Effects of Mobility Dose on Discharge Disposition in Critically Ill Stroke Patients

Study Overview
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Brief Summary
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The primary aim of the study is to assess the mobility dose in neurocritical care patients with ischemic stroke or intracranial hemorrhage and its effects on discharge disposition and patient outcomes. The investigators hypothesize that patients' mobilization dose in the intensive care unit (ICU) predicts discharge disposition, 90 day Barthel Index and other outcomes like muscle wasting (expressed as decrease in rectus femoris cross sectional area (RF-CSA) in the paretic and non-paretic limb measured by bedside ultrasound), and ICU length of stay (LOS).

Detailed Description
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The investigators have previously developed and validated the Surgical Intensive Care Unit Optimal Mobilization Score (SOMS), an algorithm to guide and facilitate early mobilization to advance mobility of surgical intensive care unit patients (NCT01363102). In addition, the investigators have established the use of bedside ultrasound technology to quantify cross sectional area of the rectus femoris muscle, which allows an objective, user-independent quantification of muscle wasting (NCT02270502). This is a prospective, observational study to observe the relation between mobility dose, muscle wasting and patient outcomes in critically ill stroke patients. Patients will be enrolled within 48 hours of ICU admission. The investigators will measure the dose of activity, that is duration and intensity of mobilization in critically ill patients with ischemic stroke and intracerebral hemorrhage. By mobility dose the investigators are referring to all provider-directed activities (by nursing, and physical therapists) meant to enhance the patient's mobility level. The investigators take into account mobility dose, defined as a function of both the mobility level (e.g., sitting at the edge of the bed, ambulating) as well as its duration. Of note, there is so far no published data available that describes patients' mobility dose in such an integrative, semi-quantitative fashion. The investigators use the existing mobility intensity quantification tool (MQS) (NCT03196960) and test the hypotheses that mobilization dose predicts muscle wasting in critically ill stroke patients, adverse hospital discharge disposition as well as 90 day Barthel Index. The investigators will apply hierarchical testing to evaluate the association between mobilization dose and discharge disposition as well as 90-day Barthel Index. The Mobilization Quantification Score (MQS) is a composition of the validated ICU mobility score (SOMS), a 0 to 10 value scale that measures the mobility milestones in critically ill patients, multiplied by a for each level previously defined time unit (5 or 30 minutes correspond to one unit depending on mobilization level). In order to capture the muscle status at ICU admission, determined by the first bedside ultrasound of the rectus femoris muscle after enrollment, and the change in rectus femoris muscle diameter throughout stay, the investigators will conduct repetitive measurements of the cross sectional area of the rectus femoris muscles (RF-CSA) of both legs. This longitudinal setting will allow to investigate muscle wasting due to immobilization and other severe illness related factors in the paretic and non-paretic limb. The investigators will conduct a scheduled phone call 30 days and 90 days after hospital discharge by getting in contact with either the patient or a family member to obtain follow-up data. This conversation will include questions that allow to identify the Barthel Index at 30 days, the Barthel Index and GOS-E score at 90 days, and if the patient has been readmitted to a hospital within 30 days of hospital discharge and mortality. Discharge disposition is defined as discharge to facilities providing long-term care assistance for daily activities, including nursing homes and skilled nursing facilities, hospice at the patient's home, hospice in a health care facility; or in-hospital mortality. The Barthel Index is a measure of functional disability originally designed to evaluate progress of rehabilitation in patients with stroke and neuromuscular disease. The GOS-E (Extended Glasgow Outcome Scale) is a global scale for functional outcome that rates patient status into eight categories: Dead Vegetative State, Upper and Lower Severe Disability, Upper and Lower Moderate Disability, Upper and Lower Good Recovery.

Official Title
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Effects of Mobility Dose on Discharge Disposition in Critically Ill Stroke Patients

Conditions
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Sarcopenia, Stroke, Acute, Muscle Weakness, Critical Illness

Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Aged 18 years and older Admitted to the neurological intensive care service within the past 48 hours an expected ICU length of stay of at least 48h New onset ischemic stroke or non-traumatic intracerebral hemorrhage Baseline functional independence: Barthel-Index of 70 or above 2 weeks before admission (obtained retrospectively from patient or proxy) Exclusion Criteria: Transfers from other institutions (hospitals, long-term rehabilitation facilities, skilled nursing facilities) with a stay >48h at the outside institution absence of lower extremities not committed to full support exclusive or clinically predominant posterior circulation ischemic stroke subarachnoid hemorrhage, subdural and epidural hemorrhage

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Adverse Hospital Discharge Disposition | Adverse hospital discharge is defined as discharge to facilities providing long-term care assistance for daily activities, including nursing homes and skilled nursing facilities, hospice at the patient's home, hospice in a health care facility, or in-hospital mortality. | patient will be followed until hospital discharge; assessed at hospital discharge; expected between study day 3 and 30 | 
| 90 day Barthel Index (hierarchical testing) | The Barthel Index is a measure of functional disability originally designed to evaluate progress of rehabilitation in patients with stroke and neuromuscular disease. | 90 days post discharge from hospital (collected through follow up phone call) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rectus Femoris Muscle Cross Sectional Area Rectus Femoris Muscle Cross Sectional Area | Rectus femoris cross sectional area will be measured by bedside ultrasound, raw numbers as well as change over time will be respected | will be measured at least twice (on day of enrollement and before discharge); if stay longer than one week, ultrasound will be performed weekly (every 7 days); expected total time period of 3 to 30 days | 
| 30 day Barthel Index | The Barthel Index is a measure of functional disability originally designed to evaluate progress of rehabilitation in patients with stroke and neuromuscular disease. | 30 days post discharge from hospital (collected through follow up phone call) | 
| Neurological ICU length of stay | number of days patient stays on the neurological ICU | admission until discharge from neurological ICU; an expected 3 to 20 days | 
| Neurological ICU length of stay until discharge readiness | number of days patient stays on the neurological ICU until time point from which patient is stable for discharge from ICU | admission until discharge readiness from neurological ICU; an expected 3 to 20 days | 
| hospital length of stay | number of days patients stays in hospital during index admission | admission until discharge from hospital: patient will be followed until discharge from hospital; an expected 3 to 30 days | 
| FIM Score at ICU discharge | Functional independence measure score in the domains transfer and locomotion at ICU discharge | assessed at discharge from neurological ICU; expected between study day 3 and 20 | 
| Days on sedation | number of days patient receives sedatives | during hospital stay; an expected 0 to 30 days | 
| mortality | we will distinguish between ICU mortality, hospital mortality and mortality within 30 or 90 days after discharge from hospital | during ICU stay, hospital stay or within the 30day or 90day follow up period (follow up data collected through phone call | 
| ICU readmission | readmission to the ICU after discharge from ICU but within hospital stay | during hospital stay; expected to be assessed between study day 3 and 30 | 
| 30-day hospital readmission | readmission to a hospital within 30 days after discharge from index stay | 30 days after discharge from hospital, obtained through follow up phone call | 
| 90-day GOS-E (Extended Glasgow Outcomes Scale) | The GOS-E is a global scale for functional outcome that rates patient status into eight categories: Dead Vegetative State, Upper and Lower Severe Disability, Upper and Lower Moderate Disability, Upper and Lower Good Recovery | obtained 90 days after discharge from hospital through follow up phone call | 
| Total costs of care | total costs of care | during hospital stay | 
| Falls | number of falls | during hospital stay; expected to be assessed between study day 3 and 30 | 
| Delirium-free days | defined by CAM-ICU (Confusion Assessment Method) | CAM-ICU will be evaluated daily during hospital stay; an expected 0 to 30 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Mobilization Therapy, Clitical Illness, Stroke, Intensive Care, Functional Mobility, Quality of Life