Nurse‑Led Mobility Models That Improve ICU Patient Outcomes

I first became interested in patient mobility when I witnessed the astonishing feat of mobilizing patients receiving mechanical circulatory support (MCS) in the intensive care unit (ICU). In our ICU, it was not uncommon for us to ambulate patients on extracorporeal membrane oxygenation (ECMO) therapy and mechanical ventilators. While this process was not without challenges, it was a worthwhile effort to see patients get stronger and progress along the recovery continuum. The patients who were able to communicate with us reported experiencing an elevated mood as they were liberated from the ICU and walked the halls of their unit and adjacent units. When clinically appropriate, patients on ECMO could even make trips to the hospital rooftop. On their way, they would wave to onlookers who lined the hall with signs and played music. This achievement truly made the patient feel that what they were doing was extraordinary - and it was! If we can walk patients on ECMO, we can do anything.

Why Mobility Matters in Critical Care

Despite the elaborate teamwork to assist patients with MCS and other medical complexities to move, I do worry about patients who seemingly get "lost" when it comes to mobility. I'm referring to the patients who do not require extensive support from physical therapists (PTs) to ambulate, yet they are not completely independent in completing activities of daily living. It can seem like resources shifted to patients who require extra support, resulting in less prioritization of mobility for patients requiring minimal support. This situation is especially true on nights and weekends when fewer staff may be present. The goal, however, is always to mobilize every patient, including those who cannot get out of bed. Literature has demonstrated time and time again that the lasting effects of prolonged immobility due to intensive care unit-acquired weakness (ICUAW) can be devastating to patients. Immobility contributes to cognitive and physical impairments in the weeks, months and even years to follow. I believe that we can help bridge the mobility gap for these patients by employing mobility teams in critical care and progressive care areas. Read patient testimonials about the positive results of mobilization as well as negative experiences with oversedation and lack of mobility in AACN's webinar "Awake and Walking ICU: Mastery of the ABCDEF Bundle."

Barriers to Implementing Mobility Teams

My personal experience with mobility has included leading a number of local quality-improvement projects related to mobility. My doctoral studies evaluated the use of a visual confirmation tool and education, and the associated impact on nurse-led mobility. A follow-up quality improvement project involved mobility champions to help the nurses identify appropriate mobility interventions. A third quality-improvement project I led looked at nurse mobility champions and their impact on the number of mobility events as well as the level of mobility the patients achieved. We found that nurses who partnered with PT at the beginning of their mobility shift to identify patients appropriate for mobilization, as well as the levels of mobility they could achieve safely, were successful in mobilizing and/or ambulating almost all appropriate patients in a 12-bed ICU within six hours of starting their shift. This finding was exciting, despite being a very small, localized quality-improvement project. It had me thinking about the impact of mobility experts on ICU patients. Despite available evidence to support mobility champions and teams, financial considerations at hospitals nationwide have prevented the adoption of yet another specialty team to achieve results. It's important to think about the benefits of mobilization and the lasting impact on patient wellness, as well as the types of resources that can be available to continue driving positive results despite upfront costs.

Why Mobilize Patients?

Substantial evidence supports the adoption of mobility teams in the ICU. Literature repeatedly demonstrates that increased levels of mobility, especially early in a patient's admission, contribute to improved outcomes such as reduced time on a mechanical ventilator, reduced incidence of complications secondary to prolonged immobilization (e.g., deep vein thromboses or pressure injury), improved mood, reduced risk of developing delirium, and reduced ICU and hospital lengths of stay.

According to the Society of Critical Care Medicine (SCCM), the average cost of an ICU per day was estimated to be $4,300 in 2010. Costs may increase substantially based on local types of adjunctive therapies (e.g., continuous veno-venous hemodialysis or MCS), patient complexity and types of medications. Patients are living longer with myriad complex health problems, which can be particularly problematic for patients and hospital systems alike when considering the rising financial pressures of modern healthcare. In a recent study, the average ICU length of stay was 10.2 +/- 25.2 days. The bare minimum calculation of $4,300 x 10.2 days equals $43,860 for the price of one ICU stay at the least. What if hospital systems and nurses could decrease the length of ICU stays and improve patient outcomes? Let's discuss how nurses can improve mobility by leading mobility teams.

Funding Constraints and Staffing Challenges

Unmistakably, the number one barrier to adopting new programs (such as mobility teams) is money. Dedicated mobility teams may be difficult to justify in light of the rising costs of delivering high-quality healthcare. It becomes easy to default to nurses as the backbone of healthcare and make general statements such as, "Nurses should be responsible for mobility over the course of their shift." However, nurses are constantly being asked to do more with less. Most patients who need assistance to mobilize require more than one nurse to move them safely. In the ICU, it may be very difficult to mobilize patients to their maximum potential multiple times a day because of the sheer number of resources required, both human and material, and the time it takes to get patients out of bed.

Here's an example: A patient receiving ECMO therapy is at a high risk of complications and rapid deconditioning as a result of metabolic demand, acuity and prolonged periods of deep sedation. Getting this patient moving as soon as possible is a must; however, it may take two or three nurses, a respiratory therapist, a PT, a perfusionist and a clinical technician to successfully walk this patient on ECMO with a mechanical ventilator. The most a nurse would be able to do independently is incorporate active range of motion into assessments and potentially elevate the head of the bed to the chair position.

A dedicated mobility team with the training and resources to mobilize every high-acuity patient is the ideal solution. However, getting a mobility team up and running may be challenging since there is no universally accepted mobility team model, which is the second largest barrier to starting mobility teams. What's the solution? Hospitals considering the use of mobility teams must carefully consider the risks and benefits of various mobility team staffing models.

What Nurse‑Led Mobility Teams Look Like

A mobility team is any team structured to get patients moving as soon as possible after admission (a term we coined "early progressive mobilization" at my hospital). A mobility team may be composed of a PT and other healthcare professionals who collaborate daily to maximize the number of patients who receive mobility therapies; or it can consist of a PT who sees patients and is available for consultation, while a nurse or other healthcare professional(s) partner to follow PT recommendations (noted in the electronic health record or standardized facility-based mobility protocols) to mobilize patients. A mobility protocol may use an evidence-based tool such as the Activity Measure for Post-Acute Care (AM-PAC) (also known as the 6-Clicks score) to identify activities a patient should be able complete based on the assessment.

Mobility Team Staffing Models

The structure of mobility teams may vary greatly. Decisions about mobility team models should be made after a thorough discussion with the multidisciplinary team. Consider factors such as hospital size, patient acuity, resource availability and patient demographics. A large academic medical center with a considerable number of critically ill patients will require different resources than a rural community hospital.

Nurse-PT collaboration models

For large healthcare centers, mobility teams consisting of a PT and a nurse per unit or specified care area could maximize the number of patients who receive higher levels of mobility. Many hospitals have a handful of PTs who cover an entire hospital, so this model would provide a PT dedicated to a specific care area in addition to the PT staffing pool. The mobility team PT and nurse can huddle at the beginning of a shift to identify which patients should be prioritized (e.g., patients who require maximum assistance and those who must meet mobility goals to proceed with care, such as being listed as candidates for solid organ transplants), which patients a PT should visit for new or revised recommendations based on clinical progression or failure to progress, and which patients the nurse can see. For example, a daily plan for this mobility structure may include the nurse and PT partnering at the beginning of the shift to see high-acuity patients, followed by the nurse branching out independently to continue with deploying higher-level mobility interventions (assisting the primary nurses to ambulate or get patients up to the edge of bed), while the PT sees patients who require PT evaluation but are not ready to progress to higher levels of mobility. In hospitals with a large number of high-acuity patients, this mobility team model may be the most effective despite the higher costs of PT and nurse salaries. It allows for maximum independent assessments by the mobility nurse and subsequent mobilization of patients because it marries PT expertise with nursing judgment. The mobility nurse, however, may still require assistance from the primary nurse to mobilize patients.

Nurse and mobility technician models

A nurse and mobility technician model allows mobility team members to initiate mobility without waiting for assistance from the primary nurse. This model might allow for a larger number of patients to be seen. While nurse-patient ratios in the ICU are lower than those in progressive care and medical-surgical units, patient acuity and clinical demands may prevent the primary nurse from dedicating a sufficient amount of time to mobility interventions. Depending on how PT resources are staffed, the mobility team nurse(s) may huddle with the hospital PT at the beginning of a mobility shift to determine a plan, or the nurse can perform a review of patients to see those who have not had a mobility consult and make general recommendations. Johns Hopkins published a toolkit that is widely available to assist with mobility decision-making. The toolkit offers visual aids such as the Johns Hopkins Activities of Daily Living (JH-ADL) Guide, which provides individual recommendations based on a patient's functional capacity. Together, a nurse and a mobility technician or a clinical technician can achieve great results by maximizing independence and reducing delays to the implementation of mobility. This model is more cost effective than the PT and nurse model and still allows for maximum mobility by partnering the mobility team nurse with a dedicated mobility technician.

UAP-based mobility support models

An independent unlicensed assist personnel (UAP) model, which may include a mobility technician or clinical technician, is a cost-effective model, but its success relies heavily on each individual's comfort and mobility training. Ideally, the UAP should shadow a mobility champion who role-models mobility interventions. The UAP should expect to consult with the primary bedside nurse about conditions that are hard stops to initiating mobility. Ideally, the unlicensed caregiver always collaborates with the primary nurse to discuss readiness to mobilize or contraindications to higher levels of mobility. These conditions may include uncontrolled pain, hemodynamic instability, bleeding, unstable spine or intracranial pressure, arrhythmias or hypoxemia. This model of care may work best in rural hospitals with a smaller number of medically complex patients who require significant rehabilitation before discharge. The UAP may identify patients to mobilize by screening them, using the 6-Clicks score to identify progressive care and critical care patients who can ambulate with little or no assistance, and/or patients who have limited mobility capacity but can tolerate passive and active range of motion in bed.

To preserve team effectiveness, it is important to note that mobility team members must not be pulled into other staffing assignments. While direct oversight of a nurse should fall under another nurse to provide a management framework that reflects clinical experience and scope, a little creativity may help ensure that the nurse and/or clinical technician cannot be pulled from the mobility team to support staffing challenges.

Although the ideal mobility team is a partnership between any of the licensed and/or unlicensed caregivers mentioned above, the nurse may also function as an independent mobility champion. Many hospitals embrace skin care, diabetes or geriatric resource nurses, but the need also exists for mobility champions. Initially, the hospital can create unique guidelines for the nurse to determine readiness to mobilize and appropriate interventions. The first-line instructions should always be any interventions that the PT has deemed appropriate for patients who are medically complex, have been bedbound for prolonged periods of time, or who have devices (e.g., MCS) that may render mobility a more difficult task. Evaluating these recommendations and comparing them to patient readiness requires some nursing judgment. If a patient is unsteady after being bedbound for two days but can be safely assisted to the bedside chair with a few other clinicians, then initiating mobility is not unreasonable. If the nurse is familiar with basic interventions for maintaining strength in addition to walking, these interventions can be easily incorporated into the plan of care. If the patient demonstrates weakness or is unable to bear weight during the transfer period, it may be more reasonable to cease mobility efforts and consult PT for an advanced assessment and recommendations. This is where a standardized mobility protocol may assist with decision-making.

For example, if a patient has a RASS of -5 to -1, preset recommendations for passive range of motion can be easily deployed without requiring PT consultation. When patients reach more awake states and are able to engage in care, standardized recommendations for exercises may include interventions such as ankle pumps, leg lifts, arm raises and pelvic tilts. Many of them can be initiated without a PT, as long as there are no percutaneous devices that might impair movement.

More advanced interventions, which include assist devices such as ergonomic bicycles or verticalization bed therapy, always require a PT consult for further guidance. An additional thought: Nurses on the mobility team can complete a 6-Clicks score to determine the level of mobility that a patient should be able to achieve. Based on the output score, the Johns Hopkins Activities of Daily Living (JH-ADL) guide populates recommendations for appropriate interventions. If the patient is unable to achieve these results, a PT consultation is likely needed to determine the etiology and specific recommendations to maintain patient safety. Overall, creating a mobility protocol can increase the number of patients a nurse can see independently without waiting for PT and decrease total time from admission to implementation of mobility interventions.

Choosing the Appropriate Mobility Team Structure

Factors that influence model selection

How does a team decide what mobility team structure is best for them? The multidisciplinary team and critical stakeholders funding the mobility team should partner to ask questions such as:

• On average, how many patients require assistance to achieve higher levels of mobility on a daily basis?
• Do patients frequently require complex medical therapies (e.g., MCS) that would impact readiness to mobilize or the appropriate mobility team model?
• Does staffing make an impact (positive or negative) on achieving sufficient nurse-led mobilization in critical care settings?

Evaluating acuity, resources and patient needs

The impact of mobility teams may expand beyond the immediate recipients of direct care to the staff who witness exemplary role modeling and incorporate mobility into their practice. Over time, leaders can track the outcomes of mobility teams to illustrate the positive impact on ICU length of stay because of the mobility team (e.g., patients who meet predicted mobility goals based on expected exercise capacity, a minimum number of times per day). It would also be helpful to track patient demographics in order to determine what patient populations benefit the most from mobility teams. While mobility teams can expand the footprint of mobility, primary nurses should still incorporate mobility interventions into their daily regimen when possible.

How Nurses Drive Mobility Culture Change

Nurse advocacy for protocols and readiness screening

In summary, barriers to actualizing mobility teams must be discussed openly. It may not be possible to have large mobility teams that consist of multiple licensed healthcare professionals; however, all hospitals with inpatients should have at least one PT available who can be a consultant as the team works to:

• Create mobility protocols in collaboration with the multidisciplinary team that allow the nurse and/or UAP to function independently to evaluate readiness to mobilize and deploy appropriate mobility interventions
• Provide recommendations for patients who are not progressing, who are progressing but require tools to achieve higher levels of mobility, or who are medically complex
• Collaborate with other members of the mobility team to strategize how to mobilize as many patients as possible over the course of a mobility shift

The role of nursing judgment in safe mobilization

The dedicated mobility nurse is an essential partner in the team who:

• Collaborates with the PT to identify clinical considerations that may impact mobility, including devices, hemodynamics, pain or changes in mentation
• Partners with the UAP to identify appropriate patients for mobility, limiting interruptions in the primary nurse's care of critically ill patients
• Consults PT for patients who may be appropriate for advanced interventions such as ergonomic bicycles, verticalization bed therapy, etc.
• Creates standardized mobility protocols that are appropriate for the unique patient populations common to their institution (e.g., patients recovering from a stroke or with MCS)
• Tracks outcomes directly related to incidence of mobility, including ICU and hospital length of stay, deep vein thromboses, pressure injuries, delirium and time on mechanical ventilation

Conclusion: Advancing Mobility Through Nurse Leadership

Implications for critical care nursing practice

Mobility is essentially a subspecialty of progressive care and critical care when considering the unique interventions required to successfully mobilize critically ill, complex patients. Nurses are instrumental in ensuring that mobility principles and interventions are disseminated to the frontline nursing staff to improve patient outcomes, including long-term wellness. Barriers to the development of mobility teams should be recognized and mitigated. Short-term trials of mobility team models may be necessary to evaluate outcomes, determine the best mobility team model of care, and prove value added to the organization by driving cost avoidance. Frontline caregivers are uniquely positioned to start conversations about mobility, using factors such as acuity scores and patient demographics to illustrate the positive impact a mobility team can have on levels and frequency of mobility achieved.

How will you overcome barriers to patient mobility in your unit?