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2011 25: 771 originally published online 19 April 2011Clin Rehabil Quinette Louw

an Hanekom, Rik Gosselink, Elizabeth Dean, Helena van Aswegen, Ronel Roos, Nicolino Ambrosino andtranslation into practice

mobilization of critically ill patients: synthesis of evidence and expert opinion and itsThe development of a clinical management algorithm for early physical activity and

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Rehabilitation in practice

The development of a clinicalmanagement algorithm for early

physical activity and mobilizationof critically ill patients: synthesis of evidence and expert opinion andits translation into practice

Susan Hanekom1, Rik Gosselink

2, Elizabeth Dean

3,

Helena van Aswegen4, Ronel Roos

5,

Nicolino Ambrosino6

and Quinette Louw1

AbstractObjective: To facilitate knowledge synthesis and implementation of evidence supporting early physicalactivity and mobilization of adult patients in the intensive care unit and its translation into practice, wedeveloped an evidence-based clinical management algorithm.Methods: Twenty-eight draft algorithm statements extracted from the extant literature by theprimary research team were verified and rated by scientist clinicians ( n 7) in an electronic threeround Delphi process. Algorithm statements which reached a priori defined consensus semi-interquartilerange < 0.5 were collated into the algorithm.Results: The draft algorithm statements were edited and six additional statements were formulated. The34 statements related to assessment and treatment were grouped into three categories. Category Aincluded statements for unconscious critically ill patients; Category B included statements for stable andcooperative critically ill patients, and Category C included statements related to stable patients withprolonged critical illness. While panellists reached consensus on the ratings of 94% (32/34) of the algo-rithm statements, only 50% (17/34) of the statements were rated essential.

1 Department of Interdisciplinary Health Sciences, Faculty of Health Sciences, Stellenbosch University, Cape Town, SouthAfrica2 Faculty of Kinesiology and Rehabilitation Sciences, KatholiekeUniversiteit Leuven, Tervuursevest, Leuven, Belgium3 Department of Physical Therapy, Faculty of Medicine,University of British Columbia, Vancouver, British Columbia,Canada4 Physiotherapy Department, Faculty of Health Sciences,University of the Witwatersrand, Parktown, South Africa

5 Department of Physiotherapy, Medical School, University of theWitwatersrand, Parktown, South Africa6 Cardio-Thoracic Department, University Hospital Pisa,Weaning CentreAuxilium Vitae Volterra, Italy

Corresponding author:Susan Hanekom, Department of Interdisciplinary HealthSciences, Faculty of Health Sciences, Stellenbosch University,PO Box 19063, Cape Town 7500, South AfricaEmail: [email protected]

Clinical Rehabilitation25(9) 771787! The Author(s) 2011Reprints and permissions:sagepub.co.uk/journalsPermissions.navDOI: 10.1177/0269215510397677cre.sagepub.com

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Conclusion: The evidence-based clinical management algorithm developed through an established Delphiprocess of consensus by an international inter-professional panel provides the clinician with a synthesis of current evidence and clinical expert opinion. This framework can be used to facilitate clinical decisionmaking within the context of a given patient. The next step is to determine the clinical utility of thisworking algorithm.

KeywordsPhysiotherapy, rehabilitation, ICU, Delphi, critical care

Received: 19 May 2010; accepted: 19 December 2010

Introduction

The early mobilization of critically ill adultpatients is a relatively new managementapproach advocated to address respiratory fail-ure 1 and limit the disability associated withintensive care unit (ICU) acquired weakness. 24

This therapeutic approach has been reported inclinical studies 57 and has been recommended bythe European Respiratory Society andEuropean Society of Intensive Care MedicineTask Force on Physiotherapy for Critically IllPatients. 8 While the detrimental physiological

effects of recumbency and restricted mobilityon organ systems in typically healthy subjectshave been widely reported for many years, 913

issues related to the use of early mobilizationof critically ill patients as a therapeutic optionhave only recently been a shared focus of inter-est to interprofessional teams practising in theICU. 1,2,5,6,14

The majority of physiotherapists surveyedin Australia, 15 South Africa 16 and the UK 17

offer some form of rehabilitation in the ICU,

while physiotherapists in the USA18

reportedgreater involvement during the recovery fromcritical illness. Apparently underutilized, only10% of Australian responders reported thatexercise therapy is indicated for all criticallyill patients who are physiologically stableand have no contra-indications. A surveyby Skinner and colleagues 15 reported that

the decision to mobilize a patient in the ICU

was predominately made by physiotherapists.However, large variations were noted in thesafety criteria used to initiate and monitor exer-cise as well as in the dosage of therapy reportedby physiotherapists. 15

Clinical decisions about patient manage-ment incorporate a range of factors, althougha necessary element should be the evidenceavailable, albeit limited. 19 To address uncer-tainties among clinicians about early mobiliza-tion, we previously conducted a systematic

review of the literature.20

Although our nd-ings illustrated that evidence to support theuse of early mobilization in critically illpatients is emerging, the published reportslacked details about the clinical decision-making factors to be considered by clinicianswhen mobilizing a patient. This lack of prac-tical information to inform clinical decisionmaking may be a barrier to the use of earlymobilization as a therapeutic option in thispopulation. The inconsistent and variable

implementation strategies which have beenreported for early mobilization, support thisreasoning. 2,15,2124 Variations in practice mayreect a paucity of research and challenges intranslating and implementing evidence intoclinical practice. 19

The formulation of evidence-based clinicalguidelines and/or best practice recommendations

772 Clinical Rehabilitation 25(9)



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has been proposed as a means of facilitatingclinical decision making. 8,14,19,2527 An algo-rithm developed by a group of recognizedexperts who appraise and contextualize evidencein the eld constitutes one means of facilitatingthe translation of best practice recommenda-tions into clinical practice potentially makingthe uptake of evidence by practitioners morecompelling. 5,28 The reported cost-effectivenessof using practice guidelines in the ICU lendsfurther support for developing an evidence-based clinical management algorithm withrespect to mobilizing patients in the ICU, themost expensive care setting. 29,30

The problem of limited evidence is notunique to the eld of critical care. In recent

years, Delphi expert panels have been used inmedical elds to help develop best practice rec-ommendations when only limited or equivocalevidence is available. 3133 This approach isless commonly applied in critical care, but itcould be a pragmatic method to supportclinical decision making, particularly related tonew advances in critical care interventions.Furthermore, the methodology provides thetools to incorporate clinical expertise in the clin-ical decision-making process, specically in grey

areas of clinical practice.34

The importance of clinical expertise in evidence-based practice iswidely recognised. 34,35

This work forms part of a larger projectin which a comprehensive evidence-based frame-work consisting of ve clinical managementalgorithms for the physiotherapeutic manage-ment of patients in ICU was developed througha process of evidence synthesis and Delphiconsensus. The aim of which was to facilitateevidence-based clinical decision making of phys-

iotherapists in the ICU and determine the effecton patient outcome. 20,36 The purpose of thispaper is to report on the development of anevidence-based clinical management algorithmto facilitate knowledge synthesis, translationand implementation with respect to early phys-ical activity and mobilization of critically illpatients.

MethodsEthical approval was provided by the ethicscommittee of Stellenbosch University andparticipants provided informed consent. Thestudy entailed a three-round Delphi processto formulate and rate the importance of draft algorithm statements. A systematicreview of the literature was conducted toanswer the specic PICO (population; interven-tion; comparison; outcome) question: Is itsafe and effective to mobilize/exercise intubatedand ventilated adult patients in the ICU?(safe no harmful outcomes, effective improved function; functional capacity;length of stay; time on ventilator; muscle

strength). The search was limited to Englishlanguage papers reporting on the adult popula-tion. Grey literature was not consulted.Experimental and observational studies wereconsidered. Six electronic databases weresearched, including Pubmed, CINAHL, Webof Science, PEDRO, Cochrane, Sciencedirect and TRIP. Manual searching throughthe contents of the South African Journal of Critical Care (SAJCC) and the South AfricanJournal of Physiotherapy (SAJP) was also

done. Two critical appraisal tools were usedto appraise the methodology of the eligiblepapers. Systematic review methodology andndings are available at www0.sun.ac.za/Physiotherapy_ICU_algorithm.

Based on the systematic review ndings theprimary research team (SH;QL) drafted vebest practice recommendations based on theGrades of Recommendation, Assessment,Development, and Evaluation (GRADE) for-mulation. 28,37 Based on data extracted from

the identied studies, 28 draft algorithm state-ments were formulated and grouped into threecategories. Category A included statementsrelated to assessment and treatment of uncon-scious critically ill patients who are unable toinitiate activity; Category B included statementson assessment and treatment of stable and coop-erative critically ill patients, who are able to

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initiate activity; and Category C included state-ments related to stable patients with prolongedcritical illness.

Selection of rehabilitation subgroupDelphi panellistsPotential panellists were identied during thesystematic review process used in the develop-ment of a comprehensive evidence-based frame-work for the physiotherapeutic management of patients in ICU. Scientist clinicians were eligi-ble to participate in the rehabilitation subpanelif 1) they had published predominately inthe area of rehabilitation and if 2) the papers

were indexed in Medline, CINAHL, Web of Science, PEDro, Science Direct, Cochrane,TRIP or published in the SAJP or SAJCC.Researchers were excluded if they were not elec-tronically contactable or declined the invitation(Figure 1).

InstrumentationAn interactive website linked to a password-protected database was developed to distrib-ute information and collate responses from theDelphi panel. The website contained the draftbest practice recommendations, algorithm state-ments and evidence synthesis reports. The func-tionality of the database changed in relation tothe specic round of the three-round Delphiprocess (Figure 2).

Delphi study procedureEach round lasted two weeks. During this time,panellists had unlimited access to the database

and an opportunity to add anonymous textcomments. Following each round, a summaryof responses not registered on the databasewas communicated electronically to individualpanellists by the principal investigator (SH) toprovide an opportunity to complete responses.

Figure 1. Flowchart of Delphi panel allocation.




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This individual communication was concernedwith logistical issues and not related to content.

Data analysis

The median rating and the semi-interquartilerange (SIQR) were calculated for each algorithmstatement. Consensus on the algorithm state-ments was dened a priori as a SIQR < 0.5.

Formulation of the final evidence-based clinical management algorithmStatements which reached consensus were col-lated into an algorithm using descriptors basedon the median rating. This resulted in a hierar-

chy of ratings. No statements were discardedbased on importance.

ResultsTen of the 42 potential panellists identiedduring the systematic review process had pub-lished predominately in the area of rehabilita-tion and were thus invited to partake in therehabilitation subgroup. Seven panellistsaccepted and were allocated to this sub-panel(Figure 1). The proles of the panellists are sum-marized in Table 1.

The three rounds of the Delphi process werecompleted online between May and August2008. A 100% response rate was achieved inrounds one and three. Due to technical diffi-culty, one panellist was unable to complete allresponses in round two.

During the verication process used in roundone,the28draftalgorithmstatementswereedited,

Figure 2. Verification and rating of the algorithm statements.

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removed or additional statements formulated,resulting in a total of 34 algorithm statements.None of the statements was rated as either unim-portant or detrimental. The verication processwas used to reformulate and add additional infor-

mation as indicated (Electronic supplement E1).In Category A (unconscious patients), threenew statements were added and the originalfour statements were edited. Editing was con-ned to sentence structure, for example, theoriginal statement Two hourly change of posi-tion supine quarter turn was changed toRegular change of position: with the aim of two hourly changes in position. Two of thethree additional statements addressed thethemes of inter-professional consultation and

individual patient assessment. The panellistsreached consensus on the rating of all sevenstatements, rating the majority of the state-ments essential 43% (3/7) or very important43% (3/7). While the assessment of cardiovascu-lar reserve before initiating activity was ratedessential, inter-professional team discussionsregarding sedation and implementation strate-gies were rated very important by the panel.

Semi-recumbent positioning and regular posi-tion change were rated essential activities toinclude in the management of this group of patients, while the inclusion of daily passivemovements was rated very important. (Refer

to Electronic supplement E2 for completedalgorithm.)In Category B (physiologically stable

patients), six new statements were addedand six draft statements were edited. The draftstatements were revised based on editorial com-ments to improve the sentence structure.For example, the original statement During allactivities, ensure SpO 2 > 90% was revised toMaintain sufficient oxygenation (SpO 2 > 94%)during all activity (can increase FiO 2 ). Three

of the six added statements referred to theimportance of an individual patient-centeredprogramme. The panellists reached consensuson the rating of 17/19 statements after thethird round. The majority of the statements(79 % (15/19)) was rated either essential (53%(10/19)) or very important (26% (5/19)).Panellists agreed that it was essential thatthere be congruency between the following

Table 1. Profiles of the panellists who participated in the rehabilitation Delphi sub-panel

Country QualificationNumber of years of clinical experience

No. of publications in field*number of publicationsIndexed in medline n

Australia Physiotherapist(PhD)

25 10*25

Belgium Physiotherapist(PhD)

30 10*74

Canada Physiotherapist(PhD)

30 20*19

Italy Intensivist(PhD)

37 15*171

USA Registered nurse andpsychologist(PhD)

20 3*57

South Africa Physiotherapist(PhD) 16 8*1South Africa Physiotherapist

(MSc)12 3




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four aspects when deciding to initiate earlyactivity for Category B patients. This included1) physiological stability (cardiovascular andpulmonary reserve) 2) practical considerations,e.g. the identication of existing precautionswhich could restrict mobility e.g. fractures,patient size, 3) inter-professional team discus-sions, and 4) clearly documented functionalgoals determined in consultation with thepatient. Panellists were unable to agree onthe ratings of two statements. This includedthe evaluation of arrhythmias and a patientsphysical appearance during activities. (Refer toElectronic supplement E3 for completedalgorithm.)

In Category C (deconditioned patients), no

statements were added but six statements wererevised based on editorial comments pertainingto the structure of the statements. The panellistsreached consensus on the rating of all eightstatements after the third round, with the major-ity of the statements (75%) being rated as essen-tial (50% (4/8)) or very important (25% (2/8)).Panellists agreed that it was essential forpatients to reach medical stability (controlledsepsis, haemorrhage and arrhythmias) beforethe implementation of an exercise programme.

This exercise programme should target thetrunk and extremities and focus on strengthen-ing and endurance. The panel agreed that itwas essential to offer this programme daily.(Refer to Electronic supplement E4 for com-pleted algorithm.)

DiscussionThis paper reports on the development of therst evidence-based clinical management algo-

rithm for the mobilization of adult patients inthe ICU. The statements rated essential by thepanel highlighted the importance of including amobilization plan for every patient admittedto an ICU. In addition the importance of indi-vidual patient assessment, clinicians judge-ment and inter-professional consultation in thedecision-making process was emphasized.Through the consensus rating of the remaining

statements ranging from desirable to veryimportant, the panellists strived to providea rating hierarchy of issues for clinicians toconsider when making this judgement. This val-idated framework could be useful in clinicalpractice to identify patients readiness for beingmobilized, thereby implementing patient- orphysiotherapist-initiated activities in a timelyfashion. This could in turn systemize pathwaysto guide clinical decision making. 8

Some panellists questioned the applicabilityof the reductionist model of analysis for themanagement of patients with complex condi-tions such as in the ICU. Patients in theICU who are typically managed by physiother-apists present with complex co-morbidities

which may directly or indirectly threaten orimpair oxygen transport. Because of the poten-tial for such heterogeneity in presentation,patients require a range of medications andmedical support. Thus, patients in the ICUrequire detailed comprehensive organ systemassessment and ongoing evaluation in orderto develop patient prescriptive parameters.While recognizing this reality, panellistsacknowledged that by providing physiothera-pists with criteria for mobilizing ICU patients,

the barriers to mobilization may be removed,thereby facilitating the exploitation of this pow-erful intervention. 1 Evident from the consensusreached, these view points were reconciled.The panellists concurred that while individ-ual clinical judgement is essential, there is arole for a framework to guide such decisionmaking. However, the progression of the patientneeds to be response dependent versus protocoldependent.

The importance given to the development

of a mobilization plan for each patient admittedto an ICU could prioritize the use of mobiliza-tion and physical activity as a therapeuticoption. 15,21,23 This plan would ensure a dailyscreening of all patients and allow for the earlyidentication of patients who are sufficientlyhaemodynamically stable to warrant beingmobilized. 1,5,38 This has the potential for phys-iotherapists to include early mobilization for

Hanekom et al. 777



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all patients in the ICU 1,2,38 rather than reservethis therapeutic option as an additional manage-ment option for specic patients. 15,17 Panellistsagreed that after the initial medical stabilizationof the patient, the goal in the management of all patients in the ICU is the timely progressionto active mobilization and eventual participa-tion within a patients state of rouse ability. 2

Therefore, discussion between the physiothera-pist and inter-professional team memberswas encouraged with respect to a range of issues including the effect of medication on apatients ability to respond to verbal commandsand the need for reduced but effective sedation. 2

While the initiation of mobilization could beexperienced as an uncomfortable procedure,

early rehabilitation has been linked toimproved emotional wellbeing following theICU stay. 39 Thus, balancing the prescription of mobilization and analgesia needs to be examinedfurther. Auto-sedation and relaxation couldhave a major role in minimizing anxiety andphysical discomfort for patients in the ICU.This could be a novel area of physiotherapyresearch.

Despite the scarcity of studies, the panellistsagreed on the rating of core activities included

for Category A (unconscious) patients. Thisincludes the use of semi-recumbent positioningwith the goal of 45 head off the bed up andhigher 8,40,41 ; regular position changes beyondthe standard every two-hour turning regimen; 42

daily passive movement of all joints, 13,43 (pas-sive) bed cycling 3 and electrical stimulation asindicated. 44,45 The additive and multiplicativeeffects of these interventions need to be evalu-ated further. The panellists agreed that it is safeto mobilize patients in Category B (physiological

stable) if screened beforehand.1,5,38,46,47

Patientsmobilized in the ICU based on specic criteriahave been reported to remain haemodynami-cally stable with few instances of adverseevents. 5,38,46 None of these adverse eventshas been reported to result in increased mortal-ity, length of stay, or additional cost. 5,38,46 Theaddition of targeted exercise to an ambulationprogramme for patients in Category C

(deconditioned) has been reported to increasemuscle strength, 48 functional activity 49 and exer-cise tolerance. 50 The panellists concurred thatfor patients who were unable to be activelymobilized within ve days of admission to theICU, a targeted strengthening programmeshould be added to a standardised ambulationprogram. The frequency and length of theseexercise sessions should be informed by thebest possible conditioning effect within the mar-gins of the patients tolerance for exercise andsafety. Despite the recommendation, panellistswere not convinced that these additional exercisesessions, over and above mobilization alone,constitute a cost-effective strategy for allpatients admitted to an ICU. The added value

of these interventions to patient outcome war-rants investigation. The identication of whichpatients would benet most from additionalinterventions is also warranted.

Studies in the literature use a variety of terms to describe physical activity and exerciserelated to the critically ill patient populationincluding activity, mobility, movement, mobili-zation and exercise. Although the terminol-ogy used in this paper is dened within thecontext of each statement, there is a need

to dene terms within the context of criticalcare. With advances in developing principlesof practice for mobilizing critically ill patients,we recommend the formation of an interna-tional taskforce to standardize terms andlanguage.

Limitations in the process of algorithm devel-opment need to be considered. First, deci-sions made regarding the compilation of thisDelphi panel could limit the external valid-ity of the algorithm. 51 The decision to limit

the panel to scientist clinicians in this eld, how-ever, was deliberate because it was expectedthat these scientist clinicians would be wellinformed about the clinical decision-makingfactors pertaining to early mobilization. 52,53

We recognize that this decision necessarilyimplies the potential of a vested discipline speci-c interest in the use of mobilization in theICU. Early mobilization in the ICU is a new




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focus of research in critical care, with a limitednumber of scientist clinicians publishing in thiseld. This could explain the small number of scientist clinicians who qualied for participa-tion on this Delphi panel. Finally, the samplewas limited to scientist clinicians with atrack record in the specic subject area. Newscientist clinicians in this specic area of inter-est were therefore not included. These decisionsare in line with current recommendationsfor Delphi panel composition. 51,52 Despitethese concerns, the results of this Delphi processare supported by recent data from random-ized controlled trials unavailable at the timeof this study. 1,2

ConclusionBased on a synthesis of the extant literaturecontextualized to clinical practice, the interna-tional panel who participated in thisDelphi study concluded that an individualmobilization plan must be developed for eachpatient admitted to an ICU. Given theunequivocal strength of the physiologic knowl-edge base supporting being upright andmoving, and progressive exercise to achieve

optimal functional capacity and life participa-tion, we make a case for these being founda-tion pillars of physiotherapy management inthe ICU. The important questions that needto be addressed and rened are how we canbetter titrate these interventions safely andtherapeutically to achieve the optimal out-comes for a given patient. A working algo-rithm provides a basis for translatingknowledge into the practice of mobilizingpatients in the ICU. This tool has the poten-

tial to reduce practice variability; maximizesafety and treatment outcome; provide abenchmark and baseline for further renementof the practice of early activity and mobilizingpatients over time; and inform future studiesin the eld.

The evidence-based clinical managementalgorithm developed through an establishedDelphi process of consensus by an international

inter-professional panel is the rst of its kind.It provides the clinician with a synthesis of cur-rent evidence and clinical expert opinion, anda framework to augment clinical decisionmaking in the context of a given patient. Thenext step is to determine the clinical utility of this working algorithm.

Clinical messages. A patient-specic mobilization plan must

be developed for each patient admitted toan ICU. The goal of this plan is the timelyimplementation of early patient-initiatedactivity.

. This plan must be developed in consulta-

tion with inter-professional team mem-bers, the patient and/or family, andinclude clear objectives and measurableoutcomes.

AcknowledgementsWe acknowledge the contributions of Dr KathyStiller and Professor Ramona Hopkins to theDelphi Process.

FundingThis work was supported by the Medical ResearchCouncil of South Africa [grant number (N05/10/185)].

Competing interestsNone.

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Hanekom et al. 781



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A p p e n d i x E 1

. P r o c e s s o f r e a c h i n g c o n s e n s u s o n t h e a l g o r i t h m s t a t e m e n t s f o r t h r e e p a t i e n t c a t e g o r i e s ( u n c o n s c i o u s , a n d c o n s c i o u s c o n d i t i o n e d o r

d e c o n d i t i o n e d )




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( c o n t i n u e d )

Hanekom et al. 783



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A p p e n d i x E 1

. C o n t i n u e

d




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A p p e n d i x E 2

. C l i n i c a l m a n a g e m e n t a l g o r i t h m f o r C a t e g o r y A

( u n c o n s c i o u s p a t i e n t s )

Hanekom et al. 785



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A p p e n d i x E 3

. C l i n i c a l m a n a g e m e n t a l g o r i t h m f o r C a t e g o r y B

( p h y s i o l o g i c a l l y s t a b l e p a t i e n t s )




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