Early Mobility in the ICU – Kelowna General Hospital
Kelowna General Hospital’s Intensive Care Unit became involved with the Safer Health Care Now Delirium Action Series in March 2011. This five session action series was based on the work by Dr. Wes Ely’s group out of Vanderbilt University icudelirium.org which is based on the A-B-C-D-E bundle (Awakening and Breathing Coordination, attention to the Choice of Sedation, Delirium monitoring, and Early mobility). This bundle is complex and involves some significant practice changes, so we have tried to focus on the five areas separately while understanding that they are all inter-related.
In November 2011 a member of our team visited Washington DC to attend an Institute for Healthcare Improvement seminar, Rethinking Critical Care: Reducing Patient Harm from Sedation, Immobility, and Delirium. The information from this workshop was brought back to our ICU group as we continue to try and move forward. Since every ICU patient has significant risk to develop ICU Delirium, we have tried to embed our approach within routine practice rather than trying to make an order set to direct care.
In January of this year we participated in the IHI Expedition: Mobility in the Intensive Care Unit. This five session webinar series explored the literature behind early mobility in the ICU, the role of the Physical Therapist (PT), developing a mobility protocol, and looked at case studies from sites that have been successful in implementing a mobility program.
To date at the KGH ICU:
- We have completed extensive in-servicing to ICU staff regarding ICU Delirium and made changes to our nursing documentation so that the CAM-ICU would be completed on every patient each shift and PRN.
- We have also completed education regarding the importance of identifying anything that can reduce the risk of developing ICU delirium i.e. family are to be encouraged to be at the bedside as much as possible, lights out and quiet at night, hearing aid and glasses as appropriate etc.
- We are currently updating our sedation protocol which will reflect the new sedation/analgesic/agitation guidelines recently published. This protocol will include choice of medication (i.e. avoiding benzodiazepines when signs of delirium are present), Daily Awakening Trials (DATs) and Spontaneous Breathing Trials (SBTs).
- We have our PT assess for mobility for each patient daily – it is written on the whiteboard in the patient’s room and on the kardex of the patient. The PT tries to facilitate the progression of each patient to maximum mobility.
- Our ICU has 11 beds for ventilated medical/surgical patients and 8 beds for non-vented medical/surgical patients. The culture on the non-vented side has embedded patient mobility as a standard piece of patient care. We are trying to spread that culture into the ventilated side of the unit as we continue to work towards mobilizing the more complex patient population.
The biggest challenge that we have experienced is the cultural belief that ventilated patients should be sedated and in bed until extubated. Many nurses express concern for patient safety if they are mobilized with ET tubes and advanced lines in place. Units that have implemented mobility programs have documented that there has not been an increased in unplanned extubations or loss of lines but our nurses have not entirely accepted this to be true. We are trying to start with the less complex patients to try and build confidence in the staff.
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Our approach has been collaborative with physician, nurse, respiratory therapists, and physiotherapist being invited to educational sessions but our PT takes the lead in encouraging early mobility for the patients. She will facilitate mobility by assessing the patients, making sure necessary equipment is available when needed, and then trying to be flexible with other care needs to ensure mobility is scheduled in the day.
Although we have a long way to go, we do feel that we have made some progress with this initiative over the past two years.
For more information, or to share resources, contact Crystal White, BSN, MSN, CCNC(C) at firstname.lastname@example.org.
- Baily P, Thomsen GE, Spuhler VJ et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007; 35(1):139-145.
- Barr J, Fraser GL, Puntillo K et al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Crit Care Med 2013; 41(1):263-306. doi: 10.1097/CCM.0b013e3182783b72.
- icudelirium.org retrieved from http://www.mc.vanderbilt.edu/icudelirium/
- Institute for Healthcare Improvement (IHI). An IHI Expedition: Mobility in the Intensive Care Unit. Five session Webinar series. 2012-2013. http://www.ihi.org/offerings/VirtualPrograms/Expeditions/MobilityintheICU/Pages/default.aspx
- Institute for Healthcare Improvement (IHI). Rethinking Critical Care: Reducing patient harm from sedation, immobility, and delirium. Seminar November 2nd and 3rd, 2011, Washington, DC. http://www.ihi.org/offerings/Training/RethinkingCriticalCare/2012MayICU/Pages/default.aspx
- Morandia A, Brummela NE, Ely EW. Sedation, delirium and mechanical ventilation: the ‘ABCDE’ approach. Curr Opin Crit Care. 2011; 17:43–49. doi:10.1097/MCC.0b013e3283427243
- Morris PE, Goad A, Thompson C et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36(8):2238-2243. doi: 10.1097/CCM.0b013e318180b90e
- Safer Healthcare Now (2011). Delirium Action Series: Reducing the Confusion. Five session Webinar series. http://www.saferhealthcarenow.ca/en/events/previousevents/pages/delirium-action-series-reducing-the-confusion.aspx
- Schweickert W, Pohlman MC, Pohlman AS et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial.The Lancet 2009; 373(9678):1874-1882. doi: 10.1016/S0140-6736(09)60658-9