Journal of the Intensive Care Society-2016-Wahab-2-11-VALE KINE

8/17/2019 Journal of the Intensive Care Society-2016-Wahab-2-11-VALE KINE

1/10

Original article

The implementation of an earlyrehabilitation program is associated withreduced length of stay: A multi-ICU study

Romina Wahab1, Natalie H Yip1, Subani Chandra1,

Michael Nguyen2, Katherine H Pavlovich3, Thomas Benson4,

Denise Vilotijevic4, Danielle M Rodier 4, Komal R Patel1,

Patricia Rychcik 5, Ernesto Perez-Mir 5, Suzanne M Boyle5,

David Berlin6, Dale M Needham7,* and Daniel Brodie1,*

Abstract

Introduction: Survivors of critical illness face many potential long-term sequelae. Prior studies showed that early rehabili-tation in the intensive care unit (ICU) reduces physical impairment and decreases ICU and hospital length of stay (LOS).However, these studies are based on a single ICU or were conducted with a small subset of all ICU patients.We examined the effect of an early rehabilitation program concurrently implemented in multiple ICUs on ICU andhospital LOS.Methods: An early rehabilitation program was systematically implemented in five ICUs at the sites of two affiliatedacademic institutions. We retrospectively compared ICU and hospital LOS in the year before (1/2011–12/2011) andafter (1/2012–12/2012) implementation.Results: In the pre- and post-implementation periods, respectively, there were a total of 3945 and 4200 ICU admissionsamong the five ICUs. After implementation, there was a significant increase in the proportion of patients who receivedmore rehabilitation treatments during their ICU stay (p< 0.001). The mean number of rehabilitation treatments per ICUpatient-day increased from 0.16 to 0.72 (p< 0.001). In the post-implementation period, four of the five ICUs had astatistically significant decrease in mean ICU LOS among all patients. The overall decrease in mean ICU LOS across allfive ICUs was 0.4 days (6.9%) (5.8 versus 5.4 days, p< 0.001). Across all five ICUs, there were 255 (6.5%) moreadmissions in the post-implementation period. The mean hospital LOS for patients from the five ICUs also decreasedby 5.4% (14.7 vs. 13.9 days, p < 0.001).Conclusions: A multi-ICU, coordinated implementation of an early rehabilitation program markedly increased rehabilita-tion treatments in the ICU and was associated with reduced ICU and hospital LOS as well as increased ICU admissions.

Keywords

Intensive care, rehabilitation, early ambulation, physical therapy, occupational therapy, length of stay

1Division of Pulmonary, Allergy, and Critical Care, Department of

Medicine, Columbia University College of Physicians and Surgeons/

New York-Presbyterian Hospital, New York, NY, USA2Department of Quality and Patient Safety Improvement, New York-

Presbyterian Hospital, New York, NY, USA3Office of Strategy, New York-Presbyterian Hospital, New York, NY,

USA4

Department of Rehabilitation and Regenerative Medicine, New York-Presbyterian Hospital, New York, NY, USA5Department of Nursing, New York-Presbyterian Hospital, New York,

NY, USA

6Division of Pulmonary and Critical Care Medicine, Department of

Medicine, Weill Cornell Medical College/New York-Presbyterian

Hospital, New York, NY, USA7Outcomes After Critical Illness & Surgery (OACIS) Group, Division of

Pulmonary and Critical Care Medicine, Department of Medicine, and

Department of Physical Medicine & Rehabilitation, Johns Hopkins

University School of Medicine, Baltimore, MD, USA

*Co-senior authors.

Corresponding author:

Daniel Brodie, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, 622 W168th Street, PH8 East, Room

101, New York, NY 10032, USA.

Email: [email protected]

Journal of the Intensive Care Society

2016, Vol. 17(1) 2–11

! The Intensive Care Society 2015

Reprints and permissions:

sagepub.co.uk/

journalsPermissions.nav

DOI: 10.1177/1751143715605118

jics.sagepub.com

by guest on April 21, 2016inc.sagepub.comDownloaded from

http://inc.sagepub.com/http://inc.sagepub.com/http://inc.sagepub.com/http://inc.sagepub.com/


2/10

Introduction

Survivors of critical illness face many potential long-

term sequelae, including neuromuscular dysfunction

and cognitive impairment.1–6 Sedation, delirium and

bed rest are considered important contributors to

these complications.3,6–8 Early rehabilitation in theintensive care unit (ICU) focuses on minimizing sed-

ation and providing early physical and occupational

therapy (PT/OT) starting promptly after stabilization

of major physiological derangements.9,10 In the USA,

this approach sharply contrasts with a more trad-

itional model of starting rehabilitation only after lib-

eration from mechanical ventilation or after ICU

discharge.11–15

Prior studies provide evidence for the benefits of

early rehabilitation in ICUs, including reduced phys-

ical impairment and decreased ICU and hospital

length of stay (LOS).

10–13,16–24

However, these studieshave often focused on a single medical ICU or were

conducted with a relatively small subset of all ICU

patients. Based on the encouraging results from

these prior studies, an early rehabilitation program

was implemented across five ICUs, encompassing

medical, surgical and cardiac ICUs, at the sites of

our two affiliated academic institutions. Our aim

was to examine the effect of the coordinated imple-

mentation of this early rehabilitation program on our

ICU and hospital LOS in this before/after quality

improvement project. Some of the results of this

study have been previously reported in the form of

an abstract.25

Methods

Setting

An early rehabilitation program was simultaneously

implemented beginning January 2012 in five ICUs

(three medical, one cardiac, one surgical) across two

affiliated academic institutions at two separate geo-

graphic sites in New York City: the New York-

Presbyterian Hospital/Columbia University College

of Physicians and Surgeons and the New York-Presbyterian Hospital/Weill Cornell Medical

College. Both these sites are urban tertiary/quaternary

referral academic medical centers that serve both the

nearby local communities and referrals from the state

of New York and the neighboring states.

Study design

To assess the effect of our early rehabilitation pro-

gram, a retrospective analysis was performed on

8145 consecutive admissions to the five study ICUs

comparing the 12-month period before versus after

implementation of the early rehabilitation program(January 2011 to December 2011 versus January

2012 to December 2012). All admissions to the

study ICUs were included. During this two-year

study period, early rehabilitation was the only inter-

vention implemented to reduce ICU LOS across the

five ICUs. This retrospective study was approved by

the Columbia University Institutional Review Board

(IRB-AAAK7951). Waiver of consent was approved

in accordance with our institutional review boardguidelines.

The ICU early rehabilitation program

The ICU early rehabilitation program consisted of a

multidisciplinary team of ICU clinicians (physicians,

nurses, physician assistants and acute care nurse prac-

titioners), physical therapists (PTs), occupational

therapists (OTs), respiratory therapists and speech-

language pathologists. The ICU clinicians together

with the PTs and OTs evaluated all patients daily,

from Monday to Saturday, for their suitability forparticipating in rehabilitation therapy. Guidelines

for rehabilitation (Table 1), including contraindica-

tions and the range of activities undertaken, were

adapted from the existing literature.16,19 Therapy

could be deferred at the discretion of the treatment

team based on their clinical judgment. On Sundays,

therapy was performed on an ad hoc basis by the ICU

clinicians.

The rehabilitation therapists determined the activ-

ities (possible activities listed in Table 1) for each ther-

apy session. Physical therapy interventions included

passive range of motion, transfers (including supine

to sitting, sitting to standing, and bed to chair), ambu-lating in place and ambulation. Occupational therapy

interventions included training with feeding, groom-

ing, and dressing. Throughout all rehabilitation ses-

sions, hemodynamic (heart rate, blood pressure) and

respiratory statuses (respiratory rate and oxygen sat-

uration) were closely monitored. Rehabilitation ses-

sions involved one or more therapist, as well as a

rehabilitation therapy assistant if extra assistance

was required. For the mobilization of mechanically

ventilated patients, a respiratory therapist was avail-

able upon request to transition the patient to a port-

able ventilator or to a bag-valve device for manuallyassisted ventilation. For patients on advanced circu-

latory support such as an extracorporeal membrane

oxygenation device, additional staff members were

available for assistance in mobility. The patient’s

nurse and a nurse practitioner or a physician were

also present in the ICU and aware of the therapy

session in progress.

Prior to the implementation of the ICU early

rehabilitation program, if any referral for physical

and occupational therapy was made, it was typically

done within one day of a patient being medically

appropriate for transfer out of the ICU to a regular

hospital ward. Physical therapy referral was rarelyrequested when a patient was endotracheally

intubated.

Wahab et al. 3




3/10

Planning and education for implementation of the

ICU early rehabilitation program took place from

August 2011 to December 2011. There may have been

heightened awareness of the benefits of early rehabilita-

tion in the ICU during this educational period; however,

there were no rehabilitation therapists dedicated to ICU

patients. Implementation of the ICU early rehabilitation

program in January 2012 involved 10 PTs and 4 OTswho focused their primary role on patients in the five

participating ICUs (with a total of 80 beds). All PTs and

OTs had prior experience of working with patients in

the ICU, but not specifically in the context of an early

ICU rehabilitation program. The PTs and OTs had an

average of 6 years and 2.5 years of work experience in

an acute care hospital, respectively. An additional five

rehabilitation therapy assistants were hired specifically

for the program. Depending on the number of patients

in each ICU that were eligible for rehabilitation activ-

ities that day as determined on the morning meeting

between the ICU clinicians and PTs and OTs, theICU rehabilitation therapists were flexible to divide

their time amongst the five ICUs. There were no fixed

staffing ratios for number of rehabilitation therapists

per ICU for each day.

As part of the ICU early rehabilitation program,

there was no pre-specified sedation protocol mandated

across the five ICUs. Individual ICUs were allowed to

implement sedation minimization protocols. Only the

Medical ICU at the Columbia campus implemented

such a protocol. Otherwise, sedation practices in the

pre- and post-implementation periods were at the dis-

cretion of the treating clinicians.

During the year of implementation in January toDecember 2012, while there were weekly multi-

disciplinary staff meetings to discuss implementation

progress, including monthly surveillance of rehabilita-

tion treatments per ICU patient-day, there were no

additional quality assessments to ensure that the

ICU early rehabilitation program was implemented

uniformly in all the study ICUs.

Data collection

All study data were obtained from a hospital-wideadministrative database for all admissions to the five

ICUs during the two-year period. Data included

patient age, sex, and primary diagnosis (classified

into medical or surgical diagnoses, with subcategories

for the medical admissions). The proportion of

patients on mechanical ventilation was not available.

Primary outcomes were ICU and hospital LOS, with

each midnight representing a one-day stay. Secondary

outcomes included the number of PT and OT treat-

ments performed in the ICU, hospital mortality and

hospital discharge destination.

When available, patients’ baseline mobility andactivity status prior to hospital admission were

obtained from the electronic medical record. Baseline

mobility and activity status was based on nursing

intake documentation and presented as mobility and

activity status scores. These scores each ranged from

0 to 3, with one point assigned if the patient was inde-

pendent (i.e. not requiring assistance or assistive

device) with each of three mobility tasks (bed mobility,

bed-to-chair transfer, and ambulation) and activity

tasks (dressing or grooming, feeding, and toileting or

bathing). For example, a mobility score of 3 means the

most independently mobile, while a score of 0 means

minimally mobile (unable to even move in bed withoutassistance). Similarly, an activity score of 3 means the

most independent in the activity tasks listed above,

Table 1. Guidelines for ICU rehabilitation.

ContraindicationsPossible Rehabilitation Activities

Physical therapy Occupational therapy

Ongoing coronary ischemia

Unstable arrhythmiaCardiac tamponade

Passive range of Motion Feeding

GroomingDressing

Respiratory distress

Hypoxemia at rest (SpO2 40 per minute Transfers

Heart rate130 beats per minute (supine to sitting,

Mean arterial pressure 200 mmHg bed to chair)

Unsecure airway Ambulating in place

Hypoglycemia (blood glucose< 50 mg/dL) Ambulation

Orthopedic contraindication

Unstable spinal cord injury

Intracranial hypertensionMorbid obesity (if unable to be managed safely)

Care focused on comfort measures only

ICU: Intensive care unit.

4 Journal of the Intensive Care Society 17(1)




4/10

while a score of 0 means inability to perform any of the

tasks listed above without assistance. Also if available,

patients’ ambulation status in the ICU was obtained by

tabulating cases where the physical therapist had

checked the ‘‘patient ambulated’’ checkbox in their

documentation.

Statistical analysis

We summarized data using standard descriptive stat-

istics with unpaired t-tests used to compare continu-

ous variables and Chi-squared tests to compare

categorical variables. LOS data were expressed as

mean with standard deviation (SD), as well as by per-

centiles. Due to its positively skewed distribution

(skewness of 5.0 and 5.2 for ICU LOS, and 4.3 and

3.2 for hospital LOS in the pre- and post-implementa-

tion periods, respectively), p-values for the differences

in LOS between the pre- versus post-implementationperiods were calculated using Poisson’s regression, as

done in previous ICU LOS analyses.26–28 The differ-

ences in the distribution of LOS data were also ana-

lyzed with the Mann–Whitney–Wilcoxon rank sum

test. For all analyses, a two-sided p-value of less

than 0.05 was considered statistically significant. In

the small number of patient hospitalizations who

had more than one ICU admission, we analyzed

data from only their first ICU admission. Analyses

were performed with Stata version 9.0 (College

Station, TX, USA).

Results

Patient characteristics

In the pre- and post-implementation periods, respect-

ively, there were a total of 3945 and 4200 ICU

admissions among the five ICUs (with 89 and 96 hos-

pitalizations having more than one ICU admission,

respectively). Both pre- and post-implementation

groups were remarkably similar in baseline character-

istics (Table 2), with a mean (standard deviation (SD))

age of 63 (17) years, and 55% male, and 80% medical

admissions. The subcategories of primary diagnosisfor medical admissions were also similar between

both groups. In the subset of patients with baseline

mobility and activity data (approximately 33% and

46% of patients, respectively), scores were similar

between the pre- and post-groups, with approximately

58% of ICU admissions in which the patient was fully

independent for both activity and mobility and

approximately 24% in which the patient was fully

dependent (Table 3).

Rehabilitation treatments

Table 4 shows the distribution of patients by the

number of ICU rehabilitation treatments received

during their ICU stay in the pre- and post-

implementation periods. There was a significant

increase in the proportion of patients who received

more rehabilitation treatments during their ICU stay

in the post-implementation period ( p< 0.001). In the

pre- versus post-implementation periods, respectively,

the mean number of rehabilitation (PT or OT) treat-

ments was 0.16 versus 0.72 per ICU patient-day

( p< 0.001, Figure 1). In the pre-implementation

period, there was similarity in mean number of

rehabilitation treatments per ICU patient-day acrossall five ICUs (range: 0.10–0.22) with a larger range

during the post-implementation period (0.58–0.98).

The mean number of rehabilitation treatments per

ICU patient-day also increased from the pre- versus

post-implementation period for all subgroups of

Table 2. Baseline patient characteristics.

Pre-implementation,

2011 (n¼3945)

Post-implementation,

2012 (n¼4200) P -valuea

Age in years, mean (SD) 63.1 (17.1) 63.0 (17.5) 0.79Male, n (%) 2152 (55) 2370 (56) 0.09

Medical admission, n (%) 3166 (80) 3347 (80) 0.53

Primary diagnosis for medical admission, n (%)b

Cardiocerebrovascular disease 1007 (32) 1083 (32) 0.149

Sepsis/Infectious disease 655 (21) 772 (23)

Toxic/Metabolic disease 195 (6) 209 (6)

Gastrointestinal/Liver disease 312 (10) 296 (9)

Pulmonary disease 339 (11) 342 (10)

Neoplastic disease 234 (7) 218 (7)

Renal disease 99 (3) 83 (2)

Otherc 325 (10) 344 (10)

aStudent’s T-test and Chi-squared tests were used to compare patient characteristics between the pre- and post- implementation periods.bPercentages do not add to 100% due to rounding.c‘‘Other’’ includes: non-malignant hematological disease, rheumatological disease, non-vascular neurological disease.

Wahab et al. 5




5/10

patients who were fully independent, intermediate,

and fully dependent for both baseline activity and

mobility, from 0.11 to 0.63, 0.14 to 0.77, and 0.13 to

0.63, respectively. Finally, in the pre- versus post-

implementation periods, patients ambulated with

physical therapy at least once during their ICU stay

in 15% versus 50% of ICU admissions ( p< 0.001).

Outcomes

Four out of five ICUs had a significantly decreased

mean ICU LOS in the post-implementation period,

ranging from a decrease of 0.4 days (6.7% of pre-

implementation LOS) to 0.6 days (10.3%). The over-

all average ICU LOS across all five ICUs was 5.8

versus 5.4 days ( p< 0.001) in the pre- versus post-

implementation period (Table 5), with a mean

decrease of 0.4 days (95% confidence interval (CI)

0.3–0.5). Across all five ICUs, the number of ICUadmissions in the post-implementation period

increased by 255 (6.5% of pre-implementation value).

In the pre- versus post-implementation period,

mean hospital LOS for admissions from all five

ICUs was 14.7 vs. 13.9 days, representing a significant

Table 3. Baseline mobility and activity status.a

ScorebPre-implementation,

2011 n (%)cPost-implementation,

2012 n (%)c P -valued

Mobility 0.410 405 (31) 605 (31)

1 61 (5) 71 (4)

2 73 (6) 93 (5)

3 782 (59) 1171 (60)

Activity 0.07

0 318 (24) 504 (26)

1 98 (7) 117 (6)

2 57 (4) 59 (3)

3 864 (65) 1288 (65)

Mobility and Activity 0.68

Fully independent 732 (57) 1110 (59)

Fully dependent 306 (23) 481 (25)

aStatus prior to hospital admission, assessed by nursing intake history from patient or family upon admission to the ICU. In the pre- and post-

implementation periods, respectively, data are available as follows: mobility score – 1321 (33%) and 1943 (46%) patients, and activity score – 1337

(34%) and 1968 (47%).bThese scores each ranged from 0 to 3, with 1 point assigned if the patient was independent (i.e. not requiring assistance or assistive device) with each

of three mobility tasks (bed mobility, bed-to-chair transfer, and ambulation) and activity tasks (dressing or grooming, feeding, and toileting or bathing).

For example, a mobility score of 3 means the most independently mobile, while a score of 0 means minimally mobile (unable to even move in bed

without assistance). Similarly, an activity score of 3 means the most independent in the activity tasks listed above, while a score of 0 means inability to

perform any of the tasks listed above without assistance.cPercentages do not add to 100% due to rounding.dChi-squared tests were used to compare categorical differences between the pre- and post-implementation periods.

Table 4. Distribution of patients by the number of ICU rehabilitation treatments received during their ICU stay.

Rehabilitation treatments

received (n)

Pre-implementation, 2011 Post-implementation, 2012

P -valueb%a %a

0 69 21 10 1 8

ICU: intensive care unit.aPercentages do not add to 100% due to rounding.bA Chi-squared test was used to compare the distribution of patients between the pre- and post-implementation periods.





6/10

mean decrease of 0.8 days (95% CI 0.6 - 0.9 days,

p< 0.001), representing a 5.4% decrease from pre-

implementation LOS. Across each of the five ICUs,

there was a decrease in hospital LOS with a range of

0.2 days (1.4%) to 2.4 days (13.7%) (Table 5). The

reduction of ICU LOS accounted for half of the

reduction in hospital LOS. The mean decrease in hos-pital LOS spent outside of the ICU in the pre- and

post-implementation periods was 0.4 days ( p


7/10

fully independent, intermediate, or fully dependent in

their pre-admission activity and mobility.

The distribution of hospital mortality and dis-

charge destinations were the same in the pre- versus

post-implementation periods (Table 7), with 17%

dying, 59% discharged home, and 20% discharged

to a health care facility (e.g. rehabilitation or other

facility).

Discussion

In this retrospective pre-post study of 8145 ICUadmissions, a multi-ICU coordinated implementation

of an early rehabilitation program, across two hos-

pital sites, resulted in a significant increase in the pro-

portion of patients who received more rehabilitation

treatments during their ICU stay and a significant

increase in the mean number of rehabilitation treat-

ments per ICU patient-day. These improvements were

associated with a significantly reduced mean ICU

LOS and hospital LOS, as well as an increase in

ICU admissions.

Our study demonstrates that implementation of a

multi-disciplinary early rehabilitation program across

different types of ICUs (medical, cardiac, surgical)across two campuses of a large academic hospital

system was able to increase rehabilitation therapy in

the ICUs. At the time of implementation planning,

guidelines for ICU rehabilitation activities were avail-

able and adapted from the existing literature.16,19 In

addition to education for the multidisciplinary ICU

staff regarding the plan for the early ICU rehabilita-

tion program, the assignment of specific physical and

occupational therapists to primarily work in the fiveICUs and the hiring of additional rehabilitation

assistants were central parts of this large implementa-

tion effort. In the post-implementation year, the mean

number of rehabilitation treatments per ICU patient-

day increased more than 4-fold from 0.16 to 0.72 per

ICU patient-day. This is consistent with prior pre-

post projects evaluating early ICU rehabilitation,

where mean treatments per day increased three-fold

from 0.33 to 0.83,19 the number of patients receiving

PT in the ICU increased by 60%,24 or physical ther-

apy billable units per day of PT doubled.29 To our

knowledge, our multisite study is among the largestof published reports of early rehabilitation of critic-

ally ill patients and adds to the growing number of

academic institutions reporting experiences with

implementation of early ICU rehabilitation

programs.10–13,16–19,23,24,29

In our study, after implementation of the early

ICU rehabilitation program, mean ICU LOS

decreased by 0.4 days (95% CI 0.3–0.5, p


8/10

implementation of the program or a different patient

response to the same program depending on the type

of ICU (e.g. surgical versus medical). Further explor-

ation is needed in other large-sized multi-ICU studies

that involve different types of ICUs.

The distribution of ICU and hospital LOS by per-

centiles also changed between the pre- and post-imple-mentation periods. In particular, we found that the

reductions in ICU and hospital LOS were in the high-

est quartile of the LOS distribution. The early ICU

rehabilitation program may have had the highest

impact on patients in highest quartile of LOS because

they were exposed to the program longest or that

these patients were the most likely to benefit from

the program. Since the benefits were concentrated in

the highest quartile, the median LOSs did not show a

reduction. For example, even if every patient in the

highest quartile had their LOS reduced by half, the

median would still not change.To further explore why our LOS reductions are

modest relative to prior reports,11,19,23–24 we examined

a subgroup of our study population where more

detailed baseline information was available. In our

study, as assessed by history at ICU admission, there

were 25% of ICU admissions where the patient was

completely dependent for both baseline activity and

mobility prior to their ICU admission and critical ill-

ness. These fully dependent patients are likely from

long-term care facilities or those with advanced ill-

nesses requiring complete care at home or at long-

term nursing facilities. As evidenced by the similar

increase in mean number of rehabilitation treatmentsper ICU patient day for the fully dependent, the

intermediate, and the fully independent subgroups

from 0.13 to 0.63 versus 0.14 to 0.77 versus 0.11 to

0.63, respectively), the severely debilitated candidates

were not excluded from participating in early rehabili-

tation in the ICU. There was no significant difference

in ICU LOS between pre- and post-implementation

periods for the fully dependent, the intermediate, or

fully independent groups. There are two possibilitiesfor these findings – either that the subgroups have inad-

equate power to detect a statistically significant differ-

ence in ICU LOS between the pre- and post-

implementation periods, or that the overall ICU LOS

reduction was driven by the group that did not have

baseline activity and mobility scores available for sub-

group analysis. The baseline activity and mobility

scores were only available for a 30–40% subset of the

total 8145 ICU admissions in the study, so we cannot

better describe the baseline status of the group of

patients that drove the decrease in overall ICU and

hospital LOS. This highlights the need for future stu-dies to help better define candidates who may benefit

from the early rehabilitation efforts while in the ICU.

There was no difference in the discharge distribu-

tion between our pre- and post-implementation peri-

ods. Existing literature has a variety of findings

regarding this outcome, with Morris et al.11 reporting

no difference in discharge disposition, Schweickert

et al.12 reporting a non-significant trend in increased

discharges to home, and Engel et al.24 reporting an

increase in the number of patients who received PT in

the ICU being discharged home. With only limited

data available regarding discharge destination within

the existing administrative data used for this analysis,we are constrained in our ability to more comprehen-

sively evaluate patients’ physical functional status

Table 7. Hospital mortality and discharge destination.

ICU

A B C D E Overall

Died, n (%)

Pre, 2011 126 (22) 142 (25) 54 (7) 104 (10) 234 (24) 660 (17)Post, 2012 153 (24) 131 (23) 53 (6) 104 (10) 261 (25) 702 (17)

Survived – Home, n (%)

Pre, 2011 276 (49) 288 (51) 571 (75) 701 (70) 433 (45) 2269 (59)

Post, 2012 288 (44) 290 (50) 608 (73) 735 (72) 496 (48) 2417 (59)

Survived – Facilitya, n (%)

Pre, 2011 136 (24) 118 (21) 127 (17) 165 (17) 212 (22) 758 (20)

Post, 2012 170 (26) 135 (23) 164 (20) 135 (13) 190 (19) 794 (19)

Survived – Otherb, n (%)

Pre, 2011 31 (5) 21 (4) 9 (1) 29 (3) 79 (8) 169 (4)

Post, 2012 40 (6) 25 (4) 9 (1) 40 (4) 77 (8) 191 (5)

P -value 0.52 0.61 0.47 0.14 0.19 0.94

ICU: intensive care unit.a‘‘Facility’’ included: long-term acute care facility, intermediate care facility, sub-acute nursing facility, long term care facility, and inpatient rehabilitation

facility.b‘‘Other’’ included patients who were discharged to: law enforcement, psychiatric hospital, left against medical advice, home hospice, and a hospice

facility.

Wahab et al. 9




9/10

upon discharge in the pre- versus post-implementa-

tion periods.

The ICU LOS reduction associated with implemen-

tation of an early ICU rehabilitation program may

have costs and savings implications. Lord et al.23

applied financial models based on LOS data from

an ICU early rehabilitation program and estimatedthat the projected net cost of implementation was

modest compared to improvement in patient out-

comes. For the implementation program in our

study, the complete profit and loss assessment data

was not made available to the investigators.

However, the hospital has indicated that there was a

positive return on investment based on the new

resources committed and the calculated savings due

to the consequent decreases in LOS.

There are several potential limitations of our study.

First, this was a retrospective observational study

using hospital-wide administrative data limitingcause–effect inferences from being drawn and having

potential bias from unmeasured confounders such as

severity of illness and need for mechanical ventilation.

Moreover, we could not control for temporal changes

between the pre- and post-implementation periods.

However, there were no other systematic interventions

implemented to reduce ICU LOS during the study

period, no systematic changes in our institution’s

ICU referral patterns, and the baseline characteristics

(Table 2) and mortality rate (Table 7) of our pre- and

post-intervention groups were remarkably similar.

Furthermore, our findings of decreased ICU LOS

were consistent with multiple prior studies.10–13,16–24

Second, pre-admission baseline mobility and func-

tional scores were available for only a subset of

patients, which limits inferences that can be made

from these data. Third, the retrospective design pre-

cluded having detailed and standardized data on

rehabilitation activities performed in the pre- versus

post-implementation periods. In future evaluations,

the integration of a reliable and feasible ICU mobility

scale would be helpful to better address this issue.30

Lastly, the generalizability of our findings is tempered

since this was a single hospital system. However, given

that the study was conducted in five ICUs (includingmedical, surgical and cardiac ICU) at two locations,

and that our results are consistent with prior literature,

this weakness may be limited.

Conclusion

A large, multi-ICU, early rehabilitation program was

concurrently implemented in two sites of our hospital

system. In this retrospective before/after comparison,

we found that the ICU early rehabilitation program

increased the proportion of patients who received

more rehabilitation treatments during their

ICU stay and increased the average number of rehabilitation treatments per ICU patient-day.

After implementation of the program, we also

observed a significantly reduced ICU and hospital

length of stay, as well as an increase in ICU admissions.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with

respect to the research, authorship, and/or publication of

this article.

Funding

The authors disclosed receipt of the following financial sup-

port for the research, authorship, and/or publication of this

article: Outside the work under consideration for publica-

tion, Dr Brodie reports receiving research support and pre-

viously provided research consulting for Maquet

Cardiovascular. All compensation is paid to Columbia

University. He is a member of the Medical Advisory

Board for ALung Technologies. All compensation is paid

to Columbia University. Outside the work under consider-

ation for publication, Dr Needham reports receiving grant

support from NIH, AHRQ, and Moore Foundation.

Authors’ contributions

RW, NY, SC, DMN, and DB contributed to literature search,

figures, study design, data collection, data analysis, data inter-

pretation, and writing. MN and KHP contributed to data

collection, data analysis, data interpretation and writing.

TB, DV, DR, KRP, PR, EPM, SMB and DB contributed

to the conception of the study, data interpretation and writ-

ing. All authors read and approved the manuscript.

References

1. Herridge MS, Tansey CM, Matte ´ A, et al. Functional

disability 5 years after acute respiratory distress syn-drome. N Engl J Med 2011; 364: 1293–1304.

2. Iwashyna TJ, Ely EW, Smith DM, et al. Long-term cog-

nitive impairment and functional disability among sur-

vivors of severe sepsis. JAMA 2010; 304: 1787–1794.

3. Pandharipande PP, Girard TD, Jackson JC, et al. Long-

term cognitive impairment after critical illness. N Engl J

Med 2013; 369: 1306–1316.

4. Bienvenu OJ, Colantuoni E, Mendez-Tellez PA, et al.

Depressive symptoms and impaired physical function

after acute lung injury: A 2-year longitudinal study.

Am J Respir Crit Care Med 2012; 185: 517–524.

5. Desai SV, Law TJ, and Needham DM. Long-term com-

plications of critical care. Crit Care Med 2011; 39:

371–379.6. Fan E, Dowdy DW, Colantuoni E, et al. Physical compli-

cations in acute lung injury survivors: A 2-year longitu-

dinal prospective study. Crit Care Med 2014; 42: 849–859.

7. Needham DM. Mobilizing patients in the intensive care

unit: Improving neuromuscular weakness and physical

function. JAMA 2008; 300: 1685–1690.

8. Brummel NE, Jackson JC, Pandharipande PP, et al.

Delirium in the ICU and subsequent long-term disability

among survivors of mechanical ventilation. Crit Care

Med 2014; 42: 369–377.

9. Gosselink R, Bott J, Johnson M, et al. 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 2008; 34:

1188–1199.





10/10

10. Engel HJ, Needham DM, Morris PE, et al. ICU early

mobilization: from recommendation to implementation

at three medical centers. Crit Care Med 2013; 41:

S69–S80.

11. Morris PE, Goad A, Thompson C, et al. Early inten-

sive care unit mobility therapy in the treatment of

acute respiratory failure. Crit Care Med 2008; 36:

2238–2243.

12. Schweickert WD, Pohlman MC, Pohlman AS, et al.

Early physical and occupational therapy in mechanic-

ally ventilated, critically ill patients: A randomised con-

trolled trial. Lancet 2009; 373: 1874–1882.

13. Zanni JM,KorupoluR, FanE, et al.Rehabilitation ther-

apy and outcomes in acute respiratory failure: an obser-

vational pilot project. J Crit Care 2010; 25: 254–262.

14. Nydahl P, Ruhl AP, Bartoszek G, et al. Early mobil-

ization of mechanically ventilated patients: a 1-day

point-prevalence study in Germany. Crit Care Med

2014; 42: 1178–1186.

15. Berney SC, Harrold M, Webb SA, et al. Intensive care

unit mobility practices in Australia and New Zealand:A point prevalence study. Crit Care Resusc 2013; 15:

260–265.

16. Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity

is feasible and safe in respiratory failure patients. Crit

Care Med 2007; 35: 139–145.

17. Thomasen GE, Snow GL, Rodriguez L, et al. Patients

with respiratory failure increase ambulation after trans-

fer to an intensive care unit where early activity is a

priority. Crit Care Med 2008; 36: 1119–1124.

18. Burtin C, Clerckx B, Robbeets C, et al. Early exercise in

critically ill patients enhances short-term functional

recovery. Crit Care Med 2009; 37: 2499–2505.

19. Needham DM, Korupolu R, Zanni JM, et al. Early

physical medicine and rehabilitation for patients with

acute respiratory failure: A quality improvement pro-

ject. Arch Phys Med Rehabil 2010; 91: 536–542.

20. Adler J, and Malone D. Early mobilization in the inten-

sive care unit: A systematic review. Cardiopulm Phys

Ther J 2012; 23: 5–13.

21. Kayambu G, Boots R, and Paratz J. Physical therapy

for the critically ill in the ICU: a systematic review and

meta-analysis. Crit Care Med 2013; 41: 1543–1554.

22. Li Z, Peng X, Zhu B, et al. Active mobilization for

mechanically ventilated patients: a systematic review.

Arch Phys Med Rehabil 2013; 94: 551–561.

23. Lord RK, Mayhew CR, Korupolu R, et al. ICU early

physical rehabilitation programs: financial modeling of

cost savings. Crit Care Med 2013; 41: 717–724.

24. Engel HJ, Tatebe S, Alonzo PB, et al. Physical thera-

pist-established intensive care unit early mobilization

program: quality improvement project for critical care

at the University of California San Francisco Medical

Center. Phys Ther 2013; 93: 975–985.

25. Wahab R, Yip NH, Chandra S, et al. Implementation

of an early rehabilitation program in multiple intensive

care units reduces length of stay. Am J Respir Crit Care

Med 2013; 187: A3622.26. Urbach DR, Govindarajan A, Saskin R, et al.

Introduction of surgical safety checklists in Ontario,

Canada. N Engl J Med 2014; 370: 1029–1038.

27. Schneider EB, Hyder O, Wolfgang CL, et al. Provider

versus patient factors impacting hospital length of stay

after pancreaticoduodenectomy. Surgery 2013; 154:

152–161.

28. Selvin S. Three statistical models for estimating length

of stay. Health Serv Res 1977; 12: 322–330.

29. Clark DE, Lowman JD, Griffin RL, et al. Effectiveness

of an early mobilization protocol in a trauma and burns

intensive care unit: A retrospective cohort study. Phys

Ther 2013; 93: 186–196.

30. Hodgson C, Needham D, Haines K, et al. Feasibility

and inter-rater reliability of the ICU mobility scale.

Heart Lung 2013; 43: 19–24.

Wahab et al. 11

Documents

Journal of the Intensive Care Society-2016-Wahab-2-11-VALE KINE