Translating Research Into Clinical Practice: The Role of Quality ...

Editorial Translating Research Into Clinical Practice: The Role of Quality Improvement in Providing Rehabilitation for People With Critical Illness

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ur goal as health care professionals is to provide patients with the best care available.

One important challenge is the slow translation of research evidence into clinical practice. It is essential that such “knowledge translation” is efficient and timely to ensure that patients receive the most effective therapies and achieve improved outcomes.1 Currently, the gap between publication of clinical research findings and their implementation into routine clinical practice is substantial2 and leads to suboptimal health care delivery.3 Alan Jette, PT, PhD, FAPTA, addressed this issue in the 43rd Mary McMillan Lecture, in which he shared his vision for the physical therapy profession to be a leader in implementing evidence-based strategies for health promotion and treatment interventions.4 One approach to facilitating the translation of research into clinical practice is the use of systematic quality improvement (QI) processes. Quality improvement attempts to change clinician behavior and, through those changes, lead to more consistent, appropriate, and efficient application of established clinical interventions, resulting in improved care and patient outcomes.5 Quality improvement is an intrinsic part of good clinical practice and is designed to bring about immediate improvements in health care in local settings.6 Quality improvement assumes that quality and safety are characteristics of health care systems, and many QI activities involve groups of clinicians, managers, and staff cooperating to improve procedures and practices.6

Listen to the podcast of the “Rehabilitation of Patients With Critical Illness” Symposium recorded at CSM 2013.

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Quality improvement differs from human subject research in that the latter identifies new, effective therapies, whereas QI interventions are designed to enhance the realworld implementation of proven therapies, such as implementing an evidence-based practice guideline.6 To increase the reliable use of clinical research, not only does practitioner behavior need to change, but changes must occur in the culture of health care teams and organizations.7 Two very successful QI projects8–10 have used a 4-step model7: (1) summarizing the evidence; (2) identifying barriers; (3) establishing performance measures; and (4) ensuring patients receive the intervention by engaging the team, educating the team, executing the intervention, and evaluating the outcomes. When reviewing the results of QI projects, readers must be aware of the risk of bias.11 Therefore, to ensure patient safety, it is essential that QI projects are rigorously designed, conducted, and evaluated.7,12,13 Without this rigor, QI reports may potentially result in patient harm, poor use of limited resources, or both.14,15 Given the increase in published QI projects, it is essential that readers carefully evaluate the quality of the publication prior to undertaking a similar QI initiative in their own setting. Several resources are available to facilitate evaluation of reports of QI projects, including recent publication of a Users’ Guide to the Medical Literature by Fan and colleagues14 and the SQUIRE (Standards for QUality Improvement Reporting

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Editorial Excellence) guidelines.16 The SQUIRE guidelines were developed to aid in appropriate reporting and evaluation of QI interventions. Quality Improvement Articles in This Issue In 2007, Bailey and colleagues17 published an important report of rehabilitation for patients in the intensive care unit (ICU) that challenged the prevailing practices of deep sedation and bed rest.18 Their 6-month prospective evaluation of mobility intervention for patients who were mechanically ventilated for more than 4 days demonstrated that such interventions were safe and feasible. Thomsen and colleagues19 extended these findings in reporting that patients requiring mechanical ventilation increased their activity when transferred into an ICU with a “culture of mobility.” Evidence for early mobility for patients with critical illness continued to grow with additional reports that early rehabilitation was safe and feasible,20 increased muscle strength,21 improved functional outcomes,21–23 decreased duration of delirium,22 and reduced duration of mechanical ventilation and ICU and hospital stay.9,23,24 Such interventions also may have a long-term effect on patient mortality and hospital readmission.25 With mounting research evidence that early and more intensive interventions improve patient outcomes,26 Needham and colleagues9 undertook the first QI project of early rehabilitation interventions for patients with acute respiratory failure being managed in a medical ICU. Using a structured QI model,7,10 in a pretest-posttest analysis, they found that their QI intervention was associated with a marked reduction in deep sedation use, increased rehabilitation activities, and higher patient function. The findings of this rigorously conducted QI intervention provided a foundation to help with implementing early mobility programs in medical and surgical ICUs nationally and internationally. Recently, these findings were extended by a multicentered QI intervention for a progressive mobility initiative to help ICU teams integrate early mobility into daily practice in 13 ICUs in 8 Veterans Health Administration hospitals.27 As the research evidence and QI interventions supporting early rehabilitation continue to accumulate, rehabilitation programs are being instituted for patients with critical illness in a number of environments beyond medical and surgical ICUs. In this issue of the PTJ Special Series on Rehabilitation for People With Critical Illness, we are pleased to publish 3 QI reports that describe the implementation of unique early rehabilitation programs. As outlined below, these QI projects illustrate impressive initiative on the part of the health care teams that reviewed current best practice and applied these principles to their unique patient populations and health care environments: • The majority of QI projects have focused on patients in respiratory,17,19 medical,9,22,23 and surgical28 ICUs. Clark and colleagues29 examined the implementation of an early mobilization protocol for patients admitted to a trauma and burn ICU. They assembled an interprofessional team and followed the Plan-Do-Check-Act QI framework to develop and assess their initiative. They report that their program was safe and feasible and was associated with a decrease in complication rate following the initiative. • Drolet and colleagues30 took a different approach to increase the number of patients ambulating during the first 72 hours of their hospital stay in an adult medical/surgical ICU or an adult intermediate care unit. In their QI initiative, their interprofessional team developed and implemented a mobility order set with an embedded algorithm to guide nursing assessment of mobility potential and requests for physical therapy and occupational therapy consultation. Six months following implementation of their initiative,

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Editorial ambulation rates rose more than 3-fold in the adult ICU and more than 4-fold in the adult intermediate care unit. • Olkowski and colleagues31 describe a QI initiative to determine the safety and feasibility of an early mobilization program for patients recovering from surgical management of aneurysmal subarachnoid hemorrhage (SAH). Survivors of aneurysmal SAH often are faced with complicated recoveries that include surgery and prolonged monitoring in the ICU. This retrospective analysis of 25 patients with aneurysmal SAH who received early mobilization by a physical therapist or an occupational therapist or both demonstrated that an early mobilization program that included upright activities and ambulation is safe and feasible for this unique, critically ill patient population. Other Articles in This Issue We also want to highlight other important publications in this issue as outlined below: • As more people are surviving critical illnesses, it is important that functional impairments acquired during a hospital stay are managed with the goal of improving long-term health, wellness, and function. Bemis-Dougherty and Smith32 discuss physical therapist practice in the management of survivors of critical illness and the importance of long-term follow-up after ICU discharge. Furthermore, they describe the steps that the American Physical Therapy Association is taking to raise awareness and education about post–intensive care syndrome,33 to address barriers to best practice, and to identify research gaps and resources. • As more and more rehabilitation programs are being instituted to manage people who are critically ill, there is an associated increase in the demand for physical therapists to be part of the ICU rehabilitation team. In their perspective article, Pawlik and Kress34 address issues facing the profession as the demand for physical therapists qualified to care for people who are critically ill increases. These authors discuss issues including physical therapist competence in managing patients with critical illness, educational strategies to develop entry-level physical therapists prepared for managing patients with critical illness, determining physical therapy staffing requirements for ICUs, and prioritizing physical therapy service provision for patients in the acute care setting. These and other issues require the profession’s attention as the rehabilitation of patients with critical illness evolves. • One method of developing a physical therapy workforce prepared to practice in the ICU is the use of immersive high-fidelity simulation. Ohtake and colleagues35 describe an educational experience where physical therapist students engaged in the early rehabilitation of a simulated patient in the ICU. Simulation provides focused, deliberate practice in a safe, controlled learning environment, as well as affording an opportunity for students to develop the technical, behavioral, and clinical decision-making skills necessary for ICU practice. The authors discuss the impact of managing a simulated patient in the ICU on student confidence and satisfaction. • Critical illness is not confined to adults; infants and children also experience lifethreatening illnesses requiring mechanical ventilation. Weaning infants from periods of mechanical ventilation can be challenging. In a case series, Smith and colleagues36 describe a unique inspiratory muscle training program provided to 2 infants who were dependent on mechanical ventilation following surgery for congenital heart defects. After multiple failed weaning attempts, short-term participa-


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Editorial tion in an inspiratory muscle training program resulted in successful weaning from the ventilator. • As more patients are surviving critical illness and are transferred to long-term acute care hospitals, innovative rehabilitation strategies for ameliorating the neuromuscular weakness and functional impairments acquired in the ICU are emerging. In a case report by Trees and colleagues,37 mobilization strategies with novel devices for therapeutic exercise and gait training are used in the management of an elderly patient with severe ICU-acquired weakness. The authors describe the application of a 4-phase, graded mobilization program in the rehabilitation of a patient who was totally dependent who regained her ability to ambulate independently. • With the increased utilization of extracorporeal membrane oxygenation (ECMO), more patients are surviving severe respiratory failure; however, they often have profound neuromuscular weakness due to bed rest. Rahimi and colleagues38 describe a case series of 3 patients with critical illness who were managed with ECMO and received rehabilitation at different stages of their illness. This case series illustrates that rehabilitation during ECMO may be feasible and safe. • As the incidence of heart failure continues to increase, more patients with end-stage heart failure are being managed with ventricular assist devices (VADs). In this perspective article, Wells39 provides a comprehensive analysis of the physical therapist’s role in managing patients with VADs. Wells discusses the common types of VADs and gives important information about optimal functional rehabilitation of these patients during the preoperative and postoperative periods and as they transition to living in the community. In summary, we hope the articles in this issue and in the prior December 2012 issue motivate you to examine your practice for patients with critical illness—from the ICU to the community. We encourage you to consider the QI projects as well as the clinical interventions described in these 2 issues of this special series and ask yourself whether you are translating research evidence into your daily practice. As more and more individuals survive critical illness, the increased involvement of rehabilitation professionals at every stage of a person’s recovery will contribute to this growing population enjoying the best possible function and quality of life. Patricia J. Ohtake, Dale C. Strasser, Dale M. Needham P.J. Ohtake, PT, PhD, is a PTJ Editorial Board member and co-editor of this special series. She is Associate Professor of Rehabilitation Science at the University at Buffalo, The State University of New York, Buffalo, New York. D.C. Strasser, MD, is a co-editor of this special series. He is Associate Professor in the Department of Rehabilitation Medicine at Emory University School of Medicine, Atlanta, Georgia. D.M. Needham, FCA, MD, PhD, is a co-editor of this special series. He is Associate Professor of Pulmonary and Critical Care Medicine and of Physical Medicine and Rehabilitation at Johns Hopkins University, Baltimore, Maryland, and Medical Director of the Critical Care Physical Medicine and Rehabilitation Program at Johns Hopkins Hospital.

References 1 Needham DM. Patient safety, quality of care, and knowledge translation in the intensive care unit. Respir Care. 2010;55:922–928. 2 Westfall JM, Mold J, Fagnan L. Practice-based research—“Blue Highways” on the NIH roadmap. JAMA. 2007;297:403–406.

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Editorial 3 McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635–2645. 4 Jette AM. 43rd Mary McMillan Lecture: Face into the storm. Phys Ther. 2012;92:1221–1229. 5 Batalden PB, Davidoff F. What is “quality improvement” and how can it transform healthcare? Qual Saf Health Care. 2007;16:2–3. 6 Lynn J, Baily MA, Bottrell M, et al. The ethics of using quality improvement methods in health care. Ann Intern Med. 2007;146:666–673. 7 Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008;337:a1714. 8 Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–2732. 9 Needham DM, Korupolu R, Zanni JM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010;91:536–542. 10 Needham DM, Korupolu R. Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model. Top Stroke Rehabil. 2010;17:271–281. 11 Thomson RG, Moss FM. QIR and SQUIRE: continuum of reporting guidelines for scholarly reports in healthcare improvement. Qual Saf Health Care. 2008;17(suppl 1):i10–i12. 12 Landefeld CS, Shojania KG, Auerbach AD. Should we use large scale healthcare interventions without clear evidence that benefits outweigh costs and harms? No. BMJ. 2008;336:1277. 13 Pronovost P, Wachter R. Proposed standards for quality improvement research and publication: one step forward and two steps back. Qual Saf Health Care. 2006;15:152–153. 14 Fan E, Laupacis A, Pronovost PJ, et al. How to use an article about quality improvement. JAMA. 2010;304:2279– 2287. 15 Auerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med. 2007;357:608–613. 16 Ogrinc G, Mooney SE, Estrada C, et al. The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration. Qual Saf Health Care. 2008;17(suppl 1):i13–i32. 17 Bailey P, Thomsen GE, Spuhler VJ, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007;35:139–145. 18 Needham DM. Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function. JAMA. 2008;300:1685–1690. 19 Thomsen GE, Snow GL, Rodriguez L, Hopkins RO. Patients with respiratory failure increase ambulation after transfer to an intensive care unit where early activity is a priority. Crit Care Med. 2008;36:1119–1124. 20 Li Z, Peng X, Zhu B, et al. Active mobilization for mechanically ventilated patients: a systematic review. Arch Phys Med Rehabil. 2012 Nov 2 [Epub ahead of print]. doi: 10.1016/j.apmr.2012.10.023. 21 Burtin C, Clerckx B, Robbeets C, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med. 2009;37:2499–2505. 22 Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373:1874–1882. 23 Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36:2238–2243. 24 Lord R, Mayhew C, Korupolu R, et al. ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care Med. In press. 25 Morris PE, Griffin L, Berry M, et al. Receiving early mobility during an intensive care unit admission is a predictor of improved outcomes in acute respiratory failure. Am J Med Sci. 2011;341:373–377. 26 Peiris CL, Taylor NF, Shields N. Extra physical therapy reduces patient length of stay and improves functional outcomes and quality of life in people with acute or subacute conditions: a systematic review. Arch Phys Med Rehabil. 2011;92:1490–1500. 27 Bassett RD, Vollman KM, Brandwene L, Murray T. Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): a multicentre collaborative. Intensive Crit Care Nurs. 2012;28:88–97. 28 Hildreth AN, Enniss T, Martin RS, et al. Surgical intensive care unit mobility is increased after institution of a computerized mobility order set and intensive care unit mobility protocol: a prospective cohort analysis. Am Surg. 2010;76:818–822. 29 Clark DE, Lowman JD, Griffin RL, et al. Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study. Phys Ther. 2013;93:186–196. 30 Drolet A, DeJuilio P, Harkless S, et al. Move to Improve: the feasibility of using an early mobility protocol to increase ambulation in the intensive and intermediate care settings. Phys Ther. 2013;93:197–207. 31 Olkowski BF, Devine MA, Slotnick LE, et al. Safety and feasibility of an early mobilization program in patients with aneurysmal subarachnoid hemorrhage. Phys Ther. 2013;93:208–215.


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Editorial 32 Bemis-Dougherty AR, Smith JM. What follows survival of critical illness? Physical therapists’ management of patients with post–intensive care syndrome. Phys Ther. 2013;93:179–185. 33 Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med. 2012;40:502–509. 34 Pawlik AJ, Kress JP. Issues affecting the delivery of physical therapy services for individuals with critical illness. Phys Ther. 2013;93:256–265. 35 Ohtake PJ, Lazarus M, Schillo R, Rosen M. Simulation experience enhances physical therapy student confidence in managing a patient in the critical care environment. Phys Ther. 2013;93:216–228. 36 Smith BK, Bleiweis MS, Neel CR, Martin AD. Inspiratory muscle strength training in infants with congenital heart disease and prolonged mechanical ventilation: a case report. Phys Ther. 2013;93:229–236. 37 Trees DW, Smith JM, Hockert S. Innovative mobility strategies for the patient with intensive care unit–acquired weakness: a case report. Phys Ther. 2013;93:237–247. 38 Rahimi RA, Skrzat J, Reddy DR, et al. Physical rehabilitation of patients in intensive care units requiring extracorporeal membrane oxygenation: a small case series. Phys Ther. 2013;93:248–255. 39 Wells CL. Physical therapist management of patients with ventricular assist devices: key considerations for the acute care physical therapist. Phys Ther. 2013;93:266–278.

Manuscript Reviewers for PTJ’s Special Series on Critical Illness Dr Rebecca Craik, Editor in Chief, and Dr Patricia Ohtake, Dr Dale C. Strasser, and Dr Dale M. Needham, Senior Co-Editors, gratefully acknowledge the manuscript reviewers who contributed their time, expertise, and constructive comments to this special series: Naeem Ali, MD Diane D. Allen, PT, PhD Polly Bailey, MS, NP Sue Berney, PT, PhD Julie Bernhardt, PT, PhD Daniel Brody, MD Lawrence Cahalin, PT, PhD, CCS Nancy Ciesla, PT Gail Dechman, PT, PhD Linda Denehy, PT, PhD Mathias Eikermann, MD, PhD Mark Elkins, PT, PhD Doug Elliott, RN, PhD Eddy Fan, MD Michael Fillyaw, PT Romer Geocadin, MD Marc Goldstein, EdD Sharon Gorman, PT, DPTSc, GCS Rik Gosselink, PT, PhD Eva Grill, PhD, MPH John Hewett, PhD Carol Hodgson, PhD Anne Holland, PhD Ramona Hopkins, PhD Catherine Hough, MD, MSc Michael Howell, MD, MPH Theodore Iwashyna, MD, PhD

Diane Jette, PT, MS, DSc Colleen Kigin, PT, DPT, FAPTA Michelle Kho, PT, PhD Karen Koo, MD John Kress, MD Daniel Malone, PT, PhD, CCS Karen McCulloch, PT, PhD, NCS Dave McWilliams, BSc Pedro Mendez-Tellez, MD Russell Miller III, MD, MPH Serafim Nanas, MD Amy Nordon-Craft, PT, PhD Pratik Pandharipande, MD, MSCI Christiane Perme, PT, CCS Andrew Ray, PT, PhD Linda Resnik, PT, PhD, OCS Tarek Sharshar, MD Elizabeth Skinner, MSW James M. Smith, PT, PhD Peter Spronk, MD, PhD, FCCP Jane Sullivan, PT, DHS Daniel S. Talmor, MD, MPH Chris Wells, PT, PhD Chris Winkleman, RN, PhD Brad Winters, MD, PhD Jennifer Zanni, PT, ScD

[DOI: 10.2522/ptj.2013.93.2.128]

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