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Critical Care Assessment

Original Editor - Justin Bryan Top Contributors - Justin Bryan, Romy Hageman, Rachael Lowe, Karen Wilson, Saud Alghamdi, Adam Vallely Farrell and Ewa Jaraczewska

Introduction

Physiotherapy for critically ill patients presents unique challenges due to the severity of their conditions. While many elements of an acute care assessment remain consistent, the specific needs of critically ill patients often require adapted or additional approaches, making this setting particularly complex.

Below we will address some of the components of the physiotherapy assessment as they pertain to the critically ill population. Given that patients in this setting often present and respond to intervention and assessment differently than patients in other settings, 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 either immediately life-threatening or presents the risk of becoming life-threatening. [1] 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 also 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.[2]

Patients in ICUs often suffer from conditions like sepsis, acute respiratory distress syndrome (ARDS), traumatic injuries, or multiple organ failure. Post-surgical patients who are at high risk for complications, as well as individuals with chronic conditions like heart failure or COPD, may also require intensive care if their condition worsens.

History, Systems Review, and Review of Systems

A comprehensive physiotherapy evaluation should always begin with a thorough review of the patient's (medical) history, followed by an examination of the patient's overall body and system functions. In the critical care setting, understanding the patient's medical background and any current organ system involvement is vital, as ICU patients often present with complex, multi-system issues. This review helps identify the primary problems and ensures that the therapeutic approach is safe and tailored to the patient's needs. More information on these aspects of physiotherapy assessment can be found on the following page: Physiotherapy Assessment of Patients in the ICU.

Physiotherapy Goals and Early Mobilisation

One of the main goals of physiotherapy in critically ill patients is to promote early mobility. Further information about Early Mobility Assessment for Critically Ill Patients can be found on this page.

Assessing Alertness and Cognition

Cognitive assessment is crucial when treating critically ill patients, as it determines not only their ability to safely participate in therapy but also the presence of ICU-acquired delirium. ICU acquired delirium has been shown to affect as much as 80% of mechanically ventilated patients in the ICU. [3]ICU delirium is particularly concerning due to its association with long-term cognitive decline post-recovery[4].

Assessing Orientation: A simple yet effective method to assess cognitive function is by determining a patient's orientation at the time of treatment or initial assessment. This can be accomplished by asking the patient a series of standard questions:

  • Person - "Can you tell me your name and date of birth?"
  • Place - "Can you tell me where you are right now?" or "Can you tell me what city we are in?" or "What is the name of this hospital?"
  • Time/date - "Can you tell me today's date?" or "What day of the week is it?" or "What year is it?"
  • Situation - "Can you tell me what brought you to the hospital?" or "What surgery did you have?"

A patient's level of orientation can convey a lot about their cognitive status, as well as the potential presence of delirium.[5]

Richmond Agitation-Sedation Scale (RASS): The RASS is commonly used to measure a patient's level of alertness and their suitability for therapy[6]. This scale is typically assessed by a physician or nursing staff and should be available to the therapist before treatment. A RASS score between -1 and +1 generally indicates that a patient is alert enough to participate in therapy with minimal risk of adverse effects. However, it is essential to consider the specific guidelines of the facility and the collective judgment of the healthcare team involved in the patient's care[7][8].

Delirium

Multiple scales have been developed to measure, assess, and monitor delirium in ICU patients. Two commonly used scales are:

  • Confusion Assessment Method for ICU (CAM-ICU): The CAM-ICU identifies the presence of delirium in mechanically ventilated patients using non-verbal means[9]. To determine the presence of delirium, patients must exhibit certain behaviors which include:[10]
    • An acute change or fluctuation in mental status
    • Inattention to auditory or visual stimulus
    • Disorganized thinking
    • Altered level of consciousness

[11]

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 patient care[12]. 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). A score of >3/13 is an indication of the presence of delirium[10].

Assessing Pain

As with most patient in the acute care setting, pain can present a significant barrier, and must be addressed during a physiotherapy assessment. At least half of these patients would have moderate to severe pain at rest[13]. Pain can trigger stress responses that could significantly impact critical illness (tachycardia, polypnea, increased oxygen consumption), and it may also lead to long-term psychological stress[14]. When a patient has the necessary cognitive and communication abilities, pain should be assessed using standard self-report tools like the Numeric Pain Rating Scale or Visual Analogue Scale[15]. However, many ICU patients may not be suitable for these scales due to factors such as sedation or mechanical ventilation[15]. In such cases, several objective measures of pain have been shown to be valid and effective for critically ill patients.[16] Proper assessment and management of pain in the ICU have been linked to better patient outcomes, including fewer days on mechanical ventilation, shorter ICU stays, and lower rates of delirium and mortality[17][18]. Effective pain relief can also lead to reduced sedation use[19], which may help decrease delirium and its long-term negative effects[20].

Critical Care Pain Observation Tool (CPOT): CPOT is an 8 point measure that utilizes 4 basic behaviors (facial expression, body movement, muscle tension, and ventilator compliance (intubated patients) or vocalizations (extubated patients) to provide an assessment of pain.[16]

[21]

Behavioral Pain Scale (BPS): The BPS is a scale intended for use in patient receiving 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.[16]

Assessing Muscular Strength

Assessing a patient's strength is a component of the physiotherapy 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 an adequate level of cognition and alertness is required for patients to properly participate in these measures.[22]

Medical Research Council Sum Score (MRC-SS) or Oxford Scale: The MRC-SS is a tool that has been developed and validated in critically ill patients and can be utilized to assess/track the presence of ICU Acquired Weakness[23]. Standard procedure for the MRC-SS involves bilateral assessment of six motions:

Scoring of the MRC-SS utilizes a 5 point scale for the Classic MRC method, and a 3 point scale for the Simplified MRC method, 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 scoring method.[22]

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.[22]

Assessing a Patient's Mobility Level

Early mobility in the 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 ability in light of the multitude of additional factors effecting a critically ill patient compared to a patient in the general acute care population.

The PERME ICU Mobility Scale is a measure developed specifically for the critically ill population that assesses a patient's ability utilizing 15 items, across 7 categories. The score rendered from completion of this scale provides a measure of a patient's mobility, as well as the presence of potential barriers[24]. A higher score indicated fewer barriers and greater mobility, while a lower score indicated more barriers and reduced mobility. Categories addressed include cognitive status, mobility barriers, functional strength, bed mobility, endurance, gait, and transfers.[25]

[26]

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 if they are deemed appropriate for such intervention. 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.[8]

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.[8]

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.[8]

  • 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 last 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 the interdisciplinary team should take place to clarify precautions and weight risks vs. benefits of mobilizing the patient
  • Caution should always be taken when mobilizing patients on vasoactive drugs (i.e. vasopressin, epinephrine, etc) with consideration given to the dosage and any recent changes in dosage, and the impacts this may have on patient safety given the proposed activity
  • Richmond Agitation-Sedation Scale (RASS) between -1 and +1 is considered low risk for mobilization
  • Patient exhibiting a percutaneous oxygen saturation (SpO2) of <90% present with high risk of adverse effects during out-of-bed activity, thus this type of mobilization should not take place unless it is approved by a senior ICU specialist in conjunction with the treating therapist.  In-bed activity is considered safer than out-of-bed activity under these circumstances, but not low risk. A discussion with the interdisciplinary team should still take place to clarify precautions and weight risks vs. benefits of proposed 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 proposed activity
  • Patients with bradycardia who are 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 neither type of mobilization should not take place unless it is approved by a senior ICU specialist in conjunction with 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 undergo this type of mobilization unless it is approved by a senior ICU specialist in conjunction with the treating therapist. In-bed activity is considered safer than out-of-bed activity under these circumstances, but not low risk. A discussion with the interdisciplinary team should still take place to clarify precautions and weight risks vs. benefits of proposed activity
  • 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 neither type of mobilization should take place unless it is approved by a senior ICU specialist in conjunction with the treating therapist

References

  1. ↑ Kayambankadzanja RK, Schell CO, Gerdin Wärnberg M. Towards definitions of critical illness and critical care using concept analysis. BMJ Open. 2022; 12: e060972
  2. ↑ Jackson M, Cairns T. Care of the critically ill patient. Surgery (Oxf) 2021; 39(1):29-36
  3. ↑ Ali M, Cascella M. ICU delirium [Internet]. StatPearls - NCBI Bookshelf. 2024.
  4. ↑ Pandharipande PP, Girard TD, Jackson JC, Morandi A, Thompson JL, Pun BT, et al. Long-term cognitive impairment after critical illness. N Engl J Med 2013; 369(14):1306-16.
  5. ↑ Fruth SJ. Fundamentals of the Physical Therapy Examination: Patient Interview and Test & Measures. 2nd Ed. Burlington: Jones & Bartlett Learning, 2018.
  6. ↑ Bush SH, Bronicki K, Dionne M, Lelievre N, Lawlor PG, Kabir M. Implementation of the Richmond Agitation-Sedation Scale (palliative version) on an inpatient palliative care unit. BMC Palliative Care. 2023; 22(171)
  7. ↑ Green M, Marzano V, Leditschke IA, Mitchell I, Bissett B. Mobilization of intensive care patients: a multidisciplinary practical guide for clinicians. J Multidiscip Healthc 2016; 25(9): 247-56.
  8. ↑ 8.0 8.1 8.2 8.3 Hodgson CL, Stiller K, Needham DM, Tipping CJ, Harrold M, Baldwin CE, et al. Expert consensus and recommendations on safety criteria for active mobilization of mechanically ventilated critically ill adults. Crit Care 2014; 18: 658.
  9. ↑ Miranda F, Gonzalez F, Plana MN, Zamora J, Quinn TJ, Seron P. Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) for the diagnosis of delirium in adults in critical care settings. Cochrane Database Systematic Review. 2023; 11(11): CD013126
  10. ↑ 10.0 10.1 Grover S, Kate N. Assessment scales for delirium: A review. World J Psychiatry 2012; 2(4): 58-70.
  11. ↑ Critical Care Nursing 101. Confusion Assessment Method (CAM-ICU). Available from https://www.youtube.com/watch?v=slCX_6iV0fg [last accessed 10/19/2017
  12. ↑ Park J, Jeong E, Lee J. The Delirium Observation Screening Scale: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy. Clinical Nursing Research. 2020; 30(4): 464-473
  13. ↑ Damico V, Macchi G, Murano L, Forastieri MA. Incidence of pain at rest and during nursing procedures in ICU patients: a longitudinal observational study. Annali di igiene: medicina preventiva e di comunita. 2020; 32(4): 407-418
  14. ↑ Devlin JW, Strobik Y, Gelinas C, Needham DM, Slooter AJC, Pandharipande PP, Watson PL, Weinhouse GL, Nunnally ME, Rochwerg B, Balas MC, van den Boogaard M, Bosma KJ, Brummel NE, Chanques G, Denehy L, Drouot X, Fraser GL, Harris JE, Joffe AM, Kho ME, Kress JP, Lanphere JA, McKinley S, Neufeld KJ, Pisani MA, Payen JF, Pun BT, Puntillo KA, Riker RR, Robinson BRH, Shehabi Y, Szumita PM, Winkelman C, Centofanti JE, Price C, Nikayin S, Misak CJ, Flood PD, Kiedrowski K, Alhazzani W. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine. 2018; 46: e825-e873
  15. ↑ 15.0 15.1 Chanques G, Gélinas C. Monitoring pain in the intensive care unit (ICU). Intensive Care Medicine. 2022; 48: 1508-1511
  16. ↑ 16.0 16.1 16.2 Kotfis K, Zegan-Barańska M, Szydłowski Ł, Żukowski M, Ely EW. Methods of pain assessment in adult intensive care unit patients - Polish version of the CPOT (Critical Care Pain Observation Tool) and BPS (Behavioral Pain Scale). Anaesthesiol Intensive Ther 2017; 49(1): 66-72.
  17. ↑ Devlin JW, Skrobik Y, Gelinas C. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine. 2028; 46(9): e825-e873
  18. ↑ Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BRH, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Skrobik Y, Jaeschke R. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine. 2013; 41(1): 263-306
  19. ↑ Gelinas C, Arbour C, Michaud C, Vaillant F, Desjardins S. Implementation of the critical-care pain observation tool on pain assessment/management nursing practices in an intensive care unit with non-verbal critically ill adults: a before and after study. 2011; 48(12): 1495-1504
  20. ↑ Nordness MF, Hayhurst CJ, Pandharipande P. Current Perspectives on the Assessment and Management of Pain in the Intensive Care Unit. Journal of Pain Research. 2021; 14: 1733-1744
  21. ↑ Lynnne. CPOT VIDEO Tool. Available from: https://www.youtube.com/watch?v=H3CBTLHnhmw [last accessed 5/14/2021
  22. ↑ 22.0 22.1 22.2 Latronico N, Gosselink R. A guided approach to diagnose severe muscle weakness in the intensive care unit. Rev Bras Ter Intensiva 2015; 7(3): 199-201.
  23. ↑ Tavares GZ, Oliveira CC, Mendes LPS, Velloso M. Muscle strength and mobility of individuals with COVID-19 compared with non-COVID-19 in intensive care. Heart & Lung. 2023; 62: 233-239
  24. ↑ Wilches Luna EC, Perme C, Gastaldi AC. Relationship between potential barriers to early mobilization in adult patients during intensive care stay using the Perme ICU Mobility score. Canadian Journal of Respiratory Therapy. 2021; 57: 148-153
  25. ↑ Perme C, Nawa RK, Winkelman C, Masud F. A tool to assess mobility status in critically ill patients: the Perme Intensive Care Unit Mobility Score. Methodist Debakey Cardiovasc J. 2014; 10(1):41-9.
  26. ↑ Christian Litz. Perme ICU Mobility Test. Availible from: https://www.youtube.com/watch?v=lXWMOQhO-FI [last accessed 10/6/2020]
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