Interventions to improve the physical function of ICU survivors: a systematic review

Effect of Home Care on Physical Function in Post-Intensive Care Unit Patients: A Meta-Analysis

BACKGROUND

A decline in physical function is commonly observed after patients transition to their homes following hospital admission; this is especially true for patients requiring mechanical ventilation in an intensive care unit (ICU).

OBJECTIVE

This meta-analysis examines characteristics and effects of home-based or outpatient+home-based interventions used to improve physical function post-discharge in patients who received mechanical ventilation in an ICU.

METHODS

PRISMA guidelines were utilized. The literature search was conducted with the assistance of a medical librarian. Study inclusion criteria were post-ICU adult patients receiving mechanical ventilation who then had home-based or outpatient+home-based care to improve physical function after discharge. Effect size (Hedges' g) was calculated with random effects models.

RESULTS

Our search yielded 11 studies that met the inclusion criteria. The majority were randomized controlled trials, with 1 quasi-experimental study. All studies included physical therapists, and 2 included nurses. The 11 studies reported results for 39 physical function measurements. The overall pooled intervention effect across the 4 studies that utilized the 6-minute walk test was 0.32 (95% confidence intervals [CI]: 0.05 to 0.58), for the 3 studies that utilized the Timed Up and Go test it was 1.38 (95% CI: -0.09 to 2.84), and for the 8 studies that used the SF-36 Physical Function subscale, it was 0.31 (95% CI: 0.09 to 0.52).

CONCLUSIONS

This review's findings show that patients may improve their physical function after participating in specific intervention programs that are home-based alone or outpatient+home-based care. However, the effect sizes are small, so it may be useful to explore how to maximize the gains in physical function.

Digital health interventions to improve recovery for intensive care unit survivors: A systematic review

OBJECTIVE

Recovery models of care for intensive care unit (ICU) survivors are limited by availability, accessibility, and efficacy. Digital health interventions represent an alternative mode of service delivery. The primary aim of this systematic review was to describe implementation factors (Reach, Effectiveness, Adoption, Implementation, and Maintenance) for digital health interventions for ICU survivors. The secondary aim was to describe any effect on patient-reported health outcomes.

DATA SOURCES

A systematic search of Medical Literature Analysis and Retrieval System Online (MEDLINE), Excertpa Medica Database (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Systematic Reviews (CENTRAL) databases was undertaken in March 2023.

STUDY SELECTION

Two independent reviewers screened abstracts and full texts against eligibility criteria. Studies of adult survivors with any post-ICU discharge care, delivered via a digital mode, were included. Studies were excluded if published before 1990 or not in English.

DATA EXTRACTION

Quantitative data were extracted using predefined data fields. Risk of bias was assessed using the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool 2.0. Implementation factors were reported according to the Reach, Effectiveness, Adoption, Implementation and Maintenance framework.

DATA SYNTHESIS

A total of 6482 studies were screened. Ten studies, with 686 participants, were included. Implementation factors were reported in all studies. Acceptability (reported in six studies) was high, with high satisfaction and usability scores, defined a priori by investigators. Eight studies reported intervention adherence rates between 46% and 100%. Nine studies report final outcome measurement retention rates up to 12 months, between 52% and 100%. Five studies included the primary outcome as the difference in a patient-reported health outcome. Appraisal of efficacy and digital health literacy was limited due to substantial methodological variation and a lack of reporting in included studies. There was some risk of bias in 50% of studies.

CONCLUSIONS

Digital health interventions can be successfully implemented for critical care survivors and have varying intervention adherence and retention rate success. To broaden reach, future research should include cultural diversity and investigate digital health access, literacy, and cost-effectiveness. INTERNATIONAL PROSPECTIVE REGISTER OF SYSTEMATIC REVIEWS REGISTRATION: CRD42022348252.

Feasibility, reliability, and validity of physical function tests and IADL survey questions in women living in rural, highland Ethiopia

Physical function is the physical ability to fulfill one's daily roles and responsibilities. Poor physical function is detrimental to health and income-generating activities. Unfortunately, there is a lack of validated methods to measure physical function in adult women in low- and middle-income countries, including Ethiopia, the locus of this study. This study evaluated the feasibility, reliability, and validity of physical tests, including the sit-to-stand (STS) and usual gait speed (UGS) and a context-appropriate instrumental activities of daily living (IADL) survey. The results of the STS were used to calculate a muscle quality index (MQI, STS accounting for body mass and leg length). Feasibility was ascertained qualitatively based on reports from the enumerators on their ability to administer the tests. Reliability was assessed by comparing the results of the tests and questions between each visit using either Cohen's κ or Pearson's ρ. The validity of MQI was assessed using relevant participant characteristics such as age and self-reported disability. The validity of the IADL was assessed using MQI. Study participants comprised 316 women between the ages of 18 and 45 years, living in rural Tigray, Ethiopia, who had previously participated in an impact evaluation of a safety net program. Over a one-week period, participants completed the STS and UGS tests and responded to the IADL survey questions three times. MQI was determined to be a feasible, reliable, and valid physical function test for women in rural, highland Ethiopia. UGS lacked feasibility and reliability; validity was not ascertained. The IADL questions were feasible and reliable, but validity was inconclusive. In rural Ethiopia, the MQI will be a valuable tool to develop interventions for improving physical function, which will have positive impacts on health and quality of life.

Early mobility and family partnerships in the intensive care unit: A scoping review of reviews

BACKGROUND

Critical illness significantly impacts the well-being of patients and families. Previous studies show that family members are willing to participate in patient care. Involving families in early mobility interventions may contribute to improved recovery and positive outcomes for patients and families.

AIM

In this scoping review, we investigated early mobility interventions for critically ill patients evaluated in randomized controlled trials and the extent to which family engagement in those interventions are reported in the literature.

STUDY DESIGN

In this scoping review of reviews, EMBASE, CINAHL, PubMed and Cochrane Central databases were searched in October 2019 and updated in February 2022. Systematic reviews were included and assessed using A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) 2. Data were synthesized using a narrative approach. PRISMA-ScR guidelines were adhered to for reporting.

RESULTS

Thirty-three reviews were included which described a range of early mobility interventions for critically ill patients; none explicitly mentioned family engagement. Almost half of the reviews were of low or critically low quality. Insufficient detail of early mobility interventions prompted information to be extracted from the primary studies.

CONCLUSIONS

There are a range of early mobility interventions for critically ill patients but few involve families. Given the positive outcomes of family participation, and family willingness to participate in care, there is a need to explore the feasibility and acceptability of family participation in early mobility interventions.

RELEVANCE TO CLINICAL PRACTICE

Family engagement in early mobility interventions for critically ill patients should be encouraged and supported. How to best support family members and clinicians in enacting family involvement in early mobility requires further investigation.

Effect of neuromuscular electrical stimulation in critically ill adults with mechanical ventilation: a systematic review and network meta-analysis

BACKGROUND

Neuromuscular electrical stimulation (NMES) is widely used as a rehabilitation methods to restore muscle mass and function in prolonged immobilization individuals. However, its effect in mechanically ventilated patients to improve clinical outcomes remains unclear.

METHODS

A comprehensive search was conducted using PubMed, Embase, Web of Science, PEDro, and the Cochrane Library from their inception until December 24th, 2023. The search targeted randomized controlled trials (RCTs) comparing NMES with physical therapy (PT) or usual ICU care (CG), for improving clinical outcomes in mechanically ventilated patients. We performed a network meta-analysis utilizing Stata version 14.0 and R 4.3.1.

RESULTS

We included 23 RCTs comprising 1312 mechanically ventilated adults. The treatments analyzed were NMES, PT, NMES combined with PT (NMES+PT), and CG. Network meta-analyses revealed that NMES or NMES+PT significantly improved extubation success rate compared to CG, with ORs of 1.85 (95% CI: 1.11, 3.08) and 5.89 (95% CI: 1.77, 19.65), respectively. Additionally, NMES exhibited a slight decrease in extubation success rate compared with NMES+PT, with OR of 0.31 (95% CI: 0.11, 0.93). Nevertheless, neither NMES nor NMES+PT showed any significant improvement in ICU length of stay (LOS), ventilation duration, or mortality when compared with PT or CG. NMES+PT emerged as the most effective strategy for all considered clinical outcomes according to the ranking probabilities. The evidence quality ranged from "low" to "very low" in this network meta-analysis.

CONCLUSIONS

NMES appears to be a straightforward and safe modality for critically ill, mechanically ventilated patients. When combined with PT, it significantly improved the extubation success rate against standard ICU care and NMES alone, and showed a better ranking over PT or NMES alone for clinical outcomes. Therefore, NMES combined with PT may be a superior rehabilitation strategy for this patient group.

Relationship of Age And Mobility Levels During Physical Rehabilitation With Clinical Outcomes in Critical Illness

Objective

To determine whether age, mobility level, and change in mobility level across the first 3 physical rehabilitation sessions associate with clinical outcomes of patients who are critically ill.

Design

Retrospective, observational cohort study.

Setting

Medical Intensive Care Unit (MICU).

Participants

Hospitalized adults (n = 132) who received 3 or more, consecutive rehabilitation sessions in the MICU.

Interventions

Not applicable.

Measurements and Main Results

Sample included 132 patients with 60 (45%) classified as younger (18-59 years) and 72 (55%) as older (60+ years). The most common diagnosis was sepsis/septicemia (32.6%). Older relative to younger patients had a significantly slower rate of improvement in ICU Mobility Scale (IMS) scores across rehabilitation sessions (mean slope coefficient 0.3 vs 0.6 points, P<.001), were less likely to be discharged to home (30.6% vs 55.0%, P=.005), and were more likely to die within 12 months (41.7% vs 25.0%, P=.046). Covariate-adjusted models indicated greater early improvement in IMS scores were associated with discharge home (P=.005). Longer time to first rehabilitation session, lower initial IMS scores, and slower improvement in IMS scores were associated with increased ICU days (all P<.03).

Conclusion

Older age and not achieving the mobility milestone of sitting at edge of bed or limited progression of mobility across sessions is associated with poor patient outcomes. Our findings suggest that age and mobility level contribute to outcome prognostication, and can aide in clinical phenotyping and rehabilitative service allocation.

Comparing the Effect of Respiratory Physiotherapy and Positive End-Expiratory Pressure Changes on Capnography Results in Intensive Care Unit Patients with Ventilator-Associated Pneumonia

Background

While critically ill patients experience a life-threatening illness, they commonly develop ventilator-associated pneumonia (VAP) which can increase morbidity, mortality, and healthcare costs. The present study aimed to compare the effect of respiratory physiotherapy and increased positive endexpiratory pressure (PEEP) on capnography results.

Materials and Methods

This randomized control clinical trial was performed on 80 adult patients with VAP in the intensive care unit (ICU). The patients were randomized to receive either PEEP at 5 cm H2O, followed by a moderate increase in PEEP to 10 cm H2O, or PEEP at 5 cm H2O with respiratory physiotherapy for 15 min. The numerical values were recorded on the capnograph at minutes 1, 5, 10, 15, and 30 in both methods. Data collection instruments included a checklist and MASIMO capnograph.

Results

As evidenced by the obtained results, the two methods significantly differed in the excreted pCO2 (partial pressure of carbon dioxide) (P<0.0001). However, the average amount of excreted pCO2 was higher in the respiratory physiotherapy and PEEP intervention (38.151mmHg) in comparison with increasing PEEP alone method (36.184mmHg). Also, PEEP elevation method prolonged the time of the first phase (inhalation time) and the second phase while shortening the third phase (exhalation time) in capnography waves.

Conclusion

CO2 excretion in patients with VAP increased after respiratory physiotherapy. Further, physiotherapy demonstrated more acceptable results in CO2 excretion compared with PEEP changes in mechanically ventilated patients.

Hemodynamic impact of early mobilization in critical patients receiving vasoactive drugs: A prospective cohort study

BACKGROUND

Vasoactive drugs are one of the most common patient-related barriers to early mobilization. Little is known about the hemodynamic effects of early mobilization on patients receiving vasoactive drugs. This study aims to observe and describe the impact of mobilization on the vital signs of critical patients receiving vasoactive drugs as well as the occurrence of adverse events.

METHODS

This is a cohort study performed in an Intensive Care Unit with patients receiving vasoactive drugs. All patients, either mobilized or non-mobilized, had their clinical data such as vital signs [heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation], type and dosage of the vasoactive drug, and respiratory support collected at rest. For mobilized patients, the vital signs were also collected after mobilization, and so was the highest level of mobility achieved and the occurrence of adverse events. The criteria involved in the decision of mobilizing the patients were registered.

RESULTS

53 patients were included in this study and 222 physiotherapy sessions were monitored. In most of the sessions (n = 150, 67.6%), patients were mobilized despite the use of vasoactive drugs. There was a statistically significant increase in heart rate and respiratory rate after mobilization when compared to rest (p<0.05). Only two (1.3%) out of 150 mobilizations presented an adverse event. Most of the time, non-mobilizations were justified by the existence of a clinical contraindication (n = 61, 84.7%).

CONCLUSIONS

The alterations observed in the vital signs of mobilized patients may have reflected physiological adjustments of patients' cardiovascular and respiratory systems to the increase in physical demand imposed by the early mobilization. The adverse events were rare, not serious, and reversed through actions such as a minimal increase of the vasoactive drug dosage.

Barriers and facilitators to resuming meaningful daily activities among critical illness survivors in the UK: a qualitative content analysis

OBJECTIVE

To identify critical illness survivors' perceived barriers and facilitators to resuming performance of meaningful activities when transitioning from hospital to home.

DESIGN

Secondary content analysis of semistructured interviews about patients' experiences of intensive care (primary analysis disseminated on the patient-facing website www.healthtalk.org). Two coders characterised patient-perceived barriers and facilitators to resuming meaningful activities. To facilitate clinical application, we mapped the codes onto the Person-Task-Environment model of performance, a patient-centred rehabilitation model that characterises complex interactions among the person, task and environment when performing activities.

SETTING

United Kingdom, 2005-2006.

PARTICIPANTS

39 adult critical illness survivors, sampled for variation among demographics and illness experiences.

RESULTS

Person-related barriers included negative mood or affect, perceived setbacks; weakness or limited endurance; pain or discomfort; inadequate nutrition or hydration; poor concentration/confusion; disordered sleep/hallucinations/nightmares; mistrust of people or information; and altered appearance. Task-related barriers included miscommunication and managing conflicting priorities. Environment-related barriers included non-supportive health services and policies; challenging social attitudes; incompatible patient-family coping (emotional trauma and physical disability); equipment problems; overstimulation; understimulation; and environmental inaccessibility. Person-related facilitators included motivation or attitude; experiencing progress; and religion or spirituality. Task-related facilitators included communication. Environment-related facilitators included support from family, friends or healthcare providers; supportive health services and policies; equipment; community resources; medications; and accessible housing. Barriers decreased and facilitators increased over time. Six barrier-facilitator domains dominated based on frequency and emphasis across all performance goals: mood/motivation, setbacks/progress, fatiguability/strength; mis/communication; lack/community support; lack/health services and policies.

CONCLUSIONS

Critical illness survivors described a comprehensive inventory of 18 barriers and 11 facilitators that align with the Person-Task-Environment model of performance. Six dominant barrier-facilitator domains seem strong targets for impactful interventions. These results verify previous knowledge and offer novel opportunities for optimising patient-centred care and reducing disability after critical illness.

Improving physical function of patients following intensive care unit admission (EMPRESS): protocol of a randomised controlled feasibility trial

INTRODUCTION

Physical rehabilitation delivered early following admission to the intensive care unit (ICU) has the potential to improve short-term and long-term outcomes. The use of supine cycling together with other rehabilitation techniques has potential as a method of introducing rehabilitation earlier in the patient journey. The aim of the study is to determine the feasibility of delivering the designed protocol of a randomised clinical trial comparing a protocolised early rehabilitation programme including cycling with usual care. This feasibility study will inform a larger multicentre study.

METHODS AND ANALYSIS

90 acute care medical patients from two mixed medical-surgical ICUs will be recruited. We will include ventilated patients within 72 hours of initiation of mechanical ventilation and expected to be ventilated a further 48 hours or more. Patients will receive usual care or usual care plus two 30 min rehabilitation sessions 5 days/week.Feasibility outcomes are (1) recruitment of one to two patients per month per site; (2) protocol fidelity with >75% of patients commencing interventions within 72 hours of mechanical ventilation, with >70% interventions delivered; and (3) blinded outcome measures recorded at three time points in >80% of patients. Secondary outcomes are (1) strength and function, the Physical Function ICU Test-scored measured on ICU discharge; (2) hospital length of stay; and (3) mental health and physical ability at 3 months using the WHO Disability Assessment Schedule 2. An economic analysis using hospital health services data reported with an embedded health economic study will collect and assess economic and quality of life data including the Hospital Anxiety and Depression Scales core, the Euroqol-5 Dimension-5 Level and the Impact of Event Score.

ETHICS AND DISSEMINATION

The study has ethical approval from the South Central Hampshire A Research Ethics Committee (19/SC/0016). All amendments will be approved by this committee. An independent trial monitoring committee is overseeing the study. Results will be made available to critical care survivors, their caregivers, the critical care societies and other researchers.

TRIAL REGISTRATION NUMBER

NCT03771014.

Health-related quality of life measured with the EQ-5D-5L in critical care survivors: A cross-sectional study

OBJECTIVES

The aim of this study was to investigate health-related quality of life (HRQOL) and related factors in intensive care unit survivors one-12 months after discharge.

RESEARCH METHODOLOGY/DESIGN

This cross-sectional survey included survivors who had been admitted to an intensive care unit for ≥48 hours.

MAIN OUTCOME MEASURES

HRQOL was measured using the EQ-5D-5L profile, which evaluates five dimensions of health (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) on five levels (no, slight, moderate, severe, and extreme problems), EQ-VAS (score range 0-100, 100 indicating best health) and EQ values (score range -0.066-1, 1 indicating best health). The factors influencing HRQOL were analyzed by Tobit regression.

SETTING

Survivors treated in an intensive care unit at six institutions in Korea.

RESULTS

Only 7.9% of the 534 participants had self-reported profiles of no health problems in all five dimensions. The proportion of participants with slight problems was highest in pain/discomfort with 85.0%. The proportion with severe problems was highest in usual activities with 21.7%, followed by mobility with 21.0%. The median and interquartile range of the EQ-VAS and EQ values were 60.00 (45.00 to 75.00) and 0.72 (0.52 to 0.80), respectively. Negative impact factors on HRQOL included older age, women, residing in a long term care facility, unemployment, emergency intensive care admission, and intensive care stay ≥ 7 days.

CONCLUSION

HRQOL among Korean intensive care survivors is low. The level of problems in physical dimensions is more severe than that in mental health dimensions. Early rehabilitation in the intensive care unit should be provided to facilitate long-term recovery.

Active Rehabilitation in a Patient During and After Venovenous Extracorporeal Membrane Oxygenation With a Diagnosis of COVID-19: A Case Report

PURPOSE

The coronavirus disease-2019 (COVID-19) pandemic has resulted in an influx of critically ill patients requiring mechanical ventilation, some receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO). The benefits of early mobility while undergoing ECMO have been previously documented. However, the COVID-19 pandemic has presented physical therapists with novel challenges, balancing the risk of a widespread shortage of personal protective equipment (PPE) with the benefits of early mobility for patients on ECMO. The purpose of this case study is to report the successful rehabilitation of a critically ill patient with COVID-19 undergoing VV ECMO.

METHODS

This is a case description of a 38-year-old man who presented to the hospital with COVID-19 and subsequent intubation and cannulation for VV ECMO. Physical therapy was initiated while the patient remained critically ill on VV ECMO. Focused coordination and education were employed to limit PPE usage by limiting the number of essential staff/therapists that entered the room as well as changing the frequency of therapy sessions dependent on how the patient was progressing functionally.

RESULTS

On VV ECMO day 11, he was able to sit up and perform a sit-to-stand. ECMO decannulation occurred on hospital day 14 with extubation on hospital day 18. The patient progressed functionally while quarantined in the room until he was discharged home with supplemental oxygen after spending 29 days in the hospital.

CONCLUSION

This case study demonstrates the clinical decision-making used to provide physical therapy services for a critically ill patient with COVID-19. High-level team coordination resulted in limiting the use of PPE as well as reducing staff exposure frequency during rehabilitation. Despite his severe critical illness, the patient was successfully discharged home within 30 days.

Health disparities of critically ill children according to poverty: the Korean population-based retrospective cohort study

Background

There is a lack of nationwide studies on critically ill patients’ health disparity under the National Health Insurance (NHI) system. We evaluated health disparities in intensive care unit (ICU) admission, outcomes, and readmission in impoverished children.

Methods

We conducted a retrospective cohort study using a national database from the Korean NHI and Medical Aid Program (MAP). MAP supports the population whose household income is lower than 40% of the median Korean household income. We defined poverty as being a MAP beneficiary and compared the poverty and non-poverty groups. Patients between 28 days and 18 years old who were admitted to the ICU were included. Hospital mortality and readmission were analyzed with adjustment for patient characteristics, hospital type, and management procedures.

Results

Out of 17,893 patients, 1153 (6.4%) patients were in poverty. The age-standardized ICU admission rate was higher in the poverty group (126.9 vs. 80.2 per 100,000 person-years). There was more age-standardized mortality in the poverty group (11.8 vs. 4.3 per 100,000 person-years). Patients in the poverty group did not have a statistically different risk of adjusted in-hospital mortality to those in the non-poverty group (odds ratio: 1.15, confidence interval [CI]: 0.84–1.55) but had a higher readmission rate (hazard ratio 1.25, CI 1.09–1.42).

Conclusion

Under the NHI system, the disparity in pediatric critical care outcomes according to poverty is not definite, but the healthcare disparity in pre- and post-hospital care is a concern. Further studies are required to improve pre- and post-hospital healthcare quality of impoverished children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11324-4.

Muscle atrophy in critically ill patients : a review of its cause, evaluation, and prevention

Critically ill patients exhibit prominent muscle atrophy, which occurs rapidly after ICU admission and leads to poor clinical outcomes. The extent of atrophy differs among muscles as follows: upper limb: 0.7%-2.4% per day, lower limb: 1.2%-3.0% per day, and diaphragm 1.1%-10.9% per day. This atrophy is caused by numerous risk factors such as inflammation, immobilization, nutrition, hyperglycemia, medication, and mechanical ventilation. Muscle atrophy should be monitored noninvasively by ultrasound at the bedside. Ultrasound can assess muscle mass in most patients, although physical assessment is limited to almost half of all critically ill patients due to impaired consciousness. Important strategies to prevent muscle atrophy are physical therapy and electrical muscular stimulation. Electrical muscular stimulation is especially effective for patients with limited physical therapy. Regarding diaphragm atrophy, mechanical ventilation should be adjusted to maintain spontaneous breathing and titrate inspiratory pressure. However, the sufficient timing and amount of nutritional intervention remain unclear. Further investigation is necessary to prevent muscle atrophy and improve long-term outcomes. J. Med. Invest. 67 : 1-10, February, 2020.

Adult Pulmonary Intensive and Intermediate Care Units: The Italian Thoracic Society (ITS-AIPO) Position Paper

The imbalance between the prevalence of patients with acute respiratory failure (ARF) and acute-on-chronic respiratory failure and the number of intensive care unit (ICU) beds requires new solutions. The increasing use of non-invasive respiratory tools to support patients at earlier stages of ARF and the increased expertise of non-ICU clinicians in other types of supportive care have led to the development of adult pulmonary intensive care units (PICUs) and pulmonary intermediate care units (PIMCUs). As in other European countries, Italian PICUs and PIMCUs provide an intermediate level of care as the setting designed for managing ARF patients without severe non-pulmonary dysfunction. The PICUs and PIMCUs may also act as step-down units for weaning patients from prolonged mechanical ventilation and for discharging patients still requiring ventilatory support at home. These units may play an important role in the on-going coronavirus disease 2019 pandemic. This position paper promoted by the Italian Thoracic Society (ITS-AIPO) describes the models, facilities, staff, equipment, and operating methods of PICUs and PIMCUs.

Pathophysiology and Treatment Strategies of Acute Myopathy and Muscle Wasting after Sepsis

Sepsis survivors experience a persistent myopathy characterized by skeletal muscle weakness, atrophy, and an inability to repair/regenerate damaged or dysfunctional myofibers. The origins and mechanisms of this persistent sepsis-induced myopathy are likely complex and multifactorial. Nevertheless, the pathobiology is thought to be triggered by the interaction between circulating pathogens and impaired muscle metabolic status. In addition, while in the hospital, septic patients often experience prolonged periods of physical inactivity due to bed rest, which may exacerbate the myopathy. Physical rehabilitation emerges as a potential tool to prevent the decline in physical function in septic patients. Currently, there is no consensus regarding effective rehabilitation strategies for sepsis-induced myopathy. The optimal timing to initiate the rehabilitation intervention currently lacks consensus as well. In this review, we summarize the evidence on the fundamental pathobiological mechanisms of sepsis-induced myopathy and discuss the recent evidence on in-hospital and post-discharge rehabilitation as well as other potential interventions that may prevent physical disability and death of sepsis survivors.

Feasibility of establishing a rehabilitation programme in a Vietnamese intensive care unit

Increasing numbers of people are surviving critical illness throughout the world, but survivorship is associated with long-term disability. In high-income settings physical rehabilitation is commonly employed to counter this and improve outcomes. These utilize highly-trained multidisciplinary teams and are unavailable and unaffordable in most low and middle income countries (LMICs). We aimed to design a sustainable intensive care unit (ICU) rehabilitation program and to evaluate its feasibility in a LMIC setting. In this project patients, care-givers and experts co-designed an innovative rehabilitation programme that can be delivered by non-expert ICU staff and family care-givers in a LMIC. We implemented this programme in adult patient with patients with tetanus at the Hospital for Tropical Diseases, Ho Chi Minh City over a 5-month period, evaluating the programme's acceptability, enablers and barriers. A 6-phase programme was designed, supported by written and video material. The programme was piloted in total of 30 patients. Rehabilitation was commenced a median 14 (inter quartile range (IQR) 10-18) days after admission. Each patient received a median of 25.5 (IQR 22.8-34.8) rehabilitation sessions out of a median 27 (22.8-35) intended (prescribed) sessions. There were no associated adverse events. Patients and staff found rehabilitation to be beneficial, enhanced relationships between carers, patients and staff and was deemed to be a positive step towards recovery and return to work. The main barrier was staff time. The programme was feasible for patients with tetanus and viewed positively by staff and participants. Staff time was identified as the major barrier to ongoing implementation.

Environmental Factors Affecting Early Mobilization and Physical Disability Post-Intensive Care: An Integrative Review Through the Lens of the World Health Organization International Classification of Functioning, Disability, and Health

BACKGROUND

Early mobilization (EM) is one of few potential protective factors associated with reduced physical disability post-intensive care (PD PIC). However, only 45% of intensive care units (ICUs) in the United States routinely practice EM despite its recognized benefits.

OBJECTIVES

To analyze the evidence on the relationship between critical care EM, PD PIC, and environmental factors, using the theoretical lens of the World Health Organization's (WHO's) International Classification of Functioning, Disability, and Health (ICF).

METHOD

The Whittemore and Knafl methodology for integrative reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines were followed. Qualitative, quantitative, and mixed-methods studies (n = 38) that evaluated EM and 1 or more domains of the WHO ICF were included. Quality was appraised using the Mixed-Methods Appraisal Tool. Study characteristics were evaluated for common themes and relationships. The ICF domains and subdomains pertaining to each study were synthesized.

RESULTS

Early mobilization was related to improved functioning on the disability continuum of the WHO ICF. Early mobilization was influenced by several WHO ICF environmental factors. Dedicated physical and occupational therapy teams in the ICU, interdisciplinary rounds, and positive family and staff perception of EM facilitated intervention delivery. However, poor staffing levels, negative unit culture, perceived workload burden, and lack of equipment, education, and financial support impeded delivery of EM.

DISCUSSION

Early mobilization is a promising intervention that may reduce PD PIC. However, environmental factors negatively influence delivery of EM in the ICU. Several gaps in EM research limit its acceptability in ICU practice. Existing EM research is challenged by poor methodological quality. Further study is necessary to better understand the role of EM on PD PIC and improve patient outcomes following critical illness.

Racial Disparities in Readmissions Following Initial Hospitalization for Sepsis

OBJECTIVES

To assess whether Black race is associated with a higher rate of all-cause readmission compared with White race following community-onset sepsis.

DESIGN

Retrospective cohort study.

SETTING

One-thousand three-hundred bed urban academic medical centers.

PATIENTS

Three-thousand three-hundred ninety patients hospitalized with community-onset sepsis between January 1, 2010, and December 31, 2017.

INTERVENTIONS

Community-onset sepsis was defined as patients admitted through the emergency department with an International Classification of Disease, ninth revision, Clinical Modification code for either severe sepsis (995.92) or septic shock (785.52). Beginning in 2015, we used International Classification of Disease, Tenth Revision, Clinical Modification codes R65.20 (severe sepsis) and R65.21 (septic shock). We excluded those individuals hospitalized at another acute care facility that were transferred to our facility. Race was abstracted electronically, and patients who expired or self-identified as a race other than Black or White race were excluded. Patients who experienced a subsequent hospitalization at our facility were considered to be readmitted.

MEASUREMENTS AND MAIN RESULTS

Compared with White race, Black race demonstrated a significantly higher rate of all-cause readmission (60.8% vs 71.1%; p < 0.001), including a higher rate of readmission for sepsis (14.0% vs 19.8%; p < 0.001). Black patients also resided in zip codes with a lower median household income and were more likely to use public insurance compared with White race. Similar rates of comorbid diseases and disease burden were observed between the two groups, but vasopressors were less likely to be administered to Black patients. Multivariable analysis showed that Black race was associated with a 50% increased odds (odds ratio, 1.52, 99% CI, 1.25-1.84) in all-cause readmission risk compared with White race.

CONCLUSIONS

Black race was associated with a higher rate of all-cause and sepsis readmission, possibly as a result of unaddressed health disparities, compared with White race. Programs addressing healthcare disparities should use readmission as another marker of equity.

Prevalence of Acute Rehabilitation for Kids in the PICU: A Canadian Multicenter Point Prevalence Study

OBJECTIVES

To evaluate mobilization practices, barriers, and mobility-related adverse events in Canadian PICUs.

DESIGN

National 2-day point prevalence study.

SETTING

Thirteen PICUs across Canada.

PATIENTS

Children with a minimum 72-hour PICU length of stay on the allocated study day.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Outcomes of interest were the prevalence and nature of mobilization activities, rehabilitation resources, adverse events, and factors associated with out-of-bed mobility and therapist-provided mobility. Two PICUs (15%) had early mobilization practice guidelines, and one PICU (8%) reported a formal process for engaging families in the mobilization of patients. The prevalence of mobilization was 110 of 137 patient-days (80%). The commonest activity was out-of-bed mobility (87/137; 64% patient-days); there was no active mobilization on 46 patient-days (34%). Therapists provided mobility on 33% of patient-days. Mobility was most commonly facilitated by nurses (74% events) and family (49% events). Family participation was strongly associated with out-of-bed mobility (odds ratio 6.4; p = 0.001). Intubated, mechanically ventilated patients were mobilized out-of-bed on 18 of 50 patient-days (36%). However, the presence of an endotracheal tube, vasoactive infusions, and age greater than or equal to 3 years were independently associated with not being mobilized out-of-bed. Barriers were reported on 58 of 137 patient-days (42%), and adverse events occurred in 22 of 387 mobility events (6%).

CONCLUSIONS

Mobilization is common and safe, and the majority of children in Canadian PICUs are being mobilized out-of-bed, even when mechanically ventilated. Family engagement in PICU-based rehabilitation is increasing. This study provides encouraging evidence that common barriers can be overcome in order to safely mobilize children in PICUs.

Organizational structures and early mobilization practices in South African public sector intensive care units-A cross-sectional study

RATIONALE

Understanding current early mobilization practice of patients in intensive care unit (ICU) is critical to the design and implementation of strategies to facilitate its application in a diverse population of critically ill patients encountered in public sector hospitals.

AIM

To evaluate the organizational structures of South African public sector hospital ICUs and to describe early mobilization practices in these units.

METHODS

A cross-sectional survey was done in participating public hospitals from eight provinces in South Africa. Convenience sampling was done. Data collected included hospital and ICU structure, adult patient demographic and clinical data, and mobilization activities done in ICU over the previous 24 hours prior to the day of the survey.

RESULTS

A total of 29 ICUs from 13 participating hospitals were surveyed resulting in 205 patient records. Majority of the surveyed ICUs were "open" type (n = 16; 55.2%). A standardized sedation scoring system was used in 18 units (62.1%) and only two units (6.9%) had an early mobilization protocol in place. Mean age of the patients surveyed was 43.5 (±17.7) years and 148 (72.2%) patients were on mechanical ventilation. Primary reasons for admission to ICU included traumatic injury (n = 86; 42%) and postoperative care (n = 33; 16.1%). Mobilization activities performed in the previous 24 hours included turning the patient in bed (n = 88; 42.9%), marching on the spot (n = 9; 4.4%) and walking (n = 10; 4.9%). Out-of-bed mobilization was done in only 40 (19.5%) patients. The most common barriers to early mobilization included patient unresponsiveness (n = 50; 24.4%) and hemodynamic instability (n = 42; 20.5%). The type of ventilation was found to have a significant positive relationship with out-of-bed patient mobilization (P = .000).

CONCLUSIONS

A small proportion of patients attained their highest level of mobilization in ICU. The type of ventilation influenced early mobilization practices in public sector ICUs in South Africa.

Post-Intensive Care Unit Care. A Qualitative Analysis of Patient Priorities and Implications for Redesign

Rationale: Although survival during critical illness is improving, little evidence exists to guide post-intensive care unit (ICU) care. Understanding patients' needs and priorities is fundamental to improving care quality.Objectives: To describe the evolution of patients' priorities for recovery across the spectrum of post-ICU care.Methods: This was a secondary analysis of 39 semistructured interviews conducted from 2005 to 2006 in participants' homes 19 days to 11 years after hospital discharge after critical illness. Adult critical illness survivors (N = 39) aged 20 years or older from multiple ICUs across the United Kingdom were purposively selected to maximize diversity with respect to time since diagnosis, disease severity, sex, age, ethnicity, socioeconomic group/status, region. age, ICU admitting diagnoses, and length of stay. We used the method of qualitative description to characterize patients' priorities for recovery and their evolution within and between individual patients across three post-ICU periods: ICU transition to wards, early period (approximately the first 2 mo) after discharge to home, and late period (>2 mo) after discharge to home.Results: The analysis revealed 12 core patient priorities during recovery: feeling safe, being comfortable, engaging in mobility, participating in self-care, asserting personhood, connecting with people, ensuring family well-being, going home, restoring psychological health, restoring physical health, resuming previous roles and routines, and seeking new life experiences. In general, priorities evolved from those pertaining to basic survival during the stay on wards to being broader and more aspirational by the late postdischarge period.Conclusions: Understanding patients' priorities for post-ICU care is critical for developing stakeholder-driven clinical guidelines. Engaging other stakeholders (e.g., family members, healthcare providers, and institutionalized and frail older adults) to inform the development of clinical guidelines for post-ICU care, together with the barriers and facilitators faced in achieving patient- and family-centered care, is an important next step.

24/7 Physical Therapy Intervention With Adult Patients in a Chilean Intensive Care Unit: A Cost-Benefit Analysis in a Developing Country

OBJECTIVES

Physiotherapy in an adult intensive care unit (ICU) affects health outcome. To justify the investment in ICU physical therapy, the cost savings associated with its benefits need to be established. The main objective of this study is to evaluate the potential cost savings of implementing 24-hour, 7-days-per-week physiotherapist (24/7-PT) in a Chilean public high-complex specialized ICU.

METHODS

Using clinical data from a literature review and a micro-costing technique, we conducted a cost-benefit analysis in the National Institute of Thorax in Chile. Our example scenario involves 697 theoretical admissions of adult patients with cardiovascular or respiratory diseases, and the costs and benefits by reduction of length of stay in ICU, days of mechanical ventilation, and days with respiratory infections during the first year and 5 years of admissions. A sensitivity analysis was considered according to the variability in total costs, production income, and clinical benefits.

RESULTS

Net cost savings generated in our example scenario demonstrate that the implementation of 24/7-PT produces a minimum saving for the institution of $16 242 during the first year and $69 351 over a 5-year interval considering individual income production. Out of the 30 scenarios included in the sensitivity analyses, 26 (87%) demonstrated net savings.

CONCLUSIONS

A financial model, based on literature review and actual cost data, projects that 24/7-PT intervention is a cost-benefit alternative in adult ICU patients with cardiovascular or respiratory diseases in Chile. It is necessary a scenario of at least 3 sessions per day with insurance payment for individual treatments to support the long-term implementation of a 24/7-PT program.

Chest physiotherapy: An important adjuvant in critically ill mechanically ventilated patients with COVID-19

In late 2019, an outbreak of a novel human coronavirus causing respiratory disease was identified in Wuhan, China. The virus spread rapidly worldwide, reaching pandemic status. Chest computed tomography scans of patients with coronavirus disease-2019 (COVID-19) have revealed different stages of respiratory involvement, with extremely variable lung presentations, which require individualized ventilatory strategies in those who become critically ill. Chest physiotherapy has proven to be effective for improving long-term respiratory physical function among ICU survivors. The ARIR recently reported the role of chest physiotherapy in the acute phase of COVID-19, pointing out limitation of some procedures due to the limited experience with this disease in the ICU setting. Evidence on the efficacy of chest physiotherapy in COVID-19 is still lacking. In this line, the current review discusses the important role of chest physiotherapy in critically ill mechanically ventilated patients with COVID-19, around the weaning process, and how it can be safely applied with careful organization, including the training of healthcare staff and the appropriate use of personal protective equipment to minimize the risk of viral exposure.

Facilitating Posttraumatic Growth After Critical Illness

The theory of posttraumatic growth arose from accounts of various trauma survivors experiencing not only distress but also growth and change. An intensive care unit admission is an unplanned, sudden, and traumatic experience, and many survivors have posttraumatic stress that can lead to posttraumatic stress disorder. Survivors leave the intensive care unit with new functional impairments that drive depression, and they frequently experience anxiety. Amidst the stress of understanding the trauma of an intensive care unit admission, survivors can grow in their world views, relationships, and sense of self. Understanding posttraumatic growth in intensive care unit survivors will inform health care providers on how to help survivors understand their new difficulties after an intensive care unit stay and facilitate growth. This article is a conceptual review of posttraumatic growth, identifiers of posttraumatic growth, and how the tenets of the posttraumatic growth theory apply to intensive care unit survivors. Health care professionals, specifically nurses, can incorporate practices into their care during and after the intensive care unit stay that encourage understanding and positive accommodation of new difficulties brought on by the intensive care unit hospitalization to support survivor growth. Opportunities for research include incorporating posttraumatic growth assessments into post-intensive care unit clinics, self-help materials, and various programs or therapies. Outcomes associated with posttraumatic growth are listed to suggest directions for research questions concerning posttraumatic growth in intensive care unit survivors.

Searching for the Responder, Unpacking the Physical Rehabilitation Needs of Critically Ill Adults: A REVIEW

Survivors of critical illness can experience persistent deficits in physical function and poor health-related quality of life and utilize significant health care resources. Short-term improvements in these outcomes have been reported following physical rehabilitation. Safety and feasibility of delivering physical rehabilitation are established; however, low physical activity levels are observed throughout the recovery of patients. We provide examples on how physical activity may be increased through interdisciplinary models of service delivery. Recently, however, there has been an emergence of large randomized controlled trials reporting no effect on long-term patient outcomes. In this review, we use a proposed theoretical construct to unpack the findings of 12 randomized controlled trials that delivered physical rehabilitation during the acute hospital stay. We describe the search for the responder according to modifiers of treatment effect for physical function, health-related quality of life, and health care utilization outcomes. In addition, we propose tailoring and timing physical rehabilitation interventions to patient subgroups that may respond differently based on their impairments and perpetuating factors that hinder recovery. We examine in detail the timing, components, and dosage of the trial intervention arms. We also describe facilitators and barriers to physical rehabilitation implementation and factors that are influential in recovery from critical illness. Through this theoretical construct, we anticipate that physical rehabilitation programs can be better tailored to the needs of survivors to deliver appropriate interventions to patients who derive greatest benefit optimally timed in their recovery trajectory.

Hintergrundtext zu Empfehlungen der DGPRM zu Struktur und Ausstattung von Akutkrankenhäusern bezüglich Physikalisch-medizinischer/Rehabilitativer Maßnahmen in Intensivmedizin und Intermediate Care

Wissenschaftlicher Hintergrund, Erläuterungen, Definitionen von Begriffen, Literaturangaben und Empfehlungen zur Empfehlungen der Deutschen Gesellschaft für Physikalische und Rehabilitative Medizin (DGPRM) zu Struktur und Ausstattung von Akutkrankenhäusern bezüglich Physikalisch-medizinischer/Rehabilitativer Maßnahmen in der Intensivmedizin und Intermediate Care. Konkrete Problemfelder und mögliche Maßnahmen werden erläutert. Sowohl für personelle Schlüssel als auch Therapiefrequenz und Dauer jeweils werden konkrete Empfehlungen benannt.

Very early exercise tailored by decisional algorithm helps relieve discomfort in ICU patients: an open-label pilot study

BACKGROUND

Existing algorithms do not allow for setting up finely tuned progression or intensity for exercise training in intensive care units (ICUs).

AIM

We aimed to assess the feasibility and tolerance of a very early exercise program tailored by using decisional algorithm that integrated both progression and intensity.

DESIGN

Open-label pilot study.

SETTING

ICU.

POPULATION

Thirty adults hospitalized in ICU.

METHODS

Once a day, patients performed manual range of motion, cycloergometry, and functional training exercises. The progression and intensity of training were standardized by using the constructed algorithm. The main outcome, discomfort on a 0-100 Visual Analog Scale, was assessed before and after each exercise session. Secondary outcomes were muscle strength, ICU length of stay and adverse events related to exercise.

RESULTS

Overall, 125 exercise sessions were performed. Discomfort during exercise sessions decreased significantly by the fifth session (P=0.049). Early exercise sessions were feasible and did not produce major adverse events.

CONCLUSIONS

We confirmed the safety and feasibility of very early exercise programs in ICUs. Early exercise tailored by using a decisional algorithm helps relieve the discomfort of ICU patients.

CLINICAL REHABILITATION IMPACT

In everyday practice, the use of decisional algorithms should be encouraged to initiate and standardize early exercise in ICUs.

Effect of Early Mobilization on Respiratory and Limb Muscle Strength and Functionality of Nonintubated Patients in Critical Care: A Feasibility Trial

Purpose. To assess the potential effectiveness or efficacy of early mobilization on respiratory and peripheral muscle strengths and functionality in nonintubated patients. Methods. For 40 nonintubated patients over 18 years of age with over 24-hour intensive care unit (ICU) stay allocated to a single intervention, an incremental mobilization protocol was initiated. Maximal inspiratory and expiratory pressures (MIP and MEP), peripheral muscle strength (handgrip strength (HGS) and Medical Research Council scale (MRC-s)), and functionality (FIM, ICF-BMS, PFIT-s, and FSS-ICU scales) were evaluated at ICU admission and discharge. Results. All outcomes were significantly improved (pre vs. post values): MIP (43.93 ± 21.95 vs. 54.12 ± 21.68 cmH2O; P<0.001), MEP (50.32 ± 28.65 vs. 60.30 ± 21.23; P=0.002), HGS (25.5 (9.58) vs. 27.5 (9.48); P=0.046), MRC-s (58.52 ± 2.84 vs. 59.47 ± 1.81; P=0.023), FIM (54.4 ± 22.79 vs. 69.48 ± 12.74), ICF-BMS (28.63 ± 16.19 vs. 14.03 ± 11.15), PFIT-s (9.55 ± 2.34 vs. 11.18 ± 1.32) (P<0.001), and FSS-ICU (28.7 ± 9.1 vs. 32.6 ± 5.0; P=0.001). The ceiling effect at admission/discharge was in MRC-s (60/82.5%), FSS-ICU (50/70%), and FIM (35/62.5%). The floor effect occurred at discharge in ICF-BMS (7.5/52.5%). Conclusions. The early mobilization protocol seemed effective at maintaining/increasing the respiratory muscle strength and functionality of nonintubated patients in critical care. Ceiling effect was high for MRC-s, FSS-ICU, and FIM scales.

The speech pathology workforce in intensive care units: Results from a national survey

BACKGROUND

Admission to the intensive care unit (ICU) with mechanical ventilation can lead to patients experiencing impaired swallowing and communication function. This can negatively affect patient experiences and outcomes. There is increasing research supporting early intervention for swallowing and communication; however, there are no published ICU workforce data to determine patient access.

PURPOSE

The purpose of this study was to describe national ICU access to speech pathology (SP) services and to describe the nature of this workforce.

METHODS

Prospective audit of Australian ICUs with a focussed workforce survey of SP service including workforce demographics, clinical practices, team environments, and training was conducted. Data are described as percentage (%, n) and as median (interquartile range). Qualitative data were analysed using thematic frameworks.

RESULTS

SP services were available at 99% (n = 165) of the sites; 62 sites provided workforce data (45% response rate). Seventy-one percent of respondents serviced the ICU ≤10 h per week, with 23% reporting dedicated funding. Almost a third (32%) reported not participating in ICU team activities, and more than half of the sites (56%) did not provide ICU-specific training with resulting varied clinical confidence ratings. Facilitator and barriers both highlighted team working relationships. Facilitator themes were building working relationships, understanding the SP role in the multidisciplinary team, physical presence in the unit, and access to resources. Barrier themes were the multidisciplinary team's understanding of SP roles and lack of presence of SP services in the ICU.

CONCLUSIONS

SP services are not standard across Australian ICUs, with variations in confidence, funding, training, and team environments. Further research into the impact of these variations on patient outcomes is needed.

Patient and family experience of physical rehabilitation on the intensive care unit: a qualitative exploration

OBJECTIVES

To explore the experience of physical rehabilitation in the intensive care unit (ICU), from the perspective of patients and relatives.

DESIGN

Exploratory, qualitative study.

PARTICIPANTS

Five former ICU patients and five family members of former ICU patients recruited from ICU support groups across the UK.

INTERVENTIONS

Semi-structured interviews.

MAIN OUTCOME MEASURES

Participants' experiences of physical rehabilitation in the ICU. Data were analysed using an iterative thematic approach.

RESULTS

Four main themes were identified: Trust and Rapport, Necessity (of treatment), Psychological Benefit, and Goal Setting: Whose goal is it anyway? Despite a lack of enjoyment, patients tend to comply with physical rehabilitation, due in part to a positive patient-therapist relationship. There was agreement across participants that physical rehabilitation should be started as soon as possible after admission to ICU and exhaustion was highlighted as the biggest challenge to participation. In addition to aiding physical recovery, physical rehabilitation in the ICU may also provide psychological support for both patients and relatives. Finally, participants described a desire for therapists to direct goal setting in the early stages of recovery as they felt unable to engage in the process due to other priorities.

CONCLUSIONS

The experience of physical rehabilitation on ICU may be influenced by key aspects of person-centred care. This study suggests that patients and relatives are keen for physical rehabilitation to start as soon as possible, which is a crucial new finding to support the practice of early rehabilitation in the ICU.

Rehabilitative treatment of patients with COVID-19 infection: the P.A.R.M.A. evidence based clinical practice protocol

BACKGROUND

The impact of the SARS-CoV-2 on the National Health System (NHS) required a reorganization of the various levels of care, which also involved the rehabilitation reality.

AIM OF THE WORK

A clinical practice review of the literature was conducted to provide operational-rehabilitation guidelines adapted to the local reality and to the recent corporate reorganization in the context of the COVID-19 emergency.

METHODS

A practice review of the available scientific evidence was regularly conducted from the start of the COVID-19 pandemic to periodically update the clinical practice guidelines. Articles that met the following inclusion criteria were included: studies conducted on human adult subjects with COVID-19 infection, undergoing rehabilitation in any hospitalization setting.

RESULTS

The results of this clinical practice update were periodically discussed with colleagues and collaborators in a multi-professional team, in order to guarantee a good clinical practice protocol, named P.A.R.M.A.

CONCLUSIONS

The P.A.R.M.A. protocol is the result of a periodic review literature update, which has allowed us to take charge of patients affected by COVID-19 according to the most up-to-date clinical evidences, guaranteeing a shared and uniform treatment within a local reality in an era of health emergency.

Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience

Although growing evidence supports the safety and effectiveness of the ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment), intensive care unit providers often struggle with how to reliably and consistently incorporate this interprofessional, evidence-based intervention into everyday clinical practice. Recently, the Society of Critical Care Medicine completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, nationwide, multicenter quality improvement initiative that formalized dissemination and implementation strategies and tracked key performance metrics to overcome barriers to ABCDEF bundle adoption. The purpose of this article is to discuss some of the most challenging implementation issues that Collaborative teams experienced, and to provide some practical advice from leading experts on ways to overcome these barriers.

Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis

BACKGROUND

Physical therapy can prevent functional impairments and improve the quality of life of patients after hospital discharge. However, the effect of early mobilization on patients with a critical illness remains unclear. This study was performed to assess the evidence available regarding the effect of early mobilization on critically ill patients in the intensive care unit (ICU).

METHODS

Electronic databases were searched from their inception to March 21, 2019. Randomized controlled trials (RCTs) comprising critically ill patients who received early mobilization were included. The methodological quality and risk of bias of each eligible trial were assessed using the Cochrane Collaboration tool. Data were extracted using a standard collection form each included study, and processed using the Mantel-Haenszel (M-H) or inverse-variance (I-V) test in the STATA v12.0 statistical software.

RESULTS

A total of 1,898 records were screened. Twenty-three RCTs comprising 2,308 critically ill patients were ultimately included. Early mobilization decreased the incidence of ICU-acquired weakness (ICU-AW) at hospital discharge (three studies, 190 patients, relative risk (RR): 0.60, 95% confidence interval (CI) [0.40, 0.90]; p = 0.013, I2 = 0.0%), increased the number of patients who were able to stand (one study, 50 patients, 90% vs. 62%, p = 0.02), increased the number of ventilator-free days (six studies, 745 patients, standardized mean difference (SMD): 0.17, 95% CI [0.02, 0.31]; p = 0.023, I2 = 35.5%) during hospitalization, increased the distance the patient was able to walk unassisted (one study, 104 patients, 33.4 (0-91.4) meters vs. 0 (0-30.4) meters, p = 0.004) at hospital discharge, and increased the discharged-to-home rate (seven studies, 793 patients, RR: 1.16, 95% CI [1.00, 1.34]; p = 0.046). The mortality (28-day, ICU and hospital) and adverse event rates were moderately increased by early mobilization, but the differences were statistically non-significant. However, due to the substantial heterogeneity among the included studies, and the low quality of the evidence, the results of this study should be interpreted with caution. Publication bias was not identified.

CONCLUSIONS

Early mobilization appears to decrease the incidence of ICU-AW, improve the functional capacity, and increase the number of ventilator-free days and the discharged-to-home rate for patients with a critical illness in the ICU setting.

Effectiveness of occupational therapy interventions in acute geriatric wards: A systematic review

OBJECTIVE

To review the evidence on the effectiveness of specific occupational therapy programs in elderly people hospitalized for acute medical pathology.

MATERIALS AND METHODS

Relevant randomized clinical trials were selected by searching the main bibliographic databases to evaluate the effectiveness of in-hospital occupational therapy interventions for people aged 65 years and over who were hospitalized for acute medical pathology.

RESULTS

Six studies were finally selected. The interventions consisted of individualized programs of occupational therapy: training and re-education in the activities of daily living (ADL); evaluation, prescription and training in the use of support devices; and providing reports regarding recommendations and referrals on discharge. In five studies, the patients in the intervention group obtained higher scores on assessment tools used to measure functionality in ADL. In one of the studies there was a statistically significant reduction in delirium, as well as an improvement in cognitive function. There was no evidence for the effectiveness of occupational therapy interventions for anxiety, fear and/or perceived safety, in any of the studies analyzed.

CONCLUSIONS

The evidence is limited as to whether specific occupational therapy programs are effective in improving functionality in ADL in this group of patients. However, occupational therapy was significantly effective in reducing delirium and improving cognitive function. There is insufficient evidence to claim that specific occupational therapy programs are effective in reducing levels of anxiety, increasing perceived quality of life, reducing readmission rates, or reducing the length of hospital stay.

I SURVIVE: inter-rater reliability of three physical functional outcome measures in intensive care unit survivors

PURPOSE

We prospectively assessed inter-rater reliability of three physical function measures in Canadian intensive care unit (ICU) survivors in the inpatient setting.

METHODS

We enrolled patients who had an ICU length of stay of ≥ three days, were mechanically ventilated for ≥ 24 hr, and were ambulating independently before hospital admission. Weekly from ICU discharge to hospital discharge, two trained frontline clinicians, blinded to each other's findings, independently performed the Physical Function ICU Test-scored (PFIT-s; score out of 10), 30-sec sit-to-stand (30STS; # of stands), and two-minute walk test (2MWT; distance in m), all within 24 hr. We calculated the intraclass correlation coefficient (ICC), standard error of measurement (SEM), and minimal detectable change (MDC₉₀).

RESULTS

We enrolled 42 patients. PFIT-s: in 36 patients with 66 paired scores, the ICC was 0.78 (95% confidence interval [CI], 0.66 to 0.86), the SEM was 1.04, and the MDC₉₀ was 2.42. 30STS: in 35 patients with 67 paired scores, the ICC was 0.85 (95% CI, 0.76 to 0.90), the SEM was 1.91, and the MDC₉₀ was 4.45. 2MWT: in 35 patients with 58 paired scores, the ICC was 0.78 (95% CI, 0.66 to 0.87), the SEM was 20.87, and the MDC₉₀ was 48.69.

CONCLUSION

These three measures show good inter-rater reliability when used by trained frontline clinicians to assess physical function in ICU survivors in the inpatient setting.

Physical function and actigraphy in intensive care survivors-A prospective 3-month follow-up cohort study

BACKGROUND

Impaired physical function after intensive care unit (ICU) stay is common. We aimed to study the association between activity levels in the ward after discharge from ICU and physical function at 3-month follow-up.

METHODS

Prospective cohort study of adult patients admitted to the ICU for more than 24 hours. Patients wore an accelerometer for up to 7 days at the ward. At discharge from ICU and at 3-month follow-up, patients were tested with the Chelsea Critical Care Physical Assessment Tool (CPAx).

RESULTS

We screened 66 consecutive, eligible patients; 41 completed actigraphy and 19 patients were visited at 3 months. The median CPAx increased from 31 (IQR 23-41) at discharge from ICU to 47 (IQR 44-49) at follow-up (P < 0.0001). Mean daily activity for the first week was correlated with CPAx at ICU discharge (R²  = 0.14, P = 0.017; all 41 patients). For the 19 visited patients, we found no significant correlation for activity levels with CPAx at ICU discharge (R²  = 0.12, P = 0.14) nor at visit (R²  = 0.2, P = 0.058).

CONCLUSION

We found improved physical function for most patients 3 months after ICU treatment. Activity levels for 1 week after ICU discharge at the ward were not associated with better physical function at 3-month follow-up.

Determinants of self-reported unacceptable outcome of intensive care treatment 1 year after discharge

PURPOSE

Survivors of critical illness often suffer from reduced health-related quality of life (HRQoL) due to long-term physical, cognitive, and mental health problems, also known as post-intensive care syndrome (PICS). Some intensive care unit (ICU) survivors even consider their state of health unacceptable. The aim of this study was to investigate the determinants of self-reported unacceptable outcome of ICU treatment.

METHODS

Patients who were admitted to the ICU for at least 48 h and survived the first year after discharge completed validated questionnaires on overall HRQoL and the components of PICS and stated whether they considered their current state of health an acceptable outcome of ICU treatment. The effects of overall HRQoL and components of PICS on unacceptable outcome were studied using multiple logistic regression analysis.

RESULTS

Of 1453 patients, 67 (5%) reported their health state an unacceptable outcome of ICU treatment. These patients had a lower score on overall HRQoL (EQ-5D-index value of 0.57 vs. 0.81; p < 0.001), but we could not determine a cutoff value of the EQ-5D-index value that reliably identified unacceptable outcome. In the multivariate analysis, only the hospital anxiety and depression scale was significantly associated with an unacceptable outcome (OR 2.06, 99% CI 1.18-3.61).

CONCLUSIONS

Although there is a strong association between low overall HRQoL and self-reported unacceptable outcome of ICU treatment, patients with low overall HRQoL may still consider their outcome acceptable. The mental component of PICS, but not the physical and cognitive component, is strongly associated with self-reported unacceptable outcome.

An Early Tailored Approach Is the Key to Effective Rehabilitation in the Intensive Care Unit

OBJECTIVE

To investigate the effectiveness, feasibility, and safety of an evidence-based rehabilitation care pathway in the intensive care unit (ICU) in different patient populations.

DESIGN

Observational prospective cohort study, with retrospective controls.

SETTING

ICUs of a university hospital.

PARTICIPANTS

Patients admitted between April 1, 2015, and June 30, 2015, were compared to a retrospective cohort admitted to the same ICUs during the same 3-month period in 2014. The number of patients studied (N=285) included 152 in the prospective group and 133 in the retrospective group.

INTERVENTIONS

The prospective cohort benefited of a rehabilitation care pathway based on (1) interdisciplinary teamwork; (2) early customized and goal-oriented rehabilitation; (3) daily functional monitoring and treatment revision; (4) agreed discharge policy; and (5) continuity of care. The retrospective cohort underwent usual care.

MAIN OUTCOME MEASURES

Included the following: (1) proportions of patients undergoing rehabilitation team evaluation; (2) latency between patient admission to ICUs and rehabilitation team assessment; (3) proportions of patients undergoing rehabilitation treatment during ICU stay; (4) latency between the patient admission to ICUs and rehabilitation start; (5) ICU stay and total acute hospital stay; and (5) proportion of ventilator-free days out of ICU stay.

RESULTS

The novel rehabilitation care pathway led to (1) an increased proportion of patients receiving rehabilitative assessment (P<.0001); (2) a decreased latency from ICU admission to both rehabilitation team assessment and rehabilitation start (P<.0001); (3) an increased proportion of patients undergoing rehabilitation (P<.0001); (4) a shorter length of stay in ICUs (P<.0001) and in hospital (P=.047); and (5) a shorter mechanical ventilation duration (P<.02). A direct relationship between rehabilitation start latency and ICU length of stay was observed.

CONCLUSIONS

An early, interdisciplinary team approach, providing a customized dynamic planning of physiotherapy programs, increases ventilator-free time and reduces total hospital stay, especially in patients admitted to the ICU after general surgery. This rehabilitation care pathway can be generalized to different geopolitical scenarios, being feasible, safe and cost effective.

Feasibility, Reliability, Responsiveness, and Validity of the Patient-Reported Functional Scale for the Intensive Care Unit: A Pilot Study

BACKGROUND

Although many performance-based measures assess patients' physical function in intensive care unit (ICU) survivors, to our knowledge, there are no patient-reported ICU rehabilitation-specific measures assessing function. We developed the Patient-Reported Functional Scale-ICU (PRFS-ICU), which measures patients' perceptions of their ability to perform 6 activities (rolling, sitting edge of bed, sit-to-stand and bed-to-chair transfers, ambulation, and stair climbing). Each item is scored from 0 (unable) to 10 (able to perform at pre-ICU level) to a maximum of 60.

OBJECTIVES

Estimate the feasibility, reliability, responsiveness, and validity of the PRFS-ICU.

METHODS

This was a substudy of TryCYCLE, a single-center, prospective cohort examining the safety and feasibility of early in-bed cycling with mechanically ventilated patients (NCT01885442). To determine feasibility, we calculated the number of patients with at least 1 PRFS-ICU assessment during their hospital stay. To assess reliability, 2 raters blinded to each other's assessments administered the PRFS-ICU within 24-hours of each other. We calculated the intraclass correlation coefficient (ICC; 95% confidence interval [CI]), standard error of measurement (SEM, 95% CI), and minimal detectable change (MDC₉₀). To assess validity, we estimated convergent validity of the PRFS-ICU with the Functional Status Score for ICU (FSS-ICU), Medical Research Council Sum Score (MRC-SS), Physical Function Test for ICU (PFIT-s), Katz Index of Independence in Activities of Daily Living (Katz ADLs), and a pooled index using Pearson's correlation coefficient (r, 95% CI).

RESULTS

Feasibility: 20 patients completed a PRFS-ICU assessment. Reliability and responsiveness: 16 patients contributed data. The ICC, SEM, and MDC₉₀ were 0.91 (0.76, 0.97), 4.75 (3.51, 7.35), and 11.04 points, respectively. Validity: 19 patients contributed data and correlations were (r [95% CI]): FSS-ICU (0.40 [-0.14, 0.76]), MRC-SS (0.51 [0.02, 0.80]), PFIT-s (0.43 [-0.13, 0.78]), Katz ADLs (0.53 [0.10, 0.79]), and pooled index (0.48 [-0.14, 0.82]).

CONCLUSIONS

Our pilot work suggests the PRFS-ICU may be a useful tool to assess and monitor patients' perceptions of function over time.

Health solutions to improve post-intensive care outcomes: a realist review protocol

BACKGROUND

While 80% of critically ill patients treated in an intensive care unit (ICU) will survive, survivors often suffer a constellation of new or worsening physical, cognitive, and psychiatric complications, termed post-intensive care syndrome. Emerging evidence paints a challenging picture of complex, long-term complications that are often untreated and culminate in substantial dependence on acute care services. Clinicians and decision-makers in the Fraser Health Authority of British Columbia are working to develop evidence-based community healthcare solutions that will be successful in the context of existing healthcare services. The objective of the proposed review is to provide the theoretical scaffolding to transform the care of survivors of critical illness by a synthesis of relevant clinical and healthcare service programs.

METHODS

Realist review will be used to develop and refine a theoretical understanding of why, how, for whom, and in what circumstances post-ICU program impact ICU survivors' outcomes. This review will follow the recommended five steps of realist review which include (1) clarifying the scope of the review and articulating a preliminary program theory, (2) searching for evidence, (3) appraising primary studies and extracting data, (4) synthesizing evidence and sharing conclusions, and (5) disseminating and implementing recommendations.

DISCUSSION

This realist review will provide a program theory, encompassing the contexts, mechanisms, and outcomes, to explain how clinical and health service interventions to improve ICU survivor outcomes operate in different contexts for different survivors, and with what effect. This review will be an evidentiary pillar for health service development and implementation by our knowledge user team members as well as advance scholarly knowledge relevant nationally and internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018087795.

Prevalence and Associated Factors of Abdominal Pain and Disability at 1-Year Follow-up After an Attack of Acute Pancreatitis

OBJECTIVE

The aim of the study was to report the prevalence and predictors of abdominal pain and disability 1 year after an acute pancreatitis (AP) attack.

METHODS

Patients were prospectively enrolled between December 2012 and April 2016. Enrolled subjects were contacted at a median of 13 months after enrollment. Multivariable regression models were used to determine factors independently associated with abdominal pain at follow-up.

RESULTS

Response rate was 71% (110/155). Of respondents, median age was 51 years, 58% were female, and 14% had severe AP. At follow-up, 24% of patients reported abdominal pain (65% intermittent, 35% constant), 10% used analgesics regularly, and 6% had regular opioids use. Furthermore, 41% of patients experienced pain-related interference with work or daily activities, and 8% developed disability. On regression analysis, idiopathic etiology (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.1-13.6) persistent organ failure (OR, 3.3; 95% CI, 1.1-7.9), and recurrent AP (OR, 2.9; 95% CI, 1.1-10.6) were independently associated with abdominal pain at follow-up. Disability at follow-up was associated with younger age, current smoking, and intensive care unit admission (all P < 0.05).

CONCLUSIONS

Abdominal pain and disability are potential long-term sequelae of AP. Certain pre-existing factors and pancreatitis features are associated with these outcomes at one-year follow-up of AP.

Management of early mobilization in intensive care units: a multicenter cross-sectional study

Objective

The aim of this study was to assess the management of early mobilization (EM) in Chinese intensive care units (ICUs).

Methods

This survey used a cross-sectional, observational design. A total of 65 tertiary and secondary hospitals were enrolled by convenience sampling and investigated using self-designed questionnaires.

Results

We identified 69 ICUs in Jiangsu, China (response rate: 94.2%). 74.2% (1,004/1,353) of the nurses and nursing managers from 65 ICUs reported mobility practice. For the mobility level, 98.1% (1,327) reported use of in-bed exercise, 5.7% (77) sitting on a side of bed, 21.7% (294) transfer to chair, and 2.4% (33) walking. The most frequently reported barriers to early mobility were unplanned extubation, nursing resource, and absence of physical therapist. Nurses’ educational backgrounds, nursing experience, the lack of nursing resources, absence of physician, and the weakness of patient were the factors that influenced ICU early rehabilitation (P<0.01).

Conclusions

Although implementation rates for EM in critically ill patients are high, the activity level is generally poor in most of the involved ICUs.

Effect of Transcutaneous Electrical Neuromuscular Stimulation on Myopathy in Intensive Care Patients

BACKGROUND

Critical illness polyneuropathy or myopathy is a severe disorder that may adversely affect patients in the intensive care unit, resulting in reduced mobilization, decline in muscle mass, and prolonged recovery periods.

OBJECTIVE

To examine whether the application of trans-cutaneous electrical neuromuscular stimulation (TENMS) reduces the incidence or severity of myopathy related to critical illness in intensive care unit patients.

METHODS

A total of 80 patients aged 18 years or older with an intensive care unit stay of 96 hours or more and receipt of mechanical ventilation for 96 hours or more were initially enrolled in a prospective, open-label randomized controlled trial in a university hospital. Patients received either conventional physical therapy alone (control group) or conventional physical therapy plus TENMS (TENMS group) for 10 days. Myopathy was assessed histologically (by needle biopsy of the quadriceps muscles) on the 4th and 14th days of the intensive care unit stay.

RESULTS

Of the 68 patients who completed the study, 27 (40%) had myopathy on the 14th day: 11 patients in the TENMS group (9 mild, 1 moderate, and 1 severe) and 16 patients in the control group (13 mild, 2 moderate, and 1 severe). Patients who progressed from mild to moderate or severe myopathy between the 4th and 14th days had significantly lower body mass index (P = .001) and longer time periods with inadequate nutrition (P = .049) compared with the other patients. Mean (SD) Rankin scale scores at 6 months were 3.2 (1.8) and 3.8 (2.1) in the TENMS and control groups, respectively (P = .09).

CONCLUSION

TENMS had no significant impact on myopathy in the critically ill patients in this study.

Chest physiotherapy with early mobilization may improve extubation outcome in critically ill patients in the intensive care units

BACKGROUND

Extubation failure can lead to a longer intensive care unit (ICU) stay, higher mortality rate, and higher risk of requiring tracheostomy. Chest physiotherapy (CPT) can help patients in reducing the accumulation of airway secretion, preventing collapsed lung, improving lung compliance, and reducing comorbidities. Much research has investigated the correlation between CPT and respiratory system clearance. However, few studies have investigated the correlation between CPT and failed ventilator extubation. Therefore, this study aimed to investigate the use of CPT for reducing the rate of failed removal from mechanical ventilators.

METHODS

This study was an intervention study with mechanical control. Subjects were divided into two groups. The control group, which received routine nursing chest care, was selected from a retrospective chart review. The intervention group was prospectively taken into the chest physiotherapy program. The chest physiotherapy treatment protocol consisted of inspiratory muscle training, manual hyperinflation, chest wall mobilization, secretion removal, cough function training, and early mobilization.

RESULTS

A total of 439 subjects were enrolled in the intervention and control groups, with a mean age of 69 years. APACHE II score (P = .09) and GCS scores (P = .54) were similar between the two groups. Compared to the control group, patients in the intervention group had a significantly lower reintubation rate (8% vs 16%; P = .01).

CONCLUSIONS

The results indicate that intensive chest physiotherapy could decrease extubation failure in mechanically ventilated patients in the ICU. In addition, chest physiotherapy could also significantly improve the rapid shallow breathing index score.

Rehabilitation and early mobilization in the critical patient: systematic review

[Purpose] To review the literature that examines rehabilitation and early mobilization and that involves different practices (effects of interventions) for the critically ill patient. [Materials and Methods] A PRISMA-Systematic review has been conducted based on different data sources: Biblioteca Virtual en Salud, CINHAL, Pubmed, Scopus, and Web of Science were used to identify randomized controlled trials, crossover trials, and case-control studies. [Results] Eleven studies were included. Early rehabilitation had no significant effect on the length of stay and number of cases of Intensive Care Unit Acquired Weaknesses. However, early rehabilitation had a significant effect on the functional status, muscle strength, mechanical ventilation duration, walking ability at discharge, and health quality of life. [Conclusion] Rehabilitation and early mobilization are associated with an increased probability of walking more distance at discharge. Early rehabilitation is associated with an increase in functional capacity and muscle strength, an improvement in walking distance and better perception of the health-related quality of life. Cycloergometer and electrical stimulation can be used to maintain muscle strength. Further research is needed to establish stronger evidences.

Effects of Early Exercise Rehabilitation on Functional Recovery in Patients with Severe Sepsis

PURPOSE

Severe sepsis is associated with functional disability among patients surviving an acute phase of infection. Efforts to improve functional impairment are important. We assessed the effects of early exercise rehabilitation on functional outcomes in patients with severe sepsis.

MATERIALS AND METHODS

A prospective, single-center, case-control study was conducted between January 2013 and May 2014 at a tertiary care center in Korea. Patients with severe sepsis and septic shock were enrolled and randomized to receive standard sepsis treatment or intervention. Intervention involved early targeted physical rehabilitation with sepsis treatment during hospitalization. Participants were assessed at enrollment, hospital discharge, and 6 months after enrollment. Functional recovery was measured using the Modified Barthel Index (MBI), Functional Independence Measure (FIM), and Instrumental Activities of Daily Living (IADL).

RESULTS

Forty participants (21 intervention patients) were included in an intention-to-treat analysis. There were no significant differences in baseline MBI, FIM, and IADL between groups. Intervention yielded greater improvement of MBI, FIM, and IADL in the intervention group at hospital discharge, but not significantly. Subgroup analysis of patients with APACHE II scores ≥10 showed significantly greater improvement of physical function at hospital discharge (MBI and FIM) in the intervention group, compared to the control group (55.13 vs. 31.75, p=0.048; 52.40 vs. 31.25, p=0.045). Intervention was significantly associated with improvement of MBI in multiple linear regression analysis (standardized coefficient 0.358, p=0.048).

CONCLUSION

Early physical rehabilitation may improve functional recovery at hospital discharge, especially in patients with high initial severity scores.

Feasibility of Immediate in-Intensive Care Unit Pulmonary Rehabilitation after Lung Transplantation: A Single Center Experience

Background

Physical function may influence perioperative outcomes of lung transplantation. We investigated the feasibility of a pulmonary rehabilitation program initiated in the immediate postoperative period at an intensive care unit (ICU) for patients who underwent lung transplantation.

Methods

We retrospectively evaluated 22 patients who received pulmonary rehabilitation initiated in the ICU within 2 weeks after lung transplantation at our institution from March 2015 to February 2016. Levels of physical function were graded at the start of pulmonary rehabilitation and then weekly throughout rehabilitation according to criteria from our institutional pulmonary rehabilitation program: grade 1, bedside (G1); grade 2, dangling (G2); grade 3, standing (G3); and grade IV, gait (G4).

Results

The median age of patients was 53 years (range, 25 to 73 years). Fourteen patients (64%) were males. The initial level of physical function was G1 in nine patients, G2 in seven patients, G3 in four patients, and G4 in two patients. Patients started pulmonary rehabilitation at a median of 7.5 days (range, 1 to 29 days) after lung transplantation. We did not observe any rehabilitation-related complications during follow-up. The final level of physical function was G1 in six patients, G3 in two patients, and G4 in 14 patients. Fourteen of the 22 patients were able to walk with or without assistance, and 13 of them maintained G4 until discharge; the eight remaining patients never achieved G4.

Conclusions

Our results suggest the feasibility of early pulmonary rehabilitation initiated in the ICU within a few days after lung transplantation.