Where: University of Chicago Medical Center and University of Iowa Hospitals in Iowa City, both academic tertiary care medical centers.
The issue: Providing physical and occupational therapy to mechanically ventilated patients.
As in most hospitals, the intensive care units at the universities of Chicago and Iowa had traditionally begun physical and occupational therapy after patients were extubated. However, recent published trials had indicated that it was safe and feasible to provide therapy to patients who were still on ventilation about a week after ICU admission.
A team of clinicians at the two hospitals decided to try initiating therapy even earlier to see if it could be done effectively, and whether it would reduce the complications that often affect patients who have been in the ICU. “Staying immobile is not good for you and mobilizing early reduces the burden of dysfunction after critical illness,” said study co-author John P. Kress, MD, associate professor of medicine and director of the medical ICU at the University of Chicago.
How it worked
Mechanically ventilated patients received daily sedative interruption, after which their ability to undergo physical and occupational therapy was assessed by a team of researchers. Therapy was started if the patient met three of the four criteria for wakefulness: opening her eyes, following an investigator with her eyes, squeezing a hand, and sticking out her tongue on request. If the patient wasn't awake, the therapists did passive range-of-motion exercises.
Forty-nine patients received early therapy in the trial, results of which were published in Critical Care Medicine in November 2010 and The Lancet in May 2009. In more than two-thirds of the therapy sessions, the patients successfully sat up on the edge of the bed. In a third, they stood and/or moved to a chair, and in 15% of the sessions the ventilated patients walked.
Upon discharge from the hospital, these patients were compared to a group who hadn't received early therapy. “We picked a primary endpoint that had to do with what would matter most to patients…whether or not you were independent with regard to your function when you left the hospital,” said Dr. Kress. They found that 59% of the early therapy patients were independently functional at discharge compared to only 35% of controls (P=0.02).
The expected potential barriers to early therapy hindered the project relatively little. “People ask the question, ‘What patients can I or can't I do this in?’ We didn't find any major barriers,” said Dr. Kress. Patients were given therapy even though they had acute lung injury, central venous catheters, or continuous renal replacement therapy, or were being infused with vasoactive medication. Some adverse event did occur in 16% of the therapy sessions, and 4% of the sessions had to be stopped, most often for patient/ventilator asynchrony or agitation.
The patients' lack of trouble with the potential barriers can be attributed to the therapists involved, according to Dr. Kress. “It is critical that you have therapists that are confident and comfortable working in a high-intensity environment and give them autonomy to do their work,” he said.
Of course, applying therapists to this new task requires resources. The results of the trial have not yet led to full implementation of early therapy in the involved ICUs. “We don't have the staffing to do it universally,” said Dr. Kress. “It's something that we are doing much more and earlier than we had previously, but at the same time, we're still interested in studying more.”
Those future studies will have a number of questions to tackle, according to Dr. Kress. “Does [early therapy] translate into a sustained benefit with regard to function? Improved cognition after recovering from intensive care? Does it translate into a cost-effective benefit?”
He hopes and predicts that other hospitals and researchers will assist in finding answers to these questions. “I think there's a move afoot to go in this direction,” he said.