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Critical Care Medicine www.ccmjournal.org S69

Objective:To compare and contrast the process used to imple-

ment an early mobility program in ICUs at three different medical

centers and to assess their impact on clinical outcomes in criti-

cally ill patients.

Design:Three ICU early mobilization quality improvement projectsare summarized utilizing the Institute for Healthcare Improvement

framework of Plan-Do-Study-Act.

Intervention:Each of the three ICU early mobilization programs

required an interprofessional team-based approach to plan, edu-

cate, and implement the ICU early mobility program. Champions

from each professionnursing, physical therapy, physician, and

respiratory carewere identified to facilitate changes in ICU cul-

ture and clinical practice and to identify and address barriers to

early mobility program implementation at each institution.

Setting:The medical ICU at Wake Forest University, the medical

ICU at Johns Hopkins Hospital, and the mixed medical-surgical

ICU at the University of California San Francisco Medical Center.Results:Establishing an ICU early mobilization quality improve-

ment program resulted in a reduced ICU and hospital length of

stay at all three institutions and decreased rates of delirium and

the need for sedation for the patients enrolled in the Johns Hop-

kins ICU early mobility program.

Conclusion: Instituting a planned, structured ICU early mobility

quality improvement project can result in improved outcomes and

reduced costs for ICU patients across healthcare systems. (Crit

Care Med2013; 41:S69S80)

Key Words:barriers; critical care; early mobility; early mobilization;

ICU-acquired weakness; interprofessional; outcomes; physical

rehabilitation; quality improvement

More than 4 million patients are admitted to ICUs in

the United States each year, with 8090% of thesepatients surviving their ICU stay (1). A high propor-

tion of these ICU survivors experience significant cognitive,psychological, and physically disabling side effects of their criti-

cal illness, regardless of their admitting diagnosis, with nearlyhalf of these individuals being unable to return to their previous

work more than 1 year after hospital discharge (25). Delirium,a temporary alteration of cognition characterized by inattention

and disorganized thinking, occurs in up to 75% of ICU patients(6). Long-term neurocognitive disability also occurs commonly

in critically ill patients, especially those with acute respiratorydistress syndrome (ARDS) and delirium, and can persist for

months to years after hospital discharge (7). In patients withARDS, Hopkins and Jackson (810) reported cognitive impair-

ments in 78% of ICU survivors at the time of hospital discharge,and in 46% of these individuals 1 year later. Girard and col-

leagues (11) found that increasing duration of delirium in ICUpatients was an independent predictor of worse cognitive perfor-

mance at 3 and 12 months after ICU discharge. In a systematicreview of psychiatric morbidity in ICU survivors, Davydow and

colleagues (12) reported a prevalence of psychiatrist-diagnosedposttraumatic stress disorder at hospital discharge, 5 years, and

8 years to be 44%, 25%, and 24%, respectively.Disabling weakness and associated impairments in physi-

cal function in ICU survivors also occur commonly (13, 14).The frequency of these impairments is approximately 50% in

ICU patients with sepsis, multiple organ failure, or prolongedmechanical ventilation (15, 16). Recent retrospective studies

from separate medical, trauma, and surgical ICUs reveal thatat least half of patients discharged, regardless of age, are unable

to return to premorbid levels of activity due primarily to weak-ness and lack of endurance (3, 4, 17, 18). It has been theorized

that the weakness experienced by survivors of critical illness

arises in part from an interaction of inflammatory and meta-

bolic changes due to critical illness and is exacerbated by the

Copyright 2013 by the Society of Critical Care Medicine and LippincottWilliams & Wilkins

DOI: 10.1097/CCM.0b013e3182a240d5

1Department of Rehabilitative Services, University of California San Fran-

cisco Medical Center, San Francisco, CA.2Division of Pulmonary and Critical Care Medicine, Johns Hopkins Univer-sity, Baltimore, MD.

3Pulmonary and Critical Care Medicine, Wake Forest University School ofMedicine, Winston Salem, NC.

4Critical Care Medicine, University of California San Francisco MedicalCenter, San Francisco, CA.

Dr. Engel holds a consultancy with the Institute for Healthcare Improve-ment. Dr. Morris has received travel support from Hill-Rom and Covidien.The remaining authors have disclosed that they do not have any potentialconflicts of interest.

For information regarding this article, E-mail: [email protected]

ICU Early Mobilization: From Recommendation toImplementation at Three Medical Centers

Heidi J. Engel, PT, DPT1; Dale M. Needham, MD, PhD2; Peter E. Morris, MD3;

Michael A. Gropper, MD, PhD4
mailto:[email protected]:[email protected]

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Engel et al

S70 www.ccmjournal.org September 2013 Volume 41 Number 9 (Suppl.)

detrimental effects of prolonged bed rest commonly imposed

on ICU patient care (1922).Recognizing the need to address the diminished quality of

life (23) experienced by ICU survivors because of cognitive(24), psychological (25), and functional (26) impairment, a

Society of Critical Care Medicine (SCCM) stakeholders con-

ference convened in 2010 created the acronym postintensive

care syndrome (PICS) (27, 28). The stakeholders conferencemet to develop collaborative interprofessional improvementsin care to reduce PICS through increasing education about

PICS, identifying areas of needed research, and identifying bar-

riers to quality improvement (QI) initiatives aimed at reducingPICS (27).

Similarly, several expert panel recommendations for reduc-ing ICU survivor impairments have been proposed, including

wide spread implementation of: 1) the awakening and breath-

ing, coordination of delirium screening, and early mobilitybundle (29, 30); 2) the ICU Pain, Agitation, and Delirium

(PAD) care bundle, as part of the SCCMs 2013 ICU PAD

guidelines (31); 3) the World Health OrganizationsInternational Classification of Functioning, Disability andHealth model of assessment and care (32); and 4) recommen-

dations of the European Respiratory Society and European

Society of Intensive Care Medicine Task Force on Physiotherapyfor Critically Ill Patients (33). All of these include recommen-

dations for implementing treatment programs to improve ICUpatients physical, cognitive, and mental health impairments,

with structured rehabilitative patient physical activity timed

closer to ICU admission rather than ICU discharge (34, 35).The health benefits of physical activity for improving lon-

gevity, physical functioning and cognitive vitality in non-

ICU patients are well established (36), even for people withchronic ailments such as cancer (37) or heart disease (38,

39). Historically, critically ill patients have not been consid-ered appropriate for early physical activity because they were

deemed to be too medically unstable or were tethered to life-sustaining equipment. More recent evidence contradicts these

assumptions and has demonstrated that early mobility of ICUpatients is both safe and feasible (34, 4044). Furthermore,

early physical therapy and mobility of ICU patients is emerging

as an evidence-based strategy for preventing long-term neuro-cognitive and physical disability in these patients (7, 4548)

Despite the safety, feasibility, and efficacy of early mobility of

ICU patients, many ICUs struggle to create the culture changeand protocols needed to provide ICU patients with early physi-

cal activity (4951). The purpose of this article is to present theexperience of three academic medical centers in their estab-

lishment of ICU early mobility programs. These experiencesmay help other institutions in their creation of an ICU early

mobility program.

METHODSFew randomized control trials (RCTs) investigating the

effects of establishing an ICU early mobility program have

been published (48, 52), most likely because of the complex-

ity and expense of conducting an RCT of a physical activity

intervention in the ICU. As a result, the design of most studies

looking at the effects of implementing an ICU early mobility

program are either prospective cohort studies or before-after

studies following implementation of an ICU early mobility QI

initiative (34, 35, 43, 5355). The ICU early mobility programs

described in this article are from three separate institutions

that established such a program. Investigations at Wake Forest

University Medical Center in Winston Salem, NC (35), and atLDS Medical Center Intermountain Health in Salt Lake City,

UT (34), were among the first descriptions of ICU early mobil-

ity projects. Both projects served as models for a comprehen-

sive structured QI initiative at Johns Hopkins Hospital (JHH)

in Baltimore, MD (55), which in turn inspired a physical ther-

apist-driven initiative at University of California San Francisco

(UCSF) Medical Center in San Francisco, CA (54). The Wake

Forest (35), JHH, and UCSF ICU early mobility programs were

all QI projects (54, 55) created through a local and individu-

alized approach, with similar interprofessional collaboration

toward a synonymous goal.

As a means of retrospectively organizing the informa-tion provided from the three programs at Wake Forest, JHH,

and UCSF, the plan-do-study-act (PDSA) (56, 57) QI frame-

work has been applied to their description. The PDSA cycle

is part of the Institute for Healthcare Improvement Model

for Improvement (58). Each of the three ICU early mobility

programs followed steps similar to the PDSA model of QI ini-

tiatives, although on a different time line and without utiliz-

ing this specific format in the process. The PDSA process is

described in more detail in Table 1(56).

Planning Phase

All three ICU Early Mobility QI initiatives began with the for-mation of a group of critical care and rehabilitation clinicians

from each discipline that would be responsible for providing

early mobility interventions in the ICU. Wake Forest estab-

lished a mobility team consisting of critical care nurses, physi-

cal therapists, nursing assistants, and intensivist physicians to

create a mobility protocol designed to standardize early physi-

cal therapy in mechanically ventilated ICU patients. The pur-

pose of the project was to determine if early physical therapy

provided to patients within 72 hours of admission to the ICU

and 48 hours of intubation via an endotracheal tube was both

safe and feasible. The Wake Forest team hypothesized that the

previously published evidence of inconsistent and infrequentphysical therapy in the ICU (59) might be due in part to a lack

of protocol-driven practice for mobility. Because protocols

for other new practice patterns in the ICU such as weaning

from mechanical ventilation and daily sedation interruption

had led to previous improvements in patient care in their

ICUs (60, 61), they believed that the same approach could be

effectively applied to implementing a physical therapy/mobil-

ity program for mechanically ventilated ICU patients. In the

planning phase of the program, the interprofessional mobil-

ity team developed a protocol for early delivery of activity and

physical therapy in ICU patients consistent with the existing

nursing and physical therapy department policies. Eligibility

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criteria for ICU patients to receive physical therapy and early

mobility were strictly set. An ICU mobility team nurse withno direct patient care duties screened all patients for eligibil-

ity. The ICU mobility team rotated through various ICUs andwhen ICU patients met criteria, they received protocolized

care from the mobility team. Simultaneously, in ICUs at WakeForest without the mobility team according to the team rota-

tion schedule, ICU patients received usual care. Patients wereenrolled in the ICU mobility program at Wake Forest over a

2-year period (20042006). Of the 1,427 patients who receivedmechanical ventilation during this period, 330 patients met

eligibility criteria (35).Johns Hopkins cited the safety and feasibility of early

mobilization of mechanically ventilated patients previouslydemonstrated by Wake Forest and Intermountain Health (34,

35) as evidence to support the Johns Hopkins QI project forcreating an early physical medicine and rehabilitation for

patients with acute respiratory failure (55). Johns Hopkinscollected and analyzed baseline data to establish their low

rate of patients receiving physical therapy (PT) in the medical

ICU (MICU) before initiation of the QI project. They found

that only 24% of patients received PT consultations and that58% of these patients were treated with deep sedation that

would make participation in early mobility impossible (62,63). Similar to Wake Forest, Johns Hopkins established an

interprofessional team to guide their ICU early mobility QIproject. This project was funded through JHH and included

a broader patient population than Wake Forest because spe-cific study design criteria were not needed for this QI project.

All ICU patients who were mechanically ventilated 4 days orlonger and cognitively intact without neuromuscular disease

were included in the Johns Hopkins project. All eligible MICUpatients were enrolled in the ICU early mobility QI project at

Johns Hopkins over a 4-month period (May to August 2007),resulting in 30 patients receiving the intervention, and later

compared with 27 eligible patients receiving usual care beforethe QI study period.

Johns Hopkins adopted a structured QI approach (64)incorporating the following components: 1) understanding the

problem of immobility within the larger healthcare system; 2)

TABLE 1.Plan-Do-Study-Act Implementation Strategies

Plan:

Critically appraise the literature to select an evidence-based initiative.

Ensure QI team is interdisciplinary and represents key stakeholdersincluding frontline staff, quality champions, and keyexecutives.

Evaluate resources within institution to provide support. Anticipate changes in resource and personnel needs associated with process change; consider the opportunity costs of the

initiative.

Utilize QI tools to identify opportunities for improvement, including root cause analysis, fishbone diagrams, run charts, Paretocharts, and prioritization matrices.

Identify SMART (specific, measurable, achievable, relevant, timely) goals/targets.

Identify a champion of the QI effort in each department or stakeholder group; create a backup plan in the event of unexpectedloss of a champion.

Perform work-flow analyses to assess how the initiative will affect the work environment.

Consider pilot testing and stepwise implementation.

Design an easy-to-use measurement tool that is integrated into the workflow and provide incentives for its use.

Do:

Market the practice change with sound evidence provided in a concise format distributed to all stakeholders.

Remind clinicians of the process change using signage and compliance monitoring.

Communicate goals/targets and the time line for achievement.

Consider creating competition among various units to increase motivation and participation.

Ensure protocol or process change is effectively incorporated into practice through tools such as order sets: Create standardwork.

Verify validity of data collection.

Study:

Reevaluate protocol.

Obtain clinician feedback.

QI = quality improvement.

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creating an interprofessional improvement team; 3) enlisting

all stakeholders to identify barriers to change and appropriate

solutions; and 4) creating a change in practice through a 4Es

approach: engage, educate, execute, and evaluate. The inter-

professional team consisting of a physical therapist, an occu-

pational therapist, a part-time mobility technician, physician

coordinator and a part-time coordinator, as well as representa-

tives from nursing, the Director of the Department of PhysicalMedicine and Rehabilitation, and physicians from critical care,

physical medicine and rehabilitation, and neurology depart-

ments met weekly for 1 year during the planning phase of the

project, in order to strategize and evaluate the issues and barri-

ers to implementing an ICU early mobility program. Education

of all clinical ICU staff as to the potential benefits of increas-

ing early physical medicine for the ventilated ICU patients and

lightening sedation was provided through the use of staff news-

letters, posters, ICU patient testimonials to the staff, and pre-

senting educational research summaries at staff meetings and

conferences. Outside experts with firsthand experience in imple-

menting ICU early mobility programs were brought in to meetwith members of the interprofessional mobility team. Mobility

team members were also sent to other institutions with existing

ICU early mobility programs. All MICU nurses were exposed

to educational sessions describing the benefits and feasibility of

maintaining light levels of sedation for patients in their clini-

cal practice in order to enable patients to actively participate in

physical therapy (PT) and rehabilitation activities.

The JHH added one full-time PT and one full-time occu-

pational therapist (OT) and a part-time rehabilitation assis-

tant to the clinical staff to help facilitate implementation of

their early mobility program. In contrast to the Wake Forest

experience, Johns Hopkins did not have standing orders forscreening all ICU patients, but instead they assigned a clinical

coordinator to screen all ICU patients at admission for appro-

priateness for early rehabilitation. Johns Hopkins also did not

employ a protocol for implementing their ICU rehabilitation

program. Rather, they changed the admitting activity order

set from the default of bed rest to as tolerated, plus they

established and disseminated simple guidelines for ordering

PT and OT consults. Utilizing the existing literature at the time

(34), the Johns Hopkins group also established safety exclusion

criteria for all patients being evaluated for early mobility and

rehabilitation. This planning phase of engaging and educating

staff before executing the QI project lasted approximately 12months, which was followed by a 4-month QI period with the

ICU rehabilitation team continuing to meet weekly during this

period to assess progress and barriers to wide spread imple-

mentation. Data collected during this 4-month QI period were

then compared with data prospectively gathered on the same

qualifying MICU patient population for 3 months before the

QI start.

The approach to planning an ICU early mobility QI project

at UCSF was modeled after the experience of Johns Hopkins

and was similar in many ways. As with both the Wake Forest

and Johns Hopkins projects, an interprofessional early mobility

committee was created at UCSF, consisting of representatives

from PT, nursing, ICU nurse practitioner, critical care physi-

cians, respiratory therapy, and medical center administration.

The UCSF QI project leaders were responsible for establishing

guidelines for ICU patient eligibility, promoting the evidence

base for early mobility, educating across and within clinical

disciplines, and making a case for adding additional clinical

staff in the ICU to help facilitate an ICU early mobility pro-

gram. Rather than limit the intervention to only mechanicallyventilated patients, the UCSF project sought to include all

medical-surgical ICU patients in order to assess the feasibil-

ity and benefits to providing early mobility to medically com-

plex surgical patients, a population which was not included in

previous published studies of ICU early mobility programs in

the United States. The UCSF Executive Director for Service

Lines served as the administrative representative on the QI

project and was instrumental in helping to create the program.

Utilizing the financial model developed at Johns Hopkins,

which demonstrated significant financial savings associated

with an ICU early mobility program, despite additional staffing

costs (55, 65), she demonstrated the potential financial benefitof implementing an ICU early mobility program at UCSF to

medical center administrators, convincing them to allocate 1

full-time PT to this ICU QI project for a 9-month period.

Similar to Johns Hopkins, preparation at UCSF (66)

included a site visit to a hospital with an established ICU early

mobility program, and experts from outside institutions were

invited to share their experiences with UCSF staff. A promo-

tional campaign including educational presentations made to

all UCSF staff, newsletters, and posters was utilized to engage

everyone in the process of promoting widespread early mobil-

ity of ICU patients. ICU mobility guidelines, which included

inclusion and exclusion criteria for mobility, were created inorder to help staff to readily identify eligible ICU patients.

The UCSF mobility QI group felt that it was important not to

implement a strict ICU mobility protocol because this might

result in some patients not receiving mobility who would oth-

erwise safely benefit from this treatment. During the 9-month

ICU early mobility QI study period (March to December

2010), 294 ICU patients received early PT. At initiation of the

QI period, the UCSF physical therapists created a flow sheet to

guide individual patient treatments with the goal of providing

an optimal intensity of mobility tailored to each patients abil-

ity during their early mobility sessions. The UCSF flow sheet

and exclusion criteria are included in the Figure 1(54).

Doing Phase

Ongoing data collection and analysis of both process and out-

come measures is a critical aspect of any QI project (67). The

group at Wake Forest collected data on patient demograph-

ics including all medications, central lines, rates of ventilator

associated pneumonia, deep vein thrombosis, reintubation,

and pulmonary embolism. Outcome measures included the

number of patient ventilator days, days until first episode out

of bed, ICU and hospital length of stay (LOS). Patients who

met eligibility criteria in the intervention group triggered an

automatic referral for PT even if they were not awake and alert

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Figure 1.Daily mobility assessment and treatment. MD = physician, NP = nurse practitioner, RASS = Richmond Agitation-Sedation Scale, PT = physicaltherapy, CAM-ICU = the Confusion Assessment Method for the ICU, PEEP = positive end-expiratory pressure, MAP = mean arterial pressure, CVA =cerebrovascular accident, SAH = subarachnoid hemorrhage, ICH = intracerebral hemorrhage.

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at the time. Patients who were unable to actively participate

received passive range of motion exercises three times per day

from mobility technicians until they were able to actively par-

ticipate. At which point, they began working with the physical

therapist, progressing along a four-stage mobility treatment

protocol.

Researchers at Wake Forest hypothesized that the perceived

dangers of lightening patients sedation (i.e., dislodging endo-tracheal tubes or catheters, stressing and destabilizing critically

ill patients in respiratory failure, etc.) prevented most mechan-

ically ventilated patients from being awake and mobile in the

ICU (6870). However, in the Wake Forest study, there were no

adverse events associated with patient participation in mobil-

ity activities (i.e., death or near death, need for reintubation,

or accidental removal of a device), demonstrating that active

physical therapy by ICU patients during their ICU stay was

both safe and feasible. The most frequent reasons for terminat-

ing a mobility session was patient fatigue without a significant

change in the patients vital signs.

Data collection for the ICU mobility QI project at JohnsHopkins was used to evaluate the projects performance and

impact on patient care and for providing ongoing incentives

for continued staff buy-in and support of early mobility in ICU

patients. The JHH team had two primary objectives that com-

plimented and reinforced each other. The first objective was

to encourage a change in nursing sedation practice in the ICU

to reduce the doses of sedative medications patients received

without causing any added discomfort. This was accomplished

by changing their routine sedation practice of administering

continuous IV infusions of benzodiazepines and narcotics, to

as-needed IV bolus doses of these medications (71, 72). The

second objective was to increase the number of ICU patientsreceiving physical medicine and rehabilitation, ideally within

48 hours of their admission to the ICU. The referral for physi-

cal therapy and the progression of patient mobility was not

automatically driven by either protocols or order sets; rather,

initiation of early mobility for patients relied upon a QI project

coordinator to assess each patients readiness for rehabilitation

therapy, based upon mobility screening guidelines devel-

oped by the mobility QI team. Implementation of the Johns

Hopkins program was systematically phased in, starting with

a small number of ICU patients, and then sharing these early

patient success stories with staff to build staff buy-in and sup-

port for the program before implementing the early mobilityprogram more broadly in the ICU. Part of the success of this

approach was demonstrating the safety of each ICU patient

mobility session to ICU staff and family members and being

transparent and proactive about preventing and dealing with

adverse events. Johns Hopkins recorded only four unexpected

events during PT sessions, which involved dislodging either

rectal tubes or feeding tubes without any significant medical

consequence for these patients. They consulted a physiatrist for

all MICU patients receiving rehabilitation therapy, increased

the number of neurology consultations obtained for these

patients, and actively collaborated with other clinical services

at Johns Hopkins.

In addition to recording data for patient demographics,

critical lines, and adverse events as Wake Forest had, the Johns

Hopkins QI project collected data on delirium screening,

medication dosing, the number of PT consultations obtained,

and the frequency and type of mobility activity used for each

patient. Baseline data for the 3-month period before the start

of the QI project were compared with similar data collected

during the 4-month QI intervention period. The short timeline for this before and after comparison enabled the QI team

to establish a sense of urgency with concrete goals and dead-

lines in order to avoid dilution of the intervention and keep the

momentum going to establish new practice patterns.

The early mobility QI project at UCSF was modeled after

the Johns Hopkins program, but did not have a project man-

ager or a reliable system for data collection. The UCSF project

was facilitated and organized by the treating PT in the ICU who

established an interprofessional group to help implement this

program. The UCSF project relied heavily on critical care nurse

practitioners (NPs) working in the ICU to determine patient

readiness for PT based on exclusion guidelines developed bythe ICU physical therapist together with other members of the

interprofessional critical care group. Critical care NPs were

granted the authority by the UCSF Medical Executive Board

to write referrals for PT for patients, as a means of increas-

ing the frequency of PT consults, and timing them closer to

patients admission to the ICU, rather than having all PT con-

sults be physician driven. During the 9-month pilot interven-

tion phase, physical therapists and rehabilitation department

aides recorded the number of days from ICU admission to

initiation of PT, daily functional mobility performed with a

physical therapist, and their distance walked. ICU and hospi-

tal LOS and disposition upon patient hospital discharge wereextracted from medical records and retrospectively analyzed by

staff from the Department of Rehabilitation Services at UCSF.

This data collection process was perceived by the UCSF team

to be lengthy and cumbersome and led to significant delays

in communicating the impact of this program on ICU patient

care, making it difficult to build widespread buy-in and sup-

port from ICU staff and hospital administrators.

Studying Phase

Once established, the early mobility programs were assessed for

barriers encountered, effectiveness of the protocols and referral

systems, and cost effectiveness. At Wake Forest, the percentageof MICU patients who underwent at least one physical therapy

session at any time during their hospital stay in the usual care

group was 47.4%, versus 80.0% in the protocol group. Of the

usual care group who received PT, 12.5% initiated it in the ICU

compared with 91.4% of patients in the protocol group. The

Wake Forest team attributed this difference to having clinical

staff dedicated strictly to facilitating patient mobility in the

ICU, an interprofessional ICU mobility team, and protocols

for initiating and delivering PT. The barriers highlighted by

the structure of this QI project are apparent for the usual care

group, but are not mentioned for the protocol group. Wake

Forest also found a significant difference between the usual

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care group and the protocol group in terms of ICU and hos-

pital LOS. The adjusted ICU LOS was 6.9 days for usual care

group versus 5.5 days for the protocol group. The hospital

LOS was 14.5 days for the usual care group versus 11.2 days

for the protocol group. When analyzing the financial impact

of their early mobility program, Wake Forest found the total

direct inpatient costs for the protocol group, inclusive of the

mobility team salaries, were $6,805,082 versus $7,309,871 indirect inpatient costs for the usual care group. This represents

a net savings of over a half a million dollars in direct patient

care costs following implementation of the ICU mobility pro-

gram at Wake Forest.

Johns Hopkins reported similar results when analyzing

their QI project and has since published detailed accounts of

both clinical and financial impacts of implementing an ICU

early mobility program (63, 65, 66, 73, 74). The percentage of

patients receiving either PT or OT in their MICU increased

from 70% to 93%, and the median number of PT/OT treat-

ments per patient increased from 1 in the pre-QI period to 7

during the QI period. The average ICU LOS across all MICUpatients decreased during the QI period by 2.1 days, and hos-

pital LOS for the QI period MICU patients decreased by 3.1

days (55). Johns Hopkins published a detailed assessment of

barriers to developing and implementing their early mobility

QI project (63, 66), which included: a need for both institu-

tional and project leadership; additional staffing and equip-

ment; increasing physician referrals for PT closer to patient

ICU admission; and management of patients pain, delirium,

and tolerance for activity and safety. Strategies used to over-

come these barriers are summarized in Table 2. Johns Hopkins

financial assessment of their early mobility QI project demon-

strated a net financial savings for the institution despite theinvestment costs of added staffing salaries. Combining their

cost data with similar data from other institutions with suc-

cessful ICU early rehabilitation programs, Johns Hopkins

created a financial model for estimating the net cost savings

of implementing an ICU early mobility program. Based on

a variety of scenarios ranging from conservative to best case,

they estimated a projected net cost of $87,611 in the most

conservative scenario and a projected net savings $3,763,149

in the best-case scenario, with the model predicting a signif-

icant net cost savings for most early mobility program cost

scenarios (65).

The design of the UCSF project benefitted from the dem-onstrated savings recorded from the Johns Hopkins QI proj-

ect. Although this information was unpublished at the time,

Johns Hopkins agreed to collaborate and share their financial

data with UCSF. This allowed the UCSF ICU early mobil-

ity administrative champion to take UCSF medical/surgical

ICU demographics and to create a UCSF-specific financial

model based upon a relatively conservative cost-benefit sce-

nario. UCSF estimated a net savings following implementa-

tion of their ICU early mobility program, including the costs

of adding an additional physical therapist in the ICU. As a

result, they were able to get approval and funding for this PT

position from the chief operating officer for the 9-month QI

pilot period. Financial analysis at the end of the pilot period

demonstrated that sufficient net savings were generated, so

that the full-time ICU PT staff position was kept indefinitely,

and additional staff were added to allow the program to be

expanded. Despite the addition of a full-time physical thera-

pist in the ICU, there was still a significant lack of nursing

and other ICU staff to help facilitate the labor intensive pro-

cess of helping critically ill patients transfer out of bed andbecome more mobile. This labor shortage was addressed in

part through the creation of an accredited ICU PT elective

for physical therapy students from the San Francisco State

University/UCSF Graduate Program in Physical Therapy.

These students were assigned to the ICU in order to gain

firsthand experience in helping to facilitate PT activities in

critically ill patients, while providing aide/mobility techni-

cian support for academic credit.

The interprofessional early mobility group at UCSF met

every 2 weeks during the QI period and assessed the project

for barriers (54), strategized solutions, and searched the litera-

ture or consulted experts at professional meetings to resolveprogram barriers (Table 2). Regular updates summarizing

program progress and clinical improvements associated with

early mobility in the ICU were made available to ICU staff and

all staff through posters, e-mails, and presentations at medi-

cal center-wide rounds. After implementation of the ICU early

mobility program at UCSF, the median number of days from

ICU admission to initial PT evaluation decreased from 3 days

to 1 day, and the median distances that patients walked in the

ICU increased from 40 to 140 ft. Similar to the experiences at

Wake Forest and Johns Hopkins, median ICU LOS at UCSF

decreased by 2 days, and median hospital LOS decreased by

2 days (54).

Acting Phase

Success of any QI project requires action well beyond the ini-

tial recorded achievements to sustain the new practice patterns

through a process of refinement, communication via internal

announcements as well as external publishing, and standard-

izing the new systems. In 2008, Wake Forest published their

QI project and demonstrated that early physical therapy com-

pared with a group receiving usual care was associated with

significant improvements in clinical outcomes for ICU patients

(35). Other institutions such as Johns Hopkins and UCSF were

able to subsequently cite this evidence as a rationale for devel-oping and implementing ICU early mobility and rehabilitation

programs at their facilities in order to improve ICU patient

outcomes. In 2011, Wake Forest published a 1-year follow-up

report that looked at the long-term outcomes of ICU survi-

vors managed under the ICU early mobility project (48). This

report demonstrated that ICU patients who had not received

treatment as part of the ICU early mobility program were at

higher risk of death or hospital readmission within 1 year of

hospital discharge, as compared with patients who received

early ICU PT (75). The initial QI project at Wake Forest also

provided the preliminary data needed to continue an ongoing

randomized controlled study for ICU early mobility.

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Johns Hopkins has since expanded their program and have

published several articles on their clinical experiences and the

economic impacts of their ICU early mobility program (7,

18, 76, 77). Johns Hopkins has also developed an interprofes-

sional continuing education course on early mobility of ICU

patients, which to date has been attended by critical care prac-

titioners from several countries (78). The ICU early mobility

program at Johns Hopkins continues to innovate and improvetheir ICU early physical medicine and rehabilitation program

by trialing new rehabilitation equipment (79, 80) and treat-

ment strategies (73, 81, 82).

The ICU early mobility program at UCSF is also expand-

ing and sustaining its momentum. An additional full-time PT

position has been added to the second mixed medical-surgical

ICU at UCSF, and a full-time mobility technician has now

been added to the program. Continuing education courses are

offered to the interprofessional critical care community from

UCSF. Funding sources are expanding to include research

grants that assist in providing data collectors and research

coordinators to help to assess the impacts of early mobility in

ICU patients. Publishing efforts by UCSF critical care person-

nel (46) further motivate the staff to continue the their early

PT efforts in the ICU.

DISCUSSIONThe long-term disabling impacts to patients caused by criti-

cal illness are becoming clearer (5, 8385). Providing earlyphysical medicine and rehabilitation to critically ill patients

as a way of improving their quality of life both functionally

and cognitively after they leave the hospital is in keeping with

the expressed goals of patients themselves (86, 87). Despite the

many barriers to developing and implementing the delivery of

this new practice pattern (50), it is imperative to the growing

numbers of ICU survivors that we address these issues (88).

A systematic approach of collaborative QI, implemented by an

interprofessional team of early physical rehabilitation in the

ICU as outlined by the experiences of three institutions here, is

a reproducible treatment strategy. Hopefully, it will encourage

widespread adoption of ICU early mobility programs, while

TABLE 2.Barriers to Early Mobility Encountered and Solution Strategies

Barriers Wake Forest Johns Hopkins University of California San Francisco

Lack of leadership Recruitedinterdisciplinaryteam

Recruited interdisciplinary team withan overall physician leader for theproject

Recruited interdisciplinary team with a PTleader and physician head of criticalcare support

Lack of staffing andequipment

QI program fundedaddition of mobilityteam

Conducted as QI pilot program

Staff added conditional to outcome

Conducted as QI pilot program

Staff added conditional to outcome

PT students taking ICU elective

Lack of knowledge andtraining

Literature review

Protocol

Education from champions to staff

Education across disciplines

Interprofessional consensus policywritten

Site visit to established ICU earlymobilization program

Education from champions to staff

Education across disciplines

Interprofessional consensus policyphysical therapist/written

Site visit to established ICU earlymobilization program

Lack of physicianreferrals for PT

Automaticphysicians order

Project coordinator screening PT and ICU nurse practitioner rounds

Inquiry at professional meetingsOver-sedation Continuous education and

reinforcement from championphysician for use of bolus ratherthan infusion sedation

Staff meeting education

Delirium Screening

Minimize sedation

Mobilize

Screening

Minimize sedation

Mobilize

Patient hemodynamictolerance of activity

Specific protocol Created exclusion guidelines

PT daily screening

Created exclusion guidelines

PT daily screening

Safety Prospectively setadverse eventsrecorded

PT and occupational therapyemphasis on untangling linesbefore therapy

Retrospective analysis of incident reports

QI = quality improvement, PT = physical therapy.

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encouraging a more rigorous approach to clinical research

on this issue with larger, multicenter studies looking at boththe effects on outcomes and costs, and identifying best clini-

cal practices, in order to improve the quality of life for ICUsurvivors.

Although significant differences in ICU cultures, personnel,institutional knowledge about early ICU rehabilitation, and

funding resulted in varying approaches to the developmentand implementation of an ICU early physical rehabilitation

program across these three institutions (89, 90), some com-mon themes emerge here which may serve as a guiding set of

principles for other hospitals and healthcare systems lookingto establish ICU early mobility and rehabilitation programs.

A detailed initial planning phase by an interdisciplinary teamis essential. The Johns Hopkins program makes a compelling

case for developing and implementing a structured QI projectthat was applied to all mechanically ventilated MICU patients

with respiratory failure, in order to keep the implementation

of the intervention on track and to keep ICU staff moti-

vated to change their practice patterns. On the other hand,the Wake Forest approach of starting on a small scale with a

select population of ICU patients and demonstrating successbefore expanding the program more broadly may also help

to facilitate implementation. It is also important to identify aclinical champion to lead an ICU early mobility effort, some-

one who works in the ICU and understands its culture andworkflow. But as the UCSF program demonstrates, a clinical

champion does not necessarily need to be an ICU physician,although support from ICU physician leadership is essential.

Both process and outcome measures must be identified at thebeginning of the project and tracked over time to evaluate

the effectiveness of the project. The interprofessional mobil-ity team needs to assess data and then work collaboratively

to overcome programmatic barriers identified during the QIprocess. Information about the progress and successes of the

project need to be communicated frequently and consistently

TABLE 3.Comparison of Three ICU Early Mobility Quality Improvement ProjectsQuality Improvementfor Early Mobility Wake Forest Johns Hopkins

University of California SanFrancisco

Objective Reduce immobility andweakness with early PT forMICU patients

Optimize patient sedation

Provide early PM&R in the ICUfor MICU patients

Provide earlier and more frequentPT in the ICU for MICU andsurgical ICU patients

Planning time frame 1 yr 1.5 yr

Comparison group n= 165 control group n= 27 retrospective comparison n= 179 retrospective comparison

Intervention group andtime frame

n= 165 patients on MV

20042006

7 days/week mobility

n= 30 on MV

2007


n= 294 all ICU patients

2010


Number of addedpersonnel and titles

1 registered nurse, 1 certifiednursing assistant, 1 physicaltherapist, 1 project manager

1 physical therapist, 1occupational therapist, 1technician, 1 coordinator, 1part-time assistant coordinator

1 physical therapist, 1 part-timeaide

Equipment added None 2 wheelchairs ICU platform walker

Outcome measures Days until out of bed

Frequency of therapy

ICU/hospital LOS

Adverse events

Percentage of ICU patientsreceiving PT

ICU/hospital LOS

Pain/delirium scores

Adverse events

Number of days to initiating PT

ICU/hospital LOS

Distance walked in ICU

Discharge disposition

Incident reports

Financial analysisperformed?

Yes Yes No

Expanded to other ICUs? Yes Yes Yes

Results Safe and feasible earliermobility

Increased number of patientsreceive ICU PM&R

Patients receive increasednumber of treatments

Decreased ICU and hospitalLOS

Net cost savings

Same results as shown in WakeForest plus:

Decreased dosages of sedatingmedications

Decreased patient delirium rates

No change in patient reportedpain scores

Same results as shown in WakeForest plus:

Applied to medical and surgical allICU patients

Increased distance patients walkedin ICU

Increased percentage of patientsable to discharge to home ratherthan rehabilitation facility

PT = physical therapy, MICU = medical ICU, PM&R = physical medicine and rehabilitation, MV = mechanical ventilation, LOS = length of stay.

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to both internal and external stakeholder groups, including

ICU staff, administrators, and patients and their families, in

order to gain widespread buy-in and ongoing support for

change, and to directly engage these individuals in improv-

ing the program over time. Finally, development of a business

model that includes a financial analysis of the local-associated

costs and savings of an ICU early mobility and rehabilitation

program will facilitate approval for additional resources from

hospital administrators. Table 3 provides a summary of the

full QI projects described in this article.

CONCLUSIONSEarly mobility and rehabilitation of critically ill patients is asso-

ciated with significant improvements in both short- and long-

term physical and neurocognitive outcomes in ICU survivors.

This article summarizes the development, implementation,

and clinical and economic impacts of ICU early mobility pro-

grams at three different institutions. The examples provided

here may help facilitate the development and implementation

of similar ICU early mobility and rehabilitation programs at

other facilities.

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