Early mobilisation practice in intensive care units: A large-scale cross-sectional survey in China.

BACKGROUND: The field of early rehabilitation has developed slowly in mainland China and there are limited data on the implementation of early mobilisation (EM) practice in intensive care unit (ICUs) in China. AIMS: To investigate the implementation of EM in ICUs in mainland China and to analyse its influencing factors. STUDY DESIGN: A cross-sectional electronic survey was conducted in 444 ICUs across 11 provinces in China. Head nurses provided data on institutional characteristics and EM practice in ICUs. Logistic regression models were used to identify factors associated with the implementation of EM. RESULTS: In all, 56.98% (253/444) of ICUs implemented EM with comprehensive or complete implementation in 86 ICUs. Of the 191 ICUs that did not use EM, 136 planned to implement EM in the near future. Of the 253 ICUs that used EM, 21.34% of ICUs implemented EM for all eligible patients, while 24.90% would evaluate and carry out EM within 48 h after ICU admission, 39.13% had collaborative EM teams, 34.39% reported the use of EM protocols, 14.63% reported multidisciplinary rounds and 17.39% had medical orders and charging standards for all EM activities. Only 18.18% of ICUs conducted frequent professional training for EM, and abnormal events occurred in 15.41% of ICUs during EM practice. Multivariate logistic regression analysis revealed that an economically strong province, the presence of a dedicated therapist team, more ICU beds and a higher staff-to-bed ratio favoured the implementation of EM. Furthermore, multidisciplinary rounds, well-established medical orders and charging standards, and a high frequency of professional training can lead to the comprehensive promotion and development of EM practice in ICUs. CONCLUSIONS: Both the implementation rate and quality of EM practice for critically ill patients require improvement. EM practice in Chinese ICUs is still nascent and requires development in a variety of domains. RELEVANCE TO CLINICAL PRACTICE: To facilitate the implementation of EM in ICUs, more human resources, especially the involvement of a professional therapist team, should be deployed. In addition, health providers should actively organize multidisciplinary rounds and professional training and formulate appropriate EM medical orders and charging standards.

Current practice and barriers to ICU-acquired weakness assessment: a cross-sectional survey.

BACKGROUND: Intensive-care-unit-acquired weakness (ICU-AW) not only leads to difficulty weaning off mechanical ventilation, prolonged hospital stay and increased medical costs, but also reduces the patient's quality of life after discharge and increases the 1-year mortality rate. Early identification and intervention can improve the prognosis of critically ill patients. However, much remains unknown about current clinical practice for ICU-AW assessment by ICU staff in China. OBJECTIVES: To investigate current practices and barriers to ICU-AW assessment among ICU staff, and provide insights to improve ICU-AW assessment in ICUs in China. METHODS: Qualitative interviews were used to construct a survey questionnaire (test-retest reliability 0.92, validity 0.96). This survey was subsequently completed by 3206 ICU staff from 31 provinces, municipalities and autonomous regions in China. RESULTS: In total, 3206 ICU staff responded to the survey (response rate 90%): 616 doctors (19%), 2371 nurses (74%), 129 respiratory therapists (4%), 51 physiotherapists (2%) and 39 dieticians (1%). Only 27% of the respondents had treated/cared for patients with ICU-AW. Reported methods for ICU-AW assessment were clinical experience (53%), ICU-AW assessment tools (12%), and physiotherapy consultation (35%). Forty-three percent of respondents felt that their ICU-AW-related knowledge did not meet clinical needs, only 10% had received ICU-AW-related training, and 19% proactively assessed whether their patients had ICU-AW. In terms of frequency of assessment, 42%, 16% and 11% of respondents considered that ICU-AW should be assessed daily, every 3 days, and on ICU admission and discharge, respectively. The Medical Research Council scale, electrophysiological assessment and the Manual Muscle Testing scale were considered to be optimal tools for ICU-AW diagnosis by 79%, 70%, and 73% of respondents, respectively. The main reported barriers to ICU-AW assessment were lack of knowledge, cognitive impairment among patients, and lack of ICU-AW assessment guidelines and procedures. CONCLUSION: Current practices for ICU-AW assessment are non-specific, and the main barriers include lack of skills and knowledge.

Chinesisation, adaptation and validation of the Chelsea Critical Care Physical Assessment Tool in critically ill patients: a cross-sectional observational study.

PURPOSE: To translate and adapt the Chelsea Critical Care Physical Assessment Tool (CPAx) into Chinese version ('CPAx-Chi'), test the reliability and validity of CPAx-Chi, and verify the cut-off point for the diagnosis of intensive care unit-acquired weakness (ICU-AW). STUDY DESIGN: Cross-sectional observational study. METHODS: Forward and back translation, cross-cultural adaptation and pretesting of CPAx into CPAx-Chi were based on the Brislin model. Participants were recruited from the general ICU of five third-grade class-A hospitals in western China. Two hundred critically ill adult patients (median age: 53 years; 64% men) with duration of ICU stay ≥48 hours and Glasgow Coma Scale ≥11 were included in this study. Two researchers simultaneously and independently assessed eligible patients using the Medical Research Council Muscle Score (MRC-Score) and CPAx-Chi. RESULTS: The content validity index of items was 0.889. The content validity index of scale was 0.955. Taking the MRC-Score scale as standard, the criterion validity of CPAx-Chi was r=0.758 (p<0.001) for researcher A, and r=0.65 (p<0.001) for researcher B. Cronbach's α was 0.939. The inter-rater reliability was 0.902 (p<0.001). The area under the receiver operating characteristic curves of CPAx-Chi for diagnosing ICU-AW based on MRC-Score ≤48 were 0.899 (95% CI 0.862 to 1.025) and 0.874 (95% CI 0.824 to 0.925) for researcher B. The best cut-off point for CPAx-Chi for the diagnosis of ICU-AW was 31.5. The sensitivity was 87% and specificity was 77% for researcher A, whereas it was 0.621, 31.5, 75% and 87% for researcher B, respectively. The consistency was high when taking CPAx-Chi ≤31 and MRC-Score ≤48 as the cut-off points for the diagnosis of ICU-AW. Cohen's kappa=0.845 (p=0.02) in researcher A and 0.839 (p=0.04) for researcher B. CONCLUSIONS: CPAx-Chi demonstrated content validity, criterion-related validity and reliability. CPAx-Chi showed the best accuracy in assessment of patients at risk of ICU-AW with good sensitivity and specificity at a recommended cut-off of 31.

[Current practice and obstacle factors of intensive care unit-acquired weakness assessment].

OBJECTIVE: To investigate the current status of intensive care unit-acquired weakness (ICU-AW) assessment, analyze the assessment barriers, and to provide reference to improve ICU-AW assessment. METHODS: A convenient sampling cross-sectional survey was conducted. First, an interview outline which based on related domestic and international literatures and combining with the research purpose of this study were designed. Thirteen medical personnel (8 ICU nurses, 3 ICU doctors, 1 respiratory therapist and 1 physiotherapist) who worked in the intensive care unit (ICU) of the First Hospital of Lanzhou University were enrolled with convenience sampling method to interview. Second, the topics were comprehensively analyzed and extracted, and then a questionnaire was constructed, and the reliability and validity was assessed. Finally, the questionnaire survey including the general situation of ICU medical staffs, the current practices of ICU-AW and influencing factors was implemented in China. RESULTS: The retest reliability was 0.92 and expert validity was 0.96 of the questionnaire. There were 3 563 respondents in 31 provinces, municipalities and autonomous regions which eliminated 357 unqualified questionnaires, including 173 respondents from neonatal or pediatric ICU, 89 respondents whose working time was less than 6 months, and 95 invalid respondents, and then there were finally 3 206 valid questionnaires and the response rate were 90.0%. Those 3 206 respondents included 616 doctors (19.2%), 2 371 nurses (74.0%), 129 respiratory therapists (4.0%), 51 physiotherapist (1.6%) and 39 dietitians (1.2%). The mean age was (30.7±6.3) years old. Most of them had bachelor's degree (65.9%), master and above was 14.1%. Associate senior physician and above was 8.0%; ICU working time was (5.94±4.50) years. In clinical practice, only 26.5% of the ICU medical staffs confirmed that they had treated or taken care for ICU-AW patients; 52.9% of medical staffs evaluated ICU-AW only based on clinical experience, and only 12.3% used ICU-AW assessment tools. The majority of respondents believed that ICU-AW knowledge training should be performed (81.8%), ICU-AW assessment should be as important as other complications (pressure sore, infected ventilator associated pneumonia, etc., 75.1%), and ICU-AW assessment should be part of daily treatment and care activities (61.2%). However, only 10.2% of respondents had received ICU-AW related knowledge training, and 42.7% respondents believed that their ICU-AW related knowledge could not meet clinical needs. Only 18.7% respondents would actively assess whether patients suffered from ICU-AW or not, and 42.3% respondents thought that ICU-AW should be assessed every day, and the assessment tools were also inconsistent. There were 44.0% respondents considered the Medical Research Council Muscle score (MRC-score) scale was the optimal tool for diagnosing ICU-AW, the following were neuro-electrophysiological examination (17.2%) and manual muscle strength (MMT, 11.1%). The main cause of the ICU-AW assessment barriers was the lack of ICU-AW related knowledge (88.1%), and the following were lack of ICU-AW assessment guidelines (76.5%), patients' cognitive impairment or limited understanding ability (84.6%), unable to cooperate with the assessment due to critical illness (83.0%), and inadequate attention to ICU-AW assessment by the department (77.5%). CONCLUSIONS: The current status of ICU-AW assessment were unsatisfying in China, and the main barriers were lack of skills and knowledge.

[Cognitive impairment after intensive care unit discharge: a Meta-analysis].

OBJECTIVE: To investigate the cognitive impairment after intensive care unit (ICU) discharge and provide theoretical basis for prevention and intervention. METHODS: Studies about cognitive impairment after ICU discharge were retrieved in PubMed, Embase, Cochrane Library, Web of Science, Wanfang data, CNKI and SinoMed from their foundation to December 2019. The literature screening and data extraction were performed by two researchers independently, and the quality of different types of researches was evaluated using Cochrane Handbook 5.1.0, Newcastle-Ottawa scale (NOS) and agency for healthcare research and quality criteria (AHRQ). The Meta-analysis was performed by Stata 13.0 software. Sensitivity analysis was used to determine the reliability of the combined effect values. Funnel plot and Egger test were used to analyze publication bias. The non-parametric clipping was used to evaluate the impact of publication bias on the results. RESULTS: A total of 35 studies were enrolled, including 27 prospective cohort studies, 4 retrospective cohort studies, 2 randomized controlled trial (RCT) studies, 1 case-control study, and 1 cross-sectional study. Three literatures were published in Chinese and 32 were in English, which covered 13 countries, and a total of 102 504 ICU survivors were followed up successfully. Literature quality evaluation results showed that the NOS scores of 31 cohort studies were between 6 and 9, of which the case-control study scored 9. The quality grade of 2 RCT studies were both B. According to the AHRQ criteria, 1 cross-sectional study's design was scientifically rigorous and of high quality. Thirty-five studies reported that the overall incidence of cognitive impairment after ICU discharge ranged from 2.47% to 66.07%. For the multiple follow-ups studies, the first survey data was selected for Meta-analysis, and the results showed that the pooled incidence was 38.44% [95% confidence interval (95%CI) was 29.32-47.55]. Each study was removed for sensitivity analysis and the pooled results did not change much, which indicated that the results were reliable. The sub-group analysis was performed on different evaluation methods for cognitive impairment after ICU discharge, different types of ICU patients, and different follow-up time. The results showed that the pooled incidence of studies using neuropsychological test to evaluate cognitive impairment after ICU discharge was 31.42% (95%CI was 21.82-41.02), the pooled incidence of studies using questionnaires or scales was 38.75% (95%CI was 29.54-47.96), and the difference between the two groups was statistically significant (P < 0.01). The pooled incidence of cognitive impairment after ICU discharge in general ICU patients was 43.42% (95%CI was 30.88-55.95), acute respiratory distress syndrome (ARDS) patients' pooled incidence was 34.40% (95%CI was 23.02-45.79), and the pooled incidence of elderly ICU patients was 12.93% (95%CI was 8.48-17.37), the difference among the three groups was statistically significant (P < 0.01). The incidences of cognitive impairment < 1 year, 1 to 4 years, ≥ 5 years after ICU discharge were 43.30% (95%CI was 29.47-57.13), 34.21% (95%CI was 26.70-41.72), and 20.22% (95%CI was 4.89-35.55), respectively, and the differences among the three groups were statistically significant (P < 0.01). The funnel plot showed that the distribution of all studies was asymmetric, and the Egger test result also suggested that there might be publication bias (P < 0.05). The non-parametric clipping was used to estimate the impact of publication bias on the results, and the result showed that the difference in the incidence of cognitive impairment after ICU discharge before and after non-parametric clipping was large, suggesting that publication bias might influence the stability of the research results. CONCLUSIONS: The incidence of cognitive impairment after ICU discharge is relatively high and persistent for a long time, but diagnostic criteria of cognitive impairment and follow-up time are quite different. It is necessary to develop consistent evaluation criteria and rigorous designed research in the further.

What is the optimum time for initiation of early mobilization in mechanically ventilated patients? A network meta-analysis.

Early mobilization has been proven to be an effective and safe intervention for preventing complications in mechanically ventilated patients; however, there is currently no unified definition of the optimal mobilization initiation time, hindering widespread clinical implementation. As clinicians are increasingly aware of the benefits of early mobilization, the definition of early mobilization is important. The purpose of this study was to evaluate the effects of different early mobilization initiation times on mechanically ventilated patients and rank these times for practical consideration. The Chinese Biomedical Literature Database, the Chinese Knowledge Infrastructure, Wanfang Data, PubMed, Cochrane Library, Web of Science, and Embase databases, along with grey literature and reference lists, were searched for randomized control trials (RCTs) that evaluated the effects of early mobilization for improving patient outcomes; databases were searched from inception to October 2018. Two authors extracted data independently, using a predesigned Excel form, and assessed the quality of included RCTs according to the Cochrane Handbook (v5.1.0). Data were analyzed using Stata (v13.0) and Review Manager (v5.3.0). A total of 15 RCTs involving 1726 patients and seven mobilization initiation times (which were all compared to usual care) were included in our analysis. Network meta-analysis showed that mechanical ventilation for 48-72 h may be optimal to improve intensive care unit acquired weakness (ICU-AW) and reduce the duration of mechanical ventilation; however, there were no significant differences in length of ICU stay according to mobilization initiation time. The results of this study indicate that initiation of mobilization within 48-72 h of mechanical ventilation may be optimal for improving clinical outcomes for mechanically ventilated patients.

[Safety criteria for early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in intensive care unit: a systematic review].

OBJECTIVE: To determine the safety criteria for early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in intensive care unit (ICU) by systematic review. METHODS: Randomized controlled trails (RCTs) and cohort studies about early goal-oriented rehabilition exercise in patients undergoing mechanical ventilation in ICU were retrieved in CBM, CNKI, Wanfang Data, PubMed, Cochrane Library and Web of Science from their foundation to March 2018, and other sources as supplement was also retrieved. The intervention program of RCT study was ICU routine nursing in control group, early activity in observation group, and early activity in cohort study without control group. Early activities included active and passive activities on the bed, sitting upright, bed-chair transfer, standing and walking. Literature screening and data extraction were performed independently by two researchers. Variables or parameters related to cardiovascular, respiratory, nervous, orthopedic and other systems were collected for safety criteria. Variables or parameters used in at least three literatures were collected for each system. Cochrane 5.1.0 was used to evaluate the quality of RCT study, and Newcastle-Ottawa scale (NOS) was used to evaluate the quality of cohort study. RESULTS: A total of 24 articles about early activity of patients undergoing mechanical ventilation in ICU were enrolled, involving 4 647 patients, including 11 RCT studies involving 1 031 patients, 509 in control group and 522 in observation group; 13 cohort studies including 3 616 patients. It was shown by systematic review that safety criteria for early activity in patients undergoing mechanical ventilation in ICU involved five systems, 20 variables or parameters. The cardiovascular system included 8 variables or parameters, such as 40 bpm < heart rate (HR) < 130 bpm (n = 4), hemodynamic stability (n = 5), no myocardial infarction (n = 3), no arrhythmia (n = 4), no vascular active drugs (n = 4), 90 mmHg < systolic blood pressure (SBP) < 200 mmHg (1 mmHg = 0.133 kPa, n = 4), 65 mmHg ≤ mean arterial pressure (MAP) ≤ 110 mmHg (n = 3), no history of cardiopulmonary resuscitation (CPR, n = 5). The respiratory system included 4 variables or parameters, involving 5 times/min < respiratory rate (RR) < 40 times/min (n = 5), fraction of inspired oxygen (FiO2) ≤ 0.60 and positive end-expiratory pressure (PEEP) ≤ 10 cmH2O (1 cmH2O = 0.098 kPa, n = 4), FiO2 < 0.60 or PEEP < 10 cmH2O (n = 3), pulse blood oxygenation (SpO2) > 0.88 (n = 5). The nervous system included 4 variables, including no neuromuscular disease (n = 7), no increase in intracranial pressure (n = 7), no coma (n = 4), understand and do the right thing (n = 4). The orthopedic system included 2 variables, including no fracture (n = 3), no unstable fracture (n = 8). Other factors included 2 variables, including no open abdomen wound (n = 4), and no palliative care (n = 3). CONCLUSIONS: This study identified safety criteria for early goal-directed rehabilition exercise in patients undergoing mechanical ventilation in ICU included five systems of cardiovascular, respiratory, neurological, orthopedic, and other systems, in which cardiovascular and respiratory systems were the most frequently cited variables or parameters. The consistency of each system security criteria or variables reported by different literatures was high, but the parameters need to be further verified by high-quality study.

[Diagnostic tools of intensive care unit acquired weakness: a systematic review].

OBJECTIVE: To explore effective and objective diagnostic tools for evaluating intensive care unit acquired weakness (ICUAW). METHODS: The studies about evaluation and diagnosis of adult ICUAW in PubMed, Embase, Web of Science, the Cochrane Library, CNKI, CBM, VIP and Wanfang databases from the date of their foundation to July 1st in 2018 were retrieved by computer. The literatures in Chinese and English were searched. Two investigators independently screened literature and evaluated the literature quality ratings, and extracted the research design, sample size, research object, evaluation item, reliability, validity, clinical application and other indicators, and then systematically analyzed the reliability and validity of ICUAW diagnostic tools, and evaluated diagnostic tools' advantages, disadvantages and application status. RESULTS: There were 19 literatures including 14 assessment scales and ultrasound diagnosis. The 14 assessment scales were medical research council score (MRC-Score), Barthel index (BI), 6-minute walk test (6MWT), clinical outcome variables scale (COVS), the Chelsea critical care physical assessment tool (CPAx), functional independence measure (FIM), functional status score for the intensive care unit (FSS-ICU), the ICU mobility scale (IMS), rivermead mobility index (RMI), the Perme ICU score (PERME), the physical function ICU test (PFIT), the physical function ICU test score (PFIT-s), the surgical ICU optimal mobility score (SOMS), and the Manchester mobility score (MMS). Nine scales (60%) were tested reliability and the rang of inter-rater reliability was 0.600-0.996, and the test reliability was 0.970, and the range of internal consistency reliability was 0.680-0.992. Validity of 6 scales (40%) were evaluated, and the range of structure validity was 0.57-0.94, the range of content validity was 0.830-0.988, the range of concurrent validity was 0.730-0.823. It was shown that the reliability of ICUAW assessment scale was relatively good at present, but the degree of accurate assessment of ICUAW was relatively low. The evaluation content of ICUAW can be divided into three categories: in the first, they measured the muscles strength of body just like MRC-Score; in the second, they evaluated the physical function and mobility, such as COVS, CPAx, FIM, FSS-ICU, IMS, PERME, PFIT, RMI, SOMS and MMS; in the third, they evaluated daily activity and physiology parameter just as 6MWT, BI and ultrasound. Different scales were correlated with the length of ICU stay (ICU-LOS), the hospital discharge, and the mortality. For example: COVS, CPAx, FSS-ICU, PFIT, PFIT-s and SOMS could predict the ICU-LOS and hospital discharge, RMI and SOMS can predict patient mortality. However, there was no evidence to testify the consistency between them. Now, the specialist consensus about the observation nodes of threshold and electrophysiological records were the complex action potential (CMAP) range < 0.43-0.65 mV and the sensory nerve action potential (SNAP) range < 17.6 µV. CONCLUSIONS: There are many diagnostic tools in ICUAW, and the reliability of each scale is relatively good. In future studies, we should collect the advantages of each scale, explore the specific indicators to evaluate ICUAW and improve the accuracy and validity of diagnostic ICUAW.