Exercise rehabilitation following intensive care unit discharge for recovery from critical illness

BACKGROUND

Skeletal muscle wasting and weakness are significant complications of critical illness, associated with degree of illness severity and periods of reduced mobility during mechanical ventilation. They contribute to the profound physical and functional deficits observed in survivors. These impairments may persist for many years following discharge from the intensive care unit (ICU) and can markedly influence health-related quality of life. Rehabilitation is a key strategy in the recovery of patients after critical illness. Exercise-based interventions are aimed at targeting this muscle wasting and weakness. Physical rehabilitation delivered during ICU admission has been systematically evaluated and shown to be beneficial. However, its effectiveness when initiated after ICU discharge has yet to be established.

OBJECTIVES

To assess the effectiveness of exercise rehabilitation programmes, initiated after ICU discharge, for functional exercise capacity and health-related quality of life in adult ICU survivors who have been mechanically ventilated longer than 24 hours.

SEARCH METHODS

We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid SP MEDLINE, Ovid SP EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host to 15 May 2014. We used a specific search strategy for each database. This included synonyms for ICU and critical illness, exercise training and rehabilitation. We searched the reference lists of included studies and contacted primary authors to obtain further information regarding potentially eligible studies. We also searched major clinical trials registries (Clinical Trials and Current Controlled Trials) and the personal libraries of the review authors. We applied no language or publication restriction. We reran the search in February 2015 and will deal with the three studies of interest when we update the review.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), quasi-RCTs and controlled clinical trials (CCTs) that compared an exercise intervention initiated after ICU discharge versus any other intervention or a control or 'usual care' programme in adult (≥ 18 years) survivors of critical illness.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by the Cochrane Collaboration.

MAIN RESULTS

We included six trials (483 adult ICU participants). Exercise-based interventions were delivered on the ward in two studies; both on the ward and in the community in one study; and in the community in three studies. The duration of the intervention varied according to length of hospital stay following ICU discharge (up to a fixed duration of 12 weeks).Risk of bias was variable for all domains across all trials. High risk of bias was evident in all studies for performance bias, although blinding of participants and personnel in therapeutic rehabilitation trials can be pragmatically challenging. For other domains, at least half of the studies were at low risk of bias. One study was at high risk of selection bias, attrition bias and other sources of bias. Risk of bias was unclear for the remaining studies across domains. We decided not to undertake a meta-analysis because of variation in study design, types of interventions and outcome measurements. We present a narrative description of individual studies for each outcome.All six studies assessed functional exercise capacity, although we noted wide variability in the nature of interventions, outcome measures and associated metrics and data reporting. Overall quality of the evidence was very low. Individually, three studies reported positive results in favour of the intervention. One study found a small short-term benefit in anaerobic threshold (mean difference (MD) 1.8 mL O2/kg/min, 95% confidence interval (CI) 0.4 to 3.2; P value = 0.02). In a second study, both incremental (MD 4.7, 95% CI 1.69 to 7.75 watts; P value = 0.003) and endurance (MD 4.12, 95% CI 0.68 to 7.56 minutes; P value = 0.021) exercise testing results were improved with intervention. Finally self reported physical function increased significantly following use of a rehabilitation manual (P value = 0.006). Remaining studies found no effect of the intervention.Similar variability was evident with regard to findings for the primary outcome of health-related quality of life. Only two studies evaluated this outcome. Individually, neither study reported differences between intervention and control groups for health-related quality of life due to the intervention. Overall quality of the evidence was very low.Four studies reported rates of withdrawal, which ranged from 0% to 26.5% in control groups, and from 8.2% to 27.6% in intervention groups. The quality of evidence for the effect of the intervention on withdrawal was low. Very low-quality evidence showed rates of adherence with the intervention. Mortality ranging from 0% to 18.8% was reported by all studies. The quality of evidence for the effect of the intervention on mortality was low. Loss to follow-up, as reported in all studies, ranged from 0% to 14% in control groups, and from 0% to 12.5% in intervention groups, with low quality of evidence. Only one non-mortality adverse event was reported across all participants in all studies (a minor musculoskeletal injury), and the quality of the evidence was low.

AUTHORS' CONCLUSIONS

At this time, we are unable to determine an overall effect on functional exercise capacity, or on health-related quality of life, of an exercise-based intervention initiated after ICU discharge for survivors of critical illness. Meta-analysis of findings was not appropriate because the number of studies and the quantity of data were insufficient. Individual study findings were inconsistent. Some studies reported a beneficial effect of the intervention on functional exercise capacity, and others did not. No effect on health-related quality of life was reported. Methodological rigour was lacking across several domains, influencing the quality of the evidence. Wide variability was noted in the characteristics of interventions, outcome measures and associated metrics and data reporting.If further trials are identified, we may be able to determine the effects of exercise-based intervention following ICU discharge on functional exercise capacity and health-related quality of life among survivors of critical illness.

Extra Physiotherapy in Critical Care (EPICC) Trial Protocol: a randomised controlled trial of intensive versus standard physical rehabilitation therapy in the critically ill

INTRODUCTION

Patients discharged from Critical Care suffer from excessive longer term morbidity and mortality. Physical and mental health measures of quality of life show a marked and immediate fall after admission to Critical Care with some recovery over time. However, physical function is still significantly reduced at 6 months. The National Institute for Health and Care Excellence clinical guideline on rehabilitation after critical illness, identified the need for high-quality randomised controlled trials to determine the most effective rehabilitation strategy for critically ill patients at risk of critical illness-associated physical morbidity. In response to this, we will conduct a randomised controlled trial, comparing physiotherapy aimed at early and intensive patient mobilisation with routine care. We hypothesise that this intervention will improve physical outcomes and the mental health and functional well-being of survivors of critical illness.

METHODS AND ANALYSIS

308 adult patients who have received more than 48 h of non-invasive or invasive ventilation in Critical Care will be recruited to a patient-randomised, parallel group, controlled trial, comparing two intensities of physiotherapy. Participants will be randomised to receive either standard or intensive physiotherapy for the duration of their Critical Care admission. Outcomes will be recorded on Critical Care discharge, at 3 and 6 months following initial recruitment to the study. The primary outcome measure is physical health at 6 months, as measured by the SF-36 Physical Component Summary. Secondary outcomes include assessment of mental health, activities of daily living, delirium and ventilator-free days. We will also include a health economic analysis.

ETHICS AND DISSEMINATION

The trial has ethical approval from Newcastle and North Tyneside 2 Research Ethics Committee (11/NE/0206). There is a Trial Oversight Committee including an independent chair. The results of the study will be submitted for publication in peer-reviewed journals and presented at national and international scientific meetings.

TRIAL REGISTRATION NUMBER

ISRCTN20436833.

The effect of race on long term mortality in mechanically ventilated patients

OBJECTIVE

Determine the impact of race on one-year mortality following mechanical ventilation.

BACKGROUND

There is a lack of prospective studies on the effect of race on survival following mechanical ventilation.

METHODS

Observational study of adult patients on ventilatory support for <24 h prior to enrollment. Socioeconomic factors, laboratory and clinical data were recorded. Primary outcome was one-year mortality.

RESULTS

We enrolled 178 patients; 100 African American (AA), 78 other races (OTH). One-year mortality for AA was 49% and 33% for OTH (p = 0.035). After correcting for covariates, race was not significantly associated with mortality (p = 0.42). AA patients had higher mean arterial blood pressure, serum creatinine, heart rate, and peak (p < 0.01) and mean (p = 0.05) airway pressures.

CONCLUSIONS

AA patients who underwent mechanical ventilation had greater one-year mortality, although race per se was not a significant factor. It remains to be determined if strict blood pressure control and lower airway pressures may improve survival in this racial group.

Improving rehabilitation after critical illness through outpatient physiotherapy classes and essential amino acid supplement: A randomized controlled trial

PURPOSE

Patients recovering from critical illness may be left with significant muscle mass loss. This study aimed to evaluate whether a 6-week program of enhanced physiotherapy and structured exercise (PEPSE) and an essential amino acid supplement drink (glutamine and essential amino acid mixture [GEAA]) improves physical and psychological recovery.

MATERIALS AND METHODS

Intensive care patients aged 45 years or older, with a combined intensive care unit stay/pre-intensive care unit stay of 5 days or more were recruited to a randomized controlled trial examining the effect of PEPSE and GEAA on recovery. The 2 factors were tested in a 2 × 2 factorial design: (1) GEAA drink twice daily for 3 months and (2) 6-week PEPSE in first 3 months. Primary efficacy outcome was an improvement in the 6-minute walking test at 3 months.

RESULTS

A total of 93 patients were randomized to the study. Patients receiving the PEPSE and GEA had the biggest gains in distance walked in 6-minute walking test (P < .0001). There were also significant reductions in rates of anxiety in study groups control supplement/PEPSE (P = .047) and GEAA supplement/PEPSE (P = .036) and for GEAA supplement/PEPSE in depression (P = .0009).

CONCLUSION

Enhanced rehabilitation combined with GEAA supplement may enhance physical recovery and reduce anxiety and depression.

Experience from multidisciplinary follow-up on critically ill patients treated in an intensive care unit

INTRODUCTION

International literature describes that former intensive care unit (ICU) patients suffer considerable physical and neuropsychological complications. Systematic data on Danish ICU survivors are scarce as standardised follow-up after intensive care has yet to be described. This article describes and evaluates the knowledge gained from outpatient follow-up at a tertiary intensive care unit at Rigshospitalet, Copenhagen, during a three-year period.

METHODS

A total of 101 adult former ICU patients attended the outpatient clinic over a three-year period. Patients included were medical and surgical patients with a length of stay exceeding four days. Patients attended the clinic after discharge from hospital and for a minimum of two months from their discharge from the ICU. The patients were assessed for physical, neuropsychological and psychological problems and, if necessary, further treatment or rehabilitation was initiated.

RESULTS

Reduced physical ability was seen in 82%. A total of 89% suffered a substantial weight loss. 83.2% had signs indicating acute brain dysfunction during the ICU stay, and approximately half of the patients still had cognitive problems. A total of 66 interventions were initiated.

CONCLUSION

Our data confirmed that a large proportion of ICU survivors suffer considerable long-term physical and neuropsychological sequelae. Intensive care follow-up may contribute to address these specific problems and to initiate the needed interventions. Research is needed to determine whether specialised rehabilitation is required.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Safety profile and feasibility of early physical therapy and mobility for critically ill patients in the medical intensive care unit: Beginning experiences in Korea

PURPOSE

To evaluate risk factors for potential safety events during mobility physical therapy sessions in the medical intensive care unit.

METHODS

The safety profiles and potential risk factors of 99 patients who were admitted to the medical intensive care unit of a single teaching hospital in Korea between May 1 and December 31, 2013, were retrospectively evaluated.

RESULTS

A total of 26 potential safety events (5.0%; 95% confidence interval [CI], 3.4%-7.3%) during 520 mobilization sessions were observed in 17 (17.2%; 95% CI, 10.6%-26.4%) of 99 patients. The common potential safety events were as follows in order of frequency: 11 events of tachypnea or bradypnea (2.1%; 95% CI, 1.1%-3.9%), 6 events of desaturation (1.2 %; 95% CI, 0.5%-2.6%), 4 events of tachypnea or bradycardia (0.8%; 95% CI, 0.3%-2.1%), 4 events of patients' intolerance (0.8%; 95% CI, 0.3%-2.1%), and 1 event of tracheostomy tube removal (0.2%; 95% CI, 0%-1.2%). In multivariate analysis, the use of extracorporeal membrane oxygenation was associated with potential adverse events with an adjusted odds ratio of 5.8 (95% CI, 2.2-15.6), respectively.

CONCLUSION

Early mobility physical therapy performed by a newly established group was feasible for critically ill patients in Korea. However, potential safety events need to be monitored carefully for patients with extracorporeal membrane oxygenation support.

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

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

Predictive validity and reliability of the Turkish version of the risk assessment pressure sore scale in intensive care patients: results of a prospective study

Multiple pressure ulcer (PU) risk assessment instruments have been developed and tested, but there is no general consensus on which instrument to use for specific patient populations and care settings. The purpose of this study was to determine the reliability and predictive validity of the Turkish version of the Risk Assessment Pressure Sore (RAPS) instrument, which includes 12 variables--5 from the modified Norton Scale, 3 from the Braden Scale, and 3 from other research results--for use in intensive care unit (ICU) patients. The English version of the RAPS instrument was translated into Turkish and tested for internal consistency and predictive validity (sensitivity, specificity, positive predictive value, and negative predictive value) using a convenience sample of 122 patients consecutively admitted to an ICU unit in Turkey. The patients were assessed within 24 hours of admission, and after that, once a week until the development of a PU or discharge from the unit. The incidence of PUs in this population was 23%. The majority of ulcers that developed were Stage I. Internal consistency of the RAPS tool was adequate (Cronbach's α = 0.81). The best balance between sensitivity and specificity for ICU patients was reached at a cut-off point of ≤ 27 (ie, sensitivity = 74.2%, specificity = 31.8%, positive predictive value = 38.7%, and negative predictive value 91.3%). This is lower than the cut-off point reported in other studies of the RAPS scale. In this population of ICU patients, the RAPS scale was found to have acceptable reliability and poor validity. Additional studies to evaluate the predictive validity and reliability of the RAPS scale in other patient populations and care settings are needed.

Exercise-based rehabilitation after hospital discharge for survivors of critical illness with intensive care unit-acquired weakness: A pilot feasibility trial

Purpose

The aim of this study was to investigate feasibility of exercise-based rehabilitation delivered after hospital discharge in patients with intensive care unit–acquired weakness (ICU-AW).

Materials and methods

Twenty adult patients, mechanically ventilated for more than 48 hours, with ICU-AW diagnosis at ICU discharge were included in a pilot feasibility randomized controlled trial receiving a 16-session exercise-based rehabilitation program. Twenty-one patients without ICU-AW participated in a nested observational cohort study. Feasibility, clinical, and patient-centered outcomes were measured at hospital discharge and at 3 months.

Results

Intervention feasibility was demonstrated by high adherence and patient acceptability, and absence of adverse events, but this must be offset by the low proportion of enrolment for those screened. The study was underpowered to detect effectiveness of the intervention. The use of manual muscle testing for the diagnosis of ICU-AW lacked robustness as an eligibility criterion and lacked discrimination for identifying rehabilitation requirements. Process evaluation of the trial identified methodological factors, categorized by “population,” “intervention,” “control group,” and “outcome.”

Conclusions

Important data detailing the design, conduct, and implementation of a multicenter randomized controlled trial of exercise-based rehabilitation for survivors of critical illness after hospital discharge have been reported.

Registration

Clinical Trials Identifier NCT00976807

The use of diaries to promote recovery after critical illness

Admission to intensive care exposes patients and family members to extreme physical and psychological stress. This stress may cause anxiety, depression and post-traumatic stress disorder (PTSD), which impairs their recovery. Nurses are actively seeking solutions and tools to assist patients and family members to recover after admission to intensive care.

[Physiotherapy in intensive care medicine]

BACKGROUND

A high amount of recently published articles and reviews have already focused on early mobilisation in intensive care medicine. However, in the clinical setting the problem of its practicability remains as each professional group in the mobility team has its own expectations concerning the interventions made by physiotherapy. Even though there are as yet no standard operation procedures (SOP), there do exist distinctive mobilisation concepts that are well implemented in certain intensive care units (http://www.fruehmobilisierung.de/Fruehmobilisierung/Algorithmen.html).

AIM

Due to these facts and the urgent need for SOPs this article presents the physiotherapeutic concept for the treatment of patients in the intensive care unit which has been developed by the author: First the patients' respiratory and motor functions have to be established in order to classify the patients and allocate them to their appropriate group (one out of three) according to their capacities; additionally, the patients are analysed by checking their so-called "surrounding conditions". Following these criteria a therapy regime is developed and patients are treated accordingly. By constant monitoring and re-evaluation of the treatment in accordance with the functions of the patient a dynamic system evolves. "Keep it simple" is one of the key features of that physiotherapeutic concept. Thus, a manual for the classification and the physiotherapeutic treatment of an intensive care patient was developed.

METHODS

In this article it is demonstrated how this concept can be implemented in the daily routine of an intensive care unit. Physiotherapy in intensive care medicine has proven to play an important role in the patients' early rehabilitation if the therapeutic interventions are well adjusted to the needs of the patients. A team of nursing staff, physiotherapists and medical doctors from the core facility for medical intensive care and emergency medicine at the medical university of Innsbruck developed the "Mobilisation Concept for the Multidisciplinary Treatment of the Intensive Care Patient" following the principles of the physiotherapeutic concept mentioned above and published it online on the homepage of the German network for early mobilisation (http://www.fruehmobilisierung.de/Fruehmobilisierung/Algorithmen.html) in spring 2012. The biggest challenge was to find one common language for all professional groups to define the aims of mobilisation.

RESULTS

The success of the implementation becomes apparent in a well structured and coordinated procedure of early mobilisation, as all partners of the rehabilitation team apply adequate treatments. As a result the patients receive the appropriate treatment at the appropriate time which greatly supports their convalescence.

Recovery post ICU

Many ICU patients struggle to recovery following critical illness and may be left with physical, cognitive and psychological problems, which have a negative impact on their quality of life. Gross muscle mass loss and weakness can take some months to recover after the patients' Intensive Care Unit (ICU) discharge, in addition critical illness polyneuropathies can further complicate physical recovery. Psychological problems such as anxiety, depression and post traumatic stress disorder (PTSD) are common and have an negative impact on the patients' ability to engage in rehabilitation after ICU discharge. Finally cognitive deficit affecting memory can be a significant problem. The first step in helping patients to recover from such a devastating illness is to recognise those who have the greatest need and target interventions. Research now suggests that there are interventions that can accelerate physical recovery and reduce the incidence of psychological problems such as anxiety, depression and PTSD. Cognitive rehabilitation, however, is still in its infancy. This review will look at the research into patients' recovery and what can be done to improve this where needed.

Acute rehabilitation practices in critically ill children: a multicenter study

OBJECTIVE

To evaluate acute rehabilitation practices in pediatric critical care units across Canada.

DESIGN

Retrospective cohort study.

SETTING

Six Canadian, tertiary care pediatric critical care units.

PATIENTS/SUBJECTS

Six hundred children aged under 17 years admitted to pediatric critical care unit during a winter and summer month of 2011 with a greater than 24-hour length of stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome of interest was the nature and timing of pediatric critical care unit rehabilitation practices.Rehabilitation was classified according to mobility and nonmobility interventions. Predictors of mobilization and the time to mobilization were evaluated through regression and time-dependent survival analyses, respectively. The most common form of rehabilitation provided in pediatric critical care unit was physical therapy (45.5% patients) followed by occupational therapy (4.5%) and speech and language therapy (1.5%). Interventions were primarily nonmobility in nature (69.7% of sessions), most frequently in the form of chest physiotherapy (42.7% of sessions). The median time to mobilization was 2 days (interquartile range, 1-6) as compared with 1 day for nonmobility interventions (interquartile range, 1-3). Only 57 patients (9.5%) received early mobilization. Regression analyses revealed that increasing age, admission during winter, neuromuscular blockade, and sedative infusions were associated with an increased likelihood of receiving mobility therapy. Increasing age was a predictor of early mobilization, while neuromuscular blockade was associated with delayed mobilization. No significant differences in adverse events were found between nonmobility and mobility interventions.

CONCLUSIONS

Only half of the children receive rehabilitation while in the pediatric critical care unit, and when it occurs, therapy is primarily focused on respiratory function. Mobilization appears to be reserved for at-risk children who were muscle relaxed and sedated; however, its implementation in these patients is delayed. Future pediatric-specific research is essential to identify patients at risk and to understand treatment priorities and rehabilitation strategies to improve functional recovery in critically ill children.

A UK survey of rehabilitation following critical illness: implementation of NICE Clinical Guidance 83 (CG83) following hospital discharge

OBJECTIVE

To determine the implementation of National Institute for Health and Care Excellence guidance (NICE CG83) for posthospital discharge critical illness follow-up and rehabilitation programmes.

DESIGN

Closed-question postal survey.

SETTING

Adult intensive care units (ICUs) across the UK, identified from national databases of organisations. Specialist-only and private ICUs were not included.

PARTICIPANTS

Senior respiratory critical care physiotherapy clinicians.

RESULTS

A representative sample of 182 surveys was returned from the 240 distributed (75.8% (95% CI 70.4 to 81.2)). Only 48 organisations (27.3% (95% CI 20.7 to 33.9)) offered a follow-up service 2-3 months following hospital discharge, the majority (n=39, 84.8%) in clinic format. 12 organisations reported posthospital discharge rehabilitation programmes (6.8% (95% CI 3.1 to 10.5)), albeit only 10 of these operated on a regular basis. Lack of funding was reported as the most frequent (n=149/164, 90%) and main barrier (n=99/156, 63.5%) to providing services. Insufficient resources (n=71/164, 43.3%) and lack of priority by the clinical management team (n=66/164, 40.2%) were also highly cited barriers to service delivery.

CONCLUSIONS

NICE CG83 has been successful in profiling the importance of rehabilitation for survivors of critical illness. However, 4 years following publication of CG83 there has been limited development of this clinical service across the UK. Strategies to support delivery of such quality improvement programmes are urgently required to enhance patient care.

Optimal management of the critically ill: anaesthesia, monitoring, data capture, and point-of-care technological practices in ovine models of critical care

Animal models of critical illness are vital in biomedical research. They provide possibilities for the investigation of pathophysiological processes that may not otherwise be possible in humans. In order to be clinically applicable, the model should simulate the critical care situation realistically, including anaesthesia, monitoring, sampling, utilising appropriate personnel skill mix, and therapeutic interventions. There are limited data documenting the constitution of ideal technologically advanced large animal critical care practices and all the processes of the animal model. In this paper, we describe the procedure of animal preparation, anaesthesia induction and maintenance, physiologic monitoring, data capture, point-of-care technology, and animal aftercare that has been successfully used to study several novel ovine models of critical illness. The relevant investigations are on respiratory failure due to smoke inhalation, transfusion related acute lung injury, endotoxin-induced proteogenomic alterations, haemorrhagic shock, septic shock, brain death, cerebral microcirculation, and artificial heart studies. We have demonstrated the functionality of monitoring practices during anaesthesia required to provide a platform for undertaking systematic investigations in complex ovine models of critical illness.

Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial

PURPOSE

Cognitive impairment after critical illness is common and debilitating. We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness.

METHODS

We randomized 87 medical and surgical ICU patients with respiratory failure and/or shock in a 1:1:2 manner to three groups: usual care, early once-daily physical therapy, or early once-daily physical therapy plus a novel, progressive, twice-daily cognitive therapy protocol. Cognitive therapy included orientation, memory, attention, and problem-solving exercises, and other activities. We assessed feasibility outcomes of the early cognitive plus physical therapy intervention. At 3 months, we also assessed cognitive, functional, and health-related quality of life outcomes. Data are presented as median (interquartile range) or frequency (%).

RESULTS

Early cognitive therapy was a delivered to 41/43 (95%) of cognitive plus physical therapy patients on 100% (92-100%) of study days beginning 1.0 (1.0-1.0) day following enrollment. Physical therapy was received by 17/22 (77%) of usual care patients, by 21/22 (95%) of physical therapy only patients, and 42/43 (98%) of cognitive plus physical therapy patients on 17% (10-26%), 67% (46-87%), and 75% (59-88%) of study days, respectively. Cognitive, functional, and health-related quality of life outcomes did not differ between groups at 3-month follow-up.

CONCLUSIONS

This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy. Future work to determine optimal patient selection, intensity of treatment, and benefits of cognitive therapy in the critically ill is needed.

Protocol for a longitudinal qualitative study: survivors of childhood critical illness exploring long-term psychosocial well-being and needs--The SCETCH Project

INTRODUCTION

Life-threatening critical illness affects over a quarter of a million children and adolescents (0-18 years old) annually in the USA and the UK. Death from critical illness is rare; however, survivors and their families can be exposed to a complex array of negative physical, psychological and social problems. Currently, within the literature, there is a distinct paucity of child and adolescent survivor self-reports, thus limiting our understanding of how survivors perceive this adversity and subsequently cope and grow in the long-term following their critical illness. This study aims to explore and understand psychosocial well-being and needs of critical illness survivors, 6-20 months post paediatric intensive care admission.

METHODS AND ANALYSIS

A longitudinal, qualitative approach will provide a platform for a holistic and contextualised exploration of outcomes and mechanisms at an individual level. Up to 80 participants, including 20 childhood critical illness survivors and 60 associated family members or health professionals/teachers, will be recruited. Three interviews, 7-9 weeks apart, will be conducted with critical illness survivors, allowing for the exploration of psychosocial well-being over time. A single interview will be conducted with the other participants enabling the exploration of contextual information and how psychosocial well-being may inter-relate between critical illness survivors and themselves. A 'tool box' of qualitative methods (semi-structured interviews, draw and tell, photo-elicitation, graphic-elicitation) will be used to collect data. Narrative analysis and pattern matching will be used to identify emergent themes across participants.

ETHICS AND DISSEMINATION

This study will provide an insight and understanding of participants' experiences and perspectives of surviving critical illness in the long term with specific relation to their psychosocial well-being. Multiple methods will be used to ensure that the findings are effectively disseminated to service users, clinicians, policy and academic audiences. The study has full ethical approval from the East Midlands Research Ethics Committee and has received National Health Service (NHS) governance clearance.

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

INTRODUCTION

The 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.

METHODS

We 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.

RESULTS

The 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.

CONCLUSIONS

Further research examining the trajectory of improvement with rehabilitation is warranted in this population.

TRIAL REGISTRATION

The trial was registered with the Australian New Zealand Clinical Trials Registry ACTRN12605000776606.

United States Critical Illness and Injury Trials Group

The United States Critical Illness and Injury Trials (USCIIT) Group is an inclusive, grassroots "network of networks" with the dual missions of fostering investigator-initiated hypothesis testing and developing recommendations for strategic plans at a national level. The USCIIT Group's transformational approach enlists multidisciplinary investigative teams across institutions, critical illness and injury professional organizations, federal agencies that fund clinical and translational research, and industry partners. The USCIIT Group is endorsed by all major critical illness and injury professional organizations spanning the specialties of anesthesiology, emergency medicine, internal medicine, neurology, nursing, pediatrics, pharmacy and nutrition, surgery and trauma, and respiratory and physical therapy. Recent successes provide the opportunity to significantly increase the dialogue necessary to advance clinical and translational research on behalf of our community. More than 200 investigators are now involved across > 30 academic and community hospitals. Collectively, USCIIT Group investigators have enrolled > 10,000 patients from academic and community hospitals in studies during the last 3 years. To keep our readership "ahead of the curve," this article provides a vision for critical illness and injury research based on (1) programmatic organization of large-scale, multicentered collaborative studies and (2) annual strategic planning at a national scale across disciplines and stakeholders.