Making sense of the outcome of a rehabilitation implementation trial in the intensive care unit: Mixed methods

Abstract

Background: Evidence for implementation of evidence-based protocols (EBPs) in resource-constrained intensive care units (ICUs) is sparse.

Objectives: To evaluate a tailored best-practice multifaceted strategy for implementation of a validated physiotherapy EBP for the management of surgical ICU (SICU) patients. Also, to explore the physiotherapists' perceptions regarding the implementation process and factors affecting protocol adherence, guided by the Consolidated Framework for Implementation Research.

Methods: A type 2 hybrid implementation study design was applied, including all adult patients admitted over 16 months to two (control and experimental) SICUs in Western Cape Province, South Africa. The physiotherapists eligible to participate in the qualitative study (N=17) were those who participated in the implementation process and worked in the experimental SICU. The Therapeutic Index Scoring System-28 (TISS-28) and four process of care indicators (POCIs) were the primary and secondary outcomes, respectively, both analysed in Stata version 15. Thematic content analysis of textual data generated physiotherapists' perceptions of the implementation process.

Results: The intervention strategy did not result in protocol adherence, with no significant difference (p>0.05) in TISS-28 and POCI outcomes during and after implementation in the experimental unit and all phases of the control. Physiotherapists (71%; n=12/17) perceived that the process affected their thinking and clinical decision-making, but not the organisation of physiotherapy services, except for a more multidisciplinary approach to care in the experimental unit. Organisational factors (time constraints, workload/flow barriers) affected adherence, explaining the lack of practice change.

Conclusion: The importance of organisational change and support of the physiotherapy departments providing services to ICUs while also addressing the healthcare needs of a diverse group of hospitalised patients is highlighted.

Contribution of the study: The study provides insights for rehabilitation implementation in resource-constrained intensive care settings. It highlights the importance of taking the next step towards implementation in complex environments and a new approach to facilitating the uptake of evidence and ensuring sustainable change through addressing the structural and organisational aspects of physiotherapy service delivery and care, and the inclusion of a multidisciplinary team approach to the implementation of any discipline-specific evidence-based protocols in the intensive care setting.

Keywords: Evidence-based practice; TISS-28; implementation; intensive care; multifaceted strategy; physiotherapy protocol; process of care; resource constrained setting.

Fig. 1

Overview of the controlled before-and-after and qualitative study design (source: authors’ own work). (Unit A = experimental unit; Unit B = control unit.)

Fig. 2

Trial study flow and patient sample (source: authors’ own work). (Red font = lost to follow-up as no folders and bed charts available.)