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Delphi Study Results
 

Phase 1: Summary of Comments

Group 3: Rehabilitation

Best practice recommendations

Recommendation 1

Safety to mobilize / exercise: All critically ill patients nursed in ICU should be screened closely before active mobilization. The decision must be based on hemodynamic; respiratory and neurological criteria as well as therapist judgment. Patients need to be monitored closely during mobilization and FiO2 can be temporarily adjusted if patient desaturates during an activity.

STRENGTH: Weak recommendation: Patients mobilized in ICU based on specific criteria remained hemodynamically stable (Stiller et al 2004; Bailey et al 2006) and few adverse effects were documented (14 of 1,449) (Bailey et al 2006). This included falls to the knees without injury, variations in systolic blood pressure, oxygen desaturation and a nasal-small bowel feeding tube removal. None of these adverse events resulted increased LOS or additional cost. The effects of these outcomes on functional outcomes are not yet clear.

Quality of evidence: Low quality evidence Two observational studies (Stiller et al 2004; Bailey et al 2006) evaluated the safety of actively mobilizing intubated patients based on specific criteria. There was insufficient cause to upgrade the evidence form these two observational studies (estimate and precision of effect can not be calculated)

Formulation of recommendation
Strength of recommendation
Quality of Evidence
AGREEMENT:4/7
DISAGREEMENT: 3/7
AGREEMENT:6/7
DISAGREEMENT: 1/7
CONSENSUS REACHED
AGREEMENT:6/7
DISAGREEMENT: 1/7
CONSENSUS REACHED

POSTED COMMENTS:

  • The therapist need to liaze with the relevant specific medical team member. E.g. if a patient is a trauma pt with head injury and lower limb orthopedic problem the okay for mobilization is also dependant on the orthopedic surgeon, not just the neurosurgeon and therapist

  • I would add a multisystem assessment and detailed assessment of oxygen transport threats and deficits.

  • I would remove the word ‘temporarily’ and word to imply that the FiO2 is adjusted to maintain optimal oxygen delivery irrespective of what the individual is doing.

  • Too simplistic. Why mention FIO2 adjustment and not other things?

  • I have difficulty putting a rating on ‘safety’. Incidences and adverse effects will happen however with judicious well prescribed intervention and on-going appropriate monitoring, we hope this risk is minimized. It is all about cost benefit at the end of the day.

  • This is where we get into a bind. We want evidence, and we have come to believe that the RCCT will give us the ‘best’ evidence. In fact, our best evidence comes from the physiologic literature, but we (and Sackett’s rating scheme which has been widely adopted) make little provision for the rigor of physiologic evidence. Thus, although, I argued in favor of such evidence being reflected in the task force report: Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. ..the consensus largely favored the traditional RCCT as the gold standard. I see this as a major limitation of our report


THE FOLLOWING ISSUES HAVE BEEN RAISED AND NEED FURTHER DISCUSSION:

  • Defining the term “therapist judgment”
  • Description of measures that could ensure continuation of activity

Recommendation 2

Mobility Plan: An individually designed mobility plan might be developed for each critically ill patient admitted to the unit in consultation with the interdisciplinary team.

STRENGTH: Weak recommendation. The implementation of a specific mobility plan for all patients in ICU did not adversely effect hemodynamic stability or resulted in an increase in adverse effects (Bailey et al 2007). However, the cost benefit of implementation has not been established.

Quality of evidence: Low quality evidence: One observational study (Bailey et al 2007) with insufficient cause to upgrade the quality of the evidence (estimate and precision of effect can not be calculated).

Formulation of recommendation
Strength of recommendation
Quality of Evidence
AGREEMENT:4/7
DISAGREEMENT: 3/7
AGREEMENT:6/7
DISAGREEMENT: 1/7
CONSENSUS REACHED
AGREEMENT:6/7
DISAGREEMENT: 1/7
CONSENSUS REACHED

POSTED COMMENTS:

  • I would suggest MUST be developed

  • I believe a recommendation should not be phrased ‘conditionally’ (e.g., might). Rather, I would say something like “Mobilization is prescribed for patients in the ICU in accordance with their assessment, needs and goals and in consultation with the interdisciplinary team.”

  • I think you need a mobility protocol that all patients move through and the level of activity is determined by patient readiness and physiologic characteristics. An individual plan without a protocol introduces too much variability and is not likely to be consistent across patients.

  • I query how can the evidence for ‘mobilizing’ ICU patients ever be viewed as weak. If one believes that the volume of RCCTs would make it so, then one would come to this conclusion. In my view, the physiologic evidence has been clear for decades that the physiologic position of human beings is ‘upright and moving’ and anything that deviates from this is ‘un-physiologic’ and has been well documented to be associated correspondingly with complications and risks. This is particularly true in older people, smokers, those who are overweight etc. In fact, the evidence is so well established, that it would be decidedly unethical to withhold ‘getting someone upright and moving as soon as possible provided this is being guided by the assessment and on-going evaluation, i.e., there is no untoward outcome and that there is improved oxygen delivery.There is no untoward outcome and that there is improved oxygen delivery.

  • Might be able to include Stiller, Phillips and Lambert as low level evidence as well

  • I would argue that a study evaluating mobilization in a RCCT could be viewed as unethical. Such a trial requires standardization of the mobilization – which could be excessive or insufficient to produce change. Intervention needs to be response-driven vs. protocol-driven, both for safety and for achieving the best result. It is no wonder that RCCTs show equivocal results given that in response to a ‘standardized’ intervention, some patients will not respond, some will respond negatively and some will respond favorably. Add all those responses together, and the result will be no response.

THE FOLLOWING ISSUES HAVE BEEN RAISED AND NEED FURTHER DISCUSSION:

  • Reformulation of recommendation
  • Strength of recommendation

Recommendation 3

Excercise Program: A specific exercise program that targets the upper extremity and trunk focusing both on endurance and strengthening might be implemented for patients that have been intubated for longer than 14 days. The daily exercise session should include at least 30 minutes 5/week and incorporate MBS rating to ensure a specific intensity.

STRENGTH : Weak recommendation the implementation of a targeted exercise program in patients intubated for longer than 14 days have not affected mortality or LOS (Nava et al 1998) but has improved functional capacity (Nava et al 1998); functional independence (Martin et al 2005; Chiang et al 2006) and muscle strength (Martin et al 2005; Porta et al 2005; Chiang et al 2006). Because these studies were performed in a respiratory rehabilitation setting (step down facility) it is not clear whether the increase burden on therapy services in a critical environment is economically justified.

Quality of evidence: Based on low quality evidence: one randomized crossover RCT (Choi et al 2005). Evidence was downgraded because of methodological quality and imprecision.


Formulation of recommendation
Strength of recommendation
Quality of Evidence
AGREEMENT:1/7
DISAGREEMENT: 6/7
AGREEMENT:4/7
DISAGREEMENT: 2/7
NO RESPONSE:1/7
AGREEMENT:6/7
DISAGREEMENT: 0/7
NO RESPONSE:1/7
CONSENSUS REACHED

POSTED COMMENTS:

  • This program can start earlier than just 14 days after intubation. It is dependent on medical/critical status of patient. The frequency of exercise can be twice daily dependant on tolerance of patient and daily instead of five times per week. Frequency more but lenght of sessions less to improve functional strength

  • What a load of rot! Why 14 days? How much evidence is there re upper extremity / trunk exs being the focus? There is NO evidence to suggest daily ex session needs to be at least 30 minutes 5/week. This is completely impractical and clinically impossible!

  • The upper limbs are not primary targets for exercise training. Related to failure of weaning other more specific training modalities (IMT) might be considered in the first place

  • I agree with upper limb and trunk exercises but what about the lower limbs - necessary for adequate weight bearing during mobilization. Intensity and frequency need to be guided by patient's exercise tolerance.

  • Bailey et al showed that such patients not only could do extremity and trunk strengthening but were able to walk considerable distances. To limit activity to only strengthening is short sighted and will likely prevent many patients from acheiving greater activity thereby likely reducing debilitation. Further Bailey et al showed that patients can tolerate safely twice daily activity. Suggest twice daily activity with once daily activity as a minimum.

  • (I would not use abbreviations, e.g., MBS, as not all of us may know what they stand for) Again, I am uncomfortable about the specifics in this recommendation. If we agree on the premise that the purpose of ICU care is to prevent oxygen transport risks and maximal support oxygen transport for optimal recovery and functional return, then the interventions that approximate that end result are the goal within safety limitations (assessment guided and response-dependent). Yes, whole body exercise is indicated as soon as possible and at the level that produces the best result in a given person with the least risk (assessment and monitoring established).

    I would not include a recommendation specifying for ‘longer than 14 days’. Whole body, extremity, trunk exercise is indicated commensurate with status and recovery. I would not include ‘at least 30 minutes’ as this depends on response. If 2 minutes is indicated and tolerated then that is done, if 40 minutes is indicated and tolerated then than is done (therapist’s time will factor into this as well).

  • As for previous comment, it is the recommendation I really disagree with, not the comment above (EDITOR: THIS COMMENT REFERS TO THE QUALITY OF EVIDENCE)

  • I disagree with the recommendation, not so much with the comments above (EDITOR: THIS COMMENT REFERS TO THE STRENGTH OF RECOMMENDATION)

  • There might be lack of research evidence re effectiveness of exercise in ICU but many of us have seen the benefits of exercise on successful weaning and shorter ICU stay clinically.

  • If this recommendation is adopted there were never be any evidence to the contrary. In the context of a well controlled study, this can be shown. Futher Bailey et al showed that there was no increased cost of therpist or nurses time given their team approach. See paper by Thomsen GE, et al (2008). Respiratory failure patients increase ambulation after transfer to an ICU where early activity is a priority. Critical Care Medicine,36(4). 1119-1124. on changing ICU culture to facilitate early mobilization.

THE FOLLOWING ISSUES HAVE BEEN RAISED AND NEED FURTHER DISCUSSION:

  • Criteria for the initiation of a specific exercise program
  • The activities to include
  • Intensity and frequency of the intervention

Expert Opinion

Mobility for unresponsive patients: Effectiveness of mobilization in unresponsive patients Patients in ICU that are not medically stable enough to be actively mobilized, must be turned two hourly and all joints should be moved through full range of motion once daily. Expert opinion of nurses; therapists and intensivists. (Topp et al 2002; Thomas et al 2006; Krishnagopalan et al 2002; Morris 2007; Winkelman 2007; Nava 2002)

AGREEMENT:3/5
DISAGREEMENT: 3/5
NO RESPONSE: 1/7

POSTED COMMENTS:


  • There is no evidence to support the need for ROM daily - in fact the evidence from other patient groups would suggest this is ineffective. I'm not sure about the evidence for 2 hourly turning - particularly in these days of inflating bed mattresses

  • I am not sure that is only necessary in the 'unreponsive' (to what? uncooperative, sedated?) patient. I am convinced that other modalities (for example bedside ergometery for lower limb exercise, electrical muscle stimulation) are applicable in these patients to target the intensity of training appropriately. This goes beyond turning and passive joint motion!

  • First, I would ask why is a patient ‘unresponsive’? Sometimes, this is medication related (excluding induced coma). Medication is used to achieve medical or nursing goals which may be at odds with the physical therapy goals where we need patients comfortable but alert. First line of attack is discussing with the team whether medications that achieve the medical and nursing goals but that keep the patient more aroused can be prescribed. This may be the case. In the case of induced coma or where a patient’s metabolic needs to be reduced, then understandable, the patient needs sedation. The goal remains ‘being upright and moving’, so mobilizing the patient to the sitting position with legs dependent is an important (evidence based) goal for this individual. Typically, in health, we are upright and moving all day long. The more we can approximate the upright position (with or without active mobilization – of course the latter is the most physiologic but not always possible), the better.

  • The ‘two-hour’ turning rule has not been supported yet has become a standard. Evidence from kinetic beds shows that with frequent turning, oxygenation can be maximized and complications reduced in patients who are medically unstable and tenuous. We have data (as yet unpublished; remains on my huge pile of manuscripts to complete) to support that more frequent turning can simulate progression to upright and moving by stimulating a gravitational response and fluid shifts, necessary hemodynamic stress.

  • Passive movements may have some role particularly in patients with neuromuscular impairments (spasticity). There is some evidence that passive movements stimulate deeper breaths. This is a minor reflex and should not be relied upon, but may have a role in some patients who are unstable or those with severe head injuries for example (but ICP and CPP would have to be monitored).

THE FOLLOWING ISSUES HAVE BEEN RAISED AND NEED FURTHER DISCUSSION:

  • Defining unresponsive patients
  • Activities included

Inspiratory Muscle Training (IMT)

IMT is not currently regarded as standard care in the management of critically ill patients and questions have been raised as to the physiological basis of this intervention. There is a lack and poor quality evidence to make any recommendations with regards to the implementation of an IMT program at this time. In the one RCT identified there was no effect on re intubation rate or TOV between the intervention group or the control group. The study was not powered to detect a change; patients were lost to follow up; no blinding was applied and data was not analyzed on an intention to treat basis. Good quality studies are urgently required in this area.

AGREEMENT:6/7
DISAGREEMENT: 1/7
CONSENSUS REACHED

POSTED COMMENTS:


  • Just because their is no scientific research regarding IMT published does not mean it is not done in clinical practice! ACBT can and are done on a patient that is ventilated, awake and following commands. ACBT with ambubagging can/ and are done on intubated patients. Physiotherapists are specialists on muscle retraining and this should be included in the management of ICU patients

  • (Re abbreviation, TOV. I think I have figured it out, but your abbreviations are not universal. I would suggest spelling everything out so there is no misunderstanding.)

  • I am heartened to learn that this has not been regarded as standard care. Like other such interventions, they have a role for some problems, in some patients, at some time. Because physical therapists feel compelled to have devices and gadgets, I find that when I lecture around the world, there is a belief that devices and gadgets are more effective than getting patients upright and moving.

  • Re last line. I would avoid the word ‘urgently’. If you believe, that studies are needed, then stating this is sufficient.
 


 
 
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