Sustained quality improvement changes in ICU benefits both patients and health care facility

Quality improvement protocols in place five years after inception sped up initiation of early physical therapy intervention

In a pre- and post-evaluation study, Johns Hopkins Medicine researchers found that quality improvement changes made in an intensive care unit (ICU) were still in practice five years later — benefiting both patients and the health care facility. Those changes included new protocols for treating critically ill patients by encouraging early physical therapy in the ICU.

The study was published in the Annals of the American Thoracic Society.

“We know that the early start of physical rehabilitation in the ICU improves patients’ outcomes,” says Dale M. Needham, M.D., Ph.D., medical director of the Critical Care Physical Medicine and Rehabilitation Program at Johns Hopkins and senior author of the study. “What we wanted to do in this study is to see whether our quality improvement project had a lasting effect on the early delivery of rehabilitation.”

Working in a single medical ICU at Johns Hopkins, Needham and his team collaborated with hospital administrators to promote the sustainability of their quality improvement project, including removal of barriers, further interdisciplinary education and communication, and the continued participation of over 20 physical therapists who started working in the medical ICU after the quality improvement period.

“None of these things happened by accident,” says Needham, “and if hospitals use a structured approach to creating this change, they can be successful too.”

For Needham, that structured approach included making the business case to hospital administrators that investing in early rehabilitation programs could improve patient outcomes while also reducing hospital costs, since these patients had shorter lengths of stay.

There are many barriers to overcome in incorporating physical rehabilitation in the ICU, but sustaining such a quality improvement project is really about changing culture. “Most people who work in an ICU were trained to think that we were supposed to care for patients by deeply sedating them and giving them bed rest,” says Needham. Introducing active physical therapy even while patients are on mechanical ventilation “really takes everything we’ve known — including how we’ve designed our intensive care units — and turns it on its head.”

To quantify the lasting effects of their quality improvement project, Needham’s team compared data that had been collected from a prospective cohort study (pre-quality improvement) with data that was collected starting a year after the initiation of the quality improvement project (post-quality improvement). Patients in both pre- and post-quality improvement groups suffered from acute lung injury, which is considered the archetypal critical illness.

“We had dramatic changes after the quality improvement project compared to before the quality improvement project,” says Needham. This included a higher proportion of patients receiving physical therapy in the ICU — 89 percent post-quality improvement versus 24 percent pre-quality improvement — and fewer days before starting physical therapy in the ICU — a median of four days post-quality improvement versus 12 days pre-quality improvement.

The team also examined the functional abilities of patients — whether patients were able to stand or walk while in the ICU — and found that 62 percent of post-quality improvement patients could, compared with only 7 percent of pre-quality improvement patients.

While a multisite quality improvement project seems like the next logical step, running such a project is not practical, says Needham. “Each ICU comes about doing this in its own time frame.” However, Needham and his team “do spend a great deal of time helping other ICUs change practices to adopt early physical rehabilitation,” including an annual critical care rehabilitation conference at Johns Hopkins for practitioners from around the world, now in its third year.

Given both the advances in critical care and the aging population, there’s a growing pool of ICU survivors who often suffer for years from certain impairments. As a result, these patients may delay returning to work and utilize the health care system more. “The key to address these things is to start rehabilitation early,” says Needham, which takes sustainably changing the culture in ICUs.

Source: http://www.hopkinsmedicine.org/