Translating Research Into Clinical Practice: The Role of Quality Improvement in Providing Rehabilitation for People With Critical Illness

Quality Improvement Articles in This Issue

In 2007, Bailey and colleagues¹⁷ published an important report of rehabilitation for patients in the intensive care unit (ICU) that challenged the prevailing practices of deep sedation and bed rest.¹⁸ Their 6-month prospective evaluation of mobility intervention for patients who were mechanically ventilated for more than 4 days demonstrated that such interventions were safe and feasible. Thomsen and colleagues¹⁹ extended these findings in reporting that patients requiring mechanical ventilation increased their activity when transferred into an ICU with a “culture of mobility.” Evidence for early mobility for patients with critical illness continued to grow with additional reports that early rehabilitation was safe and feasible,²⁰ increased muscle strength,²¹ improved functional outcomes,^21–23 decreased duration of delirium,²² and reduced duration of mechanical ventilation and ICU and hospital stay.^9,23,24 Such interventions also may have a long-term effect on patient mortality and hospital readmission.²⁵

With mounting research evidence that early and more intensive interventions improve patient outcomes,²⁶ Needham and colleagues⁹ undertook the first QI project of early rehabilitation interventions for patients with acute respiratory failure being managed in a medical ICU. Using a structured QI model,^7,10 in a pretest-posttest analysis, they found that their QI intervention was associated with a marked reduction in deep sedation use, increased rehabilitation activities, and higher patient function. The findings of this rigorously conducted QI intervention provided a foundation to help with implementing early mobility programs in medical and surgical ICUs nationally and internationally. Recently, these findings were extended by a multicentered QI intervention for a progressive mobility initiative to help ICU teams integrate early mobility into daily practice in 13 ICUs in 8 Veterans Health Administration hospitals.²⁷

As the research evidence and QI interventions supporting early rehabilitation continue to accumulate, rehabilitation programs are being instituted for patients with critical illness in a number of environments beyond medical and surgical ICUs. In this issue of the PTJ Special Series on Rehabilitation for People With Critical Illness, we are pleased to publish 3 QI reports that describe the implementation of unique early rehabilitation programs. As outlined below, these QI projects illustrate impressive initiative on the part of the health care teams that reviewed current best practice and applied these principles to their unique patient populations and health care environments:

• The majority of QI projects have focused on patients in respiratory,^17,19 medical,^9,22,23 and surgical²⁸ ICUs. Clark and colleagues²⁹ examined the implementation of an early mobilization protocol for patients admitted to a trauma and burn ICU. They assembled an interprofessional team and followed the Plan-Do-Check-Act QI framework to develop and assess their initiative. They report that their program was safe and feasible and was associated with a decrease in complication rate following the initiative.

• Drolet and colleagues³⁰ took a different approach to increase the number of patients ambulating during the first 72 hours of their hospital stay in an adult medical/surgical ICU or an adult intermediate care unit. In their QI initiative, their interprofessional team developed and implemented a mobility order set with an embedded algorithm to guide nursing assessment of mobility potential and requests for physical therapy and occupational therapy consultation. Six months following implementation of their initiative, ambulation rates rose more than 3-fold in the adult ICU and more than 4-fold in the adult intermediate care unit.

• Olkowski and colleagues³¹ describe a QI initiative to determine the safety and feasibility of an early mobilization program for patients recovering from surgical management of aneurysmal subarachnoid hemorrhage (SAH). Survivors of aneurysmal SAH often are faced with complicated recoveries that include surgery and prolonged monitoring in the ICU. This retrospective analysis of 25 patients with aneurysmal SAH who received early mobilization by a physical therapist or an occupational therapist or both demonstrated that an early mobilization program that included upright activities and ambulation is safe and feasible for this unique, critically ill patient population.

Other Articles in This Issue

We also want to highlight other important publications in this issue as outlined below:

• As more people are surviving critical illnesses, it is important that functional impairments acquired during a hospital stay are managed with the goal of improving long-term health, wellness, and function. Bemis-Dougherty and Smith³² discuss physical therapist practice in the management of survivors of critical illness and the importance of long-term follow-up after ICU discharge. Furthermore, they describe the steps that the American Physical Therapy Association is taking to raise awareness and education about post–intensive care syndrome,³³ to address barriers to best practice, and to identify research gaps and resources.

• As more and more rehabilitation programs are being instituted to manage people who are critically ill, there is an associated increase in the demand for physical therapists to be part of the ICU rehabilitation team. In their perspective article, Pawlik and Kress³⁴ address issues facing the profession as the demand for physical therapists qualified to care for people who are critically ill increases. These authors discuss issues including physical therapist competence in managing patients with critical illness, educational strategies to develop entry-level physical therapists prepared for managing patients with critical illness, determining physical therapy staffing requirements for ICUs, and prioritizing physical therapy service provision for patients in the acute care setting. These and other issues require the profession's attention as the rehabilitation of patients with critical illness evolves.

• One method of developing a physical therapy workforce prepared to practice in the ICU is the use of immersive high-fidelity simulation. Ohtake and colleagues³⁵ describe an educational experience where physical therapist students engaged in the early rehabilitation of a simulated patient in the ICU. Simulation provides focused, deliberate practice in a safe, controlled learning environment, as well as affording an opportunity for students to develop the technical, behavioral, and clinical decision-making skills necessary for ICU practice. The authors discuss the impact of managing a simulated patient in the ICU on student confidence and satisfaction.

• Critical illness is not confined to adults; infants and children also experience life-threatening illnesses requiring mechanical ventilation. Weaning infants from periods of mechanical ventilation can be challenging. In a case series, Smith and colleagues³⁶ describe a unique inspiratory muscle training program provided to 2 infants who were dependent on mechanical ventilation following surgery for congenital heart defects. After multiple failed weaning attempts, short-term participation in an inspiratory muscle training program resulted in successful weaning from the ventilator.

• As more patients are surviving critical illness and are transferred to long-term acute care hospitals, innovative rehabilitation strategies for ameliorating the neuromuscular weakness and functional impairments acquired in the ICU are emerging. In a case report by Trees and colleagues,³⁷ mobilization strategies with novel devices for therapeutic exercise and gait training are used in the management of an elderly patient with severe ICU-acquired weakness. The authors describe the application of a 4-phase, graded mobilization program in the rehabilitation of a patient who was totally dependent who regained her ability to ambulate independently.

• With the increased utilization of extracorporeal membrane oxygenation (ECMO), more patients are surviving severe respiratory failure; however, they often have profound neuromuscular weakness due to bed rest. Rahimi and colleagues³⁸ describe a case series of 3 patients with critical illness who were managed with ECMO and received rehabilitation at different stages of their illness. This case series illustrates that rehabilitation during ECMO may be feasible and safe.

• As the incidence of heart failure continues to increase, more patients with end-stage heart failure are being managed with ventricular assist devices (VADs). In this perspective article, Wells³⁹ provides a comprehensive analysis of the physical therapist's role in managing patients with VADs. Wells discusses the common types of VADs and gives important information about optimal functional rehabilitation of these patients during the preoperative and postoperative periods and as they transition to living in the community.

In summary, we hope the articles in this issue and in the prior December 2012 issue motivate you to examine your practice for patients with critical illness—from the ICU to the community. We encourage you to consider the QI projects as well as the clinical interventions described in these 2 issues of this special series and ask yourself whether you are translating research evidence into your daily practice. As more and more individuals survive critical illness, the increased involvement of rehabilitation professionals at every stage of a person's recovery will contribute to this growing population enjoying the best possible function and quality of life.