Implementation of an Interdisciplinary AACN Early Mobility Protocol

The project was conducted at a 1200-bed, university-affiliated level I trauma medical center in the Midwest with 132 ICU beds at project initiation. A staggered QI preintervention-postintervention design was used. The institution’s human research protection office deemed the project nonhuman subjects research. The American Association of Critical-Care Nurses (AACN) early progressive mobility protocol was used.³⁶ 

Baseline data were collected for 2 months in each unit. The presence of in-room ceiling lifts and a dedicated PT varied. A staggered approach with initiation in 2 ICUs every 2 to 4 months allowed for education of staff. One MICU and the SBTICU implemented the program in March 2015. The second MICU and both CTICUs implemented the program in May 2015. The last 2 units, the cardiac unit and the neurology/neurosurgery unit (NNSICU), implemented the program in August 2015. The staggered approach provided time to add a PT dedicated to each ICU immediately before implementation.

Project team members met with each unit’s nursing, therapy, and physician leadership to review and modify the AACN screening criteria specific for their patient population (Figure 1). Each ICU developed an implementation plan. The AACN 4-level mobility protocol was implemented with minor modifications (Figure 2).³⁶  Education about the project occurred over a 2-week period in the second month of preimplementation data collection. Unit champions helped with education, served as a resource, and assisted with overcoming barriers. Bedside data collection included morning and evening mobility goal, complications, and reasons the goal was not achieved.

The nurse performed the safety screen during daily spontaneous awakening and breathing trials. If screening criteria were met, the patient began at mobility level 2. The goal was written on the goals board at the entrance to each room to facilitate team communication. Level 1 activities were performed by nurses for patients who could not advance to level 2. Physical and occupational therapists communicated with nurses if patients progressed in mobility levels during treatment sessions.

Members of the project team rounded daily initially and then several times per week over the first 2 months of implementation. Team members met regularly to discuss issues and make adjustments in implementation using the plan-do-study-act method. Snapshots of results were provided at unit meetings after the first and second months of implementation to discuss progress, barriers, and opportunities for improvement and any process changes.

Data were collected for 12 months after protocol implementation to ensure sustainment. Updates on outcomes continued to be shared as part of the QI process; however, after the first 2 months, minimal changes were instituted. In phase 1, data were collected on all patients in the ICU for 24 hours or more for 2 months before and 2 months after implementation; in phase 2, data were collected monthly on at least 20 randomly selected patients or 20% of patients in the ICU for 3 days or more for 2 months before and 12 months after implementation (Tables 1 and 2).

Process measurements from bedside data collection sheets were entered by 2 research team members. Additionally, data were extracted from the electronic medical record (EMR). Mobility level achieved was based on completion of the activity at least once per day. Preadmission mobility was extracted using the following definitions: community ambulators could ambulate at least 300 feet with or without an assistive device; household ambulators could ambulate at home but needed a wheelchair or scooter in the community; wheelchair individuals needed a wheelchair or scooter for all activity; bed-bound individuals were restricted to bed. All data were entered into REDCap (Research Electronic Data Capture) by 3 team members. The individual extracting data was different from the individual entering data.

The Richmond Agitation-Sedation Scale (RASS) score was documented at least every 4 hours. Highest and lowest RASS scores were extracted for each day. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) results were documented twice per day. If at least 1 of the 2 assessments was positive, a delirium-positive day was entered. A RASS score of –4 or –5 does not allow for CAM-ICU assessment and thus was documented in the research report. Both the RASS and the CAM-ICU are validated instruments recommended in the ABCDEF bundle.^1,5 

The ICU Mobility Scale (IMS) quantifies a patient’s maximum level of mobility.³⁶  The patient is scored on the highest mobility in the previous 24 hours from 0, indicating no activity, to 10, indicating independent ambulation without an assistive device. Interrater reliability reported for the IMS between PTs and ICU nurses ranged from 0.72 to 0.69 (weighted k),³⁷  and the IMS was shown to be a valid method of measuring ICU mobility.^38,39  The IMS score was determined on the basis of retrospective review of EMR documentation by PTs and nurses of highest mobility level achieved.

All data were downloaded from REDCap into IBM SPSS Statistics, version 22. Outliers were examined and verified or corrected in REDCap. Data were downloaded again for analysis. Descriptive statistics were calculated. Means and SDs were calculated for continuous variables, and frequencies and percentages were calculated for dichotomous, nominal, and ordinal variables. Analysis of variance was used to test differences in mobility outcomes between before and after implementation of the protocol. Level of significance for preimplementation-postimplementation differences was set at α = 0.05.

In phase 1, we analyzed 1266 ICU admissions before protocol implementation and 1420 after implementation. Table 2 displays sample sizes for each unit. Overall, 44.9% (range, 19%-64%) of patients had a mobility goal set during their ICU stay, with the lowest rates in the CTICUs, which had the longest history of a dedicated PT. The mean (SD) number of days a goal was set was 1.24 (2.17), and the mean (SD) goal set was a mobility level of 2.39 (1.1). The mean (SD) mobility level achieved did not differ significantly by whether a goal was set or not set (1.7 [1] vs 1.6 [1], respectively). Reasons a goal was not achieved included medical issues (6.3%), procedure or test (3.2%), fatigue (1.7%), refusal (1.5%), equipment lacking (0.2%), nurse staffing (0.1%), PT staffing (0.3%), and multiple reasons (18%).

Results for components of the ABCDEF bundle are shown in Table 3. We found no significant difference in lowest or highest RASS score between before and after protocol implementation. The mean (SD) number of delirium-positive days in the ICUs overall decreased non-significantly, although the SBTICU and the 10-bed MICU had significant decreases, from 3 (4.7) days to 2 (3.8) days (P = .01) and from 0.65 (2) days to 0.43 (1.7) days (P = .01), respectively. Days to first PT visit in units without dedicated baseline PT decreased significantly. Both MICUs had a 1-day decrease in time to first PT visit, from 4.5 (1.76) days to 3.5 (1.77) days (P = .01).

The average LOS was approximately 7 days during both periods; therefore, we analyzed the mobility level achieved for the first 7 days and the subsequent days separately. Figure 3 shows the mean mobility level achieved in the first 7 days. The overall mean mobility level achieved increased significantly. We observed the biggest improvements in the units without dedicated PTs at baseline. The smallest unit, a CTICU, had a decrease in mean mobility level achieved after implementation; however, the mean mobility level achieved at baseline was higher than for the other ICUs, and that achieved after implementation remained higher. Mean mobility levels achieved increased with an increase in number of days that patients achieved mobility level 1 (P = .01) and level 4 (P = .01). Mean number of days achieving level 2 and level 3 did not change significantly. The NNSICU had the greatest increase in number of days that patients ambulated in phase 1 (Figure 4). Beyond the first week, mean mobility level increased nonsignificantly from 1.80 to 1.92 in units with dedicated PTs and from 1.23 to 1.41 in units without dedicated PTs.

In phase 1, most patients were discharged home (52%) or to rehabilitation (14%) before and after project implementation. Intensive care unit LOS decreased nonsignificantly overall and decreased significantly in the ICUs without dedicated PTs at baseline (Table 3). Of the units with dedicated PTs, the SBTICU had a mean (SD) decrease in LOS of more than 1 day, from 6.26 (6.05) to 5.00 (5.15) (P = .01). The frequency of major complications during mobilization was 0.02%, with 1 loss of airway, 1 loss of an arterial catheter, and 1 cardiac arrest (1 hour after patient was transferred to a chair; the patient was quickly resuscitated). Table 4 shows the changes in vital signs with mobilization in phase 1, which were most frequent in the CTICU population.

In phase 2, we analyzed 258 ICU admissions before implementation and 1681 after implementation (Table 2). Most patients were ambulatory before ICU admission: community ambulators without an assistive device (64% before and 70% after implementation), community ambulators with an assistive device (12% before and 14% after), or household ambulators (16% before and 7% after). Only 4% were wheelchair bound before and 7% after implementation, with 3% being bed bound before and 1% after implementation.

Time to the first PT visit decreased significantly (Table 3), with 20% of patients not receiving a PT visit before implementation and 15% after implementation. Significant increases were seen in the initial and ICU discharge IMS scores before and after implementation, but no significant difference was found in IMS score at hospital discharge (Table 3). With nonparametric Mann-Whitney analysis, the differences in initial and ICU discharge IMS scores remained significant whereas differences of IMS scores at hospital discharge remained nonsignificant. Time to achieve levels 2 through 4 all decreased (Figure 5), with 85% of all patients achieving out-of-bed activity after implementation.

Ventilator days decreased nonsignificantly. Intensive care unit LOS decreased significantly, whereas hospital LOS showed a nonsignificant decrease (Table 3). After implementation, more patients were discharged to home or home with home health care. In some months before implementation, only about 40% of patients were discharged home. However, after implementation, more than 50% of patients were discharged home in the first month, and the proportion remained at that level over the 12 months in phase 2, demonstrating sustainment of the results of this QI initiative (Figure 6).

The goal of this QI project was patient-driven mobilization in units with established ABCD and F bundle component implementation to achieve full implementation of the ABCDEF bundle. Introduction of a standardized early mobility protocol increased the number of patients achieving ambulation and resulted in additional improved outcomes, including decreased delirium days and decreased ICU and hospital LOS.

Our results provide further support for improved outcomes when all aspects of the bundle are implemented. Pun et al⁶  found that bundle compliance for the first 7 days in 68 ICUs with 15 226 patients with an LOS of more than 24 hours improved outcomes the most in patients who received all components of the bundle. Although we did not examine bundle compliance but rather the impact of standardized implementation of early mobility in units with established ABCDF components, we found similar results. The rate of ICU discharge to home remained above 50%, with some months above 60%, similar to 55% of survivors in the ICU Liberation Collaborative.⁶  In addition, decreased delirium was observed.

A recent meta-analysis of early mobility in patients receiving mechanical ventilation in the ICU yielded inconclusive evidence from 4 randomized controlled trials (RCTs) on outcomes including physical function, muscle strength, and adverse events.⁴⁰  Another recent meta-analysis of 4 studies indicated that patients with early mobility had no advantage in mortality but had improved muscle strength, improved ability to walk without assistance at hospital discharge, and more days alive and out of the hospital in the first 3 months.⁹  The difficulty with RCTs examining only an early mobilization intervention is separation of the impact of early mobility from other aspects of critical care in the ABCDEF bundle.

Each ICU had different improvements. For example, the NNSICU had the greatest increase in ambulation during the first 7 days. These results are similar to those of 2 pre-post studies of mobility protocol implementation that showed higher mobility level achieved, decreased ICU and hospital LOS,^23,41  and greater likelihood of being discharged home after implementation.⁴¹  However, those results were achieved with less than 12% of patients ambulating, compared with more than 50% in our NNSICU. The SBTICU outcomes of decreased delirium and LOS are similar to findings from an RCT of an early mobility protocol in 5 surgical ICUs that also found decreased delirium and LOS.⁴² 

An interdisciplinary approach is crucial to the success of an early mobility protocol. In phase 2 of our study, 85% of patients had out-of-bed activity, similar to the result in a study in Belgium using an interdisciplinary approach that achieved 86% of patients with out-of-bed activity.⁴³  In addition, those authors found that most patients received PT (61%) and that the median time from ICU admission to the first early mobilization activity was 19 hours. The majority of patients in our study had a PT session during their ICU stay (85%), and a decrease in time to first PT visit was observed. Our protocol included a PT referral for patients at mobility level 1 for 72 hours or more. The decline seen in both phases can likely be attributed to this aspect of the protocol. Therapists and nurses reviewed patients’ screening criteria and collaborated regarding who would mobilize each patient. Having a dedicated PT in each unit fostered the collaboration and likely led to the improved outcomes.

However, we did not capture exact hours to first mobilization, which would have provided more specific data on improvement in time to first mobilization.

Our findings on IMS scores are similar to those of other research. After protocol implementation, patients had a significantly higher IMS score on initial PT evaluation and at time of ICU discharge. In an RCT of an early mobilization protocol with patients receiving mechanical ventilation, the authors found an average IMS score of 5.9 in control patients and 7.3 in the intervention group, but no decrease in LOS.⁴⁴  Although their sample was restricted to patients receiving mechanical ventilation and we used a 20% random sample of patients with an LOS of 3 days or more, the consistent improvement in IMS scores demonstrates the impact of a mobility protocol in the ICU.

Many mobility protocol studies have demonstrated significant decreases in LOS. However, some studies did not show significant LOS decreases despite increased mobility in patients receiving mechanical ventilation.^44-46  We observed decreases in ICU LOS in both phases and a nonsignificant decrease in hospital LOS in phase 2. These findings in our study and other studies^{10,14,17,21-27}  that included all patients may explain the difference in results.

The AACN screening criteria were individualized for each ICU. Consensus guidelines on safety screening vary and include differences such as fraction of inspired oxygen of less than 60% and positive end-expiratory pressure of less than 10 cm⁴⁶  rather than less than 85% and less than 15 cm, respectively, in the AACN criteria.³⁶  Vasopressors are often cited as an exclusion for mobility; however, Hodgson et al⁴⁷  could not reach consensus on mobility safety for patients receiving vasopressors. Previous research in our CTICU⁴⁸  and implementation of the AACN criteria demonstrated that mobilizing patients receiving vasopressors was safe in all patient populations at our institution. Additionally, Boyd and colleagues⁴⁹  found that out-of-bed exercise was implemented 114 times for patients receiving inotropes or vasopressors in CTICU patients, with only 1 adverse event of cardiac instability for a patient on a tilt table with a moderate level of support (0.15 μg/kg/min norepinephrine). Although we observed more vital sign instability in our CTICU patients, most cases were likely secondary to atrial fibrillation with rapid ventricular response, although we did not capture baseline rhythm. Serious complications were rare, as reported in previous research and a recent meta-analysis.^{10,15,24,28-30} 

Several limitations are inherent in QI initiatives using retrospective reviews of medical records. The opportunity for missing data was high. The data we extracted from the EMR were dependent on documentation quality. The possibility of errors in data retrieval and entry can lead to inaccuracy. Data entry in REDCap with predefined limits on some variables and data cleaning and validation by 3 different individuals likely minimized errors.

Another limitation is fidelity to the intervention implementation. Although advanced practice registered nurses and educator champions were based in each unit, each patient was not followed closely for implementation after the first 2 months of phase 2. The low number of days with a goal set in some units likely decreased the potential for even further gains.

Adding an interdisciplinary early mobility protocol and a collaborative approach in ICUs with ABCD and F bundle components in place leads to further improvement in outcomes as a result of implementation of all ABCDEF bundle components. The AACN early mobility screening criteria required minor changes for our specialized patient populations. Adverse events and vital sign changes were minimal. Thus, implementing the AACN early mobility protocol is safe and feasible in a variety of ICU patient populations.

The authors thank the nurses and the physical, occupational, and respiratory therapists in each of the intensive care units who mobilized patients and changed the mobility culture. The following champions in each intensive care unit led the efforts on a daily basis: Ann Petlin, MSN, RN, CCNS, CCRN-CSC, ACNS-BC, PCCN, Mary Sauer, MSN, RN, Myra Suntrup, MSN, RN, CCNS, CCRN-CSC, Paula Mantia, MSN, RN, APRN-BC, Lisa Cracchiolo, BA, RRT, AE-C, Julie Terrell, DPT, Elisabeth Martin, DPT, Dana Torrillo, DPT, NCS, and Jennifer Barfaro, DPT, CKT, CEEAA.