Progressive Mobility in the ICU

Move to Improve
Progressive Mobility in the Intensive Care Unit
Jordan R. Atkins, BSN, RN;
Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC

Bed rest has detrimental consequences, and therefore in the ICU,

progressive early mobility should be the goal for every patient expected
to survive. This article examines the consequences of immobility, barriers
experienced when attempting to increase patients mobility, and ways
in which dedicated mobility teams can overcome these barriers.
Keywords: Barriers to mobility, Bed rest, Intensive care units, Mobility
teams, Progressive mobility
[DIMENS CRIT CARE NURS. 2014;33(5):275/277]

The intensive care unit (ICU) is a complicated place, full

of critically ill patients, life-supportive monitoring, and
emotional peaks and valleys for patients, family members, and staff. Deconditioning is a major problem in ICUs.
For every day on bed rest, a person loses 1% to 2% of muscle mass; an average 1-week stay on bed rest can mean a
loss of up to 14% of muscle mass or more.1 Unfortunately,
in critically ill patients, deconditioning may also set into
motion a cascade of complications. These patients are at
increased risk for ventilator-associated pneumonia, atelectasis, muscle mass loss, and hemodynamic instability, in addition to other problems. Mobility is a way to combat those
complications, but it must start early. Thus, even though
patients are debilitated, it is important to remember the
level of functioning they had before admission and think
about the level they need to get back to by discharge. The
goal for every patient is to return to a level of functioning
that is meaningful. The best way to achieve that goal is
progressively. This article uses case studies to show the
importance of a progressive mobility protocol, discusses
barriers in trying to implement it, and concludes with the
evidence suggesting mobility teams as an excellent way to
ensure that mobility protocols are implemented.
PROGRESSIVE MOBILITY
In progressive mobility, start with a series of planned movements and build up to the goal of returning the patient to
the previous level of functioning. Assess the patients tolDOI: 10.1097/DCC.0000000000000063

erance to an activity while escalating to more physically

challenging activities, such as getting out of bed and ambulating. Active and passive range-of-motion exercises can
be done in the bed to begin an activity session. Most ICU
beds will place the patient into the chair and chair egress
positions. The chair position places the patient upright at
90 degrees with feet hanging down, as if sitting in a chair.
The chair egress position is for patients who have the
ability to move their legs against gravity and have trunk
control. This position is like the chair position, but the
footboard is removed from the bed, and the patient is allowed
to bear weight on the floor. Both are excellent weight-bearing
exercises for patients that the nurse can do without the
help of another staff member. Just putting a patient in the
chair position in the bed forces the patients body to use
muscles that the patient would not use if lying supine, while
at the same time challenging the body to remain hemodynamically stable with fluid shifts. From this beginning, the
patient can move to more mobility.

CASE STUDIES
Jordan (one of the authors) works in an ICU at High Point
Regional, a satellite facility of The University of North
Carolina at Chapel Hill Hospital, a major research institution. She has seen the importance of progressive mobility
firsthand. Carol was a typical COPD (chronic obstructive pulmonary disease) failure to wean, intubated patient.
She was transferred from a nearby hospital as a respiratory
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Progressive Mobility in the ICU

arrest and was intubated before arriving at our facility. She

was in the ICU for a few weeks, and based on the unit
protocols criteria, she was to be mobilized by using the
chair position in the bed and then being slid over to the
stretcher chair as tolerated. If she was lying in semi-Fowlers
or even on continuous lateral rotation, she was able to
remain hemodynamically stable with systolic blood pressures in the 130s to 140s mm Hg.
Jordan assisted Carols primary nurse to get her out
of the bed and into the stretcher chair for the first time. It
was an easy transfer, and the patient was sitting upright at
almost 90 degrees. Then, after almost an hour, the staff
noticed a change in her blood pressure: it was dropping. And
it continued to do so over the course of the next 2 hours.
The patient became so hemodynamically unstable that
she had to be placed on vasopressors in order to help her
body compensate for the fluid shifts from being upright.
Her inability to maintain her blood pressure is an
example of the importance of mobility. Lying still in the
bed, her body was not challenged with the fluid shifts that
occur when a person is upright with legs hanging down. If
we had had a dedicated mobility team following a progressive
mobility protocol, the move to the stretcher chair would not
have been such a shock to her, because she would have been
mobilized sooner, consistently, and with fewer complications.
Carol ended up needing a tracheostomy and was sent to a
long-term acute care facility.
As a result of Carols experiences and those of other,
similar patients, the facility implemented a progressive mobility team. Rex was one of our first success stories once
our progressive mobility team was in place. He was a cardiac arrest patient who was nearing death. He was in
multisystem organ failure, was unconscious, and for several days did not respond to staff or family. He ended up
on daily dialysis, but not much improvement was being
made. Talk of withdrawing care was beginning to come
up, but the night before the withdrawal date, Rex woke
up. He began responding to staff and opening his eyes. We
had already been using the bed for continuous lateral rotation while he was unresponsive, but now that he could
participate, we began more meaningful therapy. We used
the ceiling lift to get him out of the bed and into a recliner.
He was soon extubated without any respiratory complications, although the physical deconditioning had taken a
toll on him. Physical therapists helped the nursing staff
work on mobilizing him, starting with leg exercises. It was
a slow start, but it was something. Soon Rex was using the
sit-to-stand lift where he was weight bearing, moving from
sitting in the chair to standing! After a few days of using
the lift, Rex was able to sit on the side of the bed, stand,
and pivot to the recliner without the use of a lift. His liver
and kidneys regained function, and he was able to come
off of dialysis. Rex was moved to our step-down unit,
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Dimensions of Critical Care Nursing

where we continued to work with him daily. After about

2 weeks there, he was discharged to home, walking.
Those are 2 very different stories, and the difference
was the use of a mobility team. In the first case, we used
only nursing staff to mobilize Carol. When Rex came along,
we had developed a mobility team consisting of physical
therapists, respiratory therapists, and staff nurses. Also,
our intensive care physician is passionate about mobility
and helped to spearhead the movement.

DECONDITIONING
Physical deconditioning in critically ill patients is a problem. Just being in ICU compromises patients, never mind
adding other complications such as ventilator-associated
pneumonia, atelectasis, plasma volume loss, and muscle
mass loss. These complications are commonly seen but can
be prevented with progressive mobility. The sooner a patient is mobilized, his/her body begins to adjust to fluid shifts
preventing orthostatic hypotension. Also, lung complications
previously mentioned are less likely to occur, because as
the patient is mobilized, he/she tends to take bigger breaths,
increasing his/her tidal volume preventing atelectasis and
ventilator-associated pneumonia, which leads to shorter
ventilator days. Muscle mass is lost quickly and poses
threats of skin breakdown along with it. When pressure
ulcers begin to form because of bed rest, the patient is at
increased risk for infection, which could lead to sepsis
and in turn a longer ICU stay.

DEVELOPING MOBILITY PROTOCOLS

AND A TEAM
Developing a progressive mobility protocol is essential.
Mobility levels 1 to 5 are assigned to the patient based
on ability to participate in activity sessions. Each level has
a set of activities that the patient should be doing that day,
for example, getting out of bed to a chair or doing standing
exercises with the sit-to-stand lift and, eventually, walking.
Defining criteria include hemodynamic stability; arm,
trunk, and leg control; and level of consciousness and the
Richmond Agitation Sedation Scale score.
Given the complexity of the patients and equipment in
intensive care, these units need a dedicated mobility team
staffed with a physical therapist and assistant, occupational
therapist, respiratory therapist, and a registered nurse, whether
the patients primary nurse or not. Having a mobility team
allows for safe transfer of patients and more productive
activity sessions. Developing a team is crucial for success
of a progressive mobility protocol. Staff nurses cannot do
it all alone, and with budget cuts, many hospitals are not
hiring extra staff. We used our managers when building
our team. We noticed that our respiratory therapists often
had multiple units to care for and could not always be at
our call for ICU mobility, so their manager became our

Vol. 33 / No. 5

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Progressive Mobility in the ICU

mobility representative for the respiratory department. Now

the physical therapists assigned to our unit attend rounds
every morning with the nurses, our physician, nutritionists,
pharmacists, social workers, the chaplain, and the unit
coordinator to ensure they know the patients condition
and can help plan mobility for the day. The physical therapist does specialized exercises with the patient, and the
respiratory therapist is there to ensure that the patients
endotracheal tube and ventilator are stable and to protect
the patients airway. A registered nurse should always be
present during activity sessions to ensure patient stability
and monitor heart rate, blood pressure, and any central
catheters the patient might have.

BARRIERS
Jordan asked the nurses on her unit about barriers to early
mobility. Common answers were lack of staff and equipment. It takes a number of people to assist a critically ill
patient to get out of bed; that is why many times it does not
get done. Lack of staff is a common answer when ICU staff
are asked why patients are not being mobilized as early as
they should be. However, when a mobility team is in place,
this issue is solved. A lack of lifts and equipment was considered to be a barrier on the unit because not all of the
rooms had lift tracks built into the ceiling. When these
exist in each room, it is easier for nurses and other staff to
mobilize and navigate patients to the chair, and this eliminates the need for other equipment in the already small
rooms. Advanced ICU beds are an important tool in mobilizing patients. Many will assist with turning the patient, as
well as sitting them in a chair position. Beds with built-in
percussion and vibration help to decrease ventilator days by
increasing pulmonary function, thus improving mobility.
Still another barrier was nurses attitudes toward mobility. Nurses will say that they cannot get their patient out
of bed because the patient will not cooperate or is too
delirious, but that is not an acceptable answer. Intensive
care unitYinduced delirium can be an issue, but with adequate agitation assessments, and proper sedation, delirium
can be managed. Once sedation and delirium are balanced,
it is easier to mobilize the patient. With a team and protocol
in place, nurses have the assistance they need to get these
patients up and moving.2
Many nurses think it is easier to leave the person in the
bed, although in reality this creates more complications.
Prolonged bed rest leads to increased ventilator time, which
means a longer ICU stay, a longer hospital stay, and increased costs to the patient and organization. Studies have
shown that ICUs with a mobility intervention group have
reached milestones much sooner than those without a

dedicated mobility group, and ICUs with a mobility group

also see a decrease in delirium and ventilator days.3 These
are the positive patient outcomes we should be striving
for, and the best way to reach those outcomes is with a
properly trained, dedicated mobility intervention team.
Education on the proper use of sedation and on the
equipment and resources available to staff and the importance of getting patients out of the bed is imperative.
For example, the units mobility protocol along with the
Confusion Assessment Method for the Intensive Care Unit
(CAM-ICU) assessment could be made a competency checkoff. Everyone should receive refresher training on all of the
functions of the beds and lifts as well as ensuring staff understand how to accurately assess the patients CAM-ICU
and Richmond Agitation Sedation Scale. In addition, progressive mobility may need to become an explicit unit goal
or core measure. Then the units governance team can monitor how the unit is doing, and report the results to everyone.
Once a mobility team becomes the standard of care, everyone will see the results, including fewer complications,
shorter stays, more satisfied nurses, and happier patients
and families.

Acknowledgment
The authors thank Ms Elizabeth Tornquist, MA, FAAN,
for her the vision, inspiration, and editorial assistance
with this article.

References
1. Brower RG. Consequences of bed rest. Crit Care Med. 2009;
37(suppl 10):S422-S428.
2. Schweickert W, Pohlman M, Pohlman AS, et al. Early physical
and occupational therapy in mechanically ventilated, critically
ill patients: a randomised controlled trial. Lancet. 2009;373:
1874-1882.
3. Adler J, Malone D. Early mobilization in the intensive care
unit: a systematic review. Cardiopulm Phys Ther J. 2012;23(1):
5-13.

ABOUT THE AUTHORS

Jordan R. Atkins, BSN, RN, is a staff nurse at High Point
RegionalYUNC Health Care.
Donald D. Kautz, PhD, RN, CRRN, CNE, ACNS-BC, is an associate
professor of nursing at the University of North Carolina at Greensboro.
The authors did not receive funding for this work.
The authors have disclosed that they have no significant relationship
with, or financial interest in, any commercial companies pertaining
to this article.
Address correspondence and reprint requests to: Donald D. Kautz,
PhD, RN, CRRN, CNE, ACNS-BC, UNC Greensboro, PO Box 26170,
Greensboro, NC 27402 (ddkautz@uncg.edu).

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