Patient Ann Bannon with Dr. Rob Green. Ann credits her recovery in large part to the early mobility initiative in the ICU.
By Margaret Angus
Ann Bannon clearly remembers lying in an intensive care bed, too weak to brush her own teeth.
A year later, she is back to full-time work at Dalhousie University and is living an active life. She credits her remarkable recovery in large part to the early mobility initiative in the Halifax Infirmary’s intensive care unit (ICU), which gets patients up and moving – with help – as soon as possible.
Bannon was hospitalized in September 2017 due to a condition called Myasthenia Gravis, which can cause extreme muscle weakness and affect one’s ability to walk, talk, eat and even breathe. Bannon, whose previous symptoms had included difficulty speaking, eating, double vision and muscle weakness in her legs, began to have difficulty breathing.
She was admitted to the QEII Health Sciences Centre, where she would end up spending 76 nights, including 34 in the ICU and 75 on a feeding tube. She was intubated four times and spent several weeks on a ventilator.
When Bannon first got up to walk, she did so with the help of a nurse, physiotherapist and respiratory therapist (RT). The RT literally pumped air into Bannon’s lungs as she took each step.
“Being able to walk – even with all that gear and needing three people to walk with you – it gives you a sense of accomplishment, of hope – that maybe you’re going to be ok,” Bannon said.
Early mobility in the ICU is still a relatively new concept, in stark contrast to the former practice of leaving patients in bed to rest.
Critical care and emergency physician Dr. Rob Green, who also serves as senior medical director of Trauma Nova Scotia, said he was inspired after hearing a physiotherapist present at a national conference on the topic of getting ICU patients to bike in bed.
“It just made sense to me. The more we get our patients up, the better,” he said.
There wasn’t much literature at the time to support the practice, aside from “some inkling it was possibly beneficial.”
“We hit things at the right time,” Dr. Green said. “Units were looking at something that RNs (registered nurses) and physios could grab onto.”
The move toward early mobility also supports Choosing Wisely Canada, a campaign to help clinicians and patients talk about unnecessary tests, treatments and procedures. Choosing Wisely recommendations identify commonly used tests and treatments in each specialty that are not supported by evidence, and could expose patients to harm.
In critical care, one of these recommendations is, “don’t prolong mechanical ventilation by over-use of sedatives and bed rest.”
Bannon’s experience is a prime example of the positive impact of early mobility over a focus on bed rest.
As Bannon described, early mobility in the ICU is resource-intensive – it requires a nurse, a physiotherapist and in some cases a respiratory therapist to all be at the patient’s side at once. It’s also benefit-intensive – for both the patient and the interdisciplinary team caring for them.
“After we created our mobility program and had a chance to fine tune it, we focused our research on investigating the impact of mobility in critically ill trauma patients,” Dr. Green said.
“Two summer Dalhousie Research in Medicine students worked on a systematic review, which found that there were not many good studies out there,” he said. “We then conducted a before-after study of trauma patients in our ICU, which showed an eight per cent increase in survival in patients we mobilize.”
In addition to reduced mortality and the physical benefits of preventing muscle loss, evidence suggests early mobility also contributes to better mental health.
Bannon can attest to these benefits: “Yes, it’s beneficial physically but even more mentally.”
“It’s been more successful than I ever could have anticipated,” Dr. Green said. “It brought the team together; everyone wants to contribute to get our patients up and going. It has absolutely changed the attitude and culture in the ICU.”
The team has developed a dedicated mobility database, filled out daily by physiotherapists for every patient. “This will allow us to conduct further investigation,” Dr. Green said.
Intensive Care Units across Nova Scotia Health Authority (NSHA) are now working to implement early mobility, while organizations across Canada are also interested in learning from the Halifax team’s experience.
Bannon remembers how hard it was get out of bed when she was in the ICU; how much effort it took, first to sit up, then to walk. On Dec. 9 of 2017, after more than two months in hospital, she was home again, celebrating her daughter’s 15th birthday.
“Looking back, (the effort) was totally worth it,” she said. Early mobility in the ICU was recognized by Accreditation Canada as a leading practice in 2017. Read more about the interdisciplinary team that has made early mobility in the ICU such a success.