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Background After critical illness, patients are often left with impairments in physical, social, emotional, and cognitive functioning. Peer support interventions have been implemented internationally to ameliorate these issues. Objective To explore what patients believed to be the key mechanisms of effectiveness of peer support programs implemented during critical care recovery. Methods In a secondary analysis of an international qualitative data set, 66 telephone interviews with patients were undertaken across 14 sites in Australia, the United Kingdom, and the United States to understand the effect of peer support during recovery from critical illness. Prevalent themes were documented with framework analysis. Results Most patients who had been involved in peer support programs reported benefit. Patients described 3 primary mechanisms: (1) sharing experiences, (2) care debriefing, and (3) altruism. Conclusion Peer support is a relatively simple intervention that could be implemented to support patients during recovery from critical illness. However, more research is required into how these programs can be implemented in a safe and sustainable way in clinical practice.

Background Intensive care follow-up clinics (ICFCs) have been implemented internationally with the aim to address the growing number of patients living with sequalae of critical illness and intensive care. However, data on Australian intensive care follow-up practice are rare. Objectives The primary objective was to determine the proportion of Australian intensive care units (ICUs) that offer a dedicated ICFC to ICU survivors, with the intention of improving long-term outcomes of critical illness. Secondary objectives were to identify models of ICU follow-up and barriers to the implementation of ICFCs. Methods A custom-designed, pilot-tested 12-question online survey was sent to the nurse unit managers and medical directors of all 167 Australian ICUs listed in the database of the Australian and New Zealand Intensive Care Society. Outcome measures included proportion of ICUs offering ICFCs, details on types of follow-up services with staffing, funding source, and reasons for not providing ICU follow-up. Results One hundred seven of the 167 ICUs contacted responded to the survey. Of these, two (2%) operated a dedicated ICFC. Both ICFC s were nursing-led, with one receiving dedicated funding and the other being unfunded. Three units (3%) conducted routine outpatient follow-up by telephone; one of these services was doctor-led, and two were nurse-led. Four units (4%) were performing outpatient follow-up as part of research studies only. Among the units not operating an ICFC, the main reason given for not doing so were financial constraints (58%), followed by lack of clinical need (19%) and perceived lack of evidence (11%). Conclusion In Australia, only two ICUs operated an ICFC. Only one outpatient follow-up service received dedicated funding, and financial constraints were the main reason given for units not offering outpatient follow-up services.

Supplemental Digital Content is available in the text., Objectives: Improved ability to predict impairments after critical illness could guide clinical decision-making, inform trial enrollment, and facilitate comprehensive patient recovery. A systematic review of the literature was conducted to investigate whether physical, cognitive, and mental health impairments could be predicted in adult survivors of critical illness. Data Sources: A systematic search of PubMed and the Cochrane Library (Prospective Register of Systematic Reviews ID: CRD42018117255) was undertaken on December 8, 2018, and the final searches updated on January 20, 2019. Study Selection: Four independent reviewers assessed titles and abstracts against study eligibility criteria. Studies were eligible if a prediction model was developed, validated, or updated for impairments after critical illness in adult patients. Discrepancies were resolved by consensus or an independent adjudicator. Data Extraction: Data on study characteristics, timing of outcome measurement, candidate predictors, and analytic strategies used were extracted. Risk of bias was assessed using the Prediction model Risk Of Bias Assessment Tool. Data Synthesis: Of 8,549 screened studies, three studies met inclusion. All three studies focused on the development of a prediction model to predict (1) a mental health composite outcome at 3 months post discharge, (2) return-to-pre-ICU functioning and residence at 6 months post discharge, and (3) physical function 2 months post discharge. Only one model had been externally validated. All studies had a high risk of bias, primarily due to the sample size, and statistical methods used to develop and select the predictors for the prediction published model. Conclusions: We only found three studies that developed a prediction model of any post-ICU impairment. There are several opportunities for improvement for future prediction model development, including the use of standardized outcomes and time horizons, and improved study design and statistical methodology.

Background: After critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among patients who have survived. Who should be screened for long-term impairments, what tools to use, and when remain unclear. Objectives: Provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for postdischarge impairments. Participants: Thirty-one international experts in risk-stratification and assessment of survivors of critical illness, including practitioners involved in the Society of Critical Care Medicine’s Thrive Post-ICU Collaboratives, survivors of critical illness, and clinical researchers. Design: Society of Critical Care Medicine consensus conference on post-intensive care syndrome prediction and assessment, held in Dallas, in May 2019. A systematic search of PubMed and the Cochrane Library was conducted in 2018 and updated in 2019 to complete an original systematic review and to identify pre-existing systematic reviews. Meeting Outcomes: We concluded that existing tools are insufficient to reliably predict post-intensive care syndrome. We identified factors before (e.g., frailty, preexisting functional impairments), during (e.g., duration of delirium, sepsis, acute respiratory distress syndrome), and after (e.g., early symptoms of anxiety, depression, or post-traumatic stress disorder) critical illness that can be used to identify patients at high-risk for cognitive, mental health, and physical impairments after critical illness in whom screening is recommended. We recommend serial assessments, beginning within 2–4 weeks of hospital discharge, using the following screening tools: Montreal Cognitive Assessment test; Hospital Anxiety and Depression Scale; Impact of Event Scale-Revised (post-traumatic stress disorder); 6-minute walk; and/or the EuroQol-5D-5L, a health-related quality of life measure (physical function). Conclusions: Beginning with an assessment of a patient’s pre-ICU functional abilities at ICU admission, clinicians have a care coordination strategy to identify and manage impairments across the continuum. As hospital discharge approaches, clinicians should use brief, standardized assessments and compare these results to patient’s pre-ICU functional abilities (“functional reconciliation”). We recommend serial assessments for post-intensive care syndrome-related problems continue within 2–4 weeks of hospital discharge, be prioritized among high-risk patients, using the identified screening tools to prompt referrals for services and/or more detailed assessments.

Objectives: \ud Investigate the challenges experienced by survivors of critical illness and their caregivers across the transitions of care from intensive care to community, and the potential problem-solving strategies used to navigate these challenges.\ud \ud Design: \ud Qualitative design—data generation via interviews and data analysis via the framework analysis method.\ud \ud Setting: \ud Patients and caregivers from three continents, identified through the Society of Critical Care Medicine’s THRIVE international collaborative sites (follow-up clinics and peer support groups).\ud \ud Subjects: \ud Patients and caregivers following critical illness.\ud \ud Interventions: \ud Nil\ud \ud Measurements and Main Results: \ud From 86 interviews (66 patients, 20 caregivers), we identified the following major themes: 1) Challenges for patients—interacting with the health system and gaps in care; managing others’ expectations of illness and recovery. 2) Challenges for caregivers—health system shortfalls and inadequate communication; lack of support for caregivers. 3) Patient and caregiver-driven problem solving across the transitions of care—personal attributes, resources, and initiative; receiving support and helping others; and acceptance.\ud \ud Conclusions: \ud Survivors and caregivers experienced a range of challenges across the transitions of care. There were distinct and contrasting themes related to the caregiver experience. Survivors and caregivers used comparable problem-solving strategies to navigate the challenges encountered across the transitions of care.

Objectives Significant variability exists in physical rehabilitation modalities and dosage used in the ICU. Our objective was to investigate the effect of physical rehabilitation in ICU on patient outcomes, the impact of task-specific training, and the dose-response profile. Data sources A systematic search of Ovid MEDLINE, Cochrane Library, EMBASE, and CINAHL plus databases was undertaken on the May 28, 2020. Study selection Randomized controlled trials and controlled clinical trials investigating physical rehabilitation commencing in the ICU in adults were included. Outcomes included muscle strength, physical function, duration of mechanical ventilation, ICU and hospital length of stay, mortality, and health-related quality of life. Two independent reviewers assessed titles, abstracts, and full texts against eligibility criteria. Data extraction Details on intervention for all groups were extracted using the template for intervention description and replication checklist. Data synthesis Sixty trials were included, with a total of 5,352 participants. Random-effects pooled analysis showed that physical rehabilitation improved physical function at hospital discharge (standardized mean difference, 0.22; 95% CI, 0.00-0.44), reduced ICU length of stay by 0.8 days (mean difference, -0.80 d; 95% CI, -1.37 to -0.23 d), and hospital length of stay by 1.75 days (mean difference, -1.75 d; 95% CI, -3.03 to -0.48 d). Physical rehabilitation had no impact on the other outcomes. The intervention was more effective in trials where the control group received low-dose physical rehabilitation and in trials that investigated functional exercises. Conclusions Physical rehabilitation in the ICU improves physical function and reduces ICU and hospital length of stay. However, it does not appear to impact other outcomes.

Background: Patients who survive critical illness have well-defined physical, cognitive, emotional, and familial problems. However, the impact of these problems on survivors’ ability to return to w...

Nonurban residential living is associated with adverse outcomes for a number of chronic health conditions. However, it is unclear what effect it has amongst survivors of critical illness.The purpose of this study is to determine whether patients living greater than 50 km from the treating intensive care unit (ICU) have disability outcomes at 6 months that differ from people living within 50 km.This was a multicentre, prospective cohort study conducted in five metropolitan ICUs. Participants were adults admitted to the ICU, who received24 h of mechanical ventilation and survived to hospital discharge. In a secondary analysis of these data, the cohort was dichotomised based on residential distance from the treating ICU:50 km and ≥50 km. The primary outcome was patient-reported disability using the 12-item World Health Organization's Disability Assessment Schedule (WHODAS 2.0). This was recorded at 6 months after ICU admission by telephone interview. Secondary outcomes included health status as measured by EQ-5D-5L return to work and psychological function as measured by the Hospital Anxiety and Depression Scale (HADS). Multivariable logistic regression was used to assess the association between distance from the ICU and moderate to severe disability, adjusted for potential confounders. Variables included in the multivariable model were deemed to be clinically relevant and had baseline imbalance between groups (p0.10). These included marital status and hours of mechanical ventilation. Sensitivity analysis was also conducted using distance in kilometres as a continuous variable.A total of 262 patients were enrolled, and 169 (65%) lived within 50 km of the treating ICU and 93 (35%) lived ≥50 km from the treating ICU (interquartile range [IQR] 10-664 km). There was no difference in patient-reported disability at 6 months between patients living50 km and those living ≥50 km (WHODAS total disability % [IQR] 10.4 [2.08-25] v 14.6 [2.08-20.8], P = 0.74). There was also no difference between groups for the six major life domains of the WHODAS. There was no difference in rates of anxiety or depression as measured by HADS score (HADS anxiety median [IQR] 4 [1-7] v 3 [1-7], P = 0.60) (HADS depression median [IQR] 3 [1-6] v 3 [1-6], P = 0.62); health status as measured by EQ-5D (mean [SD] 66.7 [20] v 69.8 [22.2], P = 0.24); or health-related unemployment (% (N) 39 [26] v 25 [29.1], P = 0.61). After adjusting for confounders, living ≥50 km from the treating ICU was not associated with increased disability (odds ratio 0.61, 95% confidence interval: 0.33-1.16; P = 0.13) CONCLUSIONS: Survivors of intensive care in Victoria, Australia, who live at least 50 km from the treating ICU did not have greater disability than people living less than 50 km at 6 months after discharge. Living 50 km or more from the treating ICU was not associated with disability, nor was it associated with anxiety or depression, health status, or unemployment due to health.

Background Despite increased emphasis on providing higher-quality patient- and family-centered care in the intensive care unit (ICU), there are no widely accepted definitions of such care in the ICU. Objectives To determine (1) aspects of care that patients and families valued during their ICU encounter, (2) outcomes that patients and families prioritized after hospital discharge, and (3) outcomes perceived as equivalent to or worse than death. Methods Semistructured interviews (n = 49) of former patients of an urban, academic medical ICU and their family members. Two investigators reviewed all transcripts line by line to identify key concepts. Codes were created and defined in a codebook with decision rules for their application and were analyzed using qualitative content analysis. Results Salient themes were identified and grouped into 2 major categories: (1) processes of care within the ICU— communication, patient comfort, and a sense that the medical team was “doing everything” (ie, providing exhaustive medical care) and (2) patient and surrogate outcomes after the ICU—survival, quality of life, physical function, and cognitive function. Several outcomes were deemed worse than death: severe cognitive/physical disability, dependence on medical machinery/equipment, and severe/constant pain. Conclusion Although survival was important, most participants qualified this preference. Simple measures of mortality rates may not represent patient- or family-centered outcomes in evaluations of ICU-based interventions, and new measures that incorporate functional outcomes and patients’ and family members’ views of life quality are necessary to promote patient-centered, evidence-based care.

Rationale: Physical restraints are used liberally in some intensive care units (ICUs) to prevent patient harm from device removal or falls. Although the intention of restraint use is patient safety, their application may inadvertently cause physical or psychological harm. Physical restraints may contribute to post-traumatic stress disorder (PTSD), but there is a paucity of supportive data.Objectives: To investigate the association between physical restraint use and PTSD symptoms in ICU survivors. Secondary objectives were to examine the cognitive and physical outcomes associated with physical restraint use and to assess interventions that may be effective in reducing restraint use.Methods: A systematic review of English language studies in PubMed, Medline, Embase, CINAHL, and CENTRAL between January 1, 1990, to February 8, 2020 was performed. Observational or randomized studies that reported on restraint use and associated outcomes, or interventions to reduce restraint use, in critically ill adult patients were identified. Two independent reviewers completed the review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.Results: We identified 794 articles, of which 37 met inclusion criteria and were included. Thirty of these studies related to patient outcomes including PTSD, delirium, mechanical ventilation hours, and physical injury. Seven related to interventions to reduce physical restraint use. The quality of studies was not high; only four of the included studies were assessed to have a low risk of bias. Three studies found a significant relationship between restraint use and PTSD, but their results could not be pooled for analysis. Pooled data indicated a significant association between physical restraint use and delirium (odds ratio [OR], 11.54; 95% confidence interval [CI], 6.66-20.01; P

Research highlights the psychosocial impact of critical illness on family who typically adopt a caregiver role to the survivor. We review evidence on informal caregiver psychosocial outcomes and interventional studies designed to improve them. We argue informal caregivers have distinct and complex needs that differ from patients. Interventional studies ought to be designed for this cohort with careful attention paid to the timing of interventions. We consider the influence of social isolation on recovery and discuss service improvement approaches to build social support networks to enhance recovery, where caregivers and survivors are involved in the design of aftercare programs.

Identifying solutions to improve recovery after critical illness is a pressing problem. We systematically evaluated studies of peer support as a potential intervention to improve recovery in critical care populations and synthesized elements important to peer support model design.A systematic search of Medical Literature Analysis and Retrieval System Online, Cumulative Index to Nursing and Allied Health Literature, PsychINFO, and Excertpa Medica Database was undertaken May 2017. Prospective Register of Systematic Reviews identification number: CRD42017070174.Two independent reviewers assessed titles and abstracts against study eligibility criteria. Studies were included where 1) patients and families had experienced critical illness and 2) patients and families had participated in a peer support intervention. Discrepancies were resolved by consensus and a third independent reviewer adjudicated as necessary.Two independent reviewers assessed study quality with the Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool, and data were synthesized according to the Preferred Reporting Items for Systematic Reviews guidelines and interventions summarized using the Template for Intervention Description and Replication Checklist.Two-thousand nine-hundred thirty-two studies were screened. Eight were included, comprising 192 family members and 92 patients including adults (with cardiac surgery, acute myocardial infarction, trauma), pediatrics, and neonates. The most common peer support model of the eight studies was an in-person, facilitated group for families that occurred during the patients' ICU admission. Peer support reduced psychologic morbidity and improved social support and self-efficacy in two studies; in both cases, peer support was via an individual peer-to-peer model. In the remaining studies, it was difficult to determine the outcomes of peer support as the reporting and quality of studies was low.Peer support appeared to reduce psychologic morbidity and increase social support. The evidence for peer support in critically ill populations is limited. There is a need for well-designed and rigorously reported research into this complex intervention.

Objectives: Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them.\ud \ud Design: Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data.\ud \ud Setting: Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents.\ud \ud Subjects: Clinicians from 21 sites.\ud \ud Measurement and Main Results: Ten enablers and nine barriers to implementation of “ICU follow-up clinics” were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of “peer support groups” were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising.\ud \ud Conclusions: Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles.

To determine predictors of inability to return to work due to health six-months after intensive care admission; and compare functional recovery between patients who had not returned to work and employed patients.Participants were working adults admitted to ICU who received24 h of mechanical ventilation. Outcomes included inability to return to work due to health at six-months post-ICU admission, disability, health status, anxiety, depression and post-traumatic stress.Of 107 patients, 31 (29%) were unable to return to work due to health at six-months after ICU admission. Predictors of inability to return to work included longer hospital stay (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02-1.08; P = .004); lower Glasgow Coma Scale (GCS) at admission (OR, 0.86; CI, 0.75-0.99; P = .03); and admission due to major trauma (OR, 8.83; CI, 2.57-30.38; P .001). Compared to employed patients, those who had not returned to work reported higher levels of disability and psychological distress, and poorer health-related quality of life.Major trauma, lower GCS and increased hospital length of stay predicted inability to return to work due to health at six-months post-ICU admission. Compared to employed patients, those who had not returned to work reported poorer functional recovery.

Rehabilitation of people who are critically ill has received increased attention in recent years, although this has not extended to specifically facilitating family involvement. Engaging families in the rehabilitation arc has the potential to optimize outcomes. Likely benefits include redirecting family psychological distress into an active participatory role, humanizing the patient illness and recovery experience, and supporting staff and the health care system beyond the constraints of therapy time. This viewpoint explores why families should be engaged in critical care rehabilitation, gives an overview of the evidence for family participation in bedside care, and provides practical implementation strategies and signpost areas for future research.

Background Almost all data on 5-year outcomes for critical care survivors come from North America and Europe. The aim of this study was to investigate long-term mortality, physical function, psychological outcomes and health-related quality of life in a mixed intensive care unit cohort in Australia. Methods This longitudinal study evaluated 4- to 5-year outcomes. Physical function (six-minute walk test) and health-related quality of life (Short Form 36 Version 2) were compared to 1-year outcomes and population norms. New psychological data (Center for Epidemiological Studies–Depression, Impact of Events Scale) was collected at follow-up. Results Of the 150 participants, 66 (44%) patients were deceased by follow-up. Fifty-six survivors were included with a mean (SD) age of 64 (14.2). Survivors’ mean (SD) six-minute walk distance increased between 1 and 4 to 5 years (465.8 m (148.9) vs. 507.5 m (118.2)) (mean difference = − 24.5 m, CI − 58.3, 9.2, p = 0.15). Depressive symptoms were low: median (IQR) score of 7.0 (1.0–15.0). The mean level of post-traumatic stress symptoms was low—median (IQR) score of 1.0 (0–11.0)—with only 9 (16%) above the threshold for potentially disordered symptoms. Short-Form 36 Physical and Mental Component Scores did not change between 1 and 4 to 5 years (46.4 (7.9) vs. 46.7 (8.1) and 48.8 (13) vs. 48.8 (11.1)) and were within a standard deviation of normal. Conclusions Outcomes of critical illness are not uniform across nations. Mortality was increased in this cohort; however, survivors achieved a high level of recovery for physical function and health-related quality of life with low psychological morbidity at follow-up. Trial registration The trial was registered with the Australian New Zealand Clinical Trials Registry ACTRN12605000776606. Electronic supplementary material The online version of this article (10.1186/s40560-018-0276-x) contains supplementary material, which is available to authorized users.

Purpose Early mobilization in intensive care unit (ICU) is safe, feasible, and beneficial. However, mobilization frequently does not occur in practice. The study objective was to elicit attitudinal, normative, and control beliefs (barriers and enablers) toward the mobilization of ventilated patients, to inform development of targeted implementation interventions. Materials and methods A 9-item elicitation questionnaire was administered electronically to a convenience sample of multidisciplinary staff in a tertiary ICU. A snowball recruitment approach was used to target a sample size of 20 to 25. Two investigators performed word count and thematic analyses independently. Themes were cross-checked by a third investigator. Results Twenty-two questionnaires were completed. Respondents wrote the most text about disadvantages. Positive attitudinal beliefs included better respiratory function, reduced functional decline, and reduced muscle wasting/weakness. The main negative attitudinal beliefs were that mobilization is perceived as time consuming and poses a risk of line dislodgement/disconnection. Positive control beliefs (enablers) included increased staff availability, positive staff attitudes, engagement, and teamwork. Negative control beliefs (barriers) included unstable patient physiology and negative workplace culture. Conclusions Intensive care unit staff expressed positive and negative attitudinal, normative, and control beliefs across the spectrum, and disadvantages were most frequently reported. Identified beliefs can be used to inform development of future interventions.

Objective: The objective of the review was to evaluate and synthesize the prevalence, risk factors, and trajectory of psychosocial morbidity in informal caregivers of critical care survivors. Data Sources: A systematic search of MEDLINE, PsychInfo, PubMed, CINAHL, Cochrane Library, Scopus, PILOTS, EMBASE, and Physiotherapy Evidence Database was undertaken between January and February 2014. Study Selection: Citations were screened independently by two reviewers for studies that investigated psychosocial outcomes (depression, anxiety, stress, posttraumatic stress disorder, burden, activity restriction, and health-related quality of life) for informal caregivers of critical care survivors (mechanically ventilated for 48 hr or more). Data Extraction: Data on study outcomes were extracted into a standardized form and quality assessed by two independent reviewers using the Newcastle-Ottawa Scale, the Physiotherapy Evidence Database, and the National Health and Medical Research Council Hierarchy of Evidence guide. Preferred Reporting Items for Systematic Reviews guidelines were followed. Data Synthesis: Fourteen studies of 1,491 caregivers were included. Depressive symptoms were the most commonly reported outcome with a prevalence of 75.5% during critical care and 22.8–29% at 1-year follow-up. Risk factors for depressive symptoms in caregivers included female gender and younger age. The greatest period of risk for all outcomes was during the patient’s critical care admission although psychological symptoms improved over time. The overall quality of the studies was low. Conclusions: Depressive symptoms were the most prevalent in informal caregivers of survivors of intensive care who were ventilated for more than 48 hours and persist at 1 year with a prevalence of 22.8–29.0%, which is comparable with caregivers of patients with dementia. Screening for caregiver risks could be performed during the ICU admission where intervention can be implemented and then evaluated. Further high-quality studies are needed to quantify anxiety, stress, caregiver burden, and posttraumatic stress disorder outcomes in informal caregivers of long-stay patients surviving ICU. (Crit Care Med 2015; XX:00–00)

© 2014 Hodgson et al.; licensee BioMed Central. Introduction: The aim of this study was to develop consensus recommendations on safety parameters for mobilizing adult, mechanically ventilated, intensive care unit (ICU) patients. Methods: A systematic literature review was followed by a meeting of 23 multidisciplinary ICU experts to seek consensus regarding the safe mobilization of mechanically ventilated patients. Results: Safety considerations were summarized in four categories: respiratory, cardiovascular, neurological and other. Consensus was achieved on all criteria for safe mobilization, with the exception being levels of vasoactive agents. Intubation via an endotracheal tube was not a contraindication to early mobilization and a fraction of inspired oxygen less than 0.6 with a percutaneous oxygen saturation more than 90% and a respiratory rate less than 30 breaths/minute were considered safe criteria for in- and out-of-bed mobilization if there were no other contraindications. At an international meeting, 94 multidisciplinary ICU clinicians concurred with the proposed recommendations. Conclusion: Consensus recommendations regarding safety criteria for mobilization of adult, mechanically ventilated patients in the ICU have the potential to guide ICU rehabilitation whilst minimizing the risk of adverse events.

Background Survivors of critical illness can experience long-standing functional limitations that negatively affect their health-related quality of life. To date, no model of rehabilitation has demonstrated sustained improvements in physical function for survivors of critical illness beyond hospital discharge. Objective The aims of this study were: (1) to describe a model of rehabilitation for survivors of critical illness, (2) to compare the model to local standard care, and (3) to report the safety and feasibility of the program. Design This was a cohort study. Methods As part of a larger randomized controlled trial, 74 participants were randomly assigned, 5 days following admission to the intensive care unit (ICU), to a protocolized rehabilitation program that commenced in the ICU and continued on the acute care ward and for a further 8 weeks following hospital discharge as an outpatient program. Exercise training was prescribed based on quantitative outcome measures to achieve a physiological training response. Results During acute hospitalization, 60% of exercise sessions were able to be delivered. The most frequently occurring barriers to exercise were patient safety and patient refusal due to fatigue. Point prevalence data showed patients were mobilized more often and for longer periods compared with standard care. Outpatient classes were poorly attended, with only 41% of the patients completing more than 70% of outpatient classes. No adverse events occurred. Limitations Limitations included patient heterogeneity and delayed commencement of exercise in the ICU due to issues of consent and recruitment. Conclusions Exercise training that commences in the ICU and continues through to an outpatient program is safe and feasible for survivors of critical illness. Models of care that maximize patient participation across the continuum of care warrant further investigation.

Introduction The purpose of this trial was to investigate the effectiveness of an exercise rehabilitation program commencing during ICU admission and continuing into the outpatient setting compared with usual care on physical function and health-related quality of life in ICU survivors. Methods We conducted a single-center, assessor-blinded, randomized controlled trial. One hundred and fifty participants were stratified and randomized to receive usual care or intervention if they were in the ICU for 5 days or more and had no permanent neurological insult. The intervention group received intensive exercises in the ICU and the ward and as outpatients. Participants were assessed at recruitment, ICU admission, hospital discharge and at 3-, 6- and 12-month follow-up. Physical function was evaluated using the Six-Minute Walk Test (6MWT) (primary outcome), the Timed Up and Go Test and the Physical Function in ICU Test. Patient-reported outcomes were measured using the Short Form 36 Health Survey, version 2 (SF-36v2) and Assessment of Quality of Life (AQoL) Instrument. Data were analyzed using mixed models. Results The a priori enrollment goal was not reached. There were no between-group differences in demographic and hospital data, including acuity and length of acute hospital stay (LOS) (Acute Physiology and Chronic Health Evaluation II score: 21 vs 19; hospital LOS: 20 vs 24 days). No significant differences were found for the primary outcome of 6MWT or any other outcomes at 12 months after ICU discharge. However, exploratory analyses showed the rate of change over time and mean between-group differences in 6MWT from first assessment were greater in the intervention group. Conclusions Further research examining the trajectory of improvement with rehabilitation is warranted in this population. Trial registration The trial was registered with the Australian New Zealand Clinical Trials Registry ACTRN12605000776606.