The effect of increased mobility on morbidity in the neurointensive care unit

Clinical article

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The detrimental effects of immobility on intensive care unit (ICU) patients are well established. Limited studies involving medical ICUs have demonstrated the safety and benefit of mobility protocols. Currently no study has investigated the role of increased mobility in the neurointensive care unit population. This study was a single-institution prospective intervention trial to investigate the effectiveness of increased mobility among neurointensive care unit patients.


All patients admitted to the neurointensive care unit of a tertiary care center over a 16-month period (April 2010 through July 2011) were evaluated. The study consisted of a 10-month (8025 patient days) preintervention observation period followed by a 6-month (4455 patient days) postintervention period. The intervention was a comprehensive mobility initiative utilizing the Progressive Upright Mobility Protocol (PUMP) Plus.


Implementation of the PUMP Plus increased mobility among neurointensive care unit patients by 300% (p < 0.0001). Initiation of this protocol also correlated with a reduction in neurointensive care unit length of stay (LOS; p < 0.004), hospital LOS (p < 0.004), hospital-acquired infections (p < 0.05), and ventilator-associated pneumonias (p < 0.001), and decreased the number of patient days in restraints (p < 0.05). Additionally, increased mobility did not lead to increases in adverse events as measured by falls or inadvertent line disconnections.


Among neurointensive care unit patients, increased mobility can be achieved quickly and safely with associated reductions in LOS and hospital-acquired infections using the PUMP Plus program.

Abbreviations used in this paper:ICU = intensive care unit; I-MOVE = Independent Mobility Validation Examination; LOS = length of stay; NHSN = National Health Safety Network; PUMP = Progressive Upright Mobility Protocol; SUF = Shands Hospital at the University of Florida; UTI = urinary tract infection; VAP = ventilator-associated pneumonia.

Article Information

Address correspondence to: J Mocco, M.D., M.S., University of Florida, P.O. Box 100265, Gainesville, Florida 32610. email:

Please include this information when citing this paper: published online March 30, 2012; DOI: 10.3171/2012.2.JNS111881.

© AANS, except where prohibited by US copyright law.



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    The PUMP Plus algorithm. BP = blood pressure; CRRT = continuous renal replacement therapy; cont. = continuous; CXR = chest x-ray (radiograph); HOB = head of bed; HR = heart rate; HTN = hypertension; mgmt = management; O2Sat = oxygen saturation; PRN = as needed; pt = patient; q2hours = every 2 hours; Q shift = every 8 hour nursing shift; TBerg = Trendelenburg bed position; TID = three times/day; tPA = tissue plasminogen activator.

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    Graph showing the change in the average number of recorded activities per day before and after implementation of the PUMP Plus program. *p < 0.05; ***p < 0.001; OOB = out of bed.

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    Total number of culture-confirmed hospital-acquired infections over time. The dashed line indicates the start of the Mobility Initiative.


  • 1

    Ahrens TBurns SPhillips JVollman KWhitman J: Progressive Mobility Guidelines for Critically Ill Patients ( [Accessed February 20 2012]

  • 2

    Allen CGlasziou PDel Mar C: Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 354:122912331999

  • 3

    Allman RMGoode PSPatrick MMBurst NBartolucci AA: Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 273:8658701995

  • 4

    Bailey PThomsen GESpuhler VJBlair RJewkes JBezdjian L: Early activity is feasible and safe in respiratory failure patients. Crit Care Med 35:1391452007

  • 5

    Batson SAdam SHall GQuirke S: The development of a pressure area scoring system for critically ill patients: a pilot study. Intensive Crit Care Nurs 9:1461511993

  • 6

    Bergel RR: Disabling effects of inactivity and importance of physical conditioning. A historical perspective. Rheum Dis Clin North Am 16:7918011990

  • 7

    Black JMEdsberg LEBaharestani MMLangemo DGoldberg MMcNichol L: Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Manage 57:24372011

  • 8

    Burns JRJones FL: Letter: Early ambulation of patients requiring ventilatory assistance. Chest 68:6081975. (Letter)

  • 9

    Chenoweth CESaint SUrinary tract infections. Jarvis WR: Bennett & Brachman's Hospital Infections ed 5PhiladelphiaLippincott, Williams & Wilkins2007. 507516

  • 10

    Clavet HHébert PCFergusson DDoucette STrudel G: Joint contracture following prolonged stay in the intensive care unit. CMAJ 178:6916972008

  • 11

    De Jonghe BBastuji-Garin SDurand MCMalissin IRodrigues PCerf C: Respiratory weakness is associated with limb weakness and delayed weaning in critical illness. Crit Care Med 35:200720152007

  • 12

    Dowdy DWEid MPDennison CRMendez-Tellez PAHerridge MSGuallar E: Quality of life after acute respiratory distress syndrome: a meta-analysis. Intensive Care Med 32:111511242006

  • 13

    Dowdy DWEid MPSedrakyan AMendez-Tellez PAPronovost PJHerridge MS: Quality of life in adult survivors of critical illness: a systematic review of the literature. Intensive Care Med 31:6116202005

  • 14

    Goldhill DRBadacsonyi AGoldhill AAWaldmann C: A prospective observational study of ICU patient position and frequency of turning. Anaesthesia 63:5095152008

  • 15

    Goldhill DRImhoff MMcLean BWaldmann C: Rotational bed therapy to prevent and treat respiratory complications: a review and meta-analysis. Am J Crit Care 16:50612007

  • 16

    Gosselink RBott JJohnson MDean ENava SNorrenberg M: Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med 34:118811992008

  • 17

    Graf JKoch MDujardin RKersten AJanssens U: Health-related quality of life before, 1 month after, and 9 months after intensive care in medical cardiovascular and pulmonary patients. Crit Care Med 31:216321692003

  • 18

    Herridge MSCheung AMTansey CMMatte-Martyn ADiaz-Granados NAl-Saidi F: One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 348:6836932003

  • 19

    Horan TCAndrus MDudeck MA: CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 36:3093322008

  • 20

    Keller BPWille Jvan Ramshorst Bvan der Werken C: Pressure ulcers in intensive care patients: a review of risks and prevention. Intensive Care Med 28:137913882002

  • 21

    Krishnagopalan SJohnson EWLow LLKaufman LJ: Body positioning of intensive care patients: clinical practice versus standards. Crit Care Med 30:258825922002

  • 22

    Kubo A: Progressive Upright Mobility (PUM) in the ICU: The How-to Guide ( [Accessed February 10 2012]

  • 23

    Manning DMKeller ASFrank DL: Home alone: assessing mobility independence before discharge. J Hosp Med 4:2522542009

  • 24

    Morris PE: Moving our critically ill patients: mobility barriers and benefits. Crit Care Clin 23:1202007

  • 25

    Morris PEGoad AThompson CTaylor KHarry BPassmore L: Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 36:223822432008

  • 26

    Needham DMWang WDesai SVMendez-Tellez PADennison CRSevransky J: Intensive care unit exposures for long-term outcomes research: development and description of exposures for 150 patients with acute lung injury. J Crit Care 22:2752842007

  • 27

    Petty TL: Suspended life or extending death?. Chest 114:3603611998

  • 28

    Rogers MAFries BEKaufman SRMody LMcMahon LF JrSaint S: Mobility and other predictors of hospitalization for urinary tract infection: a retrospective cohort study. BMC Geriatr 8:312008

  • 29

    Ross G: A method for augmenting ventilation during ambulation. Phys Ther 52:5195201972

  • 30

    Saint SWiese JAmory JKBernstein MLPatel UDZemencuk JK: Are physicians aware of which of their patients have indwelling urinary catheters?. Am J Med 109:4764802000

  • 31

    Stevens RDDowdy DWMichaels RKMendez-Tellez PAPronovost PJNeedham DM: Neuromuscular dysfunction acquired in critical illness: a systematic review. Intensive Care Med 33:187618912007

  • 32

    Stiller K: Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin 23:35532007

  • 33

    Vollman KM: Introduction to progressive mobility. Crit Care Nurse 30:S3S52010

  • 34

    Weill-Engerer SMeaume SLahlou APiette FSaint-Jean OSachet A: Risk factors for deep vein thrombosis in inpatients aged 65 and older: a case-control multicenter study. J Am Geriatr Soc 52:129913042004


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