ROOM FOR IMPROVEMENT

ICU-acquired weakness is the acute onset of neuromuscular and functional impairment in critically ill patients.([FOOTNOTE=Vasilevskis EE, Ely EW, Speroff T, Pun BT, Boehm L, Dittus RS. Reducing iatrogenic risks: ICU-acquired delirium and weakness—crossing the quality chasm. Chest. 2010;138(5):1224–1233. doi: 10.1378/chest.10-0466],[ANCHOR=],[LINK=]) Up to 80 percent of ICU patients can develop some form of it,([FOOTNOTE=Jolley SE, Bunnell AE, Hough CL. ICU-acquired weakness. Chest. 2016;150(5):1129–1140. doi: 10.1016/j.chest.2016.03.045],[ANCHOR=],[LINK=]) and it can persist after discharge, sometimes for years.([FOOTNOTE=Hermans G, Van den Berghe G. Clinical review: intensive care unit acquired weakness. Crit Care. 2015;19:274. doi: 10.1186/s13054-015-0993-7],[ANCHOR=],[LINK=])

Early mobility programs can:

• Shorten ICU and hospital stays
• Help patients return to walking unaided
• Increase functional ability and independence at discharge^3,([FOOTNOTE=Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010 Apr;91(4):536–542. doi: 10.1016/j.apmr.2010.01.002],[ANCHOR=],[LINK=])

Early mobility — combined with reduced sedation and spontaneous awakening and breathing trials as part of the ABCDEF bundle — can be safely administered to ventilated patients.([FOOTNOTE=Raoof, S, Baumann MH. Ventilator-associated events: the new definition. Am J Crit Care. 2014;23(1):7–9. doi: 10.4037/ajcc2014469.],[ANCHOR=],[LINK=]) And early mobility is associated with fewer days on a ventilator.^3,([FOOTNOTE=Balas MC, EE Vasilevskis, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility (ABCDE) bundle. Crit Care Med. 2014;42(5):1024–1036. doi: 10.1097/CCM.0000000000000129],[ANCHOR=],[LINK=])

Ventilator-associated events, such as ventilator-associated pneumonia([FOOTNOTE=Hunter, JD. Ventilator associated pneumonia. BMJ. 2012;344:e3325. doi: 10.1136/bmj.e3325.],[ANCHOR=],[LINK=]) and pulmonary embolism,([FOOTNOTE=Stevens, JP, Silva G, Gillis J, et al. Automated surveillance for ventilator-associated events. Chest. 2014;146(6):1612–1618. doi: 10.1378/chest.13-2255],[ANCHOR=],[LINK=]) correlate with longer ICU stays and greater chance of death.¹⁴

Cognitive impairment refers to a persistent loss of brain function following a critical illness. Between one- and two-thirds of mechanically ventilated patients suffer from some level of cognitive impairment, with loss of function comparable to traumatic brain injury or even mild Alzheimer’s disease.([FOOTNOTE=Girard TD, Jackson JC, Pandharipande PP, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med. 2010;38(7):1513–1520. doi: 10.1097/CCM.0b013e3181e47be1],[ANCHOR=],[LINK=])

Length of delirium has been associated with poorer cognition scores one year post-lCU.¹⁰ The reduction in delirium afforded by early mobility treatments lays a foundation for better outcomes that last beyond discharge from the ICU. 

Early mobility is part of a comprehensive set of strategies to improve patient outcomes in the ICU. Called the ABCDEF bundle, it comprises the following protocols:

• Assess, prevent, and manage pain
• Both spontaneous awakening trials and spontaneous breathing trials
• Choice of sedation/analgesia
• Delirium monitoring and management
• Early mobility
• Family engagement and empowerment.

The ABCDEF bundle is associated with shorter ICU and hospital length of stays, less delirium, shorter time on the ventilator, and higher hospital survival rates.¹⁸