Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial Early activity is feasible and safe in respiratory failure patients* Early mobilization on continuous renal replacement therapy is safe and may improve filter life Early mobilization in critically ill patients: patients' mobilization level depends on health care provider's profession. Changing support needs of survivors of complex critical illness and their family caregivers across the care continuum: a qualitative pilot study of Towards RECOVER. Early mobilisation in intensive care units in Australia and Scotland: a prospective, observational cohort study examining mobilisation practises and barriers Profile of patients and physiotherapy patterns in intensive care units in public hospitals in Zimbabwe: a descriptive cross-sectional study A quality improvement project sustainably decreased time to onset of active physical therapy intervention in patients with acute lung injury. Original Research: Implementation of an Early Mobility Program in an ICU Early intensive care unit mobility therapy in the treatment of acute respiratory failure* Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Safety and Efficacy of Mobility Interventions in Patients with Femoral Catheters in the ICU: A Prospective Observational Study Intensive care unit mobility practices in Australia and New Zealand: a point prevalence study. An Environmental Scan for Early Mobilization Practices in U.S. ICUs What Are the Barriers to Mobilizing Intensive Care Patients? Exercise-based rehabilitation after hospital discharge for survivors of critical illness with intensive care unit–acquired weakness: A pilot feasibility trial☆☆☆ Safety and feasibility of femoral catheters during physical rehabilitation in the intensive care unit. Safety and Feasibility of an Exercise Prescription Approach to Rehabilitation Across the Continuum of Care for Survivors of Critical Illness Implementing the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility Bundle into Everyday Care: Opportunities, Challenges, and Lessons Learned for Implementing the ICU Pain, Agitation, and Delirium Guidelines Factors associated with timing of initiation of physical therapy in patients with acute lung injury. Occupational therapy for patients with acute lung injury: factors associated with time to first intervention in the intensive care unit. Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project. A telerehabilitation intervention for patients with Chronic Obstructive Pulmonary Disease: a randomized controlled pilot trial Implementation of a protocol facilitates evidence-based physiotherapy practice in intensive care units. Feasibility and Safety of Physical Therapy during Continuous Renal Replacement Therapy in the Intensive Care Unit. Mobilization of Ventilated Older Adults
Purpose Cognitive impairment after critical illness is common and debilitating . We developed a cognitive therapy program for critically ill patients and assessed the feasibility and safety of administering combined cognitive and physical therapy early during a critical illness . Methods We r and omized 87 medical and surgical ICU patients with respiratory failure and /or shock in a 1:1:2 manner to three groups : usual care , early once-daily physical therapy , or early once-daily physical therapy plus a novel , progressive , twice-daily cognitive therapy protocol . Cognitive therapy included orientation , memory , attention , and problem-solving exercises , and other activities . We assessed feasibility outcomes of the early cognitive plus physical therapy intervention . At 3 months , we also assessed cognitive , functional , and health-related quality of life outcomes . Data are presented as median ( interquartile range ) or frequency ( % ) . Results Early cognitive therapy was a delivered to 41/43 ( 95 % ) of cognitive plus physical therapy patients on 100 % ( 92–100 % ) of study days beginning 1.0 ( 1.0–1.0 ) day following enrollment . Physical therapy was received by 17/22 ( 77 % ) of usual care patients , by 21/22 ( 95 % ) of physical therapy only patients , and 42/43 ( 98 % ) of cognitive plus physical therapy patients on 17 % ( 10–26 % ) , 67 % ( 46–87 % ) , and 75 % ( 59–88 % ) of study days , respectively . Cognitive , functional , and health-related quality of life outcomes did not differ between groups at 3-month follow-up . Conclusions This pilot study demonstrates that early rehabilitation can be extended beyond physical therapy to include cognitive therapy . Future work to determine optimal patient selection , intensity of treatment , and benefits of cognitive therapy in the critically ill is needed Objective : To determine whether early activity is feasible and safe in respiratory failure patients . Design : Prospect i ve cohort study . Setting : From June 1 , 2003 , through December 31 , 2003 , we assessed safety and feasibility of early activity in all consecutive respiratory failure patients who required mechanical ventilation for > 4 days admitted to our respiratory intensive care unit ( RICU ) . A majority of patients were treated in another intensive care unit ( ICU ) before RICU admission . We excluded patients who required mechanical ventilation for ≤4 days . Patients : Eight‐bed RICU at LDS Hospital . Interventions : We assessed patients for early activity as part of routine respiratory ICU care . We prospect ively recorded activity events and adverse events . We defined three activity events as sit on bed , sit in chair , and ambulate . We defined six activity‐related adverse events as fall to knees , tube removal , systolic blood pressure > 200 mm Hg , systolic blood pressure < 90 mm Hg , oxygen desaturation < 80 % , and extubation . Measurements and Main Results : During the study period , we conducted a total of 1,449 activity events in 103 patients . The activity events included 233 ( 16 % ) sit on bed , 454 ( 31 % ) sit in chair , and 762 ( 53 % ) ambulate . In patients with an endotracheal tube in place , there were a total of 593 activity events , of which 249 ( 42 % ) were ambulation . There were < 1 % activity‐related adverse events , including fall to the knees without injury , feeding tube removal , systolic blood pressure > 200 mm Hg , systolic blood pressure < 90 mm Hg , and desaturation < 80 % . No patient was extubated during activity . Conclusions : We conclude that early activity is feasible and safe in respiratory failure patients . A majority of survivors ( 69 % ) were able to ambulate > 100 feet at RICU discharge . Early activity is a c and i date therapy to prevent or treat the neuromuscular complications of critical illness Introduction Despite studies demonstrating benefit , patients with femoral vascular catheters placed for continuous renal replacement therapy are frequently restricted from mobilization . No research ers have reported filter pressures during mobilization , and it is unknown whether mobilization is safe or affects filter lifespan . Our objective in this study was to test the safety and feasibility of mobilization in this population . Methods A total of 33 patients undergoing continuous renal replacement therapy via femoral , subclavian or internal jugular vascular access catheters at two general medical-surgical intensive care units in Australia were enrolled . Patients underwent one of three levels of mobilization intervention as appropriate : ( 1 ) passive bed exercises , ( 2 ) sitting on the bed edge or ( 3 ) st and ing and /or marching .  Catheter dislodgement , haematoma and bleeding during and following interventions were evaluated . Filter pressure parameters and lifespan ( hours ) , nursing workload and concern were also measured . Results No episodes of filter occlusion or failure occurred during any of the interventions . No adverse events were detected . The intervention filters lasted longer than the nonintervention filters ( regression coefficient = 13.8 ( robust 95 % confidence interval ( CI ) = 5.0 to 22.6 ) , P = 0.003 ) . In sensitivity analyses , we found that filter life was longer in patients who had more position changes ( regression coefficient = 2.0 ( robust 95 % CI = 0.6 to 3.5 ) , P = 0.007 ) . The nursing workloads between the intervention shift and the following shift were similar . Conclusions Mobilization during renal replacement therapy via a vascular catheter in patients who are critically ill is safe and may increase filter life . These findings have significant implication s for the current mobility restrictions imposed on patients with femoral vascular catheters for renal replacement therapy . Trial registration Australian and New Zeal and Clinical Trials Registry ACTRN12611000733976 ( registered 13 July 2011 OBJECTIVE To evaluate whether the level of mobilization achieved and the barriers for progressing to the next mobilization level differ between nurses and physical therapists . DESIGN Prospect i ve , observational study . SETTING Twenty-bed surgical intensive care unit ( SICU ) of the Massachusetts General Hospital . PARTICIPANTS Sixty-three critically ill patients . METHODS Physical therapists and nurses performed 179 mobilization therapies with 63 patients . OUTCOME MEASUREMENT Mobilization was defined as the process of enhancing mobility in the SICU , including bed mobility , edge of bed activities , transfers out of bed to a chair , and gait training ; the mobilization level was measured on the SICU optimal mobilization scale , a 5-point ( 0 - 4 ) numerical rating scale . RESULTS Patients ' level of mobilization achieved by physical therapists was significantly higher compared with that achieved by nurses ( 2.3 ± 1.2 mean ± SD versus 1.2 ± 1.2 , respectively P < .0001 ) . Different barriers for mobilization were identified by physical therapists and nurses : hemodynamic instability ( 26 % versus 12 % , P = .03 ) and renal replacement therapy ( 12 % versus 1 % , P = .03 ) were barriers rated higher by nurses , whereas neurologic impairment was rated higher by physical therapists providers ( 18 % versus 38 % , P = .002 ) . No mobilization-associated adverse events were observed in this study . CONCLUSIONS This study showed that physical therapists mobilize their critically ill patients to higher levels compared with nurses . Nurse and physical therapists identify different barriers for mobilization . Routine involvement of physical therapists in directing mobilization treatment may promote early mobilization of critically ill patients INTRODUCTION Survivors of complex critical illness and their family caregivers require support during their recovery , rehabilitation , and return to community living ; however , the nature of these supports and how they may change over time remain unclear . Using the Timing It Right framework as a conceptual guide , this qualitative pilot study explored survivors ' and caregivers ' needs during the episode of critical illness through their return to independent living . METHODS Five survivors and seven family caregivers were recruited and consented from the main Towards RECOVER pilot study , design ed to characterize the long term outcomes of survivors of the ICU who have been mechanically ventilated for more than one week . Using the Timing It Right framework , we prospect ively conducted qualitative interviews to explore participants ' experiences and needs for information , emotional support , and training at 3 , 6 , 12 , and 24 months after intensive care unit ( ICU ) discharge . We completed 26 interviews , which were audio recorded , professionally transcribed , checked for accuracy , and analyzed using framework methodology . RESULTS In this small pilot sample , caregiver and patient perspectives were related and , therefore , are presented together . We identified 1 overriding theme : survivors do not experience continuity of medical care during recovery after critical illness . Three subthemes highlighted the following : ( 1 ) informational needs change across the care continuum , ( 2 ) fear and worry exist when families do not know what to expect , and ( 3 ) survivors transition from dependence to independence . CONCLUSIONS Interventions design ed to improve family outcomes after critical illness should address both survivors ' and caregivers ' support needs as they change across the illness and recovery trajectory . Providing early intervention and support and clarifying expectations for transitions in care and recovery may decrease fears of the unknown for both caregivers and survivors . Ongoing family-centered follow-up programs may also help survivors regain independence and help caregivers manage their perceived responsibility for the patients ' health . Using these insights for intervention development could ultimately improve long-term outcomes for both survivors and caregivers Introduction  Mobilisation of patients  in the intensive care unit ( ICU ) is an area of growing research . Currently , there is little data on baseline mobilisation practises and the barriers to them for patients of all admission diagnoses . Methods The objectives of the study were to ( 1 ) quantify and benchmark baseline levels of mobilisation in Australian and Scottish ICUs , ( 2 ) compare mobilisation practises between Australian and Scottish ICUs and ( 3 ) identify barriers to mobilisation in Australian and Scottish ICUs . We conducted a prospect i ve , observational , cohort study with a 4-week inception period . Patients were censored for follow-up upon ICU discharge or after 28 days , whichever occurred first . Patients were included if they were > 18 years of age , admitted to an ICU and received mechanical ventilation in the ICU . Results Ten tertiary ICUs in Australia and nine in Scotl and participated in the study . The Australian cohort had a large proportion of patients admitted for cardiothoracic surgery ( 43.3 % ) , whereas the Scottish cohort had none . Therefore , comparison analysis was done after exclusion of patients admitted for cardiothoracic surgery . In total , 60.2 % of the 347 patients across 10 Australian ICUs and 40.1 % of the 167 patients across 9 Scottish ICUs mobilised during their ICU stay ( p < 0.001 ) . Patients in the Australian cohort were more likely to mobilise than patients in the Scottish cohort ( hazard ratio 1.83 , 95 % confidence interval 1.38–2.42 ) . However , the percentage of episodes of mobilisation where patients were receiving mechanical ventilation was higher in the Scottish cohort ( 41.1 % vs 16.3 % , p < 0.001 ) . Sedation was the most commonly reported barrier to mobilisation in both the Australian and Scottish cohorts . Physiological instability and the presence of an endotracheal tube were also frequently reported barriers . Conclusions This is the first study to benchmark baseline practise of early mobilisation internationally , and it demonstrates variation in early mobilisation practises between Australia and Scotl and Background Physiotherapy is integral to patient management in the Intensive Care Unit . The precise role that physiotherapists play in the critical care differs significantly worldwide . The aim of the study was to describe the profile of patients and the current patterns of physiotherapy services  delivered for patients admitted in the five public hospital intensive care units in Zimbabwe . Methods A prospect i ve record review was performed and records of all consecutive patients admitted into the five units during a two months period were included in the analysis . The data was collected using a checklist and the following were recorded for each patient : 1 ) demographic information , 2 ) admission diagnoses , 3 ) surgery classification , 4 ) method and time of mechanical ventilation 5 )  physiotherapy techniques and frequency and 6 ) the length of stay . Results A total of 137 patients were admitted to five units during the study . The mean age of patients in the study was 36.0 years ( SD = 16.6 ) . A mortality rate of 17.5 % was observed with most of the patients being below the age of 45 years . The majority of the patients , 61(45 % ) had undergone emergency surgery and were in the ICU for postoperative treatment , whilst only 19(14 % ) were in the units for clinical treatment ( non-surgical ) . On admission , 72(52.6 % ) of the patients were on  mechanical ventilation .  The mean duration on mechanical ventilation for patients was 4.0 days ( SD = 2.7 ) and a length of stay in the unit of 4.5 days ( SD = 3.0).Of the patients who were admitted into the ICU 120 ( 87.6 % ) had at least one session of physiotherapy treatment during their stay . The mean number of days physiotherapy treatment was received was 3.71 ( SD = 3.14 ) days . The most commonly used physiotherapy techniques were  active assisted limb movements  ( 66.4 % ) , deep breathing exercises ( 65.0 % ) and forced expiratory techniques ( 65.0 % ) . Conclusion A young population admitted in the ICU for post-surgical treatment was observed across all hospital ICUs . The techniques which were executed in Zimbabwean ICUs showed that the goal of the physiotherapy treatment was mainly to prevent and treat respiratory complications and a culture of promoting bed rest still existed . Trial registration RATIONALE Rehabilitation started early during an intensive care unit ( ICU ) stay is associated with improved outcomes and is the basis for many quality improvement ( QI ) projects showing important changes in practice . However , little evidence exists regarding whether such changes are sustainable in real-world practice . OBJECTIVES To evaluate the sustained effect of a quality improvement project on the timing of initiation of active physical therapy intervention in patients with acute lung injury ( ALI ) . METHODS This was a pre-post evaluation using prospect ively collected data involving consecutive patients with ALI admitted pre- quality improvement ( October 2004-April 2007 , n = 120 ) versus post- quality improvement ( July 2009-July 2012 , n = 123 ) from a single medical ICU . MEASUREMENTS AND MAIN RESULTS The primary outcome was time to first active physical therapy intervention , defined as strengthening , mobility , or cycle ergometry exercises .  Among ICU survivors , more patients in the post- quality improvement versus pre- quality improvement group received physical therapy in the ICU ( 89 % vs. 24 % , P < 0.001 ) and were able to st and , transfer , or ambulate during physical therapy in the ICU ( 64 % vs. 7 % , P < 0.001 ) . Among all patients in the post- quality improvement versus pre- quality improvement group , there was a shorter median ( interquartile range ) time to first physical therapy  ( 4 [ 2 , 6 ] vs. 11 d [ 6 , 29 ] , P < 0.001 ) and a greater median ( interquartile range ) proportion of ICU days  with physical therapy  after initiation ( 50 % [ 33 , 67 % ] vs. 18 % [ 4 , 47 % ] , P = 0.003 ) . In multivariable regression analysis , the post- quality improvement period was associated with shorter time to physical therapy  ( adjusted hazard ratio [ 95 % confidence interval ] , 8.38 [ 4.98 , 14.11 ] , P < 0.001 ) , with this association significant for each of the 5 years during the post- quality improvement period . The following variables were independently associated with a longer time to physical  therapy : higher Sequential Organ Failure Assessment score ( 0.93 [ 0.89 , 0.97 ] ) , higher FiO2 ( 0.86 [ 0.75 , 0.99 ] for each 10 % increase ) , use of an opioid infusion ( 0.47 [ 0.25 , 0.89 ] ) , and deep sedation ( 0.24 [ 0.12 , 0.46 ] ) . CONCLUSIONS In this single-site , pre-post analysis of patients with ALI , an early rehabilitation quality improvement project was independently associated with a substantial decrease in the time to initiation of active physical therapy intervention that was sustained over 5 years . Over the entire pre-post period , severity of illness and sedation were independently associated with a longer time to initiation of active physical therapy intervention in the ICU ABSTRACT Objective : Research is needed to determine the feasibility of implementing a dedicated ICU mobility team in community hospital setting s. The purpose of this study was to assess , in one such hospital , four nurse-sensitive quality -of-care outcomes ( falls , ventilator-associated events , pressure ulcers , and catheter-associated urinary tract infections [ CAUTIs ] ) , as well as hospital costs , sedation and delirium measures , and functional outcomes by comparing ICU patients who received physical therapy from a dedicated mobility team with ICU patients who received routine care . Methods : We conducted a retrospective longitudinal study at a community acute care hospital ; patients were r and omly assigned to intervention or routine care groups . The mobility team screened patients Monday through Friday using a mobility algorithm to determine eligibility for participation in each early mobility session . Based on their strength , balance , hemodynamic stability , and ability to participate in early mobility activities , patients advanced through four progressively difficult phases of mobility . Data were collected and analyzed after patients were discharged from the hospital . Results : The 66 patients who received the mobility intervention  had significantly fewer falls , ventilator-associated events , pressure ulcers , and CAUTIs than the 66 patients in the routine care group . The mobility group also had lower hospital costs , fewer delirium days , lower sedation levels , and improved functional independence compared with the routine care group . Patients in the mobility group got out of bed on 2.5 more days than patients in the routine care group . There were also no adverse events in the mobility group . Conclusions : It is feasible for a community hospital to create and implement a dedicated ICU mobility team . Early mobilization of ICU patients contributed to fewer delirium days and improved patient outcomes , sedation levels , and functional status Objective : Immobilization and subsequent weakness are consequences of critical illness . Despite the theoretical advantages of physical therapy to address this problem , it has not been shown that physical therapy initiated in the intensive care unit offers benefit . Design and Setting : Prospect i ve cohort study in a university medical intensive care unit that assessed whether a mobility protocol increased the proportion of intensive care unit patients receiving physical therapy vs. usual care .  Patients : Medical intensive care unit patients with acute respiratory failure requiring mechanical ventilation on admission : Protocol , n = 165 ; Usual Care , n = 165 . Interventions : An intensive care unit Mobility Team ( critical care nurse , nursing assistant , physical therapist ) initiated the protocol within 48 hrs of mechanical ventilation . Measurements and Main Results : The primary outcome was the proportion of patients receiving physical therapy in patients surviving to hospital discharge .  Baseline characteristics were similar between groups . Outcome data are reflective of survivors . More Protocol patients received at least one physical therapy session than did Usual Care ( 80 % vs. 47 % , p ≤ .001 ) . Protocol patients were out of bed earlier ( 5 vs. 11 days , p ≤ .001 ) , had therapy initiated more frequently in the intensive care unit ( 91 % vs. 13 % , p ≤ .001 ) , and had similar low complication rates compared with Usual Care . For Protocol patients , intensive care unit length of stay was 5.5 vs. 6.9 days for Usual Care ( p = .025 ) ; hospital length of stay for Protocol patients was 11.2 vs. 14.5 days for Usual Care ( p = .006 ) ( intensive care unit/hospital length of stay adjusted for body mass index , Acute Physiology and Chronic Health Evaluation II , vasopressor ) . There were no untoward events during an intensive care unit Mobility session and no cost difference ( survivors + nonsurvivors ) between the two arms , including Mobility Team costs . Conclusions : A Mobility Team using a mobility protocol initiated earlier physical therapy that was feasible , safe , did not increase costs , and was associated with decreased intensive care unit and hospital length of stay in survivors who received physical therapy during intensive care unit treatment compared with patients who received usual care OBJECTIVES To ( 1 ) reduce deep sedation and delirium to permit mobilization , ( 2 ) increase the frequency of rehabilitation consultations and treatments to improve patients ' functional mobility , and ( 3 ) evaluate effects on length of stay . DESIGN Seven-month prospect i ve before/after quality improvement project . SETTING Sixteen-bed medical intensive care unit ( MICU ) in academic hospital . PARTICIPANTS 57 patients mechanically ventilated 4 days or longer . INTERVENTION A multidisciplinary team focused on reducing heavy sedation and increasing MICU staffing to include full-time physical and occupational therapists with new consultation guidelines . MAIN OUTCOME MEASURES Sedation and delirium status , rehabilitation treatments , functional mobility . RESULTS Compared with before the quality improvement project , benzodiazepine use decreased markedly ( proportion of MICU days that patients received benzodiazepines [ 50 % vs 25 % , P=.002 ] ) , with lower median daily sedative doses ( 47 vs 15 mg midazolam equivalents [ P=.09 ] and 71 vs 24 mg morphine equivalents [ P=.01 ] ) . Patients had improved sedation and delirium status ( MICU days alert [ 30 % vs 67 % , P<.001 ] and not delirious [ 21 % vs 53 % , P=.003 ] ) . There were a greater median number of rehabilitation treatments per patient ( 1 vs 7 , P<.001 ) with a higher level of functional mobility ( treatments involving sitting or greater mobility , 56 % vs 78 % , P=.03 ) . Hospital administrative data demonstrated that across all MICU patients , there was a decrease in intensive care unit and hospital length of stay by 2.1 ( 95 % confidence interval : 0.4 - 3.8 ) and 3.1 ( 0.3 - 5.9 ) days , respectively , and a 20 % increase in MICU admissions compared with the same period in the prior year . CONCLUSIONS Using a quality improvement process , intensive care unit delirium , physical rehabilitation , and functional mobility were markedly improved and associated with decreased length of stay 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 prospect i ve , 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 , st and ing 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 st and ing 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 OBJECTIVES To develop a comprehensive set of items describing physiotherapy mobilisation practice s for critically ill patients , and to document current practice s in intensive care units in Australia and New Zeal and , focusing on patients having > 48 hours of mechanical ventilation . DESIGN Prospect i ve , observational , multicentre , single-day , point prevalence study . PARTICIPANTS AND SETTING All patients in 38 Australian and New Zeal and ICUs at 10 am on one of three design ated days in 2009 and 2010 . MAIN OUTCOME MEASURES Demographic data , admission diagnosis and mobilisation practice s that had occurred in the previous 24 hours . RESULTS 514 patients were enrolled , with 498 complete data sets . Mean age was 59.2 years ( SD , 16.7 years ) and 45 % were mechanically ventilated .  Mobilisation activities were classified into five categories that were not mutually exclusive : 140 patients ( 28 % ) completed an in-bed exercise regimen , 93 ( 19 % ) sat over the side of the bed , 182 ( 37 % ) sat out of bed , 124 ( 25 % ) stood and 89 ( 18 % ) walked . Predefined adverse events occurred on 24 occasions ( 5 % ) . No patient requiring mechanical ventilation sat out of bed or walked . On the study day , 391 patients had been in ICU for > 48 hours . There were 384 complete data sets available for analysis and , of these , 332 patients ( 86 % ) were not walked . Of those not walked , 76 ( 23 % ) were in the ICU for ≥ 7 days . CONCLUSION Patient mobilisation was shown to be low in a single-day point prevalence study . Future observational studies are required to confirm the results Objective : Early mobilization improves  patient outcomes . However , diffusion of this intervention into st and ard ICU practice is unknown . Dissemination and implementation efforts may be guided by an environmental scan to detail readiness for early mobilization , current practice , and barriers to early mobilization . Design : A telephone survey . Setting : U.S. ICUs . Subjects : Five hundred r and omly selected U.S. ICUs stratified by regional hospital density and hospital size . Interventions : None . Measurements and Main Results : We surveyed 687 ICUs for a 73 % response rate ( 500 ICUs ) ; 99 % of respondents were nursing leadership . Fifty-one percent of hospitals reported an academic affiliation . Surveyed ICUs were most often mixed medical/surgical ( 58 % ) or medical ( 22 % ) with a median of 16 beds ( 12–24 ) . Thirty-four percent reported presence of a dedicated physical and /or occupational therapy team for the ICU . Overall , 45 % of ICUs reported  early mobilization practice ; two thirds of ICUs with early mobilization practice reported using a written early mobilization protocol . In ICUs with early mobilization practice , 52 % began the intervention at admission and 74 % enacted  early mobilization  for both ventilated and nonventilated patients . Early mobilization was provided a median of 6 days per week , twice daily . Factors independently associated with early mobilization protocol s include dedicated physical/occupational therapy ( odds ratio , 3.34 ; 95 % CI , 2.13–5.22 ; p < 0.01 ) , American Hospital Association region 2 ( odds ratio , 3.33 ; 95 % CI , 1.04–10.64 ; p = 0.04 ) , written sedation protocol ( odds ratio , 2.36 ; 95 % CI , 1.25–4.45 ; p < 0.01 ) , daily multidisciplinary rounds ( odds ratio , 2.31 ; 95 % CI , 1.29–4.15 ; p < 0.01 ) , and written daily goals for patients ( odds ratio , 2.17 ; 95 % CI , 1.02–4.64 ; p = 0.04 ) . Commonly cited barriers included equipment , staffing , patient and caregiver safety , and competing priorities . In ICUs without early mobilization adoption , 78 % have considered implementation but cite barriers including competing priorities and need for further planning . Conclusions : Diffusion regarding benefits of early mobilization has occurred , but adoption into practice is lagging . M and ates for multidisciplinary rounds and formal sedation protocol s may be necessary strategies to increase the likelihood of successful early mobilization implementation . Methods to accurately assess and compare institutional performance via practice audit are needed Purpose : Recently there has been increased interest in early mobilization of critically ill patients . Proposed benefits include improvements in respiratory function , muscle wasting , intensive care unit ( ICU ) , and hospital length of stay . We studied the frequency of early mobilization in our intensive care unit in order to identify barriers to early mobilization . Methods : A 4‐week prospect i ve audit of 106 patients admitted to a mixed medical‐surgical tertiary ICU ( mean age 60 ± 20 years , mean APACHE II score 14.7 ± 7.8 ) was performed . Outcome measures included number of patient days mobilized , type of mobilization , adverse events , and reasons for inability to mobilize . Results : Patients were mobilized on 176 ( 54 % ) of 327 patient days . Adverse events occurred in 2 of 176 mobilization episodes ( 1.1 % ) . In 71 ( 47 % ) of the 151 patient days where mobilization did not occur , potentially avoidable factors were identified , including vascular access devices sited in the femoral region , timing of procedures and agitation or reduced level of consciousness . Conclusions : Critically ill patients can be safely mobilized for much of their ICU stay . Interventions that may allow more patients to mobilize include : changing the site of vascular catheters , careful scheduling of procedures , and improved sedation management Purpose The aim of this study was to investigate feasibility of exercise-based rehabilitation delivered after hospital discharge in patients with intensive care unit – acquired weakness ( ICU-AW ) . Material s and methods Twenty adult patients , mechanically ventilated for more than 48 hours , with ICU-AW diagnosis at ICU discharge were included in a pilot feasibility r and omized controlled trial receiving a 16-session exercise-based rehabilitation program .  Twenty-one patients without ICU-AW participated in a nested observational cohort study . Feasibility , clinical , and patient-centered outcomes were measured at hospital discharge and at 3 months . Results Intervention feasibility was demonstrated by high adherence and patient acceptability , and absence of adverse events , but this must be offset by the low proportion of enrolment for those screened . The study was underpowered to detect effectiveness of the intervention . The use of manual muscle testing for the diagnosis of ICU-AW lacked robustness as an eligibility criterion and lacked discrimination for identifying rehabilitation requirements . Process evaluation of the trial identified method ological factors , categorized by “ population , ” “ intervention , ” “ control group , ” and “ outcome . ” Conclusions Important data detailing the design , conduct , and implementation of a multicenter r and omized controlled trial of exercise-based rehabilitation for survivors of critical illness after hospital discharge have been reported . Registration Clinical Trials Identifier OBJECTIVE Femoral catheters pose a potential barrier to early rehabilitation in the intensive care unit ( ICU ) due to concerns , such as catheter removal , local trauma , bleeding , and infection . We prospect ively evaluated the feasibility and safety of physical therapy ( PT ) in ICU patients with femoral catheters . DESIGN , SETTING , AND PATIENTS We evaluated consecutive medical ICU patients who received PT with a femoral venous , arterial , or hemodialysis catheter(s ) in situ .  MEASUREMENTS AND MAIN RESULTS Of 1074 consecutive patients , 239 ( 22 % ) received a femoral catheter  ( 81 % venous , 29 % arterial , 6 % hemodialysis ; some patients had > 1 catheter ) . Of those , 101 ( 42 % ) received PT interventions , while the catheter was in situ , for a total of 253 sessions over 210 medical ICU ( MICU ) days . On these 210 MICU days , the highest daily activity level achieved was 49 ( 23 % ) st and ing or walking , 57 ( 27 % ) sitting , 25 ( 12 % ) supine cycle ergometry , and 79 ( 38 % ) in-bed exercises . During 253 PT sessions , there were no catheter-related adverse events giving a 0 % event rate ( 95 % upper confidence limit of 2.1 % for venous catheters ) . CONCLUSIONS Physical therapy interventions in MICU patients with in situ femoral catheters appear to be feasible and safe . The presence of a femoral catheter should not automatically restrict ICU patients to bed rest Background Survivors of critical illness can experience long-st and ing functional limitations that negatively affect their health-related quality of life . To date , no model of rehabilitation has demonstrated sustained improvements in physical function for survivors of critical illness beyond hospital discharge . Objective The aims of this study were : ( 1 ) to describe a model of rehabilitation for survivors of critical illness , ( 2 ) to compare the model to local st and ard care , and ( 3 ) to report the safety and feasibility of the program . Design This was a cohort study . Methods As part of a larger r and omized controlled trial , 74 participants were r and omly assigned , 5 days following admission to the intensive care unit ( ICU ) , to a protocol ized rehabilitation program that commenced in the ICU and continued on the acute care ward and for a further 8 weeks following hospital discharge as an outpatient program . Exercise training was prescribed based on quantitative outcome measures to achieve a physiological training response . Results During acute hospitalization , 60 % of exercise sessions were able to be delivered . The most frequently occurring barriers to exercise were patient safety and patient refusal due to fatigue . Point prevalence data showed patients were mobilized more often and for longer periods compared with st and ard care . Outpatient classes were poorly attended , with only 41 % of the patients completing more than 70 % of outpatient classes . No adverse events occurred . Limitations Limitations included patient heterogeneity and delayed commencement of exercise in the ICU due to issues of consent and recruitment . Conclusions Exercise training that commences in the ICU and continues through to an outpatient program is safe and feasible for survivors of critical illness . Models of care that maximize patient participation across the continuum of care warrant further investigation Objective : The awakening and breathing coordination , delirium monitoring/management , and early exercise/mobility bundle is an evidence -based interprofessional multicomponent strategy for minimizing sedative exposure , reducing duration of mechanical ventilation , and managing ICU-acquired delirium and weakness . The purpose of this study was to identify facilitators and barriers to awakening and breathing coordination , delirium monitoring/management , and early exercise/mobility bundle adoption and to evaluate the extent to which bundle implementation was effective , sustainable , and conducive to dissemination . Design : Prospect i ve , before-after , mixed- methods study . Setting : Five adult ICUs , one step-down unit , and a special care unit located in a 624-bed academic medical center Subjects : Interprofessional ICU team members at participating institution . Interventions and Measurements : In collaboration with the participating institution , we developed , implemented , and refined an awakening and breathing coordination , delirium monitoring/management , and early exercise/mobility bundle policy . Over the course of an 18-month period , all ICU team members were offered the opportunity to participate in numerous multimodal educational efforts . Three focus group sessions , three online surveys , and one educational evaluation were administered in an attempt to identify facilitators and barriers to bundle adoption . Main Results : Factors believed to facilitate bundle implementation included : 1 ) the performance of daily , interdisciplinary , rounds ; 2 ) engagement of key implementation leaders ; 3 ) sustained and diverse educational efforts ; and 4 ) the bundle ’s quality and strength . Barriers identified included : 1 ) intervention-related issues ( e.g. , timing of trials , fear of adverse events ) , 2 ) communication and care coordination challenges , 3 ) knowledge deficits , 4 ) workload concerns , and 5 ) documentation burden . Despite these challenges , participants believed implementation ultimately benefited patients , improved interdisciplinary communication , and empowered nurses and other ICU team members . Conclusions : In this study of the implementation of the awakening and breathing coordination , delirium monitoring/management , and early exercise/mobility bundle in a tertiary care setting , clear factors were identified that both advanced and impeded adoption of this complex intervention that requires interprofessional education , coordination , and cooperation . Focusing on these factors preemptively should enable a more effective and lasting implementation of the bundle and better care for critically ill patients . Lessons learned from this study will also help healthcare providers optimize implementation of the recent ICU pain , agitation , and delirium guidelines , which has many similarities but also some important differences as compared with the awakening and breathing coordination , delirium monitoring/management , and early exercise/mobility bundle OBJECTIVES Early initiation of physical therapy ( PT ) in mechanically ventilated patients is associated with improved outcomes . However , PT is frequently delayed until after extubation or discharge from the intensive care unit ( ICU ) . We evaluated factors associated with the timing of initiation of PT in patients with acute lung injury ( ALI ) admitted to ICUs without an emphasis on early rehabilitation . DESIGN A secondary analysis of a prospect i ve cohort study was conducted . SETTING S The study was conducted in 11 ICUs in 3 teaching hospitals . PATIENTS A total of 503 patients with ALI were included in the study . INTERVENTIONS No interventions were used in this study . MEASUREMENTS AND MAIN RESULTS Thirty-four percent of patients ever received PT . In multivariable analysis , factors associated with later PT were a higher Sequential Organ Failure Assessment score ( hazard ratio , 0.89 ; 95 % confidence interval , 0.85 - 0.93 ) , higher fraction of inspired oxygen ( 0.97 , 0.96 - 0.98 ) , mechanical ventilation ( 0.31 , 0.16 - 0.59 ) , coma ( 0.32 , 0.20 - 0.51 ) , delirium ( 0.72 , 0.50 - 1.03 ) , and continuous sedation ( with daily sedation interruption : 0.49 , 0.30 - 0.81 ; without daily sedation interruption : 0.59 , 0.39 - 0.89 ) . Factors associated with earlier PT were an admitting diagnosis of trauma ( 3.31 , 1.74 - 6.31 ) and hospital study site ( 2.84 , 1.89 - 4.26 ) . CONCLUSIONS In 11 ICUs without emphasis on early rehabilitation , patients with ALI frequently received no PT .  Severity of illness , mental status , sedation practice s , and hospital site were significant barriers to initiating PT . Underst and ing these barriers may be important when introducing early ICU physical rehabilitation OBJECTIVE Very early occupational therapy intervention in the intensive care unit ( ICU ) improves patients ' physical recovery . We evaluated the association of patient , ICU , and hospital factors with time to first occupational therapy intervention  in ICU patients with acute lung injury ( ALI ) . METHOD We conducted a prospect i ve cohort study of 514 consecutive patients with ALI from 11 ICUs in three hospitals in Baltimore , MD . RESULTS Only 30 % of patients ever received  occupational therapy  during their ICU stay . Worse organ failure , continuous hemodialysis , and uninterrupted continuous infusion of sedation were independently associated with delayed occupational therapy initiation , and hospital study site and admission to a trauma ICU were independently associated with earlier occupational therapy . CONCLUSION Severity of illness and ICU practice s for sedation administration were associated with delayed occupational therapy . Both hospital study site and type of ICU were independently associated with timing of occupational therapy , indicating modifiable environmental factors for promoting early occupational therapy in the ICU PURPOSE The aim of this study was to describe the frequency , physiologic effects , safety , and patient outcomes associated with traditional rehabilitation therapy in patients who require mechanical ventilation . MATERIAL S AND METHODS Prospect i ve observational report of consecutive patients ventilated 4 or more days and eligible for rehabilitation in a single medical intensive care unit ( ICU ) during a 13-week period was conducted . RESULTS Of the 32 patients who met the inclusion criteria , only 21 ( 66 % ) received physician orders for evaluation by rehabilitation services ( physical and /or occupational therapy ) . Fifty rehabilitation treatments were provided to 19 patients on a median of 12 % of medical ICU days per patient , with deep sedation and unavailability of rehabilitation staff representing major barriers to treatment . Physiologic changes during rehabilitation therapy were minimal . Joint contractures were frequent in the lower extremities and did not improve during hospitalization . In 53 % and 79 % of initial ICU assessment s , muscle weakness was present in upper and lower extremities , respectively , with a decreased prevalence of 19 % and 43 % at hospital discharge , respectively . New impairments in physical function were common at hospital discharge . CONCLUSIONS This pilot project illustrated important barriers to providing rehabilitation to mechanically ventilated patients in an ICU and impairments in strength , range of motion , and functional outcomes at hospital discharge Objective : First , to investigate the effects of a telerehabilitation intervention on health status and activity level of patients with Chronic Obstructive Pulmonary Disease ( COPD ) , compared to usual care . Second , to investigate how patients comply with the intervention and whether compliance is related to treatment outcomes . Design : a r and omized controlled pilot trial Subjects : Thirty-four patients diagnosed with COPD . Intervention : The telerehabilitation application consists of an activity coach ( 3D-accelerometer with smartphone ) for ambulant activity registration and real-time feedback , complemented by a web portal with a symptom diary for self-treatment of exacerbations . The intervention group used the application for 4 weeks . The control group received usual care . Main measures : Activity level measured by a pedometer ( in steps/day ) , health status by the Clinical COPD Question naire at baseline and after intervention . Compliance was expressed as the time the activity coach was worn . Results : Fourteen intervention and 16 control patients completed the study .  Activity level ( steps/day ) was not significantly affected by the intervention over time . There was a non-significant difference in improvement in health status between the intervention ( −0.34±0.55 ) and control group ( 0.02±0.57 , p=0.10 ) . Health status significantly improved within the intervention group ( p=0.05 ) . The activity coach was used more than prescribed ( 108 % ) and compliance was related to the increase in activity level for the first two feedback weeks ( r=0.62 , p=0.03 ) . Conclusions : This pilot study shows the potential of the telerehabilitation intervention : compliance with the activity coach was high , which directly related to an improvement in activity levels OBJECTIVES To compare the physiotherapy service provided when therapists ' decisions are guided by an evidence -based protocol with usual care ( i.e. patient management based on therapists ' clinical decisions ) . DESIGN Exploratory , controlled , pragmatic sequential time block clinical trial . SETTING Level 3 surgical unit in a tertiary hospital in South Africa . PARTICIPANTS All patients admitted consecutively to the surgical unit over a 3-month period were allocated to usual or protocol care based on date of admission . INTERVENTIONS Usual care was provided by clinicians from the hospital department , and non-specialised physiotherapists were appointed as locum tenens to provide evidence -based protocol care . MAIN OUTCOME MEASURES Patient waiting time , frequency of treatment sessions , tasks performed and adverse events . RESULTS During protocol -care periods , treatment sessions were provided more frequently ( P<0.001 ) and with a shorter waiting period ( P<0.001 ) . It was more likely for a rehabilitation management option to be included in a treatment session during protocol -care periods ( odds ratio 2.34 , 95 % confidence interval 1.66 to 3.43 ; P<0.001 ) . No difference in the risk of an adverse event was found between protocol -care and usual-care periods ( P=0.34 ) . CONCLUSIONS Physiotherapy services provided in intensive care units ( ICUs ) when the decisions of non-specialised therapists are guided by an evidence -based protocol are safe , differ from usual care , and reflect international consensus on current best evidence for physiotherapy in ICUs . Non-specialised therapists can use this protocol to provide evidence -based physiotherapy services to their patients . Future trials are needed to establish whether or not this will improve patient outcome RATIONALE Early rehabilitation in an intensive care unit is associated with improved physical functioning and patient outcomes . However , relatively few data have been reported on physical therapy interventions during continuous renal replacement therapy ( CRRT ) for patients in intensive care units . OBJECTIVES To evaluate the feasibility and safety of physical therapy interventions , delivered as part of routine clinical care , for patients undergoing CRRT in an intensive care unit . METHODS Consecutive patients in the adult medical intensive care unit of one large tertiary care hospital who received physical therapy sessions while on CRRT were prospect ively evaluated over 13 months .  Physical therapy sessions were individualized on the basis of patients ' physical impairments and activity tolerance , with patients ' highest level of mobility recorded . Data on 15 different physiological abnormalities and potential safety events , including bleeding , dislodgement , or dysfunction of the CRRT catheter or circuit , were prospect ively collected . MEASUREMENTS AND MAIN RESULTS Eleven physical therapists delivered 268 rehabilitation sessions to 57 patients while they were receiving CRRT , with the following highest levels of mobility achieved during individual sessions : 78 ( 29 % ) bed exercises , 72 ( 27 % ) supine cycle ergometry , 80 ( 30 % ) sitting at edge of bed , 13 ( 5 % ) transfer to chair , and 25 ( 9 % ) st and ing or marching in place . No CRRT-specific safety events occurred ( 0 % ; 95 % upper confidence interval , 6.3 % ) . There were six non-CRRT-related potential safety events ( 2.2 % of all physical therapy sessions ; 95 % confidence interval , 0.6 - 8.2 % ) , all of which were transient changes in blood pressure . CONCLUSIONS In this prospect i ve observational study at one adult medical intensive care unit , we found that provision of bedside physical therapy while patients underwent CRRT is feasible , and appears safe Background : Recent studies of ventilated , critically ill patients have shown early mobilization to be safe and result ing in better functional outcomes at discharge but have not focused on older adults . Objectives : The objectives of this pilot study were to examine the feasibility of and to describe functional outcomes associated with providing early mobilization to critically ill , older adult patients . Methods : This is a prospect i ve cohort study that took place in the medical and surgical intensive care units of a tertiary , academic medical center . Participants were aged 65 years or older , were on mechanical ventilation for 72 or more hours , and had a preadmission Barthel Index score of 70 or greater . Patients with an open ventriculostomy , continuous hemodialysis , or hospitalization of 7 or more days prior to intubation were excluded . A st and ardized early mobilization protocol was applied by a trained physical and occupational therapist to eligible participants according to previously published guidelines . Demographic information , hospitalization data , R AND 36-Item Short Form Health Survey ( SF-36 ) , and Barthel Index scores from preadmission , hospital discharge , and 30-day follow-up were collected . Results : Patients who survived to hospital discharge compared with nonsurvivors were similar in their admission and hospital stay demographics . Survivors reported significantly higher functioning than nonsurvivors on preadmission functional status on both the physical functioning and general health R AND SF-36 subscales . Nonsurvivors reported significantly lower physical functioning , general health , vitality , and mental health on preadmission function when compared with the published normative R AND SF-36 data for patients aged 75 years and older . Patients who did survive hospitalization reported significantly more bodily pain at 30-day follow-up than the published normative data . Patients met criteria for therapy 92 % of planned interventions , 99 % of those sessions were completed , and adverse events occurred in less than 1 % of interventions . Conclusion : Overall results indicate the feasibility and safety of implementing an early mobilization program to critically ill older adult patients
Purpose To identify , evaluate and synthesis e studies examining the barriers and enablers for survivors of critical illness to participate in physical activity in the ICU and post-ICU setting s from the perspective of patients , caregivers and healthcare providers .