Timing and Amount of Physical Therapy Treatment are Associated with Length of Stay in the Cardiothoracic ICU

Impact of the health policy for interdisciplinary collaborative rehabilitation practices in intensive care units: A difference-in-differences analysis in Japan

BACKGROUND

Early rehabilitation in intensive care units (ICUs) may be beneficial but is not routinely performed for adults with critical illness. In April 2018, the Japanese government introduced a health policy to provide financial incentives to hospitals that met the requirements of interdisciplinary collaboration and had teams specialized in ICU rehabilitation practices.

OBJECTIVES

The present study aimed to investigate whether the health policy is associated with improved clinical practices of ICU rehabilitation.

METHODS

Using a nationwide administrative inpatient database and hospital statistics data from Japan, we identified hospitals that admitted adult patients to the ICU within two days of hospital admission from April 2016 to March 2019. Using hospital-level propensity score matching, we created matched cohorts of 101,203 patients from 108 intervention hospitals that introduced the health policy, and 106,703 patients from 108 control hospitals that did not. We then conducted patient-level difference-in-differences analyses to examine changes in the percentage of patients from the intervention and control hospitals, who underwent early ICU rehabilitation within two days of ICU admission before and after the implementation of the health policy.

RESULTS

In the intervention group, patients undergoing early ICU rehabilitation increased from 10% and 36% after the policy implementation. In the control group, it increased from 11% to 13%. The difference-in-difference in the percentage of patients who underwent early ICU rehabilitation between the two groups was 24% (95% confidence interval, 19%-29%).

CONCLUSIONS

Early ICU rehabilitation can be facilitated by financial incentives for hospitals that engage in interdisciplinary collaboration with specialist teams.

IMPLICATIONS FOR CLINICAL PRACTICE

Our Findings are relevant for hospital administrators, professional organizations, and policymakers in other nations considering strategies to support the additional deployment burdens of early ICU rehabilitation. Future studies need to explore the long-term effects and sustainability of the observed improvements in ICU rehabilitation practices.

Early Mobility Index and Patient Outcomes: A Retrospective Study in Multiple Intensive Care Units

BACKGROUND

Early mobility interventions in intensive care units (ICUs) are safe and improve outcomes in subsets of critically ill adults. However, implementation varies, and the optimal mobility dose remains unclear.

OBJECTIVE

To test for associations between daily dose of out-of-bed mobility and patient outcomes in different ICUs.

METHODS

In this retrospective cohort study of electronic records from 7 adult ICUs in an academic quarternary hospital, multivariable linear regression was used to examine the effects of out-of-bed events per mobility-eligible day on mechanical ventilation duration and length of ICU and hospital stays.

RESULTS

In total, 8609 adults hospitalized in ICUs from 2015 through 2018 were included. Patients were mobilized out of bed on 46.5% of ICU days and were eligible for mobility interventions on a median (IQR) of 2.0 (1-3) of 2.7 (2-9) ICU days. Median (IQR) out-of-bed events per mobility-eligible day were 0.5 (0-1.2) among all patients. For every unit increase in out-of-bed events per mobility-eligible day before extubation, mechanical ventilation duration decreased by 10% (adjusted coefficient [95% CI], -0.10 [-0.18 to -0.01]). Daily mobility increased ICU stays by 4% (adjusted coefficient [95% CI], 0.04 [0.03-0.06]) and decreased hospital stays by 5% (adjusted coefficient [95% CI], -0.05 [-0.07 to -0.03]). Effect sizes differed among ICUs.

CONCLUSIONS

More daily out-of-bed mobility for ICU patients was associated with shorter mechanical ventilation duration and hospital stays, suggesting a dose-response relationship between daily mobility and patient outcomes. However, relationships differed across ICU subpopulations.

Relationship of Age And Mobility Levels During Physical Rehabilitation With Clinical Outcomes in Critical Illness

Objective

To determine whether age, mobility level, and change in mobility level across the first 3 physical rehabilitation sessions associate with clinical outcomes of patients who are critically ill.

Design

Retrospective, observational cohort study.

Setting

Medical Intensive Care Unit (MICU).

Participants

Hospitalized adults (n = 132) who received 3 or more, consecutive rehabilitation sessions in the MICU.

Interventions

Not applicable.

Measurements and Main Results

Sample included 132 patients with 60 (45%) classified as younger (18-59 years) and 72 (55%) as older (60+ years). The most common diagnosis was sepsis/septicemia (32.6%). Older relative to younger patients had a significantly slower rate of improvement in ICU Mobility Scale (IMS) scores across rehabilitation sessions (mean slope coefficient 0.3 vs 0.6 points, P<.001), were less likely to be discharged to home (30.6% vs 55.0%, P=.005), and were more likely to die within 12 months (41.7% vs 25.0%, P=.046). Covariate-adjusted models indicated greater early improvement in IMS scores were associated with discharge home (P=.005). Longer time to first rehabilitation session, lower initial IMS scores, and slower improvement in IMS scores were associated with increased ICU days (all P<.03).

Conclusion

Older age and not achieving the mobility milestone of sitting at edge of bed or limited progression of mobility across sessions is associated with poor patient outcomes. Our findings suggest that age and mobility level contribute to outcome prognostication, and can aide in clinical phenotyping and rehabilitative service allocation.

Clinical effects of neuroendoscopic hematoma evacuation for hypertensive intracerebral hemorrhage

OBJECTIVE

To analyze the clinical effects of neuroendoscopic hematoma evacuation for the treatment of hypertensive intracerebral hemorrhage (ICH).

METHODS

A total of 80 patients with hypertensive ICH who were admitted to our hospital were included as the subjects of this retrospective study. The patients were assigned into a neuroendoscopic hematoma evacuation group (n=35) and a small bone window craniotomy group (n=45). The post-operative hematoma residues and the clearance rate of the hematoma were compared between the two groups. The intraoperative blood loss, duration of the surgery, and Glasgow Coma Scale (GSC) scores before and after surgery were compared between the two groups. The operation time, intraoperative blood loss, the time consumed to stop bleeding, clearance rate of hematoma, manifestation of complications, and the prognosis 6 months after surgery were analyzed statistically. Self-made questionnaires were used to evaluate the satisfaction degree of patients with their lives and to assess the quality of life after surgery.

RESULTS

The operation time, blood loss, and the time consumed to stop bleeding were less in the neuroendoscopic hematoma evacuation group than those in the small bone window craniotomy group (all P<0.05). The GCS scores in the neuroendoscopic hematoma evacuation group were significantly higher than those in the small bone window craniotomy group (P<0.05). The clearance rate of hematoma was higher in the neuroendoscopic hematoma evacuation group than that in the small bone window craniotomy group (P<0.05).

CONCLUSION

As compared with small bone window craniotomy for removing hematoma, neuroendoscopic hematoma evacuation showed a better outcome in treating patients with hypertensive ICH. It could improve patients' clinical indications, which is worthy of being widely applied in clinical settings.

Effects of Acupressure on Anxiety: A Systematic Review and Meta-Analysis

Objectives: The research aim was to perform a systematic review and meta-analysis evaluating the ability of acupressure to reduce anxiety. Design: Randomized controlled trials were obtained through a search of electronic medical databases (four in English and one in Chinese) from inception to October 5, 2020. Two authors searched the databases, evaluated studies' methodological quality, and performed data extraction independently. The final studies for analysis were identified after discussion with the third author. Results: We obtained 27 studies for our systematic review and meta-analysis. Eight studies had a low overall risk of bias, and 13 had some bias concerns with methodological quality. According to the results, acupressure significantly reduced patient anxiety (standardized mean difference = 1.152; 95% confidence interval: 0.847-1.459, p < 0.001), and the study heterogeneity was high (Q = 299.74, p < 0.001, I² = 91.333%). Two studies reported acupressure-associated adverse events. We also performed a sensitivity analysis by omitting one outlier study, which had the largest effect size; however, high heterogeneity remained (I² = 87.816%). A subgroup analysis revealed significant differences between participant types (Q = 46.573, p < 0.001), levels of methodological quality (Q = 6.228, p = 0.044), and massage equipment (Q = 4.642, p = 0.031). Conclusions: Our meta-analysis suggests that acupressure can alleviate anxiety. Acupressure was more effective for inpatients and preoperative patients when finger massage was applied. In individuals with anxiety and a stable hemodynamic status, acupressure could be a promising treatment option. However, the substantial heterogeneity across studies means that any inference from the results should be performed cautiously.

Lower AM-PAC 6-Clicks Basic Mobility Score Predicts Discharge to a Postacute Care Facility Among Patients in Cardiac Intensive Care Units

OBJECTIVE

The objective of this study was to determine the ability of the Activity Measure for Post-Acute Care "6-Clicks" Basic Mobility Short Form to predict patient discharge destination (home vs postacute care [PAC] facility) from the cardiac intensive care unit (ICU), including patients from the cardiothoracic surgical ICU and coronary care unit.

METHODS

This retrospective cohort study utilized electronic medical records of patients in cardiac ICU (n = 359) in an academic teaching hospital in the southeastern region of United States from September 1, 2017, through August 31, 2018.

RESULTS

The median interquartile range age of the sample was 68 years (75-60), 55% were men, the median interquartile range 6-Clicks score was 16 (20-12) at the physical therapist evaluation, and 79% of the patients were discharged to home. Higher score on 6-Clicks indicates improved function. A prediction model was constructed based on a machine learning approach using a classification tree. The classification tree was constructed and evaluated by dividing the sample into a train-test split using the Leave-One-Out cross-validation approach. The classification tree split the data into 4 distinct groups along with their predicted outcomes. Patients with a 6-Clicks score >15.5 and a score between 11.5 and 15.5 with primary insurance other than Medicare were discharged to home. Patients with a 6-Clicks score between 11.5 and 15.5 with Medicare insurance and those with a score ≤11.5 were discharged to a PAC facility.

CONCLUSION

Patients with lower 6-Clicks scores were more likely to be discharged to a PAC facility. Patients without Medicare insurance had to be significantly lower functioning, as indicated by lower 6-Clicks scores for PAC facility placement than those with Medicare insurance.

IMPACT

The ability of 6-Clicks along with primary insurance to determine discharge destination allows for early discharge planning from cardiac ICUs.

Efficacy of Early and Enhanced Respiratory Physiotherapy and Mobilization after On-Pump Cardiac Surgery: A Prospective Randomized Controlled Trial

Background: This randomized controlled trial aimed to investigate the influence of physical activity and respiratory physiotherapy on zero postoperative day on clinical, hemodynamic and respiratory parameters of patients undergoing cardiac surgeries under extracorporeal circulation. Methods: 78 patients undergoing coronary artery bypass graft (CABG) or/and valvular heart disease surgeries were randomly assigned into an early and enhanced physiotherapy care group (EEPC group; n = 39) and a conventional physiotherapy care group (CPC group; n = 39). Treatment protocol for the EEPC group included ≤3 Mets of physical activity and respiratory physiotherapy on zero post-operative day and an extra physiotherapy session during the first three post-operative days, whereas the CPC group was treated with usual physiotherapy care after the first post-operative day. The length of hospital and intensive care unit (ICU) stay were set as the primary study outcomes, while pre- and post-intervention measurements were also performed to assess the oxymetric and hemodynamic influence of early mobilization and physiotherapy. Results: Participants’ mean age was 51.9 ± 13.8 years. Of them 48 (61.5%) underwent CABG. Baseline and peri-procedural characteristics did not differ between the two groups. The total duration of hospital and ICU stay were significantly higher in the CPC group compared to the EEPC group (8.1 ± 0.4 days versus 8.9 ± 0.6 days and 25.4 ± 3 h versus 23.2 ± 0.6 h, p < 0.001, respectively). Statistically significant differences in pre-intervention oxygen saturation, and post-intervention PO2 and lactate levels were also observed between the two groups (p = 0.022, 0.027 and 0.001, respectively). Conclusion: In on-pump cardiac surgery, early and enhanced post-procedural physical activity (≤3 METS) can prevent a prolonged ICU stay and decrease the duration of hospitalization while ameliorating post-operative hemodynamic and oxymetric parameters.

Analysis of rehabilitation in stroke patients in a High Dependency Unit

OBJECTIVE

To analyze the rehabilitation effict of stroke patients in the High Dependency Unit (HDU).

METHODS

A retrospective study was conducted on 96 ischemic stroke patients who met the inclusion criteria and were hospitalized in the Department of Rehabilitation Medicine of Qujing No. 1 Hospital by convenience sampling. All patients were divided into two groups according to the inclusion and exclusion criteria: experimental group (n=49) and control group (n=47). The experimental group was admitted to the HDU and treated with the whole-process of full cycle rehabilitation management and treatment, and the control group was admitted to the general ward and treated with the conventional treatment model of the Department of Rehabilitation Medicine.

RESULTS

The improvement of muscle strength at discharge was compared between the two groups. The results showed that the muscle strength effective rate was 85.7% in the experimental group and 55.3% in the control group, and the difference had statistical significance (P<0.01). The Barthel index score at admission and at discharge were compared between the two groups, the results showed that there was no significant difference in the Barthel index score at admission between the two groups (t=0.668, P>0.05). The Barthel index score at discharge in the experimental group was higher than that in the control group, and the difference had statistical significance (t=7.969, P<0.05). The Montreal Cognitive Assessment (MoCA) score of the experimental group before treatment was (25.67±3.11) points, and the MoCA score after treatment was (29.01±2.21) points; the MoCA score of the control group before treatment was (24.11±4.65) points, and the MoCA score after treatment was (25.35±2.29) points. After implementation of the clinical nursing pathway, the improvement in cognitive function in the experimental group of patients was significantly higher than that in the control group, and the difference had statistical significance (P<0.01). Through the investigation of the satisfaction rate of nursing work in the two groups, it was found that the satisfaction rate in the experimental group was better than that in the control group, and the difference had statistical significance (P<0.05); there was 1 case of pressure sores that occurred in the experimental group, and 3 cases that occurred in the control group, χ²=1.133, P=0.287, and the difference had no statistical significance (P>0.05). The length of hospital stay was compared between the two groups, the results showed that the length of hospital stay was (11.76±2.06) days in the experimental group and (14.21±2.40) days in the control group, thus, the average length of hospital stay in the experimental group was less than that in the control group, and the difference had statistical significance (P<0.001).

CONCLUSION

The whole-process of full cycle rehabilitation management and treatment can improve the activities of daily living, limb muscle strength and cognitive function of patients, as well as shorten the length of hospital stay and improve the satisfaction of patients with treatment. Thus, it is worthy of being widely popularized in clinical application.

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

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 ± 15.6 years old, 44% women, body mass index 29.2 ± 9.3 kg/m²) 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 = 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.