Hospital-Level Factors Associated with Report of Physical Activity in Patients on Mechanical Ventilation across Washington State

Abstract

Rationale: Use of physical and/or occupational therapy in the intensive care unit (ICU) is safe, feasible, and demonstrates improvements in functional status with early administration. Access to physical and/or occupational therapy in the ICU is variable, with little known regarding its use in community ICUs.Objectives: Determine what proportion of hospitals across Washington State report use of physical activity in mechanically ventilated patients and investigate process of care factors associated with reported activity delivery.Methods: Cross-sectional telephone interview survey study of nurse managers in hospitals caring for patients on mechanical ventilation across Washington State in 2013. Survey responses were linked with hospital-level data available in the Washington State Department of Health Comprehensive Hospital Abstract Reporting System database. Chi-square testing was used to explore unadjusted associations between potential process of care factors and report on activity delivery. Two multivariable logistic regression models were developed to explore the association between presence of a mobility protocol and report on delivery of activity. Measurements and Main Results:We identified 54 hospitals caring for patients on mechanical ventilation; 47 participated in the survey (response rate, 85.5%). Nurse managers from 36 (76.6%) hospitals reported use of physical activity in patients on mechanical ventilation, with 22 (46.8%) reporting use of high-level physical activity (transferring to chair, standing or ambulating) and 24 (51.1%) reporting use in high-severity patients (patients requiring mechanical ventilation and/or vasopressors). Presence of a written ICU activity protocol (odds ratio [OR], 5.54; 95% confidence interval [CI], 1.60-19.18; P = 0.006), hospital volume (OR, 5.33; 95% CI, 1.54-18.48; P = 0.008), and academic affiliation (OR, 4.40; 95% CI, 1.23-15.63; P = 0.02) were associated with report of higher level activity. Presence of a written ICU activity protocol (OR, 6.00; 95% CI, 1.69-21.14; P = 0.005) and academic affiliation (OR, 4.50; 95% CI, 1.21-16.46; P = 0.02) were associated with report of delivery of physical activity to high-severity patients.Conclusions: Nurse managers at three-fourths (76.6%) of eligible hospitals across Washington State reported use of physical activity in patients on mechanical ventilation. Hospital-level factors including hospital volume, academic affiliation, and presence of a mobility protocol were associated with report of higher level activity and delivery of activity to high-severity patients.Keywords: early mobilization; critical illness myopathy; physical therapy; intensive care unit-acquired weakness

Point Prevalence Study of Mobilization Practices for Acute Respiratory Failure Patients in the United States

“…Survey of ICU administrators across Michigan reported ICU mobility use in 39% of their mechanically ventilated patients with 10% achieving ambulatory status upon ICU discharge [16]. Similarly, survey of nurse managers across Washington State reported 47% of mechanically ventilated patients received out of bed mobility [17]. Our results suggest that reported and actual delivery of mobility may differ substantially and further studies are needed to understand reasons for this discordance.…”

Intensive Care Unit Structure Variation and Implications for Early Mobilization Practices. An International Survey

“…There was a median of one ICU (IQR, 1-3) present in the hospitals surveyed. There were a median of 13 ICU beds (IQR, [9][10][11][12][13][14][15][16][17][18][19][20]. Most ICUs were mixed medical-surgical units (67% overall), and 27% were medical ICUs.…”

“…This is important to note, given that in recent point prevalence studies done in the United States, Australia and New Zealand, and Germany, actual ambulation of ventilated patients occurred rarely (12)(13)(14)(15), thus demonstrating a gap between reported perceived delivery and actual implementation. In addition, social desirability bias may play a role in respondents' answers.…”

“…Despite this evidence, surveys and point prevalence studies of EM practice have shown limited penetration, particularly in patients undergoing MV (12)(13)(14)(15). For those interested in implementing this practice in routine care, representation of regional variation may help to better contextualize the working environment and may aid in analysis of relevant barriers.…”

The authors reply

“…They appropriately note the increasing importance of ICU variability and “culture” on provision of early mobilization (3). Our work across a cohort of Washington State ICUs found that hospital-level factors including presence of an ICU activity protocol, larger hospital volume and teaching affiliation are significant predictors of perceived delivery of higher-level mobility (4). In our ARDS Network cohort, we did not collect granular data on hospital-level factors given our primary interest in patient-level predictors.…”