The implementation of an early rehabilitation program is associated with reduced length of stay: A multi-ICU study

Wahab. Journal of the Intensive Care Society. 2016, Vol. 17(1) 2–11

Clinical Question

• Does early rehabilitation reduce physical impairment and ICU length of stay in critically ill patients?

Design

• Multicenter
• Before / after cohort study
• Retrospective analysis
• No blinding
• Data was summarised using standard descriptive statistics with unpaired t-tests used to compare continuous variables and chi-squared tests to compare categorical variables. Differences in length of stay (LOS) were calculated using Poisson’s regression

Setting

• 5 ICU’s (3 medical, 1 cardiac, 1 surgical) across 2 affiliated hospital in US
• Data collected before and after implementation of the early rehabilitation programme
  • Jan 2011 – Dec 2011 & Jan 2012 – Dec 2012

Population

• Inclusion: All patients admitted to ICU
• Exclusion: None stated
• 8145 patients
• Baseline characteristics were similar: mean age 63 years, 55% male, and 80% medical admissions

Intervention

• Early rehabilitation programme
  • 4200 patients
  • Consisted of a multidisciplinary team including physicians, nurses, physician assistants and acute care nurse practitioners, as well as physical, occupational, respiratory and speech and language therapists
  • Reviewed patients daily Monday to Saturday
  • Rehabilitation activities included:
    • Physical therapy: passive movement, exercises in bed, transfers (supine to sitting, sitting to standing, bed to chair) and ambulation
    • Occupational therapy: feeding grooming and dressing
    • One or more therapists were involved as well as a rehabilitation therapy assistant if required
    • Aaditional staff were available if patients were mobilised whilst mechanically ventilated or were on ECMO
    • Guidelines for rehabilitation including contraindications were adapted from existing literature and treatment could be deferred at the discretion of the team

Control

• Standard care prior to early rehabilitation programme
  • 3945 patients
  • Physical or occupational therapy was usually done within one day of a patient being medically appropriate for transfer out of ICU to the ward
  • Physical therapy referral was rarely requested when a patient was endotracheally intubated

Outcome

• Primary outcome: The implementation of the rehabilitation programme resulted in the following changes:
  • ICU LOS: 4 out of 5 ICU’s had a statistically significant decreased mean LOS
    • overall mean LOS 5.4 vs 5.8 days (p<0.001)
    • no change in pre- and post-implementation ICU LOS in the subgroups of patients who were fully independent, intermediate, or fully dependent in their pre-admission activity and mobility
  • Hospital LOS: statistically significantly decreased mean LOS
    • overall mean LOS 13.9 vs 14.7 days (p<0.001)
  • Number of admissions to ICU increased across all five ICUs
    •  255 (6.5%) more admissions
  • Mean number of rehabilitation treatments per ICU: increased more than 4-fold
    • 0.16 to 0.72 per ICU patient-day
  • Ambulation: patients ambulated with physical therapist support on ICU more frequently
    • 15% vs 50% of patients ambulated at least once during their ICU stay (p<0.001)

Authors’ Conclusions

• A multi-ICU, coordinated implementation of an early rehabilitation programme markedly increased rehabilitation treatments in the ICU and was associated with reduced ICU and hospital LOS as well as increased ICU admissions

Strengths

• Large study numbers
• An important study evaluating the effects of regular rehabilitation provision on intensive care
• Baseline characteristics for both patient groups was similar
• Baseline mobility and activity scores were similar

Weaknesses

• Retrospective analysis
• 3 years from completion of study to publication
• No data supplied about:
  • severity of illness score
  • organ support
  • range or median length of stay
  • elective vs. emergency surgery
• Lack of detailed information about the rehabilitation activities performed in the pre- and post-implementation periods
• Variability in the number of rehabilitation treatments per ICU patient-day (0.58-0.98)
• No data about longer term physical or psychological effects of early rehabilitation
• Lack of sedation protocols may have resulted in variability with the ICU length of stay
• Although not a weakness in the methodology, it is worth highlighting that 19 new specialist staff were employed as part of this quality improvement project. With 80 beds across 5 ICU’s, this equates to 1:4 therapist:patient ratio. This high ratio of therapists is unlikely to be generalisable in UK practice

The Bottom Line

• Early rehabilitation for patients on ICU makes logical sense and this retrospective study supports the implementation of a critical care rehabilitation programme. However, with less than half a day reduction in ICU stay (which might also be attributed to other factors), it would be difficult to justify such a large scale recruitment of therapists. The descriptive statistics are however informative and perhaps it can be used to compare against our own therapy provision. Future RCT studies looking at longer term outcome measures (physical, psychological and patient experience) would be helpful, particularly in formulating larger scale programmes and cost analysis through QUALY data

External Links

• [article] The implementation of an early rehabilitation program is associated with reduced length of stay: A multi-ICU study
• [further reading] Mobilisation in the ICU by LITFL

Metadata

Summary author: @stevemathieu75
Summary date: 25th January 2016
Peer-review editor: @DuncanChambler