Opera&on

Mobiliza&onEarly mobility and

decreased ICU stays

Presenter: Liuying Wang

INTRODUCTION

The importance of early mobiliza&on in

ICU pa&ents has been understood for
decades, since WWII when early mobility
was encouraged among injured soldiers
to get them back on the baDleeld

Richard Asher, M.D. describing the

bedridden pa&ent: The blood clo+ng in
his veins, the lime draining from his
bones, the scybala stacking up in his
colon, the esh ro+ng from his seat, the
urine leaking from his distended bladder,
and the spirit evapora<ng from his soul.

Evans, B. (2009). Pa&ent mobility in the ICU. Retrieved from www.hanys.org-qualityclincal_opera&onal_ini&a&ves/vapp/docs/pa&ent_mobility_in_the_ICU.pdf

INTRODUCTION (CONT.)
Over the past recent decades,
developments in life support
technologies have increased
the use of deep sedation and
bed rest in ICU patients

Prolonged immobiliza&on associated with nega&ve

health outcomes such as: neuromuscular dysfunc&on
or ICU-acquired weakness, increased ven&lator
dependency, decreased bone mass density, decreased
peristalsis and increased risk of pressure ulcers and
hospital-acquired infec&ons risk among others.
increased LOS

INTRODUCTION (CONT.)
While some hospitals have early mobiliza&on protocols in
place, others either do not have protocols in place or rely
solely on mobility orders. Adherence to both mobility
protocols and orders is low in many cri&cal care seYngs due
to compe&ng priori&es of care, among other factors.

As nurses, we
have the most
direct contact
with patients and
are thus most
capable of
ensuring that
early mobilization
is implemented
among patients.

PICOT

In adult ICU pa&ents, hospitalized for any
length of &me, is early mobiliza&on as
compared to immobiliza&on associated
with shorter ICU stays?

Summary of Current Prac&ce

Na#onal

Hospitals throughout the country that use early

mobiliza&on interven&ons/protocols have decreased

length of stay.
Studies conducted in Iowa, North Carolina, and California showed a

reduc&on in hospital stay with implementa&on of early mobiliza&on.

Even with mobility protocols in place they are not always followed.
Hospitals without a mobility protocol have less overall

mobility of ICU pa&ents and longer ICU stays.

Minimal mobility such as turning, or transferring to a stretcher with no

other movements are being performed.

Zomorodi, M., Topley, D., & McAnaw, M. (2012). Developing a mobility protocol for early mobiliza&on of pa&ents in a surgical/
trauma ICU. Cri<cal Care Research and Prac<ce. 2012 1-10 Doi:10.1155/2012/964547

Summary of Current Prac&ce (cont.)

Observa&on:

In local hospitals protocols are not being followed

or they are par&ally carried out.
Pa&ents have liDle to no mobiliza&on or they are
fully ambulated with no transi&on in between.
Overall
Most protocols follow a similar algorithm

A 3-4 phase protocol with exclusion criteria

Many healthcare members and pa&ents are unaware of

mobility protocols and the benets of early

mobiliza&on.
Further educa&on and training is required

SYNOPSIS OF CURRENT LITERATURE FINDINGS

According to mul&ple studies, pa&ents who experienced

early mobiliza&on protocols in ICUs were shown to have

decreased lengths of stay
Immobiliza&on leads to longer days on ven&la&on and
lower levels of func&onality

59% of pa&ents who received early mobiliza&on spent less

days on mechanical vent. with higher levels of func&onal
independence
The other 35% received usual care with no interven&ons

Usual care (including no mobiliza&on) leads to 6 days on

average longer stay

Engel, H. J., Tatebe, S. Alonzo, P. B., Mustilleand, R. L., & Rivera, M. J. (2013). Physical therapist-established intensive
care unit early mobilization program: quality improvement project for critical care at the University of California San
Francisco Medical Center. Journal of the American Physical Therapy Association, 93(7), 975-985. doi: 10.2522/ptj.
20110420
Pandullo, S., Spilman, S., Smith, J., Kingery, L., Pille, S., Rondinelli, R., & Sahr, S. (2015). Time for critically ill patients to
regain mobility after early mobilization in the intensive care unit and transition to a general inpatient floor. Journal of
Critical Care. http://dx.doi.org/10.1016/j.jcrc.2015.08.007

SYNOPSIS OF CURRENT LITERATURE FINDINGS

Immobiliza&on increases care and &me dedicated to pa&ent
More &me and resources used
More money spent on sta and tools involved in pa&ent
care
Re-intuba&on rate 50% increased with immobiliza&on
60% increase in hospital-acquired infec&ons when compared
to
mobile pa&ents
In general, immobiliza&on has been proven
to be an issue in ICUs
Decreased quality of care
Increased length of stay
Decreased independence of pt upon discharge
Increase in hospital-acquired infec&ons
Increase in pt anxiety and fear related to hospital stay

Clark, D. E., Lowman, J. D., Griffin, R. L., Matthews, H. M., & Reiff, D. A. (2013). Effectiveness of an Early Mobilization Protocol in a
Trauma
and Burns Intensive Care Unit: A Retrospective Cohort Study. Physical Therapy, 93(2), 186-196. doi:10.2522/ptj.20110417
Titsworth, W. L., Correia, T., Reed, R., Guin, P., Archibald, L., Layon, A. J., & J. Mocco (2012). The effect of increased mobility on
morbidity in the neurointensive care unit. Journal of Neurosurgery, 116(6), 1379-1388. doi: 0.3171/2012.2.JNS111881

SYNOPSIS OF CURRENT LITERATURE FINDINGS

Lord, R. K., Mayhew, C. R., Koruplou, R., Mantheiy, E. C., Friedman, M. A., Palmer, J. B.,
Needleham, D. M. (2015). ICU early physical rehabilitation programs: Financial modeling of cost
savings. Critical Care Medicine, 41(3), 717-724. doi:10.1097/CCM.0b013e3182711de2

Limita&ons of Research Ar&cles

Small sample sizes
Study performed at only one

hospital
Focus on physical therapy or
occupa&onal therapy
interven&ons
Specic popula&ons (i.e.
neurological)

Strengths of Research Ar&cles

Control Groups

Cohort study

Complicated comorbid condi&ons

Study at least 1 year long

Mean age >60 years old

Studies from dierent types of
ICUs
Neuro ICU
Medical ICU
Trauma ICU
Surgical ICU

Evidence Based
Recommenda&ons

In general, research recommends that mobiliza&on should be

implemented within 24 hours of admission
Nurses should also follow an appropriate protocol that allows
pa&ents progress eciently

Posi&ve results aler an early mobiliza&on interven&on among

pa&ents in the intensive care unit (ICU)
Trauma, burn, neurological, and medical/surgical ICU.

Eight out of nine studies associated with shorter ICU staysranged

from two days to six days

Other ndings: signicant increase in ambula&on, increase in

discharges, fewer pulmonary and vascular complica&ons, fewer
physical therapy referrals, and a decrease in hospital-acquired
infec&ons

Early mobiliza&on safe and feasible

If early mobiliza&on is to be implemented among ICU pa&ents, safety

concerns should rst be addressed

REFERENCES FOR STRENGTHS, LIMITATIONS, AND

RECOMMENDATIONS

Clark, D. E., Lowman, J. D., Grin, R. L., MaDhews, H. M., & Rei, D. A. (2013). Eec&veness of an Early Mobiliza&on
Protocol in a Trauma and Burns Intensive Care Unit: A Retrospec&ve Cohort Study. Physical Therapy, 93(2), 186-196. doi:
10.2522/ptj.20110417
Drolet, A., DeJuilio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, E. A., Williams, S.
(2013). Move to improve: The
feasibility of using an early mobility protocol to increase ambula&on in the intensive and intermediate care seYngs.
Physical Therapy, 93(2), 197-207. doi:10.2522/ptj.20110400

Engel, H. J., Tatebe, S. Alonzo, P. B., Mus&lleand, R. L., & Rivera, M. J. (2013). Physical therapist-established intensive care
unit early mobiliza&on program: quality improvement project for cri&cal care at the University of California San Francisco
Medical Center. Journal of the American Physical Therapy Associa<on, 93(7), 975-985. doi: 10.2522/ptj.20110420

Klein, K., Mulkey, M., Bena, J. F., Albert, N. M. (2015). Clinical and psychological eects of early mobiliza&on in pa&ents
treated in a neurologic ICU: A compara&ve study. Cri<cal Care Medicine 43(4), p 865873 doi:10.1097/CCM.
0000000000000787
Mah, J.M., Sta, I., Fichandler, D., & Butler, K.L. (2013). Resource-ecient mobiliza&on programs in the intensive care
unit: who stands to win? The American Journal of Surgery, 206, 488-493. Retrieved from hDp://dx.doi.org/10.1016/
j.amjrug.2013.03.001

Pandullo, S., Spilman, S., Smith, J., Kingery, L., Pille, S., Rondinelli, R., & Sahr, S. (2015). Time for cri&cally ill pa&ents to
regain mobility aler early mobiliza&on in the intensive care unit and transi&on to a general inpa&ent oor. Journal of
Cri<cal Care. hDp://dx.doi.org/10.1016/j.jcrc.2015.08.007

Titsworth, W. L., Correia, T., Reed, R., Guin, P., Archibald, L., Layon, A. J., & J. Mocco (2012). The eect of increased mobility
on morbidity in the neurointensive care unit. Journal of Neurosurgery, 116(6), 1379-1388. doi: 0.3171/2012.2.JNS111881

Wang, Y. T., Haines, T. P., Ritchie, P., Walker, C., Ansell, T. A., Ryan, D. T., Lim, P., Vij, S., Acs, R., Fealy, N., & Skinner, E. H.
(2014). Early mobiliza&on on con&nuous renal replacement therapy is safe and may improve lter life. Cri<cal Care, 18(4),
R161-R170. doi:10.1186/cc14001
Witcher, R., Stoerger, L., Dzierba, A. L., Silverstein, A., Rosengart, A., Brodie, D., & Berger, K. (2015). Eect of early
mobiliza&on on seda&on prac&ces in the neurosciences intensive care unit: A preimplementa&on and pos&mplementa&on
evalua&on. Journal of Cri<cal Care, (30), 344-347. Retrieved from
hDp://zp9vv3zm2k.search.serialssolu&ons.com/?V=1.0&sid=PubMed:LinkOut&pmid=25573283

ACTION PLAN
Create a research informed, nurse-driven mobility

protocol
A comprehensive protocol will be created using a
combina&on of mul&ple protocols from dierent
facili&es and studies and include specic parameters
and instruc&ons for ini&a&ng mobility
Protocol will be implemented at a local hospitals
medical intensive care unit
Implementa&on will focus on educa&on

TIME LINE

September 1, 2015- October 29, 2016: Research current evidence,

develop protocol and plan to implement early ambula&on protocol
in hospitals intensive care units
January 1, 2016- March 15, 2016: Receive approval from unit
managers, medical execu&ve commiDee, intensive care physician
teams, and consult with a physical therapist liaison to develop
training.
March 16, 2016-March 30, 2016: Four training sessions will occur
over two week period; each training session will be 90 minutes and
held by a physical therapist. All nurses and PCTs on the medical ICU
will be expected to aDend one of the four planned training
sessions. Employees will be compensated for aDending training.
April 1, 2016- August 1, 2016: Implementa&on of protocol in the
medical ICU.
August 1, 2016- September 1, 2016: Evalua&on of successfulness of
protocol and discussion and plans to implement into the CVICU and
trauma/surgical ICU

EDUCATION
The protocol will be implemented with educa&on as a

primary focus
All nurses and PCTs will be required to aDend one 90
minute training session
Training sessions will be held over a two week period
and sta members will have four date & &me op&ons to
choose from to aDend
Sta members will be paid for the mandatory training
Training will be led by a physical therapist
Sta members will be required to pass (>70%) a
comprehension test at the end of training

TRAINING SESSION
RNs and PCTs will be educated about the protocol, when

to ini&ate, exclusion criteria, and how to implement into

their care
Sta will be trained about body mechanics and how to
safely ambulate pa&ents
How to cluster care to include protocol
When to stop mobiliza&on
How to plan with pa&ent discharge exercise and
mobility

AMBU GURU
The protocol will include the implementa&on of an

Ambula&on Guru (Ambu Guru)

At the beginning of every shil the charge nurse will
assign one nurse the job of Ambu Guru
This nurse will be expected to remind other sta
members throughout the day to u&lize Opera&on
Mobiliza&on
All RNs and PCTs will be trained to be an Ambu Guru at
their required training session

Operation Mobilization

Pre-phase
initiation
Educate the patient
and family about
protocol and
importance of
ambulation

If unable to sit unsupported

for 5 minutes consult
Physical Therapy

If unable to stand with <2

person assist consult
Physical Therapy

Phase 2
Phase 1
Passive/Active Range of
Motion

Elevate HOB 30 degrees

Successful
completion of
phase 1

Level 3: Dangle off side of bed

15 min 3x/day

Level 1: Ambulate with

assistance (PCT/RN) and
assistive device 50 feet

Level 1: stand at edge of bed

with assistance

Level 2: Sit up at 90degrees

with back support for 30 min
3x/day

Rotate Q 2 hours

Phase 4

Phase 3

Level 1: Elevate HOB 45

degrees

Level 2: Pivot to chair

Successful
completion of
phase 2

Level 2: Ambulate feet

unassisted

Successful
completion of
phase 3

Discharge
Vitals will be assessed prior to interventions and throughout mobility protocol.
Activity will be stopped immediately if the following parameters are met:
HR>150
Saturations <85% after increase in FiO2
SBP> 200 or <90
Ve> 15 L/min

Create an exercise and

mobility plan for
patient to complete
upon discharge

Completion of
phase 4 and
discharge planning

If none of the exclusion criteria is met the nurse may initiate Operation Mobilization

Pre-phase
initiation
Educate the patient
and family about
protocol and
importance of
ambulation

Phase 1
Passive/Active Range
of Motion
Rotate Q 2 hours
Elevate HOB 30
degrees

Phase 2

Level 1: Elevate HOB 45

degrees
Level 2: Sit up at
90degrees with back
support for 30 min 3x/day
Level 3: Dangle off side of
bed 15 min 3x/day

If unable to
sit
unsupported
for 5 minutes
consult
Physical
Therapy

Phase 3
Level 1: stand at
edge of bed with
assistance
Level 2: Pivot to
chair

If unable to
stand <2
person assist
consult
Physical
Therapy

Phase 4
Level 1: Ambulate
with assistance (PCT/
RN) and assistive
device 50 feet
Level 2: Ambulate 50
feet unassisted

Discharge
Create an exercise
and mobility plan for
patient to complete
upon discharge

Vitals will be assessed prior to interventions and throughout

mobility protocol. Activity will be stopped immediately if the
following parameters are met:
HR>150
SBP> 200 or <90

Saturations <85% after increase in FiO2

Ve> 15 L/min

EXCLUSION CRITERIA
All pa&ents who do not meet exclusion criteria will be

started on the mobility protocol within 24 hours of

admission to the Medical ICU
If a pa&ent meets one of the parameters listed on the
exclusion criteria the nurse must obtain physician
approval prior to implemen&ng Opera&on Mobility
Physician will assess ability to tolerate mobility prior to
star&ng
The nurse will be expected to begin mobility protocol
for all pa&ents eligible to receive interven&on

EXCLUSION CRITERIA
Neurological:
Increased intracranial pressure (ICP)
Cerebral spinal uid (CSF) leak
Acute stroke within 24 hours
Unsecured, ruptured aneurysm
Respiratory:
Posi&ve end expiratory pressure (PEEP) >12
Frac&onal expired oxygen (FiO2) > .8
Minute volume > 15 L/min
Hypoxemia (satura&on <88%)
Tachypnea (respiratory rate > 30 breaths per minute)

EXCLUSION CRITERIA
Circulatory
New deep vein thrombosis (DVT) or pulmonary
embolism (PE) within 24 hours
Unstable arrhythmia within 24 hours
New onset chest pain
Tachycardia (heart rate >150)
Systolic blood pressure (SBP) >200 mmHg or <90 mmHg
Mean arterial pressure (MAP) <60 mmHg or >140
mmHg
Ac&ve bleeding

EXCLUSION CRITERIA
Musculoskeletal:
Ordered bed rest
Unstable/acute fractures
Hematological:
Hemaglobin < 7 g/dL
Platelet count <2,000
INR > 5.0
Other:
Femoral arterial line
Recent hip surgery
Transi&on to comfort care

OPERATION MOBILIZATION PROMOTION

Protocol will be posted throughout the unit
Pa&ents will receive informa&on about protocol upon

admission
Ask your nurse about Opera&on Mobiliza&on sign will
be posted in all pa&ent rooms
The assigned Ambu Guru will enforce protocol
throughout shil

Cost Analysis
Hiring new PCT ($30,000
yearly)
Training PCT

Training nurses

$30,000 yearly salary divide by

12 months= $2,500/month x 4
months
$10,000 for four months x 10
PCT
$11.63 hourly x 90 min x 22
PCT
$34.32 hourly x 90 min x 50
nurses

$100,000.00
$383.79
$2,574.00

Trainer (physical therapist)

$20.18 x 9 hours

$181.62

Buying 10 extra walkers

$35.50 x 15 walkers

$532.50

Laminated posters in each room

$2.39 x 24 posters

$57.36
Total: $103,729.27

COMPARISON
Total cost of the resource-ecient mobility program
(REMP) came out to $63,750
Our cost for Opera&on Mobiliza&on $103,699.00
Will focus on educa&on throughout the protocol
Will focus on nursing aspect applying the protocol with
the help of PCT
The hospital will benet and will save money
Decrease length of hospitaliza&on
Reducing medical complica&ons associated with
prolong immobiliza&on

Mah, J.M., Sta, I., Fichandler, D., & Butler, K.L. (2013). Resource-ecient mobiliza&on programs in the intensive care
unit: who stands to win? The American Journal of Surgery, 206, 488-493. Retrieved from
hDp://dx.doi.org/10.1016/j.amjrug.2013.03.001

COST OF IMMOBILITY
900,000 pa&ents in the United States each year are

aected by deep vein thrombosis (DVT) and pulmonary

embolism (PE) in hospital seYngs.
DVT annual es&mated cost ranges between $4.9 to $7.5
billion and $8.5 to $19.8 billion pertains to the annual
es&mated cost for PE treatment.
A total of 28,953 pa&ents were diagnosed with DVT and
35,550 pa&ents were diagnosed with PE.
Daily cost for the rst day of trea&ng a DVT pa&ent was
$2,321, second day $1,875 and third day $1,558.
For a PE pa&ent, daily cost for the rst day was $2,981,
second day $2,034, and third day was $1,564.

Dasta, J.F., Pilon, D., Mody, S.H., LopaDo, J., Laliberte, F., Germain, G., Bookhart, B.K., Lefebvre, P., & Nutescu, E.A. (2014). Daily
hospitaliza&on costs in pa&ents with deep vein thrombosis or pulmonary embolism treated with an&coagulant therapy. EJournal of Thrombosis Research Journal. 135, 303-310. Retrieved from hDp://dx.doi.org/10.1016/j.thromres.2014.11.024

COST OF IMMOBILITY
1 million to 2.5 million pa&ents develop pressure

ulcers annually in the United States ranging from

Stage to Stage IV.
The cost to treat and heal a pressure ulcer
depends on the severity of the pressure ulcer
condi&on. For instance, it can cost hundreds of
dollars for Stage I and II pressure ulcers and up
to $5,000 to $151,700 for Stage III and IV
pressure ulcers.
Meddings, J., Reichert, H., Rogers, M.A.M., Hofer, T.P., McMahon, L.F., Grazier, K.L. (2015). Under pressure:
Financial eect of the hospital-acquired condi&ons ini&a&ve-a statewide analysis of pressure ulcer
development and payment. The American Geriatrics Society Journal, 63, 1407-1412. doi:10.1111/jps.13475

ADDITIONAL REFERENCES FOR COST ANALYSIS

Indeed (2015). Pa&ent care technician salary in Tucson, AZ. Retrieved from
hDp://www.indeed.com/salary?q1=Pa&ent+Care+Technician&l1=Tucson%2C
+AZ
Payscale: Human capital (2015).Pa&ent care technician salary. Retrieved from
hDp://www.payscale.com/research/US/Job=Pa&ent_Care_Technician/
Hourly_Rate
Payscale: Human capital (2015). Physical therapist salary in Tucson. Retrieved
from hDp://www.payscale.com/research/US/
Job=Physical_Therapist_Assistant/Salary/fa2719cd/Tucson-AZ
SalaryGenius (2015). RN salary in Tucson, Arizona. Retrieved from
hDp://salarygenius.com/az/tucson/salary/rn-salary?p=2
Walkers. (2015). Allegro medical.com. Retrieved from
hDp://www.allegromedical.com/walkers-c516/2-buDon-folding-walker-with-5wheels-p565603.html?utm_campaign=Comparison
%20Shopping&utm_source=froogle&utm_medium=feed&CS_003=9164468&CS
_010=b4b946b06f18013013d52c4138899c05&gclid
=CJDY55Dy6MgCFc5efgod1icEDQ&kwid=productadsplaid^101314403053-sku^762%20565603%2001@ADL4ALLEGRO-adType^PLAdevice^c-adid^65352197773#762+565603+01

Risk vs. Benet of Protocol

Risk for the ins#tu#on:
Increased ini&al cost
More liability

Risk for the nurse:
More responsibility
Extra documenta&on
Fa&gue

Risk vs. Benet of Protocol

Risk for the pa#ent:
Increased pain aler exercise
Increased need for pain medica&on
Increased risk of fall and injuries
Transient oxygen desatura&on
Line dislodgement
Hypotension
Cardiac arrest
Loss of consciousness

Risk vs. Benet of Protocol (cont.)

Benet to the ins#tu#on:
Pa&ent shorter length of stay
Decreased number of hospitalacquired infec&on
Decreased mortality
Reduced overall hospital cost
Increase the hospital reputa&on

Benet to the nurse:
Increased educa&on
BeDer pa&ent-nurse rela&onship

Risk vs. Benet of Protocol (cont.)

Benet to the pa#ent:
Decreased lengths of ICU and hospital stay
Decreased the use of mechanical ven&la&on
Lower the pa&ents cost
Less seda&on and delirium, and decreased depression
and anxiety

Outcomes
All nurses and PCTs will aDend one of the four mandatory

training sessions before the implementa&on of Opera&on

Mobiliza&on.
The Ambu Guru will report 100% of protocol was
accomplished each day for each pa&ent.
Each pa&ent room will have a posted protocol before
implementa&on of Opera&on Mobiliza&on.
Pa&ents will not experience any falls during the four month
trial of Opera&on Mobiliza&on
Each pa&ent and/or pa&ent family will verbalize an
understanding of the importance of early mobility upon
admission to the ICU.
The average length of hospital stay in the ICU will decrease
by two days over a period of four months.

Conclusion

Early mobiliza&on is associated with a decreased ICU length

of stay

An early mobiliza&on protocol such as Opera&on Mobiliza&on

would be safe and feasible to implement in the ICU seYng

Because nurses have the most direct contact with their

pa&ents, it is important for an early mobiliza&on protocol to
be led by nurses and enforced by nurses.

The early mobiliza&on protocol requires interdisciplinary

coordina&on and coopera&on, and thus educa&on of sta is
necessary for its eec&ve implementa&on

REFERENCES

Clark, D. E., Lowman, J. D., Grin, R. L., MaDhews, H. M., & Rei, D. A. (2013). Eec&veness of an Early Mobiliza&on
Protocol in a Trauma and Burns Intensive Care Unit: A Retrospec&ve Cohort Study. Physical Therapy, 93(2), 186-196. doi:
10.2522/ptj.20110417

Dasta, J.F., Pilon, D., Mody, S.H., LopaDo, J., Laliberte, F., Germain, G., Bookhart, B.K., Lefebvre, P., & Nutescu, E.A. (2014).
Daily hospitaliza&on costs in pa&ents with deep
vein thrombosis or pulmonary embolism treated with
an&coagulant therapy. E-Journal of Thrombosis Research Journal. 135, 303-310. Retrieved from
hDp://dx.doi.org/10.1016/j.thromres.2014.11.024

Drolet, A., DeJuilio, P., Harkless, S., Henricks, S., Kamin, E., Leddy, E. A., Williams, S.
(2013). Move to improve: The
feasibility of using an early mobility protocol to increase ambula&on in the intensive and intermediate care seYngs.
Physical Therapy, 93(2), 197-207. doi:10.2522/ptj.20110400

Engel, H. J., Tatebe, S. Alonzo, P. B., Mus&lleand, R. L., & Rivera, M. J. (2013). Physical therapist-established intensive care
unit early mobiliza&on program: quality improvement project for cri&cal care at the University of California San Francisco
Medical Center. Journal of the American Physical Therapy Associa<on, 93(7), 975-985. doi: 10.2522/ptj.20110420

Evans, B. (2009). Pa&ent mobility in the ICU. Retrieved from www.hanys.org-quality-clincal_opera&onal_ini&a&ves/vapp/

docs/pa&ent_mobility_in_the_ICU.pdf

Hogan, C. (2015). Early mobiliza&on in the hospitalized pa&ent. Medical sta newsleYer: St. Josephs healthcare. Retrieved
from: hDp://www.stjosephhospital.com/Default.aspx?DN=e6d0de38-0fc4-4b3d-b94b-bde1eef3480f

Klein, K., Mulkey, M., Bena, J. F., Albert, N. M. (2015). Clinical and psychological eects of early mobiliza&on in pa&ents
treated in a neurologic ICU: A compara&ve study. Cri<cal Care Medicine 43(4), p 865873 doi:10.1097/CCM.
0000000000000787

Lord, R. K., Mayhew, C. R., Koruplou, R., Mantheiy, E. C., Friedman, M. A., Palmer, J. B., & Needham, D. M. (2015). ICU early
physical rehabilita&on programs: Financial modeling of cost savings. Cri<cal Care Medicine, 41(3), 717-724. doi: 10.1097/
CCM.0b013e3182711de2

Mah, J.M., Sta, I., Fichandler, D., & Butler, K.L. (2013). Resource-ecient mobiliza&on programs in the intensive care
unit: who stands to win? The American Journal of Surgery, 206, 488-493. Retrieved from hDp://dx.doi.org/10.1016/
j.amjrug.2013.03.001

REFERENCES

Meddings, J., Reichert, H., Rogers, M.A.M., Hofer, T.P., McMahon, L.F., Grazier, K.L. (2015). Under
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