There is a need for improving cohort retention in longitudinal studies. Our objective was to identify cohort retention strategies and implementation approaches used in studies with high retention ...rates.
Longitudinal studies with ≥200 participants, ≥80% retention rates over ≥1 year of follow-up were queried from an Institutional Review Board database at a large research-intensive U.S. university; additional studies were identified through networking. Nineteen (86%) of 22 eligible studies agreed to participate. Through in-depth semi-structured interviews, participants provided retention strategies based on themes identified from previous literature reviews. Synthesis of data was completed by a multidisciplinary team.
The most commonly used retention strategies were: study reminders, study visit characteristics, emphasizing study benefits, and contact/scheduling strategies. The research teams were well-functioning, organized, and persistent. Additionally, teams tailored their strategies to their participants, often adapting and innovating their approaches.
These studies included specialized and persistent teams and utilized tailored strategies specific to their cohort and individual participants. Studies' written protocols and published manuscripts often did not reflect the varied strategies employed and adapted through the duration of study. Appropriate retention strategy use requires cultural sensitivity and more research is needed to identify how strategy use varies globally.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
OBJECTIVES:There is growing evidence to support early mobilization of adult mechanically ventilated patients in ICUs. However, there is little knowledge regarding early mobilization in routine ICU ...practice. Hence, the interdisciplinary German ICU Network for Early Mobilization undertook a 1-day point-prevalence survey across Germany.
DESIGN:One-day point-prevalence study.
SETTING:One hundred sixteen ICUs in Germany in 2011.
PATIENTS:All adult mechanically ventilated patients.
INTERVENTIONS:None.
MEASUREMENTS AND MAIN RESULTS:For a 24-hour period, data were abstracted on hospital and ICU characteristics, the level of patient mobilization and associated barriers, and complications occurring during mobilization. One hundred sixteen participating ICUs provided data for 783 patients. Overall, 185 patients (24%) were mobilized out of bed (i.e., sitting on the edge of the bed or higher level of mobilization). Among patients with an endotracheal tube, tracheostomy, and noninvasive ventilation, 8%, 39%, and 53% were mobilized out of bed, respectively (p < 0.001 for difference between three groups). The most common perceived barriers to mobilizing patients out of bed were cardiovascular instability (17%) and deep sedation (15%). Mobilization out of bed versus remaining in bed was not associated with a higher frequency of complications, with no falls or extubations occurring in those mobilized out of bed.
CONCLUSIONS:In this 1-day point-prevalence study conducted across Germany, only 24% of all mechanically ventilated patients and only 8% of patients with an endotracheal tube were mobilized out of bed as part of routine care. Addressing modifiable barriers for mobilization, such as deep sedation, will be important to increase mobilization in German ICUs.
Abstract Needham DM, Korupolu R, Zanni JM, Pradhan P, Colantuoni E, Palmer JB, Brower RG, Fan E. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality ...improvement project. Objectives To (1) reduce deep sedation and delirium to permit mobilization, (2) increase the frequency of rehabilitation consultations and treatments to improve patients' functional mobility, and (3) evaluate effects on length of stay. Design Seven-month prospective before/after quality improvement project. Setting Sixteen-bed medical intensive care unit (MICU) in academic hospital. Participants 57 patients mechanically ventilated 4 days or longer. Intervention A multidisciplinary team focused on reducing heavy sedation and increasing MICU staffing to include full-time physical and occupational therapists with new consultation guidelines. Main Outcome Measures Sedation and delirium status, rehabilitation treatments, functional mobility. Results Compared with before the quality improvement project, benzodiazepine use decreased markedly (proportion of MICU days that patients received benzodiazepines 50% vs 25%, P =.002), with lower median daily sedative doses (47 vs 15mg midazolam equivalents P =.09 and 71 vs 24 mg morphine equivalents P =.01). Patients had improved sedation and delirium status (MICU days alert 30% vs 67%, P <.001 and not delirious 21% vs 53%, P =.003). There were a greater median number of rehabilitation treatments per patient (1 vs 7, P <.001) with a higher level of functional mobility (treatments involving sitting or greater mobility, 56% vs 78%, P =.03). Hospital administrative data demonstrated that across all MICU patients, there was a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4–3.8) and 3.1 (0.3–5.9) days, respectively, and a 20% increase in MICU admissions compared with the same period in the prior year. Conclusions Using a quality improvement process, intensive care unit delirium, physical rehabilitation, and functional mobility were markedly improved and associated with decreased length of stay.
Reducing tidal volume decreases mortality in acute respiratory distress syndrome (ARDS). However, the effect of the timing of low tidal volume ventilation is not well understood.
To evaluate the ...association of intensive care unit (ICU) mortality with initial tidal volume and with tidal volume change over time.
Multivariable, time-varying Cox regression analysis of a multisite, prospective study of 482 patients with ARDS with 11,558 twice-daily tidal volume assessments (evaluated in milliliter per kilogram of predicted body weight PBW) and daily assessment of other mortality predictors.
An increase of 1 ml/kg PBW in initial tidal volume was associated with a 23% increase in ICU mortality risk (adjusted hazard ratio, 1.23; 95% confidence interval CI, 1.06-1.44; P = 0.008). Moreover, a 1 ml/kg PBW increase in subsequent tidal volumes compared with the initial tidal volume was associated with a 15% increase in mortality risk (adjusted hazard ratio, 1.15; 95% CI, 1.02-1.29; P = 0.019). Compared with a prototypical patient receiving 8 days with a tidal volume of 6 ml/kg PBW, the absolute increase in ICU mortality (95% CI) of receiving 10 and 8 ml/kg PBW, respectively, across all 8 days was 7.2% (3.0-13.0%) and 2.7% (1.2-4.6%). In scenarios with variation in tidal volume over the 8-day period, mortality was higher when a larger volume was used earlier.
Higher tidal volumes shortly after ARDS onset were associated with a greater risk of ICU mortality compared with subsequent tidal volumes. Timely recognition of ARDS and adherence to low tidal volume ventilation is important for reducing mortality. Clinical trial registered with www.clinicaltrials.gov (NCT 00300248).
Profound muscle weakness during and after critical illness is termed intensive care unit-acquired weakness (ICUAW).
To develop diagnostic recommendations for ICUAW.
A multidisciplinary expert ...committee generated diagnostic questions. A systematic review was performed, and recommendations were developed using the Grading, Recommendations, Assessment, Development, and Evaluation (GRADE) approach.
Severe sepsis, difficult ventilator liberation, and prolonged mechanical ventilation are associated with ICUAW. Physical rehabilitation improves outcomes in heterogeneous populations of ICU patients. Because it may not be feasible to provide universal physical rehabilitation, an alternative approach is to identify patients most likely to benefit. Patients with ICUAW may be such a group. Our review identified only one case series of patients with ICUAW who received physical therapy. When compared with a case series of patients with ICUAW who did not receive structured physical therapy, evidence suggested those who receive physical rehabilitation were more frequently discharged home rather than to a rehabilitative facility, although confidence intervals included no difference. Other interventions show promise, but fewer data proving patient benefit existed, thus precluding specific comment. Additionally, prior comorbidity was insufficiently defined to determine its influence on outcome, treatment response, or patient preferences for diagnostic efforts. We recommend controlled clinical trials in patients with ICUAW that compare physical rehabilitation with usual care and further research in understanding risk and patient preferences.
Research that identifies treatments that benefit patients with ICUAW is necessary to determine whether the benefits of diagnostic testing for ICUAW outweigh its burdens.
Pre-ICU health status and its impact on differential trajectories of recovery during and after the ICU stay are important considerations in determining response to rehabilitation. Pre-ICU health ...status, including consideration of comorbidities, frailty status, and premorbid physical functioning, in conjunction with new ICU-related physiological impairments, can impact patients’ post-ICU outcomes. Support of physiological impairments (e.g. mechanical ventilation, vasopressors) and optimisation of pain, sedation/agitation and delirium status are important, as these factors impact patients’ engagement and capacity for rehabilitation in the ICU 5. Despite potential benefits, implementation is challenging, particularly in resource-limited settings.This paper presents a guide for early physical rehabilitation and mobilisation, highlighting institution, clinician, and patient issues that are important for implementation (Fig. 1).
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Changes that can improve patients’ health are often difficult to get into practice, even when backed by good evidence. Peter Pronovost, Sean Berenholtz, and Dale Needham describe a collaborative ...model that has been shown to work
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BFBNIB, CMK, NMLJ, NUK, PNG, SAZU, UL, UM, UPUK
BACKGROUND:Long-term outcomes from sepsis are poorly understood, and sepsis in patients may have different long-term effects on mortality and quality of life. Long-term outcome studies of other ...critical illnesses such as acute lung injury have demonstrated incremental health effects that persist after hospital discharge. Whether patients with sepsis have similar long-term mortality and quality-of-life effects is unclear.
OBJECTIVE:We performed a systematic review of studies reporting long-term mortality and quality-of-life data (>3 months) in patients with sepsis, severe sepsis, and septic shock using defined search criteria.
DESIGN:Systematic review of the literature.
INTERVENTIONS:None.
MAIN RESULTS:Patients with sepsis showed ongoing mortality up to 2 yrs and beyond after the standard 28-day inhospital mortality end point. Patients with sepsis also had decrements in quality-of-life measures after hospital discharge. Results were consistent across varying severity of illness and different patient populations in different countries, including large and small studies. In addition, these results were consistent within observational and randomized, controlled trials. Study quality was limited by inadequate control groups and poor adjustment for confounding variables.
CONCLUSIONS:Patients with sepsis have ongoing mortality beyond short-term end points, and survivors consistently demonstrate impaired quality of life. The use of 28-day mortality as an end point for clinical studies may lead to inaccurate inferences. Both observational and interventional future studies should include longer-term end points to better-understand the natural history of sepsis and the effect of interventions on patient morbidities.
Objective: There are barriers to providing early physical medicine and rehabilitation (PM&R) in the intensive care unit (ICU). We present a specific model for undertaking quality improvement (QI) ...projects and a case study focused on QI for early PM&R in the ICU. Methods: The QI project was undertaken using a 4-step model: (1) summarizing the evidence, (2) identifying barriers, (3) establishing performance measures, and (4) ensuring patients receive the intervention. To evaluate the application and outcomes of this model, we present data collected during a 4-month QI period versus an immediately preceding 3-month control period. Results: Deep sedation was a major barrier to early PM&R that was addressed in the QI project. Compared to the control period, there was a decrease in medical ICU (MICU) days with any benzodiazepine use (73% vs 96% of days, P = .03) and narcotic use (77% vs 96%, P = .05) and improved delirium status (MICU days without delirium, 53% vs 21%, P = .003). In addition, more QI patients had physical therapy consultations (93% vs 59%, P = .004) and greater number of rehabilitation treatments with higher functional mobility (treatments involving sitting or greater mobility, 78% vs 56%, P = .03). Hospital data for the QI period demonstrated a decrease in average length of stay in the MICU (4.9 vs 7.0 days, P = .02) and hospital (14.1 vs 17.2, P = .03) compared to the prior year. Conclusion: A structured QI model can be applied to implementation of early PM&R in the ICU resulting in markedly improved delirium status, delivery of PM&R, functional mobility, and length of stay.
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