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

Early Mobilization Using a Mobile Patient Lift in the ICU: A Randomized Controlled Trial

OBJECTIVES

To ascertain whether a mobile patient lift facilitates early mobilization in ventilated ICU patients.

DESIGN

A single-center, open-label, randomized controlled trial.

SETTING

An academic ICU in Tokyo.

PATIENTS

Eighty patients were admitted to ICU and expected ventilation for at least 48 hours.

INTERVENTIONS

In the intervention group, in addition to the rehabilitation protocol received by the control group, patients were assisted in sitting, standing, transfers, and walking using the mobile patient lift.

MEASUREMENTS AND MAIN RESULTS

The intervention group predominantly stood faster than the control group (1.0 vs. 3.0 d, p < 0.01). The Intervention group also had significantly higher Functional Status Score-ICU scores at ICU discharge. However, the Medical Research Council score and Barthel index at discharge, length of ICU stay, and number of ventilator-free days did not differ between the two groups.

CONCLUSIONS

The use of mobile patient lifts facilitates the earlier standing of patients on ventilators. This may contribute to patients improved physical function in the ICU.

TRIAL REGISTRATION

The study protocol was registered with the University Hospital Medical Information Network (UMIN) under the registration number UMIN000044965. Registered July 30, 2021.

Exploring the influence of a financial incentive scheme on early mobilization and rehabilitation in ICU patients: an interrupted time-series analysis

BACKGROUND

Clinical guidelines recommend early mobilization and rehabilitation (EMR) for patients who are critically ill. However, various barriers impede its implementation in real-world clinical settings. In 2018, the Japanese universal healthcare coverage system announced a unique financial incentive scheme to facilitate EMR for patients in intensive care units (ICU). This study evaluated whether such an incentive improved patients' activities of daily living (ADL) and reduced their hospital length of stay (LOS).

METHODS

Using the national inpatient database in Japan, we identified patients admitted to the ICU, who stayed over 48 hours between April 2017 and March 2019. The financial incentive required medical institutions to form a multidisciplinary team approach for EMR, development and periodic review of the standardized rehabilitation protocol, starting rehabilitation within 2 days of ICU admission. The incentive amounted to 34.6 United States Dollars per patient per day with limit 14 days, structured as a per diem payment. Hospitals were not mandated to provide detailed information on individual rehabilitation for government, and the insurer made payments directly to the hospitals based on their claims. Exposure was the introduction of the financial incentive defined as the first day of claim by each hospital. We conducted an interrupted time-series analysis to assess the impact of the financial incentive scheme. Multivariable radon-effects regression and Tobit regression analysis were performed with random intercept for the hospital of admission.

RESULTS

A total of 33,568 patients were deemed eligible. We confirmed that the basic assumption of ITS was fulfilled. The financial incentive was associated with an improvement in the Barthel index at discharge (0.44 points change in trend per month; 95% confidence interval = 0.20-0.68) and shorter hospital LOS (- 0.66 days change in trend per month; 95% confidence interval = - 0.88 - -0.44). The sensitivity and subgroup analyses showed consistent results.

CONCLUSIONS

The study suggests a potential association between the financial incentive for EMR in ICU patients and improved outcomes. This incentive scheme may provide a unique solution to EMR barrier in practice, however, caution is warranted in interpreting these findings due to recent changes in ICU care practices.

Physical therapy in the intensive care unit: A cross-sectional study of three Asian countries

BACKGROUND

Physical therapy (PT) is beneficial for critically ill patients, but the extent of its application in the intensive care unit (ICU) differs between countries. Here, we compared the extent of PT intervention in the ICU in Japan, the Philippines, and Taiwan by evaluating the sociodemographic and ICU-related profiles of ICU physical therapists.

MATERIALS AND METHODS

In this cross-sectional study, a semistructured nationwide online survey was distributed to ICU physical therapists in the three countries.

RESULTS

We analyzed the responses of 164 physical therapists from Japan, Philippines, and Taiwan. Significant differences were observed between the countries in all sociodemographic variables and the following ICU-related profiles of physical therapists: ICU work experience, duration of the ICU posting, number of hours per day spent in the ICU, on-call ICU PT service engagement, source of ICU patient referral, therapist-patient ratio, and ICU-related PT training participation (p < 0.05). Medical, surgical, and neurologic ICUs were the most common ICU workplaces of the ICU physical therapists, but only surgical and neurologic ICUs exhibited significant differences between the countries (p < 0.05). Standard PT techniques in the ICU were passive and active-assisted range of motion, positioning, and breathing exercises but were implemented with significantly different frequencies between the countries (p < 0.05). The most common challenge faced in ICU PT service delivery by respondents from all three countries was lack of training prior to ICU duty, and lack of training was even bigger challenge in Japan than in other two countries after adjustment of age, highest educational attainment, and work experience.

CONCLUSION

The differences in the health-care system between Japan, the Philippines, and Taiwan were related to differences in the compliance with internationally recommended PT practice standards in the ICU, differences in the type of PT intervention prioritized, and the challenges encountered in ICU PT service delivery.

Effect of Early Rehabilitation in the Intensive Care Unit by a Dedicated Therapist Using a Rehabilitation Protocol: A Single-center Retrospective Study

Objectives:

This study investigated retrospectively the effect of early rehabilitation in the intensive care unit (ICU) by a dedicated therapist using a rehabilitation protocol.

Methods:

The subjects comprised patients admitted to our emergency ICU. A dedicated therapist and a rehabilitation protocol were instigated in April 2018. We enrolled 330 patients in phase I (April 2016–March 2018) and 383 patients in phase II (April 2018–March 2020). Patients in the ICU for only one night and pediatric patients were excluded. The following data were accessed from medical records: sex, height, age, Sequential Organ Failure Assessment, rehabilitation intervention, ventilation at admission, duration of mechanical ventilation, extubation, reintubation, tracheotomy, length of ICU stay, length of hospital stay, and outcome. The effectiveness of rehabilitation was assessed using the time from ICU admission to the first rehabilitation session, first sitting exercise, and first standing exercise. Clinical outcomes were analyzed separately for subjects discharged to home or transferred to another hospital.

Results:

The percentage of subjects undergoing rehabilitation intervention increased significantly from 23.4% to 56.7% (P<0.001) in phase II. Moreover, reintubation (P=0.045); the length of ICU stay (P=0.022); and the time from ICU admission to the first rehabilitation session (P<0.001), the first sitting exercise (P=0.001), and the first standing exercise (P=0.047) significantly decreased in phase II. Furthermore, the duration of mechanical ventilation (P=0.007) and the length of ICU stay (P=0.036) were significantly reduced in the transfer group.

Conclusions:

Although the effectiveness of early intervention was suggested, prospective multicenter studies are required to confirm this finding.

Examination of Rehabilitation Intensity According to Severity of Acute Stroke: A Retrospective Study

OBJECTIVES

To investigate the intensity and effectiveness of rehabilitation in acute stroke patients according to the severity of functional impairments in them.

MATERIALS AND METHODS

This retrospective cohort study included 294 patients with acute hemispheric stroke admitted to three acute-care hospitals who subsequently underwent an inpatient rehabilitation program. Stroke severity was classified according to neurological deficits and trunk dysfunction. The following data were obtained from medical records: age, sex, stroke type, lesion side, hospitalization duration, initial functional status determined using the National Institutes of Health Stroke Scale, rehabilitation start date, first day out of bed after admission, total treatment duration, total number of treatment sessions, rehabilitation implementation rate between start of rehabilitation and discharge, trunk control test and Barthel Index score on the first day out of bed after admission and discharge, and post-discharge outcomes. Hierarchical cluster analysis was performed with clusters categorized using the National Institutes of Health Stroke Scale and trunk control test scores. Variables were compared using the Kruskal-Wallis test, and Dunn's nonparametric comparison test was performed for post-hoc analysis to determine differences between clusters.

RESULTS

The National Institutes of Health Stroke Scale and trunk control test showed a significant correlation (r = -0.816, p < 0.01) using which cluster analysis identified three clusters. Rehabilitation showed a ceiling effect in patients with mild stroke and a floor effect in patients with severe stroke.

CONCLUSION

These results may guide the determination of rehabilitation intensity with reference to the severity of neurological deficits and trunk dysfunction.

Muscle atrophy in critically ill patients : a review of its cause, evaluation, and prevention

Critically ill patients exhibit prominent muscle atrophy, which occurs rapidly after ICU admission and leads to poor clinical outcomes. The extent of atrophy differs among muscles as follows: upper limb: 0.7%-2.4% per day, lower limb: 1.2%-3.0% per day, and diaphragm 1.1%-10.9% per day. This atrophy is caused by numerous risk factors such as inflammation, immobilization, nutrition, hyperglycemia, medication, and mechanical ventilation. Muscle atrophy should be monitored noninvasively by ultrasound at the bedside. Ultrasound can assess muscle mass in most patients, although physical assessment is limited to almost half of all critically ill patients due to impaired consciousness. Important strategies to prevent muscle atrophy are physical therapy and electrical muscular stimulation. Electrical muscular stimulation is especially effective for patients with limited physical therapy. Regarding diaphragm atrophy, mechanical ventilation should be adjusted to maintain spontaneous breathing and titrate inspiratory pressure. However, the sufficient timing and amount of nutritional intervention remain unclear. Further investigation is necessary to prevent muscle atrophy and improve long-term outcomes. J. Med. Invest. 67 : 1-10, February, 2020.

Effect of vibration therapy on physical function in critically ill adults (VTICIA trial): protocol for a single-blinded randomised controlled trial

INTRODUCTION

Vibration therapy has been used as an additional approach in passive rehabilitation. Recently, it has been demonstrated to be feasible and safe for critically ill patients, whose muscle weakness and intensive care unit (ICU)-acquired weakness are serious problems. However, the effectiveness of vibration therapy in this population is unclear.

METHODS AND ANALYSIS

This study will enrol 188 adult critically ill patients who require further ICU stay after they can achieve sitting at the edge of the bed or wheelchair. The sample size calculation is based on a 15% improvement of Functional Status Score for the ICU. They will be randomised to vibration therapy coupled with protocolised mobilisation or to protocolised mobilisation alone; outcomes will be compared between the two groups. Therapy will be administered using a low-frequency vibration device (5.6-13 Hz) for 15 min/day from when the patient first achieves a sitting position and onward until discharge from the ICU. Outcome assessments will be blinded to the intervention. Primary outcome will be measured using the Functional Status Score for the ICU during discharge. Secondary outcomes will be identified as follows: delirium, Medical Research Council Score, ICU-acquired weakness, the change of biceps brachii and rectus femoris muscle mass measured by ultrasound, ICU mobility scale and ventilator-free and ICU-free days (number of free days during 28 days after admission). For safety assessment, vital signs will be monitored during the intervention.

ETHICS AND DISSEMINATION

This study has been approved by the Clinical Research Ethics Committee of Tokushima University Hospital. Results will be disseminated through publication in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

UMIN000039616.

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.

Clinical Frailty Scale Score Before ICU Admission Is Associated With Mobility Disability in Septic Patients Receiving Early Rehabilitation

To clarify the relationship between mobility disability at the time of discharge from the ICU and clinical factors evaluated at ICU admission in septic patients.

Post-intensive care syndrome: its pathophysiology, prevention, and future directions

Expanding elderly populations are a major social challenge in advanced countries worldwide and have led to a rapid increase in the number of elderly patients in intensive care units (ICUs). Innovative advances in medical technology have enabled lifesaving of patients in ICUs, but there remain various problems to improve their long-term prognoses. Post-intensive care syndrome (PICS) refers to physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long-term prognosis of ICU patients. Its concept also applies to pediatric patients (PICS-p) and the mental status of their family (PICS-F). Intensive care unit-acquired weakness, a syndrome characterized by acute symmetrical limb muscle weakness after ICU admission, belongs to physical impairments in three domains of PICS. Prevention of PICS requires performance of the ABCDEFGH bundle, which incorporates the prevention of delirium, early rehabilitation, family intervention, and follow-up from the time of ICU admission to the time of discharge. Diary, nutrition, nursing care, and environmental management for healing are also important in the prevention of PICS. This review outlines the pathophysiology, prevention, and future directions of PICS.

Physiotherapy and Rehabilitation Implementation in Intensive Care Units: A Survey Study

OBJECTIVES

Physiotherapy in the intensive care unit (ICU) improves patient outcomes. We aimed to determine the characteristics of physiotherapy practice and critical barriers toward applying physiotherapy in ICUs.

MATERIALS AND METHODS

A 54-item survey for determining the characteristics of physiotherapists and physiotherapy applications in the ICU was developed. The survey was electronically sent to potential participants through Turkish Physiotherapy Association network. Sixty-five physiotherapists (47F and 18M; 23-52 years; ICU experience: 6.0±6.2 years) completed the survey. The data were analyzed using quantitative and qualitative methods.

RESULTS

The duration of ICU practice was 3.51±2.10 h/day. Positioning (90.8%), active exercises (90.8%), breathing exercises (89.2%), passive exercises (87.7%), and percussion (87.7%) were the most commonly used applications. The barriers were related to physiotherapist (low level of employment and practice, lack of shift); patient (unwillingness, instability, participation restriction); teamwork (lack of awareness and communication); equipment (inadequacy, non-priority to purchase); and legal (reimbursement, lack of direct physiotherapy access, non-recognition of autonomy) procedures.

CONCLUSION

The most common interventions were positioning, active, passive, and breathing exercises and percussion. Critical barriers toward physiotherapy are multifactorial and related to physiotherapists, patients, team, equipment, and legal procedures. Physiotherapist employment, service maintenance, and multidisciplinary teamwork should be considered for physiotherapy effectiveness in ICUs.

Organization of rehabilitation care in Portuguese intensive care units

Objective

To describe the different rehabilitation care models in practice in Portuguese adult intensive care units.

Methods

A simple observational (cross-sectional) study was conducted through an online survey sent to the head nurses or individuals responsible for the 58 adult intensive care units that are part of the database of the Sociedade Portuguesa de Cuidados Intensivos.

Results

We identified three models of organization of rehabilitation care: care provided by the staff of the intensive care unit (22.9%), care provided by specialized external teams (25.0%), and a mixture of the previous models, combining the two situations (52.1%). In the first model, the care was provided mainly by nurses with specialization in rehabilitation and, in the second model, the care was provided by physiotherapists. No significant differences were found between the models regarding the availability of care, in hours/day or days/week (p = 0.268 and 0.994, respectively), or results such as length of hospital stay in intensive care, ventilation time, or mortality rate in the unit (p = 0.418, 0.923, and 0.240, respectively).

Conclusion

The organization of rehabilitation care in Portuguese intensive care units is unique and heterogeneous. Despite different care organization models, the availability of hours of care is similar, as are the overall results observed in patients.

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.

The safety of a novel early mobilization protocol conducted by ICU physicians: a prospective observational study

BACKGROUND

There are numerous barriers to early mobilization (EM) in a resource-limited intensive care unit (ICU) without a specialized team or an EM culture, regarding patient stability while critically ill or in the presence of medical devices. We hypothesized that ICU physicians can overcome these barriers. The aim of this study was to investigate the safety of EM according to the Maebashi EM protocol conducted by ICU physicians.

METHODS

This was a single-center prospective observational study. All consecutive patients with an unplanned emergency admission were included in this study, according to the exclusion criteria. The observation period was from June 2015 to June 2016. Data regarding adverse events, medical devices in place during rehabilitation, protocol adherence, and rehabilitation outcomes were collected. The primary outcome was safety.

RESULTS

A total of 232 consecutively enrolled patients underwent 587 rehabilitation sessions. Thirteen adverse events occurred (2.2%; 95% confidence interval, 1.2-3.8%) and no specific treatment was needed. There were no instances of dislodgement or obstruction of medical devices, tubes, or lines. The incidence of adverse events associated with mechanical ventilation or extracorporeal membrane oxygenation (ECMO) was 2.4 and 3.6%, respectively. Of 587 sessions, 387 (66%) sessions were performed at the active rehabilitation level, including sitting out of the bed, active transfer to a chair, standing, marching, and ambulating. ICU physicians attended over 95% of these active rehabilitation sessions. Of all patients, 143 (62%) got out of bed within 2 days (median 1.2 days; interquartile range 0.1-2.0).

CONCLUSIONS

EM according to the Maebashi EM protocol conducted by ICU physicians, without a specialized team or EM culture, was performed at a level of safety similar to previous studies performed by specialized teams, even with medical devices in place, including mechanical ventilation or ECMO. Protocolized EM led by ICU physicians can be initiated in the acute phase of critical illness without serious adverse events requiring additional treatment.