Highlights
- •Out-of-bed rehabilitation was prescribed despite no evidence of strength deficits.
- •Patients met safety criteria, had weakness but did not receive rehabilitation.
- •At the point of care endotracheal tube and sedation are barriers to rehabilitation.
- •Identifying rehabilitation responders is needed to harmonize clinical decision-making.
Abstract
Objectives
To develop a decision tree that objectively identifies the most discriminative variables
in the decision to provide out-of-bed rehabilitation, measure the effect of this decision
and to identify the factors that intensive care unit (ICU) practitioners think most
influential in that clinical decision.
Design
A prospective 3-part study: (1) consensus identification of influential factors in
mobilization via survey; (2) development of an early rehabilitation decision tree;
(3) measurement of practitioner mobilization decision-making. Treating practitioners
of patients expected to stay >96 hours were asked if they would provide out-of-bed
rehabilitation and rank factors that influenced this decision from an a priori defined
list developed from a literature review and expert consultation.
Setting
Four tertiary metropolitan ICUs.
Participants
Practitioners (ICU medical, nursing, and physiotherapy staff) (N=507).
Interventions
Not applicable.
Main Outcome Measures
A decision tree was constructed using binary recursive partitioning to determine the
factor that best classified patients suitable for out-of-bed rehabilitation. Descriptive
statistics were used to describe practitioner and patient samples as well as patient
adverse events associated with out-of-bed rehabilitation and the factors prioritized
by ICU practitioners.
Results
There were 1520 practitioner decisions representing 472 individual patient decisions.
Practitioners classified patients suitable for out-of-bed rehabilitation on 149 occasions
and not suitable on 323 occasions. Decision tree analysis showed the presence of an
endotracheal tube (ETT) and sedation state were the only discriminative variables
that predicted patient suitability for rehabilitation. In contrast, medical staff
and nurses reported that ventilator status was the most influential factor in their
decision not to provide rehabilitation while physiotherapists ranked sedation most
highly. The presence of muscle weakness did not inform the decision to provide rehabilitation.
Conclusion
These results confirm previous observational reports that the presence of an ETT remains
a major obstacle to the provision of rehabilitation for critically ill patients. Despite
rehabilitation being effective for improving muscle strength, the presence of muscle
weakness did not influence the decision to provide rehabilitation.
Keywords
List of abbreviations:
ETT (endotracheal tube), Fio2 (fraction of inspired oxygen), ICU (intensive care unit), ICU-AW (intensive care unit–acquired weakness), Pao2 (partial pressure of oxygen dissolved in blood), RASS (Richmond Agitation and Sedation Scale)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: August 30, 2018
Footnotes
Disclosures: none.
Supported by National Health and Medical Research Council Early Career Fellowship (1037383).
Clinical Trial Registration No.: ACTRN12616000963426.
Identification
Copyright
© 2018 by the American Congress of Rehabilitation Medicine
