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Original Investigation | Caring for the Critically Ill Patient

Standardized Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure A Randomized Clinical Trial

Peter E. Morris, MD1; Michael J. Berry, PhD2; D. Clark Files, MD3; J. Clifton Thompson, RN3; Jordan Hauser, MS2; Lori Flores, RN3; Sanjay Dhar, MD3; Elizabeth Chmelo, MS3; James Lovato, MS4; L. Douglas Case, PhD4; Rita N. Bakhru, MD, MS3; Aarti Sarwal, MD5; Selina M. Parry, PhD6; Pamela Campbell, RN3; Arthur Mote3; Chris Winkelman, PhD7; Robert D. Hite, MD8; Barbara Nicklas, PhD9; Arjun Chatterjee, MD, MS3; Michael P. Young, MD3
[+] Author Affiliations
1Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington
2Department of Health and Exercise Science, Wake Forest University, Winston Salem, North Carolina
3Section on Pulmonary, Critical Care, Allergy, and Immunologic Disease, Wake Forest University, Winston Salem, North Carolina
4Department of Biostatistical Sciences, Wake Forest University, Winston Salem, North Carolina
5Department of Neurology, Wake Forest University, Winston Salem, North Carolina
6Physiotherapy Department, University of Melbourne, Melbourne, Australia
7Francis Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
8Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
9Division of Geriatrics, Wake Forest University, Winston Salem, North Carolina
JAMA. 2016;315(24):2694-2702. doi:10.1001/jama.2016.7201.
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Importance  Physical rehabilitation in the intensive care unit (ICU) may improve the outcomes of patients with acute respiratory failure.

Objective  To compare standardized rehabilitation therapy (SRT) to usual ICU care in acute respiratory failure.

Design, Setting, and Participants  Single-center, randomized clinical trial at Wake Forest Baptist Medical Center, North Carolina. Adult patients (mean age, 58 years; women, 55%) admitted to the ICU with acute respiratory failure requiring mechanical ventilation were randomized to SRT (n=150) or usual care (n=150) from October 2009 through May 2014 with 6-month follow-up.

Interventions  Patients in the SRT group received daily therapy until hospital discharge, consisting of passive range of motion, physical therapy, and progressive resistance exercise. The usual care group received weekday physical therapy when ordered by the clinical team. For the SRT group, the median (interquartile range [IQR]) days of delivery of therapy were 8.0 (5.0-14.0) for passive range of motion, 5.0 (3.0-8.0) for physical therapy, and 3.0 (1.0-5.0) for progressive resistance exercise. The median days of delivery of physical therapy for the usual care group was 1.0 (IQR, 0.0-8.0).

Main Outcomes and Measures  Both groups underwent assessor-blinded testing at ICU and hospital discharge and at 2, 4, and 6 months. The primary outcome was hospital length of stay (LOS). Secondary outcomes were ventilator days, ICU days, Short Physical Performance Battery (SPPB) score, 36-item Short-Form Health Surveys (SF-36) for physical and mental health and physical function scale score, Functional Performance Inventory (FPI) score, Mini-Mental State Examination (MMSE) score, and handgrip and handheld dynamometer strength.

Results  Among 300 randomized patients, the median hospital LOS was 10 days (IQR, 6 to 17) for the SRT group and 10 days (IQR, 7 to 16) for the usual care group (median difference, 0 [95% CI, −1.5 to 3], P = .41). There was no difference in duration of ventilation or ICU care. There was no effect at 6 months for handgrip (difference, 2.0 kg [95% CI, −1.3 to 5.4], P = .23) and handheld dynamometer strength (difference, 0.4 lb [95% CI, −2.9 to 3.7], P = .82), SF-36 physical health score (difference, 3.4 [95% CI, −0.02 to 7.0], P = .05), SF-36 mental health score (difference, 2.4 [95% CI, −1.2 to 6.0], P = .19), or MMSE score (difference, 0.6 [95% CI, −0.2 to 1.4], P = .17). There were higher scores at 6 months in the SRT group for the SPPB score (difference, 1.1 [95% CI, 0.04 to 2.1, P = .04), SF-36 physical function scale score (difference, 12.2 [95% CI, 3.8 to 20.7], P = .001), and the FPI score (difference, 0.2 [95% CI, 0.04 to 0.4], P = .02).

Conclusions and Relevance  Among patients hospitalized with acute respiratory failure, SRT compared with usual care did not decrease hospital LOS.

Trial Registration  clinicaltrials.gov Identifier: NCT00976833

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Figure 1.
Flow of Patients Through the Study of Rehabiliation for Patients With Acute Respiratory Failure

BMI indicates body mass index (calculated as weight in kilograms divided by height in meters squared); SRT, standardized rehabilitation therapy.

aPatients could have more than 1 exclusion. Either patient or surrogate may have provided or refused consent.

bOne patient after completing intervention was deemed technically ineligible; the patient was consented and randomized to SRT but was found to be unable to walk prior to study and included in the primary analysis.

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Figure 2.
Length of Stay for Patients With Acute Respiratory Failure Receiving SRT vs Usual Care

SRT indicates standardized rehabilitation therapy. Time zero indicates time of randomization.

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