Seguimiento Funcional hasta Seis Meses después de Sobrevivir a Cuidados Intensivos: Lecciones aprendidas de un Estudio Chileno Multicéntrico / Functional follow-up six months after surviving intensive care: lessons learned from a Chilean multicenter study

Introducción. Las tasas de retención en los estudios de seguimiento oscilan entre el 32 y 100%, demostrando el desafío que implica realizar estudios longitudinales de sobrevivientes de la unidad de cuidados intensivos (UCI). Objetivo. Identificar las estrategias implementadas y lecciones aprendidas en un estudio prospectivo multicéntrico de seguimiento de sobrevivientes de la UCI durante la pandemia. Métodos. Estudio post-hoc de las lecciones aprendidas mediante encuestas y entrevistas dirigidas a explorar la experiencia de los investigadores y coordinadores del estudio IMPACCT COVID-19, realizado en siete centros chilenos entre octubre 2020 y abril 2021 evaluando el síndrome post-cuidados intensivos de sobrevivientes hasta seis meses después. Resultados. Identificamos ocho lecciones: 1) selección de instrumentos de medición, 2) identificación de centros participantes, 3) aprobación del estudio, 4) financiamiento, 5) capacitación de evaluadores, 6) coordinación/aseguramiento de calidad, 7) reclutamiento y 8) seguimiento de pacientes. Incluso durante el primer año de pandemia, reclutamos 252 pacientes a una tasa de 1,4 pacientes/día con una retención del 48% a los 6 meses de seguimiento. El uso de redes académicas existentes y las estrategias de comunicación entre investigadores, coordinadores y evaluadores fueron aspectos positivos; mientras que la fidelización con evaluadores al egreso de la UCI y con pacientes durante el seguimiento son aspectos que deberían considerarse en futuros estudios. Conclusiones. Se evaluaron más de 250 pacientes en seis meses durante la pandemia, con tasas de retención post UCI acorde a la literatura. Futuros estudios debiesen optimizar los procesos de medición y de seguimiento para minimizar la pérdida de pacientes.

Background. Retention rates of follow-up studies range from 32 to 100%, demonstrating the challenge to conduct longitudinal studies of intensive care unit (ICU) survivors. Objective. To identify the strategies implemented and lessons learned in a multicenter prospective follow-up study of ICU survivors during pandemic times. Methods. Post-hoc study of lessons learned through surveys and interviews aimed at exploring the experience of the researchers and coordinators of the IMPACCT COVID-19 study. The original study was performed in seven Chilean sites between October 2020 and April 2021 evaluating the post-intensive care syndrome of survivors up to six-month follow-up. Results. We identified eight lessons: 1) selection of measurement instruments, 2) identification of participating sites, 3) Study approval, 4) funding, 5) evaluators training, 6) coordination/quality assurance, 7) recruitment, and 8) patient follow-up. Even during the first year of the pandemic, we recruited 252 patients at a rate of 1.4 patients/day with a retention rate of 48% at 6 months of follow-up. The use of existing academic networks and communication strategies between researchers, coordinators and evaluators were positive aspects; while evaluators fidelity at ICU discharge and patient engagement during follow-up are aspects should be considered. Conclusions. More than 250 patients were evaluated in six months during the pandemic, with post-ICU retention rates consistent with the literature. Future studies should optimize measurement and monitoring processes to minimize patient atrition.

Six-month post-intensive care outcomes during high and low bed occupancy due to the COVID-19 pandemic: A multicenter prospective cohort study.

INTRODUCTION: The COVID-19 pandemic can be seen as a natural experiment to test how bed occupancy affects post-intensive care unit (ICU) patient's functional outcomes. To compare by bed occupancy the frequency of mental, physical, and cognitive impairments in patients admitted to ICU during the COVID-19 pandemic. METHODS: Prospective cohort of adults mechanically ventilated >48 hours in 19 ICUs from seven Chilean public and private hospitals. Ninety percent of nationwide beds occupied was the cut-off for low versus high bed occupancy. At ICU discharge, 3- and 6-month follow-up, we assessed disability using the World Health Organization Disability Assessment Schedule 2.0. Quality of life, mental, physical, and cognitive outcomes were also evaluated following the core outcome set for acute respiratory failure. RESULTS: We enrolled 252 participants, 103 (41%) during low and 149 (59%) during high bed occupancy. Patients treated during high occupancy were younger (P50 [P25-P75]: 55 [44-63] vs 61 [51-71]; p<0.001), more likely to be admitted due to COVID-19 (126 [85%] vs 65 [63%]; p<0.001), and have higher education qualification (94 [63%] vs 48 [47%]; p = 0.03). No differences were found in the frequency of at least one mental, physical or cognitive impairment by bed occupancy at ICU discharge (low vs high: 93% vs 91%; p = 0.6), 3-month (74% vs 63%; p = 0.2) and 6-month (57% vs 57%; p = 0.9) follow-up. CONCLUSIONS: There were no differences in post-ICU outcomes between high and low bed occupancy. Most patients (>90%) had at least one mental, physical or cognitive impairment at ICU discharge, which remained high at 6-month follow-up (57%). CLINICAL TRIAL REGISTRATION: NCT04979897 (clinicaltrials.gov).

Inter-observer reliability of trained physiotherapists on the Functional Status Score for the Intensive Care Unit Chilean-Spanish version.

Purpose: Evaluate inter-observer reliability of trained physiotherapists administering the Chilean-Spanish version of the Functional Status Score for the Intensive Care Unit (FSS-ICU).Methods: Six adult patients in a medical-surgical ICU were assessed and video-recorded by 1 of 2 expert physiotherapists. Twelve physiotherapists were then trained using recommended Spanish-language FSS-ICU materials. The 12 physiotherapists independently scored the FSS-ICU for the 6 video-recorded patients. Intraclass Correlation Coefficient (ICC) was used to evaluate the inter-observer reliability, and modified Bland-Altman plots evaluated agreement between the physiotherapists and experts.Results: This study was performed between May and August 2018. The FSS-ICU total score had a median score of 18 (range: 6 to 34) for the 6 patients. The ICC of the total score was 0.96 (95% CI, 0.92 to 1.00), and for each of the 5 individual FSS-ICU tasks, the ICC ranged between 0.87 and 0.92. The modified Bland-Altman plot revealed a mean difference of 0.6 (95% limits of agreement: -3.3 to 4.5).Conclusions: Twelve trained physiotherapists had excellent inter-observer reliability when administering the Chilean-Spanish FSS-ICU using videos of six critically ill patients, and had excellent agreement with an expert, revealing differences within the established minimal important difference. These findings provide new data supporting clinimetric properties of the Chilean-Spanish FSS-ICU.

Evaluating a Muscle Ultrasound Education Program: Theoretical Knowledge, Hands-on Skills, Reliability, and Satisfaction of Critical Care Physiotherapists.

OBJECTIVE: To evaluate learning results of critical care physiotherapists participating in a muscle ultrasound (MUS) educational program. DESIGN: Cross-sectional study. SETTING: A custom-made 20-hour MUS course was performed over a 2-week time period, including knobs familiarization, patient positioning, anatomic landmarks, image acquisition, and limb muscle measurements. PARTICIPANTS: Nineteen critical care physiotherapists with little to no prior experience in ultrasound (N=19). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Theoretical knowledge, hands-on skills acquisition, and satisfaction were assessed. Inter- and intrarater reliability on landmarks, thickness, and pennation angle of quadriceps between participants was evaluated using intraclass correlation coefficients (ICCs). Reliability among instructors measured prior to the course was also reported as a reference. RESULTS: The percentage score (mean±SD) of knowledge questionnaires was 69±11 (pre-course), 89±10 (post-course), and 92±9 (hands-on skills). Course satisfaction scores ranged from 90%-100%. Pooled interrater reliability of participants (median ICC [interquartile range]) was good (0.70 [0.59-0.79]) for thickness, moderate (0.47 [0.46-0.92]) for landmarks, and absent (0.00 [0.00-0.05]) for pennation angle and the intrarater reliability was good (0.76 [0.51-0.91]) for thickness and weak (0.35 [0.29-0.52]) for pennation angle. Interrater ICC values for instructors were excellent (0.90) for thickness, good (0.67) for landmarks, and moderate (0.41) for pennation angle and intrarater ICC values were excellent (0.94) for thickness and good (0.75) for pennation angle. CONCLUSIONS: Although our sample was quite small and homogeneous, increased theoretical knowledge, high hands-on performance acquisition, and good satisfaction of physiotherapists were observed. Reliability was moderate to excellent for thickness and landmarks and absent to weak for pennation angle. Landmarking and pennation angle remain challenges for physiotherapist training in the application of MUS. Further studies are needed to identify variables that could modify reliability during MUS training.

Impact on Mental, Physical and Cognitive functioning of a Critical care sTay during the COVID-19 pandemic (IMPACCT COVID-19): protocol for a prospective, multicentre, mixed-methods cohort study.

INTRODUCTION: The ongoing pandemic could affect the duration, variety and severity of the mental, physical, and cognitive impairments intensive care unit (ICU) survivors and their families frequently present. We aim to determine the impact of the COVID-19 pandemic on the mental, physical, and cognitive health of survivors, the experience of their families and their treating healthcare professionals. METHODS AND ANALYSIS: Prospective, multicentre, mixed-methods cohort study in seven Chilean ICUs. SAMPLE: 450 adults, able to walk independently prior to admission, in ICU and mechanical ventilation >48 hours with and without COVID-19. Clinical Frailty Scale, Charlson comorbidity index, mobility (Functional Status Score for the Status Score for the Intensive Care Unit) and muscle strength (Medical Research Council Sum Score) will be assessed at ICU discharge. Cognitive functioning (Montreal Cognitive Assessment-blind), anxiety and depression (Hospital Anxiety and Depression Scale), post-traumatic stress (Impact of Event Scale-Revised) symptoms, disability (WHO Disability Assessment Schedule 2.0), quality of life (European Quality of Life Health Questionnaire), employment and survival will be assessed at ICU discharge, 3 months and 6 months. A sample will be assessed using actigraphy and the Global Physical Activity Questionnaire at 6 months after ICU discharge. Trajectories of mental, physical, and cognitive impairments will be estimated using multilevel longitudinal modelling. A sensitivity analysis using multiple imputations will be performed to account for missing data and loss-to-follow-up. Survival will be analysed using Kaplan-Meier curves. The perceptions of family members regarding the ICU stay and the later recovery will be explored 3 months after discharge. Healthcare professionals will be invited to discuss the challenges faced during the pandemic using semistructured interviews. Interviews will be thematically analysed by two independent coders to identify the main themes of the experience of family members and healthcare professionals. ETHICS AND DISSEMINATION: The study was approved by the Clinica Alemana Universidad del Desarrollo Ethics Committee (2020-78) and each participating site. Study findings will be published in peer-reviewed journals and disseminated through social media and conference meetings. TRIAL REGISTRATION NUMBER: NCT04979897.

Respiratory Support Adjustments and Monitoring of Mechanically Ventilated Patients Performing Early Mobilization: A Scoping Review.

This scoping review is aimed to summarize current knowledge on respiratory support adjustments and monitoring of metabolic and respiratory variables in mechanically ventilated adult patients performing early mobilization. DATA SOURCES: Eight electronic databases were searched from inception to February 2021, using a predefined search strategy. STUDY SELECTION: Two blinded reviewers performed document selection by title, abstract, and full text according to the following criteria: mechanically ventilated adult patients performing any mobilization intervention, respiratory support adjustments, and/or monitoring of metabolic/respiratory real-time variables. DATA EXTRACTION: Four physiotherapists extracted relevant information using a prespecified template. DATA SYNTHESIS: From 1,208 references screened, 35 documents were selected for analysis, where 20 (57%) were published between 2016 and 2020. Respiratory support settings (ventilatory modes or respiratory variables) were reported in 21 documents (60%). Reported modes were assisted (n = 11) and assist-control (n = 9). Adjustment of variables and modes were identified in only seven documents (20%). The most frequent respiratory variable was the Fio2, and only four studies modified the level of ventilatory support. Mechanical ventilator brand/model used was not specified in 26 documents (74%). Monitoring of respiratory, metabolic, and both variables were reported in 22 documents (63%), four documents (11%) and 10 documents (29%), respectively. These variables were reported to assess the physiologic response (n = 21) or safety (n = 13). Monitored variables were mostly respiratory rate (n = 26), pulse oximetry (n = 22), and oxygen consumption (n = 9). Remarkably, no study assessed the work of breathing or effort during mobilization. CONCLUSIONS: Little information on respiratory support adjustments during mobilization of mechanically ventilated patients was identified. Monitoring of metabolic and respiratory variables is also scant. More studies on the effects of adjustments of the level/mode of ventilatory support on exercise performance and respiratory muscle activity monitoring for safe and efficient implementation of early mobilization in mechanically ventilated patients are needed.

Construct Validity of the Chilean-Spanish Version of the Functional Status Score for the Intensive Care Unit: A Prospective Observational Study Using Actigraphy in Mechanically Ventilated Patients.

OBJECTIVE: To evaluate the construct validity (hypotheses testing) of the Chilean-Spanish version of the Functional Status Score for the Intensive Care Unit (FSS-ICU) using continuous actigraphy from intensive care unit (ICU) admission to ICU discharge. DESIGN: The Chilean-Spanish version of the FSS-ICU was used in a prospective observational study to mainly evaluate its correlation with actigraphy variables. The FSS-ICU was assessed on awakening and at ICU discharge, while actigraphy variables were recorded from ICU admission to ICU discharge. SETTING: A 12-bed academic medical-surgical ICU. PARTICIPANTS: Mechanically ventilated patients (N=30), of 92 patients screened. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Construct validity of the FSS-ICU Chilean-Spanish version was assessed by testing 12 hypotheses, including the correlation with activity counts, activity time (>99 counts/min), inactivity time (0-99 counts/min), muscle strength, ICU length of stay, and duration of mechanical ventilation. RESULTS: The median FSS-ICU was 19 points (interquartile range [IQR], 10-26 points) on awakening and 28.5 points (IQR, 22-32 points) at ICU discharge. There was no floor/ceiling effect of the FSS-ICU at awakening (0%/0%) and only a ceiling effect at ICU discharge that was acceptable (0%/10%). Less activity time was associated with better mobility on the FSS-ICU at both awakening (ρ=-0.62, P<.001) and ICU discharge (ρ=-0.79, P<.001). Activity counts and activity time were not correlated as expected with the FSS-ICU. CONCLUSIONS: The Chilean-Spanish FSS-ICU had a strong correlation with inactivity time during the ICU stay. These findings enhance the available clinimetric properties of the FSS-ICU.

Settings and monitoring of mechanical ventilation during physical therapy in adult critically ill patients: protocol for a scoping review.

INTRODUCTION: Early mobilisation has been extensively advocated to improve functional outcomes in critically ill patients, even though consistent evidence of its benefits has remained elusive. These conflicting results could be explained by a lack of knowledge on the optimal dosage of physical therapy and a mismatch between ventilatory support and exercise-induced patient ventilatory demand. Modern mechanical ventilators provide real-time monitoring of respiratory/metabolic variables and ventilatory setting that could be used for physical therapy dosage or ventilatory support titration, allowing individualised interventions in these patients. The aim of this review is to comprehensively map and summarise current knowledge on adjustments of respiratory support and respiratory or metabolic monitoring during physical therapy in adult critically ill mechanically ventilated patients. METHODS AND ANALYSIS: This is a scoping review protocol based on the methodology of the Joanna-Briggs-Institute. The search strategy will be conducted from inception to 30 June 2019 as a cut-off date in PubMed, CINAHL, Rehabilitation & Sport Medicine, Scielo Citation Index, Epistemónikos, Clinical Trials, PEDro and Cochrane Library, performed by a biomedical librarian and two critical care physiotherapists. All types of articles will be selected, including conference abstracts, clinical practice guidelines and expert recommendations. Bibliometric variables, patient characteristics, physical therapy interventions, ventilator settings and respiratory or metabolic monitoring will be extracted. The identified literature will be analysed by four critical care physiotherapists and reviewed by a senior critical care physician. ETHICS AND DISSEMINATION: Ethical approval is not required. The knowledge-translation of the results will be carried out based on the End-of-Grant strategies: diffusion, dissemination and application. The results will be published in a peer-review journal, presentations will be disseminated in relevant congresses, and recommendations based on the results will be developed through training for mechanical ventilation and physical therapy stakeholders.

Chilean version of the Functional Status Score for the Intensive Care Unit: a translation and cross-cultural adaptation. / Versión chilena de la Functional Status Score for the Intensive Care Unit: traducción y adaptación transcultural.

BACKGROUND: The Functional Status Score for the Intensive Care Unit (FSS-ICU) is a valid and reliable instrument to measure physical functioning in the intensive care unit setting. Translation and cross-cultural adaptation in Chile has not been published for the FSS-ICU. AIM: To translate and cross-culturally adapt all associated documents of the original FSS-ICU for Chile. METHOD: The Spanish version of FSS-ICU, available at www.ImproveLTO.com, was used as the starting point. This version was previously translated, with the original FSS-ICU developers, following established guidelines for this process. The Chilean pocket card version was newly developed based on the English version at www.ImproveLTO.com. Cognitive interviews were conducted for the adaptation of the FSS-ICU and pocket card version to assess understanding of relevant stakeholders (i.e., Chilean intensive care unit physiotherapists). Adaptations to the translation were made when agreement among the physiotherapists was less than 80%. RESULTS: Cognitive interviews of the Chilean FSS-ICU (85 items) and pocket card version (18 items) were performed with 30 Chilean physiotherapists from 18 hospitals (14 public and 4 private). During the interviews, modest adaptations mainly made in the general guidelines and specific instructions for three items of the FSS-ICU and two items of the pocket card. Finally, the frequently asked questions, pocket card and full version of the FSS-ICU were developed. The original developers accepted all adaptations. CONCLUSIONS: The Chilean version of the FSS-ICU was easy to understand by the physiotherapists. The FSS-ICU is freely available for non-commercial clinical and research use by Chilean Spanish-speakers.

INTRODUCCIÓN: La Functional Status Score for the Intensive Care Unit (FSS-ICU) es un instrumento válido y confiable para medir funcionamiento físico en unidades de cuidados intensivos. Sin embargo, la traducción y adaptación trans-cultural de la FSS-ICU en Chile no ha sido publicada. OBJETIVO: Traducir y adaptar transculturalmente todos los documentos asociados de la FSS-ICU original para Chile. MÉTODO: Se utilizó como punto de partida la versión en español de la FSS-ICU, disponible en www.ImproveLTO.com. Esta versión se tradujo previamente junto a los desarrolladores originales de la FSS-ICU, siguiendo las recomendaciones establecidas para este proceso. La versión de bolsillo chilena se desarrolló recientemente en base a la versión original en inglés. Se realizaron entrevistas cognitivas a kinesiólogos de la unidad de cuidados intensivos para evaluar la comprensión de la FSS-ICU y versión de bolsillo. Las adaptaciones se realizaron cuando el acuerdo entre los kinesiólogos fue inferior al 80%. RESULTADOS: Se realizaron las entrevistas cognitivas de la FSS-ICU en español (85 ítems) y versión de bolsillo (18 ítems) en 30 kinesiólogos chilenos provenientes de 18 diferentes hospitales (14 públicos y 4 privados). Durante las entrevistas se realizaron adaptaciones principalmente en las guías generales e instrucciones específicas para tres ítems de la FSS-ICU y dos ítems de la versión de bolsillo. Finalmente, se desarrollaron las preguntas frecuentes, la versión de bolsillo y la versión completa de la FSS-ICU. Todas las adaptaciones fueron aceptadas por los desarrolladores originales. CONCLUSIONES: La versión chilena de la FSS-ICU fue fácil de entender por los kinesiólogos. La FSS-ICU está disponible gratis para uso clínico e investigación no comercial en Chile.