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SURVIVING CRITICAL ILLNESS, WHAT IS NEXT?
Mel Major MSc, PhD candidate Prof. Dr. Raoul Engelbert Dr. Marike van der Schaaf
An expert consensus statement on physical rehabilitation after critical illness
CAN WE HELP THE POST-ICU PATIENT GET OUT OF THE WOODS?
CONTENT
• What do we know? • Aim of the study • Methods • Results • Follow up
AIM OF THE STUDY
To reach consensus on: • Handover information from hospital to physical therapist • Physical therapy goals • A core set of outcomes for clinical practice • Optimal physical therapy intervention
DELPHI EXPERT PANEL (N=10) Country Field of exper1se Years clinical
experience Publica1ons
Australia Physical Therapy > 20 68
Australia Physical Therapy > 20 12
Belgium Physical Therapy / Movement Sciences
> 20
128
Canada Physical Therapy 15-‐20 44
Netherlands Physical Therapy > 20 16
South Africa Physical Therapy > 20 24
United Kingdom Physical Therapy 10-‐15 3
United Kingdom Nursing / Psychology > 20 10
United Kingdom Physical Therapy 15-‐20 9
USA Intensive Care Medicine 15-‐20 > 200
DELPHI METHODOLOGY
1: GeneraNng ideas
2: Ranking statements
3: Reaching consensus
Circuit training
Inspiratory muscle training
Hand Grip Strength
Incremental shuRle walk
test
Hospital Phase
Screening
• Establish ADL function (KATZ-ADL/BI)
• Collect handover information relevant to longterm recovery and PICS
• Educate patient and family on PICS(-F) and expected recovery
Education patient and
family
Hospital discharge information
Essential:• Premorbid level of functioning• Course of recovery during hospital
stay (mental/cognitive/physical)• Current mental/cognitive/physical
stateVery Important:• Co-morbidities• Pre-ICU psychiatric symptoms• Delirium• Diagnosed ICU-AW (MRC-SS ≤ 48)• ICU and hospital LOS• Severity of illness• Complications during hospital stay• Physiological response to exerciseAdditional:• Specific patient- and/or family
characteristics• Environmental factors• Days of immobility• Type of surgery (if applicable)
BI:B
arth
el In
dex,
PIC
S (F
):Pos
t int
ensiv
e ca
re s
yndr
ome
(fam
ily),
ICU:
inte
nsive
car
e un
it, IC
U-AW
: ICU
Acq
uire
d W
eakn
ess,
MRC
-SS:
MRC
sum
sco
re, L
OS:
Len
gth
of s
tay,
ADL:
Act
ivitie
s of
Dai
ly Li
ving,
6M
WT:
6 m
inut
e wa
lk te
st, S
PPB:
Sho
rt Ph
ysica
l Per
form
ance
Bat
tery
, HHD
: Han
dhel
d Dy
nam
omet
ry, M
IP: M
axim
um In
spira
tory
Pre
ssur
e, M
EP: M
axim
um E
xpira
tory
Pre
ssur
e, iA
DL:
Inst
rum
enta
l Act
ivitie
s of
Dai
ly Li
ving,
HRR
: Hea
rt Ra
te R
eser
ve, H
ITT:
Hig
h In
tens
ity In
terv
al T
rain
ing;
MFI
: Mod
ified
Fatig
ue In
vent
ory,
RCSQ
: Rich
ard
Cam
pbel
l Sle
ep Q
uest
ionn
aire
, MUS
T:
Mal
nutri
tionU
nive
rsal
Scr
eeni
ng T
ool,
SNAQ
: Sho
rt N
utrit
iona
l Ass
essm
ent Q
uest
ionn
aire
, HAD
S: H
ospi
tal A
nxie
ty a
nd D
epre
ssio
n Sc
ale,
IES-
R: Im
pact
s of
Eve
nt S
cale
-Rev
ised,
MM
SE: M
ini
Men
tal S
tate
Exa
min
atio
n
Fatigue: MFISleep: RCSQNutrition: MUST/SNAQMental/cognition: HADS, IES-RCognition: MMSE
Referral to general physician
Additional screening tools
+
Screening
• 6MWT, 4m timed walk/gait speed (SPPB)• Sub-maximal cycle ergometry• Handgrip strength or HHD• MIP / MEP• Spirometry / MRC Dyspnea scale• Ultrasound / anthropometry• KATZ-ADL or BI or Lawton’s iADL• SF36 or TUG or FIM or DEMMI or SPPB• EuroQoL• VAS (for pain)
Set exercise intensity on: 80% average 6MWT speed or 75% peak speed ISWT or 50-70% HRR with Borg 3/4• Interval or endurance cardio training• Circuit training• HIIT• Functional exercises (incl. ROM)• Balance training• Strengthening exercises • IMT/EMT• Education (patient & family) on recovery process+ Nutritional support
Functional exercise capacity Aerobic capacity Skeletal & respiratory muscle strength ADL function Quality of Life Understanding of PICS and recovery Pain
Physical therapy goals
Physical therapy interventions
Core outcome set
RESULTS Hospital phase: Educate patient and family on PICS(-F) and recovery Essential hospital discharge information: • Premorbid level of functioning • Course of recovery (during hospital stay) • Current mental, cognitive and physical state • Comorbidities • Pre-ICU psychiatric symptoms • Delirium • Diagnosed ICU-Acquired Weakness (MRC-SS ≤ 48) • ICU and hospital length of stay • Severity of illness • Physiological response to exercise
RESULTS
RESULTS
RESULTS
RESULTS: SCREENING FOR ADDITIONAL PROBLEMS
FOLLOW UP
• What are patients’ needs and experiences with regards to physical rehabilitation?
• Feasibility testing of the consensus framework • Validation of measurement tools for post-ICU population • Training of physical therapists in primary care • Effectiveness of the physical therapy intervention
YES, WE CAN HELP THE PATIENT TO GET OUT OF THE WOODS
ACKNOWLEDGEMENTS
ACHIEVE - Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands European School of Physiotherapy, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands Academic Medical Center, University of Amsterdam, Department of rehabilitation medicine, Amsterdam, the Netherlands This research is funded by the Netherlands Organization for scientific research (NWO)
