Early Mobility and Exercise

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