Running head: EARLY MOBILIZATION IMPACT ON ICU LOS 1

Early Mobilization Impact on Intensive Care Unit Length of Stay

Jennifer Leuzinger

University of Central Florida

EARLY MOBILIZATION IMPACT ON ICU LOS 2

Abstract

The Affordable Healthcare Act continues to strongly influence the ongoing development of a

more cost-effective health-care system. Critical care services are responsible for 25% of the total

hospital budget. Intensive care unit (ICU)-acquired complications prolong ICU length of stay

(LOS) and consequently increase hospital expenditures. Research into feasibility and efficacy of

early mobilization on patients in the ICU is being conducted with primary outcomes of LOS and

days requiring mechanical ventilation. Research articles were selected for review by use of the

following search engines; CINAHL, MEDLINE, The Cochrane Central Register of Controlled

Trials, and The Cochrane databases of Systematic Reviews (CDSR), PsycINFO, and

SPORTDiscus. All ten articles included in the review examined the impact of early mobilization

on ICU LOS, nine evaluated hospital LOS, and six articles analyzed mechanical ventilation days.

Six studies consisting of 8,913 adult ICU patients resulted in a significant reduction in ICU LOS.

Four of the studies demonstrated a decrease in hospital LOS. Only 2 of the articles with a sample

size of 181 patients resulted in fewer days requiring mechanical ventilation. There is variability

amongst the studies in regards to setting (multi-center, specialized versus mixed ICU, and

international) and admission diagnoses. Three of the studies used retrospective designs. On day

one of ICU admission daily inter-disciplinary rounding evaluating the appropriateness for early

mobilization is recommended due to the positive results of increased physical therapy time,

decreased time until first session, and significant reduced ICU LOS.

Keywords: early mobilization, intensive care unit, length of stay, mechanical ventilation
EARLY MOBILIZATION IMPACT ON ICU LOS 3

Early Mobilization Impact on Intensive Care Unit Length of Stay

Background and Significance

The Affordable Care Act (ACA) signed in to law in March of 2010 is a driving force

behind streamlining a more efficient and cost-effective healthcare system promoting systemic

increased fiscal responsibility (Dogra & Dorman, 2016). In regards to finances, the intensive

care unit (ICU) is responsible for a significant portion of the hospital budget. Although only

about ten percent of a hospital’s services qualify as critical care, approximately twenty-five

percent of the total hospital budget is utilized for services provided (Dogra & Dorman, 2016).

The reduction in ICU length of stay (LOS) is beneficial for two reasons; one is because of

the opportunity to cut costs, but more importantly is the ability to prevent further complications

associated with prolonged bed rest, delayed extubation, progressive weakness, and inadequate

nutrition (Needham & Needham, 2008). Research demonstrating improved clinical outcomes and

development of new ICU health care delivery models is incentive to further explore the benefits

of early mobilization within the ICU environment with the goal to establish an efficient cost-

effective standardized early mobility program.

The early mobility programs that have been implemented thus far in general do not

present a specific time of when to start mobilization, but rather focus on the team-based approach

in order to determine on more of an individualized basis whether or not the patient is in the

position to benefit from mobilization. If this team-based evaluation on the feasibility of physical

therapy occurs as early as possible once the patient is admitted to the ICU, then the patients will

ultimately experience the benefits of early mobilization.

Towards the latter part of World War II early mobilization was provided to hospitalized

patients in order to promote a more rapid recovery for soldiers and expedite their return to the
EARLY MOBILIZATION IMPACT ON ICU LOS 4

front lines (Needham & Needham, 2008). Approaching the end of the war in 1944, the concept

that bedrest may be the best treatment for the acutely ill began to gain support (Needham &

Needham, 2008). Decades later, today’s common practice reveals that in a majority of intensive

care units patients are kept on bed rest until transferred to a regular unit (Clark, Lowman, Griffin,

Matthews, & Reiff, 2013).

The basis of prolonged bed rest in the ICU is being called into question by an abundance

of emerging literature. Bourdin et al. (2010) states that up to 40 percent of muscle strength is lost

in the back and calf after just one week of bed rest. This profound decline in muscular strength

involves the skeletal muscle, which has an adverse effect on venous return (Needham &

Needham, 2008). The practice of maintaining bed rest while in the ICU negatively impacts the

patient’s muscle fibers, changing them from slow to fast twitch. The patient’s metabolism is

altered switching to the utilization of glucose from fatty acids. There is also a reduction in

protein synthesis, as well as a notable change in inflammatory markers (Needham & Needham,

2008). Furthermore, investigational research has shown healthy individuals to develop resistance

to insulin and microvascular dysfunction after only five days of bed rest (Needham & Needham,

2008). It is glaringly apparent that the potential for complications that could be prevented with

early mobilization in the ICU extends far beyond musculoskeletal dysfunction alone.

Intensive care unit-acquired weakness (ICU-AW) has become an increasingly common

diagnosis for critically ill patients who are on prolonged bed rest. This neurological complication

consists of the development of profound weakness and severe sensory changes secondary to

peripheral motor and sensory nerve and muscle dysfunction (Wieske et al., 2013). Although the

study conducted by Clark and associates showed no significant inter-group differences of the

incidence of ICU-AW for patients who received early mobilization versus a group with the
EARLY MOBILIZATION IMPACT ON ICU LOS 5

standard hospital protocol, it did result in a significant reduction in occurrences of pneumonia

(RR=0.79, 95% CI = 0.66-0.93), deep vein thrombosis (0.67, 95% CI = 0.50 – 0.90), airway

problems (RR=0.52, 95% CI = 0.35-0.76), pulmonary problems (RR=0.84, 95% CI = 0.74-0.95),

and vascular complications (RR=0.58, 95% CI = 0.45-0.75) (Clark et al., 2013).

With the ongoing restructuring of the healthcare delivery model moving towards one of

strict fiscal responsibility, ICU LOS has shown to be an integral outcome that can be influenced

by a variety factors. Thus far, early mobilization has proven to be feasible in the critical care

environment. The purpose of this integrative literature review is to explore the impact of early

mobilization on ICU LOS in adult patients on the critical care units.

Methods

An extensive search was performed in order to find relevant research articles related to

early mobilization in the ICU. Database sources included: CINAHL, MEDLINE, The Cochrane

Central Register of Controlled Trials, The Cochrane databases of Systematic Reviews (CDSR),

PsycINFO, and SPORTDiscus.

The following search terms used were for all of the aforementioned databases

collectively; (“early mobili*" or "early ambula*" or "Early goal-directed mobili*") and (ICU or

SICU or "intensive care" or "critical care") and (surg* or post-op*or postop* or peri-op*) and

"length of stay." In order to avoid duplicate publications the limiter to exclude MEDLINE

records was selected. Due to the limitations of high levels of evidence available for a specialized

ICU, all types of ICUs are included in this review.

The search criteria for outcome was left more broad with “length of stay” in order to

expand the search results further, although the primary outcome of interest is LOS on the ICU.

A total of 113 results were retrieved and extensively reviewed. The objective of the inclusion
EARLY MOBILIZATION IMPACT ON ICU LOS 6

criteria is to include patients > 18 years of age admitted to or transferred to the ICU who are

mobilized following admission to the ICU and in the English language. Patients < 18 years of

age, inpatient rehabilitation facilities, and thesis/dissertations were the exclusion criteria.

Only eight articles satisfied all of the inclusion and exclusion criteria and an additional

two articles were located via hand searching multiple reference lists. An evidence table

(Appendix A) was used to outline each of the articles. The levels of evidence for the primary

resources range from level I to level IV according to the Rating System for the Hierarchy of

Evidence Intervention/Treatment Questions (Melnyk & Fineout-Overholt, 2015) (Appendix B).

After a thorough critical appraisal using the Melnyk and Fineout-Overholt’s (2015) Key General

Critical Appraisal Questions (Appendix C), the selected research articles were considered valid

and reliable.

Findings

Intensive Care Unit Length of Stay

Throughout the process of this integrative literature review, three common themes began

to emerge; ICU LOS, hospital LOS, and the number of days on mechanical ventilation. All of

these studies shared the outcome of ICU LOS. Five cohort studies and one randomized

controlled trial (RCT) resulted in a statistically significant reduction in the number of days spent

in the ICU for the intervention groups receiving mobilization earlier with a total combined

sample size of 8,913 patients (Lai et al., 2017; Morris et al., 2008; Needham et al., 2010;

Ronnebaum, Weir, & Hilsabeck, 2012; Schaller et al., 2016; Wahab et al., 2016). Three of these

studies took place in medical ICUs (Lai et al., 2017; Morris et al., 2008; Needham et al., 2010),

one in a surgical ICU (Schaller et al., 2016), and one in a mixed ICU (Wahab et al., 2016). Four
EARLY MOBILIZATION IMPACT ON ICU LOS 7

of the studies in the review did not result in a statistically significant impact on ICU LOS (Clark

et al., 2013; Denehy et al., 2013; Hodgson et al., 2016; Morris et al., 2016).

Four of the six studies demonstrating significant results limited their study to only

patients requiring mechanical ventilation (Lai et al., 2017; Needham et al., 2010; Ronnebaum et

al., 2012; Schaller et al., 2016). The study by Lai et al. (2017) comprised of patients on

mechanical ventilation for < 72 hours, while Schaller et al. (2016) included all mechanically

ventilated patients on the surgical ICU for < 72 hours. The number of studies involving only

mechanically ventilated patients resulting in a statistically significant reduction in ICU LOS

allows for a clearer inference of the positive impact of early mobilization on this specific

population.

Hospital Length of Stay

Nine of the studies, four RCTs (Denehy et al., 2013; Hodgson et al., 2016; Morris et al.,

2016; Schaller et al., 2016) and five cohort studies (Clark et al., 2013; Lai et al., 2017; Morris et

al., 2008; Needham et al., 2010; Wahab et al., 2016), evaluated the impact of early mobilization

on number of days in the hospital. Four of the studies demonstrated a statistically significant

decrease in hospital LOS (Morris et al., 2008; Needham et al., 2010; Schaller et al., 2016; Wahab

et al., 2016). Morris et al. (2008) resulted in a substantial increase in physical therapy initiation

while in the ICU from 13% in the standard group to 91% in the implementation group.

Morris et al. (2016) was unique from the other studies in that the mobilization protocol

was implemented and continued until hospital discharge. This protocol attempted to standardize

the frequency and specific interventions being performed during physical therapy sessions.

Depending on the needs of the patient, a team approach was available. Patient’s activity levels

ranged from passive range of motion to ambulation. There was also a method established to aid
EARLY MOBILIZATION IMPACT ON ICU LOS 8

in determining when to advance the patient’s level of activity based off their tolerance and

participation. Although this study did not demonstrate a significant decrease in hospital LOS, it

did result in a shortened time period until initiation of physical therapy and a prolonged physical

therapy session compared to the patients receiving the standard physical therapy protocols

(Morris et al., 2016).

Mechanical Ventilation Days

Four cohort studies and two RCTs shared the outcome of days on mechanical ventilation

(Clark et al., 2013; Hodgson et al., 2016; Lai et al., 2017; Morris et al., 2016; Needham et al.,

2010; Ronnebaum et al., 2012). Lai et al. (2017) and Ronnebaum et al. (2012) with a total

sample size of 181 patients resulted in a significant reduction in number of days spent requiring

mechanical ventilation, an average of 7.5 days to 4.7 days, p < .001 and 30.9 + 20.0 to 14.5 + 8.7

days, p = .007, respectively. Lai et al. (2017) was a quality improvement project with data

collection occurring before, during, and after implementation. Patients were included in the early

mobilization group within 72 hours of being on a mechanical ventilator. Ronnebaum et al. (2012)

evaluated the impact of a mobility protocol for mechanically ventilated patients where physical

therapy was implemented for those on the vent on an average of 6.1 days compared to those not

being treated by the protocol who were on the vent for an average of 12.9 days before physical

therapy was ordered.

In one study the usual care group received physical therapy only 12% of the days, while

the standardized rehabilitation group received therapy 87% of the study days (Morris et al.,

2016). The difference in physical therapy time was significant; however, the authors partially

attribute the absence of a sedation protocol to the potential cause for the lack of reduction in days

requiring mechanical ventilation (Morris et al., 2016). The other four studies demonstrated no
EARLY MOBILIZATION IMPACT ON ICU LOS 9

significant difference in number of days on mechanical ventilation for the groups receiving early

mobilization.

Limitations of Evidence

Although all of these studies shared a major similarity in regards to evaluating the impact

of mobilization on the critically ill adult patient population in the ICU, there is much variability,

including admission diagnoses, implementation and time to physical therapy, and setting. Three

studies included only patients admitted with acute respiratory failure (ARF) (Morris et al., 2008),

ARF requiring mechanical ventilation (Morris et al., 2016), and non-neurological ARF

(Ronnebaum et al., 2012). Three of the studies with a combined sample size of 400 patients took

place internationally, including Australia, New Zealand, Austria, and Germany (Denehy et al.,

2013; Hodgson et al., 2016; Schaller et al., 2016). Studies including data obtained across

multiple countries can impact the interpretation of the results due to the differences between

countries in their standard of practice in the ICU.

Four of the studies used in this integrated literature review are RCTs (Denehy et al.,

2013; Hodgson et al., 2016; Morris et al., 2016; Schaller et al., 2016) and only one of them

demonstrated statistically significant results in regards to ICU and hospital LOS (Schaller et al.,

2016). Three of the studies used a retrospective design limiting generalizability (Clark et al.,

2013; Ronnebaum et al., 2012; Wahab et al., 2016).

Recommendations

Practice

Starting day one of ICU admission, it is recommended to make daily multi-disciplinary

rounds on the critical care units to determine the safety and efficacy of initiating early

mobilization for each individual patient. According to the Strength of Recommendation

EARLY MOBILIZATION IMPACT ON ICU LOS 10

Taxonomy (SORT) tool the strength of this recommendation is A (Ebell et al., 2004). Five good

quality cohort studies and one RCT demonstrated a statistically significant decrease in ICU LOS

by means of daily multi-disciplinary rounding with a focus on initiating mobilization for each

individual patient (Lai et al., 2017; Morris et al., 2008; Needham et al., 2010; Ronnebaum et al.,

2012; Schaller et al., 2016; Wahab et al., 2016).

It is recommended to implement a quality improvement project or mobility protocol with

the aim of early mobilization for critically ill patients in order to reduce the number of days on

mechanical ventilation. The strength of this recommendation is B according to the SORT criteria

(Ebell et al., 2004). Two good quality treatment cohort studies resulted in a statistically

significant reduction in days on mechanical ventilation (Lai et al., 2017; Ronnebaum et al.,

2012).

Future Research

The future of research in early mobilization should move towards studies identifying and

grouping patients either by their admitting diagnoses or their Acute Physiology and Chronic

Health Evaluation (APACHE) score calculated within the first 24 hours of their ICU admission.

Unfortunately, due to the complexity of the critically ill patient, differentiating results based off

comorbidities can be extremely confounding. Admission diagnoses or a standardized scoring

system performed within the same time frame for each patient allows for a consistent means of

grouping the patients and evaluating the intervention efficacy within more specific groups.

Due to the variability in time to first physical therapy session and length of sessions

between the studies used in this review, an additional focus should be on the development of a

standardized early mobilization protocol initiated on day one of ICU admission. Future

integrated reviews may be more accurate as to their evaluation of the efficacy and impact of
EARLY MOBILIZATION IMPACT ON ICU LOS 11

early mobilization by excluding countries outside of the United States where the physical therapy

standard of practice may vary. All future studies should include the occurrence of ICU-acquired

complications as secondary outcomes, due to the potential for consequential patient demise and

the additional hospital expenditures, in order to further support early mobilization in the critically

ill population.

Conclusion

Research into early mobilization in the adult ICU patient is yielding positive results in

regards to patient outcomes, as well as hospital expenditures. The variability between the

methods and settings of the studies used in this review limit the ability to generalize the results.

However, there is enough research to say early mobilization is safe and feasible amongst adults

in the critical care environment and in some studies demonstrates fewer incidences of ICU-

acquired complications, as well as a reduction in ICU and hospital LOS. Future research should

continue to focus on the development of a standardized early mobility protocol that is feasible

and modifiable across the different ICU settings.

EARLY MOBILIZATION IMPACT ON ICU LOS 12

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EARLY MOBILIZATION IMPACT ON ICU LOS 15

Appendix A

Evidence Evaluation Table

Major Variables
Data Appraisal: Worth to
Citation Design/Method Sample/Setting Studied and Measurement Findings
Analysis Practice
Their Definitions
Clark, D. E., Cohort study: Level University of IV1: Standard ICU LOS Compared ICU LOS: I: Supports a shift from
Lowman, J. D., III Alabama protocol group measured in via t tests Standard multi-disciplinary to
Griffin, R. L., Birmingham IV2: Early days or χ2 tests group spent inter-disciplinary care-
Matthews, H. Retrospective (UAB) mobility program 11.0(16.2) promoting further
M., & Reiff, D. group days compared collaboration. UAB’s
A. (2013). Standard protocol 28-bed TBICU with patients PT department hired on
Effectiveness of group (control) DV: TBICU LOS, in the EMP two additional full-time
an early Control: n= Hospital LOS, group who PTs to support the
mobilization EMP (Intervention) 1044 MV days spent program.
protocol in a 10.4(14.0)
trauma and burns Int: n = 1132 days; p = .33 L: Retrospective design
intensive care limits generalizability.
unit: A May 2008 – Hospital LOS: Unable to quantify the
retrospective April 2010 (adjusted) 1.5 physical activity levels.
cohort days shorter Patients with femoral
study. Physical and lines were not
Therapy, 93(2), insignificant mobilized during this
186-196. study, however new
doi:10.2522/ptj.2 MV days: 8.9 evidence supports it is
0110417 (17.4) vs. 7.8 feasible to mobilize
(13.4), p = .08 these patients

Denehy, L., RCT: Level I 20-bed tertiary IV1: Usual care ICU LOS Continuous ICU LOS: I: First study that
Skinner, E. H., ICU in group measured in variables Usual care provided PT throughout
Edbrooke, L., Usual care (control Australia IV2: Intensive days reported as group spent a the entire hospital
Haines, K., group)- available 7 rehabilitation medians median of 7 [6 admission and then
Warrillow, S., days/week, 12 Control: n = 76 group with - 11] days after hospital discharge.
Hawthorne, G., hours/day interquartil compared with Outcome analysis in
& ... Berney, S. Int: n = 74 DV: ICU LOS e ranges patients in the early mobilization
(2013). Exercise Intensive Intensive should include long-
EARLY MOBILIZATION IMPACT ON ICU LOS 16

Major Variables
Data Appraisal: Worth to
Citation Design/Method Sample/Setting Studied and Measurement Findings
Analysis Practice
Their Definitions
rehabilitation for rehabilitation 5/2007-8/2009 rehab group term outcomes.
patients with (intervention) – who spent 8 [6
critical illness: A initiated after 5 days (12 month – 12] days L: 15 mins two times a
randomized in ICU follow-up in day at maximal level.
controlled 9/2010) Hospital LOS: Time was limited.
trial with 12 No significant Heterogenous group.
months of difference, Waiting until day 5;
follow-up. 20.0 (13.0- twice as many patients
Critical Care, 30.8) in the were diagnosed with
17(2), R156. intervention ICU-AW. Single-center
doi:10.1186/cc1 group study.
2835 compared to
23.5 (16.0 - S: Well conducted,
41.5) in the maintained single
standard group blinding, randomized.
Follow-up extended to
12 months after
discharge and
intervention continued
after discharge.
Hodgson, C. L., Pilot RCT: Level I Across 5 ICUs IV1: Standard ICU LOS Continuous ICU LOS: I: Early mobilization is
Bailey, M., in Australia and care group measured in variables Patients in the feasible and safe to
Bellomo, R., Standard care New Zealand. IV2: EGDM days reported as control group implement in the ICU.
Berney, S., Buhr, (control) 50 participants. group medians spent a median Aids in informing
H., Denehy, L., Mechanically with of 11 [8-19] future larger studies
& ... Webb, S. Early goal-directed ventilated. DV: Maximal interquartil days in the
(2016). A mobilization level of activity e ranges ICU, L: Small sample size. 1
binational (EGDM) Control: n= 21 using a compared with hour of intervention,
multicenter pilot (intervention) – standardized the EGDM including; equipment
feasibility initiated after ICU Int: n= 29 scoring system, group who set up, patient prep, and
randomized admission between 2 duration of spent a median documentation
controlled trial and 4 days. Received 9/2013 – activity per day, of 9 [6-17]
of early goal- an average of 20 10/2014 ICU LOS, days (p=.28). S: Multi-center,
directed mins/day versus the Hospital LOS, international design,
mobilization in standard care group MV duration Hospital LOS: short time to
the ICU. Critical that received on No significant randomization, and
Care Medicine, average 7 mins/day difference, 19 long-term outcome
EARLY MOBILIZATION IMPACT ON ICU LOS 17

Major Variables
Data Appraisal: Worth to
Citation Design/Method Sample/Setting Studied and Measurement Findings
Analysis Practice
Their Definitions
44(6), 1145- (14.0 - 30) assessment (6 months
1152. days in the after discharge)
doi:10.1097/CC intervention
M.00000000000 group
01643 compared to
29 (16.0 - 34)
in the standard
group, p =
0.33

MV days: 6.4
(3.6 - 10) vs.
7.0 (5.0 - 12),
p = .18

Lai, C., Chou, Cohort study: Level 19 bed medical IV1: Standard PT ICU LOS Clinical ICU LOS: I: A multidisciplinary
W., Chan, K., III ICU. 153 group measured in and lab Patients in the team and involvement
Cheng, K., participants. IV2: Early days outcome control group of the patient’s family
Yuan, K., Chao, Standard physical Mechanically mobilization differences spent an are beneficial in the
C., & Chen, C. therapy group ventilated group were average of 9.9 early mobilization
(2017). Early (control) patients < 72 examined days in the process and can lead to
mobilization hours DV: MV via ICU, reduced ICU LOS and
reduces duration Early mobilization duration, rate of univariate compared with MV days
of mechanical group (intervention) Control: n= 63 weaning, ICU and analysis. the early
ventilation and hospital LOS Continuous mobilization L: Small sample size at
intensive care Evaluating a quality Int: n= 90 data were group who a single center on MV
unit stay in improvement project. compared spent an patients. Difficult to
patients with Study took place over using 2 average of 6.9 generalize.
acute respiratory the course of 1 year, independen days, p = .001
failure. Archives divided into 3 phases; t samples t-
of Physical pre-intervention, tests with Hospital LOS:
Medicine & intervention period, Bonferroni No significant
Rehabilitation, and maintenance correction difference, p =
98(5), 931-939. .101
doi:10.1016/j.ap Early mobilization
mr.2016.11.007 (intervention) MV Days:
< 72 hrs on MV Patients in the
EARLY MOBILIZATION IMPACT ON ICU LOS 18

Major Variables
Data Appraisal: Worth to
Citation Design/Method Sample/Setting Studied and Measurement Findings
Analysis Practice
Their Definitions
control group
spent an
average of 7.5
days on the
MV,
compared with
the early
mobilization
group who
spent an
average of 4.7
days, p < .001
Morris, P., Goad, Cohort study: Level Medical ICU in IV1: Usual care ICU LOS Results ICU LOS: I: Early mobilization
A., Thompson, III patients with group measured in were log Patients in the protocol significantly
C., Taylor, K., acute IV2: Early days transforme usual care reduces ICU and
Harry, B., Prospective respiratory mobilization d for group spent an hospital LOS. It also
Passmore, L., & failure group statistical average of 6.9 dramatically increases
... Haponik, E. Usual care (control) analysis. days in the the number of ICU
(2008). Early Control: n = DV: Days until ICU, patients that receive PT
intensive care Early mobilization 165 patient out of bed compared with while in the ICU.
unit mobility (intervention) – PT for first time, MV the early
therapy in the initiation in the ICU Int: n = 165 days, ICU LOS, mobilization L: Nonrandomized.
treatment of 91% vs 13% in the hospital LOS group who Lack of blinding.
acute respiratory usual care group (p < spent an Intervention only done
failure. Critical .001) average of 5.5 while in the ICU.
Care days, p = .025
Medicine, 36(8), S: Prospective method
2238-2243. Hospital LOS: with same number of
Usual care patients in each group
group spent
14.5 days
compared to
early
mobilization
group who
spent 11.2
days (p =
EARLY MOBILIZATION IMPACT ON ICU LOS 19

Major Variables
Data Appraisal: Worth to
Citation Design/Method Sample/Setting Studied and Measurement Findings
Analysis Practice
Their Definitions
.006)

Morris, P. E., RCT: Level I Wake Forest IV1: Usual care ICU LOS Bootstrap ICU LOS: I: The presence of a
Berry, M. J., Baptist Medical group (median measured in methods Patients in the standardized
Files, D. C., Usual care (control) Center ICU. days to first days were used control group rehabilitation therapy
Thompson, J. C., Patients therapy is 7) with spent a median protocol shortens the
Hauser, J., Standardized admitted with IV2: SRT group median of 8 (4-13) days to initiation of PT,
Flores, L., & ... rehabilitation therapy acute (median days to differences days in the as well as increases the
Young, M. P. (SRT) (intervention)- respiratory first therapy is 1) of medians ICU, length of time PT is
(2016). provided from ICU failure (ARF) generating compared with received on a daily
Standardized admission through requiring MV DV: Hospital 95% CI. the SRT group basis.
rehabilitation hospital discharge LOS, MV days, who spent a
and hospital (different then Control: n= 150 ICU LOS, Short χ2 and median of 7.5 L: Usual care group
length of stay previous research Physical Wilcoxon (4-14) days received PT only 12%
among patients that stops the Int: n= 150 Performance rank-sum (p=.68). of the study days while
with acute intervention upon Battery (SPPB) tests were the SRT group received
respiratory transfer to a step- 10/2009 – score, 36-item used to Hospital LOS: PT 87% of the study
failure: A down unit) 5/2014 Short-Form assess Patients in the days. Significant
randomized Health Surveys intergroup control group difference between the
clinical trial. (SF-36) for differences spent a median groups; however,
JAMA: Journal physical and amongst of 10 (7-16) results are not
of the American mental health and patient days in the statistically significant.
Medical physical function characterist hospital, Lack of a sedation
Association, scale score, ics. compared with protocol.
315(24), 2694- Functional the SRT group
2702. Performance who spent a S: Randomized
doi:10.1001/jam Inventory (FPI) median of 10
a.2016.7201 score, Mini- (6-17) days
Mental State (p=.41).
Examination
(MMSE) score, MV Days:
and handgrip and No difference
handheld
dynamometer
strength
Needham, D., Cohort study: Level 16- bed IV1: Standard ICU LOS Average ICU LOS: I: With sufficient
Korupolu, R., III Medical ICU care group measured in ICU LOS Standard care preparation and the
EARLY MOBILIZATION IMPACT ON ICU LOS 20

Major Variables
Data Appraisal: Worth to
Citation Design/Method Sample/Setting Studied and Measurement Findings
Analysis Practice
Their Definitions
Zanni, J., with patients IV2: Early days compared group spent an implementation of this
Pradhan, P., Quality Improvement requiring MV physical medicine via t-test average of 7 structured QI project,
Colantuoni, E., (QI) project for > 4 days and rehabilitation days in the MICU LOS in an
Palmer, J., & ... group (PM&R) ICU, academic hospital can
Fan, E. (2010). Standard care group Control: n = 27 compared with be significantly reduced
Early physical – pre-QI (control) DV: Hospital and patients in the
medicine and Int: n = 30 ICU LOS intervention L: Patients were non-
rehabilitation for PM&R (intervention) group who randomized and no
patients with 3/2007 – spent 4.9 days blinding was used
acute respiratory For the purpose of 5/2007 (pre-QI) (p = .02). during evaluation.
failure: A quality ICU LOS Small sample, medical
improvement comparison, data was 5/2007 – Hospital LOS: ICU only in one
project. Archives retrieved from the 8/2007 Standard care facility.
of Physical same 4-month period (QI period) group spent an
Medicine & 1 year prior to isolate average of S: Detailed, structured,
Rehabilitation, for seasonal 17.2 days in replicable QI project
91(4), 536-542. differences the hospital,
doi:10.1016/j.ap compared with
mr.2010.01.002 patients in the
intervention
group who
spent 14.1
days (p = .03).

Ronnebaum, J. Cohort study: Level Metropolitan IV1: Standard ICU LOS Descriptive ICU LOS: I: Implementing an
A., Weir, J. P., & III ICU physical therapy measured in statistics to SPT protocol early mobilization
Hilsabeck, T. A. group (SPT) days compare spent 24.9 ± program in the ICU can
(2012). Earlier Retrospective Control: n = 13 IV2: Mobility groups 13.7 days contribute to reducing
mobilization protocol group using compared with LOS, financial
decreases the SPT (control) Int: n = 15 (MP) means and patients in the expenditures, and ICU
length of stay in SD MP group acquired complications
the intensive MP (intervention) Pts with non- DV: time elapsed Independen spent 13.3 ±
care neurological before t t-tests and 6.3 days L: Retrospective
unit. Journal of respiratory mobilization, total 95% CI for (p=.007). review.
Acute Care failure time needed on comparison Nonrandomized.
Physical requiring MV MV, ICU LOS, The difference Comorbidities
Therapy (Acute and functional between the unknown. Time to
EARLY MOBILIZATION IMPACT ON ICU LOS 21

Major Variables
Data Appraisal: Worth to
Citation Design/Method Sample/Setting Studied and Measurement Findings
Analysis Practice
Their Definitions
Care Section - status at discharge means was initiating MP was
APTA, statistically variable and based off
Inc.), 3(2), 204- Mobility Protocol significant. of daily rounding.
210. (MP) – mean of The 95% CI Small sample size.
6.1 days on vent for the
prior to protocol difference was
being ordered 3.5 to 19.7
days.
Standard Physical
Therapy (SPT) – MV Days:
mean of 12.9 days SPT group
on vent prior to (30.9 + 20.0
PT being ordered days) relative
to the MP
group (14.5 +
8.7 days; p =
.007; 95% CI
for the
difference =
4.7 to 28.1
days)
Schaller, S. J., RCT: Level I Across 5 IV1: SOC group ICU LOS Student’s t- ICU LOS: I: EGDM group
Anstey, M., SICU’s in IV2: EGDM measured in test or Patients in the resulted in improved
Blobner, M., Multicentre, teaching group days Mann- control group functional status at
Edrich, T., international Whitney U spent an discharge, increased
hospitals. 200
Grabitz, S. D., (Austria, Germany, DV: Means SICU optimal test, where average of 10 daily mobility level and
Gradwohl-Matis, and USA), parallel- participants. SOMS level mobilization appropriate days (6-15) in reduced ICU and
I., & ... group, assessor- Mechanically during stay in score (SOMS) in a the ICU, hospital LOS;
Eikermann, M. blinded, ventilated ICU, SICU LOS, – Scale used to hierarchica compared with secondary to a valid
(2016). Early, patients on the and Functional evaluate l sequence; the EGDM inter-professional
goal-directed Standard of care SICU < 72 status at time of patient’s mean group who algorithm and closed-
mobilisation in (SOC) mobilization hours discharge from mobility achieved spent an loop communication
the surgical (control) hospital using the capabilities SOMS average of 7
intensive care mmFIM ranging from 0 level, days (5-12), p L: Limited
unit: A Early goal-directed Control: n= 96 (no SICU LOS, = .0054 generalizability to non-
randomised mobilization mobilization) and vented surgical patients
controlled (EGDM) Int: n= 104 to 4 mmFIM Hospital LOS: and medical ICU
EARLY MOBILIZATION IMPACT ON ICU LOS 22

Major Variables
Data Appraisal: Worth to
Citation Design/Method Sample/Setting Studied and Measurement Findings
Analysis Practice
Their Definitions
trial. Lancet, 388 (intervention) (ambulation) score at Patients in the patients.
North American 7/2011-11/2015 discharge control group
Edition(10052), mmFIM- spent an S: Randomized multi-
1377-1388. modified average of center study.
doi:10.1016/S01 functional 21.5 days (15-
40- independence 30) in the
6736(16)31637- measure score hospital,
3 compared with
the EGDM
group who
spent an
average of 15
days (11-27),
p = .011
Wahab, R., Yip, Cohort study: Level Across 5 ICU’s IV1: Standard ICU LOS LOS data ICU LOS: I: Implementation of an
N. H., Chandra, III in two care group measured in are Standard care early rehabilitation
S., Nguyen, M., institutions IV2: Early days expressed group spent a program across
Pavlovich, K. H., Control group data (three medical, rehabilitation as means mean of 5.8 multiple ICU’s
Benson, T., & ... obtained via one cardiac, group with SD, as days compared increased the mean
Brodie, D. retrospective analysis one surgical) well as with patients number of PT
(2016). The DV: Hospital and percentiles. in the early treatments per ICU-
implementation Standard care group Control: n = ICU LOS Poisson’s rehabilitation patient day and the
of an early – pre-intervention 3945 regression group who number of ICU patients
rehabilitation (control) was used to spent 5.4 days receiving PT. This also
program is Int: n = 4200 calculate p- (p < .001) may have costs and
associated with Early rehabilitation value for Mean decrease savings implications.
reduced program 1/2011-12/2011 differences of 0.4 days
length of stay: A (intervention) (control data) between (95% CI 0.3– L: Retrospective, single
multi-ICU study. pre- and 0.5, p < 0.001) hospital system.
Journal of the and post-
Intensive Care interventio Hospital LOS: S: Study includes
Society, 17(1), 2- 1/2012-12/2012 n outcomes Mean multiple institutions
11. (intervention decreased by and a variety of ICU’s.
doi:10.1177/175 period) 5.4% (14.7
1143715605118 days vs 13.9
days, p < .001)
EARLY MOBILIZATION IMPACT ON ICU LOS 22

Appendix B

Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions

______________________________________________________________________________

Level Description

I Evidence from a systematic review or meta-

analysis of all relevant RCTs

II Evidence obtained from well-designed RCTs

III Evidence obtained from well-designed

controlled trials without randomization

IV Evidence from well-designed case-control

and cohort studies

V Evidence from systematic reviews of

descriptive and qualitative studies

VI Evidence from single descriptive or

qualitative studies

VII Evidence from the opinion of authorities

and/or reports of expert committees

Note. RCTs = randomized controlled trials. Adapted form from Melnyk, B. M. and Fineout-Overholt, E. (2015).
Evidence-based practice in nursing & healthcare: A guide to best practice (3rd ed., p. 11). Philadelphia, PA: Wolters
Kluwer.