Kimberley Haines

Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up

IntroductionThe purpose of this trial was to investigate the effectiveness of an exercise rehabilitation program commencing during ICU admission and continuing into the outpatient setting compared with usual care on physical function and health-related quality of life in ICU survivors.MethodsWe conducted a single-center, assessor-blinded, randomized controlled trial. One hundred and fifty participants were stratified and randomized to receive usual care or intervention if they were in the ICU for 5 days or more and had no permanent neurological insult. The intervention group received intensive exercises in the ICU and the ward and as outpatients. Participants were assessed at recruitment, ICU admission, hospital discharge and at 3-, 6- and 12-month follow-up. Physical function was evaluated using the Six-Minute Walk Test (6MWT) (primary outcome), the Timed Up and Go Test and the Physical Function in ICU Test. Patient-reported outcomes were measured using the Short Form 36 Health Survey, version 2 (SF-36v2) and Assessment of Quality of Life (AQoL) Instrument. Data were analyzed using mixed models.ResultsThe a priori enrollment goal was not reached. There were no between-group differences in demographic and hospital data, including acuity and length of acute hospital stay (LOS) (Acute Physiology and Chronic Health Evaluation II score: 21 vs 19; hospital LOS: 20 vs 24 days). No significant differences were found for the primary outcome of 6MWT or any other outcomes at 12 months after ICU discharge. However, exploratory analyses showed the rate of change over time and mean between-group differences in 6MWT from first assessment were greater in the intervention group.ConclusionsFurther research examining the trajectory of improvement with rehabilitation is warranted in this population.Trial registrationThe trial was registered with the Australian New Zealand Clinical Trials Registry ACTRN12605000776606.

Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults.

IntroductionThe aim of this study was to develop consensus recommendations on safety parameters for mobilizing adult, mechanically ventilated, intensive care unit (ICU) patients.MethodsA systematic literature review was followed by a meeting of 23 multidisciplinary ICU experts to seek consensus regarding the safe mobilization of mechanically ventilated patients.ResultsSafety considerations were summarized in four categories: respiratory, cardiovascular, neurological and other. Consensus was achieved on all criteria for safe mobilization, with the exception being levels of vasoactive agents. Intubation via an endotracheal tube was not a contraindication to early mobilization and a fraction of inspired oxygen less than 0.6 with a percutaneous oxygen saturation more than 90% and a respiratory rate less than 30 breaths/minute were considered safe criteria for in- and out-of-bed mobilization if there were no other contraindications. At an international meeting, 94 multidisciplinary ICU clinicians concurred with the proposed recommendations.ConclusionConsensus recommendations regarding safety criteria for mobilization of adult, mechanically ventilated patients in the ICU have the potential to guide ICU rehabilitation whilst minimizing the risk of adverse events.

A Physical Function Test for Use in the Intensive Care Unit: Validity, Responsiveness, and Predictive Utility of the Physical Function ICU Test (Scored)

Background Several tests have recently been developed to measure changes in patient strength and functional outcomes in the intensive care unit (ICU). The original Physical Function ICU Test (PFIT) demonstrates reliability and sensitivity. Objective The aims of this study were to further develop the original PFIT, to derive an interval score (the PFIT-s), and to test the clinimetric properties of the PFIT-s. Design A nested cohort study was conducted. Methods One hundred forty-four and 116 participants performed the PFIT at ICU admission and discharge, respectively. Original test components were modified using principal component analysis. Rasch analysis examined the unidimensionality of the PFIT, and an interval score was derived. Correlations tested validity, and multiple regression analyses investigated predictive ability. Responsiveness was assessed using the effect size index (ESI), and the minimal clinically important difference (MCID) was calculated. Results The shoulder lift component was removed. Unidimensionality of combined admission and discharge PFIT-s scores was confirmed. The PFIT-s displayed moderate convergent validity with the Timed “Up & Go” Test (r=−.60), the Six-Minute Walk Test (r=.41), and the Medical Research Council (MRC) sum score (rho=.49). The ESI of the PFIT-s was 0.82, and the MCID was 1.5 points (interval scale range=0–10). A higher admission PFIT-s score was predictive of: an MRC score of ≥48, increased likelihood of discharge home, reduced likelihood of discharge to inpatient rehabilitation, and reduced acute care hospital length of stay. Limitations Scoring of sit-to-stand assistance required is subjective, and cadence cutpoints used may not be generalizable. Conclusions The PFIT-s is a safe and inexpensive test of physical function with high clinical utility. It is valid, responsive to change, and predictive of key outcomes. It is recommended that the PFIT-s be adopted to test physical function in the ICU.

Safety and Feasibility of an Exercise Prescription Approach to Rehabilitation Across the Continuum of Care for Survivors of Critical Illness

Background Survivors of critical illness can experience long-standing functional limitations that negatively affect their health-related quality of life. To date, no model of rehabilitation has demonstrated sustained improvements in physical function for survivors of critical illness beyond hospital discharge. Objective The aims of this study were: (1) to describe a model of rehabilitation for survivors of critical illness, (2) to compare the model to local standard care, and (3) to report the safety and feasibility of the program. Design This was a cohort study. Methods As part of a larger randomized controlled trial, 74 participants were randomly assigned, 5 days following admission to the intensive care unit (ICU), to a protocolized rehabilitation program that commenced in the ICU and continued on the acute care ward and for a further 8 weeks following hospital discharge as an outpatient program. Exercise training was prescribed based on quantitative outcome measures to achieve a physiological training response. Results During acute hospitalization, 60% of exercise sessions were able to be delivered. The most frequently occurring barriers to exercise were patient safety and patient refusal due to fatigue. Point prevalence data showed patients were mobilized more often and for longer periods compared with standard care. Outpatient classes were poorly attended, with only 41% of the patients completing more than 70% of outpatient classes. No adverse events occurred. Limitations Limitations included patient heterogeneity and delayed commencement of exercise in the ICU due to issues of consent and recruitment. Conclusions Exercise training that commences in the ICU and continues through to an outpatient program is safe and feasible for survivors of critical illness. Models of care that maximize patient participation across the continuum of care warrant further investigation.

Association of postoperative pulmonary complications with delayed mobilisation following major abdominal surgery: an observational cohort study

OBJECTIVES Previous Australian studies reported that postoperative pulmonary complications affect 13% of patients undergoing upper abdominal laparotomy. This study measured the incidence of postoperative pulmonary complications, risk factors for the diagnosis of postoperative pulmonary complications and barriers to physiotherapy mobilisation in a cohort of patients undergoing high-risk abdominal surgery. DESIGN Prospective, observational cohort study. SETTING Two surgical wards in a tertiary Australian hospital. PARTICIPANTS Seventy-two patients undergoing high-risk abdominal surgery (participants in a larger trial evaluating a novel model of medical co-management). MAIN OUTCOME MEASURES Incidence of, and risk factors for, postoperative pulmonary complications, barriers to mobilisation and length of stay. RESULTS The incidence of postoperative pulmonary complications was 39%. Incision type and time to mobilise away from the bed were independently associated with a diagnosis of postoperative pulmonary complications. Patients were 3.0 (95% confidence interval 1.2 to 8.0) times more likely to develop a postoperative pulmonary complication for each postoperative day they did not mobilise away from the bed. Fifty-two percent of patients had a barrier to mobilisation away from the bed on the first postoperative day, with the most common barrier being hypotension, although cessation criteria were not defined objectively by physiotherapists. Development of a postoperative pulmonary complication increased median hospital length of stay (16 vs 13 days; P=0.046). CONCLUSIONS This study demonstrated an association between delayed postoperative mobilisation and postoperative pulmonary complications. Randomised controlled trials are required to test the role of early mobilisation in preventing postoperative pulmonary complications in patients undergoing high-risk upper abdominal surgery.

Psychosocial Outcomes in Informal Caregivers of the Critically Ill: A Systematic Review

Objective: The objective of the review was to evaluate and synthesize the prevalence, risk factors, and trajectory of psychosocial morbidity in informal caregivers of critical care survivors. Data Sources: A systematic search of MEDLINE, PsychInfo, PubMed, CINAHL, Cochrane Library, Scopus, PILOTS, EMBASE, and Physiotherapy Evidence Database was undertaken between January and February 2014. Study Selection: Citations were screened independently by two reviewers for studies that investigated psychosocial outcomes (depression, anxiety, stress, posttraumatic stress disorder, burden, activity restriction, and health-related quality of life) for informal caregivers of critical care survivors (mechanically ventilated for 48 hr or more). Data Extraction: Data on study outcomes were extracted into a standardized form and quality assessed by two independent reviewers using the Newcastle-Ottawa Scale, the Physiotherapy Evidence Database, and the National Health and Medical Research Council Hierarchy of Evidence guide. Preferred Reporting Items for Systematic Reviews guidelines were followed. Data Synthesis: Fourteen studies of 1,491 caregivers were included. Depressive symptoms were the most commonly reported outcome with a prevalence of 75.5% during critical care and 22.8–29% at 1-year follow-up. Risk factors for depressive symptoms in caregivers included female gender and younger age. The greatest period of risk for all outcomes was during the patient’s critical care admission although psychological symptoms improved over time. The overall quality of the studies was low. Conclusions: Depressive symptoms were the most prevalent in informal caregivers of survivors of intensive care who were ventilated for more than 48 hours and persist at 1 year with a prevalence of 22.8–29.0%, which is comparable with caregivers of patients with dementia. Screening for caregiver risks could be performed during the ICU admission where intervention can be implemented and then evaluated. Further high-quality studies are needed to quantify anxiety, stress, caregiver burden, and posttraumatic stress disorder outcomes in informal caregivers of long-stay patients surviving ICU.

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.

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.

The untapped potential of patient and family engagement in the organization of critical care

Objective: There is growing interest in patient and family participation in critical care—not just as part of the bedside, but as part of educational and management organization and infrastructure. This offers tremendous opportunities for change but carries risk to patients, families, and the institution. The objective is to provide a concise definitive review of patient and family organizational participation in critical care as a high-risk population and other vulnerable groups. A pragmatic, codesigned model for critical care is offered as a suggested approach for clinicians, researchers, and policy-makers. Data Sources: To inform this review, a systematic search of Ovid Medline, PubMed, and Embase was undertaken in April 2016 using the MeSH terms: patient participation and critical care. A second search was undertaken in PubMed using the terms: patient participation and organizational models to search for other examples of engagement in vulnerable populations. We explicitly did not seek to include discussions of bedside patient-family engagement or shared decision-making. Study Selection: Two reviewers screened citations independently. Included studies either actively partnered with patients and families or described a model of engagement in critical care and other vulnerable populations. Data Extraction: Data or description of how patient and family engagement occurred and/or description of model were extracted into a standardized form. Data Synthesis: There was limited evidence of patient and family engagement in critical care although key recommendations can be drawn from included studies. Patient and family engagement is occurring in other vulnerable populations although there are few described models and none which address issues of risk. Conclusions: A model of patient and family engagement in critical care does not exist, and we propose a pragmatic, codesigned model that takes into account issues of psychologic safety in this population. Significant opportunity exists to document processes of engagement that reflect a changing paradigm of healthcare delivery.

Predicting Physical Function and Health Related Quality of Life Following Intensive Care

Objective: This study investigated how well the Functional Comorbity Index (FCI) predicts patient reported physical function compared with objective physical function measures, return to home and health related quality of life (HRQoL) of survivors of a general intensive care unit (ICU) cohort at 12 months post ICU discharge. This study also investigated how well ICU physiotherapists and physicians predict mortality, return to home and HRQoL of survivors at 12 months post ICU discharge. Design: Prospective observational cohort study nested within a larger trial. FCI calculated at ICU admission and compared with patient reported physical function (SF36 version 2 Physical Component Score) and objective physical function measures (Six-Minute Walk Test, Timed Up and Go) at 12 months. ICU clinicians completed a four-item questionnaire at patient discharge from ICU predicting mortality, return to home and HRQoL and these were compared with 12-month patient outcomes. Setting: 18-bed closed mixed medical/surgical, tertiary ICU in a university teaching hospital in Melbourne, Australia. Participants: 34 ICU patients. 11 ICU clinicians (5 physicians and 6 physiotherapists) who were caring for the patients on day of discharge from ICU. Results: The correlations between the FCI and 12-month objective measures of physical performance were small (6MWT rho 0. 02, TUG rho 0. 15). The FCI had a large correlation with patient reported physical function (SF36 version 2 rho -0. 60). The sensitivity of the physicians’ predictions for mortality was the highest [83% (78-91%)], whilst the physiotherapists’ predictions had the greatest specificity [100% (89-100%)]. All clinicians were comparable in their predictions of who would return home. Physicians were more accurate than physiotherapists in predicting future HRQoL (p=0. 04). Conclusions: We conclude the FCI predicts patient reported physical function better than objective physical function measures. Intensive care physiotherapists and physicians have a variable ability to predict longer term outcomes for their patients and larger studies are needed to further evaluate this.