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Contents lists available at ScienceDirect
Australian Critical Care journal homepage: www.elsevier.com/locate/aucc
Review Paper
Early rehabilitation in the intensive care unit: An integrative literature review夽 Kellie Sosnowski RN, Grad Dip (ICN) a,b,∗ , Frances Lin RN, PhD c , Marion L. Mitchell RN, PhD c,d , Hayden White FCICM a,b a
Intensive Care Unit, Logan Hospital, Australia Griffith University, Australia c Centre of Health Practice Innovation, Menzies Health Institute Queensland, School of Nursing and Midwifery, Griffith University, Australia d Intensive Care Unit, Princess Alexandra Hospital, Australia b
article information Article history: Received 27 June 2014 Received in revised form 19 April 2015 Accepted 11 May 2015 Available online xxx Keywords: Critical illness Delirium Muscle weakness Quality of life Rehabilitation
a b s t r a c t Objectives: The aim of this review is to appraise current research which examines the impact of early rehabilitation practices on functional outcomes and quality of life in adult intensive care unit (ICU) survivors. Review method used: A systematic literature search was undertaken; retrieved data was evaluated against a recognised evaluation tool; research findings were analysed and categorised into themes; and a synthesis of conclusions from each theme was presented as an integrated summation of the topic. Data sources: Electronic databases of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline and Google Scholar were searched using key search terms ‘ICU acquired weakness’, ‘early rehabilitation’ ‘early mobility’ and ‘functional outcomes’ combined with ‘intensive care’ and ‘critical illness’. Additional literature was sourced from reference lists of relevant original publications. Results: Five major themes related to the review objectives emerged from the analysis. These themes included: critically ill patients do not always receive physical therapy as a standard of care; ICU culture and resources determine early rehabilitation success; successful respiratory and physical rehabilitation interventions are tailored according to individual patient impairment; early exercise in the ICU prevents the neuromuscular complications of critical illness and improves functional status; early exercise in the ICU is effective, safe and feasible. Conclusions: A limited body of research supports early rehabilitation interventions to optimise the short term outcomes and long term quality of life for ICU survivors. Critical care nurses are in an excellent position to drive change within their departments ensuring that early rehabilitation practices are adopted and implemented. © 2015 Published by Elsevier Ltd. on behalf of Australian College of Critical Care Nurses Ltd.
1. Introduction Recent attention in intensive care has shifted to include consideration of the long term impact of life saving strategies on the critically ill patient. An admission to intensive care can be associated with both physical and psychological complications including
夽 This is the best nursing review paper from 2014. ∗ Corresponding author at: Intensive Care Unit, Logan Hospital, Australia. Tel.: +61 400212755. E-mail address: [email protected] (K. Sosnowski).
muscle weakness and delirium which are related to the duration of mechanical ventilation, sedation, and forced immobility. Collectively, they impact negatively on the quality of life of intensive care unit (ICU) survivors.1 Prolonged immobility in the ICU can trigger neuromuscular weakness due to disuse atrophy, decrease in strength, and functional denervation.2 Just one week of bed rest can result in a profound loss of muscle strength of up to 20%.3 Delirium can also have devastating consequences for the ICU survivor including prolonged ventilation, increased risk of death and greater degrees of cognitive decline following hospital discharge.4,5 Post-discharge problems associated with ICU delirium include a greater likelihood
http://dx.doi.org/10.1016/j.aucc.2015.05.002 1036-7314/© 2015 Published by Elsevier Ltd. on behalf of Australian College of Critical Care Nurses Ltd.
Please cite this article in press as: Sosnowski K, et al. Early rehabilitation in the intensive care unit: An integrative literature review. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2015.05.002
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2 Table 1 Inclusion and exclusion criteria. Inclusion criteria
Exclusion criteria
No date limiter Primary research article in peer reviewed journal Investigates adult (>18 years of age) ICU patients receiving mechanical ventilation Evaluates in-ICU rehabilitation interventions Measures outcomes including functional, cognitive or quality of life
Published in language other than English Review articles, abstracts, posters from scientific meetings Patients requiring long term rehabilitation suffering stroke or acquired brain injury
of discharge to a place other than home and greater functional decline,6 a higher one year mortality7 and long term cognitive impairment.4 Given the impact on patients and the resulting effect on families and society, impaired recovery from severe critical illness is a major public health issue. Family members often become informal caregivers which can exert a secondary toll of ill-health; altered family relationships and impacted financial security.8 Whilst healthcare organisations have successfully met the challenge of keeping most critical care patients alive until hospital discharge, it has become increasingly important to consider long term health related quality of life. The clinical practice guidelines for pain, agitation and delirium (PAD)1 and the ABCDE bundle of cares (Awakening and Breathing trial Coordination; Delirium monitoring and management; and Early exercise and mobility)9 are evidenced based multidisciplinary rehabilitation approaches that aim to improve the physical and psychological outcomes of critically ill, ventilated patients.4,10,11 Considering the increasing attention on evidence based strategies to preserve the vulnerable critically ill patient’s physical, functional, and cognitive abilities, it is timely to review relevant research literature on rehabilitation strategies in the ICU. 2. Aim This critical review of the research literature aimed to answer the following research question: What is the impact of early rehabilitation practices on functional outcomes and quality of life in adult ICU survivors? 3. Methods An integrative literature review was undertaken to contribute to understanding the impact of early rehabilitation on quality of life for ICU survivors. The integrative review methodology allows for the combination of diverse methodologies to provide a comprehensive understanding of a particular healthcare problem.12 Retrieved data were evaluated against a recognised evaluation tool; research findings were analysed and categorised into themes; and a synthesis of conclusions from each theme was presented as an integrated summation of the topic.13 A comprehensive search of online databases PubMed, Cumulative Index to Nursing and Allied Health Literature, Ovid Medline and Google Scholar was conducted. Initially, only studies that related to the ABCDE bundle and PAD guideline were sought. Although several research articles were retrieved that addressed isolated components of the bundles, only one published study specifically relating to the bundles was located.9 Thus a broader approach was taken to review general rehabilitation of ICU patients with a focus on functional and quality of life outcomes. Key search terms included ‘ICU acquired weakness’ ‘early rehabilitation’ ‘early mobility’ and ‘functional outcomes’ were combined with ‘intensive care’ and ‘critical illness’. Year restrictions were not applied, however appropriate responses from electronic databases were not located prior to 2000 which reflect the
Investigates paediatric patient populations Interventions focus on post ICU or hospital discharge
clinical practice of the time where early exercise was not seen to be a priority. Additional literature was sourced from reference lists of relevant review articles and original publications. This ensured that the literature review was relevant and comprehensive. The inclusion and exclusion criteria for the research articles have been presented in Table 1. An illustration of the search trail has been presented in Fig. 1. 4. Critical appraisal The Critical Appraisal Skills Program (CASP)14 was used as a framework to systematically analyse and rigorously evaluate the chosen research articles and justified their inclusion within this literature review. The CASP tools for randomised controlled trials, cohort studies, and case control studies were used to appraise the strengths and weaknesses of the chosen studies. The studies included in this paper were reviewed to determine if the results were clinically important and statistically significant. External validity of the research was appraised to ensure that results could be transferred to real world clinical practice in the ICU. A summary demonstrates the results of the critical appraisal (Table 2). Whilst experimental research is considered the gold standard for generating valid treatment and effect evidence, descriptive and correlational studies play a key role in forming the basis of further research particularly in an area that has limited randomised control trials.15 Thus it was deemed important and appropriate to include descriptive and correlational studies to enrich critical care knowledge with regards to the implementation of early rehabilitation programmes into ICU. The integrative review may include quantitative or qualitative research, or both.16 In this review, qualitative studies were not examined as higher levels of evidence were available and met the aims of the research question. Articles that met the inclusion criteria for this literature review were each evaluated against the CASP criteria and included three randomised controlled trials, four cohort studies, one case controlled study; one descriptive study, and one retrospective analysis study. The studies were conducted in various critical care units and respiratory care centres throughout the world including seven in the United States of America, and one each in Australia, Taiwan and Belgium. Although the studies are predominantly from Northern America, they provide a world-wide perspective on a problem common to all ICU patients. A summary of the ten critiqued research articles is presented in Table 3. 4.1. Strengths and limitations of the included studies Two of the studies met all CASP criteria for randomised controlled trials.11,17 Several of the cohort studies were strengthened by the prospective and consecutive inclusion of all admitted mechanically ventilated patients over many months.18–20 This ensured the participants were representative of the wider critical care cohort. A number of studies11,18,21,22 achieved high rates of activity intervention despite the fragility of the patient condition
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Fig. 1. Flow chart of literature search.
and interruptions associated with procedures and tests. Research bias was avoided when the outcome measures were performed by a physical therapist blinded to group allocation.21,23 In contrast, some studies were exposed to potential bias related to the inability to blind healthcare workers, participants and outcome assessors.11,19,20,22,23 This may have influenced interventions and the results of functional measures. Studies were further limited by small sample size and single sites.19,20,22–24 This may impact upon the ability to generalise the results to all critically ill populations. Small sample size may have been insufficient to show between-group differences in secondary outcomes for some studies24 whilst loss of subjects further diminished sample size.22–24 5. Thematic analysis To ensure that the review focussed on core issues, a manual analysis of the research papers was performed. We used a standardised framework25 to summarise the main aim of each paper and the main results of each paper. This was noted and uploaded into a table format within Microsoft Excel 2007. The use of the CASP tools allowed comparative analysis and patterns in the extracted data to become evident. An integrated summary enabled further comparative analysis and key themes emerged following close examination of similarities and differences across studies. A unique synthesis of the studies’ data evolved from the combined processes and five recurrent themes emerged. 6. Results Five major themes were identified from the review. These included ‘critically ill patients do not always receive physical therapy as a standard of care’; ‘ICU culture and resources determine
early rehabilitation success’; ‘successful respiratory and physical rehabilitation interventions are tailored according to individual patient impairment’; ‘early exercise in the ICU prevents the neuromuscular complications of critical illness and improves functional status’; early exercise in the ICU is effective safe and feasible’. These themes were further divided into sub-themes. The themes, subthemes and their associated review articles are presented in Table 4. 6.1. Theme 1: Critically ill patients do not always receive physical therapy as a standard of care 6.1.1. Time to initiate rehabilitation Critically ill patients do not always receive physical therapy as a standard of care.19 Schweickert et al.,11 provided therapy to their intervention group at 1.5 days (1.0–2.1) compared to 7.4 days (6.0–10.9) for the control group. The commencement of physical therapy ranged from 7 days (5–11 days)21 to 10 days (7–12 days).20 6.1.2. Episodes of therapy Five papers identified the frequency and duration of rehabilitation consultations for mechanically ventilated patients as a primary outcome measure.11,19–21,26 This is particularly relevant as it has been accepted practice for this cohort of patients to receive little active physical therapy or mobility. Generally, interventions were delivered once per day.11,20,26 Exercise sessions were increased from one to two sessions per day once tolerance was increased.19,21 Treatments were performed from 14% of study days20 to 87% of study days.11,26 The duration of training sessions was fairly short and intense. Berney et al.,21 provided training for 15 min per day twice daily, six days per week. Other papers reported duration of sessions lasting from 32 min (IQR 0.17–0.48)11 to 45 min (34–47).20
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Author
Chen et al. (2012) Taiwan
Q3 Sampling
Q4 Blinding
Q5 Demographic
Q6 Equality
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Q4 Measure bias limit √
Q5 Outcome bias limit √
Q6 Confounders
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Q7 Treatment effect
Q8 Precision of the treatment effect
Statistically significant Small sample size Statistically significant
Undetermined
Statistically significant
95% CI
Requires adaptation
Q7 Follow up
Q8 Results
Q9 Applicability
Q10 Outcomes
Q11 Benefits
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95% CI
Cohort, case controlled, and descriptive studies Author
Davis et al. (2013) USA
Berney et al. (2012) Aust Zanni et al. (2010) USA Pohlman et al. (2010) USA Needham et al. (2010) USA
Bailey et al. (2007) USA Martin et al. (2005) USA
Q1 Clearly focussed issue √
Q2 Appropriate method √
Q3 Recruitment
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Lacks rigour
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Aust – Australia; USA – United States of America.
Outcome assessor not blinded Outcome assessor not blinded Outcome assessor not blinded Outcome assessor not blinded Outcome assessor not blinded
Confounders identified as limitations √
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Loss to follow up √
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Confounders identified as limitations
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Confounders may explain some associations Limited
Confounders may explain some associations Limited √
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Q1 Clearly focussed issue
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Table 2 Summary of critical appraisal.
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Table 3 Summary of reviewed articles. Author/Country
Design
Sample
Cohort
Intervention
Measure
Main finding
Davis et al. (2013) USA
Prospective Cohort
15 participants
Older adults aged over 65 MV > 48 h
Standard early mobilisation protocol – 4 phases
Early mobilisation programmes are feasible and safe for critically ill older patients.
Berney et al. (2012) Australia
Prospective Cohort
150 participants 74 intervention 76 standard care
General ICU LOS > 5 days
Protocolised rehabilitation programme in ICU, ward and outpatient
RAND SF-36 – Comparative scores at 30 days to the general community except increased pain BI – Patients recovered 89% of baseline function at 30 days post ICU ICU-DSC 38% vs 54% (9 = 0.14) ICU-PFIT (55% complete) Ward-6MWT (81% complete) OPD-6MWT (100% complete)
Chen et al. (2012) Taiwan
RCT
27 participants 12 – intervention 15 – control
Respiratory care centre MV > 21 days
BI – before/after exercise 4.3 vs. 19.3 (p = .004) FIM – before/after exercise program 28.1 vs. 44.6 (p = .005) Intervention vs. control 16.5 vs. 4.6 (p = .036)
Zanni et al. (2010) USA
Prospective Cohort
32 participants
Medical ICU MV > 4 days
An exercise training programme consisting of cardiopulmonary endurance, muscle strengthening and stretching exercises Individualised rehabilitation therapy
Pohlman et al. (2010) USA
Descriptive study of intervention arm of RCT
49 participants
Medical ICU MV < 72 h
Daily sedation interruption and early PT and OT
Needham et al. (2010) USA
Casecontrolled study Prospective before/after quality improvement project
57 participants 27 pre QI 30 post QI
Medical ICU MV > 96 h
Reduction of heavy sedation combined with increased PT and OT support and changed consultation guidelines
Schweickert et al. (2009) USA
RCT
104 participants 49 intervention 55 control
General ICU MV < 72 h
Early exercise and mobilisation plus daily interruption of sedation
FIM 59% functionally independent at hospital discharge BI before admission vs. at hosp discharge 100 vs. 75 Benzodiazepine dose (before vs. after) 47 mg vs. 15 mg (p = 0.09) Delirium status CAM-ICU – not delirious 21% vs. 53% Functional mobility 56% vs. 78% p = .03 Independent function at hospital discharge Intervention vs. control (59% vs. 35% p = 0.02) Barthel index (75 vs. 55 p = 0.05)
FSS-ICU 10 OA vs. 20 at discharge (p < 0.05)
Exercise training that commences in ICU is safe and feasible. Prescribed exercise results in increased activity. Barriers to exercise are patient safety and fatigue. Patients with prolonged mechanical ventilation show significant improvement in functional status after exercise training.
Sedated patients, unavailability of rehab staff and lack of physician orders were major barriers. Patients required ongoing rehabilitation following hospital discharge. PT & OT paired with sedative interruption and occurring immediately from MV is safe and feasible. A QI process resulted in decreased use of deep sedation and increased advanced mobilisation activity sessions.
Interruption of sedation and early rehabilitation was safe and feasible. Results included improved functional outcomes. Delirium duration was shortened.
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6 Table 3 (Continued) Author/Country
Design
Sample
Cohort
Intervention
Measure
Main finding
Burtin et al. (2009) Belgium
RCT
90 participants 45 intervention 45 control
Medical/surgical ICU MV > 7 days
Additional 20 min cycling exercise session 5 days per week to normal physiotherapy
Early exercise training enhances recovery of functional ability and muscle force at hospital discharge.
Bailey et al. (2007) USA
Prospective cohort
103 participants
Respiratory failure ICU MV > 4 days
Martin et al. (2005) USA
Retrospective analysis
49 consecutive participants
Ventilator dependent MV > 14 days
Assessment for early exercise then progressively sit on bed/sit in chair/ambulate once criteria met Structured rehabilitation programme and spontaneous breathing trials
6 MWT at hospital discharge (196 m vs. 143 m p < 0.05) SF-36 PF score 21 vs. 15 p < 0.01. Quadricep force 2.37 vs. 2.03 p < 0.01 Ambulate whilst ventilated 42% Ambulate >100 feet at hospital discharge 69%
Motor strength OA vs. at discharge Upper body 1.9 vs. 3.6 Lower body 1.5 vs. 2.7 FIM score 1.0 vs. 3.0 p < 0.001
Early activity is safe and feasible in respiratory failure patients.
Whole body rehabilitation improves motor strength and functional variables in chronic ventilated patients.
6MWT – Six Minute Walk Test; BI – Barthel Index; FIM – functional independence; FSS-ICU – functional status score for ICU; MV – mechanical ventilation; OA – on admission; OT – occupational therapy; PFIT – physical function in ICU test, PT – physiotherapy; RCT – randomised controlled trial; ICU DSC – Intensive Care Unit Delirium Screening Checklist. Table 4 Themes and sub-themes identified from reviewed articles. Themes by title (=number of studies per theme)
Subthemes
No of studies per subtheme
Empirical sources
Critically ill patients do not always receive therapy as a standard of care (=5)
Episodes and duration of therapy Time to initiate therapy
5
Martin et al. (2005), Schweickert et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Berney et al. (2012) Martin et al. (2005), Schweickert et al. (2009), Zanni et al. (2010), Berney et al. (2012)
ICU culture and resources determine early rehabilitation success (=8)
ICU culture and availability of rehabilitation staff
5
Martin et al. (2005), Bailey et al. (2007), Schweickert et al. (2009), Zanni et al. (2010), Needham et al. (2010)
Physiological and neurological instability
8
Procedures
4
Bailey et al. (2007), Burtin et al. (2009), Schweickert et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Needham et al. (2010), Berney et al. (2012), Davis et al. (2013 Bailey et al. (2007), Schweickert et al. (2009), Pohlman et al. (2010), Berney et al. (2012)
Respiratory Rehabilitation
7
Strengthening and physical rehabilitation
9
Successful respiratory and physical rehabilitation interventions are tailored according to individual patient impairment (=9) Early exercise in the ICU prevents the neuromuscular complications of critical illness and improves functional status (=10) Early exercise in the ICU is effective safe and feasible (=7)
Functional outcomes
4
10
Motor and respiratory muscle strength
2
Feasibility of the provision of early rehabilitation in ICU Tubes catheters and line safety Physiological criteria
7
Neurological criteria
4
Adverse events
6
4 7
Martin et al. (2005), Bailey et al. (2007), Burtin et al. (2009), Schweickert et al. (2009), Pohlman et al. (2010), Berney et al. (2012), Chen et al. (2012) Martin et al. (2005), Bailey et al. (2007), Schweickert et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Needham et al. (2010), Berney et al. (2012), Chen et al. (2012), Davis et al. (2013) Martin et al. (2005), Bailey et al. (2007), Burtin et al. (2009), Schweickert et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Needham et al. (2010), Davis et al. (2013), Berney et al. (2012), Chen et al. (2012) Martin et al. (2005), Chen et al. (2012)
Bailey et al. (2007), Burtin et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Berney et al. (2012), Chen et al. (2012), Davis et al. (2013) Bailey et al. (2007), Schweickert et al. (2009), Pohlman et al. (2010), Berney et al. (2012) Bailey et al. (2007), Burtin et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Berney et al. (2012), Chen et al. (2012), Davis et al. (2013) Pohlman et al. (2010), Zanni et al. (2010), Berney et al. (2012), Davis et al. (2013) Bailey et al. (2007), Burtin et al. (2009), Schweickert et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Berney et al. (2012)
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It was usual for control groups to receive little or no physical therapy.11 However, Berney and colleagues21 acknowledged that their control group received a greater amount of physical therapy including early mobilisation as is normal practice in an Australian ICU. 6.2. Theme 2 – ICU culture and resources determine early rehabilitation success Patient, health care provider and institutional level barriers to early rehabilitation in the ICU setting were recognised in eight studies.11,17–21,26,27 6.2.1. ICU culture The impact of ICU culture was recognised in five studies.11,18–20,27 The lack of early exercise programmes and a culture of high levels of sedation and tolerance of delirium contributed to low levels of independent functionality.11,19–21,26 However, changing default patient activity level from ‘bed rest’ to ‘activity as tolerated’ assisted cultural shift.27 Activity protocols provided to eligible patients18,19,27 ensured that therapy was accepted as normal practice. Medical procedures were mentioned in four articles11,18,21,26 as a major impediment although it was recognised that procedures could easily be planned around rehabilitation sessions.21,26 6.2.2. Availability of rehabilitation staff The availability of physical and occupational therapists represented a major barrier to the delivery of therapy.11,20 Zanni et al.20 reported therapy was not provided on 56% (25–68%) of ICU days due to lack of availability of rehabilitation staff. 6.2.3. Physiological and neurological instability Eight studies identified cardiac and respiratory physiological instability as a barrier to performing rehabilitation.11,17–22,26,27 Yet, exercise sessions were often successfully performed despite this instability.26 Bailey and colleagues18 found most patients could participate in activity despite multiple organ failure or high oxygen requirements. Neurocognitive impairment precluding activity sessions was identified in four papers. Decreased level of consciousness,21,22 over-sedation20 and delirium11 frequently excluded patients from therapy. 6.3. Theme 3 – Successful respiratory and physical rehabilitation interventions are tailored according to individual patient impairment 6.3.1. Respiratory rehabilitation Respiratory weaning including spontaneous breathing trials was an important component of the rehabilitation process in seven studies.11,17–19,21,24,26 The spontaneous breathing trial, sedative interruption and physical therapy were co-ordinated where possible.26 Two studies continued to use established ICU protocols to guide weaning from the ventilator.11,21 Bailey and colleagues18 delayed ventilator weaning in respiratory failure patients in favour of early activity. 6.3.2. Strengthening and physical rehabilitation All reviewed articles described physical rehabilitation strategies that were tailored to patient impairments. Six of the studies described exercise programmes that increasingly progressed from sitting on the edge of bed, to sitting out of bed, to standing and eventually walking.11,17,18,20,22,26 This progression of activities was designed to target postural muscle groups and challenge balance reactions. Ambulation was initiated once a patient had achieved
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standing balance, marching in place and weight shifting.26 Martin and colleagues19 focussed on improving trunk control and maintenance of posture using resistance bands and low weights, ambulation using parallel bars, stepping progressing to staircase exercise. They deduced that patients responded positively to ‘whole of body’ rehabilitation with improved strength and functional status. The inclusion of a bedside ergometer in the physical rehabilitation programme was described in two studies.17,24 An intervention group scored significantly better on the six minute walking distance test and showed greater isometric quadriceps strength (p = 0.05).17 One programme also resulted in significantly improved functional independence measures in the intervention group (16.5 vs. 4.6, p = 0.036).24 6.4. Theme 4: Early exercise in the ICU reduces the neuromuscular complications of critical illness and improves functional status All studies concluded that early rehabilitation in the ICU prevented the neuromuscular complications of critical illness and improved functional status. Patients who were transferred from an acute ICU were severely weak and deconditioned on admission to a chronic ventilation unit.19 However, a significant improvement occurred following an aggressive rehabilitation programme. All patients were bed bound at admission and a total of 81% were able to ambulate at discharge (0 to 52 ± 18 feet, p = .005). Schweickert and colleagues11 observed a rigorous exercise programme coupled with sedation interruption resulted in 59% of patients returning to independent functional status at hospital discharge compared with 35% in their control group. The intervention group showed improved scores of activities of daily living on the Barthel Index, improved levels of independence with activities of daily living, and statistically significant improvements in independent ambulation. Several studies significantly improved functional outcome measures at hospital discharge after the introduction of exercise training programmes in the ICU.17,21,22,24,27 6.4.1. Motor and respiratory muscle strength Two studies described a moderate positive correlation between motor and respiratory strength.19,24 Chen and colleagues24 suggested that improved lung mechanics will improve aerobic capacity and increased efficiency of oxygen delivery to muscles. A significant association was found between upper limb strength and time to wean from the ventilator with a reduction of seven days of weaning time (R = 0.72, R2 = 0.54, p < .001) in an intervention group.19 6.5. Theme 5: Early exercise in the ICU is effective, safe and feasible A primary objective of seven studies was to show that early activity was both feasible and safe despite the degree of critical illness.17,18,20–22,24,26 6.5.1. Invasive line safety The presence of lines and catheters did not always preclude activity. Catheter and line devices were secured or removed before each rehabilitation process. Femoral access devices precluded ambulation in some studies,21 but not others.26 6.5.2. Physiological criteria Strict criteria to commence or cease exercise therapy were detailed in seven articles.17,18,20–22,24,26 Criteria included acceptable parameters of oxygen saturation (ranges greater than 85–90%) systolic blood pressure (ranges less than 180–200), and mean arterial blood pressure greater than 65 mmHg. Ceiling pressor doses
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were often used to preclude exercise,17,21 though therapy was delivered in one study despite vasoactive drugs.26 6.5.3. Neurological status Four studies ensured that patients passed a neurological safety screen prior to activity sessions.20,26 Patients were then placed on a protocol for daily sedative interruption and early rehabilitation therapy. Patients were expected to be within an acceptable Richmond Agitation Sedation Scale range to participate in exercise programmes.21 However, this goal was often not reached20,21 which impacted upon successful exercise and ambulation. 6.5.4. Adverse events Adverse events involving loss of lines were described in four studies but were reported as infrequent occurrences.17,18,21,26 However, this did not impact negatively on the patient’s progress in the ICU. In one study, adverse events occurred in 14 out of 1449 activity events18 or exercise was terminated early in 16 out of 425 sessions17 because safety criteria was exceeded. Therapy was rarely discontinued permanently.11 7. Discussion The current body of evidence that explores ‘whole of body’ rehabilitation in the ICU is small. The term ‘rehabilitation’ in the literature frequently refers to exclusive mobility or exercise programmes.17,18,20–22,24 However, rehabilitation strategies in the ICU should aim to restore the patient’s physical, functional and cognitive capabilities.28 This may potentially be achieved using a bundled approach to treat and prevent both ICU acquired weakness and delirium. Effective early exercise is limited by the presence of delirium and sedation. Although ICU sedation is necessary to facilitate mechanical ventilation, improve tolerance to procedures, and relieve patient pain and anxiety; many of the reviewed studies found that neurocognitive impairment related to sedation often precluded activity sessions.11,18,20–22 Sedation protocols with light sedation and spontaneous awakening and breathing trials are strategies that reduce patient exposure to the harmful effects of excessive sedative drugs.10,29 Beneficial outcomes of these protocols are reduction of the duration of mechanical ventilation and decreased length of stay in the ICU,30,31 less pain and agitation,32 reduced drug costs and decreased episodes of ventilator associated pneumonia.33 Four of the reviewed studies ensured that patients passed a neurological and delirium safety screen prior to activity sessions.20–22,26 However, this goal was often not reached despite a sedation protocol.21 The prevalence of delirium in critically ill patients as been reported as high as 83% in the USA and has been associated with many unfavourable functional outcomes that can reach into the post ICU discharge period.34 Nurses are in an excellent position to use validated screening tools to screen patients for delirium and to maintain target sedation scores.35 Respiratory weaning from mechanical ventilation and spontaneous breathing trials was shown as an important component of the rehabilitation process.11,19,21,24,26 Spontaneous breathing trials assist the ICU clinicians to determine if the patient is ready to breathe without ventilator support.36 Potential implications of a lack of collaborative decision making for ventilator weaning include delayed recognition of weaning and extubation readiness resulting in unnecessary prolongation of ventilation.37 Furthermore, nurse led ventilation weaning protocols that include spontaneous breathing trials have resulted in shorter time to extubation when compared to physician led weaning.38,39
The literature clearly establishes that long term positive functional outcomes for the critically ill are possible with early physical exercise. Discharging patients from the ICU with profound neuromuscular weakness and persistent functional disability is unacceptable. The research demonstrated that early physical rehabilitation can be successful, feasible, and safe.17,18,20–22,24,26 Many strategies have been described that result in an attentive and active patient. The workplace environment unit was identified as both an important component of promoting the prioritisation of early rehabilitation practices18,19,27 and as an impediment to the acceptance of early activity for the critically ill patient.11,20 Work-place culture is recognised as a major source of knowledge for ICU nurses and underpins the need to consider culture when conducting research or implementing evidence based practice.40 The reviewed articles highlighted that standard practice throughout many parts of the world is for ICU patients to receive limited early exercise. Our critique of the literature highlighted both real and perceived barriers to the implementation of early exercise in the ICU including patient barriers (haemodynamic and neurological instability) and institutional barriers (lack of personnel).20,26 Further obstacles have recently been identified which include staff apprehension and poor understanding of the importance of early mobility.41 Knowledge translation can be enhanced by the identification of existing barriers including interpretating for clinicians the language used in scientific research which can be complex and challenging.42 The lack of access to rehabilitation staff was evident throughout the review. It was suggested that with more physiotherapy and occupational therapy personnel, more could be achieved.27 It could be argued that access to early rehabilitation in the ICU should not rely so heavily on the limited physiotherapist and occupational therapist resource pool. In previous decades, critical care nurses assumed responsibility for all after-hours chest physiotherapy, assisted and active exercises.43
7.1. Recommendations for clinical practice Changing patient care practices in ICU can be challenging. To enhance patient care and improve outcomes in our ICUs, a multidisciplinary approach is necessary to ensure the successful implementation and sustained change of evidencebased rehabilitation practices. Interprofessional coordination, communication and teamwork to ensure successful patient outcomes are advocated.41 There are many benefits to multidisciplinary teams working collaboratively including safer working environments,44 job satisfaction,45 and increased staff commitment.46 However, barriers to collaboration such as professional hierarchies, stereotyping, and differing value systems have been widely reported.47 A commitment from the whole team is necessary to ensure the collaborative model is effective. Interestingly, the unique leadership role of the nurse within the multidisciplinary team was rarely mentioned in the reviewed studies. Effective coordination and leadership provided by critical care nurses ensures patient care objectives are met. Nurse leaders are well placed to promote ongoing support and resources to ensure the local culture and environment is adapted to best meet the needs of the patient.29 Future research that explores and documents key elements that effective nurse leaders bring to a critical care team is recommended to support broad implementation.
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7.2. Recommendations for education
References
Critical care nursing curricula that emphasises the short and long term unintended consequences of acute interventions in the intensive care unit may help to facilitate cultural change within the ICU.48 Validated evidenced based resources and guidelines for implementing multicomponent strategies including the clinical practice guidelines for pain, agitation and delirium (PAD)1 and the ABCDE bundle29 simplify critical learning and assist to implement new initiatives. Resources can be customised and edited to meet individual facility requirements to support knowledge transition into practice. Simulation is increasingly available in ICUs and provides an excellent training medium for the multidisciplinary team to engage and practise rehabilitation strategies and to problem solve complex clinical situations in a safe and controlled learning environment.49,50 Future research that examines how simulation as the agent of learning can best be adapted for these practical situations will provide evidence to enhance skills in this area of patient care.
1. Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41(1):263–306. 2. Dang SL. ABCDEs of ICU: early mobility. Crit Care Nurs Q 2013;36(2):163–8. 3. Fan E, Zanni JM, Dennison CR, Lepre SJ, Needham DM. Critical illness neuromyopathy and muscle weakness in patients in the intensive care unit. AACN Adv Crit Care 2009;20(3):243–53. 4. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371(9607):126–34. 5. Shehabi Y, Riker RR, Bokesch PM, Wisemandle W, Shintani A, Ely EW. Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Crit Care Med 2010;38(12):2311–8. 6. Balas MC, Happ MB, Yang W, Chelluri L, Richmond T. Outcomes associated with delirium in older patients in surgical ICUs. Chest 2009;135(1):18–25. 7. Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30(1):119–41. 8. Griffiths J, Hatch R, Bishop J, Morgan K, Jenkinson C, Cuthbertson B, et al. An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study. Crit Care 2013;17(3):R100. 9. Balas MC, Vasilevskis EE, Olsen KM, Schmid KK, Shostrom V, Cohen MZ, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med 2014;42(5):1024–36. 10. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000;342(20):1471–7. 11. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373(9678):1874–82. 12. Broome ME. Integrative literature reviews for the development of concepts. Concept development in nursing: foundations, techniques and applications. Philadelphia: WB Saunders Company; 2000. p. 231–50. 13. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs 2005;52(5):546–53. 14. CASP. Critical appraisal skills programme: making sense of evidence about clinical effectiveness. Oxford: Public Health Resource Unit; 2014. Available from: http:// www.casp-uk.net [cited 02.05.14]. 15. Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008. 16. Haber J, LoBiondo-Wood G. Nursing research: methods and critical appraisal for evidence-based practice. St. Louis, Missouri: Elsevier; 2014. 17. Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009;37(9):2499–505. 18. Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007;35(1):139–45. 19. Martin UJ, Hincapie L, Nimchuk M, Gaughan J, Criner GJ. Impact of whole-body rehabilitation in patients receiving chronic mechanical ventilation. Crit Care Med 2005;33(10):2259–65. 20. Zanni JM, Korupolu R, Fan E, Pradhan P, Janjua K, Palmer JB, et al. Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project. J Crit Care 2010;25(2):254–62. 21. Berney S, Haines K, Skinner EH, Denehy L. Safety and feasibility of an exercise prescription approach to rehabilitation across the continuum of care for survivors of critical illness. Phys Ther 2012;92(12):1524–35. 22. Davis J, Crawford K, Wierman H, Osgood W, Cavanaugh J, Smith KA, et al. Mobilization of ventilated older adults. J Geriatr Phys Ther 2013;36(4): 162–8. 23. Brummel NE, Girard TD, Ely EW, Pandharipande PP, Morandi A, Hughes CG, et al. 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. Intensive Care Med 2014;40(3):370–9. 24. Chen YH, Lin HL, Hsiao HF, Chou LT, Kao KC, Huang CC, et al. Effects of exercise training on pulmonary mechanics and functional status in patients with prolonged mechanical ventilation. Respir Care 2012;57(5):727–34. 25. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008;8(1):45. 26. Pohlman MC, Schweickert WD, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med 2010;38(11):2089–94. 27. Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. Arch Phys Med Rehabil 2010;91(4):536–42. 28. Parker A, Sricharoenchai T, Needham DM. Early rehabilitation in the intensive care unit: preventing physical and mental health impairments. Curr Phys Med Rehabil Rep 2013;1(4):307–14.
7.3. Recommendations for future research Thus far, research has generally been confined to the investigation of various early exercise programmes in the ICU and the effect of those on short term functional outcomes at ICU or hospital discharge. The field is currently divided between the study of exercise programmes in ICU17,18,20–22,24 and the study of exercise programmes coupled with sedation management.11,19,26,27 However, research has not investigated the effect of bundled management approaches to over-sedation, immobility and delirium on long term outcomes. Future randomised controlled trials are advocated as they will provide a rigorous way of determining the cause-effect relationship between bundled rehabilitation strategies and short-term functional patient outcomes and long-term functional independence and quality of life. Early rehabilitation therapy is not established in the ICU community and requires further examination. Understanding the barriers and enablers to the implementation of early activity in the ICU should be explored through mixed method or qualitative methodology as suggested by proponents of knowledge translational research. As ongoing research offers new insights, the practice of evidenced based rehabilitation as a routine part of critical care will be less hampered by patient, staff or organisational constraints. Finally, research is required to enrich our understanding of the long-term consequences of interventions on critically ill patients, their families and carers. Experimental and mixed method study can assess our success at helping patients to reach the level of function and the quality of life that they possessed before their critical illness. 8. Conclusion Although limited, there is a growing body of research that confirms early rehabilitation interventions that incorporate both prevention of delirium and early physical exercise can optimise the short term outcomes and long term quality of life for intensive care unit survivors. Evidence based practice guidelines are readily available and have been shown to be safe and feasible. However, cultural issues may impede the adoption of daily rehabilitation intervention as standard practice in our intensive care units. Critical care nurses are in an excellent position to drive change within their departments ensuring that early rehabilitation practices are both adopted and implemented.
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29. Balas MC, Vasilevskis EE, Burke WJ, Boehm L, Pun BT, Olsen KM, et al. Critical care nurses’ role in implementing the “ABCDE bundle” into practice. Crit Care Nurse 2012;32(2):35–8, 40–7; quiz 8. 30. Medicine CC. Protocol directed sedation by nurses reduced the duration of mechanical ventilation in critically ill patients. Evid Based Nurs 2000;3(3):82. 31. Jackson DL, Proudfoot CW, Cann KF, Walsh T. A systematic review of the impact of sedation practice in the ICU on resource use, costs and patient safety. Crit Care (Lond, Engl) 2010;14(2):R59. 32. Chanques G, Jaber S, Barbotte E, Violet S, Sebbane M, Perrigault PF, et al. Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med 2006;34(6):1691–9. 33. Quenot JP, Ladoire S, Devoucoux F, Doise JM, Cailliod R, Cunin N, et al. Effect of a nurse-implemented sedation protocol on the incidence of ventilator-associated pneumonia. Crit Care Med 2007;35(9):2031–6. 34. Balas MC, Rice M, Chaperon C, Smith H, Disbot M, Fuchs B. Management of delirium in critically ill older adults. Crit Care Nurse 2012;32(4):15–26. 35. Morandi A, Brummel NE, Ely EW. Sedation, delirium and mechanical ventilation: the ‘ABCDE’ approach. Curr Opin Crit Care 2011;17(1):43–9. 36. Hooper MH, Girard TD. Sedation and weaning from mechanical ventilation: linking spontaneous awakening trials and spontaneous breathing trials to improve patient outcomes. Anesthesiol Clin 2011;29(4):651–61. 37. Rose L, Blackwood B, Egerod I, Haugdahl HS, Hofhuis J, Isfort M, et al. Decisional responsibility for mechanical ventilation and weaning: an international survey. Crit Care (Lond, Engl) 2011;15(6):R295. 38. Crocker C. Nurse led weaning from ventilatory and respiratory support. Intensive Crit Care Nurs 2002;18(5):272–9. 39. Ely EW, Meade MO, Haponik EF, Kollef MH, Cook DJ, Guyatt GH, et al. Mechanical ventilator weaning protocols driven by nonphysician health-care professionals: evidence-based clinical practice guidelines. Chest 2001;120(6 Suppl.):454s–63s.
40. Bringsvor HB, Bentsen SB, Berland A. Sources of knowledge used by intensive care nurses in Norway: an exploratory study. Intensive Crit Care Nurs 2014;30(3):159–66. 41. Lee C, Fan E. ICU-acquired weakness: what is preventing its rehabilitation in critically ill patients? BMC Med 2012;10(1):115. 42. Funabashi M, Warren S, Kawchuk GN. Knowledge exchange and knowledge translation in physical therapy and manual therapy fields: barriers, facilitators and issues. Phys Ther Rev 2012;17(4):227–33. 43. Wiles V, Daffurn K. There’s a bird in my hand and a bear by the bed-I must be in ICU. The Pivotal Years of Australian Critical Care Nursing. Marrickville, NSW: Southwood Press; 2002. p. 425. 44. Firth-Cozens J. Cultures for improving patient safety through learning: the role of teamwork. Qual Health Care 2001;10(Suppl. 2):ii26–31. 45. Kutzscher LI, Sabiston JA, Laschinger HK, Nish M. The effects of teamwork on staff perception of empowerment and job satisfaction. Healthc Manage Forum 1997;10(2):12–24. 46. Lauver KJ, Kristof-Brown A. Distinguishing between employees’ perceptions of person–job and person–organization fit. J Vocat Behav 2001;59(3): 454–70. 47. Irvine R, Kerridge I, McPhee J, Freeman S. Interprofessionalism and ethics: consensus or clash of cultures? J Interprof Care 2002;16(3):199–210. 48. Goddard SL, Cuthbertson BH. Rehabilitation and critical illness. Anaesth Intensive Care Med 2012;13(5):214–6. 49. Corbridge SJ, Robinson FP, Tiffen J, Corbridge TC. Online learning versus simulation for teaching principles of mechanical ventilation to nurse practitioner students. Int J Nurs Educ Scholarsh 2010;7. Article 12. 50. Rauen CA. Simulation as a teaching strategy for nursing education and orientation in cardiac surgery. Crit Care Nurse 2004;24(3):46–51.
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Contents lists available at ScienceDirect
Australian Critical Care journal homepage: www.elsevier.com/locate/aucc
Review Paper
Early rehabilitation in the intensive care unit: An integrative literature review夽 Kellie Sosnowski RN, Grad Dip (ICN) a,b,∗ , Frances Lin RN, PhD c , Marion L. Mitchell RN, PhD c,d , Hayden White FCICM a,b a
Intensive Care Unit, Logan Hospital, Australia Griffith University, Australia c Centre of Health Practice Innovation, Menzies Health Institute Queensland, School of Nursing and Midwifery, Griffith University, Australia d Intensive Care Unit, Princess Alexandra Hospital, Australia b
article information Article history: Received 27 June 2014 Received in revised form 19 April 2015 Accepted 11 May 2015 Available online xxx Keywords: Critical illness Delirium Muscle weakness Quality of life Rehabilitation
a b s t r a c t Objectives: The aim of this review is to appraise current research which examines the impact of early rehabilitation practices on functional outcomes and quality of life in adult intensive care unit (ICU) survivors. Review method used: A systematic literature search was undertaken; retrieved data was evaluated against a recognised evaluation tool; research findings were analysed and categorised into themes; and a synthesis of conclusions from each theme was presented as an integrated summation of the topic. Data sources: Electronic databases of PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Ovid Medline and Google Scholar were searched using key search terms ‘ICU acquired weakness’, ‘early rehabilitation’ ‘early mobility’ and ‘functional outcomes’ combined with ‘intensive care’ and ‘critical illness’. Additional literature was sourced from reference lists of relevant original publications. Results: Five major themes related to the review objectives emerged from the analysis. These themes included: critically ill patients do not always receive physical therapy as a standard of care; ICU culture and resources determine early rehabilitation success; successful respiratory and physical rehabilitation interventions are tailored according to individual patient impairment; early exercise in the ICU prevents the neuromuscular complications of critical illness and improves functional status; early exercise in the ICU is effective, safe and feasible. Conclusions: A limited body of research supports early rehabilitation interventions to optimise the short term outcomes and long term quality of life for ICU survivors. Critical care nurses are in an excellent position to drive change within their departments ensuring that early rehabilitation practices are adopted and implemented. © 2015 Published by Elsevier Ltd. on behalf of Australian College of Critical Care Nurses Ltd.
1. Introduction Recent attention in intensive care has shifted to include consideration of the long term impact of life saving strategies on the critically ill patient. An admission to intensive care can be associated with both physical and psychological complications including
夽 This is the best nursing review paper from 2014. ∗ Corresponding author at: Intensive Care Unit, Logan Hospital, Australia. Tel.: +61 400212755. E-mail address: [email protected] (K. Sosnowski).
muscle weakness and delirium which are related to the duration of mechanical ventilation, sedation, and forced immobility. Collectively, they impact negatively on the quality of life of intensive care unit (ICU) survivors.1 Prolonged immobility in the ICU can trigger neuromuscular weakness due to disuse atrophy, decrease in strength, and functional denervation.2 Just one week of bed rest can result in a profound loss of muscle strength of up to 20%.3 Delirium can also have devastating consequences for the ICU survivor including prolonged ventilation, increased risk of death and greater degrees of cognitive decline following hospital discharge.4,5 Post-discharge problems associated with ICU delirium include a greater likelihood
http://dx.doi.org/10.1016/j.aucc.2015.05.002 1036-7314/© 2015 Published by Elsevier Ltd. on behalf of Australian College of Critical Care Nurses Ltd.
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2 Table 1 Inclusion and exclusion criteria. Inclusion criteria
Exclusion criteria
No date limiter Primary research article in peer reviewed journal Investigates adult (>18 years of age) ICU patients receiving mechanical ventilation Evaluates in-ICU rehabilitation interventions Measures outcomes including functional, cognitive or quality of life
Published in language other than English Review articles, abstracts, posters from scientific meetings Patients requiring long term rehabilitation suffering stroke or acquired brain injury
of discharge to a place other than home and greater functional decline,6 a higher one year mortality7 and long term cognitive impairment.4 Given the impact on patients and the resulting effect on families and society, impaired recovery from severe critical illness is a major public health issue. Family members often become informal caregivers which can exert a secondary toll of ill-health; altered family relationships and impacted financial security.8 Whilst healthcare organisations have successfully met the challenge of keeping most critical care patients alive until hospital discharge, it has become increasingly important to consider long term health related quality of life. The clinical practice guidelines for pain, agitation and delirium (PAD)1 and the ABCDE bundle of cares (Awakening and Breathing trial Coordination; Delirium monitoring and management; and Early exercise and mobility)9 are evidenced based multidisciplinary rehabilitation approaches that aim to improve the physical and psychological outcomes of critically ill, ventilated patients.4,10,11 Considering the increasing attention on evidence based strategies to preserve the vulnerable critically ill patient’s physical, functional, and cognitive abilities, it is timely to review relevant research literature on rehabilitation strategies in the ICU. 2. Aim This critical review of the research literature aimed to answer the following research question: What is the impact of early rehabilitation practices on functional outcomes and quality of life in adult ICU survivors? 3. Methods An integrative literature review was undertaken to contribute to understanding the impact of early rehabilitation on quality of life for ICU survivors. The integrative review methodology allows for the combination of diverse methodologies to provide a comprehensive understanding of a particular healthcare problem.12 Retrieved data were evaluated against a recognised evaluation tool; research findings were analysed and categorised into themes; and a synthesis of conclusions from each theme was presented as an integrated summation of the topic.13 A comprehensive search of online databases PubMed, Cumulative Index to Nursing and Allied Health Literature, Ovid Medline and Google Scholar was conducted. Initially, only studies that related to the ABCDE bundle and PAD guideline were sought. Although several research articles were retrieved that addressed isolated components of the bundles, only one published study specifically relating to the bundles was located.9 Thus a broader approach was taken to review general rehabilitation of ICU patients with a focus on functional and quality of life outcomes. Key search terms included ‘ICU acquired weakness’ ‘early rehabilitation’ ‘early mobility’ and ‘functional outcomes’ were combined with ‘intensive care’ and ‘critical illness’. Year restrictions were not applied, however appropriate responses from electronic databases were not located prior to 2000 which reflect the
Investigates paediatric patient populations Interventions focus on post ICU or hospital discharge
clinical practice of the time where early exercise was not seen to be a priority. Additional literature was sourced from reference lists of relevant review articles and original publications. This ensured that the literature review was relevant and comprehensive. The inclusion and exclusion criteria for the research articles have been presented in Table 1. An illustration of the search trail has been presented in Fig. 1. 4. Critical appraisal The Critical Appraisal Skills Program (CASP)14 was used as a framework to systematically analyse and rigorously evaluate the chosen research articles and justified their inclusion within this literature review. The CASP tools for randomised controlled trials, cohort studies, and case control studies were used to appraise the strengths and weaknesses of the chosen studies. The studies included in this paper were reviewed to determine if the results were clinically important and statistically significant. External validity of the research was appraised to ensure that results could be transferred to real world clinical practice in the ICU. A summary demonstrates the results of the critical appraisal (Table 2). Whilst experimental research is considered the gold standard for generating valid treatment and effect evidence, descriptive and correlational studies play a key role in forming the basis of further research particularly in an area that has limited randomised control trials.15 Thus it was deemed important and appropriate to include descriptive and correlational studies to enrich critical care knowledge with regards to the implementation of early rehabilitation programmes into ICU. The integrative review may include quantitative or qualitative research, or both.16 In this review, qualitative studies were not examined as higher levels of evidence were available and met the aims of the research question. Articles that met the inclusion criteria for this literature review were each evaluated against the CASP criteria and included three randomised controlled trials, four cohort studies, one case controlled study; one descriptive study, and one retrospective analysis study. The studies were conducted in various critical care units and respiratory care centres throughout the world including seven in the United States of America, and one each in Australia, Taiwan and Belgium. Although the studies are predominantly from Northern America, they provide a world-wide perspective on a problem common to all ICU patients. A summary of the ten critiqued research articles is presented in Table 3. 4.1. Strengths and limitations of the included studies Two of the studies met all CASP criteria for randomised controlled trials.11,17 Several of the cohort studies were strengthened by the prospective and consecutive inclusion of all admitted mechanically ventilated patients over many months.18–20 This ensured the participants were representative of the wider critical care cohort. A number of studies11,18,21,22 achieved high rates of activity intervention despite the fragility of the patient condition
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3
Fig. 1. Flow chart of literature search.
and interruptions associated with procedures and tests. Research bias was avoided when the outcome measures were performed by a physical therapist blinded to group allocation.21,23 In contrast, some studies were exposed to potential bias related to the inability to blind healthcare workers, participants and outcome assessors.11,19,20,22,23 This may have influenced interventions and the results of functional measures. Studies were further limited by small sample size and single sites.19,20,22–24 This may impact upon the ability to generalise the results to all critically ill populations. Small sample size may have been insufficient to show between-group differences in secondary outcomes for some studies24 whilst loss of subjects further diminished sample size.22–24 5. Thematic analysis To ensure that the review focussed on core issues, a manual analysis of the research papers was performed. We used a standardised framework25 to summarise the main aim of each paper and the main results of each paper. This was noted and uploaded into a table format within Microsoft Excel 2007. The use of the CASP tools allowed comparative analysis and patterns in the extracted data to become evident. An integrated summary enabled further comparative analysis and key themes emerged following close examination of similarities and differences across studies. A unique synthesis of the studies’ data evolved from the combined processes and five recurrent themes emerged. 6. Results Five major themes were identified from the review. These included ‘critically ill patients do not always receive physical therapy as a standard of care’; ‘ICU culture and resources determine
early rehabilitation success’; ‘successful respiratory and physical rehabilitation interventions are tailored according to individual patient impairment’; ‘early exercise in the ICU prevents the neuromuscular complications of critical illness and improves functional status’; early exercise in the ICU is effective safe and feasible’. These themes were further divided into sub-themes. The themes, subthemes and their associated review articles are presented in Table 4. 6.1. Theme 1: Critically ill patients do not always receive physical therapy as a standard of care 6.1.1. Time to initiate rehabilitation Critically ill patients do not always receive physical therapy as a standard of care.19 Schweickert et al.,11 provided therapy to their intervention group at 1.5 days (1.0–2.1) compared to 7.4 days (6.0–10.9) for the control group. The commencement of physical therapy ranged from 7 days (5–11 days)21 to 10 days (7–12 days).20 6.1.2. Episodes of therapy Five papers identified the frequency and duration of rehabilitation consultations for mechanically ventilated patients as a primary outcome measure.11,19–21,26 This is particularly relevant as it has been accepted practice for this cohort of patients to receive little active physical therapy or mobility. Generally, interventions were delivered once per day.11,20,26 Exercise sessions were increased from one to two sessions per day once tolerance was increased.19,21 Treatments were performed from 14% of study days20 to 87% of study days.11,26 The duration of training sessions was fairly short and intense. Berney et al.,21 provided training for 15 min per day twice daily, six days per week. Other papers reported duration of sessions lasting from 32 min (IQR 0.17–0.48)11 to 45 min (34–47).20
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Chen et al. (2012) Taiwan
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Cohort, case controlled, and descriptive studies Author
Davis et al. (2013) USA
Berney et al. (2012) Aust Zanni et al. (2010) USA Pohlman et al. (2010) USA Needham et al. (2010) USA
Bailey et al. (2007) USA Martin et al. (2005) USA
Q1 Clearly focussed issue √
Q2 Appropriate method √
Q3 Recruitment
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
Lacks rigour
Small sample
√
√
√
√
√
√
√
√
Aust – Australia; USA – United States of America.
Outcome assessor not blinded Outcome assessor not blinded Outcome assessor not blinded Outcome assessor not blinded Outcome assessor not blinded
Confounders identified as limitations √
√
√
Loss to follow up √
√
√
Confounders identified as limitations
√
√
√
√
√
Confounders may explain some associations Limited
Confounders may explain some associations Limited √
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Q2 Randomisation
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Schweickert et al. (2009) USA Burtin et al. (2009) Belgium
Q1 Clearly focussed issue
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Table 2 Summary of critical appraisal.
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Table 3 Summary of reviewed articles. Author/Country
Design
Sample
Cohort
Intervention
Measure
Main finding
Davis et al. (2013) USA
Prospective Cohort
15 participants
Older adults aged over 65 MV > 48 h
Standard early mobilisation protocol – 4 phases
Early mobilisation programmes are feasible and safe for critically ill older patients.
Berney et al. (2012) Australia
Prospective Cohort
150 participants 74 intervention 76 standard care
General ICU LOS > 5 days
Protocolised rehabilitation programme in ICU, ward and outpatient
RAND SF-36 – Comparative scores at 30 days to the general community except increased pain BI – Patients recovered 89% of baseline function at 30 days post ICU ICU-DSC 38% vs 54% (9 = 0.14) ICU-PFIT (55% complete) Ward-6MWT (81% complete) OPD-6MWT (100% complete)
Chen et al. (2012) Taiwan
RCT
27 participants 12 – intervention 15 – control
Respiratory care centre MV > 21 days
BI – before/after exercise 4.3 vs. 19.3 (p = .004) FIM – before/after exercise program 28.1 vs. 44.6 (p = .005) Intervention vs. control 16.5 vs. 4.6 (p = .036)
Zanni et al. (2010) USA
Prospective Cohort
32 participants
Medical ICU MV > 4 days
An exercise training programme consisting of cardiopulmonary endurance, muscle strengthening and stretching exercises Individualised rehabilitation therapy
Pohlman et al. (2010) USA
Descriptive study of intervention arm of RCT
49 participants
Medical ICU MV < 72 h
Daily sedation interruption and early PT and OT
Needham et al. (2010) USA
Casecontrolled study Prospective before/after quality improvement project
57 participants 27 pre QI 30 post QI
Medical ICU MV > 96 h
Reduction of heavy sedation combined with increased PT and OT support and changed consultation guidelines
Schweickert et al. (2009) USA
RCT
104 participants 49 intervention 55 control
General ICU MV < 72 h
Early exercise and mobilisation plus daily interruption of sedation
FIM 59% functionally independent at hospital discharge BI before admission vs. at hosp discharge 100 vs. 75 Benzodiazepine dose (before vs. after) 47 mg vs. 15 mg (p = 0.09) Delirium status CAM-ICU – not delirious 21% vs. 53% Functional mobility 56% vs. 78% p = .03 Independent function at hospital discharge Intervention vs. control (59% vs. 35% p = 0.02) Barthel index (75 vs. 55 p = 0.05)
FSS-ICU 10 OA vs. 20 at discharge (p < 0.05)
Exercise training that commences in ICU is safe and feasible. Prescribed exercise results in increased activity. Barriers to exercise are patient safety and fatigue. Patients with prolonged mechanical ventilation show significant improvement in functional status after exercise training.
Sedated patients, unavailability of rehab staff and lack of physician orders were major barriers. Patients required ongoing rehabilitation following hospital discharge. PT & OT paired with sedative interruption and occurring immediately from MV is safe and feasible. A QI process resulted in decreased use of deep sedation and increased advanced mobilisation activity sessions.
Interruption of sedation and early rehabilitation was safe and feasible. Results included improved functional outcomes. Delirium duration was shortened.
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Design
Sample
Cohort
Intervention
Measure
Main finding
Burtin et al. (2009) Belgium
RCT
90 participants 45 intervention 45 control
Medical/surgical ICU MV > 7 days
Additional 20 min cycling exercise session 5 days per week to normal physiotherapy
Early exercise training enhances recovery of functional ability and muscle force at hospital discharge.
Bailey et al. (2007) USA
Prospective cohort
103 participants
Respiratory failure ICU MV > 4 days
Martin et al. (2005) USA
Retrospective analysis
49 consecutive participants
Ventilator dependent MV > 14 days
Assessment for early exercise then progressively sit on bed/sit in chair/ambulate once criteria met Structured rehabilitation programme and spontaneous breathing trials
6 MWT at hospital discharge (196 m vs. 143 m p < 0.05) SF-36 PF score 21 vs. 15 p < 0.01. Quadricep force 2.37 vs. 2.03 p < 0.01 Ambulate whilst ventilated 42% Ambulate >100 feet at hospital discharge 69%
Motor strength OA vs. at discharge Upper body 1.9 vs. 3.6 Lower body 1.5 vs. 2.7 FIM score 1.0 vs. 3.0 p < 0.001
Early activity is safe and feasible in respiratory failure patients.
Whole body rehabilitation improves motor strength and functional variables in chronic ventilated patients.
6MWT – Six Minute Walk Test; BI – Barthel Index; FIM – functional independence; FSS-ICU – functional status score for ICU; MV – mechanical ventilation; OA – on admission; OT – occupational therapy; PFIT – physical function in ICU test, PT – physiotherapy; RCT – randomised controlled trial; ICU DSC – Intensive Care Unit Delirium Screening Checklist. Table 4 Themes and sub-themes identified from reviewed articles. Themes by title (=number of studies per theme)
Subthemes
No of studies per subtheme
Empirical sources
Critically ill patients do not always receive therapy as a standard of care (=5)
Episodes and duration of therapy Time to initiate therapy
5
Martin et al. (2005), Schweickert et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Berney et al. (2012) Martin et al. (2005), Schweickert et al. (2009), Zanni et al. (2010), Berney et al. (2012)
ICU culture and resources determine early rehabilitation success (=8)
ICU culture and availability of rehabilitation staff
5
Martin et al. (2005), Bailey et al. (2007), Schweickert et al. (2009), Zanni et al. (2010), Needham et al. (2010)
Physiological and neurological instability
8
Procedures
4
Bailey et al. (2007), Burtin et al. (2009), Schweickert et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Needham et al. (2010), Berney et al. (2012), Davis et al. (2013 Bailey et al. (2007), Schweickert et al. (2009), Pohlman et al. (2010), Berney et al. (2012)
Respiratory Rehabilitation
7
Strengthening and physical rehabilitation
9
Successful respiratory and physical rehabilitation interventions are tailored according to individual patient impairment (=9) Early exercise in the ICU prevents the neuromuscular complications of critical illness and improves functional status (=10) Early exercise in the ICU is effective safe and feasible (=7)
Functional outcomes
4
10
Motor and respiratory muscle strength
2
Feasibility of the provision of early rehabilitation in ICU Tubes catheters and line safety Physiological criteria
7
Neurological criteria
4
Adverse events
6
4 7
Martin et al. (2005), Bailey et al. (2007), Burtin et al. (2009), Schweickert et al. (2009), Pohlman et al. (2010), Berney et al. (2012), Chen et al. (2012) Martin et al. (2005), Bailey et al. (2007), Schweickert et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Needham et al. (2010), Berney et al. (2012), Chen et al. (2012), Davis et al. (2013) Martin et al. (2005), Bailey et al. (2007), Burtin et al. (2009), Schweickert et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Needham et al. (2010), Davis et al. (2013), Berney et al. (2012), Chen et al. (2012) Martin et al. (2005), Chen et al. (2012)
Bailey et al. (2007), Burtin et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Berney et al. (2012), Chen et al. (2012), Davis et al. (2013) Bailey et al. (2007), Schweickert et al. (2009), Pohlman et al. (2010), Berney et al. (2012) Bailey et al. (2007), Burtin et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Berney et al. (2012), Chen et al. (2012), Davis et al. (2013) Pohlman et al. (2010), Zanni et al. (2010), Berney et al. (2012), Davis et al. (2013) Bailey et al. (2007), Burtin et al. (2009), Schweickert et al. (2009), Pohlman et al. (2010), Zanni et al. (2010), Berney et al. (2012)
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It was usual for control groups to receive little or no physical therapy.11 However, Berney and colleagues21 acknowledged that their control group received a greater amount of physical therapy including early mobilisation as is normal practice in an Australian ICU. 6.2. Theme 2 – ICU culture and resources determine early rehabilitation success Patient, health care provider and institutional level barriers to early rehabilitation in the ICU setting were recognised in eight studies.11,17–21,26,27 6.2.1. ICU culture The impact of ICU culture was recognised in five studies.11,18–20,27 The lack of early exercise programmes and a culture of high levels of sedation and tolerance of delirium contributed to low levels of independent functionality.11,19–21,26 However, changing default patient activity level from ‘bed rest’ to ‘activity as tolerated’ assisted cultural shift.27 Activity protocols provided to eligible patients18,19,27 ensured that therapy was accepted as normal practice. Medical procedures were mentioned in four articles11,18,21,26 as a major impediment although it was recognised that procedures could easily be planned around rehabilitation sessions.21,26 6.2.2. Availability of rehabilitation staff The availability of physical and occupational therapists represented a major barrier to the delivery of therapy.11,20 Zanni et al.20 reported therapy was not provided on 56% (25–68%) of ICU days due to lack of availability of rehabilitation staff. 6.2.3. Physiological and neurological instability Eight studies identified cardiac and respiratory physiological instability as a barrier to performing rehabilitation.11,17–22,26,27 Yet, exercise sessions were often successfully performed despite this instability.26 Bailey and colleagues18 found most patients could participate in activity despite multiple organ failure or high oxygen requirements. Neurocognitive impairment precluding activity sessions was identified in four papers. Decreased level of consciousness,21,22 over-sedation20 and delirium11 frequently excluded patients from therapy. 6.3. Theme 3 – Successful respiratory and physical rehabilitation interventions are tailored according to individual patient impairment 6.3.1. Respiratory rehabilitation Respiratory weaning including spontaneous breathing trials was an important component of the rehabilitation process in seven studies.11,17–19,21,24,26 The spontaneous breathing trial, sedative interruption and physical therapy were co-ordinated where possible.26 Two studies continued to use established ICU protocols to guide weaning from the ventilator.11,21 Bailey and colleagues18 delayed ventilator weaning in respiratory failure patients in favour of early activity. 6.3.2. Strengthening and physical rehabilitation All reviewed articles described physical rehabilitation strategies that were tailored to patient impairments. Six of the studies described exercise programmes that increasingly progressed from sitting on the edge of bed, to sitting out of bed, to standing and eventually walking.11,17,18,20,22,26 This progression of activities was designed to target postural muscle groups and challenge balance reactions. Ambulation was initiated once a patient had achieved
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standing balance, marching in place and weight shifting.26 Martin and colleagues19 focussed on improving trunk control and maintenance of posture using resistance bands and low weights, ambulation using parallel bars, stepping progressing to staircase exercise. They deduced that patients responded positively to ‘whole of body’ rehabilitation with improved strength and functional status. The inclusion of a bedside ergometer in the physical rehabilitation programme was described in two studies.17,24 An intervention group scored significantly better on the six minute walking distance test and showed greater isometric quadriceps strength (p = 0.05).17 One programme also resulted in significantly improved functional independence measures in the intervention group (16.5 vs. 4.6, p = 0.036).24 6.4. Theme 4: Early exercise in the ICU reduces the neuromuscular complications of critical illness and improves functional status All studies concluded that early rehabilitation in the ICU prevented the neuromuscular complications of critical illness and improved functional status. Patients who were transferred from an acute ICU were severely weak and deconditioned on admission to a chronic ventilation unit.19 However, a significant improvement occurred following an aggressive rehabilitation programme. All patients were bed bound at admission and a total of 81% were able to ambulate at discharge (0 to 52 ± 18 feet, p = .005). Schweickert and colleagues11 observed a rigorous exercise programme coupled with sedation interruption resulted in 59% of patients returning to independent functional status at hospital discharge compared with 35% in their control group. The intervention group showed improved scores of activities of daily living on the Barthel Index, improved levels of independence with activities of daily living, and statistically significant improvements in independent ambulation. Several studies significantly improved functional outcome measures at hospital discharge after the introduction of exercise training programmes in the ICU.17,21,22,24,27 6.4.1. Motor and respiratory muscle strength Two studies described a moderate positive correlation between motor and respiratory strength.19,24 Chen and colleagues24 suggested that improved lung mechanics will improve aerobic capacity and increased efficiency of oxygen delivery to muscles. A significant association was found between upper limb strength and time to wean from the ventilator with a reduction of seven days of weaning time (R = 0.72, R2 = 0.54, p < .001) in an intervention group.19 6.5. Theme 5: Early exercise in the ICU is effective, safe and feasible A primary objective of seven studies was to show that early activity was both feasible and safe despite the degree of critical illness.17,18,20–22,24,26 6.5.1. Invasive line safety The presence of lines and catheters did not always preclude activity. Catheter and line devices were secured or removed before each rehabilitation process. Femoral access devices precluded ambulation in some studies,21 but not others.26 6.5.2. Physiological criteria Strict criteria to commence or cease exercise therapy were detailed in seven articles.17,18,20–22,24,26 Criteria included acceptable parameters of oxygen saturation (ranges greater than 85–90%) systolic blood pressure (ranges less than 180–200), and mean arterial blood pressure greater than 65 mmHg. Ceiling pressor doses
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were often used to preclude exercise,17,21 though therapy was delivered in one study despite vasoactive drugs.26 6.5.3. Neurological status Four studies ensured that patients passed a neurological safety screen prior to activity sessions.20,26 Patients were then placed on a protocol for daily sedative interruption and early rehabilitation therapy. Patients were expected to be within an acceptable Richmond Agitation Sedation Scale range to participate in exercise programmes.21 However, this goal was often not reached20,21 which impacted upon successful exercise and ambulation. 6.5.4. Adverse events Adverse events involving loss of lines were described in four studies but were reported as infrequent occurrences.17,18,21,26 However, this did not impact negatively on the patient’s progress in the ICU. In one study, adverse events occurred in 14 out of 1449 activity events18 or exercise was terminated early in 16 out of 425 sessions17 because safety criteria was exceeded. Therapy was rarely discontinued permanently.11 7. Discussion The current body of evidence that explores ‘whole of body’ rehabilitation in the ICU is small. The term ‘rehabilitation’ in the literature frequently refers to exclusive mobility or exercise programmes.17,18,20–22,24 However, rehabilitation strategies in the ICU should aim to restore the patient’s physical, functional and cognitive capabilities.28 This may potentially be achieved using a bundled approach to treat and prevent both ICU acquired weakness and delirium. Effective early exercise is limited by the presence of delirium and sedation. Although ICU sedation is necessary to facilitate mechanical ventilation, improve tolerance to procedures, and relieve patient pain and anxiety; many of the reviewed studies found that neurocognitive impairment related to sedation often precluded activity sessions.11,18,20–22 Sedation protocols with light sedation and spontaneous awakening and breathing trials are strategies that reduce patient exposure to the harmful effects of excessive sedative drugs.10,29 Beneficial outcomes of these protocols are reduction of the duration of mechanical ventilation and decreased length of stay in the ICU,30,31 less pain and agitation,32 reduced drug costs and decreased episodes of ventilator associated pneumonia.33 Four of the reviewed studies ensured that patients passed a neurological and delirium safety screen prior to activity sessions.20–22,26 However, this goal was often not reached despite a sedation protocol.21 The prevalence of delirium in critically ill patients as been reported as high as 83% in the USA and has been associated with many unfavourable functional outcomes that can reach into the post ICU discharge period.34 Nurses are in an excellent position to use validated screening tools to screen patients for delirium and to maintain target sedation scores.35 Respiratory weaning from mechanical ventilation and spontaneous breathing trials was shown as an important component of the rehabilitation process.11,19,21,24,26 Spontaneous breathing trials assist the ICU clinicians to determine if the patient is ready to breathe without ventilator support.36 Potential implications of a lack of collaborative decision making for ventilator weaning include delayed recognition of weaning and extubation readiness resulting in unnecessary prolongation of ventilation.37 Furthermore, nurse led ventilation weaning protocols that include spontaneous breathing trials have resulted in shorter time to extubation when compared to physician led weaning.38,39
The literature clearly establishes that long term positive functional outcomes for the critically ill are possible with early physical exercise. Discharging patients from the ICU with profound neuromuscular weakness and persistent functional disability is unacceptable. The research demonstrated that early physical rehabilitation can be successful, feasible, and safe.17,18,20–22,24,26 Many strategies have been described that result in an attentive and active patient. The workplace environment unit was identified as both an important component of promoting the prioritisation of early rehabilitation practices18,19,27 and as an impediment to the acceptance of early activity for the critically ill patient.11,20 Work-place culture is recognised as a major source of knowledge for ICU nurses and underpins the need to consider culture when conducting research or implementing evidence based practice.40 The reviewed articles highlighted that standard practice throughout many parts of the world is for ICU patients to receive limited early exercise. Our critique of the literature highlighted both real and perceived barriers to the implementation of early exercise in the ICU including patient barriers (haemodynamic and neurological instability) and institutional barriers (lack of personnel).20,26 Further obstacles have recently been identified which include staff apprehension and poor understanding of the importance of early mobility.41 Knowledge translation can be enhanced by the identification of existing barriers including interpretating for clinicians the language used in scientific research which can be complex and challenging.42 The lack of access to rehabilitation staff was evident throughout the review. It was suggested that with more physiotherapy and occupational therapy personnel, more could be achieved.27 It could be argued that access to early rehabilitation in the ICU should not rely so heavily on the limited physiotherapist and occupational therapist resource pool. In previous decades, critical care nurses assumed responsibility for all after-hours chest physiotherapy, assisted and active exercises.43
7.1. Recommendations for clinical practice Changing patient care practices in ICU can be challenging. To enhance patient care and improve outcomes in our ICUs, a multidisciplinary approach is necessary to ensure the successful implementation and sustained change of evidencebased rehabilitation practices. Interprofessional coordination, communication and teamwork to ensure successful patient outcomes are advocated.41 There are many benefits to multidisciplinary teams working collaboratively including safer working environments,44 job satisfaction,45 and increased staff commitment.46 However, barriers to collaboration such as professional hierarchies, stereotyping, and differing value systems have been widely reported.47 A commitment from the whole team is necessary to ensure the collaborative model is effective. Interestingly, the unique leadership role of the nurse within the multidisciplinary team was rarely mentioned in the reviewed studies. Effective coordination and leadership provided by critical care nurses ensures patient care objectives are met. Nurse leaders are well placed to promote ongoing support and resources to ensure the local culture and environment is adapted to best meet the needs of the patient.29 Future research that explores and documents key elements that effective nurse leaders bring to a critical care team is recommended to support broad implementation.
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7.2. Recommendations for education
References
Critical care nursing curricula that emphasises the short and long term unintended consequences of acute interventions in the intensive care unit may help to facilitate cultural change within the ICU.48 Validated evidenced based resources and guidelines for implementing multicomponent strategies including the clinical practice guidelines for pain, agitation and delirium (PAD)1 and the ABCDE bundle29 simplify critical learning and assist to implement new initiatives. Resources can be customised and edited to meet individual facility requirements to support knowledge transition into practice. Simulation is increasingly available in ICUs and provides an excellent training medium for the multidisciplinary team to engage and practise rehabilitation strategies and to problem solve complex clinical situations in a safe and controlled learning environment.49,50 Future research that examines how simulation as the agent of learning can best be adapted for these practical situations will provide evidence to enhance skills in this area of patient care.
1. Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41(1):263–306. 2. Dang SL. ABCDEs of ICU: early mobility. Crit Care Nurs Q 2013;36(2):163–8. 3. Fan E, Zanni JM, Dennison CR, Lepre SJ, Needham DM. Critical illness neuromyopathy and muscle weakness in patients in the intensive care unit. AACN Adv Crit Care 2009;20(3):243–53. 4. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371(9607):126–34. 5. Shehabi Y, Riker RR, Bokesch PM, Wisemandle W, Shintani A, Ely EW. Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Crit Care Med 2010;38(12):2311–8. 6. Balas MC, Happ MB, Yang W, Chelluri L, Richmond T. Outcomes associated with delirium in older patients in surgical ICUs. Chest 2009;135(1):18–25. 7. Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30(1):119–41. 8. Griffiths J, Hatch R, Bishop J, Morgan K, Jenkinson C, Cuthbertson B, et al. An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study. Crit Care 2013;17(3):R100. 9. Balas MC, Vasilevskis EE, Olsen KM, Schmid KK, Shostrom V, Cohen MZ, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med 2014;42(5):1024–36. 10. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000;342(20):1471–7. 11. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009;373(9678):1874–82. 12. Broome ME. Integrative literature reviews for the development of concepts. Concept development in nursing: foundations, techniques and applications. Philadelphia: WB Saunders Company; 2000. p. 231–50. 13. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs 2005;52(5):546–53. 14. CASP. Critical appraisal skills programme: making sense of evidence about clinical effectiveness. Oxford: Public Health Resource Unit; 2014. Available from: http:// www.casp-uk.net [cited 02.05.14]. 15. Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008. 16. Haber J, LoBiondo-Wood G. Nursing research: methods and critical appraisal for evidence-based practice. St. Louis, Missouri: Elsevier; 2014. 17. Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, et al. Early exercise in critically ill patients enhances short-term functional recovery. Crit Care Med 2009;37(9):2499–505. 18. Bailey P, Thomsen GE, Spuhler VJ, Blair R, Jewkes J, Bezdjian L, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007;35(1):139–45. 19. Martin UJ, Hincapie L, Nimchuk M, Gaughan J, Criner GJ. Impact of whole-body rehabilitation in patients receiving chronic mechanical ventilation. Crit Care Med 2005;33(10):2259–65. 20. Zanni JM, Korupolu R, Fan E, Pradhan P, Janjua K, Palmer JB, et al. Rehabilitation therapy and outcomes in acute respiratory failure: an observational pilot project. J Crit Care 2010;25(2):254–62. 21. Berney S, Haines K, Skinner EH, Denehy L. Safety and feasibility of an exercise prescription approach to rehabilitation across the continuum of care for survivors of critical illness. Phys Ther 2012;92(12):1524–35. 22. Davis J, Crawford K, Wierman H, Osgood W, Cavanaugh J, Smith KA, et al. Mobilization of ventilated older adults. J Geriatr Phys Ther 2013;36(4): 162–8. 23. Brummel NE, Girard TD, Ely EW, Pandharipande PP, Morandi A, Hughes CG, et al. 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. Intensive Care Med 2014;40(3):370–9. 24. Chen YH, Lin HL, Hsiao HF, Chou LT, Kao KC, Huang CC, et al. Effects of exercise training on pulmonary mechanics and functional status in patients with prolonged mechanical ventilation. Respir Care 2012;57(5):727–34. 25. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. 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7.3. Recommendations for future research Thus far, research has generally been confined to the investigation of various early exercise programmes in the ICU and the effect of those on short term functional outcomes at ICU or hospital discharge. The field is currently divided between the study of exercise programmes in ICU17,18,20–22,24 and the study of exercise programmes coupled with sedation management.11,19,26,27 However, research has not investigated the effect of bundled management approaches to over-sedation, immobility and delirium on long term outcomes. Future randomised controlled trials are advocated as they will provide a rigorous way of determining the cause-effect relationship between bundled rehabilitation strategies and short-term functional patient outcomes and long-term functional independence and quality of life. Early rehabilitation therapy is not established in the ICU community and requires further examination. Understanding the barriers and enablers to the implementation of early activity in the ICU should be explored through mixed method or qualitative methodology as suggested by proponents of knowledge translational research. As ongoing research offers new insights, the practice of evidenced based rehabilitation as a routine part of critical care will be less hampered by patient, staff or organisational constraints. Finally, research is required to enrich our understanding of the long-term consequences of interventions on critically ill patients, their families and carers. Experimental and mixed method study can assess our success at helping patients to reach the level of function and the quality of life that they possessed before their critical illness. 8. Conclusion Although limited, there is a growing body of research that confirms early rehabilitation interventions that incorporate both prevention of delirium and early physical exercise can optimise the short term outcomes and long term quality of life for intensive care unit survivors. Evidence based practice guidelines are readily available and have been shown to be safe and feasible. However, cultural issues may impede the adoption of daily rehabilitation intervention as standard practice in our intensive care units. Critical care nurses are in an excellent position to drive change within their departments ensuring that early rehabilitation practices are both adopted and implemented.
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Please cite this article in press as: Sosnowski K, et al. Early rehabilitation in the intensive care unit: An integrative literature review. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2015.05.002
