A nine-month quality improvement project to get some of University of Colorado Hospital’s sickest patients up and moving sooner was such a success that hospital leaders are making the change permanent – and hoping to expand the program.
The project invested $304,000 starting April 1, 2015 to add three full-time-equivalent physical therapists to work with Medical Intensive Care Unit (MICU) patients. The hypothesis going in, based on evidence from other institutions and anecdotal experience at UCH, was that getting patients – even those still on ventilators – involved in PT as quickly and as often as possible would speed their healing and cut MICU and overall hospital stays. That, in turn, would improve patient well-being and cut costs.
Within three months of the project’s launch, preliminary results looked promising. The final numbers didn’t disappoint, either: Patients on mechanical ventilation who received PT stayed in the MICU an average of 1.4 fewer days and, subsequently, in inpatient units 2.2 fewer days. Given the costs of such stays, the total savings for these patients amounted to more than $1.3 million over the project’s nine months.
For MICU patients not on mechanical ventilation, the length of stay shortened by 0.2 days in the MICU, but rose 1.1 days on inpatient units. Even taking into account the cost of the pilot itself and the $360,000 associated with those extra inpatient floor days, however, the overall effort saved UCH about $791,000 in nine months – an average of nearly $1,250 per patient, according to Kyle Ridgeway, DPT, who led the QI project.
“Reducing length of stay is incredibly crucial,” Ridgeway said. “But on the patient level, to spend a day and a half less in the ICU, a couple of days less on the floor and nearly four days less in the hospital, that’s a remarkable patient-level outcome.”
Jeff Glasheen, MD, UCH’s chief quality officer and a hospital medicine specialist, agreed, calling the results “incredibly impressive.” In addition to getting patients home quicker, the speedier recoveries cut the risks facing patients in any hospital, from infections to falls to medical errors.
“They’re not only getting out earlier, but they’re also probably leaving in a better functional state, thus thriving more once at home,” Glasheen said.
Ridgeway said the uptick in non-ICU inpatient days for non-ventilated patients may have been due to the many factors affecting floor length of stay. His sense is that there’s benefit for all critical patients, as the MICU-only data proved out. Plus, he thinks the integration of PTs into the MICU team and its involvement across the patient population was central to the pilot’s success.
The pilot started with in-depth PT training and multidisciplinary meetings. Following that, the MICU increased its PT staffing from 0.5 FTEs five days a week to 3 FTEs six days a week. The planning, training, and staffing boost helped PT specialists trim patients’ average length of stay after admission to the MICU to 1.3 days, down from nearly 4 days before the pilot.
The improvement was even starker for patients on ventilators, Ridgeway said: from about a week prior to the pilot to two days during the pilot. The improved staffing also meant PTs were able to work with two-thirds of all MICU patients during the pilot – sharply higher than the 28 percent of MICU patients before.
More than merely adding staff, the pilot changed how physical therapists work in the MICU, Ridgeway said. Rather than operating as a consult service – one called in when the MICU care team identified a specific need – PTs were integrated into the unit’s care team.
“We were embedded in the unit, screening patients every day, involved in rounds, involved in different meetings – really a part of the unit and in every patient’s care,” Ridgeway said.
That involvement was essential. The PTs aimed to get patients moving as soon as possible despite life-support equipment, lines and tubes, and other specialty equipment. Working with critically ill patients takes expertise in movement, pathophysiology, patho-exercise science, and more, Ridgeway said. It’s also time-consuming: Between planning and the actual therapy session, implementing a PT visit can take one to two hours.
But it’s time well-spent. Research shows that spending days or weeks in bed ushers in a host of long-term problems. Patients lose 1 to 3 percent of their muscle strength per day in the ICU. Three weeks of bed rest in healthy adults equates to a short-term decline equivalent to 30 years of aging. For the critically ill, weakness and cognitive impairment can persist five years after hospital discharge.
Each MICU PT session is tailored to the patient, Ridgeway said. It starts with helping the patient slowly roll to his side in the bed. Sitting at the side of the bed comes next, then standing, then shifting one’s weight back and forth, then marching in place. At that point, PTs help the patient to a chair, where he stands, then marches in place. They then walk the halls with a wheelchair behind the patient as a rolling spotter. Some patients get through it all in a single session; with others, it might take a week to get to the point they can make it to the chair, Ridgeway said.
The hard work turned out to be a patient satisfier. Among the 936 MICU patients who received PT during the pilot, those who answered a brief follow-up survey felt strongly that their work with physical therapists was necessary, beneficial, and engaging.
The pilot was good for MICU staff, too. While not a formal part of the project, Ridgeway asked for emailed feedback from nurses, physicians, respiratory therapists and others who work the unit. Wrote one RN: “You guys are such a positive light. Sometimes it’s easy to get pessimistic. PT is always like, ‘What can we do? Let’s get them to rehab.’ It’s refreshing.” Another wrote, “I feel more confident having my patients do things now after seeing what you guys do. I try more. All patients can do something.”
Ellen Burnham, MD, the MICU’s medical director, added that patients reported sleeping better the nights after PT, and that “there’s a psychological benefit to the providers of seeing patients up walking in the ICU.”
Spread and refine
UCH Chief Operating Officer Tom Gronow and Tim Wimbish, until recently the hospital’s director of Rehabilitation Services, have put together a strategic budget request to make the pilot’s approach standard practice in the MICU as of fiscal 2017 (starting July 1) and expand it from six to seven days a week. Until then, the pilot’s staffing and approach will stay in place.
Glasheen said the goal now should be to “spread and refine” the program. The spreading could be to other ICUs, or to other patient populations who aren’t in ICUs but spend a long time in the hospital, such as the Acute Care for the Elderly (ACE) service. Refining may involve homing in on specific patient populations, such as those on ventilators, for whom, according to the QI data, the benefit was greatest, Glasheen said.
The innovative model to care is an example of academic medicine fulfilling its role of proving out new ideas for the common good.
“This shows the promise of doing this kind of quality-improvement work, of taking great ideas that might otherwise just sit on the mantel and operationalizing them,” Glasheen said.
For Ridgeway, the MICU experiment has been a rewarding experience.
“Health care is hard, and working in the MICU … it’s a different level of intensity,” Ridgeway said. “But when we work as a team, working toward goals together, it’s a really special thing to see happen. It shows we can do it, even in the toughest environments.”
A QI Success by the Numbers
- MICU patients on mechanical ventilation stayed in the MICU an average of 9.6 days and then in inpatient units for another 15.2 days in 2012-2014, for a total of 24.8 days. During the pilot, average ICU stays were 8.2 days and subsequent floor stays 13 days, an overall decrease of 3.6 days.