Data presented today at the American Thoracic Society (ATS) annual meeting in San Diego, Calif., highlights a major gap in patient care in intensive care units (ICU) around the country. Research has demonstrated that patients in the ICU achieve significantly better outcomes when the process of "early mobility" – having patients sit, stand and move their bodies early in critical illness – is a systematic part of their care. Yet, a review of practices at hospitals throughout the U.S. and Europe shows that more than half of hospital teams do not regularly employ early mobility with patients and only about a quarter have a formal early mobility protocol.
Major professional organizations, including the Society for Critical Care Medicine (SCCM), the American Association of Critical-Care Nurses (AACN), and the American Nurses Association (ANA) all recommend adoption of early mobility practices. The study presented at ATS is the first international survey of how closely these recommendations are being followed. The data also will be presented this week at the AACN National Teaching Institute (NTI) meeting in Denver.
"Advances in medicine mean that many patients now survive critical illnesses treated in the ICU. However, a stay in the ICU bears its own risks," says William Schweickert, MD, Assistant Professor of Medicine, Hospital of the University of Pennsylvania. "A growing body of research shows that having patients become mobile early on in their recovery helps mitigate these risks and makes a significant difference in a patient's outcome."
Few Hospitals Have Protocols But Those That Do Achieve Better Outcomes
The research team surveyed nurse managers and directors of 951 medical and mixed-medical ICUs in the U.S., France, the U.K. and Germany. Respondents were asked about the existence of an established early mobility protocol in their facility and were interviewed about the use of early mobility practices in the absence of a formal protocol. In the interim analysis presented at ATS, 27 percent of those surveyed reported having an early mobility protocol in place, with an additional 21 percent reporting they have implemented early mobility practices in the absence of a standardized protocol. The majority (52 percent) reported having neither.
The most common practices reported by those surveyed included use of early mobility sessions twice daily, every day. In hospitals without a protocol but which employed early mobility practices, the sessions were most often initiated by physician order. In the minority of hospitals with an established mobility protocol in place, sites reported shorter patient stays in the ICU, a shorter overall length of stay in the hospital, and greater patient satisfaction.
"Our study shows that hospitals are struggling to translate the research supporting early mobility into practice in the ICU," says Rita Bakhru, MD, Assistant Professor of Medicine and Associate Medical Director, Medical ICU, Wake Forest School of Medicine. "We know early mobility works. In our survey, the institutions with an established protocol reported improved outcomes. The challenge is to help the majority of institutions who are not regularly using early mobility practices to overcome the barriers they face."
Overcoming Barriers to Early Mobility Protocols
Of the hospitals without early mobility protocols or practices in place, just under half had considered implementing one. Clinicians most often cited competing priorities, additional planning requirements, lack of therapy staffing, and concern about patient and caregiver safety as barriers to adoption.
"It is no secret that hospital teams are stretched thin," says Melissa Fitzpatrick, RN, MSN, FAAN, Vice President and Chief Clinical Officer at Hill-Rom. "But in the case of early mobility, adoption of a protocol doesn't have to be difficult. There are programs and support that can help clinicians to better understand how early mobility can help their patients. These can be implemented in a way that addresses caregiver safety while overcoming the challenges of a high acuity environment to enhance patient outcomes."
Hill-Rom developed the Progressive Mobility® Program to help clinicians simplify the process of adopting an early mobility protocol. The Progressive Mobility Program provides information, education, and materials to support hospital teams in training staff to incorporate the practices of early mobility into routine clinical workflow. The company's approach of providing a comprehensive package of people, products, and programs to support hospital staff is designed to overcome some of the barriers ICUs face in establishing an early mobility protocol.
About Early Mobility
Patients in intensive care units face increased risks for a variety of complications, including delirium, ventilator-associated pneumonia (VAP), muscle wasting, and pressure ulcers, among others. In addition, prolonged periods of immobility cause a host of physical problems in nearly every major system throughout the body, and can result in persistent muscle deconditioning and weakness, and a delayed (or derailed) return to baseline health status before the illness.
Research has found that helping patients become mobile very early in their recovery helps reduce the risks of immobility, improves outcomes, and reduces length of stay in the hospital.
Implementing an early mobility protocol requires first training physicians and nurses on its importance and then instituting standardized policies, practices, and procedures to ensure early mobility for every appropriate patient. Treatment protocols must be customized to the specific institution and necessary equipment installed, such as modern beds and patient lifts, to safely and effectively carry them out. The effort pays dividends for hospitals in the form of better patient outcomes and reduced costs.