Defining minimum workforce standards for intensive care physiotherapy in Australia and New Zealand: A Dephi study.

BACKGROUND: Intensive care staffing guidelines provide recommendations for the safe and effective delivery of health care while recognising professional requirements of the workforce. To guide recommendations for physiotherapy staffing guidelines, profession-specific consultation is needed. OBJECTIVES: The objective of this study was to develop consensus-based recommendations for minimum workforce standards for physiotherapy in intensive care. METHODS: A Delphi survey process was conducted involving physiotherapists from Australia and New Zealand. RESULTS: The panel consisted of 65 physiotherapists in the first round and 60 in the second round (92% retention). Respondents were from both Australia (49, 76%) and New Zealand (16, 24%) who had been physiotherapists for an average of 18.8 ± 9.0 years and were primarily senior intensive care physiotherapists (44, 68%). Respondents had experience across level 3 (50, 77%), level 2 (18, 28%), and level 1 (5, 8%) adult intensive care units (ICUs), adult high-dependency units (27, 42%), and paediatric intensive care (6, 9%). A total of 42 statements were presented, with 37 reaching consensus after two rounds. After two rounds, consensus was achieved for a minimum staffing ratio in paediatric ICUs of one physiotherapist per six (1:6) beds. For adult ICUs, use of the median value of the participant's responses was supported to establish minimum staffing ratios of 1:8, 1:7, 1:6, and 1:8 for levels 1, 2, and 3 ICUs and high-dependency units, respectively. The requirement for an additional allocation for senior physiotherapist staffing for each ICU level was also established. Statements that also gained consensus included recommendations for access to on-call and weekend services for all ICU settings and the consideration of evening shifts specifically for level 3 and paediatric ICUs. CONCLUSIONS: Recommendations for minimum staffing for physiotherapy in intensive care settings were achieved and supported requirements for clinical service delivery, supervision, and training.

Comparison of 6-Month Outcomes of Survivors of COVID-19 versus Non-COVID-19 Critical Illness.

Rationale: The outcomes of survivors of critical illness due to coronavirus disease (COVID-19) compared with non-COVID-19 are yet to be established. Objectives: We aimed to investigate new disability at 6 months in mechanically ventilated patients admitted to Australian ICUs with COVID-19 compared with non-COVID-19. Methods: We included critically ill patients with COVID-19 and non-COVID-19 from two prospective observational studies. Patients were eligible if they were adult (age ⩾ 8 yr) and received ⩾24 hours of mechanical ventilation. In addition, patients with COVID-19 were eligible with a positive laboratory PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Measurements and Main Results: Demographic, intervention, and hospital outcome data were obtained from electronic medical records. Survivors were contacted by telephone for functional outcomes with trained outcome assessors using the World Health Organization Disability Assessment Schedule 2.0. Between March 6, 2020, and April 21, 2021, 120 critically ill patients with COVID-19, and between August 2017 and January 2019, 199 critically ill patients without COVID-19, fulfilled the inclusion criteria. Patients with COVID-19 were older (median [interquartile range], 62 [55-71] vs. 58 [44-69] yr; P = 0.019) with a lower Acute Physiology and Chronic Health Evaluation II score (17 [13-20] vs. 19 [15-23]; P = 0.011). Although duration of ventilation was longer in patients with COVID-19 than in those without COVID-19 (12 [5-19] vs. 4.8 [2.3-8.8] d; P < 0.001), 180-day mortality was similar between the groups (39/120 [32.5%] vs. 70/199 [35.2%]; P = 0.715). The incidence of death or new disability at 180 days was similar (58/93 [62.4%] vs. 99/150 [66/0%]; P = 0.583). Conclusions: At 6 months, there was no difference in new disability for patients requiring mechanical ventilation for acute respiratory failure due to COVID-19 compared with non-COVID-19. Clinical trial registered with www.clinicaltrials.gov (NCT04401254).

Physiotherapy services in intensive care. A workforce survey of Australia and New Zealand.

BACKGROUND: In Australia and New Zealand, there are currently no recommendations to guide staffing levels for intensive care unit (ICU) physiotherapy services, and there is limited information about the current services provided. OBJECTIVES: The objective of this study was to document the profile of intensive care physiotherapy services currently offered in Australia and New Zealand. METHODS: A binational survey was distributed to physiotherapists. The survey sought information on staffing and service profiles for weekday, weekend, and after-hour services including on-call and evening shifts. RESULTS: Eighty-six sites completed the survey, with responses primarily from Level 3 (47/86, 55%) and public ICUs (74/86, 86%). For weekday services, the ratio of full-time equivalent physiotherapy staff allocated per bed was similar between all intensive care levels (0.11 [0.08-0.15], p = 0.421). Thirty respondents (35%) were satisfied with their staffing and reported higher levels of physiotherapy staff per bed (0.15 [0.1-0.2], p < 0.001). Most sites reported lower levels of staffing for weekend services (76/86, 88%), and many physiotherapists indicated that they were not satisfied with this service (55/86, 64%). Most Level 2, Level 3, and paediatric ICUs had a designated senior physiotherapist, with similar levels of senior physiotherapy staff allocated per bed between all ICU levels (0.05 [0.03-0.08], p = 0.844). Few sites reported dedicated staff attributed to intensive care education, research, tracheostomy service, or outreach roles. On-call physiotherapy services were available in 49 of 86 (57%) hospitals surveyed; however, utilisation of the service by ICUs was mainly reported to be less than once per month (19/49, 39%). CONCLUSIONS: Physiotherapy staffing ratios were similar across different ICU levels. While weekend services are available for most ICUs, staffing levels are reduced. Higher staffing ratios were associated with higher levels of satisfaction to complete professional roles and responsibilities.

Correlation of patient-reported outcome measures to performance-based function in critical care survivors: PREDICTABLE.

BACKGROUND: Establishing sequela following critical illness is a public health priority; however, recruitment and retention of this cohort make assessing functional outcomes difficult. Completing patient-reported outcome measures (PROMs) via telephone may improve participant and researcher involvement; however, there is little evidence regarding the correlation of PROMs to performance-based outcome measures in critical care survivors. OBJECTIVES: The objective of this study was to assess the relationship between self-reported and performance-based measures of function in survivors of critical illness. METHODS: This was a nested cohort study of patients enrolled within a previously published study determining predictors of disability-free survival. Spearman's correlation (rs) was calculated between four performance-based outcomes (the Functional Independence Measure [FIM], 6-min walk distance [6MWD], Functional Reach Test [FRT], and grip strength) that were collected during a home visit 6 months following their intensive care unit admission, with two commonly used PROMs (World Health Organization Disability Assessment Scale 2.0 12 Level [WHODAS 2.0] and EuroQol-5 Dimension-5 Level [EQ-5D-5L]) obtained via phone interview (via the PREDICT study) at the same time point. RESULTS: There were 38 PROMs obtained from 40 recruited patients (mean age = 59.8 ± 16 yrs, M:F = 24:16). All 40 completed the FIM and grip strength, 37 the 6MWD, and 39 the FRT. A strong correlation was found between the primary outcome of the WHODAS 2.0 with all performance-based outcomes apart from grip strength where a moderate correlation was identified. Although strong correlations were also established between the EQ-5D-5L utility score and the FIM, 6MWD, and FRT, it only correlated weakly with grip strength. The EQ-5D overall global health rating only had very weak to moderate correlations with the performance-based outcomes. CONCLUSION: The WHODAS 2.0 correlated stronger across multiple performance-based outcome measures of functional recovery and is recommended for use in survivors of critical illness.

Comparison of 6-month outcomes of sepsis versus non-sepsis critically ill patients receiving mechanical ventilation.

BACKGROUND: Data on long-term outcomes after sepsis-associated critical illness have mostly come from small cohort studies, with no information about the incidence of new disability. We investigated whether sepsis-associated critical illness was independently associated with new disability at 6 months after ICU admission compared with other types of critical illness. METHODS: We conducted a secondary analysis of a multicenter, prospective cohort study in six metropolitan intensive care units in Australia. Adult patients were eligible if they had been admitted to the ICU and received more than 24 h of mechanical ventilation. There was no intervention. RESULTS: The primary outcome was new disability measured with the WHO Disability Assessment Schedule 2.0 (WHODAS) 12 level score compared between baseline and 6 months. Between enrollment and follow-up at 6 months, 222/888 (25%) patients died, 100 (35.5%) with sepsis and 122 (20.1%) without sepsis (P < 0.001). Among survivors, there was no difference for the incidence of new disability at 6 months with or without sepsis, 42/106 (39.6%) and 106/300 (35.3%) (RD, 0.00 (- 10.29 to 10.40), P = 0.995), respectively. In addition, there was no difference in the severity of disability, health-related quality of life, anxiety and depression, post-traumatic stress, return to work, financial distress or cognitive function. CONCLUSIONS: Compared to mechanically ventilated patients of similar acuity and length of stay without sepsis, patients with sepsis admitted to ICU have an increased risk of death, but survivors have a similar risk of new disability at 6 months. Trial registration NCT03226912, registered July 24, 2017.

Mobilization During Critical Illness: A Higher Level of Mobilization Improves Health Status at 6 Months, a Secondary Analysis of a Prospective Cohort Study.

OBJECTIVES: To determine the influence of active mobilization during critical illness on health status in survivors 6 months post ICU admission. DESIGN: Post hoc secondary analysis of a prospective cohort study conducted between November 2013 and March 2015. SETTING: Two tertiary hospital ICU's in Victoria, Australia. PATIENTS: Of 194 eligible patients admitted, mobility data for 186 patients were obtained. Inclusion and exclusion criteria were as per the original trial. INTERVENTIONS: The dosage of mobilization in ICU was measured by: 1) the Intensive Care Mobility Scale where a higher Intensive Care Mobility Scale level was considered a higher intensity of mobilization or 2) the number of active mobilization sessions performed during the ICU stay. The data were extracted from medical records and analyzed against Euro-quality of life-5D-5 Level version answers obtained from phone interviews with survivors 6 months following ICU admission. The primary outcome was change in health status measured by the Euro-quality of life-5D-5 Level utility score, with change in Euro-quality of life-5D-5 Level mobility domain a secondary outcome. MEASUREMENTS AND MAIN RESULTS: Achieving higher levels of mobilization (as per the Intensive Care Mobility Scale) was independently associated with improved outcomes at 6 months (Euro-quality of life-5D-5 Level utility score unstandardized regression coefficient [ß] 0.022 [95% CI, 0.002-0.042]; p = 0.033; Euro-quality of life-5D-5 Level mobility domain ß = 0.127 [CI, 0.049-0.205]; p = 0.001). Increasing the number of active mobilization sessions was not found to independently influence health status. Illness severity, total comorbidities, and admission diagnosis also independently influenced health status. CONCLUSIONS: In critically ill survivors, achieving higher levels of mobilization, but not increasing the number of active mobilization sessions, improved health status 6 months after ICU admission.

The impact of COVID-19 critical illness on new disability, functional outcomes and return to work at 6 months: a prospective cohort study.

BACKGROUND: There are few reports of new functional impairment following critical illness from COVID-19. We aimed to describe the incidence of death or new disability, functional impairment and changes in health-related quality of life of patients after COVID-19 critical illness at 6 months. METHODS: In a nationally representative, multicenter, prospective cohort study of COVID-19 critical illness, we determined the prevalence of death or new disability at 6 months, the primary outcome. We measured mortality, new disability and return to work with changes in the World Health Organization Disability Assessment Schedule 2.0 12L (WHODAS) and health status with the EQ5D-5LTM. RESULTS: Of 274 eligible patients, 212 were enrolled from 30 hospitals. The median age was 61 (51-70) years, and 124 (58.5%) patients were male. At 6 months, 43/160 (26.9%) patients died and 42/108 (38.9%) responding survivors reported new disability. Compared to pre-illness, the WHODAS percentage score worsened (mean difference (MD), 10.40% [95% CI 7.06-13.77]; p < 0.001). Thirteen (11.4%) survivors had not returned to work due to poor health. There was a decrease in the EQ-5D-5LTM utility score (MD, - 0.19 [- 0.28 to - 0.10]; p < 0.001). At 6 months, 82 of 115 (71.3%) patients reported persistent symptoms. The independent predictors of death or new disability were higher severity of illness and increased frailty. CONCLUSIONS: At six months after COVID-19 critical illness, death and new disability was substantial. Over a third of survivors had new disability, which was widespread across all areas of functioning. Clinical trial registration NCT04401254 May 26, 2020.

Chronic Heart Failure and Exercise Rehabilitation: A Systematic Review and Meta-Analysis.

OBJECTIVE: The aim of this systematic review was to identify the effect of specific exercise parameters on physical function and quality of life (QOL) in people with chronic heart failure living in the community. DATA SOURCES: A total of 5 electronic databases were searched for relevant studies published after 1994. STUDY SELECTION: The screening process was completed by 2 independent researchers, with a third independent reviewer for conflict resolution. Studies were selected if they included only chronic hHart failure participants, and the sole intervention was a structured exercise training program in an outpatient or community setting. DATA EXTRACTION: Two independent researchers completed the data extraction and qualiy assessment. Quality was assessed using the Physiotherapy Evidence Database and Grading of Recommendations Assessment, Development and Evaluation scales. DATA SYNTHESIS: In total, 40 articles (n=5411) were included in the review for meta-analysis and meta-regression, including 27 randomized control trials and 13 cohort studies. Exercise was shown to have a positive effect on QOL outcomes (standardized mean difference 1.16; 95% confidence interval [CI], 0.76-1.56) with the most commonly used measure, the Minnesota Living with Heart Failure Questionnaire, showing a clinically significant change of 8.5 points. Physical function was improved postexercise intervention in the 23 included studies (standardized mean difference 0.89; 95% CI, 0.40-1.38), with a clinically significant change of 49.8 m seen in studies using the 6-minute walk test (95% CI, 26.52-73.13). These improvements were independent of study design, study quality, participant demographics, disease severity, and exercise prescription variables. CONCLUSION: Exercise significantly improves QOL and physical function. Current evidence suggests that engagement with exercise is a more important factor in achieving improvement than how the exercise is performed. Future research should aim to identify and address barriers to engagement in exercise rehabilitation in this population.

Early Rehabilitation in Acute Respiratory Distress Syndrome.

Providing early rehabilitation during critical illness is considered best practice; however, the respiratory compromise suffered by patients with ARDS often limits their capacity to participate in active exercise. This article outlines the current evidence regarding early rehabilitation in the ICU with a specific focus on the considerations for this cohort. It provides some practical recommendations to assist clinicians in the identification of appropriate early rehabilitation techniques, taking into account disease severity and medical management strategies. It outlines methods to ensure the safe implementation of early rehabilitation with the aim of improving the outcomes of ARDS survivors.

The impact of critical illness on patients' physical function and recovery: An explanatory mixed-methods analysis.

OBJECTIVES: To determine how the perception of physical function 6-months following critical illness compares to objectively measured function, and to identify key concerns for patients during recovery from critical illness. RESEARCH METHODOLOGY AND DESIGN: A nested convergent parallel mixed methods study assessed physical function during a home visit 6-months following critical illness, with semi-structured interviews conducted at the same time. SETTING: Participants were recruited from two hospitals at one healthcare network in Melbourne, Australia from September 2017 to October 2018 with follow-up data completed in April 2019. MAIN OUTCOME MEASURES: Physical function was assessed through four objective outcomes: the functional independence measure, six-minute walk test, functional reach test, and grip strength. Semi structured interviews focused on participants function, memories of the intensive care and hospital stay, assistance required on discharge, ongoing limitations, and the recovery process. FINDINGS: Although many participants (12/20, 60%) stated they had recovered from their critical illness, 14 (70%) had function below expected population norms. Decreased function on returning home was commonly reported, although eleven participants were described as independent and safe for discharge from hospital-based staff. The importance of family and social networks to facilitate discharge was highlighted, however participants often described wanting more support and issues accessing services. The effect of critical illness on the financial well-being of the family network was confirmed, with difficulties accessing financial support identified. CONCLUSION: Survivors of critical illness perceived a better functional state than measured, but many report new limitations 6-months after critical illness. Family and friends play a crucial role in facilitating transition home and providing financial support. IMPLICATIONS FOR CLINICAL PRACTICE: Implementation of specific discharge liaison personnel to provide education, support and assist the transition from hospital-based care to home, particularly in those without stable social supports, may improve the recovery process for survivors of critical illness.

Association of active mobilisation variables with adverse events and mortality in patients requiring mechanical ventilation in the intensive care unit: a systematic review and meta-analysis.

BACKGROUND: Mobilisation during critical illness is now included in multiple clinical practice guidelines. However, a large, randomised trial and systematic review have recently identified an increased probability of adverse events and mortality in patients who received early active mobilisation in the intensive care unit (ICU). We aimed to determine the effects of mobilisation compared with usual care on adverse events and mortality in an acute ICU setting. In subgroup analyses, we specifically aimed to investigate possible sources of harm, including the timing and duration of mobilisation achieved, ventilation status, and admission diagnosis. METHODS: In this systematic review with frequentist and Bayesian analyses, we searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, SCOPUS, Web of Science, and PEDro electronic databases, as well as clinical trial registries (ICTRP and ClinicalTrials.gov), from inception to March 16, 2023, without language restrictions. Eligible studies were randomised controlled trials that examined active mobilisation compared with either no mobilisation or mobilisation commencing later, or at a lower frequency or intensity, in adults who were critically ill during or after a period of mechanical ventilation in an acute ICU setting. Two authors independently screened reports, extracted data, and assessed the risk of bias using the Cochrane risk-of-bias tool (version 1). The primary outcome was the number of adverse events that occurred during the implementation of mobilisation, with the effect of mobilisation on mortality being the secondary outcome. Risk ratios (RRs) with 95% CIs were calculated in R (version 4.0.3) using random-effects modelling, with Bayesian analysis completed to calculate the probability of treatment harm (ie, RR >1). Subgroup analyses were completed to investigate the association of various factors of mobilisation on adverse events and mortality: duration of mobilisation (longer [≥20 min per day] vs shorter [<20 min per day]), timing of commencement (early [≤72 h from ICU admission] vs late [>72 h from ICU admission]), ventilation status at commencement (all patients mechanically ventilated vs all patients extubated), and ICU admission diagnosis (surgical vs medical). This study was registered with PROSPERO, CRD42022369272. FINDINGS: After title and abstract screening of 14 440 studies and review of 466 full texts, 67 trials with 7004 participants met inclusion criteria, with 59 trials contributing to the meta-analysis. Of the 67 included studies, 15 (22%) did not mention adverse events and 13 (19%) reported no adverse events occurring across the trial period. Overall, we found no effect of mobilisation compared with usual care on the occurrence of adverse events (RR 1·09 [95% CI 0·69-1·74], p=0·71; I2 91%; 32 731 events, 20 studies; very low certainty), with a 2·96% occurrence rate (693 events in 23 395 intervention sessions; 25 studies). Mobilisation did not have any effect on mortality (RR 0·98 [95% CI 0·87-1·12], p=0·81; I2 0%; n=6218, 58 studies; moderate certainty). Subgroup analysis was hindered by the large amount of data that could not be allocated and analysed, making the results hypothesis generating only. INTERPRETATION: Implementation of mobilisation in the ICU was associated with a less than 3% chance of an adverse event occurring and was not found to increase adverse events or mortality overall, providing reassurance for clinicians about the safety of performing this intervention. Subgroup analyses did not clearly identify any specific variable of mobilisation implementation that increased harm. FUNDING: None.

The Effect of Mobilization at 6 Months after Critical Illness - Meta-Analysis.

BACKGROUND: The comparative efficacy and safety of early active mobilization compared with usual care regarding long-term outcomes for adult critically ill survivors remain uncertain. METHODS: We systematically reviewed randomized clinical trials comparing early active mobilization versus usual care in critically ill adults. The primary outcome was days alive and out of hospital to day 180 after pooling data using random effects modeling. We also performed a Bayesian meta-analysis to describe the treatment effect in probability terms. Secondary outcomes were mortality, physical function, strength, health-related quality of life at 6 months, and adverse events. RESULTS: Fifteen trials from 11 countries were included with data from 2703 participants. From six trials (1121 participants) reporting the primary outcome, the pooled mean difference was an increase of 4.28 days alive and out of hospital to day 180 in those patients who received early active mobilization (95% confidence interval, −4.46 to 13.03; I2=41%). Using Bayesian analyses with vague priors, the probability that the intervention increased days alive and out of hospital was 75.1%. In survivors, there was a 95.1% probability that the intervention improved physical function measured through a patient-reported outcome measure at 6 months (standardized mean difference, 0.2; 95% confidence interval, 0.09 to 0.32; I2=0%). Although no treatment effect was identified on any other secondary outcome, there was a 66.4% possibility of increased adverse events with the implementation of early active mobilization and a 72.2% chance it increased 6-month mortality. CONCLUSIONS: Use of early active mobilization for critically ill adults did not significantly affect days alive and out of hospital to day 180. Early active mobilization was associated with improved physical function in survivors at 6 months; however, the possibility that it might increase mortality and adverse events needs to be considered when interpreting this finding. (PROSPERO number, CRD42022309650.)

The psychometric properties and minimal clinically important difference for disability assessment using WHODAS 2.0 in critically ill patients.

Objectives: The 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) provides a standardised method for measuring health and disability. This study aimed to determine its reliability, validity and responsiveness and to establish the minimum clinically important difference (MCID) in critically ill patients. Design: Prospective, multicentre cohort study. Setting: Intensive care units of six metropolitan hospitals. Participants: Adults mechanically ventilated for > 24 hours. Main outcome measures: Reliability was assessed by measuring internal consistency. Construct validity was assessed by comparing WHODAS 2.0 scores at 6 months with the EuroQoL visual analogue scale (EQ VAS) and Lawton Instrumental Activities of Daily Living (IADL) scale scores. Responsiveness was evaluated by assessing change over time, effect sizes, and percentage of patients showing no change. The MCID was calculated using both anchor and distribution-based methods with triangulation of results. Main results: A baseline and 6-month WHODAS 2.0 score were available for 448 patients. The WHODAS 2.0 demonstrated good correlation between items with no evidence of item redundancy. Cronbach α coefficient was 0.91 and average split-half coefficient was 0.91. There was a moderate correlation between the WHODAS 2.0 and the EQ VAS scores (r = -0.72; P < 0.001) and between the WHODAS 2.0 and the Lawton IADL scores (r = -0.66; P < 0.001) at 6 months. The effect sizes for change in the WHODAS 2.0 score from baseline to 3 months and from 3 to 6 months were low. Ceiling effects were not present and floor effects were present at baseline only. The final MCID estimate was 10%. Conclusion: The 12-item WHODAS 2.0 is a reliable, valid and responsive measure of disability in critically ill patients. A change in the total WHODAS 2.0 score of 10% represents the MCID.

Early Mobilization in the Intensive Care Unit to Improve Long-Term Recovery.

This article outlines the effect of early mobilization on the long-term recovery of patients following critical illness. It investigates the safety of performing exercise in this environment, the differing types of rehabilitation that can be provided, and the gaps remaining in evidence around this area. It also attempts to assist clinicians in prescription of exercise in this cohort while informing all readers about the impact that mobilization can have for the outcomes of intensive care patients.