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From the Authors:
We thank Drs. Taito and Yasuda for their interest in our research. As stated in our article, we did not define “early” in early mobilization, because no consensus has been reached on the definition. The 2009 trial of early physical and occupational therapy (1) introduced mobility within 72 hours of admission, but it has few peers regarding the timing of mobility among published trials. Many of the trials testing mobilization, including the initial trials establishing its safety and efficacy, introduced mobility as late as 8 to 10 days into critical illness.
Our survey was designed to parallel early mobilization as an intervention, as was done a 2013 systematic review of “early mobilization”, which notably incorporated “later” mobilization trials. This clustering remains consistent with contemporary reviews (3). We agree that an opportunity exists to further define “early” as research in the field matures. We did not ask all respondents about head-of-bed elevation or passive range-of-motion practice patterns because neither meets the proposed definition of “mobilization,” nor do they have proof of benefit in clinical trials. In those programs endorsing early mobilization practice or protocol, no program reported head-of-bed elevation or passive range of motion as the maximal extent of their intervention.
Drs. Taito and Yasuda are correct; given the nature of our survey, we have no information about the patients who received care in intensive care units (ICUs). We welcome a large-scale epidemiologic study that connects ICU infrastructure, patients’ mobilization exposure, and severity of illness with patient outcomes.
Regarding the third issue raised, our study was not intended to assess for superiority of early mobilization protocols compared with practices. We purposefully investigated both approaches given the controversial nature of protocols and the recognition that some ICUs that do not have written early mobilization protocols in place may actually practice early mobilization in an exemplary way. Other investigators have also found a higher likelihood of reported early mobilization implementation when formal protocols are present (4). Institutions with clinical trial and quality improvement success in early mobilization have published their protocols as a vehicle to aid broader implementation (5).
Finally, the most recent multicenter international trial has achieved its success for surgical ICU patients guided by protocol (6). Interestingly, it offers another element: the role of the facilitator in guiding protocol adherence. We believe that surveys assessing our practice environment and adopted behaviors will improve the likelihood of successful implementation of early mobilization into everyday practice.