Thursday, September 29, 2016

Early mobilization improves outcomes, shortens length of stay in surgical ICUs

Program setting daily, challenging mobilization goals helped more patients be functionally independent when discharged from hospital

A program encouraging early mobilization of patients in surgical intensive care units (SICUs) was able to reduce the time patients spent in the ICU and their overall time in the hospital and also increased patients’ functional independence upon hospital discharge, allowing more of them to be discharged home. Results of the study – conducted at five teaching hospitals in the U.S., Germany and Austria – are being published in the October 1 issue of The Lancet.

“We have become much more successful in making sure patients hospitalized after serious injury or major surgery survive their stays in surgical ICUs,” says Matthias Eikermann, MD, clinical director of the Critical Care Division of the Massachusetts General Hospital (MGH) Department of Anesthesia, Critical Care and Pain Medicine, who led the study. “But many patients who spend a long time in the ICU develop muscle weakness that can lead to prolonged rehabilitation requirements, with some being unable to walk or take care of themselves up to a year after hospital discharge. In our study, patients who received this new protocol had shorter stays in the ICU and in the hospital and needed less help when they were discharged.”

While a few previous studies have found that early mobilization had equivocal effects on outcomes for ICU patients, none of them were conducted in surgical ICUs. Eikermann notes that delays in initiating mobilization therapy probably result from the desire to allow patients to rest and avoid discomfort after surgery but that the muscle atrophy caused by extended immobility can have long-term consequences.

As a first step in their effort to develop a program for early, goal-directed mobilization for SICU patients, the MGH team developed the SICU optimal mobilization score (SOMS), which describes patients’ current capacity on a scale from 0 to 4: 0 for no activity, 1 for passive range of motion, 2 for sitting up, 3 for standing and 4 for walking. Based on that scale, the researchers developed a protocol involving daily meetings among teams of caregivers – led by a trained facilitator (a physical therapist,  nurse, or ICU physician) – at which individual mobility goals are set, based on predefined safety criteria for each level.

Between July 2012 and July 2015, adult SICU patients at participating hospitals were enrolled in the study – 104 were randomized to early mobilization and 96 received standard care. All participants had been functionally independent two weeks before their ICU admission, had been hospitalized for no more than five days before being enrolled in the study, and had been on mechanical ventilation for less than 48 hours but were expected to remain on ventilation for another 24 hours or more. Daily mobilization goals for participants were set during morning rounds by teams consisting of the patients’ physicians, nurses and physical therapists; and signs with the targeted goal were posted at each patient’s bedside. Throughout the day, the facilitator worked with ICU staff and, if necessary, with attending physicians and other specialists to address concerns and problems that may have arisen.

Eikermann explains that implementing best practices into routine clinical treatment is a complex process that involves clinicians adopting the program and integrating it into their specific local setting. “We tested a complex intervention, rather than a new drug that simply needs to be taken three times a day. An important element of the success of this project was making sure that any caregivers who were critical of the innovative treatment had their concerns heard, while ensuring that best practices towards meeting each day’s challenging mobility goal were properly implemented. At each location, the dedicated facilitator worked to address potential barriers to meeting each patient’s goal and to develop appropriate procedures in collaboration with the SICU team.”

Within the early mobilization group, the daily mobilization goal was achieved on 89 percent of days, resulting in average mobility scores that were significantly higher than those in the control group. The length of stay in the SICU for early mobilization group was significantly shorter – an average of three days less – than for the control group, as was the overall hospital length of stay. There were no significant differences in the rates of adverse events between the two groups.

Among patients who survived until discharge from the hospital – 89 among the early mobilization group and 88 of the control group – more than half of those in the early mobilization group were completely independent on hospital discharge, compared with less than a third of the control group. As a result, significantly more early mobilization patients were discharged to their homes, instead of to a rehabilitation facility or nursing home. Early mobilization patients also had fewer incidents of delirium, a state of mental confusion that often develops in ICU patients.

“While our study did not measure hospital costs, our data demonstrating improvement in patient outcomes, along with reduced hospital and ICU length of stay, suggest that implementing this program should improve the value of care,” says Eikermann, an associate professor of Anesthesia at Harvard Medical School. “The process of implementing early, goal-direct mobilization in the SICU has already begun here at MGH and some of the other institutions participating in this study, and we predict that other hospitals will make strong efforts to implement this new approach.”

Co-authors of the Lancet paper are lead author Stefan Schaller, MD, Manfred Blobner, MD, and Markus Heim, MD, Technical University of Munich; Thomas Edrich, PhD, and Ilse Gradwohl-Matis, MD, Parcelsus Medical University, Salzburg, Austria; Matthew Anstey, MPH, Sir Charles Gairdner Hospital, Nedlands, Australia; Nicola Latronico, MD, University Hospital, Brescia, Italy; Tobias Kurth, MD, Brigham and Women’s Hospital; Daniel Talmor, MD, Beth Israel Deaconess Hospital; Matthias Walz, MD, University of Massachusetts Medical Center; Ross Zafonte, MD, Spaulding Rehabilitation Hospital; and Stephanie Grabitz, Timothy Houle PhD, Matthew Meyer MD, Thomas Peponis MD, Karen Waak, DPT, Jarone Lee, MD, and George Velmahos, MD, Massachusetts General Hospital. The study was supported by a grant from Jeffrey and Judy Buzen.

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $800 million and major research centers in HIV/AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, photomedicine and transplantation biology. The MGH topped the 2015 Nature Index list of health care organizations publishing in leading scientific journals, earned the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service. In August 2016 the MGH was once again named to the Honor Roll in the U.S. News & World Report list of "America's Best Hospitals."

Media contact: Terri Ogan, togan@partners.org, 617 726-0954

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