Commencing out of bed rehabilitation in critical care - what influences clinical decision-making?

Abstract

To develop a decision tree that objectively identifies the most discriminative variables in the decision to provide out-of-bed rehabilitation, measure the impact of this decision and to identify the factors that intensive care unit (ICU) practitioners think most influential in that clinical decision. A prospective three-part study: i) consensus identification of influential factors in mobilization via survey, ii) development of an early rehabilitation decision tree and iii) measurement of practitioner mobilisation decision-making. Treating practitioners of patients expected to stay > 96h were asked if they would provide out-of-bed rehabilitation and rank factors that influenced this decision from an a priori defined list developed from a literature review and expert consultation. Four tertiary metropolitan ICUs PARTICIPANTS: Practitioners (ICU medical, nursing and physiotherapy staff) INTERVENTIONS: Not applicable MAIN OUTCOMES: A decision tree was constructed using binary recursive partitioning to determine the factor that best classified patients suitable for out-of-bed rehabilitation. Descriptive statistics were used to describe practitioner and patient samples as well as patient adverse events associated with out-of-bed rehabilitation and the factors prioritised by ICU practitioners. There were 1520 practitioner decisions representing 472 individual patient decisions. Practitioners classified patients suitable for out-of-bed rehabilitation on 149 occasions and not suitable on 323 occasions. Decision tree analysis showed the presence of an endotracheal tube (ETT) and sedation state were the only discriminative variables that predicted patient suitability for rehabilitation. In contrast, medical staff and nurses reported that ventilator status was the most influential factor in their decision not to provide rehabilitation whilst physiotherapists ranked sedation most highly. The presence of muscle weakness did not inform the decision to provide rehabilitation. These results confirm previous observational reports that the presence of an ETT remains a major obstacle to the provision of rehabilitation for critically ill patients. Despite rehabilitation being effective for improving muscle strength, the presence of muscle weakness did not influence the decision to provide rehabilitation.