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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.

ABSTRACT: 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.

SUBMITTER: Tonna JE

PROVIDER: S-EPMC7063884 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

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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.

Tonna Joseph E JE Johnson Joshua J Presson Angela A Zhang Chong C Noren Chris C Lohse Bryan B Bento Haley H Barton Richard G RG Nirula Raminder R Mone Mary M Marcus Robin R

Critical care explorations 20191030 10

Studies of mobility during critical illness have mostly examined transitions from immobility (passive activities) or limited mobility to active "early mobility."<h4>Design</h4>Observational analysis of a quality improvement initiative.<h4>Setting</h4>Two ICUs (surgical ICU, cardiovascular ICU) at a tertiary academic medical center.<h4>Patients</h4>Critically ill surgical and cardiovascular patients.<h4>Interventions</h4>Doubling available physical therapy.<h4>Measurements and main results</h4>We ...[more]

PMID: 32166236

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Project description:Advance directives can help guide care in the ICU. As a healthcare quality improvement initiative, we sought to increase the percentage of patients with a healthcare power of attorney and/or practitioner orders for life-sustaining treatment in our ICU and to increase medical resident experience with advance directives through routine screening and documentation of advance directives in the ICU.DesignProspective analysis.SettingUrban U.S. community teaching hospital.PatientsAll patients admitted to the ICU from September 2018 to February 2019.InterventionsInternal medicine residents in the ICU received a lecture about advance directives and instructions to screen their patients for advance directives. For willing and decisional patients, residents facilitated the creation of a healthcare power of attorney and/or practitioner orders for life-sustaining treatment. Residents were anonymously surveyed at the beginning and end of the ICU rotation about their experience and level of comfort with healthcare power of attorney and practitioner orders for life-sustaining treatment completion.Measurements and main resultsThree-hundred seventy-five patients were admitted to the ICU during the study period. Healthcare power of attorney documents were generated by 34% of all ICU patients without a prior healthcare power of attorney, increased from a baseline rate of 10% (p < 0.001). The number of practitioner orders for life-sustaining treatment documents for patients with code status of "no cardiopulmonary resuscitation" did not increase significantly. The percentage of residents who facilitated completion of a healthcare power of attorney document increased significantly from 56% to 100% (p < 0.001), whereas their practitioner orders for life-sustaining treatment experience did not change significantly by the end of their ICU rotation. On a Likert scale of 0-10, mean resident comfort increased significantly both with healthcare power of attorney documentation, rising from 6.14 to 8.84 (p = 0.005) and with practitioner orders for life-sustaining treatment form completion, increasing from 6.00 to 7.84 (p = 0.008).ConclusionsTraining ICU medical residents to routinely screen for and facilitate completion of advance directives significantly increased the percentage of ICU patients with a healthcare power of attorney and significantly improved medical resident comfort with healthcare power of attorney and practitioner orders for life-sustaining treatment form completion.

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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.

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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.

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