Relationship between potential barriers to early mobilization in adult patients during intensive care stay using the Perme ICU Mobility score.

BACKGROUND: Identifying barriers to early mobilization is essential for the management of patients in the intensive care unit (ICU). Our objective was to identify the potential barriers to early mobilization in adult patients using the Perme ICU Mobility Score (Perme Score) and its relationship with days of mechanical ventilation (MV) and length of stay in ICU. METHODS: This was a pilot, observational, and prospective study. We included 142 adult patients admitted to a 14-bed ICU, in a fourth-level complexity hospital in Cali, Colombia. The Perme Score was used to evaluate potential barriers to mobility. We used the Spearman's correlation coefficient to find potential correlations between the number of barriers to mobility per patient and the duration of MV and ICU stay. RESULTS: We identified significant inverse correlations between total days in MV and the total score of barriers to mobility at ICU admission (r = -0.773; p < 0.05) and at ICU discharge (r = -0.559; p < 0.05). Also, between ICU length of stay and total score of barriers to mobility at ICU admission (r = -0.420; p < 0.05) and at ICU discharge (r = -0.283; p < 0.05). Moreover, we found a significant correlation between total score of the barriers item and total Perme score (r = 0.91; p < 0.01). CONCLUSIONS: Using the Perme Score we identified potential barriers to mobility upon admission to the ICU that were maintained until discharge. Our findings indicate a strong positive correlation at ICU admission between the total Perme Score and the total score of "Category #2 - Potential Mobility Barriers" in the Perme Score.

Spanish version of the Perme Intensive Care Unit Mobility Score: Minimal detectable change and responsiveness.

PURPOSE: The purpose of this study was to determine the minimal detectable change (MDC) and responsiveness of the Perme Score when used in the adult intensive care unit (ICU) population. METHODS: This is a prospective longitudinal study which was conducted from November 2016 to July 2017 in Cali, Colombia. Four physical therapists with observer and evaluator roles, applied the Perme Score upon ICU admission and discharge. The Consensus-based Standards for the Selection of Health Measurement Instruments Protocol standards to analyze sensitivity to change were used. The sample size was defined considering the lowest concordance proportion reported (68.6%), and a Kappa Index of 0.2784 or higher to guarantee an adequate n, and a 95% reliability level. RESULTS: One hundred and forty-two patients were enrolled in the study. There were 51.4% men with an average age of 58 ± 17 years. Invasive mechanical ventilation was employed in 42.0% of the patients. The MDC for the Perme Score was 1.36, and 80% of patients demonstrated higher or equal values, detecting a significant difference in the type of weaning and the length of stay in the ICU (p < 0.005). CONCLUSIONS: The Perme Score has an MDC of 1.36 points and shows evidence of being sensitive to change. Therefore, the findings validate the responsiveness of the instrument.

Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ICU Liberation ABCDEF Bundle Improvement Collaborative.

The ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment) improves intensive care unit patient-centered outcomes and promotes interprofessional teamwork and collaboration. The Society of Critical Care Medicine recently completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, multicenter, national quality improvement initiative that formalized dissemination and implementation strategies to promote effective adoption of the ABCDEF bundle. The purpose of this article is to describe 8 of the most frequently asked questions during the Collaborative and to provide practical advice from leading experts to other institutions implementing the ABCDEF bundle.

Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience.

Although growing evidence supports the safety and effectiveness of the ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment), intensive care unit providers often struggle with how to reliably and consistently incorporate this interprofessional, evidence-based intervention into everyday clinical practice. Recently, the Society of Critical Care Medicine completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, nationwide, multicenter quality improvement initiative that formalized dissemination and implementation strategies and tracked key performance metrics to overcome barriers to ABCDEF bundle adoption. The purpose of this article is to discuss some of the most challenging implementation issues that Collaborative teams experienced, and to provide some practical advice from leading experts on ways to overcome these barriers.

Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults.

OBJECTIVE: Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care. DESIGN: Prospective, multicenter, cohort study from a national quality improvement collaborative. SETTING: 68 academic, community, and federal ICUs collected data during a 20-month period. PATIENTS: 15,226 adults with at least one ICU day. INTERVENTIONS: We defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders. MEASUREMENTS AND RESULTS: Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17-0.62), next-day mechanical ventilation (adjusted odds ratio [AOR], 0.28; CI, 0.22-0.36), coma (AOR, 0.35; CI, 0.22-0.56), delirium (AOR, 0.60; CI, 0.49-0.72), physical restraint use (AOR, 0.37; CI, 0.30-0.46), ICU readmission (AOR, 0.54; CI, 0.37-0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51-0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001). CONCLUSIONS: ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.

Perme ICU Mobility Score (Perme Score) and the ICU Mobility Scale (IMS): translation and cultural adaptation for the Spanish language / Escalas Perme ICU Mobility Score (Perme Score) e ICU Mobility Scale (IMS): traducción y adaptación cultural para el idioma español

Abstract Introduction: The scales to measure functional mobility in critically ill patients were developed and validated in English, there is a need for these tools in Spanish speaking countries. Objective: To perform translation, cultural adaptation and inter-rater reliability of the Spanish versions of the Perme Intensive Care Unit Mobility Score and IMS tools in ICU patients. Methods: Translation and validation study between November 2016 and July 2017, following the COSMIN Protocol's recommendations. Two couples of physiotherapists with the role of observer/rater applied both scales in 150 patients upon admission and discharge of a medical-surgical ICU from a private hospital in Colombia. The sample size was defined taking into account the lowest proportion of reported agreement (68.57%), a Kappa index of 0.2784 or higher to ensure that the calculated n was adequate, and a confidence level of 95% Results: Translation and cultural adaptation were performed, the final version of both scales in Spanish was approved by the authors. The sample was 150 patients, 52% were men, the average age was 58 ± 17 years, invasive mechanical ventilation was present in 63 (42%) of the cases. Inter-rater reliability of the ICU Mobility Scale was between 0.97 and 1.00, and for the Perme Intensive Care Unit the Mobility Score it was between 0.99 and 1 in the two moments of the measurements. Conclusions: Both scales were translated and culturally adapted and presented excellent inter-rater reliability in the two pairs of raters (rater/observer).

Resumen Introducción: Las escalas para medir la movilidad funcional en el paciente crítico han sido desarrolladas y validadas en lengua inglesa, existe una necesidad de contar con estas escalas en nuestros países hispanoparlantes. Objetivo: Realizar traducción, adaptación cultural y determinar confiabilidad inter evaluador de la versión en español del Perme Intensive Care Unit Mobility Score y del ICU Mobility Scale (IMS). Métodos: Estudio de traducción y validación entre noviembre de 2016 y Julio de 2017 siguiendo las recomendaciones del Protocolo COSMIN. Dos parejas de fisioterapeutas con el rol de observador/evaluador aplicaron ambas escalas en 150 pacientes al ingreso y egreso de una UCI médico-quirúrgica de una clínica privada en Colombia. Se definió el tamaño de muestra teniendo en cuenta la menor proporción de concordancia reportada (68.6%), un índice Kappa 0.2784 o superior para garantizar que el n calculado fuera adecuado, y un nivel de confianza de 95% Resultados: Se realizó la traducción y adaptación cultural, la versión final de ambas escalas en idioma español fue aprobada por los autores. La muestra fue de 150 pacientes, 52% fueron hombres, la edad promedio fue de 58 ±17 años, la ventilación mecánica invasiva estuvo presente en 63 (42.0%) de los casos. Se encontró confiabilidad inter-evaluador del ICU Mobility Scale entre 0.97 y 1 y para Perme Intensive Care Unit Mobility Score estuvo entre 0.99 y 1.00 en los dos momentos de mediciones. Conclusiones Ambas escalas fueron traducidas y adaptadas culturalmente y presentaron excelente confiabilidad inter-evaluador en las dos parejas de evaluadores (evaluador/observador).

Perme ICU Mobility Score (Perme Score) and the ICU Mobility Scale (IMS): translation and cultural adaptation for the Spanish language.

INTRODUCTION: The scales to measure functional mobility in critically ill patients were developed and validated in English, there is a need for these tools in Spanish speaking countries. OBJECTIVE: To perform translation, cultural adaptation and inter-rater reliability of the Spanish versions of the Perme Intensive Care Unit Mobility Score and IMS tools in ICU patients. METHODS: Translation and validation study between November 2016 and July 2017, following the COSMIN Protocol's recommendations. Two couples of physiotherapists with the role of observer/rater applied both scales in 150 patients upon admission and discharge of a medical-surgical ICU from a private hospital in Colombia. The sample size was defined taking into account the lowest proportion of reported agreement (68.57%), a Kappa index of 0.2784 or higher to ensure that the calculated n was adequate, and a confidence level of 95. RESULTS: Translation and cultural adaptation were performed, the final version of both scales in Spanish was approved by the authors. The sample was 150 patients, 52% were men, the average age was 58 ± 17 years, invasive mechanical ventilation was present in 63 (42%) of the cases. Inter-rater reliability of the ICU Mobility Scale was between 0.97 and 1.00, and for the Perme Intensive Care Unit the Mobility Score it was between 0.99 and 1 in the two moments of the measurements. CONCLUSIONS: Both scales were translated and culturally adapted and presented excellent inter-rater reliability in the two pairs of raters (rater/observer).

INTRODUCCIÓN: Las escalas para medir la movilidad funcional en el paciente crítico han sido desarrolladas y validadas en lengua inglesa, existe una necesidad de contar con estas escalas en nuestros países hispanoparlantes. OBJETIVO: Realizar traducción, adaptación cultural y determinar confiabilidad inter evaluador de la versión en español del Perme Intensive Care Unit Mobility Score y del ICU Mobility Scale (IMS). MÉTODOS: Estudio de traducción y validación entre noviembre de 2016 y Julio de 2017 siguiendo las recomendaciones del Protocolo COSMIN. Dos parejas de fisioterapeutas con el rol de observador/evaluador aplicaron ambas escalas en 150 pacientes al ingreso y egreso de una UCI médico-quirúrgica de una clínica privada en Colombia. Se definió el tamaño de muestra teniendo en cuenta la menor proporción de concordancia reportada (68.6%), un índice Kappa 0.2784 o superior para garantizar que el n calculado fuera adecuado, y un nivel de confianza de 95. RESULTADOS: Se realizó la traducción y adaptación cultural, la versión final de ambas escalas en idioma español fue aprobada por los autores. La muestra fue de 150 pacientes, 52% fueron hombres, la edad promedio fue de 58 ±17 años, la ventilación mecánica invasiva estuvo presente en 63 (42.0%) de los casos. Se encontró confiabilidad inter-evaluador del ICU Mobility Scale entre 0.97 y 1 y para Perme Intensive Care Unit Mobility Score estuvo entre 0.99 y 1.00 en los dos momentos de mediciones. CONCLUSIONES: Ambas escalas fueron traducidas y adaptadas culturalmente y presentaron excelente confiabilidad inter-evaluador en las dos parejas de evaluadores (evaluador/observador).

Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting.

BACKGROUND: Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The post-intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families. OBJECTIVES: To report on engagement with non-critical care providers and survivors during the 2012 Society of Critical Care Medicine post-intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes. PARTICIPANTS: Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members. DESIGN: Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences. MEETING OUTCOMES: Future steps were planned regarding 1) recognizing, preventing, and treating post-intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post-intensive care syndrome across the continuum of care, including explicit "functional reconciliation" (assessing gaps between a patient's pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post-intensive care syndrome research topic areas were identified across the continuum of recovery: characterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families. CONCLUSIONS: Raising awareness of post-intensive care syndrome for the public and both critical care and non-critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.

A tool to assess mobility status in critically ill patients: the Perme Intensive Care Unit Mobility Score.

The benefits of early mobilization for adult patients in the intensive care unit (ICU) are reduced length of ICU and hospital stays, fewer readmissions to the ICU, decreased duration of mechanical ventilation, fewer days of detrimental bedrest, minimal adverse or unsafe events, and improved walking distance. Because there are no available tools to specifically measure mobility status of patients in the ICU setting, there is an urgent need to create a reliable tool that measures and standardizes the assessment of mobility status for these patients. The purpose of this study was to describe the development of this novel ICU-specific tool to assess a patient's mobility status, examine the initial reliability of the tool, and address its clinical application. The Perme ICU Score was quickly and easily administered by physical therapists. Overall, the inter-rater agreement was 94%. A total of six items had kappa values of < .6, and these low scores may have been the result of the procedure to collect inter-rater scores, wherein one rater assisted with the activity while a second rater observed. In order to improve reliability, the authors developed directions to standardize the assessment. The Perme ICU Mobility Score is a tool developed to measure the patient's mobility status starting with the ability to follow commands and culminating in the distance walked in two minutes. Preliminary data suggest that the validity of this tool is supported by expert concurrence, its overall reliability is high, and its clinical use is acceptable.

Initial interrater reliability for a novel measure of patient mobility in a cardiovascular intensive care unit.

PURPOSE: The purpose of this study was to determine the interrater reliability of the Perme Intensive Care Unit Mobility Score. MATERIALS AND METHODS: This was a prospective observational study. Data were collected from 20 patients admitted in a cardiovascular intensive care unit. The interrater reliability was tested using the intraclass correlation coefficient with 95% confidence interval and the Cohen κ coefficient of 0.9, using a 2-tailed α of .05 to provide a 90% power. RESULTS: The 15 items of the Perme ICU Mobility Score were individually analyzed. Interrater reliability (Cohen κ coefficient) for items 2, 3, 5, 6, 7, 8, 13, and 15 was 1.0000; for item 1, 0.8276; item 4, 0.8000; item 9, 0.6000; item 10, 0.7297; item 11, 0.7260; item 12, 0.7872; and item 14, 0.9048; the intraclass correlation coefficient (95% confidence interval) was 0.9880 (0.97743-0.99859). CONCLUSIONS: The Perme ICU Mobility Score is a reliable tool to assess mobility status of patients admitted to the cardiovascular intensive care unit in a specific moment in time, which can be an important tool for research and clinical practice.

Safety and Efficacy of Mobility Interventions in Patients with Femoral Catheters in the ICU: A Prospective Observational Study.

INTRODUCTION: There are limited data describing mobility interventions provided to patients with femoral catheters. The purpose of this study was to examine the incidence of femoral catheter related adverse effects during physical therapy (PT) sessions in a cardiovascular intensive care unit (ICU). METHODS: This was a prospective, observational study and included patients with at least one femoral catheter. Data were collected after each PT session. RESULTS: There were 77 subjects with a total of 92 femoral catheters (50 arterial, 15 central venous, and 27 dialysis) treated. A total of 210 separate PT sessions occurred with 630 mobility activities including sitting on side of bed, standing at the bedside, transfers to stretcher chair or regular chair, and walking. There were no catheter related mechanical or thrombotic complications during any of the PT sessions. CONCLUSIONS: Physical therapy sessions, including standing and walking were feasible and safe in cardiovascular ICU patients with femoral catheters who met the criteria for mobility interventions. The results from this study support the hypothesis that early mobilization in patients with femoral catheters is important to minimize functional decline and provide evidence that the presence of femoral catheters alone should not be a reason to limit progressive mobility interventions.

Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference.

BACKGROUND: Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health status which may last for months and years after hospital discharge. OBJECTIVES: To report on a 2-day Society of Critical Care Medicine conference aimed at improving the long-term outcomes after critical illness for patients and their families. PARTICIPANTS: Thirty-one invited stakeholders participated in the conference. Stakeholders represented key professional organizations and groups, predominantly from North America, which are involved in the care of intensive care survivors after hospital discharge. DESIGN: Invited experts and Society of Critical Care Medicine members presented a summary of existing data regarding the potential long-term physical, cognitive and mental health problems after intensive care and the results from studies of postintensive care unit interventions to address these problems. Stakeholders provided reactions, perspectives, concerns and strategies aimed at improving care and mitigating these long-term health problems. MEASUREMENTS AND MAIN RESULTS: Three major themes emerged from the conference regarding: (1) raising awareness and education, (2) understanding and addressing barriers to practice, and (3) identifying research gaps and resources. Postintensive care syndrome was agreed upon as the recommended term to describe new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. The term could be applied to either a survivor or family member. CONCLUSIONS: Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.

Updates on critical care management of cardiovascular patients.

Cardiology and cardiovascular surgery patients have historically been one of the sickest populations that physicians encounter. With the inherent compromise of the cardiac and/or respiratory system and the added complexity of a major surgical procedure, this patient group requires a demanding level of care. As innovations in the treatment of cardiac patients have prolonged life, we have encountered patients who require redo-redo-redo procedures. There has been a tremendous increase in the use of a wide variety of mechanical assist devices, transplantation procedures, robotic surgery, and hybrid approaches in which cardiac surgeons and cardiologists work in the same room on the same patient. Against this background, there have been quite a few changes taking place in the field of critical care. This report discusses the transformations being made in blood pressure management, blood product transfusion, prevention of healthcareassociated infections, physical therapy in cardiothoracic intensive care units (ICUs), ventilatory management, and the role of intensivists in cardiothoracic ICUs.

Early mobility and walking program for patients in intensive care units: creating a standard of care.

New technologies in critical care and mechanical ventilation have led to long-term survival of critically ill patients. An early mobility and walking program was developed to provide guidelines for early mobility that would assist clinicians working in intensive care units, especially clinicians working with patients who are receiving mechanical ventilation. Prolonged stays in the intensive care unit and mechanical ventilation are associated with functional decline and increased morbidity, mortality, cost of care, and length of hospital stay. Implementation of an early mobility and walking program could have a beneficial effect on all of these factors. The program encompasses progressive mobilization and walking, with the progression based on a patient's functional capability and ability to tolerate the prescribed activity. The program is divided into 4 phases. Each phase includes guidelines on positioning, therapeutic exercises, transfers, walking reeducation, and duration and frequency of mobility sessions. Additionally, the criteria for progressing to the next phase are provided. Use of this program demands a collaborative effort among members of the multidisciplinary team in order to coordinate care for and provide safe mobilization of patients in the intensive care unit.

Early mobilization of LVAD recipients who require prolonged mechanical ventilation.

Early mobilization and aggressive physical therapy are essential in patients who receive left ventricular assist devices (LVADs) due to long-term, end-stage heart failure. Some of these patients remain ventilator dependent for quite some time after device implantation. We report our regimen of mobilization with the aid of a portable ventilator, in patients with cardiac cachexia and LVAD implantation. Further, we describe the specific physical therapy interventions used in an LVAD patient who required prolonged mechanical ventilation after device implantation. The patient was critically ill for 5 weeks before the surgery and was ventilator dependent for 48 days postoperatively. There were significant functional gains during the period of prolonged mechanical ventilation. The patient was able to walk up to 600 feet by the time he was weaned from the ventilator and transferred out of the intensive care unit. He underwent successful heart transplantation 6 weeks after being weaned from the ventilator We believe that improving the mobility of LVAD patients who require mechanical ventilation has the potential both to facilitate ventilator weaning and to improve the outcomes of transplantation.