doi: 10.2522/ptj.20110400Originally published online September 13, 2012

2013; 93:197-207.PHYS THER. M. Lloyd, Carissa Waters and Sarah WilliamsHenricks, Elizabeth Kamin, Elizabeth A. Leddy, Joanna Anne Drolet, Patti DeJuilio, Sherri Harkless, SherryIntensive and Intermediate Care SettingsMobility Protocol to Increase Ambulation in the Move to Improve: The Feasibility of Using an Early

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Move to Improve: The Feasibility ofUsing an Early Mobility Protocol toIncrease Ambulation in the Intensiveand Intermediate Care SettingsAnne Drolet, Patti DeJuilio, Sherri Harkless, Sherry Henricks, Elizabeth Kamin,Elizabeth A. Leddy, Joanna M. Lloyd, Carissa Waters, Sarah Williams

Background. Prolonged bed rest in hospitalized patients leads to deconditioning,impaired mobility, and the potential for longer hospital stays.

Objective. The purpose of this study was to determine the effectiveness of anurse-driven mobility protocol to increase the percentage of patients ambulatingduring the first 72 hours of their hospital stay.

Design. A quasi-experimental design was used before and after intervention in a16-bed adult medical/surgical intensive care unit (ICU) and a 26-bed adult interme-diate care unit (IMCU) at a large community hospital.

Method. A multidisciplinary team developed and implemented a mobility orderset with an embedded algorithm to guide nursing assessment of mobility potential.Based on the assessments, the protocol empowers the nurse to consult physicaltherapists or occupational therapists when appropriate. Daily ambulation statusreports were reviewed each morning to determine each patient’s activity level.Retrospective and prospective chart reviews were performed to evaluate the effec-tiveness of the protocol for patients 18 years of age and older who were hospitalized72 hours or longer.

Results. In the 3 months prior to implementation of the Move to Improve project,6.2% (12 of 193) of the ICU patients and 15.5% (54 of 349) of the IMCU patientsambulated during the first 72 hours of their hospitalization. During the 6 monthsfollowing implementation, those rates rose to 20.2% (86 of 426) and 71.8% (257 of358), respectively.

Limitations. The study was carried out at only one center.

Conclusion. The initial experience with a nurse-driven mobility protocol sug-gests that the rate of patient ambulation in an adult ICU and IMCU during the first 72hours of a hospital stay can be increased.

A. Drolet, MS, ANP-BC, CCRN,Central DuPage Physician Group,25 N Winfield Rd, Winfield, IL60190 (USA). Address all corre-spondence to Ms Drolet at:anne.drolet@cadencehealth.org.

P. DeJuilio, MS, RRT-NPS, Respira-tory Therapy, Central DuPageHospital, Winfield, Illinois.

S. Harkless, MSN, APRN/CNS,CCNS, CCRN, Central DuPageHospital.

S. Henricks, MSN, ACNP-BC,CCRN, Central DuPage PhysicianGroup.

E. Kamin, RN, BSN, MSCRN, Cen-tral DuPage Hospital.

E.A. Leddy, PharmD, CentralDuPage Hospital.

J.M. Lloyd, MS, Central DuPageHospital.

C. Waters, RN, BSN, CCRN, 2ICU–Intensive Care Unit, CentralDuPage Hospital.

S. Williams, PT, MPT, CentralDuPage Hospital.

[Drolet A, DeJuilio P, Harkless S,et al. Move to Improve: the feasi-bility of using an early mobilityprotocol to increase ambulation inthe intensive and intermediatecare settings. Phys Ther.2013;93:197–207.]

© 2013 American Physical TherapyAssociation

Published Ahead of Print:September 13, 2012

Accepted: September 4, 2012Submitted: November 14, 2011

Critical IllnessSpecial Series

Post a Rapid Response tothis article at:ptjournal.apta.org

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Physical inactivity associatedwith hospital care for a range ofmedical conditions can have

many unfavorable consequences.They include neuromuscular dys-function, metabolic disturbances,and other organ system abnormali-ties that add to the disease burden.1

Prolonged bed rest is associated withextended hospital stays and persis-tent physical and neuropsychiatricdisabilities in intensive care unit(ICU) settings.1 A meta-analysis of39 randomized controlled trialsrevealed bed rest was not beneficialand may be harmful.2 Studies alsohave demonstrated that reducingthe use of sedation and introduc-ing physical activity as soon as clini-cally feasible can decrease the fre-quency and severity of thesecomplications.3,4

Although these problems have beencarefully studied in ICU settings, fewstudies are available about the com-plications of inactivity outside theICU. Studies of the consequences ofprolonged bed rest have been con-ducted in volunteers without ill-ness.5 Skeletal muscle changes canbe documented within 72 hours ofphysical inactivity.6 In addition,physiologic dysfunction has beenfound across a range of organ sys-tems and metabolic processes. Whennon-ICU patients are subjected tobed rest, it is reasonable to assume

they will experience similar degreesof dysfunction.7

The application of bed rest inhospital-based medical care is wide-spread and enduring. There exists atime-honored impression that bedrest is therapeutic and physical activ-ity harmful in the presence of illness.There are practical barriers to mobi-lizing some patients due to monitor-ing or life support equipment, frailty,and weakness. In such circum-stances, considerable resources maybe needed for safe mobilization.8

At our 313-bed acute care commu-nity hospital, we were concernedabout the adverse effects of inactiv-ity in both our adult ICU and inter-mediate care populations. Increasingpatient activity through mobilizationis associated with improved respira-tory function, reducing adverseeffects of immobility, increased lev-els of consciousness, increasedfunctional independence, improvedcardiovascular fitness, and psycho-logical well-being.9

Prior to the early mobility protocolinitiative, common practice was aslower approach to mobilizingpatients who are critically ill. Oftenthe physical therapist was the firstmember of the health care team tobegin mobilizing the patient. Thephysical therapist is only with thepatient for approximately 30 min-utes per day in our setting. As thenurses are the primary caregivers for8 to 12 hours at a time, we hypoth-esized that a nurse-driven mobilityprotocol could provide importantbenefits. Little is known about hownurses make decisions aboutwhether to ambulate, how theyambulate, and when they ambulateolder patients. In a recent qualitativestudy, factors that seemed to have agreater impact on nurses’ decisionsregarding patient ambulation werethe risk/opportunity assessment,preventing complications, and the

presence of unit expectation toambulate patients.10 Furthermore,Kalisch11 found that ambulation wasregularly missed in the provision ofnursing care. Reasons given bynurses were related to time requiredto carry out ambulation, ease of omit-ting ambulation, and believing thatambulation was the job of a physicaltherapist. Barriers to ambulationmost frequently cited by nurses wererelated to patients’ physical symp-toms such as weakness, pain, andfatigue; presence of devices such asintravenous line and urinary cathe-ters; concerns about falls; and lack ofstaff to assist with out-of-bed activ-ity.12 A recent study showed that83% of patient time is spent lying inbed,13 and during one observationalstudy, 73% of patients consideredable to walk did not walk.14 Ambula-tion should be viewed as a priorityand as a vital component of qualitynursing care.15

Considering the deleterious effectsof bed rest, the emerging literatureon ambulation of patients with acuteillness, and the potential for nursingstaff to engage in ambulation activi-ties with their patients, the Move toImprove team decided to develop aquality improvement study. Wehypothesized that implementation ofa mobility program would increasethe likelihood of early mobilizationin our ICU and intermediate careunit (IMCU) patients.

MethodThree months of data (January–March 2010) were collected beforeimplementation of the mobility pro-gram to confirm consistency of base-line information. Postimplementa-tion data were collected for 6months (March–August 2011). Toevaluate the impact of this initiative,we compared the frequency ofambulation for patients admitted tothe ICU and IMCU, or who weretransferred from the ICU to theIMCU, during these time periods.

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In February 2010, nursing manage-ment gave approval to begin thequality improvement project. A mul-tidisciplinary team consisting ofadvanced practice nurses, registerednurses, physical therapists, a criticalcare pharmacist, a respiratory thera-pist, and a critical care physician wasassembled in April 2010. The teamadopted the Plan-Do-Check-Actframework for the development andimplementation of the Move toImprove mobility program; the“Plan” stage ran from January 2010to April 2010 (see Appendix 1 forcomplete time line).

Two units were selected for the pilotstudy. The first unit was the IMCU, a26-bed unit with an average dailycensus of 21.6 patients and a nurse-to-patient ratio of 1:4. The patientpopulation included patients withcomplex medical and surgical condi-tions as well as patients who werehemodynamically stable with a tra-cheostomy on a ventilator and hadpotential for respiratory insuffi-ciency. These patients oftenrequired frequent vital sign monitor-ing and respiratory therapy manage-ment. The second pilot unit was anadult ICU, a 16-bed unit designed toprovide intensive medical/surgicalcare to patients with acute andchronic medical diagnoses. Its aver-age daily census was 11.3 patientsand a 1:2 nurse-to-patient ratio. Dur-ing the study, from March throughAugust 2011, this ICU had a standardmortality ratio of 0.726 (observeddeaths/expected deaths) utilizingthe APACHE IV scoring system.16

The average length of stay was 3.2days. For patients admitted directlyto the IMCU, the average length ofstay was 4.95 days.

In April 2010, the Move to Improveteam reviewed current evidence andexemplary protocols to determinewhether the adult ICUs were utiliz-ing best practices for mobilizingpatients. The literature review was

expanded to include ambulatingpatients in the non-ICU areas, wean-ing patients from ventilators safelyand efficiently, and sedation and painmanagement guidelines.17–19 Theteam divided into small groups tofocus on the multiple facets of theprogram.

The “Do” stage of the project ranfrom April through November of2010. Multiple order sets and proto-cols were developed for the pilotstudy. A mobility order set was cre-ated that included a screening toolbased on the exclusion criteria fromthe Critical Care Physical Medicineand Rehabilitation Program at JohnsHopkins Medical Center.20 Theexclusion criteria were modified toaddress the needs of our patient pop-ulation based on recommendationsfrom the intensivists and medicalstaff chairpersons. The mobility algo-rithm developed by the physicaltherapist on the planning team wasembedded in the order set to guidethe assessment and allowed thenurse to consult physical therapistsand occupational therapists whenappropriate (Appendix 2). The ven-tilator weaning order set was devel-oped by ICU respiratory therapists.This order set included a protocolfor pain management with appropri-ate sedation determined by clinicalpharmacists and implemented bybedside nurses, use of the RichmondAgitation Sedation Scale,21,22 andmore frequent readiness trials todetermine whether patients werecapable of ventilator discontinua-tion.23–28 A primary objective was toremove mechanical ventilation assoon as possible, as it is easier andsafer to mobilize patients withoutthe burden of an artificial airway.Pain that could worsen with move-ment was addressed to avoid patientresistance, and sedation was modi-fied so that patients were alertenough to mobilize. The sedationprotocol for ICU patients was modi-fied from a practice of continuous

infusions to a preferred practice ofusing intermittent dosing of sedationmedications when possible to main-tain goal sedation.

After careful review of the multipleorder sets, approval for the 4-weekpilot study was granted by the hos-pital’s Medical Executive Committeein September 2010. The teamreceived approval from the hospi-tal’s institutional review board inNovember 2010. Data would be col-lected on patients 18 years of age orolder who were hospitalized for 72hours or longer.

During November 2010, in prepara-tion for the pilot study, nurses andpatient care technicians completedan education program developed bythe Move to Improve team. The edu-cation included verbal presentationsby the advanced practice nurses andphysical therapists at unit staff meet-ings. The staff was instructed on theexclusion criteria, the mobility algo-rithm, and the use of gait belts whentransferring and ambulating patients.The nurses and patient care techni-cians also received self-learningpackets, and posters were placed onthe 2 units as reminders of the study.The nurses and patient care techni-cians had 1 month to complete theeducation. Respiratory therapistsreceived mandatory education inboth written and classroom formatson the use of the portable ventilator,ventilator weaning, sedation, and themobility protocols. Physical thera-pists were educated on use of acustom-designed walker with fold-down seat, funded by the hospitalfoundation, and intravenous polethat supported the portable ventila-tor (Fig. 1). They also received spe-cific instructions on handlingpatients who are critically ill and ven-tilated for safety during ambulation.

Beginning the first week of Decem-ber 2010, education was provided tothe medical staff at their quarterly

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meeting along with posters outliningthe program and pilot study. Thephysicians were made aware that themobility protocol would be manda-tory for all patients in the adult ICUand IMCU during the pilot project,which was to run from December14, 2010, through January 11, 2011.The physicians were informed thatthe nurse would have the ability toorder physical therapy or occupa-tional therapy when appropriate.Decisions about ability or appropri-ateness of activity were made by thenurse based on the mobility algo-rithm coupled with the assessmentof exclusion criteria. All patients inboth the ICU and the IMCU werescreened using the same process.

Upon completion of the pilot proj-ect, the team returned to the MedicalExecutive Committee in February2011 to complete the “Check” pro-cess. Approval was granted to pro-ceed with the program in the ICUand the IMCU with the understand-ing that the mobility protocol would

no longer be mandatory but wouldnow need a physician’s order toimplement. The Medical ExecutiveCommittee also approved hospital-wide implementation to begin in July2011.

The “Act” process began in March2011 at the beginning of the post-implementation period with theobjective of increasing the numberof adult patients ambulating duringthe first 72 hours of their hospitalstay. For the purpose of this study,we defined ambulation as the act ofwalking with or without an assistivedevice, moving self from point A topoint B. Distance was measured foreach patient’s ambulation efforts.Multiple assessments were per-formed daily by the nurse to deter-mine activity readiness.3

Ambulation was recorded before andafter implementation of the mobilityprotocol for patients admitted to theICU and the IMCU, or transferredfrom the ICU to the IMCU. Patientswho were discharged in less than 72hours or transferred to another unit(other than the IMCU) during thattime frame were excluded. Due tothese exclusions, the patient censusduring the study period appears tobe less than that seen during the pre-implementation period. Nurses andpatient care technicians wereencouraged to ambulate all patientsregardless of their length of stay inthe ICU or IMCU. Collected data cap-tured only nurse or patient care tech-nician documentation of ambulationand did not include activity per-formed by the physical therapist.Aggregated and de-identified datawere reviewed. Monthly collectionand analysis of data were reported tothe nurse managers and staff at unitmeetings. The retrospective chartreviews revealed little improvementin ambulation compared with pre-implementation data. For this rea-son, an ambulation status report(Appendix 3) was developed that

would provide real-time data for thenurses. This report was distributedto the units daily, noting eachpatient’s length of stay and the dis-tance the patient had ambulated on agiven day. The ambulation statusreport was embraced by the IMCUstaff and reviewed at multidisci-plinary rounds each morning. Withthe creation and use of this dailyreport, there was an immediateincrease in the number of patientsambulating in the IMCU. However,we did not see regular use of theambulation status report in the ICUuntil several months into the study.

Patient demographics such as ageand sex were tracked across bothdepartments studied. Data are pre-sented as means (standard deviation)for descriptive variables. Compari-sons of preimplementation and post-implementation data were per-formed using an unpaired, 2-tailedt test. Significance was set at P�.05.Analyses were performed withMicrosoft Excel 2007 software(Microsoft Corporation, Redmond,Washington).

ResultsData were collected for 193 ICUpatients and 349 IMCU patients dur-ing the 3-month preimplementationperiod and for 426 ICU patients and358 IMCU patients during the6-month postimplementation period(Table). During the preimplementa-tion period, patients in the ICU hadan average (SD) age of 67.0 (15.7)years; 42% were female. In theIMCU, the average (SD) patient agewas 65.7 (17.5) years; 55% werefemale. Patients followed in the ICUduring the postimplementationperiod had an average (SD) age of64.4 (17.0) years of age; 48% werefemale. In the IMCU, the average(SD) patient age was 68.0 (16.1)years; 51% were female. There wereno differences in average patient ageor sex distribution between the 2data collection periods.

Figure 1.Custom-designed walker and intravenouspole (purchased from Spectrum SurgicalInstruments Co, Stow, Ohio, www.spectrumsurgical.com) with ventilator(Versamed Ivent 201, GE Healthcare,www.gehealthcare.com).

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During the preimplementationperiod, only 6.2% (12 of 193) of theICU patients and 15.5% (54 of 349)of the IMCU patients ambulatedwithin 72 hours of hospital admis-sion. In contrast, following imple-mentation of the Move to Improveprogram, 20.2% (86 of 426) of theICU patients (P�.001) and 71.8%(257 of 358) of the IMCU patients(P�.001) ambulated within 72 hoursof admission (Fig. 2).

DiscussionThis quality improvement study wasundertaken to determine whetherroutine patient care could be modi-fied to include mobility. The projectutilized current evidence that a sig-nificant change in clinical practicecould be effected, as demonstratedin a quality research study by Need-ham et al.29 The Move to Improveproject was a vision of health careprofessionals who knew moreneeded to be done to improvepatients’ ability to overcome illness.The mobility initiative has enablednurses to drive the care for thepatient through an evidence-basedprotocol. Within our institution,patient activity levels were fre-quently not addressed until manydays into their hospital stay. Somepatients became deconditioned,which led to the cancellation ofdischarges or transfer to a rehabilita-tion facility. Upon realization ofthis hospital-wide problem, it wasbrought to the attention of the ICUleadership and the quality commit-tee in the IMCU.

The Move to Improve committeemet biweekly from April throughNovember 2010 to develop ordersets and algorithms to formulate amobility pathway to be used acrossthe continuum of care. A major les-son learned was that in order toimplement practice changes, theleadership and staff needed an envi-ronment and culture that supportedlearning and a commitment to bestpractice.30 Initially, the ICU staff andphysicians felt the patients with crit-ical illness were too sick to move,that it was too risky to mobilize

them, or that it was the role of thephysical therapist to do the requiredexercises. During the pilot study inthe adult ICU, there was a change inthe leadership structure and a higherthan normal staff turnover rate.These factors posed additional chal-lenges to the implementation ofchange.

Despite the challenges, after focus-ing on the topic in staff meetings andthrough education, nurses realizedthe importance of the mobility pro-gram, and it became a priority. The

Table.Summary of Patient Demographicsa

Variable

ICU IMCU

Preimplementation Postimplementation P Preimplementation Postimplementation P

Total population 193 426 349 358

Age (y), X (SD) 67.0 (15.7) 64.4 (17.0) .07 65.7 (17.5) 68.0 (16.1) .07

Female, n (%) 81 (42) 204 (48) .17 193 (55) 184 (51) .30

a ICU�intensive care unit, IMCU�intermediate care unit. Preimplementation of Move to Improve early mobility program: January–March 2010;postimplementation of Move to Improve early mobility program: March–August 2011.

Figure 2.Patient ambulation in the intensive care unit (ICU) and the intermediate care unit(IMCU) before and after implementation of the Move to Improve early mobility pro-gram. Preimplementation of Move to Improve early mobility program: January–March2010; postimplementation of Move to Improve early mobility program: March–August2011.

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staff of the IMCU and ICU gatheredto discuss the successes and obsta-cles of the program. During the opendiscussion, the nurses stressed theimportance of teamwork and makingambulation a priority as they pro-vided care to patients. It is now adaily expectation to discuss themobility plan for patients who arecritically ill.

Upon completion of the pilot study,the data were presented to the hos-pital’s Medical Executive Committeeto obtain approval for a house-wideMove to Improve initiative, whichbegan in July 2011. After receivingapproval, the committee focused onimplementation to all remainingadult patient care units. The market-ing department facilitated communi-cation and organizational support forthis project through posters andIntranet communications. The Moveto Improve team encouraged physi-cians to order the mobility protocolon admission orders so that nurseswould become familiar with theexclusion criteria and begin to thinkof mobility as part of the daily clini-cal routine. The physicians sup-ported this change, as it streamlinedcare for their patients and reducedthe number of telephone calls for thenurses and medical staff.

The outcomes of our initial data col-lection were as expected. We pre-dicted that with nurses assessing thepatient’s ability to ambulate, morepatients will be walking during theirhospital stay. Our data support Bai-ley and colleagues’ findings inpatients with respiratory failure thatearly activity is feasible and can beused to prevent or treat neuromus-cular complications of critical ill-ness.31 We have determined thatmodifications to our protocol are notneeded at this time; however, it iscritical to maintain protocol use indaily routine patient care.

In our study, we showed that imple-menting a practice and culturechange led to an improvement in thenumber of patients ambulatingwithin 72 hours of their admission inboth the ICU and the IMCU. Our dataindicate that it is feasible to ambulatethese patients.

LimitationsOne limitation of this study is that itwas carried out at only one center.There is a lack of detailed data onpatient demographics and illnessseverity. However, all patients werescreened for appropriateness ofmobility using the criteria presentedin Appendix 2; therefore, all patientsin this study met these physiologicparameters. Applicability of ourresults may be limited by changesmade to the practice of sedationmanagement in the ICU to supportthe mobility initiative, which posed achallenge to nursing and physicianstaff. Inconsistent practice patternsas well as variations in levels of seda-tion may have affected the patients’ability to participate in mobility andsubsequent ambulation trials.

ConclusionA nurse-driven protocol significantlyincreased the number of patientswho ambulated in the adult ICU andIMCU during the first 72 hours oftheir hospital stay. The health careteam consisting of nurses, physi-cians, physical therapists, respiratorytherapists, and pharmacistsapproached this project with enthu-siasm and a commitment to provideoutstanding care. When this projectwas introduced to hospital leader-ship 2 years previously, there waslittle thought given to patients’ activ-ity level. Today it has become a pri-ority throughout the hospital.Although this study was conductedin a single community hospital set-ting without additional staffing, wefeel strongly that it could be repli-cated in other settings. The ancillarystaff utilized at our hospital for this

program is present at other hospi-tals, and the biases our staff hadregarding mobility of patients arelikely to be common at other institu-tions. As only initial ambulation wasinvestigated in this study, futurestudies may be useful in determiningoverall distance improvements,impact on length of stay, the numberof inappropriate physical therapistevaluation orders, incidence of falls,and the number of patients dis-charged to rehabilitation facilities.

Ms Drolet, Ms Harkless, Ms Henricks, MsKamin, Dr Leddy, Ms Waters, and Ms Wil-liams provided concept/idea/researchdesign. Ms Drolet, Ms DeJuilio, Ms Harkless,Ms Henricks, Dr Leddy, Ms Waters, and MsWilliams provided writing. Ms Drolet, MsHarkless, Ms Henricks, and Ms Waters pro-vided data collection. Ms Drolet, Ms Hen-ricks, and Ms Lloyd provided data analysis.Ms Drolet provided project managementand facilities/equipment. Ms Drolet, Ms Har-kless, and Dr Leddy provided consultation(including review of manuscript beforesubmission).

The authors thank the following individualsfor their expertise, guidance, and assistancein the design and performance of the studyand in preparation and editing of the man-uscript: Jeffrey Huml, MD; David Cooke, MD;Jeffrey Hinchman, BS, MS; Patricia Raetz,APN, CNRN; Alice Siehoff, RN, MSN, DNP;and Julie Stielstra, MLS.

The project was presented at the Interna-tional ICU Physical Medicine & Rehabilita-tion meeting, May 14, 2011; Denver,Colorado.

DOI: 10.2522/ptj.20110400

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An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings

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Appendix 2.Non–Intensive Care Unit Mobililty Order and Mobility Protocola

Non–ICU Mobility Order

1. Evaluate patient for presence of any exclusion criteria (see #2). If exclusion criteria are present, do not initiatemobility protocol until cleared by physician.

2. Exclusion Criteriaa. Respiratory Criteria

i. FIO2 greater than 0.6ii. PEEP greater than 5 cm H2Oiii. Hypoxemia: pulse oximeter less than 88%iv. Tachypnea: respiratory rate greater than 35v. Acidosis: Arterial pH less than 7.25

b. Circulatory Criteriai. Continuous infusion of a vasodilator medicationii. Addition of a new anti-arrhythmic agent within previous 24 hoursiii. Unstable arrhythmia within previous 24 hoursiv. New cardiac ischemia within 24 hoursv. MAP greater than 140 mm Hg or less than 65 mm Hgvi. New DVT/pulmonary emboli (first 24 hours)vii. Compartment syndrome

c. Neurologic Criteriai. Acute stroke (first 24 hours)ii. CSF leak

d. Orthopedic Criteriai. Acute fracture

e. Hematologic Criteriai. Hemoglobin less than 7 g/dLii. Platelet count less than 20,000iii. INR greater than 5.0

3. Prevent Excessive Work of Breathing–Desaturationa. Increase baseline FIO2 up to 20% as needed to keep SaO2 greater than 90% with maximum FIO2 80%b. If trached and not on ventilator during activity, have BVM with 100% oxygen availablec. If newly extubated: NO AMBULATION ON DAY OF EXTUBATION

4. Document patient’s previous level of mobility and exercise capacity (prior to admission).5. If patient does not progress through the activity algorithm, consult PT and OT for evaluation and treatment.6. If PT/OT are consulted, the nursing staff/PCTs are to mobilize the patient 1–2 times daily in addition to physical

therapy/occupational therapy as tolerated.7. If patient tolerates chair activity, then patient should be up in chair for all meals as tolerated.8. Patients requiring airborne or AFB precautions may not participate in physical activity outside their room.9. Patients in isolation, please refer to isolation policy for preparation of patients prior to ambulating outside their

room.

Signature: Provider Number: Date: Time:

[PLACE PATIENT LABEL HERE]

(Continued)

An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings

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Appendix 2.Continued

a ICU�intensive care unit, FIO2�fraction of inspired oxygen, PEEP�positive end-expiratory pressure (cm H2O), MAP�mean arterial pressure, DVT�deep veinthrombosis, CSF�cerebrospinal fluid, INR�international normalized ratio, SaO2�arterial oxygen saturation, BVM�bag value mark, PT�physical therapist,OT�occupational therapist, PCT�patient care technician, AFB�acid fast bacilli, WOB�work of breathing. 1 ft�0.3048 m.

An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings

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Appendix 3.Intermediate Care Unit (IMCU) Ambulation Status Reporta

a LOS�length of stay. 1 ft�0.3048 m.

An Early Mobility Protocol to Increase Ambulation in Intensive and Intermediate Care Settings

February 2013 Volume 93 Number 2 Physical Therapy f 207 at George Washington University on February 6, 2014http://ptjournal.apta.org/Downloaded from

doi: 10.2522/ptj.20110400Originally published online September 13, 2012

2013; 93:197-207.PHYS THER. M. Lloyd, Carissa Waters and Sarah WilliamsHenricks, Elizabeth Kamin, Elizabeth A. Leddy, Joanna Anne Drolet, Patti DeJuilio, Sherri Harkless, SherryIntensive and Intermediate Care SettingsMobility Protocol to Increase Ambulation in the Move to Improve: The Feasibility of Using an Early

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