FUNCTIONAL RECOVERY AFTER ICU AND HOSPITAL DISCHARGE: FEASIBILITY AND PRELIMINARY EFFICACY OF THE REACH PROGRAM

M. Major^1,2,3, D. Dettling-Ihnenfeldt¹, S. Ramaekers^2,1, R. Engelbert^2,1, M. Van der Schaaf^1,2

Background: As more patients survive critical illness and ICU stay, the need for community-based rehabilitation interventions after hospital discharge increases. Long-term physical, mental and psychological problems have been identified in survivors of critical illness, described as the Post-Intensive Care Syndrome (PICS). The current COVID-19 crisis highlights the need for evidence-based multi-dimensional rehabilitation programs after ICU and hospital discharge targeting PICS. Although international consensus recommendations for physical therapy (PT) interventions exist, studies on feasibility and efficacy of interdisciplinary rehabilitation programs after critical illness are lacking. A network of expert rehabilitation professionals from 7 hospitals and 19 private practices in the Netherlands formed the REACH network (REhabilitation after Critical Illness and Hospital discharge) in 2018. A PT intervention targeting PICS was developed in a community of practice and evaluated in a non-randomized, two-armed feasibility study.

Purpose: To investigate the feasibility and the preliminary efficacy of an interdisciplinary community-based intervention targeting physical recovery after ICU and hospital discharge.

Methods: Patients were recruited from participating hospitals and allocated to the intervention or the control group (usual care) based on convenience sampling. Eligibility criteria were having received mechanical ventilation for ≥ 48 hours, being discharged home, proficiency in Dutch or English language and absence of cognitive or psychiatric impairments. Feasibility outcomes were: safety of the REACH program, patient and professional satisfaction and adherence to the protocol. Physical outcomes were respiratory muscle strength (PImax and PEmax), hand grip strength (HG, kg), exercise capacity (Two-Minute Step Test - TMST) and malnutrition prevalence (SNAQ65+ score). Data were collected during home visits at 2 weeks, 3 months and 6 months after hospital discharge.
Demographic data were analyzed descriptively, physical measures at 3 time points were compared to normative reference values using paired sample t-tests or the one sample Wilcoxon Signed Rank test as applicable for (non)parametric data. Between group data were analyzed using the independent t-test or Mann-Whitney-U test as applicable for (non)parametric data.

Results: 43 participants (19 intervention, 24 control) participated in this study (65% male, mean age 59 (SD±12.7). Reason for ICU admission was primarily respiratory (76.7%, ARDS or COVID-19) or cardiac in origin (20.9%). The groups were similar for ICU length of stay or mechanical ventilation days. At hospital discharge HG, PImax, PEmax and exercise capacity were significantly decreased (p < 0.000), and malnutrition prevalence was 83.7%. Between group analysis shows no significant differences at any of the time points for physical outcomes. COVID-19 participants showed a tendency towards better physical outcomes at 3 months, compared to non-COVID participants. No adverse events took place. Participant drop-out rate was lower in the intervention (5.2%, n=1) versus the control group (25%, n=6), and satisfaction with the PT was higher in the intervention group.

Conclusion(s): This REACH PT intervention is feasible, safe and showed high professional and patient adherence. This study highlights the physical deconditioning of ICU patients directly after hospital discharge.

Implications: An infrastructural network of professionals can effectively provide rehabilitation in the home situation after (COVID-19 induced) critical illness. The REACH network is expanded nationally and a randomized controlled trial is in preparation.

Funding, acknowledgements: Mel Major's PhD research is funded by the Dutch Research Council (NWO).

Keywords: physical deconditioning, post-intensive care syndrome, interprofessional collaboration

Topic: Critical care

Did this work require ethics approval? Yes

Institution: Amsterdam University Medical Centers, ethical review board

Committee: METC-AMC

Ethics number: 2019_012#82019201