Implementing early and structured rehabilitation for patients admitted to critical care

This project aimed to improve the level of rehabilitation provided to patients admitted to critical care. Specifically the aim was to facilitate earlier mobilisation and achieve higher levels of mobility at the point of critical care discharge.

A multi-professional rehabilitation team was established in 2012 to promote early and enhanced rehabilitation for patients at high risk following intensive care unit (ICU) and prolonged hospital stays. The structure of rehabilitation delivery was based on key recommendations from NICE CG83, including key workers for all patients and individualised rehabilitation programmes for those at high risk of the physical and psychological sequelae of critical illness (Recommendation 1.6).

Patients admitted to critical care suffer significant loss of functioning, with muscle loss as high as 20% in the first 7 days of admission for those in multi organ failure. As a result, although mortality from critical illness is improving, survivors often suffer from prolonged weakness and psychological and cognitive impairments.

A baseline assessment performed within critical care at UHB NHS Foundation trust demonstrated rehabilitation levels to be low, with patients extremely dependent on transfer to the ward. The result of this was lengthy periods of ongoing rehabilitation and poor functional outcomes.

With over 3500 admissions annually to our critical care unit, we believed a more structured approach to rehabilitation had the potential for significant benefits including reduced length of stay in both critical care and hospital, in turn reducing patients’ costs and improving hospital flow. We also felt this would lead to better functional outcomes and an improved quality of life for critical care survivors.

A one-year study was set up to evaluate the impact of early rehabilitation programmes for patients suffering critical illness to address prolonged physical and psychological morbidity. The service was introduced in April 2012 and data to March 2013 was evaluated and compared with historical data collected from April 2011 – March 2012.

All patients admitted to critical care and ventilated for ≥ 5 days throughout the duration of the study were included in the analysis, excluding major trauma injuries and severe brain injuries. The service was set up comprising a newly appointed permanent Band 8a clinical specialist physiotherapist (David McWilliams) tasked with improving rehabilitation within critical care, in addition to two senior band 6 physiotherapists funded internally and supported by the Queen Elizabeth Hospital Birmingham charity (fixed term posts for one year).

Prior to implementation of the service key stakeholders were engaged by the clinical specialist physiotherapist, with a view to providing education sessions around safety and effectiveness of structured rehabilitation programmes. Additional hands on training sessions were also provided to existing physiotherapy and nursing staff. This was supported by the development of safety criteria for mobilisation to help guide clinical reasoning and decision making.

A total of 292 patients met the study criteria during the intervention period. Patients were assessed as usual within 24 hours of admission and received the established physiotherapy interventions. Patients ventilated for ≥ 5 days were assigned a physiotherapy key worker who implemented an individualised and structured rehabilitation programme. The plan was shared and reviewed at weekly multi-professional team meetings, including physiotherapists, critical care consultants, nursing staff, and a critical care dietitian and the next seven days’ of individual’s programme developed.

The progressive rehabilitation programmes and goals were written on wall charts as motivational guidance for patients, carers, and the multidisciplinary team. Weekly meetings to review progress and set goals for the following week also ensured continued focus on rehabilitation which was essential to ensure continued improvement or new plans to be formulated when progress was slow.

Results of data analysis showed:

• Reduction in average hospital LOS (length of stay) for patients admitted to critical care and invasively ventilated for at least 5 days from 35.3 days pre- to 30.1 days post-study).
• Reduction of average critical care LOS reduced from 16.9 days to 14.4 days.
• Reduction of average duration of invasive ventilation from 11.7 days to 9.3 days.
• Shorter times to first mobilise (9.3 vs 6.3 days) and a higher level of mobility at the point of critical care discharge (Manchester Mobility Score 3 vs 5).
• Although there was no significant difference observed in terms of critical care mortality between the pre-study data and study data, the in-hospital mortality was significantly lower after the introduction of the programme from 39% pre- to 28% post-study.

Mortality rate data:

The introduction of early and enhanced rehabilitation within the ICU was associated with a significant reduction in 3-year mortality of hospital survivors. The three-year mortality rate was 81/201 (40.3%) in the Pre QI group vs 60/222 (27%) in the Post QI group; p = 0.004.

Cost and savings:

The project cost £75,192 to employ the 2 band 6 posts. The reduction in ICU and hospital length of stay (LOS) equates to a reduction in patient costs of £951,200 for this cohort. In real terms this was reflected by bed day savings and an increased capacity of 3.7 ICU beds and 2.5 ward beds. Following the outcomes of the project, recurrent funding has been allocated and the two band 6 physiotherapists are now established to support this ongoing work. Patient feedback to the project has been excellent.

The results of this project have demonstrated that rehabilitation in critical care has the potential to significantly improve patient outcomes and recovery from critical illness. Physiotherapists are ideally placed to take a leading role in this area, supportive efficient pathways of care and improving capacity within the NHS. Implementing a new service model is challenging but with perseverance, education and a clear plan to evaluate outcomes a great deal can be achieved.

This project was introduced at a time when physiotherapy funding was being reduced and rather than simply saving posts it has managed to prove the vital worth of physiotherapy and actually create new ones. This study highlights the importance of attaching tangible measures to therapy structure and outcomes. The use of a daily score to track mobility helped to prove the added benefit of introducing the critical care rehabilitation team, helping to support the role of physiotherapists in improving overall outcomes.

Reference:

McWilliams D, Weblin J, Atkins G et al. (2014) Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: A quality improvement project. Journal of critical care. 30(1):13-8