What Follows Survival of Critical Illness? Physical Therapists' Management of Patients With Post–Intensive Care Syndrome

Physical Therapists in the ICU

In September 2010, the Society of Critical Care Medicine (SCCM) held a meeting of stakeholders from rehabilitation, outpatient, and community care settings to develop an action plan to initiate improvements for ICU survivors, and their families, across the continuum of care.²⁰ Because of the growing number of ICU survivors and the previously described consequences of PICS, the SCCM placed high importance on obtaining input from a multidisciplinary group of stakeholders outside the critical care community. The American Physical Therapy Association (APTA) was one of the invited stakeholders. Three major areas addressed during the 2-day meeting were: (1) raising awareness and education about PICS among clinicians, survivors, family members, administrators, payers, and policy makers; (2) understanding and addressing the barriers to best practice; and (3) identifying research gaps and resources.²⁰

The traditional goal and focus of the ICU team has been the measurement and treatment of critical physiologic impairments (eg, circulatory, respiratory, and renal function) to decrease immediate mortality and ensure patient survival of the ICU stay.^21,22 We endorse an earlier proposal that an episode of critical illness is not just the ICU stay; rather it begins with the onset of acute deterioration and ends when a patient's risk of further sequelae returns to baseline.²² Accepting that perspective obliges health care providers and researchers to develop an appreciation for the precursors of PICS and to expand attentiveness to the importance of functioning beyond the ICU stay. We propose that physical therapists are well prepared for evaluating and treating alterations in function during and following a stay in the ICU, although their services are unevenly provided across practice settings.²³

Physical therapists have not been consistently involved in traditional ICU care because patients in the ICU often were considered to be too critically ill to receive or benefit from physical therapy.²⁴ Recent evidence has established that as success at achieving survival has improved, there is growing capacity for managing these patients with attention to preventive interventions that improve the sequelae beyond survival of the ICU experience.^21,25–30 Physical therapist practice in the ICU involves the early mobilization of patients following stabilization of hemodynamic and respiratory parameters, beginning as early as 24 to 48 hours after admission to the ICU.^25,31 Based on the results of the physical therapist's examination, the plan of care may include interventions such as training for bed mobility or sitting balance on the edge of the bed, transfer training, pre-gait activities, and therapeutic exercise, including balance activities, passive or active range of motion, strengthening or breathing exercises, positioning, education, and airway clearance.³² Studies have shown that applying these interventions to achieve early mobilization in the ICU is feasible and safe^26,33 and improves the patient's ability for ambulation, independent of the underlying pathophysiology.

In pilot work by Nordon-Craft et al,²⁹ patients admitted to the ICU received physical therapy interventions 5 times per week, with a target of 30 minutes per session. Interventions included education, positioning, respiratory techniques, therapeutic exercise, and functional mobility retraining. Baseline strength test and Functional Independence Measure scores for the study participants increased by their discharge from the ICU. Another study compared early mobility with usual care, and the patients who participated in early mobility sessions were out of bed after an average of 5 days compared with 11 days for the control group and had a significantly shorter length of stay in the ICU, by 3.3 days.³¹ These examples, and the evidence included in this special series of Physical Therapy, should be used by physical therapists to inform practice within the ICU and to raise awareness about the capacity to reduce the severity of the PICS symptoms.

Barriers to Best Practices Related to PICS

Patients hospitalized for an acute illness or injuries are at risk for loss of function, not only in the short term but also extending well past the acute care hospitalization.^4,11,12 In a study by van der Schaaf et al,³⁴ patients who required mechanical ventilation in the ICU for more than 48 hours were followed for 1 year after discharge from the ICU. Sixty-nine percent were found to have persisting limitations performing daily activities, and only 50% had resumed work. For individuals at risk for PICS, the health care team should anticipate needs beyond the acute care stay, educate accordingly, and promote transitions that accommodate persisting impairments and reduced functioning.

Müller et al³⁵ translated patients' statements of important goals they wanted to achieve into the classifications defined by the World Health Organization's International Classification of Functioning, Disability and Health (ICF).³⁶ The most frequently reported patient goals while hospitalized were walking (d450); sensation of pain (b280); health services, systems, and policies (e580); recreation and leisure (d920); washing oneself (d510); caring for household objects (d650); and sensations associated with cardiovascular and respiratory functions (b460).³⁵ These goals demonstrated that while patients are hospitalized for medical problems, the concerns to which they attributed great importance are basic areas of activity, participation, and environmental factors. When these goals were met, it translated to improved functioning.³⁵ We propose that the patient's concerns relating to limitations in walking, self-care, and problems with pain are responsive to physical therapy interventions, medical interventions, and education that should be included in the strategies for patient management in the ICU. Research has shown that early intervention with rehabilitation services in the ICU can be applied safely to promote greater physical abilities while reducing the loss of functioning and disability that otherwise would develop during critical illness.^21,24,37,38 In addition, it has been proposed that the reduction of the length of stay in the ICU achieved with these services has the potential to reduce costs.³¹

There are challenges encountered in the provision of multidisciplinary care both within the ICU and after hospital discharge. Within the ICU, the traditional focus has been on short-term outcomes such as physiological integrity, organ function, and preservation of life. Once physiologic stability is achieved, patients generally are transferred from the ICU to a general hospital unit, where planning for discharge is paramount. The ICU staff are rarely involved in discharge planning and become disconnected from the challenges that patients may face at the time of hospital discharge and beyond.³⁹ Integration of physical therapists providing early mobility in the ICU should foster discussion and appreciation among the ICU team about the importance of long-term goals and outcomes that address functioning and the patient's role in society (refer to the Figure). Infusing early mobilization in the ICU requires a team approach that may require a change in the ICU culture, perceptions about mobilization by ICU personnel, and the practices of the ICU staff.³⁹ Physical therapists in the ICU will rely on ICU staff for interruption of sedation, assistance in managing ventilatory equipment, and assistance with lines, tubes, and drains during physical therapy interventions. Barriers also may include clinicians' knowledge deficits and lack of human resources. Based on workforce reports, APTA's Model to Project the Supply and Demand of Physical Therapists, 2010–2020, shows the shortage of physical therapists will increase over the next 10 years from the current deficit of 19,344 to 25,295.⁴⁰ This shortage of physical therapists has implications for achieving resources to provide physical therapy services, not only in the ICU but also throughout the continuum of care. An APTA task force is developing strategies to address this issue.

There also are gaps in the recognition of those patients who may benefit from rehabilitation after ICU discharge.¹² As a result of this shortcoming, some ICU survivors do not receive consultation or timely physical therapy interventions while on the general hospital unit and following discharge from the hospital. The National Institute for Health and Clinical Excellence (NICE) Guidelines recommend a streamlined process for the transfer of patients from the ICU to a general medical unit or hospital discharge, which includes plans for rehabilitation for those patients with, or at risk for, PICS. Key to the process is a comprehensive, multidisciplinary assessment before ICU discharge to evaluate physical and psychological problems, including PICS.⁴¹

Raising Awareness of PICS

Increasing awareness of PICS among health care providers is necessary for achieving consistent recognition and optimal management of patients with PICS. This awareness should start with consistent terminology for the constellation of consequences following critical illness. Terms that have been used in the literature, such as “ICU-acquired weakness”⁸ and “ICU-acquired paresis,”⁴² have not described the full constellation of impairments to physical, cognitive, and mental health. The term “post–intensive care syndrome” is preferred to describe the “new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization.”^20(p505) This statement accurately describes the multiple consequences experienced by ICU survivors. There is some evidence that ICU-based early mobility programs may reduce complications in the immediate post-ICU period.^27,28,31,43 Unfortunately, the reduced functioning experienced by ICU survivors is slow to resolve, and interventions after hospital discharge have not been effective at improving recovery from impairments, reduced functioning,⁴⁴ and poor health-related quality of life.^44,45 This lack of response highlights the value of early mobility interventions initiated in the ICU to prevent the loss of functioning and the need for additional research to reveal interventions that could decrease the impact of PICS.

Awareness of the long-term outcomes following survival of a stay in an ICU should improve with growth of the available evidence. Attention to the long-term outcomes following a stay in an ICU has been facilitated through efforts of APTA, which is the membership organization representing and promoting the profession of physical therapy, and the Acute Care Section (ACS), a component of APTA. In June 2011, the ACS responded to the growing interest among physical therapists by creating a community that communicates on an e-mail listserv. Over an 8-month period, the listserv grew to 272 members⁴⁶ sharing information about practice in the ICU and care for ICU survivors. There also has been an increasing number of course offerings at APTA meetings focused on the care of patients in the ICU and throughout the continuum of care. For example, at APTA's 2012 Combined Sections Meeting, the ACS sponsored 10 platform and poster presentations that addressed physical therapy services in the ICU. In addition, APTA has several course offerings in various formats (eg, text based, online, blended learning) that are specific to physical therapist practice in critical care.⁴⁷

We recommend that work to educate clinicians about PICS needs to continue. In addition, educational resources for survivors of an ICU stay, family members, administrators, payers, and policy makers need to be developed and assessed for effectiveness.

Identifying Research Gaps and Resources

The appeal for research about PICS and the management of patients with critical illness extends across the health care community. Our observation is that there are concerns unique to physical therapist practice in the ICU that are consistent with APTA's research agenda.⁴⁸ That research should include strategies for mitigating or preventing PICS and for managing patients who develop it. Examples of lines of research are included in the Appendix.

Accompanying this call for research focused on PICS, we propose that the language of the ICF will be advantageous to those endeavors.³⁶ As an example, Hanekom et al⁴⁹ developed an evidence-based algorithm to facilitate clinical decision making for early mobility of patients in the ICU. They found the variability in defining terms such as “activity,” “mobility,” and “mobilization” was a challenge and that differences in understanding these concepts ultimately became a barrier to communication among the caregivers.⁴⁹ To streamline communication and improve clarity among the team when describing the patient's needs, progress, and outcomes, a standard system for describing human functioning is necessary.⁵⁰ We propose that the language of the ICF provides the best resource for bridging the gap in communication by standardizing the language related to describing an individual's functioning and associated variables.⁵¹ A secondary benefit will be an orientation on outcomes, with the accompanying focus on functioning that is valued by patients and families.