Early Rehabilitation in the Medical and Surgical Intensive Care Units for Patients With and Without Mechanical Ventilation: An Interprofessional Performance Improvement Project.

BACKGROUND: Most early mobility studies focus on patients on mechanical ventilation and the role of physical and occupational therapy. This Performance Improvement Project (PIP) project examined early mobility and increased intensity of therapy services on patients in the intensive care unit (ICU) with and without mechanical ventilation. In addition, speech-language pathology rehabilitation was added to the early mobilization program. OBJECTIVE: We sought to assess the efficacy of early mobilization of patients with and without mechanical ventilation in the ICU on length of stay (LOS) and patient outcomes and to determine the financial viability of the program. DESIGN: PIP. Prospective data collection in 2014 (PIP) compared with a historical patient population in 2012 (pre-PIP). SETTING: Medical and surgical ICUs of a Level 2 trauma hospital. PATIENTS: There were 160 patients in the PIP and 123 in the pre-PIP. INTERVENTIONS: Interprofessional training to improve collaboration and increase intensity of rehabilitation therapy services in the medical and surgical intensive care units for medically appropriate patients. MEASUREMENTS: Demographics; intensity of service; ICU and hospital LOS; medications; pain; discharge disposition; functional mobility; and average cost per day were examined. MAIN RESULTS: Rehabilitation therapy services increased from 2012 to 2014 by approximately 60 minutes per patient. The average ICU LOS decreased by almost 20% from 4.6 days (pre-PIP) to 3.7 days (PIP) (P = .05). A decrease of over 40% was observed in the floor bed average LOS from 6.0 days (pre-PIP) to 3.4 days (PIP) (P < .01). An increased percentage of PIP patients, 40.5%, were discharged home without services compared with 18.2% in the pre-PIP phase (P < .01). Average cost per day in the ICU and floor bed decreased in the PIP group, resulting in an annualized net cost savings of $1.5 million. CONCLUSIONS: The results of the PIP indicate that enhanced rehabilitation services in the ICU is clinically feasible, results in improved patient outcomes, and is fiscally sound. Most early mobility studies focus on patients on mechanical ventilation. The results of this PIP project demonstrate that there are significant benefits to early mobility and increased intensity of therapy services on ICU patients with and without mechanical ventilation. Benefits include reduced hospitalization LOS, decreased health care costs, and decreased need for postacute care services. LEVEL OF EVIDENCE: III.

Validity of the stroke rehabilitation assessment of movement scale in acute rehabilitation: a comparison with the functional independence measure and stroke impact scale-16.

OBJECTIVE: To demonstrate sensitivity to change of the Stroke Rehabilitation Assessment of Movement (STREAM) as well as the concurrent and predictive validity of the STREAM in an acute rehabilitation setting. DESIGN: Prospective cohort study. SETTING: Acute, in-patient rehabilitation department within a tertiary-care teaching hospital in the United States. PARTICIPANTS: Thirty adults with a newly diagnosed, first ischemic stroke. METHODS: Clinical assessments were conducted on admission and then again on discharge from the rehabilitation hospital with the STREAM (total STREAM and upper extremity, lower extremity, and mobility subscales), Functional Independence Measure (FIM), and Stroke Impact Scale-16 (SIS-16). Sensitivity to change was determined with the Wilcoxon signed rank test and by the calculation of standardized response means. Spearman correlations were used to assess concurrent validity of the total STREAM and STREAM subscales with the FIM and SIS-16 on admission and discharge. We determined predictive validity for all instruments by correlating admission scores with actual and predicted length of stay and by testing associations between admission scores and discharge destination (home vs subacute facility). MAIN OUTCOMES: Not applicable. RESULTS: For all instruments, there was statistically significant improvement from admission to discharge. The standardized response means for the total STREAM and STREAM subscales were large. Spearman correlations between the total STREAM and STREAM subscales and the FIM and SIS-16 were moderate to excellent, both on admission and discharge. Among change scores, only the SIS-16 correlated with the total STREAM. All 3 instruments were significantly associated with discharge destination; however, the associations were strongest for the total STREAM and STREAM subscales. All instruments showed moderate-to-excellent correlations with predicted and actual length of stay. CONCLUSIONS: The STREAM is sensitive to change and demonstrates good concurrent and predictive validity as compared with the FIM and SIS-16 in the acute inpatient rehabilitation population.