Robert Millett meets the critical care team that is proving how early rehabilitation saves money and improves patients’ health
Treatment from Queen Elizabeth Hospital Birmingham's critical care rehabilitation physiotherapy team
Exercise and rehabilitation are not the first things that spring to mind when one thinks of an intensive care unit (ICU). Patients are often immobilised by critical conditions and attached to an assortment of life-supporting equipment. They are vulnerable to the harmful effects of prolonged inactivity, including muscle loss, pain and respiratory and musculoskeletal problems.
As a result the National Institute for Health and Care Excellence (NICE) recommends that critical care patients receive comprehensive clinical assessments and ‘start rehabilitation as early as clinically possible’.
This advice is being championed by David McWilliams, lead physiotherapist for the critical care rehabilitation service at Queen Elizabeth Hospital Birmingham (QEHB), part of University Hospitals Birmingham NHS Foundation Trust. It’s the largest critical care unit in Europe on a single site.
Mr McWilliams is passionate about the benefits of early rehab and has contributed to the development group for the NICE guideline Rehabilitation after critical illness, published in 2009.
He believes the guideline’s recommendations should be adopted by critical care services across the UK, with the goal of improving patient outcomes and mitigating the adverse effects of ICU-related inactivity.
‘If you take a healthy person and confine them to bed rest they lose about five per cent of their muscle in a week,’ says Mr McWilliams.
‘But when you add in critical illness and factors such as inflammation, sepsis, malnutrition and the use of medications frequently used in critical care – such as steroids and paralysing agents – the muscle loss increases. It has been shown, in some cases, to be as much as six per cent a day.’
Mr McWilliams, who has worked in the field since 2005, has conducted research into rehabilitation that has appeared in leading publications.
Prior to his arrival at QEHB in 2012 the service had lost the equivalent of two band 5 posts, following a service evaluation. A subsequent reduction in staffing resulted in a ratio of only one full-time equivalent physiotherapy post for every 10 patients.
Mr McWilliams combated this by securing temporary funding from QEHB Charity, which supported two additional physiotherapy posts.
Then, in an effort to bring about more permanent change, he benchmarked the service’s current provision and set out to implement a range of service improvements, based closely on the recommendations outlined in the NICE guideline on rehabilitation after critical illness.
‘I wanted to create a structured and seamless pathway for rehabilitation, which would start as early as clinically possible and continue throughout a patient’s recovery,’ Mr McWilliams explains.
As a result he developed a care pathway that provides patients receiving long-term ventilation with early and structured rehab.
The hospital’s critical care physiotherapists are responsible for the assessment and treatment of complex ventilated patients and work across a variety of specialties. These include general surgery, liver transplants, trauma, burns, neurosurgery and cardiothoracic procedures.
All patients are assessed within 24 hours of admission by a physiotherapist and, when appropriate, encouraged to leave their beds and exercise as soon as possible. ‘When a patient is unconscious we do passive movements to try and preserve their limbs,’ says Mr McWilliams.
‘Once they regain consciousness and open their eyes we assess their balance, by sitting them on the edge of the bed, and we get them to kick their legs and move their arms.’
The pre-rehab assessment involves a comprehensive review of each patient’s life history and clinical status. It takes account of a diverse range of factors, including physical capabilities prior to admission, hobbies and interests, employment status, sleep patterns and nutrition.
Following assessment, short and medium-term goals are established and a structured rehab programme is devised and documented.
In instances when a patient is too weak, or unable to move much, the physiotherapy team can still offer rehabilitation. This is often facilitated by transferring the patient to a chair using a hoist or a patient transfer board.
‘If they are still on a breathing machine we attach them to a portable ventilator and get them up to walk,’ says Mr McWilliams.
‘Depending on the patient they might walk 10 or 20 metres with the ventilator, which really helps to progress their weaning.’
Alongside physiotherapists the pathway also includes nursing staff, dieticians, occupational therapists and ICU consultants. The multidisciplinary team meets weekly to establish or review rehab plans for each patient, and assign key workers for longer-term patients.
Mr McWilliams explains that the key worker system allows individual physiotherapists to attend to high risk patients, or those who have been ventilated for more than five days.
The key workers are responsible for coordinating a patient’s goals and updating their plans when they move from ICU on to the ward.
‘What we are doing is getting people moving sooner, and getting them fitter before they leave hospital,’ explains Mr McWilliams.
‘If someone is fitter they are less likely to relapse and be readmitted, so there is quite a significant benefit in both the short and long term.’
With the help of additional funding from the Queen Elizabeth Hospital Charity, Mr McWilliams has also ushered in a post-hospital discharge rehab programme, which allows patients to maintain a structured exercise regime once they are back home.
‘Early rehab is very important, because the sooner we start the sooner we halt the decline,’ explains Mr McWilliams.
‘But it’s also key that rehab is regular and structured, because if it’s every other day or a bit ad hoc then it doesn’t work.’
Patients and their families have welcomed the early mobilisation and structured rehab scheme.
Mr McWilliams says seeing patients actively participate in their own recovery is rewarding, and is crucial to improving long-term outcomes.
‘A patient might be in bed on a ventilator, with a lot of equipment attached, looking petrified and not really moving,’ says Mr McWilliams.
‘But as soon as you start getting them more active you almost give them permission to break that cycle. The next day you see that they are sat up and interacting, and they’ve gone from being an intensive care patient to a person again. And when a family member sees that they’re now sitting up in a chair it’s a massive lift psychologically.’
Now, more than a year on from when they started, Mr McWilliams’ improvements to the service have proved both clinically and cost effective.
The emphasis on early rehab has reduced the time taken to mobilise longer-term ventilated patients by three days, and led to a much higher level of mobility within critical care. There has also been a reduction in the length of time patients stay on mechanical ventilation.
‘We’ve proven the worth of physiotherapy in intensive care and the fantastic difference physios can make,’ says Mr McWilliams. ‘A year ago this cohort of patients was leaving ICU in bed and requiring a hoist to transfer, whereas now they are standing or taking steps. It’s a huge change.’
‘A lot of services want to admit more patients, but they need more beds. So we are saying invest in physiotherapy, and that way we can create more beds within your current service,’ says Mr McWilliams.
The improved clinical outcomes have been associated with a reduction of almost eight days in the average length of stay for each patient. This has increased capacity in ICU and on the wards, and is estimated to have saved the trust more than £2 million.
An abstract about the service’s revamped pathway, titled ‘Structured rehabilitation within critical care, a service improvement project’ received an award from the European Society of Intensive Care Medicine in 2013.
Additionally, the project’s success raised the profile of physiotherapy in the trust and highlights the valuable role physios can play in critical care.
So much so that Mr McWilliams is using data from the scheme to bolster the case for more physiotherapy posts to be created.
‘A lot of services are being put under the spotlight and challenged to be cost effective and to prove their worth,’ says Mr McWilliams
‘But we have gone from a position two years ago where the service was being scrutinised and part of our funding was being withdrawn, to submitting a business case for an additional six physio posts.’
Mr McWilliams says physios interested in adopting the early mobilisation model need to start by benchmarking their service.
He recommends using a physical measure, such as his own Manchester mobility score (see reference below), in order to establish a baseline before any improvements are implemented. This approach is absolutely vital if physiotherapists are to demonstrate ‘the considerable impact’ they can have, he says.
‘Early mobilisation and structured rehab is something that physios can lead on and make such a difference with,’ says Mr McWilliams. ‘In this time of cost savings, staffing pressures and loss of funding the model we used is very reproducible and could easily be followed by others.’ fl
NICE guideline Rehabilitation after critical illness: Visit: www.nice.org.uk and search for ‘CG83’.
Reference: McWilliams DJ, Pantelides KP. Does physiotherapy led early mobilisation affect length of stay in ICU? Journal of the Association of Chartered Physiotherapists in Respiratory Care 2008; 40: 5-10.
Patient case study: Alan Brown
Alan Brown, 66, was admitted to the ICU at Queen Elizabeth Hospital Birmingham last July, and was diagnosed with dehydration, kidney and liver failure, and blood clots around his aorta.
He was ventilated, given a tracheotomy and remained in critical care for the next eight weeks. During that time he received early mobilisation and structured rehab from Mr McWilliams and the multidisciplinary team.
‘Because I was lying on my back for so long my legs were very weak,’ says Mr Brown.
‘So they had me do exercises in the bed every day, until I was able to stand up and get in a chair.’
From the chair Mr Brown advanced to walking. He was taken off the ventilator and given an oxygen bottle as he walked – at first just going two or three metres, but progressing gradually to 20 metres and more.
He was also provided with exercise bike sessions, first using a specially designed bike that slid over his bed, and later using one in the hospital gym.
After being transferred on to the ward he continued to receive structured rehab.
‘As I live on my own they got me to climb stairs and before I was discharged I managed to walk up 14 flights of the hospital staircase, which I was very pleased about.’
Since going home he has been invited to attend weekly gym sessions at the hospital and has continued to recover, thanks in no small part he says to the ‘excellent’ care and early rehab he received.
‘Before I left one of the doctors saw me walking around and said “I never expected to see you like this Mr Brown” because I’d been in such a bad state when I came in.’
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