5 th European Conference on Weaning & Rehabilitation in Critically Ill Patients

Transcription

1 5 th European Conference on Weaning & Rehabilitation in Critically Ill Patients Guy s and St Thomas NHS Foundation Trust, London, UK 11 th & 12 th November 2017 Conference Book

2 TABLE OF CONTENTS WELCOME LETTER... 3 THE EUROPEAN BOARD... 5 VENUE AND TRANSPORTATION... 8 GENERAL INFORMATION A-Z PROGRAMME SATURDAY 11 TH NOVEMBER PROGRAMME SUNDAY 12 TH NOVEMBER FACULTY ABSTRACTS THANK YOU TO OUR SPONSORS OTHER EVENTS TO LOOK OUT FOR... 86

3 WELCOME LETTER Dear Colleagues It gives us great pleasure to welcome you to the 5 th European Conference on Weaning and Rehabilitation in Critically Ill Patients in London, UK, 11 th -12 th November, The programme focuses on multiprofessional weaning and rehabilition of critically ill patients in and after admission to the Intensive Care Unit. The annual conference is an exciting forum to network and share advances and experiences in clinical practice around the management of this patient group. The 2017 conference includes updates on current evidence and its application into the clinical field of weaning and rehabilitation. The London Conference is the fifth meeting of its kind, following previous conferences in Vienna, Athens, Copenhagen and Hamburg. As the conference establishes its place on the European meeting calendar, so we have maintained the emphasis of the meeting on interprofessional discussion, sharing of experiential learning, and clinical application of the relevant evidence base, rather than solely focus on scientific output. The two-day programme includes invited lectures from our international Faculty, including our keynote speaker Professor Margaret Herridge (Canada). In addition 12 abstracts will be presented in spoken sessions and a further 30 posters will be exhibited throughout the course of the conference. We have our largest delegate audience for this conference to date, which promises to offer huge opportunity for thought-provoking questions and broad representation of practice. Welcome to London! One of the most exciting, diverse and well-loved cities in the world.full of instantly recognizable sights, history, arts and entertainment. Welcome to Guy s and St Thomas NHS Foundation Trust and King s College London two of the UK s most renowned clinical and academic institutions, located in the heart of the city and offering the perfect backdrop to the conference. We thank you for joining us in making the 5 th European Conference on Weaning & Rehabilitation in Critically Ill Patients a successful, interesting and memorable conference. Sincerely, Dr Bronwen Connolly (Conference Director) on behalf of the UK Organizing Committee Page 3 of 89

4 ICU RECOVERY NETWORK Welcome to ICU Recovery Network, the international network for early mobilization and rehabilitation of critical care patients. The ICU RECOVERY NETWORK is an international, multidisciplinary and multiprofessional organization with more than 900 members representing all five continents. It was founded in Participation is for free, but exclusively to clinicians. ICU Recovery Network includes sub-networks, located in several countries. To date, there are subnetworks in Brazil, Denmark, Germany, Greece and Japan. The website of the network is If you want to join the network, please the local representative in your region of the world or just with your affiliation to Peter Nydahl: You will receive an invitation to join ICU Recovery Network, which is located on a server from MedConcert. Chair of the network is Professor Dale Needham, MD PhD, Baltimore, USA. Prof. Needham s a newsletter once per month to all participants of ICU Recovery Network, including details of new publications, resources, conferences and other information. Page 4 of 89

5 THE EUROPEAN BOARD The European conferences are established and organized by the European Board. THE EUROPEAN BOARD comprises of a group of highly engaged and collaborative clinicians specializing in the field of critical illness weaning and rehabilitation. Each conference is led by a local organizing committee. Mette Brøkner Hansen PT, BSc. Department of Occupational and Physiotherapy, Intensive Care Unit, Copenhagen University Hospital, Denmark Bronwen Connolly MSc, PhD, MCSP, Consultant Clinical Research Physiotherapist, Critical Care, NIHR Postdoctoral Research Fellow. Lane Fox Respiratory Unit, St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, UK Eve Corner BSc (hons), MRes., PhD, NIHR CLAHRC Lecturer in Physiotherapy, Brunel University London Vicky Gerovasili MD, PhD. Consultant in Respiratory and Transplant Medicine Queen Elisabeth Hospital, University Hospitals Birmingham NHS Foundation Trust Rik Gosselink Prof. Dr., PhD, PT, Department Rehabilitation Sciences. Faculty Kinesiology and Rehabilitation Sciences. Respiratory Rehabilitation. University Hospitals Leuven, Belgium Page 5 of 89

6 Nicholas HartHart Prof. MB, BS, BSc, PhD, MRCP, FFICM, Clinical Director. Lane Fox Respiratory Service. St. Thomas Hospital, Guy's & St. Thomas' NHS Foundation Trust, UK Greet Hermans. MD, PhD, Professor, Medical Intensive Care Unit, Department of General Internal Medicine. University Hospitals Leuven, Belgium Lefteris Karatzanos MSc, PhD, Clinical & Exercise Physiologist Clinical Ergospirometry, Exercise & Rehabilitation Lab Evagelismos Hospital, School of Medicine National & Kapodistrian University of Athens, Greece Peter Nydahl. RN, MScN, Nursing Research. University Hospital of Schleswig-Holstein, Kiel, Germany Irini Patsaki PT, MSc, ICU. General Hospital of Athens "Evangelismos, Greece Katrine Sørensen PT, Master of Science in Physiotherapy. Department of Occupational and Physiotherapy. Intensive Care Unit, Aarhus University Hospital, Denmark Page 6 of 89

7 Peter Spronk. MD, PhD, EDIC, FCCP, Internist-intensivist. Department of ICU, Gelre Hospitals Apeldoorn, Academic Medical Center, University of Amsterdam, The Netherlands Marike van der Schaaf PhD, Associate Professor Acute Care Rehabilitation. Academic Medical Center, University of Amsterdam, The Netherlands Page 7 of 89

8 VENUE AND TRANSPORTATION New Hunt s House Guy s Hospital Campus London SE1 1UL Tel: +44 (0) www: New Hunts House is in the heart of the Guy s Hospital Campus. The building is directly opposite to the main entrance of Guy s Hospital, however access to the building will be via the revolving doors in the middle of the building on the Memorial Gardens side. The doors opposite the hospital will not be open at the weekend. TRANSPORTATION Guy s Campus is situated next to London Bridge Rail Station and London Bridge Underground (Tube). Both stations are a 5 minute walk to the hospital. Travelling by train From Kings Cross St Pancras travel time: 30 minutes Please take the southbound Northern Line Tube (Bank branch) to London Bridge and follow the exit signs for Guy s Hospital. From Euston Station travel time: 35 minutes Please take the southbound Northern Line Tube (Bank branch) to London Bridge and follow the exit signs for Guy s Hospital. From Paddington Station travel time: 45 minutes The easiest option is to take the southbound Bakerloo Line to Waterloo and then change on the Jubilee Line to London Bridge. Please then follow the exit signs for Guy s Hospital. From Waterloo Station travel time: 20 minutes From Waterloo Station you have two options to get to London Bridge: Take the eastbound Jubilee Line on the Underground (Tube) to London Bridge Or, use Waterloo East Station which is on the first floor of Waterloo Station. Regular trains (approx. every 10 minutes) depart for London Bridge Station. Travelling by London Underground (Tube) Guy s Hospital is situated next to London Bridge Underground (Tube) which is on both the Northern Line and Jubilee Lines. Page 8 of 89

9 Please follow the exit signs for Guy s Hospital it is a 5 minute walk to the hospital. Travelling by car Guy s Hospital is situated in the south-east part of Central London. Please use the hospitals post code for sat-nav directions: SE1 9RT. However, parking is very limited at the hospital. Guy s Tower car park is used only for short-term parking and patient drop-off. The nearest NCP car park (post code SE1 3RU) is situated at the junction of Snowsfield and Kipling Streets, about a 2 minute walk from the hospital. Disabled parking is available at Guy s Tower car park but is limited and on a first come, first served basis. Guy s Hospital is in the Congestion Charging zone, so please use public transport whenever possible. The Transport for London website ( gives information about how to pay this and who qualifies for refunds or discounts. Page 9 of 89

10 GENERAL INFORMATION A-Z CERTIFICATE OF ATTENDANCE We kindly ask you to evaluate the conference via an online-survey, which will be ed to you after the conference. We ask you for your opinion about the conference, each session and other questions. You can also suggest topics and improvements, which will help in our planning of future conferences. After filling out the evaluation form, you can download your personalised certificate of attendance. CLOAKROOM There is a manned cloak room inside the building, located in classroom G3. A floor plan will be visible in reception area. The cloakroom will be open at: 08:00-18:30 on Saturday, November 11 th :00 16:00 on Sunday, November 12 th 2017 CURRENCY All vendors and venues in London accept cash and most major credit cards. Local currency is the Pound Sterling ( /GBP). FOOD AND BEVERAGES Refreshments and a sandwich packed lunch are included in the conference registration. To ease congestion during the lunch hour, please take note of the lunch time slot printed on your name badge. Please do not take food into the lecture theatres. LIABILITY AND INSURANCE The organizer assumes no liability for personal injury or loss of or damage to private property. Please remember to take out a private travel and health insurance. MOBILE PHONES Please ensure mobile phones are turned off or muted during presentations. NAME BADGE You will receive your name badge at the registration desk. Please wear your name badge at all times during the conference for access to all areas as well as food and beverages. Please also note the lecture you should start in for breakout sessions is noted on your name badge. OFFICIAL LANGUAGE The official language of the Conference is English. Page 10 of 89

11 REGISTRATION Please sign in upon arrival. Registration opens at: 08:00 on Saturday, November 11 th :00 on Sunday, November 12 th 2017 SOCIAL MEDIA Please feel free to use our conference-specific hashtag on Twitter: #ICUrecovery17 Please kindly refrain from taking pictures of slides and/or sharing on social media if they contain either of the following logos, as the slides may contain sensitive material: SOCIAL NETWORKING A drinks reception will be held in the foyer area of the venue, to which everyone is welcome. This will run from 17:30 18:30 on Saturday 11 th November. SMOKING POLICY Smoking is prohibited in all internal and external areas of the venue. WATER The tap water is safe to drink. WEATHER IN LONDON The weather continues to get colder in November in London. Temperatures are likely to be around 10 C. It is advisable to bring warm clothes and an umbrella or a raincoat. Sunrise: 07:11 am, sunset: 04:16: pm. WIFI You can use the free wifi at the conference venue. Login information will be displayed at reception and in the main conference hall welcome slides. Page 11 of 89

12 PROGRAMME SATURDAY 11 TH NOVEMBER Time Session Speaker Location 8.00am Registration - Lobby 8.50am Welcome and conference info Dr Bronwen Connolly G am Current landscape in weaning and rehabilitation Chairs: Dr Bronwen Connolly Dr Peter Spronk G02 1. Current understanding of ICU survivorship 2. Skeletal muscle dysfunction in critical illness 3. The role of NIV in weaning from mechanical ventilation Prof Margaret Herridge, Canada Prof Steffen Weber-Carstens, Germany Prof Nicholas Hart, UK 10.30am Coffee, poster viewing - Lobby and G am Aspects of acute rehabilitation Chairs: Prof Rik Gosselink Prof Louise Rose G02 1. Physiological cost of mobilisation in the ICU; how to inform exercise prescription 2. Psychological support for patients in critical care 3. Reconstrucing a future after critical illness Dr Claire Black, UK Dr Dorothy Wade, UK Dr Eve Corner, UK 12.30pm Lunch, poster viewing - Lobby and G4 1.30pm Breakout sessions (in parallel) And repeated at 1. Motivational interviewing in critical care rehabilitation Chairs: Dr Eve Corner G11 Dr Jeff Breckon, UK Page 12 of 89

13 2.30pm 2. Topics in complex weaning and rehabilitation Chairs: Prof Nicholas Hart Dr Vicky Gerovasili G02 i. Functional and cognitive rehabilitation, the OT perspective Mr James Bruce, UK ii. Dysphagia and communication, the SLT perspective Ms Jackie McRae, UK iii. Managing cough and using the inexsufflator ( Cough Assist ) Dr Louise Rose, Canada (Nurse), Mrs Rachael Moses, UK (Physiotherapist) 3.30pm Coffee break, poster viewing Lobby and G4 4.00pm Spoken abstract presentations Titles TBC 6x15mins (10mins + 5mins q) 5.30pm Close of Day 1 Chairs: A/Prof Marike Van der Schaaf Prof Steffen Webber-Carstens G02 Social drinks Lobby Page 13 of 89

14 PROGRAMME SUNDAY 12 TH NOVEMBER Time Session Speaker Location 8.00am Coffee, poster viewing Lobby and G4 9.00am Supporting recovery from the ICU onwards Chairs: Prof Margaret Herridge Mr Peter Nydahl G02 1. Nutritional recovery and rehabilitation after ICU 2. Using patient-centred websites as support resources Dr Judith Merriweather, UK Dr Pam Ramsay, UK 3. Psychological profiling of ICU staff Prof Steve Brett, UK 4. Can ICU diaries enhance recovery and rehabilitation? Prof Leanne Aitken, UK 10.30am Coffee, poster viewing - Lobby and G am Spoken abstract presentations Chairs: A/Prof Greet Hermans Prof Steve Brett G02 Titles TBC 6x15mins (10mins + 5mins q) 12.30pm Lunch, poster viewing - Lobby and G4 1.30pm Quality improvement in care Chairs: Prof Leanne Aitken Mr James Bruce G02 1. Patient- and family-centred performance measures for enhancing quality of care for persistent/chronic critical illness Dr Louise Rose, Canada 2. Optimising sedation practice; influence on delirium Dr Valerie Page, UK Page 14 of 89

15 3. Weaning units and long-term acute care; tales from the new and the old Dr Peter Spronk, Netherlands, Dr Patrick Murphy, UK 3.00pm Plenary Lecture Chair: Dr Eve Corner G02 The future of ICU survivorship Prof Margaret Herridge pm Summary, evaluation, conference Resource portal, 2018 venue Chair: Dr Bronwen Connolly G02 Close of conference Page 15 of 89

16 FACULTY Professor Leanne Aitken Professor of Critical Care City, University of London Professor Leanne Aitken is Professor of Critical Care at City, University of London. In this role she is responsible for leading research and scholarship in acute and critical care nursing as well as implementing her own programme of research that focuses on recovery after critical illness and injury and a range of clinical practice issues within critical care. Other responsibilities include teaching, supervision of research students and leadership of new developments within the discipline of nursing at City, University of London. Professor Aitken holds visiting appointments with Griffith University and Princess Alexandra Hospital, as well as the University of Dundee in the UK. She is a Fellow of both the American Academy of Nursing and the Australian College of Nursing as well as a Life Member and Fellow of the Australian College of Critical Care Nurses. She is also a Fulbright Alumnus after receiving a Fulbright Senior Scholarship to undertake research examining recovery after trauma at the University of Pennsylvania, Philadelphia. Professor Aitken has published more than 120 original publications in peer reviewed journals and edits ACCCN s Critical Care Nursing textbook. Dr Claire Black Clinical Specialist in Cardiorespiratory Physiotherapy UCL Claire Black is the Clinical Specialist in Cardiorespiratory Physiotherapy at UCL Hospitals where she is the clinical lead for the long-term patients at University College Hospital. Claire completed her Doctorate at UCL on the feasibility of monitoring exercise intensity in mechanically ventilated patients recovering from critical illness. Her research interest is the rehabilitation of patients with and recovering from critical illness in ICU. Claire has delivered a number of invited contributions to national UK allied health professional and medical conferences. She convenes the annual UCL Update in Critical Care for Physiotherapists and peer reviews for a number of allied health professional journals. Page 16 of 89

17 Dr Jeff Breckon PhD., CPsychol., AFBPsS., FHEA. Head of the Behaviour Change Research Group Sheffield Hallam University Dr Jeff Breckon is Head of the Behaviour Change Research Group at Sheffield Hallam University. He is a BPS and HCPC Chartered Psychologist and a member of MINT (Motivational Interviewing Network of Trainers), BPS (British Psychological Association) and BASES (British Association of Sport and Exercise Sciences). Jeff was trained in MI in 1996 and as an MI trainer by Professor Bill Miller and Professor Steve Rollnick (Quebec, 2000) and has provided MI training to organisations across the UK, Europe and North America and delivered the international MI 'Training New Trainers' (TNT) programme in Barcelona (June, 2009) and Krakow (October, 2013) and is a reviewer for TNT applicants. Jeff has published and presented internationally on the role of MI in health behaviour change and is part of trials and intervention study research teams exploring the role of counselling and lifestyle interventions as well as the impact of MI training on workforce development programmes. Professor Stephen Brett Consultant, Intensive Care, Imperial College Healthcare NHS Trust Professor Stephen Brett is a consultant in intensive cae medicine at Imperial College Healthcare NHS Trust and Professor of Critical care at Imperial College London. He has a long standing clinical and academic interest in understanding and optimising long-term outcome for patients who have come through a period of severe illness- this developed after he started seeing patients in an intensive care clinic some 17 years ago. He has published a number of papers in the field and was chair of the guideline development group for the NICE guideline "Rehabilitation after critical illness" and regularly lectures on this and related topics in the UK and abroad. He is a past president of the Intensive Care Society. Page 17 of 89

18 Mr James Bruce OT/ ICU Rehabilitation Team leader ICU Torbay Hospital, Devon I qualified as an Occupational Therapist in 2002 from Coventry University. I started my junior rotations in West Dorset. I moved to London in 2007 and worked at the Royal National Orthopaedic Hospital (Stanmore) and completed a senior specialist rotation which included working for the London Spinal Injury Unit, the Specialist Upper Limb and Peripheral Nerve Injury unit, Complex Bone Tumour, and the Adult and Paediatric Corrective Spinal Deformity Unit. I was lucky enough to work with patients in ICU/HDU both in the spinal injury unit and complex spinal deformity unit. After time in London my wife and I missed the sea and the West Country accent and moved home to Devon and I was very lucky to find a job at Torbay Hospital. They required an OT to set up their ICU Rehabilitation service, as a rehab co-ordinator. I started this post in late 2011 and have never looked back. I have been very fortunate to work with a positive and proactive MDT which has allowed me to shape the service to the needs of the patients. Early this year our hospital opened a state of the art ICU, which has enabled further progress with implementing early rehabilitation. With the new build fund and benchmarking against the GPICs recommendations, we have been able to build a rehabilitation team funded by the ICU. This has given our team the flexibility to offer the most complex patients the service they require at any point of their in-and-out patient journey. We have strong links with our medical and nursing team and are fully integrated with service developments. These strong links are paramount to provide the best evidence based practice for our service users. My main professional interests are ICU acquired weakness, upper limb rehabilitation, cognitive dysfunction post critical illness and long term outcomes post-icu. Our current service developments at Torbay ICU include: improving CAM ICU screening (nursing and therapist); long term outcomes linked to admitting Frailty Score; long term vocational rehabilitation; outcomes of a twice weekly health and wellbeing group. To aid these projects, I am embarking on an MSc in Rehabilitation at UWE, commencing in September Dr Bronwen Connolly MSc, PhD, MCSP, Consultant Clinical Research Physiotherapist, Critical Care, NIHR Postdoctoral Research Fellow. Lane Fox Respiratory Unit, St. Thomas' Hospital, Guy's & St. Thomas' NHS Foundation Trust, UK Page 18 of 89

19 Dr Eve Corner BSc (hons), MRes., Physiotherapy Lecturer and Research Fellow, Clinical Lead Physiotherapist for Respiratory and Critical Care. Chelsea and Westminster Hospital, London, UK Dr Eve Corner is a Lecturer in Physiotherapy at Brunel University London. Prior to this she worked as the Clinical Lead Physiotherapist in Critical Care at Chelsea and Westminster Hospital, where she still holds an honorary contract. Eve completed her BSc at The University of Manchester. Eve has a particulate interest in critical illness induced muscle wasting, measurement of functional recovery and patient experience of early rehabilitation, which has formed the focus of her Masters of Research (St George's University of London, 2010) and her recently awarded PhD (Imperial College London). Eve is also a Quality Improvement Fellow with the National Institute of Health and Clinical Excellence Collaboration for Applied Health Research and Care (NIHR CLAHRC) and sits on the editorial board of the Journal of the Intensive Care Society. Dr Vicky Gerovasili MD, PhD. Consultant in Respiratory and Transplant Medicine Queen Elisabeth Hospital, University Hospitals Birmingham NHS Foundation Trust Professor Rik Gosselink Prof. dr., PhD, PT, Department Rehabilitation Sciences. Faculty Kinesiology and Rehabilitation Sciences. Respiratory Rehabilitation. University Hospitals Leuven. Belgium Page 19 of 89

20 Professor Nicholas Hart MB, BS, BSc, PhD, MRCP, FFICM, Clinical Director. Lane Fox Respiratory Service. St. Thomas Hospital, Guy's & St. Thomas' NHS Foundation Trust, UK Professor Hart was appointed as the Clinical Director of the Lane Fox Respiratory Service in 2012, which is an internationally recognised weaning, rehabilitation and home mechanical ventilation service. It is the largest weaning and rehabilitation service in the UK. Professor Hart s research is focused on improving health-related quality of life and reducing hospital admission in patients with chronic respiratory disease and post critical illness. Professor Hart established the Lane Fox Clinical Respiratory Physiology Research Centre in 2007 and he has developed a programme of translational physiological research focused on: Mechanism of skeletal muscle wasting in non-neuromuscular conditions Advanced physiological monitoring in acute illness to prevent inpatient deterioration and readmission Rehabilitation strategies to improve outcome in patients with chronic respiratory disease and post critical illness Clinical trials to improve outcome in chronic respiratory failure Professor Greet Hermans MD, PhD, Professor, Medical Intensive Care Unit, Department of General Internal Medicine. University Hospitals Leuven, Belgium Professor Margaret Herridge Professor of Medicine, Critical Care and Pulmonary Medicine, University Health Network; Senior Scientist, Toronto General Research Institute; Director of Research, Interdepartmental Division of Critical Care Medicine, University of Toronto Dr. Margaret S. Herridge obtained her MD from Queen s University at Kingston, completed her clinical training in Respiratory and Critical Care Medicine at the University of Toronto and her MPH at the Harvard School of Public Health. Since 1997, her group has completed 3 cohort studies: 5-year outcomes in survivors of ARDS (co-pi Angela Cheung); 1-year outcomes in survivors of SARS (co-pi Catherine Tansey PhD); 2-year outcomes in patients after 7 days of mechanical ventilation and their family caregivers (co-pi RECOVER Program Phase I- Jill Cameron PhD). Dr. Herridge is currently Director of the RECOVER Clinical and Research Program for patient-and family-centred follow-up care after critical illness, conducted in collaboration with the Canadian Critical Care Trials group (CCCTG). Dr. Herridge has authored or co-authored over 150 manuscripts and book chapters on topics related to outcomes after critical illness in patients and family caregivers. and is the co-editor of the textbook of post-icu medicine with co-editors Drs. Stevens and Hart. She has published 2 editorials and 3 manuscripts in the New England Journal of Medicine on outcomes after ARDS and family caregivers after prolonged mechanical ventilation and is a frequent international speaker on outcomes after critical illness. Page 20 of 89

21 Mrs Jackie McRae BSc(Hons) MClinRes RegMRCSLT. Consultant Speech and Language Therapist St George s Hospital Jackie McRae is Consultant Speech and Language Therapist at St George s Hospital, London. She has 25 years critical care experience working in teaching and specialist hospitals including St. Bartholomew s, Charing Cross, Papworth and Harefield. Whilst working with complex spinal cord injury patients at the London Spinal Cord Injury Centre she developed effective weaning strategies as part of the multi-disciplinary tracheostomy team to optimise patients speech and swallowing functions. Jackie has recently completed an NIHR doctoral fellowship, investigating the early identification and management of dysphagia in acute cervical spinal cord injury, developing a screening tool for multi-professional use. She is a member of the Intensive Care Society Nursing and AHP committee and professional advisor to the Royal College of Speech and Language Therapists. She is chair of the strategic group for Speech and Language Therapists working in critical care aiming to raise standards of practice and improve collaborative working. Dr Judith Merriweather BSc, MSc, PhD, Critical Care Research Dietitian. Royal Infirmary of Edinburgh, Scotland, UK Judith Merriweather is a clinical academic dietitian in the Department of Critical Care at the Royal Infirmary of Edinburgh. Judith has worked as a critical care dietitian for the last 20 years and her interest in the nutritional recovery of ICU survivors led to a PhD which explored the factors that influence nutritional intake after ICU. She was awarded an NHS Research Scotland (NRS) fellowship to develop a patient-centred strategy to promote nutritional recovery after critical illness. Judith is part of the Edinburgh Critical Care Research Group and was involved in the RECOVER study, a randomized clinical trial that looked at the effect of providing increased hospital-based physical rehabilitation and information provision after ICU discharge. Her research interests include nutrition in and after ICU, rehabilitation and patient experience. Mrs Rachael Moses Consultant Respiratory Physiotherapist Lancashire Teaching Hospitals NHS Foundation Trust Rachael graduated from the University of Hertfordshire and after spending some time working for the British Army and London Hospitals settled at the Newcastle Upon Tyne NHS Foundation Trust in Rachael specialised in respiratory physiotherapy initially within cardiothoracic transplantation before moving into a rotational ICU Band 7 post. She developed a specialist interest in neuro-trauma and this role evolved to become the senior physiotherapy link within the North East long term ventilation team. More recently Rachael was Respiratory Lead at St Georges Hospital, London managing a diverse team and specialities to now working in a new Consultant Physiotherapy post at Royal Preston Hospital. Rachael s area of expertise include complex ventilation and weaning and advanced airway clearance techniques for which she lectures and presents both in the UK and internationally and at pre and post graduate level. Rachael currently sits on BTS Council and the Critical Care Specialist Advisory Group representing AHPs, is an expert member of NHSE Patient Safety Group, AHP representative on the NIV NCEPOD study, Co-chair HMV-UK and Chair Respiratory Leaders in Physiotherapy UK. Page 21 of 89

22 Dr Patrick Murphy Consultant Respiratory Physician Lane Fox Unit, Guy's & St Thomas' NHS Foundation Trust, London Dr Murphy was appointed a consultant at the Lane Fox Respiratory Unit, Guy s and St Thomas Hospital in 2014 and honorary senior lecturer at King s College London in The Lane Fox Unit is an internationally recognised centre for weaning from prolonged mechanical ventilation and management of home mechanical ventilation. He completed a PhD studying respiratory physiology in acute and chronic respiratory failure secondary to COPD and obesity. He has presented primary research data at international conferences and has been awarded travel grants by both the European Respiratory Society and American Thoracic Society. His research interests involve respiratory physiology and respiratory support in acute and chronic respiratory failure which has led to publications of physiological and clinical trial data in leading respiratory journals. Mr Peter Nydahl RN, MScN, Nursing Research. University Hospital of Schleswig-Holstein, Kiel, Germany Dr Valerie Page Consultant in Anaesthesia and Critical care Watford General Hospital Valerie Page trained in Manchester and is a Consultant in Anaesthesia and Critical Care at Watford General Hospital. She is the UK clinical leader in ICU delirium and a hands-on clinical trialist having been the Chief Investigator on two interventional delirium RCTs in mechanically ventilated patients at Watford General Hospital. She is a key member of the international initiative to develop core outcome sets (COS) for delirium research. She is the author of a number of original research papers, reviews, editorials and clinical handbook Delirium in Critical Illness, currently in its 2nd edition. Dr Page is the Vice-President of the European Delirium Association, and an Honorary Senior Clinical Lecturer at Imperial College and University of Hertfordshire Page 22 of 89

23 Dr Pam Ramsay Research Fellow/Lecturer, Edniburgh Napier University Pam is an ICU nurse by background. She completed a mixed methods PhD on quality of life among long-term patients at the University of Edinburgh in Her research uses patient experience to help inform the re-design or development of interventions and support services for patients recovering from critical illness. Completed work includes: a process evaluation of the RECOVER trial (enhanced post-icu rehabilitation); a longitudinal qualitative study of survivors support needs during the year after hospital discharge, and a qualitative study of Home Ventilation among patients and family members. Ongoing research includes a pilot study of counselling for patients and families after ICU (including those bereaved) and the development of a support needs questionnaire for ICU survivors. Her current focus is on the development and implementation of a novel website, based predominantly on patient experience, and specifically designed to support self-management: Originally developed in Edinburgh, the website is readily customisable to other ICUs, and is currently being rolled out across 8 Scottish ICUs. Professor Louise Rose RN, PhD, FAAN Associate Professor at the Lawrence S. Bloomberg Faculty of Nursing University of Toronto Dr Louise Rose, RN, PhD, FAAN holds the TD Nursing Professorship in Critical Care Research based at Sunnybrook Health Sciences Centre, is an Associate Professor at the Lawrence S. Bloomberg Faculty of Nursing at the University of Toronto, Canada, and is an honorary visiting professor at the Lane Fox Respiratory Unit, at Saint Thomas Hospital, London, UK. She is a PhD prepared nurse with an active research program and over 110 peer-reviewed publications focused on improving outcomes and experience of the ventilated patient in diverse settings including the intensive care unit, emergency department, specialized weaning centre, long-term care, and the community. Dr Rose has many years of clinical experience in various critical care settings in four countries. Dr Rose also is the Research Director for the Provincial Centre of Weaning Excellence at the Michal Garron Hospital, and an adjunct scientist at the Institute for Clinical Evaluative Sciences, and West Park Healthcare Centre Toronto, Canada. Page 23 of 89

24 Professor Marike van der Schaaf PhD, Associate Professor Acute Care Rehabilitation. Academic Medical Center, University of Amsterdam, The Netherlands Marike van der Schaaf (PT PhD) is Associate Professor Acute Care Rehabilitation and epidemiologist / physiotherapist at ACHIEVE-Centre of Expertise, Faculty of Health, Amsterdam University of Applied Sciences, and the Department of Rehabilitation Medicine of the Academic Medical Center, University of Amsterdam. Marike graduated from Amsterdam University of Applied Sciences in 1991 with a Bachelor of Applied Science (Physiotherapy). Following which, she worked as a physiotherapist at the Academic Medical Center, University of Amsterdam, covering the spectrum of physiotherapy from critical care through outpatient care. She completed a clinical epidemiologist Evidence Based Practice Master of Science (Cum Laude, 2004) and her PhD on Functional Recovery after Critical Illness (2009), both with the University of Amsterdam. Marike s research interests include Acute Care Rehabilitation of critical care, surgical and elderly patients. The papers published in national and international peer reviewed journals, presentations at international and national scientific gatherings underscores her belief that the primary role of the university is to develop and disseminate new knowledge. Dr Peter Spronk MD, PhD, EDIC, FCCP, Internist-intensivist. Department of ICU, Gelre Hospitals Apeldoorn, Academic Medical Center, University of Amsterdam, The Netherlands Peter Spronk is an internist-intensivist who is director of research in Gelre hospitals Apeldoorn, The Netherlands. He has been involved in longterm outcomes in survivors of critical illness since 2002 and has published extensively on quality of life. An ICU follow-up clinic was established in his hospital since In the last 10 years he has been increasingly working on the situation in the ICU environment including coping by family members and patients, delirium, implementation of pain and agitation bundles, sleep, weaning programs, and, of course early mobilisation. Intensive collaboration with PTs and rehab specialists in his hospital are part of routine ICU care. Also, regular training sessions of long stay ICU patients in the hospital s swimming pool is considered standard of care now. He is currently actively involved in several interactive gaming programs to facilitate the engagement of patients in their rehabilitation programs and projects addressing dysphagia in the ICU. Page 24 of 89

25 Dr Dorothy Wade Chartered Health Psychologist University College Hospital, London Dorothy Wade is a chartered health psychologist working with patients, families and staff in the critical care department at University College Hospital, London. She is a registered practitioner psychologist, and has a PhD in psychology and healthcare from University College London. She is a member of the Nursing & allied health professionals committee of the UK Intensive Care Society and the NICE quality standards advisory committee on rehabilitation after intensive care. She conducts research into psychological stress in critical care patients, the impact of hallucinations and delusions, psychological outcomes including post-traumatic stress disorder, psychological assessment in critical care and interventions to reduce patient stress or provide staff support. She is Lead clinical investigator of the POPPI study, a randomised clinical trial funded by the National Institute of Health Research, to evaluate nurse-led provision of psychological support for critical care patients ( Professor Steffen Weber-Carstens MD, PhD Department of Anesthesiology and Operative Intensive Care Medicine Charité - Universitätsmedizin Berlin Page 25 of 89

26 ABSTRACTS Page 26 of 89

27 TRANSLATION AND CROSS-CULTURAL ADAPTATION OF THE CHELSEA CRITICAL CARE PHYSICAL ASSESSMENT TOOL INTO DANISH (POSTER DISPLAY: SUNDAY 12 NOVEMBER 10:30) Katrine Astrup 1, 4, PT, MSc, Evelyn J. Corner 2, PT Lecturer, MSc, PhD student, Marianne Godt Hansen 3, MA (International Business Communication), External consultant, Annemette Krintel Petersen 1,4,5, Senior Researcher, Associated Professor, PT, MSc, PhD 1 Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Denmark 2 Department of Clinical Sciences, Brunel University London; Department of Surgery and Cancer, Imperial College London; Chelsea and Westminster NHS Foundation Trust, London. England. 3 Aarhus University Hospital, Denmark 4 Centre of Research in Rehabilitation (CORIR), Department of Clinical Medicine, Aarhus University Hospital and Aarhus University, Denmark 5 Department of Clinical Medicine, Aarhus University, Denmark Introduction A valid measurement tool is important both in clinical practice and research to assess physical function and evaluate treatment effect. The Chelsea Critical Care Physical Assessment Tool (CPAx) has shown to be valid and practical and is a recommended measurement tool. The CPAx has demonstrated great clinimetric properties in measuring physical function in critically ill patients in the intensive care unit (ICU). There is a lack of Danish-language standardised and validated measurement tools to assess physical function in critically ill patients in the ICU. Aim To translate and validate the CPAx tool into Danish, including assessment of cross-cultural adaptations and face validity. Furthermore, to pre-test the translated version in a population of critically ill patients in the ICU. Method We followed the international recommendations for translation and cross-cultural adaptation of outcome measures. During the process of forward-backward translation, synthesis, expert committee meeting and pre-test, a few cultural adaptations were needed. A team of physiotherapists with ICU experience pre-tested the Danish version of CPAx among 30 critically ill patients at three different ICUs to investigate user-friendliness and face validity. Furthermore, a focus group interview was carried out to examine face validity of the CPAx tool. Results Translation and pre-test of the Danish version of CPAx have resulted in a measurement tool with good face validity. A few adaptations were made in the item descriptions, considering agreement between the Danish and the original English version. The physiotherapists pre-testing the translated version evaluated the CPAx tool as appropriate and user-friendly in an ICU setting. The author of the original version of CPAx, Evelyn Corner, approved the Danish translation. Conclusion The Danish-language version of CPAx appears to be an appropriate and user-friendly tool with good face validity for clinimetric evaluation of physical function of patients in the ICU. This study is the first step towards a validation and implementation of a Danish version of the CPAx tool. However, further research is needed to investigate reliability and responsiveness among patients in the ICU. Page 27 of 89

28 INTER-TESTER RELIABILITY AND RESPONSIVENESS OF THE DANISH VERSION OF THE CHELSEA CRITICAL CARE PHYSICAL ASSESSMENT TOOL (POSTER DISPLAY: SUNDAY 12 NOVEMBER 10:30) Katrine Astrup 1,3, PT, MSc, Evelyn J. Corner 2, PT Lecturer, MSc, Ph.d. stud, Annemette Krintel Petersen 1,3,4, Senior Researcher, Associated Professor, PT, MSc, Ph.d. 1 Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Denmark 2 Department of Clinical Sciences, Brunel University London; Department of Surgery and Cancer, Imperial College London; Chelsea and Westminster NHS Foundation Trust, London. England. 3 Centre of Research in Rehabilitation (CORIR), Aarhus University and Aarhus University Hospital, Denmark 4 Department of Clinical Medicine, Aarhus University Introduction A valid measurement tool is important in clinical practice and research to assess physical function and evaluate treatment effects. Recently, we completed translation and cross-cultural adaptation of the Chelsea Critical Care Physical Assessment Tool (CPAx) into Danish (CPAx-D). However, the clinimetric properties of the CPAx-D have not been evaluated. Aim We aimed to investigate the relative and absolute inter-tester reliability and the responsiveness of the CPAx-D in a Danish ICU setting. Method Between January 2017 and June 2017, 66 critically ill patients admitted to Aarhus University Hospital were included in the study and tested with CPAx-D. The tests were performed by seven physiotherapists with 2-15 years of experience in treating ICU patients. To calibrate the testers prior to the study each physiotherapist tested patients with the CPAx-D. During admission on the ICU, patients were assessed for eligibility. Patients who fulfilled the inclusion criteria were randomly assigned to the inter-tester group and assessed by two blinded testers during the same treatment session. The treatment session was performed by a third physiotherapist not involved in the testing procedure. To evaluate responsiveness of the CPAx-D, a follow-up test was carried out in 24 patients at time of ICU discharge. The follow-up test was performed by one of the two testers, who assessed the patient at the pretest. Floor and ceiling effects were also examined. Results Mean difference in total CPAx-D score between two testers was 0.3 point (95% confidence intervals (CI): -0.2; 0.3 points) (P=0.8). A scatter plot of differences against means revealed no heteroscedacity. The limits of agreement (LOA) were +2.0/- 2.0 points. Standard error of measurement (SEM) was 0.7 point (95% CI: 0.6; 0.9), and the minimal detectable change (MDC) was 2.0 point. The intra class correlation coefficient (ICC) was 0.99 (95% CI: 0.993; 0.997). The mean difference in CPAx-D score between the first test and follow-up test was 9.8 point (95% CI 6.9; 13.5) (P=<0.0001). The effect size ratio (ES) was 1.2 and the standardized response mean (SRM) was 1.1. The range of CPAx scores at the first test and follow up was and respectively. Conclusion The CPAx-D showed excellent inter-tester reliability with an ICC > 0.95 and a MDC of 2.0 points. Values of ES and SRM were high indicating that measurement tool is responsive. No floor or ceiling effect was present in the study population. Page 28 of 89

29 DESCRIPTION OF CLINICAL PRACTICE FOR ENHANCED PSYCHOLOGICAL CARE (EPC) ON ITU. (POSTER DISPLAY: SATURDAY 11 NOVEMBER 15:30) Sue Baskind; ITU team at Harrogate and District NHS Foundation Trust Introduction: Harrogate and District NHS Foundation Trust is an integrated trust providing acute hospital and community services to Harrogate district, North East and West Leeds. This is a population of approximately 900,000 people in the North of England. The Care Quality Commission inspected Harrogate and District NHS Foundation Trust in February The services within critical care were deemed, Outstanding as people s individual needs were central to the planning and delivery of the service. There was a proactive approach to understanding the individual needs of patients and designing the delivery of care around these. Aim: The ITU team is asking to present a poster of our clinical practice supporting the Enhanced Psychological Care (EPC) of our patients in ITU. We would like to chart a patient s EPC pathway including * Assessment on ITU admission, * Sharing our diary protocol and setting up a patient diary (with photographs) * Clinical practice that contains an individual s psychological distress during their ITU stay * Training ITU staff to be CBT informed and illustrating how this guides their professional decision making. For example, what to do if a patient is unwilling or refusing to mobilise from bed. * The role of the Critical Care Outreach team and * The role of the SITUP (Supporting Intensive Therapy Unit) service on step down from ITU to the general ward. * Referral to ITU Follow Up clinic (approximately three months post discharge from hospital). * Further individual assessment and the opportunity for psychological therapy after Follow Up clinic. The presentation will also include case studies of typical patient presentations featuring low mood, anxiety and PTSD symptoms; difficulties pacing rehabilitation and too high expectations of patients own set goals in the immediate period following ITU and hospital discharge. The rationale for future planned developments for EPC in ITU will be outlined including: * The involvement of physiotherapy as part of ITU rehabilitation * A planned diary evaluation (e.g. with and without photographs) * A support group for ex patients and their families. Page 29 of 89

30 MENTAL AND PHYSICAL HEALTH OF ARDS SURVIVORS SIX MONTHS AFTER DISCHARGE FROM ICU: FINDINGS FROM THE DACAPO-COHORT (PRESENTATION: SUNDAY 12 NOVEMBER 12:15) Susanne Brandstetter, Frank Dodoo-Schittko, Magdalena Brandl, Sebastian Blecha, Thomas Bein, Christian Apfelbacher Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg Department of Anesthesia, Operative Intensive Care, University Hospital Regensburg, Germany Background Acute respiratory distress syndrome (ARDS) requires intensive care unit (ICU) treatment and mandatory mechanical ventilation. Survivors of ARDS often suffer from long term reduction of health-related quality of life (HRQoL), impaired return to work and an increased prevalence of psychiatric sequelae like depression, anxiety disorders and posttraumatic stress disorder (PTSD). Aim This study aimed at investigating HRQoL, return to work and symptoms of depression and PTSD in a German cohort of ARDS survivors (DACAPO-cohort). Methods The DACAPO-study was set up to determine the influence of quality of care on HRQoL and return to work ARDS-patients were enrolled prospectively in 61 German ICUs. Care-related, disease-related and socio-demographic variables were recorded at ICU-admission. 390 out of 881 ICU survivors completed mailed self-report questionnaires at six months after discharge. Depression was assessed by Patient Health Questionnaire (PHQ-D) which is based on the diagnostic criteria of the DSM-IV. PTSD was determined by Post-Traumatic Stress Syndrome 14-Questions Inventory (PTSS-14). HRQoL was assessed by the 12-Item Short Form Health Survey (SF-12). Data were analysed descriptively. Results Mean age of the 390 ARDS survivors who completed the follow up questionnaires was 54.1 (SD = 15.3) years. About two thirds (66.9%) were male. Before the onset of disease 47.9% of the respondents had been in full- or part-time employment. At six months after ICU discharge 91.0% lived at home again and 23.1% had returned to their previous employment. Regarding HRQoL, the mean physical component summary score (M = 36.7; SD = 11.1) was lower than the mean mental health component summary score (M = 47.6; SD = 11.3). Symptoms indicating at least a latent depression were present in 56.5% of the former ICU-patients. 42.8% were at elevated risk of PTSD. Discussion Six months after ICU discharge, impairments in the physical component of HRQoL were markedly more pronounced compared to impairments in the mental HRQoL component. However, the high proportion of ARDS-survivors at increased risk for PTSD and depression is also remarkably. The findings of our study point out the need for specialised diagnostic, curative and rehabilitative health services in survivors of ARDS. Page 30 of 89

31 USE OF A WHITE BOARD LAMINATE TO AID COMMUNICATION IN THE MULTI-DISCIPLINARY TEAM (POSTER DISPLAY: SATURDAY 11 NOVEMBER 15:30) Susan Calvert, Philippa Wright Objective: Historically rehabilitation assessments and plans have been documented within the Critical Care computer information system. This is often not reviewed routinely by the multi-disciplinary team members and is not accessible by patients or their relatives. Our objective was to improve the communication and involvement of the multi-disciplinary team, patients and their family in the rehabilitation planning and implementation. Methods: Initially A1 sized white boards that were in each bed space were utilised to write up key information. A template example was created to ensure consistency of what and how the therapy team were including on these boards. It was then recognised that a pre-printed laminate could be attached to the boards in order to reduce time taken writing up headings & to ensure clear, professional and consistent appearance of information. The template example was adapted, printed & laminated to A1 size. These were attached to the white boards using Velcro so the information could be moved easily between bed spaces (when the patients changed bed spaces). A pocket was included to hold the rehabilitation booklet that should be provided to these patients. Results: The boards are consistently used in high risk patients who have required a comprehensive assessment. Whilst no formal review of the innovation has been undertaken, subjective feedback from patients, relatives and the MDT has been positive. The therapy team report they have been more adherent to using the boards & issuing the rehabilitation booklets as the laminates act as a visual prompt. Conclusion: The use of a pre-printed, laminated communication board has encouraged multi-disciplinary communication and improved patient involvement with the rehabilitation process. Page 31 of 89

32 IS COUGH REFLEX TESTING (CRT) A USEFUL SCREENING TOOL TO DETECT SILENT ASPIRATION IN POST EXTUBATION PATIENTS? (POSTER DISPLAY: SATURDAY 11 NOVEMBER 15:30) Hannah Chalke, Victoria Eley Introduction CRT involves nebulising citric acid to the upper airway and subjectively rating cough strength. It assesses laryngeal sensation, identifying those who may silently aspirate and their ability to clear airway aspirate. Dysphagia is frequently reported post extubation, with incidence ranging from 3%-62% 1. Evidence suggests that those intubated for longer periods are more dysphagic. Leder et al (1998) found 45% of post extubation patients presented with dysphagia, of which 44% silently aspirated 2. CRT has high specificity and sensitivity as a screening tool for silent aspiration in other patient groups; however validity post extubation remains unknown 3. With high rates of silent aspiration, clinical presentation is subtle, difficult to diagnose and poses a challenge to rehabilitation and recovery. Aim To evaluate whether CRT is a useful screening tool in detecting silent aspiration post extubation, and whether there are other variables to consider (i.e. length of intubation) to improve its use. Method Data was collected retrospectively from two hospital sites between August 2016 and July A total of 28 patients (19 male) with age range years. Information was obtained from CRT and SLT logs to include: Results Diagnosis Length of intubation Time to CRT CRT result Outcome following Fibreoptic Endoscopic Evaluation of Swallowing (FEES) or bedside swallow assessment. 43% of patients failed CRT, 43% passed with a weak cough and 14% passed with a strong cough. CRT result Silent aspiration on FEES Dysphagic with overt bedside signs Normal Swallow Unable to complete swallow assessment Fail 58% 0% 25% 17% Pass weak 8% 8% 76% 8% Pass strong 0% 25% 75% 0% There was a negative correlation between length of intubation and CRT outcome indicating laryngeal sensation is likely to be impaired following prolonged intubation. There was a negative correlation between timing of CRT administration post extubation and CRT result with some patients still exhibiting impaired sensation at 15 days post extubation. Page 32 of 89

33 Conclusion Our study suggests that CRT is a useful adjunct to swallow assessment to detect silent aspiration post extubation. Administration of CRT should be considered on an individual basis, taking into account length of intubation. Referral for instrumental assessment should not be from CRT outcome alone and should consider other predisposing factors for dysphagia i.e underlying diagnosis. Future studies to determine recovery of laryngeal sensation in this population is recommended. References 1. Skoretz SA, Flowers HL, Martino R. The incidence of dysphagia following endotracheal intubation: a systematic review. Chest 2010;137(3): Leder SB, Cohn SM, Moller BA. Fiberopticendoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients. Dysphagia Fall; 13 (4): Kallesen M, Psirides A, Huckabee ML. Comparison of cough reflex testing with videoendoscopy in recently extubated intensive care unit patients. Journal of Critical Care. 2016; Page 33 of 89

34 AN AUDIT OF SPEECH AND LANGUAGE THERAPY INTERVENTION IN CRITICAL CARE; CAN PATIENTS MEET THE GUIDELINES? (PRESENTATION: SATURDAY 11 NOVEMBER 16:15) Jenny Clark, Sally K Archer Introduction: Speech and Language therapy (SLT) is recommended to optimise communication and swallowing for patients in critical care (CC) with the aim of improving overall outcome i. The Intensive care society (ICS) guidelines for provision of CC services ii advise patients are offered 45 minutes of intervention for a minimum of 5 days per week as long as intervention is tolerated and patients continue to benefit. Whether patients are able to tolerate this level of intervention and therefore if it is realistic has not previously been examined. Aim: To audit SLT intervention in CC at a London Teaching Hospital against ICS recommendations of session length and frequency and, where appropriate, to determine why ICS recommendations were not met. Method: Data were collected on all CC patients on the SLT caseload for one month. The amount of direct/indirect intervention provided daily per patient and patient need (dysphagia, tracheostomy weaning and/or communication) was reported. If direct intervention was <45 minutes daily clinicians provided a reason for this. Results: Data on 30 patients was collected. Patients received SLT input on 73% (n= 178) of the days they were on the SLT caseload (direct input 86% n= 153, indirect 14% n= 25). Dysphagia, communication and tracheostomy needs were represented. Over half of patients had multiple, simultaneous SLT needs (57% n= 142). 21% (n= 51) received 45 minutes or more direct SLT intervention per day (range minutes). Only 28% (n= 69) were not well enough for any direct intervention at all. Of those patients who could not tolerate 45 minutes direct input, the most common reason was lack of tolerance (73% n=142) followed by lack of SLT resource (22%, n=43). Patient refusal or inability to access the patient accounted for 0.5% (n= 1) and 2.5% (n= 5) respectively. Conclusion: Most patients referred to SLT on CC were able to tolerate direct SLT input. However, 45 minutes of direct intervention was largely not achieved. The nature of critical illness with the soliloquy of delirium iii and fatigue iv could account for the shorter session lengths. These findings show the complexity of SLT intervention in CC with patients frequently requiring intervention for multiple SLT needs simultaneously, demonstrating the necessary broad skill-mix of the CC SLT team. Splitting sessions into multiple, shorter sessions throughout the day may improve tolerance. Further research into the best way to optimise patient tolerance and outcome with SLT in CC is recommended. i Department of Health (2005) Quality Critical Care. Beyond Comprehensive Critical Care. A Report by the Critical Care Stakeholder Forum ii Intensive care society (ICS) (20015) Guidelines for the provision of intensive care services. iii NICE (2010) Delirium: prevention, diagnosis and management Clinical guideline, nice.org.uk/guidance/cg103 iv Kress, Hall, Jesse (2014) ICU-Acquired Weakness and Recovery from Critical Illness. New England Journal of Medicine , vol. / Page 34 of 89

35 DOES AN INTENSIVE CARE EARLY MOBILISATION PROGRAM BENEFIT BOTH MEDICAL AND SURGICAL PATIENT GROUPS? (POSTER DISPLAY: SUNDAY 12 NOVEMBER 10:30) Nikki Collings 1, Zoe van Willigen 2 and Dr Rebecca Cusack 1 1 University Hospital Southampton Foundation Trust, Critical Care Research Department, Southampton, United Kingdom 2 University Hospital Southampton Foundation Trust, Physiotherapy Department, Southampton, United Kingdom Introduction Early rehabilitation on the intensive care unit (ICU) is defined as active exercise within the first 2-5 days of the ICU stay 1. Early mobilisation is associated with accelerated return to pre-admission mobility status 2 and improved functional outcome at ICU discharge 3. However, delivery of early rehabilitation can be difficult to achieve in practice and requires dedicated rehabilitation staff, specialist equipment and a coordinated team approach 4. We have previously demonstrated 5, in a cohort of medical patient survivors, that investment in a dedicated therapy team on intensive care, over a five-year period, results in earlier delivery of rehabilitation (out of bed mobilisation achieved at 4.3 days from 16.3 days) and reduced ventilator days (from 15.8 days to 8.7 days), ICU length of stay (LOS) (from 20.8 days to 11.2 days) and hospital LOS (from 45.4 days to 29.6 days). Aim We were interested to see if the expansion of this team to provide an equivalent service for surgical patients surviving to ICU discharge is able to produce similar results. Method In 2012, the ICU therapy team at UHS were successful in a bid for additional assistant therapy staff and rehabilitation equipment to deliver an early mobilisation program for medical ICU patients. Following the success of this project the team have been able to expand further, extending the service to also include surgical ICU patients. Prospective baseline data for surgical patients surviving to ICU discharge were collected for the period of January to March, New team members were recruited in October 2016, followed by a period of induction and competency training. Data collection for surviving surgical patients was then repeated for the period of January to March, Results Pre EMP (2014) Post EMP (2017) January to March n = 13 n = 11 Time to first out of bed mobilisation (days) No. of therapy sessions, per day, per patient ICU length of stay (days) 7.3 (5.6) 0.4 (0.4) 6.5 (5.8) 3.1 (1.7) 0.7 (0.3) 5.6 (4.0) Page 35 of 89

36 Hospital length of stay (days) Duration of mechanical ventilation (days) Ventilator-free days (within first 28 days) 27.9 (18.5) 4.4 (4.6) 23.6 (4.6) 22.9 (13.8) 4.4 (3.0) 21.9 (7.7) Conclusion This project has demonstrated that an established ICU early mobilisation program targeting a medical patient cohort can also be successfully introduced to support surgical patients. Increased therapy input is associated with earlier out of bed mobilisation and reduced ICU and hospital LOS. References 1. Hodgson et al. (2013). Clinical review: early patient mobilization in the ICU. Critical Care, 17 (1), Schweickert et al. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet, 373 (9678), Brummel et al. (2014). Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial. Intensive Care Medicine, 40 (3), Lee et al. (2012). ICU-acquired weakness: what is preventing its rehabilitation in critically ill patients? BMC Medicine, 10 (115). 5. Van Willigen et al. (2016) Quality improvement: the delivery of true early mobilisation in an intensive care unit. BMJ Quality Improvement Reports, 5. Page 36 of 89

37 A MULTI-DISCIPLINARY APPROACH TO WEANING AND REHABILITATION: A PATIENT CASE STUDY (POSTER DISPLAY: SATURDAY 11 NOVEMBER 15:30) Rachel Corbett 1, Rebecca Corbett 1, Katherine Gargett 1, Denise Gibson 1,2 1 University Hospital Southampton NHS Foundation Trust 2 Faculty of Health Sciences, University of Southampton Introduction: Successful weaning from prolonged mechanical ventilation (PMV) is dependent on knowledge of potential barriers and how to address them. Failure to wean is linked to age; barriers to weaning and co morbidities. Patients with increased evidence of barriers such as chest wall deformities may be unsuitable for weaning. A long term tracheostomy or one way wean may be the only option. Despite these barriers we must look at the pre admission quality of life of the patient and their drive to participate. Currently there is no evidence of weaning protocols that fit all patient groups. A successful wean involves a dedicated team and a willing patient. Aim: The aim of this case study is to demonstrate the effectiveness of a multi-disciplinary team (MDT) approach to weaning and rehabilitation of a patient from PMV via tracheostomy. Method: This case documents the journey of a post polio patient with kyphoscoliosis, limited functional use of his arms and long term nocturnal nasal Non-Invasive Ventilation (NIV). The patient was intubated after an admission with pneumonia; after 2 failed extubations a surgical tracheostomy was performed. Seven weeks after admission he had a single profession led decannulation. However, despite NIV and intensive chest physiotherapy, the patient deteriorated and was re-intubated. What followed was an MDT approach to weaning and rehabilitation: Ventilator: Physiotherapy and nursing led tracheostomy mask time. Weaning ventilator settings to home settings. Progression from V60, to Trilogy to A40. Establishing ventilation via nasal mask; using a speaking valve as a cap. Tracheostomy: MDT decision on downsizing from 8 to 6 to mini tracheostomy. Deflation of cuff and use of speaking valve to aid communication and nutrition. Secretion Management: Physiotherapy led instigation of Nippy Clearway and suctioning. Competencies completed with nursing staff, enabling them to use the Nippy Clearway. Rehabilitation: Therapy and nursing staff led exercises and transfers. Patient centred and functionally orientated goals involving an Occupational Therapy led access and home visit. The final steps to functional independence were the removal of the mini tracheostomy, the ability to self manage secretions and successful day leave with family. Page 37 of 89

38 Results: He was successfully decannulated, using his domiciliary NIV overnight with previous settings. He had returned to his baseline level of function. Conclusion: The evidence of the successful second decannulation suggests that MDT led weaning and rehabilitation, in the complex patient groups may improve outcome. Page 38 of 89

39 SPECIALIST REHABILITATION SERVICES: CAN ECONOMIC EVALUATION SUPPORT LOCAL DECISION MAKERS? (PRESENTATION: SUNDAY 12 NOVEMBER 11:00) A. Duarte 1, C. Bojke 2, W. Cayton 3, A. Salawu 3,4,5, B. Case 6, L. Bojke 1, and G. Richardson 1 1 Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK 2 Academic Unit of Health Economics, Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, LS2 9NL 3 Hull and East Yorkshire Hospitals NHS Trust, Hull, HU3 2JZ, UK 4 Hull York Medical School, Hull, HU6 7RX, UK 5 Department of Health, Sports and Exercise Science, University of Hull, Hull, HU6 7RX, UK 6 NHS Vale of York Clinical Commissioning Group, York, YO1 6GA, UK Introduction: Provision of specialist rehabilitation services in North Yorkshire and Humberside may be suboptimal. Local commissioning bodies need to prioritise investments in health care, but previous studies provide limited evidence to inform the decision to expand existing services. The economic evaluation of health services provides a framework to identify the best course of action under constrained resources, and is commonly used to inform policy at national level. These methods are seldom adopted by local authorities. In this study, we apply economic evaluation methods and routinely collected data to inform decisions at a local authority level. Aim: To examine the impact of specialist rehabilitation services in the sub region on hospital length of stay (LOS) and associated costs compared to routine care using local level data. Methods: Comparison of hospital LOS and associated costs in centres with greater access (Hull) and limited access (i.e. routine care, York and Northern Lincolnshire), to specialist rehabilitation services for patients with complex disabilities following illness or injury, using Hospital Episodes Statistics data. Results: Average LOS and duration costs by Healthcare Resource Group (HRG) were lower for the majority of patients with greater access to specialist rehabilitation compared to routine care. Difference in LOS between groups widened with level of complexity within each HRG. For the more frequent HRG codes, the LOS difference was as high as 34 days longer for York compared to Hull and 7,900 more costly. Conclusion: Rehabilitation patients within York and Northern Lincolnshire areas appear to have longer LOS and higher associated costs compared to those admitted to the Hull Trust. This analysis suggests that specialist rehabilitation may be cost saving compared to routine care and supports the case for expansion of the existing services to improve coverage in the area. The study also provides an illustration of how standard economic evaluation methods that take advantage of available local level data can be used to support decision making by local commissioning bodies. Page 39 of 89

40 POST EXTUBATION DYSPHAGIA IN CARDIAC SURGERY ICU: PRELIMINARY FINDINGS FROM A PROSPECTIVE STUDY (POSTER DISPLAY: SATURDAY 11 NOVEMBER 15:30) Sallyanne Duncan MSc., Speech and Language Therapy Department, Royal Victoria Hospital, Belfast Health and Social Care Trust. Introduction ICU related swallowing disorders are being increasingly explored and described in dysphagia literature. Research teams from Canada and New Zealand have recently focused on cardiac surgery ICU populations. These studies have been largely retrospective in nature, confirming dysphagia is a recognised complication of cardiac surgery, with varying incidence levels depending on intubation length. Aims 1. To investigate preliminary prospective data for the presence, severity and recovery rates of dysphagia in five different intubation duration groups. 2. To explore pre- peri- and postoperative factors associated with dysphagia across the entire sample. Method Forty consecutive patients completed a Speech and Language Therapy clinical swallow assessment post extubation and pre commencing oral intake. If clinically indicated, SLT follow up was provided. Functional oral intake scale (FOIS) scores were used as outcome measures at time of initial assessment and at final review. Patients were grouped according to length of intubation period: Group 1 (<12hr), Group 2 (>12-<48hr), Group 3 (>48-<120hr), Group 4 (>120-<240 hr: 5-10 days) and Group 5 (>240 hr: 10 days or more). Eligible patients were >18 years and had coronary artery bypass or cardiac valve surgery. Tracheostomy patients were also included. Results Across the entire sample, dysphagia frequency was 45% but varied by group. Group 1, 0% dysphagia; Group 2, 9%; Group 3, 43%; Group 4, 80% and Group 5, 100%. Dysphagia was more severe and recovery took longer in groups 4&5. Presence of delirium, post extubation dysphonia, critical illness polyneuropathy, reintubation, tracheostomy and peri operative stroke were at highest levels in Group 5. The overall incidence of dysphagia in this sample is higher than currently reported in retrospective studies in the literature. However, the small sample size warrants a large scale prospective observational study to confirm these findings. Conclusion Early identification and ongoing assessment and management by speech and language therapy of cardiac surgery patients with dysphagia following prolonged intubation is strongly recommended. Page 40 of 89

41 DEVELOPMENT OF CRITICAL CARE REHABILITATION GUIDELINES IN CLINICAL PRACTICE; A QUALITY IMPROVEMENT PROJECT (POSTER DISPLAY: SATURDAY 11 NOVEMBER 15:30) Sarah Elliott, Physiotherapy Practitioner, Medway NHS Foundation Trust INTRODUCTION Rehabilitation in critical care has the potential to restore lost function and improve quality of life on discharge, but patients are often viewed as too unstable to participate in physical rehabilitation. Following a physiotherapy service evaluation of the provision of critical care rehabilitation, a number of concerns were raised in our practice. It was identified that there was a need to standardise pathways for clinical decision making in early rehabilitation so interventions are safe, timely and consistent. AIM To develop rehabilitation guidelines to aid decision making and promote early mobilisation. METHODS PDSA cycles were used as a method for quality improvement within this setting. After consideration of the literature, the participants identified the guidelines devised by Stiller et al (2007) as a protocol that could be trialled within clinical practice. However, after trialling these guidelines the participants felt it did not fully meet the needs of clinicians and patients at the Hospital. Therefore we developed our own, local evidence based critical care rehabilitation guidelines which incorporate core components from existing literature. The participants suggested that our guidelines should be; flexible, patient centred, time efficient, be in a user friendly flow chart in order to standardise our approach to rehabilitation. RESULTS The guidelines have been designed not as a formal protocol, but to highlight key considerations that physiotherapists may consider when clinically reasoning whether or not the patient is suitable for rehabilitation. Type and duration of exercise are considered and the physiotherapist is prompted to review the therapeutic intervention and its impact before making future plans. The guidelines are presented in an easy to follow flow chart. The overwhelming reflections by physiotherapists regarding the use of rehabilitation guidelines was that they didn t take into account the individual needs of the patient and the psychological benefit that exercise may bring. It also highlighted that we need to review the types and frequency of exercises and the MDT s understanding of the term rehabilitation as this often caused conflict between physiotherapists and MDT when deciding treatment plans. CONCLUSION Following this project the participants surmised that in our clinical setting we were seeking to create Trust critical care rehabilitation guidelines that can act as a reference or teaching aid for all members of the MDT and that they may guide; assessment, clinical decision making, patient centred care, adherence to guidelines and options of rehabilitation Page 41 of 89

42 THE CRITICAL CARE PATIENT: IMPROVING STAFF ENGAGEMENT IN THE PROVISION AND COMPLETION OF PATIENT DIARIES TO ASSIST PSYCHOLOGICAL RECOVERY (PRESENTATION: SATURDAY 11 NOVEMBER 16:30) Sarah Elliott MA, BSc(Hons), PGCert, PGCert Physiotherapy Practitioner, Medway NHS Foundation Trust Olivia Padfield Medical Student, Kings College London Aysa Veloso Costa Medical Student, Kings College London Background: Patients surviving critical illness are at high risk of developing psychological problems after discharge, with as many as 10% developing symptoms of post-traumatic stress disorder (Wake & Kitchener, 2013), positively correlated with length of intensive care unit (ICU) stay. NICE recommends commencement of rehabilitation as soon as clinically possible in this group. Diaries have been shown to assist patients with fragmented delusional memories and difficulty recollecting their experience, and are hypothesized to work similarly to cognitive behavioural therapy. Factors including lack of awareness, time constraints and the non-compulsory nature has led to inconsistent staff engagement with the patient diary system at Medway Maritime Hospital. Aims: This project aimed to increase provision, consistency and overall multidisciplinary team (MDT) engagement with diaries for patients admitted to ICU for over 72 hours. Methods: Plan-Do- Study-act (PDSA) cycles were used as a method for quality improvement within this study. The three cycles included trialled methods included adding reminders to the online patient note system (Metavision), providing education sessions and raising awareness, and introducing a bedside guidance document to facilitate entry completion. Data was collected using information inputted to Metavision; a total of 129 patients were sampled over 105 days, with 77 receiving diaries. Results: Baseline average diary provision rate (26%) increased to 83% after the first Plan-Do-Study-Act (PDSA) cycle. During cycle two, we saw a further increase to 100%, with a subsequent decrease to 75%. However, final changes saw a return to 100% by the end of cycle three. Frequency of daily entry completion also increased, and physiotherapists (engaged in cycles 1 and 2) and an occupational therapist (engaged in cycle 2) completed entries alongside nurses. Conclusion: On three distinct data collection points, all patients admitted for over 72 hours received diaries. Also, an increased number and variety of the ICU MDT completed more regular diary entries. Although additional methods may be needed to ensure long term sustainability, we hope to have implemented effective changes. Page 42 of 89

43 COGNITIVE FUNCTION THREE MONTHS AFTER INTENSIVE CARE A PROSPECTIVE COHORT STUDY (PRESENTATION: SATURDAY 11 NOVEMBER 17:00) Estrup S 1, Kjer CKW 1, Vilhelmsen F 1, Poulsen LM 1, Gøgenur I 2, Mathiesen O 1 1 Department of Anesthesiology, Zealand University Hospital, Koege 2 Department of Gastrointestinal Surgery, Zealand University Hospital, Koege Introduction Studies have shown impaired cognitive function after Intensive Care Unit (ICU) discharge affecting significant aspects of life for both patients and their families, including institutionalization, independency and mortality. We aimed to describe long-term cognitive functions in a Danish cohort of patients who had been treated in an ICU. Methods We conducted a prospective cohort study of all adult patients admitted for more than 24 hours in the period of February 1 st 2016 to January 31 st 2017 at the ICU, Zealand University Hospital, Koege. Exclusion criteria were severe dementia, inability to communicate in Danish (including aphasia, deafness or severe brain damage), moribund or actively psychotic patients, transferal to another ICU, and patients living outside the Region of Zealand. Three months after discharge, a home visit took place and the patients were tested with Repeatable Battery for the Assessments of Neuropsychological Status (RBANS), Chelsea Critical Care Physical Assessment Tool (CPAx), Short Form Health Survey (SF 36) and Hospital Anxiety and Depression Scale (HADS). Information about use of medication and healthcare since hospital discharge was recorded. The results of CPAx, SF36 and HADS are reported in a following paper. Results A total of 504 ICU admissions, with 444 patients, were screened, 161 patients were included and 79 home visits took place. Median age was 70 (IQR 63-76) yrs., 55% was male and 35% were surgical patients. The mean RBANS score was 67 (SD 21), compared to an age corrected normal value of 100 (SD 15). We examined protective and risk factors using multiple linear regression (Table 2) and found protective associated effects of being employed before admission (p=0.005) and being admitted to ICU from a surgical ward (p=0.019). Discussion We found a RBANS score that was two standard deviations below normal level, corresponding to the cognitive function of patients with mild Alzheimers disease. As we do not know the pre-admission cognitive level of these ICU patients, results should be interpreted carefully. Conclusion In this prospective cohort study, we found reduced cognitive function three months after discharge from the ICU and that surgical admission and pre-admission employment was associated with a better cognitive function. Page 43 of 89

44 Table 1 Demographics and clinical characteristics of population Included (n=161) Visited (n=79) p-value: difference visited/not visited Age, years, median (IQR) 70 (63-76) 67 (59-74) Gender, male % BMI, median (IQR) 26 (23-31) 26 (24-32) Opioids, % Statins, % Antidepressants, % Admission type, surgical % LOS hospital, days, median (IQR) LOS ICU, days, median (IQR) (11-33) 20 (10-33) (2-7) 3 (2-7) 0.50 Circadian light, % SAPS II, mean (SD) 52 (15) 49 (13) APACHE II, mean (SD) 22 (7) 21 (7) Mortality, % 30 Ventilator, % Time on ventilator, hours, median (IQR) 13 (0-65) 15 (0-66) 0.60 Dialysis, % Delirium, % Delirium, days, median (IQR) General anesthesia, % - All - Before ICU - During - After 0 (0-2) 0 (0-1) Missing: SAPS II: 0 included, 0 visited. Apache II: 2 included, 1 visited IQR: Inter Quartile Range. BMI: Body Mass Index LOS: Length of stay Page 44 of 89

45 Table 2 Multiple linear regression models for cognition measured by RBANS Model 1 Model 2 Model 3 Estimate and 95% CI P-value Estimate and 95% CI P-value Estimate and 95% CI Age, pr 10 yrs (-8.34, 0.31) (-2.68, 7.43) (-8.27, 0.88) 0.11 Gender (-10.80, 9.34) (-7.08, 11.40) (-12.86, 8.73) 0.70 Admission type (2.03, 21.43) Working preadmission (11.56, 39.55) Opioids (-12.70, 8.52) 0.69 Anti-depressants (-22.61, 5.99) 0.25 LOS ICU (-0.82, 0.79) 0.96 LOS hosp 0.16 (-0.11, 0.44) 0.19 APACHE II (-1.19, 0.37) 0.30 Delirium (-17.99, 5.25) 0.28 P-value Reference group is unexposed to light and medication, medical admission and male sex. Page 45 of 89

46 PHYSICAL FUNCTION AND ACTIGRAPHY IN INTENSIVE CARE SURVIVORS A PROSPECTIVE COHORT STUDY (PRESENTATION: SATURDAY 11 NOVEMBER 17:00) Estrup S 1, Kjer CKW 1, Vilhelmsen F 1, Poulsen LM 1, Gøgenur I 2, Mathiesen O 1 1 Department of Anesthesiology, Zealand University Hospital, Koege 2 Department of Gastrointestinal Surgery, Zealand University Hospital, Koege Introduction Impaired physical function after treatment in the Intensive Care Unit (ICU) affecting long term outcome and mortality has been demonstrated. Early mobilization in the ICU has shown a positive effect on outcomes. We wanted to study the association between level of activity in the ward after discharge from ICU and the physical function at three-month follow-up. Methods We conducted a prospective cohort study of all adult patients admitted for more than 24 hours from September 2016 to February Exclusion criteria were severe dementia, inability to communicate in Danish, moribund or actively psychotic patients, transferal to another ICU, paraplegic patients (no ambulation) and patients living outside the Region of Zealand. Patients were equipped with an Actigraph (Ambulatory Monitoring Ardsley, NY, USA) at discharge from ICU and monitored for 7 days at the ward or until death or discharge from hospital. At discharge from the ICU and at the three months post-discharge home visit, patients were tested with the Chelsea Critical Care Physical Assessment Tool (CPAx). Results We screened 66 patients for inclusion. Forty-one patients completed the actigraphy measurement. A total of 19 patients were available for follow up visit at three months and were included in the analyses. Mean (SD) age were 72 (10) years, 59% were males and 36% were admitted from a surgical ward (Table 1). The CPAx increased significantly from ICU-discharge, median (IQR): 31 (23-41) to follow-up, 47 (44-49), p< Seventeen of nineteen patients improved CPAx level over time (Fig. 1). The maximum reference CPAx level is 50. We found a negative association between actigraphy measured activity and change in CPAx; (regression slope estimate pr activity counts pr. day: (-0.18; ), p=0.028). Discussion In this sample of 19 patients, we found that nearly all had improved their physical function from ICU discharge to 3 months after ICU treatment. The few that did not improve, kept their high functional score. A higher activity level at the ward was associated with a smaller increase in the CPAx-measured physical function. This could be due to ceiling effect or that these patients had good physical function before their admission. It remains to be shown if patients with low activity measurements will benefit from extra rehabilitation efforts. Conclusion In this prospective cohort, we found that all patients maintained or improved their physical function form ICU discharge to three-month follow-up. We also found a negative correlation between level of early physical activity in the ward and difference in physical function from ICU discharge to three-month follow-up. Page 46 of 89

47 Table 1 Demographics and clinical characteristics Included (n=44) Visited (n=19) p-value difference visited/not visited Age, years, mean (SD) 72 (10) 69 (10) 0.12 Gender, male % BMI, mean (SD) 28 (8) 31 (10) Opioids, % Admission type, surgical % LOS hosp, days, median (IQR) LOS ICU, days, median (IQR) 17 (12-33) 18 (12-33) (2-7) 3 (2-8) 0.84 SAPS II, mean (SD) 54 (15) 49 (14) APACHE II, mean (SD) 20 (6) 18 (5) 0.14 Mortality, % 27 Ventilator, % Fig. 1 CPAx at intensive care discharge and at three-month follow-up. Page 47 of 89

48 AN EVALUATION OF THE PROVISION OF OCCUPATIONAL THERAPY IN A POST CRITICAL CARE FOLLOW-UP CLINIC IN THE UK (PRESENTATION: SUNDAY 12 NOVEMBER 12:00) Penelope Firshman 1, Nicole Walmsley 1, Andrew Slack 2, Joel Meyer 2, Bronwen Connolly 3 1.Occupational Therapy, Guy s and St Thomas NHS Foundation Trust 2. Critical Care Unit, Guy's and St. Thomas' Hospital NHS Foundation Trust, 3. Lane Fox Respiratory Unit, Guy s and St. Thomas' Hospital NHS Foundation Trust Introduction: Critical care admission can lead to cognitive, psychological and functional impairments 1,2,3 known as post-intensive care syndrome (PICS) 4. PICS impacts negatively on care needs, employment status and family income 5. National Institute for Clinical Excellence (NICE, 2009) Guideline 83 recommends follow-up at 2-3 months following hospital discharge 7,8,9. This has driven the expansion of post critical care clinic (PCCC) follow-up services designed to identify and address aspects of PICS. Occupational therapy (OT) focuses on facilitating recovery and overcoming barriers that prevent people from participating in meaningful occupations. Intervention is provided when physical and non-physical morbidities affect elf-care, leisure and productivity. Despite this, UK critical care units have limited OT with only 5.5% of clinics including an OT 10. Guy's and St Thomas Foundation NHS Trust PCCC has been running fortnightly since September Patients who were mechanically ventilated for 72 hours or more, or received extra-corporeal membrane oxygenation (ECMO), are invited to attend a comprehensive multidisciplinary face-to-face assessment at 8-12 weeks following hospital discharge. OT was incorporated as a core component and is now embedded in this fully-commissioned service (NICE, 2017). A 12 month prospective evaluation was completed to describe the role and contribution of OT to ameliorate PICS in our PCCC. Aim To evaluate the contribution of OT in PCCC in addressing PICS. Method: All patients attending the PCCC between September 2016 and August 2017 were assessed by an OT. Data was collected prospectively by two clinic OTs. Numbers of:. Patients seen by OT. Patients who benefited from OT assessment. Patients requiring OT intervention in clinic. Patients requiring onward referrals Types of:. OT intervention. Onward referral Page 48 of 89

49 Percentages are calculated and presented. Results A total of 77 new patients attended 24 clinics during the 12-month study period. 71 were seen by OT (92%). 76% required OT advice in the clinic or onward referral. 59% required advice, including: - returning to work, grading tasks, fatigue management, environmental adaptation, cognitive strategies, finances and driving. 46% were referred to community rehabilitation, outpatient therapy, falls clinic, memory clinic or social services. During the same period, 8 patients were provided follow-ups by OT. 100% required OT input, 25% during clinic and 75% onward referral. Conclusion: Most patients attending PCCC required OT for aspects of PICS. OT provided unique insight into how impairments affect everyday occupations. OT can particularly assist with reducing care needs and return to work. These findings are relevant to providers and commissioners. References: 1. Pandharipande PP, Girard TD, Jackson JC et al Brain-ITU study investigator. Long term cognitive impairment after critical illness. N Eng J Med 369(14): , Hopkins RO & Brett S, Chronic Neurocognitive effects of critical illness. Current Opinion in Critical Care, 11: , Parker A, Sricharoenchai T, Needham DM (2013) Early Rehabilitation in the Intensive Care Unit: Preventing Physical and Mental Health Impairments. Current Physical Medicine and Rehabilitation Reports. 2013;1(4) Needham DM, Davidson J, Cohen H (2012) Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Critical Care Medicine Feb 40(2): National Institute for Clinical Excellence (2009) Rehabilitation after critical illness in adults (CG83). NICE: London. Available from: [accessed August 2017] 6. Griffiths J, Hatch RA, Bishop J, Morgan K, Jenkinson C, Cuthbertson BH, Brett S 2013 An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study. Critical Care 17(3):R College of Occupational Therapists Practice Briefing: Occupational Therapy in Critical Care The Faculty of Intensive Care Medicine & The Intensive Care Service Standards Committee (2015) Guidelines for Provision of Intensive Care Services 9. Intensive Care Society Core Standards for Intensive Care Units (2013) Page 49 of 89

50 10. National Critical Care Non-Medical Workforce Survey, Overview Report. Critical Care Operational Delivery Networks England, Wales and Northern Ireland. (2016) 11. NICE (2017) Development of a Multidisciplinary Post Critical Care Clinic at Guy's and St Thomas' NHS Foundation Trust. Available from: [accessed August 2017] Page 50 of 89

51 FOLLOWING INTENSIVE THERAPY (FIT) GROUP (POSTER DISPLAY: SATURDAY 11 NOVEMBER 10:30) Introduction - People who experience intensive care stays, whether pre-planned or following crisis, experience deconditioning beyond the average fallout from illness and research has shown that critical illness has a significant effect on patients long after they are discharged from critical care. Many patients experience weakness, loss of energy, anxiety, depression. post-traumatic stress (PTS) phenomena or a decrease in cognitive function, to name a few. 1 Our service was set up in 2010 following a visit to the McWilliams programme in Manchester Royal Infirmary, to take those post ITU patients who are medically stable and those recently discharged home following an ITU admission. Aim To provide a conditioning and exercise class for those who have been in intensive care and provide a groupsupport environment for recovery, through activity and advice. Method - The group individuals are assessed, given reconditioning programmes, talks and peer support through their recovery. The service is integrated into the care plan to help with rehabilitation as soon as possible. Outcomes are measured using the Hospital Anxiety and Depression Score, Short Form 36, Incremental Shuttle Walk and 6 minute walk test. Results - The vast majority of patients report a definite benefit to attending the class. The main impact data collected has focused on quality of life and rate of recovery of the individuals. Patients analyzed with complete sets of data have shown improvements in physical, psychological and social objective markers, although the number of results is insufficient to use for clinically relevant statistical analysis. Conclusion The Following Intensive Therapy (FIT) Group provides multidisciplinary support, education talks and peer support to those who have experienced critical illness and are facing a long rehabilitation. It links into the ITU Rehabilitation Network and Follow-up clinic for on-going communication with regards to patients discharged home. Currently we are looking to use the CPAX as a means of identifying patients earlier, who may be appropriate for FIT Group in order to maximise an individual s potential to return to their previous function and in the last year, patients who have been medically fit on the ward, have been attending the group prior to discharge. 1. NICE clinical guideline 83 Rehabilitation after critical illness: Page 51 of 89

52 CORRELATION BETWEEN RESPIRATORY CHANGES AND LEVEL OF ACTIVITY IN PATIENTS IN THE INTENSIVE CARE UNIT (PRESENTATION: SUNDAY 12 NOVEMBER 11:30) Fragoso AS 1,Schujmann DS 1, Neri C 2,Lamano MZ 1,Pimentel M 1,Fu C 2 1 Hospital das Clínicas of School of Medicine, University of Sao Paulo. Department of Physical Therapy. Sao Paulo, Brazil 2 Department of Physical Therapy, Communication Sciences & Disorders and Occupational Therapy. School of Medicine. University of Sao Paulo, Sao Paulo, Brazil INTRODUCTION. Patients in Intensive Care Unit (ICU) are more susceptible to a period of immobility during hospitalization. Some studies suggest that immobility can cause damage to the respiratory system and changes in respiratory capacities and strength of respiratory muscles. AIM. To verify if the times in different level of activity are correlated to changes in the respiratory system in ICU discharge moment. METHOD This observational study included ICU patients, aging over than 18 years, without neurological pathology and contraindication for mobilization. Exclusion criteria were less than 3 days in ICU and death. We placed an accelerometer on the patient s ankle during all ICU stay to verify the percentage of the time in different level of activities: inactive, light and moderate activity. The respiratory system performance was assessement using maximal voluntary ventilation (MVV) in 10 seconds, forced vital capacity (FVC), FEV1, maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). A digital spirometer and a manovacuometer were used for the evaluations. The tests were performed with no more than two days after discharge from the ICU.We used the Pearson and Spearman correlation tests for the analysis. RESULTS We analyzed 83 patients, were 57±17 years old, 53% male, Charlson INDEX 4 (0 8), SAPS III 55±14, 60% were under mechanical ventilation, 58% vasoactive drugs, 54% sedactive drugs. Patients spent 93.49%±3.35 of the time in inactivity, 3.5±1.8 % in light level of activity and 0.75%±0.07 in moderate level. In the respiratory tests, the patients presented an average in the MMV of 24±12 l/min, in the FVC 2.1±1.2ml, FEV1 1.8±0.9, MIP 50±20 and MEP 65±30. The time in inactive was inverse correlated with MVV (r -0.4; p<0,001), FVC (r -0.5;p=0,01) and MEP (-0.4, p=0.01). The time in light activity was also correlated with MMV(r 0.3; p<0,001) and FVC (0.3, p<0.01). There is a correlation between time in moderate level of activity and VVM (r 0.4,p<0.01). For the MIP and MEP there is no correlation (r 0.06,p=0.8 and r0.1, p=0.09). CONCLUSION This study continuously monitored the time in different levels of activity during the ICU stay and respiratory tests. There is a inverse correlation between time in inactivity and pulmonary assessments. A positive correlation between time in activity and respiratory performance in spirometer tests. There is no correlation between respiratory pressures and level of activity. Page 52 of 89

53 KEYWORDS Activity level Accelerometer Intensive Care Respiratory capacities FUNDING ACKNOWLEDGEMENTS THIS WORK WAS FUNDED BY FAPESP, BRAZIL. Ethics approval: Approved by Comissão de Ética para Análise de Projetos de Pesquisa do Hospital das Clínicas da Faculdade de Medicina Da Universidade de São Paulo Page 53 of 89

54 INSPIRATORY MUSCLE TRAINING WITH TAPERED FLOW RESISTIVE LOADING VERSUS MECHANICAL THRESHOLD LOADING IN ICU DIFFICULT TO WEAN PATIENTS: A PILOT STUDY (PRESENTATION: SATURDAY 11 NOVEMBER 16:45) Intensive care, Respiratory muscle, Mechanical ventilation - weaning M. Van Hollebeke 1, M. Hoffman Barbosa 1, B. Clerckx 1, Hermans G 2, Muller J. 2, D. Langer 1, R. Gosselink 1 1 KULeuven - Leuven (Belgium) 2 UZ Leuven, Department of Intensive Care Medicine, Belgium Introduction: Inspiratory muscle training (IMT) might be an efficient treatment modality for patients with weaning failure. It has been shown that IMT is feasible and safe in difficult to wean patients. A recently developed IMT device applies a tapered flow resistive load (TFRL) with visual breathing pattern feedback that might result in better training responses than the typically used mechanical threshold loading (MTL). Aim: To investigate the difference in breathing pattern response during IMT using either MTL or TFRL in difficult to wean ICU patients. Method: Six patients (1female), age 46±16 years, BMI 23±6Kg/m 2, MIP 41±19cmH 2O performed IMT sessions using both the MTL and TFRL devices. The inspiratory load was set on the highest tolerable intensity adjusted according to the Borg score (4-6) and the volume responses. The intensity corresponded to 40±7% of the weekly measured MIP plateau. IMT was performed in 4 sets of 6-10 breaths with one minute rest in between. Two sets were performed with the TFRL device and 2 sets with the MTL device against the same absolute load. Patients were instructed to achieve a fast and forceful full inspiration during the training with every breath. Breathing parameters from one training session performed with both devices at the same absolute load were compared using paired T-test. Results: TFRL-IMT enabled patients to achieve higher inspiratory volume and larger work of breathing while resulting in a potentially less fatiguing contraction pattern (Tension Time Index) than MTL-IMT (Table). Conclusion: The TFRL is better adapted to the length tension characteristics of the inspiratory muscles than MTL. This results in higher inspiratory tidal volumes at similar externai loads leading to higher work of breathing. It should be evaluated whether TFRL-IMT is better tolerated by these patients and if it will result in larger respiratory muscle function improvements than MTL-IMT. Page 54 of 89

55 Mean(SD)MTL Mean(SD)TFRL p-value Tidal Volume,L 0.65± ± * Absolute Load,cmH 2O(%MIP) Average Load, cmh 2O(%MIP) Work of breathing, J/breath 23±3(40±7) 23±3(40±7) >0.99(>0.99) 20±7(39±7) 14±4(27±7) 0.001*(<0.001*) 0.11± ± * Mean Insp Flow, L/s 0.56± ± Ti,s 1.15± ± Ti/Ttot(%) 19±2 19±5 >0,99 Respiratory Rate,breaths/min 11±3 9± Pressure Time 28±15 24± Product,cmH 2O*s/min Tension Time Index,Pi/MIP*Ti/Ttot 0.07± ± * Page 55 of 89

56 QUALITY IMPROVEMENT PROJECT: IMPROVING THE AMOUNT OF ACTIVE PHYSIOTHERAPY IN PATIENTS WITH NEUROLOGICAL AND NEUROSURGICAL ADMISSION DIAGNOSIS ON THE INTENSIVE CARE UNIT (PRESENTATION: SUNDAY 12 NOVEMBER 11:15) D.S. Jaenicke, MSc, A. Beelen, PhD, M. van der Schaaf, PhD Academic Medical Centre, Amsterdam, the Netherlands. Department of Rehabilitation Introduction Early activation and mobilization have become an important part of physiotherapy treatment strategies of critically ill patients. The 2015 published Evidence Statement (ES) for physiotherapy in the Intensive Care Unit (ICU), provides recommendations on treatments along with safety criteria to determine patients safety before and during activation and mobilization by screening on red flags and contra indications. In patients with neurological and neurosurgical admission diagnosis on the ICU, adherence to the ES appeared to be low, with underuse of activation strategies like mobilization in the chair or using the bed-cycle-ergometer. Aim The objective of this study was to improve the amount of active physiotherapy interventions in neurological and neurosurgical ICU patients. We undertook a quality improvement project to raise awareness for mobilization in the chair and the use of the bed-cycle-ergometer according to ES recommendations and to evaluate its effects on ES adherence. Method A before-after evaluation, performed at the ICU of a university hospital, comparing retrospective collected data of applied physiotherapy treatment strategies in 172 physiotherapy sessions before and 108 physiotherapy sessions after the intervention. The intervention consisted of interviewing ICU-physiotherapists specialized in neurology to explore perceived barriers towards implementation of the ES with respect to mobilization in the chair and the use of the bed-cycle-ergometer. Subsequently we addressed the identified barriers with different strategies: (1) enhancing knowledge of the ES, including safety criteria for activation and mobilization, (2) enhancing knowledge of the indication for and the skills to use the bed-cycle-ergometer, (3) removing organizational barriers and (4) developing an additional protocol targeting the special needs of neurological patients on the ICU. Main outcome measures were the number of active physiotherapy interventions as indicated by the ES, in terms of mobilization in the chair or using the bed-cycle-ergometer, in neurological patients. Descriptive and inferential statistics were used to compare before-after intervention numbers. Results After the intervention, the number of active physiotherapy interventions in patients without contra-indications for active physiotherapy according to the safety criteria, increased from 47% to 71% (P = 0.0). Adherence to ES recommendation increased from 55% to 73% (P = 0.0). Mobilization in the chair increased from 32% to 50% (P = 0.0). The use of the bed-cycle-ergometer increased, yet non-significantly (16% vs. 21%, P = 0.4). Conclusion Implementing targeted interventions on identified barriers improved guideline adherence and increased the frequency of activation and mobilization of neurological and neurosurgical patients on the ICU. Page 56 of 89

57 NEUROMUSCULAR ELECTRICAL STIMULATION ACUTE EFFECTS ON CYTOKINES AND VASCULAR ENDOTHELIAL GROWTH FACTOR IN SEPTIC ICU PATIENTS (POSTER DISPLAY: SUNDAY 12 NOVEMBER 10:30) E. Karatzanos 1, G Mitsiou 1, K. Psarra 2, C. Stefanou 1, V. Gerovasili 1, C. Routsi 1, S. Nanas 1 1 1st Critical Care Department, Evangelismos General Hospital, School of Medicine, National & Kapodistrian University of Athens, Ypsilantou Str., , Athens, Greece 2 Immunology & Histocompatibility Department, Evangelismos General Hospital, Ypsilantou Str, , Athens, Greece Introduction: Neuromuscular electric stimulation (NMES), acutely applied on septic ICU patients, has been previously shown to beneficially affect systemic microcirculation and increase counts of endothelial progenitor cells. Both are related to endothelial function, which is impaired in this category of critically ill patients and associated with multi-organ failure. Cytokines and vascular endothelial growth factor (VEGF) have been associated with alterations in microcirculation and mobilization of progenitor cells. The potential mediating role of these factors in severe ICU patients, however, are not known. Aim: The aim of this study was to explore the acute effects of NMES on cytokines and vascular endothelial growth factor (VEGF) in septic ICU patients. Methods: Thirty two septic patients, aged 58±14 years (mean±sd) were randomized to one of two 30-min NMES protocols of different characteristics; a high-frequency (75 Hz, 6s on 21s off) or a medium-frequency (45 Hz, 5s on 12s off) protocol. These protocols were applied in maximally tolerated intensity on vastus lateralis, vastus medialis and peroneus longus of both lower extremities. Blood was sampled before and immediately after NMES sessions, and analysed for interleukin 1a (IL1a), interleukin 10 (IL10), interleukin 6 (IL6) and VEGF employing Multiplex Cytometric Bead Array. Fluorescence intensity (FI) values are presented as median (25 th, 75 th percentiles). Results: NMES was not observed to change FI expression values of IL1a [pre: 83 (76, 88), post: 80 (75, 84), p=0.14], IL10 [pre: 135 (87, 283), post: 106 (88, 206), p=0.52], IL6 [pre: 367 (58, 1139), post: 207 (29, 753), p=0.25], VEGF [pre: 119 (94, 188), post: 100 (82, 154), p=0.24] after session. Power analysis suggested sample size as a potential confounding factor. Conclusion: Acutely applied NMES in severe ICU patients was not observed to affect selected cytokines and VEGF. These results, however, are underpowered to reach definite conclusion. The potential role of corticosteroids administration and muscle contraction strength has also to be investigated. Page 57 of 89

58 CORRELATION BETWEEN MUSCLE ANALYSIS AND STATUS FUNCTIONAL IN PATIENTS ADMITTED IN INTENSIVE CARE UNIT (POSTER DISPLAY: SUNDAY 12 NOVEMBER 10:30) Lamano MZ 1, Schujmann DS 1, Gomes TT 1, Fragoso AS 1, Pimentel M 1,Fu C 1 1 Department of Physical Therapy, Communication Sciences & Disorders and Occupational Therapy. School of Medicine. University of Sao Paulo, Sao Paulo, SP, Brasil Introduction: The musculoskeletal system is essential for maintenance functionality. Muscle disorders have been reported after a period of hospitalization and may include alterations in the contraction of force, in function and muscle activation. However, little is known in the literature which muscle alterations may be correlated with the functional loss in ICU. Aim: To evaluate the muscle disorders in critically ill patients at discharge from the ICU and correlate these changes with functional status in this moment. Methods: This longitudinal study included ICU patients, over 18 years of age, without neurological diseases and mobilization restriction. The exclusion criteria were patients who do not understand simple commands, less than 4 days in ICU. We used Barthel Index (BI) to evaluate the functionality score. For muscle evaluations we used The 30- Second Chair stand test, test of stationary gear of two minutes and Timed Up and Go (TUG). The grip strength was used as evaluation of muscle strength through a dynamometer. We analyzed muscular activation through the electromyography of the tibialis anterior, vastus lateralis and gastrocnemius muscles. The tests were performed with no more than two days after discharge from the ICU. Results: We analyzed 47 patients, 47±17 years old, SAPS III 47±11 points, 47% were under mechanical ventilation and stay in ICU during 10.6±6.5 days. The handgrip was 24.4±9.3kgf, the mean for the test of stationary gear of two minutes was 50±19 steps, The 30- Second Chair stand test was 7.8±3 times and TUG 14.6±9. The percentage of activation of the tibial was 28%±16, the vastus lateralis was 32%±15, and the gastrocnemius was 7%±3. The difference between initial and final BI (delta) was 14±11 points. The correlation between BI delta and hand grip strength was r -0.3; p=0.03. The correlation between delta BI and The 30- Second Chair stand test was r -0.6; p < 0,001. There was a inverse correlation between delta BI and test of stationary gear (-o.6;p<0,01). TUG not were related to the functional status (r.0,1; p.0,3). The percentage of muscular activation not was correlated with delta functional. Conclusion: The test of stationary of two minutes, The 30- Second Chair stand test and handgrip force were correlated with functional status in ICU discharge moment. The test of stationary gear of two minutes and The 30- Second Chair stand had a strong inverse correlation with functionallity. Timed Up and Go and muscular activation not were correlated with delta functional. KEYWORDS Muscle weakness acquired in the ICU Status functional Critical care FUNDING ACKNOWLEDGEMENTS THIS WORK WAS FUNDED BY FAPESP, BRAZIL. Ethics approval: Approved by Comissão de Ética para Análise de Projetos de Pesquisa do Hospital das Clínicas da Faculdade de Medicina Da Universidade de São Paulo Page 58 of 89

59 IMPLEMENTATION OF THE ICU DIARY WITHIN A MEDICAL INTENSIVE CARE UNIT (POSTER DISPLAY: SATURDAY 11 NOVEMBER 10:30) Lyndsay Laxton, Jho leen Visaya, Dana Christianson University of Colorado Hospital, Aurora, CO, USA Introduction Post Intensive Care Syndrome (PICS) is characterized by new or worsening physical, cognitive, or mental health problems after critical illness. In an effort to reduce the occurrence of PICS, health care professionals have utilized numerous non-pharmacological interventions, including early mobilization, environmental modifications, and the ICU diary. Aim The ICU Diary quality improvement project was targeted at strengthening staff awareness of the benefits of this intervention and at increasing the frequency of implementation of the ICU Diary within a Medical Intensive Care Unit (MICU). A secondary goal was to obtain subjective feedback from patients and family members regarding their perceived value of the ICU Diary intervention. Method One occupational therapist (OT) and two registered nurses (RN) provided training on the purpose and benefit of the ICU Diary intervention, strategies for implementation, and recommendations for diary content through an in-service presentation supplemented by a written handout. An online survey using a Likert scale format was administered pre- and post-training to collect subjective feedback from MICU staff regarding their level of understanding and comfort with the ICU Diary intervention, as well as frequency of implementation and current perceived barriers to implementation. Additionally, we collected subjective feedback from patients and family members regarding their perceptions of the intervention. Feedback was obtained via informal conversation and comment cards. Results MICU staff (N= 31) reported an increased awareness regarding the purpose of the ICU Diary intervention following the training session (61.5%) as compared to before training (29%). Also, staff reported an increase in the frequency of implementation of the ICU Diary into their clinical practice with 9.7% of staff implementing the intervention weekly prior to training as compared 17.2% following training. However, the majority of staff identifies time (36.9%) and poor understanding of which content to include (29%) as barriers to implementing the ICU Diary more frequently. Four common themes emerged when analyzing subjective feedback received from patients and family members (N=8) related to the ICU Diary intervention. These themes included gratitude, perceived value, assistance with memory and orientation, and improved participation in care coordination. Conclusion Patients and family report positive feedback related to the ICU Diary as it increased their orientation to medical events during their hospitalization and improved their participation in care coordination. Similarly, MICU staff report an increased understanding of the benefits and purpose of the ICU Diary, as well as increased utilization of the intervention following training and education. Page 59 of 89

60 COMPLEX HOME DISCHARGE OF 24 HOUR TRACHEOSTOMY VENTILATED PATIENT PATIENT S JOURNEY (POSTER DISPLAY: SATURDAY 11 NOVEMBER 10:30) Jeong Su Lee Introduction The occupational therapy service at Lane Fox respiratory unit provides various services to mechanically ventilated patients and the discharging these patients involve complex interventions. Aim To share experience of discharging complex tracheostomy ventilated patient and to evaluate future needs for service development Method A single case study and reflection Result Most of the interventions being provided are routine occupational therapy activities such as occupation based rehabilitation (washing and dressing practice and transfers) and access visits. However, the expert knowledge and skills are needed to work with long term ventilated patients who can be medically unpredictable and are undergoing weaning process. The Lane Fox occupational therapists are involved in leading the health care funding forms and liaising with the local authorities to secure health and/ or social care funding. Recommending an appropriate care package is more complex. The majority of mechanically ventilated patients require medically trained carers for tracheostomy care or NIV management with consideration of over night care needs. Therefore one of the important role s of occupational therapists is to recommend the care package for ventilation care, as well as daily activities such as personal care assistance and manual handling. Whilst the access visit is required to establish the safe home environment in light of the patient s functional level; the primary focus is to determine whether the home environment can accommodate ventilation equipment and allow for appropriate space for tracheostomy care provision. This assessment is vital as such can dictate discharge destination. Equipment provision is dependent on patient s care and ventilation needs. In light of complex care needs a discharge home visit is provided as protocol. This ensures all equipment and care package sufficiently meets patient s needs. Here via a case study example, we demonstrate the patient journey from the weaning centre to home to highlight the complexity of this process. CASE STUDY : 73 year old male Page 60 of 89

61 Admission date Local hospital admission April 2016 (Tracheostomy inserted in May 2016) Transfer to LFU in October 2016 for complex and prologed ventiltion weaning Dianosis Motor Neuron Disease (September 2016) Triple coronary artery disease Reactive depression and anxeity Ventilation setting on discharge Weaning trial for 4 months but due to the progressive nature of medical condition patient is advised to have 24 hour ventilation via tracheostomy. Established ventilation setting, cough assistance and PEG regime Rehabilitation on ward Previous level of function : independent with all personal care and transfers Function on admission : assistance of one for personal care and tranfers Early OT rehabilitation : Grooming, personal care, tranfers practice Funding application Discharge destination disucssed - home vs nursing home. Family and patient both wished patient to be discharged home. MDT Contiuing health care funding form completed and sent in January 2017 Discharge planning Complex family meeting to clear family expectation on weaning potential and the risks involved in home discharge. Cognitive assessment to establish patient's baseline cognition MDT meeting to discuss challenging behaviour and trachestomy care at home Access visit to ensure the home setting met patient's needs Feb 2016 Page 61 of 89

62 Prepareing for home discharge Eqiupment ordered - hospital bed, chair, commode, table Carer training : manual handling report to the care agency, on site trache, PEG and cough assist training Request care package : 24 hour trache trained single carer Discharge setting Post discharge service 24 hour bilevel trache ventilation 24 hour trache trained carer support Discharge function : assistance of one for trache care only Single level living with micro home environment as unsafe to use stairs ie risks of falls and accidental decannulation Family support / 24 hour accessible LFU service Discharge home in June 2017 ( 8 months LFU stay) Occupational therapy home visit to ensure the environment and the care arrangements were sufficient Further referral made to the community occupational therapist for bathroom adaptation and a stair lift Implication and Conclusion There is a lack of guidelines specific for the discharge of mechanically ventilated patients. Coinciding with this, there is limited knowledge and expertise within the social sector to take over the care of these patients. From our experience this has implication s with regard to timely discharge and risk of readmission. Page 62 of 89

63 PREVALENCE OF COGNITIVE IMPAIRMENT AMONGST NON INVASIVE VENTILATION (NIV) USERS AND IMPLICATIONS FOR MANAGEMENT OF NIV MASK. A PILOT STUDY. (POSTER DISPLAY: SATURDAY 11 NOVEMBER 15:30) Paula Redden Senior Occupational Therapist Jeong Su Lee Senior Specialist Occupational Therapist Background: It is well known that there is association between acute critical illness and cognitive impairment (Ehlenbach et al). However there is very little evidence available to demonstrate the prevalence of cognitive impairment amongst NIV users and the impact this may have on NIV mask management. A pilot study was completed by using the Montreal Cognitive Assessment (MoCA) to determine the presence and/or severity of cognitive impairment amongst older NIV users and if this would impact on NIV mask management. Patients over sixty five years were chosen as this group is more a risk of developing cognitive impairment. Aim: To determine whether decline in cognitive function was greater amongst adults over 65 years who use NIV and to determine whether the presence of cognitive impairment impacts ability to use the NIV machine/mask independently. Method: Patients who were admitted to a respiratory weaning unit over an eleven week period who were over the age of 65 and who used NIV were included in the study (total of 22 patients). Patients were included regardless of their diagnosis. Both long term NIV users and new users were included. As this study focused on the use of non-invasive ventilation, patients who were invasively ventilated were excluded. The MoCA was conducted by an occupational therapist on the weaning unit. Result The study reviewed a total of twenty two patients (12 female, 10 male). Thirteen were new NIV users and nine had previously used NIV. Seven of the patients studied cognition was within normal limits. Eleven of the patients studied had cognitive impairments (nine mild and two moderate). Two of the patient studied had known dementia. Eighteen patients used their NIV independently and four had difficulty using NIV. These four patients were more severely impaired. Discussion: The results showed the majority of the patients studied had a cognitive impairment, with the majority of those having a mild cognitive impairment. A small number of patients had difficulty using their NIV machines/masks. Those who had more moderate/severe cognitive impairment were more likely to require assistance on discharge. Conclusion: Patients who have mild cognitive impairment appeared to be able to learn to use how to use NIV mask/machine independently within their hospital admission. Patients who have a moderate cognitive impairment were more likely to require support at home. Page 63 of 89

64 EFFECTIVENESS OF EARLY MOBILIZATION INITIATING IN THE ACUTE PHASE OF SEPTIC SHOCK. A QUALITY IMPROVEMENT PROGRAM FOR SEPSIS (POSTER DISPLAY: SUNDAY 12 NOVEMBER 10:30) Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital Keibun Liu MD, Takayuki Ogura MD, Mitsunobu Nakamura MD, PhD, Dai Miyazaki MD, and Hiroyuki Suzuki MD. Introduction Sepsis is a major contributor for sustaining physical and cognitive dysfunction after ICU and hospital discharge. Although early mobilization (EM) is recommended to prevent these impairment, the actual effectiveness of EM for sepsis is unknown. To improve the outcomes of such patients, we conducted the Maebashi Early Mobilization Protocol. Aim To investigate the effectiveness of the Maebashi EM protocol for septic shock. Method This is a single center retrospective pre-post intervention study. All consecutive patients who diagnosed septic shock and admitted to our ICU was included. The definition of septic shock followed the sepsis 3 definition. The patients who included from June 2014 to May 2015 before the implementation of the Maebashi EM Protocol were defined as the pre-group, and the patients from June 2015 to May 2016 after the implementation were defined as the post-group. We compared the clinical variables between the two groups, using appropriate statistic measures. The primary outcome is the hospital mortality. The secondary outcome is the length of hospital stay and the total medical cost during the hospital admission. Results We included 61 patients for the pre-group, and 55 patients for the post-group. There were no significant differences between the two group, including age (77 vs 76), male (59% vs 55%), BMI (21 vs 21), SOFA at ICU admission (8 vs 9), the percentage of the patients receiving mechanical ventilation (45% vs 50%), except APACHE Ⅱ (22 vs 25, p<0.01). The post-group could initiate the active rehabilitation sessions earlier (6.1days vs 1.7days, p<0.01) and exhibit the improvement of the percentage of the patients who received the active rehabilitation during the ICU stay (25% vs 70%, p<0.01). The mortality is not significantly difference between the two group (21% vs 9%, p=0.08). The length of hospital stay significantly becomes shorter (38.5days vs 24.7days, p=0.02) and the total medical cost during the hospitalization decreases after the introduction of the Maebashi EM Protocol ($32891 vs $19614, p<0.01). Conclusion The mortality between the pre-group and the post-group is not significantly different. The Maebashi Early Mobilization Protocol was associated with the decreased length of hospital stay and the reduction of the total medical costs. Page 64 of 89

65 POST CRITICAL CARE REHABILITATION SERVICE REVIEW (POSTER DISPLAY: SATURDAY 11 NOVEMBER 10:30) Kirsten Mitchell Introduction NICE CG 83 Rehabilitation after critical illness for adults highlights that 75% of patients admitted to critical care units survive to be discharged home being at increased risk of experiencing physical and/or non-physical problems. From April , 909 patients were admitted to ESHT critical care. Recommendations state rehabilitation may help patient outcomes so we set up a follow-up clinic and Post critical care rehabilitation group to address and evaluate this. Aim Improve patient outcomes post critical care by piloting new services, comprising of follow-up clinic and weekly rehabilitation group with specialist consultants, nurses, clinical psychologist and physiotherapists. Method Patients triaged by telephone to attend a follow-up clinic appointment. From 87 patients reviewed in clinic, 50 patients referred for weekly, hour long rehabilitation programme, 40 attended the group. Patient outcome measures taken on initial assessment and after 6weeks. Notably: 10m timed walk test, 6min timed walk test, Distress thermometer, PAS amended for ICU and patient feedback. A weekly programme was individualised for each patient based working towards their personalised goals, commonly based on increasing strength, balance, endurance and confidence. Results Overall, all the outcome metrics demonstrated a clinically significant in mean measurements from week m timed walk test: Mean improvement 23.3% ± min timed walk test: Mean improvement 43.6% ± 39.9 Distress thermometer and PAS amended for ICU data being collected Eleven patients have returned to previous employment, with advice and support. Many others returned to hobbies such as farming, tractor shows, singing, football, swimming, walking, gardening, gym based classes. Patients increased function and independence. Patients further surgeries now possible and they were no longer falling. Many patients reported less fatigue, pain and fear. Improving their confidence, ability to express problems, increased positive mindset, feeling more normal. More positive family interactions and sociability. Relatives were more confident with what patients could manage. Signposting to patient support group, clinical psychologist and wellbeing support. Not all completed the rehabilitation programme due to personal choice, hospital re-admission, terminal diagnosis, further investigations or death. Conclusion The Post critical care follow-up clinic and rehabilitation group has demonstrated positive impact on patients physical and non-physical abilities. Including muscle strengthening, balance, fitness and co-ordination improvements. Improving knowledge and skills to manage their fatigue, frustrations, and expectations. Patients attending the rehabilitation group have found it beneficial and would recommended it. We are looking to develop a therapy garden. Page 65 of 89

66 NON-INVASIVE VENTILATION AS AN AID TO BRIDGE DECANNULATION IN A SEVERE NEUROPATHIC PATIENT VENTILATED FOR 6 MONTHS ON A REGIONAL INTENSIVE CARE UNIT. (POSTER DISPLAY: SATURDAY 11 NOVEMBER 15:30) Moses R, Moore S, Vyas A and Moss D. Lancashire Teaching Hospitals, Preston. Introduction: Mrs P presented to the Emergency department with neuropathic pain and general weakness that progressively worsened. She was unable to perform a Forced Vital Capacity (FVC) so the decision was made to electively intubate and underwent a surgical tracheostomy 6 days later. The initial diagnosis was Guillain-Barré Syndrome but further studies confirmed a very severe acute motor and sensory axonal neuropathy (AMSAN). Aim Mrs P had been ventilated for 156 days struggling to wean conventionally and using adaptive support ventilation (ASV) due to hypoventilation, desaturations and increased volume of secretions. At this point Mrs P had been deemed potentially un-weanable. Her motor level was C4/5, she had no cough strength, poor diaphragmatic activity, unable to tolerate cuff deflation or periods of sustained rehabilitation. She was referred to a long term ventilation team for specialist input. Method On day 156 we commenced an alternative approach to weaning with spontaneous breathing using a waters circuit. This was used in 5 minute intervals until she was tolerating >10 minutes when we transferred to a tracheostomy mask wean. We then slowly increased time intervals whilst using regular lung volume recruitment and airway clearance using a Mechanical In-Exsufflator (MI-E) device. We combined this with a laryngeal wean and downsized her tracheostomy. She had no voice effort initially but we continued using a one way speaking valve (Passy Muir) to encourage weaning. Once Mrs P was tolerating 4 hours spontaneously breathing we introduced non-invasive ventilation (NIV) through the day and using MI-E through her upper airway. This approach then continued until her tracheostomy could be capped off using NIV day and night and she was ready for decannulation onto non-invasive support. Results After just 26 days of using this approach to wean we managed to safely decannulate Mrs P onto NIV support and regular MI-E (6 x a day). Mrs P was still requiring >14 hours of ventilator support a day. On laryngoscopy was very weak and fatigued with poor vocal cord movement but it was essential normal laryngeal patterns. Simple bedside assessment would have shown that decannulation risk was too high however instrumental assessment showed that the upper airway was functional and safe to proceed Conclusion NIV and MI-E is an essential modality to aid decannulation in patients with severe neuromuscular disease in the ICU setting. It is a recognised approach in some specialist centres in the UK but hugely underutilised in the majority of units. Page 66 of 89

67 TIME IN DIFFERENT POSTURES IS CORRELATED TO PERFORMANCE IN MOBILITY TESTS AFTER HOSPITALIZATION IN THE INTENSIVE CARE UNIT (PRESENTATION: SATURDAY 11 NOVEMBER 16:00) Neri C 1, Schujmann DS 2, Lamano MZ 2, Fragoso AS 2, Pimentel M 2,Fu C 2 1 Hospital das Clínicas of School of Medicine, University of Sao Paulo. Department of Physical Therapy. Sao Paulo, Brazil 2 Department of Physical Therapy, Communication Sciences & Disorders and Occupational Therapy. School of Medicine. University of Sao Paulo, Sao Paulo, Brazil INTRODUCTION. Patients in Intensive Care Unit (ICU) may stay in bed rest for long periods. This position for long periods can damage several body systems, including the musculoskeletal system. This system is of great importance for activities that include mobility. Thus, the time spent lying down could be related to worse performance in ICU post-discharge mobility tests. AIM. To verify if the time in different postures is correlated to performance in mobility tests after hospitalization in the intensive care unit. METHOD. This observational study included ICU patients, aging over than 18 years, without neurological pathology and contraindication for mobilization. Exclusion criteria were less than 3 days in ICU and death. We placed an accelerometer on the patient s ankle during all ICU stay to verify the percentage of the time in different postures: lying, sitting and standing. The mobility performance was assessement using three tests: Time up and go (TUG), Sit to Stand for 30 seconds and Stationary walking test for two minutes in ICU discharge moment. We used the Pearson and Spearman correlation tests for the analysis. RESULTS. We analyzed 68 patients, were 57±17 years old, 53% male, Charlson INDEX 4 (0 8), SAPS III 55±14, 60% were under mechanical ventilation, 58% vasoactive drugs, 54% sedactive drugs. Patients spent 90.19%±3.35 of the time in lying, 4.5±1.8 % sitting and 2.35%±1.07 in standing. In the mobility tests, the patients presented an average performance in the TUG of 14±9 seconds, in the Sit to Stand 7±3 repeats and in the Stationary walking test 50±19 repeats. The time in sitting position was correlated with higher repeats in the Sit to Stand (r 0.4; p<0,001) and Stationary walking test (r 0.3;p=0,01). The time in standing position was also correlated with best performance in the Sit to Stand (r 0.3; p<0,001) and Stationary walking test (r 0.3;p=0,01). The time in lying position was inversely correlated with performance in Sit to Stand test (r -0.4; p<0,001) and Stationary walking test (r -0.3;p=0,01). TUG test was not correlated with time in any of the three different positions. CONCLUSION. This study continuously monitored the time in different positions during the ICU stay and performance in mobility tests. There is a positive correlation between time in sitting and standing positions with performance in Sit to Stand test and Stationary walking test, and an inverse correlation between time in lying position and performance in this tests in ICU discharge moment. Page 67 of 89

68 KEYWORDS Immobility Accelerometer Intensive Care Mobility tests FUNDING ACKNOWLEDGEMENTS THIS WORK WAS FUNDED BY FAPESP, BRAZIL. Ethics approval: Approved by Comissão de Ética para Análise de Projetos de Pesquisa do Hospital das Clínicas da Faculdade de Medicina Da Universidade de São Paulo Page 68 of 89

69 PRO-MOTION A STEPPED-WEDGE, CLUSTER RANDOMIZED PILOTSTUDY TO EVALUATE PROTOCOL-BASED MOBILIZATION ON INTENSIVE CARE UNITS (POSTER DISPLAY: SUNDAY 12 NOVEMBER 10:30) Peter Nydahl 1, Dr. Ulf Günther 3, Dr. Burkhard Haastert 3, Stephanie Hesse 4, Christian Kerschensteiner 5, Prof. Dr. Sascha Köpke 6 1. MScN, Nursing Research, University Hospital Schleswig-Holstein, Campus Kiel 2. University Hospital Oldenburg 3. medistatistica, Neuenrade 4. General Hospital, Kiel 5. B.A., Hospital Neumarkt, Neumarkt 6. Institute for Social Medicine and Epidemiology, University Lübeck Background: Despite convincing evidence for early mobilization of patients on Intensive Care Units (ICU) 1, implementation in practice is limited 2,3,. Protocols for early mobilization, including in- and exclusion criteria, assessments, safety criteria and an approach of stepwise-mobilization may increase the rate of implementation and mobilization 4. Hypothesis: (Population) patients on ICUs, (Intervention) with a protocol for early mobilization, (Control) compared to patients on ICUs without protocol, (Outcome) will be more frequently mobilized. Method: Multicentre, stepped-wedge, cluster-randomized pilot study 5. Five ICUs will receive an adapted, interprofessional protocol for early mobilization in randomized order. Before and after implementation, mobilization of ICU patients will be evaluated by randomized monthly one-day point prevalence surveys. Primary outcome is the percentage of patients mobilized out of bed, operationalized as a score of 3 on the ICU Mobility Scale. Secondary outcome parameters will be presence and/or length of mechanically ventilation, delirium, stay on ICU and in hospital, barriers to early mobilization, adverse events, and process parameters as identified barriers, used strategies, and adaptions to local conditions. Expected results: Exploratory evaluation of study feasibility and estimation of effect sizes as basis for a future explanatory study. Page 69 of 89

70 References 1. Stiller K. Physiotherapy in intensive care: an updated systematic review. Chest 2013;144(3): Connolly BA, Mortimore JL, Douiri A, Rose JW, Hart N, Berney SC. Low Levels of Physical Activity During Critical Illness and Weaning: The Evidence-Reality Gap. J Intensive Care Med Jan 1: Dubb R, Nydahl P, Hermes C, Schwabbauer N, Toonstra A, Parker AM, et al. Barriers and Strategies for Early Mobilization of Patients in Intensive Care Units. Ann Am Thorac Soc 2016; 13(5): Nydahl P, Dubb R, Filipovic S, Hermes C, Jüttner F, Kaltwasser A, et al. [Algorithms for early mobilization in intensive care units]. Med Klin Intensivmed Notfmed 2016; 112(2): Mdege ND, Man M-S, Taylor Nee Brown CA, Torgerson DJ. Systematic review of stepped wedge cluster randomized trials shows that design is particularly used to evaluate interventions during routine implementation. J Clin Epidemiol 2011;64(9): Page 70 of 89

71 OCCUPATIONAL THERAPY NEEDS OF PATIENTS ONE YEAR POST CRITICAL CARE THE IMPORTANCE OF HAVING AN OCCUPATIONAL THERAPIST IN CRITICAL CARE FOLLOW UP CLINICS (POSTER DISPLAY: SATURDAY 11 NOVEMBER 10:30) Deirdre O Reilly Background It is well established that patients admitted to Critical Care can suffer long term cognitive, physical and psychosocial outcomes which may prevent them returning to independent functioning at home, work and in the community. It is therefore recommended patients physical and non-physical needs are addressed whilst in Critical Care, but also on discharge from Critical Care/hospital and through to the community. NICE guidelines (CG83) recommend MDT involvement in Critical Care Outpatient follow-up clinics with particular focus on physical, cognitive and psychological patient outcomes. Occupational Therapists are primarily concerned with facilitation of functional performance through rehabilitation or task adaptation with consideration to an individual s impairments, the occupation (task) and environment. Occupational therapists have the skillset to provide holistic assessment and treatment to the heterogeneous cohort of patients both within the Critical Care environment and through to primary care. Method A tool was developed to identify patient s current physical, cognitive and psychological impairments, which was piloted at the Critical Care Follow up clinic. All patients who attended the clinic over a nine month period were screened by the occupational therapist. Questions were aimed at identifying the impact of impairments on a patient s self-care, productivity and leisure. Results A total of 37 patients attended the clinic (21 male and 16 female). Of the patients who attended, 17 (46%) reported ongoing cognitive impairment, 18 (49%) reported psychological issues and 18 physical impairments (limb weakness/joint problems). 19 (51%) patients reported fatigue and 10 (27%) reported ongoing family psychological issues. 16 patients worked (14 full time; 2 part time) prior to their Critical Care admission. Of these only 10 patients (62%) had returned to work During the clinic 25 (68%) patients required OT input e.g. fatigue management advice, cognitive rehabilitation strategies etc. A subsequent 9 (24%) patients required follow up/onward referral. Conclusion Approximately 50% of patients who attended Critical Care Follow up clinic during the nine month period had cognitive, psychological and / or physical problems up to 1 year post Critical Care admission. This data supports the role of Occupational Therapy within at the Critical Care follow up clinic Page 71 of 89

72 THE CHELSEA CRITICAL CARE PHYSICAL ASSESSMENT TOOL AS A PREDICTIVE MEASURE FOR READMISSION TO ICU (POSTER DISPLAY: SUNDAY 12 NOVEMBER 10:30) Putt E, Tantam K, Gardiner R, Fewings J Introduction: Rehabilitation in intensive care (ICU) has become an important evidence-based component in the management of patients with critical illness (Gosselink et al 2012). The NICE guideline (CG83) Rehabilitation after critical illness (2009) advocates that rehabilitation should start as soon as clinically possible after critical illness. Rehabilitation in ICU has been associated with improved functional outcomes and reduced ICU and hospital length of stay. In 2013, Corner et al published The Chelsea Critical Care physical Assessment Tool (CPAx) and proved it is a validated to measure physical morbidity in the general adult critical care population. In 2014 Corner at al observed that CPAx score on discharge from critical care can be predictive of hospital discharge destination. However no data has explored the value of the CPAx outcome measure in relation to readmission to ICU and length of stay (LOS). Aim: Method: Explore the relationship of Chelsea Critical Care Physical Assessment Tool and length of stay. Sub analysis of the relationship between respiratory component score, LOS and readmission rate. Retrospective review of ICU electronic rehabilitation notes against core clinical demographic data. Following provision of an enhanced physiotherapy service focused on rehabilitation. Data was collected from a 19 bedded general (mixed medical and surgical ICU) for patients admitted more than 48 hours. CPAx data was collected at baseline physiotherapy assessment and on ICU discharge. The relationships between different domains of the CPAx and length of stay and readmission rates were then explored. Results: 6 months of preliminary data is underway. We are currently comparing CPAx discharge scores with ICU and hospital length of stay and expect to find a positive correlation with poor mobility function on ICU discharge, hospital LOS and re-admission. Core readmission risk factors will also be presented - such as age, severity of illness. Conclusion: Preventing readmission to ICU is a key clinical issue. This is the first project to explore the relationship between CPAx and readmission data in a general ICU. References: Corner E, Wood H, Englebretson C, Thomas A, Grant R, Nikoletou D, Soni N. (2013) Physiotherapy 99 p33-41 Corner E, Soni N, Handy J, Bret S. (2014) Construct validity of the Chelsea critical care physical assessment tool: an observational study of recovery from critical illness. Critical Care 18:R55 Gosselink, Rik; Needham, Dale; Hermans, Greet (2012) Current Opinion in Critical Care 18 (5) p Rehabilitation after Critical Illness in Adults (CG83) NICE 2009 Page 72 of 89

73 DEVELOPMENT OF AN ELECTRONIC PATIENT DIARY APP FOR USE IN A NEURO-CRITICAL CARE UNIT (POSTER DISPLAY: SATURDAY 11 NOVEMBER 10:30) Louise Roberts Introduction NCCU is a busy 23 bedded Neuro Critical Care and Major-trauma unit in Cambridge, admitting over 900 patients a year. Over the last 5 years we have had limited success in introducing paper based patient diaries. When surveyed, staff reported the reasons for this were due to not having enough time, forgetting to write in them or not being considered a priority. The use and benefit of patient diaries within critical care has been well documented (Phillips 2011) and NICE recommends that services should be developed to meet the psychological care needs of patients following critical illness. Aim The aim of this project is to increase the use of patient diaries by developing a secure, user friendly electronic diary which is easy to access and edit. It will be saved following discharge and then printed out and given to the patient at an appropriate time during their rehabilitation phase. Methods CUH has recently invested in electronic patient records. Creating an electronic patient diary seemed to be a natural progression. The format of the electronic diary is based on the current paper based diary. The diary content will be stored securely on the NHS IG complaint server and accessed via a webpage. This will enable the Multi-disciplinary team to complete the diary at the bedside computer, with the ability to upload photographs. Photographs will be kept securely until the patient is able to give consent for release. Discussion KPI reports will be built into the app to enable the administrators to identify which patient needs an entry writing, best nurse performers etc. There will also be the ability to edit entries as and when required. Phase 2 of the diary development will provide password protected access for the patients relatives who can add entries and photographs to the diary as they wish. Initially the patient diary will only be used within critical care, but we do plan for the diary to continue being used by the patient and their family when they are discharged to the ward, continuing to support their recovery. Conclusions This is an on-going project which is in development at the time of writing, therefore the conclusions of this project are yet to be made. At a recent patient focus group meeting, the concept of electronic patient diaries was very well received References Phillips C (2011) Use of patient diaries in critical care. Nursing Standard. 26, 11, Date of acceptance: August National Institute of Health and Clinical Excellence (2009) Rehabilitation after critical illness Page 73 of 89

74 INCREASE IN PHYSICAL ACTIVITY LEVELS IN INTENSIVE CARE UNIT PATIENTS USING AN EARLY AND PROGRESSIVE MOBILITY PROGRAM AND FUNCTIONALITY AFTER DISCHARGE: RANDOMIZED CONTROLLED TRIAL (POSTER DISPLAY: SUNDAY 12 NOVEMBER 10:30) Schujmann DS 1, Lunardi AC 1,3, Gomes TT 1, Lamano MZ 1, Fragoso AS 1, Peso CN 2, Fu C 1 1 Department of Physical Therapy, Communication Sciences & Disorders and Occupational Therapy. School of Medicine. University of Sao Paulo, Sao Paulo, Brazil 2 Hospital das Clínicas of School of Medicine, University of Sao Paulo. Department of Physical Therapy. Sao Paulo, Brazil 3 Master and Doctoral Programs, Universidade Cidade São Paulo, Sao Paulo, Brazil INTRODUCTION Patients in Intensive Care Unit (ICU) may experience low mobility. Studies have shown that activity for ICU patients is safe and can be beneficial. Few studies in the ICU have investigated the level of activity generated by mobilization protocols and the impact of activity level on post-discharge functionality. PURPOSE To verify if the early and progressive mobility program is able to increase the level of physical activity during the ICU period and functionality after discharge. METHODS This randomized controlled trial included ICU patients, aging over than 18 years, without neurological pathology and contraindication for mobilization. Exclusion criteria were less than 3 days in ICU and death. Patients were randomly divided into two groups. The intervention group (IG) had a progressive mobility and the control group (CG) received conventional physical therapy. The progressive mobilization program included musculoskeletal, cardiovascular and functional exercises. The program was pre-established and executed using the recent technologies and devices. Conventional therapy consisted in mobilization exercises prescribed by physiotherapist, without a pre-established program and without use of technology. We placed an accelerometer on the patient s ankle during all ICU stay. The percentage of time the patient spent in each activity intensity was determined and the functionality was assessement using a Barthel Index. RESULTS We analyzed 68 patients, 38 were from IG and 30 in CG. The patients were 57±17 years old, 53% male, Charlson INDEX 4 (0 8), SAPS III 55±14, 54% sedactive drugs, 60% were under mechanical ventilation, 58% vasoactive drugs and 48% sepsis. In the analysis of time spent in each activity level, differences were noticed in all activity levels between groups. The CG patients were inactive for longer periods during their stay when compared to the IG group (94.8±3.2 vs. 88.9±5.8; p=0.01). Patients from IG spent 9,4±5% of the time in light activity, while the CG patients spent only 3.13±0.9% in that activity level (p<0.05). There was also a difference between IG and CG as to the time spent in moderate activity level (1,45±1,3 vs. 0,3±0,2; p<0.05). Regarding the functionality at discharge, 36 patients (95%) in IG versus 16 (53%) in CG were independent (p<0,001). CONCLUSION The patients that were not submitted to the rehabilitation program were more inactive during ICU stay. The patients in the program spent more time in light and moderate activity levels. The mobilization protocol proved to be effective for the patients to be discharged from the ICU functionally independent. Page 74 of 89

75 KEYWORDS Activity level Accelerometer Intensive Care FUNDING ACKNOWLEDGEMENTS THIS WORK WAS FUNDED BY FAPESP, BRAZIL. Ethics approval: Approved by Comissão de Ética para Análise de Projetos de Pesquisa do Hospital das Clínicas da Faculdade de Medicina Da Universidade de São Paulo THIS WORK IS REGISTERED IN CLINICALTRIALS.GOV NCT Page 75 of 89

76 VIRTUAL REALITY AS MOBILIZATION IN INTENSIVE CARE UNIT: LEVEL OF ACTIVITY, FEASIBILITY AND SATISFACTION (POSTER DISPLAY: SUNDAY 12 NOVEMBER 10:30) Schujmann DS 1, Gomes TT 1,Lunardi AC 1,2, Peso CN 3,fu C 1 1 Department of Physical Therapy, Communication Sciences & Disorders and Occupational Therapy. School of Medicine. University of Sao Paulo, Sao Paulo, Brazil 2 Master and Doctoral Programs, Universidade Cidade São Paulo, Sao Paulo, Brazil 3 Hospital das Clínicas of School of Medicine, University of Sao Paulo. Department of Physical Therapy. Sao Paulo, Brazil Introduction: The patients in ICU can experience physical inactivity during this period. This can lead to changes in the muscular and cognitive systems. One new possibility as a mobilization technique in ICU is the virtual reality Nintendo Wii that is much used in different types of rehabilitation outside the hospital. Purpose: To analyze which level of activity the Nintendo Wii can provide in patients in ICU. Additionally, the other objective is analyzing the feasibility, security and patients satisfaction. Methods: This cross-sectional study including patients admitted in ICU, aging 18 years old or more, without neurological disorders and mobilization restriction. The exclusion criterion is patients that don t understand the games. We use a monitor activity to evaluate the intensity of activity. The Nintendo Wii with 2 games is been tested: a sword and a game as ping-pong. Both games last 6 minutes. The vital signs and BORG of patients are monitored in the beginning and immediately after the end of activity, and we also apply the satisfaction questionnaire. Results: 70 sessions of 40 patients was evaluated. 10 of the 70 sessions of the rehabilitation were with patients standing and 60 sitting. The population were 63.7 ± 16,2 years, SAPS III 61 ± 5,6 points. 1 patient underwent to mechanical ventilation, in 14% of the sessions patients use of vasoactive drugs, 21% of the sessions they used oxygen therapy and in 81% cateters. During the games, patients spent 59% ± 22 of time in light activity and 38% ± 21 in moderate activity. Only 2 patients out of 70 do not reach a moderate level of activity. 9 patients achieved a very intense and 4 intense activity level. Of the patients that reached these levels, 16% were in intense activity and 8% in very intense. The BORG after the end of games were 2.8 ± 0.8 points. 600% of patients prefer play videogame, 10% prefer walking and 30% prefer do all activities proposed in ICU. They graded the activity with a note of 8,8 in a scale of 0 to patient felt dizziness during the game. Patients didn t have significant alteration in vital signs and no device removal. Conclusion: Nintendo Wii can generate a pleasant physical activity in an ICU population, generating activities light to moderate intensity. This type of rehabilitation is feasibility in ICU and patients enjoyed and related that they are able to do this activity. Keywords: Early mobilization, Intensive Care Unit, virtual reality, Nintendo Wii. Funding acknowledgment: This work is funding by FAPESP, Brazil. Ethics approval: Approved by Comissão de Ética para Análise de Projetos de Pesquisa do Hospital das Clínicas da Faculdade de Medicina Da Universidade de São Paulo Page 76 of 89

77 BODY WEIGHT-SUPPORTED TREADMILL TRAINING PROMOTES VERY EARLY AMBULATION IN PATIENTS IN THE INTENSIVE CARE UNIT: A FEASIBILITY STUDY (POSTER DISPLAY: SUNDAY 12 NOVEMBER 10:30) Sommers J. 1, Wieferink D. 1, Nollet F. 1, Dongelmans D. 2, Engelbert R.H.H. 1,3, van der Schaaf M. 1,3 1: Department of Rehabilitation Medicine, Academic Medical Centre, University of Amsterdam (AMC), Amsterdam, The Netherlands; 2: Department of Intensive Care Medicine, University Hospital Amsterdam (AMC), Amsterdam, The Netherlands. 3:ACHIEVE - Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands. Introduction: Up to 65% of the Intensive Care Unit (ICU) patients develop ICU acquired muscle weakness (ICU-AW) due to inactivity and critical illness. 1 ICU- AW is strongly associated with short- and long- term physical impairments and impaired functional status. 2 It has been shown that early mobilization and ambulation of patients admitted to the ICU improve functional recovery. 3-9 However, the implementation of these interventions remains difficult within physiotherapy practice due to safety and practical issues. To illustrate, ambulation with ICU patients is difficult, because of the reduced muscle strength, as well as the limited length of infusion lines, drains and mechanical ventilation tubes. To be able to start earlier with ambulation with critically ill patients we developed a transportable body weightsupported treadmill (BWST) for the use in the ICU. Aim: In this study we explored the feasibility of Body Weight-Supported Treadmill Training (BWSTT) in ICU patients. Methods: Twenty patients of the ICU of the Academic Medical Center with muscle strength m. quadriceps MRC 2, sitting mobility, who had been on mechanical ventilation for more than 48 hours and who fulfilled the safety criteria for exercise according to the Evidence Statement for ICU Physiotherapy were enrolled in the study. 10 The BWSTT consisted of walking on a treadmill positioned at the bedside of the patient. A safety harness with a weight bearing utility supported the patients. The BWSST was stopped if the patient was fatigued or safety criteria were violated. The feasibility of the BWSTT was evaluated according to: Number of, and reasons that sessions could not be completed; (Serious) Adverse Events ((S) AE s); Number of staff needed and treatment duration; Patient satisfaction; Acceleration of the first time to ambulation Results: BWSTT was performed in twenty patients and 54 sessions. This study showed that BWSTT is feasible with patients in the ICU. There were no (S)AE s, the patients were very satisfied with the BWST, were not anxious (median/ (IQR ) of NRS 0-10: 0 (0-5)) and the needed number of staff was 2 persons with a median duration of 25 minutes treatment time. All participants should not have been able to walk or should have walked shorter distance without the BWST. Conclusion: BWSTT is feasible and safe and facilitates early ambulation with critically ill patients in the ICU. Moreover, in order to perform BWSTT less staff is necessary compared to ambulation without BWSTT. Page 77 of 89

78 A RETROSPECTIVE CASE COHORT AUDIT PROJECT EVALUATING HEALTH RELATED QUALITY OF LIFE OUTCOMES AND PREVALENCE OF POST-TRAUMATIC STRESS DISORDER IN SURVIVORS OF INTENSIVE CARE AT 6 MONTHS (PRESENTATION: SUNDAY 12 NOVEMBER 11:45) Kate Tantum Introduction Post Intensive Care Syndrome (PICS) is the collection of symptoms seen in Intensive Care Unit (ICU) survivors and their relatives. These symptoms manifest clinically in 3 main groups - cognitive impairment, physical impairment and mental-health problems. Post-Traumatic Stress Disorder (PTSD) is seen in 20% of ICU survivors. Health Related Quality of Life (HRQoL) is directly affected by PICS and PTSD (Griffiths et al 2013) and this in turn creates a burden for patients and their loved ones. The aim of the project was to analyse regional PTSD symptom prevalence, ICU related risk factors and HRQoL to support the case for an ICU follow-up service. Methods and Analysis A retrospective, observational, case-cohort audit project was run over an 18 month period. The project evaluated HRQoL in ICU survivors at 6 months using the Nottingham Health Profile (NHP). These outcomes were then linked to a PTSD screening tool (Post Traumatic Stress Score 14 (PTSS-14)). Data were also gathered from a retrospective review of clinical ICU notes. Patients with ICU stay 72 hours, 18 years old and non-uk residents after discharge were excluded. Data were analysed using descriptive and inferential statistics (Logistic regression). Results 2201 patients were treated in ICU, with 1882 surviving at discharge. Of these survivors 542 had an ICU length of stay of >72 hours and 240 responded (response rate= 45%). 33% of this respondent population screened positive for PTSD on the PTSS-14. The mean scores for the PTSD population were higher across all 6 domains of the NHP. The strongest predictor of a positive PTSS-14 score was emotional reactivity (OR=1.083) with social isolation (OR=1.02), energy level (OR=1.017) and sleep (OR=1.017) also predictive. Risk factor analysis found that age (p=0.000), length of ICU stay (p=0.001), duration of sedation (p=0.002), previous mental health problems (p=0.001) and use of benzodiazepines (p=0.001) all significantly related to PTSS-14 score. Conclusions The NHP demonstrated a positive correlation across 4 domains (emotional reactivity, sleep, energy level and social isolation). Therefore the NHP has a cross sensitivity in identifying patients with PTSD. Patients with PTSD are often resistant to engage in assessment and treatment. Potentially the cross-sensitivity for PTSD of the NHP could support PTSD assessment in this population. PTSD is a significant problem in the ICU population and negatively impacts HRQoL. Specialist post ICU services are variable and policy and clinicians need to build services to cater for the population (Parry et al 2017). Further research is needed to examine what treatments best meet this needs of this population. References Griffiths, J., Hatch, R., Bishop, J., Morgan, K., Jenkinson, C., Cuthbertson, B., and Brett, S. (2013) An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12- month follow-up study, Critical care 17(3), p Parker, A., Sricharoenchai, T., Raparla, S., Schneck, K., Bienvenu, O and Needham, D. (2015) Posttraumatic stress disorder in critical illness survivors: a metaanalysis, Critical Care Med. 43(5) p Parry, S.. Connolly, B. Baldwin, C. Puthucheary, Z. Morris, P. Mortimore, J. Hart, N. Denehy, L and Granger, C. (2017) Factors influencing physical activity and rehabilitation in survivors of critical illness: a systematic review of quantitative and qualitative studies, Intensive Care Med 43(4):p Page 78 of 89

79 REHABILITATION OF CRITICALLY ILL PATIENTS (POSTER DISPLAY: SATURDAY 11 NOVEMBER 10:30) Titova E., Appazova I., Podkorytova O., Arbolishvili G., Tsvetkov D., Lysenko M. Moscow municipal hospital 52. Introduction. There are many modern materials that early mobilization of ICU patients helps to decrease the number of ICU days and to significantly improve functional state. Nevertheless, physical therapy in ICU is not a routine practice in most hospitals and it deals with a lot of objective and subjective barriers. Aim. Organization of work of multi-disciplinary team in a municipal emergency hospital to provide early mobilization for critical patients. Method. Patients under mobilization were more than 7 days in ICU or mechanically ventilated more than 48 hours. They were patients with hemodialysis, ones with severe pneumonia, sepsis and emergency surgery. Activization criteria are the following: discontinuation of drug sedation, level of consciousness more than 8 points by SCG, decrease of vasopressor support, using SIMV or PSV. Rehabilitation consisted of physical therapy, speech therapist exercises, verticalization procedures including sitting on a bed with legs down, sitting in a chair, standing at a parapodium. The exercises started in ICU, continued up in the specialized departments to their discharging from hospital. Rehabilitation team consisted of neurologist, resuscitator, two kinesiotherapists, speech therapist and neuropsychologist. Total number of patients were 55. Three of them were on ECMO. Average data are the following: age 67.9 (range 25-87); APACHE II status 20.6 (range 11-32); hospital days 24.8 (range 9-59); ICU days 16.5 (range 6-56); ventilation days 11.2 (range 2-42). ICU-acquired weakness syndrome was detected in 30 (54.5%), patients, dysphagia was detected in 25 (45%) patients. Results. Functional state of patients was estimated by their ability to walk and by degree of independence in life. Rivermead mobility index (RMI) and Bartel index were used. Early activization of ICU patients resulted in significant increase of mobility. RMI points went from 2.26 to 5.28, it means that 28 out of 55 patients (51%) were able to walk in a short distance. 26% of patients were fully dependent on somebody s help in everyday life, 20% of patients were strongly dependent and 54% of patients were partially dependent. The latter ones were able to walk a short distance, to perform simple everyday tasks such as eating and hygienic procedures. But some surveillance and support from another person was needed. 14 patients (56%) fully recovered their ability to swallow. Conclusion. Early activization in ICU and continuation of exercises after discharge from ICU improves mobility of critical patients (APACHE II 20.6) and makes them more independent in everyday life. Page 79 of 89

80 THE INTRODUCTION OF A PHYSIOTHERAPY ASSOCIATE PRACTITIONER ROLE ON CRITICAL CARE: AN INNOVATIVE SERVICE REORGANISATION TO ENHANCE DELIVERY OF SEVEN DAY SERVICES AND IMPROVE EFFICIENCY AND QUALITY OF CARE (POSTER DISPLAY: SATURDAY 11 NOVEMBER 10:30) Clare Wade, Helen Sanger, Catherine Baker. Introduction Rehabilitation after Critical Illness (RaCI) and Enhanced Recovery after Surgery (ERAS) have been areas of increasing focus in acute care over the last decade. Physiotherapy is integral to the delivery of both these pathways. Historical physiotherapy staffing on ICU did not allow the current team to optimise the delivery of post-operative enhanced mobilisation, or to deliver adequate follow-up care for long term ICU patients. To address these insufficiencies, we developed a non-qualified Physiotherapy Associate Practitioner (PAP) role within ICU to carry a caseload of elective surgical patients. This increased the mobilisation of ERAS patients, and also released a physiotherapist with specialist critical care skills and knowledge to coordinate a multi-disciplinary RaCI service. Aim Improve outcomes and recovery pathway for surgical patients. Dedicate more therapeutic time to patients with complex needs. Provide a more consistent physiotherapy service on the ICU, seven days a week. Develop a multidisciplinary team (MDT) RaCI service, consisting of weekly outreach rounds and monthly outpatient clinic. Method 1.8 WTE Band 4 PAPs were recruited on a pilot basis. This enabled ERAS over seven days, and facilitated the release of specialist physiotherapy time for RaCI service delivery. A competency framework and training package was developed to ensure the PAPs were able to meet the specifications of the role. Functional mobility outcome scores at discharge from ICU, and weekend productivity statistics were collected for six months. These were compared with data from the 6 months prior to the pilot commencing. The senior physiotherapist coordinated a MDT RaCI pathway, as per NICE CG83. This included involvement in each RaCI patient s rehabilitation on ICU, ward-based follow-up and subsequent outpatient review. Data throughout the first six months of RaCI service delivery was collected and analysed. Page 80 of 89

81 Results Before pilot At 6 months Difference Average no. of surgical patient reviews per weekend Average ICU LOS for surgical patients (hours) ICU capacity (admissions) Average functional score (out of 40) at discharge from ICU NICE CG83 0% >90% >90% compliance Long stay ICU patients followed up on ward Long stay ICU patients attending MDT outpatient follow up Results of six month service improvement pilot. Conclusion We have described an innovative service change within the ICU physiotherapy team. This has allowed implementation of an enhanced mobility service 7 days a week, a key component of an ERAS pathway. It has also facilitated the development of a RaCI service, to address the complex needs of long-term ICU patients. The recruitment of PAPs represents a relatively small financial investment, but one that has facilitated a restructure the physiotherapy team, allowing optimisation of resource allocation to different ICU patient groups. Given the current financial constraints on NHS services, this project represents a unique and practical approach to achieving NHS England s recommendation for safe, sustainable staffing with the right staff, with the right skills, in the right place, at the right time (National Quality Board 2016). Page 81 of 89

82 THE SCOPE OF EARLY MOBILISATION: A LARGE GENERAL INTENSIVE CARE UNIT S EXPERIENCE OF DELIVERING EARLY MOBILISATION, IN PICTURES (POSTER DISPLAY: SUNDAY 12 NOVEMBER 10:30) Watts M, Tovey B, Van Willigen Z, Collings N, Richardson, D Cusack, R. The scope of early mobilisation: A large general intensive care unit s experience of delivering early mobilisation, in pictures. Introduction Many patients survive critical illness but suffer considerable physical and psychological morbidity (1) Early therapy input can reduce length of ICU stay and improve outcomes. (2). In 2012 we developed a novel model of care using non-qualified therapy assistants to deliver early rehabilitation to critically ill intubated patients. Aim We present a pictorial review together with updated results of our previously published data (3). Our aim is to promote early rehabilitation within an acute setting, demonstrating that early mobilisation is feasible and safe within an ICU. Method Medical patients requiring mechanical ventilation for longer than 24 hours, with a preceding hospital stay of less than one week were selected. An early mobilisation project (EMP) was started within 72 hours of intensive care admission. Patients followed a structured programme, promoting both physical and functional activities, particularly focussing on mobilising patients out of bed. Activities were selected using patient centred goals which optimised compliance with therapy. Results 767 patients have been enrolled on the EMP to date. Annual three-month cohort data was analysed and compared to a baseline group. These results have shown that mean critical care length of stay reduced from 20.8 (+/- 15.5) days in 2012 to 12.3 (+/- 7.8) days in In addition, hospital length of stay reduced from 45.4 (+/- 50.4) to 25.2 (+/- 16.1) days. Patient ventilator days reduced from 15.8 (+/- 14.6) to 7.7 (+/- 7.1). Patients also mobilised earlier; the EMP cohort mobilised 4.5 (+/- 3.0) days after admission, compared to 16.3 (+/- 10.9) in the baseline group. Illness severity and ventilator parameters were similar between the 2 groups. Patient and family member feedback has been universally positive. In addition only two adverse events have been recorded in the five years that the project has been running and neither of these incidents have had a negative impact on patient outcome. Page 82 of 89

83 Conclusion Our results have demonstrated that early mobilisation and physical rehabilitation of a critically ill cohort is feasible and safe. They also show that early physical intervention has a positive effect on patient outcomes by reducing critical care and hospital length of stay. References 1. Herridge MS, Tansey CM, Matt A et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med 2011; 364: Schweickert WD, Pohlman M, Pohlman A, Nigos C, Pawlik A, Esbrook C. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373: Van Willigen et al. (2016) Quality improvement: the delivery of true early mobilisation in an intensive care unit. BMJ Quality Improvement Reports, 5. Page 83 of 89

84 THANK YOU TO OUR SPONSORS ArjoHuntleigh is a world-leading provider of integrated products and solutions that improve the lives of patients and residents with reduced mobility. We help healthcare facilities deliver wellness and effective everyday care, early mobilisation, safe patient handling, venous thromboembolism prevention, pressure injury prevention, personal hygiene, bariatric care and diagnostics. With extensive knowledge and experience, we strive to improve efficiency and ensure a safer and dignified environment for caregivers and their patients. We are delighted to support the 5th European Conference on Weaning and Rehabilitation in Critically Ill Patients and invite you to talk to us during the conference to learn how Sara Combilizer is helping caregivers to mobilise sicker ICU patients earlier in their hospital stay. For further information please visit Page 84 of 89

85 Established over 20 years ago, Medimotion Limited has built a strong reputation as provider of high quality therapy equipment to the NHS, therapy centres, private organisations and home users throughout Great Britain. Medimotion is the sole GB distributor for Reck MOTOmed MovementTherapySystems. Passive/ active exercise machines of particular value to neurological and neuromuscular diseases such as multiple sclerosis, stroke, paraplegia, Parkinson's disease, muscle diseases and many other heath issues resulting in limited mobility. The MOTOmed LETTO and VIVA2 units are used throughout the UK in ICU/ Critical Care and dialysis units and have been proven to cut hospital stay times and for patients to leave ICU with improved functional scores and greater independence. Enabling better health and better care at lower cost Philips is a leading health technology company focused on improving people s lives across the health continuum from healthy living and prevention, to diagnosis, treatment and home care. Applying advanced technologies and deep clinical and consumer insights, Philips delivers integrated solutions that improve people s health and enable better outcomes. Partnering with its customers, Philips seeks to transform how healthcare is delivered and experienced. The company is a leader in diagnostic imaging, image-guided therapy, patient monitoring and health informatics, as well as in consumer health and home care. Page 85 of 89

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