Developing a reflection and analysis tool (We-ReAlyse) for readmissions to the intensive care unit: A quality improvement project.

BACKGROUND: Readmissions to the intensive care unit are associated with poorer patient outcomes and health prognoses, alongside increased lengths of stay and mortality risk. To improve quality of care and patients' safety, it is essential to understand influencing factors relevant to specific patient populations and settings. A standardized tool for systematic retrospective analysis of readmissions would help healthcare professionals understand risks and reasons affecting readmissions; however, no such tool exists. PURPOSE: This study's purpose was to develop a tool (We-ReAlyse) to analyze readmissions to the intensive care unit from general units by reflecting on affected patients' pathways from intensive care discharge to readmission. The results will highlight case-specific causes of readmission and potential areas for departmental- and institutional-level improvements. METHOD: A root cause analysis approach guided this quality improvement project. The tool's iterative development process included a literature search, a clinical expert panel, and a testing in January and February 2021. RESULTS: The We-ReAlyse tool guides healthcare professionals to identify areas for quality improvement by reflecting the patient's pathway from the initial intensive care stay to readmission. Ten readmissions were analyzed by using the We-ReAlyse tool, resulting in key insights about possible root causes like the handover process, patient's care needs, the resources on the general unit and the use of different electronic healthcare record systems. CONCLUSIONS: The We-ReAlyse tool provides a visualization/objectification of issues related to intensive care readmissions, gathering data upon which to base quality improvement interventions. Based on the information on how multi-level risk profiles and knowledge deficits contribute to readmission rates, nurses can target specific quality improvements to reduce those rates. IMPLICATIONS FOR CLINICAL PRACTICE AND RESEARCH: With the We-ReAlyse tool, we have the opportunity to collect detailed information about ICU readmissions for an in-depth analysis. This will allow health professionals in all involved departments to discuss and either correct or cope with the identified issues. In the long term, this will allow continuous, concerted efforts to reduce and prevent ICU readmissions. To obtain more data for analysis and to further refine and simplify the tool, it may be applied to larger samples of ICU readmissions. Furthermore, to test its generalizability, the tool should be applied to patients from other departments and other hospitals. Adapting it to an electronic version would facilitate the timely and comprehensive collection of necessary information. Finally, the tool's emphasis comprises reflecting on and analyzing ICU readmissions, allowing clinicians to develop interventions targeting the identified problems. Therefore, future research in this area will require the development and evaluation of potential interventions.

Predictive validity of the Chelsea Critical Care Physical Assessment tool (CPAx) in critically ill, mechanically ventilated adults: a prospective clinimetric study.

PURPOSE: To investigate the predictive validity of the Chelsea Critical Care Physical Assessment tool (CPAx) at intensive care unit (ICU) discharge in critically ill adults for their 90-day outcomes. MATERIALS AND METHODS: This prospective clinimetric study investigated four theory-driven, a-priori hypotheses in critically ill adults recruited within 72-144 h of mechanical ventilation. The primary hypothesis was a moderate accuracy (AUROC = 0.750) in predicting residence at home within 90 days. Secondary hypotheses included discrimination between hospital discharge destinations, correlation with subsequent health-related quality of life and length of ICU stay. RESULTS: We observed a good accuracy (AUROC = 0.778) of the CPAx at ICU discharge in predicting a return to home within 90 days. The CPAx score significantly increased between the discharge groups "undesirable" ≤ "rehabilitation" ≤ "home" (p < 0.001), but was not associated with 90-day health-related quality of life (physical: r = 0.261, mental: r = 0.193). Measured at baseline, CPAx scores correlated as expected with length of ICU stay (r = -0.443). CONCLUSIONS: The CPAx at ICU discharge had a good predictive validity in projecting residence at home within 90 days and general discharge destinations. The CPAx might therefore have clinical value in prediction, though it does not seem useful to predict subsequent health-related quality of life. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) identification number: DRKS00012983, registered on September 20, 2017IMPLICATIONS FOR REHABILITATIONThe CPAx is a valid and reliable measurement instrument to evaluate critically ill adults' physical function and activity, in addition the CPAx might be useful to predict rehabilitation needs.The CPAx had a moderate to good predictive validity with three out of four a-priori hypotheses accepted.A CPAx score of ≥18 at critical care discharge has a sensitivity of 80% and a specificity of 70% in predicting a return to home within 90 days.The CPAx might consequently be valuable to identify critically ill adults' rehabilitation needs, to advise on their potential trajectory of recovery or to screen patients for follow-up after hospital discharge.

German version of the Chelsea Critical Care Physical Assessment Tool (CPAx-GE): translation, cross-cultural adaptation, validity, and reliability.

PURPOSE: To translate and cross-culturally adapt the Chelsea Critical Care Physical Assessment tool from English to German (CPAx-GE) and to examine its validity and reliability. MATERIALS AND METHODS: Following a forward-backward translation including an expert round table discussion, the measurement properties of the CPAx-GE were explored in critically ill, mechanically ventilated adults. We investigated construct, cross-sectional, and cross-cultural validity of the CPAx-GE with other measurement instruments at pre-specified timepoints, analysed relative reliability with intraclass correlation coefficients (ICCs) and determined absolute agreement with the Bland-Altman plots. RESULTS: Consensus for the translated CPAx-GE was reached. Validity was excellent with >80% of the pre-specified hypotheses accepted at baseline, critical care, and hospital discharge. Interrater reliability was high (ICCs > 0.8) across all visits. Limit of agreement ranged from -2 to 2 points. Error of measurement was small, floor, and ceiling effects limited. CONCLUSIONS: The CPAx-GE demonstrated excellent construct, cross-sectional, and cross-cultural validity as well as high interrater reliability in critically ill adults with prolonged mechanical ventilation at baseline, critical care, and hospital discharge. Consequently, the CPAx-GE can be assumed equal to the original and recommended in the German-speaking area to assess physical function and activity of critically ill adults across the critical care and hospital stay. Trial registration: German Clinical Trials Register (DRKS) identification number: DRKS00012983 (https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00012983), registered on 20 September 2017, first patient enrolled on 21 November 2017.Implications for rehabilitationEarly rehabilitation of critically ill patients is recommended to prevent and treat the subsequent functional disability, but a suitable measurement instrument for the German-speaking area is lacking.The translated, cross-culturally adapted German CPAx demonstrated excellent validity and reliability in assessing physical function and activity in critically ill adults.Cross-sectional validity of the CPAx has been newly established and allows the use of this tool at clinically relevant time-points in the course of a critical illness.The CPAx-GE can therefore be used in clinical practice by German-speaking therapists to assess physical function and activity during early rehabilitation in the ICU and hospital.

[COVID-19 in the Intensive Care Unit: Medical, Nursing, and Physical Therapy Challenges]. / COVID-19 in der Intensivstation: medizinische, pflegerische und physiotherapeutische Herausforderungen.

COVID-19 in the Intensive Care Unit: Medical, Nursing, and Physical Therapy Challenges Abstract. The treatment of patients with COVID-19 is a big challenge for intensive care units: substantial additional staff and material is needed to treat the surge of patients admitted in short time. Treatment is difficult as many patients present with multiple organ failure, including acute respiratory distress syndrome (ARDS). Mostly, oxygenation is substantially impaired and compliance low, and many patients need prone positioning. This article deals with the difficulties during the first surge of patients with COVID-19. The suffering of the relatives who were not allowed to visit must also be considered.

Early Physical Therapist Interventions for Patients With COVID-19 in the Acute Care Hospital: A Case Report Series.

OBJECTIVE: The aim of this case series was to describe the experience of Swiss physical therapists in the treatment of patients with COVID-19 during their acute care hospital stay and to discuss challenges and potential strategies in the clinical management of these patients. METHODS: We report 11 cases of patients with COVID-19 from 5 Swiss hospitals that illustrate the various indications for physical therapy, clinical challenges, potential treatment methods, and short-term response to treatment. RESULTS: Physical therapists actively treated patients with COVID-19 on wards and in the intensive care unit. Interventions ranged from patient education, to prone positioning, to early mobilization and respiratory therapy. Patients were often unstable with quick exacerbation of symptoms and a slow and fluctuant recovery. Additionally, many patients who were critically ill developed severe weakness, postextubation dysphagia, weaning failure, or presented with anxiety or delirium. In this setting, physical therapy was challenging and required specialized and individualized therapeutic strategies. Most patients adopted the proposed treatment strategies, and lung function and physical strength improved over time. CONCLUSION: Physical therapists clearly have a role in the COVID-19 pandemic. Based on our experience in Switzerland, we recommend that physical therapists routinely screen and assess patients for respiratory symptoms and exercise tolerance on acute wards. Treatment of patients who are critically ill should start as soon as possible to limit further sequelae. More research is needed for awake prone positioning and early breathing exercises as well as post-COVID rehabilitation. IMPACT: To date, there are few data on the physical therapist management of patients with COVID-19. This article is among the first to describe the role of physical therapists in the complex pandemic environment and to describe the potential treatment strategies for countering the various challenges in the treatment of these patients.