Early and Structured Rehabilitation Team Collaboration. David McWilliams Clinical Specialist Physiotherapist - UHB

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Regina Gallagher
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1 Early and Structured Rehabilitation Team Collaboration David McWilliams Clinical Specialist Physiotherapist - UHB

3 Start early

4 Moving through milestones Schweikert et al (2009)

5 Increase frequency of higher level functional activities

6 Improve outcomes Decreased length of stay / Increased flow Cost savings Faster weaning Improved functional outcomes Reduced delirium Improved quality of life

7 So what do we know about what s happening currently

Thomas et al (2009) Incidence of rehabilitation in general ICU population 82 Patients (mean age 59) admitted consecutively to an 8-bed district general ICU over a 3-month period were included.

8 Thomas et al (2009) Incidence of rehabilitation in general ICU population 82 Patients (mean age 59) admitted consecutively to an 8-bed district general ICU over a 3-month period were included. ET (N = 185) Trache (N = 308) Self Ventilating (N = 194) NIV (N = 35) CPAP (N = 53) Controlled Ventilation (N = 131) Inotropes (N = 101) Passive transfers Active assisted exercise Free active exercise Sitting on the bed edge <1 1 Sitting to standing Standing transfer Walking

9 514 patients from 38 Australian and New Zealand ICUs at 10 am on one of three designated days in 2009 and 2010 Mean age was 59.2 years 45% were mechanically ventilated 391 (76%) were on ICU > 48 hours 76 (15%) > 7 days

10 Frequency of mobilisation activities for patients in ICU > 48 hours (n=391)

11 1 Day point prevalence survey for early rehabilitation in mechanically ventilated patients

13 Barriers to Early Mobility and Solution Strategies 4

16 Birmingham Feb 2012 Rehabilitation service still in infancy Lack of coordination across 4 areas Staffing within critical care was reduced following a service evaluation = ratio of 1 physiotherapist to 10 patients.

17 Barriers Lack of leadership / responsibility Insufficient staffing levels Lack of knowledge and training Lack of communication between MDT with regards to rehabilitation Lack of standardisation of assessment and documentation Concerns regarding patient safety and appropriate equipment

18 Method Lack of leadership / responsibility New clinical specialist physiotherapist appointed with a focus on rehabilitation A key worker system was introduced for patients ventilated > 5 days Insufficient staffing levels Additional funding for 2 band 6 rehabilitation physiotherapists supported by QEHB charities Led to the creation of a new supportive rehabilitation team for critical care on 1 st April 2012.

19 Lack of knowledge and training Regular training sessions provided to physiotherapists and MDT on importance of early rehabilitation Staff induction Lack of communication between MDT with regards to rehabilitation Weekly goal setting at specific therapy rehabilitation meetings. Documented rehab plans using magic whiteboards at bed space MDT meeting was also introduced for patients ventilated > 14 days to allow more collaborative plans for weaning and rehabilitation.

20 Lack of consistency of assessment and documentation New comprehensive assessment performed Standardised documentation and milestones created Concerns regarding patient safety and appropriate equipment Early mobility guideline developed Education regarding safety of mobilisation and safe levels for activity Supportive equipment for rehabilitation New Stretcher chairs and a Portable ventilator Increased use of avialable equipment Tilt tables, over bed bikes, adjustable chairs, mobile hoists

21 Method Baseline data was collected retrospectively for the period from 1 st April st March 2012 Data the collected prospectively for the period from 1 st April st March 2013.

22 Outcomes Primary outcome - Mean physical function at ICU discharge - assessed via the Manchester Mobility Score (MMS) Secondary Mean ICU LOS Number of days ventilated Post ICU LOS Mortality

23 Manchester Mobility Score Developed due to a lack of robust / useful outcome measures in ICU Looks at stages of rehabilitation Quick and simple bedside measurement 1 Passive Movements, Active exercise, chair position in bed 2 Sit on edge of bed 3 Hoisted to chair (incl. standing Hoist) 4 Standing practice 5 Step Transfers with assistance 6 Mobilising with or without assistance 7 Mobilising > 30m A Agitated U - Unwell

24 Baseline Info Pre QI QI phase Total number of patients Age, median (IQR) years 58 (45-69) 55 (44-67) p= 0.24 Female 117 (40) 111 (38) p=0.69 Apache II score, median (IQR) 16 (13-20) 18 (13-23) p< 0.05 Charlson Comorbidity Index, median (IQR) Admission Diagnosis: 2 (1-4) 2 (1-4) p=0.45 General Surgery Cardiac Neuro Respiratory Liver Trauma Other NOTE. Values are n (%) or as otherwise indicated. 77 (26) 24 (8) 19 (7) 67 (23) 49 (17) 20 (7) 34 (12) 67 (23) 18 (6) 17 (6) 72 (25) 42 (14) 22 (7) 54 (19)

25 Physiotherapy activity levels and physical outcomes Pre Quality improvement n=290 Quality improvement n=292 p value Received Physiotherapy 290 (100%) 292 (100%) within ICU Number of treatments per 0.95 (+/- 0.49) 1.3 (+/-0.64) p=0.054 day Mean (+/- SD) Time to 1 st Mobilisation 9.3 ( ) 6.2 ( ) p<0.001 (days)* Manchester Mobility 3 (2-5) 5 (3-6) P<0.05 Score on ICU discharge, median (IQR) * geometric means and 95% confidence intervals

26 Results Pre Quality Quality improvement P value improvement ICU LOS (days)* 16.9 ( ) 14.4 ( ) p=0.007 Post ICU LOS (days)* 14.5 ( ) 12.6 ( ) p=0.197 Total hospital LOS 35.3 ( ) 30.1 ( ) p=0.016 (days)* Advanced respiratory 11.7 ( ) 9.3 ( ) p<0.05 support days* Sedation days* 5.9 ( ) 5.2 ( ) p=0.12 Readmission during 21 (10%) 19 (8%) p=0.45 same hospital episode ICU mortality 88 (30%) 67 (23%) p=0.091 In-Hospital mortality 114 (39%) 83 (28%) p=0.028 * geometric means and 95% confidence intervals

27 ICU Length of stay per month

28 Conclusion Increased focus on early rehabilitation has led to an increased level of function at critical care discharge This was associated with reductions in length of stay figures and mortality Close MDT working and communication is crucial to success - Literature is positive but needs to be seen in perspective - Within organisations key is to benchmark current service and objectively evaluate change

29 Consider What barriers exist to collaboration in your units? What strategies can be implemented to improve collaboration?

30 Thank you

Rehabilitation within critical care

Rehabilitation within critical care Why consider Rehab on ITU? 110,000 people admitted to critical care units in England and Wales each year (ICNARC) 75% survive and are discharged home Long Term Effects