QI Process Promotes Early Mobilization of ICU Patients

Abstract & Commentary

By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh Dr. Hoffman reports no financial relationship to this field of study. This article originally appeared in the December issue of Critical Care Alert. It was edited by David J. Pierson, MD, and peer reviewed by William Thompson, MD.

Synopsis: Using a quality improvement (QI) process, ICU delirium, physical rehabilitation, and functional mobility were significantly improved and associated with a decreased length of stay.

Source: Needham DM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: A quality improvement project. Arch Phys Med Rehabil 2010;91:536-542.

Following a chart review that indicated few (24%) medical ICU (MICU) patients received consultation for physical therapy (PT) or occupational therapy (OT) — a percentage almost 50% lower than at two other academic medical centers in the same city — as well as a higher prevalence of deep sedation, the authors elected to initiate a QI project designed to reduce the use of deep sedation and improve patients' functional ability. The project, based on the "4Es" (Engage, Educate, Execute, Evaluate), involved the following steps:

  • MICU admission orders were modified to change the default activity level from "bed rest" to "as tolerated";
  • Clinicians were encouraged to order benzodiazepines and narcotics "as needed" rather than by continuous infusion;
  • Guidelines were disseminated to encourage PT and OT consultation;
  • New safety-related guidelines were developed to identify eligible patients;
  • Staffing was changed to include a full-time PT and OT; and,
  • Consultations to a neurologist were encouraged for patients with severe muscle weakness.

Compared to before the QI project was initiated, the proportion of days on which patients received benzodiazepines decreased (from 50% to 25%; P = 0.002), with lower median daily sedative doses (47 mg vs 15 mg midazolam equivalents [P = 0.09]; 71 mg vs 24 mg morphine equivalents [P = 0.01]). Patients had more days when they were alert (30% vs 67%; P < 0.001) and not delirious (21% vs 53%; P = 0.003). There were a greater number of rehabilitation treatments per patient (P < 0.001) with a higher level of functional mobility (56% vs 78%; P = 0.03). Patients had similar (low) pain ratings prior to and following the QI project (0.6 vs 0.6; P = 0.79) based on nursing assessments using a 0-10 scale. Comparison with historical controls indicated a decrease in ICU and hospital lengths of stay by 2.1 days (95% confidence interval [CI], 0.4-3.8) and 3.1 days (95% CI, 0.3-5.9), respectively. The only adverse events were four instances in which a rectal or feeding tube was dislodged.

Commentary

Historically, early mobilization of ICU patients was promoted by eminent clinicians such as Thomas Petty and Louise Nett, who observed that "when we first started our unit in 1964, patients who required mechanical ventilation were awake and alert and often sitting in a chair."1 However, early mobilization was uncommon until recently when clinicians, prompted by concerns about complications faced by ICU survivors and evidence regarding the benefits of less sedation, began to test the ability to safely provide mobility interventions.

Following an initial survey that identified the need to change practice, Needham and colleagues implemented a QI project that involved many meetings aimed at presenting the problem, identifying barriers and solutions, and developing the structure of the project. A unique component of this process involved having patients who participated in early mobilization activities return to the MICU to share feedback about their experiences and subsequent recovery. These patient visits provided compelling evidence of potential benefits and lack of adverse consequences (videos of patient interviews are available at www.hopkinsmedicine.org/oacis).

The subsequent QI project achieved significant changes in routine clinical practice in a relatively short period of time (4 months). Notably, since implementation of the project, the hospital funded a program that allowed the multidisciplinary team used for the project to be sustained, solidify gains, and design new projects to implement and evaluate additional approaches to promote early mobility, such as cycle ergometry and neuromuscular electrical stimulation therapy.

Reference

  1. Petty TL. Suspended life or extending death? Chest 1998;114:360-361.