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Toni Talks about PT Today

Early Mobilization

Published June 7, 2011 12:50 PM by Toni Patt

In last week's issue of ADVANCE for Physical Therapy& Rehab Medicine, the cover story described a three-month clinical trial of early mobilization in the ICU. I wanted to cut it out and post it prominently at work. I think all medically stable ICU patients should be mobilized, and I mean out of bed. Author Lisa West points out there is significant evidence to support getting those patients moving. She also mentions the biggest barrier I run into - reluctance to try.

She addressed a few of my other barriers as well. My ICU is for neuro-trauma. Those patients are frequently sedated. Unlike with Lisa's patients, a "sedation vacation" isn't always possible. The problem isn't getting the doctors to agree. It is coordinating with nursing to hold off until therapy is available to turn the sedation off. I usually arrive to see someone just after nursing restarted the sedation after a nursing procedure. It doesn't matter how often I approach them in the morning, the patients always seem to need their vacation before I can arrive.

Another problem for me is reluctance to put orally intubated, sedated or unresponsive patients in neuro chairs. I did it with a quad for three days. His lungs remained open. The day I didn't, he developed respiratory distress and was orally intubated. The doctor was amazed that just setting the man up made such a difference. Our beds go into chair position, which is an improvement but not the same.

I am currently being teased because I want to stand up a patient who is cognitively intact but nearly locked-in. He has proximal leg motor activation bilaterally. Standing is a normal movement. The brain needs to experience normal sensations to facilitate neuroplasticity. I don't see the problem. I'll build him up to it.

We may need a paradigm shift in the treatment of these patients. Evidence shows we can get them out of the ICU faster. Evidence also shows we can shorten hospitalizations by moving patients sooner. It isn't that much of a leap to a relationship between early ICU mobilization, decreased length of stay and improved functional outcome. Either end of such a study would be doable. The problem lies in following the patients long enough for outcome data. I've seen studies that look at discharge disposition but not at actual functional values.

It's something to think about. My stroke patients are out of bed the first day if I can do it safely. If not, they go into chair position using pillows for propping. None of my attending MDs hold me to the 24-hour tPA rule as long as I'm selective. I know we're getting excellent outcomes there. I keep dropping hints about doing a study. I would need an MD for that and so far no takers.

2 comments

Dr Patt,

Excellent points all. My question for you is; do you really need an MD on board to do a study? I would assume you'd need your facility's approval. Might I suggest approaching a business manager on the topic? Make a business case for the study, make it clear how you are positive you can demonstrate better outcomes and show the facility in a good light. Once the business side is on board, they may help get any necessary MDs on board as well. Good luck with it!

Dean

Dean Metz June 8, 2011 12:37 PM

Hey Toni-

Thanks for the wonderful blog this week.  I agree with some many things you highlighted.  It would be wonderful to follow patients for a longer duration for evidence of early mobility translating into increased quality of life after discharge from the hospital.  There are a few smaller studies aimed at outlining those outcomes, but like you said, following patients for a longer time takes more responsibility onto the researcher.  

One article titled "Effects of Physical Training on Functional Status in Patients With Prolonged Mechanical Ventilation" (PT Journal Sept 2006), looks at FIM scores and the Barthel Index at baseline, 3 weeks and 6 weeks following PT interventions.  Although the time frame isn't very long, but at least the measured outcomes are related to functional outcomes.  

I would definitely recommend you to keep pushing for more evidence at your facility.  While having a supporting MD will add collaborative support, you will be surprised how much you can accomplish just withing your own practice.  

Lisa West, DPT

Lisa West June 7, 2011 10:14 PM

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