Strategies to optimize early mobilization and rehabilitation in ICU patients

Delhi: There have been more than 40 randomized trials evaluating early mobilization and rehabilitation in intensive care units (ICU) in the last decade. Such trials aimed to reduce the incidence of ICU-acquired weakness (ICUAW) which is associated with poor long-term survival, physical functioning, and quality of life. At least eight international guidelines have recommended ICU early mobilization and rehabilitation

Implementation of ICU mobilization and rehabilitation remains highly variable despite supporting evidence and guidelines. Considering this, Carol L. Hodgson, Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia, and colleagues report 10 steps to help ICU clinicians in optimizing early mobilization and rehabilitation. 

Create multidisciplinary team with designated champions

Early mobilization and rehabilitation is more successful in ICUs with a culture that prioritizes and values this intervention. Mobility champions can help develop this culture using leadership and communication skills to educate, train, coordinate, and promote patient mobilization. 

Use structured quality improvement (QI) processes

A structured QI approach can greatly enhance successful implementation of early mobilization and rehabilitation [7]. One approach to QI includes four steps: (1) summarizing the evidence; (2) identifying barriers (e.g., sedation or lack of equipment); (3) establishing performance measures (e.g., sedation targets, frequency, and level of patient mobilization); and (4) ensuring all eligible patients receive the intervention (via appropriate engagement, education, execution, and evaluation).

Identify barriers and facilitators

There are many strategies to effectively overcome barriers, including implementation of safety guidelines; use of mobility protocols; interprofessional training, education, and rounds; and inclusion of physician champions.

Promote multi-professional communication

The multi-professional team effort required for early mobilization and rehabilitation program depends on optimal communication. We recommend that interprofessional communication is facilitated using a structure adapted to the individual ICU that allows (algorithm-based) mobilization goals, including an opportunity for all team members to raise concerns and ensure the flow of information regarding mobility goals and achievement across staff and overtime. 

Understand patient preferences

ICU patients' experience with early mobilization and rehabilitation is variable. It may be tiring, uncomfortable and difficult, while at other times be motivating and rewarding for patients.

Adopt safety criteria

Meta-analyses have demonstrated the safety of in-bed and out-of-bed ICU mobilization, with rare occurrence of serious events. One method of assessing safety is a traffic light system that provides specific criteria, across respiratory, hemodynamic, neurological, and other body systems, to be considered in mobilizing individual patients.

Implement care bundles for pain, sedation, delirium, and sleep

Patients' sedation and delirium status is a common barrier to early mobilization and rehabilitation. More broadly, pain, sedation, delirium, sleep, and early mobilization and rehabilitation are closely inter-related, as considered in clinical guidelines. Assessment and management of these issues, via existing evidence-based practices (as synthesized in the guidelines), are important to maximize patients' ability to participate in rehabilitation.

Obtain any necessary equipment

Barriers to early mobilization and rehabilitation may include ICUAW, impaired physical functioning, traumatic injuries, and obesity. Equipment can expand treatment options, increase patient mobility and activity levels, and reduce risk of injury to staff. electing rehabilitation equipment may be challenging, with important considerations including the equipment cost/availability, ability to share equipment between units or patients (including infection control considerations), and the physical space available for patient mobilization and for convenient storage of equipment.

Evaluate optimal timing, type, and dose of intervention

Important knowledge gaps exist regarding exercise, including the timing, type, and dose of interventions. There is some evidence suggesting that starting rehabilitation within 2 or 3 days of ICU admission may be superior to later initiation. Types of interventions to be considered include active functional mobilization, in-bed cycle ergometry, electrical muscle stimulation (with or without passive/active exercises), tilt tables, and use of various rehabilitation equipment. In addition, the intensity, duration, and frequency of each intervention type are important considerations.

Assess outcomes and performance

Mobility and rehabilitation-related measures, appropriate to the ICU setting and integrated into clinical care, are needed to set patient goals and track their progress, allocate scarce rehabilitation resources to those patients who may benefit the most, and conduct evaluations of structured quality improvement programs. Understanding patients' functioning prior to critical illness, and their own goals, are also important considerations.

Reference:

Hodgson, C.L., Schaller, S.J., Nydahl, P. et al. Ten strategies to optimize early mobilization and rehabilitation in intensive care. Crit Care 25, 324 (2021). https://doi.org/10.1186/s13054-021-03741-z