Authors:10.1007... · Web viewRepresentatives of hospitals attending the January 2012 annual state QI meeting for improving ICU outcomes NR NR NR NR Balas 2014, United States [] Total,

ONLINE SUPPLEMENTARY MATERIAL

Title: Factors influencing physical activity and rehabilitation in survivors of critical illness: A systematic review

of quantitative and qualitative studies

Authors:

Selina M Parry, Laura D Knight, Bronwen Connolly, Claire Baldwin, Zudin Puthucheary, Peter Morris, Jessica

Mortimore, Nicholas Hart, Linda Denehy, Catherine L Granger

This online supplementary material includes the following:

1. Extended Methodology Text2. ETable 1 Search Strategy3. ETable 2: Characteristics of reviewed studies 4. ETable 3: Summary of Main Findings 5. ETable 4: Study aims and methodology6. Online supplementary reference list

1

ETable 1: Search strategy

Database Search fields Search termsMedlineCINAHLEMBASEScopusCochrane Library

Title, abstract, keywords, topic

1. “intensive care*” OR “critical care” OR “ICU” OR “crit* ill*” OR “sepsis” OR “MODS” OR “multi* organ dysfunction syndrome”2. “culture” OR “enabler*” OR “facilitat*” OR “determinant” OR “process evaluation” OR “implementation” OR “barrier*” OR "hinder*" OR "quality improvement" OR “quality assurance” OR “clinical outcomes” OR “focus group” OR “qualitative” OR “preference”3. “exercise” OR “physical function” OR “rehabilitation” OR “physical activity” OR “physiotherapy” OR “physical therapy”4. #1 and #2 and #3

Abbreviations: CINAHL, Cumulative Index to Nursing and Allied Health Literature; EMBASE, the Excerpta Medica Database.

4

ETable 2: Characteristics of reviewed studies

Qualitative studiesHealth Care Provider StudiesFirst author, year, country

n Staffing population Gender M:F Age, yrs mean ± SD Yrs of clinical experience mean

(range)

Yrs of ICU experience, mean

(range)Boehm 2016, USA [1]

Total n=16NS, n=10

Rehab staff, n=3Respiratory therapist, n=3

MDT working in SICU/MICU at one hospital who had employed 1 or more of the ABCDE bundle components at least twice in the prior month

2:14 NR NR NR

Parry 2016, Australia [2]

Total n=26

Medical, n=6NS, n=4PT, n=16

Medical, NS and PT working clinically in the ICU setting

7:19 28 [25-32] 5 [3=9]

Medical: 9 [7-18]NS: 12

PT: 4 [2-6]

3 [1-7]

Medical: 5 [1-15]NS: 11

PT: 3 [1-5]

Barber 2015, Australia [3]

Total n=25


Medical, NS and PT from a national quaternary hospital with an ICU

capacity of 45-beds

Medical: 11:1NS: 2:4PT: 1:6

Medical: 47 (range 32-65)NS: 35 (range 29-48)PT: 32 (range 22-42)

Medical: 23 (9-57)NS: 9 (3-12)PT: 8 (1-16)

Medical: 17 (4-33)NS: 7 (1-15)PT: 5 (1-14)

Eakin 2015, United States [4]

Total n=20

Medical, n=5Nursing, n=5

Rehab staff, n=7Other n=3

Staff involved in implementing and/or sustaining ER within MICU

8:12 <40, n=1340-60, n=4>60, n=3

≤5, n=36-10, n=411-20, n=9>20, n=4

≤5, n=106-10, n=411-20, n=2>20, n=4

Balas 2013, United States [5]

n=36 participants attended 3 focus group sessions, n=99 completed knowledge / impediment surveys and n=328 completed online education and evaluation

MDT team working in ICU (NS, Medical, PT, RT, Pharmacist, etc).

NR NR NR NR

4

Williams 2013, United Kingdom [6]

PT, n=6 PT qualified for > 1yr with recent experience of working on a general ICU

unit within a single hospital

0:6 NR Range 1-8 yrs Range 6mo-4 yrs

Bassett 2012, United States [7]

13 ICU teams, 8 hospitals (n NR) MDT team (medical, NS, PT, and RT) NR NR NR NR

Winkelman 2010, United States [8]

NS, n=33 NS providing direct care to a sub-sample of pts involved in larger study including a mobility intervention in several ICUs of an academic centre

4:29 32 (range 22-58) yrs NR 6 (range 0.1-25) yrs

Patient / Caregiver Qualitative StudiesFirst author, year, country

n Population eligibility Gender M:F Age yrs mean ± SD APACHE II scoremean ± SD

ICU LOS (days)mean ± SD

Czerwonka 2015, Canada [9]

ICU pts, n=5Caregivers, n=7

Participants of longitudinal ‘Towards RECOVER’ study; pts ≥16yrs and MV

≥7 days; and caregivers (≥18yrs) responsible for providing and/or coord

any assistance to survivor w/ofinancial compensation

3:21:6

No.≥50 yrs:n=4n=2

24 (range 17-30)17 (range 9-33) (for

family/caregiver)

24 (range 10-61) days

29 (range 10-64) days (for

family/caregiver)

Walker 2015, United Kingdom [10]

ICU pts, n=16 Participants enrolled into parallel RCT of a post ICU rehab programme

11:5 43±15 yrs 16.0±7.3 17 (range 11-26) days

Deacon 2012, United Kingdom [11]

ICU pts, n=35 (65% response rate) Respondents to questionnaire who accessed via a link advertised on the

websites of 2 pt support groups based in UK and US

5:30 48±10 (range 22-70) yrs NR 36±28 days

4

Lee 2009, Canada [12]

ICU pts, n=25 Pts from Toronto ARDS survivor cohort involving clinical FU at 3mo

post ICU DC, then 6mo intervals for 5 yrs: ≥16yrs; PaO2/FiO2 ratio <200; 4

quadrant opacity CXR changes; 1 risk factor for ARDs; excl if immobile

before ICU adm; documented psychiatric or neuro disease; Hx of

pulmonary resection.

14:11 Median 48 (IQR NR) Median 24 (IQR NR) Median 28 (IQR NR)

5

Quantitative studiesHealth Care Providers Quantitative StudiesFirst author, year, country

n Staffing population Gender M:F Age yrs mean ± SD Yrs of clinical experience mean (range)

Yrs of ICU experience, mean (range)

Bakhru 2016, USA*[13]

MDT, n=951 out of 1484 (64% response rate)

Nurse leaders in ICU centres in USA and nurse leaders or physiotherapists in European countries (single respondent per ICU and/or hospital allowed)

ICU leaders responding were – NS: 88%; physician: 2% and physiotherapist: 11%

NR NR NR NR

Koo 2016, Canada [14] MDT, n=311 out of 436 (71% response rate)

Medical, n=194 out of 302 (64% response rate) and PT, n=117 out of 134 (87% response rate)

Physicians and physiotherapists working in an academic ICU in Canada

NR NR <5 yrs: n=90 (28%)5-20 yrs: n=160 (51%)>20 yrs: n=61 (20%)

NR

Bakhru 2015, United States [15]*

NS, n=500 respondents from 687 contacted (73% response rate)

Targeted ICU NS leaders (NUM or directors and ICU nurse specialists); completed in 99% of cases by this staff member, profile of remaining 1% of respondents NR

NR NR NR NR

Holdsworth 2015, Australia [16]

22 MDT respondents from 123 contacts (18% response rate)

MDT at one tertiary hospital in Australia

NR NR NR NR

Jolley 2015, United States (hospital level factors) [17]

NS, n=47 respondents out of 54 contacts (87% response rate)

NUMs ID for participation from acute care hospitals in one state in US excl those not providing MV

NR NR NR NR

6

Malone 2015, United States [18]

PT, n=667 respondents out of 2320 contacts (29% response rate)

PT members of the Acute Care Section of the APTA

NR NR NR NR

Messer 2015, United States [19]

NS, n=41 NS working in ICU at time education sessions were delivered

9:32 < 25yrs = 126-40yrs = 2441-55yrs = 10≥56yrs = 6

<5yrs = 75-10yrs = 1711-20yrs = 6>20yrs = 11

<5yrs = 155-10yrs = 1411-20yrs = 3>20yrs = 9

Miller 2015, United States [20]

Total, n=212 respondents out of 278 contacts (76% response rate)

Medical , n=13NS, n=142Rehab staff, n=17Other, n=40

Representatives of hospitals attending the January 2012 annual state QI meeting for improving ICU outcomes

NR NR NR NR


Total, n=328

Medical, n=26NS, n=224Rehab, n=72Pharmacist, n=5Physician assistant n=1

All full- and part-time members of the MDT ICU teams in 5 adult ICUs, a medical/surgical step-down unit, and a haematology/oncology special care unit in a large regional academic medical centre

NR NR NR NR

Connolly 2014, United Kingdom [22]

PTs, n=182 respondents out of 240 contacts (76% response rate)

Senior ICU PTs at all adult ICUs across the UK

NR NR NR NR

7

Jolley 2014, United States (Medical perceptions) [23]

Total, n=120

Medical: n=91 respondents out of 111 contacts (82% response rate)

NS: n=17 respondents out of 78 contacts (22% response rate)

PT: n=12 respondents out of 14 contacts (86% response rate)

Targeted medical, NS and PT staff at a large, urban, academic MICU

NR NR NR NR

Palmeiri 2012, United States [24]

PTPre: 20Post: 12

MDTPre: 22Post: 31

All acute care PT and other health care team members who work with patients requiring MV in ICU

NR NR NR NR

Appleton 2011, Scotland [25]

96% of lead clinicians; 100% of lead PT

Lead clinicians and PT for the 23 general adult ICUs in Scotland

NR NR NR NR

Hodgin 2009, United States [26]

PT, n=482 (50% response rate)

PTs who were members of Acute Care Section of APTA

NR NR NR NR

Skinner 2008, Australia [27]

PT, n=126 respondents out of 167 (75% response rate); 111 evaluable response

PT from each adult ICU across Australia and listed in the ANZICs database

NR NR NR <1 yr, n=9 (8%)1-2, n=12 (11%)2-5, n=31 (28%)>5, n=54 (49%)Unspecified, n=5 (5%)

8

Lewis 2003, United Kingdom [28]

PT, n=29 responses out of 36 contacts (80.5%)

PT at teaching hospitals and large district general hospitals listed within the UK from Directory of Surgery which either had specialist or large general ICUs

NR NR NR NR

King 1998, Canada [29] Total, n=114


PT from all hospitals with ICUs ≥10beds as listed in national Hospital Directory; sub-group of hospitals, ICU NS and physician added

NR NR Medical: 19.8±8.1 (range 6-32) yrsNS: 13.9±6.4 (range 5-22) yrsPT: 13±9 (range .25-38) yrs

Medical: 11±6 (range 4-25) yrsNS: 10±6(range 3-22) yrsPT: 6±5 (range .25-21) yrs

9

Patient / Family Quantitative StudiesFirst author, year, country

n Population eligibility Gender M:F Age yrs mean ± SD APACHE II scoremean ± SD

ICU LOS (days)mean ± SD

Hickmann 2016, Belgium [30]

ICU pts, n=171 Consecutive patients admitted to ICU 98: 73 Mobilized: 59±17Never mobilized: 62±17

Mobilized: 17±7Never mobilized: 22±9

Mobilized: 6±12Never mobilized: 1±2

McWilliams 2016, United Kingdom [31]

ICU pts, n=63Intervention n=32Control n=31

Consecutive pts from trauma, neurosciences and general ICU in single centre MV≥5 days

21:1020:12

50±1649±18

13±516±7

17 [14-21]15 [13-18]

Ramsay 2016, United Kingdom[90]

ICU pts, n=22Intervention, n=10Usual care, n=12

N=22 participated in comparative focus group within a RCT for ICU pts 5:5

8:455 [36-69]70 [63-78]

18 [15-21]23 [17-26]

7 [5-10]12 [4-16]

Reames 2016, United States [32]

Pre: n=79Post (2months): n=55Post (12-months): n=50

US based progressive care unit for chronically critically ill individuals

NR NR NR NR

Schaller 2016, Austria/Germany/USA [33]

ICU pts, n=200 SICU pts aged 18 and above, MV<48hrs and expected to require MV for ≥ 24 hrs at time of screening

126:74 65 [46-74] 16 [12-22] Intervention: 7 [5-12]Control: 10 [6-15]

Sigler 2016, USA [34] ICU pts, n=32 ICU pts admitted to MICU 17:15 55±17 NR NR

Toonstra 2016, USA [35] ICU pts, n=57 received PT during CRRT

ICU pts admitted to MICU over 13-month period

32:25 55 [49-64] 30 [23=36] 13 [7-22]

Wahab 2016, United States [36]

Pre: 3945Post: 4200

All ICU adm across 5 hospitals over 2 yrs

2152:18032370:1830

63±1763±18

NR 6±85±7


n=5 organisations Participating organisations in IHI-RCC NR NR NR NR

Berney 2015, Australia [38]

ICU pts, n=41 MV ≥48 hrs and expected to remain in ICU for a further 24 hrs

22:20 62±16 22±6 At time of observation:9 [6-16]

Overall:21 [13-35]

10

Castro 2015, United States [39]

n=37/56 responses at 2 weeks pre implementation

n=34/56 responses at 6mo post implementation

n=36/56 responses at 1yr post implementation

NS working on the SICU NR NR NR NR


ICU pts, n=41RCT: 20Cohort: 21

Adult ≥18yrs ICU patients MV≥48-hrs, survival to hospital DC, sufficient mobility to participate in rehab after DC, presence of ICUAW (for RCT) on ICU DC, no ICUAW on ICU DC (cohort)

C 3:7I 3:7Pooled 6:14Cohort 16:5

C 69 [64-78]I 63 [47-72]

67 [55-73] yrs pooled RCT cohort

63 [50-70] yrs observational cohort

C 24 [21-30] I 25 [19-30]

24 [20-30] pooled RCT cohort

17 [13-20] observational cohort

C 13 [10-21]I 15 [7-18]

14 [9-19] days pooled RCT cohort

10 [7-27] days observational cohort

Dafoe 2015, Australia (staff perceptions)[41]

Dafoe 2016, Australia (overcoming barriers) [42]

Part 1: 207Part 2: 200

Survey total, n=93Medical, n=10NS, n=79PT, n=4

All pts admitted to ICU. No excl criteria.

All permanent / semi-permanent staff working in the ICU (across all disciplines).

148:59144:56

NR

59 ± 1758 ± 17

NR

18± 716 ± 7

NR

3 [2-6]3 [1-5]

ICU experience in RAH ICU< 1 yr, n=31-5 yrs, n=38>5 yrs, n=52

Duncan 2015, Canada [43]

PRE= 1 PT to cover weekends

POST= 3 PT’s to cover weekends

*Only data for ICU patients included in data reported here

Pre: 165

Post:737

Survey: 17

Quant. – All adult patients admitted to ICUs and medical/surgical wards referred for weekend PT.

Qual. – Full/part time PT’s who worked weekdays in 2013 and had worked at least one weekend in pre/post study period

114:51

428:307

3:14

59±18

60±6

NR

NR

NR

Years ICU Exp NR

NR

NR

Clinical Exp:<6 yrs (n =4)>6 yrs (n=13)

11

Engel 2015, United States [44]

ICU pts, n=382 Pts > 48 hrs ICU adm and received PT over 6 mo period in MICU/SICU

NR 64 [55-74] 19 [13-25] NR

Fraser 2015, United States [45]

ICU pts, n= 132 Adults adm to ICU 66:66 65±16 21±7 NR

Harrold 2015, Australia and Scotland [46]

Australia: ICU pts, n=347Scotland: ICU pts, n=171

Adults > 18 yrs adm to ICU for MV 212:13597:70

56±1856±17

18±818±7

3 [1-6]4 [2-8]

Hodgson 2015, Australia and New Zealand [47]

ICU pts, n=192 Adults MV>24 hrs, expected stay MV for additional ≥48hrs

117:75 58±16 19±8 11 [6-17]

Knott 2015, United Kingdom [48]

ICU pts, n=35 In ICU > 48 hrs 19:16 52 [51-66] 23±5 5 [3-8]


Pre QI ICU pts, n=290Post QI: ICU pts, n=292

Adults MV≥5 days 173:117181:111

58 [45-69]55 [44-67]

16[13-20]18[13-23]

17±1514±14

Pandullo 2015, United States [50]

ICU pts, n=182 Adults adm ICU > 48 hrs ≥18yrs old 99:83 65[53-75] NR 4[3-6]

Sottile 2015, United States [51]

ICU pts: n=55 respondents out of 65 contacts (85% response rate)

Family n=49

ICU patients MV≥4 days (enrolled in rehab RCT)

Family members (regardless of whether they had observed a PT session)

33:22 (patients)

8: 41 (family members)

52±16 17±7 15 [9-23]days

Tadyanemhandu 2015, Zimbabwe [52]

ICU pts, n=137 All consecutive adult pts admitted into the 5 main ICUs in the study region during a 2mo period (including deaths)

57:80 36±17 (range 18-83) NR for overall sample

NR for overall sample

Abrams 2014, United States [53]

ICU pts, n=35 Pts receiving ECMO in the MICU 15:20 45±19 24±8 NR

Brummel 2014, United States [54]

ICU pts, n=87C:22PT:22Cog+PT:43

Adults ≥18yrs Rx for ARF and/or septic, cardiogenic or haemorrhagic shock, and within 72 hrs critical illness

C: 8:14PT: 13:9Cog+PT: 28:15

C: 60 [51-59]PT: 62 [48-67]Cog+PT: 62 [54-69]

C: 27 [18-31]PT: 22 [20-29]Cog+PT: 25 [20-30]

NR

12

Dinglas 2014, United States[55]

ICU pts, n=243Pre 120Post 123

Dx of ALI with MV ≥5 days 116:12763:5753:70

49[40-59]48 [40, 57]51 [37, 63]

29 [24-35]29 [23-36]29 [25-35]

NR

Harris 2014, United States [56]

ICU pts, n=21

Survey: 32

ICU stay > 3 days who participated in PT in the ICU over 12-mo period

MDT team (RT and NS)

10:11

NR

60±15

NR

NR

NR

9 [5-18]

NRJolley 2014, United States (factors) [57]

ICU pts, n=175 Adults MV ≥14 days for ARF 115:60 50±19 NR 24 [20-33]

Nydahl 2014, Germany [58]

116 ICUs with n=783 ICU pts

n=54 (47%) university hospitals

n=38 (32%) MICU/SICUs

ICUs within an acute care hospital providing care for MV adults, excluding rehab centres

NR NR NR NR

Roberts 2014, United States [59]

ICU pts, n=71 Adults ≥ 18 yrs in ICU 45:26 Female: 66.0±19.76Male:68.62±12.43

NR NR

Wang 2014, Australia [60]

ICU pts, n=33 Adm to ICU and required insertion of a vascular catheter for CRRT

22:11 64±15 26± 7 15± 10

Berney 2013, Australia and New Zealand [61]

ICU pts, n=514, 38 ICUs Adults (≥16years) adm to the ICU at a 10am census point

NR 59±17 <10, n=53 (11%)10-20, n=232 (48%)21-20, n=149 (31%)≥30, n=46 (10%)

<2, n=177 (42%)2-7, n=106 (25%)>7 n=136 (32%)

Carrothers 2013, United States [62]

4 hospital ICUs81 staff (survey)

Participating regional hospitals in a Clinical Impact Interest Group

NR NR NR NR

Damluji 2013, United States [63]

ICU pts, n=101 Adults adm to ICU who received any PT intervention with a femoral catheter in situ over 17-mo period

41:60 55 [46-68] NR 4 [3-8]

13

Dammeyer 2013, United States [64]

Pre pilot: 314

Early Mobility Pilot: 381

Education: 425

ABCDE program: 388

Adults MV in ICU.

NR NR NR 9

7

6

6

*Reported as averagesDavis 2013, United States [65]

ICU pts, n=15 Adults > 65 yrs, MV>48 hrs and anticipated to remain MV for further 24 hrs

8:7 75±776±8

23±724±4

NR

Dinglas 2013, United States [66]

ICU pts, n=514 MV pts with ALI 286:228 52 [42-63] 26 [20-33] NR

Drolet 2013, United States [67]

Pre, ICU pts n=193Post, ICU pts n=426

Adults >18 yrs adm to ICU > 72 hrs 112:81222:204

67±1664±17

NR NR


ICU pts,Pre QI: n=179Post QI: n=294

Mixed SICU/MICU – pts receiving PT Pre QI: 99: 80Post QI: 149: 145

Pre QI: 64±15

Post QI: 62±17

NR NR

Hanekom 2013, South Africa [69]

ICU pts, n=193 Adults > 16 yrs adm to SICU over 3 mo period

I: 59:37C: 60:37

I: 52±19C: 50±18

I: 18±27C: 16±23

NR

Mah 2013, United States [70]

ICU pts, n=59 Pts adm to ICU for MV and passed safety mobility protocol

I: 13:15

C: 21:10

I: 66±17

C: 62±17

I: 27±5

C: 26±5

I: 18 [8-44]

C: 22 [9-37]Mendez-Tellez 2013, United States [71]

ICU pts, n=503 MV adults >18yrs in ICU with Dx of ALI

279:224 52[42-63] 21[16-28] NR

Talley 2013, United States [72]

ICU pts, n=109 Adults in MICU/SICU undergoing ER with CRRT > 48 hrs

NR NR NR NR

14

Perme 2013, United States [73]

ICU pts, n=77 Adults > 18 yrs adm to ICU with at least one femoral catheter in situ and able to follow commands (excl femoral sheath)

41:36 59±17 NR 21±20


ICU pts, n=74 Adults > 18 yrs adm to ICU > 5 days 51:23 61±16 19±6 8 [6-11]

Leditschke 2012, Australia [75]

ICU pts, n=106 Adults > 18 yrs adm to MICU/SICU over 1 mo period

70:36 60±20 15±8 1 (range 1-198)

Garzon-Serrano 2011, United States [76]

ICU pts, n=63

(NS performed 131 Ax, and PT 48 Ax, demographics reported for pts based on discipline who Ax suitability to mobilise)

Adults > 18 yrs adm to SICU

.

42:21 58±15 NS group: 9±8PT group: 12±12

NR


ICU pts, n=30 Adults >18yrs who received PT and had a femoral arterial catheter

18:12 65± 12 NR NR

Hildredth 2010, United States [78]

ICU pts, n=100(2 groups of n=50 each)

Patients adm to SICU who were not MV, or MV with a trache in situ >24hrs.

23:27

26:27

60±1650± 11

NR 7±11

5± 6

Needham 2010, United States (early physical) [79]

Needham 2010, United States (rehab) [80]*same pt group*

Pre QI: 27Post QI: 30

MV > 4 days 8:199:21

50 [43-59]53 [43-69]

26 [21-29]27 [21-32]

75

Pohlman 2010, United States (interventional arm of Schweickert 2009*) [81]

ICU pts, n=49 Adults ≥18 yrs, <72hrs MV expected to have >24hrs MV, baseline functional independence

20:29 58 [36-69] 20[16-24] 5.9[5-13]

15

Zanni 2010, United States [82]

ICU pts, n=32 Adults MV > 4 days 12:20 49[42-57] 27[21-30] NR

Schweickert 2009, United States [83]

ICU pts, n=104 Adults ≥ 18 yrs, <72hrs MV expected to have >24hrs MV, baseline functional independence

I: 20:29

C: 22:23

I: 58 [36-69]

C: 54 [47-66]

I: 20 [16-24]

C: 19 [13-23]

I: 6 [5-13]

C: 8 [6-13]


ICU pts, n=65 Adults adm to ICU who stayed for >48hrs

39:26 60 (range 21-83) 17 (range 3-37) Mobilised:Median 4 (range 2-18)Not mobilised: 9(range 3-29)Not app to mobilise: median 16.5 (range 5-86)

Morris 2008, United States [85]

ICU pts, n=330 Adults > 18 yrs, MV> 48 hrs I: 88:77

C: 93:72

I: 55±17C: 54±17

I: 22± 8

C: 24±9

I: 8 (CI:7-9)

C: 8 (CI: 7-9)

Thomsen 2008, United States [86]

ICU pts, n=104 Patients with ARF MV > 4 days, hospitalised for > 2 days before RICU TF

48:56 58± 18 18 (SD NR) 26± 14

Bailey 2007, United States[87]

Hopkins 2007, United States [88]*same pt group*

ICU pts, n=103

N NR, however examined a total of 1449 activity events

ARF MV>4 days requiring TF to RICU

Pts with ARF in the RICU

59:44

NR

63±16

NR

ICU adm: 21±6RICU adm:17±5

NR

23±16

NR

Abbreviations: adm, admitted; ALI, acute lung injury; ANZIC, Australian and New Zealand Intensive Care Society; APACHE II, Acute Physiology and Chronic health evaluation 2; app, appropriate; APTA, American Physical Therapy Association; ARDS, Acute respiratory distress syndrome; ARF, acute respiratory failure; C, control; Cog;

16

cognitive; CRRT, continuous renal replacement therapy; CXR, chest x-ray; DC, discharge; Dx, diagnosis; ECMO, extracorporeal membrane oxygenation; ER, early rehabilitation; excl, excluding; F, female; FiO2; fraction of inspired oxygenation; FU, follow-up; hrs, hours; Hx, history; I, intervention; ICU, intensive care unit; ICUAW, intensive care unit acquired weakness; ID, identified; IQR, interquartile range; LOS, length of stay; M, male; MDT, multidisciplinary team; MICU, medical intensive care unit; mo, months; MV, mechanical ventilation; n, number; neuro, neurological; NUM, nurse unit manager; NR, not reported; NS, nursing; PaO2; partial pressure of oxygen; pts, patients; PT, physiotherapist; QI, quality improvement; Quant, Quantitative; Qual, Qualitative; RAH, Royal Adelaide Hospital; RCT, randomized controlled trial; rehab, rehabilitation; RICU, respiratory intensive care unit; RT, respiratory therapist; Rx, treatment; SD, standard deviation; SICU, surgical intensive care unit; TF, transfer; trache, tracheostomy; UK, United Kingdom; US, United States; w/o, without; yrs, years; >, greater than; <, less than; %, percentage.

17

ETable 3: Summary of findings in relation to the themes identified

Themes Description References of primary studies1. Patient physical and psychological influencesAdmitting diagnosis

- Admitting diagnosis not associated with PA (+/-)- Poor prognosis / withdrawal of care

- [8]- [2, 30]

Severity of illness - Severity of illness as a general concept (including MV, resp support, coma and opioids) (+/-)- Reports of both + and - associations between timing of rehab commencement and ability to do PA (+/-)- NS concerns about severity of illness and safety (-)

- [25, 55, 66, 71, 87]- [55, 66, 71, 84, 86]- [56]

Age - Age not associated with commencement or receipt of early rehab in ICU (+/-)- Younger age associated with receipt of rehab in ICU (-)

- [44, 84, 87]- [71]

Comorbidity - Weight is not a barrier (+)- Weight is a barrier (-)- Reports that higher comorbidity is both a barrier and does not influence time to ambulation (+/-)- Being non-ambulant prior to ICU associated with receipt of rehab in ICU (+)

- [81]- [1, 13-15, 39, 41, 58, 81]- [68, 87]- [57]

Symptoms - Pain, discomfort, fatigue, patient refusal, declined consent, ltd co-op (-)

- Thorough pain Ax and Mx prior to PA (+)

- [25, 39, 41, 46, 48, 58, 64, 74, 80, 81, 85] [13, 30]

- [80]Strength - Weakness (-) - [47, 58, 61]Sedation, delirium and cooperation

- Sedation (-)

- Sedation more common barrier in presence of ETT (compared to tracheostomy) (-)- Sedation Mx, optimisation of pain relief and screening for delirium/and minimise use of drugs for delirium (+)

- Agitation, delirium, inadequate pain relief (-)

- Consciousness and awakening (+/-)- Pt/family refusal, anxiety, co-op, fear / lack of confidence, low pt motivation, lack of understanding of ICUAW (-)- Gaining patient trust, addressing concerns, reassurance, patient motivation and goal setting, encouraging indep in

ADLs to facilitate adherence (+)- Involve patients families (+)- Sleep (+)

- [2, 3, 8, 13, 14, 17, 23, 34, 35, 37, 39, 41, 42, 46-48, 52, 55-58, 61, 65, 68, 71, 74, 80, 82, 84, 87]

- [58]- [4, 15, 20, 34, 37, 80, 86, 88]- [14, 23, 37, 41, 47, 61, 64, 68, 74, 75,

80, 81]- [6, 20, 38, 41, 42, 61, 75]- [2, 6, 8, 46, 54, 74, 81]- [2, 6]

- [3]- [88]

Neurological impairment

- Neurological /cognitive impairment (-) - [14, 16, 46, 75]

2. Safety influences

4

Physiological stability

- General physiological instability or medical status (-)- Haemodynamic instability (-)- Resp instability, distress or insufficient reserve (-)- FiO2 did not impact of patients’ ability to participate in activity, except at high levels (+/-)- Good oxygenation reserve (+)- Ventilator dysynchrony(-)- Active bleeding (-)- Open abdomen (-)- Orthopaedic orders (-)- Medical contraindication (-)- Development of physiological stability guidelines; ability to mob majority within a priori defined criteria (+)

- [1, 2, 8, 13, 14, 16, 29, 30, 35, 46, 48, 54, 64, 74, 75, 80, 87]

- [30, 39, 41, 42, 47, 52, 58, 61, 68, 76, 80, 81, 85]

- [8, 41, 46, 47, 61, 65, 81] [30]- [38, 87] [30]- [8, 30]- [81]- [46, 81]- [1, 30, 48]- [14, 46]- [55]- [68, 80, 83]

Lines - Staff concerns about line safety (-)

- Presence of unnecessary lines and location choice of lines limits mob (-)- Ensure devices are secured and untangling of lines (+)- PAC: barrier in MV patients and less likely to be TF to chair (-)- Arterial line: not barrier to TF to chair (+/-)- Renal replacement therapy (-)- Vascath presence or location for CRRT : mob not associated with adverse events (+/-)- Femoral catheters: mob not associated with adverse events (+/-)- Continuous haemodialysis (+/-)- ECMO:- mobilisation no adverse events (+/-)

- [8, 29, 39, 41, 48, 56, 68, 80] [1, 2, 14]- [3]- [80]- [29, 58]- [29]- [38, 76, 81]- [35, 60, 72]- [47, 63, 73, 75, 77]- [46, 66, 72]- [53]

Mobilisation of MV pts with ETT

- Presence of ETT perceived / actual barrier (-)- ETT not a barrier to transferring to chair or mobilising (+/-)- Trache to SOOB for MV patients (+)- Barriers of mob MV pts: physiological instability, lack of buy in from MD/NS, resources, equipment, staffing, time,

lack of trained/skilled staff, sedation, delirium, agitation, femoral line, patient safety, medical complications, risk of staff injury, work stress, risk of line/tube/device dislodge/disconnection (-)

- Enablers to mob of MV pts: staffing, team work, cooperation and flexibility, engagement from MDT, whole team approach, haemodynamic stability, patient awake and co-op (+)

- [3, 14, 16, 27, 38, 46-48, 61]- [23, 29, 38, 61, 87]- [38]- [16, 23, 58, 75]

- [16, 23]

Safety of patients, caregivers and clinicians

- Staff concerns of patient safety (-)- Staff concerns for risk of airway dislodgement (-)- Staff concerns of patient falling (-)- Caregiver safety (-)

- [4, 7, 13, 15, 16, 23, 68, 80, 85]- [41]- [8, 68]- [13, 15]

19

- Risk of staff injury (musculoskeletal / work stress) for mob MV pts (-)- Safety concerns less significant over time as staff experience benefits of PA (+)

- [23, 41]- [4]

3. Clinician and team influencesCulture - Culture and tradition (-)

- Staff attitude, lack of trust, resistance to change, morale, lack of interprofessional respect (-)- Lack of team work (-)- Teamwork facilitated rehabilitation (+)- Culture change including gaining buy-in from clinicians, develop new team of NS/staff to establish new culture of

team work, use of team-building meetings, improve team work, cross discipline training to increase flexibility and team work, collaboration of MDT, cultural shift over time, staff need to believe it is beneficial (+)

- Visible mobility goal targets for unit to show progress (+)- Perception rest = healing (-)- To secure buy in emphasise evidence and safety and collect/sharing of performance data (+)- Overcoming family perceptions that loved ones are too sick for rehab (+)- Barriers to lack of mob not identified (-)- Senior staff perceived to be more supportive of rehabilitation compared to junior staff (hypothesised related to

knowledge and expertise/confidence)

- [2, 3, 13, 15, 41, 68]- [39, 62, 64]- [64]- [1, 13, 30]- [4, 32, 41, 62, 85, 88, 89]

- [88]- [7]- [7]- [2, 7]- [38, 46, 58]- [2]

Communication - Lack of MDT communication, coordination and goal setting (-)- Need for MD orders (-)- Communication, cooperation and team work of MDT (+)- Presence of MD orders, liaison with other medical teams (+)- Daily ward rounds (discuss mobility) or rounding checklist (+)- Documentation or documented daily goals for patient (+)- Planning and prompts (+)- Continuous feedback to team about outcome data (+)- Weekly team meetings (review treatment goals/ patient goals, coordinate group schedules); feedback on patient

outcomes from rehab; team planning for patient daily goals (+)- Difficulty for patient to communicate while on MV leads to frustration and anxiety and poor adherence (-)- SP tools to facilitate communication with pts who are MV (+)

- [3, 5, 13, 14, 32, 41, 42, 62, 64, 68]- [29]- [2, 4, 6, 7, 37, 41, 42]- [3, 8]- [5, 15, 39, 42, 62]- [15, 62]- [62]- [32, 37, 39]- [3, 4]

- [6]- [6]

Leadership - Lack of leadership and champion of mobility (-)- Designation of overall leader and individual discipline champions (+)- Engagement of implementation leaders/champions and leadership support (+)- Inconsistent support from MDs leading to mixed messages (-)- Senior MDT leadership for rehab (+)

- [2, 14, 41, 42, 64, 80, 88]- [1-4, 7, 8, 37, 41, 68, 80]- [5, 62]- [7]- [3]

Expertise and - Lack of knowledge, training and confidence to provide PA interventions (-) - [1, 2, 5, 13, 14, 18, 37, 39, 42, 62, 68,

20

training - Education (+)- Lack of MD understanding of mob and evidence rarely a barrier (+/-)- Profession (level of mob achieved was higher with PTs than NS) (+)- Staff profile not associated with patients who sat OOB (+/-)- Site visits to establish programs, benchmarking against other programs, partner with a successful hospital (+)- Limited staff training for safety, manual handling, equipment use and patient specific precautions/limitations (-)- Need for mob champion for 1:1 and small group teaching and learning, emphasis positive outcomes rather than

policing rules (+)

80, 85]- [2-5, 19, 32, 41, 42, 62, 68, 80, 88]- [23]- [76]- [37, 68, 80]- [8]- [1, 75]- [7]

Role clarity and accountability

- Lack of role delineation, or belief that mobility is role of single profession (-)- Lack of understanding of role of different disciplines especially physiotherapy in EM (-)- Clarification of MDT roles to champion mob sessions (+)- Lack of accountability, for example (MDs write order for mob on chart but not carried through /F/U) (-)- All staff believed mob could not be carried out by one discipline (-)- MD to follow up if mob orders have been performed (+)- PTs identified PT to be key member of team to facilitate I/P rehab (+)- Importance of MDT (+)

- [41, 64]- [1]- [32, 68]- [3, 62]- [32]- [3]- [7]- [1, 4]

4. Motivation and beliefsClinicians’ anticipated impact or experiences of PA

- PA associated with improved pt outcomes (physical/psych), ICU and hosp LOS, and staff satisfaction (+)

- Limited or conflicting evidence/opinions in support of PA or ABCDE bundle benefits, lack of perceived importance when balanced with risks, lack of awareness of longer term impact, staff skepticism (-)

- [2, 4, 6, 16, 23, 27, 29, 56]

- [1, 2, 5, 14, 16, 18, 23, 25, 68, 88]

Patient experiences of PA

- PA was beneficial, enjoyable and satisfying (although of mod difficulty/exertion); desire to cont post hosp DC (+)- levels of enjoyment and difficulty for patients needing prolonged MV; education delivered as O/P not specific to

needs; limited recollection of ICU care (-)

- [9-11, 40, 51]- [9, 12, 16, 40, 51]

Family experiences of PA

- PA was beneficial and necessary (+)- Can be disapproving of mobilising MV patients, perceived discomfort for patients (-)

- [51]- [16, 51]

5. Environment and structural influencesAccess to services - Lack of funding in ICU and post-ICU settings (-)

- Lack of access and referral for PT in the ICU (-)- MD order needed to initiate PT/OT consultation in ICU (-)- Lack of dedicated space for EM in ICU setting (-)- Lack of dedicated rehab space for O/P program (-)- Lack of patient numbers to justify O/P program (-)- Automatic referral pathways for rehab/early mob, systems for prompting referral, removal of bed-rest orders,

- [13, 25, 40, 88]- [14, 18, 39, 52, 64, 68, 80, 85]- [1, 7, 14]- [1, 14]- [40]- [40]- [3, 7, 23, 34, 64, 68, 80, 85]

21

daily mob standard care (opt-out) (+)- Possible to improve outcomes by restructure and care protocols without additional funding

Views from patients:- rehab was a key need from transfer from ICU to general ward but transition was emotionally challenging (+)- rehab and physiotherapy seen as valuable to the recovery process (+_- Concerns with late onset of rehab as I/P on general ward (-)- Concerns regarding lack of staffing / resource constraints and perceived impact on recovery (-)- Want to know what they should / shouldn’t do to facilitate recovery, desire to continue rehab after hosp D/C and

return to doing ADLs, desire for more practical information on ways to access services in community (+)- Experienced delays in receiving O/P rehab in transition from hosp to home; had to fight to access services such as

PT post D/C, unhappy about having to be so pro-active when it is something that should be provided (-)- Preferences for rehab after hosp D/C: bright, cheerful atmosphere, music, guidance on what do to outside of

therapy, knowledgeable staff for ICU issues, info and education on what happened to them and what to expect after critical illness (what is normal recovery), Ax/Rx for physical and psych problems; longer duration O/P rehab programs (+)

- Highly valued tailoring of timing and delivery of physiotherapy according to individual abilities, needs and preferences, and felt more engaged in process (+)

- Explanation, support and encouragement to perform exercises unsupervised were highly valued (+)- Valued continuity of care and consistency of care provided (+)- Preference for inclusion of UL exercise, individualised targets, and incorporation into wards (+)- Preference for group ex instead of HEP to enhance motivation, provide structure/routine and social benefits (+)- Need to educate caregiver and HCPs outside of the ICU regarding recovery times (+)- Member of health care team to co-ord rehab process and access to a person such as ICU NS to call if needed to

discuss rehab (+)

- [88]

- [12]- [90]- [9]- [90]- [12]

- [10]- [10, 11]- [10]

[90]

[90]- [90]- [10]- [10]- [11]

Hospital administration

- Limited enthusiasm for change by hospital administrators (-)- Constrained hospital budget / EM considered to be too expensive (-)- O/P rehab program not considered required service at managerial level (-)- Need administrator support (hosp leadership) and funding for staff, resources and to support protocol changes (+)- Illustrate cost saving benefit to obtained sustained hosp funding (+)- Business case based on literature (+)- Hosp review of safety and adverse event statistics (+)

- [88]- [4, 13, 14]- [22]- [3, 4]- [4]- [37]- [68]

Location of patients

- Trauma ICU associated with time to OT intervention (vs MICU) (+)- T/F to RICU prob of amb (+)- Move patients to a unit where activity is proactive (+)- T/F to acute ward setting from ICU delay to regaining mob, or barrier to mobility session (-)

- [66]- [86]- [88]- [41, 46, 50]

22

- Change to permit PTs to continue to see patients if T/F to ICU (+)- Large volume hosp ICU, academic hospital/ICU, ACPs in ICU (+)- Patients more likely to receive PT in community rather than uni hospital (+/-)

- [56]- [57]- [26]

Equipment and resources

- Inadequate equipment and lack of resources (-)

- Adequate dedicated equipment and resources for rehab (+)- Lack of specialised equipment should not be a barrier and a minimum of equipment is sufficient (+)- Available equipment not associated with in-bed or OOB activities by NS (+/-)- Platform or lifting devices an enabler for OOB activities (+)- Sara Combiliser equipment an enabler for OOB activities and EM (+)- More equipment could allow patients to be active outside of therapy and involve caregivers

- [1-3, 7, 13-15, 18, 25, 37, 39, 41, 42, 46, 48, 53, 62, 68, 80, 85]

- [3, 4, 6, 41, 42, 68, 80]- [4]- [8]- [58, 59]- [31]- [6]

Staffing - Lack of staffing in particular physiotherapists (-)

- Workload and documentation burden barrier to ABCDE implementation (-)- Workload and time management (-)- Lack of dedicated rehab staff particularly PTs/OTs or skilled staff (-)- Dedicated rehab staff (+)- Coordination of schedules due to multiple providers of early rehab- Staffing not related to in bed or OOB activities by NS, patients mob away from bed without NS assist (+/-)- staffing is an enabler (+)- Lack of dedicated staff or permanent full time staff (-)- Presence of dedicated PT/OT (+)- assistance from PT returning patient to bed as enabler (+)

- [1-3, 13, 14, 17, 18, 22-25, 30, 32, 35, 39, 41, 42, 56, 80, 84, 85]

- [5]- [4, 7]- [1, 3, 4]- [4]- [8, 38]- [41, 80]- [42, 43]- [15, 28, 62, 68, 82]- [15, 56, 62, 64]- [41]

Time and competing priorities

- Time constraints (-)- Lower prioritisation/competing priorities (especially by NS and medical staff) (-)- Higher prioritisation by NS associated with OOB activities (+)- Scheduling conflicts (-)- Procedures and investigations (-)- Prioritisation of mob by MDT and plan schedules to fit rehab into care (+)- Dedicated time (+)

- [1, 2, 15, 23, 32, 39, 41, 42, 56]- [3, 15, 18, 39, 41, 48, 83, 84] [13, 14]- [8]- [1, 2, 18, 35]- [1, 2, 30, 41, 42, 46, 52, 61, 64, 74, 75,

81, 87]- [3, 6, 7]- [3]

Protocol and mobility teams

- Lack of clear recommendations / protocols regarding mob (-)- mob protocol (+)- Goal directed mobilisation and MDT communication (+)- mob team (+)- Documentation and medical orders (+)

- [1, 41, 42]- [8, 15, 17, 65, 78, 85]- [33]- [3]- [8, 41, 42]

23

- Change default activity from bedrest to mob (+)- Restructure staff tasks so team members can do activity (+)- ABCDE bundle hospitals (+)- Visible mob tool at bedside (+)- Early mob protocol not implemented due to need for further planning (-)- Patient goals/protocol pathway changed to comfort care/palliation

- [42]- [88]- [20, 21]- [7]- [15]- [46, 58, 83]

QI project to implement mobility program

- Success at PA with implementation of QI project or ICU mob team (+) - [5, 21, 24, 32, 36, 37, 39, 42, 45, 49, 55, 56, 62, 64, 67-70, 79, 80] [34]

Abbreviations: ABCDE, Awakening, and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility Bundle; ACPs, advanced care providers; ADLs, Activities of daily living; Ax, assessment; co-op, co-operation; Ax, assessment; co-ord, co-ordination; DC, discharge; ECMO, extracorporeal membrane oxygenation; ETT, endotracheal tube; ex, exercise; FiO2, Fraction of inspired oxygenation; HCP, healthcare provider; HEP, home exercise program; hosp, hospital; ICU, intensive care unit; ICUAW, intensive care unit acquired weakness; indep, independent; I/P, inpatient; LOS, length of stay; MD, medical doctor; MICU, medical ICU; mob, mobilisation/mobility; MV, mechanical ventilation; Mx, management; NS, nursing staff; OOB, out of bed; O/P, outpatient; OT, Occupational therapy; PA, physical activity; PAC, pulmonary artery catheter; psych, psychological; Pt, patient; PT, physiotherapist; QI, quality improvement; rehab, rehabilitation; resp, respiratory; Rx, treatment; TF, transfer; Trache, tracheostomy; UL, upper limb; uni, university; =, equals; 1:1, one-to-one.

(+) = enabler to physical activity or exercise(-) = barrier to physical activity of exercise

24

ETable 4: Study aims and methodology

First author, year Primary Aims Methodological approach Qualitative data collectionQualitative studiesHealth Care ProvidersBoehm 2016, United States [1]

To understand variations in ABCDE bundle implementation Qualitative descriptive – methodological approach not explicitly stated

Purposive sampling into focus groups

Parry 2016, Australia [2]

To identify the barriers and enablers that influence clinicians’ implementation of early rehabilitation in critical care

Qualitative descriptive – content analysis

Purposive sampling for semi-structured focus groups

Barber 2015, Australia [3]

To examine the main barriers and facilitators to mobilisation in ICUs, to inform strategies for better practice. The research questions for this study were 1. What are the barriers to and facilitators of early mobilisation? 2. Are these issues similar or different amongst different clinician groups in the ICU (medical, NS, PT)?

Qualitative descriptive – methodological approach not explicitly stated


Eakin 2015, United States [4]

To retrospectively evaluate implementation of an ER program and to identify factors that sustained the programme from a MDT perspective, using qualitative, semi-structured interviews

Consolidated Framework for Implementation Research

Purposive sampling for semi-structured interviews


To identify facilitators and barriers to ABCDE bundle adoption and to evaluate effectiveness, sustainability and whether conducive to dissemination

Mixed methods study 1) Qualitative descriptive – methodological approach not explicitly stated and 2) cross-sectional survey

Purposive sampling into focus groups and cross-sectional survey

Williams 2015, United Kingdom [6]

To explore PT understanding / experience of implementing ER in ICU patients


Purposive sampling for semi-structured interviews (range 40-55mins)


A multicentre collaborative was undertaken to introduce an EBP progressive mobility programme whilst simultaneously addressing cultural change in ICU


NR

Winkelman 2010, United States [8]

To investigate the feasibility of a protocol to implement early, progressive activity among SICU/MICU patients MV > 48hrs; specifically examining NS perception of barriers to and facilitators for use of progressive mobility


Semi-structured interviews

25

Patient / CaregiversCzerwonka 2015, Canada [9]

To delineate the needs and experiences of survivors of complex critical illness and their family caregivers across the illness and recovery trajectory

Timing It Right framework; interviews analysed using framework methodology

Convenience sample from RECOVER study cohort for in-depth interviews, length median 23 (range 15-52) mins

Walker 2015, United Kingdom [10]

To gain a more in-depth insight into patients’ perceptions of their QOL after hospital DC and experiences of aftercare services, usual care or rehab programme (examined in a parallel RCT)

Focus groups adhering to Wilkinson’s guidance and analysed using thematic analysis


Deacon 2012, United Kingdom [11]

To explore former patients’ views on key components of a post ICU rehab programme. The primary research question was: (1) What did ex-ICU patients feel were the key components of a rehab programme following DC from ICU?


Web-based study using bespoke online questionnaire

Lee 2009, Canada [12]

To explore the support needs of ARDS survivors during and after their acute episode of critical illness as they re-integrate into the community

Adapted Timing It Right Framework methodology

In-depth interviews of between 45-90mins

First author, year Primary Aims Quantitative data collection method Quality Rating#

Quantitative studiesHealth Care ProvidersBakhru 2016, USA [13]

To evaluate current EM practice and examine environmental factors that may influence practice

Cross-sectional study – multicentre bespoke telephone survey 4

Koo 2016, Canada [14]

To assess physician and physiotherapist knowledge of acquired weakness and EM in ICU and perceived barriers to EM

Cross-sectional study – multicentre bespoke written survey 4

Bakhru 2015, United States [15]*

To evaluate the current level of diffusion of EM practice and examine environmental factors that may influence practice


Holdsworth 2015 Australia [16]

To elicit attitudinal, normative, and control beliefs toward mobilizing MV patients in the ICU to generate items for a second-phase questionnaire and inform the development of a tailored implementation intervention

Cross-sectional study – single centre bespoke open-ended electronic survey

4

Jolley 2015, United States [17]

To determine what proportion of hospitals caring for MV patients across Washington State use PA in the ICU and to identify process of care factors associated with reported activity delivery.


26

Malone 2015, United States [18]

To characterize current PT practice, specifically, practitioner demographics, ICU staffing patterns, methods of training for ICU practice, barriers to providing rehab services, and the influence of characteristics of patients on PT decision making regarding their plan of care

Cross-sectional study – multicentre bespoke postal survey 4

Messer 2015, United States [19]

To increase mobilisation of pts on ICU. To determine how providing educational sessions to ICU NS about a progressive mobility programme affected subsequent knowledge and pt care practice

Pre test / Post test Case Series - single centre 4

Miller 2015, United States [20]

To assess the level of self- reported implementation of aspects of ABCDE implementation

Cross-sectional multicentre bespoke written survey 4


To identify facilitators and barriers to ABCDE bundle adoption and evaluated the extent to which bundle implementation was effective, sustainable, and conducive to dissemination

Prospective cohort single centre 2


To comprehensively determine, across the UK, implementation of NICE CG83 during the post-hospital DC period with detailed characterisation of available FU and rehab services, and including establishing barriers to service provision

Cross-sectional study – multi-centre bespoke postal survey 4

Jolley 2014, United States [23]

To investigate whether clinicians in the MICU our institution are knowledgeable regarding the benefits of EM and to identify perceived barriers to delivery of mobility in the ICU

Cross-sectional study - single-centre bespoke survey (medical on paper, PT/NS electronic)

4

Palmeiri 2012, United States [24]

To improve PT and other MDT team approach to Ax and Mx of ICU patients requiring MV

Single centre pre/post implementation written survey 4

Appleton 2011, Scotland [25]

Some of the aims were to establish (in the context of this systematic review):• The awareness of the NICE clinical guideline among Scotland’s ICU lead clinicians and PT• The current provision of information to patients, their families/caregivers and GPs regarding the patient’s illness, treatments and potential sequelae.• The perceived barriers to the provision of rehabilitation within Scottish ICUs.• The opinion of Scottish ICU clinicians regarding benefits of rehab and value of NICE guideline• The percentage of Scottish ICUs receiving funding specifically for rehabilitation within the ICU

Cross-sectional multicentre survey - bespoke two-part telephone survey (Part A for MDT clinicians; Part B for PT)

4

27

Hodgin 2009, United States [26]

To understand current PT practices for patients recovering from critical illness, including hospital staffing patterns, likelihood of ICU patients would receive PT and identify most common types of PT performed

Cross-sectional multicentre study – bespoke postal survey 4

Skinner 2008, Australia [27]

Some of the aims were to identify/investigate (in the context of this systematic review):To identify methods of ex prescription (including types of ex activities) by PTs in Australian ICUs;• To investigate the factors that influence PTs in determining initiation of exercise along with the frequency, duration and progression of exercise

Cross-sectional multicentre study - bespoke postal survey 4

Lewis 2003, United Kingdom [28]

Some of the aims (in context of this systematic review) were to: explore current provision of rehab within ICU t/out the UK; to look at PT experiences and perception of FU services


King 1998, Canada [29]

To gather information on the current practices in Canadian ICUs regarding amb in MV patients


Patient and CaregiversHickmann 2016, Belgium [30]

Primary aim to examine feasibility of early mobilisation in critically ill patients

Single centre case series 4


Primary aim to determine whether use of a Sara Combiliser (equipment) reduces time to first mobilisation for patients MV at least 5 days and at risk of ICU-AW

Pre test / post rest case series single centre 4

Ramsay 2016, United Kingdom [90]

To understand and compare patients’ experiences of rehab in a trial, and explore effects on perceived quality of care

Mixed methods study – qualitative focus group and patient experience questionnaire

4

Reames 2016, United States [32]

To describe the process and outcome of implementing an evidence-based EM protocol in the progressive care population

Historical control single centre 3

Schaller 2016, Austria, Germany, United States [33]

To test if goal direct EM using a strict EM algorithm combined with facilitated MDT communication improves mobility during SICU

RCT 1

Sigler 2016, United States [34]

To provide a guideline for ICU early mobilization program development and implementation

Pre test / post test case series single centre 4

28

Toonstra 2016, United States[35]

To examine the feasibility and safety of physiotherapy in ICU pts undergoing CRRT


Wahab 2016, United States [36]

To examine the effect of an ER programme on ICU and hospital LOS before and after QI

Historical control multicentre 3

Basset 2015, United States [37]

Institute for Healthcare Improvement’s Rethinking Critical Care in-person seminar to replicate powerful changes proven in other healthcare settings to incorporate human factors and change culture; report of five participating organisations to gain insights about their success and challenges in making these changes

Historical control, 5 single centres reported on separately 3


To (1) prospectively quantify the amount, location, and type of PA undertaken by ICU patients between 8:00 AM and 5:00 PM on a single day; (2) quantify the effect of MV status, sedation state, and ICU LOS at the time of observation on PA levels; and (3) describe who is present at the bedside

Cross-sectional study – behavioural mapping observational study single centre

4

Castro 2015, United States [39]

To Ax and change the mindset of the SICU staff toward early mobilisation of patients receiving MV

Pre test / post test case series single centre 4


Primary aim to examine feasibility of ex-based rehab delivered after hospital DC in ICU-AW patients

RCT (pilot, feasibility) and nested cohort study multicentre 2

Dafoe 2015, Australia [41]

To evaluate ICU staff perceptions of the barriers to mobilising ICU patients

Cross-sectional study – single centre bespoke internal/external mail survey

4

Dafoe 2016, Australia [42]

To identify barriers to mobilisation and to determine if strategies implemented on the basis of a staff survey and audit increased the frequency of mobilisation in the ICU

Cross-sectional study - single centre bespoke internal/external mail surveyHistorical control

4

Duncan 2015, Canada [43]

To evaluate the impact of increased weekend PT on patient volumes, Rx provided and conditions treated in ICUs and wards; and (2) to understand the PTs’ perspectives on the new coverage model

Historical control (Quantitative) Single centreCross Sectional Survey – electronic (Qualitative)

3


To examine delivery of PT services to patients in ICU and factors determining post DC destination

Retrospective cohort 3

Fraser 2015, United States [45]

To compare outcomes of ICU patients who received PT from a dedicated mobility team with ICU patients who received routine care

Historical Control 3

Harrold 2015, Australia and

1.Quantify and benchmark mobility levels in Australian and Scottish ICU’s in MV patients. 2.Compare mobility practices

Case series multi-centre 4

29

Scotland [46] between Australia and Scottish ICU’s. 3.Identify barriers to mobilisation in both ICU’s

Hodgson 2015, Australia and New Zealand [47]

To investigate current mobility practices, strength at ICU DC and functional recovery at 6mo among MV ICU patients

Case series multi-centre 4

Knott 2015, United Kingdom [48]

To quantify the amount of active rehab provided for patients in the ICU and identify specific barriers

Cross sectional single centre - audit 4


To evaluate the impact of an enhanced ER program for MV patients in a large, mixed-population ICU


Pandullo 2015 , United States [50]

To determine if patient mobility achievements in an ICU setting are sustained during subsequent phases of hospitalisation, specifically after TF to inpatient floors on day of hospital DC.

Retrospective post test case series single centre 4

Sottile 2015 , United States [51]

To examine the degree of pt and family satisfaction with early PT and to identify family- and patient-related factors associated with a high degree of satisfaction

Cross-sectional study - Bespoke survey study; nested within RCT single centre

4

Tadyanemhandu 2015, Zimbabwe [52]

1) To establish the profile of patients admitted into the five central ICUs in Zimbabwe over a period of 2 months in terms of age groups, gender and type of condition across all hospitals. 2) To determine the nature of the current PT services being offered in terms of the most frequently utilized methods of intervention and the frequency of service provision

Cross sectional multi centre audit 4

Abrams 2014, United States [53]

To describe the feasibility and impact of active PT on ECMO patients

Retrospective post test case series single centre 4

Brummel 2014, United States [54]

To establish the feasibility and safety of combining early cognitive therapy and early PT/OT therapy with prolonged (up to 12-weeks) outpatient cognitive therapy in critically ill adult medical and surgical patients

RCT single centre 2

Dinglas 2014, United States

To evaluate the sustainability of an ER QI project in a single MICU and to evaluate how the QI project and other patient- and ICU-related factors are associated with timing of active PT


Harris 2014, United States [56]

QI study to determine effectiveness of MDT meetings and education sessions provided to ICU staff on patient engagement in EM.

Post test case series single centreCross sectional electronic survey

4

Jolley 2014, United States (factors) [57]

To identify factors associated with the receipt of PT in patients requiring prolonged MV

Retrospective cohort 3

30

Nydahl 2014 , Germany [58]

To undertake a 1-day point-prevalence study of mobilization of MV patients in ICUs across Germany, including evaluating associations with perceived barriers to mobilization and complications during mobilization

Cross-sectional study – national one day point prevalence study multicentre

4

Roberts 2014, United States [59]

To compare a mobility platform with standard equipment for ICU patients (efficiency, effectiveness, and safety evaluated)

Pseudo-randomised controlled study 2

Wang 2014, Australia [60]

To test the safety and feasibility of EM in patients on early CRRT.

Prospective comparator cohort multi centre 2

Berney 2013, Australia and New Zealand [61]

To document current PT mobilisation practices across a large sample of general (medical and surgical) ICU patients and focus specifically on mobilisation practices in patients MV>48hrs

Cross-sectional study - national one day point prevalence study multicentre

4

Carrothers 2013, United States [62]

To identify which contextual factors facilitate/hinder the implementation of the ABCDE bundle in four San Francisco Bay Area hospitals’ ICUs for guidance in future studies

Pre test / post test case series multicentreCross sectional electronic survey

4

Damluji 2013, United States [63]

To evaluate the feasibility and safety of PT in ICU patients with femoral catheters.

Prospective post test case series single centre 4

Dammeyer 2013, United States [64]

To describe the MDT change process and partnerships necessary to provide EM to MV patients


Davis 2013, United States [65]

To examine feasibility and describe outcomes associated with EM in critically ill older adults


Dinglas 2013, United States [66]

To evaluate the association of patient, ICU and hospital factors with time to first OT intervention in ICU patients with ALI

Prospective comparator cohort study multicentre 2

Drolet 2013, United States [67]

To evaluate the effectiveness of a NS driven EM protocol to increase % of pts amb in first 72 hours



To describe a QI project est. by a PT at University of California San Francisco Medical Centre aimed at increasing the no. of pts in the ICU receiving PT


Hanekom 2013, South Africa [69]

To compare PT service provided when PT decisions are guided by an EBP protocol with usual care

Pseudo-randomised controlled trial single centre 2

Mah 2013, United States [70]

To determine if a resource-efficient mobility programme was effective in improving patient mobility in the surgical ICU


Mendez-Tellez 2013, United States [71]

To evaluate factors associated with the timing of initiation of PT in patients with ALI adm to ICU

Prospective comparator cohort multicentre 2

Perme 2013, To examine the incidence of femoral catheter related adverse Post test case series single centre 4

31

United States [73] effects during PT sessionsTalley 2013, United States [72]

To review an EM protocol for patients undergoing CRRT Post test case series multi centre 4


To describe a model of rehab for survivors of ICU; compare the model to local and national standard care; and report the safety and feasibility of the program

Intervention arm of a RCT single centre (cohort study) 1

Leditschke 2012, Australia [75]

To identify barriers to EM in the ICU Cross sectional single centre 4

Garzon-Serrano 2011, United States [76]

To evaluate whether the level of mobilisation achieved and the barriers for progressing to the next mobility level differ between NS and PT.

Prospective comparator cohort study single centre 2


To explore whether PT directed mobility of patients with femoral arterial catheters resulted in AEs

Post test case series single centre 4

Hildredth 2010, United States [78]

To investigate mobility orders in the SICU and the effect on patient PA levels

Pre post test case series single centre 4

Needham 2010, United States [79]

To reduce deep sedation and delirium to permit mobilisation, increase the frequency of rehab consultations and Rx, and evaluate effects on LOS


Needham 2010, United States [80]

To deliver a specific model for undertaking QI projects in ICU and evaluate application / outcomes


Pohlman 2010, United States [81]

To describe a protocol of daily sedative interruption and early PT and OT and to specify details of ICU based therapy (detailed description of intervention arm of RCT, - RCT = Schweickert 2009)

Intervention arm of RCT multicentre 1

Zanni 2010, United States [82]

To describe the frequency, physiologic effects, safety and pt outcomes associated with traditional rehab therapy in patients who require MV.

Cross sectional single centre 4

Schweickert 2009 , United States [83]

To assess the efficacy of combining daily interruption of sedation with PT and OT on functional outcomes in patients receiving MV in the ICU

RCT single centre 1


To determine the effect of EM on ICU LOS and to identify any limiting factors to EM

Case series single centre 4

Morris 2008, United States [85]

To assess the frequency of PT, site of initiation and patient outcomes comparing respiratory failure patients who received usual care compared with patients who received PT from a mobility team

Prospective comparator cohort study single centre 2

Thomsen 2008, To determine whether TF of respiratory failure patients to the Case series single centre 4

32

United States [86] RICU improved ambulation, independent of underlying patho-physiology

Bailey 2007, United States [87]

To determine whether early PA is feasible and safe in respiratory failure patients

Case series single centre 4

Hopkins 2007, United States [88]

To determine the safety and feasibility of the implementation of an PA protocol to address problems of prolonged immobilisation in patients with respiratory failure

Prospective post test case series single centre 4

Abbreviations: ABCDE, Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early exercise/mobility bundle; adm, admission; AEs, adverse events; ALI, acute lung injury; amb, ambulation; ARDs, acute respiratory distress syndrome; Ax, assessment; CRRT, continuous renal replacement therapy; DC, discharge; EBP, evidence based practice; ECMO, extracorporeal membrane oxygenation; EM, early mobilisation; ex, exercise; ER, early rehabilitation; est, establish; FU, follow-up; GP, general practitioners; hrs, hours; ICU, intensive care unit; ICUAW, intensive care unit acquired weakness; LOS, length of stay; MDT, multidisciplinary; MICU, medical intensive care unit; mins, minutes; mo, months; MV, mechanical ventilation; Mx, management; no, number; NS, nursing; OT, occupational therapy; PA, physical activity; rehab, rehabilitation; RICU, respiratory intensive care unit; pt, patient; PT, physiotherapy; QI, quality improvement; QOL, quality of life; RCT, randomised controlled trial; Rx, treatment; SICU, surgical intensive care unit; TF, transfer; t/out; through-out; UK, United Kingdom; >, greater than; %, percentage.

*, same patient group represented by two papers by same author with different study aims. # Quality rating for studies according to the Oxford Centre for Evidence Based Medicine for rating of individual studies.

33

ETable 5: Risk of bias in qualitative studies

QualitativeCOREQ checklist[91]

Team & reflexivity (/8) Study design (/15) Analysis & findings(/9) (/32)Boehm 2016 3 13 8 24Parry 2016 7 14 8 29Barber 2016 2 10 8 20Eakin 2015 2 12 8 22Balas 2013 1 6 4 11Williams 2013 2 10 7 19Bassett 2012* 0 0 1 1Winkleman 2010* 0 3 1 4Czerwonka 2015 0 13 9 22Walker 2015 4 11 7 22Deacon 2012+ NA 9 4 13+

Lee 2009 2 12 7 21Mean (SD) 21 [11-22]Abbreviations: COREQ, Consolidated criteria for reporting qualitative research; SD, standard deviation; yr, year.* These studies were mixed methods – qualitative and quantitative in design

+ This study was a web-based qualitative study – therefore there was no specified interviewer, thus the first domain was not applicable in the assessment of risk of bias

4

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Authors:10.1007... · Web viewRepresentatives of hospitals attending the January 2012 annual state QI meeting for improving ICU outcomes NR NR NR NR Balas 2014, United States [] Total,