Early Mobility in Critical Care

E MOBILITY IN THE
ARLY
INTENSIVE CARE UNIT:
STANDARD EQUIPMENT VS
A MOBILITY PLATFORM
By Melanie Roberts, MS, APRN, CCRN, CCNS, Laura Adele Johnson, RN, BSN, CCRN,
and Trent L. Lalonde, PhD

Background Despite the general belief that mobility and exercise

play an important role in the recovery of functional status, mobil-
ity is difficult to implement in patients in intensive care units.
Objectives To compare a mobility platform with standard
equipment, assessing efficiency (decreased time and staff
required to prepare patient), effectiveness (increased activity
time), and safety (no falls, unplanned tube removals, or emer-
gency situations) for intensive care patients.
Methods This observational study was approved by the insti-
tutional review board, and informed consent was obtained
from the patient or the medical decision maker. Intensive care
patients were assigned to a room in the usual manner, with
platforms in odd-numbered rooms and standard equipment in
even-numbered rooms. Standardized data collection tools
were designed to collect data for 24 hours for each patient.
The nurses caring for the patients completed the data collec-
tion tools in real time during the activity. The stages of activity
and the physiological states that would preclude mobility were
very specifically defined for the research study.
Results Data were collected for a total of 71 patients and 238
activities. Important (although not significant) descriptive sta-
tistics regarding early mobility in the intensive care unit were
discovered. The unintended result of the research study was a
change in the culture and practice regarding early mobility in
the intensive care unit.

EBR
Evidence-Based Review on pp 458-459
©2014 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2014878
Conclusions Early mobility can be implemented in intensive
care units. Standard equipment can be used to mobilize such
patients safely; however, for patients who ambulate, a plat-
form may increase efficiency and effectiveness. (American
Journal of Critical Care. 2014;23:451-457)

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 D
espite the general belief that mobility and exercise play an important role in
the recovery of functional status, mobility is difficult to implement in patients
in intensive care units (ICUs). Several studies1-4 in the past 2 decades have
documented the outcomes of early mobility in critical care. Early and frequent
mobilization of ICU patients decreases hospital length of stay, ICU length
of stay, and ventilator days.1-4 Common critical care complications, neuromuscular weakness,
deconditioning, and delirium are decreased with early mobility.2,5-8 Morris et al9 demonstrated
that the lack of early mobility therapy in ICUs was 1 of the 4 variables associated with readmis-
sion or death during the first year for ICU survivors of acute respiratory failure.

Hospitals nationwide are attempting to develop Methods

mobility programs, but actualizing the goal is diffi-
cult. Lack of resources, a lack of established proto-
cols, and staff resistance prevent many facilities
from implementing a successful mobility program.10
Numerous articles exist indicating the importance
of mobilization; however, little detail can be found
to explain how to implement a successful mobility
program. Published reports demon-
Lack of early strate the importance of mobility
protocols in determining individual
mobility is patients’ appropriateness for mobil-
ity and to define progression of
associated with mobility, but few such protocols
Setting
The study was completed at Medical Center of
the Rockies, a 136-bed nonprofit, tertiary care hos-
pital. Clinical areas involved in the research study
included a 12-bed cardiac/cardiovascular surgery ICU
(CICU) and a 12-bed surgical/trauma ICU (SICU).
Mobility stages had been implemented in the ICUs
before the study but were not integrated into practice.
A research protocol was designed to identify human
resources required for early mobility in the ICU, to
compare standard equipment with a platform, and
to validate the safety of the protocol.

readmission to the have been published.11 Sample

The culture of the ICU must be
intensive care unit addressed early in any initiative to
or death during implement a mobility program.
Successful implementation of early
the first year. mobility requires a change in ICU
culture, nurses’ personal percep-
tions, and teamwork.10 This article describes how a
community-based hospital developed a mobility
program despite limited resources and changed the
culture of the ICU to accept the challenge of mobi-
lizing patients.
About the Authors
Melanie Roberts is a critical care Clinical Nurse Specialist
at Medical Center of the Rockies in Loveland, Colorado.
Laura Adele Johnson is a student registered nurse anes-
thetist at Westminster College in Salt Lake City, Utah.
Trent L. Lalonde is an associate professor of applied sta-
tistics at the University of Northern Colorado and a sta-
tistical consultant at the Medical Center of the Rockies.
Corresponding author: Melanie Roberts, MS, APRN, CCRN,
CCNS, Medical Center of the Rockies, 2500 Rocky Mountain
Avenue, Loveland, CO 80538 (e-mail: Melanie.Roberts@
uchealth.org).
The study included all intensive care patients
who were at least 18 years old and spoke English.
Critical care patients are a vulnerable population of
patients; many are unable to make decisions because
of cognitive impairment from medications and criti-
cal illness. To protect the patients, informed consent
was obtained from individual patients if their results
on the Confusion Assessment Method12 were nor-
mal and the patient was not receiving any sedatives
or pain medication. If the patient did not meet
both criteria, the patient’s medical decision maker
provided consent. Consent was obtained by spe-
cially trained ICU nurses at an appropriate time
after the patient had been admitted to the ICU,
depending on the patient’s condition and planned
mobility. For planned ICU admissions, consent was
obtained before admission.
Data were collected for 4 months, with a total
of 71 patients enrolled in the study and 238 total
mobility events. Of the 71 patients, 26 (37%) were
female with a mean age of 66.00 (SD, 19.76) years,
whereas the 45 males (63%) had a mean age of 68.62
(SD, 12.43) years. A total of 49 patients (69%) were
in the CICU and 22 (31%) were in the SICU. The

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CICU patients consisted of 15 females (31%) and 34
males (69%), with a mean age of 69.79 (SD, 12.37)
years. The platform was assigned to 23 (47%) of
the CICU patients. The SICU patients consisted of
11 females (50%) and 11 (50%) males, with a mean
age of 62.91 (SD, 20.24) years. The platform was
assigned to 12 (55%) of the SICU patients.
Design
A prospective, randomized, controlled, observa-
tional research study was designed to compare a
platform with standard equipment for ICU patients.
The research hypothesis stated expected improvements
in efficiency, effectiveness, and safety of ICU mobil-
ity when the platform was used rather than standard
equipment. Effectiveness is defined as the duration
of activity performed by the patient. Efficiency is
defined as the time to prepare the patient for
mobility as well as the number of staff required to
assist the patient with the activity. Safety is defined
by the number of falls or unplanned tube removals.
The standard equipment used for the study
includes a gait belt, no-slip socks, a walker, and a
wheelchair if the patient was ambulating. The plat-
form is a mobile support device that consolidates
equipment (intravenous poles, multiple hooks for
drainage bags, and a secure location for oxygen)
into a small area. The patient still requires a gait
belt and no-slip socks for safety. The design of the
platform is to allow mobility with the assistance of
fewer staff. All patients were monitored, had oxy-
gen, and if the patient was receiving mechanical
ventilation, a respiratory therapist had to be part
of the mobility team.
The study was approved by the organization’s
institutional review board. Platforms were placed in
odd-numbered rooms. Patients were admitted to
rooms by the usual process. Data were collected by
the ICU nurses during the activity session, and time
was documented to the nearest minute. Standard-
ized data collection sheets were used to ensure that
all appropriate information was recorded. The fol-
lowing information was collected for each activity:
date, time of day, preparation time (minutes),
activity time (minutes), type of activity (chair, dan-
gle, stand or march in place, walk), number of staff
required, frequency of activities per patient per day,
and unplanned tube removals or falls. Each patient
had a data collection sheet for each day, starting at
midnight with the new ICU flow sheet. Before the
beginning of the study, the nurses had 2 weeks to
practice with the platform as well as the data collec-
tion sheets to ensure that the data collection process
would work as expected. This process allowed nurses
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Table 1
Stages of mobility
Stage Activity Research requirement
1 Bed in chair position Not part of the research study
2 Dangle legs at edge of bed Minimum 2 min
3 Stand upright, weight bearing Minimum 1 min
4 Chair, stand, pivot/march Minimum 15 min in chair
5 Ambulate Minimum 10 ft (3 m)
to reeducate themselves on the equipment and the
data collection tool as needed before data collection.
During the 2 weeks before the study, the nurses
were given instructions by physical therapists on
the proper method for assisting a patient out of bed
to the chair and getting the patient back to bed
using a gait belt to promote staff and patient safety.
The data collection sheets were gathered weekly
and correlated with informed consent. If consent
had been obtained, the data sheets were entered
into a data spreadsheet. If consent had not been
obtained, the data collection sheet was shredded
The ICU nurses determined that it was easier to
collect the data sheets every day for all patients to
avoid bias created by their knowledge of who was
enrolled in the study. The nurses were using a mobil-
ity protocol with which they were familiar except
for the addition of the platform. The mobility pro-
tocol used had 5 stages (Table 1), with specific
definitions given for each stage. ICU nurses were
responsible for determining whether it was safe for
the patient to mobilize. The expec-
tation of the ICU nurse is to use
the absolute exclusion criteria and Mobility was
relative contraindications to deter- defined as
mine the patient’s ability to mobi-
lize. Patients start the protocol after purposeful
24 hours unless they meet 1 of the
exclusion criteria.
movement with
The absolute exclusion criteria the patient’s
are based on the patient’s physiolog-
ical condition: intracranial monitor, participation.
unstable pelvic or spinal fractures,
physician’s order for deep sedation, therapeutic
hypothermia, vasoactive medication titration, active
bleeding, intra-aortic balloon pump or ventricular
assist device, comatose, open abdomen, and traction.
Relative contraindications such as vasoactive infusions
or changes in respiratory status or vital signs are deter-
mined by the nurse caring for the patient.
Stage 1 activity, bed in chair position, would not
be included in the research study as mobility. Before
the research study, the ICU had determined that
mobility would be defined as purposeful movement
453
 Table 2
Sample size of activities (n) for number of staff,
by activity type
To assess the impact of the platform on activity
No. of staff time, preparation time, number of staff, falls, and
Activity 0 1 2 3 4 5 Total unintended tube removals (endotracheal, gastric,
urinary, chest, and drains), means and standard
Platform deviations are reported for both treatments, by type
Chair 0 9 27 8 1 1 46
Dangle 0 2 14 11 4 0 31
of activity. To evaluate the significance of the dif-
Stand/march 1 2 8 9 3 1 24 ferences in mean activity time, preparation time,
Walk 2 4 9 4 0 0 19 number of staff, falls, and unintended tube removals
Total 3 17 58 32 8 2 120 between treatments, a mixed Poisson log-linear count
Standard regression model is applied.13 This model will account
Chair 0 10 44 8 1 0 63 for the skewness inherent in the strictly positive
Dangle 0 0 17 9 1 2 29 data observed (activity and preparation times; staff,
Stand/march 0 3 8 1 0 0 12
fall, and tube removal counts). The model is mixed
Walk 0 4 6 4 0 0 14
Total 0 17 75 22 2 2 118 with a normal random effect to account for repeated
observation of patients. The independent variables
included are treatment (platform/standard) and
type of activity, along with an interaction between
the 2 variables. Analyses were performed by using
Table 3
Activity time, preparation time, and number of SAS version 9.3.
staff by activity type
Mean (SD)
Results
No unintended tube removals or falls were
Variable Platform Standard
recorded, so safety is not addressed further. The data
Activity time, min set included 118 observations of standard activities
Chair 79.07 (68.53) 62.56 (49.30) and 120 observations of platform activities. Table 2
Dangle 8.97 (4.09) 12.20 (7.40) provides descriptive statistics of the activities observed
Stand/march 9.31 (5.39) 19.64 (20.48) for both treatments. The table shows the number of
Walk 39.53 (36.80) 31.25 (40.63)
activities according to the number of staff required,
Total 39.51 (54.05) 41.87 (45.03)
by activity type.
Preparation time, min Activities involved between 0 and 5 staff, with
4.85 (4.51) 3.75 (2.81)
Chair
5.00 (3.39) 4.60 (3.39) 2 staff the most common (133 activities with 2
Dangle
4.39 (2.97) 3.00 (4.22) staff). The type of staff was not included in the study.
Stand/march
3.95 (3.34) 6.31 (5.50)
Walk The ICU nurse is responsible for determining if
4.65 (3.75) 4.17 (3.55)
Total the patient is safe for mobility and to ensure that
No. of staff 2.08 (0.81) 2.00 (0.60) mobility occurs. Of the 238 activities, 60 involved
Chair 2.55 (0.81) 2.59 (0.87) a dangle, 109 progressed to the chair, 38 involved
Dangle 2.58 (1.10) 1.83 (0.58) standing/marching in place, and 33 involved walk-
Stand/march 1.79 (0.92) 2.00 (0.78)
ing. The number of stand/walk activities was greater
Walk 2.26 (0.93) 2.13 (0.73)
Total for the platform (24 activities) than for standard
equipment (12 activities). Similarly, the number
of walking activities was greater for the platform
with the patient’s participation. Bed in chair posi- (19 activities) than for standard equipment (14
tion did not require patients to use their muscles or activities).
actively participate. This stage is a safety check to To assess the effectiveness of the platform,
see if the patient can tolerate mobility without sig- means and standard deviations of activity times by
nificant changes in their vital signs. type of activity, for both treatments, are reported in
Table 3. Both treatments showed large amounts of
Statistical Analysis variation in activity time. Although the standard
Analysis includes a description of the activities equipment showed longer mean activity times for a
observed. The total numbers of activities (activity dangle or a stand/march in place, the mean activity
sample size) for both treatments are reported. Activ- times for a walk was greater for platform patients
ity sample size is further classified according to the (39.53 minutes) than for standard patients (31.25
type of activity and the number of staff required for minutes). Thus the platform may be more effective
each activity. in terms of activity time when patients walk. Using

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a mixed Poisson count regression (MPCR) model,
accounting for repeated observation of patients and
controlling for the effect of different activity types,
no significant difference was found in mean activity
time between the platform and standard treatments
(P = .62).
To assess the efficiency of the platform in terms
of time, means and standard deviations of prepara-
tion times by type of activity, for both treatments,
are reported in Table 3. Although the standard equip-
ment showed faster preparation times for a sit, dan-
gle, or stand/march, the mean preparation time
was shorter for platform patients (3.95 minutes)
than for standard patients (6.31 minutes) who walk.
Therefore, the platform may be more efficient in
terms of preparation time with patients who walk.
Using another MPCR model, no significant differ-
ence was found in mean activity time between the
platform and standard treatments (P = .19).
To assess the efficiency of the platform in terms
of staff, means and standard deviations of number
of staff by type of activity, for both treatments, are
reported in Table 3. Use of the platform allowed 3
patients to be active without the help of any staff
(1 stand/march, 2 walk), whereas no standard
patients were active without the help of any staff.
For patients involved in walking, use of the plat-
form allowed fewer staff to be involved on average
(1.79) than was possible with standard treatment
(2.00). This result suggests that the platform may be
more efficient in terms of required staff with
patients who walk and in terms of encouraging
individual activity. Using another MPCR model, a
marginally significant difference was found in mean
activity time between the platform and standard
treatments (P = .08), with the platform showing
lower mean staff expected after the differences in
mean staff across activity types were accounted for.
Discussion
Although the study findings were not statistically
significant, several very important descriptive statis-
tics were discovered. No information documenting
the resources required to mobilize ICU patients has
been published; this study documents the human
resources needed. Most of the time, 2 staff members
were required to mobilize the patient, with a prepa-
ration time of 5 minutes. The most frequent activity
is getting up and into the chair, and the patient
stays up approximately 40 minutes.
Mobilizing patients to the chair was also the
most frequent activity in a study conducted by
Bourdin et al14 published in 2010. Nurses can use
this information when planning a mobility program
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and workflow in the ICU. The study did not show
any significantly improved efficiency, effectiveness,
or safety with the platform compared with standard
equipment, proving to ICU nurses that they can mobi-
lize ICU patients with the equipment they have avail-
able. New equipment may be less efficient for the
nurses to use than equipment with which they are
familiar. That possibility, coupled with the low sam-
ple size, could have affected statistical significance.
The preparation for the research study provided
training to the ICU nurses in using gait belts to assist
with mobilizing patients out of bed, thus improving
safety for both staff and patients. The safety check-
list provided for the nurses to use before activity to
ensure a standard process during the research study
could be used in other mobility protocols.
The study validated that the mobility protocol
is safe; there were no falls, unplanned tube removals,
or emergency events. Two other studies15,16 report
similar results, an unplanned tube removal rate of
0.8% in 1 study,15 and 1 unplanned
tube removal and no falls in a dif-
ferent study of 75 patients.16 Allow- Activity time did
ing the nurses to prove that the not differ signifi-
mobility protocol was safe had a
huge impact in changing the cul- cantly between
ture of the ICU. In order to change
culture, the nurses’ perceptions and
the platform
teamwork must be addressed. Dur- and standard
ing the research study, the nurses
had the opportunity to change their equipment.
perception as they witnessed suc-
cessful mobility. A study done by Thomsen et al17 in
2008 illustrated the importance of culture; the
strongest predictor of a patient ambulating was the
ICU to which they were admitted. Patients admitted
to the respiratory ICU, where mobility is a key clini-
cal intervention, had a statistically significant increase
in ambulation. Mobilizing ICU patients is demand-
ing: the ICU nurses must be committed to coordi-
nation of care and teamwork. The nurses need to
see the connection between mobilizing their ICU
patients and the patients’ outcomes.
The research study allowed the ICU nurses to
test the protocol, determine it was safe, define how
they would implement the practice, and ultimately
to see the difference it made for their patients. Six
months before the research study, the mobility
protocol used in the research study had been
implemented in the ICU; however, practice had
not changed. The goal of the research study was to
compare equipment needs for mobility, but the
unintended result of the study was a change in the
individual nurses’ perceptions and beliefs regarding
455
 mobility. It is unclear what part of the research
process created this change: increased education,
changes in equipment, the rigor of a research study,
or a combination of factors. The net result was an
improvement in mobility of ICU patients. Although
not reported as part of this research study but tracked
for quality purposes, the percentage of patients who
are mobilized in the ICUs has increased fourfold.
Similar results were found in a study published by
Drolet et al18: implementation of a nurse-driven
protocol increased ambulation of ICU patients from
6.2% to 20.2%, and even bigger increases were seen
in the intermediate unit. The nurses proved to them-
selves the value of early mobility and the value of
bedside research in changing clinical practice. It has
changed the culture not just with mobility but also
with sedation. Patients have to be awake to partici-
pate in mobility. Numerous recently published
studies5,19-24 have documented the value of lighter
sedation of patients undergoing mechanical ventila-
tion. This experience has empowered the nurses to
make other decisions about changing their practice
to improve patient care.
Limitations and Strengths
Our study had several limitations. It was a sin-
gle-site study; however, both medical and surgical
patients were included in the sample. The study
lacked a sample size large enough to establish sta-
tistical significance, but the number was adequate
for descriptive statistics. The activity times of selected
patients varied, reducing the power of associated
tests. Mobility was not correlated with severity of
illness, use of mechanical ventilation, or sedation
levels. The sample includes patients receiving mechan-
ical ventilation and patients who were not. Results
are not stratified on the basis of severity of illness,
mechanical ventilation, or sedation levels. Adding
this information to future studies would be impor-
tant for ICU practice. The study did not address
evaluation of patients’ participation or effort. The
scope of the study did not include collection of data
regarding readmission or post-ICU outcomes. The
study results were not correlated with ICU length
of stay, days of mechanical ventilation, delirium
rates, or hospital length of stay. These outcomes are
already well established in published reports, so our
limited resources were not used for this correlation.
Conclusion
Conducting the mobility research study promoted
both earlier initiation and progression of mobility
in the ICU. The study demonstrated that a nurse-
driven protocol can be effective. It is clear from this
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study as well as recent publications that early mobil-
ity is both safe and feasible. Actualizing a mobility
protocol does require interruption in sedation or
nonsedated ICU patients, so that the patient can
participate. Further research is needed to determine
the optimal amount of activity for ICU patients.
FINANCIAL DISCLOSURES
None reported.
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457
Early Mobility in the Intensive Care Unit: Standard Equipment vs a Mobility Platform
Melanie Roberts, Laura Adele Johnson and Trent L. Lalonde
Am J Crit Care 2014;23 451-457 10.4037/ajcc2014878
©2014 American Association of Critical-Care Nurses
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The American Journal of Critical Care is an official peer-reviewed journal of the American Association of Critical-Care Nurses
(AACN) published bimonthly by AACN, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext.
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