Early mobilisation – physiotherapists
demonstrate the impact of their work
The fear for one’s own existence as a physiotherapist in an increasingly dynamic market and a health sector where the focus is on cost-effectiveness is understandable, but not necessarily justified. Some examples show why changes also bring opportunities and how they can be used.
Patients who are treated in an intensive care unit suffer significant functional losses due to prolonged immobilisation, which can only be compensated for to a limited extent with follow-up rehabilitation. Muscle loss in patients with multiple organ failure can be up to 20% in the first seven days after admission. Therefore, although mortality from critical illness improves, survivors often suffer from persistent weakness and psychological and cognitive impairment.
Fortunately, more and more clinicians share the view that a structured early mobilisation process can significantly improve the functional outcome of ICU survivors and contribute to an enhanced quality of life following hospitalisation. The length of stay both in the intensive care unit and in hospital can be significantly reduced by early mobilisation measures. This not only optimises the entire care process, but also sustainably reduces the treatment costs per patient.
Physiotherapist David McWilliams and his colleagues at the University Hospitals Birmingham played a considerable role in this positive development. In a one-year study, they assessed the impact of early rehabilitation programmes on the long-term morbidity of patients with critical illnesses. Between April 2012 and March 2013, they documented the progress of patients who received a specific rehabilitation programme during their stay in an intensive care unit. They compared the results with data sets from the previous year, when patients did not receive early mobilisation in the intensive care unit.
All patients admitted to the ICU and requiring ventilation for more than five days were included in the analyses. Only patients with severe trauma and brain injuries were excluded. The main contributors to the project were specialist physiotherapist David McWilliams, who was tasked with improving rehabilitation within critical care, and two senior physiotherapists from Queen Elizabeth Hospital Birmingham.
Before the actual implementation of the rehabilitation programme, the main parties involved were first encouraged to undergo training on the safety and effectiveness of structured rehabilitation programmes in the ICU. In addition, specialised practical training was provided for the existing physiotherapy and nursing staff. The training programme was accompanied by the development of algorithms, checklists and safety criteria for mobilisation to support clinical decision-making.
A total of 292 patients met the inclusion criteria of the study during the intervention period. After the preparation phase, patients were examined as usual within 24 hours of admission and received the already established physiotherapy interventions. The patients who were ventilated for more than five days were assigned to a therapist who then carried out an individualised and structured rehabilitation programme. The treatment plan was reviewed in weekly multi-professional team meetings with the doctors, physiotherapists, intensive care nurses and an intensive care nutritionist, and the individual programme for the next seven days was determined.
The team used visualisation to motivate everyone involved. The progressive training plan for each week and the associated rehabilitation goals were written on wall charts as an incentive for the multidisciplinary team. Together with the weekly meetings to review progress and set new goals for the following week, this allowed for a consistent focus on rehabilitation, which was essential for graduated therapy with the aim of continuous improvement.
The results of the study are clear. The average length of stay in the intensive care unit was reduced by 2.5 days from 16.9 to 14.4; the average length of stay in hospital was even reduced from 35.3 to 30.1 days. The average duration of invasive ventilation also decreased from 11.7 to 9.3 days.
In addition to a shorter time for initial mobilisation (9.3 vs. 6.3 days), there was also a higher level of mobility (Manchester Mobility Score 3 vs. 5) at the time of discharge from intensive care.
Although no significant difference was found between the preparatory study and study data in terms of ICU mortality, in-hospital mortality was significantly lower after the introduction of the programme (39% vs. 28%). In addition, the introduction of the early rehabilitation programme in the ICU was associated with a significant reduction in 3-year mortality (81/201 = 40.3% vs. 60/222 = 27%).
The project initially cost the hospital £75,192 to fund two additional physiotherapy posts. However, the reduction in length of stay due to early rehabilitation ultimately equated to a reduction in patient costs of £951,200 for the cohort. In real terms, this was reflected in the saving of bed days and an increased capacity of 3.7 intensive care beds and 2.5 ward beds. Following the results of the project, the financial resources for the early rehabilitation programme were permanently allocated and the two physiotherapists were taken on to continue the project. The feedback from patients and staff on the project was excellent.
The results of this project show very impressively that early rehabilitation in the intensive care unit has the potential to significantly improve the outcome of patients. Physiotherapists have the opportunity to take a leading role in the implementation process and support more efficient care processes without having to worry about their own livelihood. The project was initiated at a time when funding for physiotherapy was drastically reduced. But instead of a simple cut in jobs, the project has succeeded in demonstrating the crucial value of physiotherapy and even creating entirely new values.
Implementing a new treatment pathway is a challenge. But with perseverance, education and a clear plan to evaluate the results, much can obviously be achieved. The study highlights the importance of tying objective measures to the structure and outcomes of therapies. The use of assessments and mobility scores in this case was instrumental in demonstrating the added value of introducing an early rehabilitation programme and in illustrating the role of physiotherapy in improving the overall outcome.
Other studies, such as the one by Alice Chiarici and her colleagues, confirm that this finding is not an isolated case. In their study “An Early Tailored Approach Is the Key to Effective Rehabilitation in the Intensive Care Unit”, the researchers confirmed that an interdisciplinary team approach that enables early and individualised planning of physiotherapy programmes increases the ventilator- free time of intensive care patients and reduces the overall length of stay in hospital. This is especially true of patients who are being treated in the intensive care unit after general surgery. Moreover, the authors describe that such a rehabilitation path can be generalised for different geopolitical scenarios, as it is feasible, safe and cost-effective. The results were presented at the American Congress of Rehabilitation Medicine in 2019 and published in the journal “Archives of Physical Medicine and Rehabilitation”.
 Chiarici A, Serpilli O, Andreolini M et al. (2019). An Early Tailored Approach Is The Key To Effective Rehabilitation In The Intensive Care Unit. Archives of Physical Medicine and Rehabilitation 100(8):1506-1514. doi: 10.1016/j.apmr.2019.01.015.…
 McWilliams D, Weblin J, Atkins G et al. (2014). Enhancing rehabilitation of mechanically ventilated patients in the intensive care unit: A quality improvement project. Journal of critical care. 30(1):13-8. doi: 10.1016/j.jcrc.2014.09.018.