Morris

Standardized Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure

Morris. JAMA 2016; 315:2694-2702. doi:10.1001/jama.2016.7201

In patients with acute respiratory failure, does early delivery of a standardised ICU and hospital rehabilitation programme improve physical function and reduce hospital length of stay?

Single centre, assessor blind randomised study
Computer generated variable size randomisation using blocks of 2, 4, 6 or 8
Intention to treat analysis
Physical function assessed at ICU discharge, hospital discharge, and at 2, 4, and 6 months post enrolment
Quality of life measured at hospital discharge and at 2, 4, and 6 months post enrolment
Initial plan was to recruit 326 patients to give 80% power to detect a 30% decrease in median length of stay at a 5% 2 sided level of significance, presuming 20% in hospital mortality, an exponential LOS distribution, and a loss of 5% of patients to follow up

Inclusion:
- Admission to medical ICU
- >18 years
- Mechanical ventilation via ET tube or NIV via Mask
- P/F ratio <300 mmHg
Exclusion:
- Inability to walk without assistance prior to acute illness (however canes/walkers not an exclusion)
- Cognitive impairment prior to ICU admission described by surrogate
- BMI >50
- Neuromuscular disease impairing weaning from mechanical ventilation
- Acute hip fracture
- Unstable C-spine or pathological fracture
- Mechanically ventilated >80 hours
- Current hospitalisation (including transferring hospital) >7 days
- Do not intubate order on admission
- Considered to be moribund by primary attending
- Enrolled in another research study
4084 screened, 618 eligible, 300 randomised- recruitment stopped early due to lower than anticipated drop out rate

Standardised Rehabilitation Therapy (SRT)
- 3 exercises – passive range of motion, physical therapy (bed mobility, transfer and balance training) and progressive resistance exercises
- Done 3x/day 7 days a week
- If patient unconscious only passive ROM done

Physical therapy ordered by clinical team as felt necessary. Only Monday to Friday

Significant differences seen in amounts of physical therapy delivered:
- Intervention group: 87% passive ROM/54.6% physical therapy/35.7% resistance exercises
- Control group: 11.7% received physical therapy
Primary outcome: No difference in median length of stay (both 10 days).
Secondary outcome: No significant difference in any secondary outcomes at ICU discharge, 2 months and 4 months
- at 6 months, significant differences seen in :
  - Short Performance Physical Battery (9 vs 8, P< 0.004)
  - SF-36 PFS (31.1 vs 30.8; P< 0.04)
  - Functional performance Index (2.2 vs 2.0, P<0.02)

Among patients hospitalised with acute respiratory failure, Standardised rehabilitation therapy compared with usual care did not decrease hospital length of stay.

An important question to ask. Weakness post ICU is increasingly recognised as a priority for patients
Registered with clinicaltrials.gov
Assessors blinded to intervention
Clear separation of between intervention and control group regarding delivery of therapy

Single centre study- this limits its external validity
Very narrow cohort of patients based on inclusion/exclusion criteria. While improving the internal validity of the trial, this again places limits on its external validity.
There was significant variability in patients in the intervention groups receiving treatment – 13% did not receive passive ROM, 45.4% did not receive physical therapy, and 74.3% did not receive resistance exercises. While the overall “dose” of therapy was higher in the intervention group, the “effective dose” may not have been that much more than the control.
Other aspects of patient care were not standardised – e.g. sedation, nutrition.
Control group physical therapy activities not specified or standardised.
Length of stay as an outcome measure is prone to multiple biases, and may not have detected increases in strength and balance that may have occurred.
Significant drop out rate over the 6 months post hospitalisation (44%)- this limits the significance of differences seen in secondary outcomes.

In this single centre study of patients with acute respiratory failure, a standardised hospital rehabilitation programme did not reduce hospital length of stay.
However, this is a study with very limited external validity due to a narrow cohort in a single centre.
Early mobilisation may have other benefits. I will follow my unit’s protocols regarding physiotherapy while awaiting a large multi-centre RCT to provide more information on the best “dose” and timing of physical therapy in ICU patients.

Summary author: Segun Olusanya
Summary date: 17/08/2016
Peer-review editor: Duncan Chambler