Early mobilization on continuous renal replacement therapy is safe and may improve filter life

Outcomes of a COVID Mobility Team

The detrimental effects of immobility are well documented in the literature, yet immobility still plagues the hospitalized adult. As the influx of COVID-19 patients began, patient mobility was further compromised. The purpose of this quality improvement project was to assess the impact of COVID mobility teams, composed of deployed coworkers, on COVID-19–positive and person under investigation patient outcomes. Using mobility teams improved mobility in COVID-positive and person under investigation patients. Increasing patient mobility results in improved patient outcomes by preventing hospital-acquired functional decline, preventing intensive care unit transfers, and decreasing length of stay.

Care and treatments related to intensive care unit-acquired muscle weakness: A cohort study

BACKGROUND

Intensive care unit-acquired muscle weakness (ICUAW) has an incidence of 40-46%. Early mobilisation is known to be a protective factor.

OBJECTIVE

The aim of the study was to identify the incidence of ICUAW in Spain and to evaluate variables likely to contribute to the development of ICUAW.

METHODS

A 4-month, prospective observational multicentre cohort study was conducted on patients receiving invasive mechanical ventilation for at least 48 h. Data were collected from ICU day 3 until ICU discharge. The primary outcome was presence of ICUAW (diagnosed using the Medical Research Council [MRC] scale). The secondary outcome was nurse-patient ratio, physiotherapist availability, analgesia, sedation and delirium management, glycaemic control, and daily level of mobility during the ICU stay as per the ICU Mobility Scale. A logistic regression model was constructed based exclusively on days 3-5 of the ICU stay.

RESULTS

The data of 642 patients were analysed from 80 ICUs, accounting for 35% of all ICUs in Spain. The incidence of ICUAW was 58% (275 of 474 patients; 95% confidence interval [CI] [53-62]). The predictors for ICUAW were older age (odds ratio [OR] = 1.01; 95% CI [1.00-1.03]) and more days with renal replacement therapy (OR = 1.01; 95% CI [1.00-1.02]). The protective factors for ICUAW were male gender (OR = 0.58; 95% CI [0.38-0.89]), higher Barthel Index (showing prehospital functional independence) (OR = 0.97; 95% CI [0.95-0.99]), more days of being awake and cooperative (defined by a feasible MRC assessment) (OR = 0.98; 95% CI [0.97-0.99]), presence of delirium (OR = 0.98; 95% CI [0.97-0.99]), and more days with active mobilisation (ICU Mobility Scale ≥ 4) (OR = 0.98; 95% CI [0.97-0.99]).

CONCLUSIONS

The risk factors for ICUAW were functional dependence before admission, female gender, older age, and more days on renal replacement therapy. The protective factors for ICUAW were feasibility of MRC assessment, the presence of delirium, and being actively mobilised during the first 5 days in the ICU.

Intra-dialytic hypotension following the transition from continuous to intermittent renal replacement therapy

Background

Transition from continuous renal replacement therapy (CRRT) to intermittent renal replacement therapy (IRRT) can be associated with intra-dialytic hypotension (IDH) although data to inform the definition of IDH, its incidence and clinical implications, are lacking. We aimed to describe the incidence and factors associated with IDH during the first IRRT session following transition from CRRT and its association with hospital mortality. This was a retrospective single-center cohort study in patients with acute kidney injury for whom at least one CRRT-to-IRRT transition occurred while in intensive care. We assessed associations between multiple candidate definitions of IDH and hospital mortality. We then evaluated the factors associated with IDH.

Results

We evaluated 231 CRRT-to-IRRT transitions in 213 critically ill patients with AKI. Hospital mortality was 43.7% (n = 93). We defined IDH during the first IRRT session as 1) discontinuation of IRRT for hemodynamic instability; 2) any initiation or increase in vasopressor/inotropic agents or 3) a nadir systolic blood pressure of < 90 mmHg. IDH during the first IRRT session occurred in 50.2% of CRRT-to-IRRT transitions and was independently associated with hospital mortality (adjusted odds ratio [OR]: 2.71; CI 1.51–4.84, p < 0.001). Clinical variables at the time of CRRT discontinuation associated with IDH included vasopressor use, higher cumulative fluid balance, and lower urine output.

Conclusions

IDH events during CRRT-to-IRRT transition occurred in nearly half of patients and were independently associated with hospital mortality. We identified several characteristics that anticipate the development of IDH following the initiation of IRRT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00885-7.

Safety and Feasibility of Physical Rehabilitation and Active Mobilization in Patients Requiring Continuous Renal Replacement Therapy: A Systematic Review

OBJECTIVES

To evaluate the safety and feasibility of physical rehabilitation and active mobilization in patients requiring continuous renal replacement therapy in the ICU.

DATA SOURCES

Medline, CINAHL, PubMed, Pedro, and Cochrane Library were used to extract articles focused on physical activity and mobility in this population.

STUDY SELECTION

Research articles were included in this review if 1) included adult patients greater than or equal to 18 years old requiring continuous renal replacement therapy located in the ICU; 2) described physical rehabilitation, active mobilization, or physical activity deliverables; 3) reported data on patient safety and/or feasibility. The primary outcome was safety, defined as number of adverse events per total number of sessions.

DATA EXTRACTION

Five-hundred seven articles were evaluated based on title and abstract with reviewers selecting 46 to assess by full text. Fifteen observational studies were included for final analysis with seven studies focused solely on physical activity in patients requiring continuous renal replacement therapy.

DATA SYNTHESIS

Four-hundred thirty-seven adult ICU patients requiring continuous renal replacement therapy participated in some form of physical rehabilitation, physical activity, or active mobilization. Two major adverse events (hypotension event requiring vasopressor and continuous renal replacement therapy tube disconnection, pooled occurrence rate 0.24%) and 13 minor adverse events (pooled occurrence rate 1.55%) were reported during a total of 840 individual mobility or activity sessions. Intervention fidelity was limited by a low prevalence of higher mobility with only 15.5% of incidences occurring at or above level 5 of ICU Mobility Scale (transfer to chair, marching in place or ambulation away from bed, 122/715 reports). Feasibility in the provision of these interventions and/or continuous renal replacement therapy-specific deliverables was inconsistently reported.

CONCLUSIONS

Early rehabilitation and mobilization, specifically activity in and near the hospital bed, appears safe and mostly feasible in ICU patients requiring continuous renal replacement therapy. A cautious interpretation of these data is necessary due to limited aggregate quality of included studies, heterogeneous reporting, and overall low achieved levels of mobility potentially precluding the occurrence or detection of adverse events.

Mobilization in the evening to prevent delirium: A pilot randomized trial

BACKGROUND

Delirium is a common complication in patients in Intensive Care Units (ICU). Interventions such as mobilization are effective in the prevention and treatment of delirium, although this is usually completed during the daytime.

AIM

The aim of this study was to assess the feasibility of mobilization in the evening to prevent and treat ICU patients from delirium by an additional mobility team over 2 weeks.

METHODS

The design was a pilot, multi-centre, randomized, controlled trial in four mixed ICUs over a period of 2 weeks. The mobility team consisted of trained nurses and physiotherapists. Patients in the intervention group were mobilized onto the edge of the bed or more between 21.00 and 23.00. Patients in the control group received usual care. The primary outcome parameter was the feasibility of the study, measured as recruitment rate, delivery rate, and safety. Secondary outcomes were duration and incidence of delirium, mortality, duration of mechanical ventilation (MV), and hospital length of stay for 28 days follow-up, and power calculation for a full trial.

RESULTS

Out of 185 patients present in the ICUs, 28.6% (n = 53) were eligible and could be recruited, of which 24.9% (n = 46, Intervention = 26, Control = 20) were included in the final analysis. In the intervention group, mobilization could be delivered in 75% (n = 54) of 72 possible occasions; mobilization-related safety events appeared in 16.7% (n = 9) without serious consequences. Secondary parameters were similar, with less delirium in the intervention group albeit not significant. With an association of Cramer's V = 0.237, a complete study reaching statistical significance would require at least 140 patients, last 6 weeks, and cost >30 000 €.

CONCLUSIONS

In a mixed ICU population, mobilization in the evening was feasible in one-quarter of patients with a low rate of safety events. Future trials seem to be feasible and worth conducting.

Decreased CRRT Filter Lifespan in COVID-19 ICU Patients

(1) Background: Increased thromboembolic events and an increased need for continuous renal replacement therapy (CRRT) have been frequently reported in COVID-19 patients. Our aim was to investigate CRRT filter lifespan in intensive care unit (ICU) COVID-19 patients. (2) Methods: We compared CRRT adjusted circuit lifespan in COVID-19 patients admitted for SARS-CoV-2 infection to a control group of patients admitted for septic shock of pulmonary origin other than COVID-19. Both groups underwent at least one session of CRRT for AKI. (3) Results: Twenty-six patients (13 in each group) were included. We analysed 117 CRRT circuits (80 in the COVID-19 group and 37 in the control group). The adjusted filter lifespan was shorter in the COVID-19 group (17 vs. 39 h, p < 0.001). This trend persisted after adjustment for confounding factors (-14 h, p = 0.037). Before CRRT circuit clotting, the COVID-19 group had a more procoagulant profile despite higher heparin infusion rates. Furthermore, we reported a decreased relation between activated partial thromboplastin time (aPTT) and cumulative heparin dose in COVID-19 patients when compared to historical data of 23,058 patients, suggesting a heparin resistance. (4) Conclusion: COVID-19 patients displayed a shorter CRRT filter lifespan that could be related to a procoagulant profile and heparin resistance.

Perceived barriers to early mobilization of intensive care unit patients by nurses in hospitals affiliated to Jundishapur University of Medical Sciences of Ahvaz in 2019

Early mobilization (EM) of patients in the intensive care unit (ICU) is a safe, feasible, and beneficial approach. However, the implementation of EM as a part of routine clinical care can be challenging. As a result, the present study aimed to identify the potential barriers to EM of ICU patients. The statistical population of this descriptive-analytical study included 107 critical care nurses working in hospitals affiliated with the Jundishapur University of Medical Sciences of Ahvaz. The participants were selected using the census method among the eligible critical care nurses, and the researcher-made questionnaire was used for data collection. This questionnaire included a demographic questionnaire and an inventory of barriers to EM. In total, 72% of the nurses had a highly positive attitude towards EM implementation, whereas relatively few had a slightly positive attitude. The major human-resource-related barriers included the lack of trained staff (76.6%), inadequate shift nurses (74%), and inadequate time for this procedure (57.9%). Approximately 88.9%, 82.2%, 62%, and 57.9% of the nurses reported coma or a deep degree of sedation, mobilization of obese patients, mobilization of patients with agitation, and pain, respectively, as the major patient-related barriers. The lack of EM implementation and recording according to the checklist (90.4%), the lack of an approved EM implementation protocol (88.8%), and inadequate equipment for the mobilization of mechanically ventilated patients (58%) were among the major equipment-related barriers. The participating nurses were aware of the EM advantages, and the majority of them had a highly positive attitude towards its implementation in the ICU. However, nurses believed that the actual EM implementation is associated with challenges such as human resources limitations, equipment-related barriers, and patient-related barriers.

Frailty status among older critically ill patients with severe acute kidney injury

BACKGROUND

Frailty status among critically ill patients with acute kidney injury (AKI) is not well described despite its importance for prognostication and informed decision-making on life-sustaining therapies. In this study, we aim to describe the epidemiology of frailty in a cohort of older critically ill patients with severe AKI, the outcomes of patients with pre-existing frailty before AKI and the factors associated with a worsening frailty status among survivors.

METHODS

This was a secondary analysis of a prospective multicentre observational study that enrolled older (age > 65 years) critically ill patients with AKI. The clinical frailty scale (CFS) score was captured at baseline, at 6 months and at 12 months among survivors. Frailty was defined as a CFS score of ≥ 5. Demographic, clinical and physiological variables associated with frailty as baseline were described. Multivariable Cox proportional hazard models were constructed to describe the association between frailty and 90-day mortality. Demographic and clinical factors associated with worsening frailty status at 6 months and 12 months were described using multivariable logistic regression analysis and multistate models.

RESULTS

Among the 462 patients in our cohort, median (IQR) baseline CFS score was 4 (3-5), with 141 (31%) patients considered frail. Pre-existing frailty was associated with greater hazard of 90-day mortality (59% (n = 83) for frail vs. 31% (n = 100) for non-frail; adjusted hazards ratio [HR] 1.49; 95% CI 1.11-2.01, p = 0.008). At 6 months, 68 patients (28% of survivors) were frail. Of these, 57% (n = 39) were not classified as frail at baseline. Between 6 and 12 months of follow-up, 9 (4% of survivors) patients transitioned from a frail to a not frail status while 10 (4% of survivors) patients became frail and 11 (5% of survivors) patients died. In multivariable analysis, age was independently associated with worsening CFS score from baseline to 6 months (adjusted odds ratio [OR] 1.08; 95% CI 1.03-1.13, p = 0.003).

CONCLUSIONS

Pre-existing frailty is an independent risk factor for mortality among older critically ill patients with severe AKI. A substantial proportion of survivors experience declining function and worsened frailty status within one year.

Safety Assessment Criteria for Early Active Mobilization in Mechanically Ventilated ICU Subjects

BACKGROUND

Although studies have confirmed the safety and feasibility of early active mobilization, its implementation status is still unsatisfactory. The most important obstacle is ensuring patient safety. Comprehensively assessing the physical condition of patients considered for mobilization is the basis of safety. However, appropriate guidance is lacking. We performed a systematic review to extract and summarize current safety assessment criteria for the early active mobilization of mechanically ventilated patients in the ICU.

METHODS

A systematic literature search was conducted using English and Chinese databases according to the PRISMA checklist and guidelines to identify relevant original studies that evaluated safety assessment variables and specific parameters.

RESULTS

A total of 24 medium- and high-quality articles involving a total of 4,842 subjects were included in the analysis. Among these studies, there were 15 randomized controlled trials involving 1,777 subjects (888 in the control groups, 889 in the interventional groups) and 9 cohort studies involving 3,065 subjects (1,240 in the control groups, 1,825 in the exposure groups). There were 5 safety assessment criteria, including cardiovascular, respiratory, neurological, musculoskeletal, and other. Within these were 17 different variables and 48 specific parameters.

CONCLUSIONS

The safety assessment criteria should focus on cardiac reserve, respiratory reserve, consciousness, and muscle strength. It is especially important to note whether the parameters are stable because parameter stability can be more representative of a patient's condition than absolute values. We provide a flow diagram for clinical safety assessments; however, some limitations exist, and this assessment requires further validation and optimization.

A cross-sectional study of early mobility practice in intensive care units in Sarawak Hospitals, Malaysia

Aims

To determine the prevalence, characteristics of EM activities, the relationship between level of activity and mode of ventilation and adherence rate of EM protocol.

Background

Mobilizing ICU patients remains a challenge, despite its safety, feasibility and positive short-term outcomes.

Design

A cross-sectional point prevalence study.

Methods

All patients who were eligible and admitted to the adult ICUs during March 2018 were recruited. Data were analysed by using the Statistical Package for Social Sciences version 24 for Windows.

Results

The prevalence of EM practice was 65.6%. The most frequently reported avoidable and unavoidable factors inhibit mobility were deep sedation and vasopressor infusion, respectively. Level II of activity was the most common level of activity performed in ICU patients. The invasive ventilated patient had 12.53 the odds to stay in bed as compared to non-invasive ventilated patient. An average adherence rate of EM protocol was 52.5%.

Walking While Dialyzing: A Retrospective Observation of Early Mobility and Ambulation for Patients on Continuous Renal Replacement Therapy

Objectives

To describe the practice of physical therapy for patients requiring continuous renal replacement therapy and assess data related to the safety and feasibility of physical therapy interventions.

Design

A retrospective observational cohort study.

Patients

Surgical and cardiovascular patients receiving continuous renal replacement therapy during a 2-year period from December 2016 to November 2018.

Setting

Two ICUs at a single academic medical center.

Intervention

Physical mobility and ambulation while on continuous renal replacement therapy.

Measurements and Main Results

Therapy data including ICU Mobility Scale score, number of physical therapy sessions with and without ambulation and gait distance, along with safety data including filter life, safety events, and mortality were analyzed. The cohort of patients receiving continuous renal replacement therapy during the 2-year period was 206. Of these, 172 (83.49%) received simultaneous physical therapy. The median ICU Mobility Scale was 5 (interquartile range, 4-7) over a total of 1,517 physical therapy sessions. Ambulation with concomitant continuous renal replacement therapy connected was achieved in 78 patients (37.86%). There were 377 ambulation sessions (24.85% of all sessions) with a mean of 4.83 (sds 4.94) ambulation sessions per ambulatory patient. Patients walked an average of 888.53 feet (sd 1,365.50) while on continuous renal replacement therapy and a daily average of 150.61 feet (sd 133.50). In-hospital mortality was lowest for patients who ambulated (17.95%) and highest for patients who received no therapy (73.53%). Continuous renal replacement therapy filter life was longest for patients who ambulated (2,047.20 min [sd 1,086.50 min]), and shortest in patients who received no therapy (1,682.20 min [sd 1,343.80 min]). One safety event was reported during this time (0.0007% of all physical therapy sessions).

Conclusions

Ambulation while on continuous renal replacement therapy was not associated with an increased risk of safety events and was feasible with the use of nonfemoral catheters and dialysis equipment with internal batteries.

Knowledge of physiotherapists working in adult ICU on contraindications to mobilization

Abstract Introduction: Mobilization is an effective therapy to combat the deleterious effects of immobility, but not all patients are in a condition to be moved; thus, knowledge about contraindication criteria is fundamental. Objective: To evaluate the knowledge of physiotherapists working in adult ICUs on contraindications to the mobilization of critical patients. Method: This was a cross-sectional study in which a survey was applied to physiotherapists working in an adult ICU in the city of Recife. Results: Out of the 36 criteria presented, only five were considered contraindication criteria. Clinical parameters were those that obtained higher frequency for not being considered criteria for contraindication, nor were there observed differences in the relation between the time of working in the ICU. Conclusion: Most physiotherapists did not consider the criteria presented as contraindications to mobilization, so that professional training in mobilization practices and the creation of protocols are necessary.

Safety, Feasibility, and Efficacy of Early Rehabilitation in Patients Requiring Continuous Renal Replacement: A Quality Improvement Study

INTRODUCTION

Early rehabilitation in critically ill patients is associated with improved outcomes. Recent research demonstrates that patients requiring continuous renal replacement therapy (CRRT) can safely engage in mobility. The purpose of this study was to assess safety and feasibility of early rehabilitation with focus on mobility in patients requiring CRRT.

METHODS

Study design was a mixed methods analysis of a quality improvement protocol. The setting was an intensive care unit (ICU) at a tertiary medical center. Safety was prospectively recorded by incidence of major adverse events including dislodgement of CRRT catheter, accidental extubation, bleeding, and hemodynamic emergency; and minor adverse events such as transient oxygen desaturation >10% of resting. Limited efficacy testing was performed to determine if rehabilitation parameters were associated with clinical outcomes.

RESULTS

A total of 67 patients (54.0 ± 15.6 years old, 44% women, body mass index 29.2 ± 9.3 kg/m²) received early rehabilitation under this protocol. The median days of CRRT were 6.0 (interquartile range [IQR], 2-11) and 72% of patients were on mechanical ventilation concomitantly with CRRT at the time of rehabilitation. A total of 112 rehabilitation sessions were performed of 152 attempts (74% completion rate). No major adverse events occurred. Patients achieving higher levels of mobility were more likely to be alive at discharge (P = 0.076).

CONCLUSIONS

The provision of early rehabilitation in critically ill patients requiring CRRT is safe and feasible. Further, these preliminary results suggest that early rehabilitation with focus on mobility may improve patient outcomes in this susceptible population.

Exercise interventions are delayed in critically ill patients: a cohort study in an Australian tertiary intensive care unit

OBJECTIVES

This study aims to (i) describe the time to exercise commencement (sitting and upright activities) relative to ICU admission and relative to achievement of initial neurological, respiratory and cardiovascular stability; (ii) examine factors associated with whether sitting and upright activities occurred in ICU; and (iii) examine factors associated with time taken to commence these activities after stability has been achieved.

DESIGN

Five-year historical cohort study.

SETTING

An Australian tertiary mixed medical, surgical, trauma ICU.

PARTICIPANTS

The cohort (n=3222, mean (SD) age 54 (18) years, 67% male) included consecutive ICU patients with length of stay over 48hours admitted to a tertiary ICU who achieved stability.

MAIN OUTCOME MEASURES

Time from stability to patients' first completed sitting and upright activities was calculated. Logistic regression (and Cox proportional hazard models) examined whether sitting and upright activities in ICU occurred (and time to these events).

INTERVENTIONS

None.

RESULTS

For patients who completed exercise interventions (n=1845/3222, 57%), this commenced a median (IQR) 2.3 (1.3-4.4) days after stability for upright activities and 2.7 (1.5-5.7) days for sitting. A large proportion of patients did not complete exercise interventions despite achieving stability (n=1377/3222, 43%). Elective surgical admissions, lower illness severity and older age were associated with completion (and earlier completion) of sitting and upright activity (P<0.01).

CONCLUSIONS

Many stable patients did not commence sitting or upright activity in ICU despite known benefits, or commencement was somewhat delayed. Opportunities may exist to improve patient outcomes through timely implementation of exercise-based interventions.

Association between Blood Potassium Level and Recovery of Postoperative Gastrointestinal Motility during Continuous Renal Replacement Therapy in Patient Undergoing Open Abdominal Surgery

Background

The aim of this study was to identify the blood potassium level beneficial to the postoperative recovery of gastrointestinal motility during continuous renal replacement therapy (CRRT) in patient undergoing open abdominal surgery.

Materials and Methods

538 critically ill patients after open abdominal surgery and receiving CRRT were retrospectively recruited as the study cohort. Demographic and clinical data were recorded along with an evaluation of the postoperative gastrointestinal motility.

Results

Correlation analysis was used to assess the correlation coefficient, and then the variables with correlation coefficient value less than 0.5 were included in the binary logistic regression model. Binary logistic regression model indicated that the postoperative blood potassium level was independently associated with the recovery of gastrointestinal motility (OR=0.109, 95% CI= 0.063 to 0.190, p<0.001). Based on the normal range of blood potassium level, we selected the cut-off point of blood potassium level via Weight of Evidence analysis, which was 4.00 mmol/L. Compared with the patients with insufficient blood potassium levels (plasma potassium concentration < 4.00 mmol/L), those with sufficient blood potassium levels (plasma potassium concentration≥ 4.00 mmol/L) conferred an increase in the rate of 4-day postoperative recovery of gastrointestinal motility (OR= 4.425, 95% CI = 2.933 to 6.667, p<0.001).

Conclusions

Maintaining the blood potassium concentrations at a relatively high level of the normal blood potassium range during CRRT would be beneficial to postoperative recovery of gastrointestinal motility.

[PROtocol-based MObilizaTION on intensive care units : Design of a cluster randomized pilot study]

BACKGROUND

Despite convincing evidence for early mobilization of patients on intensive care units (ICU), implementation in practice is limited. Protocols for early mobilization, including in- and exclusion criteria, assessments, safety criteria, and step schemes may increase the rate of implementation and mobilization.

HYPOTHESIS

Patients (population) on ICUs with a protocol for early mobilization (intervention), compared to patients on ICUs without protocol (control), will be more frequently mobilized (outcome).

METHODS

A multicenter, stepped-wedge, cluster-randomized pilot study is presented. Five ICUs will receive an adapted, interprofessional protocol for early mobilization in randomized order. Before and after implementation, mobilization of ICU patients will be evaluated by randomized monthly one-day point prevalence surveys. Primary outcome is the percentage of patients mobilized out of bed, operationalized as a score of ≥3 on the ICU Mobility Scale. Secondary outcome parameters will be presence and/or length of mechanical ventilation, delirium, stay on ICU and in hospital, barriers to early mobilization, adverse events, and process parameters as identified barriers, used strategies, and adaptions to local conditions.

EXPECTED RESULTS

Exploratory evaluation of study feasibility and estimation of effect sizes as the basis for a future explanatory study.

Physical rehabilitation interventions in the intensive care unit: a scoping review of 117 studies

BACKGROUND

Physical rehabilitation (PR) interventions in the intensive care unit (ICU) can improve patients' functional outcomes, yet systematic reviews identified discordant effects and poor reporting. We conducted a scoping review to determine the extent of ICU PR interventions and how they were reported and measured.

METHODS

We searched five databases from inception to December 2016 for prospective studies evaluating adult ICU PR interventions. Two independent reviewers screened titles, abstracts, and full texts for inclusion. We assessed completeness of reporting using the Consolidated Standards of Reporting Trials, Strengthening the Reporting of Observational Studies in Epidemiology, or Standards for Quality Improvement Reporting Excellence guidelines, as appropriate. For planned PR interventions, we evaluated reporting with the Consensus on Exercise Reporting Template (CERT) and assessed intervention and control groups separately. We calculated completeness of reporting scores for each study; scores represented the proportion of reported items. We compared reporting between groups using Kruskal-Wallis with Bonferroni corrections and t tests, α = 0.05.

RESULTS

We screened 61,774 unique citations, reviewed 1429 full-text publications, and included 117: 39 randomized trials, 30 case series, 9 two-group comparison, 14 before-after, and 25 cohort. Interventions included neuromuscular electrical stimulation (NMES) (14.5%), passive/active exercises (15.4%), cycling (6.8%), progressive mobility (32.5%), and multicomponent (29.9%). The median (first,third quartiles) study reporting score was 75.9% (62.5, 86.7) with no significant differences between reporting guidelines. Of 87 planned intervention studies, the median CERT score was 55.6%(44.7,75.0); cycling had the highest (85.0%(62.2,93.8)), and NMES and multicomponent the lowest (50.0% (39.5, 70.3) and 50.0% (41.5, 58.8), respectively) scores. Authors reported intervention groups better than controls (p < 0.001).

CONCLUSIONS

We identified important reporting deficiencies in ICU PR interventions, limiting clinical implementation and future trial development.

Safety criteria to start early mobilization in intensive care units. Systematic review

Mobilization of critically ill patients admitted to intensive care units should be performed based on safety criteria. The aim of the present review was to establish which safety criteria are most often used to start early mobilization for patients under mechanical ventilation admitted to intensive care units. Articles were searched in the PubMed, PEDro, LILACS, Cochrane and CINAHL databases; randomized and quasi-randomized clinical trials, cohort studies, comparative studies with or without simultaneous controls, case series with 10 or more consecutive cases and descriptive studies were included. The same was performed regarding prospective, retrospective or cross-sectional studies where safety criteria to start early mobilization should be described in the Methods section. Two reviewers independently selected potentially eligible studies according to the established inclusion criteria, extracted data and assessed the studies' methodological quality. Narrative description was employed in data analysis to summarize the characteristics and results of the included studies; safety criteria were categorized as follows: cardiovascular, respiratory, neurological, orthopedic and other. A total of 37 articles were considered eligible. Cardiovascular safety criteria exhibited the largest number of variables. However, respiratory safety criteria exhibited higher concordance among studies. There was greater divergence among the authors regarding neurological criteria. There is a need to reinforce the recognition of the safety criteria used to start early mobilization for critically ill patients; the parameters and variables found might contribute to inclusion into service routines so as to start, make progress and guide clinical practice.

Integrating a Standardized Mobility Program and Safe Patient Handling

Early, routine mobilization of critically ill patients is safe and reduces hospital length of stay, shortens the duration of mechanical ventilation, and improves muscle strength and functional independence. At the University of Michigan, we have turned the tides by creating a structured process to get our patients moving while keeping them and our staff safe through the use of a standardized mobility protocol that incorporates the components of safe patient handling. Our protocol is simple and can easily be adapted for all patient populations by simply modifying some of the inclusion and exclusion criteria. The protocol incorporates safe patient handling and mobility preassessment guidelines, mobility standards, equipment guidelines, and documentation tools. The activities are grounded in the evidence and well thought out to prevent complications, promote mobilization, and prevent patient and staff injuries. This article will discuss a how a tertiary care facility incorporated a safe patient-handling initiative into an existing mobility program and operationalized it across a health care system to keep our patients and staff safe.

Defining new barriers to mobilisation in a highly active intensive care unit - have we found the ceiling? An observational study

BACKGROUND

Mobilisation of intensive care (ICU) patients attenuates ICU-acquired weakness, but the prevalence is low (12-54%). Better understanding of barriers and enablers may inform practice.

OBJECTIVES

To identify barriers to mobilisation and factors associated with successful mobilisation in our medical /surgical /trauma ICU where mobilisation is well-established.

METHODS

4-week prospective study of frequency and intensity of mobilisation, clinical factors and barriers (extracted from electronic database). Generalized linear mixed models were used to describe associations between demographics, clinical factors and successful mobilisation.

RESULTS

202 patients accounted for 742 patient days. Patients mobilised on 51% of patient days. Most frequent barriers were drowsiness (18%), haemodynamic/respiratory contraindications (17%), and medical orders (14%). Predictors of successful mobilisation included high Glasgow Coma Score (OR = 1.44, 95%CI=[1.29-1.60]), and male sex (OR = 2.29, 95%CI=[1.40-3.75]) but not age (OR = 1.05, 95%CI=[1.01-1.08]).

CONCLUSIONS

Our major barriers (drowsiness, haemodynamic/respiratory contraindications) may be unavoidable, indicating an upper limit of feasible mobilisation therapy in ICU.

Safety of Patient Mobilization and Rehabilitation in the Intensive Care Unit. Systematic Review with Meta-Analysis

BACKGROUND

Early mobilization and rehabilitation of patients in intensive care units (ICUs) may improve physical function, and reduce the duration of delirium, mechanical ventilation, and ICU length of stay. However, safety concerns are an important barrier to widespread implementation.

OBJECTIVES

To synthesize safety data regarding patient mobilization and rehabilitation in the ICU, including falls, removal of endotracheal tubes, removal or dysfunction of intravascular catheters, removal of other catheters/tubes, cardiac arrest, hemodynamic changes, and desaturation.

DATA SOURCES

Systematic literature review, including searches of five databases. Eligible studies evaluated patients who received mobilization-related interventions in the ICU. Exclusion criteria included: (1) case series with fewer than 10 patients; (2) majority of patients under 18 years of age; and (3) data not reported to permit calculation of incidence of safety events.

DATA EXTRACTION

Number of patients, mobilization/rehabilitation sessions, potential safety events, and events with negative consequences (e.g., requiring intervention or additional therapy).

SYNTHESIS

Heterogeneity was assessed by I² statistics, and bias assessed by the Newcastle-Ottawa Scale and Cochrane risk of bias assessment. The literature search identified 20,660 titles. There were 48 eligible publications evaluating 7,546 patients, with 583 potential safety events occurring in 22,351 mobilization/rehabilitation sessions. There was a total of 583 (2.6%) potential safety events with heterogeneity in the definitions for these events. For the safety event types that could be meta-analyzed, pooled incidences per 1,000 mobilization/rehabilitation sessions (95% confidence interval), were: hemodynamic changes, 3.8 (1.3-11.4), and desaturation, 1.9 (0.9-4.3). A total of 24 studies of 3,404 patients reported on any consequences of potential safety events (e.g., needing to increase dose of vasopressor due to mobility-related hypotension), with a frequency of 0.6% in 14,398 mobilization/rehabilitation sessions.

CONCLUSIONS

Patient mobilization and physical rehabilitation in the ICU appears safe, with a low incidence of potential safety events, and only rare events having any consequences for patient management. Heterogeneity in the definition of safety events across studies emphasizes the importance of implementing existing consensus-based definitions.

Feasibility and Safety of Physical Therapy during Continuous Renal Replacement Therapy in the Intensive Care Unit

RATIONALE

Early rehabilitation in an intensive care unit is associated with improved physical functioning and patient outcomes. However, relatively few data have been reported on physical therapy interventions during continuous renal replacement therapy (CRRT) for patients in intensive care units.

OBJECTIVES

To evaluate the feasibility and safety of physical therapy interventions, delivered as part of routine clinical care, for patients undergoing CRRT in an intensive care unit.

METHODS

Consecutive patients in the adult medical intensive care unit of one large tertiary care hospital who received physical therapy sessions while on CRRT were prospectively evaluated over 13 months. Physical therapy sessions were individualized on the basis of patients' physical impairments and activity tolerance, with patients' highest level of mobility recorded. Data on 15 different physiological abnormalities and potential safety events, including bleeding, dislodgement, or dysfunction of the CRRT catheter or circuit, were prospectively collected.

MEASUREMENTS AND MAIN RESULTS

Eleven physical therapists delivered 268 rehabilitation sessions to 57 patients while they were receiving CRRT, with the following highest levels of mobility achieved during individual sessions: 78 (29%) bed exercises, 72 (27%) supine cycle ergometry, 80 (30%) sitting at edge of bed, 13 (5%) transfer to chair, and 25 (9%) standing or marching in place. No CRRT-specific safety events occurred (0%; 95% upper confidence interval, 6.3%). There were six non-CRRT-related potential safety events (2.2% of all physical therapy sessions; 95% confidence interval, 0.6-8.2%), all of which were transient changes in blood pressure.

CONCLUSIONS

In this prospective observational study at one adult medical intensive care unit, we found that provision of bedside physical therapy while patients underwent CRRT is feasible, and appears safe.

Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units

Early mobilization of patients in the intensive care unit (ICU) is safe, feasible, and beneficial. However, implementation of early mobility as part of routine clinical care can be challenging. The objective of this review is to identify barriers to early mobilization and discuss strategies to overcome such barriers. Based on a literature search, we synthesize data from 40 studies reporting 28 unique barriers to early mobility, of which 14 (50%) were patient-related, 5 (18%) structural, 5 (18%) ICU cultural, and 4 (14%) process-related barriers. These barriers varied across ICUs and within disciplines, depending on the ICU patient population, setting, attitude, and ICU culture. To overcome the identified barriers, over 70 strategies were reported and are synthesized in this review, including: implementation of safety guidelines; use of mobility protocols; interprofessional training, education, and rounds; and involvement of physician champions. Systematic efforts to change ICU culture to prioritize early mobilization using an interprofessional approach and multiple targeted strategies are important components of successfully implementing early mobility in clinical practice.

Current Concepts Burn Rehabilitation, Part I: Care During Hospitalization

This article summarizes current interventions for several of the most common challenges faced by patients during their rehabilitation from burn injury. These include preservation of range of motion through scar contracture management, and achieving maximal independence through exercise, and training in activities of daily living.

Low Levels of Physical Activity During Critical Illness and Weaning: The Evidence-Reality Gap

BACKGROUND

Physical rehabilitation can benefit critically ill patients during intensive care unit (ICU) admission, but routine clinical practice remains inconsistent nor examined in prolonged mechanical ventilation patients transferred to a specialist ventilator weaning unit (VWU). Behavioral mapping is a sampling approach that allows detailed reporting of physical activity profiles. The objective of this study was to characterize the physical activity profile of critically ill patients in a UK ICU and VWU.

METHODS

Single-center, prospective observational study in a university teaching hospital. Patient observations, conducted Monday through Sunday from 08:30 am to 08:00 pm and for 1 minute every 10 minutes, included data points of patient location, people in attendance, and highest level of activity. Descriptive statistics were utilized to analyze and report data.

RESULTS

Forty-two ICU and 11 VWU patients were recruited, with 2646 and 693 observations, respectively, recorded. In the ICU, patients spent a median (interquartile range) of 100% (96%-100%) of the day (10.5 [10.0-10.5] hours) located in bed, with minimal/no activity for 99% (96%-100%) of the day (10.4 [9.7-10.5] hours). Nursing staff were most frequently observed in attendance with patients irrespective of ventilation or sedation status, although patients still spent approximately two-thirds of the day alone. Bed-to-chair transfer was the highest activity level observed. In the VWU, patients spent 94% (73%-100%) of the day (9.9 [7.7-10.5] hours) in bed and 56% (43%-60%) of time alone. Physical activity levels were higher and included ambulation. All physical activities occurred during physical rehabilitation sessions.

CONCLUSIONS

These profiles of low physical activity behavior across both patients in the ICU and VWU highlight the need for targeted strategies to improve levels beyond therapeutic rehabilitation and support for a culture shift toward providing patients with, and engaging them in, a multidisciplinary, multiprofessional environment that optimizes overall physical activity.

What makes weekend allied health services effective and cost-effective (or not) in acute medical and surgical wards? Perceptions of medical, nursing, and allied health workers

Background

There is strong public support for acute hospital services to move to genuine 7-day models, including access to multidisciplinary team assessment. This study aimed to identify factors that might enable an effective and cost-effective weekend allied health services on acute hospital wards.

Methods

This qualitative study included 22 focus groups within acute wards with a weekend allied health service and 11 telephone interviews with weekend service providers. Data were collected from 210 hospital team members, including 17 medical, 97 nursing, and 96 allied health professionals from two Australian tertiary public hospitals. All were recorded and imported into nVivo 10 for analysis. Thematic analysis methods were used to develop a coding framework from the data and to identify emerging themes.

Results

Key themes identified were separated into issues perceived as being enablers or barriers to the effective or cost-effective delivery of weekend allied health services. Perceived enablers of effectiveness and cost-effectiveness included prioritizing interventions that prevent decline, the right person delivering the right service, improved access to the patient’s family, and ability to impact patient flow. Perceived barriers were employment of inexperienced weekend staff, insufficient investment to see tangible benefit, inefficiencies related to double-handling, unnecessary interventions and/or inappropriate referrals, and difficulty recruiting and retaining skilled staff.

Conclusions

Suggestions for ensuring effective and cost effective weekend allied health care models include minimization of task duplication and targeting interventions so that the right patients receive the right interventions at the right time. Further research into the effectiveness and cost effectiveness of these services should factor in hidden costs, including those associated with managing the service.

Non anti-coagulant factors associated with filter life in continuous renal replacement therapy (CRRT): a systematic review and meta-analysis

BACKGROUND

Optimising filter life and performance efficiency in continuous renal replacement therapy has been a focus of considerable recent research. Larger high quality studies have predominantly focussed on optimal anticoagulation however CRRT is complex and filter life is also affected by vascular access, circuit and management factors. We performed a systematic search of the literature to identify and quantify the effect of vascular access, circuit and patient factors that affect filter life and presented the results as a meta-analysis.

METHODS

A systematic review and meta-analysis was performed by searching Pubmed (MEDLINE) and Ovid EMBASE libraries from inception to 29th February 2016 for all studies with a comparator or independent variable relating to CRRT circuits and reporting filter life. Included studies documented filter life in hours with a comparator other than anti-coagulation intervention. All studies comparing anticoagulation interventions were searched for regression or hazard models pertaining to other sources of variation in filter life.

RESULTS

Eight hundred nineteen abstracts were identified of which 364 were selected for full text analysis. 24 presented data on patient modifiers of circuit life, 14 on vascular access modifiers and 34 on circuit related factors. Risk of bias was high and findings are hypothesis generating. Ranking of vascular access site by filter longevity favours: tunnelled semi-permanent catheters, femoral, internal jugular and subclavian last. There is inconsistency in the difference reported between femoral and jugular catheters. Amongst published literature, modality of CRRT consistently favoured continuous veno-venous haemodiafiltration (CVVHD-F) with an associated 44% lower failure rate compared to CVVH. There was a trend favouring higher blood flow rates. There is insufficient data to determine advantages of haemofilter membranes. Patient factors associated with a statistically significant worsening of filter life included mechanical ventilation, elevated SOFA or LOD score, elevations in ionized calcium, elevated platelet count, red cell transfusion, platelet factor 4 (PF-4) antibodies, and elevated fibrinogen. Majority of studies are observational or report circuit factors in sub-analysis. Risk of bias is high and findings require targeted investigations to confirm.

CONCLUSION

The interaction of patient, pathology, anticoagulation, vascular access, circuit and staff factors contribute to CRRT filter life. There remains an ambiguity from published data as to which site and side should be the first choice for vascular access placement and what interaction this has with patient factors and timing. Early consideration of tunnelled semi-permanent access may provide optimal filter life if longer periods of CRRT are anticipated. There remains an absence of robust evidence outside of anti-coagulation strategies despite over 20 years of therapy delivery however trends favour CVVHD-F over CVVH.

Factors influencing physical activity and rehabilitation in survivors of critical illness: a systematic review of quantitative and qualitative studies

PURPOSE

To identify, evaluate and synthesise studies examining the barriers and enablers for survivors of critical illness to participate in physical activity in the ICU and post-ICU settings from the perspective of patients, caregivers and healthcare providers.

METHODS

Systematic review of articles using five electronic databases: MEDLINE, CINAHL, EMBASE, Cochrane Library, Scopus. Quantitative and qualitative studies that were published in English in a peer-reviewed journal and assessed barriers or enablers for survivors of critical illness to perform physical activity were included. Prospero ID: CRD42016035454.

RESULTS

Eighty-nine papers were included. Five major themes and 28 sub-themes were identified, encompassing: (1) patient physical and psychological capability to perform physical activity, including delirium, sedation, illness severity, comorbidities, weakness, anxiety, confidence and motivation; (2) safety influences, including physiological stability and concern for lines, e.g. risk of dislodgement; (3) culture and team influences, including leadership, interprofessional communication, administrative buy-in, clinician expertise and knowledge; (4) motivation and beliefs regarding the benefits/risks; and (5) environmental influences, including funding, access to rehabilitation programs, staffing and equipment.

CONCLUSIONS

The main barriers identified were patient physical and psychological capability to perform physical activity, safety concerns, lack of leadership and ICU culture of mobility, lack of interprofessional communication, expertise and knowledge, and lack of staffing/equipment and funding to provide rehabilitation programs. Barriers and enablers are multidimensional and span diverse factors. The majority of these barriers are modifiable and can be targeted in future clinical practice.

[Physiotherapy interventions in the ICU : Outcome-relevant measurement parameters]

BACKGROUND

Guidelines cannot provide differentiated recommendations for physiotherapy (PT) in intensive care medicine. Scientific publications for PT in the intensive care unit (ICU) usually only have low levels of evidence and often express safety and feasibility of PT in the ICU.

OBJECTIVE

Which measurement parameters are relevant for defining outcome and what interventions should one take into consideration?

MATERIALS AND METHODS

A literature review was conducted. This was based on a PubMed search with full text access, as well as specific definitions for physical therapy, intensive care and four out of seven conditions from the manual "Physiotherapy in intensive care".

RESULTS

The availability of 172 studies clearly shows that there is certainly PT research concerning the critical environment of the ICU. However, parameters for quantitative and qualitative detection of vigilance and state of consciousness as well as assessments to evaluate the mobility and the ability to help themselves are important for everyday use.

CONCLUSIONS

The difficulties of using PT in the ICU are not useful in ensuring the safety of the patient or performing a PT treatment. The conditions of the intensive care environment are not an obstacle. It is of immanent importance to use the limited resources of PT in an optimal and targeted manner in the ICU environment. The determination of ICU-adapted goals plays a crucial role.

The scope of physiotherapy services provided in public ICUs in Greece: A pilot study

The aim of the present study was to determine the scope of physiotherapy services provided in Greek ICUs in Athens. A cross-sectional study was conducted with two postal questionnaires administered separately, one for ICU directors and one for ICU physiotherapists. Responses were received from 19 ICU directors and 103 physiotherapists employed in all the adult public mixed medical and surgical ICUs across Athens. The response rate for the survey completion was 100% for ICU directors and 68.7% for physiotherapists. The results showed a 1:50 to 1:12 range in the ratio of physiotherapists to ICU beds. Among the 19 ICUs, 15 (78.9%) employed physiotherapists on a rotational basis, while four (21.0%) retained them exclusively. On weekdays, all surveyed ICUs were covered by physiotherapists in the morning and 10/19 (52.6%) during the afternoon. On weekends, 12/19 (63.2%) of the surveyed ICUs reported physiotherapy care during the morning and 4/19 (21.0%) during both morning and afternoon. All 103 physiotherapists conducted airway clearance techniques and progressive mobilization, 92/103 (89.3%) were involved in extubating patients, 102/103 (99.0%) in passive and active range of motion exercises, and 61/103 (59.2%) in walking. In conclusion, all Greek ICUs in Athens surveyed had physiotherapy cover. The physiotherapists working in these ICUs in Athens were involved in respiratory care and mobilization.

The Sara Combilizer® as an early mobilisation aid for critically ill patients: A prospective before and after study

BACKGROUND

Early mobility within the ICU is associated with a number of positive outcomes including reductions in ICU and hospital length of stay and better functional recovery. The exact definition of 'early' mobility is still not defined, with the actual ability to mobilise limited by a number of perceived factors. The Sara Combilizer^® is a combined tilt table and stretcher chair, which allows passive transfer of patients out of bed. This study aimed to assess whether the introduction of the Sara Combilizer^® reduced time taken to first mobilise for patients mechanically ventilated for at least five days and at risk of ICU acquired weakness.

METHODS

Patients admitted to a large UK critical care unit during the trial period and ventilated for ≥5days were included in the study. Baseline data was collected prospectively for a period of four months. The Sara Combilizer^® was then introduced for a one month training and familiarisation period, followed by a further four months prospective data collection. The primary outcome was time to first mobilisation, defined as a Manchester Mobility Score ≥2.

RESULTS

Following the introduction of the Sara Combilizer^®, time taken to mobilise reduced significantly from 13.6 to 10.6days (p=0.028). SOFA scores were significantly higher at the point of first mobilisation in the Combilizer group (mean: 2.9±0.5 vs. 5.1±2.4; p=0.005). There was no statistical difference in therapy time between the groups, or ICU or hospital length of stay.

CONCLUSIONS

The introduction of the Sara Combilizer^® was associated with a significant reduction in time to mobilise patients ventilated for ≥5days, and patients were mobilised with a higher degree of organ failure. This was achieved without any increase in therapy time. The Sara Combilizer^® may be a useful adjunct to an early mobility protocol within the ICU.

[Algorithms for early mobilization in intensive care units]

Immobility of patients in intensive care units (ICU) can lead to long-lasting physical and cognitive decline. During the last few years, bundles for rehabilitation were developed, including early mobilization. The German guideline for positioning therapy and mobilization, in general, recommends the development of ICU-specific protocols. The aim of this narrative review is to provide guidance when developing a best practice protocol in one's own field of work. It is recommended to a) implement early mobilization as part of a bundle, including screening and management of patient's awareness, pain, anxiety, stress, delirium and family's presence, b) develop a traffic-light system of specific in- and exclusion criteria in an interprofessional process, c) use checklists to assess risks and preparation of mobilization, d) use the ICU Mobility Scale for targeting and documentation of mobilization, e) use relative safety criteria for hemodynamic and respiratory changes, and Borg Scale for subjective evaluation, f) document and evaluate systematically mobilization levels, barriers, unwanted safety events and other parameters.

Early Mobilization and Rehabilitation of Patients Who Are Critically Ill

Neuromuscular disorders are increasingly recognized as a cause of both short- and long-term physical morbidity in survivors of critical illness. This recognition has given rise to research aimed at better understanding the risk factors and mechanisms associated with neuromuscular dysfunction and physical impairment associated with critical illness, as well as possible interventions to prevent or treat these issues. Among potential risk factors, bed rest is an important modifiable risk factor. Early mobilization and rehabilitation of patients who are critically ill may help prevent or mitigate the sequelae of bed rest and improve patient outcomes. Research studies and quality improvement projects have demonstrated that early mobilization and rehabilitation are safe and feasible in patients who are critically ill, with potential benefits including improved physical functioning and decreased duration of mechanical ventilation, intensive care, and hospital stay. Despite these findings, early mobilization and rehabilitation are still uncommon in routine clinical practice, with many perceived barriers. This review summarizes potential risk factors for neuromuscular dysfunction and physical impairment associated with critical illness, highlights the potential role of early mobilization and rehabilitation in improving patient outcomes, and discusses some of the commonly perceived barriers to early mobilization and strategies for overcoming them.

Mobilization of intensive care patients: a multidisciplinary practical guide for clinicians

Objectives

To describe our experience and the practical tools we have developed to facilitate early mobilization in the intensive care unit (ICU) as a multidisciplinary team.

Background

Despite the evidence supporting early mobilization for improving outcomes for ICU patients, recent international point-prevalence studies reveal that few patients are mobilized in the ICU. Existing guidelines rarely address the practical issues faced by multidisciplinary ICU teams attempting to translate evidence into practice. We present a comprehensive strategy for safe mobilization utilized in our ICU, incorporating the combined skills of medical, nursing, and physiotherapy staff to achieve safe outcomes and establish a culture which prioritizes this intervention.

Methods

A raft of tools and strategies are described to facilitate mobilization in ICU by the multidisciplinary team. Patients without safe unsupported sitting balance and without ≥3/5 (Oxford scale) strength in the lower limbs commence phase 1 mobilization, including training of sitting balance and use of the tilt table. Phase 2 mobilization involves supported or active weight-bearing, incorporating gait harnesses if necessary. The Plan B mnemonic guides safe multidisciplinary mobilization of invasively ventilated patients and emphasizes the importance of a clearly articulated plan in delivering this valuable treatment as a team.

Discussion

These tools have been used over the past 5 years in a tertiary ICU with a very low incidence of adverse outcomes (<2%). The tools and strategies described are useful not only to guide practical implementation of early mobilization, but also in the creation of a unit culture where ICU staff prioritize early mobilization and collaborate daily to provide the best possible care.

Conclusion

These practical tools allow ICU clinicians to safely and effectively implement early mobilization in critically ill patients. A genuinely multidisciplinary approach to safe mobilization in ICU is key to its success in the long term.

Critical Care Updates for the Nephrologist, 2016

With improvements in supportive care, mortality from sepsis and the acute respiratory distress syndrome has declined over the past 20 years. However, mortality associated with these conditions is still high. We will review the latest clinical trial findings in these fields, along with implications for the nephrologist. Very recently, there have been significant changes with regard to the management of anterior ischemic strokes; given the high rate of cerebrovascular disease in patients with CKD or ESRD, we will review those studies here. Finally, we will comment on best care practices in the intensive care unit, which are relevant to the nephrologist.

Development, implementation and evaluation of a clinical research engagement and leadership capacity building program in a large Australian health care service

BACKGROUND

Health professionals need to be integrated more effectively in clinical research to ensure that research addresses clinical needs and provides practical solutions at the coal face of care. In light of limited evidence on how best to achieve this, evaluation of strategies to introduce, adapt and sustain evidence-based practices across different populations and settings is required. This project aims to address this gap through the co-design, development, implementation, evaluation, refinement and ultimately scale-up of a clinical research engagement and leadership capacity building program in a clinical setting with little to no co-ordinated approach to clinical research engagement and education.

METHODS/DESIGN

The protocol is based on principles of research capacity building and on a six-step framework, which have previously led to successful implementation and long-term sustainability. A mixed methods study design will be used. Methods will include: (1) a review of the literature about strategies that engage health professionals in research through capacity building and/or education in research methods; (2) a review of existing local research education and support elements; (3) a needs assessment in the local clinical setting, including an online cross-sectional survey and semi-structured interviews; (4) co-design and development of an educational and support program; (5) implementation of the program in the clinical environment; and (6) pre- and post-implementation evaluation and ultimately program scale-up. The evaluation focuses on research activity and knowledge, attitudes and preferences about clinical research, evidence-based practice and leadership and post implementation, about their satisfaction with the program. The investigators will evaluate the feasibility and effect of the program according to capacity building measures and will revise where appropriate prior to scale-up.

DISCUSSION

It is anticipated that this clinical research engagement and leadership capacity building program will enable and enhance clinically relevant research to be led and conducted by health professionals in the health setting. This approach will also encourage identification of areas of clinical uncertainty and need that can be addressed through clinical research within the health setting.

Usual Care Physiotherapy During Acute Hospitalization in Subjects Admitted to the ICU: An Observational Cohort Study

BACKGROUND

Physiotherapists play an important role in the provision of multidisciplinary team-based care in the ICU. No studies have reported usual care respiratory management or usual care on the wards following ICU discharge by these providers. This study aimed to investigate usual care physiotherapy for ICU subjects during acute hospitalization.

METHODS

One hundred subjects were recruited for an observational study from a tertiary Australian ICU. The frequency and type of documented physiotherapist assessment and treatment were extracted retrospectively from medical records.

RESULTS

The sample had median (interquartile range) APACHE II score of 17 (13-21) and was mostly male with a median (interquartile range) age of 61 (49-73) y. Physiotherapists reviewed 94% of subjects in the ICU (median of 5 [3-9] occasions, median stay of 4.3 [3-7] d) and 89% of subjects in acute wards (median of 6 [2-12] occasions, median stay of 13.3 [6-28] d). Positioning, ventilator lung hyperinflation, and suctioning were the most frequently performed respiratory care activities in the ICU. The time from ICU admission until ambulation from the bed with a physiotherapist had a median of 5 (3-8) d. The average ambulation distance per treatment had a median of 0 (0-60) m in the ICU and 44 (8-78) m in the acute wards. Adverse event rates were 3.5% in the ICU and 1.8% on the wards.

CONCLUSIONS

Subjects received a higher frequency of physiotherapy in the ICU than on acute wards. Consensus is required to ensure consistency in data collection internationally to facilitate comparison of outcomes.

Mobilization of ventilated patients in the intensive care unit: An elicitation study using the theory of planned behavior

PURPOSE

Early mobilization in intensive care unit (ICU) is safe, feasible, and beneficial. However, mobilization frequently does not occur in practice. The study objective was to elicit attitudinal, normative, and control beliefs (barriers and enablers) toward the mobilization of ventilated patients, to inform development of targeted implementation interventions.

MATERIALS AND METHODS

A 9-item elicitation questionnaire was administered electronically to a convenience sample of multidisciplinary staff in a tertiary ICU. A snowball recruitment approach was used to target a sample size of 20 to 25. Two investigators performed word count and thematic analyses independently. Themes were cross-checked by a third investigator.

RESULTS

Twenty-two questionnaires were completed. Respondents wrote the most text about disadvantages. Positive attitudinal beliefs included better respiratory function, reduced functional decline, and reduced muscle wasting/weakness. The main negative attitudinal beliefs were that mobilization is perceived as time consuming and poses a risk of line dislodgement/disconnection. Positive control beliefs (enablers) included increased staff availability, positive staff attitudes, engagement, and teamwork. Negative control beliefs (barriers) included unstable patient physiology and negative workplace culture.

CONCLUSIONS

Intensive care unit staff expressed positive and negative attitudinal, normative, and control beliefs across the spectrum, and disadvantages were most frequently reported. Identified beliefs can be used to inform development of future interventions.

Early mobilization in the critical care unit: A review of adult and pediatric literature

Early mobilization of critically ill patients is beneficial, suggesting that it should be incorporated into daily clinical practice. Early passive, active, and combined progressive mobilizations can be safely initiated in intensive care units (ICUs). Adult patients receiving early mobilization have fewer ventilator-dependent days, shorter ICU and hospital stays, and better functional outcomes. Pediatric ICU data are limited, but recent studies also suggest that early mobilization is achievable without increasing patient risk. In this review, we provide a current and comprehensive appraisal of ICU mobilization techniques in both adult and pediatric critically ill patients. Contraindications and perceived barriers to early mobilization, including cost and health care provider views, are identified. Methods of overcoming barriers to early mobilization and enhancing sustainability of mobilization programs are discussed. Optimization of patient outcomes will require further studies on mobilization timing and intensity, particularly within specific ICU populations.