Early Mobility

Nurse-Led Vertical Mobility: Facilitating Optimal Patient Recovery

The negative effects of immobility are well documented. Immobility can have adverse consequences on various aspects of health, both short term and for years after hospital discharge. Immobility leads to the loss of muscle mass and strength. Muscle atrophy is one significant and commonly occurring negative consequence of immobility. Moreover, immobility affects cellular activity, leading to physical dysfunction. In the critical care setting, immobility can contribute to ICU-acquired weakness and prolonged ventilation, resulting in longer ICU length of stay and lingering complications far beyond hospital discharge.

The benefits of mobility are also well documented. Early mobilization can improve or maintain muscle strength, reduce the duration of mechanical ventilation, and improve quality of life. Early mobility is associated with low adverse events related to patient outcomes. Early mobility is not only tied to improved physical outcomes but also to improved financial outcomes.

Mobilizing all patients

The human body is designed to move. So, why are patients not mobilized early and often in the hospital? Keeping the patient’s mobility level as close as possible to their prehospitalization level is key to preventing long hospital stays and optimizing outcomes.

How to mobilize

Many studies suggest which patients should be mobilized and when to do so, but very few studies suggest how to mobilize them. This situation is mostly because each patient has different disease processes, and stability looks different in each situation. Moving some patients safely may pose challenges due to multiple lines, machines and/or a patient’s weight.

How can nurses safely mobilize while minimizing injury risks? Verticalization. Verticalizing patients allows the patient and clinician to mobilize safely. If the patient has a negative response during the verticalization session, the clinician simply moves the bed back to a lower tilted angle.

What is verticalization?

Verticalization is a concept under the “early mobility” umbrella. The term verticalization or vertical mobility simply means moving to or toward a vertical position. Verticalization is in the literature with synonyms such as tilting, reverse Trendelenburg and upright positioning. Verticalization is a therapeutic approach using various technologies to gradually tilt a patient from a supine to a standing position in a slow and controlled manner with no hip flexion and the head/upper body in a higher position than the rest of the body. Historically, verticalization has been accomplished using tilt tables. This therapeutic approach can be accomplished passively or actively, allowing for a dynamic rehabilitation process and contributing to the patient’s overall recovery.

Vertical mobility, often employed as a therapeutic modality, can play a crucial role in the recovery and rehabilitation of medically complex patients. This approach is typically used in hospital settings and other care environments where patients struggle to attain an upright position independently or require close monitoring of various physiological responses.

The interdisciplinary care team can leverage vertical mobility to address the needs of patients who may face challenges with autonomic and hemodynamic responses, consciousness, and musculoskeletal and neuromuscular functions. By carefully helping patients achieve an upright position and closely monitoring their responses, verticalization can contribute to the overall improvement of patients’ health and well-being during the recovery process.

When to initiate vertical mobility

For hospitalized patients, studies suggest that mobility should begin as soon as possible to keep the patient as close to baseline as possible. The literature is clear that if the patient can tolerate it, mobility should begin within 72 hours from admission.

What are the benefits of verticalization?

Verticalization has the potential to benefit every system in the body. Studies highlight some of the benefits of verticalization.

Pulmonary

Vertical positioning has positive effects on the pulmonary system, particularly in the context of secretion management and respiratory function. When the patient is in a tilted position, abdominal tissue shifts downward, which alleviates thoracic pressure, provides room for the diaphragm to drop, and facilitates thoracic cavity expansion. This increased ability for thoracic cavity expansion is crucial for alveolar recruitment, aiding in optimizing ventilation and improving ventilation/perfusion (V/Q) matching. Improved V/Q matching is essential for efficient gas exchange in the lungs, which enhances respiratory function. In addition, the vertical position allows gravity to pull intra-abdominal structures down, helping reduce the risk of aspiration. This intervention is significant in healthcare settings, especially when treating patients who may be at risk for these complications.

Therefore, incorporating upright positioning as part of patient care strategies can play a role in mitigating risks associated with aspiration and optimizing respiratory mechanics. It underlines the importance of considering body positioning in the comprehensive care of patients, especially those with complex medical conditions or during recovery.

Prolonged ventilation is an independent predictor of ICU-acquired weakness (ICU-AW). Ventilator-induced diaphragm dysfunction occurs in 80% of ICU patients receiving mechanical ventilation. So, if this is not your patient’s first time on a ventilator, chances are they already have a weak diaphragm.

Musculoskeletal

Muscle strength drops 3% to 11% for each additional day of immobility, and when it reaches 40% reduction, patient mortality increases significantly. The ability to bear weight contributes to muscle maintenance and bone integrity. The diaphragm is a muscle that plays a significant role in respiration. Mechanical ventilation, while necessary for some critically ill patients, contributes to diaphragm weakness. Studies show that 80% of mechanically ventilated patients exhibit diaphragm weakness, which is a leading cause of failure to wean from the ventilator. Diaphragm weakness occurs twice as often as limb weakness in critically ill patients. Studies note that passive orthostatic training via vertical mobility helps preserve diaphragm thickness and strength.

Cardiovascular

The cardiovascular system is less stressed when the patient is in a passive vertical tilt position compared to a supine position. During an active vertical position, venous return is challenged. If the vessels are not stretched and acclimated to positional changes, the patient might experience orthostatic hypotension (OH). Baroreceptors, central nervous system receptors in blood vessels and in the heart, relay information responsible for changes in heart rate, blood pressure and cardiac output, and are stimulated when vessel walls are stretched. This process occurs with positional changes. Immobility contributes to deconditioning of the baroreceptors due to the lack of vessel wall stretching, which can lead to positional change intolerance or OH.

Identified as a common cause of falls and syncope in hospitalized patients, OH is also a common cause of hospitalization in older people. It is defined as a drop in systolic blood pressure ≥ 20 mm Hg or a drop in diastolic blood pressure ≥ 10 mm Hg. Tilt tables are often used to assess and diagnose hospitalized patients, primarily to provide a safe process for the patient and the staff. If the patient experiences symptoms during the verticalization/tilt process, the staff can simply put the patient at a lower angle until negative symptoms resolve.

Skin

Skin is the body’s largest organ and its first defense against potential external insults. Pressure is one of the extrinsic factors that lead to pressure injuries. The majority of hospital-acquired pressure injuries (HAPIs) occur in the sacral region, and verticalization helps redistribute and offload sacral pressure. Immobility is detrimental to the skin and greatly contributes to HAPIs.

Critically ill patients are at 10 times higher risk for developing a HAPI due to hypoperfusion, inadequate tissue oxygenation, poor nutrition and immobility. HAPIs, especially in critically ill patients, can be difficult to heal. They impact the quality of life for patients and their loved ones. Once a patient has a HAPI, they are at high risk of developing another one during future hospitalizations.

HAPIs are extremely costly for facilities and the healthcare industry. According to the National Pressure Injury Advisory Panel (NPIAP), in 2019 HAPIs cost the healthcare industry over $26.8 billion with HAPI care costs between $21,000 and $151,700 for individual patients. NPIAP also reports that HAPIs are the most commonly reported preventable patient injury with 2.5 million patients per year developing a HAPI and 60,000 patients dying every year as a result of them.

Neurologic

Cognitive stimulation, increased arousal and improved alertness are some potential benefits achieved with verticalization for the stroke population that are not obtained in the seated or Fowler’s position. Verticalization also benefits patients with refractory intracranial pressure (ICP) by aiding in lowering the number ICP spikes and assisting in maintaining desired ICP pressure parameters.

Patients with spinal cord injury, especially injuries occurring at T6 or higher, are at risk of developing autonomic dysfunction. A head-up tilt test is the recommended way to assess the patient’s response to positional changes. Continued progressive verticalization can help improve neurogenic OH.

Studies show that early mobility coupled with decreased sedation is associated with a decreased risk of developing delirium. If a patient develops delirium, meds increase, days on the ventilator increase, and critical care unit and hospital lengths of stay increase. It becomes a vicious cycle of trying to control delirium while unintentionally, but inevitably, prolonging hospital stay and potentially negatively impacting the patient’s quality of life.

Summary

Verticalization provides safe early mobilization for the most complex patients and severely deconditioned patients. Evidence shows that mobilizing patients early and often helps achieve better outcomes. Verticalization should be considered as soon as possible for critically ill and/or ventilated patients to facilitate the earliest level of mobility possible. Verticalization can be discontinued once the patient is free of femoral lines, able to demonstrate core strength, sit at the side of the bed independently, stand and pivot independently or mobilize independently without experiencing negative physiologic symptoms.

Verticalization can be achieved via bed technology that prevents the need for the patient to be transferred to a tilt table; thus minimizing potential adverse events such as line and tube migration and falls, as well as musculoskeletal injuries for the staff.

Verticalization protocols are in the literature with the overarching approach of titrating angles based on patient tolerance.

In many facilities, mobility is driven by physical therapy (PT). While PT should certainly be involved in an intradisciplinary approach, nurses should take the lead in early mobility. Nurses are responsible for completing admission and discharge assessments, which include assessing mobility levels. In addition, they spend more time with patients than does any other discipline in the hospital. Verticalization can be integrated into typical workflows by combining nursing-related activities while the patient is in a tilted position. So, who is better to lead mobilizing patients at the earliest point in time than nurses?

What is your organization’s program on early mobility?

By Nikki Stephens, DNP, APRN, FNP-C, NE-BC

Published in American Association of Critical Care Nurses Blog. View by clicking here