a Department of Epidemiology, Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Switzerland
b Swiss Society of Intensive Care Medicine, Basel, Switzerland
c Intensive Care Unit, Spital Thun, Switzerland
d Intensive Care Unit, University Basel, University Hospital, Basel, Switzerland
e Institute of Pharmaceutical Medicine (ECPM), University of Basel, Switzerland
* Shared first authorship
** Shared last authorship
BACKGROUND: Patients in intensive care units (ICUs) are at high risk of developing physical, functional, cognitive, and mental impairments. Early mobilisation aims to improve patient outcomes and is increasingly considered the standard of care. This survey aimed to investigate the characteristics, current use and variations of early mobilisation and rehabilitation in Swiss ICUs.
METHODS: We conducted a cross-sectional survey among all ICU lead physicians, who provided data on their institutional characteristics, early mobilisation and rehabilitation practices, and their perceptions of the use and variation of early rehabilitation practices in Switzerland.
RESULTS: The survey response rate was 44% (37/84). Among ICUs caring for adults (34/37), 26 were in the German-speaking region, five in the French-speaking region, and three in the Italian-speaking region. All ICUs regularly involved physiotherapy in the rehabilitation process and 50% reported having a specialised physiotherapy team. All ICUs reported performing early mobilisation, starting within the first 7 days after ICU admission. About half reported the use of a rehabilitation (45%) or early mobilisation protocol (50%). Regular, structured, interdisciplinary rounds or meetings of the ICU care team to discuss rehabilitation measures and goals for patients were stated to be held by 53%.
The respondents stated that 82% of their patients received early mobilisation measures during their ICU stay. Most frequently provided mobilisation measures included passive range of motion (97%), passive chair position in bed (97%), active range of motion muscle activation and training (88%), active side to side turning (91%), sitting on the edge of the bed (94%), transfer from bed to a chair (97%), and ambulation (94%). The proportion of ICUs providing a specific early mobilisation measure, the proportion of patients receiving it, and the time dedicated to it varied across language regions, hospital types, ICU types, and ICU sizes.
Almost one third of the ICU lead physicians considered early rehabilitation to be underused in their own ICU and about half considered it to be underused in Switzerland more generally. ICU lead physicians stressed lack of personnel, financial resources, and time as key causes for underuse. Moreover, they highlighted the importance of early and systematic or protocol-based rehabilitation and interprofessional approaches that are adaptive to the patients' rehabilitation needs and potential.
CONCLUSION: This survey suggests that almost all ICUs in Switzerland practice some form of early mobilisation with the aim of early rehabilitation. However, the described approaches, as well as the reported use of early mobilisation measures were heterogenous across Swiss ICUs.
Critically ill patients admitted to intensive care units (ICUs) are at high risk of developing physical, functional, cognitive, and mental impairments [1–4]. This may lead to decreased quality of life, as well as increased mortality, healthcare utilisation, and costs [5–8]. Several clinical trials and systematic reviews suggested that early mobilisation in the ICU, as well as early rehabilitation approaches including early mobilisation, may improve physical function and muscle strength in ICU patients [9–11]. Such benefits were shown both in adult and paediatric ICU populations . However, other studies found no or very limited evidence for a potential benefit of early mobilisation [9, 13–16].
Despite uncertainties regarding its effectiveness, the early mobilisation of ICU patients is widely considered a standard of care . So far, not much is known about current ICU practices regarding early mobilisation and rehabilitation in Switzerland and internationally. According to Swiss experts, most ICUs in Switzerland commonly perform rehabilitative activities, starting early during the ICU stay. A Swiss study published by Sibilla et al. including 161 mechanically ventilated ICU patients reported that 33% of the patients received active mobilisation . Although the structures and practices of ICUs are quite heterogenous globally , several other studies showed similar results. For example, in a German study investigating early mobilisation in routine ICU practice only 185 out of 783 patients (24%) were mobilised out of bed . Other studies from the USA and Australia also showed comparable proportions [20, 21].
Meanwhile, it is reasonable to assume that ICU practices regarding early mobilisation and rehabilitation may vary across different regions, hospital types, or hospital sizes. Studies investigating other indications and treatments in Switzerland suggested that there are large, poorly explained geographical and demographic differences in the provision of care [22–26]. One international study that investigated inequalities in accessing inpatient rehabilitation after stroke across 14 countries reported a strong variability in rehabilitation rates, ranging from 13% in Sweden to 57% in Israel .
Investigating and understanding practice variation in ICUs across Switzerland may help to develop and implement national guidelines, leading to an improvement of the quality of care and patient outcomes at a national level. This study aimed to investigate the characteristics, current approaches, and variation of early mobilisation and more generally early rehabilitation practices in Swiss ICUs.
Materials and methods
We conducted a cross-sectional, exploratory survey on early mobilisation and rehabilitation practices in ICUs in Switzerland. This survey complements a health technology assessment (HTA) conducted by the Swiss Medical Board (SMB) and the Swiss Federal Office of Public Health (SFOPH) evaluating the effectiveness and safety of early rehabilitation .
This cross-sectional survey did not require ethics approval under the Swiss Human Research Act ("Humanforschungsgesetz"). Participation in the survey was voluntary for the addressed ICU lead physicians and there was no collection of individual-level (patient or staff) data.
We developed a survey questionnaire targeting the lead physicians of all certified Swiss ICUs. The survey was developed in collaboration with four Swiss ICU experts and the Swiss Society of Intensive Care (SGI-SSMI-SSMI) , based on findings from the international literature. We administered the survey exclusively in the English language, as we expected the respondents to be adequately fluent in English to understand and answer the questionnaire.
The survey elicited information on institutional characteristics (canton, hospital type and size, ICU type and size, staff involved in ICU care, and average patient characteristics), early mobilisation practices and protocols, general rehabilitation practices and protocols, including measures related to swallowing, speech, nutrition, and psychological impact, as well as measurement of patient outcomes (supplementary table S1 in the appendix). We defined early mobilisation as active or passive physical mobilisation measures starting within 7 days of ICU admission for questions eliciting the frequency of provision of early mobilisation measures. This is a conservative timeframe in line with previous systematic reviews [9, 13]. We also asked ICU lead physicians to provide definitions for early mobilisation as they were applied in their ICU. Early rehabilitation was defined as any rehabilitative activities that include, but are not limited to, mobilisation within 7 days of ICU admission (e.g., additional rehabilitative activities targeted at swallowing, speech, nutrition, and psychological impact). We prompted participants to use the minimal dataset of the SGI-SSMI-SSMI (MDSi), which collects summary information on the patient characteristics of individual ICUs, as a basis for answering questions related to patient characteristics (age distribution and main diagnoses of patient collective) . Furthermore, we elicited information on the perceptions of ICU lead physicians regarding overuse, underuse, and practice variation of early rehabilitation in Switzerland.
A pilot test with a convenience sample of four ICU lead physicians (two each from academic and regional hospitals) was conducted to evaluate the understandability of the questionnaire and relevant inconsistencies in the obtained responses.
The survey was administered electronically via an online platform between 6 May 2019 and 9 June 2019. A contact list of lead physicians of the 84 Swiss ICUs that were recognised and certified at that time was provided by the SGI-SSMI-SSMI. An invitation letter supported by the SMB, SFOPH, SGI-SSMI-SSMI, and the research group leaders at the Universities of Zurich and Basel was mailed to the lead physicians on 24 April 2019. We aimed to elicit data from all Swiss ICUs in order to gather the most comprehensive information possible and to minimise risks of selection bias. If ICU lead physicians were absent, we additionally contacted their deputies. In total, we sent three email reminders over the course of the survey timeframe.
Descriptive statistics for the collected quantitative data are reported using frequencies and percentages, means with standard deviations (SDs), or medians and ranges, as appropriate. Where data on proportions of patients were provided, means of proportions are reported throughout the document, and full results are additionally presented in tables. Based on the study objectives, descriptive results were stratified by language region (German, French, Italian), hospital type (academic, cantonal/regional, private), ICU size (1–8 beds: "small"; 9–16 beds: "medium-sized"; ≥17 beds: "large"), and ICU type (adult or paediatric), as defined a priori. We present data from ICUs caring for adults only in the main manuscript, while data from paediatric ICUs are provided in the supplementary material.
Qualitative data retrieved through free text fields were summarised using an iterative coding approach. Data on general rehabilitation approaches, specific early mobilisation practices, over-/underuse, and practice variation were assigned to the following categories: different practices, intervention criteria, goals, organisational factors, and determinants of care.
The representativeness of the data collected through our survey was investigated by comparing our results with those reported by the SGI-SSMI-SSMI in the most recent MDSi report at the time of conduct (data from 2018, document version 10 June 2019), wherever this was possible .
Since we invited all ICUs in Switzerland and since the analysis was descriptive, no statistical testing was conducted. All descriptive analyses were performed using R (version 3.6.1) and Microsoft Excel® 2016.
Intensive care unit characteristics
The response rate of the survey was 44% (37/84 Swiss ICUs). The cumulative number of represented ICU beds was 473, corresponding to 48.3% of ICU beds in Switzerland (total 980 according to the list of Swiss ICUs by the SGI-SSMI-SSMI in September 2019). Among the 34 ICUs caring for adult patients, most were from the German-speaking region of Switzerland (76%; 26/34), and 15% (5/34) and 9% (3/34) were from the French-speaking and Italian-speaking regions, respectively. Most were located in cantonal/regional hospitals (23/34 ICUs; 68%), three were in academic hospitals (9%), and eight in private hospitals (24%).
The number of ICU beds and patients treated per year was higher in academic hospitals than cantonal/regional hospitals and private hospitals (table 1). ICU bed capacity and case load were similar across the language regions. Details on paediatric ICUs are provided in the appendix material (supplementary table S2).
|Institution characteristics||All (n = 34)||Language region||Hospital type||ICU size|
|German (n = 26)||French (n = 5)||Italian (n = 3)||Acad. (n = 3)||Cant./ Reg. (n = 23)||Private (n = 8)||1–8 beds (n = 17)||9–16 beds (n = 10)||≥17 beds (n = 7)|
|Number of ICU beds||Mean (SD)||12.5 (9.4)||12.6 (9.5)||13.4 (12.1)||10.3 (5.1)||38.0 (3.6)||10.4 (5.1)||9.2 (4.7)||7.0 (0.9)||10.9 (2.5)||28.3 (9.5)|
|Median (range)||9 (6–42)||9 (6–42)||9 (7–35)||9 (6–16)||37 (35–42)||9 (6–24)||8 (6–20)||7 (6–8)||10 (9–16)||24 (18–42)|
|Number of ICU patients per year||Mean (SD)||1325 (1034)||1403 (1149)||1149 (545)||943 (425)||3700 (1510)||1097 (597)||1092 (788)||761 (180)||1072 (178)||3057 (1115)|
|Median (range)||952 (514–5100)||980 (514–5100)||915 (780–2100)||870 (559–1400)||3900 (2100–5100)||921 (514–3000)||894 (600–3000)||711 (514–1033)||1033 (870–1400)||3000 (2100–5100)|
|Specific ICU physiotherapy team employed||% (n/N)||50.0 (16/32)||46.2 (12/26)||40.0 (3/5)||66.7 (2/3)||100 (3/3)||47.8 (11/23)||16.7 (1/6)||25.0 (4/16)||77.8 (7/9)||71.4 (5/7)|
|ICU staffing (in FTE)|
|Senior physicians||Mean (SD)||5.2 (4.8)||5.4 (5.2)||5.7 (4.4)||3.6 (2.7)||17.0 (3.9)||3.5 (2.7)||6.0 (2.6)||3.0 (1.9)||4.4 (3.1)||12.7 (5.5)|
|Median (range)||3.0 (1.0–20.0)||2.9 (1.0–20.0)||4.0 (1.0–12.6)||3.0 (1.3–6.5)||18.4 (12.6–20.0)||2.5 (1.0–10.0)||5.8 (2.0–10.0)||2.3 (1.0–7.0)||3.0 (1.0–10.0)||11.3 (6.0–20.0)|
|Assistant physicians||Mean (SD)||7.2 (5.8)||6.7 (5.0)||10.5 (9.5)||5.3 (3.2)||20.1 (7.2)||6.2 (3.6)||3.6 (2.7)||3.7 (1.9)||6.8 (2.4)||16.4 (6.6)|
|Median (range)||5.0 (1.0–27.4)||5.0 (1.0–20.0)||7.0 (5.0–27. 0)||4.0 (3.0–9.0)||20.0 (13.0–27.0)||5.0 (1.0–17.0)||2.0 (1.0–7.0)||3.5 (1.0–7.0)||6.5 (4.0–11.0)||15.0 (10.0–27.0)|
|Nurses1||Mean (SD)||42.3 (42.1)||39.9 (39.7)||56.0 (63.6)||39.0 (25.9)||179.4(15.0)||35.9 (24.5)||24.2 (10.0)||21.4 (5.0)||38.2 (14.1)||121.5 (58.6)|
|Median (range)||26.0 (12.8–190)||25.8 (12.8–190.0)||26.0 (19.5–168.8)||31.0 (18.0–68.0)||179.4 (168.8–190.0)||27.7 (12.8–105.0)||22.1 (13.8–45.0)||22.1 (12.8–29.0)||36.0 (23.0–68.0)||105.0 (43.7–190.0)|
|Physiotherapists||Mean (SD)||2.3 (2.4)||2 .0 (1.3)||5.5 (6.4)||0.9 (0.9)||4.7 (4.7)||1.7 (1.3)||2 .0 (NA)||0.8 (0.8)||1.9 (1.2)||4.0 (3.5)|
|Median (range)||1.8 (0.2–10.0)||2.0 (1.0–4.0)||5.5 (1.0–10.0)||0.9 (0.2–1.5)||3.0 (1.0–10.0)||1.3 (0.0–4.0)||2.0 (2.0–2.0)||0.5 (0.2–2.0)||1.5 (1.0–4.0)||3.0 (1.0–10.0)|
The average number of senior physicians, assistant physicians, and nurses was higher in academic hospitals (17.0, 20.1, 179.4 full time equivalents [FTEs], respectively) compared with cantonal/regional hospitals (3.5, 6.2, 35.9 FTEs, respectively). In private hospitals, the number of senior physicians was slightly higher (6.0 FTEs), and the number of assistant physicians and nurses was lower (3.6 and 24.2 FTEs) than in cantonal/regional hospitals.
All adult ICUs regularly involved physiotherapy in the rehabilitation process. Half of the respondents (50%; 16/32; two missing) reported a specialised physiotherapy team specifically employed for the ICU. Most reported regular involvement of occupational therapists (82%, 27/34), speech therapists (64%, 21/33; one missing), nutritional therapists (79%, 26/34), psychological care teams (48%, 16/34), spiritual care teams (82%, 27/34), and relatives (79%, 26/33; one missing) in the rehabilitation process. Larger ICUs and those located in academic hospitals were more likely to have a specific physiotherapy team and had higher numbers of physiotherapists. Only one ICU in a private hospital reported employing an ICU-specific physiotherapy team. There were no substantial variations between language regions with respect to the involved physiotherapy teams.
Overall, ICUs reported that about one-third of their patients received mechanical ventilation during their ICU stay (supplementary table S3). The proportion of mechanically ventilated patients widely ranged from 4% to 70% across ICUs and was generally higher in academic hospitals (56%). About 40% of the patients were admitted to the ICU after surgery (range 5–75%). Private hospitals reported the highest proportions of postoperative patients (60%), followed by academic hospitals (49%) and cantonal/regional hospitals (30%). The overall patient collective consisted of 37% patients aged 16–65 years and 37% patients aged 65–80 years, with patients younger than 16 years and older than 80 years being less frequent (8% and 17%, respectively). The main diagnoses among adults related to cardiovascular (28%), respiratory (13%), gastrointestinal (15%), and neurological disorders (13%).
Implementation of rehabilitation and early mobilisation practices
All participating ICUs reported early mobilisation of their patients, starting within the first 7 days after admission (table 2, supplementary table S4). A specific early mobilisation protocol was stated to be available in 50% (17/34) of the participating adult ICUs. This was the case for 62% (16/26) of the ICUs in the German-speaking region, none (0/5) in the French-speaking region, and 33% (1/3) in the Italian-speaking region. Specific early mobilisation protocols were more frequently reported to be used in large ICUs compared to medium-sized and small ICUs. Among those with an early mobilization protocol, six ICUs (35%) reported starting mobilisation measures on the first day after ICU admission and seven (41%) on the first day after stabilisation. Two ICUs reported starting early mobilisation from day 2 according to their protocol and one ICU on day 1, without specifying whether this related to admission or stabilisation.
|General rehabilitation||All (n = 34)||Language region||Hospital type||ICU size|
|German (n = 26)||French (n = 5)||Italian (n = 3)||Acad. (n=3)||Cant./ Reg. (n = 23)||Private (n = 8)||1–8 beds (n = 17)||9–16 beds (n = 10)||≥17 beds (n = 7)|
|ICUs providing any rehabilitation||% (n/N)||85.3 (29/34)||84.6 (22/26)||80.0 (4/5)||100 (3/3)||100 (3/3)||87.0 (20/23)||75 (6/8)||82.4 (14/17)||90.0 (9/10)||85.7 (6/7)|
|ICUs with general rehabilitation protocol||% (n/N)||44.8 (13/29)||50.0 (11/22)||25.0 (1/4)||33.3 (1/3)||100.0 (3/3)||40.0 (8/20)||33.3 (2/6)||21.4 (3/14)||44.4 (4/9)||100 (6/6)|
|Patients receiving any rehabilitation (% of ICU collective)||Mean (SD)||53.9 (32.6)||57.0 (33.9)||45.0 (37.6)||43.3 (15.3)||41.6 (31.8)||50.7 (32.2)||70.8 (33.4)||49.9 (31.8)||56.1 (36.6)||60.0 (32.4)|
|Median (range)||60 (3–100)||60 (3–100)||43 (5–90)||40 (30–60)||60 (5–60)||50 (3–100)||82.5 (10–95)||45 (3–100)||60 (5–100)||60 (5–95)|
|Early mobilisation protocol available||% (n/N)||50.0 (17/34)||61.5 (16/26)||0 (0/5)||33.3 (1/3)||66.7 (2/3)||47.8 (11/23)||50.0 (4/8)||29.4 (5/17)||60.0 (6/10)||85.7 (6/7)|
|Proportion of patients receiving early mobilisation (%)||Mean (SD)||81.9 (22.1)||87.3 (14.4)||68.0 (37.7)||60.0 (30.0)||65.0 (18.0)||79.2 (24.0)||95.6 (7.3)||84.9 (21.3)||77.0 (26.3)||82.1 (19.3)|
|Median (range)||90 (10–100)||90 (40–100)||90 (10–100)||60 (30–90)||80 (50–90)||90 (10–100)||100 (80–100)||90 (30–100)||80 (10–100)||90 (50–100)|
|Proportion of mechanically ventilated patients among those receiving early mobilisation (%)||Mean (SD)||65.1(31.6)||63.6 (34.1)||58.8 (17.5)||86.7 (15.3)||53.3 (15.3)||62.9 (32.2)||77.1 (34.6)||59.6 (34.3)||72.5 (29.6)||66.4 (30.6)|
|Median (range)||70 (3–100)||70 (3–100)||50 (50–85)||90 (70–100)||50 (40–70)||65 (3–100)||95 (10–100)||50 (3–100)||82.5 (10–100)||70 (20–100)|
|Age distribution of patients receiving early mobilisation (%)|
|<16 years||Mean (SD)||0.1 (0.4)||0 (0.5)||0 (0)||0 (0)||0 (0)||0 (0.5)||0.1 (0.4)||0.2 (0.6)||0 (0.3)||0 (0)|
|16–65 years||Mean (SD)||44.1 (13.3)||42.1 (9.3)||54.0 (24.9)||43.3 (14.4)||45.0 (5.0)||43.8 (9.6)||44.5 (22.5)||44.7 (17.7)||42.8 (10.5)||44.6 (3.4)|
|66–80 years||Mean (SD)||38.4 (10.2)||39.7 (8.4)||33.4 (18.0)||36.7 (7.6)||44.0 (5.3)||38.2 (8.4)||36.9 (15.3)||37.5 (13.1)||37.5 (8.3)||41.9 (3.8)|
|>80 years||Mean (SD)||17.4 (7.5)||18.0 (7.0)||12.6 (8.3)||20.0 (10.0)||11.0 (1.7)||17.9 (7.0)||18.5 (9.4)||17.7 (9.3)||19.6 (6.0)||13.6 (2.7)|
When asked about the provision of rehabilitation more generally, slightly fewer adult ICUs (85%; 29/34) reported providing some form of rehabilitation in their ICU. Overall, 45% (13/29) of the participating ICUs reported use of a written rehabilitation protocol. Such a protocol was stated to be available in 50% (11/22), 25% (1/4), and 33% (1/3) of the ICUs in the German-speaking, French-speaking, and Italian-speaking regions, respectively. Most academic hospital ICUs and large ICUs reported having a protocol, whereas private hospital ICUs and small ICUs did so less frequently.
The participating adult ICUs stated that about half (54%) of ICU patients would receive general rehabilitative measures. The reported proportion of patients receiving early mobilisation was much higher (82%). Generally, the proportion of patients receiving general rehabilitation and early mobilisation measures was lower than average in the ICUs in the French-speaking and Italian-speaking regions, and higher in private hospitals.
The proportion of mechanically ventilated and postoperative patients among those receiving early mobilisation were reported to be higher than the respective proportions in the total ICU patient collective (65% vs 30% and 77% vs 40%, respectively). The reported proportion of patients undergoing early mobilisation varied considerably across language regions (64% in German-speaking, 59% in French-speaking, and 87% in Italian-speaking ICUs) and hospital types (50% in academic hospitals, 65% in cantonal/regional hospitals, and 95% in private hospitals).
Regular, structured interdisciplinary rounds or meetings to discuss rehabilitation measures and goals for patients were reported to be held by slightly more than half of the adult ICUs (53%; 18/34). Such rounds were reported to be held more frequently in ICUs in academic hospitals (100%; 3/3), as well as in the German-speaking (54%; 14/26) and Italian-speaking regions (67%; 2/3). In contrast, they were less frequently conducted in private hospitals (25%; 2/8) and the French-speaking part of Switzerland (40%; 2/5).
Four out of 34 adult ICUs (12%) reported that patients’ relatives were involved in the provision of early mobilisation measures.
Early mobilisation measures
Specific early mobilisation measures that were reported to be provided by most adult ICUs included passive range motion (97%; 33/34), passive chair position in bed (97%; 33/34), active range of motion muscle activation and training (88%; 30/34), active side to side turning (91%; 31/34), sitting on the edge of the bed (94%; 32/34), transfer from bed to a chair (97%; 33/34), and ambulation (94%; 32/34) (table 3). Other measures were provided less frequently. The proportion of ICUs providing a specific early mobilisation measure, the proportion of patients receiving it, as well as the time dedicated to it (minutes per day, number of days) seemed to vary across language regions, hospital types, ICU types, and by ICU size. Several early mobilisation measures were provided more frequently in German-speaking or Italian-speaking ICUs, whereas French-speaking ICUs reported lower percentages. The proportion of patients reported to be receiving a specific mobilisation measure was generally higher for German-speaking ICUs, whereas Italian-speaking ICUs reported in many cases very low proportions. French-speaking ICUs had proportions comparable to those in the German-speaking ICUs for 7 out of 12 mobilisation measures. The average duration that the measures were reported to be provided per day, as well as the average numbers of days that were reported to be dedicated to providing each specific mobilisation measure were highly variable across language regions, hospital types, ICU types, and by ICU size (supplementary tables S5–S16).
|Early mobilisation measure (total n = 34)||ICUs providing the measure, % (n/N)||Proportion of patients receiving the measure, mean % (SD)||Average daily time dedicated to providing the measure, minutes (SD)||Average number of days on which the measure is provided, days (SD)|
|Transfers from bed to a chair||97.1 (33/34)||79.6 (22.6)||61.2 (52.5)||3.3 (1.5)|
|Passive range of motion||97.1 (33/34)||69.3 (33.6)||27.1 (16.2)||3.5 (3.3)|
|Passive chair position in bed, tilt table||97.1 (33/34)||54.8 (38.3)||57.7 (48.2)||3.3 (1.6)|
|Sitting on the edge of the bed||94.1 (32/34)||86.0 (19.1)||49.5 (36.3)||3.3 (1.3)|
|Active side to side turning||91.1 (31/34)||71.8 (33.9)||38.2 (38.2)||3.5 (1.7)|
|Active range of motion muscle activation and training||88.2 (30/34)||68.1 (51.7)||32.9 (19.5)||4.0 (1.3)|
|Ambulation (walking with patient)||94.1 (32/34)||28.1 (23.5)||23.1 (9.5)||3.4 (1.6)|
|Other active exercises in bed||64.7 (22/34)||56.1 (39.0)||46.5 (40.7)||4.3 (2.4)|
|Active cycling in bed||64.7 (22/34)||11.8 (13.1)||39.2 (30.7)||4.5 (2.6)|
|Passive cycling in bed||52.9 (18/34)||12.0 (13.5)||33.8 (30.5)||3.8 (2.5)|
|Active resistance exercises, bedside cycling||47.1 (16/34)||21.1 (26.5)||34.3 (11.3)||3.6 (1.4)|
|Neuro-muscular electrostimulation||11.8 (4/34)||264.0 (41.9)||46.7 (23.1)||2.3 (2.5)|
Additional general rehabilitation practices and patient follow-up
Most of the participating adult ICUs reported screening for swallowing abnormalities in their patients (91%; 31/34); whereas there were no major variations across language regions, trends were visible for hospital type (higher screening use in academic and cantonal/regional hospitals, lower in private hospitals) and ICU size (higher in large ICUs, lower in small ICUs). Regular visits by occupational therapists, speech therapy specialists, or nutritional therapy specialists were scheduled in 35% (12/34), 29% (10/34), and 36% (12/33; one missing) of the participating ICUs, respectively. We noted variations between language regions, hospital types, ICU type, and by ICU size (supplementary table S17). We additionally elicited information on rehabilitation measures aimed at mitigating the psychological impact of critical illness on patients and their relatives, as well as patient follow-up (supplementary table S18). Half of the participating adult ICUs (17/34) reported keeping a diary for their patients' ICU stay. Diaries were mainly kept by nurses (100%; 17/17), patients' relatives (71%; 12/17), physicians (35%; 6/17), and physiotherapists (29%; 5/17). Most of the participating ICUs reported that the involvement of a psychological support or care team was possible to support ICU patients (85%; 28/33; one missing) and relatives (79%; 27/34). Only five of the participating adult ICUs (15%) stated that they routinely evaluated patient outcomes.
Underuse and variation of early mobilisation and rehabilitation practices in Switzerland
Participating Swiss ICU lead physicians defined underuse as a failure to provide rehabilitation early and in all patients with a rehabilitation potential or need, and as a failure to achieve optimal outcomes due to a lack of knowledge, motivation, or prioritisation. Overuse was defined as an inefficient use of resources by not adapting efforts to the rehabilitation potential, need and clinical status of patients, providing rehabilitation beyond the patients' limits, and providing more care than necessary to achieve optimal recovery. ICU lead physicians defined appropriate use as rehabilitation according to the patients' needs and potential for rehabilitation, involving the screening and evaluation of eligible patients, starting rehabilitation efforts early, systematically using protocols, and taking an interprofessional approach.
At a team level, factors such as awareness, knowledge and motivation were mentioned as important drivers of practice variation within Switzerland. At an organisational level, the lack of a national consensus or protocols with resulting local team cultures and leadership challenges were seen as important issues. Differences in the available resources, such as specialized personnel, finances, and time, as well as differences in case mix were also seen to contribute to practice variation between Swiss ICUs.
Almost one third of the ICU lead physicians (12/37) considered early rehabilitation to be underused in their own ICU and about half (19/37) considered it to be underused in Switzerland more generally. About two thirds (24/37) saw it as being appropriately used in their ICU, and only 41% (15/37) had that perception for ICUs across Switzerland in general. The lack of resources such as personnel, finances, and time, was stressed as a key determinant for underuse. Additional reasons seen by ICU lead physicians within their own ICU were a lack of motivation or internal resistance, whereas they perceived a lack of awareness, knowledge, and motivation in other Swiss ICUs more generally. Finally, ICU lead physicians identified a need for protocols and standardised practices to improve rehabilitation efforts in Swiss ICUs.
The present report describes the early mobilisation and more general early rehabilitation practices in Switzerland according to information provided by 37 out of 84 Swiss ICUs, representing 48% of Swiss ICU beds. All ICU lead physicians reported the use of early mobilization, starting within the first seven days after ICU admission, but only about half reported use of a rehabilitation or early mobilisation protocol. Most ICUs with an early mobilisation protocol reported starting rehabilitative measures within one day after admission (35%) or stabilisation (41%) of the patient. The proportion of ICUs providing a specific early mobilisation measure, the proportion of patients receiving it, as well as the time dedicated to it varied considerably across language regions, hospital types, ICU types, and by ICU size. Almost one third of the ICU lead physicians considered early rehabilitation to be underused in their own ICU and about half considered it to be underused in Switzerland more generally. The lack of personnel, of financial resources, and of time were stressed as key causes for underuse.
Overall, ICU lead physicians reported that postoperative patients accounted for approximately 40% of ICU admissions. The age distribution and diagnoses of the patient collective in the participating ICUs were comparable to those reported by the SGI-SSMI-SSMI in the 2018 MDSi report based on data from 76 Swiss ICUs, which reported that 17% of the patients were over 80 years, 31% had cardiovascular problems, 12% respiratory problems, 12% gastrointestinal problems, 14% problems of the nervous system, and 6% were admitted due to accidents . Similarly, the proportion of patients receiving mechanical ventilation reported in the MDSi report (32%) was comparable to the proportion reported in this survey (33%). Therefore, we believe that the sample of ICUs that participated in our survey is sufficiently representative for all the ICUs in Switzerland.
The proportion of mechanically ventilated and postoperative patients among those receiving early mobilisation were reported to be higher than the respective proportions in the total ICU patient collective. This may indicate a special perceived importance of mobilising such patients and may imply that other patient groups receive less mobilisation than mechanically ventilated and postoperative patients. Although it appears plausible that mechanically ventilated patients receive early mobilisation more frequently due to their increased risk of ICU-acquired weakness (ICUAW) and post-intensive care syndrome (PICS), it may be less likely that patients admitted after surgery are in special need for mobilisation compared with the rest of the ICU population. A reason for this discrepancy could be that reported proportions in the general ICU population were based on MDSi data, whereas proportions for mechanically ventilated patients were based on the ad hoc estimates of survey respondents. Further reasons could be that postoperative patients are more often able to mobilise on their own, or that there are more established standards or protocols for the postoperative care of patients.
The proportion of ICUs conducting regular interdisciplinary rounds was somewhat lower than reported in the point prevalence study by Sibilla et al. in 35 ICUs in Switzerland (53% vs 69%) . However, this apparent difference might be due to differences in wording, as Sibilla et al. reported on ICUs conducting multidisciplinary discussions, which might not have been regularly scheduled (as requested in our survey).
Overall, about half of the participating ICUs reported use of written protocols for rehabilitation (45%) and early mobilisation (50%) of their patients. These estimates are lower than the one reported by Sibilla et al., who found 74% of the surveyed ICUs to have an early mobilisation protocol . Another study from the United States by Bakhru et al. reported that two thirds of ICUs performing early mobilisation had a written protocol . Reasons for the differences between our findings and those of other studies are unclear and they may have arisen because of differences in study design and associated biases, changes in rehabilitation practices over time (the study by Sibilla et al. was conducted in 2014), or differences between countries. Furthermore, in Switzerland, provided care is often documented in separate systems by medical, nursing, physical, and occupational therapy staff. This may further have affected the mutual awareness of the extent of rehabilitative activities performed and influence the results of different surveys depending on the population surveyed. Shared documentation of all medical professions involved in ICU care may thus be useful.
The participating ICUs reported that about 80% of patients receive early mobilisation and about half receive rehabilitation in general. The described early mobilisation and rehabilitation approaches, as well as the early mobilisation measures were heterogenous across the participating ICUs.
The majority of the respondents saw early rehabilitation as being appropriately used in Switzerland, but about 35–40% reported perceiving an underuse in their own ICU or in other Swiss ICUs. ICU lead physicians identified a need for an increase in awareness and knowledge about early mobilisation in Switzerland and stressed the importance of the creation and implementation of early, systematic protocols or (national) standards, as well as ensuring adequate resources for ICUs to provide early rehabilitation and optimise outcomes of their patients, according to their needs and potential.
In this survey, we were able to collect information on early mobilisation and rehabilitation practices and present estimates stratified by different language regions, hospital types, ICU types, and between ICUs of different size. However, there are several limitations that have to be considered. First, the response rate was rather low (44%). This may have led to selection bias as ICUs participating in this survey might have been more interested and active in providing early mobilisation and rehabilitation to patients than nonparticipating ICUs. Consequently, the proportion of patients receiving early mobilisation measures in Switzerland might have been overestimated. It may further explain the finding that early mobilisation was considered to be underused more frequently in Switzerland than in the ICUs of participating ICU lead physicians. However, comparisons of the data collected in this survey and the MDSi statistics of the SGI-SSMI-SSMI suggested that a representative sample was reached . A second limitation concerns the analyses stratified by language region, hospital type, ICU type, and ICU size, which were based on a limited and sometimes incomplete number of answers. For example, stratified analyses were based on only three ICUs for the Italian-speaking region and on five ICUs caring for adults for the French-speaking region. Equally, data for academic ICUs caring for adults was limited to three ICUs. For this reason, it is important to emphasise that the actual practices related to rehabilitation and early mobilisation in all Swiss ICUs may differ from those found in this survey owing to selection effects and chance. Especially within subgroups, our results may not be generalisable to all Swiss ICUs within the respective subgroup and need to be interpreted with caution. A third limitation is that all responses were self-reported by ICUs, which may have led to response bias. In fact, a few discrepancies in the responses were identified. For example, all ICUs stated that they provided early mobilisation, whereas 85% of them stated that they provided rehabilitation more generally. The proportion of patients receiving any rehabilitation was also reported to be lower than the proportion of patients receiving early mobilisation. It remains unclear whether these variations were due to different wording in the question or other reasons. It may be that the survey respondents did not consider early mobilisation to be part of rehabilitation in general. Alternatively, the discrepancy may have arisen because information on general rehabilitation measures was elicited first and that awareness for early mobilisation as a mainstay of rehabilitation in the ICU increased during the completion of the survey. A fourth limitation is the quality of reporting. Despite conducting a pilot test and adapting the questionnaire design, the survey was relatively long and complicated (supplementary table S1). We noticed that questions in the first half of the survey (including institution characteristics, general rehabilitation measures, and general early mobilisation information) were answered by almost all participating ICUs. Thereafter, the number of ICUs providing full answers decreased for some questions. It cannot be excluded that the length of the survey, combined with the general lack of time available to ICU staff to participate in such research, may have led to a lower quality of answers, especially in the second part of the survey (focusing on specific early rehabilitation measures, outcome evaluation, and perception of underuse and overuse). Lastly, the results of this survey are based on aggregated data. These may provide a general idea of how early mobilisation and rehabilitation practices are implemented in Switzerland. This is especially important since the evidence suggests that the current standard of care seems to be an important determinant of whether additional efforts dedicated to early mobilisation would also provide a benefit to patients . However, it is important to emphasise that ICU patients are an extremely heterogeneous population, often requiring personalised care. The use of early mobilisation and rehabilitation practices within specific patient collectives thus should be further investigated. This survey represents only a first step towards a better understanding of practice variation regarding early mobilisation across Switzerland. The results, combined with a thorough investigation of patient-relevant outcomes, may emphasise the importance and need of national guidelines, leading to an overall improvement of quality of care and patient outcomes at a national level.
A final remark concerns the ongoing pandemic of coronavirus disease 2019 (COVID-19). This survey illustrates the status quo of early mobilisation and rehabilitation in the pre-pandemic era. Although a return to “normality” may be possible in the mid to long term, it is evident that COVID-19 had an enormous impact on health systems worldwide. The care in ICUs was particularly affected by the sudden increase of patients requiring mechanical ventilation . Because of resource limitations, many hospitals were forced to re-allocate their staff/beds to deal with the unexpected high number of cases requiring mechanical ventilation [32–34]. The overcrowding of the ICUs led in many cases to critical situations and presumably had an important influence on early mobilisation and rehabilitation practices. Several recommendations to deal with COVID patients have been published [32, 35–37]. The way ICUs are managed and structured, from the number of available beds to the availability of trained personnel, may significantly change in order to be better prepared to face future pandemics. Repeating this survey after the current pandemic may provide important information on the potential evolution/changes of ICU practices and organisation in the future.
In summary, the results of this survey suggest that early mobilisation and early rehabilitation more generally are practiced in almost all ICUs in Switzerland. However, the described approaches, as well as the use of specific early mobilisation measures were heterogenous across different language regions, hospital types, ICU types, and ICU sizes. The participating ICU lead physicians highlighted the importance of early and systematic or protocolised, as well as interprofessional approaches, which are adaptive to patients' rehabilitation needs and potential.
Funding sources and conflicts of interest
This survey was commissioned by the Swiss Medical Board (SMB) and the Swiss Federal Office of Public Health (SFOPH) as part of a health technology assessment (HTA) evaluating the effectiveness and safety of early rehabilitation . The funding bodies had no influence on the conduct, analysis and interpretation of the study and were not involved in writing the manuscript.
The authors would like to thank Prof. Dr. med. Marco Maggiorini (UniversitätsSpital Zürich, Switzerland) for his valuable support and expertise in the development of the study. Furthermore, we thank Prof. Dr. med. Martin Tramèr (Hôpitaux Universitaires Genève, Switzerland), Dr. Klazien Matter-Walstra (Health Technology Assessment Department, Swiss Federal Office of Public Health), Adrian Jaggi and Markus Gnägi (santésuisse, Switzerland), as well as Markus Tschanz (H+, Switzerland) for their critical feedback on this research project. Last, the authors thank the Swiss Society of Intensive Care (SGI-SSMI-SSMI) for its valuable support and endorsement of the study.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Thierry Fumeaux is an employee of Kinarus AG and of Acthera Therapeutics Ltd. No other potential conflict of interest was disclosed.
Header image: © Sudok1 | Dreamstime.com
Yuki Tomonaga, PhD
Department of Epidemiology
Epidemiology, Biostatistics and Prevention Institute (EBPI)
University of Zurich
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Appendix: Suplementary tables
The appendix is available in the PDF version of the article.
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