive/Active ROM 2x/day
2) Progressive bed sitting to full chair mode x 20 min, 3x/day:
a) HOB 45°
b) HOB 45°, legs dependent
c) HOB 65°, legs dependent
d) Full chair mode
c. PT/OT Order per nurse driven protocol, MD co-sign needed.
d. Move to Level 3 when patient able to lift arms against gravity
3. Level 3:
a. Goal: trunk strength, readiness to weight bear (i.e.: can move
leg against gravity)
b. Activity:
1) Sitting on edge of bed with assistance of PT, RN, RT
2) Progressive bed sitting x 20+ min, 3x/day
3) Or, passive pivot to chair 2x/day
c. Advance to Level 4 when patient able to raise legs against
gravity.
4. Level 4:
a. Goal: weight bear, active transfer to chair, march/stepping in
place (i.e.: can stand with minimum to moderate assist and
shift weight)

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b. Activity:
1) Progressive bed sitting, 20+ min, 3x/day
2) Sitting on edge of bed, then standing with assistance of PT,
RN, RT
3) Active transfer to chair with assistance of PT, RN, RT
minimum of 2x/day
5. Level 5:
a. Goal: increase ambulation distance and ability to perform some
ADLs
b. Activity:
1) Chair (OOB) with assistance of PT, RN, RT 3x/day
2) Meals consumed while in chair or while dangling legs over
edge of bed
D. Mobility equipment: Equipment to promote and facilitate patient and
staff safety includes but is not limited to bed with cardiac chair mode,
transfer belts, ceiling lifts with accompanying transfer and ambulation
slings, walkers, and stretcher/chairs
Algorithm: Protocol is illustrated at the end of this document.

Evidence:

1. Hopkins RO, Weaver LK, Pope D, et al. Neuropsychological sequelae and


impaired health status in survivors of severe acute respiratory distress
syndrome. Am J Resp Crit Care Med 1999; 160(1):50-6
2. Herridge MS, Cheung AM, Tansey CM et al. One year outcomes in survivors
of the acute respiratory distress syndrome. N Eng J Med 2003; 348(8):683-
93

3. DeJonghe B, Sharshar T. et al. Paresis acquired in the intensive care unit.


JAMA 2002;288(22):2859-67

4. Leijten FS. The role of polyneuropathy in motor convalescence after


prolonged mechanical ventilation. JAMA 1995;274(15):1221-5

5. Levine S, Nguyen T, Taylor N et al. Rapid disuse atrophy of diaphragm


fibers in mechanically ventilated humans. N Engl J Med 2008; 358(13)1327-
35

6. Stiller K. Safety issues that should be considered when mobilizing critically


ill patients. Crit Care Clin 2007;23(1)35-53

7. Bailey P, Thomsen GE. Early activity is feasible and safe in respiratory


failure patients. Crit Care Med 2007;35(1):139-45

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8. Morris PE, Goad A, Thompson C et al. Early intensive care unit mobility
therapy in the treatment of acute respiratory failure. Crit Care Med; 2008;
36(8):2238-43

9. Schweickert WD; Pohlman MC et al. Early physical and occupational therapy


in mechanically ventilated, critically ill patients: a randomized controlled
trial. Lancet 2009; 373(9678):1874-82

10. Needham DM. Mobilizing patients in the intensive care unit: improving
neuromuscular weakness and physical function. JAMA 2008;300(14)1685-
90

List of Implementation Items and Patient Education:

I. Update ICU physicians, nurses, respiratory therapists, physical and


occupational therapists as they come on board

II. Disseminate guideline to all stakeholders who provide Early Progressive


Mobility in the ICU

III. Educate and inform patients and their families on the importance of daily
safe mobility

Metrics Plan:
Bi-annual review of data to include: percent use of early mobility, selected
outcome metrics, safety of protocol and adverse mobility related events.

PDCA Plan:
This Care Guideline will be reviewed and update every 3 years by the Critical
Care Collaborative.

Point of Contact: Medical Leader – Critical Care Collaborative


Approval By: Date of Approval:
Collaborative (Critical Care) 04/2016; 04/2018
MHS/Other Committee N/A
MCC/Collaborative Leadership 05/2016; 04/2018
Tacoma Ops Collaborative X/XX
Original Date: 02/2016
Revision Dates: 06/2016
Reviewed with no Changes Dates: 04/2018
Distribution: MultiCare Connected Care + MultiCare Health System

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START HERE Level III Level IV Level V
Level I Level II
(intubated & non- (intubated & non- (pts nearing transfer or
(unconscious, (Conscious stable patient, may
intubated intubated discharge)
• Perform Initial mobility screen uncooperative, agitated,
confused or unstable
include some non-intubated
patients)
hemodynamically hemodynamically
w/in 24 hours of ICU admission stable/stabilizing pts, no stable/stabilizing pts,
patients)
contraindications) no contraindications)
• Reassess mobility level at least
every 24 hours (Recommended
at shift change) MAAS 0 – 1 MAAS 2 & UP MAAS 3 & UP MAAS 3 & UP MAAS 3 & UP

For each position/activity change,


allow 5-10 min. for equilibrium
• PT: N/A • PT: consultation • PT: Active Resistance
• PT: X 2 daily
• PT: X 2 daily
X1 day, strength
before determining patient is
intolerant
• OT: N/A • OT: consultation PRN
exercises • OT: consult for
• OT: X 1 daily
ADL’s
• OT: consultation PRN

Refer to the following criteria to Goals: Goals:


assist in determining mobility Goals: Goals:
• Move legs against • Stand w/ min. to Goals:
level: • Clinical stability • Move arms against gravity
gravity moderate assist • Perform some ADLs
• Tolerate passive ROM • Tolerate upright sitting
• • March in place •
• FiO2 < 60% Demonstrate Increase distance in

• PEEP < 10
readiness to weight • Weight bear and ambulation
bear transfer to chair
• O2 Sat > 90%
• RR 10 - 30 ACTIVITY ACTIVITY ACTIVITY ACTIVITY ACTIVITY
• No new onset cardiac
• HOB > 30º • Q 2 hr turning • Self or assisted Q2 hr • Self or assisted Q2 • Self or assisted Q2
arrhythmias or ischemia
turning hr turning hr turning
within past 12 hrs • Q 2 hr turning, • Passive/Active ROM
• HR: 60-120 bpm Passive ROM 2X/day 2x/day • Passive ROM 2x day • Passive ROM 2 x day
1. OOB to chair w/
• MAP: 55-140 mmHg • Bed in chair position • Active resistive PT once a • Active resistive PT at • Active resistive PT RN or PT assist
as tolerated day least once a day at least once a day minimum 3X/day
• SBP: 90-180 mmHg
• •
Initiate OT Continue OT 2. Consume meals
• No new or increasing Level I and II provided
by ICU/CVICU nursing or
Progressive Bed Chair Mode
while dangling on
vasopressor infusions 1. HOB 45º for +/- 15 min. Progressive Sitting 1. Bed sitting Position edge of bed or in
CNA staff
• MAAS > 3 2. HOB 45º, Legs dependent minimum of 20 chair
Role of the physician is for +/- 15 min. 1. Full chair mode X min. 3X/day 3. Ambulate
ensuring patient stability 3. HOB 65º, Legs dependent 20 min. 3X/day 2. Sitting on edge of progressively
Does This Patient Meet All Of
and mobility orders are for +/- 15 min. 2. Sitting on edge of bed; stand w/ RN longer distances
in EMR
The Above Criteria? 4. Full chair mode for 20 min. bed w/ RN or PT or PT assist with less
assist for 15 min assistance 2x/day
3X/day 3. Active Transfer to
or 3x/day
3. Pivot to chair 2X/day Chair (OOB) w/
YES NO assist minimum
3X/d
Start at Level Start at
II & Progress Level I

Tolerates Can move arms against Can move leg against Tolerates
Level I activities, lighten gravity. Tolerates gravity. Tolerates Level IV activities,
sedation & Level II activities, lighten Level III activities, minimize sedation &
progress to level II sedation & progress to level III minimize sedation & progress to level V
progress to level IV

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