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
- Wake Forest Baptist Medical Centre, Winston, Salem, North Carolina
- Oct 2009 to Nov 2014
- Admission to medical ICU
- >18 years
- Mechanical ventilation via ET tube or NIV via Mask
- P/F ratio <300 mmHg
- 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)
- at 6 months, significant differences seen in :
- 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.
The Bottom Line
- 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.
- [article] Standardised Rehabilitation And Hospital Length of Stay Amongst Patients with Acute Respiratory Failure: A Randomised Clinical Trial.
- [Editorial] The Challenging Task of Improving the Recovery of ICU Survivors. (abstract only)
- [further reading] Increased Hospital-based physical rehabilitation and Information Provision after Intensive Care Unit discharge. (open access)
- [further reading] the Life in the Fast Lane Critical Care Compendium: Physiotherapy in the ICU.
Summary author: Segun Olusanya
Summary date: 17/08/2016
Peer-review editor: Duncan Chambler