Impact of early intervention and rehabilitation on functional decline in patients hospitalised for acute heart failure

Purpose

Acute heart failure (AHF) is the most common cause of admissions for patients aged 65 and over in the UK. The occurrence of functional decline in elderly adults with hospitalisation for acute illness is well established with decline occurring as early as day 2 of admission. With an average length of stay of 18.7 days, patient age of 71.4 years, and 77.1% of patients having at least one other chronic disease, the patients admitted to the Heart Failure Unit at St George's Hospital are high risk for functional decline throughout their stay. Traditionally these patients would not be seen by a physiotherapist until after their intravenous diuretic treatment was completed. The aim was to assess the impact of early and specialist physiotherapy assessment and intervention on functional decline during hospitalisation of patients with AHF.

Approach

The Elderly Mobility Scale (EMS) was used to assess mobility on both admission and discharge from the heart failure unit. Patients were provided with individualised physiotherapy intervention whilst an inpatient aimed at preventing functional decline, planning for discharge, and promoting rehabilitation and self-management. Admission and discharge EMS scores for patients admitted between March 2016 and October 2017 were compared. Patients who passed away, transferred for onward medical care, or who were at the ceiling of the EMS on both admission and discharge were excluded. 153 sets of data were compared in total. Details on admission date to first assessment by physiotherapy were collected.

Outcomes

The median length of stay was 10.0 (range 1-72) days. Patients waited for physiotherapy on average less than 24 hours (range 0-7 days). Patient EMS scores increased significantly (p < 0.001) from admission (Mdn 14.00: IQR 11.00-18.00) to discharge (Mdn 16.00: IQR 13.00-18.00). Seven patients (5%) had a decrease, seventy-four patients (48%) showed no change and seventy-two patients (47%) had an increase in their EMS score on discharge compared with admission. 

The EMS categorises patients into dependency levels based on score achieved. For dependent patients (EMS 0-9, n=30) on admission the median EMS score changed from 5.0 to 12.5. For borderline category patients (EMS 10-13, n=42) median EMS changed from 12.5 to 13.0. Patients in the independent category on admission (EMS 14-20, n=81) had no change in their median admission EMS score of 18.0.  On admission 20% of patients were in the dependent category.  This reduced to 6.5% on discharge.  Patients categorised as independent increased from 53% on admission to 71% on discharge.

Implications

Physiotherapy intervention appears beneficial to increase mobility and decrease dependence of a predominantly elderly population with multiple comorbidities who at high risk of functional decline when admitted to hospital in acute heart failure.

Implications for patients are improved quality of life, particularly those at high risk of functional decline.  Social benefits are a reduced reliance on care services in the community.  This work also assists with work force planning for new or evolving acute heart failure services.

Top three learning points

  1. Early physiotherapy intervention prevents functional decline and reliance on community services
  2. High risk patients benefit the most from early physiotherapy intervention
  3. Physiotherapy is beneficial for patient’s hospitalised with acute heart failure

Fund acknowledgements

This work was unfunded.

Additional notes

This work was presented at Physiotherapy UK 2018.

For further information about this work contact Susan Eriksen.