When is evocation necessary in patients who are not ambulatory (non-ambulatory)?

Early Mobilization in Non-Ambulatory Patients

Early mobilization should be implemented in all non-ambulatory patients within 24-48 hours of admission unless contraindicated, as it reduces the risk of venous thromboembolism, improves functional outcomes, and decreases mortality. 1, 2

Indications for Early Mobilization

• All patients admitted with acute conditions (particularly stroke) should be assessed by rehabilitation professionals within 48 hours of admission to determine mobility status and develop an appropriate mobilization plan 1
• Frequent, brief, out-of-bed activity involving active sitting, standing, and walking should begin within 24 hours of admission for non-ambulatory patients if there are no contraindications 1, 2
• Early mobilization should be implemented as part of a comprehensive care bundle that includes pain management, anxiety control, and delirium prevention 1

Contraindications to Early Mobilization

• Arterial puncture for an interventional procedure 1
• Unstable medical conditions 1
• Low oxygen saturation 1
• Lower limb fracture or injury 1
• Hemodynamic instability (e.g., mean arterial pressure <60 mmHg) 1

Protocol for Mobilization in Non-Ambulatory Patients

Initial Assessment

• Determine baseline mobility status and functional capacity 1
• Screen for contraindications to mobilization 1
• Establish appropriate mobilization goals based on patient condition 1

Implementation

• Begin with passive mobilization for patients with impaired consciousness or inability to participate actively 1
• Progress to active mobilization as soon as the patient is able to participate 1
• Follow a stepwise approach to reach the highest possible level of mobility 1
• Ensure adequate staffing and secure all lines, tubes, and drains before mobilization 1

Monitoring During Mobilization

• Discontinue mobilization if any of the following occur 1:
  • Oxygen desaturation <86%
  • Heart rate increase >30% from baseline
  • Systolic blood pressure rise ≥40 mmHg from baseline
  • Mean arterial pressure <60 mmHg
  • New onset or worsened cardiac arrhythmia
  • Deterioration in level of consciousness
  • Unmanageable pain

Venous Thromboembolism (VTE) Prevention in Non-Ambulatory Patients

• Intermittent pneumatic compression (IPC) devices should be applied within 24 hours of admission for non-ambulatory patients 1
• IPC should be continued until the patient becomes independently mobile, is discharged, develops adverse effects, or reaches 30 days (whichever comes first) 1
• Daily skin integrity assessment is required for patients using IPC devices 1
• Low-molecular-weight heparin should be considered for high-risk patients with acute ischemic stroke 1
• Anti-embolism stockings alone are not recommended for post-stroke VTE prophylaxis 1
• For patients remaining immobile longer than 30 days, ongoing pharmacological VTE prophylaxis is recommended 1

Assistive Devices for Non-Ambulatory Patients

• Appropriate assistive devices should be prescribed based on individual patient needs 1:

  • Single-point canes for patients requiring minimal support
  • Tripod or quad canes for patients needing more stability
  • Walkers (two-wheeled, four-wheeled) for patients requiring substantial support
  • Wheelchairs for patients unable to ambulate safely

• An ankle-foot orthosis (AFO) is recommended for patients with foot drop to improve mobility and gait mechanics 1

Common Pitfalls and Caveats

• Delaying mobilization beyond 48 hours increases risk of complications including VTE, pressure injuries, and functional decline 1, 3
• Overaggressive early mobilization (within first 24 hours of stroke) may be harmful for some patients - clinical judgment is essential 1
• Failure to assess skin integrity daily when using IPC devices can lead to skin breakdown 1
• Inadequate staffing or preparation before mobilization attempts increases risk of adverse events 1
• Neglecting to secure lines and tubes before mobilization can lead to accidental dislodgement 1

By implementing early, appropriate mobilization strategies for non-ambulatory patients, healthcare providers can significantly reduce complications, improve functional outcomes, and enhance quality of life.