Objective: To compare and contrast the process used to imple-ment an early mobility program in ICUs at three different medical centers and to assess their impact on clinical outcomes in criti-cally ill patients.Design: Three ICU early mobilization quality improvement projects are summarized utilizing the Institute for Healthcare Improvement framework of Plan-Do-Study-Act.Intervention: Each of the three ICU early mobilization programs required an interprofessional team-based approach to plan, edu-cate, and implement the ICU early mobility program. Champions from each profession—nursing, physical therapy, physician, and respiratory care—were identified to facilitate changes in ICU cul-ture and clinical practice and to identify and address barriers to early mobility program implementation at each institution.Setting: The medical ICU at Wake Forest University, the medical ICU at Johns Hopkins Hospital, and the mixed medical-surgical ICU at the University of California San Francisco Medical Center.Results: Establishing an ICU early mobilization quality improve-ment program resulted in a reduced ICU and hospital length of stay at all three institutions and decreased rates of delirium and the need for sedation for the patients enrolled in the Johns Hop-kins ICU early mobility program.Conclusion: Instituting a planned, structured ICU early mobility quality improvement project can result in improved outcomes and reduced costs for ICU patients across healthcare systems. (Crit Care Med 2013; 41:S69–S80)
Key Words: barriers; critical care; early mobility; early mobilization; ICU-acquired weakness; interprofessional; outcomes; physical rehabilitation; quality improvement
More than 4 million patients are admitted to ICUs in the United States each year, with 80–90% of these patients surviving their ICU stay (1). A high propor-
tion of these ICU survivors experience significant cognitive, psychological, and physically disabling side effects of their criti-cal illness, regardless of their admitting diagnosis, with nearly half of these individuals being unable to return to their previous work more than 1 year after hospital discharge (2–5). Delirium, a temporary alteration of cognition characterized by inattention and disorganized thinking, occurs in up to 75% of ICU patients (6). Long-term neurocognitive disability also occurs commonly in critically ill patients, especially those with acute respiratory distress syndrome (ARDS) and delirium, and can persist for months to years after hospital discharge (7). In patients with ARDS, Hopkins and Jackson (8–10) reported cognitive impair-ments in 78% of ICU survivors at the time of hospital discharge, and in 46% of these individuals 1 year later. Girard and col-leagues (11) found that increasing duration of delirium in ICU patients was an independent predictor of worse cognitive perfor-mance at 3 and 12 months after ICU discharge. In a systematic review of psychiatric morbidity in ICU survivors, Davydow and colleagues (12) reported a prevalence of psychiatrist-diagnosed posttraumatic stress disorder at hospital discharge, 5 years, and 8 years to be 44%, 25%, and 24%, respectively.
Disabling weakness and associated impairments in physi-cal function in ICU survivors also occur commonly (13, 14). The frequency of these impairments is approximately 50% in ICU patients with sepsis, multiple organ failure, or prolonged mechanical ventilation (15, 16). Recent retrospective studies from separate medical, trauma, and surgical ICUs reveal that at least half of patients discharged, regardless of age, are unable to return to premorbid levels of activity due primarily to weak-ness and lack of endurance (3, 4, 17, 18). It has been theorized that the weakness experienced by survivors of critical illness arises in part from an interaction of inflammatory and meta-bolic changes due to critical illness and is exacerbated by the
1Department of Rehabilitative Services, University of California San Fran-cisco Medical Center, San Francisco, CA.
2Division of Pulmonary and Critical Care Medicine, Johns Hopkins Univer-sity, Baltimore, MD.
3Pulmonary and Critical Care Medicine, Wake Forest University School of Medicine, Winston Salem, NC.
4Critical Care Medicine, University of California San Francisco Medical Center, San Francisco, CA.
Dr. Engel holds a consultancy with the Institute for Healthcare Improve-ment. Dr. Morris has received travel support from Hill-Rom and Covidien. The remaining authors have disclosed that they do not have any potential conflicts of interest.
S70 www.ccmjournal.org September 2013 • Volume 41 • Number 9 (Suppl.)
detrimental effects of prolonged bed rest commonly imposed on ICU patient care (19–22).
Recognizing the need to address the diminished quality of life (23) experienced by ICU survivors because of cognitive (24), psychological (25), and functional (26) impairment, a Society of Critical Care Medicine (SCCM) stakeholders con-ference convened in 2010 created the acronym postintensive care syndrome (PICS) (27, 28). The stakeholders’ conference met to develop collaborative interprofessional improvements in care to reduce PICS through increasing education about PICS, identifying areas of needed research, and identifying bar-riers to quality improvement (QI) initiatives aimed at reducing PICS (27).
Similarly, several expert panel recommendations for reduc-ing ICU survivor impairments have been proposed, including wide spread implementation of: 1) the awakening and breath-ing, coordination of delirium screening, and early mobility bundle (29, 30); 2) the ICU Pain, Agitation, and Delirium (PAD) care bundle, as part of the SCCM’s 2013 ICU PAD guidelines (31); 3) the World Health Organization’s International Classification of Functioning, Disability and Health model of assessment and care (32); and 4) recommen-dations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients (33). All of these include recommen-dations for implementing treatment programs to improve ICU patients’ physical, cognitive, and mental health impairments, with structured rehabilitative patient physical activity timed closer to ICU admission rather than ICU discharge (34, 35).
The health benefits of physical activity for improving lon-gevity, physical functioning and cognitive vitality in non-ICU patients are well established (36), even for people with chronic ailments such as cancer (37) or heart disease (38, 39). Historically, critically ill patients have not been consid-ered appropriate for early physical activity because they were deemed to be too medically unstable or were tethered to life-sustaining equipment. More recent evidence contradicts these assumptions and has demonstrated that early mobility of ICU patients is both safe and feasible (34, 40–44). Furthermore, early physical therapy and mobility of ICU patients is emerging as an evidence-based strategy for preventing long-term neuro-cognitive and physical disability in these patients (7, 45–48) Despite the safety, feasibility, and efficacy of early mobility of ICU patients, many ICUs struggle to create the culture change and protocols needed to provide ICU patients with early physi-cal activity (49–51). The purpose of this article is to present the experience of three academic medical centers in their estab-lishment of ICU early mobility programs. These experiences may help other institutions in their creation of an ICU early mobility program.
METHODSFew randomized control trials (RCTs) investigating the effects of establishing an ICU early mobility program have been published (48, 52), most likely because of the complex-ity and expense of conducting an RCT of a physical activity
intervention in the ICU. As a result, the design of most studies looking at the effects of implementing an ICU early mobility program are either prospective cohort studies or before-after studies following implementation of an ICU early mobility QI initiative (34, 35, 43, 53–55). The ICU early mobility programs described in this article are from three separate institutions that established such a program. Investigations at Wake Forest University Medical Center in Winston Salem, NC (35), and at LDS Medical Center Intermountain Health in Salt Lake City, UT (34), were among the first descriptions of ICU early mobil-ity projects. Both projects served as models for a comprehen-sive structured QI initiative at Johns Hopkins Hospital (JHH) in Baltimore, MD (55), which in turn inspired a physical ther-apist-driven initiative at University of California San Francisco (UCSF) Medical Center in San Francisco, CA (54). The Wake Forest (35), JHH, and UCSF ICU early mobility programs were all QI projects (54, 55) created through a local and individu-alized approach, with similar interprofessional collaboration toward a synonymous goal.
As a means of retrospectively organizing the informa-tion provided from the three programs at Wake Forest, JHH, and UCSF, the plan-do-study-act (PDSA) (56, 57) QI frame-work has been applied to their description. The PDSA cycle is part of the Institute for Healthcare Improvement Model for Improvement (58). Each of the three ICU early mobility programs followed steps similar to the PDSA model of QI ini-tiatives, although on a different time line and without utiliz-ing this specific format in the process. The PDSA process is described in more detail in Table 1 (56).
Planning PhaseAll three ICU Early Mobility QI initiatives began with the for-mation of a group of critical care and rehabilitation clinicians from each discipline that would be responsible for providing early mobility interventions in the ICU. Wake Forest estab-lished a mobility team consisting of critical care nurses, physi-cal therapists, nursing assistants, and intensivist physicians to create a mobility protocol designed to standardize early physi-cal therapy in mechanically ventilated ICU patients. The pur-pose of the project was to determine if early physical therapy provided to patients within 72 hours of admission to the ICU and 48 hours of intubation via an endotracheal tube was both safe and feasible. The Wake Forest team hypothesized that the previously published evidence of inconsistent and infrequent physical therapy in the ICU (59) might be due in part to a lack of protocol-driven practice for mobility. Because protocols for other new practice patterns in the ICU such as weaning from mechanical ventilation and daily sedation interruption had led to previous improvements in patient care in their ICUs (60, 61), they believed that the same approach could be effectively applied to implementing a physical therapy/mobil-ity program for mechanically ventilated ICU patients. In the planning phase of the program, the interprofessional mobil-ity team developed a protocol for early delivery of activity and physical therapy in ICU patients consistent with the existing nursing and physical therapy department policies. Eligibility
Supplement
Critical Care Medicine www.ccmjournal.org S71
criteria for ICU patients to receive physical therapy and early mobility were strictly set. An ICU mobility team nurse with no direct patient care duties screened all patients for eligibil-ity. The ICU mobility team rotated through various ICUs and when ICU patients met criteria, they received protocolized care from the mobility team. Simultaneously, in ICUs at Wake Forest without the mobility team according to the team rota-tion schedule, ICU patients received usual care. Patients were enrolled in the ICU mobility program at Wake Forest over a 2-year period (2004–2006). Of the 1,427 patients who received mechanical ventilation during this period, 330 patients met eligibility criteria (35).
Johns Hopkins cited the safety and feasibility of early mobilization of mechanically ventilated patients previously demonstrated by Wake Forest and Intermountain Health (34, 35) as evidence to support the Johns Hopkins QI project for creating an early physical medicine and rehabilitation for patients with acute respiratory failure (55). Johns Hopkins collected and analyzed baseline data to establish their low rate of patients receiving physical therapy (PT) in the medical
ICU (MICU) before initiation of the QI project. They found that only 24% of patients received PT consultations and that 58% of these patients were treated with deep sedation that would make participation in early mobility impossible (62, 63). Similar to Wake Forest, Johns Hopkins established an interprofessional team to guide their ICU early mobility QI project. This project was funded through JHH and included a broader patient population than Wake Forest because spe-cific study design criteria were not needed for this QI project. All ICU patients who were mechanically ventilated 4 days or longer and cognitively intact without neuromuscular disease were included in the Johns Hopkins project. All eligible MICU patients were enrolled in the ICU early mobility QI project at Johns Hopkins over a 4-month period (May to August 2007), resulting in 30 patients receiving the intervention, and later compared with 27 eligible patients receiving usual care before the QI study period.
Johns Hopkins adopted a structured QI approach (64) incorporating the following components: 1) understanding the problem of immobility within the larger healthcare system; 2)
Critically appraise the literature to select an evidence-based initiative.
Ensure QI team is interdisciplinary and represents key stakeholders—including frontline staff, quality “champions,” and key executives.
Evaluate resources within institution to provide support.
Anticipate changes in resource and personnel needs associated with process change; consider the opportunity costs of the initiative.
Utilize QI tools to identify opportunities for improvement, including root cause analysis, fishbone diagrams, run charts, Pareto charts, and prioritization matrices.
Identify a champion of the QI effort in each department or stakeholder group; create a backup plan in the event of unexpected loss of a champion.
Perform work-flow analyses to assess how the initiative will affect the work environment.
Consider pilot testing and stepwise implementation.
Design an easy-to-use measurement tool that is integrated into the workflow and provide incentives for its use.
Do:
Market the practice change with sound evidence provided in a concise format distributed to all stakeholders.
Remind clinicians of the process change using signage and compliance monitoring.
Communicate goals/targets and the time line for achievement.
Consider creating competition among various units to increase motivation and participation.
Ensure protocol or process change is effectively incorporated into practice through tools such as order sets: Create standard work.
Verify validity of data collection.
Study:
Reevaluate protocol.
Obtain clinician feedback.
QI = quality improvement.
Engel et al
S72 www.ccmjournal.org September 2013 • Volume 41 • Number 9 (Suppl.)
creating an interprofessional improvement team; 3) enlisting all stakeholders to identify barriers to change and appropriate solutions; and 4) creating a change in practice through a “4Es” approach: engage, educate, execute, and evaluate. The inter-professional team consisting of a physical therapist, an occu-pational therapist, a part-time mobility technician, physician coordinator and a part-time coordinator, as well as representa-tives from nursing, the Director of the Department of Physical Medicine and Rehabilitation, and physicians from critical care, physical medicine and rehabilitation, and neurology depart-ments met weekly for 1 year during the planning phase of the project, in order to strategize and evaluate the issues and barri-ers to implementing an ICU early mobility program. Education of all clinical ICU staff as to the potential benefits of increas-ing early physical medicine for the ventilated ICU patients and lightening sedation was provided through the use of staff news-letters, posters, ICU patient testimonials to the staff, and pre-senting educational research summaries at staff meetings and conferences. Outside experts with firsthand experience in imple-menting ICU early mobility programs were brought in to meet with members of the interprofessional mobility team. Mobility team members were also sent to other institutions with existing ICU early mobility programs. All MICU nurses were exposed to educational sessions describing the benefits and feasibility of maintaining light levels of sedation for patients in their clini-cal practice in order to enable patients to actively participate in physical therapy (PT) and rehabilitation activities.
The JHH added one full-time PT and one full-time occu-pational therapist (OT) and a part-time rehabilitation assis-tant to the clinical staff to help facilitate implementation of their early mobility program. In contrast to the Wake Forest experience, Johns Hopkins did not have standing orders for screening all ICU patients, but instead they assigned a clinical coordinator to screen all ICU patients at admission for appro-priateness for early rehabilitation. Johns Hopkins also did not employ a protocol for implementing their ICU rehabilitation program. Rather, they changed the admitting activity order set from the default of “bed rest” to “as tolerated,” plus they established and disseminated simple guidelines for ordering PT and OT consults. Utilizing the existing literature at the time (34), the Johns Hopkins group also established safety exclusion criteria for all patients being evaluated for early mobility and rehabilitation. This planning phase of engaging and educating staff before executing the QI project lasted approximately 12 months, which was followed by a 4-month QI period with the ICU rehabilitation team continuing to meet weekly during this period to assess progress and barriers to wide spread imple-mentation. Data collected during this 4-month QI period were then compared with data prospectively gathered on the same qualifying MICU patient population for 3 months before the QI start.
The approach to planning an ICU early mobility QI project at UCSF was modeled after the experience of Johns Hopkins and was similar in many ways. As with both the Wake Forest and Johns Hopkins projects, an interprofessional early mobility committee was created at UCSF, consisting of representatives
from PT, nursing, ICU nurse practitioner, critical care physi-cians, respiratory therapy, and medical center administration. The UCSF QI project leaders were responsible for establishing guidelines for ICU patient eligibility, promoting the evidence base for early mobility, educating across and within clinical disciplines, and making a case for adding additional clinical staff in the ICU to help facilitate an ICU early mobility pro-gram. Rather than limit the intervention to only mechanically ventilated patients, the UCSF project sought to include all medical-surgical ICU patients in order to assess the feasibil-ity and benefits to providing early mobility to medically com-plex surgical patients, a population which was not included in previous published studies of ICU early mobility programs in the United States. The UCSF Executive Director for Service Lines served as the administrative representative on the QI project and was instrumental in helping to create the program. Utilizing the financial model developed at Johns Hopkins, which demonstrated significant financial savings associated with an ICU early mobility program, despite additional staffing costs (55, 65), she demonstrated the potential financial benefit of implementing an ICU early mobility program at UCSF to medical center administrators, convincing them to allocate 1 full-time PT to this ICU QI project for a 9-month period.
Similar to Johns Hopkins, preparation at UCSF (66) included a site visit to a hospital with an established ICU early mobility program, and experts from outside institutions were invited to share their experiences with UCSF staff. A promo-tional campaign including educational presentations made to all UCSF staff, newsletters, and posters was utilized to engage everyone in the process of promoting widespread early mobil-ity of ICU patients. ICU mobility guidelines, which included inclusion and exclusion criteria for mobility, were created in order to help staff to readily identify eligible ICU patients. The UCSF mobility QI group felt that it was important not to implement a strict ICU mobility protocol because this might result in some patients not receiving mobility who would oth-erwise safely benefit from this treatment. During the 9-month ICU early mobility QI study period (March to December 2010), 294 ICU patients received early PT. At initiation of the QI period, the UCSF physical therapists created a flow sheet to guide individual patient treatments with the goal of providing an optimal intensity of mobility tailored to each patient’s abil-ity during their early mobility sessions. The UCSF flow sheet and exclusion criteria are included in the Figure 1 (54).
Doing PhaseOngoing data collection and analysis of both process and out-come measures is a critical aspect of any QI project (67). The group at Wake Forest collected data on patient demograph-ics including all medications, central lines, rates of ventilator associated pneumonia, deep vein thrombosis, reintubation, and pulmonary embolism. Outcome measures included the number of patient ventilator days, days until first episode out of bed, ICU and hospital length of stay (LOS). Patients who met eligibility criteria in the intervention group triggered an automatic referral for PT even if they were not awake and alert
Supplement
Critical Care Medicine www.ccmjournal.org S73
Figure 1. Daily mobility assessment and treatment. MD = physician, NP = nurse practitioner, RASS = Richmond Agitation-Sedation Scale, PT = physical therapy, CAM-ICU = the Confusion Assessment Method for the ICU, PEEP = positive end-expiratory pressure, MAP = mean arterial pressure, CVA = cerebrovascular accident, SAH = subarachnoid hemorrhage, ICH = intracerebral hemorrhage.
Engel et al
S74 www.ccmjournal.org September 2013 • Volume 41 • Number 9 (Suppl.)
at the time. Patients who were unable to actively participate received passive range of motion exercises three times per day from mobility technicians until they were able to actively par-ticipate. At which point, they began working with the physical therapist, progressing along a four-stage mobility treatment protocol.
Researchers at Wake Forest hypothesized that the perceived dangers of lightening patients’ sedation (i.e., dislodging endo-tracheal tubes or catheters, stressing and destabilizing critically ill patients in respiratory failure, etc.) prevented most mechan-ically ventilated patients from being awake and mobile in the ICU (68–70). However, in the Wake Forest study, there were no adverse events associated with patient participation in mobil-ity activities (i.e., death or near death, need for reintubation, or accidental removal of a device), demonstrating that active physical therapy by ICU patients during their ICU stay was both safe and feasible. The most frequent reasons for terminat-ing a mobility session was patient fatigue without a significant change in the patient’s vital signs.
Data collection for the ICU mobility QI project at Johns Hopkins was used to evaluate the project’s performance and impact on patient care and for providing ongoing incentives for continued staff buy-in and support of early mobility in ICU patients. The JHH team had two primary objectives that com-plimented and reinforced each other. The first objective was to encourage a change in nursing sedation practice in the ICU to reduce the doses of sedative medications patients received without causing any added discomfort. This was accomplished by changing their routine sedation practice of administering continuous IV infusions of benzodiazepines and narcotics, to “as-needed” IV bolus doses of these medications (71, 72). The second objective was to increase the number of ICU patients receiving physical medicine and rehabilitation, ideally within 48 hours of their admission to the ICU. The referral for physi-cal therapy and the progression of patient mobility was not automatically driven by either protocols or order sets; rather, initiation of early mobility for patients relied upon a QI project coordinator to assess each patient’s readiness for rehabilitation therapy, based upon mobility screening guidelines devel-oped by the mobility QI team. Implementation of the Johns Hopkins program was systematically phased in, starting with a small number of ICU patients, and then sharing these early patient success stories with staff to build staff buy-in and sup-port for the program before implementing the early mobility program more broadly in the ICU. Part of the success of this approach was demonstrating the safety of each ICU patient mobility session to ICU staff and family members and being transparent and proactive about preventing and dealing with adverse events. Johns Hopkins recorded only four unexpected events during PT sessions, which involved dislodging either rectal tubes or feeding tubes without any significant medical consequence for these patients. They consulted a physiatrist for all MICU patients receiving rehabilitation therapy, increased the number of neurology consultations obtained for these patients, and actively collaborated with other clinical services at Johns Hopkins.
In addition to recording data for patient demographics, critical lines, and adverse events as Wake Forest had, the Johns Hopkins QI project collected data on delirium screening, medication dosing, the number of PT consultations obtained, and the frequency and type of mobility activity used for each patient. Baseline data for the 3-month period before the start of the QI project were compared with similar data collected during the 4-month QI intervention period. The short time line for this before and after comparison enabled the QI team to establish a sense of urgency with concrete goals and dead-lines in order to avoid dilution of the intervention and keep the momentum going to establish new practice patterns.
The early mobility QI project at UCSF was modeled after the Johns Hopkins program, but did not have a project man-ager or a reliable system for data collection. The UCSF project was facilitated and organized by the treating PT in the ICU who established an interprofessional group to help implement this program. The UCSF project relied heavily on critical care nurse practitioners (NPs) working in the ICU to determine patient readiness for PT based on exclusion guidelines developed by the ICU physical therapist together with other members of the interprofessional critical care group. Critical care NPs were granted the authority by the UCSF Medical Executive Board to write referrals for PT for patients, as a means of increas-ing the frequency of PT consults, and timing them closer to patients’ admission to the ICU, rather than having all PT con-sults be physician driven. During the 9-month pilot interven-tion phase, physical therapists and rehabilitation department aides recorded the number of days from ICU admission to initiation of PT, daily functional mobility performed with a physical therapist, and their distance walked. ICU and hospi-tal LOS and disposition upon patient hospital discharge were extracted from medical records and retrospectively analyzed by staff from the Department of Rehabilitation Services at UCSF. This data collection process was perceived by the UCSF team to be lengthy and cumbersome and led to significant delays in communicating the impact of this program on ICU patient care, making it difficult to build widespread buy-in and sup-port from ICU staff and hospital administrators.
Studying PhaseOnce established, the early mobility programs were assessed for barriers encountered, effectiveness of the protocols and referral systems, and cost effectiveness. At Wake Forest, the percentage of MICU patients who underwent at least one physical therapy session at any time during their hospital stay in the usual care group was 47.4%, versus 80.0% in the protocol group. Of the usual care group who received PT, 12.5% initiated it in the ICU compared with 91.4% of patients in the protocol group. The Wake Forest team attributed this difference to having clinical staff dedicated strictly to facilitating patient mobility in the ICU, an interprofessional ICU mobility team, and protocols for initiating and delivering PT. The barriers highlighted by the structure of this QI project are apparent for the usual care group, but are not mentioned for the protocol group. Wake Forest also found a significant difference between the usual
Supplement
Critical Care Medicine www.ccmjournal.org S75
care group and the protocol group in terms of ICU and hos-pital LOS. The adjusted ICU LOS was 6.9 days for usual care group versus 5.5 days for the protocol group. The hospital LOS was 14.5 days for the usual care group versus 11.2 days for the protocol group. When analyzing the financial impact of their early mobility program, Wake Forest found the total direct inpatient costs for the protocol group, inclusive of the mobility team salaries, were $6,805,082 versus $7,309,871 in direct inpatient costs for the usual care group. This represents a net savings of over a half a million dollars in direct patient care costs following implementation of the ICU mobility pro-gram at Wake Forest.
Johns Hopkins reported similar results when analyzing their QI project and has since published detailed accounts of both clinical and financial impacts of implementing an ICU early mobility program (63, 65, 66, 73, 74). The percentage of patients receiving either PT or OT in their MICU increased from 70% to 93%, and the median number of PT/OT treat-ments per patient increased from 1 in the pre-QI period to 7 during the QI period. The average ICU LOS across all MICU patients decreased during the QI period by 2.1 days, and hos-pital LOS for the QI period MICU patients decreased by 3.1 days (55). Johns Hopkins published a detailed assessment of barriers to developing and implementing their early mobility QI project (63, 66), which included: a need for both institu-tional and project leadership; additional staffing and equip-ment; increasing physician referrals for PT closer to patient ICU admission; and management of patients’ pain, delirium, and tolerance for activity and safety. Strategies used to over-come these barriers are summarized in Table 2. Johns Hopkins financial assessment of their early mobility QI project demon-strated a net financial savings for the institution despite the investment costs of added staffing salaries. Combining their cost data with similar data from other institutions with suc-cessful ICU early rehabilitation programs, Johns Hopkins created a financial model for estimating the net cost savings of implementing an ICU early mobility program. Based on a variety of scenarios ranging from conservative to best case, they estimated a projected net cost of –$87,611 in the most conservative scenario and a projected net savings $3,763,149 in the best-case scenario, with the model predicting a signif-icant net cost savings for most early mobility program cost scenarios (65).
The design of the UCSF project benefitted from the dem-onstrated savings recorded from the Johns Hopkins QI proj-ect. Although this information was unpublished at the time, Johns Hopkins agreed to collaborate and share their financial data with UCSF. This allowed the UCSF ICU early mobil-ity administrative champion to take UCSF medical/surgical ICU demographics and to create a UCSF-specific financial model based upon a relatively conservative cost-benefit sce-nario. UCSF estimated a net savings following implementa-tion of their ICU early mobility program, including the costs of adding an additional physical therapist in the ICU. As a result, they were able to get approval and funding for this PT position from the chief operating officer for the 9-month QI
pilot period. Financial analysis at the end of the pilot period demonstrated that sufficient net savings were generated, so that the full-time ICU PT staff position was kept indefinitely, and additional staff were added to allow the program to be expanded. Despite the addition of a full-time physical thera-pist in the ICU, there was still a significant lack of nursing and other ICU staff to help facilitate the labor intensive pro-cess of helping critically ill patients transfer out of bed and become more mobile. This labor shortage was addressed in part through the creation of an accredited ICU PT elective for physical therapy students from the San Francisco State University/UCSF Graduate Program in Physical Therapy. These students were assigned to the ICU in order to gain firsthand experience in helping to facilitate PT activities in critically ill patients, while providing aide/mobility techni-cian support for academic credit.
The interprofessional early mobility group at UCSF met every 2 weeks during the QI period and assessed the project for barriers (54), strategized solutions, and searched the litera-ture or consulted experts at professional meetings to resolve program barriers (Table 2). Regular updates summarizing program progress and clinical improvements associated with early mobility in the ICU were made available to ICU staff and all staff through posters, e-mails, and presentations at medi-cal center-wide rounds. After implementation of the ICU early mobility program at UCSF, the median number of days from ICU admission to initial PT evaluation decreased from 3 days to 1 day, and the median distances that patients walked in the ICU increased from 40 to 140 ft. Similar to the experiences at Wake Forest and Johns Hopkins, median ICU LOS at UCSF decreased by 2 days, and median hospital LOS decreased by 2 days (54).
Acting PhaseSuccess of any QI project requires action well beyond the ini-tial recorded achievements to sustain the new practice patterns through a process of refinement, communication via internal announcements as well as external publishing, and standard-izing the new systems. In 2008, Wake Forest published their QI project and demonstrated that early physical therapy com-pared with a group receiving usual care was associated with significant improvements in clinical outcomes for ICU patients (35). Other institutions such as Johns Hopkins and UCSF were able to subsequently cite this evidence as a rationale for devel-oping and implementing ICU early mobility and rehabilitation programs at their facilities in order to improve ICU patient outcomes. In 2011, Wake Forest published a 1-year follow-up report that looked at the long-term outcomes of ICU survi-vors managed under the ICU early mobility project (48). This report demonstrated that ICU patients who had not received treatment as part of the ICU early mobility program were at higher risk of death or hospital readmission within 1 year of hospital discharge, as compared with patients who received early ICU PT (75). The initial QI project at Wake Forest also provided the preliminary data needed to continue an ongoing randomized controlled study for ICU early mobility.
Engel et al
S76 www.ccmjournal.org September 2013 • Volume 41 • Number 9 (Suppl.)
Johns Hopkins has since expanded their program and have published several articles on their clinical experiences and the economic impacts of their ICU early mobility program (7, 18, 76, 77). Johns Hopkins has also developed an interprofes-sional continuing education course on early mobility of ICU patients, which to date has been attended by critical care prac-titioners from several countries (78). The ICU early mobility program at Johns Hopkins continues to innovate and improve their ICU early physical medicine and rehabilitation program by trialing new rehabilitation equipment (79, 80) and treat-ment strategies (73, 81, 82).
The ICU early mobility program at UCSF is also expand-ing and sustaining its momentum. An additional full-time PT position has been added to the second mixed medical-surgical ICU at UCSF, and a full-time mobility technician has now been added to the program. Continuing education courses are offered to the interprofessional critical care community from UCSF. Funding sources are expanding to include research grants that assist in providing data collectors and research coordinators to help to assess the impacts of early mobility in
ICU patients. Publishing efforts by UCSF critical care person-nel (46) further motivate the staff to continue the their early PT efforts in the ICU.
DISCUSSIONThe long-term disabling impacts to patients caused by criti-cal illness are becoming clearer (5, 83–85). Providing early physical medicine and rehabilitation to critically ill patients as a way of improving their quality of life both functionally and cognitively after they leave the hospital is in keeping with the expressed goals of patients themselves (86, 87). Despite the many barriers to developing and implementing the delivery of this new practice pattern (50), it is imperative to the growing numbers of ICU survivors that we address these issues (88). A systematic approach of collaborative QI, implemented by an interprofessional team of early physical rehabilitation in the ICU as outlined by the experiences of three institutions here, is a reproducible treatment strategy. Hopefully, it will encourage widespread adoption of ICU early mobility programs, while
TABLE 2. Barriers to Early Mobility Encountered and Solution Strategies
Barriers Wake Forest Johns Hopkins University of California San Francisco
Lack of leadership Recruited interdisciplinary team
Recruited interdisciplinary team with an overall physician leader for the project
Recruited interdisciplinary team with a PT leader and physician head of critical care support
Lack of staffing and equipment
QI program funded addition of mobility team
Conducted as QI pilot program
Staff added conditional to outcome
Conducted as QI pilot program
Staff added conditional to outcome
PT students taking ICU elective
Lack of knowledge and training
Literature review
Protocol
Education from champions to staff
Education across disciplines
Interprofessional consensus policy written
Site visit to established ICU early mobilization program
Site visit to established ICU early mobilization program
Lack of physician referrals for PT
Automatic physician’s order
Project coordinator screening PT and ICU nurse practitioner rounds
Inquiry at professional meetings
Over-sedation Continuous education and reinforcement from champion physician for use of bolus rather than infusion sedation
Staff meeting education
Delirium Screening
Minimize sedation
Mobilize
Screening
Minimize sedation
Mobilize
Patient hemodynamic tolerance of activity
Specific protocol Created exclusion guidelines
PT daily screening
Created exclusion guidelines
PT daily screening
Safety Prospectively set adverse events recorded
PT and occupational therapy emphasis on untangling lines before therapy
Retrospective analysis of incident reports
QI = quality improvement, PT = physical therapy.
Supplement
Critical Care Medicine www.ccmjournal.org S77
encouraging a more rigorous approach to clinical research on this issue with larger, multicenter studies looking at both the effects on outcomes and costs, and identifying best clini-cal practices, in order to improve the quality of life for ICU survivors.
Although significant differences in ICU cultures, personnel, institutional knowledge about early ICU rehabilitation, and funding resulted in varying approaches to the development and implementation of an ICU early physical rehabilitation program across these three institutions (89, 90), some com-mon themes emerge here which may serve as a guiding set of principles for other hospitals and healthcare systems looking to establish ICU early mobility and rehabilitation programs. A detailed initial planning phase by an interdisciplinary team is essential. The Johns Hopkins program makes a compelling case for developing and implementing a structured QI project that was applied to all mechanically ventilated MICU patients with respiratory failure, in order to keep the implementation
of the intervention on track and to keep ICU staff moti-vated to change their practice patterns. On the other hand, the Wake Forest approach of starting on a small scale with a select population of ICU patients and demonstrating success before expanding the program more broadly may also help to facilitate implementation. It is also important to identify a clinical champion to lead an ICU early mobility effort, some-one who works in the ICU and understands its culture and workflow. But as the UCSF program demonstrates, a clinical champion does not necessarily need to be an ICU physician, although support from ICU physician leadership is essential. Both process and outcome measures must be identified at the beginning of the project and tracked over time to evaluate the effectiveness of the project. The interprofessional mobil-ity team needs to assess data and then work collaboratively to overcome programmatic barriers identified during the QI process. Information about the progress and successes of the project need to be communicated frequently and consistently
TABLE 3. Comparison of Three ICU Early Mobility Quality Improvement Projects
Quality Improvement for Early Mobility Wake Forest Johns Hopkins
University of California San Francisco
Objective Reduce immobility and weakness with early PT for MICU patients
Optimize patient sedationProvide early PM&R in the ICU
for MICU patients
Provide earlier and more frequent PT in the ICU for MICU and surgical ICU patients
Planning time frame 1 yr 1.5 yr
Comparison group n = 165 control group n = 27 retrospective comparison n = 179 retrospective comparison
Intervention group and time frame
n = 165 patients on MV2004–20067 days/week mobility
Number of days to initiating PTICU/hospital LOSDistance walked in ICUDischarge dispositionIncident reports
Financial analysis performed?
Yes Yes No
Expanded to other ICU’s? Yes Yes Yes
Results Safe and feasible earlier mobility
Increased number of patients receive ICU PM&R
Patients receive increased number of treatments
Decreased ICU and hospital LOS
Net cost savings
Same results as shown in Wake Forest plus:
Decreased dosages of sedating medications
Decreased patient delirium rates No change in patient reported
pain scores
Same results as shown in Wake Forest plus:
Applied to medical and surgical all ICU patients
Increased distance patients walked in ICU
Increased percentage of patients able to discharge to home rather than rehabilitation facility
PT = physical therapy, MICU = medical ICU, PM&R = physical medicine and rehabilitation, MV = mechanical ventilation, LOS = length of stay.
Engel et al
S78 www.ccmjournal.org September 2013 • Volume 41 • Number 9 (Suppl.)
to both internal and external stakeholder groups, including ICU staff, administrators, and patients and their families, in order to gain widespread buy-in and ongoing support for change, and to directly engage these individuals in improv-ing the program over time. Finally, development of a business model that includes a financial analysis of the local-associated costs and savings of an ICU early mobility and rehabilitation program will facilitate approval for additional resources from hospital administrators. Table 3 provides a summary of the full QI projects described in this article.
CONCLUSIONSEarly mobility and rehabilitation of critically ill patients is asso-ciated with significant improvements in both short- and long-term physical and neurocognitive outcomes in ICU survivors. This article summarizes the development, implementation, and clinical and economic impacts of ICU early mobility pro-grams at three different institutions. The examples provided here may help facilitate the development and implementation of similar ICU early mobility and rehabilitation programs at other facilities.
REFERENCES 1. Joint Commission: Improving Care in the ICU. Oakbrook Terrace
Illinois: Joint Commission Resources; 2004 2. van der Schaaf M, Beelen A, Dongelmans DA, et al: Poor functional
recovery after a critical illness: A longitudinal study. J Rehabil Med 2009; 41:1041–1048
3. Timmers TK, Verhofstad MH, Moons KG, et al: Long-term qual-ity of life after surgical intensive care admission. Arch Surg 2011; 146:412–418
4. Livingston DH, Tripp T, Biggs C, et al: A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit. J Trauma 2009; 67:341–348
5. Herridge MS, Tansey CM, Matté A, et al; Canadian Critical Care Trials Group: Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364:1293–1304
6. Morandi A, Jackson JC, Ely EW: Delirium in the intensive care unit. Int Rev Psychiatry 2009; 21:43–58
7. Hopkins RO, Suchyta MR, Farrer TJ, et al: Improving post-inten-sive care unit neuropsychiatric outcomes: Understanding cogni-tive effects of physical activity. Am J Respir Crit Care Med 2012; 186:1220–1228
8. Hopkins RO, Jackson JC: Short- and long-term cognitive out-comes in intensive care unit survivors. Clin Chest Med 2009; 30: 143–153
9. Hopkins RO, Jackson JC: Long-term neurocognitive function after critical illness. Chest 2006; 130:869–878
10. Hopkins RO, Jackson JC: Neuroimaging after critical illness: Implications for neurorehabilitation outcome. NeuroRehabilitation 2012; 31:311–318
11. Girard TD, Jackson JC, Pandharipande PP, et al: Delirium as a predic-tor of long-term cognitive impairment in survivors of critical illness. Crit Care Med 2010; 38:1513–1520
12. Davydow DS, Desai SV, Needham DM, et al: Psychiatric morbidity in survivors of the acute respiratory distress syndrome: A systematic review. Psychosom Med 2008; 70:512–519
13. Ali NA, O’Brien JM Jr, Hoffmann SP, et al; Midwest Critical Care Consortium: Acquired weakness, handgrip strength, and mortality in critically ill patients. Am J Respir Crit Care Med 2008; 178:261–268
14. Stevens RD, Marshall SA, Cornblath DR, et al: A framework for diag-nosing and classifying intensive care unit-acquired weakness. Crit Care Med 2009; 37:S299–S308
15. de Jonghe B, Lacherade JC, Sharshar T, et al: Intensive care unit-acquired weakness: Risk factors and prevention. Crit Care Med 2009; 37:S309–S315
16. Stevens RD, Dowdy DW, Michaels RK, et al: Neuromuscular dysfunc-tion acquired in critical illness: A systematic review. Intensive Care Med 2007; 33:1876–1891
17. Herridge MS, Cheung AM, Tansey CM, et al; Canadian Critical Care Trials Group: One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 2003; 348:683–693
18. Needham DM, Dinglas VD, Bienvenu OJ, et al; NIH NHLBI ARDS Network: One year outcomes in patients with acute lung injury ran-domised to initial trophic or full enteral feeding: Prospective follow-up of EDEN randomised trial. BMJ 2013; 346:f1532
19. Allen C, Glasziou P, Del Mar C: Bed rest: A potentially harmful treat-ment needing more careful evaluation. Lancet 1999; 354:1229–1233
20. Batt J, dos Santos CC, Cameron JI, et al: Intensive care unit-acquired weakness: Clinical phenotypes and molecular mechanisms. Am J Respir Crit Care Med 2013; 187:238–246
21. Puthucheary Z, Rawal J, Ratnayake G, et al: Neuromuscular blockade and skeletal muscle weakness in critically ill patients: Time to rethink the evidence? Am J Respir Crit Care Med 2012; 185:911–917
22. Winkelman C: Bed rest in health and critical illness: A body systems approach. AACN Adv Crit Care 2009; 20:254–266
23. Dowdy DW, Eid MP, Dennison CR, et al: Quality of life after acute respiratory distress syndrome: A meta-analysis. Intensive Care Med 2006; 32:1115–1124
24. Jackson JC, Mitchell N, Hopkins RO: Cognitive functioning, mental health, and quality of life in ICU survivors: An overview. Anesthesiol Clin 2011; 29:751–764
25. Bienvenu OJ, Colantuoni E, Mendez-Tellez PA, et al: Depressive symptoms and impaired physical function after acute lung injury: A 2-year longitudinal study. Am J Respir Crit Care Med 2012; 185:517–524
26. Iwashyna TJ, Ely EW, Smith DM, et al: Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010; 304:1787–1794
27. Needham DM, Davidson J, Cohen H, et al: Improving long-term out-comes after discharge from intensive care unit: Report from a stake-holders’ conference. Crit Care Med 2012; 40:502–509
28. Bemis-Dougherty AR, Smith JM: What follows survival of critical ill-ness? Physical therapists’ management of patients with post-inten-sive care syndrome. Phys Ther 2013; 93:179–185
29. Banerjee A, Girard TD, Pandharipande P: The complex interplay between delirium, sedation, and early mobility during critical illness: Applications in the trauma unit. Curr Opin Anaesthesiol 2011; 24:195–201
30. Morandi A, Brummel NE, Ely EW: Sedation, delirium and mechani-cal ventilation: The ‘ABCDE’ approach. Curr Opin Crit Care 2011; 17:43–49
31. Barr J, Fraser GL, Puntillo K, et al; American College of Critical Care Medicine: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263–306
32. Iwashyna TJ, Netzer G: The burdens of survivorship: An approach to thinking about long-term outcomes after critical illness. Semin Respir Crit Care Med 2012; 33:327–338
33. Gosselink R, Bott J, Johnson M, et al: Physiotherapy for adult patients with critical illness: Recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med 2008; 34:1188–1199
34. 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
35. Morris PE, Goad A, Thompson C, et al: Early intensive care unit mobil-ity therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36:2238–2243
Supplement
Critical Care Medicine www.ccmjournal.org S79
36. Warburton DE, Nicol CW, Bredin SS: Health benefits of physical activity: The evidence. CMAJ 2006; 174:801–809
37. Courneya KS: Exercise in cancer survivors: An overview of research. Med Sci Sports Exerc 2003; 35:1846–1852
38. Holtermann A, Marott JL, Gyntelberg F, et al: Does the benefit on survival from leisure time physical activity depend on physical activity at work? A prospective cohort study. PLoS One 2013; 8:e54548
39. Mathieu RAt, Powell-Wiley TM, Ayers CR, et al: Physical activity par-ticipation, health perceptions, and cardiovascular disease mortality in a multiethnic population: The Dallas Heart Study. Am Heart J 2012; 163:1037–1040
40. Kayambu G, Boots R, Paratz J: Physical therapy for the critically ill in the ICU: A systematic review and meta-analysis. Crit Care Med 2013; 41:1543–1554
41. Adler J, Malone D: Early mobilization in the intensive care unit: A sys-tematic review. Cardiopulm Phys Ther J 2012; 23:5–13
42. Mendez-Tellez PA, Needham DM: Early physical rehabilitation in the ICU and ventilator liberation. Respir Care 2012; 57:1663–1669
43. Titsworth WL, Hester J, Correia T, et al: The effect of increased mobil-ity on morbidity in the neurointensive care unit. J Neurosurg 2012; 116:1379–1388
44. Zomorodi M, Topley D, McAnaw M: Developing a mobility protocol for early mobilization of patients in a surgical/trauma ICU. Crit Care Res Pract 2012; 2012:964547
45. Choi J, Tasota FJ, Hoffman LA: Mobility interventions to improve outcomes in patients undergoing prolonged mechanical ventilation: A review of the literature. Biol Res Nurs 2008; 10:21–33
46. Lipshutz AK, Gropper MA: Acquired neuromuscular weakness and early mobilization in the intensive care unit. Anesthesiology 2013; 118:202–215
47. Winkelman C, Johnson KD, Hejal R, et al: Examining the positive effects of exercise in intubated adults in ICU: A prospective repeated measures clinical study. Intensive Crit Care Nurs 2012; 28:307–318
48. 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
49. Hopkins RO, Spuhler VJ, Thomsen GE: Transforming ICU culture to facilitate early mobility. Crit Care Clin 2007; 23:81–96
50. Pawlik AJ, Kress JP: Issues affecting the delivery of physical ther-apy services for individuals with critical illness. Phys Ther 2013; 93:256–265
51. Fan E: What is stopping us from early mobility in the intensive care unit? Crit Care Med 2010; 38:2254–2255
52. 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
53. Clark DE, Lowman JD, Griffin RL, et al: Effectiveness of an early mobi-lization protocol in a trauma and burns intensive care unit: A retro-spective cohort study. Phys Ther 2013; 93:186–196
54. Engel HJ, Tatebe S, Alonzo PB, et al: A Physical Therapist-Established Intensive Care Unit Early Mobilization Program: A quality improvement project for critical care at the University of California San Francisco Medical Center. Phys Ther 2013; 93:975–985
55. 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
56. Lipshutz AK, Fee C, Schell H, et al: Strategies for success: A PDSA analysis of three QI initiatives in critical care. Jt Comm J Qual Patient Saf 2008; 34:435–444
57. Nembhard IM: Learning and improving in quality improvement col-laboratives: Which collaborative features do participants value most? Health Serv Res 2009; 44:359–378
58. Institute for Healthcare Improvement: Plan-do-study-act work-sheet. Available at: http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx. Accessed July 18, 2013
59. Norrenberg M, Vincent JL: A profile of European intensive care unit physiotherapists. European Society of Intensive Care Medicine. Intensive Care Med 2000; 26:988–994
60. Ely EW, Baker AM, Dunagan DP, et al: Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996; 335:1864–1869
61. Kress JP, Pohlman AS, O’Connor MF, et al: Daily interruption of seda-tive infusions in critically ill patients undergoing mechanical ventila-tion. N Engl J Med 2000; 342:1471–1477
62. Needham DM, Wang W, Desai SV, et al: Intensive care unit expo-sures for long-term outcomes research: Development and description of exposures for 150 patients with acute lung injury. J Crit Care 2007; 22:275–284
63. Zanni JM, Korupolu R, Fan E, et al: Rehabilitation therapy and out-comes in acute respiratory failure: An observational pilot project. J Crit Care 2010; 25:254–262
64. Pronovost PJ, Berenholtz SM, Needham DM: Translating evidence into practice: A model for large scale knowledge translation. BMJ 2008; 337:a1714
65. Lord RK, Mayhew CR, Korupolu R, et al: ICU early physical rehabili-tation programs: Financial modeling of cost savings. Crit Care Med 2013; 41:717–724
66. 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
67. Institute for Healthcare Improvement: Science of improvement: Establishing measures. Available at: http://www.ihi.org/knowleged/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx. Accessed July 18, 2013
68. Goldhill DR, Badacsonyi A, Goldhill AA, et al: A prospective obser-vational study of ICU patient position and frequency of turning. Anaesthesia 2008; 63:509–515
69. Weinert CR, Calvin AD: Epidemiology of sedation and sedation ade-quacy for mechanically ventilated patients in a medical and surgical intensive care unit. Crit Care Med 2007; 35:393–401
70. Stiller K: Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin 2007; 23:35–53
71. Brook AD, Ahrens TS, Schaiff R, et al: Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999; 27:2609–2615
72. Treggiari MM, Romand JA, Yanez ND, et al: Randomized trial of light versus deep sedation on mental health after critical illness. Crit Care Med 2009; 37:2527–2534
73. Needham DM, Chandolu S, Zanni J: Interruption of sedation for early rehabilitation improves outcomes in ventilated, critically ill adults. Aust J Physiother 2009; 55:210
74. Needham DM: Mobilizing patients in the intensive care unit: Improving neuromuscular weakness and physical function. JAMA 2008; 300:1685–1690
75. 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
76. Needham DM, Feldman DR, Kho ME: The functional costs of ICU sur-vivorship. Collaborating to improve post-ICU disability. Am J Respir Crit Care Med 2011; 183:962–964
77. Needham DM, Kamdar BB, Stevenson JE: Rehabilitation of mind and body after intensive care unit discharge: A step closer to recovery. Crit Care Med 2012; 40:1340–1341
78. Johns Hopkins Critical Care Rehabilitation Conference: Understanding and Improving ICU Patient Outcomes. Available at: http://www.hopkinscme.edu/CourseDetail.aspx/80032299. Accessed July 18, 2013
79. Kho ME, Damluji A, Zanni JM, et al: Feasibility and observed safety of interactive video games for physical rehabilitation in the intensive care unit: A case series. J Crit Care 2012; 27:219.e1–219.e6
80. Needham DM, Truong AD, Fan E: Technology to enhance physi-cal rehabilitation of critically ill patients. Crit Care Med 2009; 37:S436–S441
81. Hager DN, Dinglas VD, Subhas S, et al: Reducing deep sedation and delirium in acute lung injury patients: A quality improvement project*. Crit Care Med 2013; 41:1435–1442
S80 www.ccmjournal.org September 2013 • Volume 41 • Number 9 (Suppl.)
82. Kamdar BB, King LM, Collop NA, et al: The effect of a quality improve-ment intervention on perceived sleep quality and cognition in a medi-cal ICU. Crit Care Med 2013; 41:800–809
83. Jones C: Surviving the intensive care: Residual physical, cognitive, and emotional dysfunction. Thorac Surg Clin 2012; 22:509–516
84. Nordon-Craft A, Moss M, Quan D, et al: Intensive care unit-acquired weakness: Implications for physical therapist management. Phys Ther 2012; 92:1494–1506
85. Bienvenu OJ, Gellar J, Althouse BM, et al: Post-traumatic stress dis-order symptoms after acute lung injury: A 2-year prospective longitu-dinal study. Psychol Med 2013:1–15
86. Müller M, Strobl R, Grill E: Goals of patients with rehabilitation needs in acute hospitals: Goal achivement is an indicator for improved func-tioning. J Rehabil Med 2011; 43:145–150
87. Misak CJ: ICU-acquired weakness: Obstacles and interventions for rehabilitation. Am J Respir Crit Care Med 2011; 183:845–846
88. Iwashyna TJ: Trajectories of recovery and dysfunction after acute ill-ness, with implications for clinical trial design. Am J Respir Crit Care Med 2012; 186:302–304
89. Hopkins RO, Spuhler VJ: Strategies for promoting early activity in criti-cally ill mechanically ventilated patients. AACN Adv Crit Care 2009; 20:277–289
90. Ohtake PJ, Strasser DC, Needham DM: Translating research into clinical practice: The role of quality improvement in provid-ing rehabilitation for people with critical illness. Phys Ther 2013; 93:128–133
![Analytical and - docshare02.docshare.tipsdocshare02.docshare.tips/files/9186/91864173.pdf · chromatography [GC], high-performance liquid chromatography [HPLC]) were quite adequate](https://static.documents.pub/doc/80x56/5e2d840c63d7c445257855b6/analytical-and-chromatography-gc-high-performance-liquid-chromatography-hplc.jpg)
