Critical Care Assessment

Original Editor - Justin Bryan Top Contributors - Justin Bryan, Rachael Lowe, Karen Wilson and Adam Vallely Farrell

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (24/01/2023

Introduction

Assessing critically ill patients as a physical therapist is a unique undertaking given the wide spectrum of patients that one may be asked to treating in this setting. At a basic level, many of the major components of a PT acute care assessment will remain the same. However, the unique nature and condition of many of the patients in the critical care setting often warrant approaches that differ from the more general acute care population.

Below we will address some of the components of the PT assessment as they pertain to the critically ill. Given that patients in this population often present and respond to intervention and assessment differently than patients in other populations, there are certain assessment components that may need to be completed additionally, or approached in a different fashion.

What makes a patient critically ill?

Critical care is an area of medicine that focuses on the management and treatment of patients who are deemed to have a condition that is immediately life-threatening or possesses the risk of becoming life-threatening. These patients are generally cared for in a dedicated intensive care unit (ICU) or ward where specific monitoring of physiology and organ function is possible at a level above that of other units or wards in a hospital. Staffing in ICUs is generally provided at a lower patient to provider ratio (i.e. 1:1). There is a greater emphasis on multidisciplinary care in ICUs, encompassing individuals from many different backgrounds, and coordinated under a physician with a specialty in critical care medicine. Goals of care often focus on prevention of acute complications, early detection of distress or condition advancement, and immediate response to evolving situations.

History, Systems Review, and Review of Systems

A good physical therapy evaluation should always begin with a thorough review of patient history, and an examination of the patient's overall body and system functions. More information on these aspects of of PT assessment can be found on the following page: Physiotherapy Assessment of Patients in the ICU.

Physical Therapy Goals and Early Mobility

One of the major goals of physical therapy in the critically ill population is to address aspects including ICU acquired deficits through the promotion of early mobilization. Information specifically addressing the assessment of critically ill patient being considered for early mobilization can be found on the following page: Early Mobility Assessment for Critically Ill Patients.

Assessing Alertness and Cognition

Assessing a patient's cognitive status is an aspect of considerable importance when treating critically ill patients. Cognitive status is crucial in not only determining if a patient can safely participate in therapy, but also whether they are experiencing ICU Acquired Delirium. Delirium is common in critically ill patients and can result from factors such as medication or sedation and pain control. ICU acquired delirium is of key concern for this patient population as its development has been associated with reduced cognitive function in the long term following recovery.

Assessing Orientation: A simple method of quickly assessing a patient cognitive status is by assessing their orientation at the time of treatment or initial assessment. This can be accomplished by asking the patient a series of standard person, place, time, and situation questions. A patient's level of orientation can convey a lot about their cognitive status, as well as the potential presence of delirium.

Richmond Agitation-Sedation Scale (RASS): RASS is a measure used to reflect a patient's level of alertness, which can provide insight as to the patient's appropriateness for therapy. A RASS score of -1 or greater is sometimes used as an indication that a patient possesses the required level of alertness for participation in therapy. However, consideration should be given to the guidelines set forth by individual facilities (if available) and the general confidence of the treating therapist and other staff participating in a therapy session.

Delirium

Multiple scales have been developed to measures, assess, and track delirium in ICU patients. Below are several tools that are useful for physical therapists in the ICU to understand.

Confusion Assessment Method for ICU (CAM-ICU): The CAM-ICU identifies the presence of delirium in mechanically ventilated patients using non-verbal means. To determine the presence of delirium, patients must exhibit certain behaviors which include:

• An acute change or fluctuation in mental status
• Inattention to auditory or visual stimulus
• Disorganized thinking
• Altered level of consciousness

Delirium Observation Screening Scale (DOSS): DOSS is a 25 item scale designed for early detection of delirium which can be completed by nursing staff during normal patients care. Daily completion of this assessment is achieved by administering the test during three different nursing shifts, with the daily score recorded as the average of the three individual shift scores (each measured on 0-13 scale). An score of >3/13 is an indication of the presence of delirium.

Assessing Pain

As with most patient in the acute care setting, pain can be a significant barrier, as well as a factor that needs to be addressed during a physical therapy assessment. If a patient possesses the given cognition and communication abilities, pain should be assessed using a standard self report tool such as a Numeric Pain Rating Scale or Visual Analog Scale. However, many ICU patients are not appropriate for these scale due to factors such as sedation or mechanical ventilation. In these instances several objective measures of pain have be found to be valid and effective for critically ill patients.

Critical Care Pain Observation Tool (CPOT): CPOT is an 8 point measure that utilizes 4 basic behaviors (facial expressions, body movement, muscle tension, and ventilator compliance (intubated)/vocalizations (extubated)) to assess a patients level of pain.

Behavioral Pain Scale (BPS): The BPS is a scale intended for use in patient undergoing mechanical ventilation. The BPS is a 12 point scale the uses 3 basic behaviors (facial expression, upper extremity movement, and ventilator compliance) to assess pain.

Assessing Muscular Strength

Assessing a patient's strength is a component of the physical therapy assessment that is not only crucial for assessing function, but also for determining the presence of ICU Acquired Weakness. Several measures can be utilized for this purpose in the critically ill population. It should be noted that a adequate level of cognition and alertness is required for patients to properly participate in these measures.

Medical Research Council (MRC) Scale: MRC scale is a strength scale that has been developed and validated in critically ill patients and can be utilized to assess/track the presence of ICU acquired weakness. Standard procedure for the MRC scale involves bilateral assessment of six motions:

• UE abduction
• Forearm flexion
• Wrist extension
• Hip Flexion
• Knee extension
• Ankle dorsiflexion.

Scoring of the MRC scale utilizes a 5 point scale for the Classic MRC, and a 3 point scale for the Simplified MRC, assessed for each motion to give an overall score out of 60 points or 36 point, respectively.

Cutoff score for ICU acquired weakness is <48/60 for the Classic MRC scale.

Handheld Dynamometry: Grip strength can also be used to assess strength, but more specifically, it is useful as a measure for determining the presence of ICU acquired weakness. A cutoff score of less than 11 Kg for men and 7 Kg for women indicates the presence of ICU acquired weakness.

Assessing a Patient's Mobility Level

Early mobility in this ICU is a practice that is becoming more accepted as an integral part of care. Given this, it is important to assess mobility in a way that accurately reflects a patient's ability given the multitude of additional factors that effects an ICU patient's ability when compared to patients in the general acute care population.

The PERME ICU Mobility Scale is a measure developed specifically for the ICU population that assesses a patient's ability utilizing 15 items across 7 categories. The score rendered from completion of this scale provides a measures of the patient's mobility, as well as well as the presence of potential barriers to mobility. A higher score indicated fewer barriers and greater mobility, and a lower score indicated more barriers and reduced mobility. Categories addressed include cognitive status, mobility barriers, functional strength, bed mobility, endurance, gait, and transfers.

Considerations for Mechanically Ventilated Patients

Traditionally, mechanically ventilated patients were not often mobilized, kept under heavy sedation or paralysis as it was believed that this was the safest option.  However, much research and expert experience now supports the safety, effectiveness, and even necessity of mobilizing such patients. In 2014, an expert consensus was released which addressed recommendations and considerations to allow mechanically ventilated patients to be mobilized while maximizing safety and minimizing adverse responses.

One of the first considerations that should be made when mobilizing mechanically ventilated patients (whether for assessment or treatment) is that the safety of the patient is of the utmost concern.  Any guidelines used to decide if a patient can be mobilized should be treated as just that, guidelines.  Decisions regarding mobilization should be made in a multidisciplinary fashion, with input from all members of a patient's care team being considered.  The final decision and ultimate responsibility for the patent should then fall on the clinician (i.e. PT) who will be performing the treatment.

Below are a some of the key points outline by the 2014 consensus statement.  It is important to note that this is a summary, not an exhaustive list, and as such the reader is encouraged to view the full consensus statement here: Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults.

• Prior to mobilization, the responsible/appropriate personnel (generally defined by facility policy) should check that any artificial airways are placed properly and secured adequately for the planned activity

• For patients requiring supplemental oxygen, an adequate supply should be available to persist for the expected activity duration with access to a reserve supply pre-planned in the event of delay

• Use of an endotracheal tube is not an immediate contraindication, but if one is present, the patient should require an FiO2 of <0.6 with no other contraindication present for mobilization to be considered low risk.  If required FiO2 is >0.6, risk is heightened and discussion with interdisciplinary team should take place to clarify precautions and weight risks vs. benefits of activity.

• Caution should always be taken mobilizing patients on vasoactive drugs with consideration being given to the dosage and any recent changes in dosage with respect to how this may impact patient safety during activity

• Richmond Agitation Sedation Scale between -1 and +1 is considered low risk during mobilization

• A percutaneous oxygen saturation of <90% presents a high risk of adverse effects during out-of-bed activity, thus mobilization should not take place unless it is approved by a senior ICU specialist in conjunction the treating therapist.  In-bed activity is considered safer, but a discussion with the interdisciplinary team should still take place to clarify precautions and weight risks vs. benefits of activity

• A safe and appropriate range for Mean Arterial Pressure should be determine by the interdisciplinary team prior to mobilization to allow decisions to be made regarding safety and appropriateness of activity

• Patients with bradycardia that is being treated pharmacologically or with a planned pacemaker insertion are at high risk for adverse effects during both in-bed and out-of-bed activity and thus mobilization should not take place unless it is approved by a senior ICU specialist in conjunction the treating therapist.

• Patients with tachyarrythmias resulting in a ventricular rate >150 bpm are at high risk for adverse effects during out-of-bed activity and thus these patients should not be mobilized unless it is approved by a senior ICU specialist in conjunction the treating therapist

• Patients undergoing active management of intracranial hypertension are at high risk for adverse effects during both in-bed and out-of-bed activity and thus these patients should not be mobilized unless it is approved by a senior ICU specialist in conjunction the treating therapist