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Delphi Study Results

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Delphi Study Results
 

Phase 3: RESULTS

Group 3: Rehabilitation


BEST PRACTICE RECOMMENDATIONS:
CONSENSUS FORMULATION BY PANEL

 

6/7 Agree
CONSENSUS

 

RECOMMENDATION 1:

Every critically ill patient nursed in ICU must be screened daily and active patient initiated activity commenced as soon as the patient is physiologically stable based on specific hemodynamic; respiratory and neurological criteria. The specific activities included and the progression of these activities is based on the patient’s response to activity as well as the therapist’s judgment. Patients must be monitored closely during activities and when necessary the adjustment of FiO2 to maintain adequate oxygenation should allow for continuation of activity STRONG RECOMMENDATION Patients that were mobilized in ICU based on specific criteria remained hemodynamically stable (Stiller et al 2004; Bailey et al 2006; and Thomsen et al 2008) and few adverse effects were documented. These adverse events 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 in increased mortality, LOS or additional cost. MODERATE QUALITY EVIDENCE Two observational studies (Stiller et al 2004; Bailey et al 2006) specifically evaluated the safety of actively mobilizing intubated patients based on specific criteria. The calculated event rate for the two studies is 1% (one in one hundred sessions). The consistent results are further supported by two additional studies evaluating the effect of early mobility on patient outcome (Thomsen et al 2008; Morris et al 2008). These studies did not report any adverse events. The evidence is upgraded to moderate based on consistent results from four studies and a low event rate.

POSTED COMMENTS:

  • I agree with most of this recommendation, except the opening sentence that each critically ill patient MUST be screened daily. What about weekends and public holidays? It is pretty unrealistic to expect staffing levels that will enable daily screening of all these patients.



6/7 Agree
CONSENSUS

 

RECOMMENDATION 2:

An individually designed mobility plan MUST be developed for each critically ill patient admitted to an ICU, in accordance with their assessment and needs and in consultation with the interdisciplinary team. This plan MUST include objective measures linked to specific formulated goals. STRONG RECOMMENDATION The implementation of a mobility plan for patients in ICU compared (n=145) to usual care (n=135) did not result in an increase in adverse effects (safe) or cost and resulted in a significant reduction in time spent in the unit (-1.4 days CI -1.51 to -1.29) and time in hospital (-3.3 days CI -3.7 to -2.9) (Morris et al 2008). No difference was reported in the time on the ventilator or mortality. Also, in a cohort observational study where patients acted as their own controls (Thomsen et al 2008), an unit where mobility was the focus was independently associated with an increase in activity levels MODERATE QUALITY EVIDENCE: One randomized control trail (Morris et al 2008) was downgraded due to moderate risk of bias (randomization not concealed and analysis not on intention to treat). This evidence is further supported by an observational study (Thomsen et al 2008) who reported increased activity levels when mobility is a focus

POSTED COMMENTS:

  • This is actually an AGREE but with some modification. Re 'objective measures' should be objective outcome measures to emphasize the thrust toward outcomes in the profession, and that such outcomes consistent with the International Classification of Functioning, Disability and Health should be used wherever possible which includes activity measures and participation measures including quality of life. The literature supports that if the patient is unable to provide indication of premorbid or current participation outcomes or quality of life, this can be done 'by proxy' (close friend or a family member). Adoption of the ICF is consistent with the WCPT and an increasing number of its member organizations.

    The use of RCTs for physical therapy studies can be questionable particularly in the ICU. I strongly believe we need to be guided by principles in our practice and patient response. In RCTs, the results are mean results. We do not know who among the cohort responded favorably, poorly or not at all, or why. The latter is the salient and most relevant factor. Physical therapists need to conduct their clinical reasoning on a case by case basis particularly in the ICU where patients have complicated backgrounds and presentations, and often on potent medication, and in addition their status changes quickly).

    Based on the physiological hierarchy and sound physiologic evidence, mobilization and body position need to be exploited in every patient. Sometimes RCTs lead practitioners down the garden path. For example, when some RCTs were published on inspiratory muscle training, I observed that this intervention was being used indiscriminately around the world. During my international invitations to speak I am often invited to tour facilities and participate in some way such as rounds. At times, I observed that this type of intervention would be used when valuable mobilization time was being forfeited. Our physiologic evidence for what we need to be doing in the ICU in my view is perhaps our strongest evidence and I expect will remain so, yet such evidence appears to carry little to no weight in systems designed to formally evaluate interventions. We as a profession need to be more analytic and critical of models of practice and research that are uniquely suited for and developed for invasive biomedicine but pale with respect to the needs of non invasive practitioners, specifically, physical therapists.





6/7 Agree
CONSENSUS

 

RECOMMENDATION 3:

A patient specific targeted exercise program should be developed and implemented for patients that have been physiologically to unstable to commence with patient initiated activity within the first five days of ICU admission. This program must commence once the underlying cause of the physiologic instability has been resolved. This program should include a progressive ambulation program (when possible) and be targeted at improving endurance and strengthening of the trunk, upper extremity, and lower extremity muscles. The aim must be to implement at least one session daily with progression based on patient response and therapist’s judgment. WEAK RECOMMENDATION the implementation of a targeted exercise program in chronically ventilated patients (intubated for longer than 14 days) did not affect 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. LOW QUALITY EVIDENCE: Three RCT’s (Nava et al 1998; Porta et al 2005; Chiang et al 2006) downgraded due to study limitations (moderate risk of bias); indirectness and imprecision

POSTED COMMENTS:

  • The intention to treat in my view in unequivocally based on an individual's needs and assessment. Treatment in terms of mobilization is comparable to prescribing exercise for anyone with attention to type, intensity, duration and frequency, and progressed (or cut back even discontinued) as indicated. Once a day is by convention (just like treating a patient five times a week (coincidently the number of days in a work week, or three days a week as in private practice which coincidently is Mon, Wed and Fri) and has nothing to with patient need. If we are to be practice at our highest level with the best cost effective outcomes, we need to practice in a world of potential not lack of it. So, if a patient needs treatment twice a day or three times, then we need to indicate this.

    Unless we make the demands on resources that are needed in the best interest of our patients, we shall never increase these resources or our overall numbers. Bottom line: advocate treatment 'always' in accordance with need. We may not to be able to fulfill that, but at least we need to know every day and our administrators that we are unable to practice at a maximal level.



 
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