Early Mobilization of Older Adults in the Cardiovascular Intensive Care Unit
Conditions: Physical Activity, Older Adults, Cardiovascular Diseases
Sponsor: Lady Davis Institute

Early Mobilization of Older Adults in the CICU                                           PI: Dr. Michael Goldfarb 
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Early Mobilization of Older Adults in the Cardiovascular Intensive Care Unit 
 
I. RESEARCH QUESTION 
Is an early progressive mobilization program safe, feasible, and effective in older adults in the 
Cardiovascular Intensive Care Unit (CICU)? 
 
II. HYPOTHESES 
1. An early mobilization (EM) program is safe, feasible, and effective in older adults in a 
Canadian tertiary care academic CICU. 
2. Level of function on CICU discharge and time spent lying in bed during hospitalization is 
associated with health-related quality of life scores and functional status at longer-term follow-
up. 
 
III. SPECIFIC AIMS 
Aim #1: To determine functional status and longer-term patient-centered outcomes of older adults 
admitted to the CICU prior to the implementation of the EM program (“pre-intervention” 
cohort) 
Aim #2: To assess the safety and feasibility of an EM program in a Canadian academic tertiary 
care CICU 
Aim #3: To determine the effectiveness of EM at improving the functional status of older adults 
during CICU admission and improving longer term patient-centered outcomes (“intervention” 
cohort) 
Aim #4: To evaluate the association of daily time spent lying in bed with functional status at CICU 
discharge and following hospital discharge 
Aim #5: To assess the amount of skeletal muscle mass loss during admission for acute 
cardiovascular disease 
 
IV. BACKGROUND 
A. Physical Function and Impairment in Older Adults in the Critical Care Unit 
Older adults (age 60 ≥ years old) comprise the majority of patients admitted to the 
CICU.1 Older adults have a higher burden of prehospital functional impairment, which is an 
important predictor of morbidity and mortality during and following critical care unit 
hospitalization.2, 3 During hospitalization, older adults are at risk for rapid loss of muscle mass 
and strength from critical illness, immobility, and prolonged bedrest.4 As a result, survivors of 
critical illness frequently develop physical impairments, such as a reduced ability to ambulate 
and difficulty performing activities of daily living (ADLs), which can endure well-beyond index 
hospitalization.5-7 Up to 70% of older adults in the critical care unit are unable to return to 
prehospital levels of activity at discharge and have significant physical impairments that persist 
months later.5 The enduring physical impairments following critical care unit hospitalization can 
have devastating effects on the ability of older adults to maintain independence and quality of 
life and also results in increased morbidity and mortality.8 
 
B. Early Mobilization in the Intensive Care Unit: Opportunities and Challenges 
EM describes progressive mobilization activities that start immediately upon 
hemodynamic and respiratory stabilization, typically within 24-48 hours of intensive care unit 
admission.5 The objectives of EM is to prevent loss of muscle function, promote rapidity in 

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mobility recovery, and to maintain or help patients regain prehospital functional capabilities. 
There is evidence that EM is associated with improvements in muscle strength, physical 
function, and quality of life in patients admitted to critical care units.9, 10 In addition, EM has also 
been shown to decrease critical care delirium, improve long-term cognitive outcomes, decrease 
critical care and hospital length of stay, reduce hospital readmissions, decrease long-term 
mortality, and result in considerable cost savings.5, 11-14 The safety of EM programs in critically 
ill patients has also been established with only rare reports of serious adverse events and catheter 
dislodgement. The most commonly reported complications are transient physiologic changes.15, 
16  
Yet despite the demonstrated effectiveness and safety in the peer-reviewed literature for 
EM practices in critical care units, there is evidence that actual practice is lacking.17 A recent 
survey of Canadian physicians working in critical care units reported that, while more than half 
of physicians believed that mobilization should begin as early as possible after unit admission, 
almost three-quarters felt that they lacked adequate knowledge or training to mobilize patients.18 
In addition, the physicians noted a number of barriers to early mobilization, such as a lack of a 
standardized protocol and concern over patient safety. Addressing these barriers is essential to 
the successful implementation of an EM program.  
 
C. Frailty in Older Adults with Cardiovascular Disease 
Older adults are at increased risk of developing frailty, a syndrome characterized by 
sarcopenia, subclinical multi-organ dysfunction, and reduced capability of handling 
physiological stress.19 Sarcopenia is the age-related alteration in protein metabolism, decline in 
muscle mass, strength, and functional capacity. The prevalence of frailty in the critical care unit 
ranges from 10-40%, depending on the population and setting.20, 21 Frail older adults are more 
likely to have increased muscle loss during periods of acute illness and immobilization, 
functional decline during hospitalization, and long-term disability following discharge. Frailty in 
cardiovascular patients is also a strong predictor beyond the chronological age of increased 
morbidity, hospital and critical care unit stays, mortality, discharge to rehabilitation facilities and 
institutionalization, and higher rates of readmission. Early progressive mobilization activities 
may have an even greater impact on frail older adults than on their non-frail counterparts. 
 
D. Knowledge gaps targeted in this proposal 
Recent reviews of EM programs in the peer-reviewed literature have identified a number 
of evidence gaps to be directly addressed by this study.22 
1. Safety and feasibility of EM in the CICU: The majority of EM intervention studies were 
performed in the medical intensive care unit or in populations with low rates of primary acute 
cardiovascular disease and it is unknown whether the findings can be generalized to the CICU. 
The CICU contains a unique population of patients with primary cardiovascular disease, high 
illness acuity, and a considerable burden of non-cardiovascular disease.23 Barriers to mobility for 
cardiac patients may also differ from those of the general critical care population. To date, 
minimal data exist in the literature on the use of EM in acute cardiovascular populations.5, 24 An 
expert panel from Health Quality Ontario reviewed the literature for articles assessing EM 
interventions in hospitalized acute heart failure patients and could not identify any relevant 
studies.25 A retrospective Canadian study of post-TAVR patients demonstrated a reduction in 
median hospital length of stay with an early discharge protocol including EM as part of a 
multimodal intervention strategy.26 

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2. EM in older adults: Whether older adults, particularly frail older adults, benefit more from 
EM than younger or nonfrail older adults is uncertain. Prior EM intervention studies were 
composed of younger patient cohorts and there have been no studies that specifically focus on 
EM in older adults.24 
3. EM and patient-centered outcomes: Prior studies on the impact of EM on outcomes have 
focused mainly on healthcare resource outcomes (i.e., length of stay, readmission rates) and there 
are limited data on the effect of EM on patient-centered outcomes. The Canadian Institute for 
Health Research has identified patient-centered research as a priority for the healthcare system.27 
Health-related quality of life and functional status are patient-centered measures that are 
recommended as key metrics when studying older adults with cardiovascular disease.28  
4. Lack of published nurse-driven EM protocols 
Prior published EM protocols typically include intensive involvement in daily EM by 
physiotherapists.22, 29 However, given the limited availability of physiotherapists for 24/7 care in 
the critical care setting and the need for protocol generalizability, it is essential to establish a 
protocol that can be easily implemented by nursing staff and will provide enough details for 
replication. 
5. Knowledge translation 
There are few available tools on how to implement an EM program, particularly in an acute 
cardiovascular unit. A lack of written protocols or guidelines, as well as insufficient clinician 
knowledge, has been identified as a barrier to implementing EM in critical care units.18 
6. Patient positioning and activity in patients with acute cardiovascular disease: Precise 
identification of patient position (lying, sitting, and standing) and physical activity using body-
worn sensors is now possible due to improvement in accelerometer technology. Accelerometry 
has been validated in numerous populations, including in the ICU, mainly in the context of 
mechanically ventilated patients.30 However, previous studies in the ICU were limited by small 
sample sizes and short duration of patient monitoring, ranging from 60 minutes to 48 hours, and 
monitoring did not extend beyond ICU unit stay.30 There are also no studies in the literature 
specifically looking at positioning and activity in patients with acute CV disease. It is important 
to understand the time spent in the different mobility positions and the relationship with 
functional outcomes in older adults with acute CV disease. Decreasing the duration of time spent 
in a lying position is a potentially modifiable factor. 
 
V. PRELIMINARY STUDIES 

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During my Cardiac Intensive Care fellowship at Cedars-Sinai Medical 
Center in Los Angeles, CA, I participated in the EM program and instituted 
frailty screening in the CICU. We used a level of function (LOF) assessment 
tool in the EM program that ranged from 1 to 5, where 1 was bedbound and 5 
was ability to walk > 50 feet (see sidebar). Preliminary analysis of the 
retrospective cohort of 264 patients with acute cardiovascular disease 
undergoing EM showed that 90 (34.1%) patients were frail, 65 (24.6%) were 
vulnerable, and 109 (41.3%) were not frail. We found a moderate correlation 
between prehospital LOF and frailty (r = -0.580, P=0.01). 
Prehospital LOF was higher in nonfrail elderly than in frail 
elderly (mean score of 3.71±0.61 vs. 2.59±1.03; P<0.001). 
LOF improved in both nonfrail and frail elderly during 
CICU stay, however, there was greater improvement in 
LOF in the frail group (mean increase of 0.53 vs 0.70; 
P<0.01). The initial data analysis suggests that frailty status 
is a potential predictor of responsiveness to EM. Further 
analysis of this dataset is needed to identify other predictors 
of responsiveness to EM in the CICU. 
The current mobility practices and LOF 
assessment for patients admitted to the CICU of the 
Jewish General Hospital were reviewed by a nurse 
educator on two separate dates as part of continuous 
quality improvement requested by the quality of care 
committee of the division of cardiology. We looked at a convenience sample of patients in the 
CICU on two separate dates. There were 26 patients in the analysis (mean age 71.7 years old, 
standard deviation (SD) ± 10.9, female 38.4% (n=10)). There were 10 patients (38.5%) who 
would not be initially eligible for entry into the study (see eligibility criteria below; four due to 
age, two on noninvasive or invasive ventilation, two with a transvenous pacemakers, and two 
who were not hemodynamically stable). For patients who were initially eligible for the study, the 
mean prehospital LOF was 4.7 (SD±0.6) and the mean LOF on CICU admission was 2.3 
(SD±1.2). Of the eligible patients, 14 patients (87.5%) said they would agree to participate in an 
EM study and 12 patients (75%) were followed prior to hospitalization by a hospital-affiliated 
cardiologist. 
 
VI. METHODS 
Design, participants and setting 
An EM program is being developed as a quality improvement project in conjunction with 
the Quality and Safety Committee of the Division of Cardiology at the Jewish General Hospital 
(JGH). For our study, we will perform a prospective, pre/post-EM intervention study in adults 
aged ≥60 years old admitted to the CICU at the JGH. During a 3-month period, we will 
prospectively enrol patients to the pre-intervention cohort. The EM intervention will then be 
implemented. During a 12-month period, we will prospectively enrol patients to the intervention 
cohort. 1 and 12 months following hospital discharge, patients in the pre-intervention and post-
intervention cohorts will be contacted by phone by a member of the research team to assess for 
functional status and quality of life measures. 
3.27
1.94
2.32
0
0.5
1
1.5
2
2.5
3
3.5
Level of Function
Change in Mean Level of 
Function During CICU 
Admission

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A multidisciplinary EM implementation team developed a LOF assessment tool targeted 
for the CICU patient population. The assessment tool was created to be easy to use, quantitative, 
nurse-driven, and potentially generalizable to other CICUs. The creation of the EM team and EM 
program was an initiative of the Quality of Care Committee in the Division of Cardiology at the 
Jewish General Hospital. 
All patients admitted to the CICU are eligible for the EM program, except for patients 
meeting pre-defined hemodynamic, respiratory, neurologic, or in-dwelling device criteria. The 
exclusion criteria were chosen based on expert guidelines for EM safety31 and adapted for the 
acute cardiovascular patient population through collaboration with the multidisciplinary EM 
team. 
For entry into our study, the inclusion criterion is age ≥ 60 years and exclusion criteria 
are CICU stays less than 24 hours and patients with prehospital LOF 0 (immobile), LOF 1 
(bedbound) or 2 (can sit in chair only). Cardiac surgery patients will also be excluded. Patients 
with a pacemaker or defibrillator will not be included in the bioimpedance substudy 
(contraindication for use of bioimpedance scale). For the pre-intervention cohort, patients will be 
prospectively enrolled over a 3-month period by a member of the research team during CICU 
admission. Following the 3-month pre-intervention period, the intervention (EM program) will 
be implemented and patients will be prospectively enrolled during CICU admission over a 12-
month period by a member of the research team. Informed consent will be obtained for all 
participants during enrolment by a member of the research team. 
 
Pre-intervention 
Prior to the implementation of the EM intervention, nurses will ascertain and record the 
prehospital LOF, admission LOF, and LOF on the day of CICU transfer (Appendix A), but will 
continue usual mobilization practices. Patients who meet eligibility criteria for the EM 
intervention will be prospectively enrolled over a 3-month period (“pre-intervention cohort”) by 
a member of the research team during CICU admission. Informed consent will be obtained by a 
member of the research team. Following discharge, a member of the research team will review 
the medical record to extract demographic data (age, sex), comorbid illnesses, primary admission 
diagnosis, frailty status, adverse events during mobilization (falls, dislodgements, and injuries), 
mobilization activities, length of critical care unit stay, length of hospital stay, mortality, and 
discharge location. 
 
Intervention 
On admission to the CICU, the patient’s treating nurse will assess the patient for the EM 
program. Patients participating in the EM program will be assessed for enrolment in our study by 
a member of the research team and will obtain informed consent during CICU admission 
(“intervention cohort”). The potential participants are likely to be competent and medically fit to 
be approached for informed consent as patients who are not medically fit will be excluded from 
the early mobilization program based on clinical factors, which include hemodynamic criteria.  
The EM program consists of a progression of functional activities from LOF 0 (lowest 
mobility) to 5 (highest mobility). Each LOF has 3 primary activities designed to promote the 
patient to the next level. The nurse will begin with mobility activities based on the LOF that 
matches the patient’s current status. The nurse and clinical partner will attempt and/or complete 
each LOF activity once per shift. Physiotherapy assistance is available if required, although not 
obligatory. Nurses will also provide documentation and education to patients and families on 

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how to perform and assist with certain activities. LOF, activity attempts/completion, and adverse 
safety events will be recorded on an EM flowsheet. The intervention will start while the patient 
is in the CICU and will continue until discharge from the CICU. 
To introduce the EM protocol to the nursing staff, the nurse and physician champion will 
provide a series of in-service training sessions. Physicians routinely caring for older adults in the 
CICU and rotating trainees will receive education in the CICU through “Lunch and Learn” 
conferences. Weekly audits will be performed by the nurse champion to assess for adherence to 
the EM protocol. Reminders and further education will be provided if necessary. Monthly status 
reports will be created and disseminated to the nurses and the CICU team. 
Frailty will be assessed on admission using the Clinical Frailty Scale (CFS) by the 
patient’s nurse or a member of the research team (Appendix B).32 The CFS is a simple bedside 
assessment tool that uses a single global judgement-based measure to assign a score from 1 (very 
fit) to 9 (terminally ill) with increasing scores from 5 to 8 indicating more advanced frailty.20 The 
CFS correlates with more comprehensive frailty tools, has been shown to accurately diagnose 
frailty in critically ill and acute cardiac populations, and provides short and long-term prognostic 
information.20, 21, 33  
Enrolled participants will be approached to participate in this prospective substudy. 
Patients accepting participation will be asked to wear an accelerometer monitor during CICU 
stay until the end of hospitalization to capture the time spent in each mobility position. Body 
composition parameters including skeletal muscle mass and fat mass will be measured daily with 
a segmental multi-frequency bioimpedance scale. 
 
Instruments 
The ActiGraph GT9X Link Bluetooth Activity Monitor (ActiGraph, Pensacola, Florida) 
is an activity monitoring device worn on the thigh that uses a 3-axis accelerometer and 
inclinometer to provide information on position (lying, sitting, and standing), and physical 
activity (time spent walking and exercise intensity). The ActiGraph GT9X Link has been shown 
to accurately and reliably identify lying, sitting, standing and activity in hospitalized inpatients 
recovering from acute or critical illness.34 It is superior in position identification compared to 
other commonly used accelerometers that use a dual-axis approach.35 The device uses Bluetooth 
to communicate with the ActiLife software, which uses validated algorithms to differentiate 
between the various mobility positions.35 Tabular and graphic displays of position data are 
automatically reported by the software. The average battery life of the device is 14 days, 
ensuring that it will not require recharging in the vast majority of participants. The monitors are 
to be removed temporarily if participants will be exposed to water (i.e., shower). The device is 
reusable and will be cleaned using standard isopropyl alcohol-based solutions as clinically 
required for disinfection and by the research coordinator between participants. The device 
includes a wear time sensor that detects if the device has been removed in order to measure 
compliance. Five Actigraph monitors will be purchased, so that up to five patients can be 
enrolled in the accelerometer substudy at a given time. The cost for five Actigraph monitors, 
software, and necessary support is $4,280. An application for Investigational Testing 
Authorization will be submitted to Health Canada for the use of the Actigraph monitoring 
system. The Actigraph monitor has already been approved for investigational use in another 
Canadian-based research study.36 
The InBody 770 segmental multi-frequency bioimpedance (BIA) scale has been validated 
for the determination of skeletal muscle mass (Appendix A). The BIA scales are currently 

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housed in the Frailty Assessment Unit of the JGH’s cardiovascular ward and can be used at the 
point of care. The BIA scales provide a full analysis of body composition in less than 1 minute, 
including determination of skeletal muscle mass. There are no risks associated with the 
bioimpedance scale, except for patients with a permanent pacemaker or defibrillator, who will be 
excluded from this trial (the reason being that bioimpedance scale currents may disrupt the 
functioning of pacemakers or defibrillators). 
 
Post-discharge follow-up 
One month and 12-months post-discharge a member of the research team will call 
participants by phone to assess for health-related quality of life and functional status. The 
member of the research team will determine the current LOF and administer the Short-Form 36-
Item Health Survey (SF-36) and Barthel index.  
 
Outcome Measures 
The primary outcome will be the LOF at CICU discharge and at 1 and 12 months post-
hospitalization. Secondary outcomes are (1) Short Form (SF)-36 physical component summary 
score at 1 and 12 months, (2) SF-36 mental component summary score at 1 and 12 months, (3) 
Barthel index score at 1 and 12 months, (4) length of hospital stay, and (5) discharge to 
healthcare facility (including rehabilitation facility, convalescence, transfer to another acute care 
facility, and long-term care placement).  
The SF-36 is a patient-reported survey of health and is the most widely used health-
related quality of life instrument.53 The physical and mental component scores are subsets of the 
SF-36 with score ranges from 0-100 and are calibrated for an average score of 50, using 
Canadian normative data, with higher scores indicating less disability.54 The Barthel index is a 
disability measure validated in elderly cardiac patients that incorporates ten activities of daily 
living (i.e., feeding, dressing, incontinence).55, 56 Only two components of the Barthel index 
address mobility issues (transfer and mobility), so there is minimal direct overlap with the LOF 
scale score. The score range is 0–20, with lower scores indicating increased disability. 
 
In the patients wearing the accelerometer, data will be recorded on the total time spent in 
each mobility position, the daily average time spent in each mobility position, the average 
duration of time for each bout of sitting, standing, and walking, and sleep duration. The step 
count will also be recorded. The change in skeletal muscle mass from CICU admission to 
hospital discharge will be recorded. 
We will determine which covariates predict improvement in LOF (“responsiveness”) and 
which ones do not (“non-responsiveness”). We will assess the recovery of physical function at 1 
month and 12 months as measured by the SF-36 physical component summary score. We will 
compare the SF-36 scores of the highest scoring tertile of LOF on hospital discharge with the 
lowest scoring tertile. We will also compare hospital readmission at 30 days and discharge home 
vs. healthcare facility.  
For safety, we will record the composite and individual components of the number of 
falls, injuries, and dislodgements over the total number of attempted mobility activities. The 
results from the intervention cohort will be compared to the pre-intervention cohort for all 
results. 
 
Data Collection Procedures 

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Following discharge, a member of the research team will capture the following 
hospitalization data from the electronic medical record (Chartmaxx, Quest Diagnostics, Madison, 
New Jersey) for each subject: age, sex, primary admission diagnosis, comorbidities, level of 
function assessments, CFS score, length of CICU stay, length of hospital stay, discharge 
location, and referral to cardiac rehabilitation.  
 
Availability of Participants 
In the fiscal year 2016-2017, there were 1,356 admissions to the JGH CICU (mean age 
68 years old; 477 female (35%)). There were 1,034 patients (76.3%) age ≥ 60 years old. The 
mean CICU length of stay was 3.3 days and the mean hospital length of stay was 9.5 days. Only 
one in five patient stays was less than 24 hours in length. 
From the pilot data, we conservatively estimate that about one-third of patients will not 
be eligible for the study and about 70% will agree to participate. We estimate that the loss of 
patients to 12 month follow-up will be approximately 10% as the vast majority of CICU patients 
are followed by hospital-affiliated cardiologists prior to admission or are assigned to one 
following CICU discharge. Given these estimates, approximately 75 patients are expected to be 
enrolled and followed during the pre-intervention period and 300 patients are expected to be 
enrolled and followed during the 12 month intervention period. 
 
 
Data Analysis 
Since the response variable, LOF mobility, is an ordinal variable measured at different 
timepoints, a cumulative logit model for repeated measurements will be fitted using generalized 
estimating equations. The model permits us to take into consideration the structure of the 
correlation between the observations. The model will then be adjusted using covariates of 
interest, such as age, sex, EM adherence, time spent lying in bed, and illness severity score. 
Predictors of change in LOF during CICU stay and following hospitalization will be assessed 
using linear regression. Predictors of EM adherence will also be evaluated using linear 
regression. All statistical analyses will be performed using SAS version 9.4 by Dr. Abbas 
Kezouh, a senior biostatistician affiliated with the Lady Davis Institute Center for Epidemiology.  
 
VII. RESOURCE AVAILABILITY AND SUPPORT  
The CICU at the JGH has 16 beds equipped for advanced hemodynamic support and 32 
ward beds with telemetry available. Patients are admitted to the CICU mainly for acute primary 
cardiovascular disease. 
The nurse champion’s role is to attend EM team meetings, provide education to nursing 
and clinical partners, and ensure nursing adherence to the protocol. A review of the CICU 
environment conducted with physiotherapists from the EM team has ensured that the CICU is 
already equipped with the standard equipment necessary for patient mobilization, particularly for 
bedbound and immobile patients, and nurses have been trained to use the equipment. 
A research assistant will be based in the Division of Cardiology at the JGH and will have 
a dedicated space and workstation with computer access in the clinical research department. The 
research assistant will be responsible for obtaining informed consent, extracting data from the 
patient record, putting it into the database system, auditing nursing adherence to the study 
protocol, publishing monthly status updates, and interviewing patients by phone. Funds to 
support a research assistant on a part-time basis (20 hours per week) will be provided for a one-
year period by the JGH’s Division of Cardiology. 

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The EM team has support and representation from leaders in various disciplines at the 
JGH including Diane Brault, the head of the CICU nursing department, Dr. Lawrence Rudski, 
Chief of the JGH Division of Cardiology and Director of the Integrated Cardiovascular Science 
Program, Dr. Jean-Francois Morin, Chief of Cardiac Surgery, and Dr. Richard Sheppard, 
Director of the CICU. 
 
The JGH’s Division of Cardiology has given me approximately 50% protected research 
time with a salary support of $50k per annum to pursue my research program. I also receive a 
salary support for research of $20k per annum from the JGH’s Department of Medicine. Funds to 
support a research assistant on a part-time basis (20 hours per week) for a 1 year period – 
renewable for up to 3 years - will be provided by the cardiology division as well. 
 
VIII. KNOWLEDGE DISSEMINATION 
We will develop simple to follow instructional materials, including the detailed EM 
protocol and videos on how to perform the level of function assessment and mobility activities. 
These will be made available on a dedicated web portal. 
We intend to publish the EM protocol and the study results in a peer-reviewed cardiology 
journal, as well as present the findings at a major national cardiology conference. Through 
membership in the Canadian Cardiovascular Critical Care Society, a member society of the 
Canadian Cardiovascular Society, the results of the study will be disseminated to healthcare 
professionals involved in acute cardiovascular care.  
In order to gauge the value of the EM program in the CICU, we will use the Information 
Assessment Method (IAM),38, 39 a self-administered 1-page questionnaire endorsed by the 
Canadian Institute for Health Research. We will distribute the professional and patient versions 
of the IAM to healthcare staff and to patients involved in the EM program, respectively. The 
IAM is used to systematically evaluate the (1) acquisition and relevance of new information, (2) 
practical impact, (3) expected health benefits, and (4) intent to use the information and associated 
barriers or facilitators. We will review the IAM responses to understand the factors associated 
with the EM program and to generate recommendations and feedback to the participants. 
 
IX. POTENTIAL CHALLENGES & MITIGATION STRATEGIES 
The study will attempt to directly address frequently reported barriers to EM 
implementation.18 Biweekly multidisciplinary EM team meetings and availability of the 
physician and nurse champion will ensure any issues that arise will be dealt with promptly. 
Barriers for EM 
Solution Strategy 
Lack of knowledge and training 
Education by physician and nurse champions to 
healthcare staff 
No written protocols or guidelines 
A simple, straightforward written protocol 
Inadequate equipment 
Standard critical care mobility equipment is available 
Requirement for intensive 
physiotherapy involvement 
Nurse-led protocol with physiotherapist consultation 
availability 
Requirement for physician orders 
prior to mobilization 
No requirement for physician orders prior to mobilization 
Not an institutional priority 
Support and involvement by hospital leadership 
Concern over medical instability 
Exclusion criteria based on safety parameters 
Delayed recognition of suitable 
patients to mobilize 
Screening patients on admission for EM and re-screening 
each shift for suitability. 

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Concern over dislodgement 
of tubes, lines or devices 
Education of nursing and clinical partners on proper 
mobilization techniques 
Education of healthcare team of low rates of adverse 
events found in prior studies 
 
X. QUALIFICATIONS 
I am a clinician-scientist trained in both cardiology and experimental medicine at McGill 
University and critical care medicine at Cedars-Sinai Medical Center. Over the past 3 years, I 
have had 11 publications (10 as first author) and was a co-author on the State-of-the-Art paper on 
the future of the field of Cardiac Intensive Care published in the Journal of the American College 
of Cardiology.40 My primary research interest has been improving outcomes in older adults with 
acute cardiovascular disease. My Master’s thesis (in submission process) focused on the impact 
of frailty in older adults undergoing invasive cardiac interventions.41 I was involved with the EM 
program during my critical care medicine fellowship. 
 
XI. TIMETABLE 
 
Months 
0-3 
Months 
4-16 
Months 
17-22 
Months 
23-30 
Months 
31-36 
Obtain ethics approval 
X 
 
 
 
 
Pre-intervention period 
X 
 
 
 
 
Intervention period  
 
X 
 
 
 
Post-discharge follow-up  
 
X 
X 
X 
 
Data analysis 
 
 
 
X 
 
Manuscript submission 
 
 
 
X 
X 
Knowledge translation 
 
 
 
 
X 
 
XII. POTENTIAL IMPACT OF THE STUDY 
The proposed study will generate much needed evidence for the safety, efficacy, and 
feasibility of a structured EM program in older patients with acute cardiovascular disease. The 
simple, practical EM protocol and the knowledge translation plan are designed to educate 
cardiologists involved in acute care and encourage the implementation of EM programs as routine 
practice into CICUs.  
 
XII. REFERENCES 
 
 
1. 
Lilly CM, Zuckerman IH, Badawi O and Riker RR. Benchmark data from more than 
240,000 adults that reflect the current practice of critical care in the United States. Chest. 
2011;140:1232-1242. 
2. 
Mattison ML, Rudolph JL, Kiely DK and Marcantonio ER. Nursing home patients in the 
intensive care unit: Risk factors for mortality. Crit Care Med. 2006;34:2583-7. 
3. 
de Rooij SE, Abu-Hanna A, Levi M and de Jonge E. Factors that predict outcome of 
intensive care treatment in very elderly patients: a review. Critical Care. 2005;9:R307-R314. 
4. 
Kress JP and Hall JB. ICU-acquired weakness and recovery from critical illness. The 
New England journal of medicine. 2014;371:287-8. 

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5. 
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Appendix A: Validation Studies of Segmental Multi-Frequency Bioimpedence (BIA) 
 
 
 

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