Introduction: Mobilisation of patients in the intensive care unit (ICU) is an area of growing research. Currently, there is little data on baseline mobilisation practises and the barriers to them for patients of all admission diagnoses. Methods: The objectives of the study were to (1) quantify and benchmark baseline levels of mobilisation in Australian and Scottish ICUs, (2) compare mobilisation practises between Australian and Scottish ICUs and (3) identify barriers to mobilisation in Australian and Scottish ICUs. We conducted a prospective, observational, cohort study with a 4-week inception period. Patients were censored for follow-up upon ICU discharge or after 28 days, whichever occurred first. Patients were included if they were >18 years of age, admitted to an ICU and received mechanical ventilation in the ICU. Results: Ten tertiary ICUs in Australia and nine in Scotland participated in the study. The Australian cohort had a large proportion of patients admitted for cardiothoracic surgery (43.3 %), whereas the Scottish cohort had none. Therefore, comparison analysis was done after exclusion of patients admitted for cardiothoracic surgery. In total, 60.2 % of the 347 patients across 10 Australian ICUs and 40.1 % of the 167 patients across 9 Scottish ICUs mobilised during their ICU stay (p < 0.001). Patients in the Australian cohort were more likely to mobilise than patients in the Scottish cohort (hazard ratio 1.83, 95 % confidence interval 1.38–2.42). However, the percentage of episodes of mobilisation where patients were receiving mechanical ventilation was higher in the Scottish cohort (41.1 % vs 16.3 %, p < 0.001). Sedation was the most commonly reported barrier to mobilisation in both the Australian and Scottish cohorts. Physiological instability and the presence of an endotracheal tube were also frequently reported barriers. Conclusions: This is the first study to benchmark baseline practise of early mobilisation internationally, and it demonstrates variation in early mobilisation practises between Australia and Scotland.

Novice students may have limited learning opportunities during their early exposure to complex clinical environments, due to the priorities of patient care. Immersive, high-fidelity simulation provides an opportunity for physiotherapy students to be exposed to relatively complex scenarios in a safe learning environment before transitioning to the clinical setting. The present study evaluated the influence of immersive simulation on student confidence and competence. Sixty penultimate year physiotherapy students completed an 18-day full-time immersive simulation placement. The placement involved students spending 6 days working in each of three core practice areas (cardiopulmonary, musculoskeletal, neurological) in which they interacted with simulated patients portrayed by professional role-play actors. The patient scenarios were developed by groups of expert practitioners and incorporated full documentary and imaging information. Students completed a questionnaire to evaluate their confidence in the clinical environment at the start and completion of each 6-day rotation. Their clinical competence was evaluated at the end of each 6-day rotation using the Assessment of Physiotherapy Practice (APP) tool. In a secondary analysis, the clinical competence of this cohort was evaluated in comparison to a matched cohort of students from the same year group that had not completed an immersive simulation placement. Student confidence improved significantly in each 6-day rotation (p < 0.001); however, it reduced again at the commencement of the next rotation, and there was no cumulative improvement in confidence over the 18-day placement (p = 0.22). Students who had completed the immersive simulation placement achieved higher APP (p < 0.001) scores in an evaluation of their competence to practice during their subsequent clinical placement. Immersive simulation provides a beneficial learning environment to enable physiotherapy students to transition from university-based education to working in the clinical environment.

Objectives: Early mobilization is recommended by the Society of Critical Care Medicine ICU Liberation Bundle. The Treatment of Mechanically Ventilated Adults With Early Activity and Mobilization (TEAM) randomized controlled trial (RCT) compared early active mobilization to usual care mobilization and found no difference in the primary outcome of days alive and out of hospital to day 180; however, it did find an increase in adverse events in the intervention group. To date, no RCT of early mobilization has reported costs or cost-effectiveness. We aimed to determine the cost-effectiveness of early active mobilization from the perspective of the healthcare sector. Design: We conducted a prospective, within-trial cost-effectiveness analysis alongside the TEAM study. Setting: Forty-nine ICUs in six countries (Australia, New Zealand, United Kingdom, Ireland, Germany, and Brazil). Patients: The cost-effectiveness analysis included 733 adult ICU patients who were undergoing invasive mechanical ventilation and enrolled in the TEAM study. Interventions: Early active mobilization or usual care mobilization Measurements and Main Results: A significantly higher number of hours were spent by staff in delivering high-dose early active mobilization vs. usual care mobilization; however, incremental costs were not significantly different between the groups ($1,823; 95% CI, –$10,552 to $12,027). EuroQoL-5D 5-level utility scores at 6 months were not significantly different between the groups (0.532 [se, 0.021] vs. 0.548 [se, 0.021]; p = 0.585). The probability of early active mobilization being cost-effective is less than 50%, even at a willingness-to-pay threshold of $200,000/quality-adjusted life year (QALY). Sensitivity analyses incorporating meta-analysis data indicated that early active mobilization may be cost-saving; however, this involves the occurrence of lower QALY gains when compared with usual care mobilization. Conclusions: Our trial-based analysis found no evidence that higher-dose early active mobilization is a cost-effective intervention compared with usual care mobilization for mechanically ventilated adult ICU patients; however, results from sensitivity analyses provided some evidence that it may be cost saving if one is willing to accept poorer outcomes. Further research is necessary to determine whether there are scenarios in which early active mobilization provides value for money.

The Treatment of Mechanically Ventilated Adults with Early Activity and Mobilisation (TEAM) trial reported a higher occurrence of adverse events with greater mobilisation. However, their timing and nature remained unexplored. We conducted an in-depth exploration of such events. The purpose of this paper is to thoroughly examine the timing and characteristics of adverse events reported within the TEAM trial. Adverse event data were collected daily in real time. Categorical data were compared using the Fisher's exact test. The relationship between adverse events and patient survival was analysed using a Cox-regression frailty model. Overall, 37 out of 371 patients (10.0%) in the early mobilisation group and 16 out of 370 patients (4.3%) in the usual care group experienced adverse events, with 71 events in the early mobilisation group compared to 24 events in the usual care group. The most common adverse events were altered blood pressure in 21 out of 53 patients (39.6%), arrhythmia in 17 out of 53 patients (32.1%), and oxygen desaturation in nine of 53 patients (17.0%). Patients with an adverse event were more likely to have congestive heart failure (absolute percentage difference: 16.1, 95% confidence interval [CI]: 6.1 to 26.1), peripheral vascular disease (absolute percentage difference: 6.4, 95% CI: 1.3 to 11.5), heart attack (absolute percentage difference: 13.5, 95% CI: 5.9 to 21.1), or stroke (absolute percentage difference: 9.3, 95% CI: 3.5 to 15.1). Adverse events occurred at a median of 4 days with early mobilisation and 7 days with usual care. There was no significant difference in survival for patients who experienced an adverse event compared to those without an adverse event. Adverse events were more common in patients randomised to early active mobilisation, were cardiovascular and respiratory in nature, tended to occur earlier with active mobilisation, and cardiovascular comorbidities were more common in such patients. This information can help guide future studies in this field. TEAM ClinicalTrials.gov number, NCT03133377, registered 28 April 2017.