Objective To develop a scoring system to measure physical morbidity in critical care -the Chelsea Critical Care Physical Assessment Tool (CPAx). Method The development process was iterative involving content validity indices (CVI), a focus group and an observational study of 33 patients to test construct validity against the Medical Research Council score for muscle strength, peak cough flow, Australian Therapy Outcome Measures score, Glasgow Coma Scale score, Bloomsbury sedation score, Sequential Organ Failure Assessment score, Short Form 36 (SF-36) score, days of mechanical ventilation and inter-rater reliability. Participants Trauma and general critical care patients from two London teaching hospitals. Results Users of the CPAx felt that it possessed content validity, giving a final CVI of 1.00 (P < 0.05). Construct validation data showed moderate to strong significant correlations between the CPAx score and all secondary measures, apart from the mental component of the SF-36 which demonstrated weak correlation with the CPAx score (r = 0.024, P = 0.720). Reliability testing showed internal consistency of α = 0.798 and inter-rater reliability of κ = 0.988 (95% confidence interval 0.791 to 1.000) between five raters. Conclusion This pilot work supports proof of concept of the CPAx as a measure of physical morbidity in the critical care population, and is a cogent argument for further investigation of the scoring system.
RationalePhysical rehabilitation (encompassing early mobilisation) of the critically ill patient is recognised best practice; however, further work is needed to explore the patients’ experience of rehabilitation qualitatively; a better understanding may facilitate implementation of early rehabilitation and elucidate the journey of survivorship.ObjectivesTo explore patient experience of physical rehabilitation from critical illness during and after a stay on intensive care unit (ICU).DesignExploratory grounded theory study using semistructured interviews.SettingAdult medical/surgical ICU of a London teaching hospital.ParticipantsA purposive sample of ICU survivors with intensive care unit acquired weakness (ICUAW) and an ICU length of stay of >72 hours.AnalysisData analysis followed a four-stage constant comparison technique: open coding, axial coding, selective coding and model development, with the aim of reaching thematic saturation. Peer debriefing and triangulation through a patient support group were carried out to ensure credibility.Main resultsFifteen people were interviewed (with four relatives in attendance). The early rehabilitation period was characterised by episodic memory loss, hallucinations, weakness and fatigue, making early rehabilitation arduous and difficult to recall. Participants craved a paternalised approach to care in the early days of ICU.The central idea that emerged from this study was recalibration of the self. This is driven by a lost sense of self, with loss of autonomy and competence; dehumanised elements of care may contribute to this. Participants described a fractured life narrative due to episodic memory loss, meaning that patients were shocked on awakening from sedation by the discrepancy between their physical form and cognitive representation of themselves.ConclusionsRecovery from ICUAW is a complex process that often begins with survivors exploring and adapting to a new body, followed by a period of recovering autonomy. Rehabilitation plays a key role in this recalibration period, helping survivors to reconstruct a desirable future.
BackgroundPulmonary Rehabilitation (PR) is an important treatment for patients with chronic obstructive pulmonary disease (COPD) but it is not established whether any baseline parameter can predict response or compliance.AimTo identify whether baseline measures can predict who will complete the programme and who will achieve a clinically significant benefit from a Minimum Clinical Important Difference (MCID) in terms of exercise capacity and health-related quality of life (HRQoL).MethodsData were collected prospectively from patients with COPD at their baseline assessment for an outpatient PR programme in one of eight centres across London. ‘Completion’ was defined as attending at least 75% of the designated PR visits and return for the follow-up evaluation. The MCID for outcome measures was based on published data.Results787 outpatients with COPD (68.1±10.5 years old; 49.6% males) were included. Patients who completed PR (n=449, 57.1%) were significantly older with less severe airflow obstruction, lower anxiety and depression scores, less dyspnoea and better HRQoL. Only baseline CAT score (OR=0.925; 95% CI 0.879 to 0.974; p=0.003) was retained in multivariate analysis. Patients with the lowest baseline walking distance were most likely to achieve the MCID for exercise capacity. No baseline variable could independently predict achievement of an MCID in HRQoL.ConclusionsPatients with better HRQoL are more likely to complete PR while worse baseline exercise performance makes the achievement of a positive MCID in exercise capacity more likely. However, no baseline parameter could predict who would benefit the most in terms of HRQoL.
Background There has been a recent surge in the creation and adaptation of instruments to measure physical functioning (PF) in the intensive care unit (ICU). Selecting the right measurement instrument depends on understanding the core constructs that it measures in terms of the International Classification of Functioning, Disability and Health (ICF) domains. Purpose The purpose of this study was to map systematically the ICF domains and subdomains included in the PF measurement instruments used for adult patients during the ICU stay. Data Sources A systematic search was carried out in Cochrane CENTRAL, PubMed, CINAHL, and LILACS as well as a hand search up to May 17, 2017. Study Selection Study selection included all types of research articles that used at least 1 PF measurement instrument in adult patients within the ICU. Data Extraction Study design, year of publication, study population, and the measurement instruments reported were recorded. A consensus of experts analyzed the ICF domains included in each instrument. Data Synthesis We found 181 articles containing 60 PF measurement instruments used during the ICU stay. Twenty-six ICF domains were identified, 38 instruments included Mobility , and 13 included Muscle function . Limitations Studies not written in English or Spanish were excluded. Conclusions There are numerous PF measurement instruments used in adult patients in the ICU. The most frequent ICF domain measured is Mobility . This study highlights the ICF domains contained in the instruments that can be used clinically, providing a complete database of instruments that could facilitate selection of the most appropriate measure based on the patients’ needs.
IntroductionIntensive care unit-acquired weakness (ICU-AW) is common in survivors of critical illness, resulting in global weakness and functional deficit. Although ICU-AW is well described subjectively in the literature, the value of objective measures has yet to be established. This project aimed to evaluate the construct validity of the Chelsea Critical Care Physical Assessment tool (CPAx) by analyzing the association between CPAx scores and hospital-discharge location, as a measure of functional outcome.MethodsThe CPAx was integrated into practice as a service-improvement initiative in an 11-bed intensive care unit (ICU). For patients admitted for more than 48 hours, between 10 May 2010 and 13 November 2013, the last CPAx score within 24 hours of step down from the ICU or death was recorded (n = 499). At hospital discharge, patients were separated into seven categories, based on continued rehabilitation and care needs. Descriptive statistics were used to explore the association between ICU discharge CPAx score and hospital-discharge location.ResultsOf the 499 patients, 171 (34.3%) returned home with no ongoing rehabilitation or care input; 131 (26.2%) required community support; 28 (5.6%) went to inpatient rehabilitation for <6 weeks; and 25 (5.0%) went to inpatient rehabilitation for >6 weeks; 27 (5.4%) required nursing home level of care; 80 (16.0%) died in the ICU, and 37 (7.4%) died in hospital. A significant difference was found in the median CPAx score between groups (P < 0.0001). Four patients (0.8%) scored full marks (50) on the CPAx, all of whom went home with no ongoing needs; 16 patients (3.2%) scored 0 on the CPAx, all of whom died within 24 hours. A 0.8% ceiling effect and a 3.2% floor effect of the CPAx is found in the ICU. Compliance with completion of the CPAx stabilized at 78% of all ICU admissions.ConclusionThe CPAx score at ICU discharge has displayed construct validity by crudely discriminating between groups with different functional needs at hospital discharge. The CPAx has a limited floor and ceiling effect in survivors of critical illness. A significant proportion of patients had a requirement for postdischarge care and rehabilitation.
ObjectiveTo evaluate the efficacy of eLearning in the widespread standardised teaching, distribution and implementation of the Chelsea Critical Care Physical Assessment (CPAx) tool—a validated tool to assess physical function in critically ill patients.DesignProspective educational study. An eLearning module was developed through a conceptual framework, using the four-stage technique for skills teaching to teach clinicians how to use the CPAx. Example and test video case studies of CPAx assessments were embedded within the module. The CPAx scores for the test case studies and demographic data were recorded in a secure area of the website. Data were analysed for inter-rater reliability using intraclass correlation coefficients (ICCs) to see if an eLearning educational package facilitated consistent use of the tool. A utility and content validity questionnaire was distributed after 1 year to eLearning module registrants (n=971). This was to evaluate uptake of the CPAx in clinical practice and content validity of the CPAx from the perspective of clinical users.SettingThe module was distributed for use via professional forums (n=2) and direct contacts (n=95).ParticipantsCritical care clinicians.Primary outcome measureICC of the test case studies.ResultsBetween July and October 2014, 421 candidates from 15 countries registered for the eLearning module. The ICC for case one was 0.996 (95% CI 0.990 to 0.999; n=207). The ICC for case two was 0.988 (0.996 to 1.000; n=184). The CPAx has a strong total scale content validity index (s-CVI) of 0.94 and is well used.ConclusionseLearning is a useful and reliable way of teaching psychomotor skills, such as the CPAx. The CPAx is a well-used measure with high content validity rated by clinicians.
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