National survey of the awareness and implementation status of early pulmonary rehabilitation for patients with critical illness in departments of pulmonary and critical care medicine in 2019.

Abstract

To the Editor: The aim of early pulmonary rehabilitation (PR) in the intensive care unit (ICU) is to reduce the incidence of post-ICU syndrome, increase the number of ventilator-free days, reestablish and improve functional capacity, improve health-related life quality, promote mental health, and enhance participation in everyday life. PR in the ICU is highly effective and plays an important role in recovery of patients with reduced exercise endurance, functional capacity, and health-related life quality. Several surveys outside China have assessed the implementation of early rehabilitation in the ICU,[1] but there are few data from China. This study aimed to investigate the awareness and implementation of early PR in secondary- and tertiary-class hospitals with pulmonary and critical care medicine (PCCM) standardized certification. PCCM staff members were recruited to fill out a self-designed questionnaire. We defined early PR as PR within 5 days of ICU admission. The questionnaire was discussed and developed by a multidisciplinary team of pulmonary and rehabilitation physicians, nurses, one cardiopulmonary physiotherapist, one member of the Department of Clinical Research and Data Management, and two PCCM standardization development officers all in China-Japan Friendship hospital. We designed two versions of the questionnaire: one for department directors and the other for general medical staff. Two questions on principles of and contraindications to early PR for patients with critical illnesses were used for quality control and were only answered by staff familiar with PR. Respondents who answered correctly were considered familiar with the relevant knowledge and were automatically directed to answer the subsequent questions. The questionnaires [Supplementary File 1, https://links.lww.com/CM9/B463] were posted on an online survey platform and distributed to medical staff across the country by our hospital's PCCM standardization development office via WeChat links. The 414 hospitals participating in the study were all members of the PCCM Standardized Construction Base of Chinese Association of Chest Physicians (licensed units). A liaison in each hospital was responsible for questionnaire distribution and collection. Questionnaires were distributed from May 27, 2019, to June 16, 2019. PCCM standardization development officers issued reminders to department directors and liaisons 14, 7, and 1 day before the deadline to ensure a relatively high completion rate. All variables were treated as categorical variables and presented as numbers and percentages. The differences between groups for each variable were determined by chi-square tests. Logistic regression analysis was performed to identify factors associated with conduction of early rehabilitation. All data analysis was performed with SPSS Version 20.0 (SPSS Inc., Chicago, IL, USA), and a P value less than 0.05 was deemed statistically significant. A total of 1537 participants were investigated in 407 hospitals in China, including 110 directors of different ICUs. The proportion of conducting PR was 83.6% (92/110, 95% CI: 77.2%–91.0%), and the proportion of conducting early PR in patients with critical illnesses in 110 ICUs was 62.7% (69/110, 95% CI: 54.3%–71.1%). Nurses accounted for the highest proportion of members who participated in early PR for critically ill patients (94.1%, 910/967), followed by doctors (92.3%, 893/967); caregivers/family members accounted for 46.1% (446/967) [Supplementary Figure 1, https://links.lww.com/CM9/B204]. The survey results showed that the proportion of participants who had heard of PR was 95.0% (1460/1537, 95% CI: 93.8%–96.0%), and the proportion of participants who knew the specifics of PR was 55.5% (811/1460, 95% CI: 53.0%–58.1%) [Supplementary Table 1, https://links.lww.com/CM9/B206]. The proportion of participants who had heard of early PR in patients with critical illness was 85.0% (1241/1460, 95% CI: 83.1%–86.8%), but the proportion of those who knew the specific details was only 47.9% (595/1241, 95% CI: 45.2%–50.7%). Respiratory therapists had the highest awareness of the specific details of early PR in patients with critical illnesses (74.4%, 29/39, Supplementary Table 2, https://links.lww.com/CM9/B207). Of the 1537 participants, 967 (62.9%, 95% CI: 61.3%–65.4%) had performed early rehabilitation for patients with critical illness. Among these participants, the source of knowledge was reported as departmental training (82.5%, 798/967), participation in meetings (68.7%, 664/967), online learning (37.6%, 364/967), short-term courses (31.3%, 303/967), and school training (8.7%, 84/967). The number of participants willing to participate in such programs was higher than the number who had actually participated. This difference was especially large among respiratory therapists, cardiopulmonary physiotherapists, and dietitians. For example, 96.5% (1197/1241) of those who had heard of early PR believed that cardiopulmonary physiotherapists should be involved in the early rehabilitation of patients with critical illnesses, but only 69.3% (670/967) had actually participated [Supplementary Figure 2, https://links.lww.com/CM9/B205]. Female medical workers performed early rehabilitation less often than male (OR = 0.53, 95% CI: 0.35–0.80), and medical workers aged 36 to 45 years were more likely to perform early rehabilitation than those aged ≤25 years (OR = 2.28, 95% CI: 1.24–4.20). Respiratory therapists were more likely than doctors to perform early rehabilitation in patients with critical illnesses (OR = 5.39, 95% CI: 1.76–16.56). Medical staff in general ICU departments were more likely to perform early rehabilitation than those in pneumology departments (OR = 2.44, 95% CI: 1.66–3.59). Participants with senior job titles were more likely to perform early rehabilitation than those with junior titles (OR = 2.38, 95% CI: 1.23–4.61) [Supplementary Table 3, https://links.lww.com/CM9/B208]. The most frequently stated reasons for not performing pulmonary rehabilitation were understaffing (77.78%, 14/18), personnel lack of professional skills (61.11%, 11/18), personnel under-training (55.56%, 10/18), and lack of equipment (38.89%, 7/18) [Supplementary Table 4, https://links.lww.com/CM9/B209]. Compared with a 2017 cross-country survey of PR,[2] this study demonstrates that the proportion of medical personnel who obtain professional knowledge by participating in academic conferences and reading professional literature has substantially increased. Departmental training, participation in meetings, and online learning are major contributors to professional knowledge increase in medical staff. However, the proportion of medical professionals who acquire knowledge of rehabilitation in school is extremely low. A 2016 national survey demonstrated that only 30.6% of participating respiratory therapists had graduated from a bachelor's degree program.[3] At present, only 50,000 professional and technical personnel are engaged in PR in China, among whom professional cardiopulmonary physiotherapists are particularly scarce.[4] Medical schools lack the relevant programs to train professional staff; thus, the compilation of relevant textbooks, the arrangement of relevant courses, and the establishment of professional certification or licensure programs are essential for the development of successful rehabilitation programs. In this study, 96.5% of cardiopulmonary physiotherapists believed that they should be involved in the early rehabilitation of patients with critical illness, but only 69.3% had actually participated. The reasons for the discrepancy between these values may be similar to the above-mentioned reasons for not performing early rehabilitation in patients with critical illness. Approximately 93% of participants surveyed believed that insufficient staffing is the main reason for the failure to develop an adequate rehabilitation program; recruiting additional staff may help reduce this barrier. Additional reasons include personnel lack of professional skills, personnel under-training, and lack of equipment. Studies outside China have reported strategies to address these barriers, such as enhancing staff training and multiprofessional education, establishing a culture of early ICU rehabilitation, and daily multidisciplinary discussions. The rate of early PR in critically ill patients in tertiary-class hospitals was 65.3% (64/98), compared with 41.7% (5/12) in secondary-class hospitals in this study. Compared with the results of an online PR survey by Liu et al[5] in 2016, which claimed rates of 12.2% in tertiary-class hospitals and 6.0% in secondary-class hospitals, the current rates of early PR in critically ill patients have increased substantially in China. However, we should acknowledge the gap between the PR situation in China versus the international environment. In 2015, a survey by Bakhru et al[6] showed that early rehabilitation was being used in 45% of U.S. ICUs, and the utilization rate was 39% in small hospitals, 40% in medium hospitals, and 58% in large hospitals. The results of most recent randomized controlled studies have confirmed that early rehabilitation for ICU patients benefits patients’ recovery and life quality. However, no studies or guidelines have defined how early rehabilitation should be. Currently, the start time, rehabilitation exercise plan, and end time of early rehabilitation for critically ill patients are set by medical staff based on their own experiences. Therefore, developing unified standards and guidelines may help the development of early PR programs. As this was a survey study, selection bias was inevitable. The sample size was small, as the scope of the investigation was limited to hospitals with PCCM standardized certification. Therefore, the findings only partly indicate the awareness and implementation status of early PR for patients with critical illnesses in PCCM departments. Nonetheless, to our knowledge, this is one of the first studies to investigate and identify a lack of awareness and implementation of early PR for critically ill patients in PCCM departments. Although the awareness and implementation of PR in China have improved in recent years, there is further need for improvement. Our results suggest that there is an urgent need to raise awareness of PR. Medical staff are willing to participate in PR programs but often do not because of a lack of staffing, equipment, and guidelines. These issues will need to be resolved to promote and develop PR programs. This study provides a theoretical basis to assist in the development of PR policies. Funding This work was supported by a grant from the Capital Foundation of Medical Development (CN) (No. 2020-3-4068). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Conflicts of interest None.