Archives of Physical Medicine and Rehabilitation
Volume 91, Issue 4 , Pages 536-542, April 2010

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

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

  • Dale M. Needham, MD, PhD

      Affiliations

    • Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD
    • OACIS Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
    • Corresponding Author InformationCorrespondence to Dale M. Needham, MD, PhD, 1830 E Monument St, 5th Fl, Baltimore, MD 21205
    • ,
  • Radha Korupolu, MBBS, MS

      Affiliations

    • OACIS Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
    • ,
  • Jennifer M. Zanni, PT, MSPT

      Affiliations

    • Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD
    • ,
  • Pranoti Pradhan, MBBS, MPH

      Affiliations

    • OACIS Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
    • ,
  • Elizabeth Colantuoni, PhD

      Affiliations

    • Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
    • Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
    • ,
  • Jeffrey B. Palmer, MD

      Affiliations

    • Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD
    • ,
  • Roy G. Brower, MD

      Affiliations

    • OACIS Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
    • ,
  • Eddy Fan, MD

      Affiliations

    • OACIS Group, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD

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.

Key Words: Critical care, Early ambulation, Muscle weakness, Rehabilitation, Respiration, artificial

List of Abbreviations: CI, confidence interval, ICU, intensive care unit, LOS, length of stay, MICU, medical intensive care unit, OT, occupational therapy, PM&R, physical medicine and rehabilitation, PT, physical therapy, QI, quality improvement

 

 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.

PII: S0003-9993(10)00034-1

doi:10.1016/j.apmr.2010.01.002

Archives of Physical Medicine and Rehabilitation
Volume 91, Issue 4 , Pages 536-542, April 2010

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