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

OBJECTIVE: To examine the effect of increasing physical therapy (PT) staff in a cardiovascular intensive care unit (CVICU) on temporal measures of PT interventions and on outcomes important to patients and hospitals. DESIGN: Retrospective pre/post subgroup analysis from a quality improvement initiative. SETTING: Academic medical center. PARTICIPANTS: Cardiovascular patients in either a baseline (N=52) or quality improvement period (N=62) with a CVICU length of stay (LOS) ≥7 days and use of any one of the following: mechanical ventilation, continuous renal replacement therapy, or mechanical circulatory support. INTERVENTIONS: The 6-month quality improvement initiative increased CVICU-dedicated PT staff from 2 to 4. MAIN OUTCOME MEASURES: Changes in physical therapy delivery were examined using the frequency and daily duration of PT intervention. Post-CVICU LOS was the primary outcome. CVICU LOS, mobility change, and discharge level of care were secondary outcomes. A secondary analysis of hospital survivors was also conducted. RESULTS: Compared to those in the baseline period, cardiovascular patients in the quality improvement period participated in PT for an additional 9.6 minutes (95% confidence interval [CI]: 1.9, 17.2) per day for all patients and 15.1 minutes (95% CI: 7.6, 22.6) for survivors. Post-CVICU LOS decreased 2.2 (95% CI: -6.0, 1.0) days for all patients and 2.6 days (95% CI: -5.3, 0.0) for survivors. CVICU LOS decreased 3.6 days (95% CI: -6.4, -0.8) for all patients and 3.1 days (95% CI: -6.4, -0.9) for survivors. Differences in mobility change and discharge level of care were not significant. CONCLUSIONS: 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.

Walking While Dialyzing: A Retrospective Observation of Early Mobility and Ambulation for Patients on Continuous Renal Replacement Therapy.

OBJECTIVES: To describe the practice of physical therapy for patients requiring continuous renal replacement therapy and assess data related to the safety and feasibility of physical therapy interventions. DESIGN: A retrospective observational cohort study. PATIENTS: Surgical and cardiovascular patients receiving continuous renal replacement therapy during a 2-year period from December 2016 to November 2018. SETTING: Two ICUs at a single academic medical center. INTERVENTION: Physical mobility and ambulation while on continuous renal replacement therapy. MEASUREMENTS AND MAIN RESULTS: Therapy data including ICU Mobility Scale score, number of physical therapy sessions with and without ambulation and gait distance, along with safety data including filter life, safety events, and mortality were analyzed. The cohort of patients receiving continuous renal replacement therapy during the 2-year period was 206. Of these, 172 (83.49%) received simultaneous physical therapy. The median ICU Mobility Scale was 5 (interquartile range, 4-7) over a total of 1,517 physical therapy sessions. Ambulation with concomitant continuous renal replacement therapy connected was achieved in 78 patients (37.86%). There were 377 ambulation sessions (24.85% of all sessions) with a mean of 4.83 (sds 4.94) ambulation sessions per ambulatory patient. Patients walked an average of 888.53 feet (sd 1,365.50) while on continuous renal replacement therapy and a daily average of 150.61 feet (sd 133.50). In-hospital mortality was lowest for patients who ambulated (17.95%) and highest for patients who received no therapy (73.53%). Continuous renal replacement therapy filter life was longest for patients who ambulated (2,047.20 min [sd 1,086.50 min]), and shortest in patients who received no therapy (1,682.20 min [sd 1,343.80 min]). One safety event was reported during this time (0.0007% of all physical therapy sessions). CONCLUSIONS: Ambulation while on continuous renal replacement therapy was not associated with an increased risk of safety events and was feasible with the use of nonfemoral catheters and dialysis equipment with internal batteries.

Short-Term Clinical and Quality Outcomes Have Inconsistent Changes From a Quality Improvement Initiative to Increase Access to Physical Therapy in the Cardiovascular and Surgical ICU.

Studies of mobility during critical illness have mostly examined transitions from immobility (passive activities) or limited mobility to active "early mobility." DESIGN: Observational analysis of a quality improvement initiative. SETTING: Two ICUs (surgical ICU, cardiovascular ICU) at a tertiary academic medical center. PATIENTS: Critically ill surgical and cardiovascular patients. INTERVENTIONS: Doubling available physical therapy. MEASUREMENTS AND MAIN RESULTS: We examined the outcomes of therapy time/patient/day, ICU and hospital length of stay, disposition location, and change in functional status. We adjusted for age, sex, illness severity, and number of surgeries. Among 1,515 patients (703 baseline, 812 quality improvement), total therapy time increased from 71,994 to 115,389 minutes and from 42,985 to 93,015 minutes, respectively, in each ICU. In the cardiovascular ICU per patient therapy increased 17% (95% CI, -4.9 to 43.9; p = 0.13), and in the surgical ICU, 26% (95% CI, -1 to 59.4; p = 0.06). In the cardiovascular ICU, there was a 27.4% decrease (95% CI, -52.5 to 10.3; p = 0.13) in ICU length of stay, and a 12.4% decrease (95% CI, -37.9 to 23.3; p = 0.45) in total length of stay, whereas in the surgical ICU, the adjusted ICU length of stay increased 19.9% (95% CI, -31.6 to 108.6; p = 0.52) and total length of stay increased 52.8% (95% CI, 1.0-130.2; p = 0.04). The odds of a lower level of care discharge did not change in either ICU (cardiovascular ICU: 2.6 [95% CI, 0.6-12.2; p = 0.22]); surgical ICU: 3.6 [95% CI, 0.9-15.4; p = 0.08]). CONCLUSIONS: Among diverse cardiothoracic and surgical patients, a quality improvement initiative doubling physical therapy shifts is associated with increased total administered therapy time, but when distributed among a greater number of patients during the quality improvement period, the increase is tempered. This was not associated with consistent changes in ICU length of stay or changes in disposition location.