Discussion Guide for the Krupp Article

Early mobilization of critically ill patients is associated with reductions in complications of prolonged bed rest such as muscle atrophy, cardiovascular deconditioning, respiratory impairments, and intensive care unit (ICU) delirium. Encouraging physical activity in these patients promotes physical and psychological recovery, reduces ICU length of stay, and improves overall patient outcomes. Implementation of early mobility interventions can reduce the duration of delirium, mechanical ventilation, and ICU/hospital stay. Thus, clinical practice guidelines recommend early mobilization in critically ill adults, and early mobility interventions are an essential element in the Society of Critical Care Medicine’s (SCCM) ICU Liberation Bundle (ie, the ABCDEF bundle). Although the ABCDEF bundle is consistently associated with improvements in patient-centered clinical outcomes, its adoption on a wide scale remains low and highly variable. The underuse of early mobility interventions contributes to incomplete bundle execution. For instance, fewer than one-third of patients in SCCM’s ICU Liberation Collaborative received early mobility interventions during their ICU stay. This underuse is linked to more than 100 complex and resource-intensive patient, practice, and organizational barriers. However, the actual impact of these barriers on mobility performance is unclear. To address this gap, the authors sought to determine which factors were associated with early mobility performance in critically ill adults and evaluate their relative impact in predicting next-day early mobility performance.The authors conducted a secondary analysis of data from the SCCM’s ICU Liberation Collaborative. They included all adults who had spent at least 24 hours in the ICU and had not died or had a palliation-focused plan of care in the following 24 hours. The authors used mixed-effects logistic regression to examine predictive associations between preselected factors and next-day early mobility performance (ie, dangling legs from side of bed at a minimum). Of the 12 489 patients, nearly 50% were at least 60 years old, 56% were male, and 72% were White. Significant pain, documentation of targeted sedation levels, performance of spontaneous awakening trials (SATs) spontaneous breathing trials (SBTs), early mobility safety screening, and prior-day physical/occupational therapy sessions were associated with higher odds of next-day early mobility. Conversely, deep sedation, delirium, benzodiazepine administration, physical restraints, and prior-day mechanical ventilation were associated with lower odds of next-day early mobility. Notably, Black and Hispanic patients were less likely to be mobilized than White and non-Hispanic patients. These findings underscore the critical need to address modifiable barriers and systemic inequities that influence early mobility practices in the ICU.Anna E. Krupp, PhD, MSHP, RN, CCRN, the corresponding author, draws on her extensive clinical ICU experience. Krupp shares, “My motivation to research novel and pragmatic approaches to improve the uptake of evidence-based interventions is grounded in 14 years of clinical ICU experience.” She completed her PhD in nursing focusing on ICU nurse decision-making and patient mobility. During her postdoctoral training at the University of Pennsylvania, she developed skills in secondary analysis of large multilevel datasets and implementation science. Reflecting on her transition to academia, Dr Krupp notes, “Since joining the University of Iowa College of Nursing in 2019, I have developed my research in 2 key areas: (1) developing and testing clinical decision support for promoting patient mobility and (2) developing and testing implementation strategies for increasing adoption of evidence-based practices.”This project provided a valuable opportunity to join a large, multisite research team. Dr Krupp emphasizes the importance of professional organizations, stating, “It’s been so important for my clinical and research career to be an active member of professional organizations such as [the American Association of Critical-Care Nurses] and SCCM.” This networking facilitated meeting other critical care researchers interested in the ABCDEF bundle. Dr Krupp adds, “I was fortunate to join an established and very experienced team for this project, which made the work of team meetings and writing the article … an enjoyable and valuable experience.”Dr Krupp explains, “We found several potentially modifiable patient practice and organizational factors that are associated with the delivery of early mobility interventions in the ICU. Some of these factors such as goal-directed light sedation, coordination of SAT and SBT, and avoiding benzodiazepines for sedation further confirm evidence of the synergy between ABCDEF bundle elements.” She continues, “Addressing these modifiable factors at the bedside is important in helping to progress a patient’s activity, meet their activity goals, and hopefully prevent long-term physical impairments.”Dr Krupp acknowledges the complexity of integrating early mobility into routine ICU care. She reflects on the practical challenges and the value of comprehensive, guideline-based care in enhancing patient outcomes. Krupp encourages clinicians to use these insights to refine and adapt early mobility interventions, improving care delivery and patient outcomes in the ICU.This feature briefly describes the personal journey and background story of the EBR article’s lead investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.Anna E. Krupp, PhD, MSHP, RN, CCRN, recalls, “I started my nursing career in an adult medical/surgical/trauma ICU after graduating with my BSN and I later transitioned to a unit-based clinical nurse specialist in the same unit.” Her involvement in the SCCM’s ICU Liberation Collaborative between 2015 and 2017 laid the groundwork for her current research focus. Krupp reflects, “This project was a great opportunity to analyze a dataset that my former unit had contributed to. I first met Dr Michele Balas through the ICU Liberation Collaborative—she continues to be an amazing mentor and collaborator.”Krupp’s dedication to improving critical care practices through research is evident in her future plans. She currently multisite pragmatic implementation trial led by Dr Balas, that “will test 2 different implementation strategies for increasing ABCDEF bundle adoption across 12 ICUs over the next 4 years.” Additionally, she sees significant potential in redesigning electronic health records to support nurse decision-making about patient mobility: “our team is developing a clinical decision support tool for early mobility with nurse end users and will plan to evaluate its feasibility and effectiveness in delivering evidence-based mobility interventions.” Krupp encourages clinicians to actively engage in research and quality improvement initiatives, believing that every small improvement in practice can lead to significant benefits for patients.