Feasibility of mobilisation in ICU: a multi-centre point prevalence study of mobility practices in the UK.

BACKGROUND: Early mobilisation in critical care is recommended within clinical guidance; however, mobilisation prevalence across the UK is unknown. The study aimed to determine the proportion of patients mobilised out of bed within 48-72 h, to describe their physiological status, and to compare this to published consensus safety recommendations for out-of-bed activity. METHODS: A UK cross-sectional, multi-centre, observational study of adult critical care mobility practices was conducted. Demographic, physiological and organ support data, mobility level, and rationale for not mobilising out of bed, were collected for all patients on 3rd March 2022. Patients were categorised as: Group 1-mobilised ICU Mobility Scale (IMS) ≥ 3; Group 2-not-mobilised IMS < 3 with physiological reasons; or Group 3-not-mobilised IMS < 3 with non-physiological barriers to mobilisation. Rationale for the decision to not mobilise was collected qualitatively. Regression analysis was used to compare the physiological parameters of Group 1 (mobilised) versus Group 2 (not-mobilised with physiological reasons). Patients were stratified as 'low-risk', 'potential-risk' or 'high-risk' using published risk of adverse event ratings. RESULTS: Data were collected for 960 patients across 84 UK critical care units. Of these 393 (41%) mobilised, 416 (43%) were not-mobilised due to physiological reasons and 151 (16%) were not mobilised with non-physiological reasons. A total of 371 patients had been admitted for ≤ 3 days, of whom 180 (48%) were mobilised, 140 (38%) were not mobilised with physiological reasons, and 51 (14%) were not mobilised with non-physiological reasons. Of the 809 without non-physiological barriers to mobilisation, 367 (45%) had a low risk of adverse event rating and 120 (15%) a potential risk, of whom 309 (84%) and 78 (65%) mobilised, respectively. Mobility was associated with a Richmond Agitation-Sedation Scale of - 1 to + 1, lower doses of vasoactive agents, a lower inspired oxygen requirement. CONCLUSION: Although only 40% of patients mobilised out of bed, 89% of those defined 'low-risk' did so. There is significant overlap in physiological parameters for mobilisation versus non-mobilisation groups, suggesting a comprehensive physiological assessment is vital in decision making rather than relying on arbitrary time points. CLINICAL TRIALS REGISTRATION: NCT05281705 Registered March 16, 2022. Retrospectively registered.

The clinically led worforcE and activity redesign (CLEAR) programme: a novel data-driven healthcare improvement methodology.

BACKGROUND: The NHS is facing substantial pressures to recover from the COVID-19 pandemic. Optimising workforce modelling is a fundamental component of the recovery plan. The Clinically Lead workforcE and Activity Redesign (CLEAR) programme is a unique methodology that trains clinicians to redesign services, building intrinsic capacity and capability, optimising patient care and minimising the need for costly external consultancy. This paper describes the CLEAR methodology and the evaluation of previous CLEAR projects, including the return on investment. METHODS: CLEAR is a work-based learning programme that combines qualitative techniques with data analytics to build innovations and new models of care. It has four unique stages: (1) Clinical engagement- used to gather rich insights from stakeholders and clinicians. (2) Data interrogation- utilising clinical and workforce data for cohort analysis. (3) Innovation- using structured innovation methods to develop new models of care. (4) Recommendations- report writing, impact assessment and presentation of key findings to executive boards. A mixed-methods formative evaluation was carried out on completed projects, which included semi-structured interviews and surveys with CLEAR associates and stakeholders, and a health economic logic model that was developed to link the inputs, processes, outputs and the outcome of CLEAR as well as the potential impacts of the changes identified from the projects. RESULTS: CLEAR provides a more cost-effective delivery of complex change programmes than the alternatives - resulting in a cost saving of £1.90 for every £1 spent independent of implementation success. Results suggest that CLEAR recommendations are more likely to be implemented compared to other complex healthcare interventions because of the levels of clinical engagement and have a potential return on investment of up to £14 over 5 years for every £1 invested. CLEAR appears to have a positive impact on staff retention and wellbeing, the cost of a CLEAR project is covered if one medical consultant remains in post for a year. CONCLUSIONS: The unique CLEAR methodology is a clinically effective and cost-effective complex healthcare innovation that optimises workforce and activity design, as well as improving staff retention. Embedding CLEAR methodology in the NHS could have substantial impact on patient care, staff well-being and service provision.

Early identification of patients at risk of long-term critical illness-associated physical disability: is it possible?

ICU-acquired weakness can hinder and determine the course of recovery from critical illness, leading to life-changing disability. Risk factors include multiorgan failure and prolonged bed rest; however, no prognostic model or screening tool for new-onset disability has been established to date. With no way of targeting the at-risk population, it is difficult to demonstrate the benefit of rehabilitation interventions in research and prioritize resources clinically. In a recent issue of Critical Care, Schandl and colleagues aimed to establish a predictive screening tool for new-onset disability using 23 possible predictors. They found that using the following risk factors--low educational level, fractures, reduced core stability and length of ICU stay over 2 days--they were able to develop a risk score predictive of disability at 2 months after hospital discharge. These investigators propose that this will help to identify patients requiring follow-up and may increase the power to detect change in interventional studies. Whilst this is promising work, further validation is essential: firstly, to make it a clinically workable tool in terms of appropriate 'cut offs'; secondly, to ensure that it is transferable in different socio-economic environments; and finally, to make sure that those identified as 'at risk' are those that would benefit the most from targeted intervention.

Construct validity of the Chelsea critical care physical assessment tool: an observational study of recovery from critical illness.

INTRODUCTION: Intensive care unit-acquired weakness (ICU-AW) is common in survivors of critical illness, resulting in global weakness and functional deficit. Although ICU-AW is well described subjectively in the literature, the value of objective measures has yet to be established. This project aimed to evaluate the construct validity of the Chelsea Critical Care Physical Assessment tool (CPAx) by analyzing the association between CPAx scores and hospital-discharge location, as a measure of functional outcome. METHODS: The CPAx was integrated into practice as a service-improvement initiative in an 11-bed intensive care unit (ICU). For patients admitted for more than 48 hours, between 10 May 2010 and 13 November 2013, the last CPAx score within 24 hours of step down from the ICU or death was recorded (n = 499). At hospital discharge, patients were separated into seven categories, based on continued rehabilitation and care needs. Descriptive statistics were used to explore the association between ICU discharge CPAx score and hospital-discharge location. RESULTS: Of the 499 patients, 171 (34.3%) returned home with no ongoing rehabilitation or care input; 131 (26.2%) required community support; 28 (5.6%) went to inpatient rehabilitation for <6 weeks; and 25 (5.0%) went to inpatient rehabilitation for >6 weeks; 27 (5.4%) required nursing home level of care; 80 (16.0%) died in the ICU, and 37 (7.4%) died in hospital. A significant difference was found in the median CPAx score between groups (P < 0.0001). Four patients (0.8%) scored full marks (50) on the CPAx, all of whom went home with no ongoing needs; 16 patients (3.2%) scored 0 on the CPAx, all of whom died within 24 hours. A 0.8% ceiling effect and a 3.2% floor effect of the CPAx is found in the ICU. Compliance with completion of the CPAx stabilized at 78% of all ICU admissions. CONCLUSION: The CPAx score at ICU discharge has displayed construct validity by crudely discriminating between groups with different functional needs at hospital discharge. The CPAx has a limited floor and ceiling effect in survivors of critical illness. A significant proportion of patients had a requirement for postdischarge care and rehabilitation.

Reliability and responsiveness of the Danish version of The Chelsea Critical Care Physical Assessment tool (CPAx).

INTRODUCTION: Measurement instruments are important in clinical practice and research for assessing physical function in critically ill patients in the intensive care unit (ICU). OBJECTIVE: To investigate inter-rater reliability and responsiveness of the Danish version of the CPAx (CPAx-D). METHOD: Critically ill patients from three Danish ICUs were included. Patients were assessed with CPAx-D by two blinded testers during a regular physiotherapy session. Follow-up tests were performed in patients who stayed in the ICU for more than 24 hours, were not transferred to another hospital or received palliative care. Floor and ceiling effects were examined in all assessments.Results For the reliability analysis 66 patients were included.Results Showed no significant difference between raters. For the total score, intra class correlation coefficient (ICC) was 0.996 (95% CI: 0.993; 0.997), standard error of measurement was 0.72 point and minimal detectable change 2.0 points. Bland-Altman plot revealed no heteroscedacity. The responsiveness results of 24 patients showed that the effect size was 1.2 and the standardized response mean 1.1, which was in accordance with the hypothesis. No ceiling or floor effect was revealed. CONCLUSION: The CPAx-D showed excellent inter-rater reliability and responsiveness.

The Post-ICU presentation screen (PICUPS) and rehabilitation prescription (RP) for intensive care survivors part II: Clinical engagement and future directions for the national Post-Intensive care Rehabilitation Collaborative.

Background: Many Intensive Care Unit (ICU) survivors suffer from a multi- system disability, termed the post-intensive care syndrome. There is no current national coordination of either rehabilitation pathways or related data collection for them. In the last year, the need for tools to systematically identify the multidisciplinary rehabilitation needs of severely affected COVID-19 survivors has become clear. Such tools offer the opportunity to improve rehabilitation for all critical illness survivors through provision of a personalised Rehabilitation Prescription (RP). The initial development and secondary refinement of such an assessment and data tools is described in the linked paper. We report here the clinical and workforce data that was generated as a result. Methods: Prospective service evaluation of 26 acute hospitals in England using the Post-ICU Presentation Screen (PICUPS) tool and the RP. The PICUPS tool comprised items in domains of a) Medical and essential care, b) Breathing and nutrition; c) Physical movement and d) Communication, cognition and behaviour. Results: No difference was seen in total PICUPS scores between patients with or without COVID-19 (77 (IQR 60-92) vs. 84 (IQR 68-97); Mann-Whitney z = -1.46, p = 0.144. A network analysis demonstrated that requirements for physiotherapy, occupational therapy, speech and language therapy, dietetics and clinical psychology were closely related and unaffected by COVID-19 infection status. A greater proportion of COVID-19 patients were referred for inpatient rehabilitation (13% vs. 7%) and community-based rehabilitation (36% vs.15%). The RP informed by the PICUPS tool generally specified a greater need for multi-professional input when compared to rehabilitation plans instituted. Conclusions: The PICUPS tool is feasible to implement as a screening mechanism for post-intensive care syndrome. No differences are seen in the rehabilitation needs of patients with and without COVID-19 infection. The RP could be the vehicle that drives the professional interventions across the transitions from acute to community care. No single discipline dominates the rehabilitation requirements of these patients, reinforcing the need for a personalised RP for critical illness survivors.

Covid-19 ICU remote-learning course (CIRLC): Rapid ICU remote training for frontline health professionals during the COVID-19 pandemic in the UK.

Background: The unprecedented increase in critically ill patients due to the COVID-19 pandemic mandated rapid training in critical care for redeployed staff to work safely in intensive care units (ICU). Methods: The COVID-19 ICU Remote-Learning Course (CIRLC) is a remote delivery course developed in response to the pandemic. This was a one-day course focused on the fundamentals of Intensive Care. The course used blended learning with recorded lectures and interactive tutorials delivered by shielding and frontline ICU trained professionals. The course was developed within one week and piloted at three NHS Trusts. It was then made publicly available free of charge to redeployed healthcare professionals across the UK and Ireland. An iterative cycle of improvement was used to update the course content weekly. A course confidence questionnaire with quantitative and qualitative questions was used to evaluate effectiveness. Data is reported as n (%), means (SD) and thematic analysis was used for the open questions. Results: 1,269 candidates from 171 organisations completed the course, with 99 volunteer trainers. 96% of respondents rated the course as very or extremely useful. 86% rated the online platform as excellent. Overall confidence improved from 2.7/5 to 3.9/5. Qualitative data showed that the course was pitched at the appropriate level, accessible and built clinicians confidence to work in intensive care. Conclusion: This model of educational delivery with a rapid iteration cycle was a pragmatic, effective solution to knowledge-based training under social distancing measures. Whilst full course evaluation was not possible, we believe that this work demonstrates practical guidance on educational response in a pandemic as well as highlighting the altruistic nature of the critical care community.

Mixed methods evaluation of the impact of the COVID-19 ICU remote-learning rehabilitation course for frontline health professionals during the COVID-19 pandemic in the UK.

Background: Optimising outcomes for critically ill patients with COVID-19 patients requires early interdisciplinary rehabilitation. As admission numbers soared through the pandemic, the redeployed workforce needed rapid, effective training to deliver these rehabilitation interventions. Methods: The COVID-19 ICU Remote-Learning Rehab Course (CIRLC-rehab) is a one-day interdisciplinary course developed after the success of CIRLC-acute. The aim of CIRLC-rehab was to rapidly train healthcare professionals to deliver physical, nutritional and psychological rehabilitation strategies in the ICU/acute setting. The course used blended learning with interactive tutorials delivered by shielding critical care professionals. CIRLC-rehab was evaluated through a mixed-methods approach, including questionnaires, and follow-up semi-structured interviews to evaluate perceived impact on clinical practice. Quantitative data are reported as n (%) and means (SD). Inductive descriptive thematic analysis with methodological triangulation was used to analyse the qualitative data from the questionnaires and interviews. Results: 805 candidates completed CIRLC-rehab. 627 (78.8%) completed the post-course questionnaire. 95% (n = 596) found CIRLC-rehab extremely or very useful and 96.0% (n = 602) said they were very likely to recommend the course to colleagues. Overall confidence rose from 2.78/5 to 4.14/5. The course promoted holistic and humanised care, facilitated informal networks, promoted interdisciplinary working and equipped the candidates with practical rehabilitation strategies that they implemented into clinical practice. Conclusion: This pragmatic solution to educating redeployed staff during a pandemic increased candidates' confidence in the rehabilitation of critically ill patients. There was also evidence of modifications to clinical care utilising learning from the course that subjectively facilitated holistic and humanised rehabilitation, combined with the importance of recognising the humanity, of those working in ICU settings themselves. Whilst these data are self-reported, we believe that this work demonstrates the real-term benefits of remote, scalable and rapid educational delivery.

The post-ICU presentation screen (PICUPS) and rehabilitation prescription (RP) for intensive care survivors part I: Development and preliminary clinimetric evaluation.

Background: Patients who have had prolonged stays in intensive care have ongoing rehabilitation needs. This is especially true of COVID-19 ICU patients, who can suffer diverse long-term ill effects. Currently there is no systematic data collection to guide the needs for therapy input for either of these groups nor to inform planning and development of rehabilitation services. These issues could be resolved in part by the systematic use of a clinical tool to support decision-making as patients progress from the Intensive Care Unit (ICU), through acute hospital care and onwards into rehabilitation. We describe (i) the development of such a tool (the Post-ICU Presentation Screen (PICUPS)) and (ii) the subsequent preparation of a person-centred Rehabilitation Prescription (RP) to travel with the patient as they continue down the care pathway. Methods: PICUPS development was led by a core group of experienced clinicians representing the various disciplines involved in post-ICU rehabilitation. Key constructs and item-level descriptors were identified by group consensus. Piloting was performed as part of wider clinical engagement in 26 acute hospitals across England. Development and validation of such a tool requires clinimetric analysis, and this was based on classical test theory. Teams also provided feedback about the feasibility and utility of the tool. Results: Initial PICUPS design yielded a 24-item tool. In piloting, a total of 552 records were collated from 314 patients, of which 121 (38.5%) had COVID-19. No obvious floor or ceiling effects were apparent. Exploratory factor analysis provided evidence of uni-dimensionality with strong loading on the first principal component accounting for 51% of the variance and Cronbach's alpha for the full-scale score 0.95 - although a 3-factor solution accounted for a further 21%. The PICUPS was responsive to change both at full scale- and item-level. In general, positive responses were seen regarding the tool's ability to describe the patients during their clinical course, engage and flag the relevant professionals needed, and to inform what should be included in an RP. Conclusions: The PICUPS tool has robust scaling properties as a clinical measure and is potentially useful as a tool for identifying rehabilitation needs as patients step down from ICU and acute hospital care.

Cross-cultural adaptation and inter-rater reliability of the Swedish version of the Chelsea critical care assessment tool (CPAX-Swe) in critically ill patients.

OBJECTIVES: To translate and culturally adapt the Chelsea Critical Care Physical Assessment Tool into Swedish and to test the inter-rater reliability of the Swedish version in critically ill patients. DESIGN: This is an observational study. METHODS: Translation and cross-cultural adaptation was performed in line with international recommendations, including forward and backward translation and expert round table discussions. The inter-rater reliability of the Chelsea Critical Care Physical Assessment Tool - Swedish was then explored in 50 critically ill adult patients, pragmatically recruited, in a University Hospital clinical setting. Reliability was calculated using intraclass correlation coefficient for aggregated scores and quadratic weighted Cohen's kappa analysis for individual items. RESULTS: The expert round table discussion group agreed that the translation was a satisfactory equivalent to the original version and applicable for use within the clinical setting. Reliability of aggregated scores and individual items were very good (intraclass correlation coefficient of 0.97 and quadric weighted kappa values ranging from 0.88 to 0.98). The measurement error for aggregated scores was low, with a standard error of measurement of 1.79, smallest detectable change of 4.95, and limits of agreement of 5.20 and -4.76. The percentage agreement for individual items ranged from 64% to 88%. CONCLUSION: The Chelsea Critical Care Physical Assessment Tool - Swedish was found applicable and appropriate for assessment of functioning in critically ill patients in an acute setting in Sweden, and it displayed high inter-rater reliability. This implies that the Swedish version can be used as assessment tool within intensive care and acute wards in Sweden.Implications for rehabilitationThere is a lack of validated instruments to test the functional status of critically ill patients in Sweden.The Chelsea Critical Care Physical Assessment Tool is validated and reliable in English.The Chelsea Critical Care Physical Assessment Tool - Swedish is considered reliable for use by physiotherapist in intensive care settings in Sweden.The Swedish version is feasible for use within clinical practice due to its simplicity and strong clinical relevance.