Rehabilitation Quality Improvement in an Intensive Care Unit Setting: Implementation of a Quality Improvement Model

Dale M. Needham, MD, PhD,13 and Radha Korupolu, MBBS, MS1

1

OACIS Group, Division of Pulmonary & Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland; 2 Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, Maryland; 3Critical Care Physical Medicine and Rehabilitation Program, Johns Hopkins Hospital, Baltimore, Maryland

Objective: There are barriers to providing early physical medicine and rehabilitation (PM&R) in the intensive care unit (ICU). We present a specic model for undertaking quality improvement (QI) projects and a case study focused on QI for early PM&R in the ICU. Methods: The QI project was undertaken using a 4-step model: (1) summarizing the evidence, (2) identifying barriers, (3) establishing performance measures, and (4) ensuring patients receive the intervention. To evaluate the application and outcomes of this model, we present data collected during a 4-month QI period versus an immediately preceding 3-month control period. Results: Deep sedation was a major barrier to early PM&R that was addressed in the QI project. Compared to the control period, there was a decrease in medical ICU (MICU) days with any benzodiazepine use (73% vs 96% of days, P = .03) and narcotic use (77% vs 96%, P = .05) and improved delirium status (MICU days without delirium, 53% vs 21%, P = .003). In addition, more QI patients had physical therapy consultations (93% vs 59%, P = .004) and greater number of rehabilitation treatments with higher functional mobility (treatments involving sitting or greater mobility, 78% vs 56%, P = .03). Hospital data for the QI period demonstrated a decrease in average length of stay in the MICU (4.9 vs 7.0 days, P = .02) and hospital (14.1 vs 17.2, P = .03) compared to the prior year. Conclusion: A structured QI model can be applied to implementation of early PM&R in the ICU resulting in markedly improved delirium status, delivery of PM&R, functional mobility, and length of stay. Key words: critical care, delirium, early ambulation, health care, intensive care units, muscle weakness, quality assurance, rehabilitation

imilar to the sequelae faced after a stroke, patients with acute respiratory failure requiring mechanical ventilation in the intensive care unit (ICU) frequently experience neuromuscular weakness, impaired physical function, decreased quality of life, and delayed return to work.14 Physical medicine and rehabilitation (PM&R) interventions delivered early have the potential to improve these complications in patients with acute stroke5 and with critical illness in the ICU setting. 6,7 However, there are many barriers related to early PM&R in the ICU, including ICU culture, clinicians lack of knowledge, patients physiological instability, and stafng issues.2,810 In this article, we describe a quality improvement (QI) project undertaken to address early PM&R in the medical ICU (MICU) at Johns Hopkins Hospital.11 This project represents a case study for understanding PM&R QI in the ICU setting and for illustrating how a specic model for QI can be applied. We will rst describe the context for the QI project at Johns Hopkins Hospital and then provide an overview of the QI model. Thereafter, we will discuss application of the model, step by

step, in the context of this case study, which can be generalized to improving outcomes in patients with stroke. Context for QI Project at Johns Hopkins Hospital Johns Hopkins Hospital is a quaternary care, academic teaching hospital with more than 1,000 beds, located in an inner city neighborhood in Baltimore, Maryland. The MICU has 16 beds and is staffed with physicians (2 attendings, 2 fellows, and 6 housestaff), registered nurses (staff to patient ratio of 1:2), and respiratory therapists (staff to patient ratio of 1:8). Physical medicine and rehabilitation and neurology physicians and physical and occupational therapy (PT and OT) consultations are available when ordered by a MICU physician. In the MICU, bed rest was the
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default activity level in the standard admission orders, and there were no guidelines for PT or OT consultation or treatment. Nursing care included use of standardized pain and sedation scales, with a nurse-titrated sedation protocol. Standardized delirium assessments were not part of routine nursing care. Mobilizing mechanically ventilated patients in the ICU is feasible, safe, and benecial in improving physical function. 7,12,13 However, early mobilization is seldom practiced in most ICUs.14 In the MICU at Johns Hopkins Hospital, neuromuscular complications and early mobilization became areas of interest. As the lead study site for a prospective cohort study evaluating the long-term outcomes of patients surviving acute lung injury/acute respiratory distress syndrome,15 clinicians from the Johns Hopkins MICU became interested in these areas after witnessing the weakness and functional impairments experienced by research participants who had been discharged from the MICU. In addition, preliminary data analysis from this cohort study indicated that only 24% of ARDS patients ever received consultation for PT and/or OT in the Johns Hopkins Hospital MICU, which was almost 50% lower than for similar patients at 2 other academic hospitals in Baltimore.16 In addition, preliminary data analysis also indicated a higher prevalence of deep sedation in the MICU patients (58% vs 27% of ICU days) and a very low proportion (<15%) of ICU days in which patients were not deeply sedated or delirious. Based on this experience, a QI project was undertaken that focused on patients receiving mechanical ventilation for 4 days. Two major QI goals were (1) to improve patient sedation and delirium status and (2) to increase rehabilitationrelated consults and treatments in order to improve functional mobility. The QI project was undertaken using a specic multistep QI model as discussed in the next section. Description of a Model for QI Figure 1 illustrates the established QI model used for this project. The model is briefly described here with additional details available in other publications.1719 Key aspects of the

model considered throughout all steps of the QI process included understanding the problem within the larger health care system and creating a multidisciplinary QI team. Moreover, there are 4 steps in the model: (1) summarizing the evidence, (2) identifying barriers to implementation, (3) establishing performance measures, and (4) ensuring that patients receive the intervention. In the last stage, a 4 Es process was undertaken involving engaging, educating, executing, and evaluating the implementation in an iterative manner. Although described as 4 separate steps, aspects of this QI model may occur simultaneously. Application of QI Model for Early PM&R in the MICU
Overall considerations

It was clear that the improvement process involved a patient care system larger than the regular multidisciplinary MICU team (consisting of physicians, nurses, and respiratory therapists) and that more extensive collaboration would be needed. Moreover, based on the experience of another hospital10 and local experience in the Johns Hopkins MICU, it was anticipated that the necessary culture change to successfully adopt early PM&R would be challenging but important for a successful QI project.20 Moreover, those involved in the QI project wanted to rigorously evaluate it to obtain data regarding its feasibility, safety, and effectiveness. Convincing hospital leaders of these issues was considered critical to help sustain the QI process. Consequently, approximately 1 year was required for planning the QI project prior to implementing early PM&R in the MICU. We believed that appropriate planning, preparation, and collaboration were key to succeeding with a major change in culture regarding early PM&R in our MICU.
Step 1: Summarize the evidence

Relevant evidence regarding the harms of bed rest and the safety, feasibility, and potential benets of early mobilization of acute and longterm ICU patients was reviewed.4,12,2135 Moreover,

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1. Summarise the evidence Identify interventions associated with improved outcomes Select interventions with the largest benefit and lowest barriers to use Convert interventions to behaviours 2. Identify local barriers to implementation Observe staff performing the interventions Walk the process to identify defects in each step of implementation Enlist all stakeholders to share concerns and identify potential gains and losses associated with implementation 3. Measure performance Select measures (process or outcome) Develop and pilot test measures Measure baseline performance 4. Ensure all patients receive the interventions Implement the four Es targeting key stakeholders from front line staff to executives Engage Explain why the interventions are important Evaluate Regularly assess for performance measures and unintended consequences Educate Share the evidence supporting the interventions

Overall concepts Envision the problem within the larger healthcare system Engage collaborative multidisciplinary teams centrally (stages 13) and locally (stage 4)

Execute Design an intervention toolkit targeted at barriers, standardisation, independent checks, reminders, and learning from mistakes

Figure 1. Model for quality improvement process. A model for conducting quality improvement within the health care setting. Reproduced, with permission, from Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008;337:a1714. Copyright 2008 by BMJ Publishing Group Ltd.

additional evidence and practice guidelines specifically addressing early PM&R of MICU patients arose during the QI project to further solidify the evidence base.7,13,14,36 This evidence, along with our local MICU data regarding sedation and rehabilitation practices,16 were summarized and disseminated via newsletters, posters, and presentations.
Step 2: Identify local barriers to implementation

Systematic methods for identifying and documenting barriers to QI interventions are evolving.17,37 We carefully considered the steps involved in preparing the patient and ordering

and delivering early rehabilitation therapy through engaging all relevant stakeholders (MICU, PM&R and neurology physicians, and RN, RT, PT, and OT) in small group meetings and presentations. In particular, our project started with gaining support of the organizational leaders (directors of PM&R, MICU, and Pulmonary and Critical Care Medicine) and supervisors for PT, OT, and RT. In addition, grassroots support was established via champions from each discipline: MICU and PM&R physicians, PT, OT, RN, and RT. A MICU physician (D.M.N.) who was well known to many of the involved clinicians and who had experience with QI methods was the overall leader for the QI project and received regular

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support and advice from the long-time MICU Director. Through a series of meetings with each clinical discipline and regular group meetings with all of the multidisciplinary champions, specic barriers from each disciplines unique perspective could be obtained. Moreover, given the goal of formally evaluating the QI project, data were collected on the type and frequency of barriers to rehabilitation as well as patients rehabilitation-related outcomes during their hospitalization.11 Important barriers to the QI project, arising from the previously described process, are

detailed in Table 1. Critical to the QI process was having the QI project leader acknowledge each global and patient-specic barrier raised by stakeholders and address it on a timely basis. This validation ensured that stakeholders felt that their concerns were being heard and addressed. The process of addressing the barriers often included seeking multidisciplinary input and brainstorming for solutions. During the QI process, it was emphasized that implementing this intervention required learning and that the approach would be continually rened throughout its implementation.

Table 1.
Barrier

Barriers to early physical medicine and rehabilitation in the Johns Hopkins MICU
Strategy to overcome barrier Designated an overall leader who was involved and committed to quality improvement (D.M.N.) Involved a champion from every discipline, including physician, PT, OT, RN, and RT Obtained strong support from both MICU and PM&R leadership Obtained dedicated full-time OT & PT in MICU and part-time technician Initiated PM&R physician consultations in MICU Purchased 2 wheelchairs to assist with sitting patients out of bed Educated the multidisciplinary team regarding the rationale and evidence for early PM&R interventions Created simple guidelines for consultation of OT & PT in the MICU setting Consulted neurologists regarding patients with severe and/or persistent muscle weakness Cross-trained staff, including: Training PTs regarding basic EKG interpretation and suctioning Orienting PTs and OTs to ventilator settings, use of portable ventilator, and troubleshooting alarms Training RNs regarding patient transfer from bed to chair Project coordinator (R.K.) screened patients using pre-dened eligibility criteria6 Project coordinator (R.K.) prompted physicians for timely consultations to PT and OT when screening criteria met Interdisciplinary education regarding changing from continuous infusion to as needed boluses for sedation Screening patients sedation status using the validated RASS scale43 For specic MICU patients who were deeply sedated, the project leader (D.M.N.) had: One-on-one discussions with MICU clinical fellows and attending physicians Frequent bedside discussions with day and night shift nurses regarding changes in sedation practice Screening for delirium by PTs and OTs, using the validated CAM-ICU instrument44 Minimized use of drugs associated with delirium (eg, benzodiazepines) Encouraged use of antipsychotics to treat agitated delirium Assessed pain and ordered pain medication, as needed, prior to rehabilitation therapy Requested patient feedback on comfort during and after rehabilitation therapy Created guidelines for screening patients for physiological stability for PM&R therapy6 PT and OT screened patients on a daily basis to ensure safety before therapy initiated Changed mechanical ventilation mode and increased FiO2 by 0.2, as needed, prior to starting therapy PTs and OTs ensured securement of devices prior to therapy Untangling of lines and tubes occurred prior to therapy to avoid accidental dislodgement

Lack of leadership

Lack of stafng & equipment

Lack of knowledge & training

Lack of physician referrals

Oversedation

Delirium

Perceived pain and discomfort Physiological instability

Safety

Note: CAM-ICU = Confusion Assessment Method for the ICU; EKG = electrocardiogram; MICU = medical intensive care unit; OT = occupational therapist; PM&R = physical medicine and rehabilitation; PT = physical therapist; RASS = Richmond Agitation and Sedation Scale; RN = registered nurse; RT = respiratory therapist.

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Step 3: measure performance

Performance measures, or quality indicators, for the QI project can be process- or outcomeoriented as described in an accompanying article in this issue.38 As outlined in Table 2, performance measures developed as part of the QI process were often specically targeted at the previously identied barriers. Not all of these performance measures were feasible to collect on an ongoing basis after the QI project, due to issues with their accuracy, feasibility, or time

requirement for measurement.11 Table 2 indicates which measures were used on an ongoing basis after the intensive evaluation phase of the QI project was nished.
Step 4: ensure patients receive the intervention: the 4 Es model

To ensure that patients received the QI intervention, an iterative 4 Es model (engage, educate, execute, and evaluate) was used as described in this section.

Table 2.

Performance measures and results for quality improvement projecta

Pre-QI period (n=27 QI period (n=30 patients with 312 patients with 482 MICU patient days) MICU patient days) 41% 59% 74% 30% 7% 93% 90% 67%

Barrier Lack of stafng Lack of physician referrals Oversedation

Performance measure Proportion of ICU days with no therapy for patients Physical therapy consultations, proportion patients Occupational therapy consultations, proportion patients Alert during sedation assessment (RASS score -1 to +1), proportion of ICU days Benzodiazepines: Ever receiving benzodiazepine in ICU, proportion of patients Daily midazolam-equivalent dose, median (IQR) mg Narcotics: Ever receiving narcotics in ICU, proportion of patients Daily morphine-equivalent dose, median (IQR) mg Not delirious (CAM-ICU negative), proportion of ICU days Ever receiving haloperidol in ICU, proportion of patients Daily haloperidol dose, median (IQR) mg Pain scale (range 010), mean (SD) of daily scores Among all of rehabilitation treatments: Change in heart rate (baseline to maximum during therapy), median (IQR) beats per minb Change in systolic blood pressure (baseline to end of therapy), median (IQR) mmHgb Change in oxygen saturation (baseline to lowest during therapy), median (IQR)b Unexpected eventsc, proportion of rehabilitation treatments Functional mobility: proportion of treatments with sitting at the edge of bed or greater Among all MICU admissions: MICU average length of stay, days Hospital average length of stay, days In-hospital mortality, proportion of admissions

P .004 .004 .17 <.001

96% 47 (21114) 96% 71 (30180) 21% 26% 4 (2, 6) 0.6 (1.9) n=50 6 (2 to 10) 3 (-4 to 13) -1 (-2 to 0) 0% 56% n=262 7.0 17.2 23.3%

73% 15 (359) 77% 24 (3120) 53% 7% 2 (1, 2) 0.6 (1.7) n=294 9 (2 to 16) 2 (-6 to 8) -2 (-3 to 0) 1% 78% n=314 4.9 14.1 21.0%

.03 .09 .05 .01 .003 .05 .15 .79 .10 .40 .07 >.99 .03

Delirium

Perceived pain Physiological instability

Safety Benets

.02 .03 .55

Note: CAM = confusion assessment method; ICU = medical intensive care unit; IQR = interquartile range; OT = occupational therapist; PT = physical therapist; RASS = Richmond Agitation and Sedation Scale, SD = standard deviation. a Measures for both the pre-QI and QI periods and the P values obtained from a published report of the Johns Hopkins medical intensive care unit quality improvement project.19 b Sample size ranges from 46 to 49 and 258 to 277 treatments for pre-QI and QI period, respectively, because of missing data. c Dened as cardiopulmonary arrest, loss of consciousness, fall, removal of any medical device, or oxygen desaturation <85% for >3 minutes.

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Engage

For education to be benecial and clinical practice to change, it was key that all stakeholders (from leaders and supervisors to frontline clinical staff) were engaged in the QI project and understood why the interventions were important. Engagement for our QI project occurred via many routes, including (a) sharing patient anecdotes, (b) having patients return to the MICU to share their stories of difculties encountered during the recovery process (eg, muscle weakness, physical impairment), (c) providing local data regarding MICU performance compared to peer hospitals, and (d) having guest speakers from another hospital experienced in ICU early mobility10,12 discuss their approach with our staff.
Educate

trip to a hospital with an established ICU early rehabilitation program was undertaken by one MD, RN, and PT. Each clinician then formally and informally shared their learning experience with others in their discipline after their return. This trip provided the chance for a member from each clinician group to actually see the rehabilitation process and to speak with experienced peers.
Execute

For busy clinicians, education must occur in an easy-to-access manner. Full research papers are often not readily accessible to clinicians. Hence, brief summaries of important research for educating clinicians were disseminated via a MICU newsletter, posters, bulletin boards, and invited speakers giving brief presentations. In addition, assessment of the local barriers for our QI project (step 2) revealed some specific educational barriers that required intervention during the QI implementation. For example, PTs received training on basic EKG interpretation and general orientation to ventilator modes, settings, and alarms in preparation for ambulating mechanically ventilated patients. RTs provided specific orientation to PTs regarding the portable ventilator (iVent201; VersaMed GE Healthcare, Piscataway, NJ) used for ambulation of mechanically ventilated patients. PTs trained RNs regarding transfer techniques and use of wheelchairs for seating patients out of bed. To educate RNs regarding the necessary changes in sedation and the rehabilitation interventions by PT and OT, 16 small group meetings were held by the MICU physician leaders. Two large group training sessions were held with RTs, and 5 presentations were given to the MICU physicians. In addition, a 2-day educational

Execution of the QI project required specic interventions to overcome the identied barriers. General approaches to successfully addressing barriers included (a) standardizing care, (b) using independent checks and reminders, (c) maximizing convenience and simplicity, and (d) learning from situations in which there were problems with implementation.17 Table 1 describes some specic interventions used to address barriers identied in our QI project. This approach resulted in the delivery of 294 PT and OT treatments for 30 patients during their MICU stay. These treatments involved the following specic mobilization activities: moving from supine to sit (72% of treatments), sitting at the edge of bed (77%), transfer from bed to chair (38%), transfer from sitting to standing (49%), and ambulation (13%). These mobilization activities were performed by a PT or OT with the assistance of an RN or technician, as needed. In general, RNs did not routinely initiate any of these activities in mechanically ventilated patients. To ensure safety, all patients were screened, on a daily basis, by PT and OT before initiating any mobilization activities as described in Figure 2.
Evaluate

Via weekly multidisciplinary meetings, problems arising during the QI intervention were discussed and resolved on a timely basis. A summary of key results from the QI project are presented in Table 2. These results indicate what was achieved during a 4-month QI period compared to either a 3-month period immediately prior to the QI period or to the same 4-month

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Neurologic criteria: Opens eyes to verbal stimulation

Yes

No

Primary CNS etiology

Sedation-related medication

Attempt to decrease sedation via: - interrupting continuous infusions - changing from continuous infusion to as needed bolus doses - using anti-psychotic medication for treatment of hyperactive delirium

Reassess tomorrow

Respiratory criteria: FiO2 > 0.6 PEEP > 10 cm H2O Circulatory criteria: New or increased vasopressor dose within past 2 hrs Continuous infusion of a vasodilator medication Addition of a new anti-arrhythmic agent New cardiac ischemia Carefully evaluate appropriateness of therapy

No

Yes to 1 or more

Consult therapist for rehabilitation

Other criteria: Hypoxemia: Pulse oximetry <88%, Tachypnea: Respiratory rate >45 bpm, Acidosis: Arterial pH <7.25, Hypotension: Mean arterial pressure <55 mmHg, Hypertension: Mean arterial pressure >140 mmHg, or New deep venous thrombosis

No

Yes

Discuss with ICU physician regarding appropriateness for therapy

Carefully initiate activity

Figure 2. A screening algorithm for patient mobilization in the intensive care unit. CNS = central nervous system; FiO2 = fraction of inspired oxygen; ICU = intensive care unit; PEEP = positive end expiratory pressure. Reproduced, with permission, from Korupolu R, Gifford JM, Needham DM. Early mobilization of critically ill patients: reducing neuromuscular complications after intensive care. Contemp Crit Care. 2009; 6(9):112. Copyright 2009 Lippincott Williams & Wilkins.

period in the prior year. A photograph illustrating successful ambulation of a mechanically ventilated patient in the MICU is provided in Figure 3. The magnitude of these improvements helped

demonstrate that the extensive planning was successful in changing culture to make early PM&R in the MICU feasible, safe, and benecial to patients.

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Figure 3. Early mobilization of a mechanically ventilated patient in the Johns Hopkins Hospital medical intensive care unit (MICU). Photograph of a 56-year-old man with severe chronic obstructive pulmonary disease and acute renal failure who is ambulating 4 days after admission to the Johns Hopkins Hospital MICU. He is ambulating while receiving mechanical ventilation via an oral endotracheal tube with a Physical Therapist supporting the patient from behind and a Respiratory Therapist in front with a portable mechanical ventilator. Reproduced, with permission, from Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. J Am Med Assoc. 2008;300:16851690 Copyright 2008 American Medical Association. All rights reserved.

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Follow-up From the QI Project Based on our rigorous evaluation of the QI project and the substantial decrease in MICU and hospital length of stay (Table 2), the hospital funded a comprehensive Critical Care Physical Medicine and Rehabilitation program after completion of the QI project. This program started July 1, 2008, and provided funding for the following staff dedicated to early PM&R in the MICU: 2 fulltime PTs who provide services 6 days per week, 1 full-time technician to assist the PTs 5 days per week, 1 full-time clinical coordinator (R.K.), and 1 full-time assistant to the coordinator. Given a strong focus on early mobility and the availability and skills of existing rehabilitation staff within the hospital, the stafng pattern was changed from 1 OT and 1 PT during the QI project to 2 PTs for this new hospital-funded program. The technician assisting with early PM&R also changed from a part-time to a full-time member of the team. The program includes support for MICU physicians to continue efforts to sustain and improve the culture change, including a MICU physician to serve as Medical Director for the multidisciplinary Critical Care Physical Medicine and Rehabilitation program (D.M.N.). The program continues to collect data on performance measures regarding both PM&R activities and length of stay for both clinicians and hospital administrators (Table 2). To further improve the early PM&R program, a new sedation protocol was created that formalized the approach undertaken during the QI project. In addition, delirium assessment became part of routine practice for MICU RNs and a delirium quality improvement project was undertaken. These quality improvements have also spread to 4 other ICUs at Johns Hopkins Hospitals using the foundation created from the MICU QI project. Building on this success, a new QI project aimed at improving the quality of patients sleep in the MICU, in order to improve patients cognition and participation with early PM&R activities, has been started. There is growing enthusiasm among many of the multidisciplinary clinicians working in the MICU to suggest quality improvements for other aspects of clinical care. Early PM&R is also being continuously rened, such as with the introduction of cycle ergometry (video

available online39), new biomedical engineering devices to assist with ambulation of mechanically ventilated patients (video available online40), and a randomized controlled trial of neuromuscular electrical stimulation therapy.41 Conclusion Stroke rehabilitation involves a diverse set of professional skills delivered in a team approach.42 Delivery of coordinated, patient outcomeoriented, intensive physical medicine and rehabilitation therapies to achieve maximum functional improvement is key for successful stroke rehabilitation. Efforts to introduce similar early PM&R interventions in the MICU at Johns Hopkins Hospital involved many challenges that may help inform QI efforts in the stroke rehabilitation setting. In our experience, these challenges were overcome using a structured QI process. Our QI project resulted in a reduction in deep sedation and increased early PM&R activities for mechanically ventilated patients. Through these changes, substantial improvement was observed in the prevalence of ICU delirium and in patients functional mobility in the ICU, with a substantial decrease in MICU and hospital length of stay. The positive results of our QI project were sustained after its conclusion and resulted in a hospital-funded program for early PM&R and stimulated changes in other ICUs within our institution and at our peer hospitals. Acknowledgments All members of the multidisciplinary team involved in the Johns Hopkins Hospital Medical Intensive Care Unit quality improvement project provided important contributions to the early mobility program. The team members were Roy Brower, MD; Nancy Ciesla, PT; Victor Dinglas, BS; Eddy Fan, MD; Kenroy Greenidge, OT; Aline Hauber, OT; Kashif Janjua, MD; Landon King, MD; Chris Moghimi, OT; David Pitts, MD; Jeffrey B. Palmer, MD; Pranoti Pradhan, MBBS, MPH; Maggie Price, OT; Didi Rosell-Missler, RN; Jessica Rossi, PT, DPT; Janette Scardillo, PT; Edwin Szetela, OT; Lauren Waleryszak, RN; Mohommad Yavari Rad, MD; and Jennifer Zanni, PT, MSPT.

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