Can Early Rehabilitation on the General Ward After an Intensive Care Unit Stay Reduce Hospital Length of Stay in Survivors of Critical Illness?: A Randomized Controlled Trial

Mobilisation of post-ICU patients - a crucial teamwork between physiotherapists and nurses at surgical wards: a qualitative study

PURPOSE

To describe experiences of the ward nurse in relation to extended physiotherapy and mobilising of post-ICU patients.

METHODS

Individual semi-structured interviews were conducted with 17 registered nurses working on surgical wards in a Swedish regional hospital. Qualitative content analysis was used to analyse the data. The study was reported according to the consolidated criteria for reporting qualitative research (COREQ).

RESULTS

The study findings are presented in three categories: challenges to mobilising post-ICU patients, shared responsibility facilitates mobilisation, and extended physiotherapy is beneficial for patients' wellbeing. Nurses stated that they lacked knowledge and skills to perform the safe mobilisation of post-ICU patients due to their complex medical history and needs. Collaboration with physiotherapists was perceived to facilitate mobilisation and to be beneficial for patients' wellbeing outcome.

CONCLUSIONS

The study indicates that post-ICU patients are at risk of remaining immobilised because ward nurses find mobilisation too complex to conduct without support from physiotherapists. Shared responsibility through multi-professional teamwork regarding patient rehabilitation is perceived as contributing the knowledge required to achieve safe mobilisation that enhances autonomy and physical ability in post-ICU patients.

Extended physiotherapy after Intensive Care Unit (ICU) stay: A prospective pilot study with a before and after design

OBJECTIVE

To examine whether extended compared to standard level of physiotherapy is feasible and has beneficial effects on physical function in ICU survivors.

METHODS

This prospective pilot study with a before and after design included patients discharged from ICU to a surgical ward. The comparison group were recruited between January and April 2019 and received standard level of physiotherapy. The intervention group were recruited between May and December 2019 and received extended physiotherapy, corresponding to 50% additional physiotherapist, working 4 hours per weekday. The intervention participants received an individual rehabilitation plan developed in collaboration with a ward-based physiotherapist, and an extended number of sessions provided by the extra resource included practicing individualized exercises, for example walking and stair climbing. Physical function was measured with the Chelsea Critical Care Physical Assessment tool (CPAx) at ICU discharge, during hospital stay and discharge. Group differences were analyzed using the Mann-Whitney U-test and Chi2 test.

RESULTS

Out of 46 eligible patients, 39 (85%) fulfilled the study (comparison n = 12, intervention n = 27) and were included in the final analyses. No adverse events occurred, and the attendance rate was high (98.5%). There were no statistically significant differences between the groups regarding physical function, hospital stay, and readmissions, but there were tendencies to better outcomes in all these parameters in favor of the intervention group. Additionally, patients in the intervention group had statistically significantly higher scores in the CPAx items "transferring from bed to chair" (median 5 vs 4, p = .039) and "stepping" (median 5 vs 4, p = .005) at hospital discharge.

CONCLUSION

This pilot study indicates that extended physiotherapy after ICU discharge is feasible and does not entail patient safety risks. However, determining the potential beneficial effects for the patients remains to be evaluated in a larger trial.

The effectiveness and safety of centralized early rehabilitation care for critically ill children with severe acquired brain injury: A retrospective cohort and implementation study

BACKGROUND

Most children with neurocritical illness are at risk of physical, neurocognitive, and psychosocial sequelae and need centralized early rehabilitation care.

OBJECTIVE

To identify the effectiveness and safety of centralized early rehabilitation care for children with severe acquired brain injury.

METHODS

This is a mixed methods study-an implementation study and single-center retrospective cohort study with historical control. All children with severe acquired brain injury hospitalized in a specialized rehabilitation center in a comprehensive tertiary pediatric hospital between September 2016 and August 2020 were included. Patients treated in the centralized early rehabilitation unit were compared to historical controls dispersed in the normal inpatient rehabilitation ward. The effectiveness outcomes were measured by the Pediatric Cerebral Performance Category (PCPC) scale and the incidence of newly onset comorbidities. The safety outcomes were indicated by the mortality rate and the incidence of unexpected referrals.

RESULTS

One hundred seventy-five patients were included. The delta PCPC scores of the first 4 weeks of inpatient rehabilitation in the intervention group were significantly lower than the control group (Z = -2.395, p = 0.017). The PCPC scores at 1 year in the intervention group were significantly reduced as compared to the control group (Z = -3.337, p = 0.001). The incidence of newly onset pneumonia/bronchitis was also decreased in the intervention group (χ2 = 4.517, p = 0.034). No death of patients was recorded, and there was no significant difference in unexpected referral rate between the two groups (χ2 = 0.374, p = 0.541).

CONCLUSIONS

The centralized pediatrics early rehabilitation unit is effective and safe for children with severe acquired brain injury. Further multicenter prospective implementation studies on effectiveness, safety, and economic evaluation are needed.

Hong Kong general ward nurses' experiences of transitional care for patients discharged from the intensive care unit: An inductive thematic analysis

OBJECTIVES

The aim of this study was to explore and better understand the experiences of Hong Kong general ward nurses who care for post-intensive care patients.

RESEARCH METHODOLOGY/DESIGN

Inductive thematic analysis and focus groups interviews were used in this study.

SETTING

A purposive sample of 20 ward-based registered nurses were recruited, formed five focus groups and interviewed online using video-conferencing media.

FINDINGS

The ward nurses in this study described the difficulties and challenges they experienced caring for the post-intensive care patient. Issues around workload and patient allocation figured highly along with a lack of education and training. Many felt scared and helpless when caring for these patients which significantly increased their anxiety. Some were compelled to spend more time with their other patients while others were so consumed with the post-ICU patient that they often neglected their other patients. The handover from the intensive care unit nurse was filled with trepidation and concern because of the level of information being handed-over was alien and complex to them so was the medications and the level of monitoring the intensive care unit nurse expected which was not often forthcoming on the ward simply because they didn't know what they were doing.

CONCLUSION

The findings of this study demonstrate that these ward-nurses found themselves in a difficult situation with trying to understand of the needs of the post-intensive care patient. A lack of support, a lack of education and an increased workload made this situation hard. One possible solution is the development and evaluation of a critical care outreach team to support ward-based decision-making. Combined with formal training and education around the acutely ill and /or the deteriorating patient would be a positive step forward.

IMPLICATIONS FOR CLINICAL PRACTICE

The post-intensive care patient poses significant challenges to ward nurses unfamiliar with the level of care they require. Unlike intensive care unit nurses whose focus is on survival and preventing deterioration, the ward nurse's attention is meeting the activities of daily living and progressing the patient's rehabilitation. One of the major obstacle experienced was at handover and the transferring of responsibility where the information conveyed was overly complex and to the ward nurse mostly irrelevant. For this, critical nurses must improve their proficiency at handover so that information is tailored to the needs of the ward environment. One way would be the development of a intensive care unit/Ward handover tool developed collaboratively so as maximise the priorities of care and improve patient outcome.

Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023)

Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.

Efficiency of the Japanese Hospitalist System for Patients with Urinary Tract Infection: A Propensity-matched Analysis

Objective The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example. Methods We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system. Results In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups. Conclusion The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.

Worse pre-admission quality of life is a strong predictor of mortality in critically ill patients

Objectives

In this study, we aimed to investigate whether quality of life (QoL) before intensive care unit (ICU) admission could predict ICU mortality in critically ill patients.

Patients and methods

Between January 2019 and April 2019, a total of 105 ICU patients (54 males, 51 females; mean age: 58 years; range, 18 to 91 years) from two ICUs of a tertiary care hospital were included in this cross-sectional, prospective study. Pre-admission QoL was measured by the Short Form (SF)-12- Physical Component Scores (PCS) and Mental Component Scores (MCS) and EuroQoL five-dimension, five-level scale (EQ-5D-5L) within 24 h of ICU admission and mortality rates were estimated.

Results

The overall mortality rate was 28.5%. Pre-admission QoL was worse in the non-survivors independent from age, sex, socioeconomic and education status, and comorbidities. During the hospitalization, the rate of sepsis and ventilator/hospital-acquired pneumonia were similar among the two groups (p>0.05). Logistic regression analysis adjusted for sex, age, education status, and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores showed that pre-admission functional status as assessed by the SF-12 MCS (odds ratio [OR]: 14,2; 95% confidence interval [CI]: 2.5-79.0), SF-12 PCS (OR: 10.6; 95% CI: 1.8-62.7), and EQ-5D-5L (OR: 8.0; 95% CI: 1.5-44.5) were found to be independently associated with mortality.

Conclusion

Worse pre-admission QoL is a strong predictor of mortality in critically ill patients. The SF-12 and EQ-5D-5L scores are both valuable tools for this assessment. Not only the physical status, but also the mental status before ICU admission should be evaluated in terms of QoL to better utilize ICU resources.

Implementation of early rehabilitation for critically ill children in China: A survey and narrative review of the literature

INTRODUCTION

The focus of this survey was to understand the current status of implementation of early rehabilitation for critically ill children in China. We also reviewed the available literature on this topic for further insights to inform its future development.

MATERIALS AND METHODS

We used a cross-sectional study design to survey tertiary hospitals nationwide. Questionnaires were distributed via the social media platform "WeChat Questionnaire Star" within the framework of the Rehabilitation Group of the Pediatrics Branch of the Chinese Medical Association. A narrative literature review on the implementation of the early rehabilitation for critically ill pediatric and/or adult patients was carried out.

RESULTS

A total of 202 valid questionnaires were received. About half (n = 105, 52.0%) of respondent hospitals reported that they implement early rehabilitation for critically ill children. Among these 105 hospitals, 28 implemented a continuous chain of early rehabilitation. A total of 24 hospitals had set up permanent specialized centralized early rehabilitation units for critically ill children.

IMPLICATIONS AND FUTURE DIRECTIONS

Early rehabilitation for critically ill children is not widely available in China and only a minority of hospitals implement a continuous chain of early rehabilitation. To improve this undesirable situation, we suggest creating a two-level integrated system comprising centralized early rehabilitation units and surrounding early rehabilitation networks within a region.

High-protein intake and early exercise in adult intensive care patients: a prospective, randomized controlled trial to evaluate the impact on functional outcomes

Background

We evaluated the efficacy of high protein intake and early exercise versus standard nutrition care and routine physiotherapy on the outcome of critically ill patients.

Methods

We randomized mechanically ventilated patients expected to stay in the intensive care unit (ICU) for 4 days. We used indirect calorimetry to determine energy expenditure and guide caloric provision to the patients randomized to the high protein and early exercise (HPE) group and the control group. Protein intakes were 1.48 g/kg/day and 1.19 g/kg/day medians respectively; while the former was submitted to two daily sessions of cycle ergometry exercise, the latter received routine physiotherapy. We evaluated the primary outcome physical component summary (PCS) score at 3 and 6 months) and the secondary outcomes (handgrip strength at ICU discharge and ICU and hospital mortality).

Results

We analyzed 181 patients in the HPE (87) and control (94) group. There was no significant difference between groups in relation to calories received. However, the amount of protein received by the HPE group was significantly higher than that received by the control group (p < 0.0001). The PCS score was significantly higher in the HPE group at 3 months (p = 0.01) and 6 months (p = 0.01). The mortality was expressively higher in the control group. We found an independent association between age and 3-month PCS and that between age and group and 6-month PCS.

Conclusion

This study showed that a high-protein intake and resistance exercise improved the physical quality of life and survival of critically ill patients.

Trial registration

Research Ethics Committee of Hospital São Domingos: Approval number 1.487.683, April 09, 2018. The study protocol was registered in ClinicalTrials.gov (NCT03469882, March 19,2018).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01492-6.

Cohort study on the prognosis of acute cerebral infarction in different circulatory systems at 1-year follow-up

Background

To evaluate the prognosis of acute cerebral infarction at 1-year follow-up in different circulation infarctions.

Methods

Clinical data of 858 consecutive patients with acute cerebral infarction were collected. Of the 858 cases, 21 (2.45%) were lost to follow-up and 837 completed follow-up and thus were enrolled in this study. At 1-year follow-up, death or moderate-to-severe dysfunction (modified Rankin Scale (mRS) ≥ 3 points) was regarded as the poor prognostic endpoint. Univariate analysis and multivariate logistic stepwise regression analysis were performed to assess the prognosis. The prediction probability of indicators was obtained for the multivariate model, and the receiver operating characteristic curve was delineated to calculate the area under the curve (AUC) to predict the fitness of the model.

Results

The older the age, the greater the probability of a poor prognosis. Patients with previous diabetes and cerebral infarction had a poor prognosis. The higher the National Institutes of Health Stroke Scale and mRS scores and the lower the Barthel index at admission, the worse the prognosis of the patients. The longer the hospital stay, the worse the prognosis of the patients. The prognosis of different circulation infarctions was different. The AUC of the multivariate model was AUC = 0.893, and the 95% confidence interval was 0.870–0.913, indicating a good fit. The prognosis of anterior circulation infarction (ACI) was worse than that of posterior circulation infarction (PCI) (P < 0.05). The prognosis of patients with ACI and PCI was not significantly different from that of patients with ACI or PCI alone (P > 0.05).

Conclusions

Diabetes, the Barthel index at admission and previous cerebral infarction are poor prognostic factors of acute cerebral infarction. The prognosis of ACI is worse than that of PCI. Different factors affect the prognosis of different circulatory system infarctions.

A comparative approach to quantifying provision of acute therapy services

This study aims to compare delivery of acute rehabilitation therapy using metrics reflecting distinct aspects of rehabilitation therapy services. Seven general medical-surgical hospitals in Illinois and Indiana prospectively collected rehabilitation therapy data. De-identified data on all patients who received any type of acute rehabilitation therapy (n = 35,449) were extracted and reported as aggregate of minutes of therapy services per discipline. Metrics included therapy types, total minutes, and minutes per day (intensity), as charted by therapists. Extended hospital stay was defined as a length of stay (LOS) longer than Medicare's geometric mean LOS. Discharge destination was coded as postacute care or home discharge. Substantial variability was observed in types, number of minutes, and intensity of therapy services by condition and hospital. The odds of an extended hospital stay increased with increased number of minutes, increased number of therapy types, and decreased with increased rehabilitation intensity. This comparative approach to assessing provision of acute therapy services reflect differential effects of service provision on LOS and discharge destination. Investigators, policymakers, and hospital administrators should examine multiple metrics of rehabilitation therapy provision when evaluating the impact of health care processes on patient outcomes.

Early mobilisation algorithm for the critical patient. Expert recommendations

INTRODUCTION

Intensive care unit (ICU)-acquired weakness is developed by 40%-46% of patients admitted to ICU. Different studies have shown that Early Mobilisation (EM) is safe, feasible, cost-effective and improves patient outcomes in the short and long term.

OBJECTIVE

To design an EM algorithm for the critical patient in general and to list recommendations for EM in specific subpopulations of the critical patient most at risk for mobilisation: neurocritical, traumatic, undergoing continuous renal replacement therapy (CRRT) and with ventricular assist devices (VAD) or extracorporeal membrane oxygenation (ECMO).

METHODOLOGY

Review undertaken in the Medline, CINAHL, Cochrane and PEDro databases of studies published in the last 10 years, providing EM protocols/interventions.

RESULTS

30 articles were included. Of these, 21 were on guiding EM in critical patients in general, 7 in neurocritical and/or traumatic patients, 1 on patients undergoing CRRT and 1 on patients with ECMO and/or VAD. Two figures were designed: one for decision-making, taking the ABCDEF bundle into account and the other with the safety criteria and mobility objective for each.

CONCLUSIONS

The EM algorithms provided can promote early mobilisation (between the 1st and 5th day from admission to ICU), along with aspects to consider before mobilisation and safety criteria for discontinuing it.

How to Increase Muscle Mass in Critically Ill Patients: Lessons Learned from Athletes and Bodybuilders

PURPOSE OF REVIEW

Decades of research on nutrition and exercise on athletes and bodybuilders has yielded various strategies to promote anabolism and improve muscle health and growth. We reviewed these interventions in the context of muscle loss in critically ill patients.

RECENT FINDINGS

For critically ill patients, ensuring optimum protein intake is important, potentially using a whey-containing source and supplemented with vitamin D and leucine. Agents like hydroxyl β-methylbutyrate and creatine can be used to promote muscle synthesis. Polyunsaturated fatty acids stimulate muscle production as well as have anti-inflammatory properties that may be useful in critical illness. Adjuncts like oxandralone promote anabolism. Resistance training has shown mixed results in the ICU setting but needs to be explored further with specific outcomes. Critically ill patients suffer from severe proteolysis during hospitalization as well as persistent inflammation, immunosuppression, and catabolism syndrome after discharge. High protein supplementation, ergogenic aids, anti-inflammatories, and anabolic adjuncts have shown potential in alleviating muscle loss and should be used in intensive care units to optimize patient recovery.

Rehabilitation to enable recovery from COVID-19: a rapid systematic review

OBJECTIVES

To establish the evidence for rehabilitation interventions tested in populations of patients admitted to ICU and critical care with severe respiratory illness, and consider whether the evidence is generalizable to patients with COVID-19.

METHODS

The authors undertook a rapid systematic review. Medline (via OvidSP), CINAHL Complete (via EBSCOhost), Cochrane Library, Cochrane Database of Systematic Reviews and CENTRAL (via Wiley), Epistemonikos (via Epistemonikos.org), PEDro (via pedro.org.au) and OTseeker (via otseeker.com) searched to 7 May 2020. The authors included systematic reviews, RCTs and qualitative studies involving adults with respiratory illness requiring intensive care who received rehabilitation to enhance or restore resulting physical impairments or function. Data were extracted by one author and checked by a second. TIDier was used to guide intervention descriptions. Study quality was assessed using Critical Skills Appraisal Programme (CASP) tools.

RESULTS

Six thousand nine hundred and three titles and abstracts were screened; 24 systematic reviews, 11 RCTs and eight qualitative studies were included. Progressive exercise programmes, early mobilisation and multicomponent interventions delivered in ICU can improve functional independence. Nutritional supplementation in addition to rehabilitation in post-ICU hospital settings may improve performance of activities of daily living. The evidence for rehabilitation after discharge from hospital following an ICU admission is inconclusive. Those receiving rehabilitation valued it, engendering hope and confidence.

CONCLUSIONS

Exercise, early mobilisation and multicomponent programmes may improve recovery following ICU admission for severe respiratory illness that could be generalizable to those with COVID-19. Rehabilitation interventions can bring hope and confidence to individuals but there is a need for an individualised approach and the use of behaviour change strategies. Further research is needed in post-ICU settings and with those who have COVID-19. Registration: Open Science Framework https://osf.io/prc2y.

Early mobilisation algorithm for the critical patient. Expert recommendations

INTRODUCTION

Intensive care unit (ICU)-acquired weakness is developed by 40%-46% of patients admitted to ICU. Different studies have shown that Early Mobilisation (EM) is safe, feasible, cost-effective and improves patient outcomes in the short and long term.

OBJECTIVE

To design an EM algorithm for the critical patient in general and to list recommendations for EM in specific subpopulations of the critical patient most at risk for mobilisation: neurocritical, traumatic, undergoing continuous renal replacement therapy (CRRT) and with ventricular assist devices (VAD) or extracorporeal membrane oxygenation (ECMO).

METHODOLOGY

Review undertaken in the Medline, CINAHL, Cochrane and PEDro databases of studies published in the last 10 years, providing EM protocols/interventions.

RESULTS

30 articles were included. Of these, 21 were on guiding EM in critical patients in general, 7 in neurocritical and/or traumatic patients, 1 on patients undergoing CRRT and 1 on patients with ECMO and/or VAD. Two figures were designed: one for decision-making, taking the ABCDEF bundle into account and the other with the safety criteria and mobility objective for each.

CONCLUSIONS

The EM algorithms provided can promote early mobilisation (between the 1^st and 5^th day from admission to ICU), along with aspects to consider before mobilisation and safety criteria for discontinuing it.

Effects of an acute care brain injury medicine continuity consultation service on health care utilization and rehabilitation outcomes

INTRODUCTION

Although general physiatry acute-care consultation services are commonplace and improve length of stay (LOS), the benefits of a subspecialty physiatric continuity consultation service targeting patients with severe brain injury have not been reported.

OBJECTIVES

Our primary objective was to characterize patient care recommendations from a Brain Injury Medicine (BIM) Continuity Consult Service, and to investigate the effects on acute-care LOS relative to brain injury patients receiving General Physical Medicine & Rehabilitation (PM&R) Consult Services. Our secondary objectives were to examine inpatient rehabilitation (IPR) health care utilization metrics and costs between groups and evaluate clinical improvements during IPR and discharge disposition.

DESIGN

Retrospective cohort comparison study.

SETTING

Academic medical center with level 1 trauma center.

PARTICIPANTS

Adults with severe brain injury admitted to a single-site acute-care facility and subsequently admitted to a single inpatient brain injury rehabilitation unit over the same time period.

PHYSIATRIC CARE MODELS

BIM Continuity Consult Service versus General PM&R Consult Service.

MAIN OUTCOME MEASURES

Acute-care LOS; unplanned discharges to acute-care.

RESULTS

Despite no major demographic or clinical group differences, the BIM Consult Service had more patient comorbidities than General PM&R Consult Service (17.5±5.3 versus 16±5.1;P = .04). BIM Consult Service patients spent fewer days in acute care (30±11.8 versus 36±22.8; P = .008), and early BIM consult (≤7 days after admission) was associated with shorter acute-care LOS (P < .002). IPR LOS was similar between groups when considering unplanned transfers. Unplanned transfers among General PM&R Consult Service patients occurred twice as frequently as in BIM Consult Service patients; average readmission costs were $2778 per patient on the BIM Consult Service and $6702 per patient on the General PM&R Consult Service. More BIM Consult Service (85.7%) than General PM&R Consult Service (27.3%) patients emerged from disorders of consciousness during IPR (P = .02).

CONCLUSIONS

BIM Continuity Consultation Services were associated with shorter acute-care LOS, fewer unplanned acute-care transfers, and an increased likelihood of emerging from a minimally conscious state during IPR.

[Effect of rehabilitation initiation timing in the intensive care unit on outcomes in patients with pneumonia]

Early rehabilitation in the intensive care unit is a promising component of post-intensive care syndrome (PICS) treatment and prevention. However, the optimal time to start mobilizing critically ill patients is still to be determined.

OBJECTIVE

To evaluate the effect of rehabilitation initiation timing on outcomes in patients with pneumonia.

MATERIAL AND METHODS

The study included 106 patients with pneumonia (27 patients with community-acquired pneumonia and 79 patients with early-onset healthcare associated pneumonia) who received daily rehabilitation treatment for at least 7 days in the intensive care unit. All patients were retrospectively assigned to the early rehabilitation (ER) group if rehabilitation treatment was started within the first 48 hours of admission to the intensive care unit or the delayed rehabilitation (DR) group if mobilization was not initiated within this time frame.

RESULTS

The baseline clinical and demographic characteristics of the patients did not differ between the groups. During rehabilitation, rates of catecholamine use and the psychiatric signs of PICS frequency were also comparable. The duration of mechanical ventilation was 1.5 times shorter in ER group patients than in DR group (8 vs. 6 days and 13 vs. 9 days, respectively; p=0.003). The ICU and hospital stay were also significantly shorter in ER group compared with the DR group (12 (9-16) vs. 19 (13-30), respectively; p<0.001; 23 (12) vs. 31 (13) as inpatients, respectively; p=0.005). Mortality and severe complications rate were comparable between the groups.

CONCLUSIONS

The earliest possible start of rehabilitation provided the patient's condition is stable, can reduce the duration of respiratory support and hospital stay for patients with pneumonia.

Survivors of Acute Lung Injury Have Greater Impairments in Strength and Exercise Capacity Than Survivors of Other Critical Illnesses as Measured Shortly After ICU Discharge

PURPOSE

To compare the physical function on ICU discharge in adults who survived an ICU admission for acute lung injury (ALI) with those admitted for a critical illness other than ALI.

MATERIALS AND METHODS

Two groups were recruited, (i) those who survived an ICU admission for ALI and, (ii) those who survived an ICU admission for a critical illness other than ALI. Within 7 days of discharge from ICU, in all participants, measures were collected of peripheral muscle strength, balance, walking speed and functional exercise capacity.

RESULTS

Recruitment was challenging and ceased prior to achieving the desired sample size. Participants with ALI (n = 22) and critical illness (n = 33) were of similar median age (50 vs. 57 yr, p = 0.09), sex proportion (males %, 45 vs. 58, p = 0.59) and median APACHE II score (21.5 vs. 23.0, p = 0.74). Compared with the participants with critical illness, those with ALI had lower hand grip (mean ± SD, 18 ± 9 vs. 13 ± 8 kg, p = 0.018) and shoulder flexion strength (10 ± 4 vs. 7 ± 3 kg, p = 0.047), slower 10-meter walk speed (median [IQR], 1.03 [0.78 to 1.14] vs. 0.78 [0.67 to 0.94] m/s, p = 0.039) and shorter 6-minute walk distance (265 [71 to 328] vs. 165 [53 to 220] m, p = 0.037). The Berg balance scores were similar in both groups.

CONCLUSIONS

Compared with survivors of a critical illness that is not ALI, those with ALI are likely to have greater physical impairment when measured shortly after discharge to the ward.

Rehabilitation of a Post-Intensive Care Unit Patient After Severe COVID-19 Pneumonia

The recent novel severe acute respiratory syndrome coronavirus 2 infection resulted in a coronavirus disease 2019 pandemic that significantly strained healthcare systems globally. The early wave of patients in Singapore with severe pneumonia requiring intensive care units are gradually being referred for post-critical illness management with our inpatient medical rehabilitation unit. There is growing information regarding the actual rehabilitation process for patients severely affected by coronavirus disease 2019. This case report shares experiences and challenges faced during rehabilitation of severe coronavirus disease 2019 pneumonia and post-intensive care syndrome. It also describes the post-discharge rehabilitation program in a setting of strict nationwide safe distancing and stay-home policies.

Assisted Walking Program on Walking Ability in In-Hospital Geriatric Patients: A Randomized Trial

OBJECTIVES

The main aim of this study was to evaluate if an individualized assisted walking program (IAWP) for hospitalized older patients could improve walking ability compared with usual geriatric care and rehabilitation.

DESIGN

A randomized controlled trial with an active control group, open labeled with parallel assignment was conducted between October 2018 and January 2020.

SETTING

Geriatric ward.

PARTICIPANTS

A total of 387 hospitalized patients (≥65 years) were randomly assigned to an intervention or control (usual-care) group.

INTERVENTION

The control group received usual hospital care. The intervention group received also an IAWP.

MEASUREMENTS

The primary endpoint was change in walking ability from hospital admission (considering both current and pre-admission status) to discharge, as assessed with the Braden Activity subscale measures. The secondary endpoint was the occurrence of in-hospital adverse events, such as complications of mobility, pressure ulcers, falls, pain and mortality, and the length of hospital stay. Intention-to-treat and per-protocol analyses were performed.

RESULTS

Baseline characteristics were similar between intervention and control groups. The intervention group, relative to the control group, had significantly improved walking ability at discharge (P < .001). There were no statistically significant differences between the groups in terms of in-hospital adverse events. No adverse effects were detected.

CONCLUSION

In in-hospital patients aged 65 and older, an IAWP improves walking ability at discharge.

The Association of a Frailty Index and Incident Delirium in Older Hospitalized Patients: An Observational Cohort Study

Introduction/Background

Frailty identifies patients that have vulnerability to stress. Acute illness and hospitalization are stressors that may result in delirium and further accelerate the negative consequences of frailty.

Purpose

The purpose of this study was to determine whether frailty, identified at hospital admission and as measured by a frailty index, is associated with incident delirium.

Methods

A retrospective, observational, cohort study was done at a Veterans hospital between January 2013 and March 2014. English-speaking patients over 55 years were eligible. Exclusion criteria included inability to complete baseline assessments due to pre-existing cognitive impairment, emergent surgery; and/or admission from a nursing home, pre-existing delirium, and those with psychiatric disease or substance use disorder.

Main Outcomes and Measures

Frailty index (FI) variables included cognitive screening, physical function and comorbidities. The FI was calculated as a proportion of possible deficits (range 0 to 1; higher scores indicate increased frailty). Incident delirium was measured daily by an expert clinician interview.

Results

A total of 247 patients were admitted and 218 met inclusion/exclusion criteria, with a mean age of 71.54 years (SD = 9.53 years) and were predominantly white (92.7%) and male (91.7%). Participants were grouped using FI ranges as non-frail (FI <0.25, n=56 (26%)), pre-frail (FI =0.25–0.35, n=86 (39%)), and frail (FI >0.35, n=76 (35%)). Pre-frailty and frailty were associated with incident delirium (non-frail: 3.6% vs pre-frail: 20.9% vs frail: 29.3%, p=0.001) and total delirium days (mean day =non-frail 0.04 vs pre-frail 0.35 vs frail 0.57, p=0.003). After adjustment for sociodemographic factors, pre-frail (adjusted OR=5.64, 95% CI: 1.23, 25.99) and frail status (adjusted OR=6.80, 95% CI: 1.38, 33.45) were independently associated with delirium.

Conclusion

This study demonstrates that a frailty index is independently associated with incident delirium and suggests that admission assessments for frailty may identify patients at high risk of developing delirium.

Advances in the rehabilitation of intensive care unit acquired weakness: A case report on the promising use of robotics and virtual reality coupled to physiotherapy

INTRODUCTION

Traditional physiotherapy is currently the best approach to manage patients with intensive care unit acquired weakness (ICUAW). We report on a patient with ICUAW, who was provided with an intensive, in-patient regimen, that is, conventional plus robot-assisted physiotherapy. Aim of this case study was to assess the efficacy of a combined approach (conventional plus robot-assisted physiotherapy), on muscle strength, overall mobility, and disability burden in a patient with ICUAW in post-ICU intensive rehabilitation setting.

PATIENT CONCERNS

A 56-years-old male who was unable to stand and walk independently after hospitalization in an Intensive Care Unit. He initially was provided with daily sessions of conventional physiotherapy for 2 months, with mild results.

DIAGNOSIS

The patient was affected by ICUAW.

INTERVENTION

Given that the patient showed a relatively limited improvement after conventional physiotherapy, he was provided with daily sessions of robot-aided training for upper and lower limbs and virtual reality-aided rehabilitation for other 4 months, beyond conventional physiotherapy.

OUTCOMES

At the discharge (6 months after the admission), the patient reached the standing station and was able to ambulate with double support.

CONCLUSIONS

Our case suggests that patients with ICUAW should be intensively treated in in-patient regimen with robot-aided physiotherapy. Even though our approach deserves confirmation, the combined rehabilitation strategy may offer some advantage in maximizing functional recovery and containing disability.

Impact of the Hospitalist System in Japan on the Quality of Care and Healthcare Economics

Objective The hospitalist system is considered successful with respect to the quality of care and cost effectiveness in the United States. Studies have consistently demonstrated an improved clinical efficiency with this system. In Japan, however, the efficacy of the hospitalist system has not yet been examined. As a "super-aged society", Japan has a high number of elderly patients with multiple comorbidities who may theoretically receive better care by the hospitalist system than by the conventional system. This study investigates the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population. Methods We analyzed 274 patients ≥65 years of age in whom the most resource-consuming diagnosis at admission was aspiration pneumonia over a 1-year period. We categorized patients as those managed by hospitalists and those managed by various departments (control group) and compared the groups. Propensity score matching was used to minimize selection bias. Results For matched pairs, the length of hospital stay in the hospitalist group was shorter than that in the control group. Care by the hospitalist system was associated with significantly lower hospital costs. The quality of care (rate of switching from intravenous to oral antibiotics, duration of antibiotics therapy, number of chest X-rays and blood tests during hospitalization) was also considered to be favorably impacted by the hospitalist system. There was no statistically significant difference in the mortality rate or readmission rate between the groups. Conclusion This study showed that the hospitalist system had a favorable impact on the quality of care and cost effectiveness, suggesting the potential utility of its implementation in the Japanese medical system.

Evaluation of a technology assisted physical activity intervention among hospitalised patients: A randomised study

BACKGROUND

Physical inactivity is common during hospitalisation and poses a threat to functional capacity and independency in the elderly.

AIM

We aimed to assess the effect of physical activity measurements with visual feedback about time spent in various activities on the average daily time spent out of bed during hospitalisation.

METHODS

We recorded physical activity during hospitalisation by accelerometers and compared the effect of the visual feedback (intervention) with no feedback (control) on time spent out of bed. Patients admitted to the pulmonary ward were invited and assigned to intervention with feedback or control with no feedback in 6 alternating waves of approximately 18 patients each. The order of feedback/no feedback was randomised at the outset of the study. The visual feedback intervention group was provided with visual feedback of the daily time spent in bed, sitting, standing, and walking. The control group did not receive feedback.

RESULTS

93 patients completed the study with a median length of stay of 5 days. Across all patients there were no statistically significant group differences in daily time out of bed; however, patients with independent mobility spent 51 minutes (95% CI 0 to 102; P = .049) more out of bed when provided with visual feedback compared to no feedback.

CONCLUSIONS

A simple technology assisted physical activity intervention with visual feedback to encourage mobility was not effective at increasing time spent out of bed among hospitalised patients. With feedback, a subgroup of patients with independent walking abilities increased time out of bed and may benefit from this type of intervention.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01945749.

The effect of early mobilization in critically ill patients: A meta-analysis

BACKGROUND

The aim of this meta-analysis was to assess if early mobilization and rehabilitation in the intensive care unit (ICU) could reduce ICU-acquired weakness (ICU-AW), improve functional recovery, improve muscle strength, shorten the length of ICU and hospital stays, and reduce the mortality rate.

METHODS

A comprehensive literature search in PubMed, Embase, Web of Science, SinoMed (Chinese BioMedical Literature Service System, China), and National Knowledge Infrastructure, China (CNKI) was performed. Results were expressed as a risk ratio (RR) with 95% confidence intervals (95% CIs) or weight mean difference (WMD) with 95% CIs. Pooled estimates were calculated using a fixed-effects or random-effects model according to the heterogeneity among studies.

RESULTS

Fifteen randomized controlled trials involving a total of 1941 patients were included in this meta-analysis. Pooled estimates suggested that early mobilization significantly reduced the incidence of ICU-AW (RR = 0.49, 95% CI: 0.26, 0.91; P = .025), shortened the length of ICU (WMD = -1.82 days, 95% CI: -2.88, -0.76; P = .001) and hospital (WMD = -3.90 days, 95% CI: -5.94, -1.85; P < .001) stays, and improved the Medical Research Council score (WMD = 4.47, 95% CI: 1.43, 7.52; P = .004) and Barthel Index score at hospital discharge (WMD = 21.44, 95% CI: 10.97, 31.91; P < .001). Moreover, early mobilization also decreased complications such as deep vein thrombosis (RR = 0.16, 95% CI: 0.04, 0.59; P = .006), ventilator-associated pneumonia (RR = 0.26, 95% CI: 0.11, 0.63; P = .003), and pressure sores (RR = 0.14, 95% CI: 0.04, 0.44; P = .001). However, early mobilization did not reduce the ICU mortality rate (RR = 1.31, 95% CI: 0.97, 1.76; P = .074), improve the handgrip strength (WMD = 4.03 kg, 95% CI: -0.68, 8.74; P = .094), and shorten the duration of mechanical ventilation (WMD = 0.20 days, 95% CI: -0.10, 0.50; P = .194).

CONCLUSION

This study indicated that early mobilization was effective in preventing the occurrence of ICU-AW, shortening the length of ICU and hospital stay, and improving the functional mobility. However, it had no effect on the ICU mortality rate and ventilator-free days.

RELEVANCE TO CLINICAL PRACTICE

ICU-AW is a common neuromuscular complication of critical illness, and it is predictive of adverse outcomes. Early mobilization of critically ill patients is a candidate intervention to reduce the incidence and severity of ICU-AW. Some clinical studies have demonstrated this, whereas others found opposite results. The aim of our study is to assess if early mobilization and rehabilitation in the ICU could reduce the ICU-AW, improve functional recovery, improve muscle strength, shorten length of ICU and hospital stay, and reduce the mortality rate.

Defining anabolic resistance: implications for delivery of clinical care nutrition

PURPOSE OF REVIEW

Skeletal muscle mass with aging, during critical care, and following critical care is a determinant of quality of life and survival. In this review, we discuss the mechanisms that underpin skeletal muscle atrophy and recommendations to offset skeletal muscle atrophy with aging and during, as well as following, critical care.

RECENT FINDINGS

Anabolic resistance is responsible, in part, for skeletal muscle atrophy with aging, muscle disuse, and during disease states. Anabolic resistance describes the reduced stimulation of muscle protein synthesis to a given dose of protein/amino acids and contributes to declines in skeletal muscle mass. Physical inactivity induces: anabolic resistance (that is likely exacerbated with aging), insulin resistance, systemic inflammation, decreased satellite cell content, and decreased capillary density. Critical illness results in rapid skeletal muscle atrophy that is a result of both anabolic resistance and enhanced skeletal muscle breakdown.

SUMMARY

Insofar as atrophic loss of skeletal muscle mass is concerned, anabolic resistance is a principal determinant of age-induced losses and appears to be a contributor to critical illness-induced skeletal muscle atrophy. Older individuals should perform exercise using both heavy and light loads three times per week, ingest at least 1.2 g of protein/kg/day, evenly distribute their meals into protein boluses of 0.40 g/kg, and consume protein within 2 h of retiring for sleep. During critical care, early, frequent, and multimodal physical therapies in combination with early, enteral, hypocaloric energy (∼10-15 kcal/kg/day), and high-protein (>1.2 g/kg/day) provision is recommended.

Optimized calorie and high protein intake versus recommended caloric-protein intake in critically ill patients: a prospective, randomized, controlled phase II clinical trial

OBJECTIVE

To evaluate differences in outcomes for an optimized calorie and high protein nutrition therapy versus standard nutrition care in critically ill adult patients.

METHODS

We randomized patients expected to stay in the intensive care unit for at least 3 days. In the optimized calorie and high protein nutrition group, caloric intake was determined by indirect calorimetry, and protein intake was established at 2.0 to 2.2g/kg/day. The control group received 25kcal/kg/day of calories and 1.4 to 1.5g/kg/day protein. The primary outcome was the physical component summary score obtained at 3 and 6 months. Secondary outcomes included handgrip strength at intensive care unit discharge, duration of mechanical ventilation and hospital mortality.

RESULTS

In total, 120 patients were included in the analysis. There was no significant difference between the two groups in calories received. However, the amount of protein received by the optimized calorie and high protein nutrition group was significantly higher compared with the control group. The physical component summary score at 3 and 6 months did not differ between the two groups nor did secondary outcomes. However, after adjusting for covariates, a negative delta protein (protein received minus predetermined protein requirement) was associated with a lower physical component summary score at 3 and 6 months postrandomization.

CONCLUSION

In this study optimized calorie and high protein strategy did not appear to improve physical quality of life compared with standard nutrition care. However, after adjusting for covariates, a negative delta protein was associated with a lower physical component summary score at 3 and 6 months postrandomization. This association exists independently of the method of calculation of protein target.

Psychocognitive sequelae of critical illness and correlation with 3 months follow up

PURPOSE

Over a third of critical illness survivors manifest significant psychocognitive impairments following discharge from the intensive care unit (ICU). It is not known which patient populations are at highest risk or if assessment at ICU discharge can guide outpatient treatment prioritization.

MATERIALS AND METHODS

Prospective single center study in an academic medical center encompassing six types of ICUs assessed prevalence of psychocognitive morbidity based on ICU type and associations between initial and 3 month follow-up evaluation. Adult patients with >48 h ICU stays completed the Hospital Anxiety and Depression Scale (HADS), Impact of Events Scale-Revised (IES-R), and Montreal Cognitive Assessment-Blind (MoCA-blind).

RESULTS

Of 299 patients who underwent initial assessment, 174 (58%) completed follow-up. Length of stay, MoCA-Blind, HADS-A/D and IES-R scores were similar across ICUs. Most commonly observed impairment in-hospital was cognitive (58%) followed by anxiety (45%), acute stress (39%) and depression (37%). There were significant correlations between in-hospital and follow-up psychocognitive outcomes.

CONCLUSIONS

There was no significant difference in impairment by ICU type. Significant correlation between the initial assessment and follow-up scores suggests that early screening of high risk patients may identify those at greatest risk of sustained morbidity and facilitate timely intervention.

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.

Effect of Exercise Intervention on Functional Decline in Very Elderly Patients During Acute Hospitalization: A Randomized Clinical Trial

IMPORTANCE

Functional decline is prevalent among acutely hospitalized older patients. Exercise and early rehabilitation protocols applied during acute hospitalization can prevent functional and cognitive decline in older patients.

OBJECTIVE

To assess the effects of an innovative multicomponent exercise intervention on the functional status of this patient population.

DESIGN, SETTING, AND PARTICIPANTS

A single-center, single-blind randomized clinical trial was conducted from February 1, 2015, to August 30, 2017, in an acute care unit in a tertiary public hospital in Navarra, Spain. A total of 370 very elderly patients undergoing acute-care hospitalization were randomly assigned to an exercise or control (usual-care) intervention. Intention-to-treat analysis was conducted.

INTERVENTIONS

The control group received usual-care hospital care, which included physical rehabilitation when needed. The in-hospital intervention included individualized moderate-intensity resistance, balance, and walking exercises (2 daily sessions).

MAIN OUTCOMES AND MEASURES

The primary end point was change in functional capacity from baseline to hospital discharge, assessed with the Barthel Index of independence and the Short Physical Performance Battery (SPPB). Secondary end points were changes in cognitive and mood status, quality of life, handgrip strength, incident delirium, length of stay, falls, transfer after discharge, and readmission rate and mortality at 3 months after discharge.

RESULTS

Of the 370 patients included in the analyses, 209 were women (56.5%); mean (SD) age was 87.3 (4.9) years. The median length of hospital stay was 8 days in both groups (interquartile range, 4 and 4 days, respectively). Median duration of the intervention was 5 days (interquartile range, 0); there was a mean (SD) of 5 (1) morning and 4 (1) evening sessions per patient. No adverse effects were observed with the intervention. The exercise intervention program provided significant benefits over usual care. At discharge, the exercise group showed a mean increase of 2.2 points (95% CI, 1.7-2.6 points) on the SPPB scale and 6.9 points (95% CI, 4.4-9.5 points) on the Barthel Index over the usual-care group. Hospitalization led to an impairment in functional capacity (mean change from baseline to discharge in the Barthel Index of -5.0 points (95% CI, -6.8 to -3.2 points) in the usual-care group, whereas the exercise intervention reversed this trend (1.9 points; 95% CI, 0.2-3.7 points). The intervention also improved the SPPB score (2.4 points; 95% CI, 2.1-2.7 points) vs 0.2 points; 95% CI, -0.1 to 0.5 points in controls). Significant intervention benefits were also found at the cognitive level of 1.8 points (95% CI, 1.3-2.3 points) over the usual-care group.

CONCLUSIONS AND RELEVANCE

The exercise intervention proved to be safe and effective to reverse the functional decline associated with acute hospitalization in very elderly patients.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02300896.

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.

Effect of In-Bed Leg Cycling and Electrical Stimulation of the Quadriceps on Global Muscle Strength in Critically Ill Adults: A Randomized Clinical Trial

IMPORTANCE

Early in-bed cycling and electrical muscle stimulation may improve the benefits of rehabilitation in patients in the intensive care unit (ICU).

OBJECTIVE

To investigate whether early in-bed leg cycling plus electrical stimulation of the quadriceps muscles added to standardized early rehabilitation would result in greater muscle strength at discharge from the ICU.

DESIGN, SETTING, AND PARTICIPANTS

Single-center, randomized clinical trial enrolling critically ill adult patients at 1 ICU within an 1100-bed hospital in France. Enrollment lasted from July 2014 to June 2016 and there was a 6-month follow-up, which ended on November 24, 2016.

INTERVENTIONS

Patients were randomized to early in-bed leg cycling plus electrical stimulation of the quadriceps muscles added to standardized early rehabilitation (n = 159) or standardized early rehabilitation alone (usual care) (n = 155).

MAIN OUTCOMES AND MEASURES

The primary outcome was muscle strength at discharge from the ICU assessed by physiotherapists blinded to treatment group using the Medical Research Council grading system (score range, 0-60 points; a higher score reflects better muscle strength; minimal clinically important difference of 4 points). Secondary outcomes at ICU discharge included the number of ventilator-free days and ICU Mobility Scale score (range, 0-10; a higher score reflects better walking capability). Functional autonomy and health-related quality of life were assessed at 6 months.

RESULTS

Among 314 randomized patients, 312 (mean age, 66 years; women, 36%; receiving mechanical ventilation at study inclusion, 78%) completed the study and were included in the analysis. The median global Medical Research Council score at ICU discharge was 48 (interquartile range [IQR], 29 to 58) in the intervention group and 51 (IQR, 37 to 58) in the usual care group (median difference, -3.0 [95% CI, -7.0 to 2.8]; P = .28). The ICU Mobility Scale score at ICU discharge was 6 (IQR, 3 to 9) in both groups (median difference, 0 [95% CI, -1 to 2]; P = .52). The median number of ventilator-free days at day 28 was 21 (IQR, 6 to 25) in the intervention group and 22 (IQR, 10 to 25) in the usual care group (median difference, 1 [95% CI, -2 to 3]; P = .24). Clinically significant events occurred during mobilization sessions in 7 patients (4.4%) in the intervention group and in 9 patients (5.8%) in the usual care group. There were no significant between-group differences in the outcomes assessed at 6 months.

CONCLUSIONS AND RELEVANCE

In this single-center randomized clinical trial involving patients admitted to the ICU, adding early in-bed leg cycling exercises and electrical stimulation of the quadriceps muscles to a standardized early rehabilitation program did not improve global muscle strength at discharge from the ICU.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02185989.

Physical Rehabilitation Core Outcomes In Critical illness (PRACTICE): protocol for development of a core outcome set

Background

Existing data on physical rehabilitation interventions in critical illness are challenged by outcome heterogeneity that limits data synthesis and translation of research findings into clinical practice. This protocol describes the PRACTICE study to develop a core outcome set (COS) for trials of physical rehabilitation interventions delivered across the continuum of a patient’s recovery from the intensive care unit until reintegration in the community following hospital discharge.

Methods

Mixed methods will be used including: systematic reviews of quantitative and qualitative literature; qualitative interviews with patients and caregivers; a modified Delphi consensus process with researcher, clinician and patient/caregiver stakeholder groups; and consensus meetings for ratification of findings, resolving uncertainty, or developing an action plan for COS implementation.

Discussion

The PRACTICE COS will inform relevant stakeholders about important outcomes regarding physical rehabilitation in critical illness, and may enhance the future design and conduct of trials in this area.

Trial registration

COMET database (www.comet-initiative.org/, Record ID 288, 01/03/13). PROSPERO database (CRD42014008908, CRD42017078549).

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2678-4) contains supplementary material, which is available to authorized users.

Analysis of length of hospital stay using electronic health records: A statistical and data mining approach

Background

The length of stay (LOS) is an important indicator of the efficiency of hospital management. Reduction in the number of inpatient days results in decreased risk of infection and medication side effects, improvement in the quality of treatment, and increased hospital profit with more efficient bed management. The purpose of this study was to determine which factors are associated with length of hospital stay, based on electronic health records, in order to manage hospital stay more efficiently.

Materials and methods

Research subjects were retrieved from a database of patients admitted to a tertiary general university hospital in South Korea between January and December 2013. Patients were analyzed according to the following three categories: descriptive and exploratory analysis, process pattern analysis using process mining techniques, and statistical analysis and prediction of LOS.

Results

Overall, 55% (25,228) of inpatients were discharged within 4 days. The department of rehabilitation medicine (RH) had the highest average LOS at 15.9 days. Of all the conditions diagnosed over 250 times, diagnoses of I63.8 (cerebral infarction, middle cerebral artery), I63.9 (infarction of middle cerebral artery territory) and I21.9 (myocardial infarction) were associated with the longest average hospital stay and high standard deviation. Patients with these conditions were also more likely to be transferred to the RH department for rehabilitation. A range of variables, such as transfer, discharge delay time, operation frequency, frequency of diagnosis, severity, bed grade, and insurance type was significantly correlated with the LOS.

Conclusions

Accurate understanding of the factors associating with the LOS and progressive improvements in processing and monitoring may allow more efficient management of the LOS of inpatients.

Extended Mortality and Chronic Kidney Disease After Septic Acute Kidney Injury

PURPOSE

To evaluate 1-year mortality in patients with septic acute kidney injury (AKI) and to determine association between initial AKI recovery patterns (reversal within 5 days, beyond 5 days but recovery, or nonrecovery) and chronic kidney disease (CKD) progression.

METHODS

Prospective observational study, with retrospective evaluation of initial nonconsenters, of critically ill patients with septic AKI.

RESULTS

We studied 207 patients (age, mean [SD]: 64 [16] years, 39% males), of which 56 (27%), 18 (9%), and 9 (4%) died in intensive care unit (ICU), post-ICU in hospital, and posthospitalization, respectively. Infections (including pneumonia) and major adverse cardiac events accounted for 64% and 12% of deaths, respectively. Factors independently associated with 1-year mortality include older age, ischemic heart disease, higher Simplified Acute Physiology Score II, central nervous system or musculoskeletal primary infections, higher daily fluid balance (FB), and frusemide administration during ICU stay (all P < .05). Among 63 patients receiving renal replacement therapy (RRT), hospital mortality was higher with cumulative median FB >8 L versus ≤8 L at RRT initiation (57% vs 24%; P = .009); there was trend for less ICU- and RRT-free days at day 28 in patients with higher FB pre-RRT (P = NS). Chronic kidney disease progression over 1 year developed in 21%, 30%, and 79% of 105 initial survivors with AKI reversal, recovery, and nonrecovery, respectively (P < .001). Acute kidney injury nonrecovery during hospitalization independently predicted CKD progression (P = .001).

CONCLUSIONS

Patients with septic AKI had 40% 1-year mortality, mainly associated with infections. High FB and frusemide administration were modifiable risk factors. Risk of CKD progression is high especially with initial AKI nonrecovery.