Progressive Mobility Program in a Neuro-ICU: What Makes It Different?
The study by Hester et al (6) published in this issue of Critical Care Medicine is a retrospective observational pilot study building on an earlier evaluation of their Progressive Upward Mobility program (PUMP plus) in a large neuro–critical care unit. The PUMP plus algorithm directs nursing staff to administer progressive activities moving toward unassisted ambulation as patients are able. The authors studied a convenience sample of patients with acute ischemic stroke (18.6%, 20.1%, and 21.9%), other unspecified diagnoses (15.4%, 15.5%, and 18.8%), and tumor (14.4%, 15.3%, and 14.3%) (preintervention, postintervention, and sustained period, respectively). Patients were admitted to this neuro-ICU over three time periods: preintervention (1,118 patients), postintervention (731 patients), and a postintervention sustained period (2 yr after initiation of intervention) (796 patients). The three groups were similar in demographics; however, administrative changes limited their ability to collect Glasgow Coma Scale (GCS), a surrogate for severity of neurologic illness, on all patients in the baseline group. The authors did perform random sampling of GCS on 29% of the baseline sample, which when compared with the subsequent two groups suggested similarity. The study results reveal a significant decrease in hospital LOS (11.3 ± 14.1 [preintervention], 9.2 ± 14.5 [postintervention], and 8.8 ± 9.3 [sustained period]; p < 0.001) without a significant decrease in ICU LOS. The authors report a decrease in cost per case; however, the effect of the intervention on functional outcome cannot be ascertained as there was not an increase in the percentage of patients being discharged to home (38.3% [preintervention], 37.5% [postintervention], and 31.7% [sustained period]), an appreciable increase in patients discharged to acute inpatient rehabilitation (20.4% [preintervention], 21.4% [postintervention], and 21.6% [sustained period]) or other clinical measure of functional outcome. Furthermore, this group of neuro-ICU patients has been evaluated in aggregate making it difficult to appreciate the impact of early mobility on individual diseases.
Non–patient-specific outcomes such as LOS are insufficient in determining the safety and efficacy of mobility interventions in neurocritical care patients as the goal of treatment in neurocritical care is to optimize neurologic (motor and cognitive) outcomes in addition to achieving systemic stability. Although the authors report on outcomes for diagnosis groups based on global or localized distribution and brain versus spine pathology, the pathophysiology of these diseases is fundamentally different. Due to differences in physiology, the timing, type, and dose of mobility interventions have the potential to affect patients with global and localized disease processes differently.
A deeper understanding of the neurologic recovery process including the time course for neuronal repair and plasticity will add to the body of knowledge pertaining to optimal timing and dose of mobility interventions. For example, the existence of a “sensitive period” after ischemic stroke during which motor recovery occurs and after which recovery slows suggests that the timing of mobility is critical (7–10). Additional research in humans pertaining to the sensitive or critical period after stroke is in process (11).