Ventilator-tube holder for mobilising patients with a tracheostomy: A pilot usability study (TrachVest).

INTRODUCTION: Patients in intensive care may have a tracheostomy and be dependent on a respiratory ventilator while yet conscious and able to mobilise. Early rehabilitation is known to be key to patient recovery. However, for these patients, therapy staff members are required to manage the ventilator tubing in addition to other patient-connected equipment whilst focussing on patient mobility and progress. A technical garment (TrachVest) was designed to hold the ventilator tubing securely during these therapeutic mobilisations. METHODS: We conducted a mixed-methods study to evaluate the use of this garment in an intensive care unit setting. The aim was to determine potential effects on patient safety, its potential benefits, and usability. Research methods included direct observations, user questionnaires (quantitative and qualitative), and staff focus groups. RESULTS: A total of 14 therapy sessions with the garment were observed, involving nine patients and 10 staff. Eleven staff members participated in two focus groups, including two previously involved in the therapy sessions. Therapy sessions consisted of a range of activities including sitting on the edge of the bed, transferring from bed to chair (including use of hoists), and mobilising with walking aids. Overall, staff members felt that the garment was easy to use and would likely improve patient safety during mobilisations. The main benefits were staff reassurance, allowing them to focus on therapy, and in potentially reducing the number of staff members needed for particular activities. Patient characteristics were found to be influential on the perceived utility, and TrachVest may have greater benefit for patients who have greater physical function (e.g., able to actively participate in rehabilitation) and can mobilise at least from bed to chair. Experience of using the TrachVest and of patient capabilities was thought to be key to knowing when it would be most useful. CONCLUSION: Within this pilot usability study, participants, both staff and patients, reported that the TrachVest garment designed to support ventilator tubing during rehabilitation to be highly useable and beneficial to supporting rehabilitation in this patient group.

A 5-Year Review of a Tracheostomy Quality Improvement Initiative: Reducing Adverse Event Frequency and Severity.

OBJECTIVE: The number of tracheostomies performed annually in resource-rich countries is estimated at 250,000. While an essential procedure, approximately 20% to 30% of patients will experience at least 1 tracheostomy-related adverse event. Within tracheostomy care and across wider health care environments, quality improvement (QI) programs have been shown to reduce patient harm and improve outcomes. Herein we report on a 5-year long, tracheostomy QI initiative aimed at improving patient experience and reducing the frequency and severity of adverse events. METHODS: A 5-year (ongoing) QI initiative led by the Cardiff and Vale University Health Board tracheostomy team, within a tertiary, 1000-bedded hospital in South Wales, United Kingdom. The QI initiative has focused on 3 main themes: (1) Education and training; (2) Clinical oversight and decision making; and (3) improved data collection. Data were collected from existing tracheostomy databases. RESULTS: Over the past 5 years, we have observed a sustained reduction in both the frequency and severity of adverse events, with less than 1 patient per 100 experiencing a moderate or severe adverse event. This has resulted in improvements in patient experience and a cost reduction of £GBP364,726 per annum. DISCUSSION: Our 5-year ongoing tracheostomy QI initiative has resulted in improved outcomes with increased achievement of tracheostomy weaning markers and sustained reductions in both the frequency and severity of adverse events. IMPLICATIONS FOR PRACTICE: A continuous focus on QI is associated with improved patient and service outcomes. These improvements can be spread and scaled to benefit more patients and organizations.

Therapy professionals in critical care: A UK wide workforce survey.

Introduction: National guidelines suggest recommended staffing levels for therapies. The aim of this study was to capture information on existing staffing levels, roles and responsibilities and service structures. Methods: An observational study using online surveys distributed to 245 critical care units across the United Kingdom (UK). Surveys consisted of a generic and five profession specific surveys. Results: Eight hundred sixty-two responses were received from 197 critical care units across the UK. Of those that responded, over 96% of units had input from dietetics, physiotherapy and SLT. Whereas only 59.1% and 48.1% had an OT or psychology service respectively. Units with ring fenced services had improved therapist to patient ratios. Discussion: There is significant variation in access to therapists for patients admitted to critical care in the UK, with many services not having services for core therapies such as psychology and OT. Where services do exist, they fall below the recommended guidance.

Protected therapy services for critical care: A subanalysis of the UK-wide workforce survey.

BACKGROUND: The existing United Kingdom (UK) allied health professional (AHP) workforce in critical care does not meet national standards, with widespread variation in the source of funding, service availability, and regularity of input. OBJECTIVES: The aim of this subanalysis was to determine the impact of protected services on the involvement of AHPs on direct and nondirect aspects of patient care. METHODS: This is a subanalysis of the previously published AHPs in critical care UK-wide workforce survey, an observational study using online surveys distributed to 245 critical care units across the UK. RESULTS/FINDINGS: Services with protected funding provided more daily input within critical care. This was most apparent for occupational therapy where daily input varied from 82.1% of units with protected services compared to just 10.3% in those without (p < 0.001). For all professions, most notably occupational therapy and speech and language therapy, protected services increased the regularity in which specific interventions were completed and had impact on involvement in nonclinical aspects of care including involved in multidisciplinary team meetings, clinical governance, and research. CONCLUSIONS: The absence of protected AHP services reduces compliance with national standards for therapy workforce. Based on these findings, UK and international critical care guidelines should promote protected AHP services for critical care.

Comparison of perceptions and barriers to mobilization in critical care: A comparison of nursing staff and physiotherapists-A single-site service evaluation.

BACKGROUND: Mobilization is a key component in the recovery of those admitted to critical care. However, previous research has demonstrated challenges in the implementation of mobilization within critical care, including staff knowledge, attitudes, and behaviours. AIM: The aim of the current study was to explore the perceived barriers and limitations to mobilization from the perspective of nursing staff, and to compare these with physiotherapists. STUDY DESIGN: Single-site service evaluation utilizing the patient mobilizations attitudes and beliefs survey for ICU and locally developed barriers to rehabilitation questionnaire. RESULTS: About 135 participants (126 nurses and 9 physiotherapists) were invited to anonymously complete the questionnaires (either paper or electronic), with a response rate of 73.0% (n = 92) for nursing staff and 100% for physiotherapists. Nursing staff reported significantly higher perceived barriers to rehabilitation on both questionnaires when compared with physiotherapy staff, which was not associated with years of experience within critical care. Behavioural barriers were most frequent in both professions which included items such as time availability and presence of perceived contra-indications to mobilization. CONCLUSION: Nursing staff reported greater perceived barriers to rehabilitation when compared with physiotherapists. Further quality improvement projects are now required to reduce these barriers and assist the implementation of mobilization as part of the rehabilitation process. RELEVANCE TO CLINICAL PRACTICE: Rehabilitation is an essential element of practice within critical care. Understanding the system, local and personal barriers will allow for improvement projects to enhance the delivery of care and improve clinical outcomes.

Exploration of therapists' views of practice within critical care.

INTRODUCTION: Therapists are increasing recognised as core members of the critical care multiprofessional team. Each therapy profession provides specialist assessments and interventions, but also work collaboratively across the rehabilitation pathway. Despite inclusion in several national guidance documents, there remains a lack of evidence regarding the perceived role of therapists working within critical care, the unique contributions of each profession and opinion on the day-to-day tasks and responsibilities of each therapy profession. METHOD: A descriptive qualitative methodology was used involving seven focus groups. Purposeful sampling was used to recruit therapists via professional specialist interest groups. All focus groups were uniprofessional and discussions based on a predesigned framework. Data were analysed thematically. RESULTS: Participants (n=65) from across the UK were recruited to seven focus groups with an average of 18.3 years postgraduate clinical experience of which 11.6 years was within critical care. Three core themes were generated from 875 codes and 237 potential subthemes. The final themes were (1) professional characteristics; (2) multidisciplinary team and (3) staffing. An additional theme of 'COVID-19 pandemic' was also identified. Findings were similar across all profession groups particularly regarding the need for holistic, patient-centred care. Expected variation was observed for professional characteristics especially regarding specific assessments and interventions. DISCUSSION: Therapy services are an essential component to the delivery of critical care especially regarding recovery and rehabilitation. Through three core themes, this qualitative study has provided new evidence of the perceptions and opinions of the role that therapists undertake within critical care.

Enhancing care of patients requiring a tracheostomy: A sustained quality improvement project.

INTRODUCTION: Within the UK approximately 5000 surgical and 12,000 percutaneous tracheostomies are performed annually. Whilst an essential component of patient care, the presence of a tracheostomy is not without concern. Landmark papers have demonstrated recurrent themes related to the provision of training, staff and equipment, leading to avoidable patient harm, life-altering morbidity and mortality. The development of the Global Tracheostomy Collaborative (GTC) and the Improving Tracheostomy Care (ITC) project have provided the necessary infrastructure to make improvements, with individual organizations responsible for its implementation. METHOD: This quality improvement project, funded by the NHS Wales Critical Care and Trauma Network, developed a dedicated tracheostomy team to improve the quality of care provided to those patients requiring a tracheostomy through staff education, equipment standardisation and multidisciplinary tracheostomy ward rounds. Global Tracheostomy membership was funded through involvement in the ITC project. RESULTS: Formal tracheostomy teaching was delivered by the tracheostomy team to 165 clinicians involved in tracheostomy care. Improvements in self-assessed confidence with knowledge and were observed for all aspects of tracheostomy care. Standardisation and centralisation resulted in reduction in waste and unnecessary variation. Compliance with 'emergency tracheostomy blue box' availability with an increase from 5% to 100%. Comparison of data from the QI period against baseline data, demonstrated improvement in rates of decannulation, and non-significant improvements in time to decannulation, critical care and hospital length of stay. Additionally, there were associated reductions in adverse events. CONCLUSION: This QI project, supported by involvement with the GTC and ITC, resulted in reductions in adverse events, improved patient safety, non-significant reduction in time to achieve weaning milestones and a reduction in hospital length of stay.

Minimum standards of clinical practice for physiotherapists working in critical care settings in the United Kingdom: A modified Delphi technique.

INTRODUCTION: Across the United Kingdom, physiotherapy for critical care patients is provided 24 h a day, 7 days per week. There is a national drive to standardise the knowledge and skills of physiotherapists which will support training and reduce variability in clinical practice. METHODS: A modified Delphi technique using a questionnaire was used. The questionnaire, originally containing 214 items, was completed over three rounds. Items with no consensus were included in later rounds along with any additional items suggested. RESULTS: In all, 114 physiotherapists from across the United Kingdom participated in the first round, with 102 and 92 completing rounds 2 and 3, respectively. In total, 224 items were included: 107 were deemed essential as a minimum standard of clinical practice; 83 were not essential and consensus was not reached for 34 items. ANALYSIS/CONCLUSION: This study identified 107 items of knowledge and skills that are essential as a minimum standard for clinical practice by physiotherapists working in United Kingdom critical care units.

Effect of hypercapnia on respiratory and peripheral skeletal muscle loss during critical illness - A pilot study.

INTRODUCTION: Critical illness has profound effects on muscle strength and long-term physical morbidity. However, there remains a paucity of evidence for the aetiology of critical illness related weakness. Recent animal model research identified that hypercapnia may reduce the rate of muscle loss. The aim of this study was to determine the effect of hypercapnia on respiratory and peripheral skeletal muscle in patients with critical illness. METHODS: A pilot observational study of mechanically ventilated critically ill patients at a tertiary critical care unit who were retrospectively categorised as: 1) Respiratory failure with normocapnia; 2) Respiratory failure with hypercapnia; and 3) brain injury. Diaphragm thickness and quadriceps rectus femoris cross-sectional area (RFCSA) were measured using ultrasound imaging at baseline and at days 3, 5, 7 and 10 of mechanical ventilation. RESULTS: Significant reductions in RFCSA muscle loss were observed for all time-points when compared to baseline [day 10: -14.9%±8.2 p< 0.001], and in diaphragm thickness between baseline and day 7 [day 7: -5.8%±9.5 p=0.029). No correlation was identified between the rate of muscle mass loss in the diaphragm and RFCSA. CONCLUSION: In this pilot study, peripheral skeletal muscle weakness occurred early and rapidly within the critical care population, irrespective of carbon dioxide levels.

Critical Care Functional Rehabilitation Outcome Measure: developing a validated measure.

INTRODUCTION: In 2009, the National Institute for Health and Clinical Excellence (NICE) developed guidelines, which recognized that rehabilitation plays a vital role in recovery from illness and in returning patients to their previous activity levels. NICE recommended the use of valid and reliable "outcome measures" as an evaluation tool. AIM: To develop and evaluate the validity and reliability of a new Critical Care Functional Rehabilitation Outcome Measure (CcFROM). METHOD: The CcFROM was developed by physiotherapists working within the authors' institution and was based on an evaluation of current measures. Face and content validity were investigated using a questionnaire posted to 21 physiotherapists. Same-day and between-day intra-rater reliability and inter-rater reliability were investigated by three physiotherapists viewing 20 physiotherapy rehabilitation sessions and completing the CcFROM. Data were analysed for relative and absolute reliability. RESULTS: The questionnaire demonstrated very high face validity and moderate content validity. 43% of the physiotherapists also suggested including an upper limb activity. Clinically acceptable same-day and between-day intra-rater reliability was demonstrated with ICCs of 0.985 (CI, 0.968-0.993) and 0.985 (CI, 0.871-0.972), respectively. Inter-rater reliability was recorded with an ICC of 0.906 (CI: 0.816-0.959). CONCLUSION: This study has shown that the CcFROM is a valid and reliable outcome measure for use in Critical Care.