Sarah E. Jolley

Medical intensive care unit clinician attitudes and perceived barriers towards early mobilization of critically ill patients: a cross-sectional survey study

BackgroundEarly mobilization (EM) of patients on mechanical ventilation (MV) is shown to improve outcomes after critical illness. Little is known regarding clinician knowledge of EM or multi-disciplinary barriers to use of EM in the intensive care unit (ICU). The goal of this study was to assess clinician knowledge regarding EM and identify barriers to its provision.MethodsSimultaneous cross-sectional surveys of medical ICU (MICU) nurses (RN)/physical therapists (PT) respondents and physician (MD) respondents in a single MICU at an academic hospital in Seattle, WA in 2010–2011. Responses were indicated on a 5 point Likert scale and reported as proportion of respondents agreeing or disagreeing. Chi-square testing and Fisher’s exact testing was performed to determine whether responses differed by duration of employment or prior EM experience.ResultsA total of 120 clinicians responded to the survey (91 MDs (response rate 82% (91/111)), 17 RNs (response rate 22%, (17/78)), and 12 PTs (response rate 86%, (12/14)), overall response rate 86%). Most clinicians indicated knowledge regarding benefits of EM. More attending physicians reported knowledge of EM benefits, but also that risks of EM outweigh the benefits compared to trainees (p = 0.02 and 0.01). Clinicians across disciplines reported near universal agreement to use of EM for patients on MV, while the minority reported agreement to EM for patients on vasoactive agents. The most frequently reported cross-disciplinary barriers to EM were staffing and time. Risk of self-injury and excess work stress were indicated as barriers by RN and PT respondents.ConclusionsMICU clinicians, at our institution, reported knowledge of EM in the ICU. Staffing and clinician time were frequently identified cross-disciplinary barriers. Risk of self-injury and excess work stress were frequently reported RN and PT barriers.

Point Prevalence Study of Mobilization Practices for Acute Respiratory Failure Patients in the United States

Objective: Early mobility in mechanically ventilated patients is safe, feasible, and may improve functional outcomes. We sought to determine the prevalence and character of mobility for ICU patients with acute respiratory failure in U.S. ICUs. Design: Two-day cross-sectional point prevalence study. Setting: Forty-two ICUs across 17 Acute Respiratory Distress Syndrome Network hospitals. Patients: Adult patients (≥ 18 yr old) with acute respiratory failure requiring mechanical ventilation. Interventions: We defined therapist-provided mobility as the proportion of patient-days with any physical or occupational therapy–provided mobility event. Hierarchical regression models were used to identify predictors of out-of-bed mobility. Measurements and Main Results: Hospitals contributed 770 patient-days of data. Patients received mechanical ventilation on 73% of the patient-days mostly (n = 432; 56%) ventilated via an endotracheal tube. The prevalence of physical therapy/occupational therapy–provided mobility was 32% (247/770), with a significantly higher proportion of nonmechanically ventilated patients receiving physical therapy/occupational therapy (48% vs 26%; p ⩽ 0.001). Patients on mechanical ventilation achieved out-of-bed mobility on 16% (n = 90) of the total patient-days. Physical therapy/occupational therapy involvement in mobility events was strongly associated with progression to out-of-bed mobility (odds ratio, 29.1; CI, 15.1–56.3; p ⩽ 0.001). Presence of an endotracheal tube and delirium were negatively associated with out-of-bed mobility. Conclusions: In a cohort of hospitals caring for acute respiratory failure patients, physical therapy/occupational therapy–provided mobility was infrequent. Physical therapy/occupational therapy involvement in mobility was strongly predictive of achieving greater mobility levels in patients with respiratory failure. Mechanical ventilation via an endotracheal tube and delirium are important predictors of mobility progression.

Hospital-Level Factors Associated with Report of Physical Activity in Patients on Mechanical Ventilation across Washington State

RATIONALE Use of physical and/or occupational therapy in the intensive care unit (ICU) is safe, feasible, and demonstrates improvements in functional status with early administration. Access to physical and/or occupational therapy in the ICU is variable, with little known regarding its use in community ICUs. OBJECTIVES Determine what proportion of hospitals across Washington State report use of physical activity in mechanically ventilated patients and investigate process of care factors associated with reported activity delivery. METHODS Cross-sectional telephone interview survey study of nurse managers in hospitals caring for patients on mechanical ventilation across Washington State in 2013. Survey responses were linked with hospital-level data available in the Washington State Department of Health Comprehensive Hospital Abstract Reporting System database. Chi-square testing was used to explore unadjusted associations between potential process of care factors and report on activity delivery. Two multivariable logistic regression models were developed to explore the association between presence of a mobility protocol and report on delivery of activity. MEASUREMENTS AND MAIN RESULTS We identified 54 hospitals caring for patients on mechanical ventilation; 47 participated in the survey (response rate, 85.5%). Nurse managers from 36 (76.6%) hospitals reported use of physical activity in patients on mechanical ventilation, with 22 (46.8%) reporting use of high-level physical activity (transferring to chair, standing or ambulating) and 24 (51.1%) reporting use in high-severity patients (patients requiring mechanical ventilation and/or vasopressors). Presence of a written ICU activity protocol (odds ratio [OR], 5.54; 95% confidence interval [CI], 1.60-19.18; P = 0.006), hospital volume (OR, 5.33; 95% CI, 1.54-18.48; P = 0.008), and academic affiliation (OR, 4.40; 95% CI, 1.23-15.63; P = 0.02) were associated with report of higher level activity. Presence of a written ICU activity protocol (OR, 6.00; 95% CI, 1.69-21.14; P = 0.005) and academic affiliation (OR, 4.50; 95% CI, 1.21-16.46; P = 0.02) were associated with report of delivery of physical activity to high-severity patients. CONCLUSIONS Nurse managers at three-fourths (76.6%) of eligible hospitals across Washington State reported use of physical activity in patients on mechanical ventilation. Hospital-level factors including hospital volume, academic affiliation, and presence of a mobility protocol were associated with report of higher level activity and delivery of activity to high-severity patients.

Factors Associated With Receipt of Physical Therapy Consultation in Patients Requiring Prolonged Mechanical Ventilation

Background/Introduction:Mobilization of critically ill patients in the intensive care unit is associated with improved function at hospital discharge and reduced duration of mechanical ventilation (MV). Few studies, however, focus on physical therapy (PT) in patients on prolonged mechanical ventilation (PMV) despite their high risk of immobility and poor outcomes. Objective/Aims:The objective of this study was to identify factors associated with the receipt of PT consultation among patients requiring PMV. We hypothesized that key factors including age, severity of illness, and presence of a tracheostomy are associated with PT consultation. MethodsThis was a retrospective cohort study of adults on MV for 14 days or longer for acute respiratory failure at an academic medical center. Primary outcome was PT consultation by day 14 of MV. We examined associations between the following key predictors chosen a priori and PT consultation: age, tracheostomy, illness severity, oxygenation status, shock, hemodialysis, and medical service using multivariable logistic regression. Wilcoxon rank sum testing was used to test relationship between sedation and PT. Results:We identified 175 patients requiring PMV at our institution. Most were middle-aged (mean, 49.7 [SD, 18.5] years old) men (65%) with high illness severity (mean Acute Physiology and Chronic Health Evaluation III score, 86 [SD, 40]). Less than half of all patients requiring PMV (78/175, 45%) received PT consultation in the intensive care unit, and most failed to progress with therapy beyond range-of-motion exercises (85%). Failure to progress was associated with level of sedation (med Ramsay score 4.5 [interquartile range, 3-6] vs 3.5 [interquartile range, 3-5]; P = .01). Presence of a tracheostomy and prehospital nonambulatory status were associated with receipt of PT by day 14 of MV (odds ratio, 6.94 and 3.42, respectively; P ⩽ .05). Conclusions:In our study, we found that PT for PMV patients occurs infrequently and is generally of low intensity. Level of sedation, presence of a tracheostomy, and prehospital nonambulatory status were associated with receipt of PT consultation by day 14 of MV.

Relationship between Race and the Effect of Fluids on Long-term Mortality after Acute Respiratory Distress Syndrome. Secondary Analysis of the National Heart, Lung, and Blood Institute Fluid and Catheter Treatment Trial

Rationale: Short‐term follow‐up in the Fluid and Catheter Treatment Trial (FACTT) suggested differential mortality by race with conservative fluid management, but no significant interaction. Objective: In a post hoc analysis of FACTT including 1‐year follow‐up, we sought to estimate long‐term mortality by race and test for an interaction between fluids and race. Methods: We performed a post hoc analysis of FACTT and the Economic Analysis of Pulmonary Artery Catheters (EAPAC) study (which included 655 of the 1,000 FACTT patients with near‐complete 1‐year follow up). We fit a multistate Markov model to estimate 1‐year mortality for all non‐Hispanic black and white randomized FACTT subjects. The model estimated the distribution of time from randomization to hospital discharge or hospital death (available on all patients) and estimated the distribution of time from hospital discharge to death using data on patients after hospital discharge for patients in EAPAC. The 1‐year mortality was found by combining these estimates. Results: Non‐Hispanic black (n = 217, 25%) or white identified subjects (n = 641, 75%) were included. There was a significant interaction between race and fluid treatment (P = 0.012). One‐year mortality was lower for black subjects assigned to conservative fluids (38 vs. 54%; mean mortality difference, 16%; 95% confidence interval, 2‐30%; P = 0.027 between conservative and liberal). Conversely, 1‐year mortality for white subjects was 35% versus 30% for conservative versus liberal arms (mean mortality difference, −4.8%; 95% confidence interval, −13% to 3%; P = 0.23). Conclusions: In our cohort, conservative fluid management may have improved 1‐year mortality for non‐Hispanic black patients with ARDS. However, we found no long‐term benefit of conservative fluid management in white subjects.

Soluble Vascular Cell Adhesion Molecule-1 (sVCAM-1) Is Elevated in Bronchoalveolar Lavage Fluid of Patients with Acute Respiratory Distress Syndrome

Introduction Pulmonary vascular endothelial activation has been implicated in acute respiratory distress syndrome (ARDS), yet little is known about the presence and role of endothelial activation markers in the alveolar space in ARDS. We hypothesized that endothelial activation biomarkers would be differentially expressed in bronchoalveolar lavage fluid from patients with ARDS compared with healthy volunteers, and that biomarker concentrations would be associated with ARDS severity. Methods We performed a cross-sectional analysis of data from 26 intubated patients with ARDS undergoing evaluation for clinically suspected ventilator-associated pneumonia and five healthy volunteers. Patients underwent bronchoalveolar lavage a median of five days after intubation. Healthy volunteers also underwent bronchoalveolar lavage. Endothelial activation biomarkers (soluble vascular cell adhesion molecule-1 [sVCAM-1], soluble endothelial selectin [sESEL], angiopoietin-1 [Ang-1] and angiopoietin-2 [Ang-2]) were measured in bronchoalveolar lavage fluid. Clinically suspected ventilator-associated pneumonia was confirmed with microbiologic culture data. Results Patients with ARDS had significantly higher median sVCAM-1 concentrations in the bronchoalveolar lavage fluid compared with healthy volunteers (985 vs 119 pg/mL, p = 0.03). Additionally, there was a trend toward greater bronchoalveolar lavage fluid sVCAM-1 concentrations among patients with moderate/severe compared to mild ARDS (1395 vs 209 pg/mL, p = 0.06). We did not detect significant differences in bronchoalveolar lavage fluid levels of sESEL, Ang-1 or Ang-2 between patients with ARDS and healthy volunteers. Median bronchoalveolar lavage fluid biomarker levels did not differ between patients with and without microbiologically-confirmed ventilator-associated pneumonia. Conclusions sVCAM-1 concentrations were significantly higher in the bronchoalveolar lavage fluid of patients with ARDS compared to healthy controls, and tended to be higher in moderate/severe ARDS compared to mild ARDS. Our findings add to the growing evidence supporting the concept that endothelial activation plays an important mechanistic role in the pathogenesis of ARDS. Further studies are necessary to characterize the role and/or clinical significance of sVCAM-1 and other endothelial activation markers present in the alveolar space in ARDS.

Physical Activity and Weight Gain Over 20 Years

To the Editor: Dr Hankinson and colleagues reported on the relationship of activity and body mass index (BMI) over 20 years in a large, ethnically diverse cohort of young to middle-aged adults participating in the CARDIA study. Weight gain is a major underlying risk factor for mortality secondary to the development of diabetes, heart disease, and cancer. In their analysis, being in the highest tertile of activity was associated with a reduction in the rate of increase in both BMI and waist circumference. However, individuals in this highest activity tertile still experienced significant increases in both BMI and waist circumference over time. In their study, was there an activity level that was associated with no increase in BMI or waist circumference? If so, that level of activity might actually prevent increases in BMI during the transition from young adulthood to middle age. Did that activity level differ by sex or race? Also, was there an ideal ratio of activity to caloric intake at which the observed increases in BMI were minimized? Such information would be useful in counseling young adults about the level of activity needed to maintain a healthy weight and minimize the risk of obesity-related morbidity and mortality.

Low tidal volume ventilation use remains low in patients with acute respiratory distress syndrome at a single center

Purpose: Low tidal volume ventilation (LTVV) reduces mortality in acute respiratory distress syndrome (ARDS) patients. Understanding local barriers to LTVV use at a former ARDS Network hospital may provide new insight to improve LTVV implementation. Methods: A cohort of 214 randomly selected adults met the Berlin definition of ARDS at Harborview Medical Center between 2008 and 2012. The primary outcome was the receipt of LTVV (tidal volume of ≤6.5 mL/kg predicted body weight) within 48 h of ARDS onset. We constructed a multivariable logistic regression model to identify factors associated with the outcome. Results: Only 27% of patients received tidal volumes of ≤6.5 mL/kg PBW within 48 h of ARDS onset. Increasing plateau pressure (OR 1.11; 95% CI 1.03 to 1.19; p‐value < 0.01) was positively associated with LTVV use while increasing PaO2:FIO2 ratio was negatively associated (OR 0.75; 95% CI 0.57 to 0.98; p‐value 0.03). Physicians documented an ARDS diagnosis in only 21% of the cohort. Neither patient height nor gender was associated with LTVV use. Conclusions: Most ARDS patients did not receive LTVV despite implementation of a protocol. ARDS was also recognized in a minority of patients, suggesting an opportunity for improvement of care.

Nighttime ICU Staffing and Mortality: Still in the Dark.

patient’s own environment to enable a comparison with quality of life. As Dr Turner points out, our sample size of subjects who underwent study of spontaneous cough was underpowered for comparisons with quality-of-life measures, which also may be relevant. A more suitable comparison may be possible once ambulatory measures of cough intensity are developed. Combining longitudinal assessments of cough intensity with already available measures of cough frequency may allow a comprehensive objective assessment of cough and help establish their relationship with patients’ perception of cough severity and effect on quality of life.