Improving Outcomes for Critically Ill Cardiovascular Patients Through Increased Physical Therapy Staffing

Johnson, Joyce M.; Lohse, Bryan; Bento, Haley A.; Noren, Christopher S.; Marcus, Robin L.; Tonna, Joseph E.

doi:10.1016/j.apmr.2018.07.437

Cited by 21 publications

(34 citation statements)

References 40 publications

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“…Prior literature demonstrates that increasing rehabilitation staff can affect outcomes. 41 Patients in this study had a high severity of acute illness (median SOFA score of 13), high percentage of concomitant MV, high frequency of receiving blood products, and a high prevalence of liver disease and end-stage kidney disease. Of the 112 rehabilitation sessions, 72% were performed in patients with both CRRT and MV.…”

Section: Discussionmentioning

confidence: 83%

Safety, Feasibility, and Efficacy of Early Rehabilitation in Patients Requiring Continuous Renal Replacement: A Quality Improvement Study

Mayer

Hornsby

Ortiz-Soriano

et al. 2020

Kidney International Reports

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Introduction: Early rehabilitation in critically ill patients is associated with improved outcomes. Recent research demonstrates that patients requiring continuous renal replacement therapy (CRRT) can safely engage in mobility. The purpose of this study was to assess safety and feasibility of early rehabilitation with focus on mobility in patients requiring CRRT. Methods: Study design was a mixed methods analysis of a quality improvement protocol. The setting was an intensive care unit (ICU) at a tertiary medical center. Safety was prospectively recorded by incidence of major adverse events including dislodgement of CRRT catheter, accidental extubation, bleeding, and hemodynamic emergency; and minor adverse events such as transient oxygen desaturation >10% of resting. Limited efficacy testing was performed to determine if rehabilitation parameters were associated with clinical outcomes. Results: A total of 67 patients (54.0 AE 15.6 years old, 44% women, body mass index 29.2 AE 9.3 kg/m 2) received early rehabilitation under this protocol. The median days of CRRT were 6.0 (interquartile range [IQR], 2-11) and 72% of patients were on mechanical ventilation concomitantly with CRRT at the time of rehabilitation. A total of 112 rehabilitation sessions were performed of 152 attempts (74% completion rate). No major adverse events occurred. Patients achieving higher levels of mobility were more likely to be alive at discharge (P ¼ 0.076). Conclusions: The provision of early rehabilitation in critically ill patients requiring CRRT is safe and feasible. Further, these preliminary results suggest that early rehabilitation with focus on mobility may improve patient outcomes in this susceptible population.

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Section: Discussionmentioning

confidence: 83%

Safety, Feasibility, and Efficacy of Early Rehabilitation in Patients Requiring Continuous Renal Replacement: A Quality Improvement Study

Mayer

Hornsby

Ortiz-Soriano

et al. 2020

Kidney International Reports

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“…Although data suggest that application of early mobilization is safe and feasible, its impact on mortality is not well defined. Limited studies have prospectively assessed the effect of early mobilization on patients receiving ECMO, but suggest a benefit [ 18 , 19 , 20 , 21 ].…”

Section: Discussionmentioning

confidence: 99%

“…In conclusion, management of patients with refractory respiratory failure on ECMO without positive pressure ventilation is a promising and increasingly utilized therapeutic strategy. The rationale of endotracheal extubation is based on minimizing exposure to the known complications of positive-pressure ventilation [ 22 ] and supporting early mobilization [ 21 ]. In this study, we demonstrated that patients with ARDS removed from positive pressure ventilation had increased survival to hospital discharge, increased ventilator free days, and earlier mobilization.…”

Section: Discussionmentioning

confidence: 99%

Characteristics of Patients Managed without Positive Pressure Ventilation While on Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome

Levin

Ciullo

Overton

et al. 2021

JCM

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Background: Extracorporeal membrane oxygenation (ECMO) has expanding indications for cardiopulmonary resuscitation including severe acute respiratory distress syndrome (ARDS). Despite the adjunct of ECMO for patients with severe ARDS, they often have prolonged mechanical ventilation and are subject to many of its inherent complications. Here, we describe patients who were cannulated for venovenous (VV) ECMO and were taken off positive pressure ventilation. Methods: This is a primary analysis of patients admitted at a tertiary medical center between the dates of August 2014 to January 2020 who were cannulated to ECMO for refractory respiratory failure. We included all patients ≥18 years old. Patients who were extubated or had a tracheostomy and taken off positive pressure while on ECMO were classified as “off positive pressure ventilation (PPV)” and were compared to patients who remained “on PPV” while on ECMO. Primary outcome was survival to hospital discharge. Secondary outcomes were ventilator free days at 30 days and 60 days after ECMO cannulation, time from cannulation to date of first out-of-bed (OOB), and hospital length of stay (LOS). Patient characteristics were derived from routine clinical information in the electronic health record (EHR). Categorical characteristics were compared using chi-square test or Fisher exact test. Continuous characteristics were compared using independent samples t-test or Wilcoxon–Mann–Whitney test. p-values were reported from all analysis. Results: Sixty-five patients were included in this retrospective analysis. Forty-eight were managed on ECMO with PPV and 17 patients were removed from PPV. Patients removed from PPV had significantly higher lung injury scores prior to cannulation (2.5 ± 0.6 vs. 1.04 ± 0.3; p = 0.031) and non-significantly longer duration of ventilation prior to ECMO (6.1 days ± 2.1 vs. 5.0 days ± 01.1; p = 0.634). One hundred percent (100%) of patients removed from PPV survived to hospital discharge compared to 45% who received PPV throughout their duration of ECMO management (p < 0.001). The mean ventilator free days at day 60 was 15 with PPV and 36 without PPV (p = 0.003). The average duration from cannulation to mobilization (i.e., out-of-bed) was 18 days with PPV and 7 days without PPV (p = 0.015). Conclusions: Patients taken off PPV while on ECMO had a very high likelihood of survival to discharge and were mobilized in half as many days. While this likely reflects patient selection, the benefit of early mobilization is well documented and the approach of extubating while on ECMO warrants further investigation.

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“…Johnson et al recently described a retrospective pre-/post-subgroup analysis in 114 acute critically ill cardiovascular patients with a mean daily treatment time at baseline of 51.7 min and a mean frequency of treatment in the ICU of 0.59 per day (36). Their analysis showed that an increased amount of therapies resulted in shorter length of stay.…”

Section: Discussionmentioning

confidence: 99%

“…described highly active therapies, such as sit-to-stand transfers and marching on the spot (36), and used a clinical decision-making flowsheet for progression.…”

Section: Discussionmentioning

confidence: 99%

Effect of physiotherapy on regaining independent walking in patients with intensive-care-unit-acquired muscle weakness: A cohort study

Thomas¹,

Mehrholz²,

Bodechtel³

et al. 2019

J Rehabil Med

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The aim of this study was to describe physiotherapeutic interventions during post-acute inpatient rehabilitation of chronic critically ill patients with intensive-care-unitacquired muscle weakness, and to determine the relationship of such interventions with patients' recovery of walking ability. The study included 150 patients with chronic critical illness and acquired muscle weakness, and documented what interventions physiotherapists applied during rehabilitation and how well patients regained walking function. The most frequent interventions in the first 2 weeks of rehabilitation in patients who regained walking ability were: practicing walking, sit-to-stand training, and balance training while sitting. In those who did not regain walking ability the most frequent interventions were: passive-assistive movements, sit-to-stand training, and balance training while sitting. The time spent walking in physiotherapy was correlated with walking function. Physiotherapy in the rehabilitation of chronically critically ill patients with intensive-care-unit-acquired muscle weakness may be correlated with achieving independent walking. Objectives: To describe physiotherapeutic interventions used in the post-acute inpatient rehabilitation of chronic critically ill patients with intensive-careunit-acquired muscle weakness, and to determine the influence of such interventions on patients' ability to walk. Methods: Chronic critically ill patients with intensive-care-unit-acquired muscle weakness who were in post-acute and rehabilitation units were included in a cohort study. During post-acute rehabilitation, the patients' functional status at baseline, all daily physiotherapeutic interventions, and ability to walk were documented. Results: A total of 150 patients were investigated. In patients who regained walking ability, the most frequent interventions in the first 2 weeks of postacute rehabilitation were practicing walking, sit-tostand training, and balance training while sitting (total time per week: 48.03 (standard deviation (SD) 41.10), 20.13 (SD 21.12), and 12.37 (SD 26.95) min, respectively). The most frequent interventions in those who did not regain walking ability were passive-assistive movements, sit-to-stand training, and balance training while sitting (total time per week: 15.29 (SD 22.93), 15.15 (SD 22.75), and 14.85 (SD 16.99) min, respectively). The time spent walking increased the chance of regaining walking ability (adjusted hazard ratio = 1.017 per min walking, p < 0.0001). Conclusion: These results suggest that physiotherapy interventions in the rehabilitation of chronic critically ill patients with intensive-care-unit-acquired muscle weakness may stimulate walking function.

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Improving Outcomes for Critically Ill Cardiovascular Patients Through Increased Physical Therapy Staffing

Abstract: Additional CVICU-dedicated PT staff was associated with increased PT treatment and reductions in CVICU and post-CVICU LOS. The effects of each were greatest for hospital survivors.

Cited by 21 publications

References 40 publications

Safety, Feasibility, and Efficacy of Early Rehabilitation in Patients Requiring Continuous Renal Replacement: A Quality Improvement Study

Safety, Feasibility, and Efficacy of Early Rehabilitation in Patients Requiring Continuous Renal Replacement: A Quality Improvement Study

Characteristics of Patients Managed without Positive Pressure Ventilation While on Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome

Effect of physiotherapy on regaining independent walking in patients with intensive-care-unit-acquired muscle weakness: A cohort study

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