Rehabilitation and exercise prescription in Australian intensive care units

Workload of physiotherapy procedures in the adult intensive care unit: a descriptive study in a Brazilian teaching hospital

BACKGROUND

Physiotherapy techniques applied in intensive care units (ICU) aim to counteract functional decline and manage acute respiratory conditions. Treatment strategies vary depending on factors such as diagnosis, disease severity, and costs. Staffing resources and workload impact the duration and frequency of interventions. Understanding the workload of procedures may enhance patient care quality.

OBJECTIVE

To determine the frequency, duration, and workload of physiotherapy procedures applied to adult ICU patients. Secondarily, we analyzed the time spent per shift on teaching-related and non-procedure-related activities.

METHODS

Longitudinal panel study conducted in a 12-bed university hospital. Physiotherapy sessions applied to adult ICU patients were included. The list of procedures was derived using the Delphi method. The investigator followed physiotherapists to measure the duration of procedures and calculate a workload index for each (determined as duration x frequency). Duration of teaching-related and non-procedure-related tasks was also recorded.

RESULTS

A total of 339 physiotherapy sessions were analyzed across 79 shifts, involving 181 patients and 19 physiotherapists. Procedures with the highest workload index were: out-of-bed mobilization, patient positioning, passive limb mobilization, active exercises, artificial airway suctioning, and equipment management. Time distribution across the shifts was as follows: direct patient care 40% (SD 12%), non-procedure-related activities 20% (SD 6%), and teaching-related activities 10% (range: 4%-19%).

CONCLUSION

The procedures with the highest workload index were those directly related to rehabilitation, such as mobilization and exercises, and those not specific to patient condition, like positioning and equipment management. Physiotherapists spent most of their time in direct patient care, followed by indirect care activities and teaching.

Instruments used by physiotherapists to assess functional capacity in hospitalized patients with COVID-19: An online survey

BACKGROUND

Assessing functional capacity in hospitalized patients with COVID-19 may have been neglected due to a great demand for resources at the height of pandemic and the lack of specific assessment instruments for this population.

OBJECTIVES

To identify the instruments used to evaluate functional capacity in COVID-19 patients hospitalized in COVID-19 wards and ICUs and the associations between use of assessment instruments and physiotherapist characteristics METHODS: The survey was conducted using REDCap web-based application, following the Consensus-Based Checklist for Reporting of Survey Studies guidelines. A non-probability recruitment approach aimed at physiotherapists who had treated hospitalized patients with COVID-19 in Brazil. The instruments were classified into four domains: muscle strength, mobility, activities of daily living, and physical performance, as for the International Classification of Functioning, Disability, and Health RESULTS: Overall, 485 physiotherapists responded to the survey, 81.9% of whom used one or more instruments to assess functional capacity. The Medical Research Council (59.6%) and the Six-Minute Walk Test (21.7%) were the most commonly used instruments in COVID-19 wards; the MRC (63.9%) and the Intensive Care Mobility Scale (33.1%), in ICUs. In COVID-19 wards, higher probability of using assessment instruments was associated with being male, having training on COVID-19 management, and working > 50 h/week. In ICUs, having training on COVID-19 management and working in university hospitals were associated with higher probability of using these instruments CONCLUSIONS: Most physiotherapists used one or more instruments to assess functional capacity, assessed more than one physical domain, and used the obtained results to plan interventions.

Predictive Factors for Physiotherapy Session Length at an Adult Intensive Care Unit: A Longitudinal Panel Study

OBJECTIVE

To identify predictive factors for the length of physiotherapy sessions for adult intensive care unit (ICU) patients.

DESIGN

Longitudinal panel study.

SETTING

ICU of a secondary-care public teaching hospital, the University Hospital at the University of Sao Paulo, Brazil.

PARTICIPANTS

Medical and surgical patients who received physiotherapy (N=181) assessed in 339 physiotherapy sessions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The study investigator followed physiotherapists during their work shift and timed the physiotherapy session's length with a stopwatch. The association between session length and patient, physiotherapist, and service-related factors was evaluated by a mixed model.

RESULTS

Assessed in this study were 339 physiotherapy sessions during 79 periods of observation that involved 181 patients and 19 physiotherapists. Median session length was 29 (interquartile range: 22.6-38.9) minutes; median number of patients assisted per physiotherapist per 6-hour shift was 5 (4-5). Physiotherapist's median age was 35 (26-39) years old, and median ICU experience was 13.0 (0.4-16.0) years. Patients were mostly older adults who were post surgery and had been at the ICU for 5 (2-9) days. Factors associated with physiotherapy session length (min) were the following: performing both motor- and respiratory-related physiotherapy procedures during the session (β=6.5; 95% confidence interval [CI], 3.8-9.2), altered chest x-ray (β=2.8; 95% CI, 0.3-5.3), ICU mobility scale (IMS) (β=1.2; 95% CI, 0.4-2.0), contraindication to any level of out-of-bed mobilization (β=-6.9; 95% CI, -10.5 to -3.3), afternoon shift (β=-4.0; 95% CI, -6.7 to -1.4), and Barthel index (β=-0.2; 95% CI, -0.3 to -0.1).

CONCLUSIONS

The factors associated with longer session lengths were performing both motor- and respiratory-related physiotherapy procedures during the session, altered chest x-ray, and the IMS. Contraindication to any level of out-of-bed mobilization and sessions performed during the afternoon shift (vs the morning shift) were associated with shorter session lengths.

Public sector physiotherapists’ organisation and profile: Implications for intensive care service

Background

Physiotherapists are essential in the management of hospitalised patients. The way in which a physiotherapy service is offered in intensive care units (ICUs) can affect ICU patient outcomes.

Objectives

To provide a clear picture of the organisation and structure of physiotherapy departments, the number and types of ICUs requiring physiotherapy services and the profile of physiotherapists working in South African public-sector central, regional and tertiary hospitals that house Level I-IV ICUs.

Method

Cross-sectional survey design using SurveyMonkey, analysed descriptively.

Results

One hundred and seventy units (the majority Level I, functioning as mixed [37%, n = 58] and neonatal [22%, n = 37] units) are serviced by 66 physiotherapy departments. The majority of physiotherapists (61.5%, n = 265) were younger than 30 years, had a bachelor's degree (95.1%, n = 408) and were employed in production Level I and community service posts (51%, n = 217) with a physiotherapy-to-hospital-bed ratio of 1:69.

Conclusion

Insight into the organisational structure of physiotherapy departments and physiotherapists working in public-sector hospitals with ICU facilities in South Africa was provided. It is evident that physiotherapists employed within this sector are young and early in their career development. The large number of ICUs functioning within these hospitals and high bed-to-physiotherapist ratio is concerning, highlighting the high burden of care within this sector and the possible effect on physiotherapy services in the ICUs.

Clinical implications

A high burden of care is placed on public-sector hospital-based physiotherapists. The number of senior-level posts within this sector raises concern. It is not clear how the current staffing levels, physiotherapist profile and structure of hospital-based physiotherapy departments affect patient outcomes.

Perceived barriers to mobility in the intensive care units of Singapore: The Patient Mobilisation Attitudes and Beliefs Survey for the intensive care units

Purpose

Prolonged bed rest and immobility in the intensive care units (ICU) increase the risk of ICU-acquired weakness (ICUAW) and other complications. Mobilisation has been shown to improve patient outcomes but may be limited by the perceived barriers of healthcare professionals to mobilisation. The Patient Mobilisation Attitudes and Beliefs Survey for the ICU (PMABS-ICU) was adapted to assess perceived barriers to mobility in the Singapore context (PMABS-ICU-SG).

Methods

The 26-item PMABS-ICU-SG was disseminated to doctors, nurses, physiotherapists, and respiratory therapists working in ICU of various hospitals across Singapore. Overall and subscale (knowledge, attitude, and behaviour) scores were obtained and compared with the clinical roles, years of work experience, and type of ICU of the survey respondents.

Results

A total of 86 responses were received. Of these, 37.2% (32/86) were physiotherapists, 27.9% (24/86) were respiratory therapists, 24.4% (21/86) were nurses and 10.5% (9/86) were doctors. Physiotherapists had significantly lower mean barrier scores in overall and all subscales compared to nurses (p < 0.001), respiratory therapists (p < 0.001), and doctors (p = 0.001). A poor correlation (r = 0.079, p < 0.05) was found between years of experience and the overall barrier score. There was no statistically significant difference in the overall barriers score between types of ICU (χ2(2) = 4.720, p = 0.317).

Conclusion

In Singapore, physiotherapists had significantly lower perceived barriers to mobilisation compared to the other three professions. Years of experience and type of ICU had no significance in relation to barriers to mobilisation.

Clinicians' knowledge and attitude towards early mobilization in intensive care units in Ethiopian tertiary hospitals: A multi-centre study

Objectives

To assess clinicians' knowledge, attitude and associated factors towards patients' early mobilization in intensive care units in the tertiary hospitals in Northwest Ethiopia.

Methods

A multi-centre, cross-sectional study was conducted at the tertiary hospitals in Northwest Ethiopia from April to June, 2022. Data were collected by using self-administered, structured questionnaire; ordinal logistic regression analysis was performed and associations were described in adjusted odds ratios.

Results

A total of 304 clinicians were included (response rate of 89.7%). The proportions of poor, fair and good knowledge towards early mobilization in intensive care unit among clinicians were 16.8%, 57.9% and 25.3%, respectively; while that of negative, fair and positive attitude were 16.4%, 60.2% and 23.4%, respectively. Factors associated with better knowledge were being a physiotherapist (adjusted odds ratio = 2.9, confidence interval = 1.2-6.7), having a total work experience >5 years (adjusted odds ratio = 4.6, confidence interval = 1.7-12.1), having an intensive care unit work experience >5 years (adjusted odds ratio = 2.8, confidence interval = 1.1-6.8), previous in-service training (adjusted odds ratio = 1.8, confidence interval = 1.1-3.0) and reading guidelines (adjusted odds ratio = 1.9, confidence interval = 1.1-3.2). Better attitude was associated with in-service training (adjusted odds ratio = 1.9, confidence interval = 1.2-3.1), attending early mobilization courses (adjusted odds ratio = 1.8, confidence interval = 1.1-3.0), presence of mobilization advocators (adjusted odds ratio = 1.7, confidence interval = 1.0-2.8), good knowledge (adjusted odds ratio = 2.6, confidence interval = 1.2-5.8) and fair knowledge (adjusted odds ratio = 2.5, confidence interval = 1.3-4.8).

Conclusion

Most of the clinicians had demonstrated fair knowledge and attitude towards early mobilization in intensive care unit. However, there were significant proportion of clinicians who had poor knowledge and negative attitude. We recommended active engagement of physiotherapists and experienced clinicians in intensive care units. Clinicians need to have self-learning habits and attend regular training/courses related to early mobilization in intensive care unit.

Minimum standards of clinical practice for physiotherapists working in adult intensive care units in Singapore

Background

Physiotherapists play a crucial role in rehabilitating critically ill patients in intensive care units (ICU). However, variations are found in clinical practice amongst physiotherapists working in the ICU, both locally and internationally, due to the lack of minimum clinical standards and varying knowledge on critical care rehabilitation resulting in inconsistent quality of care.

Purpose

To establish a framework of the minimum standards of clinical practice for physiotherapists working in ICU in Singapore and compare the standards with existing literature.

Methods

A three-round modified Delphi questionnaire survey technique collated responses from ICU physiotherapists. The questionnaire contained 222 items, categorised into assessments, conditions and treatments. Responses to the items were either: “Yes, it is essential”, “No, it is not essential”, or “I am not sure”. Consensus for an item was reached when 70% of participants ranked it essential or non-essential. Participants comprised registered physiotherapists who have worked in the ICU for at least six months in the last 12 months and are currently working in the ICU.

Results

23 physiotherapists (median ICU-experience 7.0 (4.3–9.8) years) gave consent and completed the initial survey. 13 completed all three rounds of questionnaires. Overall, 163 items were regarded as essential, 21 as non-essential, and 38 did not reach consensus. The identified 163 items varied from similar studies due to different scopes of physiotherapy practice and professional autonomy.

Conclusion

This framework may guide the content of the physiotherapy education curriculum on critical care rehabilitation and minimise variability in clinical practice across different healthcare institutions in Singapore.

Mobility Levels With Physical Rehabilitation Delivered During and After Extracorporeal Membrane Oxygenation: A Marker of Illness Severity or an Indication of Recovery?

OBJECTIVE

The aims of this study were to determine whether physical rehabilitation intervention for individuals who required extracorporeal membrane oxygenation (ECMO) is associated with clinical outcomes and to assess whether the patient mobility response over initial rehabilitation sessions early in the intensive care unit (ICU) course predicts or is associated with survival, lengths of stay, discharge disposition, and 30-day readmissions.

METHODS

This study was a 10-year retrospective practice analysis of adults who were critically ill and required ECMO for >72 hours in the cardiothoracic ICU at an academic medical center. Physical rehabilitation implemented during or following the initiation of ECMO was quantified on the basis of timing, frequency, and change in mobility level in response to the intervention over the first 4 consecutive sessions. The primary dependent outcome was in-hospital mortality. Secondary outcomes included 30-day readmission and discharge disposition ranked on an ordinal scale.

RESULTS

Three hundred fifteen individuals (mean age = 50 years [SD = 15 years]; 63% men; mean Sequential Organ Failure Assessment score = 11.6 [SD = 3.3]) met the inclusion criteria. Two hundred eighteen individuals (69%) received at least 1 physical rehabilitation session while requiring ECMO, 70 (22%) received rehabilitation after ECMO was discontinued, and 27 (9%) never received rehabilitation. Individuals discharged alive achieved higher mobility levels and had a steeper, more positive rate of change in mobility over the first 4 sessions than individuals who died in the hospital (2.8 vs 0.38; degrees of freedom = 199, t = 8.24). Those who received rehabilitation and achieved the milestones of sitting on the edge of the bed and walking for >45 m were more likely to survive (47% vs 13%; χ2 = 156) than those who did not (26% vs 3.5%; χ2 = 80).

CONCLUSION

A positive rate of change in mobility and the ability to achieve mobility milestones with rehabilitation were associated with improved clinical outcomes.

IMPACT

An individual's mobility response to physical rehabilitation early in the ICU course is an important indicator of illness and should be used with clinical presentation to guide clinical decision-making and predict outcomes.

A Constructivist Grounded Theory of Staff Experiences Relating to Early Mobilisation of Mechanically Ventilated Patients in Intensive Care

Early mobilisation of mechanically ventilated patients has been suggested to be effective in mitigating muscle weakness, yet it is not a common practice. Understanding staff experiences is crucial to gain insights into what might facilitate or hinder its implementation. In this constructivist grounded theory study, data from two Scottish intensive care units were collected to understand healthcare staff experiences relating to early mobilisation in mechanical ventilation. Data included observations of mobilisation activities, individual staff interviews and two focus groups with multidisciplinary staff. Managing Risks emerged as the core category and was theorised using the concept of risk. The middle-range theory developed in this study suggests that the process of early mobilisation starts by staff defining patient status and includes a process of negotiating patient safety, which in turn enables performing accountable mobilisation within the dynamic context of an intensive care unit setting.

Physiotherapy Practice Pattern in the Adult Intensive Care Units of Singapore – A Multi-Centre Survey

Background

The roles of physiotherapy in Intensive Care Unit (ICU) have significantly developed from the traditional management of respiratory conditions to early rehabilitation and mobilisation of patients on mechanical ventilation. Surveys of United Kingdom, Australia and regional ICU physiotherapy practice have been published but there are no local data sets. This study aims to report the physiotherapy practices across the adult ICUs of Singapore.

Methods

Twenty-nine item questionnaire was mailed to 90 physiotherapists working in 15 adult ICUs across restructured and private hospitals in Singapore. Data sets were summarised from the returned questionnaires. This includes identifying common physiotherapy techniques and exercise prescription protocols for both mechanically and non-mechanically ventilated patients in the ICU.

Results

A total of 63 (70%) questionnaires were returned. The most used physiotherapy interventions were airway secretion clearance, techniques to improve lung ventilation and mobilisation out of bed. Positioning was most used respiratory technique (60/61, 98%). Sitting on the edge of bed is the most preferred physical activity for ICU patients (43/44, 98%). Exercise was routinely prescribed (50/61, 83%) although only a minority (8/50, 16%) have established exercise prescription protocols. For mechanically ventilated patients, active/active assisted exercises were most used (40/44, 91%). 12% of ICU use either Chelsea Critical Care Physical Assessment Tool or the Functional Status Score for the Intensive Care Unit as routine outcome measures.

Conclusion

Airway clearance was stated as the most used physiotherapy technique. Exercise is routinely prescribed in ICU. Validated outcome measures are only used by few.

Survey of Physiotherapy Practice in Ontario Cardiac Surgery Intensive Care Units

Purpose: This article describes current physiotherapy practice for critically ill adult patients requiring prolonged stays in critical care (> 3 d) after complicated cardiac surgery in Ontario. Method: We distributed an electronic, self-administered 52-item survey to 35 critical care physiotherapists who treat adult cardiac surgery patients at 11 cardiac surgical sites. Pilot testing and clinical sensibility testing were conducted beforehand. Participants were sent four email reminders. Results: The response rate was 80% (28/35). The median reported number of cardiac surgeries performed per week was 30 (interquartile range [IQR] 10), with a median number of 14.5 (IQR 4) cardiac surgery beds per site. Typical reported caseloads ranged from 6 to 10 patients per day per therapist, and 93% reported that they had initiated physiotherapy with patients once they were clinically stable in the intensive care unit. Of 28 treatments, range of motion exercises (27; 96.4%), airway clearance techniques (26; 92.9%), and sitting at the edge of the bed (25; 89.3%) were the most common. Intra-aortic balloon pump and extracorporeal membrane oxygenation appeared to limit physiotherapy practice. Use of outcome measures was limited. Conclusions: Physiotherapists provide a variety of interventions to critically ill cardiac surgery patients. Further evaluation of the limited use of outcome measures in the cardiac surgical intensive care unit is warranted.

Barriers and Facilitators to Early Rehabilitation in the ICU: A Theory Driven Delphi Study

OBJECTIVES

There is conflicting evidence for the effectiveness of early rehabilitation in the intensive care and marked variation in rates of implementation in practice. We aimed to identify barriers and facilitators to early rehabilitation in mechanically ventilated patients and their relevance to practice, as perceived by key ICU clinicians across North America.

DESIGN

A Delphi study using the Theoretical Domains Framework, consisting of an initial qualitative round and subsequent quantitative rounds, was conducted to gather clinician agreement and perceived importance of barriers and facilitators to early rehabilitation. The survey included questions on the range of individual, sociocultural, and broader organizational influence on behaviors.

SETTING

Clinical practice in North America.

SUBJECTS

Four clinician groups (intensive care physicians, nurses, therapists, and respiratory therapists).

INTERVENTIONS

A three-round Delphi study.

MEASUREMENTS AND MAIN RESULTS

Fifty of 74 (67%) of invited clinicians completed the study. Agreement and consensus with Delphi survey items were high in both rounds within and between professional groups. Agreement was highest for items related to the domain "Beliefs about Consequences" (e.g., mortality reduction) and lowest for items related to the domain "Behavioral Regulation" (e.g., team discussion of barriers). Beliefs expressed about improved mortality and improvements in a variety of other long-term outcomes were not consistent with the current evidence base. Individual agreement scores changed very little from Round 2 to Round 3 of the Delphi, suggesting stability of beliefs and existing consensus.

CONCLUSIONS

This study identified a wide range of beliefs about early rehabilitation that may influence provider behavior and the success and appropriateness of further implementation. The apparent inconsistency between the optimism of stakeholders regarding mortality reductions and a low level of implementation reported elsewhere represent the most major challenge to future implementation success. Other foci for future implementation work include planning, barriers, feedback, and education of staff.

Knowledge, Attitudes, and Perceived Barriers of Healthcare Providers toward Early Mobilization of Adult Critically Ill Patients in Intensive Care Unit

Background

Early mobilization (EM) of critically ill adult patients in intensive care units (ICUs) is a newer concept. It is known to improve overall outcomes, but little is known regarding the attitude and knowledge of healthcare providers (HCPs) and multidisciplinary barriers to its use in the Indian scenario.

Aims and objectives

To study the knowledge and attitude of HCPs in ICU about the EM of adult patients who are critically ill and identify perceived barriers to the application of EM.

Materials and methods

In a cross-sectional survey conducted in a tertiary care academic institute, the HCPs, namely, physicians, anesthetists, surgeons, nursing staff, and physiotherapists working in ICU were interviewed using a self-structured questionnaire. The data were presented as descriptive statistics.

Results

There was 80% response rate. The benefits of EM as shortened length of mechanical ventilation (MV) were acknowledged by 78% respondents and 54% believed that it maintains muscle strength. It was considered crucial by 44% respondents, who opined that it should be started as the patient's cardiorespiratory status stabilizes. The favorable attitudes observed were recognition of benefits for patients under MV exceeded the risks and readiness by physicians to reduce sedation levels and change the parameters of MV. The main barriers identified were the absence of written guidelines or protocols for EM, limited staff to mobilize patients, inadequate training of HCP to facilitate EM, excessive sedation, and medical instability.

Conclusion

There exists an awareness of the benefits of EM and favorable attitudes to its application. However, the actual performance of EM was perceived as a challenge due to barriers identified in the study.

How to cite this article

Akhtar PM, Deshmukh PK. Knowledge, Attitudes, and Perceived Barriers of Healthcare Providers toward Early Mobilization of Adult Critically Ill Patients in Intensive Care Unit. Indian J Crit Care Med 2021;25(5):512–518.

Impact of a Rehabilitation Protocol and a Dedicated Therapist in the Intensive Care Unit on Physical Function and Activities of Daily Living

Objectives:

The goal of this study was to determine the effects of an intensive care unit (ICU) rehabilitation protocol with dedicated therapists on the physical function and activities of daily living (ADL) of patients on discharge from the ICU.

Methods:

This retrospective study included patients who started rehabilitation during their ICU stay. Patients were divided into three groups: the Usual Care group (before the introduction of the rehabilitation protocol), the Protocol group (after the introduction of the rehabilitation protocol), and the PT + Protocol group (with a dedicated therapist in addition to the rehabilitation protocol). The standard interventions in the Protocol group and the PT + Protocol group were set according to the protocol based on the level of consciousness and strength of each individual patient. Patients’ age, APACHE II score, length of ICU stay, length of hospital stay, and the Functional Status Score for the ICU (FSS-ICU) and Medical Research Council score (MRC score) on discharge from the ICU were compared among the three groups.

Results:

There were no significant differences among the three groups in age and APACHE II score. The MRC and FSS-ICU scores were significantly higher in the PT + Protocol and Protocol groups than in the Usual Care group. Furthermore, the lengths of ICU stay and hospital stay were lower in the PT + Protocol group than in the Usual Care group.

Conclusions:

Introduction of the rehabilitation protocol improved the limb strength and ADL of patients. Moreover, the presence of dedicated therapists in addition to the protocol reduced the lengths of ICU and hospital stays.

What Interventions Do Physical Therapists Provide for Patients With Cardiorespiratory Conditions, Neurological Conditions, and Conditions Requiring Acute Hospital Care? A Systematic Review

OBJECTIVE

The aim of this systematic review was to determine what percentages of physical therapists provide interventions that are of high value, low value, or unknown value for cardiorespiratory conditions, neurological conditions, or conditions requiring acute hospital care. Whether an intervention was considered high or low value was determined by reference to guidelines or systematic reviews.

METHODS

Searches of numerous databases were performed by combining terms synonymous with "practice patterns" and "physical therapy" until April 2018. Studies that investigated what interventions physical therapists provide for any cardiorespiratory condition, neurological condition, or condition requiring acute hospital care through surveys and audits of clinical notes were included. Through the use of medians and interquartile ranges, the percentages of physical therapists who provided interventions that were of high value, low value, or unknown value were summarized.

RESULTS

Twenty-six studies were included. The median percentages of physical therapists who provided interventions of high, low, and unknown value for chronic obstructive pulmonary disease ranged from 78% to 96%, 67% to 100%, and 56% to 91%, respectively. These percentages ranged from 61% to 97%, 87% to 98%, and 83% to 98% for adults who were critically ill in intensive care units; 70% to 93%, 38% to 50%, and 8% to 95% before or after cardiac/thoracic surgery; 25% to 96%, 23% to 84%, and 96% for acute stroke; and 11% (high value) and 13% (unknown value) for Parkinson disease, respectively.

CONCLUSIONS

This review found patterns of physical therapist practice for cardiorespiratory conditions, neurological conditions, and conditions requiring acute hospital care that were both evidence based and not evidence based. A concern is that a substantial percentage of physical therapists provided interventions that were of low or unknown value despite the availability of high-value interventions.

IMPACT

This systematic review is the first, to our knowledge, to summarize the percentage of physical therapist treatment choices that were high versus low value for cardiorespiratory conditions, neurological conditions, and conditions requiring acute hospital care. The findings highlight areas of practice where low-value care could be replaced with high-value care-such as in the management of patients who have chronic obstructive pulmonary disease or who are in intensive care-and identify an urgent need to develop and test strategies to ensure that patients with these conditions receive the interventions most likely to improve their outcomes.

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

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

Early mobilisation in mechanically ventilated patients: a systematic integrative review of definitions and activities

Background

Mechanically ventilated patients often develop muscle weakness post-intensive care admission. Current evidence suggests that early mobilisation of these patients can be an effective intervention in improving their outcomes. However, what constitutes early mobilisation in mechanically ventilated patients (EM-MV) remains unclear. We aimed to systematically explore the definitions and activity types of EM-MV in the literature.

Methods

Whittemore and Knafl’s framework guided this review. CINAHL, MEDLINE, EMBASE, PsycINFO, ASSIA, and Cochrane Library were searched to capture studies from 2000 to 2018, combined with hand search of grey literature and reference lists of included studies. The Critical Appraisal Skills Programme tools were used to assess the methodological quality of included studies. Data extraction and quality assessment of studies were performed independently by each reviewer before coming together in sub-groups for discussion and agreement. An inductive and data-driven thematic analysis was undertaken on verbatim extracts of EM-MV definitions and activities in included studies.

Results

Seventy-six studies were included from which four major themes were inferred: (1) non-standardised definition, (2) contextual factors, (3) negotiated process and (4) collaboration between patients and staff. The first theme indicates that EM-MV is either not fully defined in studies or when a definition is provided this is not standardised across studies. The remaining themes reflect the diversity of EM-MV activities which depends on patients’ characteristics and ICU settings; the negotiated decision-making process between patients and staff; and their interdependent relationship during the implementation.

Conclusions

This review highlights the absence of an agreed definition and on what constitutes early mobilisation in mechanically ventilated patients. To advance research and practice an agreed and shared definition is a pre-requisite.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Early mobilization practices of mechanically ventilated patients: a 1-day point-prevalence study in southern Brazil

OBJECTIVES

To assess early mobilization practices of mechanically ventilated patients in southern Brazilian intensive care units (ICUs) and to identify barriers associated with early mobilization and possible complications.

METHODS

A prospective, observational, multicenter, 1-day point-prevalence study was conducted across 11 ICUs and included all mechanically ventilated adult patients. Hospital and ICU characteristics and patients' demographic data, the highest level of mobilization achieved in the 24 hours prior to the survey and related barriers, and complications that occurred during mobilization were collected in the hospital and the ICU.

RESULTS

A total of 140 patients were included with a mean age of 57±17 years. The median and interquartile range was 7 (3-17) days for the length of ICU stay to the day of the survey and 7 (3-16) days for the duration of mechanical ventilation (MV). The 8-level mobilization scale was classified into two categories: 126 patients (90%) remained in bed (level 1-3) and 14 (10%) were mobilized out of bed (level 4-8). Among patients with an endotracheal tube, tracheostomy, and noninvasive ventilation, 2%, 23%, and 50% were mobilized out of bed, respectively (p<0.001 for differences among the three groups). Weakness (20%), cardiovascular instability (19%), and sedation (18%) were the most commonly observed barriers to achieving a higher level of mobilization. No complications were reported.

CONCLUSIONS

In southern Brazilian ICUs, the prevalence of patient mobilization was low, with only 10% of all mechanically ventilated patients and only 2% of patients with an endotracheal tube mobilized out of bed as part of routine care.

The use of periodized exercise prescription in rehabilitation: a systematic scoping review of literature

OBJECTIVE

To describe the use of periodized exercise prescription with patients in the context of rehabilitation.

DATA SOURCE

The following databases were searched: The Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, CINAHL, ScienceDirect, PEDro, Web of Science, SPORTDiscus, SAGE and Google Scholar. Databases were searched from inception to March 2018.

RESULTS

The literature search yielded 1772 articles with 1755 being excluded leaving 17 articles in total for the full review. Methodological quality and internal validity of the included papers were lacking. The included studies failed to indicate in which phase rehabilitation had occurred. Programme structure relating to the use of a familiarization phase, sequencing of exercises and structuring of specific phases (i.e. macrocycle, mesocycle and microcycle) was not present and lacked consistency across the board.

CONCLUSION

Periodization models of exercise prescription are being used within a variety of population groups in the rehabilitation setting. Integration of periodization principles into a rehabilitation programme still however remains a challenge. Although there is a lack of consistency with regard to the structure and implementation of a periodized model of exercise prescription in the rehabilitation context, it seems to be an alternative way in which to prescribe exercise within the rehabilitation setting.

Out-of-bed mobilization of patients undergoing mechanical ventilation with orotracheal tubes: A survey study

PURPOSE

The aim of this study is to clarify intensive care unit (ICU)-level factors facilitating out-of-bed mobilization defined as a range of activities from sitting on edge of bed up to walking in mechanically ventilated patients with orotracheal tubes.

MATERIALS AND METHODS

We conducted a survey of all intensive care units (ICUs) certified by the Japanese Society of Intensive Care Medicine (excluding pediatric ICUs) as training facilities for intensivists.

RESULTS

We surveyed 294 ICUs, with a response rate of 57% (n = 168). A dedicated physical and/or occupational and/or speech therapy team was present in 34 ICUs (20%). In 86 ICUs (51%), mechanically ventilated patients with orotracheal tubes also routinely underwent out-of-bed mobilization, and 38 ICUs (23%) used a written mobilization protocol. Factors independently associated with routine out-of-bed mobilization were the presence of a dedicated therapist in the ICU (odds ratio [OR], 6.83; 95% confidence interval [CI], 2.17-21.50; p = 0.001) and a high intensity physician staffing (OR, 2.37; 95% CI, 1.03-5.51; p = 0.043).

CONCLUSIONS

Based on impression of professionals, the presence of dedicated therapist in the ICU, and the high intensity physician staffing are significantly associated with an increased rate of out-of-bed mobilization for mechanically ventilated patients with orotracheal tubes.

Progressive mobility program and technology to increase the level of physical activity and its benefits in respiratory, muscular system, and functionality of ICU patients: study protocol for a randomized controlled trial

Background

Enhanced mobility in the Intensive Care Unit (ICU) could minimize the negative effects of critical illness, such as declines in cognitive, muscular, respiratory, and functional capacity. We aim to compare the functional status at ICU discharge of patients who underwent a progressive mobilization protocol versus patients who received conventional physiotherapy. We also examine the level of physical activity in the ICU, the degree of pulmonary and muscle function, and the length of stay to analyze correlations between these variables.

Methods

This is a protocol for a randomized controlled trial with blind evaluation. Ninety-six ICU patients will be recruited from a single center and randomly assigned to a control group or an intervention group. To determine the level of protocol activity the patient will receive, the patients’ ability to participate actively and their muscle strength will be considered. The protocol consists of five phases, ranging from passive therapies to walking and climbing stairs. The primary outcome will be the functional status at ICU discharge, measured with the Barthel Index and the ICU Mobility Scale (IMS). Measured secondary outcomes will include the level of physical activity, maximal inspiratory and expiratory pressures, forced expiratory volume in 1 second, maximum voluntary ventilation, handgrip strength, surface electromyography of the lower limb muscles, and results of the Timed Up and Go and 2-Minute Walk tests. Evaluations will be made within 2 days of ICU discharge except for the level of activity, which will be evaluated daily. Physiological variables and activity level will be analyzed by chi-square and t tests, according to the intention-to-treat paradigm.

Discussion

Mobility and exercise in the ICU should be undertaken with intensity, quantity, duration, and frequency adjusted according to the patients’ status. The results of this study may contribute to new knowledge of early mobility in the ICU, activity level, and varying benefits in critical patients, directing new approaches to physiotherapeutic interventions in these patients.

Trial registration

Recruitment will begin in February 2017, and the expected completion date is August 2018. Patients are already being recruited.

ClinicalTrials.gov, ID: NCT02889146. Registered on 3 March 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2641-4) contains supplementary material, which is available to authorized users.

Barriers and facilitators to early rehabilitation in mechanically ventilated patients-a theory-driven interview study

Background

Despite a supportive evidence base and a push to implement, the uptake of early rehabilitation in critical care has been inconsistent. The objective of this study was to explore barriers and facilitators to early rehabilitation for critically ill patients receiving invasive mechanical ventilation.

Methods

Using the Theoretical Domains Framework (TDF) of behavior change, we conducted semi-structured interviews exploring barriers and facilitators to early rehabilitation among four purposively sampled ICU clinician groups (nurses, rehabilitation professionals, respiratory therapists, and physicians). The TDF is a comprehensive framework of 14 “construct domains,” synthesized from 33 theories of behavior that was developed to study determinants of behavior and to design interventions to improve evidence-based healthcare practice. A topic guide was developed and piloted based on the TDF and expert knowledge. Interviews were audio-recorded and transcribed verbatim. Transcripts were content analyzed by coding items into domains and then synthesized into more specific, over-arching themes or “beliefs.” An expert consensus group used structured decision rules to classify beliefs as high, moderate, or low in importance.

Results

We interviewed 40 stakeholders from the four clinician groups and identified 135 separate beliefs. Of these, 19 were classified as high, 40 as moderate, and 76 of low importance as barriers or facilitators. All beliefs classified as highly important fell within one of seven TDF domains: skills, social/professional role and identity, beliefs about capabilities, beliefs about consequences, environmental context/resources, social influences, and behavioral regulation. Beliefs of lower importance fell under the following seven domains: knowledge; optimism; reinforcement; intention; goals; memory, attention, and decision processes; and emotion. Quantitative differences in stated beliefs about early rehabilitation between professional groups were not common.

Conclusions

This study identified important barriers and facilitators to early rehabilitation in critical care patients. Domains identified as important should be considered when designing interventions to increase uptake of early rehabilitation.

Electronic supplementary material

The online version of this article (10.1186/s40560-018-0273-0) contains supplementary material, which is available to authorized users.

The scope of physiotherapy services provided in public ICUs in Greece: A pilot study

The aim of the present study was to determine the scope of physiotherapy services provided in Greek ICUs in Athens. A cross-sectional study was conducted with two postal questionnaires administered separately, one for ICU directors and one for ICU physiotherapists. Responses were received from 19 ICU directors and 103 physiotherapists employed in all the adult public mixed medical and surgical ICUs across Athens. The response rate for the survey completion was 100% for ICU directors and 68.7% for physiotherapists. The results showed a 1:50 to 1:12 range in the ratio of physiotherapists to ICU beds. Among the 19 ICUs, 15 (78.9%) employed physiotherapists on a rotational basis, while four (21.0%) retained them exclusively. On weekdays, all surveyed ICUs were covered by physiotherapists in the morning and 10/19 (52.6%) during the afternoon. On weekends, 12/19 (63.2%) of the surveyed ICUs reported physiotherapy care during the morning and 4/19 (21.0%) during both morning and afternoon. All 103 physiotherapists conducted airway clearance techniques and progressive mobilization, 92/103 (89.3%) were involved in extubating patients, 102/103 (99.0%) in passive and active range of motion exercises, and 61/103 (59.2%) in walking. In conclusion, all Greek ICUs in Athens surveyed had physiotherapy cover. The physiotherapists working in these ICUs in Athens were involved in respiratory care and mobilization.

Current rehabilitation practices in intensive care units: a preliminary survey by the Japanese Society of Education for Physicians and Trainees in Intensive Care (JSEPTIC) Clinical Trial Group

We conducted an internet survey targeting healthcare providers in intensive care units (ICUs) in Japan and received 318 responses. Eighteen percent of respondents replied that full-time physical therapists (PTs) exist in their ICUs. Practicing sitting upright or sitting in a chair is frequently performed, while standing and walking are occasionally performed for patients undergoing mechanical ventilation. However, only 16 % of respondents use staged rehabilitation protocols. This preliminary survey suggests that full-time involvement of PTs in the ICU and introduction of rehabilitation protocols may not be common in Japanese ICUs.

Early Mobilization of Mechanically Ventilated Patients

Critically ill patients requiring mechanical ventilation are least likely to be mobilized and, as a result, are at-risk for prolonged complications from weakness. The use of bed rest and sedation when caring for mechanically ventilated patients is likely shaped by historical practice; however, this review demonstrates early mobilization, with little to no sedation, is possible and safe. Assessing readiness for mobilization in context of progressing patients from passive to active activities can lead to long-term benefits and has been achievable with resource-efficient implementations and team work.

From Persuasion to Coercion: Responding to the Reluctant Patient in Rehabilitation

Early mobilization of patients while in hospital has been demonstrated to provide better outcomes for patients and use fewer resources. Physical therapy-based rehabilitation is central to achieving those goals. Successful rehabilitation requires that patient's and therapist's goals align, and this is commonly the case. However, occasionally, physical therapists will come across patients who are competent but reluctant to mobilize. This situation leaves the physical therapist in an ethical quandary: either accept the patient's right to refuse proposed treatment or utilize other strategies to encourage the patient to adhere to treatment. Practically, physical therapists will use a range of treatment pressures, including persuasion, offering incentives, inducements, possibly threatening or coercing, and even explicitly overriding the patient's wishes (compulsion). Deciding which treatment pressure is ethically acceptable involves the physical therapist balancing his or her therapeutic view of what is in a patient's best interests against the therapist's ethical responsibility to respect patient autonomy. This article evaluates some common strategies used by physical therapists to influence, persuade, or perhaps pressure patients to adhere to rehabilitation. The work of Szmukler and Appelbaum is utilized in analyzing treatment pressures. The authors conclude that there is a spectrum of treatment pressures, with some (persuasion and incentives) being more acceptable than others (threats and compulsion). As physical therapists balance health system pressures for rapid turnover of beds with obligations to benefit patients within limited reimbursement models, while respecting the patients' autonomy, they must be mindful of the effects of treatment pressure on patient care.

Mobilization of patients in neurological Intensive Care Units of India: A survey

Context:

The rehabilitation needs of the patients in neurological Intensive Care Units (ICUs) vary from that of a medical ICU patient. Early mobilization is known to improve the various neurological outcomes in patients admitted to neurological ICUs, although little is known about the practice pattern among physiotherapists. The mobilization practice pattern may vary significantly than that of developed countries due to the reasons of differences in training of professionals, availability of equipment, and financial assistance by health insurance.

Aim of the Study:

To study the current mobilization practices by the physiotherapists in neurological ICUs of India.

Subjects and Methods:

A cross-sectional survey was conducted with a content validated questionnaire about the mobilization practices. Online questionnaire was distributed to physiotherapists working in neurological ICUs of India. Descriptive statistics were used.

Results:

Out of 185 e-mails sent, 82 physiotherapists completed the survey (survey response rate = 44%). Eighty participants (97.6%) mentioned that the patients received some form of mobilization during the day. The majority of the physiotherapists (58.5%), “always” provided bed mobility exercises to their patients when it was found appropriate for the patients. Many physiotherapists (41.5%) used tilt table “sometimes” to introduce orthostatism for their patients.

Conclusion:

Mobilization in various forms is being practiced in the neurological ICUs of India. However, fewer mobilization sessions are conducted on weekends and night hours in Indian Neurological ICUs.

Early mobilization of critically ill adults: a survey of knowledge, perceptions and practices of Canadian physicians and physiotherapists

BACKGROUND

The promotion of early mobilization following critical illness is tempered by national reports of patient and institutional barriers to this approach. We carried out a survey to assess current knowledge, perceptions and practices of Canadian physicians and physiotherapists with respect to acquired weakness and early mobilization in adults in the intensive care unit (ICU).

METHODS

We conducted a cross-sectional, self-administered postal survey among critical care physicians and physiotherapists in all 46 academic ICUs in Canada in 2011-2012. To identify all physicians and physiotherapists working in the ICUs, we contacted division heads and senior physiotherapists by telephone or email. We designed, tested and administered a questionnaire with the following domains: knowledge of ICU-acquired weakness and early mobilization; personal views of, perceived barriers to and adequacy of technical skills for early mobilization; assessments for initiation of early mobilization and permissible activity levels by patient physiologic characteristics, diagnoses and therapies; staffing issues; and sedation practices.

RESULTS

The overall response rate was 71.3% (311/436); it was 64.2% (194/302) among physicians and 87.3% (117/134) among physiotherapists. A total of 214 respondents (68.8%) underestimated the incidence of ICU-acquired weakness in the general medical-surgical ICU population, and 186 (59.8%) stated they had insufficient knowledge or skills to mobilize patients receiving mechanical ventilation. Excessive sedation, medical instability, limited staffing, safety concerns, insufficient guidelines and insufficient equipment were common perceived barriers to early mobilization.

INTERPRETATION

Physicians and physiotherapists in the ICU underestimated the incidence of ICU-acquired weakness and felt inadequately trained to mobilize patients receiving mechanical ventilation. We identified multiple modifiable barriers to early mobilization at the institutional, health care provider and patient levels that need to be addressed when designing mobilization programs for critically ill adults.

Physiotherapy practice patterns in Intensive Care Units of Nepal: A multicenter survey

Context:

As physiotherapy (PT) is a young profession in Nepal, there is a dearth of insight into the common practices of physiotherapists in critical care.

Aims:

To identify the availability of PT services in Intensive Care Units (ICUs) and articulate the common practices by physiotherapists in ICUs of Nepal.

Settings and Design:

All tertiary care hospitals across Nepal with ICU facility via an exploratory cross-sectional survey.

Subjects and Methods:

An existing questionnaire was distributed to all the physiotherapists currently working in ICUs of Nepal with 2 years of experience. The survey was sent via E-mail or given in person to 86 physiotherapists.

Statistical Analysis Used:

Descriptive and inferential statistics according to nature of data.

Results:

The response rate was 60% (n = 52). In the majority of hospitals (68%), PT service was provided only after a physician consultation, and few hospitals (13%) had established hospital criteria for PT in ICUs. Private hospitals (57.1%) were providing PT service in weekends compared to government hospitals (32.1%) (P = 0.17). The likelihood of routine PT involvement varied significantly with the clinical scenarios (highest 71.2% status cerebrovascular accident, lowest 3.8% myocardial infarction, P < 0.001). The most preferred PT treatment was chest PT (53.8%) and positioning (21.2%) while least preferred was therapeutic exercise (3.8%) irrespective of clinical scenarios.

Conclusions:

There is a lack of regular PT service during weekends in ICUs of Nepal. Most of the cases are treated by physiotherapists only after physician's referral. The preferred intervention seems to be limited only to chest PT and physiotherapists are not practicing therapeutic exercise and functional mobility training to a great extent.

Overcoming barriers to the mobilisation of patients in an intensive care unit

We conducted a quality improvement project aimed at increasing the frequency of mobilisation in our ICU. We designed a four-part quality improvement project comprising: an audit documenting the baseline frequency of mobilisation; a staff survey evaluating perceptions of the barriers to mobilisation; identification of barriers that were amenable to change and implementation of strategies to address these; and a follow-up audit to determine their effectiveness. The setting was a tertiary care, urban, public hospital ICU in South Australia. All patients admitted to the ICU during the two audit periods were included in the audits, while all permanent/semi-permanent ICU staff were eligible for inclusion in the staff survey. We found that patient- and institution-related factors had the greatest impact on the mobilisation of patients in our ICU. Barriers identified as being amenable to change included insufficient staff education about the benefits of mobilisation, poor interdisciplinary communication and lack of leadership regarding mobilisation. Various strategies were implemented to address these barriers over a three-month period. Multivariable analyses showed that three out of four mobility outcomes did not significantly change between the baseline and follow-up audits, with a significant difference in favour of the baseline audit found for the fourth mobility outcome (maximum level of mobility). We concluded that implementing relatively simple measures to improve staff education, interdisciplinary communication and leadership regarding early progressive mobilisation was ineffective at improving mobility outcomes for patients in a large tertiary-level Australian ICU. Other strategies, such as changing sedation practices and/or increasing staffing, may be required to improve mobility outcomes of these patients.

Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations

OBJECTIVE

To develop evidence-based recommendations for effective and safe diagnostic assessment and intervention strategies for the physiotherapy treatment of patients in intensive care units.

METHODS

We used the EBRO method, as recommended by the 'Dutch Evidence Based Guideline Development Platform' to develop an 'evidence statement for physiotherapy in the intensive care unit'. This method consists of the identification of clinically relevant questions, followed by a systematic literature search, and summary of the evidence with final recommendations being moderated by feedback from experts.

RESULTS

Three relevant clinical domains were identified by experts: criteria to initiate treatment; measures to assess patients; evidence for effectiveness of treatments. In a systematic literature search, 129 relevant studies were identified and assessed for methodological quality and classified according to the level of evidence. The final evidence statement consisted of recommendations on eight absolute and four relative contra-indications to mobilization; a core set of nine specific instruments to assess impairments and activity restrictions; and six passive and four active effective interventions, with advice on (a) physiological measures to observe during treatment (with stopping criteria) and (b) what to record after the treatment.

CONCLUSIONS

These recommendations form a protocol for treating people in an intensive care unit, based on best available evidence in mid-2014.

Profile of patients and physiotherapy patterns in intensive care units in public hospitals in Zimbabwe: a descriptive cross-sectional study

Background

Physiotherapy is integral to patient management in the Intensive Care Unit. The precise role that physiotherapists play in the critical care differs significantly worldwide. The aim of the study was to describe the profile of patients and the current patterns of physiotherapy services delivered for patients admitted in the five public hospital intensive care units in Zimbabwe.

Methods

A prospective record review was performed and records of all consecutive patients admitted into the five units during a two months period were included in the analysis. The data was collected using a checklist and the following were recorded for each patient: 1) demographic information, 2) admission diagnoses, 3) surgery classification, 4) method and time of mechanical ventilation 5) physiotherapy techniques and frequency and 6) the length of stay.

Results

A total of 137 patients were admitted to five units during the study. The mean age of patients in the study was 36.0 years (SD = 16.6). A mortality rate of 17.5 % was observed with most of the patients being below the age of 45 years. The majority of the patients, 61(45 %) had undergone emergency surgery and were in the ICU for postoperative treatment, whilst only 19(14 %) were in the units for clinical treatment (non-surgical). On admission, 72(52.6 %) of the patients were on mechanical ventilation. The mean duration on mechanical ventilation for patients was 4.0 days (SD =2.7) and a length of stay in the unit of 4.5 days (SD = 3.0).

Of the patients who were admitted into the ICU 120 (87.6 %) had at least one session of physiotherapy treatment during their stay. The mean number of days physiotherapy treatment was received was 3.71 (SD = 3.14) days. The most commonly used physiotherapy techniques were active assisted limb movements (66.4 %), deep breathing exercises (65.0 %) and forced expiratory techniques (65.0 %).

Conclusion

A young population admitted in the ICU for post-surgical treatment was observed across all hospital ICUs. The techniques which were executed in Zimbabwean ICUs showed that the goal of the physiotherapy treatment was mainly to prevent and treat respiratory complications and a culture of promoting bed rest still existed.

Trial registration

PACTR201408000829202

[Early mobilization. Competencies, responsibilities, milestones]

BACKGROUND

Early mobilization is an evident, interprofessional concept to improve the outcome of intensive care patients. It reduces psychocognitive deficits and delirium and attenuates a general deconditioning, including atrophy of the respiratory pump and skeletal muscles. In this regard the interdisciplinary approach of early mobilization, taking into account different levels of mobilization, appears to be beneficial. The purpose of this study was to explore opinions on collaboration and tasks between different professional groups.

METHOD

During the 25th Bremen Conference on Intensive Medicine and Nursing on 20 February 2015, a questionnaire survey was carried out among the 120 participants of the German Early Mobilization Network meeting.

RESULTS

In all, 102 questionnaires were analyzed. Most participants reported on the interdisciplinarity of the approach, but none of the tasks and responsibilities concerning early mobilization can be assigned to a single professional group. The practical implementation of mobilizing orally intubated patients may require two registered nurses as well as a physical therapist. Implementation in daily practice seems to be heterogeneous.

CONCLUSIONS

There is no consensus regarding collaboration, competencies, and responsibilities with respect to early mobilization of intensive care patients. The approach to date has been characterized by a lack of interprofessional communication, which may lead to an inefficient use of the broad and varied base of knowledge and experienceof the different professions.

Discordance Between Distance Ambulated as Part of Usual Care and Functional Exercise Capacity in Survivors of Critical Illness Upon Intensive Care Discharge: Observational Study

BACKGROUND

People who have had a prolonged admission to an intensive care unit (ICU) commonly have profound debilitation and weakness. For the delivery of effective exercise training, an accurate assessment of exercise capacity is essential.

OBJECTIVE

The study objectives were to investigate how much ground-based walking is undertaken by inpatients recovering from critical illness within 1 week of discharge from an ICU and to evaluate the feasibility and safety of the Six-Minute Walk Test (6MWT) for this population.

DESIGN

This was an observational study.

METHODS

Within 1 week of discharge from the ICU, functional exercise capacity was measured with the 6MWT. The maximum distance ambulated on the ward in a single session as part of usual clinical management was extracted from the medical notes. The distance achieved during the 6MWT and the maximum distance ambulated on the ward were compared.

RESULTS

The participants (N=23) were survivors of a critical illness; their mean age was 57 years (SD=11). The median length of ICU stay was 11 days (interquartile range [IQR]=7). The mean 6-minute walk distance (6MWD) was 179 m (SD=101), and the maximum distance ambulated on the ward was 30 m (IQR=65). There was a moderate association between the distance participants ambulated on the ward and the 6MWD (r=.54). The maximum distance ambulated on the ward, expressed as a percentage of the 6MWD, was 29% (IQR=34%). Five participants (22%) experienced oxygen desaturation (oxygen saturation of <85%) and recovered within 1 minute of resting.

LIMITATIONS

The maximum distance ambulated on the ward was estimated with premeasured distances.

CONCLUSIONS

Most participants ambulated at a low percentage of their measured exercise capacity. The 6MWT appears to be a safe and useful test for inpatients recently discharged from the 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.

What are the hemodynamic and respiratory effects of passive limb exercise for mechanically ventilated patients receiving low-dose vasopressor/inotropic support?

Passive limb exercises (PLEs) are used widely in the management of unconscious patients and an early start is recommended. The aim of this study was to determine the effects of PLEs on hemodynamic and respiratory parameters in mechanically ventilated critically ill patients receiving low-dose vasopressor/inotropic support. The charts of 120 mechanically ventilated patients who underwent PLEs were evaluated retrospectively between January 2000 and July 2002. Patients were grouped on the basis of administration of vasopressor/inotropic support. Thirty-eight patients did not get vasopressor/inotropic support (group 1) and 82 patients received low-dose vasopressor/inotropic support (dopamine <10 μg/kg/min, noradrenaline/adrenaline <0.1; group 2). Central venous pressure, heart rate, mean arterial pressure, and oxygen saturation were recorded before and immediately after PLEs. After PLEs in group 1 patients, central venous pressure and mean arterial pressure values increased significantly, and in group 2 patients, central venous pressure increased significantly (P < .05). No statistically significant difference was observed in the rate of change of hemodynamic or respiratory parameters between the 2 groups after the PLEs (P > .05). This retrospective study confirmed that PLEs result in similar hemodynamic and respiratory changes in critically ill patients who received low-dose vasopressor/inotropic support versus those who do not.

Effect of Early Rehabilitation during Intensive Care Unit Stay on Functional Status: Systematic Review and Meta-Analysis

Background and Aim

Critically ill survivors may have functional impairments even five years after hospital discharge. To date there are four systematic reviews suggesting a beneficial impact for mobilisation in mechanically ventilated and intensive care unit (ICU) patients, however there is limited information about the influence of timing, frequency and duration of sessions. Earlier mobilisation during ICU stay may lead to greater benefits. This study aims to determine the effect of early rehabilitation for functional status in ICU/high-dependency unit (HDU) patients.

Design

Systematic review and meta-analysis. MEDLINE, EMBASE, CINALH, PEDro, Cochrane Library, AMED, ISI web of science, Scielo, LILACS and several clinical trial registries were searched for randomised and non-randomised clinical trials of rehabilitation compared to usual care in adult patients admitted to an ICU/HDU. Results were screened by two independent reviewers. Primary outcome was functional status. Secondary outcomes were walking ability, muscle strength, quality of life, and healthcare utilisation. Data extraction and methodological quality assessment using the PEDro scale was performed by primary reviewer and checked by two other reviewers. The authors of relevant studies were contacted to obtain missing data.

Results

5733 records were screened. Seven articles were included in the narrative synthesis and six in the meta-analysis. Early rehabilitation had no significant effect on functional status, muscle strength, quality of life, or healthcare utilisation. However, early rehabilitation led to significantly more patients walking without assistance at hospital discharge (risk ratio 1.42; 95% CI 1.17-1.72). There was a non-significant effect favouring intervention for walking distance and incidence of ICU-acquired weakness.

Conclusions

Early rehabilitation during ICU stay was not associated with improvements in functional status, muscle strength, quality of life or healthcare utilisation outcomes, although it seems to improve walking ability compared to usual care. Results from ongoing studies may provide more data on the potential benefits of early rehabilitation in critically ill patients.

Early mobilization practice in a single Brazilian intensive care unit

OBJECTIVES

To characterize the provision of early mobilization therapy in critically ill patients in a Brazilian medical intensive care unit (ICU) and to investigate the relationship between physical activity level and clinical outcomes.

METHODS

Intensive care unit and physiotherapy data were collected retrospectively from 275 consecutive patients. Here we report on the subset of patients (n = 120) who were mechanically ventilated during their ICU stay (age, 49 ± 18 years; Simplified Acute Physiology Score 3, 45 [25]).

RESULTS

Median (interquartile range) time of mechanical ventilation and ICU length of stay were 3 (4) and 8 (10) days, respectively. Intensive care unit and 1-year mortality were 31% and 50%, respectively. During the ICU stay, these patients all received respiratory physiotherapy and 90% (n = 108) received mobilization therapy. When intubated and ventilated, mobilization therapy was performed in 76% (n = 92) of the patients with no adverse events. The most common activity was in-bed exercises (55%), and the number of out-of-bed activities (sitting out of bed, standing, or walking) was small (29%) and more prevalent in patients with tracheostomy than with an endotracheal tube (27% × 2%, respectively).

CONCLUSION

In our Brazilian ICU, mobilization therapy in critically ill patients was safe and feasible; however, similar to other countries, in-bed exercises were the most prevalent activity. During mechanical ventilation, only a small percentage of activities involved standing or mobilizing away from the bed.

What is the role of the physiotherapist in paediatric intensive care units? A systematic review of the evidence for respiratory and rehabilitation interventions for mechanically ventilated patients

BACKGROUND

Physiotherapy in intensive care units (ICU) has traditionally focussed on the respiratory management of mechanically ventilated patients. Gradually, focus has shifted to include rehabilitation in adult ICUs, though evidence of a similar shift in the paediatric ICU (PICU) is limited.

OBJECTIVES

Review the evidence to determine the role of physiotherapists in the management of mechanically ventilated patients in PICU.

DATA SOURCES

A search was conducted of: PEDro, CINAHL, Medline, PubMed and the Cochrane Library.

ELIGIBILITY CRITERIA

Studies involving PICU patients who received physiotherapy while invasively ventilated were included in this review. Those involving neonatal or adult ICU patients, or patients on non-invasive or long-term ventilation, were not included in the study.

STUDY APPRAISAL

All articles were critically appraised by two reviewers and results were analysed descriptively.

RESULTS

Six studies on chest physiotherapy (CPT) met the selection criteria. Results support the use of the expiratory flow increase technique and CPT, especially manual hyperinflation and vibrations, for secretion clearance. Evidence does not support the routine use of either CPT or suction alone. No studies investigating rehabilitation in PICU met selection criteria.

LIMITATIONS

A lack of high level evidence was available to inform this review.

CONCLUSION

Evidence indicates that CPT is still the focus of physiotherapy intervention in PICU for mechanically ventilated patients, and supports its use for secretion clearance in this setting. PROSPERO register for systematic reviews (registration no. CRD42014009582).

Implementing and sustaining an early rehabilitation program in a medical intensive care unit: A qualitative analysis

PURPOSE

Early rehabilitation programs in a medical intensive care unit can improve patient outcomes, but clinicians face barriers in implementing and sustaining such programs. We sought to describe a multidisciplinary team perspective regarding how to implement and sustain a successful early rehabilitation program.

METHODS

Semistructured interviews were conducted with 20 staff and faculty who were involved in the early rehabilitation program at the Johns Hopkins Hospital Medical Intensive Care Unit. Transcripts were evaluated using the Consolidated Framework of Implementation Research Theory.

RESULTS

Four major constructs emerged as important, as follows: (1) necessary components, (2) implementation strategies, (3) perceived barriers, and (4) positive outcomes. All participants reported that staff buy-in was necessary, whereas having a multidisciplinary team with good communication among team members was reported as helpful by 90% of participants. The most common barrier reported was increased staff workload (80%). All participants (100%) noted improved patient outcomes as an important benefit, and 95% reported improved job satisfaction.

CONCLUSIONS

This qualitative study of a successful early rehabilitation program highlights the importance of assessing and engaging a multidisciplinary team before implementation and the positive outcomes of early rehabilitation on staff by improving job satisfaction and changing the culture of a hospital unit.

Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study

Introduction

The aim of this study was to investigate current mobilization practice, strength at ICU discharge and functional recovery at 6 months among mechanically ventilated ICU patients.

Method

This was a prospective, multi-centre, cohort study conducted in twelve ICUs in Australia and New Zealand. Patients were previously functionally independent and expected to be ventilated for >48 hours. We measured mobilization during invasive ventilation, sedation depth using the Richmond Agitation and Sedation Scale (RASS), co-interventions, duration of mechanical ventilation, ICU-acquired weakness (ICUAW) at ICU discharge, mortality at day 90, and 6-month functional recovery including return to work.

Results

We studied 192 patients (mean age 58.1 ± 15.8 years; mean Acute Physiology and Chronic Health Evaluation (APACHE) (IQR) II score, 18.0 (14 to 24)). Mortality at day 90 was 26.6% (51/192). Over 1,351 study days, we collected information during 1,288 planned early mobilization episodes in patients on mechanical ventilation for the first 14 days or until extubation (whichever occurred first). We recorded the highest level of early mobilization. Despite the presence of dedicated physical therapy staff, no mobilization occurred in 1,079 (84%) of these episodes. Where mobilization occurred, the maximum levels of mobilization were exercises in bed (N = 94, 7%), standing at the bed side (N = 11, 0.9%) or walking (N = 26, 2%). On day three, all patients who were mobilized were mechanically ventilated via an endotracheal tube (N = 10), whereas by day five 50% of the patients mobilized were mechanically ventilated via a tracheostomy tube (N = 18).

In 94 of the 156 ICU survivors, strength was assessed at ICU discharge and 48 (52%) had ICU-acquired weakness (Medical Research Council Manual Muscle Test Sum Score (MRC-SS) score <48/60). The MRC-SS score was higher in those patients who mobilized while mechanically ventilated (50.0 ± 11.2 versus 42.0 ± 10.8, P = 0.003). Patients who survived to ICU discharge but who had died by day 90 had a mean MRC score of 28.9 ± 13.2 compared with 44.9 ± 11.4 for day-90 survivors (P <0.0001).

Conclusions

Early mobilization of patients receiving mechanical ventilation was uncommon. More than 50% of patients discharged from the ICU had developed ICU-acquired weakness, which was associated with death between ICU discharge and day-90.

Clinical trial registration

ClinicalTrials.gov NCT01674608. Registered 14 August 2012.

A repeated measures, randomised cross-over trial, comparing the acute exercise response between passive and active sitting in critically ill patients

BACKGROUND

Early mobilisation of critically ill patients is safe and beneficial, but the metabolic cost of exercise remains unquantified. This study compared the acute exercise response in critically ill participants during passive and active sitting.

METHOD

We conducted a prospective, randomised, cross-over study, in ventilated patients receiving rehabilitative physiotherapy. Ten participants completed a passive chair transfer, or a sit on the edge of the bed, followed by the alternate exercise activity on the consecutive day. The primary outcome measure was oxygen consumption.

RESULTS

In comparison to resting supine, a passive chair transfer elicited no change in oxygen consumption, carbon dioxide production or minute ventilation; but mean arterial pressure (91.86 mmHg (95% CI 84.61 to 99.10) to 101.23 mmHg (95% CI 93.35 to 109.11) (p = 0.002)) and heart rate (89.13 bpm (95% CI 77.14 to 101.13) to 97.21 bpm (95% CI 81.22 to 113.20) (p = 0.008)) increased. Sitting on the edge of the bed resulted in significant increases in oxygen consumption (262.33 ml/min (95% CI 201.97 to 322.70) to 353.02 ml/min (95% CI 303.50 to 402.55), p = 0.002), carbon dioxide production (171.93 ml/min (95% CI 131.87 to 211.98) to 206.23 ml/min (95% CI 151.03 to 261.43), p = 0.026), minute ventilation (9.97 l/min (95% CI 7.30 to 12.65) to 12.82 l/min (95% CI 10.29 to 15.36), p < 0.001), mean arterial pressure (86.81 mmHg (95% CI 77.48 to 96.14) to 95.59 mmHg (95% CI 88.62 to 102.56), p = 0.034) and heart rate (87.60 bpm (95% CI 73.64 to 101.56) to 94.91 bpm (95% CI 79.57 to 110.25), p = 0.007). When comparing the 2 activities, sitting on the edge of the bed elicited a significantly larger increase in oxygen consumption (90.69 ml/min (95% CI 44.04 to 137.34) vs 14.43 ml/min (95% CI -27.28 to 56.14), p = 0.007) and minute ventilation (2.85 l/min (95% CI 1.70 to 3.99) vs 0.74 l/min (95% CI -0.92 to 1.56), p = 0.012).

CONCLUSION

Sitting on the edge of the bed is a more metabolically demanding activity than a passive chair transfer in critically ill patients.

Passive orthostatism (tilt table) in critical patients: Clinicophysiologic evaluation

PURPOSE

To assess the effects of passive orthostatism on various clinicophysiologic parameters of adult intensive care unit (ICU) patients, by daily placement on a tilt table.

MATERIALS AND METHODS

This prospective cohort study was performed in a general ICU. Twenty-three patients 18 years or older, intubated or tracheostomized, without sedation and under weaning from mechanical ventilation, were analyzed. All variables were evaluated at tilting of 30°, 45°, 60°, 75°, and 90°.

RESULTS

Glasgow Coma Scale increased during tilt in the first and second day, as well as Richmond Agitation-Sedation Scale. No significant differences were detected in the physiological parameters; however, there was a nonsignificant decrease on the mean arterial pressure at angles of 75° and 90°. The maximum inspiratory pressure significantly increased at 60° compared with 30° on day 1 of the intervention. No significant differences were observed for maximum expiratory pressure, rapid shallow breathing index, and the tidal volume.

CONCLUSION

A protocol with daily use of a tilt table for ICU patients is safe and improves the level of consciousness and inspiratory maximum pressure, without causing deleterious acute physiological effects.

Future of specialised roles in allied health practice: who is responsible?

Allied health professions have developed specialised advanced and extended scope roles over the past decade, for the benefit of patient outcomes, allied health professionals’ satisfaction and to meet labour and workforce demands. There is an essential need for formalised, widely recognised training to support these roles, and significant challenges to the delivery of such training exist. Many of these roles function in the absence of specifically defined standards of clinical practice and it is unclear where the responsibility for training provision lies. In a case example of physiotherapy practice in the intensive care unit, clinical placements and independence of practice are not core components of undergraduate physiotherapy degrees. Universities face barriers to the delivery of postgraduate specialised training and, although hospital physiotherapy departments are ideally placed, resources for training are lacking and education is not traditionally considered part of healthcare service providers’ core business. Substantial variability in training, and its evaluation, leads to variability in practice and may affect patient outcomes. Allied health professionals working in specialised roles should develop specific clinical standards of practice, restructure models of health care delivery to facilitate training, continue to develop the evidence base for their roles and target and evaluate training efficacy to achieve independent practice in a cost-effective manner. Healthcare providers must work with universities, the vocational training sector and government to optimise the ability of allied health to influence decision making and care outcomes for patients.

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.