Original article

The implementation of an early

rehabilitation program is associated with
reduced length of stay: A multi-ICU study

Journal of the Intensive Care Society

2016, Vol. 17(1) 211
! The Intensive Care Society 2015
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DOI: 10.1177/1751143715605118
jics.sagepub.com

Romina Wahab1, Natalie H Yip1, Subani Chandra1,

Michael Nguyen2, Katherine H Pavlovich3, Thomas Benson4,
Denise Vilotijevic4, Danielle M Rodier4, Komal R Patel1,
Patricia Rychcik5, Ernesto Perez-Mir5, Suzanne M Boyle5,
David Berlin6, Dale M Needham7,* and Daniel Brodie1,*

Abstract
Introduction: Survivors of critical illness face many potential long-term sequelae. Prior studies showed that early rehabilitation in the intensive care unit (ICU) reduces physical impairment and decreases ICU and hospital length of stay (LOS).
However, these studies are based on a single ICU or were conducted with a small subset of all ICU patients.
We examined the effect of an early rehabilitation program concurrently implemented in multiple ICUs on ICU and
hospital LOS.
Methods: An early rehabilitation program was systematically implemented in five ICUs at the sites of two affiliated
academic institutions. We retrospectively compared ICU and hospital LOS in the year before (1/201112/2011) and
after (1/201212/2012) implementation.
Results: In the pre- and post-implementation periods, respectively, there were a total of 3945 and 4200 ICU admissions
among the five ICUs. After implementation, there was a significant increase in the proportion of patients who received
more rehabilitation treatments during their ICU stay (p < 0.001). The mean number of rehabilitation treatments per ICU
patient-day increased from 0.16 to 0.72 (p < 0.001). In the post-implementation period, four of the five ICUs had a
statistically significant decrease in mean ICU LOS among all patients. The overall decrease in mean ICU LOS across all
five ICUs was 0.4 days (6.9%) (5.8 versus 5.4 days, p < 0.001). Across all five ICUs, there were 255 (6.5%) more
admissions in the post-implementation period. The mean hospital LOS for patients from the five ICUs also decreased
by 5.4% (14.7 vs. 13.9 days, p < 0.001).
Conclusions: A multi-ICU, coordinated implementation of an early rehabilitation program markedly increased rehabilitation treatments in the ICU and was associated with reduced ICU and hospital LOS as well as increased ICU admissions.

Keywords
Intensive care, rehabilitation, early ambulation, physical therapy, occupational therapy, length of stay

Division of Pulmonary, Allergy, and Critical Care, Department of

Medicine, Columbia University College of Physicians and Surgeons/
New York-Presbyterian Hospital, New York, NY, USA
2
Department of Quality and Patient Safety Improvement, New YorkPresbyterian Hospital, New York, NY, USA
3
Office of Strategy, New York-Presbyterian Hospital, New York, NY,
USA
4
Department of Rehabilitation and Regenerative Medicine, New YorkPresbyterian Hospital, New York, NY, USA
5
Department of Nursing, New York-Presbyterian Hospital, New York,
NY, USA

Division of Pulmonary and Critical Care Medicine, Department of

Medicine, Weill Cornell Medical College/New York-Presbyterian
Hospital, New York, NY, USA
7
Outcomes After Critical Illness & Surgery (OACIS) Group, Division of
Pulmonary and Critical Care Medicine, Department of Medicine, and
Department of Physical Medicine & Rehabilitation, Johns Hopkins
University School of Medicine, Baltimore, MD, USA
*Co-senior authors.
Corresponding author:
Daniel Brodie, Columbia University College of Physicians and Surgeons/
New York-Presbyterian Hospital, 622 W168th Street, PH8 East, Room
101, New York, NY 10032, USA.
Email: hdb5@cumc.columbia.edu

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Wahab et al.

Introduction
Survivors of critical illness face many potential longterm sequelae, including neuromuscular dysfunction
and cognitive impairment.16 Sedation, delirium and
bed rest are considered important contributors to
these complications.3,68 Early rehabilitation in the
intensive care unit (ICU) focuses on minimizing sedation and providing early physical and occupational
therapy (PT/OT) starting promptly after stabilization
of major physiological derangements.9,10 In the USA,
this approach sharply contrasts with a more traditional model of starting rehabilitation only after liberation from mechanical ventilation or after ICU
discharge.1115
Prior studies provide evidence for the benets of
early rehabilitation in ICUs, including reduced physical impairment and decreased ICU and hospital
length of stay (LOS).1013,1624 However, these studies
have often focused on a single medical ICU or were
conducted with a relatively small subset of all ICU
patients. Based on the encouraging results from
these prior studies, an early rehabilitation program
was implemented across ve ICUs, encompassing
medical, surgical and cardiac ICUs, at the sites of
our two aliated academic institutions. Our aim
was to examine the eect of the coordinated implementation of this early rehabilitation program on our
ICU and hospital LOS in this before/after quality
improvement project. Some of the results of this
study have been previously reported in the form of
an abstract.25

Methods
Setting
An early rehabilitation program was simultaneously
implemented beginning January 2012 in ve ICUs
(three medical, one cardiac, one surgical) across two
aliated academic institutions at two separate geographic sites in New York City: the New YorkPresbyterian Hospital/Columbia University College
of Physicians and Surgeons and the New YorkPresbyterian
Hospital/Weill
Cornell
Medical
College. Both these sites are urban tertiary/quaternary
referral academic medical centers that serve both the
nearby local communities and referrals from the state
of New York and the neighboring states.

Study design
To assess the eect of our early rehabilitation program, a retrospective analysis was performed on
8145 consecutive admissions to the ve study ICUs
comparing the 12-month period before versus after
implementation of the early rehabilitation program
(January 2011 to December 2011 versus January
2012 to December 2012). All admissions to the

study ICUs were included. During this two-year

study period, early rehabilitation was the only intervention implemented to reduce ICU LOS across the
ve ICUs. This retrospective study was approved by
the Columbia University Institutional Review Board
(IRB-AAAK7951). Waiver of consent was approved
in accordance with our institutional review board
guidelines.

The ICU early rehabilitation program

The ICU early rehabilitation program consisted of a
multidisciplinary team of ICU clinicians (physicians,
nurses, physician assistants and acute care nurse practitioners), physical therapists (PTs), occupational
therapists (OTs), respiratory therapists and speechlanguage pathologists. The ICU clinicians together
with the PTs and OTs evaluated all patients daily,
from Monday to Saturday, for their suitability for
participating in rehabilitation therapy. Guidelines
for rehabilitation (Table 1), including contraindications and the range of activities undertaken, were
adapted from the existing literature.16,19 Therapy
could be deferred at the discretion of the treatment
team based on their clinical judgment. On Sundays,
therapy was performed on an ad hoc basis by the ICU
clinicians.
The rehabilitation therapists determined the activities (possible activities listed in Table 1) for each therapy session. Physical therapy interventions included
passive range of motion, transfers (including supine
to sitting, sitting to standing, and bed to chair), ambulating in place and ambulation. Occupational therapy
interventions included training with feeding, grooming, and dressing. Throughout all rehabilitation sessions, hemodynamic (heart rate, blood pressure) and
respiratory statuses (respiratory rate and oxygen saturation) were closely monitored. Rehabilitation sessions involved one or more therapist, as well as a
rehabilitation therapy assistant if extra assistance
was required. For the mobilization of mechanically
ventilated patients, a respiratory therapist was available upon request to transition the patient to a portable ventilator or to a bag-valve device for manually
assisted ventilation. For patients on advanced circulatory support such as an extracorporeal membrane
oxygenation device, additional sta members were
available for assistance in mobility. The patients
nurse and a nurse practitioner or a physician were
also present in the ICU and aware of the therapy
session in progress.
Prior to the implementation of the ICU early
rehabilitation program, if any referral for physical
and occupational therapy was made, it was typically
done within one day of a patient being medically
appropriate for transfer out of the ICU to a regular
hospital ward. Physical therapy referral was rarely
requested when a patient was endotracheally
intubated.

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Journal of the Intensive Care Society 17(1)

Table 1. Guidelines for ICU rehabilitation.
Possible Rehabilitation Activities
Contraindications
Ongoing coronary ischemia
Unstable arrhythmia
Cardiac tamponade
Respiratory distress
Hypoxemia at rest (SpO2 <88%)
Respiratory rate < 5 or > 40 per minute
Heart rate < 40 or > 130 beats per minute
Mean arterial pressure < 55 mmHg
Systolic blood pressure > 200 mmHg
Unsecure airway
Hypoglycemia (blood glucose < 50 mg/dL)
Orthopedic contraindication
Unstable spinal cord injury
Intracranial hypertension
Morbid obesity (if unable to be managed safely)
Care focused on comfort measures only

Physical therapy

Occupational therapy

Passive range of Motion

Feeding
Grooming
Dressing

Exercises in bed
Transfers
(supine to sitting,
sitting to standing,
bed to chair)
Ambulating in place
Ambulation

ICU: Intensive care unit.

Planning and education for implementation of the

ICU early rehabilitation program took place from
August 2011 to December 2011. There may have been
heightened awareness of the benets of early rehabilitation in the ICU during this educational period; however,
there were no rehabilitation therapists dedicated to ICU
patients. Implementation of the ICU early rehabilitation
program in January 2012 involved 10 PTs and 4 OTs
who focused their primary role on patients in the ve
participating ICUs (with a total of 80 beds). All PTs and
OTs had prior experience of working with patients in
the ICU, but not specically in the context of an early
ICU rehabilitation program. The PTs and OTs had an
average of 6 years and 2.5 years of work experience in
an acute care hospital, respectively. An additional ve
rehabilitation therapy assistants were hired specically
for the program. Depending on the number of patients
in each ICU that were eligible for rehabilitation activities that day as determined on the morning meeting
between the ICU clinicians and PTs and OTs, the
ICU rehabilitation therapists were exible to divide
their time amongst the ve ICUs. There were no xed
stang ratios for number of rehabilitation therapists
per ICU for each day.
As part of the ICU early rehabilitation program,
there was no pre-specied sedation protocol mandated
across the ve ICUs. Individual ICUs were allowed to
implement sedation minimization protocols. Only the
Medical ICU at the Columbia campus implemented
such a protocol. Otherwise, sedation practices in the
pre- and post-implementation periods were at the discretion of the treating clinicians.
During the year of implementation in January to
December 2012, while there were weekly multidisciplinary sta meetings to discuss implementation

progress, including monthly surveillance of rehabilitation treatments per ICU patient-day, there were no
additional quality assessments to ensure that the
ICU early rehabilitation program was implemented
uniformly in all the study ICUs.

Data collection
All study data were obtained from a hospital-wide
administrative database for all admissions to the ve
ICUs during the two-year period. Data included
patient age, sex, and primary diagnosis (classied
into medical or surgical diagnoses, with subcategories
for the medical admissions). The proportion of
patients on mechanical ventilation was not available.
Primary outcomes were ICU and hospital LOS, with
each midnight representing a one-day stay. Secondary
outcomes included the number of PT and OT treatments performed in the ICU, hospital mortality and
hospital discharge destination.
When available, patients baseline mobility and
activity status prior to hospital admission were
obtained from the electronic medical record. Baseline
mobility and activity status was based on nursing
intake documentation and presented as mobility and
activity status scores. These scores each ranged from
0 to 3, with one point assigned if the patient was independent (i.e. not requiring assistance or assistive
device) with each of three mobility tasks (bed mobility,
bed-to-chair transfer, and ambulation) and activity
tasks (dressing or grooming, feeding, and toileting or
bathing). For example, a mobility score of 3 means the
most independently mobile, while a score of 0 means
minimally mobile (unable to even move in bed without
assistance). Similarly, an activity score of 3 means the
most independent in the activity tasks listed above,

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Wahab et al.

while a score of 0 means inability to perform any of the

tasks listed above without assistance. Also if available,
patients ambulation status in the ICU was obtained by
tabulating cases where the physical therapist had
checked the patient ambulated checkbox in their
documentation.

Statistical analysis
We summarized data using standard descriptive statistics with unpaired t-tests used to compare continuous variables and Chi-squared tests to compare
categorical variables. LOS data were expressed as
mean with standard deviation (SD), as well as by percentiles. Due to its positively skewed distribution
(skewness of 5.0 and 5.2 for ICU LOS, and 4.3 and
3.2 for hospital LOS in the pre- and post-implementation periods, respectively), p-values for the dierences
in LOS between the pre- versus post-implementation
periods were calculated using Poissons regression, as
done in previous ICU LOS analyses.2628 The dierences in the distribution of LOS data were also analyzed with the MannWhitneyWilcoxon rank sum
test. For all analyses, a two-sided p-value of less
than 0.05 was considered statistically signicant. In
the small number of patient hospitalizations who
had more than one ICU admission, we analyzed
data from only their rst ICU admission. Analyses
were performed with Stata version 9.0 (College
Station, TX, USA).

Results
Patient characteristics
In the pre- and post-implementation periods, respectively, there were a total of 3945 and 4200 ICU

admissions among the ve ICUs (with 89 and 96 hospitalizations having more than one ICU admission,
respectively). Both pre- and post-implementation
groups were remarkably similar in baseline characteristics (Table 2), with a mean (standard deviation (SD))
age of 63 (17) years, and 55% male, and 80% medical
admissions. The subcategories of primary diagnosis
for medical admissions were also similar between
both groups. In the subset of patients with baseline
mobility and activity data (approximately 33% and
46% of patients, respectively), scores were similar
between the pre- and post-groups, with approximately
58% of ICU admissions in which the patient was fully
independent for both activity and mobility and
approximately 24% in which the patient was fully
dependent (Table 3).

Rehabilitation treatments
Table 4 shows the distribution of patients by the
number of ICU rehabilitation treatments received
during their ICU stay in the pre- and postimplementation periods. There was a signicant
increase in the proportion of patients who received
more rehabilitation treatments during their ICU stay
in the post-implementation period (p < 0.001). In the
pre- versus post-implementation periods, respectively,
the mean number of rehabilitation (PT or OT) treatments was 0.16 versus 0.72 per ICU patient-day
(p < 0.001, Figure 1). In the pre-implementation
period, there was similarity in mean number of
rehabilitation treatments per ICU patient-day across
all ve ICUs (range: 0.100.22) with a larger range
during the post-implementation period (0.580.98).
The mean number of rehabilitation treatments per
ICU patient-day also increased from the pre- versus
post-implementation period for all subgroups of

Table 2. Baseline patient characteristics.

Age in years, mean (SD)

Male, n (%)
Medical admission, n (%)
Primary diagnosis for medical admission, n (%)b
Cardiocerebrovascular disease
Sepsis/Infectious disease
Toxic/Metabolic disease
Gastrointestinal/Liver disease
Pulmonary disease
Neoplastic disease
Renal disease
Otherc

Pre-implementation,
2011 (n 3945)

Post-implementation,
2012 (n 4200)

P-valuea

63.1 (17.1)
2152 (55)
3166 (80)

63.0 (17.5)
2370 (56)
3347 (80)

0.79
0.09
0.53

1007
655
195
312
339
234
99
325

1083
772
209
296
342
218
83
344

0.149

(32)
(21)
(6)
(10)
(11)
(7)
(3)
(10)

(32)
(23)
(6)
(9)
(10)
(7)
(2)
(10)

Students T-test and Chi-squared tests were used to compare patient characteristics between the pre- and post- implementation periods.
Percentages do not add to 100% due to rounding.
c
Other includes: non-malignant hematological disease, rheumatological disease, non-vascular neurological disease.
b

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Journal of the Intensive Care Society 17(1)

patients who were fully independent, intermediate,

and fully dependent for both baseline activity and
mobility, from 0.11 to 0.63, 0.14 to 0.77, and 0.13 to
0.63, respectively. Finally, in the pre- versus postimplementation periods, patients ambulated with
physical therapy at least once during their ICU stay
in 15% versus 50% of ICU admissions (p < 0.001).

Outcomes
Four out of ve ICUs had a signicantly decreased
mean ICU LOS in the post-implementation period,

ranging from a decrease of 0.4 days (6.7% of preimplementation LOS) to 0.6 days (10.3%). The overall average ICU LOS across all ve ICUs was 5.8
versus 5.4 days (p < 0.001) in the pre- versus postimplementation period (Table 5), with a mean
decrease of 0.4 days (95% condence interval (CI)
0.30.5). Across all ve ICUs, the number of ICU
admissions in the post-implementation period
increased by 255 (6.5% of pre-implementation value).
In the pre- versus post-implementation period,
mean hospital LOS for admissions from all ve
ICUs was 14.7 vs. 13.9 days, representing a signicant

Table 3. Baseline mobility and activity status.a

Scoreb
Mobility
0
1
2
3
Activity
0
1
2
3
Mobility and Activity
Fully independent
Fully dependent

Pre-implementation,
2011 n (%)c

Post-implementation,
2012 n (%)c

405
61
73
782

(31)
(5)
(6)
(59)

605
71
93
1171

(31)
(4)
(5)
(60)

318
98
57
864

(24)
(7)
(4)
(65)

504
117
59
1288

(26)
(6)
(3)
(65)

P-valued
0.41

0.07

0.68
732 (57)
306 (23)

1110 (59)
481 (25)

a
Status prior to hospital admission, assessed by nursing intake history from patient or family upon admission to the ICU. In the pre- and postimplementation periods, respectively, data are available as follows: mobility score 1321 (33%) and 1943 (46%) patients, and activity score 1337
(34%) and 1968 (47%).
b
These scores each ranged from 0 to 3, with 1 point assigned if the patient was independent (i.e. not requiring assistance or assistive device) with each
of three mobility tasks (bed mobility, bed-to-chair transfer, and ambulation) and activity tasks (dressing or grooming, feeding, and toileting or bathing).
For example, a mobility score of 3 means the most independently mobile, while a score of 0 means minimally mobile (unable to even move in bed
without assistance). Similarly, an activity score of 3 means the most independent in the activity tasks listed above, while a score of 0 means inability to
perform any of the tasks listed above without assistance.
c
Percentages do not add to 100% due to rounding.
d
Chi-squared tests were used to compare categorical differences between the pre- and post-implementation periods.

Table 4. Distribution of patients by the number of ICU rehabilitation treatments received during their ICU stay.
Pre-implementation, 2011

Post-implementation, 2012

Rehabilitation treatments
received (n)

%a

%a

P-valueb

0
1
2
3
4
510
>10

69
15
7
3
2
4
1

21
21
16
10
8
16
8

<0.001

ICU: intensive care unit.

a
Percentages do not add to 100% due to rounding.
b
A Chi-squared test was used to compare the distribution of patients between the pre- and post-implementation periods.

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Wahab et al.

Figure 1. The mean number of rehabilitation treatments per intensive care unit patient-day in the pre- versus post-implementation
period.

Table 5. Length of stay outcomes.a

ICU

Number of ICU admissions, n

Pre, 2011
Post, 2012
% Change
Mean (SD) ICU LOS, days
Pre, 2011
Post, 2012
Change in Mean ICU LOS, days
% Change
P-value
Mean (SD) Hospital LOS, days
Pre, 2011
Post, 2012
Decrease in Mean Hospital LOS, days
Change (%)
P-value

Overall

587
687
17.0

594
608
2.4

779
853
9.5

1011
1022
1.1

974
1030
5.7

3945
4200
6.5

5.8 (5.9)
5.2 (6.3)
0.6
10.0
<0.001

5.7 (5.9)
5.9 (7.3)
0.2
3.5
0.124

5.0 (9.6)
4.6 (7.4)
0.4
8.0
<0.001

6.2 (7.7)
5.7 (7.3)
0.5
8.1
<0.001

6.0 (7.6)
5.6 (6.4)
0.4
6.7
0.001

5.8 (7.6)
5.4 (7.0)
0.4
6.9
<0.001

17.5 (20.0)
15.1 (15.2)
2.4
13.7
<0.001

16.2 (20.7)
15.9 (15.7)
0.3
1.9
0.187

14.3 (13.7)
14.1 (15.5)
0.2
1.4
0.406

11.2 (12.8)
10.4 (12.4)
0.8
7.1
<0.001

16.3 (17.0)
15.5 (18.1)
0.8
4.9
<0.001

14.7 (16.7)
13.9 (15.6)
0.8
5.4
<0.001

ICU: Intensive care unit; SD: standard deviation; LOS: length of stay.
a
ICUs A, B and E are purely medical ICUs, while ICU D is a non-surgical cardiac ICU, and ICU C is the surgical ICU.

mean decrease of 0.8 days (95% CI 0.6 - 0.9 days,

p < 0.001), representing a 5.4% decrease from preimplementation LOS. Across each of the ve ICUs,
there was a decrease in hospital LOS with a range of
0.2 days (1.4%) to 2.4 days (13.7%) (Table 5). The
reduction of ICU LOS accounted for half of the
reduction in hospital LOS. The mean decrease in hospital LOS spent outside of the ICU in the pre- and
post-implementation periods was 0.4 days (p < 0.001).

Table 6 shows the distribution of LOS outcomes by

percentiles in the pre- and post-implementation periods. The change in ICU LOS distribution had a pvalue of 0.06. The change in hospital LOS distribution
had a p-value of 0.005. The reductions in ICU and
hospital LOS were in the highest quartile of the LOS
distribution.
There was no change in pre- and post-implementation ICU LOS in the subgroups of patients who were

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Journal of the Intensive Care Society 17(1)

Table 6. Distribution of length of stay outcomes.

Pre, 2011

Post, 2012

Percentiles, %

ICU LOS, Days

1st
5th
10th
25th
Median, 50th
75th
90th
95th
99th

1
1
1
2
3
7
13
19
37

Percentiles, %

Hospital LOS, Days

1st
5th
10th
25th
Median, 50th
75th
90th
95th
99th

1
2
3
5
9
18
32
44
82

P value

0.06

1
1
1
2
3
6
12
17
34.5
0.005

1
2
3
5
9
17
31
44
76

ICU: Intensive care unit; LOS: length of stay.

a
MannWhitneyWilcoxon rank sum test was used to compare the
distribution of ICU and hospital LOS between the pre- and post-implementation periods.

fully independent, intermediate, or fully dependent in

their pre-admission activity and mobility.
The distribution of hospital mortality and discharge destinations were the same in the pre- versus
post-implementation periods (Table 7), with 17%
dying, 59% discharged home, and 20% discharged
to a health care facility (e.g. rehabilitation or other
facility).

Discussion
In this retrospective pre-post study of 8145 ICU
admissions, a multi-ICU coordinated implementation
of an early rehabilitation program, across two hospital sites, resulted in a signicant increase in the proportion of patients who received more rehabilitation
treatments during their ICU stay and a signicant
increase in the mean number of rehabilitation treatments per ICU patient-day. These improvements were
associated with a signicantly reduced mean ICU
LOS and hospital LOS, as well as an increase in
ICU admissions.
Our study demonstrates that implementation of a
multi-disciplinary early rehabilitation program across
dierent types of ICUs (medical, cardiac, surgical)
across two campuses of a large academic hospital
system was able to increase rehabilitation therapy in

the ICUs. At the time of implementation planning,

guidelines for ICU rehabilitation activities were available and adapted from the existing literature.16,19 In
addition to education for the multidisciplinary ICU
sta regarding the plan for the early ICU rehabilitation program, the assignment of specic physical and
occupational therapists to primarily work in the ve
ICUs and the hiring of additional rehabilitation
assistants were central parts of this large implementation eort. In the post-implementation year, the mean
number of rehabilitation treatments per ICU patientday increased more than 4-fold from 0.16 to 0.72 per
ICU patient-day. This is consistent with prior prepost projects evaluating early ICU rehabilitation,
where mean treatments per day increased three-fold
from 0.33 to 0.83,19 the number of patients receiving
PT in the ICU increased by 60%,24 or physical therapy billable units per day of PT doubled.29 To our
knowledge, our multisite study is among the largest
of published reports of early rehabilitation of critically ill patients and adds to the growing number of
academic institutions reporting experiences with
implementation of early ICU rehabilitation
programs.1013,1619,23,24,29
In our study, after implementation of the early
ICU rehabilitation program, mean ICU LOS
decreased by 0.4 days (95% CI 0.30.5, p < 0.001)
and mean hospital LOS decreased by 0.8 days (95%
CI 0.60.9, p < 0.001). This nding reinforces earlier
studies demonstrating that implementation of early
rehabilitation in the ICU can contribute to a reduction in LOS,1013,1624 though our LOS reduction is
modest relative to prior studies. The ICU LOS reduction from prior retrospective and prospective studies
ranged from 1.4 to 2.1 days (2033% reduction),
while the hospital LOS reduction ranged from 2 to
3.3 days (1423% reduction).1112,19,24,29 These LOS
reduction ranges come from studies of dierent types
of ICUs, with dierent eligibility (for example,
patients on mechanical ventilation versus allcomers), and so precludes direct comparison to the
LOS changes observed in our study of all-comers to
ve ICUs. Since we do not have detailed patient-level
information such as those on mechanical ventilation
or those specically with acute lung injury, we were
unable to examine LOS dierences in these subgroups
that might have had additional benet from early
ICU rehabilitation. A meta-analysis21 of other prospectively controlled studies that included surgical
and medical ICU patients found a modest but statistically signicant pooled eect size for both ICU
(n 597, Hedges g 0.34 [0.51 to 0.18],
p < 0.01) and hospital LOS (n 441, Hedges g
0.34 [0.53 to 0.15], p < 0.01). There was variability in the amount that our ICU early rehabilitation
program increased rehabilitation treatments per ICUpatient day among the ve ICUs. The range of ICU
and hospital LOS in the post-implementation period
could reect a dierence in adherence to

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Wahab et al.

Table 7. Hospital mortality and discharge destination.

ICU

Died, n (%)
Pre, 2011
Post, 2012
Survived Home, n (%)
Pre, 2011
Post, 2012
Survived Facilitya, n (%)
Pre, 2011
Post, 2012
Survived Otherb, n (%)
Pre, 2011
Post, 2012
P-value

126 (22)
153 (24)

142 (25)
131 (23)

276 (49)
288 (44)

Overall

54 (7)
53 (6)

104 (10)
104 (10)

234 (24)
261 (25)

660 (17)
702 (17)

288 (51)
290 (50)

571 (75)
608 (73)

701 (70)
735 (72)

433 (45)
496 (48)

2269 (59)
2417 (59)

136 (24)
170 (26)

118 (21)
135 (23)

127 (17)
164 (20)

165 (17)
135 (13)

212 (22)
190 (19)

758 (20)
794 (19)

31 (5)
40 (6)
0.52

21 (4)
25 (4)
0.61

9 (1)
9 (1)
0.47

29 (3)
40 (4)
0.14

79 (8)
77 (8)
0.19

169 (4)
191 (5)
0.94

ICU: intensive care unit.

a
Facility included: long-term acute care facility, intermediate care facility, sub-acute nursing facility, long term care facility, and inpatient rehabilitation
facility.
b
Other included patients who were discharged to: law enforcement, psychiatric hospital, left against medical advice, home hospice, and a hospice
facility.

implementation of the program or a dierent patient

response to the same program depending on the type
of ICU (e.g. surgical versus medical). Further exploration is needed in other large-sized multi-ICU studies
that involve dierent types of ICUs.
The distribution of ICU and hospital LOS by percentiles also changed between the pre- and post-implementation periods. In particular, we found that the
reductions in ICU and hospital LOS were in the highest quartile of the LOS distribution. The early ICU
rehabilitation program may have had the highest
impact on patients in highest quartile of LOS because
they were exposed to the program longest or that
these patients were the most likely to benet from
the program. Since the benets were concentrated in
the highest quartile, the median LOSs did not show a
reduction. For example, even if every patient in the
highest quartile had their LOS reduced by half, the
median would still not change.
To further explore why our LOS reductions are
modest relative to prior reports,11,19,2324 we examined
a subgroup of our study population where more
detailed baseline information was available. In our
study, as assessed by history at ICU admission, there
were 25% of ICU admissions where the patient was
completely dependent for both baseline activity and
mobility prior to their ICU admission and critical illness. These fully dependent patients are likely from
long-term care facilities or those with advanced illnesses requiring complete care at home or at longterm nursing facilities. As evidenced by the similar
increase in mean number of rehabilitation treatments
per ICU patient day for the fully dependent, the
intermediate, and the fully independent subgroups

from 0.13 to 0.63 versus 0.14 to 0.77 versus 0.11 to

0.63, respectively), the severely debilitated candidates
were not excluded from participating in early rehabilitation in the ICU. There was no signicant dierence
in ICU LOS between pre- and post-implementation
periods for the fully dependent, the intermediate, or
fully independent groups. There are two possibilities
for these ndings either that the subgroups have inadequate power to detect a statistically signicant dierence in ICU LOS between the pre- and postimplementation periods, or that the overall ICU LOS
reduction was driven by the group that did not have
baseline activity and mobility scores available for subgroup analysis. The baseline activity and mobility
scores were only available for a 3040% subset of the
total 8145 ICU admissions in the study, so we cannot
better describe the baseline status of the group of
patients that drove the decrease in overall ICU and
hospital LOS. This highlights the need for future studies to help better dene candidates who may benet
from the early rehabilitation eorts while in the ICU.
There was no dierence in the discharge distribution between our pre- and post-implementation periods. Existing literature has a variety of ndings
regarding this outcome, with Morris et al.11 reporting
no dierence in discharge disposition, Schweickert
et al.12 reporting a non-signicant trend in increased
discharges to home, and Engel et al.24 reporting an
increase in the number of patients who received PT in
the ICU being discharged home. With only limited
data available regarding discharge destination within
the existing administrative data used for this analysis,
we are constrained in our ability to more comprehensively evaluate patients physical functional status

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10

Journal of the Intensive Care Society 17(1)

upon discharge in the pre- versus post-implementation periods.

The ICU LOS reduction associated with implementation of an early ICU rehabilitation program may
have costs and savings implications. Lord et al.23
applied nancial models based on LOS data from
an ICU early rehabilitation program and estimated
that the projected net cost of implementation was
modest compared to improvement in patient outcomes. For the implementation program in our
study, the complete prot and loss assessment data
was not made available to the investigators.
However, the hospital has indicated that there was a
positive return on investment based on the new
resources committed and the calculated savings due
to the consequent decreases in LOS.
There are several potential limitations of our study.
First, this was a retrospective observational study
using hospital-wide administrative data limiting
causeeect inferences from being drawn and having
potential bias from unmeasured confounders such as
severity of illness and need for mechanical ventilation.
Moreover, we could not control for temporal changes
between the pre- and post-implementation periods.
However, there were no other systematic interventions
implemented to reduce ICU LOS during the study
period, no systematic changes in our institutions
ICU referral patterns, and the baseline characteristics
(Table 2) and mortality rate (Table 7) of our pre- and
post-intervention groups were remarkably similar.
Furthermore, our ndings of decreased ICU LOS
were consistent with multiple prior studies.1013,1624
Second, pre-admission baseline mobility and functional scores were available for only a subset of
patients, which limits inferences that can be made
from these data. Third, the retrospective design precluded having detailed and standardized data on
rehabilitation activities performed in the pre- versus
post-implementation periods. In future evaluations,
the integration of a reliable and feasible ICU mobility
scale would be helpful to better address this issue.30
Lastly, the generalizability of our ndings is tempered
since this was a single hospital system. However, given
that the study was conducted in ve ICUs (including
medical, surgical and cardiac ICU) at two locations,
and that our results are consistent with prior literature,
this weakness may be limited.

Conclusion
A large, multi-ICU, early rehabilitation program was
concurrently implemented in two sites of our hospital
system. In this retrospective before/after comparison,
we found that the ICU early rehabilitation program
increased the proportion of patients who received
more rehabilitation treatments during their
ICU stay and increased the average number of
rehabilitation treatments per ICU patient-day.
After implementation of the program, we also

observed a signicantly reduced ICU and hospital

length of stay, as well as an increase in ICU admissions.
Declaration of Conflicting Interests
The authors declared no potential conicts of interest with
respect to the research, authorship, and/or publication of
this article.

Funding
The authors disclosed receipt of the following nancial support for the research, authorship, and/or publication of this
article: Outside the work under consideration for publication, Dr Brodie reports receiving research support and previously provided research consulting for Maquet
Cardiovascular. All compensation is paid to Columbia
University. He is a member of the Medical Advisory
Board for ALung Technologies. All compensation is paid
to Columbia University. Outside the work under consideration for publication, Dr Needham reports receiving grant
support from NIH, AHRQ, and Moore Foundation.

Authors contributions
RW, NY, SC, DMN, and DB contributed to literature search,
gures, study design, data collection, data analysis, data interpretation, and writing. MN and KHP contributed to data
collection, data analysis, data interpretation and writing.
TB, DV, DR, KRP, PR, EPM, SMB and DB contributed
to the conception of the study, data interpretation and writing. All authors read and approved the manuscript.

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