Mobilization of intensive care patients: a multidisciplinary practical guide for clinicians

Margot Green, Vince Marzano, I Anne Leditschke, Imogen Mitchell, Bernie Bissett, Margot Green, Vince Marzano, I Anne Leditschke, Imogen Mitchell, Bernie Bissett

Abstract

Objectives: To describe our experience and the practical tools we have developed to facilitate early mobilization in the intensive care unit (ICU) as a multidisciplinary team.

Background: Despite the evidence supporting early mobilization for improving outcomes for ICU patients, recent international point-prevalence studies reveal that few patients are mobilized in the ICU. Existing guidelines rarely address the practical issues faced by multidisciplinary ICU teams attempting to translate evidence into practice. We present a comprehensive strategy for safe mobilization utilized in our ICU, incorporating the combined skills of medical, nursing, and physiotherapy staff to achieve safe outcomes and establish a culture which prioritizes this intervention.

Methods: A raft of tools and strategies are described to facilitate mobilization in ICU by the multidisciplinary team. Patients without safe unsupported sitting balance and without ≥3/5 (Oxford scale) strength in the lower limbs commence phase 1 mobilization, including training of sitting balance and use of the tilt table. Phase 2 mobilization involves supported or active weight-bearing, incorporating gait harnesses if necessary. The Plan B mnemonic guides safe multidisciplinary mobilization of invasively ventilated patients and emphasizes the importance of a clearly articulated plan in delivering this valuable treatment as a team.

Discussion: These tools have been used over the past 5 years in a tertiary ICU with a very low incidence of adverse outcomes (<2%). The tools and strategies described are useful not only to guide practical implementation of early mobilization, but also in the creation of a unit culture where ICU staff prioritize early mobilization and collaborate daily to provide the best possible care.

Conclusion: These practical tools allow ICU clinicians to safely and effectively implement early mobilization in critically ill patients. A genuinely multidisciplinary approach to safe mobilization in ICU is key to its success in the long term.

Keywords: critical care; intensive care; multidisciplinary communication; physiotherapy (techniques).

Figures

Figure 1
Figure 1
Mobilization flowchart. Notes: (A) Decision making flowchart for mobilization of ICU patients. *If hemiplegic, ≥ 3/5 on intact side. (B) Nursing guideline for mobilization of ICU patients. Abbreviation: ICU, intensive care unit.
Figure 1
Figure 1
Mobilization flowchart. Notes: (A) Decision making flowchart for mobilization of ICU patients. *If hemiplegic, ≥ 3/5 on intact side. (B) Nursing guideline for mobilization of ICU patients. Abbreviation: ICU, intensive care unit.
Figure 2
Figure 2
Passive mobilization. Notes: Passive mobilization – hoist transfer from bed to chair for an unresponsive intubated patient. Note the support of the airway and organization of lines.
Figure 3
Figure 3
Phase 1 mobilization. Notes: (A) Tilt table for an awake intubated patient performing squats with assistance. This patient was unable to achieve supported weight-bearing with a gait harness. Note the nurse managing airway and physiotherapists providing support to knees. (B) Sitting balance with a ventilator-dependent patient. Note the nurse providing airway support while physiotherapists assist balance behind and in front of the patient.
Figure 4
Figure 4
Phase 2 mobilization: supported weight-bearing for an intubated patient with primary central nervous system pathology. Notes: Note the gait harness providing body weight support through the pelvis and physiotherapists assisting with hip and knee control while the nurse supports the airway.
Figure 5
Figure 5
Phase 2 mobilization: active mobilization of awake intubated patients. Notes: (A) With a ventilator and portable monitoring. Note the spare oxygen cylinders suspended from the forearm support frame. Support staff are following the patient with a chair. (B) With resuscitator bag. Note the bariatric forearm support frame and organization of attachments on the portable pole. Both the physiotherapist and nurse are assisting the patient to steer the frame.
Figure 6
Figure 6
Plan B mnemonic for mobilization of intubated patients. Abbreviation: MDT, multidisciplinary team.

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