Early mobilization in the ICU has been linked with improved patient outcomes. A study published in Nursing in Critical Care found that early mobilization did significantly reduce the incidence of ICU-acquired weakness, shortened the length of ICU and hospital stays, and improved functional recovery [1]. Successful implementation of early mobility depends on a number of factors, including patient status, and ICU-related processes, structures, and culture. This review identifies potential barriers to early mobility, as well as strategies to address those barriers, which may be helpful to clinicians as they implement early mobility programs in the ICU. A multi-professional approach to early mobility implementation and a change in ICU culture, making early mobility a high priority, are especially important. Barriers and strategies may change during the implementation process, indicating a need for ongoing, interprofessional reflection and evaluation [2].
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The Patient-related barriers were diverse and often required individualized solutions. Physical barriers were mainly related to high severity of illness such as hemodynamic instability, severe hypoxemia, CRRT, or advanced disease stage. ICU device barriers included femoral devices (i.e., Impella, IABP), ECMO, tubes, or drains that may limit the mobility of the patient. Finally, neuropsychological barriers related to patient refusal, lack of motivation, or anxiety. It could also be related to deep sedation, delirium, or agitation A variety of interventions may be necessary to address the various patient-related barriers encountered in ICU early mobilization. Strategies to address these barriers fall into three categories: protocol development incorporated with safety checks and a stepwise approach to mobility, interprofessional protocols to coordinate patient mobilization, and tailored exclusion criteria that clearly identify conditions where mobility is contraindicated.
Structural barriers included limited staff, time constraints, inadequate staff training, or limited equipment and safety devices. Strategies clearly include the development of financial modeling of economic and outcome improvement benefits to discuss with the administrators and the decision makers to increase funds for staffing and equipment. Administrative support for independent mobility teams would be key to the success of such programs. Organizational changes, such as staff turnover or changes in leadership, can also hamper the sustainability of early mobility programs. It is therefore important to identify these potential barriers in advance and develop plans to address them.
Lack of mobility culture is reported as a major barrier to the implementation of the early mobility program. Barriers identified included lack of staff knowledge regarding the benefits, safety, and techniques of mobility; inadequate staff buy-in regarding early mobility as a priority; lack of communication and unclear delineation of staff roles; and low staff morale. In addition, a lack of patient and family knowledge has also been reported as a barrier to the success of such programs. Strategies to overcome these barriers include multimedia education such as sharing presentations, literature, and videos, staff training such as bedside teaching, workshops, and hands-on, and improve communication with Interprofessional rounds, checklists, and protocols. Change in decision-making processes, goals-sharing, timely feedback about successes with patient mobilization (experience sharing), and interprofessional champions are important for promoting early mobility programs.
Process-related barriers to patient mobility were commonly due to a lack of planning and communication between different members of the care team. Unclear expectations, roles, and responsibilities, missing/delayed daily screening for eligibility, and standing bedrest orders for patients are a few examples that can hinder the progress of a mobility program. The strategies identified to overcome process-related barriers provide a roadmap for improving patient mobility. Many of these interventions require interprofessional collaboration in order to be successful. Central champions and coordinators are needed to ensure that everyone is on the same page with regard to expectations, roles, and responsibilities. Education is also essential to promote early mobilization and preventative measures such as screening for appropriate patients.
In conclusion, the barriers to early mobilization in the ICU are many and varied. This barriers could be related to patient status, organizational structural issues, lack of mobility culture in the ICU, or process-related. There are strategies that have been shown to be effective in overcoming these barriers. Successful implementation of early mobility in the ICU requires a multi-professional approach and changing the ICU culture so that early mobilization is a high priority. Barriers and strategies may change during the implementation process, indicating a need for ongoing, interprofessional reflection and evaluation.
REFERENCES
Zang K, Chen B, Wang M, Chen D, Hui L, Guo S, Ji T, Shang F. The effect of early mobilization in critically ill patients: A meta-analysis. Nurs Crit Care. 2020 Nov;25(6):360-367. doi: 10.1111/nicc.12455. Epub 2019 Jun 20. PMID: 31219229.
Dubb R, Nydahl P, Hermes C, Schwabbauer N, Toonstra A, Parker AM, Kaltwasser A, Needham DM. Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units. Ann Am Thorac Soc. 2016 May;13(5):724-30. doi: 10.1513/AnnalsATS.201509-586CME. PMID: 27144796.
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