18.

Provide access to physiotherapy and occupational therapy 7 days a week for people admitted to hospital with a medical emergency.

Two RCTs were identified that compared enhanced therapy access to physiotherapy to standard access in 2 populations (stroke patients and older people). They were analysed separately.

Older People

One study comprising 47 people evaluated the role of enhanced access to physiotherapy in older people. The evidence suggested that enhanced access to physiotherapy may provide a benefit in reduced mortality (at 3 months) and quality of life (change in mobility from baseline). However, there was no effect on readmission, adverse events (non- injurious falls) and mortality at discharge.

Stroke patients

One study comprising 283 people evaluated the role of enhanced access to physiotherapy in stroke patients. The evidence suggested those with enhanced access to physiotherapy had more adverse events (falls and other unspecific events) but it did provide a benefit in a reduced length of rehabilitation stay.

The committee considered that the reduced length of stay may coincide with an improved quality of life (for example, by enhancing mobility), but this was not measured by the study. There was some evidence to suggest more adverse events, falls in particular, in the enhanced access group. The committee noted that this might be a result of increasing rehabilitation and mobility resulting in an increased number of falls.

No evidence was found for discharge to normal place of residency, patient and/or carer satisfaction, time to mobilisation and delayed transfers of care.

The committee discussed that physiotherapists and occupational therapists serve 2 major functions; they can potentially avert or reduce the risk of complications (for example, DVTs, pressure ulcers, postural instability) but may also increase the speed with which patients can be discharged as early mobilisation improves function.

Assessment by a qualified therapist is required to develop a treatment plan in order to mobilise patients early, reduce or avert secondary complications and shorten their length of stay. The committee felt that early mobilisation is crucial but noted that if patients are admitted on a Friday for example, their treatment is delayed by 2 days if no qualified therapist can assess the patient before Monday. The committee were aware that qualified therapists are also required to facilitate patient discharge. The committee felt that if a hospital already provided a 7-day service, physiotherapy and occupational therapy assessment should be provided as part of this service to facilitate discharge and improve patient flow. It also facilitates a more equitable NHS service to patients irrespective of the day of their admission. The committee considered that, once the management plan had been formed by a qualified therapist, it could be implemented by assistants or nurses, which may reduce the costs of this intervention.

The committee highlighted that the enhanced service should be targeted for patients in need of therapy and may be unnecessary for those already mobile or bedbound.

The committee decided to make a strong recommendation because there was high quality evidence for a reduction in length of stay and moderate/low quality evidence for benefits to mortality at 3 months and quality of life.

There was no evidence for occupational therapy but the committee considered that the evidence for physiotherapy was likely to be applicable to occupational therapy as well.

No economic studies were identified.

The clinical review showed reduced length of stay and an increase in quality of life as well as a slight improvement in survival, which supports a recommendation of enhanced access to physiotherapy in terms of clinical effectiveness.

The committee noted that the cost of the intervention could be reduced if conducted partly by a therapy assistant or as part of an exercise class where multiple people are being treated together. They also noted that physiotherapy and occupational therapy are usually delivered by a team of staff with mixed skills and therefore, it is not appropriate to evaluate the two separately.

New cost-effectiveness analyses were conducted for 2 areas of enhancing therapy access, the ED and medical wards. A cohort model was built to assess the costeffectiveness of enhanced therapy access. A hospital simulation model was also built to explore how the intervention’s impact on hospital flow could affect its cost-effectiveness. Both models used inputs from bespoke data analysis, national data and treatment effects (primarily length of stay reduction and modest reductions in adverse events) that were informed by the above review but elicited from the committee members. The full model write up can be found in Chapter 41.

Extended access to physiotherapy/occupational therapy in the emergency department

The models compared extended access to therapy in the ED versus standard staffing hours. Extended access involves additional availability of physiotherapists and occupational therapists in the ED, using additional resources in terms of staff time at an incremental cost to normal care.

The cohort model found that extended access in the ED was slightly cost increasing in the base case analysis with assumed no effect on quality of life, hence no gain in quality-adjusted life-years. With less conservative assumptions about the effect of the extended access on admission, it was cost saving. The committee noted that extended access is a costly intervention with a limited amount of time to impact on the patients. The main impact of extended access in the ED is likely to be on hospital flow, not fully taken into account by the cohort model.

In the hospital simulation model, extended access in ED was cost increasing with no gain in quality-adjusted life-years. There were decreases in admissions, but only a small impact on four-hour breeches and hospital length of stay. However, there was no impact on other important outcomes, such as number of medical outliers and mortality.

The committee could not conclude that extended access in the ED would be cost effective. It might have a significantly positive impact on hospital flow and patient outcomes at a cost-effective level in some hospitals operating at sub-optimal levels of efficiency within the emergency department

Extended access to physiotherapy/occupational therapy in the general medical wards

Both models compared daily therapy on medical wards with weekday access only. Extended access involves additional availability of physiotherapists and occupational therapists in the general medical wards, using additional resources in terms of staff time at an incremental cost to normal care.

In both models, extended access in the wards was dominant, cost saving with a gain in quality-adjusted life-years. These findings are similar to those found in a randomised trial of rehabilitation at the weekend in Australia, albeit in a mixed medical/surgical population¹⁴. The committee also noted the impact on important outcomes linked to hospital flow. There were decreases in four-hour breeches and medical outliers and a modest reduction in mortality.

The committee concluded that extended access on medical wards could have a significantly positive impact on hospital flow and patient outcomes at a costeffective level in hospitals. This result was robust to sensitivity analysis.

Conclusions

The committee concluded that extended access to therapy on medical wards was likely to be cost saving. When assessing the uncertainty in these costs, the committee also considered the increase in quality of life and improved mortality, and believed that extended access would remain cost effective even if there was a small increase in cost. The committee therefore agreed that extended access to physiotherapy and/or occupational therapy on medical wards was likely to be cost effective.

To implement this recommendation, some Trusts will need to increase the provision of physiotherapy and occupational therapy services. This cost should be offset by cost savings from reduced length of stay.

Two RCTs were identified by the search that compared enhanced versus standard access to therapy in a relevant AME population. One study, including older patients had a small sample size. The evidence was graded high for mortality (at discharge) and readmission. The other outcomes were graded moderate to very low quality due to imprecision and risk of bias. The evidence for stroke patients was graded as high quality for length of rehabilitation stay and low quality for adverse events due to serious imprecision. The committee felt, however, that the evidence identified in stroke patients should be cautiously extrapolated to other populations, given that the needs of these patients were quite specific. All evidence identified was for physiotherapy access only but the committee considered that physiotherapy and occupational therapy services are closely linked with the former concerned with physical function and the latter focused on the application of that function. These services becoming increasingly integrated with staff frequently having a mixture of both sets of skills and the committee wanted to reflect this in its recommendation.

The original health economic modelling was assessed to be directly applicable but still had potentially serious limitations due to the treatment effects being based on expert opinion, albeit conservative and informed by the guideline’s systematic review.

The committee were aware of other NICE guidelines, for example, stroke (CG68, rec 1.7.1.1), hip fracture (CG124, rec 1.7.1 and 1.7.2) and venous thromboembolism (CG92, rec 1.2.2.),^39–41 that recommend early mobilisation of patients. The committee discussed the advantages of early mobilisation to reduce morbidity and length of stay of patients with an acute medical emergency. Providing increased access to physiotherapy and occupational therapy would facilitate this and hence the committee made a strong positive recommendation.

Bed rest was historically used therapeutically in the management of many chronic illnesses in patients admitted to hospitals. Unfortunately, the deleterious consequences of immobility predispose patients, particularly the elderly (as they have less functional reserve), to significant functional decline and reduced quality of life. Prolonged inactivity reduces the physiologic reserve of most organ systems, particularly the musculoskeletal and cardiopulmonary systems. Consequently, muscle weakness, contracture formation, postural hypotension and thrombogenic events are common in bed-bound patients. Fortunately, contemporary studies have dispelled the myth that inactivity fosters healing and have suggested techniques that may prevent immobility-induced dysfunction and ensure beneficial outcome particularly in the fragile and aging populations.