Early Mobilization in the Neurological ICU?

The many studies that established the benefits of early mobilization for patients in intensive care units (ICUs) all had at least one thing in common: They failed to include patients in neurological ICUs.

“Studies of early mobilization in the ICU have traditionally excluded patients with acute brain injuries,” says Cleveland Clinic’s Kate Klein, ACNP-BC, CCRN, noting that such patients raise particular concern about the potential for safety compromises during mobilization. As a result, mobilizing patients with neurological injury early in the course of their care has been infrequently tried, and its potential physiologic and psychological benefits have been poorly understood.

Bringing early mobilization to the neuro ICU

In the context of this uncertainty, evidence on the health risks of inpatient immobility prompted Klein and her neurological ICU team to develop a nurse-designed and -driven early progressive mobility protocol with the support of Cleveland Clinic’s nursing research team directed by associate chief nursing officer of research and innovation Nancy M. Albert, PhD, CCNS, CCRN, NE-BC, FAHA, FCCM. After the protocol was implemented in Cleveland Clinic’s 22-bed neurological ICU, they evaluated its impact by conducting a three-phase prospective, longitudinal comparative analysis that included data collection in the neurological ICU over four-month periods before (n = 260) and after (n = 377) protocol implementation.

Comparative results from these first two phases of the study were recently published in Critical Care Medicine and demonstrated that the early mobility protocol improved a number of clinical outcomes, reduced length of stay without compromising patient safety and helped patients feel significantly better.

Specifically, compared with the pre-intervention group, patients managed in the neurological ICU after protocol implementation had the following:

• Higher levels of maximum mobility (P < .001)
• Shorter length of stay in both the hospital and the neurological ICU (P < .001 for both)
• Greater likelihood of being discharged home (P = .002)

All these advantages for the early mobility group were maintained at statistically significant levels after multivariable analysis.

Additionally, patients in the early mobility group felt better, with significantly reduced scores for depression and anxiety compared with the pre-intervention group.

“Not only did we reduce hospital complications across the board,” says Klein, “but our patients spent 36 percent less time in the neurological ICU following implementation of the early mobilization protocol. Overall hospital stay was reduced by 33 percent, days on the ventilator decreased by 70 percent for patients who needed ventilator therapy, and overall cost was reduced by 30 percent. All these results tell us that getting patients out of bed sooner is best practice.”

Not only feasible, but practical too

An accompanying editorial in Critical Care Medicine concurs, calling the study by Klein and colleagues “an important addition to the (neuro)critical care literature [that] shows that early mobilization is not only feasible [but] can be a standard part of the nurses’ ICU routine.” The editorial says the study “gives a practical approach on how to mobilize Neuro ICU patients early, thereby not only improving their mobility but also increasing their chances of doing what every Neuro ICU patient wants most: to go home.”

Building a mobility program for all inpatients

In an effort to fill an obvious need of patients at all stages of their recovery, Klein teamed with Nancy Kaser, CNS, and other Cleveland Clinic colleagues to translate these research findings into practice by developing and implementing a novel nurse-led early mobility program. “During our neuro ICU investigation and early in the development of this program, another critical need was identified,” Klein explains. “Keeping patients and caregivers safe while providing early mobilization requires safe patient handling equipment.”

With the guidance of Jeff Hildreth, Director of Safety in Cleveland Clinic’s Department of Environmental Health and Safety, the program devoted exquisite attention to keeping caregivers safe while promoting patient mobilization, as reflected in the program’s name: the Mobility with Safe Patient Handling Care Path. Essential program elements include:

• A literature-based progressive mobility protocol
• An interdisciplinary team, to include the patient’s family, with specific roles for each member
• An assessment tool for gauging a patient’s readiness for out-of-bed progressive mobilization
• An objective scoring system to measure and celebrate functional mobility progression
• Defined activities and proper equipment selection for each level of mobility
• Meaningful, measurable documentation
• Education and training strategies to sustain the program

The Mobility with Safe Patient Handling Care Path can be applied only in units that contain safe patient handling equipment. Each unit across the continuum of neurological care at Cleveland Clinic is outfitted with safe patient handling equipment, which Klein says speaks volumes about the Neurological Institute’s commitment to patient and caregiver safety. Thus, the care path was piloted in the Neurological Institute to assist in the care of neurological patients throughout their hospital stay.

Emphasis on safety all around

Klein underscores the early mobility program’s dual emphasis on safety — both for patients and for caregivers — as being central to its success. “Cumulative musculoskeletal injury is the most costly occupational health problem among healthcare providers,” she says, “and nursing assistants are the provider type most affected by such injuries, with registered nurses among the top 5. In light of this, we must outfit our patient care environments with equipment that allows caregivers to safely provide the best care to patients.”

She notes that slings and ceiling lifts are now used to securely move patients out of bed to a chair (see image above) and progress them toward ambulation — and that manual lifting is being eliminated across the board. “We expect this will improve our success at avoiding caregiver injuries while ensuring we keep patients safe as we provide this necessary intervention,” she explains.

“We have gained tremendously valuable information from piloting this care path across the Neurological Institute’s care continuum,” Klein adds. “Building a culture of early mobilization by applying this program throughout the Cleveland Clinic enterprise promises to improve clinical outcomes in several domains and enhance patients’ experience throughout their recovery. At its core, this program is about engaging patients early in normalizing their activities of daily living and giving them the opportunity to realize the potential of their recovery. We’re finding that in the process, it’s also instilling hope for their recovery.”