A Progressive Early Mobilization Program Is Significantly Associated With Clinical and Economic Improvement: A Single-Center Quality Comparison Study

Abstract

Objectives: To determine whether a progressive early mobilization protocol improves patient outcomes, including in-hospital mortality and total hospital costs. Design: Retrospective preintervention and postintervention quality comparison study. Settings: Single tertiary community hospital with a 12-bed closed-mixed ICU. Patients: All consecutive patients 18 years old or older were eligible. Patients who met exclusion criteria or were discharged from the ICU within 48 hours were excluded. Patients from January 2014 to May 2015 were defined as the preintervention group (group A) and from June 2015 to December 2016 was the postintervention group (group B). Intervention: Maebashi early mobilization protocol. Measurements and Main Results: Group A included 204 patients and group B included 187 patients. Baseline characteristics evaluated include age, severity, mechanical ventilation, and extracorporeal membrane oxygenation, and in group B additional comorbidities and use of steroids. Hospital mortality was reduced in group B (adjusted hazard ratio, 0.25; 95% CI, 0.13–0.49; p < 0.01). This early mobilization protocol is significantly associated with decreased mortality, even after adjusting for baseline characteristics such as sedation. Total hospital costs decreased from $29,220 to $22,706. The decrease occurred soon after initiating the intervention and this effect was sustained. The estimated effect was $–5,167 per patient, a 27% reduction. Reductions in ICU and hospital lengths of stay, time on mechanical ventilation, and improvement in physical function at hospital discharge were also seen. The change in Sequential Organ Failure Assessment score and Sequential Organ Failure Assessment score at ICU discharge were significantly reduced after the intervention, despite a similar Sequential Organ Failure Assessment score at admission and at maximum. Conclusions: In-hospital mortality and total hospital costs are reduced after the introduction of a progressive early mobilization program, which is significantly associated with decreased mortality. Cost savings were realized early after the intervention and sustained. Further prospective studies to investigate causality are warranted.

Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study

“…These results suggest that COVID-19 affects the care of not only patients with COVID-19 infections but also patients without COVID-19 infections and this effect may have been present since the beginning of the pandemic. Numerous studies strongly show that each element of the ABCDEF bundle or an ICU diary itself has a beneficial effect on patient outcomes (7,(22)(23)(24)(25)(26), while low and incomplete implementation can result in adverse outcomes including increased time of ventilatory support, longer ICU and hospital lengths of stay, increased incidence of delirium, functional disability, and increased medical costs and mortality (13,27). Efficient ways to incorporate evidence-based ICU care into clinical practice during the pandemic are urgently needed.…”

Effects of the Intensity and Activity Time of Early Rehabilitation on Activities of Daily Living Dependence in Mechanically Ventilated Patients

“…However, in the current study, unlike in previous studies, there were no significant differences in total medical costs, ICU and hospital lengths of stay, the duration of mechanical ventilation, the rate of discharge to home, or the incidence of delirium. [7][8][9][10] Since each median, other than total medical cost, tended to improve in the high-dose rehabilitation group, future multicenter studies using larger samples of patients should be carried out to strengthen these findings. Furthermore, the long-term medical costs after acute discharge or transfer should be investigated in future studies.…”

“…For example, data regarding medications, sedation dose, pain, infections, ventilator settings, and weaning were not collected but might have influenced the findings. 6 , 10 , 33 , 36 ) Finally, we did not conduct a detailed assessment of the subjects’ physical function, and the assessment of dysfunction was limited to that for ADL dependence at discharge. Consequently, further prospective studies are needed to investigate the influence of these factors.…”

“…Early goal-directed protocols for rehabilitation are used in our day-to-day procedures at the hospital, and safety verification data have already been reported. 9 , 10 , 17 , 18 ) In the current study, we sought to mobilize all patients equally every day according to our hospital protocol, which has five rehabilitation levels based on the patient’s medical condition: level 1, passive range of motion and respiratory physical therapy; level 2, active range of motion; level 3, sitting exercise; level 4, standing exercise; and level 5, walking exercise. To increase the intensity of the rehabilitation above level 3, it was necessary for the patient to meet the stability criteria listed in Table 1 .…”

“…6) The effects of early rehabilitation have been widely reported, including for the prevention of delirium, 7) shortening of the mechanical ventilation period, 7,8) improvement of physical function, 9) shortening of ICU length of stay, 9) and reduction of medical costs. 10) However, in Japan, early rehabilitation programs vary depending on the situation in each hospital and the experience of therapists, and many hospitals cannot create or follow evidence-based protocols. 11) Previous clinical trials have quantified the maximum rehabilitation level achieved (e.g., range of motion, sitting, standing, and walking), but not the activity time of rehabilitation.…”