Forced rest in intensive care units (ICU) often results in muscle weakness within days. The term ICU-acquired weakness refers to myopathy and/or polyneuropathy secondary to critical illness and immobilization among other factors.1,2 ICU-acquired weakness occurs in 25%–50% of ventilated patients.3 Bed rest is also associated with long-term complications, manifesting as post intensive care syndrom comprising physical, cognitive, and psychiatric sequelae that prevent patients from recovering their prior quality of life after discharge from the ICU.4

Although benefits of mobilization have been known for decades, early mobilization (EM) was first implemented in ICUs only 20 years ago.5,6 EM is safe and feasible,7,8 and it is associated with better outcomes, including improved functional status, shorter duration of mechanical ventilation (MV), lower incidence of delirium, increased muscle strength, and better quality of life.9–11

EM has recently been included in a package of measures, the ABCDEF care bundles. They are defined as a set of evidence-based interventions that are addressed to minimize the risks derived from sedation, delirium and immobilization, with the aim of potentially reducing the incidence of PICS.12,13

Advances in technology and medicine have increased the complexity of critical care medicine, making clinical information systems (CIS) useful to ensure safe, timely, and effective care. CIS include databases, allowing us to measure what we do, analyze adherence to recommendations based on scientific evidence, improve professional performance, and evaluate the impact of improvement strategies.14

Although some studies have evaluated the practice of EM in ICU,15,16 few have evaluated daily mobilization practices in mechanically ventilated patients,15 and most of these measured adherence at a single point in time.16 To our knowledge, no reports of longitudinal studies evaluating mobilization practices in MV patients in routine clinical practice have been published. The current study aimed to analyze EM in our ICU over a 3-year period. To this end, we used data from our CIS database to determine adherence to EM protocols, the incidence of adverse events, the role of ventilator support, and barriers.

The primary endpoint was adherence to the EM protocol, defined as the percentage of stay-days in which the EM form extracted from the CIS contained information regarding the type of mobilization or justified reasons for not mobilizing the patient. Secondary endpoints were (a) total number mobilizations, defined as the percentage of stay-days in which patients were mobilized in relation to total stay-days; (b) putative hidden adherence, defined as the percentage of stay-days in which the mobilization form had not been completed, but patients did not meet clinical stability criteria for mobilization; (c) delay in beginning the EM protocol, defined as stay-days before begining the EM protocol in which the EM form was not completed and patients met de clinical stability criteria; (d) barriers; (e) levels of mobilization according to the ventilatory support, type of airway and level of sedation; (f) analysis of non-working days, and (g) adverse events during mobilization, defined as arrhythmias, falls, accidental removal of devices, hypertension (systolic blood pressure >200mmHg), hypotension (systolic blood pressure <80mmHg), hypoxemia (SatO2 <80%), and accidental extubation.7

Of the 2924 patients admitted to the ICU during the study period, 1231 (42.1%) required MV; of these 771 (62.6%) received MV>48h and after excluded 383 (49.7%) for meeting the exclusion criteria, we included 388 (50.3%) patients (Fig. 2) (median age, 63 [51–72]y; 273 (70.4%) men). At admission, the median APACHE II score was 23 (18–29) and the median SOFA score was 3 (1–5.8). The most frequent reason for admission was respiratory failure 23.5%, followed by postsurgical care 19.8% and septic shock 18.3%.

Figure 2.

Flowchart study: number patients. ICU, intensive care unit; IMV, invasive mechanical ventilation; BMI, body mass index; TBI, trauma brain injury.

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Primary outcome

The ICU stays for these 388 patients comprised a total of 4568 stay-days; of these, 1299 fell on weekends or holidays when patients were not screened for EM. Thus, a total of 3269 stay-days were analyzed to obtain the adherence (Fig. 3). The EM form was completed in 2040 stay-days; of these, patients were mobilized in 1472 stay-days. Since the lack of a physiotherapist in 190 stay-days is a cause of non-adherence to the protocol, they were not taken into account within the 2040 stay-days, so the adherence was 1850 (56.6%) stay-days compared to the 3269 stay-days evaluated.

Figure 3.

Flowchart showing reasons for not implementing the early mobilization protocol. EM, early mobilization; CCS, criteria for clinical stability; PT, physiotherapist.

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Our study shows that using real-world data stored in the CIS the EM took place in 56.6% stay-days, showing that there is much room for improvement. The main barrier was failure to meet the clinical stability criteria, followed by the unavailability of physiotherapists.

Dubb et al.18 identified 28 barriers to EM, concluding that successful implementation of EM protocols requires each ICU to identify barriers based on its patient mix, equipment, staff expertise, and local culture. Most studies report that patient-related factors such as hemodynamic instability, delirium, or sedation levels are major barriers to EM. In our study, the main barrier to EM was failure to meet the safety criteria, which was the reason mobilization was not performed in half of the cases; these findings corroborate those reported in other studies.7,15,19 Although consensus recommendations regarding the safety criteria for mobilizing mechanically ventilated patients can be used to guide rehabilitation in the ICU while minimizing the risk of adverse events,17 the absence of clinical practice guidelines suggests that cautious application of more flexible criteria guided by analyses of data from the CIS might enable more patients to benefit from EM.

EM in critically ill patients requires coordination, commitment, and physical effort by the multidisciplinary team. Physiotherapists play a key role in EM; however, our country's ICU culture assigns a limited role for physiotherapists compared to other countries.20 A recent study in our country found that 18.6% of ICU teams included no physiotherapists; 10.5% had a physiotherapist for less than 5h a week, 12.8% had one between 5 and 10h a week, 10.5% between 10 and 15h a week, 8.1% between 15 and 20h a week, and only 4.6% had one for more than 24h a week. In the remaining 34.9%, physiotherapists could be consulted through the rehabilitation service.21 Our protocol was designed considering that physiotherapists would be present for 6h a day on weekdays that were not on non-working-days. Our results show that in 851 non-working stay-days patients met the safety criteria but were not mobilized because physiotherapists were unavailable.

One way to mitigate the unavailability of physiotherapists is to involve nurses and family members in EM. Integrating EM training into nursing education can help nurses understand the risks and benefits of mobilization in critically ill patients; increasing nurses’ knowledge can improve outcomes through better management of personnel needed to complete transfers of patients being mobilized.22 Rukstele et al.23 found that the participation of family members in mobilization efforts increased adherence to recommendations for mobility in the ICU constantly over a 6-month period.

In our study, patients were still connected to invasive MV in 48% of mobilizations, and patients remained in bed in 66%. This is logical, considering that patients were in the subacute phase of their disease and were sedated or being weaned from sedation. RASS scores show that patients were sedated in 82.7% of the stay-days in which Level I early mobilizations took place. Reviewing sedation protocols with the aim of shortening the time under sedation, as recommended in recent guidelines,24 might also improve the rate of early mobilizations. Nonetheless, 34% of mobilizations in our study were done outside the bed; of these, 22.2% took place after patients no longer required ventilatory support, although patients remained connected to MV in 7.1% of all mobilizations, mostly through tracheostomy tubes (5% of all mobilizations). Recent point-prevalence studies have also found low rates of out-of-bed mobilizations. Although a German study reported that 24% of mobilizations took place outside bed, 50% of the patients in that study were on noninvasive MV. Another study, done in Australia and New Zealand, reported that none of the patients who required MV sat out of bed, stood, or walked, and only 12% sat over the side of the bed.5 A recent study in Brazil reported that only 3 of 158 mechanically ventilated patients stood, marched on spot, or walked during mobilizations.16 Although the rate of out-of-bed mobilizations in patients undergoing invasive MV in our study is low, it is to our knowledge the highest reported to date.

The lack of data in one-third of all stay-days reveals the need to establish mechanisms to audit routine data collection in our unit. In the stay-days in which the EM form was not completed, it would not have been possible to carry out the mobilization in 720 (59%) stay-days because patients failed to meet the clinical stability criteria; however, in the other 509 (41%) stay-days, patients met the criteria and should have been mobilized. Our group recently developed and validated a tool that can help us to improve data collection through real-time random safety audits, which have proven effective in detecting and correcting errors of omission in real time, thereby improving adherence to guidelines.25,26 Including the audit of the EM form in our routine real-time random safety audits will improve adherence to our EM protocol.

We found that EM started a median of 3 days after admission; this finding is similar to the time to mobilization reported by Basset et al.27 However, a recently published meta-analysis concluded that the time when patients are mobilized varies widely, ranging from the first to the eighth day after ICU admission.28 It is important to note that some studies define the starting point of EM as the initiation of passive mobilizations27 and others define it as the initiation of active mobilizations.29

The incidence of adverse events (0.4%) was even lower than those reported by Bourdin et al.8 (3%) and Bailey et al.7 (<1%), corroborating that EM is safe.

Our study has several limitations. This was a single-center, so caution is warranted in extrapolating our results and conclusions to other ICU. Our EM protocol was designed following the recommendations of experts and published studies, adapting them to the resources available at our institution. The lack of guidelines to unify protocols in terms of the criteria for clinical stability, types of mobilization, and duration of treatment makes comparisons with other studies difficult.

Our study analyzed data stored in the CIS, and the reliability of some of these data depends on the staff's commitment to collecting and entering them during routine daily practice. In this regard, it is important to highlight that the ETL enabled us to determine that patients did not meet the safety criteria for mobilization in 509 of 1229 stay-days for which no EM form was registered in the CIS (considered stay-days in which protocol was not adhered to). It is possible that in some of these cases the staff decided not to perform EM without completing the form in the CIS, and failure to register the decision could account for up to 15.6% of the cases that would be classified as failure to adhere to protocol.

Our study shows that it is possible to use data from the CIS to evaluate many aspects of an EM protocol during a long period of clinical practice. Although adherence to the protocol was high, patients were mobilized in only one-third of all stay-days. The information from this study points to ways we can improve EM in our ICU, including reviewing the sedation protocol, assessing the suitability of the criteria for clinical stability, and increasing the presence of physiotherapists or trying to involve family members. Importantly, the entire study required no extra efforts in data collection thanks to staff registering information in the CIS in their daily routine. The lack of data for one-third of all the stay-days pointed out the need to implement mechanisms (e.g., real-time random safety audits) to audit routine data collection in our ICU.

M.M., P.P. and J.G. designed the study, design of statistical analyses and data analysis. All authors contributed to critical examination of the paper for important intellectual content and approval of the final manuscript. All authors have read and agreed to the published version of the manuscript.

This study was supported by grants from the Fondo de Investigación Sanitaria (Carlos III Institute of Health, Spain, FIS grants, project PI20/01674). Agència de gestió d’Ajuts Universitaris i de Recerca 2017 SGR 00127. FEDER.

The authors declare that they have no conflict of interest.