EARLY MOBILITY AND WALKING PROGRAM FOR PATIENTS IN INTENSIVE CARE UNITS: CREATING A STANDARD OF CARE.

American Journal of Critical Care, May 2009 by Christiane Perme, Rohini Chandrashekar Summary: e! technolo"ies in critical care and mechanical #entilation ha#e led to lon"$term sur#i#al of critically ill %atients& An early mobility and !alkin" %ro"ram !as de#elo%ed to %ro#ide "uidelines for early mobility that !ould assist clinicians !orkin" in intensi#e care units, es%ecially clinicians !orkin" !ith %atients !ho are recei#in" mechanical #entilation& Prolon"ed stays in the intensi#e care unit and mechanical #entilation are associated !ith functional decline and increased morbidity, mortality, cost of care, and len"th of hos%ital stay& 'm%lementation of an early mobility and !alkin" %ro"ram could ha#e a beneficial effect on all of these factors& (he %ro"ram encom%asses %ro"ressi#e mobili)ation and !alkin", !ith the %ro"ression based on a %atient*s functional ca%ability and ability to tolerate the %rescribed acti#ity& (he %ro"ram is di#ided into + %hases& ,ach %hase includes "uidelines on %ositionin", thera%eutic e-ercises, transfers, !alkin" reeducation, and duration and fre.uency of mobility sessions& Additionally, the criteria for %ro"ressin" to the ne-t %hase are %ro#ided& /se of this %ro"ram demands a collaborati#e effort amon" members of the multidisci%linary team in order to coordinate care for and %ro#ide safe mobili)ation of %atients in the intensi#e care unit&A0S(RAC( 1R2M A/(32RCo%yri"ht of American Journal of Critical Care is the %ro%erty of American Association of Critical Care urses and its content may not be co%ied or emailed to multi%le sites or %osted to a listser# !ithout the co%yri"ht holder*s e-%ress !ritten %ermission& 3o!e#er, users may %rint, do!nload, or email articles for indi#idual use& (his abstract may be abrid"ed& o !arranty is "i#en about the accuracy of the co%y& /sers should refer to the ori"inal %ublished #ersion of the material for the full abstract& ,-cer%t from Article: ,arly Mobility in Critical Care ,AR45 M20'4'(5 A 6 7A48' 9 PR29RAM 12R PA(', (S ' ' (, S':, CAR, / '(S: CR,A(' 9 A S(A 6AR6 21 CAR, 0y Christiane Perme, P(, CCS, and Rohini Chandrashekar, P(, MS, CCS (his article is follo!ed by an AJCC Patient Care Pa"e on %a"e 222& ;c<2009 American Association of Critical$Care urses doi: =0&+0>?@aAcc2009B9C

e! technolo"ies in critical care and mechanical #entilation ha#e led to lon"$term sur#i#al of critically ill %atients& An early mobility and !alkin" %ro"ram !as de#elo%ed to %ro#ide "uidelines for early mobility that !ould assist clinicians !orkin" in intensi#e care units, es%ecially clinicians !orkin" !ith %atients !ho are recei#in" mechanical #entilation& Prolon"ed stays in the intensi#e care unit and mechanical #entilation are associated !ith functional decline and increased morbidity, mortality, cost of care, and len"th of hos%ital stay& 'm%lementation of an early mobility and !alkin" %ro"ram could ha#e a beneficial effect on all of these factors& (he %ro"ram encom%asses %ro"ressi#e mobili)ation and !alkin", !ith the %ro"ression based on a %atient*s functional ca%ability and ability to tolerate the %rescribed acti#ity& (he %ro"ram is di#ided into + %hases& ,ach %hase includes "uidelines on %ositionin", thera%eutic e-ercises, transfers, !alkin" reeducation, and duration and fre.uency of mobility sessions& Additionally, the criteria for %ro"ressin" to the ne-t %hase are %ro#ided& /se of this %ro"ram demands a collaborati#e effort amon" members of the multidisci%linary team in order to coordinate care for and %ro#ide safe mobili)ation of %atients in the intensi#e care unit& ;American Journal of Critical Care& 2009D=C:2=2$22=< 2=2 AJCC AM,R'CA J2/R A4 21 CR'('CA4 CAR,, May 2009, :olume =C, o& > !!!&aAcconline&or" e! technolo"ies in critical care and mechanical #entilation ha#e led to lon"term sur#i#al of critically ill %atients and a dramatic increase in the number of #entilator$de%endent %atients& ,ach year, more than = million %atients !ho re.uire mechanical #entilation are admitted to intensi#e care units ;'C/s< in the /nited States&= 'n addition to their comorbid diseases, %atients !ho re.uire mechanical #entilation ha#e many barriers to mobility& (hey are surrounded by catheters, tubes, and life su%%ort and monitorin" e.ui%ment& Mobili)ation is %ercei#ed as a com%le- task, and therefore these %atients are often treated !ith bed rest& After = !eek of bed rest, muscle stren"th may decrease as much as 20E, !ith an additional 20E loss of remainin" stren"th each subse.uent !eek& 7eakened muscles "enerate an increased o-y"en demand&2 (his !eakness %resents challen"es to !eanin" from #entilatory su%%ort& 0ed rest and inacti#ity are amon" the contributin" risk factors for 'C/$ac.uired neuromuscular !eakness, and a stron" correlation bet!een this ty%e of !eakness and %rolon"ed mechanical #entilation has been obser#ed&> 0oth res%iratory and limb muscle stren"th are altered after = !eek of mechanical #entilation, and res%iratory muscle !eakness is associated !ith delayed e-tubation and %rolon"ed #entilatory su%%ort&+

Considerable %ublished e#idence indicates that %atients in intensi#e care units ha#e hi"h morbidity and mortality, hi"h costs of care,B,F and a marked decline in functional status&F$C 1aced !ith the res%onsibility of addressin" these issues, health care %rofessionals ha#e been challen"ed to %romote im%ro#ed functional status early in the treatment of critically ill %atients& 'nterestin"ly, e#en hi"h$intensity e-ercises done in bed do not counteract the ad#erse effects of bed rest& (his findin" is related to the shift of intra#ascular fluid a!ay from the e-tremities to the thoracic ca#ity caused by the remo#al of "ra#itational stress& Assumin" an u%ri"ht %osition, ho!e#er, hel%s maintain an o%timal fluid distribution and therefore im%ro#es orthostatic tolerance& 2n the basis of these findin"s, it has been recommended that u%ri"ht %ositionin" be included in a mobility %lan of care&9 (he im%ortance of early !alkin" has been discussed before& 'n =9?2, 1oss=0 described a techni.ue for au"mentin" #entilation durin" ambulation of %atients recei#in" mechanical #entilation& 1oss also described the thera%eutic benefits of such %hysical acti#ity: an im%ro#ed sense of !ell$bein" and an increase in "eneral stren"th& 'n =9?B, 0urns and About the Authors Christiane Perme is a senior %hysical thera%ist at Methodist 3os%ital in 3ouston, (e-as& Rohini Chandrashekar is a %hysical thera%ist at (rium%h 3os%ital, Clear 4ake, in 7ebster, (e-as& Corres%ondin" author: Christiane Perme, P(, CCS, 6e%artment of Physical and 2ccu%ational (hera%y, Methodist 3os%ital ;M=$02+<, ?B?B 1annin, 3ouston, (G ??0>0 ;email: c%ermeHtmhs&or"<& Jones== ;in a letter to the editor< described use of a !alker that can accommodate the #entilator, o-y"en, and intra#enous catheters and has an attached bench !here the %atient can sit and rest& (hey also stated that %ro#idin" early ambulation for %atients recei#in" mechanical #entilation facilitated !eanin" from #entilatory su%%ort and minimi)ed the %roblems associated !ith %rolon"ed bed rest&== A similar #entilator !alker !as used successfully to rehabilitate a %atient !ho had com%lications after heart sur"ery and re.uired %rolon"ed mechanical #entilation&=2 'n one study,=> an acti#ity %rotocol !as %ros%ecti#ely a%%lied to all %atients !ith res%iratory failure !ho !ere admitted to an C$bed res%iratory 'C/& (he %rotocol !as started + days after mechanical #entilation !as initiated& (he e-tent of comorbid diseases did not necessarily affect !hen ambulation !as started or limit the ability of %atients to ambulate& 'n the same study,=> no e-tubations or com%lications that added to the %atient*s cost of care occurred& (he conclusion !as that early acti#ity in %atients !ith res%iratory failure is not only

feasible and safe, but also is an inter#ention that has the %otential to %re#ent or treat the neuromuscular com%lications of critical illness& 'n another study=+ in !hich a mobility %rotocol !as deli#ered by an 'C/ mobility team, both the 'C/ stay and the hos%ital stay !ere shortened for %atients !ith res%iratory failure !ho re.uired mechanical #entilation& 'n a 22$month %eriod, >09 ,#en hi"hintensity e-ercises done in bed do not counteract the ad#erse effects of bed rest& !!!&aAcconline&or" AJCC AM,R'CA J2/R A4 21 CR'('CA4 CAR,, May 2009, :olume =C, o& > 2=> (able = Physical thera%y e#aluation Re#ie! of medical and sur"ical history Pre#ious le#el of function Mental status Skin inte"rity Medications Cardiac status Pulmonary status eurolo"ical status Musculoskeletal status 1unctional assessment Physical thera%y "oals Physical thera%y %lan of care Physical thera%ists ha#e the e-%ertise to accurately assess neuromuscular function in 'C/ %atients& %atients !ere assi"ned to either a %rotocol "rou% or a non%rotocol "rou% !hen admitted to the 'C/& (he mobility team !as com%osed of nurses, nursin" assistants, and %hysical thera%ists&=+ Physical thera%y %rofessionals ha#e been considered %art of the interdisci%linary team that %ro#ides care for critically ill %atientsD ho!e#er, %ublished e#idence of the effecti#eness of %hysical thera%y in this area is limited&=B Physical thera%y in the 'C/ could include any of the follo!in" thera%eutic inter#entions: %ositionin"D educationD manual hy%erinflationD %ercussionD #ibrationD suctionD cou"hD ran"e of motion, stren"thenin", and@or breathin" e-ercisesD and mobili)ation& Althou"h mobili)ation in#ol#in" "ra#itational stimulus and ambulation of %atients !ho re.uire mechanical #entilation is recommended, such mobili)ation is not al!ays %art of the %hysical thera%y treatment& 2ne reason for that inconsistency could be the lack of a standard for the %hysical thera%y %rofession in 'C/s due to si"nificant differences in %ractice across hos%itals, 'C/s, countries, staffin" le#els, trainin", and e-%ertise& Althou"h res%iratory thera%y is an established %rofession in the /nited States, in most other countries, %hysical thera%ists !orkin" in the 'C/ are %rimarily res%onsible for air!ay clearance and res%iratory care& 0ecause the s%ecific role of %hysical thera%ists in the 'C/ is not !ell defined, it #aries considerably, and inter#entions are used at the discretion of each %rofessional& ,arly mobili)ation of critically ill %atients recei#in" mechanical #entilation is an ad#anced %hysical thera%y %ractice& Such mobili)ation re.uires education and s%eciali)ed skills in s%ecific areas that affect

the clinical decision makin" as !ell as the treatment %rescri%tion for such %atients& 9ait reeducation for %atients !ho re.uire mechanical #entilation in the 'C/ is the link bet!een bed rest and the ability to bear !ei"ht, !alk, and im%ro#e functional mobility&=F Physical thera%ists should be an inte"ral %art of the interdisci%linary team in the 'C/ in#ol#ed in the im%lementation of this %ro"ram, because %hysical thera%ists are in a uni.ue %osition !ith skills and e-%ertise to assess neuromuscular function accurately and to %ro#ide the a%%ro%riate rehabilitation techni.ues& (he %ur%ose of the early mobility and !alkin" %ro"ram is to %ro#ide "uidelines that can assist clinicians !ho !ork !ith %atients in the 'C/, es%ecially %atients recei#in" mechanical #entilation& (he %ro"ram facilitates the de#elo%ment of a treatment %lan !ith the focus on indi#idual functional ca%ability, %ro"ressi#e mobili)ation, and early !alkin" acti#ities& A thorou"h initial %hysical thera%y e#aluation is hel%ful for de#elo%in" a%%ro%riate "oals and a %lan of care for mobility of %atients in the 'C/ ;(able =<& 2n the basis of this information, %hysical thera%y "oals and an indi#iduali)ed %lan of care are outlined& At this %oint, the %atient is included in the a%%ro%riate %hase of the early mobility and !alkin" %ro"ram& (he %atient*s %hysician and the nurse should be a#ailable to assist in the decision makin" related to on"oin" medical issues& 6escri%tion of the Pro"ram (he %ro"ram is di#ided into + %hases and is easy to use ;(ables 2 and ><& (he information %ro#ided includes the ty%es of %atients for !hom each %hase is a%%ro%riate, bed mobility, transfers, "ait, thera%eutic e-ercises, %ositionin", education, and duration and fre.uency of mobility sessions& Additionally, "eneral criteria for %ro"ression of thera%eutic inter#entions are offered& (he early mobility and !alkin" %ro"ram %ro#ides a %ractical a%%roach to assist clinicians in the mana"ement of %atients in the 'C/, es%ecially %atients !ho re.uire mechanical #entilation& ,arly mobility can be defined as be"innin" the mobility %ro"ram !hen the %atient is minimally able to %artici%ate !ith thera%y, has a stable hemodynamic status, and is recei#in" acce%table le#els of o-y"en& ,m%hasis is %laced on %ro"ressi#e mobility, indi#idual functional ca%ability, and ambulation of %atients !ho meet s%ecific criteria& 9ood communication !ithin the 'C/ multidisci%linary team, !hich includes a %hysician, %hysical thera%ist, nurse, and res%iratory thera%ist, is crucial to %ro#ide a%%ro%riate mobili)ation, de%endin" on the %atient*s medical stability& Medical stability is 2=+

AJCC AM,R'CA J2/R A4 21 CR'('CA4 CAR,, May 2009, :olume =C, o& > !!!&aAcconline&or" (able 2 ,arly mobility and !alkin" %ro"ram for %atients in intensi#e care units Phase = 6escri%tion Patients in an acute %hase !ith multi%le medical %roblems, condition unstable at times, unable to fully %artici%ate !ith thera%y Also includes %atients !ithout si"nificant medical %roblems but !ith %rofound !eakness, limited acti#ity tolerance, and@or inability to !alk 2 Patients in an acute@ subacute %hase !ith multi%le medical %roblems, condition stable most of the time, able to %artici%ate better !ith acti#ities Patients still !eak but able to stand, also ha#e limited tolerance for acti#ity > Patients in an acute@ subacute %hase, !ith multi%le medical %roblems or resol#in" medical %roblems, able to %artici%ate acti#ely in thera%y Patients still !eak but able to tolerate increased le#els of acti#ity + Patients in a subacute %hase !ho ha#e been !eaned from mechanical #entilation, able to %artici%ate acti#ely in thera%y Patients !orkin" to!ard functional inde%endence and hos%ital dischar"e 9eneral criteria for Patient follo!s %ro"ressin" to ne-t %hase commands 3emodynamic status is stablea 2-y"enation acce%table Patient stands !ith !alker and tolerates %re!alkin" acti#ities, includin" I full standin" %osture I !ei"ht shiftin" on le"s Patient follo!s commands 3emodynamic status is stablea 2-y"enation acce%table Patient transfers to chair !ith !alker and assistance Patient safely tolerates !alkin" reeducation !ith !alker and assistance for limited distances 'nitiate transfer trainin" J Diakses pada a!""a# $% &a!'a(i da(i : htt%:@@!!!&britannica&com@b%s@additionalcontent@=C@>C90+9F2@,AR45$M20'4'(5$A 6$ 7A48' 9$PR29RAM$12R$PA(', (S$' $' (, S':,$CAR,$/ '(S$CR,A(' 9$A$ S(A 6AR6$21$CAR,