Implementing a cycle ergometry protocol for patients with critical illness

Purpose

Early rehabilitation of patients in critical care (CC) units demonstrates clear patient benefits for outcomes of physical function, muscle strength and length of stay. Cycle-ergometry as a modality for early rehabilitation is safe and feasible in mechanically ventilated patients once they are medically stable. However, it is widely recognised that implementing such an intervention outside of a clinical trial can be challenging.

Nottingham University Hospitals NUS Trust introduced a protocol for cycle ergometry for all eligible adult patients in CC. The aim of this service evaluation (SE) was to determine whether an early cycle-ergometry protocol could be safely delivered and was operationally feasible. The SE also aimed to highlight any barriers to implementation that were modifiable. The SE was registered with the Trust number 17-239C

Approach

Implementation of the protocol was supported by two therapy support workers (TSW) between September-December 2017. The intervention was delivered by the TSW to eligible patients whose length of stay was ≥ 5 days. Data were collected on patient demographics, diagnosis, pre-morbid function, sedation levels, the day the cycle protocol was commenced, adverse events, reasons for not completing the protocol, first day to stand and length of stay.

Outcomes

During the data collection period 18 out of 242 patients admitted to CC received cycle-ergometry. 224 patients did not meet eligibility because their length of stay was < 5 days (n=175), they were medically unstable or met exclusion criteria (n=24) or were already mobile (n=15). The mean day for initiating the protocol was day 8 (range 1-28). A total of 50 cycle-ergometry sessions were delivered but 17 sessions were not completed as per protocol. The main reason for early cessation was patient request due to fatigue. No adverse events occurred. Several barriers to operational implementation were cited. These included 'time constraints', 'patient fatigue/refusal' and 'staffing issues'.

Cost and savings

The focus of this project was to assess the feasibility of the implementation of a cycle ergometry protocol prior to testing its efficacy.

The project did not incur any costs to run or set up and cost savings were not investigated.

Implications

In this CC setting cycle ergometry was shown to be safe but operational feasibility was more problematic. This was due to 'staffing issues' and 'lack of time' from the therapist perspective and patient reported fatigue or refusal. This resulted in the intervention not having been implemented as per protocol in 34% of the planned sessions. Identification of factors necessary for successful integration of such protocols into CC setting are likely to be multifaceted and may include training needs, capacity and staffing issues, problems integrating into usual service, flexibility of intervention protocol, organisational context and culture, patient/staff interaction and patients preferences.

Further work to determine why the cycle ergometry protocol was not fully implemented in this setting is required.

Top three learning points

  1. Delivering cycle ergometry was demonstrated to be safe in this setting, there were no adverse events (an adverse event was classed as an event where medical intervention was required to stabilise the patient).
  2. Delivering the protocol was challenging due to patients reporting fatigue and lack of time/staff prevented the delivery as per protocol.
  3. Since the project the therapy team have changed practice to focus on delivering cycle ergometry to a smaller number of high risk patients to ensure consistency in achieving the prescribed dose.

Fund acknowledgements

This work was unfunded. This was a 3rd Year undergraduate student´s dissertation project

Additional notes

This work was presented at Physiotherapy 2018.

For further information about this work, contact Eleanor Douglas at: Eleanor.Douglas@nottingham.ac.uk