Early Mobilization

A group of 23 multidisciplinary experts who had considerable clinical experience and were currently involved in research about early mobilization of adult ICU patients were invited to participate in a consensus meeting. All participants were based at tertiary centers. All 23 invitees attended a face-to-face meeting on 21 June 2013. These 23 participants comprised 17 physiotherapists, 5 intensivists and 1 nurse, who were from Australia (n = 19), United States (n = 2), New Zealand (n = 1) and Finland (n = 1).
Prior to the face-to-face meeting, a systematic review of the literature was performed by two members of the group (CH, CT). Protocols and publications that outlined safety criteria for early mobilization in ICU were identified and distributed to the group. Additionally, any publication or protocol that a member of the consensus committee deemed important was circulated prior to the meeting.
The face-to-face meeting was divided into three parts. First, there were presentations from individual panel members of any published or unpublished safety criteria for mobilization. Second, the panel members were divided into small working groups to determine where there was clear agreement and where further discussion was required regarding safety criteria. Third, the entire group then re-formed and discussed the recommendations from the smaller working parties in order to determine where consensus had been reached and where further discussion was required. Following the face-to-face meeting, a summary of the safety criteria for mobilization was drafted and, using an iterative process, was circulated to panel members via email until the group had reached consensus or agreed that they could not reach consensus. Consensus was defined as 100% agreement amongst the group.

We collected detailed information at initial hospitalization and ICU discharge. We also collected data regarding independent gait ability upon hospital discharge. All data were obtained as a usual clinical practice.
Information at admission included age, sex, body weight, body mass index (BMI), main cause of ICU admission, Charlson’s Comorbidity Index (CCI) [20 (link)], Acute Physiology and Chronic Health Evaluation (APACHE) II score [21 (link)], and the Sequential Organ Failure Assessment (SOFA) score [22 (link)]. Data during ICU stay included the time to first rehabilitation assessment, duration of mechanical ventilation, time to first out-of-bed mobilization, and highest score achieved on the ICU-mobility scale (IMS) [23 (link)]. We also investigated the incidence of adverse events during rehabilitation, such as cardiopulmonary arrest, fall to knees or the ground, inadvertent removal of medical devices, desaturation (< 90%) or more than 10% decrease from the baseline, bradypnea (< 5 breaths/min), tachypnea (> 40 breaths/min), bradycardia (< 40 beats/min), tachycardia (> 130 beats/min), hypotension (systolic blood pressure [SBP] < 80 mmHg), hypertension (SBP > 200 mmHg), and newly occurring arrhythmia. At ICU discharge, we collected incidence of ICU-acquired weakness (ICU-AW) and delirium, respectively. As mentioned above, early mobilization was performed according to the previous protocol [19 (link)] consisted with five session levels (see Appendix 1). We investigated the number of times levels 3, 4, and 5 were achieved, and total number of times levels higher than level 2 were achieved. We calculated ICU length of stay at ICU discharge, and hospital length of stay and ratio of home discharge at hospital discharge.
The IMS provides a quick and simple bedside method of measuring the mobility of a critically ill patient. As functional endpoints in studies of rehabilitation in the ICU, the IMS provides a sensitive 11-point ordinal scale, ranging from nothing (lying/passive exercises in bed, score of 0) to independent ambulation (score of 10). ICU-AW was evaluated using Medical Research Council (MRC) sum-score by the responsible physical therapist, and a value of less than 48 was defined as having developed an ICU-AW [24 (link), 25 (link)]. The cooperation-level assessment was carried out, and muscle strength tests were only performed when the subject correctly answered the five questions [26 (link)]. For the assessment of delirium, either the delirium screening tool of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) [27 (link)] or the Intensive Care Delirium Screening Checklist (ICDSC) [28 (link)] was used according to the usual practice of each participating hospital. Outcomes other than home discharge included transfers to rehabilitation hospitals and to nursing homes.
Patients who could walk 45 m or more with or without braces were determined as gait independent. We also used mobility scale of the Barthel Index (BI) to quantitatively assess gait independence [18 (link), 29 (link)]. BI is the most widely used ADL scale, and its reliability and relevance have been recognized [30 (link)]. Because we previously determined BI was an effective mobility parameter to assess the achievement of gait independence [31 ], we used this parameter in the current study. BI was measured at ICU and hospital discharge.

This single center, prospective observational sequential-group study was conducted at Thorax Centrum Twente (Medisch Spectrum Twente, Enschede, The Netherlands), a tertiary non-academic teaching hospital. Consecutive adult patients undergoing non-salvage cardiac surgery were included. Patients were excluded with a Katz Index of Independence in Activities of Daily Living ≤ 2 before surgery (i.e. all patients included were preoperatively independent in daily life mobilization) [21 (link)] and patients with an intensive care unit (ICU) stay longer than 72 h were also excluded from analysis.
All patients were admitted to the ICU after surgery. An A1 paper size (84 × 59 cm) mobilization poster for each patient room was developed (Fig. 1) based on preliminary external work with a smaller A4 paper size leaflet [22 (link)].Fig. 1

A Design of mobilization poster to promote early mobilization at cardio-thoracic surgery ward attached to every patient room; B Poster situated in patient room in original language (Dutch)

The “Moving is Improving!” practice improvement initiative recruited from 03 to 20 October 2016 as UCG, and from 31 October 2016 to 22 November 2016 for the poster mobilization group (PMG). This practice improvement was initiated when nurses and physiotherapists observed that patients were not motivated for early mobilization. A best practice unit leadership program was started with the underlying study.
7 dedicated physical therapists trained for cardio-thoracic physiotherapy practice participated in the study. Physical therapists were trained in ACSM and TCT classification and a pocket card was handed out for daily use. Nurses and surgical staff were also educated on the importance of early mobilization. One physical therapy intern was added to the team in the PMG, and received similar training. A physiotherapist noted down patient-reported ACSM score daily at each patient room, and was collected after discharge. After interim analysis, the mobilization poster (Translated from Dutch to English, Fig. 1) was implemented as new standard care in the cardio-thoracic surgery ward and patients were also included from 10 September 2017 to 26 March 2018 (PMG).
ACSM score (see Table 1 for definitions) was used to compare UCG to PMG during postoperative hospital stay. No other changes than the poster were implemented during the study.
Change in in-hospital ACSM score and a more detailed Thorax Centrum Twente score (TCT) were defined as primary endpoints. Secondary endpoints included ICU length of stay, surgical ward stay and 30-, 120-day and overall survival. Follow-up on mortality was 100% and ended 1 February 2021. Baseline characteristics were determined based on EuroSCORE II definitions [23 (link)]. Rethoracotomy within 30 days, red blood cell transfusions, and rhythm problems were defined according to Netherlands Heart Registry definitions [24 ]. Temporary pacemaker leads were removed at postoperative day 2 to 5, depending on the type of surgery and underlying rhythm. Having a temporary pacemaker lead was no constraint for mobilization.
A 3 weeks interval of cardio-thoracic surgery determined UCG study size. A consecutive 3 weeks interval determined PMG size and was followed by 6 months use of the poster as new standard care (PMG).
The investigation conforms with the principles outlined in the Declaration of Helsinki [25 (link)]. This study was exempted from the Medical Research Involving Human Subjects Act by the Medical Ethics Committee Twente (METC Twente: K16-85) and was approved by the local institutional review board. Patients therefore did not sign informed consent.

Details on on-site ICU physician coverage, the Tele-ICU staffing, and daily tasks of the Tele-ICU team are showed in Fig. 1. The Tele-ICU system (eCareManager® 4.1, Philips, U.S.A) used in the study supports the decision-making process by patient information centralization and real-time physiological severity evaluation based on automatic analysis (Fig. 2). The Tele-ICU staff consists of a board-certified intensivist, specially trained nurses, and a clerical assistant to the doctor. One nurse is responsible for up to 50 patients. A support center nurse is stationed 24/7. Daily Tele-ICU team tasks involve communication with on-site staff and patients using a secured audio–video system on demand and proactive survey of high risk or physiologically worsening patients to prevent unfavorable events. Venous thrombosis prophylaxis, stress ulcer prophylaxis, medication dosing appropriateness such as catecholamines, vasopressor, analgesics and sedatives, recommendation of early mobilization, early enteral feeding, and sepsis management were included in the tasks. Because the role of Tele-ICU is severity evaluation and advice in this study, the Tele-ICU physicians do not order instead of the on-site physician and only record the contents of the consultation. In addition, as the Tele-ICU physicians expertise in respiratory care and lung protective ventilation, they performed scheduled and/or on demand respiratory round. Tele-ICU physicians are given full authority of bed placement and transfer in university hospital ICU.Fig. 1

Details on on-site ICU physician coverage, the Tele-ICU staffing, and daily tasks of the Tele-ICU of Showa University Hospital

Fig. 2

Outlines of the Tele-ICU system used in the study. BGA blood gas analysis, GCS Glasgow Coma Scale, RASS Richmond agitation–sedation scale, ICDSC Intensive Care Delirium Screening Checklist, CAM–ICU Confusion Assessment Method for the ICU, NMBA neuromuscular blocking agent, ECMO extracorporeal membrane oxygenation, IABP intra-aortic balloon pumping, VAD ventricular assist device, RRT renal replacement therapy