Moving Toward Recovery

​Vicki Spuhler, RN, MS, can tell you exactly when she decided to pursue what seemed like a crazy idea. It was 1997, after she spotted a former patient in the hallway of the LDS Hospital in Salt Lake City, Utah, where she worked as an intensive care unit (ICU) nurse. The teenager had developed an embolism in his lung from a dirt-bike accident and spent four months on a mechanical ventilator in Spuhler’s unit. A year after discharge, “he was still in a wheelchair,” says Spuhler. “I was stunned. I expected him to be back on his feet.” Young as he was, the teen’s body had drastically weakened during the months he’d spent nearly motionless with a breathing tube in his throat and he still hadn’t recovered.

 

The incident crystallized an idea that had been growing in Spuhler’s mind. As a veteran ICU nurse, she already knew that prolonged immobility causes severe and durable muscle weakness. Studies found that 12 to 24 months after discharge, only 56 to 77 percent of ventilated patients regained their prior body strength. Yet conventional medical wisdom held that physical activity just wasn’t an option for seriously ill patients tethered to life-saving equipment.

 

Spuhler — an Institute for Healthcare Improvement (IHI) faculty lead for IHI’s Improving Outcomes for High-Risk and Critically Ill Patients Learning and Innovation Community — didn’t buy it. “Even if we weren’t worried about the long-term effects of immobility, we want to wean patients off the vent as quickly as possible to avoid short-term complications like pneumonia. Physical strengthening supports that process.” Spuhler reasoned that, with the right encouragement and support, her ventilator patients could walk, even with breathing equipment and IV lines in place, and the activity would benefit all aspects of their recovery.

 

Convincing a physician to approve the plan in her 12-bed ICU, Spuhler began to fine-tune her protocol based on these principles:

  • Unconscious or heavily sedated patients are not candidates for mobility, so sedation or narcotics must first be minimized or discontinued.
  • Once a patient responds to verbal stimuli, initiate activity by sitting the patient up with legs off the side of the bed. Progress as quickly as possible to standing, transferring to a chair, walking with assistance, and walking independently.
  • For safety, follow the patient with a wheelchair.
  • The goal is for the patient to walk 200 feet before discharge.
  • Activity can be suspended for no longer than 24 hours if the patient becomes unstable, but otherwise is part of required care.
  • Activity should continue despite a patient’s agitation or delirium, which often improve with reconditioning.
  • If the patient isn’t strong enough to tolerate both weaning from the ventilator and physical activity, pursue activity first.
 
By 2003, Spuhler was managing an eight-bed Respiratory ICU (RICU) at LDS Hospital, and anecdotal results were good enough to encourage her to collect data on the safety and feasibility of mobilizing patients. In 2007, the Journal of Critical Care Medicine (Vol. 35, No.1) published a six-month study by Spuhler and several others of 103 patients in respiratory failure. The authors found that the majority of patients were able to walk at least 100 feet by discharge with no major adverse events, such as accidental extubation. The study did not try to determine whether or how activity affected long-term outcomes, but its conclusions were still controversial. “The journal editors were skeptical,” notes Spuhler. “They kept asking us for more data, but eventually one of them wrote an editorial calling it ‘landmark work.’”
 
Kelly McCutcheon Adams, the director of IHI’s Improving Outcomes for High-Risk and Critically Ill Patients Learning and Innovation Community, couldn’t agree more. She calls Spuhler’s determination to get ventilator patients out of bed as soon as possible “the heart and soul of quality improvement” for this population. “It focuses attention on the main issue, which is that the sooner you get patients moving, the sooner you can wean them off the vent, and the sooner you do that, the less chance of complications.”
 
Now nurse manager of the RICU at Intermountain Medical Center in Murray, Utah, Spuhler presented on mobilizing vented patients at a May 2007 meeting of the Community’s 33 hospital teams. “When people saw the pictures [see below], their jaws dropped,” says McCutcheon Adams, “and everyone went home with the protocol.”
 
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Mobility starts slowly with assisting a patient to first sit up (photo above), then gradually to walk (photo below) as much as 200 feet.
 
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Unlike most teams at the Learning and Innovation Community meeting, the team from the University of Rochester Medical Center (URMC) in New York had already developed their own ICU mobility protocol. “Initially, we were just looking to avoid pressure sores by repositioning patients in bed or sitting them in a chair,” says Barry Evans, RN, MSN, URMC’s Adult Critical Care Quality Improvement Leader. “Our medical director thought we could do more.” So, in February 2007, Evans did a literature search and pulled together an algorithm on mobility in the ICU with four levels ranging from repositioning to walking.
 
After testing the algorithm on a few patients and educating the staff, Kate Ireland, RN, MSN, Nurse Manager in the Medical ICU at URMC, implemented it in her 12-bed unit and began tracking compliance. Results were not impressive. In May 2007, only 19 percent of MICU patients were mobilized. By July, compliance had only increased to 46 percent, so Evans and Ireland took a new tack. Every morning, a nurse leader went to each of the seven nurses on duty to discuss prospects and plans for mobilizing their patients that day. “At first, it took an average of five hours per day because the nurses were not really convinced it was safe,” says Ireland. “So some of the time was spent convincing and educating, not just planning.” The approach worked, though, and by September 2007 compliance had shot up to 97 percent. “Now leadership rounds take only an hour a day,” says Ireland. Better yet, between February 2007 and June 2008 length of stay in the MICU dropped by 1.4 days and time on the ventilator dropped by 1.8 days.
 
Encouraged by the success, URMC has expanded the protocol to all four ICUs and has set a new goal of multiple mobility sessions per day and faster progression of activity levels. “There was some concern that it would be too labor intensive to do more mobility work,” says Evans, “but we don’t think that’s going to be true because as you are able to increase patients’ physical conditioning, you actually reduce the other work involved in their care.”
 
The Innovation and Learning Community is eager to spread the benefits of mobility, says McCutcheon Adams, and members are testing and adapting the protocol in their own hospitals. “Once we can demonstrate that it works well in all settings, we’re going to start spreading the process as widely as we can.”  
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