ICU patient reaching for recovery, blocked by endotracheal tube.

Critical Care Crossroads: How Rehabilitation Decisions Are Really Made

Avery Sinclair in Health & Wellness June 2025 • 4 min read.

"Uncover the surprising factors influencing out-of-bed rehabilitation in the ICU and what it means for patient recovery."

For patients battling critical illnesses, early rehabilitation, including getting them out of bed, is increasingly recognized as a game-changer. The goal? To combat intensive care unit-acquired weakness (ICU-AW) and improve long-term outcomes. International guidelines champion this approach, even for those on ventilators. But the big question is: What truly drives the decision to initiate this crucial therapy?

Despite the growing momentum, real-world data reveals a significant gap. Studies from around the globe show that out-of-bed rehabilitation for mechanically ventilated patients is far from standard practice, occurring on only a fraction of patient days. This disconnect highlights the need to understand the factors that influence these critical decisions.

Sue C. Berney and team conducted a prospective study to investigate the factors influencing the provision of out-of-bed rehabilitation in the ICU. The study aimed to identify the most influential factors perceived by ICU practitioners and researchers in decision-making, develop a decision tree to objectively identify discriminative variables, and measure practitioner mobilization decision-making in four tertiary ICUs.

Behind the Bedside: Unmasking the Real Influencers in ICU Rehabilitation

ICU patient reaching for recovery, blocked by endotracheal tube.

To understand what influences rehabilitation decisions, the researchers conducted a comprehensive three-part study involving 507 practitioners (ICU medical, nursing, and physiotherapy staff) in four metropolitan ICUs. Patients expected to stay in the ICU for >96 hours were included in the study.

The study design was broken down into the following key stages:

Identifying Influential Factors: Through surveys and literature reviews, researchers pinpointed key factors that practitioners consider when deciding about mobilization.
Building a Decision Tree: Using collected data, they created a tool to objectively identify the most important variables in the out-of-bed rehabilitation decision.
Measuring Decision-Making: Practitioners were observed and surveyed to understand how they prioritize factors when making real-time decisions about patient mobilization.

The Results show that 1520 practitioner decisions representing 472 individual patient decisions. Decision tree analysis showed the presence of an endotracheal tube (ETT) and sedation state were the only discriminative variables that predicted patient suitability for rehabilitation. In contrast, medical staff and nurses reported that ventilator status was the most influential factor in their decision not to provide rehabilitation while physiotherapists ranked sedation most highly. The presence of muscle weakness did not inform the decision to provide rehabilitation.

Bridging the Gap: Moving Towards Better Rehabilitation Decisions

This study underscores a critical need to re-evaluate how decisions about out-of-bed rehabilitation are made in the ICU. While clinical guidelines exist, the presence of an ETT and concerns about sedation often overshadow the potential benefits of early mobilization. Further research is needed to identify the patients who would truly benefit from these interventions, ensuring that those at risk of ICU-acquired weakness receive the rehabilitation they need to improve their long-term outcomes. By addressing these challenges, we can move closer to a future where every ICU patient has the best chance at a full and speedy recovery.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1016/j.apmr.2018.07.438, Alternate LINK

Title: Commencing Out-Of-Bed Rehabilitation In Critical Care—What Influences Clinical Decision-Making?

Subject: Rehabilitation

Journal: Archives of Physical Medicine and Rehabilitation

Publisher: Elsevier BV

Authors: Sue C. Berney, Joleen W. Rose, Linda Denehy, Catherine L. Granger, George Ntoumenopoulos, Elise Crothers, Bronwyn Steel, Sandy Clarke, Elizabeth H. Skinner

Published: 2019-02-01

Everything You Need To Know

Why is out-of-bed rehabilitation considered so important in the ICU?

Early rehabilitation in the ICU, which includes getting patients out of bed, is vital because it combats intensive care unit-acquired weakness (ICU-AW) and improves long-term patient outcomes. This approach is particularly important for patients battling critical illnesses, as it can significantly impact their recovery trajectory. The study highlights the significance of addressing ICU-AW through interventions like out-of-bed rehabilitation to enhance patient recovery.

What are the main factors that determine whether a patient receives out-of-bed rehabilitation in the ICU?

The primary factors that influence the decision to initiate out-of-bed rehabilitation are the presence of an endotracheal tube (ETT) and the sedation state of the patient. These variables were found to be the only discriminative factors that predicted patient suitability for rehabilitation according to decision tree analysis. Additionally, the ventilator status was deemed most influential by medical staff and nurses, while physiotherapists ranked sedation the highest.

What does the study reveal about the current practice of out-of-bed rehabilitation compared to established guidelines?

Despite international guidelines supporting early rehabilitation, there's a gap in its application. Studies reveal that out-of-bed rehabilitation for mechanically ventilated patients isn't standard practice. This disconnect shows that the presence of an ETT and concerns around sedation frequently take precedence, overshadowing the advantages of early mobilization. This signifies a need to bridge the divide between best practices and real-world implementation to better align patient care with established guidelines.

How was the study conducted to investigate the factors influencing out-of-bed rehabilitation decisions?

The study included a comprehensive three-part process involving surveys, decision tree creation, and real-time decision-making observations across 507 practitioners in four metropolitan ICUs. This thorough approach enabled the identification of influential factors, the objective identification of important variables, and the understanding of how practitioners prioritize factors when making real-time decisions about patient mobilization.

What are the broader implications of the study's findings for patient care in the ICU?

The implications of the study's findings are far-reaching. The study's findings underscore the need to re-evaluate out-of-bed rehabilitation decisions in the ICU. Further research is needed to pinpoint patients who would benefit from rehabilitation. By addressing these challenges, the goal is to move closer to a future where all ICU patients receive the best possible care, increasing their chances of a full and swift recovery, highlighting the need for a shift in decision-making to prioritize patient outcomes.