Early mobilisation and rehabilitation in intensive care unit—ready for implementation?

The recent trial by Schaller and colleagues of early mobilisation in surgical patients managed in an intensive care unit (ICU) published in The Lancet (Lancet 2016;388:1377-88), represents an interesting addition to a growing number of ICU rehabilitation trials. Conducted in five hospitals in Austria, Germany and the USA between 2011 and 2015, this single-blind trial tested whether previously independent patients recently admitted to surgical ICU (SICU) and randomised to an early goal-directed mobilisation protocol, achieved a higher mobilisation level (the SICU optimal mobilisation score, SOMS), compared to patients who received institutional standard of care. The two key secondary outcomes were length of SICU stay and a modified functional independence measure of functional mobility at hospital discharge. The sample size of 200 patients (n=100 per group) was based on SOMS and length of stay data from previous studies. The study was conducted as planned, recruiting 104 patients to intervention and 96 to control. The groups appear well balanced. The intervention began within a day of enrolment, although the time from admission to SICU to start of treatment is unclear. The primary outcome in my mind reflects an important feasibility question, was the goal-directed protocol, which required strong interdisciplinary team coordination and communication, followed? If it was, we would expect to see higher levels of mobilisation. The intention-to-treat analysis showed just that, patients in the intervention group had significantly higher mean SOMS level than controls. The key secondary outcomes were analysed per-protocol rather than intention-to-treat, and were also found to be significantly different between intervention and controls in favour of the early mobilisation group. The investigators conclude that ‘early’ goal directed mobilisation improved mobilisation during SICU stay, shortened length of stay in the SICU and improved patients’ functional mobility at hospital discharge’. That is, the treatment is feasible and has some short term patient benefit. So is the treatment ready for widespread implementation?