Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project

doi:10.1016/j.apmr.2010.01.002

Archives of Physical Medicine and Rehabilitation

Volume 91, Issue 4, April 2010, Pages 536-542

Presented to the American Academy of Physical Medicine and Rehabilitation, October 25, 2009, Austin, TX.

https://doi.org/10.1016/j.apmr.2010.01.002 Get rights and content

Abstract

Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project.

Objectives

To (1) reduce deep sedation and delirium to permit mobilization, (2) increase the frequency of rehabilitation consultations and treatments to improve patients' functional mobility, and (3) evaluate effects on length of stay.

Design

Seven-month prospective before/after quality improvement project.

Setting

Sixteen-bed medical intensive care unit (MICU) in academic hospital.

Participants

57 patients mechanically ventilated 4 days or longer.

Intervention

A multidisciplinary team focused on reducing heavy sedation and increasing MICU staffing to include full-time physical and occupational therapists with new consultation guidelines.

Main Outcome Measures

Sedation and delirium status, rehabilitation treatments, functional mobility.

Results

Compared with before the quality improvement project, benzodiazepine use decreased markedly (proportion of MICU days that patients received benzodiazepines [50% vs 25%, P=.002]), with lower median daily sedative doses (47 vs 15mg midazolam equivalents [P=.09] and 71 vs 24 mg morphine equivalents [P=.01]). Patients had improved sedation and delirium status (MICU days alert [30% vs 67%, P<.001] and not delirious [21% vs 53%, P=.003]). There were a greater median number of rehabilitation treatments per patient (1 vs 7, P<.001) with a higher level of functional mobility (treatments involving sitting or greater mobility, 56% vs 78%, P=.03). Hospital administrative data demonstrated that across all MICU patients, there was a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4–3.8) and 3.1 (0.3–5.9) days, respectively, and a 20% increase in MICU admissions compared with the same period in the prior year.

Conclusions

Using a quality improvement process, intensive care unit delirium, physical rehabilitation, and functional mobility were markedly improved and associated with decreased length of stay.

Section snippets

Overview of Project Design and Timing

This multifaceted QI project was conducted using a structured QI framework and evaluated using a before/after design. The initial phases of the QI project (ie, the “engage” and “educate” processes, as described in the Quality Improvement Process section) started in spring 2006 with increasing intensity until the 4-month “execution” phase (May to August 2007), during which early PM&R was implemented. For purposes of the before/after comparison, this execution phase is referred to as the “QI

Results

All eligible MICU patients during the pre-QI and QI periods were included in the project, representing a total of 27 and 30 patients requiring 312 and 482 MICU patient days, respectively. These patients represented approximately 10% of all MICU admissions during each of the 2 time periods. Compared with the immediately prior pre-QI period, patients in the QI period tended to be slightly older with greater comorbidities at baseline and greater severity of illness in the MICU (table 1).

Discussion

Through a structured model for QI, we learned that deep sedation was generally not necessary for patients' comfort and tolerance of mechanical ventilation. Moreover, with a change in sedation practice, ICU delirium was substantially lower and early PM&R was feasible and safe, with increased functional mobility in the MICU and substantially decreased LOS.

To our knowledge, given the relatively recent onset of interest in early PM&R in ICUs in the United States, there are no prior published QI

Conclusions

Using a structured and multifaceted QI process, we quickly and markedly reduced the use of deep sedation and increased early PM&R activities for mechanically ventilated patients. Through these activities, substantial improvements were observed in ICU delirium and patients' functional mobility, with a decrease in MICU and hospital LOS.

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: Supported by the Department of Physical Medicine and Rehabilitation and the Division of Pulmonary and Critical Care Medicine, Johns Hopkins University.

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

: Reprints are not available from the author.

View full text

Original articleEarly Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project

Abstract

Objectives

Design

Setting

Participants

Intervention

Main Outcome Measures

Results

Conclusions

Section snippets

Overview of Project Design and Timing

Results

Discussion

Conclusions

Paresis acquired in the intensive care unit: a prospective multicenter study

JAMA

Persistent neuromuscular and neurophysiologic abnormalities in long-term survivors of prolonged critical illness

Crit Care Med

One-year outcomes in survivors of the acute respiratory distress syndrome

N Engl J Med

Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in a medical and surgical intensive care unit

Crit Care Med

A prospective observational study of ICU patient position and frequency of turning

Anaesthesia

Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function

JAMA

Lower limb skeletal muscle function after 6 wk of bed rest

J Appl Physiol

Effect of 10 days of bed rest on skeletal muscle in healthy older adults

JAMA

Quality of life after acute respiratory distress syndrome: a meta-analysis

Intensive Care Med

Physical inactivity rapidly induces insulin resistance and microvascular dysfunction in healthy volunteers

Arterioscler Thromb Vasc Biol

Joint contracture following prolonged stay in the intensive care unit

CMAJ

Early activity is feasible and safe in respiratory failure patients

Crit Care Med

Early intensive care unit mobility therapy in the treatment of acute respiratory failure

Crit Care Med

Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial

Lancet

Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients

Intensive Care Med

Study protocol: The Improving Care of Acute Lung Injury Patients (ICAP) study

Crit Care 2005

Intensive care unit exposures for long-term outcomes research: development and description of exposures for 150 patients with acute lung injury

J Crit Care

Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation

N Engl J Med

Translating evidence into practice: a model for large scale knowledge translation

BMJ

Randomized trial of light versus deep sedation on mental health after critical illness

Crit Care Med

Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation

Crit Care Med

Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS)

JAMA

Original article
Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project