Critical Care Cycling to Improve Lower Extremity Strength (CYCLE): protocol for an international, multicentre randomised clinical trial of early in-bed cycling for mechanically ventilated patients

INTRODUCTION

In-bed leg cycling with critically ill patients is a promising intervention aimed at minimising immobility, thus improving physical function following intensive care unit (ICU) discharge. We previously completed a pilot randomised controlled trial (RCT) which supported the feasibility of a large RCT. In this report, we describe the protocol for an international, multicentre RCT to determine the effectiveness of early in-bed cycling versus routine physiotherapy (PT) in critically ill, mechanically ventilated adults.

METHODS AND ANALYSIS

We report a parallel group RCT of 360 patients in 17 medical-surgical ICUs and three countries. We include adults (≥18 years old), who could ambulate independently before their critical illness (with or without a gait aid), ≤4 days of invasive mechanical ventilation and ≤7 days ICU length of stay, and an expected additional 2-day ICU stay, and who do not fulfil any of the exclusion criteria. After obtaining informed consent, patients are randomised using a web-based, centralised system to either 30 min of in-bed cycling in addition to routine PT, 5 days per week, up to 28 days maximum, or routine PT alone. The primary outcome is the Physical Function ICU Test-scored (PFIT-s) at 3 days post-ICU discharge measured by assessors blinded to treatment allocation. Participants, ICU clinicians and research coordinators are not blinded to group assignment. Our sample size estimate was based on the identification of a 1-point mean difference in PFIT-s between groups.

ETHICS AND DISSEMINATION

Critical Care Cycling to improve Lower Extremity (CYCLE) is approved by the Research Ethics Boards of all participating centres and Clinical Trials Ontario (Project 1345). We will disseminate trial results through publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT03471247 (Full RCT); NCT02377830 (CYCLE Vanguard 46 patient internal pilot).

Learning needs and perceived barriers and facilitators to end-of-life care: a survey of front-line nurses on acute medical wards

OBJECTIVES

Caring for dying hospitalised patients is a healthcare priority. Our objective was to understand the learning needs of front-line nurses on the general internal medicine (GIM) hospital wards, and perceived barriers to, and facilitators of, optimal end-of-life care.

METHODS

We developed an 85-item survey informed by the Theoretical Domains Framework and Capability-Opportunity-Motivation-Behaviour system. We included demographics and two main domains (knowledge and practice; delivering end-of-life care) with seven subsections. Nurses from four GIM wards and the nursing resource team completed this survey. We analysed and compared results overall, by Capability, Opportunity, and Motivation, and by survey domain. We considered items with median scores <4/7 barriers. We conducted an a priori subgroup analysis based on duration of practice (≤5 and >5 years).

RESULTS

Our response rate was 60.5% (144/238). 51% had been practising for >5 years; most respondents were female (93.1%). Nurses had similar scores on the knowledge (mean 76.0%; SD 11.6%) and delivering care (mean 74.5% (8.6%)) domains. Scores for items associated with Capability were higher than those associated with Opportunity (median (first, third quartiles) 78.6% (67.9%, 87.5%) vs 73.9% (66.0%, 81.8%); p=0.04). Nurses practising >5 years had significantly higher scores on all analyses. Barriers included engaging with families having strong emotional reactions, managing goals of care conflicts between patients and families, and staffing challenges on the ward. Additional requested resources included formal training, information binders and more staff. Opportunities for consideration include formalised on-the-job training, access to comprehensive information, including symptom management at the end of life, and debriefing sessions.

CONCLUSIONS

Front-line nurses reported an interest in learning more about end-of-life care and identified important barriers that are feasible to address. These results will inform specific knowledge translation strategies to build capacity among bedside nurses to enhance end-of-life care practices for dying patients on GIM wards.

Enhancing end of life care on general internal medical wards: the 3 Wishes Project

BACKGROUND

Initially developed in the intensive care unit (ICU) at St. Joseph's Healthcare Hamilton (SJHH) the 3 Wishes Project (3WP) provides personalized, compassionate care to dying patients and their families. The objective of this study was to develop and evaluate 3WP expansion strategies for patients cared for on General Internal Medicine (GIM) wards in our hospital.

METHODS

From January 2020-November 2021, we developed a phased, multicomponent approach for program expansion. We enrolled patients on the GIM wards who had a high probability of dying in hospital, then elicited, implemented, and documented wishes for them or their families. Data were analyzed descriptively.

RESULTS

From March 2020 to November 2020, we implemented staff education and engagement activities, created an Expansion Coordinator position, held strategic consultations, and offered enabling resources. From March 2020 to November 2021, we enrolled 62 patients and elicited 281 wishes (median [1^st, 3^rd quartiles] 4 [4, 5] wishes/patient). The most common wish categories were personalizing the environment (67 wishes, 24%), rituals and spiritual support (42 wishes, 15%), and facilitating connections (39 wishes, 14%). The median [1^st, 3^rd] cost/patient was $0 [0, $10.00] (range $0 to $86); 91% of wishes incurred no cost to the program.

CONCLUSIONS

The formal expansion of the 3WP on GIM wards has been successful despite COVID-19 pandemic disruptions. While there is still work ahead, these data suggest that implementing the 3WP on the GIM wards is feasible and affordable. Increased engagement of the clinical team during the pandemic suggests that it is positively received.

Clinician Perspectives on Caring for Dying Patients During the Pandemic : A Mixed-Methods Study

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has affected the hospital experience for patients, visitors, and staff.

OBJECTIVE

To understand clinician perspectives on adaptations to end-of-life care for dying patients and their families during the pandemic.

DESIGN

Mixed-methods embedded study. (ClinicalTrials.gov: NCT04602520).

SETTING

3 acute care medical units in a tertiary care hospital from 16 March to 1 July 2020.

PARTICIPANTS

45 dying patients, 45 family members, and 45 clinicians.

INTERVENTION

During the pandemic, clinicians continued an existing practice of collating personal information about dying patients and "what matters most," eliciting wishes, and implementing acts of compassion.

MEASUREMENTS

Themes from semistructured clinician interviews that were summarized with representative quotations.

RESULTS

Many barriers to end-of-life care arose because of infection control practices that mandated visiting restrictions and personal protective equipment, with attendant practical and psychological consequences. During hospitalization, family visits inside or outside the patient's room were possible for 36 patients (80.0%); 13 patients (28.9%) had virtual visits with a relative or friend. At the time of death, 20 patients (44.4%) had a family member at the bedside. Clinicians endeavored to prevent unmarked deaths by adopting advocacy roles to "fill the gap" of absent family and by initiating new and established ways to connect patients and relatives.

LIMITATION

Absence of clinician symptom or wellness metrics; a single-center design.

CONCLUSION

Clinicians expressed their humanity through several intentional practices to preserve personalized, compassionate end-of-life care for dying hospitalized patients during the SARS-CoV-2 pandemic.

PRIMARY FUNDING SOURCE

Canadian Institutes of Health Research and Canadian Critical Care Trials Group Research Coordinator Fund.

Project management lessons learned from the multicentre CYCLE pilot randomized controlled trial

Background

Clinical trials management can be studied using project management theory. The CYCLE pilot randomized controlled trial (RCT) was conducted to determine the feasibility of a future rehabilitation trial of early in-bed cycling in the intensive care unit (ICU). In-bed cycling is a novel intervention, not typically available in ICUs. Implementation of this intervention requires personnel with specialized clinical expertise caring for critically ill patients and use of the in-bed cycle. Our objective was to describe the implementation and conduct of our pilot RCT using a project management approach.

Methods

We retrospectively reviewed activities, timelines, and personnel involved in the trial. We organized activities into four project management phases: initiation, planning, execution, and monitoring and controlling. Data sources included Methods Centre documents used for trial coordination and conduct, and the trial data set. We report descriptive statistics as counts and proportions and also medians and quartiles, and we summarize the lessons learned.

Results

Seven ICUs in Canada participated in the trial. Time from research ethics board and contracts submission to first enrolment was a median (first quartile, third quartile) of 185 (146, 209) and 162 (114, 181) days, respectively. We trained 128 personnel on the CYCLE pilot RCT protocol, and 80 (63%) completed trial-related activities. Four sites required additional training after start-up due to staff turnover and leaves of absence. Over 15 months, we screened 864 patients: 256 were eligible and 66 were enrolled. Despite an 85% consent rate, 74% (190/256) of eligible patients were not randomized, largely (80% [152/190]) due to physiotherapist availability. Thirteen percent of recruitment weeks were lost due to physiotherapist staffing shortages. We highlight five key lessons learned: (1) prepare and anticipate site needs; (2) communicate regularly; (3) proactively analyse and act on process measure data; (4) develop contingency plans; (5) express appreciation to participating sites.

Conclusions

Our analysis highlights the scope of relevant activities, rigorous training and monitoring, number and types of required personnel, and time required to conduct a multicentre ICU rehabilitation intervention trial. Our lessons learned can help others interested in implementing complex intervention trials, such as rehabilitation.

Trial registration

ClinicalTrials.gov, NCT02377830. Registered prospectively on 4 March 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3634-7) contains supplementary material, which is available to authorized users.

Determinants of Depressive Symptoms at 1 Year Following ICU Discharge in Survivors of ≥ 7 Days of Mechanical Ventilation: Results From the RECOVER Program, a Secondary Analysis of a Prospective Multicenter Cohort Study

BACKGROUND

Moderate to severe depressive symptoms occur in up to one-third of patients at 1 year following ICU discharge, negatively affecting patient outcomes. This study evaluated patient and caregiver factors associated with the development of these symptoms.

METHODS

This study used the Rehabilitation and Recovery in Patients after Critical Illness and Their Family Caregivers (RECOVER) Program (Phase 1) cohort of 391 patients from 10 medical/surgical university-affiliated ICUs across Canada. We determined the association between patient depressive symptoms (captured by using the Beck Depression Inventory II [BDI-II]), patient characteristics (age, sex, socioeconomic status, Charlson score, and ICU length of stay [LOS]), functional independence measure (FIM) motor subscale score, and caregiver characteristics (Caregiver Assistance Scale and Center for Epidemiologic Studies-Depression Scale) by using linear mixed models at time points 3, 6, and 12 months.

RESULTS

BDI-II data were available for 246 patients. Median age at ICU admission was 56 years (interquartile range, 45-65 years), 143 (58%) were male, and median ICU LOS was 19 days (interquartile range, 13-32 days). During the 12-month follow-up, 67 of 246 (27.2%) patients had a BDI-II score ≥ 20, indicating moderate to severe depressive symptoms. Mixed models showed worse depressive symptoms in patients with lower FIM motor subscale scores (1.1 BDI-II points per 10 FIM points), lower income status (by 3.7 BDI-II points; P = .007), and incomplete secondary education (by 3.8 BDI-II points; P = .009); a curvilinear relation with age (P = .001) was also reported, with highest BDI-II at ages 45 to 50 years. No associations were found between patient BDI-II and comorbidities (P = .92), sex (P = .25), ICU LOS (P = .51), or caregiver variables (Caregiver Assistance Scale [P = .28] and Center for Epidemiologic Studies Depression Scale [P = .74]).

CONCLUSIONS

Increased functional dependence, lower income, and lower education are associated with increased severity of post-ICU depressive symptoms, whereas age has a curvilinear relation with symptom severity. Knowledge of risk factors may inform surveillance and targeted mental health follow-up. Early mobilization and rehabilitation aiming to improve function may serve to modify mood disorders.

Multicentre pilot randomised clinical trial of early in-bed cycle ergometry with ventilated patients

Introduction

Acute rehabilitation in critically ill patients can improve post-intensive care unit (post-ICU) physical function. In-bed cycling early in a patient's ICU stay is a promising intervention. The objective of this study was to determine the feasibility of recruitment, intervention delivery and retention in a multi centre randomised clinical trial (RCT) of early in-bed cycling with mechanically ventilated (MV) patients.

Methods

We conducted a pilot RCT conducted in seven Canadian medical-surgical ICUs. We enrolled adults who could ambulate independently before ICU admission, within the first 4 days of invasive MV and first 7 days of ICU admission. Following informed consent, patients underwent concealed randomisation to either 30 min/day of in-bed cycling and routine physiotherapy (Cycling) or routine physiotherapy alone (Routine) for 5 days/week, until ICU discharge. Our feasibility outcome targets included: accrual of 1-2 patients/month/site; >80% cycling protocol delivery; >80% outcomes measured and >80% blinded outcome measures at hospital discharge. We report ascertainment rates for our primary outcome for the main trial (Physical Function ICU Test-scored (PFIT-s) at hospital discharge).

Results

Between 3/2015 and 6/2016, we randomised 66 patients (36 Cycling, 30 Routine). Our consent rate was 84.6 % (66/78). Patient accrual was (mean (SD)) 1.1 (0.3) patients/month/site. Cycling occurred in 79.3% (146/184) of eligible sessions, with a median (IQR) session duration of 30.5 (30.0, 30.7) min. We recorded 43 (97.7%) PFIT-s scores at hospital discharge and 37 (86.0%) of these assessments were blinded.

Discussion

Our pilot RCT suggests that a future multicentre RCT of early in-bed cycling for MV patients in the ICU is feasible.

Trial registration number

NCT02377830.

Feasibility, Reliability, Responsiveness, and Validity of the Patient-Reported Functional Scale for the Intensive Care Unit: A Pilot Study

BACKGROUND

Although many performance-based measures assess patients' physical function in intensive care unit (ICU) survivors, to our knowledge, there are no patient-reported ICU rehabilitation-specific measures assessing function. We developed the Patient-Reported Functional Scale-ICU (PRFS-ICU), which measures patients' perceptions of their ability to perform 6 activities (rolling, sitting edge of bed, sit-to-stand and bed-to-chair transfers, ambulation, and stair climbing). Each item is scored from 0 (unable) to 10 (able to perform at pre-ICU level) to a maximum of 60.

OBJECTIVES

Estimate the feasibility, reliability, responsiveness, and validity of the PRFS-ICU.

METHODS

This was a substudy of TryCYCLE, a single-center, prospective cohort examining the safety and feasibility of early in-bed cycling with mechanically ventilated patients (NCT01885442). To determine feasibility, we calculated the number of patients with at least 1 PRFS-ICU assessment during their hospital stay. To assess reliability, 2 raters blinded to each other's assessments administered the PRFS-ICU within 24-hours of each other. We calculated the intraclass correlation coefficient (ICC; 95% confidence interval [CI]), standard error of measurement (SEM, 95% CI), and minimal detectable change (MDC₉₀). To assess validity, we estimated convergent validity of the PRFS-ICU with the Functional Status Score for ICU (FSS-ICU), Medical Research Council Sum Score (MRC-SS), Physical Function Test for ICU (PFIT-s), Katz Index of Independence in Activities of Daily Living (Katz ADLs), and a pooled index using Pearson's correlation coefficient (r, 95% CI).

RESULTS

Feasibility: 20 patients completed a PRFS-ICU assessment. Reliability and responsiveness: 16 patients contributed data. The ICC, SEM, and MDC₉₀ were 0.91 (0.76, 0.97), 4.75 (3.51, 7.35), and 11.04 points, respectively. Validity: 19 patients contributed data and correlations were (r [95% CI]): FSS-ICU (0.40 [-0.14, 0.76]), MRC-SS (0.51 [0.02, 0.80]), PFIT-s (0.43 [-0.13, 0.78]), Katz ADLs (0.53 [0.10, 0.79]), and pooled index (0.48 [-0.14, 0.82]).

CONCLUSIONS

Our pilot work suggests the PRFS-ICU may be a useful tool to assess and monitor patients' perceptions of function over time.

The RECOVER Program: Disability Risk Groups and 1-Year Outcome after 7 or More Days of Mechanical Ventilation

RATIONALE

Disability risk groups and 1-year outcome after greater than or equal to 7 days of mechanical ventilation (MV) in medical/surgical intensive care unit (ICU) patients are unknown and may inform education, prognostication, rehabilitation, and study design.

OBJECTIVES

To stratify patients for post-ICU disability and recovery to 1 year after critical illness.

METHODS

We evaluated a multicenter cohort of 391 medical/surgical ICU patients who received greater than or equal to 1 week of MV at 7 days and 3, 6, and 12 months after ICU discharge. Disability risk groups were identified using recursive partitioning modeling.

MEASUREMENTS AND MAIN RESULTS

The 7-day post-ICU Functional Independence Measure (FIM) determined the recovery trajectory to 1-year after ICU discharge and was an independent risk factor for 1-year mortality. The 7-day post-ICU FIM was predicted by age and ICU length of stay. By 2 weeks of MV, ICU patients could be stratified into four disability groups characterized by increasing risk for post ICU disability, ICU and post-ICU healthcare use, and disposition. Patients less than 42 years with ICU length of stay less than 2 weeks had the best function and fewest deaths at 1 year compared with patients greater than 66 years with ICU length of stay greater than 2 weeks who sustained the worst disability and 40% 1-year mortality. Depressive symptoms (17%) and post-traumatic stress disorder (18%) persisted at 1 year.

CONCLUSIONS

ICU survivors of greater than or equal to 1 week of MV may be stratified into four disability groups based on age and ICU length of stay. These groups determine 1-year recovery and healthcare use and are independent of admitting diagnosis and illness severity. Clinical trial registered with www.clinicaltrials.gov (NCT 00896220).

One-Year Outcomes in Caregivers of Critically Ill Patients

BACKGROUND

Few resources are available to support caregivers of patients who have survived critical illness; consequently, the caregivers' own health may suffer. We studied caregiver and patient characteristics to determine which characteristics were associated with caregivers' health outcomes during the first year after patient discharge from an intensive care unit (ICU).

METHODS

We prospectively enrolled 280 caregivers of patients who had received 7 or more days of mechanical ventilation in an ICU. Using hospital data and self-administered questionnaires, we collected information on caregiver and patient characteristics, including caregiver depressive symptoms, psychological well-being, health-related quality of life, sense of control over life, and effect of providing care on other activities. Assessments occurred 7 days and 3, 6, and 12 months after ICU discharge.

RESULTS

The caregivers' mean age was 53 years, 70% were women, and 61% were caring for a spouse. A large percentage of caregivers (67% initially and 43% at 1 year) reported high levels of depressive symptoms. Depressive symptoms decreased at least partially with time in 84% of the caregivers but did not in 16%. Variables that were significantly associated with worse mental health outcomes in caregivers were younger age, greater effect of patient care on other activities, less social support, less sense of control over life, and less personal growth. No patient variables were consistently associated with caregiver outcomes over time.

CONCLUSIONS

In this study, most caregivers of critically ill patients reported high levels of depressive symptoms, which commonly persisted up to 1 year and did not decrease in some caregivers. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00896220.).

Roles of iNOS and nNOS in sepsis-induced pulmonary apoptosis

Apoptosis(programmed cell death) is induced in pulmonary cells and contributes to the pathogenesis of acute lung injury in septic humans. Previous studies have shown that nitric oxide (NO) is an important modulator of apoptosis; however, the functional role of NO derived from inducible NO synthase (iNOS) in sepsis-induced pulmonary apoptosis remains unknown. We measured pulmonary apoptosis in a rat model of Escherichia coli lipopolysaccharide (LPS)-induced sepsis in the absence and presence of the selective iNOS inhibitor 1400W. Four groups were studied 24 h after saline (control) or LPS injection in the absence and presence of 1400W pretreatment. Apoptosis was evaluated using DNA fragmentation, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling staining, and caspase activation. LPS administration significantly augmented pulmonary cell apoptosis and caspase-3 activity in airway and alveolar epithelial cells. Pretreatment with 1400W significantly enhanced LPS-induced pulmonary apoptosis and increased caspase-3 and -7 activation. The antiapoptotic effect of iNOS was confirmed in iNOS-/- mice, which developed a greater degree of pulmonary apoptosis both under control conditions and in response to LPS compared with wild-type mice. By comparison, genetic deletion of the neuronal NOS had no effect on LPS-induced pulmonary apoptosis. We conclude that NO derived from iNOS plays an important protective role against sepsis-induced pulmonary apoptosis.

Efficacy of daytime continuous positive airway pressure titration in severe obstructive sleep apnoea

The aim of this study was to evaluate manual nasal continuous positive airway pressure (nCPAP) titration during daytime polysomnography compared with conventional overnight titration for patients with severe obstructive sleep apnoea. Thirty-two patients who underwent daytime titration were retrospectively matched (for age, sex, body mass index and apnoea/hypopnoea index (AHI)) to a group titrated overnight during the same period. Successful titration was defined as the identification of the nCPAP level (effective nCPAP (Peff)) required to eliminate respiratory events during all sleep stages. After 3 months of therapy on nCPAP at Peff, nCPAP utilization history was obtained and a group of patients underwent a repeat polysomnogram (PSG) and completed a follow-up Epworth Sleepiness Scale (ESS) score. Initial titration was successful in 91% of daytime patients and 91% of overnight patients. The success of daytime titration was not related to diagnostic AHI or ESS score. Subjective nCPAP utilization was statistically similar in both groups. On the follow-up PSG, there were no significant differences between daytime (n=11) and overnight (n=11) patients in measures of sleep quality or respiratory disturbance. Both groups demonstrated similar and significant improvements in ESS score. These findings suggest that the effective nasal continuous positive airway pressure can be accurately established during daytime titration in a substantial proportion of severe, symptomatic obstructive sleep apnoea patients.