An Established Early Rehabilitation Therapy Demonstrating Higher Efficacy and Safety for Care of Intensive Care Unit Patients

Conscious care: a proposed model to improve interprofessional care of patients with disorders of consciousness in the acute hospital setting

BACKGROUND

Forty percent of individuals within the Disorders of Consciousness (DoC) spectrum are misdiagnosed as in a vegetative state/unresponsive wakefulness syndrome (VS/UWS) when in fact they are minimally conscious or emerged, underscoring a need to optimize evaluation techniques and interprofessional care management.

PRIMARY OBJECTIVE

Conscious Care is a proposed care model that aims to improve interprofessional care of patients with DoC in the hospital setting. The aim of this paper is to describe this model's key ingredients and various components.

CONCLUSIONS

This care model will advance clinician and caregiver preparedness to manage the complexities of this population and advocate for equal access to post-hospital medical and rehabilitative services. Evaluation and treatment of survivors of DoC should incorporate current evidence which drives continuous quality improvement and education to clinicians across the continuum of care. Immediate action must be taken to decrease the vulnerability and neglect of this marginalized population. Conscious Care is an innovative, sustainable solution that will improve interprofessional awareness of best practices and available science, strengthen care, and advocate for the right to quality of life that this population is so often denied.

Early Rehabilitation Activity and Rehabilitation in ICU Wards in Central China: A Cross-Sectional Survey

Background

Patients in Intensive Care Units (ICUs) face high risks of physical, functional, cognitive, and mental impairments. Early rehabilitation activities are crucial for reducing mortality and complication rates. This survey investigates the characteristics, current implementation, and detailed status of early rehabilitation activities in ICUs across Central China.

Methods

A cross-sectional survey was conducted involving 158 hospitals, with 131 responding. Data on institutional characteristics and early rehabilitation activities were collected through questionnaires. Descriptive statistical analysis described the current status, and a univariate regression model identified factors associated with the implementation of early rehabilitation measures.

Results

A total of 131 ICUs completed the survey, with a response rate of 82.91% (131/158). Results indicated that 82.44% (108/131) of ICUs implemented early rehabilitation activities, but only 65 (49.62%) had explicit early rehabilitation exercise protocols or standards/procedures. Before implementing early rehabilitation activities, approximately 89.97% (110/131) of ICUs conducted assessments, and 46.56% (61/131) regularly held structured interdisciplinary rounds to discuss early activity measures and goals. More than half of the participating adult ICUs reported screening patients for swallowing function (64.89%; 85/131), and 55.73% (73/131) of adult ICUs reported having a nutrition therapy specialist conduct regular consultations/visits. Only 26.72% (35/131) of adult ICUs reported having a speech therapist conduct consultations/visits. A total of 81.68% (107/131) of ICUs believed that the current implementation of early rehabilitation activities was insufficient. In the analysis of influencing factors, the presence of rehabilitation therapists in the ICU was a significant factor for the implementation of early rehabilitation activities (P<0.05).

Conclusion

The majority of ICUs in hospitals in central China have implemented early rehabilitation activities; however, less than half have explicit early rehabilitation exercise protocols or standards/procedures. The presence of professional rehabilitation therapists in the ICU is a key factor in the implementation of early rehabilitation activities in ICUs in hospitals in Central China.

Optimal timing for early mobilization initiatives in intensive care unit patients: A systematic review and network meta-analysis

OBJECTIVES

Analyse the effect of varying start times for early exercise interventions on the prevention of intensive care unit-acquired weakness.

RESEARCH METHODOLOGY

We conducted a comprehensive search on PubMed, Cochrane Library, Web of Science, Embase, China Biology Medicine Disc, China National Knowledge Infrastructure, Wan Fang Database, and reference lists up to May 2023.

SETTING

We systematically searched the literature for all randomized controlled trials on the effect of early mobilization in patients with critical illness.

MAIN OUTCOME MEASURES

The primary outcome assessed was the incidence of intensive care unit-acquired weakness. The secondary outcomes included: the Medical Research Council Score, the Barthel Index, duration of mechanical ventilation, length of intensive care unit stay, total length of hospital stay, mortality and incidence of intensive care unit-related complications.

RESULTS

The results of meta-analysis showed that compared with routine care, less than 24 hours after admission (RR = 0.44, 95 %CI: 0.28-0.68), more than 24 hours (RR = 0.33, 95 %CI: 0.16-0.67), less than 72 hours after admission (RR = 0.33, 95 %CI: 0.20-0.52) may lead to a lower incidence of intensive care unit-acquired weakness. The results of under surface cumulative ranking showed that early mobilization within 72 hours may have the lowest incidence of intensive care unit-acquired weakness (SUCRA = 81.9 %).

CONCLUSIONS

The current empirical evidence from intensive care unit patients suggests that initiating mobilization protocols within 24-72 hours timeframe following admission to the intensive care unit could potentially be the most beneficial strategy to reduce the incidence of intensive care unit-acquired weakness and the related medical complications. Moreover, this strategy seems to significantly improve rehabilitation and treatment outcomes for these patients.

IMPLICATIONS FOR CLINICAL PRACTICE

According to this study, medical and nursing staff in the intensive care unit have the chance to identify the most suitable timing for the implementation of early rehabilitative measures for patients. This can potentially prevent intensive care unit-acquired weakness and enhance various clinical outcomes for patients.

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.

Effect of neuromuscular electrical stimulation combined with early rehabilitation therapy on mechanically ventilated patients: a prospective randomized controlled study

BACKGROUND

This study aimed to investigate the effectiveness of neuromuscular electrical stimulation (NMES) blended with early rehabilitation on the diaphragm and skeletal muscle in sufferers on mechanical ventilation (MV).

METHOD

This is a prospective randomized controlled study. Eighty patients on MV for respiratory failure were divided into a study group (40 cases) and a control group (40 cases) randomly. The study group adopted a treatment method of NMES combined with early rehabilitation and the control group adopted the method of early rehabilitation only. The diaphragmatic excursion (DE), diaphragmatic thickening fraction (DTF), variation of thickness of intercostal muscles (TIM), variation of thickness of rectus abdominis (TRA), and variation of the cross-sectional area of rectus femoris (CSA-RF) were measured to evaluate the therapeutic effect by ultrasound before and after intervention at the first day of MV, the 3rd and 7th day of intervention and the day discharged from ICU.

RESULTS

No significant difference was found in the general demographic information and ultrasound indicators between the two groups before treatment (all P > 0.05). After treatment, the variation of DTF (0.15 ± 0.05% vs. 0.12 ± 0.04%, P = 0.034) was significantly higher in the study group than that in the control group on the day discharged from ICU. The variation of TRA (0.05 ± 0.09% vs. 0.10 ± 0.11%, P = 0.029) and variation of CSA-RF (0.13 ± 0.07% vs. 0.19 ± 0.08%, P < 0.001) in the study group were significantly lower than that in the control group. The duration of MV in the study group was significantly shorter than that in the control group [109.5 (88.0, 213.0) hours vs. 189.5 (131.5, 343.5) hours, P = 0.023]. The study group had better muscle strength score than the control group at discharge (52.20 ± 11.70 vs. 44.10 ± 15.70, P = 0.011).

CONCLUSION

NMES combined with early rehabilitation therapy is beneficial in reducing muscle atrophy and improving muscle strength in mechanically ventilated patients. This treatment approach may provide a new option for patients to choose a rehabilitation program; however, more research is needed to fully evaluate the effectiveness of this treatment option.

Inpatient Physical Therapy in Moderate to Severe Traumatic Brain Injury in in Older Adults: A Scoping Review

BACKGROUND

Around 500/100,000 Canadians experience a traumatic brain injury (TBI) resulting in long-term disabilities and premature death. Physiotherapy is known to positively impact the prognosis of young adults following a TBI.

OBJECTIVE

This is a scoping review that aimed to identify research topics in physiotherapy interventions for seniors after a TBI, describe potential knowledge gaps, and uncover needs for future research.

METHODOLOGY

Ten databases were interrogated (January-March 2022). We included texts published after 2010, in English or French, scientific papers, guidelines, and gray literature sources targeting in-hospital, acute-to-subacute interventions for people aged ≥55 years old with a moderate-to-severe TBI. The outcomes sought were physical/functional capacities, injury severity, and quality of life.

RESULTS

From 1296 articles, 16 were selected. The number of participants from the studies altogether was 248,794. We identified eight retrospectives studies, three clinical trials, and five articles from the gray literature. Articles were classified according to the nature of their analysis and outcomes: (1) interventional studies including physiotherapy (at least 10 types of rehabilitative or preventive interventions were identified); (2) studies evaluating prognostic factors (five factors identified); and (3) recommendations from clinical practical guidelines and other sources (gray literature). Our results provide evidence that physiotherapy is effective in TBI acute rehabilitation for the elderly to prevent complications arising from the primary injury and to improve functional capacities.

CONCLUSION

The heterogeneity of our results does not allow us to infer the effectiveness of one intervention over another. However, we found that the elderly population benefits from physiotherapy interventions as much as adults, but the gap must be filled with higher-quality studies to make definite recommendations.

A Comparison of Early Rehabilitation in the Intensive Care Units of Patients With Severe COVID-19: A Propensity Score Matching Analysis

Aim This study aimed to investigate early rehabilitation in the intensive care unit (ICU) for patients with severe coronavirus disease 2019 (COVID-19) who require mechanical ventilation Methods Twenty patients with severe COVID-19 (COVID-19 group) who were admitted to the ICU between April 2020 and March 2022 were included. For the control (non-COVID-19) group, 20 individuals were selected among ICU patients admitted between April 2018 and March 2020. The controls were propensity score-matched by age, sex, and Sequential Organ Failure Assessment (SOFA) score. Results In the COVID-19 group, the percentage of extubated patients was significantly higher. Furthermore, mechanical ventilation and lengths of ICU stay were also significantly longer. There were no significant differences in discharge outcomes or mortality, but there was a significant difference in the number of muscle relaxants and steroid treatments utilized with the COVID-19 group, requiring more of these medications. The percentage of patients who achieved sitting on the edge of a bed was also significantly higher in the COVID-19 group, but the days between the first rehabilitation and first sitting were significantly greater in this group. Conclusion Early rehabilitation of patients with COVID-19 may be an effective measure to promote recovery. However, continued investigation is warranted.

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.

Early rehabilitation nursing in ICU promotes rehabilitation of patients with respiratory failure treated with invasive mechanical ventilation

OBJECTIVE

This paper aimed at exploring the application value of early rehabilitation nursing (ERN) in intensive care unit (ICU) for nursing patients with respiratory failure (RF) treated with invasive mechanical ventilation (IMV).

METHODS

Admitted to the ICU of our hospital from January 2019 to June 2020, 172 RF patients that was treated with IMV were selected as the research objects. Those in the general group (n=80) received routine nursing in ICU, whereas those in the recovery group (n=92) received ERN on the basis of the general group. The recovery of their vital signs, blood gas functions and pulmonary functions was monitored. Their treatment time in ICU, mechanical ventilation time (MVT), total hospitalization time (THT) and incidence of complications were recorded. Their negative emotions, quality of life (QOL) and nursing satisfaction were assessed.

RESULTS

After intervention, the body temperature, the respiratory rate and the heart rate in the recovery group were lower than those in the general group (P<0.05). The arterial partial pressure of oxygen (PaO₂) and blood oxygen saturation (SpO₂) were remarkably higher in the recovery group, while the arterial partial pressure of carbon dioxide (PaCO₂) was remarkably lower (P<0.05). One-second forced expiratory volume (FEV₁), FEV₁/forced vital capacity (FVC) and FEV₁% were remarkably higher in the recovery group (P<0.05). The treatment time in ICU, the MVT and the THT were remarkably shorter in the recovery group (P<0.05). During intervention, the total incidence of complications was lower in the recovery group (P<0.05). While after intervention, the scores of the Self-rating Anxiety Scale (SAS), the Self-rating Depression Scale (SDS) and the St. George's Respiratory Questionnaire (SGRQ; symptom, activity, impact) were lower in the recovery group, but the nursing satisfaction was remarkably higher (P<0.05).

CONCLUSION

During the treatment of RF patients with IMV, ERN can promote their recovery, reduce the incidence of complications, relieve their negative emotions, and improve their QOL and nursing satisfaction. So, this nursing model is worthy of clinical application.

Early rehabilitation relieves diaphragm dysfunction induced by prolonged mechanical ventilation: a randomised control study

BACKGROUND

Prolonged mechanical ventilation (MV) induces diaphragm dysfunction in patients in the intensive care units (ICUs). Our study aimed to explore the therapeutic efficacy of early rehabilitation therapy in patients with prolonged MV in the ICU.

METHODS

Eighty eligible patients who underwent MV for > 72 h in the ICU from June 2019 to March 2020 were enrolled in this prospective randomised controlled trial. The patients were randomly divided into a rehabilitation group (n = 39) and a control group (n = 41). Rehabilitation therapy included six levels of rehabilitation exercises. Diaphragm function was determined using ultrasound (US).

RESULTS

Diaphragmatic excursion (DE) and diaphragm thickening fraction (DTF) were significantly decreased in all patients in both groups after prolonged MV (p < 0.001). The rehabilitation group had significantly higher DTF (p = 0.008) and a smaller decrease in DTF (p = 0.026) than the control group after 3 days of rehabilitation training. The ventilator duration and intubation duration were significantly shorter in the rehabilitation group than in the control group (p = 0.045 and p = 0.037, respectively). There were no significant differences in the duration of ICU stay, proportion of patients undergoing tracheotomy, and proportion of recovered patients between the two groups.

CONCLUSIONS

Early rehabilitation is feasible and beneficial to ameliorate diaphragm dysfunction induced by prolonged MV and advance withdrawal from the ventilator and extubation in patients with MV. Diaphragm US is suggested for mechanically ventilated patients in the ICU. Trial registration Chinese Clinical Trial Registry, ID: ChiCTR1900024046, registered on 2019/06/23.