ICU Adult Early Mobilization Page 1 of 7

Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.

Order received to
implement ICU Refer to Level 0 (see Appendix A) and re-evaluate
Early Mobilization in 24 hours (refer back to Box A)
Yes Continued Yes
A Discuss with team prior to initiating Ensure endotracheal
● signs of
Are any tube (ETT) or intolerance during
contraindications1 mobilization activity
tracheostomy is re-evaluation?
present?
Yes secure before
No
moving patient
Evaluate for Precautions2 ● RN/PT/OT to ● For Level 2 and 3,
precautions2 present? assess mobility call Respiratory
level and Therapist or ● Suspend activity and
No re-evaluate in 4-6 hours
proceed with Advanced Practice
● If Level 0, consider
mobilization Yes Provider (APP) for
interventions assistance if patient continuous lateral
(see Appendix A) has a difficult rotation therapy
Is patient on (CLRT) [see
● Guidelines for airway
invasive mechanical Appendix C] No
Monitoring
ventilation? ● Discuss increasing
During Activity,
see Page 2 hemodynamic and
Yes respiratory support
1
Contraindications No
during activity with
● Increased intracranial pressure (ICP) greater than or equal to 15 mmHg ● Active cardiac ischemia
● Acute or uncontrolled intracranial event ● Blood pressure instability despite vasopressors ICU team
● Positive end expiratory pressure (PEEP) greater than or equal ● Richmond Agitation Sedation Score (RASS) +4 (Appendix B) Signs of
to 15 on invasive mechanical ventilation ● Fraction of inspired oxygen (FiO 2) greater than or equal to 0.85 intolerance3?
● Volumetric diffusive respiration (VDR) or ● Uncontrolled arrythmias ● Re-assess mobility
high frequency oscillatory ventilation (HFOV) ● Unstable fracture
level every 12 hours
● Unsecured airway ● Active hemorrhage No ● Continue with
2 3
Precautions Signs of Intolerance (those which do not resolve within 5-10 minutes) mobilization
● Continuous dialysis ● Venous thromboembolism (VTE) ● Respiratory rate (RR) greater than 40 bpm
interventions as
● Lumbar drain ● External ventricular drain ● Oxygen saturation less than 88%
● Plastic surgery ● Orthopedic surgery ● Mean arterial pressure (MAP) less than 50 mmHg or greater than 130 mmHg indicated by
● RASS +3 (Appendix B) ● Tracheostomy within 24 hours ● Heart rate (HR) less than 50 bpm or less or greater than 130 bpm appropriate level
● Difficult airway ● Development of any contraindications
Department of Clinical Effectiveness V4
Approved by the Executive Committee of the Medical Staff on 06/26/2018
 ICU Adult Early Mobilization Page 2 of 7
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.

GUIDELINES FOR MONITORING DURING ACTIVITY Continue to progress mobility as tolerated per
A Yes
Page 1 with monitoring
Do signs of
intolerance resolve
Return patient to safe resting position
with 5-10 minutes rest
Patient break? ● Return patient to supine position in bed
Yes
participating in Signs of ● Suspend activity and re-evaluate in 4-6 hours
ICU adult early No
intolerance1 ● Continue with mobilization intervention as
mobilization observed? indicated by appropriate level
activities with No
current level of
monitoring
Progress mobility to OOB or short
distance ambulation within room Yes
with current level of monitoring

OOB = out of bed

Signs of Continue to progress mobility as tolerated per
1
Signs of Intolerance (those which do intolerance1 Page 1 with full monitoring within room
not resolve within 5-10 minutes) observed? No
● Respiratory rate (RR) greater than 40 bpm
● Oxygen saturation less than 88% ● Return patient to safe resting
● Mean arterial pressure (MAP) less than Yes Refer to
position
50 mmHg or greater than 130 mmHg Was Box A
● Heart rate (HR) less than 50 bpm or less or ● Alert and recruit RN for
cardiopulmonary above
greater than 130 bpm ● Progress mobility to Yes assistance
● Development of any contraindications or neurological dysfunction2 outside of ICU room within
observed within the last the same pod ● Notify ICU team
2
Signs of Cardiopulmonary or Neurological Dysfunction 24 hours? No Signs of
● Use portable pulse ● Progress mobility to outside of ICU
(those that developed or were observed within the last 24 hours) intolerance1
● Increased intracranial pressure (ICP) greater than 10 mmHg oximetry for monitoring ● Use portable pulse oximetry for monitoring
observed?
● Intracranial event ● Recruit RT for assistance if No ● Continue to observe for signs of intolerance
● Decline in mental status patient requires mechanical ● When necessary, recruit RN and/or APP for
● Initiation of high flow oxygen delivery system with FiO 2 greater than 60% or flow greater than 25 L/minute assistance if patient will mobilize outside
● Initiation of or increasing vasopressor requirement ● Acute myocardial event
ventilation
● New onset of arrythmias despite antiarrythmia medications ● Acute pulmonary embolism
of ICU
● Blood pressure instability with MAP less than 65 mmHg or greater than 110 mmHg Department of Clinical Effectiveness V4
Approved by the Executive Committee of the Medical Staff on 06/26/2018
 ICU Adult Early Mobilization Page 3 of 7
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.

APPENDIX A: Mobility Levels

Level 0 Level 1 Level 2 Level 3

1 1 1
RASS -5 to +2 RASS -5 to +2 RASS -2 to +2 RASS1 -1 to +2
Functional Level: Functional Level: Functional Level: Functional Level:
Total Assist2 Total Assist2 Maximum to Moderate Assist2 Moderate Assist to Supervision2

Interventions Interventions Interventions Interventions

● Attempt manual turn to lateral position
● Pre-oxygenate
● Use slow speed of turn
● Use wedge, start with 15 degree turn, hold
for 15 seconds; if tolerance criteria met,
increase to 30 degrees for 15 seconds; if
tolerated, increase to 45 degrees
● Weight shift patient every hour
● Reposition head, arms and legs every hour
with heel elevation
● PROM twice a day x 10 repetitions
3
● Daily implementation of Morning Bundle
● PROM twice daily x 10 repetitions
with nursing staff
● Reposition every 2 hours by nursing staff
● Heel elevation
● Bed in chair position twice a day by
nursing staff greater than 20 minutes but
less than 2 hours
● Skilled therapeutic interventions by
PT/OT as indicated
3 ● Skilled therapeutic interventions by
● Daily implementation of Morning Bundle
● ROM exercises twice daily with
family/nursing staff x 10 repetitions
● Reposition every 2 hours by nursing staff
● Heel elevation
● Bed in chair position twice a day by
nursing staff greater than 20 minutes but
less than 2 hours
● OOB to neuro chair greater than
30 minutes but less than 2 hours
PT/OT as indicated
● Participate in ADL
3
● Daily implementation of Morning Bundle
● Home exercise program twice a day
● Reposition every 2 hours while in bed
● Heel elevation
● OOB to bedside chair with nursing
three times a day greater than
30 minutes but less than 2 hours
● Ambulate as directed by PT/OT
● Skilled therapeutic interventions by
PT/OT as indicated
● Participate in ADL
3
● Daily implementation of Morning Bundle

1
Refer to Appendix B for scale definition 3
Morning Bundle Components: PROM = passive range of motion
2
Total Assist (patient performs 0-24%) By 8 AM: ROM = range of motion
Maximum Assist (patient performs 25-49%) ● Lights on OOB = out of bed
Moderate Assist (patient performs 50-74%) ● Window shades up ADL = activities of daily living
Minimal Assist (patient performs 75-99%) ● Head of bed (HOB) elevated
Supervision (assist patient with set up and/or cuing) ● Sedation holiday
By 10 AM:
● Up in chair position or OOB to chair

Department of Clinical Effectiveness V4

Approved by the Executive Committee of the Medical Staff on 06/26/2018
ICU Adult Early Mobilization Page 4 of 7
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.

APPENDIX B: Richmond Agitation Sedation Scale (RASS)

Overly combative, violent, immediate

+4 Combative danger to staff
Pulls or removes tube(s) or catheter(s);
+3 Very agitated aggressive
Frequent, non-purposeful movement, fights
+2 Agitated ventilator
Anxious, but movements not aggressive or
+1 Restless vigorous
0 Alert and calm -
Not fully alert, but has sustained awakening
-1 Drowsy (eye-opening/eye contact) to voice (greater
than or equal to 10 seconds)
Briefly awakens with eye contact to voice
-2 Light sedation (less than 10 seconds)
Movement or eye openings to voice
-3 Moderate sedation (but no eye contact)
No response to voice, but movement or eye
-4 Deep sedation opening to physical stimulation
-5 Unarousable Unarousable

Department of Clinical Effectiveness V4

Approved by the Executive Committee of the Medical Staff on 06/26/2018
 ICU Adult Early Mobilization Page 5 of 7
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.

APPENDIX C: Continuous Lateral Rotation Therapy (CLRT)

CLRT for hemodynamically unstable patients

● Maintain head of bed (HOB) greater than or equal to 15 degrees and 15 degrees reverse Trendelenberg position (to achieve 30 degrees)
● CLRT 18 hours per day, minimum of 6 complete rotations (optimally 8-10 rotations)
● Use training mode, or if not tolerated, set rotation at 60% and pause two minutes for right/left/center (minimum settings)
● Monitor that one lung is above the other lung with a turn. If not, increase rotation percentage as tolerated.
● Increase pause to one minute as patient adjusts
● Every 2 hours, check to ensure that the patient is in optimal position to promote effective turn. Shoulders should be aligned with the lung picture on the bed.
● Use custom settings to adjust for body types

Department of Clinical Effectiveness V4

Approved by the Executive Committee of the Medical Staff on 06/26/2018
 ICU Adult Early Mobilization Page 6 of 7
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.

SUGGESTED READINGS

Adler, J., & Malone, D. (2012). Early mobilization in the intensive care unit: a systematic review. Cardiopulmonary Physical Therapy Journal, 23(1), 5.

Bailey, P., Thomsen, G. E., Spuhler, V. J., Blair, R., Jewkes, J., Bezdjian, L., ... Hopkins, R. O. (2007). Early activity is feasible and safe in respiratory failure patients. Critical Care Medicine,
35(1), 139-145.

Brower, R. G. (2009). Consequences of bed rest. Critical Care Medicine, 37(10), S422-S428.

Burtin, C., Clerckx, B., Robbeets, C., Ferdinande, P., Langer, D., Troosters, T., ... Gosselink, R. (2009). Early exercise in critically ill patients enhances short-term functional recovery.
Critical Care Medicine, 37(9), 2499-2505.

Morris, P. E., Goad, A., Thompson, C., Taylor, K., Harry, B., Passmore, L., ... Penley, L. (2008). Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Critical
Care Medicine, 36(8), 2238-2243.

Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J., Esbrook, C. L., ... Schmidt, G. A. (2009). Early physical and occupational therapy in mechanically ventilated,
critically ill patients: a randomised controlled trial. Lancet (London, England), 373(9678), 1874-1882.

Tod Brindle, C., Malhotra, R., O'rourke, S., Currie, L., Chadwik, D., Falls, P., . . . Creehan, S. (2013). Turning and repositioning the critically ill patient with hemodynamic instability: A literature
review and consensus recommendations. Journal of Wound, Ostomy and Continence Nursing, 40(3), 254-267.

Vollman, K. M. (2012). Hemodynamic instability: Is it really a barrier to turning critically ill patients? Critical Care Nurse, 32(1), 70-75.

Department of Clinical Effectiveness V4

Approved by the Executive Committee of the Medical Staff on 06/26/2018
 ICU Adult Early Mobilization Page 7 of 7
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.

DEVELOPMENT CREDITS

This practice consensus statement is based on majority expert opinion of the ICU Adult Early Mobilization experts at the University of Texas MD Anderson Cancer Center for the
patient population. These experts included:

Wendy Garcia, BS♦

Bobak Habibi, PT, DPT (Rehab/Physical Therapy)
Rhea Herrington, MSN, RN-BC, CCRN (Nursing Education)
Vi Nguyen, OTR, BSRC, MOT (Rehab/Occupational Therapy)Ŧ
Amy Pai, PharmD♦
S. Egbert Pravinkumar, MD, FRCP (Critical Care & Respiratory Care)Ŧ
Amber Tarvin, MSN, RN, CNL (Nursing ICU)
Mary Lou Warren, DNP, RN, CNS-CC (Critical Care & Respiratory Care)Ŧ

Ŧ
Development Leads
♦
Clinical Effectiveness Development Team

Department of Clinical Effectiveness V4

Approved by the Executive Committee of the Medical Staff on 06/26/2018