Early Mobility and Exercise

Within the ABCDEF bundle, the E element refers to Early Mobility and Exercise.

The E Element focuses on understanding the physical deficits that ICU survivors face, and identifying strategies for successful implementation of early mobilization programs.
 

The key question to ask during rounds is: Did the patient achieve maximum mobility or exercise today? If early mobilization is falling short, it is important to determine the reasons. Some factors to consider are:

  • Was the patient walking before admission?
  • Is the patient hemodynamically stable?
  • Is the patient awake?

Also take into account the following aspects before mobilizing a patient in the ICU:

  • Neurologic (level of alertness)
  • Cardiac (hemodynamic stability and vasoactive medications)
  • Pulmonary (ventilation/oxygenation needs)
  • Risk versus benefit
  • Guidelines versus protocols (fewer absolute contraindications, importance of interdisciplinary collaboration)
Implementing the E Element of the ABCDEF Bundle

Search E Element Resources
 
Step 1: Patient Selection Process
Do any of the following exclusion criteria apply?
  • Patient has immediate plans to transfer to outside hospital
  • Patient requires significant doses of vasopressors for hemodynamic stability (maintain mean arterial pressure > 60 mm Hg)
  • Patient is mechanically ventilated and requires Fio2 > 0.8 and/or positive end-expiratory pressure > 12 mm Hg, or has acutely worsening respiratory failure
  • Patient is maintained on neuromuscular paralytic agents
  • Patient has an acute neurologic event (e.g., cerebrovascular accident, subarachnoid hemorrhage, or intracranial hemorrhage) with reassessment for mobility every 24 hours
  • Patient is unresponsive to verbal stimuli
  • Patient has an unstable spine or extremity fracture
  • Patient has a grave prognosis and is transferring to comfort care
  • Patient has an open abdomen with a risk for dehiscence
These are guidelines, not precautions. In the presence of any exclusion criterion, consult with patient’s providers to determine if participation in physical activity or exercise is safe.

Step 2: Assess Patient’s Activity History
What was the patient’s level of activity in the past two hours, two days, two weeks, two months, and two years?

Step 3: Grossly Assess Patient’s Strength
How easily can the patient lift legs off the bed? How well does the patient bear weight on the legs?

Step 4: Assess Patient’s Ability to Engage
How well does the patient follow commands and engage in activity?
While encouraging and physically supporting patients in their efforts to achieve their individual goals, staff must watch the patient, watch the monitors, and watch the lines while gradually increasing the activity level.

Mobility therapy steps
Step 1: Untangle and create slack on the lines. Secure the lines. Connect the portable monitor.
Step 2: Initiate bed exercise. Watch the patient, watch the monitor, and watch the lines. 
Step 3: Sit the patient on the edge of the bed. Assess for pain and orthostatic blood pressure.
Step 4: Assist seated patient in standing.
Step 5: Initiate walking. Keep a chair close to the patient. Utilize aides, volunteers and students to push chair and intravenous poles.
Step 6: Seat and rest the patient as needed.

Consider the following factors with each physical rehabilitation or ICU mobility session: 
  • Determine whether the level of activity is therapeutic. 
  • Identify the available equipment. 
  • Schedule a time to work on physical activity with the patient, family, nurse and respiratory therapist. Ascertain whether sedation should be suspended. 
  • Assess and manage the patient’s pain before, during and after mobility activity. 
  • Optimize the work of breathing and patient level of alertness to make treatment beneficial.
  • Create activities that are goal-oriented for the patient.
  • Do not delay or defer physical activity and rehabilitation even if the patient is to be extubated that day.
  • Do not delay or defer physical activity because of agitation if it can be safely managed by the nurse and therapist. For patients who are agitated or experiencing disorganized thinking and delirium, a focused task provides an opportunity for reorienting conversation.
Stop and rest the patient if the patient:
  • Is unresponsive
  • Is fatigued or appears pale
  • Has a respiratory rate consistently > 10 beats/min above baseline
  • Has decreased muscle recruitment
  • Loses balance
  • Has decreased weight-bearing ability
  • Has diaphoresis
Functional Status Score for the Intensive Care Unit (FSS-ICU): An International Clinimetric Analysis of Validity, Responsiveness, and Minimal Important Difference
Citation: Crit Care Med. 2016 Dec; 44(12): e1155–e1164.
Population: Adult
Bundle: E Element
View Reference
Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans
Citation: Am J Respir Crit Care Med. 2011 Feb 1;183(3):364-71
Population: Adult
Bundle: E Element
View Reference
Mechanisms of Chronic Muscle Wasting and Dysfunction After an Intensive Care Unit Stay: A Pilot Study
Citation: Am J Respir Crit Care Med. 2016 Oct 1;194(7):821-830
Population: Adult
Bundle: E Element
View Reference
Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults
Citation: Crit Care. 2014 Dec 4;18(6):658
Population: Adult
Bundle: E Element
View Reference
Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations
Citation: Clin Rehabil. 2015 Nov;29(11):1051-63
Population: Adult
Bundle: E Element
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Implementing early physical rehabilitation and mobilisation in the ICU: institutional, clinician, and patient considerations
Citation: Intensive Care Med. 2018 Apr;44(4):470-473
Population: Adult
Bundle: E Element
View Reference
Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial
Citation: Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial
Population: Adult
Bundle: E Element
View Reference
Early Mobilization Reduces Duration of Mechanical Ventilation and Intensive Care Unit Stay in Patients With Acute Respiratory Failure
Citation: Arch Phys Med Rehabil. 2017 May;98(5):931-939
Population: Adult
Bundle: E Element
View Reference
Early Mobilization and Rehabilitation of Patients Who Are Critically Ill
Citation: https://www.ncbi.nlm.nih.gov/pubmed/26997241
Population: Adult
Bundle: E Element
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Physical rehabilitation interventions for adult patients during critical illness: an overview of systematic reviews
Citation: Thorax. 2016 Oct;71(10):881-90
Population: Adult
Bundle: E Element
View Reference
Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices
Citation: Ann Am Thorac Soc. 2016 Sep;13(9):1527-37
Population: Adult
Bundle: E Element
View Reference
Physiotherapy for Patients on Awake Extracorporeal Membrane Oxygenation: A Systematic Review
Citation: Physiother Res Int. 2016 Dec;21(4):203-209
Population: Adult
Bundle: E Element
View Reference
Safety of physical therapy interventions in critically ill patients: A single-center prospective evaluation of 1110 intensive care unit admissions
Citation: J Crit Care. 2014 Jun;29(3):395-400
Population: Adult
Bundle: E Element
View Reference
Early ambulation after diagnostic transfemoral catheterisation: a systematic review and meta-analysis
Citation: Int J Nurs Stud. 2014 Jan;51(1):39-50
Population: Adult
Bundle: E Element
View Reference
Early activity is feasible and safe in respiratory failure patients
Citation: Crit Care Med. 2007 Jan;35(1):139-45
Population: Adult
Bundle: E Element
View Reference
Interventions to improve the physical function of ICU survivors: a systematic review
Citation: Chest. 2013 Nov;144(5):1469-148
Population: Adult
Bundle: E Element
View Reference
Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit
Citation: J Crit Care. 2013 Aug;28(4):535.e9-15
Population: Adult
Bundle: E Element
View Reference
Critical illness neuromuscular syndromes
Citation: Crit Care Clin. 2006 Oct;22(4):805-18; abstract xi
Population: Adult
Bundle: E Element
View Reference
An official American Thoracic Society Clinical Practice guideline: the diagnosis of intensive care unit-acquired weakness in adults
Citation: Am J Respir Crit Care Med. 2014 Dec 15;190(12):1437-46
Population: Adult
Bundle: E Element
View Reference
Diaphragm muscle thinning in patients who are mechanically ventilated
Citation: Chest. 2012 Dec;142(6):1455-1460
Population: Adult
Bundle: E Element
View Reference
One-year outcomes in survivors of the acute respiratory distress syndrome
Citation: N Engl J Med. 2003 Feb 20;348(8):683-93
Population: Adult
Bundle: E Element
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Functional disability 5 years after acute respiratory distress syndrome
Citation: N Engl J Med. 2011 Apr 7;364(14):1293-304
Population: Adult
Bundle: E Element
View Reference
Physical Therapy on the wards after early physical activity and mobility in the intensive care unit
Citation: Phys Ther. 2012 Dec;92(12):1518-23
Population: Adult
Bundle: E Element
View Reference
Early physical rehabilitation in intensive care patients with sepsis syndromes: a pilot randomized controlled trial
Citation: Intensive Care Med. 2015 May;41(5):865-74
Population: Adult
Bundle: E Element
View Reference
Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis
Citation: Crit Care Med. 2013 Jun;41(6):1543-54
Population: Adult
Bundle: E Element
View Reference
ICU-acquired weakness and recovery from critical illness
Citation: N Engl J Med. 2014 Apr 24;370(17):1626-35
Population: Adult
Bundle: E Element
View Reference
Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans
Citation: N Engl J Med. 2008 Mar 27;358(13):1327-35
Population: Adult
Bundle: E Element
View Reference
ICU early physical rehabilitation programs: financial modeling of cost savings
Citation: Crit Care Med. 2013 Mar;41(3):717-24
Population: Adult
Bundle: E Element
View Reference
Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure
Citation: Am J Med Sci. 2011 May;341(5):373-7
Population: Adult
Bundle: E Element
View Reference
Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project
Citation: Arch Phys Med Rehabil. 2010 Apr;91(4):536-42
Population: Adult
Bundle: E Element
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Long-Term Cognitive Impairment after Critical Illness
Citation: N Engl J Med. 2013 Oct 3; 369(14): 1306–1316
Population: Adult
Bundle: E Element
View Reference
Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation
Citation: Crit Care Med. 2010 Nov;38(11):2089-94
Population: Adult
Bundle: E Element
View Reference
Acute skeletal muscle wasting in critical illness
Citation: JAMA. 2013 Oct 16;310(15):1591-600
Population: Adult
Bundle: E Element
View Reference
Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial
Citation: Lancet. 2009 May 30;373(9678):1874-82
Population: Adult
Bundle: E Element
View Reference
Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority
Citation: Crit Care Med. 2008 Apr;36(4):1119-24
Population: Adult
Bundle: E Element
View Reference
Ambulating with pulmonary artery or femoral catheters in place
Citation: Crit Care Nurse. 2011 Oct;31(5):70-3
Population: Adult
Bundle: E Element
View Reference
Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): a multicentre collaborative
Citation: Intensive Crit Care Nurs. 2012 Apr;28(2):88-97
Population: Adult
Bundle: E Element
View Reference
Healthy hearts--and the universal benefits of being physically active: physical activity and health
Citation: Ann Epidemiol. 2009 Apr;19(4):253-6
Population: Adult
Bundle: E Element
View Reference
J.B. Wolffe Memorial Lecture. Health consequences of physical activity: understanding and challenges regarding dose-response
Citation: Med Sci Sports Exerc. 1994 Jun;26(6):649-60
Population: Adult
Bundle: E Element
View Reference
Clinical trials of early mobilization of critically ill patients
Citation: Crit Care Med. 2009 Oct;37(10 Suppl):S442-7
Population: Adult
Bundle: E Element
View Reference
Early Mobilization in the Intensive Care Unit: Evidence and Implementation
Citation: Cardiopulm Phys Ther J. 2012 Mar; 23(1): 5–13
Population: Adult
Bundle: E Element
View Reference
A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit
Citation: J Trauma. 2009 Aug;67(2):341-8; discussion 348-9
Population: Adult
Bundle: E Element
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Early intensive care unit mobility therapy in the treatment of acute respiratory failure
Citation: Crit Care Med. 2008 Aug;36(8):2238-43
Population: Adult
Bundle: E Element
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Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model
Citation: Top Stroke Rehabil. 2010 Jul-Aug;17(4):271-81
Population: Adult
Bundle: E Element
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Early mobility and walking program for patients in intensive care units: creating a standard of care
Citation: Am J Crit Care. 2009 May;18(3):212-21
Population: Adult
Bundle: E Element
View Reference
Safety and Efficacy of Mobility Interventions in Patients with Femoral Catheters in the ICU: a Prospective Observational Study
Citation: Cardiopulm Phys Ther J. 2013 Jun; 24(2): 12–17
Population: Adult
Bundle: E Element
View Reference
Early mobilization of LVAD recipients who require prolonged mechanical ventilation
Citation: Tex Heart Inst J. 2006; 33(2): 130–133
Population: Adult
Bundle: E Element
View Reference
Long-term quality of life after surgical intensive care admission
Citation: Arch Surg. 2011 Apr;146(4):412-8
Population: Adult
Bundle: E Element
View Reference
Health benefits of physical activity: the evidence
Citation: CMAJ. 2006 Mar 14; 174(6): 801–809
Population: Adult
Bundle: E Element
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Early mobilization in the critical care unit: A review of adult and pediatric literature
Citation: J Crit Care. 2015 Aug;30(4):664-72
Population: Adult
Bundle: E Element
View Reference
Early mobilization in the pediatric intensive care unit: a systematic review
Citation: J Pediatr Intensive Care. 2015; 2015: 129–170.
Population: Pediatrics
Bundle: E Element
View Reference
PICU Up!: Impact of a Quality Improvement Intervention to Promote Early Mobilization in Critically Ill Children
Citation: Pediatr Crit Care Med. 2016 Dec; 17(12): e559–e566
Population: Pediatrics
Bundle: E Element
View Reference
Optimizing Sedation Management to Promote Early Mobilization for Critically Ill Children
Citation: J Pediatr Intensive Care. 2015;4(4):188-193. Epub 2015 Sep 1
Population: Pediatrics
Bundle: E Element
View Reference
Transforming PICU culture to facilitate early rehabilitation
Citation: J Pediatr Intensive Care. 2015 Dec; 4(4): 204–211
Population: Pediatrics
Bundle: E Element
View Reference
Early mobilization in the critical care unit: a review of adult and pediatric literature
Citation: J Crit Care. 2015 Aug;30(4):664-72
Population: Pediatrics
Bundle: E Element
View Reference
Early mobilization in critically ill children: a survey of Canadian practice
Citation: Crit Care Med. 2013 Jul;41(7):1745-53
Population: Pediatrics
Bundle: E Element
View Reference
Acute rehabilitation practices in critically ill children: a multicenter study
Citation: Pediatr Crit Care Med. 2014 Jul;15(6):e270-9
Population: Pediatrics
Bundle: E Element
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