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Ann Am Thorac Soc. 2016 Sep;13(9):1527-37. doi: 10.1513/AnnalsATS.201601-078OC.

Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices. An International Survey.

Author information

1 Section of Pulmonary, Critical Care, Allergy and Immunologic Diseases, Department of Internal Medicine, and.
2 Critical Illness Injury and Recovery Research Center, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
3 Department of Critical Care, Queen Elizabeth Hospital, Birmingham, United Kingdom.
4 Center for Clinical Epidemiology and Biostatistics.
5 Department of Emergency Medicine.
6 Division of Traumatology and Surgical Critical Care, Department of Surgery, and.
7 University of Utah College of Nursing, Salt Lake City, Utah; and.
8 Adult ICU Faculty, Institute for Healthcare Improvement, Cambridge, Massachusetts.
9 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.



Early mobilization (EM) improves outcomes for mechanically ventilated patients. Variation in structure and organizational characteristics may affect implementation of EM practices.


We queried intensive care unit (ICU) environment and standardized ICU practices to evaluate organizational characteristics that enable EM practice.


We recruited 151 ICUs in France, 150 in Germany, 150 in the United Kingdom, and 500 in the United States by telephone. Survey domains included respondent characteristics, hospital and ICU characteristics, and ICU practices and protocols.


We surveyed 1,484 ICU leaders and received a 64% response rate (951 ICUs). Eighty-eight percent of respondents were in nursing leadership roles; the remainder were physiotherapists. Surveyed ICUs were predominantly mixed medical-surgical units (67%), and 27% were medical ICUs. ICU staffing models differed significantly (P < 0.001 each) by country for high-intensity staffing, nurse/patient ratios, and dedicated physiotherapists. ICU practices differed by country, with EM practices present in 40% of French ICUs, 59% of German ICUs, 52% of U.K. ICUs, and 45% of U.S. ICUs. Formal written EM protocols were present in 24%, 30%, 20%, and 30%, respectively, of those countries' ICUs. In multivariate analysis, EM practice was associated with multidisciplinary rounds (odds ratio [OR], 1.77; P = 0.001), setting daily goals for patients (OR, 1.62; P = 0.02), presence of a dedicated physiotherapist (OR, 2.48; P < 0.001), and the ICU's being located in Germany (reference, United States; OR, 2.84; P < 0.001). EM practice was also associated with higher nurse staffing levels (1:1 nurse/patient ratio as a reference; 1:2 nurse/patient ratio OR, 0.59; P = 0.05; 1:3 nurse/patient ratio OR, 0.33; P = 0.005; 1:4 or less nurse/patient ratio OR, 0.37; P = 0.005). Those responding rarely cited ambulation of mechanically ventilated patients, use of a bedside cycle, or neuromuscular electrical stimulation as part of their EM practice. Physical therapy initiation, barriers to EM practice, and EM equipment were highly variable among respondents.


International ICU structure and practice is quite heterogeneous, and several factors (multidisciplinary rounds, setting daily goals for patients, presence of a dedicated physiotherapist, country, and nurse/patient staffing ratio) are significantly associated with the practice of EM. Practice and barriers may be far different based upon staffing structure. To achieve successful implementation, whether through trials or quality improvement, ICU staffing and practice patterns must be taken into account.


critical care; early mobilization; intensive care unit; physical therapy/physiotherapy; survey

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