Describing Usual Care Mobilization with Mechanically Ventilated Patients According to the Rehabilitation Treatment Specification System

Summary

To characterize common intensive care unit (ICU)-based mobilization activities delivered by physiotherapists and the ICU multidisciplinary team as part of usual care. Activities are described according to the Rehabilitation Treatment Specification System.

Abstract

Mobilization in the intensive care unit (ICU) for mechanically ventilated patients is a complex intervention. In critical care rehabilitation, patient recovery should not be limited by hospital location (e.g., ICU or hospital ward). Critically ill patients are among the most medically complex in the hospital; therefore, clinicians providing mobilization require a thorough understanding of critical illness, patient recovery trajectories, and available rehabilitation techniques. Mobilization requires coordination among multidisciplinary team members, careful preparation, and strong clinical assessment and decision-making skills. Usual care is the most common comparator group in randomized controlled trials of ICU mobilization; however, it is often under-specified. As a result, there is limited understanding of the specific activities, clinical decision-making processes, and therapist actions that constitute usual care. In this manuscript, the Rehabilitation Treatment Specification System (RTSS) is applied to describe protocols for common usual care mobilization activities for mechanically ventilated ICU patients. Preparation, clinician actions (e.g., instructions, feedback, and equipment provision), progression considerations, and clinical decision-making are described for each activity to enhance transparency and support reproducibility of usual care mobilization practices.

Introduction

Individuals who survive a critical illness are likely to experience debilitating physical and functional deficits, largely resulting from prolonged immobility while receiving life-saving treatment(s) in the intensive care unit (ICU)¹. Rehabilitation encompasses a broad range of interventions aimed at restoring or improving function², whereas mobilization is a subset of rehabilitation that includes passive or active physical activities aimed at restoring or improving movement³. Both rehabilitation and/or mobilization initiated in the ICU are recommended by the Society of Critical Care Medicine (SCCM) to help mitigate these deficits and support improved patient outcomes following ICU discharge⁴. As standards of usual care continue to evolve, as reflected in recent guideline updates recommending enhanced rehabilitation and/or mobilization in addition to usual care, it is essential to understand which activities comprise usual care⁴.

Clinical research aims to reflect real-world practice to ensure that findings from interventional trials are relevant, generalizable, and readily applicable to patients and clinicians. As a result, “usual care” often serves as the comparator in ICU rehabilitation research and is intended to reflect the day-to-day practice of clinicians providing rehabilitation in the ICU⁵. Usual care typically encompasses a broad range of activities. The delivery of usual care depends on the patient’s ability, the therapist’s skill, and clinical judgement⁵. Therefore, usual care is highly variable.

Usual care in the context of ICU rehabilitation is not well understood. Secondary analyses⁶ and point prevalence studies^{7,8,9,10,11,12,13} provide detailed descriptions of usual care in the ICU. However, these descriptions have largely focused on the activities delivered or the highest level of activity achieved, but do not reflect clinical decision-making. A practical guide for mobilization published in 2016 addressed clinical decision-making; however, it lacked detail reflecting the complexity of therapists’ actions during mobility sessions¹⁴. From a scoping review of 125 trials of ICU-based physical rehabilitation, two-thirds (n=80) included a usual care comparator group¹⁵. Across these 80 trials, 55 unique rehabilitation activities were reported. In 1 in 5 trials, ambiguous terminology prevented classification into individual activities (e.g., mobility)¹⁵. To facilitate comparisons, it is essential that rehabilitation activities are documented clearly and thoroughly.

The Rehabilitation Treatment Specification System (RTSS) was developed to facilitate a transparent and thorough description of rehabilitation treatments in terms of their relationship with patient outcomes¹⁶. The RTSS has a tripartite structure, in which rehabilitation treatments are specified according to Targets (aspects of a patient’s functioning that the clinician intends to change), Ingredients (what the clinician does or provides to directly influence targets), and Mechanisms of Action (how ingredients are hypothesized to achieve the target)^16,17. The scope of the RTSS includes treatments provided to individual patients during individual sessions¹⁷ which offers a level of granularity not addressed by common rehabilitation reporting tools such as the Template for Intervention Description and Replication (TIDieR)¹⁸ or the Consensus on Exercise Reporting Template (CERT)¹⁹. Therefore, the aim of this manuscript is to apply the RTSS to describe protocols for providing usual care mobilization to mechanically ventilated patients in the ICU.

Protocol

This protocol follows institutional guidelines for research involving human participants. Ethics approval was not required for this descriptive methods paper. Ethical approval for the Critical Care Cycling to Improve Lower Extremity Strength (CYCLE) randomized clinical trial (RCT) was obtained at each of the 17 participating sites. Written informed consent for publication of photographs was obtained from the individuals shown in Figure 1 and Figure 2.

The CYCLE RCT²⁰ compared the effects of early in-bed cycling along with usual care rehabilitation versus usual care alone on physical function and safety (NCT03471247). The trial enrolled 360 patients from 16 sites across three countries. To date, CYCLE is the largest technology-based trial in the field and the second-largest ICU-based rehabilitation trial²¹. Herein, common mobilization activities delivered during usual care in the CYCLE RCT are described.

In a previous complementary paper, the RTSS is described in detail, including the rationale for its application for rehabilitation reporting²². The RTSS can be incorporated into clinical documentation to create a detailed description of usual care treatments that facilitates continuity of care, supports clinical reasoning, and provides a clear record of a patient’s recovery journey. The “SOAP Note” framework may be used to structure documentation²³, with targets included in the assessment (clinical interpretation of subjective and objective where problems are identified) and ingredients included in the objective (observable data or physical examination findings) and plan (clinician’s plans for treatment).

1. Room set-up

1. Room overview and layout
   1. Identify the patient bay layout, including an adjustable ICU bed and surrounding equipment (Figure 1 and Figure 2).
   2. Identify equipment, including patient vital sign monitors (e.g., heart rate, rhythm, blood pressure, oxygen saturation), a mechanical ventilator, intravenous therapy pumps, a continuous renal replacement therapy (CRRT) machine, a patient chair, a gait aid (e.g., walking frame), and a mechanical lift or hoist (Figure 1 and Figure 2).
   3. Identify patient attachments or devices, including lines, drains, and indwelling catheters.
   4. Individualize room setup and planning according to ICU layout variations²⁴.
2. Goal of activity and room set-up
   1. Ensure a safe operating environment for the planned mobilization activity.
   2. Review the medical chart and determine the expected highest functional level for the session.
   3. Organize the room according to the planned activity. For example, if the expected functional level is ambulation away from the bedside, ensure that suitable equipment is readily available including a walking frame, mobile pole for attachments, portable oxygen and suitable clothing for the patient (e.g., ensure patient’s torso is covered anteriorly and posteriorly, non-slip socks). 
   4. Ensure that appropriate equipment is readily available (e.g., walking frame, mobile pole for attachments, portable oxygen, and suitable patient clothing such as non-slip socks and adequate coverage).
   5. Identify and clearly communicate a backup plan with the team¹⁴. An example of this may be having equipment (such as a bedside chair or wheelchair) and additional staff nearby in the event the patient requires a rest during ambulation. 
   6. Prepare contingency equipment (e.g., bedside chair or wheelchair) and additional staff if required.
3. Room set-up process
   1. Environmental scan
      1. Re-screen for contraindications and precautions related to mobilization.
      2. Identify contraindications related to cardiac, respiratory, or neurological instability (e.g., myocardial infarction, unstable or uncontrolled arrhythmia, abnormal mean arterial pressure, abnormal heart rate, low oxygen saturation, neuromuscular blockers)²⁰.
      3. Identify additional contraindications (e.g., uncontrolled pain, active bleeding, severe agitation)²⁰.
      4. Visually scan and identify all equipment, lines, and attachments connected to the patient from head to toe.
      5. Determine which attachments can be removed or consolidated in collaboration with the multidisciplinary team.
      6. Screen for infection control risks and plan accordingly.
      7. Ensure that all equipment is clean and in good working order.
      8. Assess manual handling risks and identify appropriate mechanical aids (e.g., bed mechanics, mechanical hoists, standing devices).
   2. Preparation of environment, team, and patient
      1. Remove or consolidate attachments identified during the environmental scan.
      2. Ensure that the patient has received adequate analgesia and reduce or cease sedation as appropriate.
      3. Assign roles among team members and designate a team leader.
      4. Assign airway monitoring responsibilities to appropriate staff (e.g., nursing staff or respiratory therapists).
      5. Ensure that airway equipment and appropriately trained personnel are available in the event of an unplanned extubation.
      6. Ensure that an adequate number of staff are present based on institutional policies, treatment targets, clinician expertise, and staff availability.
      7. Review the mobilization plan and backup plans with the team.
      8. Communicate the plan to the patient and address any questions.

Figure 1: Simulated ICU patient with an endotracheal tube and bay setup.
Common ICU equipment, attachments, and devices (e.g., lines, drains, indwelling catheters) are labeled. Please click here to view a larger version of this figure.

Figure 2: Simulated ICU patient with an endotracheal tube and bay setup. (A) Typical ICU bay with surrounding equipment and patient attachments.
(B) Patient equipment consolidated onto the ventilator side of the bed and arranged to facilitate sitting at the edge of the bed. A therapist is positioned to assist the patient while maintaining adequate slack in lines and attachments. A walking frame is used for support.
(C) Patient progressed to sitting independently at the edge of the bed. A walking frame is available for support as needed. Please click here to view a larger version of this figure.

2. Case patient

1. For this protocol, a 61-year-old male with acute respiratory failure following abdominal surgery was considered.
2. Confirm that the patient is mechanically ventilated via an endotracheal tube.
3. Identify the presence of a right internal jugular central venous catheter, a peripheral intravenous catheter, an abdominal surgical drain, and a Foley catheter attached to a urine collection bag.
4. Monitor heart rate, blood pressure, oxygen saturation, and respiration rate using bedside monitoring equipment.
5. Assess baseline mobility using the ICU mobility scale (IMS)^25,26,27.
6. In the previous session, the patient achieved an initial IMS score of 1. The therapist set a treatment target of independent sitting at the edge of the bed (IMS = 3) for the session.

3. Description of usual care activities

1. Targets
   1. Classifies rehabilitation activities into Representations, Organ Functions, and Skills and Habits¹⁷.
   2. Representations are activities targeting a change in knowledge, attitudes, behaviors, and/or emotional responses through cognitive and/or affective information processing (e.g., increase knowledge about post-intensive care syndrome)¹⁷.
   3. Skills and habits activities are those targeting skill acquisition or automaticity of a behaviour through structured repetition and practice (e.g., increase independence in sitting at the edge of the bed)¹⁷.
   4. Organ functions activities are those targeting changes in the function(s) of organs, organ systems or body structures (e.g., increase rectus femoris muscle strength), physiological or structural function¹⁷.
   5. Incorporate progression (e.g., increase difficulty) as a key ingredient to promote change¹⁷.
2. Activities
   1. Progress mobilization activities from in-bed exercises to ambulation away from the bedside²⁸.
   2. Identify targets and ingredients (clinician actions and equipment) for each activity. Each activity may include multiple targets.
   3. Note that the Representation targets are not applicable to the selected activities for this case patient.
   4. Apply essential clinician actions (e.g., preparation, assessment, reassessment, and progression decisions) across activities.
3. Range of motion (Figure 3)
   1. Target Examples
      1. Organ function - Maintain or improve joint mobility.
      2. Organ function -  Prevent the development of contractures.
      3. Organ function - Assess readiness for further mobilization.
      4. Organ function - Improve cardiovascular circulation.
      5. Organ function - Increase muscle strength.
      6. Organ function - Increase muscle endurance.
      7. Skills and Habits - Improve mobility.
      8. Skills and Habits - Improve alertness and participation.
   2. Ingredients
      1. Clinician actions
         1. Prepare the team, patient, and environment, and set up the room.
         2. Select target joints (e.g., shoulder, elbow, wrist, hand, hip, knee, ankle).
         3. Determine whether movements will be passive (entirely by the clinician, with the patient unable to assist), active-assisted (with the patient initiating movement and the clinician assisting as required), or active (patient able to move independently throughout the available range without assistance).
         4. Position the patient supine with the head slightly elevated.
         5. Support proximal and distal joints appropriately.
         6. Move joints slowly through anatomical planes.
         7. Avoid movement in the presence of pain or resistance.
         8. Repeat movements as tolerated using clinical judgement. Prioritize high-quality movements.  
         9. Stop the activity if physiologic instability, pain, or fatigue occurs, leading to compensatory movements.
         10. Return the patient to a neutral position.
         11. Monitor tolerance and safety continuously.
         12. Apply criteria for commencing and ceasing activity according to consensus guidelines²⁹.
         13. Provide opportunities for practice as patients progress. As patients progress from non-volitional (passive) to volitional (active-assisted or active) movements, they require opportunities to practice to move their limb independently, develop muscle strength, and require less physical assistance.
         14. Provide instructions, feedback, knowledge of results, and motivation.
         15. Adjust progression based on patient response.
      2. Equipment
         1. Use bed mechanics to position the patient.
         2. Use assistive devices (e.g., arm or leg cycle ergometer, continuous passive motion machine).
         3. Use resistance equipment (e.g., free weights or resistance bands) to progress difficulty.
4. Sitting at the Edge of the Bed (Figure 4)
   1. Target Examples
      1. Organ function - Increase head, neck, and trunk muscle activation and endurance.
      2. Organ function - Increase postural control in sitting.
      3. Organ function - Increase alertness.
      4. Organ function - Increase cardiovascular tolerance to upright posture.
      5. Organ function - Improve respiratory function.
      6. Skills and Habits - Improve independence in transfers from lying to sitting.
      7. Skills and Habits - Improve independent sitting balance (static and dynamic).
   2. Ingredients
      1. Clinician actions
         1. Prepare the team, patient, and environment, and set up the room.
         2. Assist the patient to bend the contralateral knee and reach toward the intended sitting side.
         3. Position staff on either side of the patient and assist into side-lying as required³⁰.
         4. Elevate the head of the bed while moving the patient’s lower limbs over the edge of the bed.
         5. Position the patient upright in sitting. Provide assistance as required. The amount of staff assistance required may decrease as the patient’s clinical status improves. 
         6. Lower the bed until the patient’s feet are supported on the floor.
         7. Assess head, neck, and trunk control and determine assistance level.
         8. Return the patient to bed by reversing the procedure.
         9. Provide opportunities to practice and increase duration and complexity.
         10. Progress to dynamic sitting activities (e.g., reaching, leaning).
         11. Assess readiness for progression to standing.
         12. Monitor safety continuously and intervene if required.
         13. Apply criteria for commencing and ceasing activity according to consensus guidelines²⁹.
         14. Provide instructions, feedback, knowledge of results, and motivation.
      2. Equipment
         1. Use ICU bed mechanics to assist transitions.
         2. Use a mechanical hoist when required for safe positioning.

Figure 3: Application of the RTSS to the range of motion.
This figure provides an overview of exemplar targets, hypothesized mechanisms of action, ingredients, and measures used to quantify targets for range of motion. A continuum of non-volitional to fully volitional activities is shown, corresponding to passive, active-assisted, and active range of motion. Dotted arrows indicate ingredients or measures applied across treatment sessions. For example, limb assistance is required for passive and active-assisted range of motion. See the main text for additional details. Figure based on information from Van Stan et al^16,32. Please click here to view a larger version of this figure.

Figure 4: Application of the RTSS to sitting at the edge of the bed.
This figure provides an overview of exemplar targets, hypothesized mechanisms of action, ingredients, and measures used to quantify targets for sitting at the edge of the bed. A continuum of non-volitional to fully volitional activities is shown, ranging from passive to active-assisted to active sitting. Dotted arrows indicate ingredients or measures applied across treatment sessions. For example, clinicians adjust bed height and rails for passive, active-assisted, and active sitting. See the main text for additional details. Figure based on information from Van Stan et al^16,32. Please click here to view a larger version of this figure.

4. Progression

1. Recognize mobilization activities as a continuum.
2. Progress activities based on patient engagement, strength, and cooperation.
3. Use clinical expertise to determine the starting point.
4. Conduct an initial assessment to determine treatment targets.
5. Guide progression using prior performance and the highest level achieved.
6. Adjust progression according to changes in patient clinical status.

5. Additional considerations

1. Identify additional devices (e.g., chest tubes, drains, intracranial pressure monitors).
2. Ensure sufficient slack in all device connections.
3. Ensure that devices tolerate the required range of motion for an activity.
4. Communicate with the multidisciplinary team regarding mobilization safety.
5. Refer to additional guidance for mobilization with devices in situ.²⁹.

Results

Recent guidelines from the Society of Critical Care Medicine (SCCM) recommend delivering rehabilitation or mobilization for critically ill adults as part of usual care, as it is safe, feasible, and may improve patient outcomes⁴. This manuscript provides detailed guidance on how to deliver common mobilization activities for mechanically ventilated patients in the ICU that can be implemented by trained ICU clinicians.

Following the implementation of this protocol, trained...

Discussion

The protocol describes activities commonly delivered during usual care mobilization for mechanically ventilated patients in the ICU. By detailing these activities, it becomes evident that ICU mobilization encompasses far more than ambulation, contrary to common perceptions. This description emphasizes the complex and nuanced decision-making undertaken by ICU clinicians when determining which activities are appropriate for a given patient and when, informed by continually changing physiological status and functional abili...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Central venous catheter	Equipment use and availability may vary by patient and/or by centre.
Central venous catheter pressure bag
Continuous passive motion (CPM) machine
Continuous renal replacement therapy (CRRT) machine
Cycle ergometer (arm/leg)
Endotracheal tube
Foley catheter
Free weights
Gait aid
ICU bed (adjustable bed with mechanics and rails)
Intravenous (IV) infusion pump
Mechanical lift/hoist (ceiling or mobile)
Mechanical ventilator
Mobile pole for patient attachments
Patient chair/bedside chair
Patient virtal signs monitor
Peripheral IV catheter
Resistance bands
Standing device
Surgical drain collection bag
Urine collection bag
Walking frame
Wheelchair