developing a progressive mobility activity protocol

© 2012 by National Association of Orthopaedic Nurses Orthopaedic Nursing • September/October 2012 • Volume 31 • Number 5 253Copyright © 2012 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

Developing a Progressive Mobility Activity Protocol

Lisa King

Lisa King, MSN, ACNS-BC, Lecturer, Kent State University Ashtabula, Ashtabula, Ohio.

The author has disclosed that she has no fi nancial interests to any com-mercial company related to this educational activity.

DOI: 10.1097/NOR.0b013e31826649f2

nym PMAP was chosen to appropr iately describe the protocol purpose, to map a course of direction for the critically ill patient’s progressive mobility on the road to recovery. The PMAP provides nurses and interdisciplin-ary team members a roadmap for increasing patient movement through a series of progressive steps from passive range of motion to ambulating independently as their medical stability increases (Hopkins & Spuhler, 2009; Kubo, 2008; Perme & Chandrashekar, 2009). A pilot study is to be implemented later this year and ad-ditional data will be gathered. The expected patient out-comes of the PMAP include improved physical condi-tioning, prevention of complications associated with deconditioning and immobility, and return to activity levels prior to hospitalization.

Effects of ImmobilityAlthough consequences of immobility are well known to orthopaedic nurses, gaps in nurses’ knowledge and the-oretical understanding of deconditioning may lead to prolonged periods of bed rest in patients (Gillis, MacDonald, & MacIssac, 2008). Deconditioning is a term that is used to describe the complex physiological and potentially reversible effects that result from peri-ods of inactivity or immobility (O’Keefe, 2002). Many nurses may be unaware of how quickly physiological changes can lead to functional decline (Figure 1).

Sarcopenia, a loss of muscle mass, can begin after only 2 days of bed rest, decreasing muscle strength by 1%–3% per day. One week of bed rest can result in a 20% decrease in muscle strength and an additional 20% muscle strength loss for each week on bed rest (De Jonghe et al., 2007; Topp, Ditmyer, King, Doherty, & Hornyak, 2002). Lack of weight bearing is known to ac-celerate bone demineralization leading to fractures and kidney stones (Winkleman, 2009). Profound loss of lean muscle mass and strength, particularly in the lower ex-tremities, was found by Kortebein, Ferrando, Lombeida, and Evans (2007), in 12 healthy older adults after 10 days of bed rest. Deconditioning has a signifi cant effect

Orthopaedic nurses specialize in preventing musculoskeletal disorders and complications in postoperative patients through early mobility. A review of the literature reveals re-cent studies that discuss the benefi ts of early mobility in in-tensive care patients. Early progressive mobility programs use a systematic progression of activity to prevent decon-ditioning and its complications in critically ill patients. Increasing patient mobility in the intensive care unit can help the orthopaedic nurse continue the promotion of well-ness and self-care and the prevention of injury in the care of individuals with musculoskeletal disorders. This article in-cludes a description of the development of an innovative progressive mobility activity protocol for intensive care unit patients in a community hospital, using a detailed, methodi-cal approach to identify the need for practice change and to create a plan for achieving this change.

Patients sustaining orthopaedic injuries or or-thopaedic surgery represent a signifi cant and growing proportion of patients in intensive care units (ICUs; Taylor & Gropper, 2006). Admission

rates of orthopaedic patients to ICUs are rising because of increases in hip and knee arthroplasties in an aging population with a rising prevalence of signifi cant co-morbid conditions (Weissman, 2000). Critically ill pa-tients in ICUs are often placed on strict bed rest and heavily sedated, greatly increasing the risk for compli-cations associated with immobility. To prevent immo-bility-associated complications, more intensive care set-tings are using progressive mobility protocols to increase activity in critically ill patients. Progressive mobility protocols promote a collaborative, multidisci-plinary approach between physicians, nurses, and phys-ical, occupational, and respiratory therapists to provide early mobility for critically ill patients, many of whom are mechanically ventilated.

To promote best practice through the dissemination of research fi ndings, this article addresses the useful-ness to orthopaedic nurses of an innovative nurse-driven, evidence-based protocol developed to increase ICU patient mobility in a small community hospital. Immobility-associated complications are reviewed and the steps for developing a progressive mobility activity protocol (PMAP) are discussed with strategies for its continuation after discharge from the ICU. The acro-

NOR200332.indd 253NOR200332.indd 253 28/08/12 7:35 PM28/08/12 7:35 PM

254 Orthopaedic Nursing • September/October 2012 • Volume 31 • Number 5 © 2012 by National Association of Orthopaedic Nurses

Copyright © 2012 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.

on the skeletal muscles used in standing and walking and has been linked to falls, functional decline, in-creased frailty, and immobility (Gillis et al., 2008).

Signs of cardiovascular deconditioning are apparent within 3–4 days of bed rest (Winkleman, 2009). Baroreceptors, located in the aorta and the carotid sinus, regulate blood pressure by responding to smooth muscle fi ber length with position changes. The barore-ceptors stimulate the autonomic nervous system to con-strict or dilate blood vessels with changes in body posi-tion. When an individual changes position from lying to sitting, the body goes through a series of physiological adaptations to maintain cardiovascular homeostasis.

However, when an individual is lying immobile, the baroreceptor sensitivity decreases. Orthostatic intoler-ance and syncope develop from a loss of baroreceptor responsiveness (McCance & Heuther, 2006).

Additional complications from immobility (Figure 2) include pneumonia, atelectasis, pressure ulcers, consti-pation, urinary stasis, and depression. Immobility-associated metabolic changes are hypoglycemia, insulin resistance, decreased protein synthesis, and decreased fatty acid metabolism. Reductions in skeletal muscle contraction can lead to venous stasis and deep vein thrombosis as well as decreased venous return to the heart (Hamburg et al., 2007; Winkleman, 2009).

FIGURE 1. Physiological changes during 1 week of bed rest. CO � cardiac output; HR � heart rate; MV � mechanical ventilation; SV � stroke volume Based on data from De Jonghe et al. (2007); Hamburg et al. (2007); Kortebein, Ferrando, Lombeida, and Evans (2007); McCance and Heuther (2006); Topp, Ditmyer, King, Doherty, and Hornyak (2002); and Winkleman (2009).

FIGURE 2. Complications of immobility. ARDS � acute respiratory distress syndrome; CNS � central nervous system; CO � cardiac output; DVT � deep vein thrombosis; PE � pulmonary embolism; SV � stroke volume; UTI � urinary tract infection. Based on data from De Jonghe et al. (2007); Hamburg et al. (2007); Kortebein, Ferrando, Lombeida, and Evans (2007); McCance and Heuther (2006); Topp, Ditmyer, King, Doherty, and Hornyak (2002); and Winkleman (2009).



A Model for Planned ChangeTo develop the PMAP, Rosswurm and Larrabee’s (1999) model for evidence-based practice was used. This model, based on research utilization and change theory, provides a framework for integrating evidence-based in-terventions into practice. Ther e are six steps in the model: (1) assess the need for a change in practice, (2) link the problem with interventions and outcomes, (3) synthesize the best evidence, (4) design the practice change, (5) implement and evaluate the change in prac-tice, and (6) integrate and maintain the change in prac-tice. The PMAP was formulated using these steps as follows.

ASSESS THE NEED FOR A CHANGE IN PRACTICE

In this fi rst step, a retrospective audit of 30 patient charts was conducted to assess the need for a practice change. The charts were reviewed for PMAP eligibility and contraindications. All patients admitted to the ICU for more than 24 hours and free of contraindications were considered eligible for PMAP. Contraindications included cardiovascular, respiratory, or neurological in-stability, temporary femoral lines, traction as deter-mined by the physician and do-not-resuscitate comfort care (DNRCC) patients. Of the 30 records audited, most patients were ineligible because of ICU stays less than 24 hours and DNRCC status. Eight patients met eligibil-ity criteria. Their medical records were examined for ICU length of stay (LOS), total hospital LOS, activity orders, physical therapy (PT) and occupational therapy (OT) referrals, and documented activity. Institutional review board approval was obtained for the use of these existing data.

The audit results revealed an average patient age of 71.4 years. All of the patients were ambulatory before their hospitalization, two with the use of a walker and one with a cane. The average ICU LOS was 4.13 days and the average total hospital LOS was 11.7 days. Physical therapy and OT referrals were ordered on fi ve of the eight patients. All patients met PMAP eligibility for most of their stay; however, three patients remained on bed rest during their entire hospital LOS without documented indication. One patient chart had no physi-cian orders for activity. The audit results also showed a lack of nursing documentation for patient activity, indi-cating little or no activity in each of the eight eligible patients during their ICU stay and after transfer to step-down and regular units. Six of the eight patients lived at home prior to hospitalization, and seven patients were discharged to skilled nursing facilities or long-term acute care facilities. Only one patient returned home after discharge.

Rosswurm and Larrabee’s (1999) fi rst step includes identifying potential barriers. There are several poten-tial barriers for maintaining PMAP that include lack of mobility education, safety concerns, and lack of inter-disciplinary collaboration. Time constraints due to in-creased patient acuity and limits in staffi ng have low-ered the priority and time available for basic mobility (Gillis et al., 2008; Markey & Brown, 2002). A lack of nursing education on deconditioning and patients’ per-ceptions that they need to rest; being passive recipients

of care is also an impediment to activity (Bynon, Wilding, & Eyres, 2007). Nurses and physicians have identifi ed that patient symptoms of weakness and pain, safety concerns related to maintaining airways, feeding tubes, intravenous lines or urinary catheters, fear of patient falls, lack of mobility equipment, and lack of patient motivation are common barriers to patient mobility (Brown, Williams, Woodby, Davis, & Allman, 2007; Winkelman, Johnson, Peereboom, Hejal, & Rowbottom, 2009).

Step-down, orthopaedic, and general fl oor nurses may also be concerned about the safety in mobilizing the patient recently transferred from the ICU because of substantial functional disabilities in walking ability, muscle strength, cognitive functioning, and activities of daily living in patients not participating in early activity in the ICU (VanDerSchaaf et al., 2007). Patients have identifi ed that a lack of assistance in getting out of bed was a major barrier to their activity (Brown et al., 2007; Winkelman et al., 2009).

Additional potential deterrents to patient activity are concerns for physical harm to staff when mobilizing patients, especially the obese patient. A hospital lift team was formed in the past year to assist with the movement of larger patients and will be used with progressive mobility in ICU patients as appropriate. The hospital education department recently provided education with active participation of all nursing care staff on proper body mechanics with the proper use of mobility aids including standing lifts and pneumatic lifts. Mobility equipment needs for their patient care areas were assessed, and budget requests were submitted. The National Association of Orthopaedic Nurses (2011) has long advocated for safe nursing practices and developed evidence-based guidelines for safe patient handling and movement. These guidelines include algorithms for selecting the safest equipment and techniques based on specifi c patient characteristics and provide best safety practices for orthopaedic nurses (Sedlak, Doheny, Nelson, & Waters, 2009).

Lack of collaboration among interdisciplinary team members is a potential barrier and can lead to inconsis-tencies in patient functional and mobility interventions. When the patient is seen by an occupational or physical therapist, there is often confusion where the responsi-bility for activity lies (Markey & Brown, 2002). The PMAP is written so that roles are clearly delineated using language familiar to all disciplines.

Hospital administrators may be reluctant to justify possible expenditures for workforce and equipment related to PMAP. A cost–benefi t analysis for LOS was done to link potential outcome data with cost data as a method for communicating the value of the protocol. If each of the eight PMAP eligible patients, as identifi ed in the medical record audit, had outcomes of a 1.4-day decrease in ICU LOS and hospital LOS by 3.3 days as demonstrated in recent studies (Bailey et al., 2007; Morris et al., 2008; Pennington Caraviello, Nemeth, & Dumas, 2010; Winkelman et al., 2009), the total healthcare cost could be reduced by $18,544.80 in 1 month. This conservative estimate is based on current hospital charges and represents a signifi cant potential fi nancial impact from just eight patients.




Administrative support and sanctioning are vital to the success of practice changes. A summary of the pro-gressive mobility evidence, audit fi ndings, and potential fi nancial considerations was presented to several key stakeholders within the hospital. Approval to proceed with PMAP development was received from all.

LINK THE PROBLEM WITH INTERVENTIONS AND OUTCOMES

The second step in developing the PMAP was to link the problem, lack of mobility in ICU patients, with interven-tions and outcomes. Recent studies have indicated that early progressive activity for ICU patients is safe and cost-effective, resulting in decreased immobility-related complications. Functional mobility was increased and functional independence was more likely in patients re-ceiving early mobility (Bailey et al., 2007; Morris et al., 2008; Pennington Caraviello et al., 2010; Schweickert et al., 2009; Winkelman et al., 2009).

The PMAP intervention is to be initiated if the patient is at risk for deconditioning from immobility and is free from any contraindications. Each patient will be as-sessed upon admission and every 8 hours for inclusion in PMAP. At the initiation of PMAP, patients may re-quire life support equipment, such as mechanical venti-lators, or interventions, such as drugs for sedation. Patients receiving sedatives will have sedation decreased as their condition allows for participation in PMAP. Patient cardiovascular, neurologic, and respiratory status is assessed before, during, and after each activity.

The PMAP begins with nursing interventions that include turning from side to side every 2 hours (Institute for Clinical Systems Improvement, 2010), range of mo-tion three times per day, and orthostatic conditioning to an upright position. The primary purpose of orthostatic conditioning is to prevent orthostatic intolerance by in-ducing orthostatic stress caused by raising the patient gradually to a sitting position (Kubo, 2008). The PMAP steps (Figure 3) include orthostatic conditioning pro-gressing from elevating the head of the bed 30° to 45° and then lowering the foot of the bed to a partial sitting position. The beds in this hospital ICU can be placed in

a partial sitting and full sitting position to facilitate ac-tivity to occur in a comfortable manner for the patient. When the patient is able to follow commands and per-form active range of motion, occupational and physical therapists begin working with the patient.

As the patient’s condition allows, activity is to be pro-gressed to elevating the head of the bed to 65° and low-ering the foot of the bed to a full-sitting position. Once the patient is conscious and following commands, activ-ity should progress to the patient’s feet touching the fl oor. In collaboration with PT and respiratory therapy as appropriate, the patient should be assisted in th e standing position and advance to taking one to two steps to a chair and sitting for 30 minutes or longer. The next step is to walk with assistance, using a walker if necessary, and fi nally, independent ambulation.

The PMAP is evaluated through data comparison of activity documentation, immobility-related complica-tions, ventilator-associated pneumonia and deep vein thrombosis rates, and ICU LOS, days of mechanical ventilation (MV), and total hospital LOS before and after implementation. Outcome data on immobility-re-lated complications and LOS for PMAP patients will be reported quarterly to administrators. De monstrating a meaningful impact of PMAP will be helpful to hospital administrators who seek optimal patient outcomes but must weigh costs for multiple competing programs throughout the hospital.

SYNTHESIZING BEST EVIDENCE

In the third step of the model for change (Rosswurm & Larrabee, 1999), a literature review was conducted. A synthesis of several studies demonstrates the benefi ts of early progressive mobility in critical care patients. Morris et al. (2008) conducted a prospective cohort study of mobility in ICU patients with acute respiratory failure requiring MV. Patients who received early progressive mobility were out of bed 5 days earlier, the average length of ICU stay was decreased by 1.4 days, and overall length of hospital stay was decreased by 3.3 days. There was a lower incidence of ventilator-associated pneumonia and deep vein thrombosis in the

FIGURE 3. Progressive mobility activity protocol steps. HOB � head of the bed.



Progressive mobility protocols should be maintained until the patient is ambulating independently or dis-charged from the hospital (Hopkins & Spuhler, 2009; Kubo, 2008; Perme & Chandrashekar, 2009). The last steps of the PMAP often occur after the patient is trans-ferred out of the intensive care unit (ICU); however, there was no discussion in the literature of barriers or facilitators in continuing progressive mobility after ICU. Studies indicating low levels of mobility in patients on general hospital units and lack of documented activity

intervention group. There were no untoward events during the mobility sessions, and there was a reduction of costs averaging more than $3,000.00 per patient even with additional costs associated with the mobility team. Winkelman et al. (2009) demonstrated similar results with a signifi cant reduction in ICU LOS by 4.1 days and the duration of MV was reduced by 3.4 days in patients receiving early mobility.

In a study of 1,449 activity events in 103 MV patients, Bailey et al. (2007) found that 69% were able to ambu-late more than 100 feet upon transfer from the ICU. There were less than 1% activity-related adverse events, all resolved quickly with no additional treatment. Daily interruption of sedation and PT and OT was well toler-ated and resulted in better functional outcomes, shorter duration of delirium, and decreased days on ventilation, as demonstrated by Schweickert et al. (2009). The evi-dence indicates that progressive mobility prevents com-plications and is feasible, safe, and cost-effective in critically ill patients.

With attention consumed by higher acuity patients in the general hospital units, many nurses have lost focus on the importance of basic care such as ambulation (Markey & Brown, 2002). In studies of mobility in hos-pitalized patients, 72.9%–83% of patient hospital stays were spent lying in bed, despite an ability to walk inde-pendently, and there were no documented medical indi-cations for bed rest in 60% of patients with physician-ordered bed rest (Brown, Friedkin, & Inouye, 2004; Brown, Redden, Flood, & Allman, 2009; Callen, Mahoney, Grieves, Wells, & Enloe, 2004).

DESIGN THE PRACTICE CHANGE

The presence of an activity protocol to provide clear guidelines and assessment parameters for patients has been shown to facilitate out-of-bed activity in ICU pa-tients (Winkelman & Peereboom, 2010). The PMAP was drafted from a synthesis of current research and ap-proved by the director of critical care and the critical care clinical nurse specialist in the community hospital where PMAP will be implemented. An interdisciplinary team of additional stakeholders from OT, PT, respira-tory therapy, and ICU registered nurse (RN) staff was gathered to obtain input for further development and implementation of the protocol. After several revisions, the PMAP and standard of care (Table 1) were approved by the interdisciplinary team. Protocol champions have been shown to facilitate out-of-bed activity in ICU pa-tients (Winkelman & Peereboom, 2010). Two RNs were identifi ed as PMAP champions in the ICU. The role of the champions is to oversee and promote PMAP in ICU. The intensive care RN champions rotate to the step-down unit regularly and promote continuation of PMAP after ICU transfer.

The PMAP will be added to the ICU standard orders and to the ICU daily rounding tool when adopted, where the interdisciplinary team can discuss each patient’s progress and coordinate activity for the day. A daily PMAP documentation record (Figure 4) was developed to assist in documenting the patient assessment before and after activity, the step attempted and achieved, and the patient’s tolerance.

TABLE 1. PROGRESSIVE MOBILITY ACTIVITY PROTOCOL STANDARDS OF PRACTICE

STANDARDS OF PRACTICE—Progressive Mobility/Activitya

In the care of all patients, the RN will:

Assess the patient for PMAP eligibility within 8 hours of admis-sion and every 8 hours. Initiate PMAP if the patient:

1. is at risk for deconditioning due to immobility.

2. requires orthostatic training to an upright position.

3. is free from contraindications.

Question complete bed rest orders for prolonged periods if a legitimate reason is not apparent. Bed rest should be a rare exception.

Educate and reassure the patient about activity.

Perform ROM of extremities every 8 hours.

Reposition patient and perform skin assessment every 2 hours.

Consult PT/OT and RT as appropriate for evaluation and assist with mobility.

Consult lift team as appropriate.

Minimize sedation as per (protocol/policy) during daytime hours to allow for PMAP.

Implement PMAP three times during the day and more as tolerated.

Evaluate cardiopulmonary tolerance to each position change by assessing vital signs, ECG and SpO2 before and after each activity. Allow a 5-minute equilibrium period after the position change before determining cardiopulmonary stability.

Progress each step duration 30 to 60 minutes as tolerated.

If cardiopulmonary instability develops, decrease duration to 15 minutes, and if intolerance continues, return to previous step.

Repeat each step until the patient demonstrates hemodynamic and physical tolerance to stated activity/position for 60 minutes.

Advance to the next step.

Initiate orthostatic training three times a day by placing the pa-tient in a reverse Trendelenburg position if the patient demon-strates cardiopulmonary intolerance or contraindications to P MAP. Continue to assess for PMAP (re)initiation when the pa-tient demonstrates stability with upright mobility.

PMAP is to continue until the patient is ambulating indepen-dently or discharged from the hospital.

Note. ECG � electrocardiogram; PMAP � progressive mobility activity protocol; PT � physical therapist; OT � occupational therapist; RN � registered nurse; ROM � range of motion; RT � respiratory therapist; SpO2 � oxygen saturation.aSTANDARDS OF PRACTICE—Progressive Mobility/Activity is the property of Salem Community Hospital, Salem, OH.




found in the chart audit are reasons for concern regard-ing potential gaps in the continuation of PMAP after ICU transfer (Brown et al., 2009; Callen et al., 2004; Markey & Brown, 2002).

To facilitate PMAP progression after ICU transfer, a nursing care plan (Figure 5) was developed to bridge continuation of activity after transfer from the ICU. The PMAP care plan includes the progressive mobility steps and strategies for mobility after transfer from the ICU. These include the following: patient out of bed for meals, ambulation three times a day, discouraging day-time sleeping, reducing or eliminating barriers such as urinary catheters, and increasing sensory stimulation by encouraging the wearing of eye glasses and hearing aids (Markey & Brown, 2002). The care plan is individu-alized for each patient through interdisciplinary col-laboration with daily activity goals. Patient and family PMAP education material was developed to promote understanding and cooperation with activity.

The RNs will review PMAP education, care plan, and daily activity goals with patients and families. Each pa-

tient’s progress with activity goals will be reported daily by the RN in shift reports and in interdisciplinary meet-ings. Assistive devices such as lifts and walkers were placed in convenient locations on each patient care unit.

Education was provided for stakeholders hospital-wide, which included a review of the complications of immobil-ity and deconditioning, early progressive mobility studies, and evidence-based PMAP interventions. Continuing education hour presentations, fl yers, bulletin boards, and communication in team meetings were used to dissemi-nate information. An independent study continuing educa-tion consisting of a PMAP PowerPoint presentation with narration on compact discs and digital versatile discs with handouts, posttest, and evaluation was available for staff unable to attend education offerings in person.

IMPLEMENT AND EVALUATE THE CHANGE IN PRACTICE

It was determined that a pilot study for PMAP will be used to determine the results of the protocol, the costs and feasibility data, and feedback from the stakeholders.

FIGURE 4. Progressive mobility ac tivity protocol documentation record. BP � blood pressure; ECG � electrocardiogram; FiO2 = fraction of inspired oxygen; HOB � head of the bed; HR � heart rate; PM � progressive mobility; R � respiration; ROM � range of motion; SpO2 � oxygen saturation. aProgressive Mobili ty Record is the property of Salem Community Hospital, Salem, OH.



FIGURE 5. Progressive mobility activity protocol care plan. HOB � head of the bed; PMP � progressive mobility protocol; PT � physical therapy; OT � occupational therapy; ROM � range of motion. aProgressive Mobility Activity Protocol Care Plan is the property of Salem Community Hospital, Salem, OH. (continues)




A 3-month pilot is scheduled to be implemented this year. On the basis of the results of the pilot study, the PMAP interdisciplinary team will decide to adapt, adopt, or reject the protocol.

INTEGRATE AND MAINTAIN THE CHANGE IN PRACTICE

If adopted, the sixth step of Rosswurm and Larrabee’s model (1999) is to integrate and maintain the change in practice by using the organization’s mechanisms to inte-

grate new practice as policies, protocols, or standards of care. Communication of any PMAP changes to stakehold-ers needs to occur, and the information needs to be dis-seminated to the staff. To maintain the protocol, ongoing monitoring of the process and outcomes is warranted.

SummaryThe importance of activity to prevent the hazards of immobility has been known to nurses for decades.

FIGURE 5. (Continued)



However, attention to this basic aspect of patient care is often overshadowed by other more urgent patient care needs, resulting in a lack of ambulation in hospitalized patients. The presence of an evidence-based activity protocol provides clear guidelines and assessment pa-rameters for nurses to facilitate patient out-of-bed activ-ity in ICU patients. Using a model for planned change is an effective way for nurses to facilitate new evidence-based patient interventions in the practice setting. This nurse-driven protocol is a key intervention to improve nurse-sensitive patient outcomes, reduce immobility complications, reduce LOS, and decrease cost to the pa-tient and organization. The PMAP empowers the nurse to regain direction of this critical element in the care of ICU patients.

REFERENCESBailey, 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.

Brown, C . J., Friedkin, R. J., & Inouye, S. K. (2004). Prevalence and outcomes of low mobility in hospital-ized older patients. Journal of American Geriatrics Society, 32(8), 1263–1270.

Brown, C. J., Redden, D. T., Flood, K. L., & Allman, R. A. (2009). The under-recognized epidemic of low mobil-ity during hospitalization of older adults. Journal of American Geriatrics Society, 57(9), 1660–1665.

Brown, C. J., Williams, B. R., Woodby, L. L., Davis, L. L., & Allman, R. M. (2007). Barriers to mobility during hos-pitalization from the perspective of older patients and their nurses and physicians. Journal of Hospital Medicine, 2(5), 305–313.

Bynon, S., Wilding, C., & Eyres, L. (2007). An innovative occupation-focussed service to minimis e decondition-ing in hospital: Challenges and solutions. Australian Occupational Therapy Journal, 54, 225–227. doi:10.1111/j.1440-1630.206.00623x

Callen, B. L., Mahoney, J. E., Grieves, C. B., Wells, T. J., & Enloe, M. (2004). Frequency of hallway ambulation by hospitalized older adults on medical units of an aca-demic hospital. Geriatric Nursing, 25(4), 212–217.

De Jonghe, B., Bastuji-Garin, S., Durand, M. C., Malissin, I., Rodrigues P., Cerf, C., … Sharshar, T. (2007). Respiratory weakness is associated with limb weak-ness and delayed weaning in critical illness. Critical Care Medicine, 35(9), 2007–2015.

Gillis, A., MacDonald, B., & MacIssac, A. (2008). Nurses’ knowledge, attitudes, and confi dence regarding pre-venting and treating deconditioning in older adults. The Journal of Continuing Education in Nursing, 39(12), 547–554.

Hamburg, N. M., McMackin, C. J., Huang, A. L., Shenouda, S. M., Widlansky, M. E., Schulz, E., …Vita, J. A. (2007). Physical inactivity rapidly induces insulin resistance and microvascular dysfunction in healthy volunteers. Arteriosclerosis, Thrombosis and Vascular Biology, 27, 2650–2656. doi:10.1161/ATVBAHA.107.153288

Hopkins, R. O., & Spuhler, V. J. (2009). Strategies for pro-moting early activity in critically ill mechanically ven-tilated patients. AACN Advanced Critical Care, 20(3), 277–289.

Institute for Clinical Systems Improvement. (2010). Pressure ulcer prevention and treatment. Health care protocol. Bloomington, MN: Institute for Clinical Systems Improvement. Retrieved from http://www.

guideline.gov/content.aspx?id�16004&search�mobility

Kortebein, P., Ferr ado, A., Lombieda, J., Wolfe, R., & Evans, J. (2007). Effect of 10 days of bedrest on skele-tal muscle in healthy older adults. Journal of the American Medical Association, 297(16), 1772–1774. doi: 10:1001/jama.297.16.1772-b

Kubo, A. (2008). Progressive mobility therapy in the ICU. Retrieved from http://www.steomedical.com/criticalcare/pdf/153308.pdf

Markey, D. W., & Brown, R. J. (2002). An interdisciplinary approach to addressing patient activity and mobility in the medical–surgical patient. Journal of Nursing Care Quarterly, 16(4), 1–12.

McCance, K. L., & Heuther, S. E. (Eds.). (2006). Pathophysiology: The biological basis for disease in adults and children (5th ed., pp. 1092–1094). St. Louis, MO: Elsevier.

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

National Association of Orthopaedic Nurses. (2011). Algorithms for safe patient handling and movement in the orthopaedic setting. Retrieved from http://ww w.orthonurse.org/ResearchandPractice/SafePatientHandling/tabid/403/Default.aspx

O’Keefe, S. (2002). Deconditioning. Retrieved from http://www.encyclopedia.c om/doc1G2-3402200094.html

Penningt on Caraviello, K. A., Nemeth, L. S., & Dumas, B. P. (2010). Using the beach chair position in ICU patients. Critical Care Nurse, 30(2), 9–11.

Perme, C., & Chandrashekar, R. (2009). Early mobility and walking program for patients in intensive care units: Creating a standard of care. American Journal of Critical Care, 18(3), 212–221. doi:10.4037/ajcc2009598

Rosswurm, M. A., & Larrabee, J. H. (1999). A model for change to evidence-based practice. Journal of Nursing Scholarship, 31(4), 317–322.

Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigros, C., Pawlik, A. J., Esbrook, C. L., … Kress, J. P. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: A ran-domised controlled trial. Lancet, 373, 1874–1882. doi:10.1016/S0140-6736(09)60658-9

Sedlak, C. A., Doheny, M. O., Nelson, A., & Waters, T. W. (2009). Development of the national association of or-thopaedic nurses guidance statement on safe patient handling and movement in the orthopaedic setting. Orthopaedic Nursing, 28(2S), S2–S8.

Taylor, J. M., & Gropper, M. A. (2006). Critical care chal-lenges in orthopedic surgery patients. Critical Care Medicine, 34(9), 191–199.

Topp, R., Ditmyer, M., King, K., Doherty, K., & Hornyak, J. (2002). The effect of bed rest and potential of preha-bilitation on patients in the intensive care unit. AACN Clinical Issues: Advanced Practice in Acute & Critical Care, 13(2), 263–276.

VanDerSchaaf, M., Dettling, D. S., Beelin, A., Lucas, C., Dongelmans, D. A., & Nollet, F. (2007). Poor functional status immediately after discharge from an intensive care unit. Disability and Rehabilitation, 30(23), 1812–1818.

Weissman, C. (2000). Factors infl uencing changes in surgi-cal intensive care unit utilization. Critical Care Medicine, 28(6), 1766–1771.

Winkelma n, C. (2009). Bed rest in health and critical illness. AACN Advanced Critical Care, 20(3), 254–266.




uthor1�Winkelman&andorexactfulltext�and&searchid�1&FIRSTINDEX � 0&sortspec �relevance&resourcetype�HWCIT

Winkelman, C., & Peereboom, K. (2010). Staff-perceived barriers and facilitators. Critical Care Nurse, 30(2), 13–16. doi:10.4037/ccn2010393

Winkelman, C., Johnson, K., Peereboom, K., Hejal, R., & Rowbottom, J. (2009). Feasibility of a protocol to imple-ment early progressive mobility among ICU patients with prolonged critical illness [Abstract]. Retrieved from http://meeting.chestpubs.org/cgi/content/abstract/136/4/58S- g?maxtoshow�&hits�10&RESULTFORMAT�&a

For 58 additional continuing nursing education articles on orthopaedic topics, go to nursingcenter.com/ce.


developing a progressive mobility activity protocol

Documents