Can early extubation and intensive physiotherapy decrease length of stay of acute quadriplegic patients in intensive care? A retrospective case control study

Abstract

Background and purpose: Respiratory complications remain a major cause of morbidity and mortality in the acute quadriplegic patient population. The literature has suggested that early insertion of a tracheostomy facilitated pulmonary management and an earlier discharge from the intensive care unit (ICU). Recently, a change in practice has meant that these patients are considered for extubation and intensive physiotherapy treatment, including an overnight on-call service, rather than tracheostomy. The aim of the present retrospective, case-controlled study was to determine if either practice resulted in a difference in length of stay in intensive care and if an on-call physiotherapy service for these patients was cost effective.

Method: A case control design was used. Between April 1997 and November 1999, seven patients who did not require a tracheostomy were identified; case control subjects were matched for severity with seven patients who did receive a tracheostomy. Length of stay in intensive care and on the acute ward, days from injury to fixation and the overall number of respiratory physiotherapy and night physiotherapy treatments were recorded.

Results: Five of the seven patients in the non-tracheostomy group received on-call overnight physiotherapy treatment, with an average of five sessions over a total of three nights. This group's length of stay in an ICU was significantly less than patients who were tracheostomized (p = 0.02). The overall number of physiotherapy treatments between the two groups was not significantly different.

Conclusions: The results of this study suggest that if extubation and intensive physiotherapy is undertaken for suitable patients, the length of stay in intensive care can be significantly reduced. This represents a considerable cost saving for ICUs and more than covers the added cost of providing an after hours on-call physiotherapy treatment service. A prospective evaluation is required to confirm these findings.