The Surgical Optimal Mobility Score predicts mortality and length of stay in an Italian population of medical, surgical, and neurologic intensive care unit patients

Guideline on positioning and early mobilisation in the critically ill by an expert panel

A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.

Robotic-Assisted In-Bed Mobilization in Ventilated ICU Patients With COVID-19: An Interventional, Randomized, Controlled Pilot Study (ROBEM II Study)

OBJECTIVES

The COVID-19 pandemic significantly impacted global healthcare systems, particularly in managing critically ill mechanically ventilated patients. This study aims to assess the feasibility of robotic-assisted mobilization in COVID-19 patients.

DESIGN

Randomized controlled pilot study.

SETTING

Four COVID-19 specialized ICUs at Charité-Universitätsmedizin Berlin (March 2021 to February 2022).

PATIENTS

Twenty critically ill COVID-19 patients expected to require greater than 24 hours of ventilation.

INTERVENTIONS

A 5-day intervention phase with bid robotic-assisted mobilization greater than or equal to 20 minutes and follow-up at day 180, compared with standard care.

MEASUREMENTS AND MAIN RESULTS

Intervention sessions were conducted in 98.9% according to protocol, with one session missing due to staff shortage. Primary outcome was the mobilization level measured with the ICU Mobility Scale (IMS) and Surgical ICU Optimal Mobilization Score (SOMS), assessed until day 5 or extubation. Safety events were recorded during mobilization. The median IMS and SOMS were 0 (0-0.16) and 1 (1-1.03) in the intervention group, and 0 (0-0.15) ( p = 0.77) and 0.8 (0.65-1.20) ( p = 0.08) in the standard care group, respectively. Significant secondary outcomes included average number of mobilization sessions (intervention: 8.5 [7.75-10] vs. standard care: 4.5 [3.5-5]; p = 0.001), total mobilization time (intervention: 232.5 min [187.25-266.5 min] vs. standard care: 147.5 min [107.5-167.5 min]; p = 0.011), and healthcare providers per session (intervention: 2 [2-2] vs. standard care: 1 [1-1.4]; p = 0.001) during intervention. Four safety events (hypertension and agitation, n = 2 each) in the intervention group and none in the standard care group were reported.

CONCLUSIONS

Robotic-assisted mobilization in mechanically ventilated COVID-19 patients appears to be safe and feasible.

The optimal dose of mobilisation therapy in the ICU: a prospective cohort study

BACKGROUND

This study aimed to assess the impact of duration of early mobilisation on survivors of critical illness. The hypothesis was that interventions lasting over 40 min, as per the German guideline, positively affect the functional status at ICU discharge.

METHODS

Prospective single-centre cohort study conducted in two ICUs in Germany. In 684 critically ill patients surviving an ICU stay > 24 h, out-of-bed mobilisation of more than 40 min was evaluated.

RESULTS

Daily mobilisation ≥ 40 min was identified as an independent predictor of an improved functional status upon ICU discharge. This effect on the primary outcome measure, change of Mobility-Barthel until ICU discharge, was observed in three different models for baseline patient characteristics (average treatment effect (ATE), all three models p < 0.001). When mobilisation parameters like level of mobilisation, were included in the analysis, the average treatment effect disappeared [ATE 1.0 (95% CI - 0.4 to 2.4), p = 0.16].

CONCLUSIONS

A mobilisation duration of more than 40 min positively impacts functional outcomes at ICU discharge. However, the maximum level achieved during ICU stay was the most crucial factor regarding adequate dosage, as higher duration did not show an additional benefit in patients with already high mobilisation levels.

TRIAL REGISTRATION

Prospective Registry of Mobilization-, Routine- and Outcome Data of Intensive Care Patients (MOBDB), NCT03666286. Registered 11 September 2018-retrospectively registered, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT03666286 .

Factors Affecting the Length of Stay in the Intensive Care Unit among Adults in Saudi Arabia: A Cross-Sectional Study

This study aimed to assess patient-related factors associated with the LOS among adults admitted to the ICU in Saudi Arabia. The Ministry of Health provided a cross-sectional dataset for 2021, which served as the data source for this study. The data included data on adults admitted to different ICUs at various hospitals. The number of days spent in the ICU was the outcome variable of interest. The potential predictors were age, sex, and nationality, as well as clinical data from the time of admission. Descriptive statistics and bivariate analysis were used to analyse the association between the predictors and the ICU LOS and characterize how they were distributed. We used negative binomial regression to examine the relationship between the study predictors and the ICU LOS. A total of 42,884 individuals were included in this study, of whom 25,520 were men and 17,362 were women. The overall median ICU LOS was three days. This study showed that the ICU LOS was highly influenced by the patient's age, sex, nationality, source of admission, and clinical history. Several predictors that affect how long adults stay in the ICU in Saudi Arabian hospitals were identified in this study. These factors can be attributed to variances in health care delivery systems, patient demographics, and cultural considerations. To allocate resources efficiently, enhance patient outcomes, and create focused treatments to reduce ICU LOS, it is essential to comprehend these elements.

What factors predict length of stay in the intensive care unit? Systematic review and meta-analysis

PURPOSE

Studies have shown that a small percentage of ICU patients have prolonged length of stay (LoS) and account for a large proportion of resource use. Therefore, the identification of prolonged stay patients can improve unit efficiency. In this study, we performed a systematic review and meta-analysis to understand the risk factors of ICU LoS.

MATERIALS AND METHODS

We searched MEDLINE, Embase and Scopus databases from inception to November 2018. The searching process focused on papers presenting risk factors of ICU LoS. A meta-analysis was performed for studies reporting appropriate statistics.

RESULTS

From 6906 citations, 113 met the eligibility criteria and were reviewed. A meta-analysis was performed for six factors from 28 papers and concluded that patients with mechanical ventilation, hypomagnesemia, delirium, and malnutrition tend to have longer stay, and that age and gender were not significant factors.

CONCLUSIONS

This work suggested a list of risk factors that should be considered in prediction models for ICU LoS, as follows: severity scores, mechanical ventilation, hypomagnesemia, delirium, malnutrition, infection, trauma, red blood cells, and PaO2:FiO2. Our findings can be used by prediction models to improve their predictive capacity of prolonged stay patients, assisting in resource allocation, quality improvement actions, and benchmarking analysis.

Brazilian Guidelines for Early Mobilization in Intensive Care Unit

Immobility can cause several complications, including skeletal muscle atrophy and weakness, that influence the recovery of critically ill patients. This effect can be mitigated by early mobilization. Six key questions guided this research: Is early mobilization safe? Which patients are candidates for early mobilization? What are the contraindications? What is the appropriate dose, and how should it be defined? What results are obtained? What are the prognostic indicators for the use of early mobilization? The objective of this guideline was to produce a document that would provide evidence-based recommendations and suggestions regarding the early mobilization of critically ill adult patients, with the aim of improving understanding of the topic and making a positive impact on patient care. This guideline was based on a systematic review of articles conducted using the PICO search strategy, as recommended by the Guidelines Project of the Associação Médica Brasileira. Randomized clinical trials, prognostic cohort studies, and systematic reviews with or without meta-analysis were selected, and the evidence was classified according to the Oxford Center for Evidence-based Medicine Levels of Evidence. For all the questions addressed, enough evidence was found to support safe and well-defined early mobilization, with prognostic indicators that support and recommend the technique. Early mobilization is associated with better functional outcomes and should be performed whenever indicated. Early mobilization is safe and should be the goal of the entire multidisciplinary team.

Measurement of mobility and physical function in hospitalised trauma patients: A systematic review of instruments and their measurement properties

Introduction

It is well recognised that organised trauma systems reduce trauma patient mortality. As established systems mature, there is an increasing need to better understand the patient recovery trajectory. Mobility and physical function are key aspects of recovery, but the optimal instruments for measurement in the acute hospital setting remain unclear.

Methods

A systematic review was undertaken to identify and describe mobility and physical function instruments scored by direct patient assessment, in adult trauma patients in an acute hospital setting. Databases were searched with no date restrictions. Instruments that were specific to subgroups or related to individual conditions, diseases or joints were excluded. The consensus-based standards for the selection of health measurement instruments checklist was used to assess risk of bias where relevant. Clinimetric properties were reported where possible, including reliability, validity and responsiveness.

Results

Fourteen thousand one hundred and fourteen articles were identified with 37 eligible for final review, including six instruments. None had been specifically designed for use in a heterogeneous range of trauma patients. The Functional Independence Measure was the most commonly cited (n = 10 studies), with evidence of construct validity, responsiveness and minimal floor/ceiling effects (<3%). The Acute Care Index of Function (n = 1 study) was found to be valid and responsive whilst the modified Iowa Level of Assistance (n = 2 studies) was reliable and responsive, but ceiling effects ranged from 26% to 37%. Little clinimetric data were available for other measures.

Conclusion

Evidence from a few studies show promise for the use of the Functional Independence Measure, Acute Care Index of Function and modified Iowa Level of Assistance to measure mobility and physical function in trauma patients, however comprehensive clinimetric data are lacking. Future research should test these scores in specifically designed clinimetric property studies in defined trauma patient populations. This would enable the identification of a gold standard measure for evaluating treatment effectiveness, enabling benchmarking between centres, allow prediction of recovery pathways and optimise trauma patient outcomes.

Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ICU Liberation ABCDEF Bundle Improvement Collaborative

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) improves intensive care unit patient-centered outcomes and promotes interprofessional teamwork and collaboration. The Society of Critical Care Medicine recently completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, multicenter, national quality improvement initiative that formalized dissemination and implementation strategies to promote effective adoption of the ABCDEF bundle. The purpose of this article is to describe 8 of the most frequently asked questions during the Collaborative and to provide practical advice from leading experts to other institutions implementing the ABCDEF bundle.

Identifying Barriers to Nurse-Facilitated Patient Mobility in the Intensive Care Unit

BACKGROUND

Nurse-facilitated mobility of patients in the intensive care unit can improve outcomes. However, a gap exists between research findings and their implementation as part of routine clinical practice. Such a gap is often attributed, in part, to the barrier of lack of time. The Translating Evidence Into Practice model provides a framework for research implementation, including recommendations for identifying barriers to implementation via direct observation of clinical care.

OBJECTIVES

To report on design, implementation, and outcomes of an approach to identify and understand lack of time as a barrier to nurse-facilitated mobility in the intensive care unit.

METHODS

An interprofessional team designed the observational process and evaluated the resulting data by using qualitative content analysis.

RESULTS

During three 4-hour observations of 2 nurses and 1 nursing technician, 194 distinct tasks were performed (ie, events). A total of 4 categories of nurses' work were identified: patient care (47% of observation time), provider communication (25%), documentation (18%), and down time (10%). In addition, 3 types of potential mobility events were identified: in bed, edge of bed, and out of bed. The 194 observed events included 34 instances (18%) of potential mobility events that could be implemented: in bed (53%), edge of bed (6%), and out of bed (41%).

CONCLUSIONS

Nurses have limited time for additional clinical activities but may miss potentially important opportunities for facilitating patient mobility during existing patient care. The proposed method is feasible and helpful in empirically investigating barriers to nurse-facilitated patient mobility in the intensive care unit.

Intensive care unit-acquired weakness: unanswered questions and targets for future research

Intensive care unit-acquired weakness (ICU-AW) is the most common neuromuscular impairment in critically ill patients. We discuss critical aspects of ICU-AW that have not been completely defined or that are still under discussion. Critical illness polyneuropathy, myopathy, and muscle atrophy contribute in various proportions to ICU-AW. Diagnosis of ICU-AW is clinical and is based on Medical Research Council sum score and handgrip dynamometry for limb weakness and recognition of a patient's ventilator dependency or difficult weaning from artificial ventilation for diaphragmatic weakness (DW). ICU-AW can be caused by a critical illness polyneuropathy, a critical illness myopathy, or muscle disuse atrophy, alone or in combination. Its diagnosis requires both clinical assessment of muscle strength and complete electrophysiological evaluation of peripheral nerves and muscles. The peroneal nerve test (PENT) is a quick simplified electrophysiological test with high sensitivity and good specificity that can be used instead of complete electrophysiological evaluation as a screening test in non-cooperative patients. DW, assessed by bilateral phrenic nerve magnetic stimulation or diaphragm ultrasound, can be an isolated event without concurrent limb muscle involvement. Therefore, it remains uncertain whether DW and limb weakness are different manifestations of the same syndrome or are two distinct entities. Delirium is often associated with ICU-AW but a clear correlation between these two entities requires further studies. Artificial nutrition may have an impact on ICU-AW, but no study has assessed the impact of nutrition on ICU-AW as the primary outcome. Early mobilization improves activity limitation at hospital discharge if it is started early in the ICU, but beneficial long-term effects are not established. Determinants of ICU-AW can be many and can interact with each other. Therefore, future studies assessing early mobilization should consider a holistic patient approach with consideration of all components that may lead to muscle weakness.

Influence of the initial level of consciousness on early, goal-directed mobilization: a post hoc analysis

PURPOSE

Early mobilization within 72 h of intensive care unit (ICU) admission improves functional status at hospital discharge. We aimed to assess the effectiveness of early, goal-directed mobilization in critically ill patients across a broad spectrum of initial consciousness levels.

METHODS

Post hoc analysis of the international, randomized, controlled, outcome-assessor blinded SOMS trial conducted 2011-2015. Randomization was stratified according to the immediate post-injury Glasgow Coma Scale (GCS) (≤ 8 or > 8). Patients received either SOMS-guided mobility treatment with a facilitator or standard care. We used general linear models to test the hypothesis that immediate post-randomization GCS modulates the intervention effects on functional independence at hospital discharge.

RESULTS

Two hundred patients were included in the intention-to-treat analysis. The significant effect of early, goal-directed mobilization was consistent across levels of GCS without evidence of effect modification, for the primary outcome functional independence at hospital discharge (p = 0.53 for interaction), as well as average achieved mobility level during ICU stay (mean achieved SOMS level) and functional status at hospital discharge measured with the functional independence measure. In patients with low GCS, delay to first mobilization therapy was longer (0.7 ± 0.2 days vs. 0.2 ± 0.1 days, p = 0.008), but early, goal-directed mobilization compared with standard care significantly increased functional independence at hospital discharge in this subgroup of patients with immediate post-randomization GCS ≤ 8 (OR 3.67; 95% CI 1.02-13.14; p = 0.046).

CONCLUSION

This post hoc analysis of a randomized controlled trial suggests that early, goal-directed mobilization in patients with an impaired initial conscious state (GCS ≤ 8) is not harmful but effective.

Recent evidence on early mobilization in critical-Ill patients

PURPOSE OF REVIEW

To examine the benefits of early mobilization and summarize the results of most recent clinical studies examining early mobilization in critically ill patients followed by a presentation of recent developments in the field.

RECENT FINDINGS

Early mobilization of ICU patients, defined as mobilization within 72 h of ICU admission, is still uncommon. In medical and surgical critically ill patients, mobilization is well tolerated even in intubated patients. In neurocritical care, evidence to support early mobilization is either lacking (aneurysmal subarachnoid hemorrhage), or the results are inconsistent (e.g. stroke). Successful implementation of early mobilization requires a cultural change; preferably based on an interprofessional approach with clearly defined responsibilities and including a mobilization scoring system. Although the evidence for the majority of the technical tools is still limited, the use of a bed cycle ergometer and a treadmill with strap system has been promising in smaller trials.

SUMMARY

Early mobilization is well tolerated and feasible, resulting in improved outcomes in surgical and medical ICU patients. Implementation of early mobilization can be challenging and may need a cultural change anchored in an interprofessional approach and integrated in a patient-centered bundle. Scoring systems should be integrated to define daily goals and used to verify patients' achievements or identify barriers immediately.

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

BACKGROUND

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

OBJECTIVES

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

DATA SOURCES

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

DATA EXTRACTION

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

SYNTHESIS

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

CONCLUSIONS

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

Comparison between a nurse-led weaning protocol and weaning based on physician's clinical judgment in tracheostomized critically ill patients: a pilot randomized controlled clinical trial

Background

Weaning protocols expedite extubation in mechanically ventilated patients, yet the literature investigating the application in tracheostomized patients remains scarce. The primary objective of this parallel randomized controlled pilot trial (RCT) was to assess the feasibility and safety of a nurse-led weaning protocol (protocol) compared to weaning based on physician’s clinical judgment (control) in tracheostomized critically ill patients.

Results

We enrolled 65 patients, 27 were in the protocol group and 38 in the control group. Of 27 patients in the protocol group, 1 (3.7%) died in the ICU, 24 (88.9%) were successfully weaned from tracheostomy, and 2 (7.4%) were transferred still on the ventilator. Of 38 patients in the control group, 2 (5.3%) died in the ICU, 22 (57.9%) were successfully weaned from tracheostomy, and 14 were transferred still on the ventilator (36.8%). Risk of being discharged from the ICU on the ventilator was higher in the control group (relative risk: 1.5, IC 95% 1.14–2.01). Concerning safety and feasibility, no patients were excluded after randomization. There was no crossover between the two study arms nor missing data, and no severe adverse event related to the study protocol application was recorded by the staff. Weaning time and rate of successful weaning were not different in the protocol group compared to the control group (long-rank test, p = 0.31 for MV duration, p = 0.45 for weaning time). Based on our results and assuming a 30% reduction of the weaning time for the protocol group, 280 patients would be needed for a RCT to establish efficacy.

Conclusions

In this pilot RCT we demonstrated that a nurse-led weaning protocol from tracheostomy was feasible and safe. A larger RCT is justified to assess efficacy.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0354-1) contains supplementary material, which is available to authorized users.

Evaluating physical functioning in critical care: considerations for clinical practice and research

The evaluation of physical functioning is valuable in the intensive care unit (ICU) to help inform patient recovery after critical illness, to identify patients who may require rehabilitation interventions, and to monitor responsiveness to such interventions. This viewpoint article discusses: (1) the concept of physical functioning with reference to the World Health Organization International Classification of Functioning, Disability and Health; (2) the importance of measuring physical functioning in the ICU; and (3) methods for evaluating physical functioning in the ICU. Recommendations for clinical practice and research are made, along with discussion of future directions.

Neuromuscular Recovery Is Prolonged After Immobilization or Superimposition of Inflammation With Immobilization Compared to Inflammation Alone: Data From a Preclinical Model

OBJECTIVES

Recovery from ICU-acquired muscle weakness extends beyond hospital stay. We hypothesized that immobilization, more than inflammation, plays a prominent role in the delayed recovery from critical illness.

DESIGN

Prospective, randomized, controlled, experimental study.

SETTING

Animal laboratory, university hospital.

SUBJECTS

Male Sprague-Dawley rats.

INTERVENTIONS

Animals were divided to have one hind limb immobilized (n = 129) or sham-immobilized (n = 129) on day -12. After surgery, rats were further assigned to two subgroups. To induce inflammation, rats received three IV injections of Corynebacterium parvum on days -12, -8, and -4. Controls received saline at the respective time-points. At day 0, the limbs were remobilized and recovery from inflammation and/or immobilization was followed for 36 days.

MEASUREMENTS AND MAIN RESULTS

At day 0 and after 4, 12, or 36 days of recovery, maximum tetanic tension and tetanic fade (functional parameters = primary outcome variables) as well as nicotinic acetylcholine receptor expression, muscle mass, and histologic changes (structural parameters = secondary outcome variables) were measured. Impaired maximum tetanic tension, decreased tibialis muscle mass, and fiber diameter due to inflammation alone recovered by day 4. Tetanic fade was not affected by inflammation. Immobilization-induced loss of tibialis muscle mass, decreased fiber diameter, and tetanic fade did not return to normal until day 36, while maximum tetanic tension had recovered at that time. In the presence of inflammation and immobilization, the decrease in tibialis muscle mass, fiber diameter, and maximum tetanic tension, as well as decreased tetanic fade persisted until day 36. Up-regulation of nicotinic acetylcholine receptors normalized before day 4 following inflammation, but persisted until day 4 following immobilization.

CONCLUSIONS

In our model, muscle function and structure recovered from inflammation within 4-12 days. Immobilization-induced neuromuscular changes, however, persisted even at day 36, especially if inflammation was concomitant.

Functional Status Score for the ICU: An International Clinimetric Analysis of Validity, Responsiveness, and Minimal Important Difference

OBJECTIVES

To evaluate the internal consistency, validity, responsiveness, and minimal important difference of the Functional Status Score for the ICU, a physical function measure designed for the ICU.

DESIGN

Clinimetric analysis.

SETTINGS

Five international datasets from the United States, Australia, and Brazil.

PATIENTS

Eight hundred nineteen ICU patients.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Clinimetric analyses were initially conducted separately for each data source and time point to examine generalizability of findings, with pooled analyses performed thereafter to increase power of analyses. The Functional Status Score for the ICU demonstrated good to excellent internal consistency. There was good convergent and discriminant validity, with significant and positive correlations (r = 0.30-0.95) between Functional Status Score for the ICU and other physical function measures, and generally weaker correlations with nonphysical measures (|r| = 0.01-0.70). Known group validity was demonstrated by significantly higher Functional Status Score for the ICU scores among patients without ICU-acquired weakness (Medical Research Council sum score, ≥ 48 vs < 48) and with hospital discharge to home (vs healthcare facility). Functional Status Score for the ICU at ICU discharge predicted post-ICU hospital length of stay and discharge location. Responsiveness was supported via increased Functional Status Score for the ICU scores with improvements in muscle strength. Distribution-based methods indicated a minimal important difference of 2.0-5.0.

CONCLUSIONS

The Functional Status Score for the ICU has good internal consistency and is a valid and responsive measure of physical function for ICU patients. The estimated minimal important difference can be used in sample size calculations and in interpreting studies comparing the physical function of groups of ICU patients.

Early, goal-directed mobilisation in the surgical intensive care unit: a randomised controlled trial

BACKGROUND

Immobilisation predicts adverse outcomes in patients in the surgical intensive care unit (SICU). Attempts to mobilise critically ill patients early after surgery are frequently restricted, but we tested whether early mobilisation leads to improved mobility, decreased SICU length of stay, and increased functional independence of patients at hospital discharge.

METHODS

We did a multicentre, international, parallel-group, assessor-blinded, randomised controlled trial in SICUs of five university hospitals in Austria (n=1), Germany (n=1), and the USA (n=3). Eligible patients (aged 18 years or older, who had been mechanically ventilated for <48 h, and were expected to require mechanical ventilation for ≥24 h) were randomly assigned (1:1) by use of a stratified block randomisation via restricted web platform to standard of care (control) or early, goal-directed mobilisation using an inter-professional approach of closed-loop communication and the SICU optimal mobilisation score (SOMS) algorithm (intervention), which describes patients' mobilisation capacity on a numerical rating scale ranging from 0 (no mobilisation) to 4 (ambulation). We had three main outcomes hierarchically tested in a prespecified order: the mean SOMS level patients achieved during their SICU stay (primary outcome), and patient's length of stay on SICU and the mini-modified functional independence measure score (mmFIM) at hospital discharge (both secondary outcomes). This trial is registered with ClinicalTrials.gov (NCT01363102).

FINDINGS

Between July 1, 2011, and Nov 4, 2015, we randomly assigned 200 patients to receive standard treatment (control; n=96) or intervention (n=104). Intention-to-treat analysis showed that the intervention improved the mobilisation level (mean achieved SOMS 2·2 [SD 1·0] in intervention group vs 1·5 [0·8] in control group, p<0·0001), decreased SICU length of stay (mean 7 days [SD 5-12] in intervention group vs 10 days [6-15] in control group, p=0·0054), and improved functional mobility at hospital discharge (mmFIM score 8 [4-8] in intervention group vs 5 [2-8] in control group, p=0·0002). More adverse events were reported in the intervention group (25 cases [2·8%]) than in the control group (ten cases [0·8%]); no serious adverse events were observed. Before hospital discharge 25 patients died (17 [16%] in the intervention group, eight [8%] in the control group). 3 months after hospital discharge 36 patients died (21 [22%] in the intervention group, 15 [17%] in the control group).

INTERPRETATION

Early, goal-directed mobilisation improved patient mobilisation throughout SICU admission, shortened patient length of stay in the SICU, and improved patients' functional mobility at hospital discharge.

FUNDING

Jeffrey and Judy Buzen.

The German Validation Study of the Surgical Intensive Care Unit Optimal Mobility Score

PURPOSE

Immobilization of critically ill patients leads to muscle weakness, which translates to increased costs of care and long-term functional disability. We tested the validity of a German Surgical Intensive Care Unit (ICU) Optimal Mobilization Score (SOMS) in 2 different cohorts (neurocritical and nonneurocritical care patients).

MATERIALS AND METHODS

Physical therapists estimated the patients' mobilization capacity by using the German version of the SOMS the morning after admission. We tested the prognostic value of the prediction for ICU and hospital length of stay (LOS) as well as for mortality, and built a model to account for other known predictors of these outcomes in the 2 cohorts.

RESULTS

A total of 128 patients were included in the analysis, 48 of these were neurocritical care patients. The SOMS predicted mortality and ICU and hospital LOS. Neurocritical care patients stayed significantly longer in the ICU (median 12 vs 4 days, P < .001) and in the hospital (25 vs 17 days, P = .02). The SOMS predicted ICU and hospital LOS. It predicted mortality only in nonneurocritical patients.

CONCLUSIONS

The German SOMS assessed by physical therapists on the day after ICU admission predicts ICU and hospital LOS, and mortality. Our data suggest that the association between early mobilization and mortality is more complex in neurocritical care patients.