Strong steps toward recovery

In the realm of medical specialties, critical care is a relatively young field. For most of its existence it has striven to stabilize patients enduring major insults from trauma or disease. In recent years, however, physicians and other caregivers have looked beyond basic survival. Patients may spend days or weeks sedated and bedridden, and leave the medical intensive care unit (MICU) weaker than before.

“People would survive their ICU stay but went home and were having trouble with physical function, cognitive function, and mental health,” said Lauren Ferrante, MD, FW ’15, MHS ’16, assistant professor of medicine (pulmonary), and director of the operations core at the Yale Claude D. Pepper Older Americans Independence Center. “Someone who was ambulatory beforehand would go home and find that they had trouble walking up the stairs to their house.”

In March 2015, Yale New Haven Hospital implemented the STEPS-ICU program, which speeds recovery and improves quality of life through a regimen of early mobilization that starts in the ICU. The program’s leaders reported last year that their protocol led to shorter hospital stays; less time on a respirator; and an increased likelihood that patients would go home instead of to a nursing or rehab facility. Ferrante, the program’s physician director, said “Early mobilization helps improve patient outcomes. With the STEPS-ICU program, we have seen a reduction in ventilator hours and length of stay, and an increase in the number of patients able to go home from the hospital.”

Program planning began in 2013 when a team of physicians, nurses, and therapists surveyed nurses; identified barriers to implementation; determined what additional assets would be needed; and crafted a business plan. Physical therapy seemed to be an afterthought, they found. Orders were typically placed on the eighth day of an ICU stay and not filled for another three days. “It really wasn’t until day 11 in the ICU that [patients] were getting any type of therapy,” said Dawn Wicker, a physical therapist and a leader of the project. “And they were only seen two or three times per week.”

With support from hospital administration, the team launched their program. “It took a lot of time and persistence,” Ferrante said. “At the beginning there were many people who were not comfortable with the idea of mobilizing ICU patients. With the literature growing in this area and having leadership support this, we did achieve culture change.”

They adapted the hospital’s electronic medical record to make documentation of therapy more user-friendly. All ICU rooms were outfitted with walkers, reclining chairs, and chair alarms. Two physical therapists, an occupational therapist, and a rehab aide were assigned to the MICU. Nurses now receive training in mobilization. The team developed a protocol of exercises that would start early in an ICU stay, depending on the patient’s condition, and therapy sessions were increased from three to six days a week. “While they are stabilizing medically, we are beginning early mobilization,” Wicker said.

Mobilization begins with knee bends in bed; works up to sitting up and dangling legs over the side of the bed; then walking a few steps to a chair with a walker or assistance from therapists; finally, walking in the hallways. In a pre-/post-intervention analysis, patients benefitted from a 51% decline in the median length of stay in the MICU; a median reduction in ventilator hours of nearly 20%; and an increase in patients who went home rather than to a nursing or rehab facility from 17.8% to 24.9%.

“Everyone knows now that we don’t keep people sedated and in bed and it’s important to get people up and moving,” Ferrante said. “The patients love it. They love being able to move and get up.”