OBJECTIVE:Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle ...performance and patient-centered outcomes in critical care.
DESIGN:Prospective, multicenter, cohort study from a national quality improvement collaborative.
SETTING:68 academic, community, and federal ICUs collected data during a 20-month period.
PATIENTS:15,226 adults with at least one ICU day.
INTERVENTIONS:We defined ABCDEF bundle performance (our main exposure) in two ways1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomespatient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders.
MEASUREMENTS AND RESULTS:Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomeshospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17–0.62), next-day mechanical ventilation (adjusted odds ratio AOR, 0.28; CI, 0.22–0.36), coma (AOR, 0.35; CI, 0.22–0.56), delirium (AOR, 0.60; CI, 0.49–0.72), physical restraint use (AOR, 0.37; CI, 0.30–0.46), ICU readmission (AOR, 0.54; CI, 0.37–0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51–0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001).
CONCLUSIONS:ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.
New technologies in critical care and mechanical ventilation have led to long-term survival of critically ill patients. An early mobility and walking program was developed to provide guidelines for ...early mobility that would assist clinicians working in intensive care units, especially clinicians working with patients who are receiving mechanical ventilation. Prolonged stays in the intensive care unit and mechanical ventilation are associated with functional decline and increased morbidity, mortality, cost of care, and length of hospital stay. Implementation of an early mobility and walking program could have a beneficial effect on all of these factors. The program encompasses progressive mobilization and walking, with the progression based on a patient's functional capability and ability to tolerate the prescribed activity. The program is divided into 4 phases. Each phase includes guidelines on positioning, therapeutic exercises, transfers, walking reeducation, and duration and frequency of mobility sessions. Additionally, the criteria for progressing to the next phase are provided. Use of this program demands a collaborative effort among members of the multidisciplinary team in order to coordinate care for and provide safe mobilization of patients in the intensive care unit.
BACKGROUND:Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The ...post–intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families.
OBJECTIVES:To report on engagement with non–critical care providers and survivors during the 2012 Society of Critical Care Medicine post–intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes.
PARTICIPANTS:Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members.
DESIGN:Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences.
MEETING OUTCOMES:Future steps were planned regarding 1) recognizing, preventing, and treating post–intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post–intensive care syndrome across the continuum of care, including explicit “functional reconciliation” (assessing gaps between a patient’s pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post–intensive care syndrome research topic areas were identified across the continuum of recoverycharacterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families.
CONCLUSIONS:Raising awareness of post–intensive care syndrome for the public and both critical care and non–critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.
Physical therapy for patients in the ICU is advanced practice demanding specialized knowledge and skills. However, ICU physical therapy competency standards lack uniformity or defined processes.
To ...describe the development process of the Perme ICU Physical Therapy Competency and to assess its face and content validity.
Quantitative research study for the content validation of the Perme ICU Physical Therapy Competency using a panel of experts. The face validity assessment consisted of two informal surveys and discussions with clinicians representing various disciplines in ICU.
A content validation survey included analysis of sufficiency, clarity, coherence, and relevance for items in the Perme ICU Physical Therapy Competency. For the quantitative analysis of content validity, the item-level content validity index (I-CVI) was used. Scale-level content validity index based on the universal agreement method (S-CVI/UA) was calculated as the proportion of items on the scale that achieve a relevance scale of 3 or 4 by all experts. Scale-level content validity index was calculated based on the average method (S-CVI/Ave).
The sufficiency, clarity, coherence, and relevance of the Perme ICU Physical Therapy Competency items presented S-CVI/Ave greater than 80 % (97 %, 97 %, 99 %, 95 %, respectively).
This study establishes that the Perme ICU Physical Therapy Competency has a satisfactory level of face and content validity.
The Perme ICU Physical Therapy Competency, with its solid framework, is a valuable assessment tool applicable for integration in any ICU competency program. It can be utilized as a self-assessment tool by individual therapists or in collaboration with mentors and evaluators to evaluate knowledge and skills effectively. This innovative tool not only enhances clinical practice but also presents an opportunity for advancing the physical therapy profession within the ICU setting.
Although growing evidence supports the safety and effectiveness of the ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of ...analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment), intensive care unit providers often struggle with how to reliably and consistently incorporate this interprofessional, evidence-based intervention into everyday clinical practice. Recently, the Society of Critical Care Medicine completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, nationwide, multicenter quality improvement initiative that formalized dissemination and implementation strategies and tracked key performance metrics to overcome barriers to ABCDEF bundle adoption. The purpose of this article is to discuss some of the most challenging implementation issues that Collaborative teams experienced, and to provide some practical advice from leading experts on ways to overcome these barriers.
Abstract Purpose The purpose of this study was to determine the interrater reliability of the Perme Intensive Care Unit Mobility Score. Materials and methods This was a prospective observational ...study. Data were collected from 20 patients admitted in a cardiovascular intensive care unit. The interrater reliability was tested using the intraclass correlation coefficient with 95% confidence interval and the Cohen κ coefficient of 0.9, using a 2-tailed α of .05 to provide a 90% power. Results The 15 items of the Perme ICU Mobility Score were individually analyzed. Interrater reliability (Cohen κ coefficient) for items 2, 3, 5, 6, 7, 8, 13, and 15 was 1.0000; for item 1, 0.8276; item 4, 0.8000; item 9, 0.6000; item 10, 0.7297; item 11, 0.7260; item 12, 0.7872; and item 14, 0.9048; the intraclass correlation coefficient (95% confidence interval) was 0.9880 (0.97743-0.99859). Conclusions The Perme ICU Mobility Score is a reliable tool to assess mobility status of patients admitted to the cardiovascular intensive care unit in a specific moment in time, which can be an important tool for research and clinical practice.
Early mobilization and aggressive physical therapy are essential in patients who receive left ventricular assist devices (LVADs) due to long-term, end-stage heart failure. Some of these patients ...remain ventilator dependent for quite some time after device implantation. We report our regimen of mobilization with the aid of a portable ventilator, in patients with cardiac cachexia and LVAD implantation. Further, we describe the specific physical therapy interventions used in an LVAD patient who required prolonged mechanical ventilation after device implantation. The patient was critically ill for 5 weeks before the surgery and was ventilator dependent for 48 days postoperatively. There were significant functional gains during the period of prolonged mechanical ventilation. The patient was able to walk up to 600 feet by the time he was weaned from the ventilator and transferred out of the intensive care unit. He underwent successful heart transplantation 6 weeks after being weaned from the ventilator We believe that improving the mobility of LVAD patients who require mechanical ventilation has the potential both to facilitate ventilator weaning and to improve the outcomes of transplantation.
BACKGROUND:Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health ...status which may last for months and years after hospital discharge.
OBJECTIVES:To report on a 2-day Society of Critical Care Medicine conference aimed at improving the long-term outcomes after critical illness for patients and their families.
PARTICIPANTS:Thirty-one invited stakeholders participated in the conference. Stakeholders represented key professional organizations and groups, predominantly from North America, which are involved in the care of intensive care survivors after hospital discharge.
DESIGN:Invited experts and Society of Critical Care Medicine members presented a summary of existing data regarding the potential long-term physical, cognitive and mental health problems after intensive care and the results from studies of postintensive care unit interventions to address these problems. Stakeholders provided reactions, perspectives, concerns and strategies aimed at improving care and mitigating these long-term health problems.
MEASUREMENTS AND MAIN RESULTS:Three major themes emerged from the conference regarding(1) raising awareness and education, (2) understanding and addressing barriers to practice, and (3) identifying research gaps and resources. Postintensive care syndrome was agreed upon as the recommended term to describe new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. The term could be applied to either a survivor or family member.
CONCLUSIONS:Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.
Purpose
The purpose of this study was to determine the minimal detectable change (MDC) and responsiveness of the Perme Score when used in the adult intensive care unit (ICU) population.
Methods
This ...is a prospective longitudinal study which was conducted from November 2016 to July 2017 in Cali, Colombia. Four physical therapists with observer and evaluator roles, applied the Perme Score upon ICU admission and discharge. The Consensus‐based Standards for the Selection of Health Measurement Instruments Protocol standards to analyze sensitivity to change were used. The sample size was defined considering the lowest concordance proportion reported (68.6%), and a Kappa Index of 0.2784 or higher to guarantee an adequate n, and a 95% reliability level.
Results
One hundred and forty‐two patients were enrolled in the study. There were 51.4% men with an average age of 58 ± 17 years. Invasive mechanical ventilation was employed in 42.0% of the patients. The MDC for the Perme Score was 1.36, and 80% of patients demonstrated higher or equal values, detecting a significant difference in the type of weaning and the length of stay in the ICU (p < 0.005).
Conclusions
The Perme Score has an MDC of 1.36 points and shows evidence of being sensitive to change. Therefore, the findings validate the responsiveness of the instrument.
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