Improving ICU Patient Mobility to Shorten Hospital Stays

The operation of healthcare providers differs from that of most other businesses in three important ways: 

1. The most important outcomes are not measured in dollars, but in terms of patient survival and quality of life.
2. They cannot fully control their revenues—rates are often subject to influence by HMOs, insurance companies, and Medicare/Medicaid.
3. They cannot control major components of their costs. For example, the number of staff, such as nurses, is often dictated by state or national regulations. 

These factors make it imperative that healthcare providers use the best methods available that will let them improve patient outcomes while controlling the parts of the cost equation that they can control.
This article is one in a series from Strong America Now that illustrate how  forward-thinking healthcare providers are using quality improvement methods to meet the dual goals of improving patient outcomes and controlling the costs.
The operation of healthcare providers differs from that of most other businesses in three important ways: 

1. The most important outcomes are not measured in dollars, but in terms of patient survival and quality of life.
2. They cannot fully control their revenues—rates are often subject to influence by HMOs, insurance companies, and Medicare/Medicaid.
3. They cannot control major components of their costs. For example, the number of staff, such as nurses, is often dictated by state or national regulations. 
4. These factors make it imperative that healthcare providers use the best methods available that will let them improve patient outcomes while controlling the parts of the cost equation that they can control.

This article is one in a series from Strong America Now that illustrate how  forward-thinking healthcare providers are using quality improvement methods to meet the dual goals of improving patient outcomes and controlling the costs.
Overview In recent years, the University of California–San Francisco (UCSF) Medical Center has begun using quality improvement methods in key areas as a way to tackle rising healthcare costs and quality of care challenges. In March 2010, they undertook a project to help ICU patients in one ward become mobile much sooner than had traditionally been attempted. The changes are projected to create more than $2 million in direct costs savings annually in addition to leading to better outcomes for the patients. 
Problem Patients in an intensive care unit (ICU) who require life support equipment are often kept sedated so they are more comfortable and can better tolerate the required tubes. Side effects of the inactivity resulting from this approach to treatment include weakening of the lung, facial, and skeletal muscles; side effects of the sedation includes delirium and even long-term impairment of their mental faculties. 
Following in the footsteps of pioneering work at Johns Hopkins and the LDS Medical Center in Utah, UCSF began a program to get critically ill ICU patients who were medically stable up out of their beds despite still being attached to mechanical ventilators, catheters, dialysis machines, and other types of life support equipment. 
Approach A principle physical therapist (PT) at UCSF witnessed firsthand the benefits of early mobility for ICU patients and learned about the positive outcomes of the research and programs at John Hopkins and LDS Medical Center. She then began championing the idea that UCSF adopt a similar program. Initially, other UCSF staff were concerned about this new treatment approach—some because of skepticism that it could be done without harming patients, and some due to concerns that it would increase costs because of extra care and staffing requirements. 
Following 18 months of research and internal promotion of the idea, UCSF Medical Center agreed to dedicate the PT full time to implementing a new mobility program for patients in one ICU ward. She then worked with an administrative sponsor and multidisciplinary team at UCSF to develop and implement a similar ICU Early Mobility program. 
Under the new procedures, any critically ill patient who was stabilized in the ICU was required to trying getting out of bed (and walking, if possible) within 48 hours of their admission to the ICU (with the help of the physical therapist) even through most were still connected to life support equipment. 
In addition, on the recommendation of the PT, the medical center purchased equipment to safely support patient mobility and allow patients to exercise even if they were confined to their beds. 
Results Table 1 summarizes key outcomes. The percentage of patients receiving physical therapy more than doubled from 2009 to 2010. Getting the patients out of bed sooner allowed them to gain more physical strength before being released (as demonstrated by 45% increase in the distance they could walk). The hospital stay dropped by a third, and a much greater percentage of patients could go directly home rather than having to go to a rehabilitation or skilled nursing facility first. 
Table 1: Results

2009
2010
Change

% of ICU patients who received physical therapy
23%
53%
More than doubled

Average distance walked
87 feet
147 feet
69% increase

Avg. length of hospital stay
24 days
19 days
21% shorter

% of patients released directly to home care*
55%
71%
+16%

* instead of a rehabilitation unit or skilled nursing facility
Early initiation of physical therapy helped keep goals of reducing sedation, and weaning from the ventilator focused and progressive. 
Lessons Learned
Improvements in mobility progress and discharge outcome were linked to having earlier, more intense PT intervention, and greater distance walked
Requires physical therapy assessment and treatment
Requires multi-discipline involvement, ICU physical rehabilitation equipment and adequate physical therapy staffing
Having an ICU Early mobilization program with a physical therapist dedicated to the ICU allows for establishing a foundation of mobility, independence and orientation for the patient, preparing the patient for active out-of-bed rehabilitation when the patient is transferred out of the ICU.
Patients do not miss physical therapy sessions when the Physical Therapist is dedicated to the ICU since the therapist is available to coordinate mobilization with other staff members and make the treatment sessions a priority.
ICU early Mobilization is an investment in successful restoration of the patient and overall cost savings for the medical center.
Credits: Thanks to Karen Rago for her help in developing this case study. Thanks to Heidi Engel, PT, for her passion and persistence in developing this innovative program.