Impact of a Quality Improvement Intervention to Promote Early Mobilization in Patients in the Trauma ICU

Background:

Early mobilization is a component of the ABCDE bundle (Awaken from sedation; Breathe independently from ventilator; Choice of sedation; Delirium management; Early mobilization), an interdisciplinary, patient-centered strategy to facilitate evidence-based practices in intensive care unit (ICU) settings. In patients who underwent early mobilization, specific benefits were fewer ventilator days, fewer ICU and hospital days, fewer hospital complications, less sedation and delirium days, and improved in-hospital functional outcomes. Despite the fact that several lines of evidence demonstrated the safety and efficacy of early mobilization in the ICU, studies conducted in neurological or trauma ICU settings are scarce, possibly because of safety considerations such as physiologic instability (hemodynamic or intracranial pressure) and invasive device integrity. It has only recently been suggested that such programs are effective, safe, and potentially beneficial in critically ill neurological patients. Nevertheless, there is no set protocol in place for moving these patients, nor any suggested parameters to monitor.

Evidence regarding early mobilization has been based on reports from general medical and surgical ICU environments, rather than from neurosurgical ICU (NSICU) or trauma ICU settings. In NSICU patients with acute brain injury mostly, safety during mobilization could be compromised because of hemiparesis or hemiplegia, cognitive impairment, tenuous intracerebral pressure and cerebral perfusion, or dislodgement of cerebral monitoring or other indwelling devices. In trauma ICU, trauma patients often have extensive orthopedic and neurosurgical injuries, creating additional barriers to mobility. Little is known about the potential effects of mobilizing patients with acute brain or server injuries admitted to the trauma ICU. In one pre- and post-intervention research study of early mobilization in patients with neurologic injury treated in a ICU, mobility levels increased post-intervention, without adverse events. The results also supported the notion that progressive early mobilization program leads to shorter ICU and hospital length of stay (LOS), fewer patient restraint days, and fewer hospital-acquired infections. Another relevant study showed that implementation of a progressive mobility algorithm was safe and was associated with a higher likelihood of mobilization in the first week after spontaneous intracerebral hemorrhage (ICH) in the neurological ICU. For trauma patients, previous studies demonstrated the safety of a mobility protocol in a trauma and burn ICU and, additionally, showed a decrease in airway, pulmonary, and vascular complications. Results from another study revealed favorable functional outcomes for patients involved in a structured mobility program with physical therapy in the neuro/trauma ICU. Overall, the lack of available evidence highlights the fact that there remains much research to be done regarding early rehabilitation for patients in the trauma ICU and there are specific questions to be answered regarding the timing of intervention, the intensity and the type of exercises.

Previously, in the trauma ICU of National Taiwan University Hospital (NTUH), the referral of patients for physical therapy and mobilization occurred at the discretion of the medical providers with very low the proportion of patients with physical therapist (PT) consultations. Therefore, the overall objective of this quality improvement (QI) project will be to evaluate a structured and interdisciplinary early rehabilitation and progressive mobility protocol for critically ill patients in a trauma ICU.

Purpose： The goals of the project will be to provide a standardized, evidence-based, interdisciplinary mechanism to increase each patient's activity level safely while simultaneously initiating and promoting a culture of mobility. The investigators will also conduct this project to evaluate the effects of this early mobilization program on the outcomes of patients in the trauma ICU.