title: A quality improvement project sustainably decreased time to onset of active physical therapy intervention in patients with acute lung injury.
abstract: BACKGROUND
  Rehabilitation started early during an intensive care unit (ICU) stay is associated with improved outcomes and is the basis for many quality improvement (QI) projects showing important changes in practice. However, little evidence exists regarding whether such changes are sustainable in real-world practice.
  
  
  OBJECTIVE
  To evaluate the sustained effect of a quality improvement project on the timing of initiation of active physical therapy intervention in patients with acute lung injury (ALI).
  
  
  METHODS
  This was a pre-post evaluation using prospectively collected data involving consecutive patients with ALI admitted pre-quality improvement (October 2004-April 2007, n = 120) versus post-quality improvement (July 2009-July 2012, n = 123) from a single medical ICU.
  
  
  RESULTS
  The primary outcome was time to first active physical therapy intervention, defined as strengthening, mobility, or cycle ergometry exercises. Among ICU survivors, more patients in the post-quality improvement versus pre-quality improvement group received physical therapy in the ICU (89% vs. 24%, P < 0.001) and were able to stand, transfer, or ambulate during physical therapy in the ICU (64% vs. 7%, P < 0.001). Among all patients in the post-quality improvement versus pre-quality improvement group, there was a shorter median (interquartile range) time to first physical therapy (4 [2, 6] vs. 11 d [6, 29], P < 0.001) and a greater median (interquartile range) proportion of ICU days with physical therapy after initiation (50% [33, 67%] vs. 18% [4, 47%], P = 0.003). In multivariable regression analysis, the post-quality improvement period was associated with shorter time to physical therapy (adjusted hazard ratio [95% confidence interval], 8.38 [4.98, 14.11], P < 0.001), with this association significant for each of the 5 years during the post-quality improvement period. The following variables were independently associated with a longer time to physical therapy: higher Sequential Organ Failure Assessment score (0.93 [0.89, 0.97]), higher FiO2 (0.86 [0.75, 0.99] for each 10% increase), use of an opioid infusion (0.47 [0.25, 0.89]), and deep sedation (0.24 [0.12, 0.46]).
  
  
  CONCLUSIONS
  In this single-site, pre-post analysis of patients with ALI, an early rehabilitation quality improvement project was independently associated with a substantial decrease in the time to initiation of active physical therapy intervention that was sustained over 5 years. Over the entire pre-post period, severity of illness and sedation were independently associated with a longer time to initiation of active physical therapy intervention in the ICU.
authors.affiliation: 1 Division of Pulmonary and Critical Care Medicine, and.
authors.forename: Victor D
authors.initials: VD
authors.lastname: Dinglas
authors.forename: Ann M
authors.initials: AM
authors.lastname: Parker
authors.forename: Dereddi Raja S
authors.initials: DR
authors.lastname: Reddy
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Colantuoni
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Zanni
authors.forename: Alison E
authors.initials: AE
authors.lastname: Turnbull
authors.forename: Archana
authors.initials: A
authors.lastname: Nelliot
authors.forename: Nancy
authors.initials: N
authors.lastname: Ciesla
authors.forename: Dale M
authors.initials: DM
authors.lastname: Needham
mesh_terms: D055371:Acute Lung Injury / Q000534:rehabilitation*; D000328:Adult; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D026741:Physical Therapy Modalities / Q000592:standards*; D058996:Quality Improvement / Q000639:trends*; D012189:Retrospective Studies
keywords: acute lung injury; critical illness; intensive care unit; quality improvement; rehabilitation