Physical therapy in ICU can reduce hospital stays

The results of the first study to show the effectiveness of early physical therapy in a medical intensive care unit (ICU) were presented by a researcher from Wake Forest University Baptist Medical Center at the national meeting of the American College of Chest Physicians in Chicago.

The length of stay for a group of respiratory-failure patients who received mobility therapy within 48 hours of the insertion of a breathing tube was reduced by an average of three days compared to the stay for patients who did not receive the therapy. This reduced length of stay included a reduction of time in the ICU of more than a day.

Initial therapy – called passive range of motion – was provided by nursing assistants who flexed the joints of the patients' upper and lower limbs three times a day, seven days a week. As patients progressed, they received more advanced physical therapy from a physical therapist. The therapy proved safe, and there was also no addition to hospital costs because the salaries of the employees who provided mobility therapy were offset by reduced lengths of stay in the hospital, according to Peter Morris, M.D., lead investigator and associate professor in the Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases.

Immobility and the resulting loss of physical conditioning are common problems for patients with respiratory failure, which means they cannot breathe without the assistance of a ventilator, said Morris. However, little data exist on whether early mobility therapy for ICU patients is associated with improved outcomes or cost benefits.

“Although there are data for efficacy of exercise for emphysema patients and for congestive heart failure patients in the outpatient setting, this was the first time for ICU administration of exercise as a therapeutic agent,” said Morris. “The project confirms that it is safe to administer early mobility to ICU patients and that it is of benefit.”

Phase I of a planned two-phase study was designed to address this lack of data by conducting a structured project, or protocol, over 24 consecutive months from 2004 to 2006 in which respiratory-failure patients admitted to the Medical Center's ICUs were assigned to one of two groups: 165 to a protocol group, which received early therapy from a mobility team (a critical care nurse, a nursing assistant and a physical therapist), and 165 to a control group, which received usual care. Some of those patients who received usual care also received therapy, although not as early or as frequently as those in the protocol group. Once patients were transferred to a regular nursing unit, both groups received usual care.

In addition to shorter hospital stays, the protocol patients also progressed more quickly to active physical therapy, were out of bed earlier and experienced no adverse events during an ICU therapy session.

Morris said further studies are needed in order to clarify the optimum number and duration of exercise sessions. Phase II of the study at the Medical Center will look at a broader range of ICU patients, both more and less ill, and will continue through hospital discharge. In addition, a study funded by the Medical Center's Claude D. Pepper Older Americans Independence Center will examine the effect of early mobility therapy for the elderly, who may be more at risk than younger patients for ICU-related arm and leg weakness.

Morris will make additional presentations on the study in February at the 37th Critical Care Congress of the Society of Critical Care Medicine, and in May at the 2008 International Conference of the American Thoracic Society.

Phase I of the early mobility therapy study was conducted by a team from both N.C. Baptist Hospital and Wake Forest University School of Medicine representing hospital administration, nursing leadership, the Division of Public Health Sciences, physical therapy, and the Section on Pulmonary Care. The study was funded primarily by Baptist Hospital.

The Medical Center's ICUs are one of 10 sites for the adult respiratory distress syndrome (ARDS) network of the National Institutes of Health, which is the critical care research network for the United States.