We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

IMPORTANCE Physical rehabilitation in the intensive care unit (ICU) may improve the outcomes of patients with acute respiratory failure. OBJECTIVE To compare standardized rehabilitation therapy (SRT) to usual ICU care in acute respiratory failure. DESIGN, SETTING, AND PARTICIPANTS Single-center, randomized clinical trial at Wake Forest Baptist Medical Center, North Carolina. Adult patients (mean age, 58 years; women, 55%) admitted to the ICU with acute respiratory failure requiring mechanical ventilation were randomized to SRT (n=150) or usual care (n=150) from October 2009 through May 2014 with 6-month follow-up. INTERVENTIONS Patients in the SRT group received daily therapy until hospital discharge, consisting of passive range of motion, physical therapy, and progressive resistance exercise. The usual care group received weekday physical therapy when ordered by the clinical team. For the SRT group, the median (interquartile range [IQR]) days of delivery of therapy were 8.0 (5.0–14.0) for passive range of motion, 5.0 (3.0–8.0) for physical therapy, and 3.0 (1.0–5.0) for progressive resistance exercise. The median days of delivery of physical therapy for the usual care group was 1.0 (IQR, 0.0–8.0). MAIN OUTCOMES AND MEASURES Both groups underwent assessor-blinded testing at ICU and hospital discharge and at 2, 4, and 6 months. The primary outcome was hospital length of stay (LOS). Secondary outcomes were ventilator days, ICU days, Short Physical Performance Battery (SPPB) score, 36-item Short-Form Health Surveys (SF-36) for physical and mental health and physical function scale score, Functional Performance Inventory (FPI) score, Mini-Mental State Examination (MMSE) score, and handgrip and handheld dynamometer strength. RESULTS Among 300 randomized patients, the median hospital LOS was 10 days (IQR, 6 to 17) for the SRT group and 10 days (IQR, 7 to 16) for the usual care group (median difference, 0 [95% CI, −1.5 to 3], P = .41). There was no difference in duration of ventilation or ICU care. There was no effect at 6 months for handgrip (difference, 2.0 kg [95% CI, −1.3 to 5.4], P = .23) and handheld dynamometer strength (difference, 0.4 lb [95% CI, −2.9 to 3.7], P = .82), SF-36 physical health score (difference, 3.4 [95% CI, −0.02 to 7.0], P = .05), SF-36 mental health score (difference, 2.4 [95% CI, −1.2 to 6.0], P = .19), or MMSE score (difference, 0.6 [95% CI, −0.2 to 1.4], P = .17). There were higher scores at 6 months in the SRT group for the SPPB score (difference, 1.1 [95% CI, 0.04 to 2.1, P = .04), SF-36 physical function scale score (difference, 12.2 [95% CI, 3.8 to 20.7], P = .001), and the FPI score (difference, 0.2 [95% CI, 0.04 to 0.4], P = .02). CONCLUSIONS AND RELEVANCE Among patients hospitalized with acute respiratory failure, SRT compared with usual care did not decrease hospital LOS.

Research that identifies treatments that benefit patients with ICUAW is necessary to determine whether the benefits of diagnostic testing for ICUAW outweigh its burdens.

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Introduction Hospitals are under pressure to provide care that not only shortens hospital length of stay, but reduces subsequent hospital admissions. Hospital readmissions have received increased attention in outcome reporting. We identified survivors of acute respiratory failure who then required subsequent hospitalization. A cohort of acute respiratory failure survivors, who participated in an early ICU-mobility program, was assessed to determine if variables from the index hospitalization predict hospital readmission or death, within 12 months of hospital discharge. Methods Hospital database and responses to letters mailed to 280 ARF survivors. Univariate predictor variables shown to be associated with hospital readmission or death (p<0.1) were included in a multiple logistic regression. A stepwise selection procedure was used to identify significant variables (p<0.05). Results Of the 280 survivors, 132 (47%) had at least one readmission or died within the first year, 126 (45%) were not readmitted, and 22 (8%) were lost to follow-up. Tracheostomy [OR 4.02 (CI 1.72, 9.40)], female gender [OR1.94 (CI 1.13, 3.32)], a higher Charlson Comorbidity Index assessed upon index hospitalization discharge [OR 1.15 (CI 1.01, 1.31)], and lack of early ICU mobility therapy [OR 1.77 CI (1.04, 3.01)] predicted readmission or death in the first year post-Index hospitalization. Conclusions Tracheostomy, female gender, higher Charlson Comorbidity Index and lack of early ICU mobility were associated with readmissions or death during the first year. Although the mechanism(s) of increased hospital readmission are unclear, these findings may provide further support for early ICU mobility for acute respiratory failure patients.

is advocated as a treatment to reduce iCu-acquired weakness and delirium. 15, 16 emphasis should be placed on progressive mobility, individual functional capability, and ambulation of patients who meet specific criteria. 17 patients in the iCu who receive early mobilization have had variable functional responses. 4, 18, 19 it is possible that this variability may be a result of the different tools used to capture function. in many of the iCu studies related to mobility interventions, the tools used to measure mobility status were not designed for patients tethered to tubes and lines, nor were they designed to detect changes in function in critically ill patients. several functional mobility tools have been used in published studies, including the functional independence Measure (fiM), 20 katz index of independence in activities of daily living, 21 Barthel index, 22 acute Care index of function, 23 university of rochester acute Care evaluation, 24 physical function iCu test, 25 and functional status score for intensive Care unit (fss-iCu). 26 however, these tools are not sensitive to measuring iCu mobility

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The purpose of this review was to summarize the findings of published reports that investigated quality-related outcomes and emergency department (ED) crowding. Of 276 data-based articles, 23 reported associations between patient outcomes and crowding. These articles were grouped into 3 categories: delay in treatment, decreased satisfaction, and increased mortality. Although these studies suggest that crowding results in poor outcomes, it is possible that other factors such as nursing care contribute to these adverse outcomes. Nursing care has been shown to contribute to both positive and negative patient outcomes in other settings. Building an understanding of how ED crowding affects the practice of the emergency nurse is essential to examining how nursing care, surveillance, and communication impact outcomes of emergency patients. Investigation into nurse-sensitive quality indicators in the ED has potential to develop strategies that deliver high quality of care, regardless of crowded conditions.