A quality improvement project sustainably decreased time to onset of active physical therapy intervention in patients with acute lung injury.
A quality improvement project sustainably decreased time to onset of active physical therapy intervention in patients with acute lung injury.
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DOI：
10.1513/annalsats.201406-231oc
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发表时间：
2014-10-01
影响因子：
8.3
通讯作者：
Needham, Dale M
中科院分区：
文献类型：
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作者：
Dinglas, Victor D;Parker, Ann M;Needham, Dale M
理由：在重症监护病房 (ICU) 住院期间尽早开始康复与改善结果相关，并且是许多在实践中显示出重要变化的质量改进 (QI) 项目的基础。然而，关于这种变化在现实世界实践中是否可持续的证据很少。 目的：评估质量改进项目对急性肺损伤（ALI）患者开始积极物理治疗干预的时间的持续影响。方法：这是使用前瞻性收集的数据进行的前后评估，涉及连续承认的 ALI 患者的质量改善前（2004 年 10 月至 2007 年 4 月，n = 120）与质量改善后（7 月） 2009 年至 2012 年 7 月，n = 123）来自单个内科 ICU。测量和主要结果：主要结果是首次积极物理治疗干预的时间，定义为力量、活动度或自行车测功练习。在 ICU 幸存者中，质量改善后组与质量改善前组相比，更多患者在 ICU 接受物理治疗（89% vs. 24%，P < 0.001），并且在 ICU 物理治疗期间能够站立、转移或走动（64% vs. 7%，P < 0.001）。与质量改善前组相比，质量改善后组的所有患者中，首次物理治疗的中位时间（四分位距）较短（4 [2, 6] 与 11 天 [6, 29]，P < 0.001），并且开始物理治疗后 ICU 天数的中位（四分位距）比例较大（50% [33, 67%] 与 18% [4, 47%]，P = 0.003）。在多变量回归分析中，质量改善后阶段与物理治疗时间较短相关（调整后的风险比 [95% 置信区间]，8.38 [4.98，14.11]，P < 0.001），这种关联在质量改善后阶段的 5 年中每年都很显着。以下变量与较长的物理治疗时间独立相关：较高的序贯器官衰竭评估评分（0.93 [0.89, 0.97]）、较高的 FiO2（每增加 10% 为 0.86 [0.75, 0.99]）、使用阿片类药物输注（0.47 [0.25, 0.89]）和深度镇静（0.24 [0.12， 0.46]）。结论：在这项针对 ALI 患者的单中心事前分析中，早期康复质量改善项目与开始持续 5 年以上的积极物理治疗干预时间的大幅缩短独立相关。在整个前后期间，疾病的严重程度和镇静与在 ICU 中开始积极物理治疗干预的较长时间独立相关。
RATIONALE: Rehabilitation started early during an intensive care unit (ICU) stay is associated with improved outcomes and is the basis for many quality improvement (QI) projects showing important changes in practice. However, little evidence exists regarding whether such changes are sustainable in real-world practice.OBJECTIVES: To evaluate the sustained effect of a quality improvement project on the timing of initiation of active physical therapy intervention in patients with acute lung injury (ALI).METHODS: This was a pre-post evaluation using prospectively collected data involving consecutive patients with ALI admitted pre-quality improvement (October 2004-April 2007, n = 120) versus post-quality improvement (July 2009-July 2012, n = 123) from a single medical ICU.MEASUREMENTS AND MAIN RESULTS: The primary outcome was time to first active physical therapy intervention, defined as strengthening, mobility, or cycle ergometry exercises. Among ICU survivors, more patients in the post-quality improvement versus pre-quality improvement group received physical therapy in the ICU (89% vs. 24%, P < 0.001) and were able to stand, transfer, or ambulate during physical therapy in the ICU (64% vs. 7%, P < 0.001). Among all patients in the post-quality improvement versus pre-quality improvement group, there was a shorter median (interquartile range) time to first physical therapy (4 [2, 6] vs. 11 d [6, 29], P < 0.001) and a greater median (interquartile range) proportion of ICU days with physical therapy after initiation (50% [33, 67%] vs. 18% [4, 47%], P = 0.003). In multivariable regression analysis, the post-quality improvement period was associated with shorter time to physical therapy (adjusted hazard ratio [95% confidence interval], 8.38 [4.98, 14.11], P < 0.001), with this association significant for each of the 5 years during the post-quality improvement period. The following variables were independently associated with a longer time to physical therapy: higher Sequential Organ Failure Assessment score (0.93 [0.89, 0.97]), higher FiO2 (0.86 [0.75, 0.99] for each 10% increase), use of an opioid infusion (0.47 [0.25, 0.89]), and deep sedation (0.24 [0.12, 0.46]).CONCLUSIONS: In this single-site, pre-post analysis of patients with ALI, an early rehabilitation quality improvement project was independently associated with a substantial decrease in the time to initiation of active physical therapy intervention that was sustained over 5 years. Over the entire pre-post period, severity of illness and sedation were independently associated with a longer time to initiation of active physical therapy intervention in the ICU.