Early Mobility Among Pediatric Ventilated ICU patients: in 2015 a comprehensive Respiratory therapy protocol for intubated patients was implemented with a dynamic pediatric healthcare organization; with monitored patient care outcomes, ventilator weaning, and minimizing patient waste while on life support without the placement of a tracheotomy etc.

1. Children’s Healthcare of Atlanta
Respiratory Therapy Department
Melinda Marshall MPA, RRT-NPS

2. OBJECTIVES
 Describe the benefits of early mobilization of patients
in the ICU environment.
 Seek viable change within hospital culture related to
patient mobility practices in the Intensive Care Unit.
 Discuss respiratory therapists role in early
mobilization of patients in the Intensive Care Units.
 Encourage teamwork for successful implementation of
Early Mobility and improved patient outcomes.
 Seeks to provide adequate signs and symptoms of
patient distress in early mobility efforts.
 Improve Quality Outcomes among ICU patients

3. Early Mobilization By Definition
 Early Mobility is the
initiation of mobility
among patient’s in
the ICU; thereby
facilitating
physiological
stabilization that
continues
throughout the
patients entire
hospital stay
(www.ucsf.com, 2010)
Kangaroo Care
constitutes for
Early Mobility

4. Benefits of
Early Mobility
In The ICU
•Ensures patient
homeostasis of blood
sugar levels
•Increases Endothelial
function
•Regulates hormones
•Decreases Depression
among patients on long
term hospital stays
•Improves Cognition
•Increases patients
cardiovascular function
and strengthening
•Improves patient’s
outcomes

5. What Can I Do To Improve
Patient Outcomes In The ICU
Work As A Team
Speak Up When A Patient Is At
Risk for Harm During Mobility

6. Interdisciplinary Team
Center Approach
Interdisciplinary Early
Mobility Team consists of:
•Clinical Pharmacists
•Rehab Therapists/Nurse
liaison (consult rehab after
>24hrs of admission)
•Physical Therapists
•Occupational Therapists
•Respiratory Therapists
•Intensivists
•Nurse

7. The Respiratory Therapist Role and
Responsibilities In Early Mobility
 Ensure working with RN/RT combo for
adequate screening of patient criterion for
mobilization
 Seeks to advocate for patient when
appearance of fatigue or respiratory
compromise
 Guide Mechanical Ventilator Tubing for
safety
 Check Endo-tracheal Tube/Tracheostomy
to ensure stability from dislodgement;
 Place/Adjust the patient’s vent settings for
a successful mobilization trial
 Monitor O2 requirement, monitor SPO2,
Blood Pressure, PEEP and level of
respiratory exertion (WOB)

8. Sitting babies upright
and parental playtime
at Bedside are
mobility exercises

9. Early Mobility
Patient Exclusion
Criteria
 Increased PEEP requirements
 Hemo-dynamically Unstable
 Impaired Poor Trunk Control
 Intra-cranial Bleed
 Patient Dangles legs without
dizziness
 Assess/Reassess patient
baseline vital sign changes
>20%
 Vaso-pressors for MAP >55
 Increased O2 requirements

10. Benefits of Early
Mobility in the ICU
 Decreases Muscle Waste
 Regulates Hormone Levels
 Decreases Chronic
Inflammation
 Preserves
Musculoskeletal/Neuro-muscle
Integrity
 Minimizes Depression
 Improves Cognitive Skills
(www.iculiberation.org, 2012)

11. Mechanical Ventilator
Associated Effects On Mobility
 Delirium
 Muscle Wasting
 Neuromuscular
Weakness in 25-50% of
patients
(www.nih.iculiberation.o
rg, 2012)
 Longer Rehab Time

12. Clinical Barriers
to Mobilizing
Patients in the
Intensive Care
Unit
Fearful attitudes
Patient Sedation
Maximized
Culture of Immobility in
the ICU
Patient Drains
Lack of Clinician
Awareness
Femoral Lines
Continuous Hemo-dialysis
Lines
Lack of Leadership in
Policy
Lack of MD referrals for PT
Lack of Staffing and
Equipment
Safety
Over-Sedation
Minimal Education on
Mobility

13. Signs of Distress During
Early Mobilization
 Increased Work Of Breathing
 Hypertension
 Agitation
 Anxiety
 Hypotension with standing
 Decreased SPO2
 >20% Change in Baseline Vital
Signs
 Increased O2 requirement

14. Respiratory
Parameters That
Will Dictate Early
Mobilization
Among ICU Patients
 Patient Oxygen Requirements
 PEEP Setting
 FiO2 Setting
 EtCo2 reading
 Blood Pressure
 Patients MAP
 ABG Results
 RBSI
 Consider PS levels
(www.aarc.org 2012

15. Experienced Barriers to
Implementing Early Mobility
 Perception of too much
work
 Patient Safety Issues
 Not enough evidence
 Poor staffing in ICU
 Management skeptical
 Poor protocols in place
 Poor start dates
 Patient too sick for
movement

16. Indicator of Patients Placed On Early
Mobility Protocol
Sign will be placed on
the patients door
With Team Members
from Rehab Services
(PT/OT and ST)
ASCOM Phones for
Therapists are available
Patients do an array of
activities while placed on
Early Mobility
Team will work
together to ensure all
devices, lines and drains
are stabilized when
ambulating

17. What does Mobility in the ICU
look like?
Patients Placed Semi- Flowers in
The Bed
Infants that are placed in a
Swing/Parent Arms

18. Mobility in the ICU Can
Include: Semi-Flower
Position, Dangling Legs,
Ambulating Walking
Sitting on the
edge of the
bed
Standing in
Crib

19. Positions in Mobility
Please assess your
patients vitals signs
in lying, sitting and
standing positions
before/during
mobility

20. Early Mobility Successfulness
Is Dependent Upon You!
 Working as a team
 Ensuring that all patient
parameters have been.
checked for mobilization
 Talk with your Nurse and
other therapists (RT/PT)
to ensure a collaborative
team approach in
mobility
 Ensure patient criteria is
appropriate

21. Intensive Care Unit Early Mobilization at University of
California San Francisco (2010). Retrieved from:
http://www.ptrehab/ucsf.edu
National Institute of Health (2012). Retrieved from:
http://www.nih.iculiberation.com

22. Changing the Mindset of ICU Culture
 Introduction: Pediatric patients on
mechanical ventilators in the Intensive
Care Unit experience muscle wasting due
to immobilization and delivery.
 Methods
 Patient population: All intubated neonatal-
pediatric inpatients with an artificial airway from
Respiratory Distress, Pneumonia, Hypoxia, ARDS, and
Respiratory Viruses.
 Inclusion Criteria: Patients with artificial airways at
least 24 hours.
 Data Sources: Clinical Measures extracted from the
medical record (EPIC) included
 *ICU length of Stay (LOS)
 *Mortality
 *Ventilator Settings (PEEP, FIO2, PS,Ve*)
 *Diagnosis
 *Age
 *Sex
 *Level of Sedation
 Statistical Methods: Median and inter-quartile
ranges were calculated for the continuous variable pre
and -post extubation guidelines.

23. How Are We Doing With Mobility in the ICU?

24. Results Graphs
 100 Patients Successfully
Extubated
 250 Early Mobilizations in the
PICU
 32 Neonates (0-6months)
 64 Pediatric (1-17yrs)
 4 Adults (18+)
 Pt. Avg. PEEP =6cmH20
 Pt. Avg. PS=10
 Pt Avg. FI02=25%