Lessons From 10 Years of Early Mobility

A key feature of the Society of Critical Care Medicine’s ICU Liberation Bundle (A-F) is physically mobilizing critically ill patients, which offers a range of salutary benefits, from shorter ventilator durations to improved cognitive outcomes and more discharges to home.^1,2 But in a real-world modern ICU where patient volumes, service budgets, and clinician time are frequently near their limit, how can an early mobility program overcome the practical barriers to implementation and sustainability?

This year marks the 10-year anniversary of STEPS-ICU, the ICU mobility program that first launched in 2015 at Yale New Haven Hospital's (YNHH) medical ICU in New Haven, Connecticut, USA, and later expanded to other ICUs in the health system. The STEPS-ICU model at YNHH uses a skilled therapy team dedicated to the ICU (including a physical therapist, occupational therapist, and rehabilitation technician), supported by a mobility screening tool, staff training, and thoughtful protocols for specific scenarios, such as mobilizing on CVVH. The STEPS-ICU program’s medical director Lauren Ferrante, MD, MHS, who is also an intensivist and researcher on recovery from critical illness, shared lessons learned from the past decade of mobility at Yale New Haven Hospital with Brandon Oto, PA-C, FCCM.
 

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Like setting a boulder into motion, launching a new quality initiative requires an investment of time and effort. How did the initial stakeholders in your program secure the necessary buy-in from both bedside clinicians and institutional leadership to fuel this process?

The first step was securing buy-in from institutional leadership. It was important to present stories of real ICU patients who had benefitted from early mobility and to demonstrate the potential cost savings of an ICU mobility program through a business plan. Once institutional investment was secured, the STEPS-ICU leadership team worked to engage the entire multiprofessional ICU team, including nurses, physicians, skilled rehabilitation specialists, patient care associates, and trainees. We used a multifaceted approach for this effort.

First, it was important that the STEPS-ICU leadership team was a true, equal partnership among nursing, rehabilitation services, and physicians. To this day, our leadership team has this structure. Second, we designated a space in our ICU for the STEPS-ICU team. This space, called the Rehab Corner, has computers for charting and cabinets for storing materials. Establishing the Rehab Corner reinforces the message that the team is embedded in the ICU. Third, we developed educational plans that included both didactic education and live interaction. For example, new ICU nurses completed a formal online module on early mobility, as well as one-on-one training with an existing STEPS-ICU team member. The one-on-one sessions also allowed the STEPS-ICU team and new ICU nurses to build relationships. Fourth, we built dashboards to track process metrics and outcomes. Finally, we scheduled regular meetings of the STEPS-ICU leadership team to review metrics and discuss issues on the ground. In the early years of the program, we met frequently; meetings now occur on an average of every other month but remain critically important.
 

Two different models for ICU mobility are common: a nurse-driven model that primarily relies on bedside nursing (with support from skilled therapists), and a therapist-driven model, which often involves additional therapy staff dedicated to the ICU. For administrators concerned about the bottom line, the nursing model may seem more appealing than budgeting for additional skilled therapists. Your ICU uses a therapist-driven model. What benefits have you found with this model?

Nurse-driven mobility is important and should absolutely take place in a complementary manner to therapist-driven mobility. However, we have found that many ICU patients, particularly early in the course of their illness, need the support of skilled rehabilitation specialists to realistically progress in a program of active mobility. Although we are fortunate to have a dedicated ICU mobility team at Yale New Haven Hospital, an alternative model was implemented last year at one of our smaller system hospitals where ICU patients have priority status (much like orthopedic patients) for the general pool of physical therapists.
 

How do you maintain an ICU culture that prioritizes mobility—as well as the institutional knowledge of how to get it done—in an era where clinical staff, such as bedside nurses and house staff, are frequently in flux?

It took about two and a half years of implementation efforts before a culture of early mobility was firmly ingrained in our ICU. Now, when a new hire joins the ICU team, they are told by other staff that mobilization “is what we do here.” This culture of mobility is the most important way to maintain buy-in from new staff. On a more formal level, we have maintained our educational initiatives throughout the past decade. Nursing and nursing assistant hires receive a formal educational module in addition to one-on-one training as needed. Residents rotating through the ICU receive a formal ICU Liberation bundle lecture, where they learn about best practices for the  bundle and the evidence supporting these practices, followed the next day by a live mobility demonstration with the STEPS-ICU team and a real ICU patient.

We still track metrics on processes and outcomes through dashboards that extract data from the electronic medical record. With these data, we presented a pre- and post-intervention analysis demonstrating improved outcomes at a health system conference. It is also important to celebrate milestones—we recently celebrated the 10-year anniversary celebration of the STEPS-ICU program with cake in our ICU!
 

What challenges did you encounter early in your rollout?

It is normal for clinical staff to feel some discomfort or reluctance when they first learn about mobilizing ICU patients, but through our implementation efforts and multiprofessional leadership setting examples for their staff, we were able to change culture. After that initial phase, when the program was up and running, we also encountered challenges that required us to develop protocols for specific scenarios. For example, we developed a protocol to mobilize patients requiring continuous venovenous hemofiltration. We also developed a protocol for mobilizing ICU patients with femoral dialysis catheters and femoral arterial lines. The STEPS-ICU team took the lead on writing a manuscript on the femoral line quality improvement project. The article was published in the March 2025 issue of Journal of Acute Care Physical Therapy.³
 

How does sedation play a role in early mobility? Should sedation practices be considered when a mobility program is being designed?

Sedation is uniformly the biggest barrier to early mobility in the ICU. Although there are some scenarios where an ICU patient might need deeper sedation, most ICU patients should have a Richmond Agitation-Sedation Scale goal of 0 to -1. We should all be working to minimize sedation in our patients for many reasons, one of which is promoting early mobility. In our ICU, we discuss our plan for minimizing sedation on rounds every day, and we also screen for mobility when running the checklist at the end of rounds on each patient; the two go hand-in-hand. The STEPS-ICU team and nursing also coordinate their timing in terms of weaning sedation and planning for mobility.


References

1. Tipping CJ, Harrold M, Holland A, Romero L, Nisbet T, Hodgson CL. The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review. Intensive Care Med. 2017 Feb;43(2):171-183.
2. Patel BK, Wolfe KS, Patel SB, et al. Effect of early mobilisation on long-term cognitive impairment in critical illness in the USA: a randomised controlled trial. Lancet Respir Med. 2023 Jun;11(6):563-572.
3. Bennett K, Carbone A, Ferrante LE, Cooper D, Foley BR. Removing rehabilitation barriers to early mobility in the intensive care unit for adult patients with femoral arterial and hemodialysis catheters. J Acute Care Phys Ther. 2025 Mar;16(2):49-54.