Outcomes after in-reach multidisciplinary rehabilitation in the acute ward
rehabilitation for such patients is often now provided
by an in-reach rehabilitation team. This model of care
has emerged over the last decade and has been adopted
by a number of Australian hospitals since 2010 (13). In-
reach rehabilitation teams are mobile (treating patients
on different wards), multidisciplinary (involving at least
3 disciplines), coordinated, and are staffed to provide an
intensity of therapy that is comparable to the rehabilita-
tion setting (at least 2 therapy sessions per day).
At the time this pilot study was conceived, there were
no randomized controlled trials to guide the provision
of early rehabilitation for critical care survivors on an
acute ward after discharge from ICU (14). This study
therefore aimed to explore the feasibility, efficiency
and effectiveness of a coordinated inpatient early
rehabilitation programme, delivered by an in-reach
rehabilitation team as early as possible to critical care
survivors on the acute ward.
Objectives
• To assess the feasibility of an in-reach multidisci-
plinary rehabilitation programme in critical care
survivors, commencing soon after discharge from
the ICU and delivered on the acute ward.
• To determine whether in-reach rehabilitation re-
duces hospital length of stay (LOS) and improves
functional and psychological outcomes in critical
care survivors, compared with usual ward therapy.
METHODS
The trial was granted ethical approval by the Human Re-
search Ethics Committee of St Vincent’s Hospital Sydney
(HREC/12/SVH/324), and was retrospectively registered with
the Australian New Zealand Clinical Trials Registry (Trial Id:
ACTRN12618000539235). The trial is reported according to
the Consolidated Standards of Reporting Trials (CONSORT)
guidelines.
Design
A single-site, prospective pilot randomized controlled trial was
conducted with blinded outcome assessment at 6 and 12 months.
Participants
Participants were recruited from the ICU of one metropolitan
hospital in Sydney, Australia. The hospital is a tertiary referral
and heart and lung transplant centre. The ICU is a 15-bed unit
that cares for approximately 1,100 patients per year. Critical
care survivors were included in the trial if they met the follo-
wing inclusion criteria: aged 18–75 years; ICU stay ≥ 5 days;
predicted LOS on the acute ward ≥ 5 days; and premorbid fun-
ctional independence, defined a priori as a Barthel Index score
≥ 70, obtained from a proxy describing patient function during
the 2 weeks prior to admission. Patients were excluded if they
were not expected to survive their admission (e.g. withdrawal
of life support and considered for palliation); were unable to
599
be followed-up (e.g. overseas visitor, homeless, severe hearing
impairment); were unable to speak English; had a pre-existing
diagnosis of dementia (of any aetiology); severe psychiatric
disorders with recent hospitalization (within 6 months) or an
active substance use disorder.
Recruitment and allocation
Participants were recruited within 72 hours of transfer from ICU
to an acute ward. After baseline assessment, participants were
randomly allocated to 1 of 2 groups, either the early rehabilita-
tion intervention group, or usual care. A web-based, computer-
generated randomization procedure (accessed from: http://www.
graphpad.com/quickcalcs/randomize1.cfm 12/11/2012) was
used for random sequence generation. Group allocation was
placed in sealed envelopes, prepared by an administrative staff
member with no role in clinical care or the study procedures,
and numbered sequentially.
Intervention
The intervention group received involvement of an in-reach
mobile rehabilitation team. This multidisciplinary team con-
sisted of a rehabilitation physician (0.2 full-time equivalent),
nurse (0.2 full-time equivalent), full-time physiotherapist and
full-time occupational therapist. The mobile rehabilitation team
had a caseload of 6–8 patients at any one time. This team was
available 5 days per week and commenced rehabilitation im-
mediately after baseline assessment, as soon as possible after
ICU discharge to the acute ward.
Participants in the intervention group were all visited by the
rehabilitation physician for an initial assessment. Subsequent vi-
sits by the physician were based on clinical need, typically once
or twice per week. A structured multidisciplinary rehabilitation
programme was devised for each patient. This aimed to address
individual patient needs, involved the patient in decision-making
and goal-setting, and was reviewed regularly during the patient
journey via twice weekly multidisciplinary team meetings.
The in-reach therapists worked with ward therapists so that
the therapy frequency delivered was over and above what the
patient would normally receive from acute ward therapists. The
expected frequency was a 2-fold increase in therapy sessions
for the intervention group compared with usual care.
The duration of the study intervention was also determined
by clinical need, i.e. patients could be discharged from the
service once all rehabilitation goals during the acute stay were
achieved. For those patients who required inpatient rehabilita-
tion, the in-reach team remained involved until acute hospital
discharge and transfer to rehabilitation.
Control
The control group received usual care, as directed by the acute
physicians or surgeons on the acute ward. This involved acute
ward allied health and nursing interventions, which were not
coordinated by a rehabilitation physician or nurse. Each therapy
discipline prioritized their interventions based on resources,
clinical need and patient flow pressures, without reference to
other team members. However, the in-reach rehabilitation team
is well established at the hospital, and referrals based on clinical
grounds by the acute medical/surgical teams can be considered
part of usual care. The treating team always had the option of
referring patients for additional therapy via the in-reach reha-
bilitation team at any time-point during the acute ward stay, if
they perceived a clinical need.
J Rehabil Med 51, 2019