Exploring a Culture of Nurse-Led Mobility to Advance Hospitalized Patients on the Recovery Continuum.

Empirical research on multi-disciplinary health care teams has yet to explore the development of mutual understanding between team members in the course of their collective clinical decision-making. This paper addresses this gap in the literature directly by examining changes in mutual understanding and the extent to which its facilitation is shared by individual members of multi-disciplinary health care teams. A Habermasian theoretical framework is used to operationalize mutual understanding. Social network analysis is used to analyze survey data on team-based clinical decision-making collected from multi-disciplinary health care teams in a Canadian province. The results of the study indicate that mutual understanding between team members ebbs and flows over the course of their collective clinical decisions. Further, as the extent of mutual understanding within the team increases, its facilitation becomes more equally shared among team members. The paper closes by specifying a practical outcome of the future work: a typology of clinical decisions that health care teams are able to use as an evaluation tool to assess how effectively they are making collective clinical decisions. As an evaluation tool, the typology would foster open and deliberative discussion, enable critical self-reflection, and thereby further enhancing mutual understanding within the teams.

ObjectiveThe primary objective of this study was to identify the occurrence and factors associated with intensive care unit (ICU)–acquired weakness (ICUAW) in patients with COVID-19. Secondarily, we monitored the evolution of muscle strength and mobility among patients with ICUAW and patients without ICUAW and the association of these variables with length of stay, mechanical ventilation (MV), and other clinical variables.MethodsIn this prospective observational study, patients admitted to the ICU for >72 h with COVID-19 were evaluated for muscle strength and mobility at 3 times: when being weaned from ventilatory support, discharged from the ICU, and discharged from the hospital. Risk factors for ICUAW were monitored.ResultsThe occurrences of ICUAW at the 3 times evaluated among the 75 patients included were 52%, 38%, and 13%. The length of the ICU stay (29.5 [16.3–42.5] versus 11 [6.5–16] days; P ≤ .001), the length of the hospital stay (43.5 [22.8–55.3] versus 16 [12.5–24] days; P ≤ .001) and time on MV (25.5 [13.8–41.3] versus 10 [5–22.5] days; P ≤ .001) were greater in patients with ICUAW. Muscle strength and mobility were lower at all times assessed in patients with ICUAW (P < .05). Bed rest time for all patients (relative risk = 1.14; 95% CI = 1.02–1.28; P = .03 per week) and use of corticosteroids (relative risk = 1.01; 95% CI = 1.00–1.03; P = .01 per day) for those who required MV were factors independently associated with ICUAW. Muscle strength was found to have a positive correlation with mobility and a negative correlation with lengths of stay in the ICU and hospital and time on MV.ConclusionsThe occurrence of ICUAW was high upon patients’ awakening in the ICU but decreases throughout hospitalization; however, strength and mobility remained compromised at hospital discharge. Bed rest time and use of corticosteroids (for those who needed MV) were factors independently associated with ICUAW in patients with COVID-19.

Marfan syndrome (MFS) is a rare, severe, chronic, life-threatening disease with multiorgan involvement that requires optimal multidisciplinary care to normalize both prognosis and quality of life. In this article, each key team member of all the medical disciplines of a multidisciplinary health care team at the Hamburg Marfan center gives a personal account of his or her contribution in the management of patients with MFS. The authors show how, with the support of health care managers, key team members organize themselves in an organizational structure to create a common meaning, to maximize therapeutic success for patients with MFS. First, we show how the initiative and collaboration of patient representatives, scientists, and physicians resulted in the foundation of Marfan centers, initially in the US and later in Germany, and how and why such centers evolved over time. Then, we elucidate the three main structural elements; a team of coordinators, core disciplines, and auxiliary disciplines of health care. Moreover, we explain how a multidisciplinary health care team integrates into many other health care structures of a university medical center, including external quality assurance; quality management system; clinical risk management; center for rare diseases; aorta center; health care teams for pregnancy, for neonates, and for rehabilitation; and in structures for patient centeredness. We provide accounts of medical goals and standards for each core discipline, including pediatricians, pediatric cardiologists, cardiologists, human geneticists, heart surgeons, vascular surgeons, vascular interventionists, orthopedic surgeons, ophthalmologists, and nurses; and of auxiliary disciplines including forensic pathologists, radiologists, rhythmologists, pulmonologists, sleep specialists, orthodontists, dentists, neurologists, obstetric surgeons, psychiatrist/psychologist, and rehabilitation specialists. We conclude that a multidisciplinary health care team is a means to maximize therapeutic success.

IntroductionEarly diagnosis of intensive care unit – acquired weakness (ICU-AW) using the current reference standard, that is, assessment of muscle strength, is often hampered due to impaired consciousness. Biological markers could solve this problem but have been scarcely investigated. We hypothesized that plasma levels of neurofilaments are elevated in ICU-AW and can diagnose ICU-AW before muscle strength assessment is possible.MethodsFor this prospective observational cohort study, neurofilament levels were measured using ELISA (NfHSMI35 antibody) in daily plasma samples (index test). When patients were awake and attentive, ICU-AW was diagnosed using the Medical Research Council scale (reference standard). Differences and discriminative power (using the area under the receiver operating characteristic curve; AUC) of highest and cumulative (calculated using the area under the neurofilament curve) neurofilament levels were investigated in relation to the moment of muscle strength assessment for each patient.ResultsBoth the index test and reference standard were available for 77 ICU patients. A total of 18 patients (23%) fulfilled the clinical criteria for ICU-AW. Peak neurofilament levels were higher in patients with ICU-AW and had good discriminative power (AUC: 0.85; 95% CI: 0.72 to 0.97). However, neurofilament levels did not peak before muscle strength assessment was possible. Highest or cumulative neurofilament levels measured before muscle strength assessment could not diagnose ICU-AW (AUC 0.59; 95% CI 0.37 to 0.80 and AUC 0.57; 95% CI 0.32 to 0.81, respectively).ConclusionsPlasma neurofilament levels are raised in ICU-AW and may serve as a biological marker for ICU-AW. However, our study suggests that an early diagnosis of ICU-AW, before muscle strength assessment, is not possible using neurofilament levels in plasma.Electronic supplementary materialThe online version of this article (doi:10.1186/cc13699) contains supplementary material, which is available to authorized users.

The objective of this prospective cohort study was to investigate the incidence of intensive care unit (ICU)-acquired weakness (ICUAW) and compare handgrip strength (HGS) and inspiratory muscle strength, measured by maximum inspiratory pressure (MIP), between critical illness survivors with and without ICUAW. Additionally, we examined whether HGS and MIP could serve as surrogate measures for ICUAW and establish reference cut-off values for both HGS and MIP in Taiwanese ICU survivors. A total of 274 ICU survivors aged ≥20 yrs without prior systemic weakness from six medical ICUs at a tertiary care hospital in Taiwan were consecutively enrolled. ICUAW was identified at the time of ICU discharge using standardised manual muscle testing based on the Medical Research Council scale. Simultaneously, HGS and MIP were assessed. A receiver operating characteristic curve analysis was performed to evaluate whether HGS and MIP could serve as surrogate markers for ICUAW and to establish their cut-off values. Among the 406 enrolled participants, 310 survived their ICU stay, and 274 completed the Medical Research Council test upon ICU discharge. The survivors were predominantly male (65.7%), with a median age of 70 years (interquartile range: 59-80). Acute respiratory failure was the leading cause of ICU admission (52.9%), and 60.2% of patients required mechanical ventilation during their ICU stay, with a median duration of 8 days (interquartile range: 3-8). ICUAW was identified in 23.0% of survivors. Fewer participants in the ICUAW group were able to complete HGS (87.1%) and MIP (45.2%) assessments, likely due to physical limitations. Compared with those without ICUAW, the ICUAW group was significantly older, had higher Acute Physiology and Chronic Health Evaluation scores at admission, required longer mechanical ventilation, had longer ICU stays, and displayed weaker HGS and lower MIP at ICU discharge. The receiver operating characteristic curve analysis demonstrated that both HGS and MIP served as promising surrogate markers with areas under the curve of 0.842 and 0.822, respectively, and optimal cut-offs of 10.9 kg-force for HGS and 22.5 cmH2O for MIP. Additionally, sex-specific cut-offs were also identified. HGS and MIP show promise as surrogate markers for ICUAW, with our ICU survivor cohort revealing comparable HGS and lower MIP cut-off values compared to previous recommendations. These results emphasise the importance of tailored cut-offs and screening approaches for different ethnic and geographic regions. Additionally, they provide preliminary reference values for ICU survivors in Taiwan and highlight the need for further studies in the region.

Patients with COVID-19 may develop a range of neurological disorders. We report here 4 COVID-19 subjects with intensive care unit-acquired weakness and their functional outcome. In addition, a scoping review of COVID-19 literature was performed to investigate this issue. Of the post-COVID-19 patients admitted to our Neuro-Rehabilitation Unit, 4 (3 males, 1 female; mean age 59.2 ± 8.62 years) had intensive care unit-acquired weakness, diagnosed with electromyography. Muscle strength and functional evaluation were performed on all patients with Medical Research Council, Disability Rating Scale and Functional Independence Measure, respectively, at admission, discharge and 6-month follow-up after discharge. Electromyography revealed that 3 subjects had critical illness polyneuropathy and 1 had critical illness polyneuropathy/critical illness myopathy. At follow-up, the 3 subjects with critical illness polyneuropathy reached full recovery. The patient with critical illness polyneuropathy/critical illness myopathy showed moderate disability requiring bilateral ankle foot-orthosis and support for ambulation. The scoping review retrieved 11 studies of COVID-19 patients with intensive care unit-acquired weakness, concerning a total of 80 patients: 23 with critical illness myopathy (7 probable), 21 with critical illness polyneuropathy (8 possible), 15 with critical illness polyneuropathy and myopathy (CIPNM) and 21 with intensive care unit-acquired weakness. Of 35 patients who survived, only 3 (8.5%) reached full recovery. All 3 had critical illness myopathy, but 2 of these had a diagnosis of probable critical illness myopathy. Intensive care unit-acquired weakness commonly occurred in subjects with COVID-19. Recovery was variable and a low percentage reached full recovery. However, the heterogeneity of studies did not allow definitive conclusions to be drawn.LAY ABSTRACTPatients with COVID-19 may develop a range of neurological disorders. We report here 4 cases of COVID-19 patients with intensive care unit-acquired weakness and their functional outcome. In addition, a scoping review of the COVID-19 literature was performed to investigate the occurrence of, and recovery from, intensive care unit-acquired weakness and sub-types (critical illness polyneuropathy, critical illness myopathy and critical illness polyneuropathy/critical illness myopathy) in subjects with COVID-19. Of these 4 patients, the 3 patients with critical illness polyneuropathy reached full recovery. The patient with critical illness polyneuropathy/critical illness myopathy showed moderate disability, requiring use of a bilateral device (ankle foot-orthosis). The scoping review of studies of COVID-19 patients with intensive care unit-acquired weakness retrieved a total of 80 patients: 21 with intensive care unit-acquired weakness, 23 with critical illness myopathy, 21 with critical illness polyneuropathy, and 15 with critical illness polyneuropathy/critical illness myopathy. Intensive care unit-acquired weakness commonly occurred in COVID-19 subjects, but the outcome was variable and a low percentage reached full recovery. COVID-19 subjects can develop long-term consequences and limitations, particularly those with intensive care unitacquired weakness, who need more rehabilitation. New rehabilitative strategies and well-designed studies investigating the benefit of rehabilitation are necessary.

Intensive care unit-acquired weakness (ICU-AW) is prevalent and adversely affects patient outcomes. Muscle strength progression and response to rehabilitation differ across ICU populations. However, the trajectories, determinants and prognoses of muscle strength changes remain unclear. This study aimed to investigate the trajectory and determinants of ICU-AW in critical illness and its impact on 60-day postadmission mortality. A multicentre prospective cohort study was conducted, involving critically ill patients from 10 ICUs across five tertiary hospitals in Fujian Province, China. Patients were evaluated using the Medical Research Council (MRC) scale at three time points: within 48 h of ICU admission or within 24 h of regaining consciousness (T1), within 24 h of ICU discharge (T2) and at the time of hospital discharge (T3). The latent class growth mixed model was utilized for data analysis, and multivariable logistic regression was employed to examine the determinants of muscle strength trajectories. This study encompassed 343 patients from five tertiary hospitals. Three latent trajectory groups were identified: a low-level decline group (5.83%), a medium-level stability group (25.36%) and a high-level recovery group (68.81%). Multivariable logistic regression revealed that Charlson comorbidity index (CCI) and alcohol consumption significantly influenced the trajectory of muscle strength development in ICU patients (p < .05). The mortality rate at 60 days was significantly higher in both the low-level decline and medium-level stability groups compared with the high-level recovery groups (p < .05). This study identified three muscle strength trajectories in ICU patients: low-level decline, medium-level stability and high-level recovery. CCI and alcohol consumption significantly influenced these trajectories. The lower 60-day mortality rate in the high-level recovery group underscores the need for early intervention and tailored care. Developing targeted rehabilitation strategies for those at risk of low-level decline or medium-level stability group is challenging and may potentially improve recovery and outcomes.

ObjectiveTo examine the effect of in-bed leg cycling exercise on patients with intensive care unit-acquired weakness (ICU-AW).DesignSingle-center retrospective study.Subjects/PatientsPatients admitted to the ICU between January 2019 and March 2023 were enrolled in the ergometer group, and those admitted to the ICU between August 2017 and December 2018 were enrolled in the control group.MethodsThe ergometer group performed in-bed leg cycling exercises 5 times per week for 20 min from the day of ICU-AW diagnosis. Furthermore, the ergometer group received 1 early mobilization session per day according to the early mobilization protocol, whereas the control group received 1 or 2 sessions per day. The number of patients with recovery from ICU-AW at ICU discharge and improvement in physical functions were compared.ResultsSignificantly more patients in the ergometer group recovered from ICU-AW than in the control group (87.0% vs 60.6%, p = 0.039). Regarding physical function, the ergometer group showed significantly higher improvement efficiency in Medical Research Council sum score (1.0 [0.7–2.1] vs 0.1 [0.0–0.2], p < 0.001).ConclusionIn-bed leg cycling exercise, in addition to the early mobilization protocol, reduced the number of patients with ICU-AW at ICU discharge.LAY ABSTRACTRecent developments in intensive care have dramatically improved the short-term prognosis of critically ill patients; however, intensive care unit-acquired weakness (ICU-AW) is a specific systemic muscle weakness that occurs in these patients. ICU-AW has been demonstrated to reduce health-related quality of life, as well as contribute to cognitive impairment and functional disability, in survivors of critical illnesses for months to years. Therefore, the development of effective interventions to prevent and improve ICU-AW is required. The study showed that in-bed leg cycling exercises 5 times per week for 20 min in addition to usual care improved muscle strength in patients with ICU-AW. In-bed leg cycling exercises may be a potentially useful exercise therapy for patients with ICU-AW.

Background &amp; objective: Intensive Care Unit-Acquired Weakness (ICU-AW) is a weakness found in critically ill patients, and this weakness can persist even after discharge from the Intensive Care Unit (ICU). Various rehabilitation medicine procedures have been shown to be effective in prevention as well as managing the established weakness in this cohort of the patients. We analyzed the effect of Neuromuscular Electrical Stimulation (NMES) therapy on the global muscle strength, quadriceps femoris muscle, and creatine kinase examination in patients known to have ICU-AW. Methodology: The type of study used a pre-experimental one-group pre-posttest, and the study population consisted of 23 patients who experienced ICU-AW. Patients were given NMES therapy at the beginning of treatment in the ICU and then evaluated using the Medical Research Council Scale for Muscle Strength (MRC-SS), Manual Muscle Test (MMT), and creatine kinase levels. Results: NMES therapy provides significant results on increasing muscle strength on the fifth day with MRC-SS 42.78 (24-60) and MMT 3.57 (2-5) (P &lt; 0.001), as well as a significant decrease in creatine kinase levels given therapy at the beginning of ICU admission. Conclusion: NMES therapy increases global muscle strength and quadriceps femoris muscle and decreases creatine kinase levels. Abbreviations: ICU-AW - Intensive Care Unit-Acquired Weakness, NMES - Neuromuscular Electrical Stimulation, ICU - Intensive care unit, MRC-SS - Medical Research Council Scale for Muscle Strength, MMT - Manual Muscle Testing, CK-MM - Creatine kinase muscle specific Key Words: Neuromuscular electrical stimulation; Intensive Care Unit-Acquired Weakness, Creatine kinase Citation: Yustiawan A, Semedi BP, Arfianti L, Maulydia, Edwar PPM, Airlangga PS, Santoso KH, Andriana M. The effect of early neuromuscular electrical stimulation in intensive care unit-acquired weakness. Anaesth. pain intensive care 2024;28(4):706−711; DOI: 10.35975/apic.v28i4.2405 Received: March 04, 2024; Reviewed: April 29, 2024; Accepted: May 10, 2024

Background The impact of intensive care unit acquired weakness (ICUAW) is associated with reduced muscle mass, strength, function and health related quality of life (HRQoL). Patients suffering from severe cardio-respiratory failure are known to lose considerable muscle mass and strength in the first 7 days of admission to the intensive care unit (ICU). Furthermore, patients surviving critical illness have a considerable less HRQoL and physical function with long term outcomes such as inability to return to work being reported. However, more information regarding muscle loss and recovery is required when patients leave hospital. Currently there are no treatments for ICUAW as once the process is established management is supportive, such as physical therapy. Purpose We Sought to investigate the effects of severe cardio-respiratory failure, in patients receiving extra corporeal membrane oxygenation (ECMO), on ICUAW (including muscle mass, strength, function and HRQoL). Researching a real life model of ICUAW allows the observation of the loss of muscle mass and strength in the first stages of critical illness and severe cardio-respiratory failure. Methods Adults receiving ECMO for severe cardiorespiratory failure were included. Muscle mass was measured using ultrasound of the rectus femoris cross sectional area (RFcsa). Muscle strength was measured using hand held dynamometry for both hand held grip strength and isometric leg extension. HRQoL was measured using the EQ-5D-5L. Function was measured using the short physical performance battery (SPPB). Measurements were taken on day 0, day 7, ICU discharge, hospital discharge and at out-patient follow up. Results 17 patients were recruited with 10 patients completing follow up. Patients lost 24% muscle mass in the first 7 days of ICU admission and ECMO initiation, with muscle loss continuing up until ICU discharge. Contrary to the hypothesis only 50% of the patients were seen to recover muscle mass at follow up. Strength and function all considerably improved between ICU discharge and out patient follow up. The EQ5D crosswalk index supported this suggesting considerable functional improvement. Conclusion Patients in severe cardio-respiratory failure lose considerable muscle mass in the first 7 days of admission, with only 50% of these patients recovering the initial muscle loss at follow up. However, strength, function and HRQoL all improve following ICU discharge suggesting an element of functional recovery. Strength and function have shown to improve regardless of the status of the muscle mass. Therefore, given the advantages of the real-life model and novel findings, this could serve as a platform to assess muscle loss and recovery over a longer time frame continuing to build the understanding of the patients recovery trajectory from critical illness.Rectus Femoris Muscle MassHand-Held Grip Strength

Intensive care unit acquired weakness (ICU-AW) is a secondary neuromuscular complication in critically ill patients, characterized by profound weakness in all four limbs. Studies have shown that bundles of care are nursing strategies that combine a series of evidence-based interventions, which collectively optimize patients' clinical outcomes compared to individual interventions. This study aims to conduct a meta-analysis of the effects of bundle interventions on ICU-AW deeply exploring the characteristics of bundle interventions, patient outcomes related to ICU-AW, and primarily investigating the effects of bundle interventions on ICU-AW. The main focus is to explore the clinical value of bundle interventions in treatment of ICU-acquired weakness in patients. Computer and manual searches were conducted using keywords to retrieve relevant studies on the effects of bundle interventions on ICU-AW from databases such as PubMed, Web of Science, Cochrane Library and EMbase. The search period ranged from database inception to the present. The control group received standard ICU care, including basic nursing, while the intervention group received bundle nursing interventions. A total of 10 randomized controlled trials (RCTs) involving 1545 participants (790 in the intervention group and 755 in the control group) were included. Meta-analysis results showed that the intervention group had significantly higher muscle strength (MD = 7.41, 95% CI: 6.65-8.16, P< 0.00001) and daily living ability (MD = 34.01, 95% CI: 32.54-35.48, P< 0.00001) than the control group. Additionally, the incidence of ICU-AW (OR = 0.39, 95% CI: 0.26-0.59, P< 0.00001), mechanical ventilation time (MD =-3.71, 95% CI: -3.58∼-2.76, P< 0.0001), and ICU length of stay (MD =-2.73, 95% CI: -3.14∼-2.31, P< 0.00001) were significantly lower in the intervention group than in the control group. ICU-AW has a severe negative impact on the recovery and functional restoration of ICU patients, increasing the treatment complexity for healthcare providers and the mortality and disability rates for patients. The bundled care approach may help reduce the incidence of ICU-AW, promote the restoration of daily activity function, enhance muscle strength, and reduce ICU stay and mechanical ventilation time for ICU patients. However, the long-term effects of bundle interventions still require further in-depth research.

To investigate the current status of intensive care unit-acquired weakness (ICU-AW) assessment, analyze the assessment barriers, and to provide reference to improve ICU-AW assessment. A convenient sampling cross-sectional survey was conducted. First, an interview outline which based on related domestic and international literatures and combining with the research purpose of this study were designed. Thirteen medical personnel (8 ICU nurses, 3 ICU doctors, 1 respiratory therapist and 1 physiotherapist) who worked in the intensive care unit (ICU) of the First Hospital of Lanzhou University were enrolled with convenience sampling method to interview. Second, the topics were comprehensively analyzed and extracted, and then a questionnaire was constructed, and the reliability and validity was assessed. Finally, the questionnaire survey including the general situation of ICU medical staffs, the current practices of ICU-AW and influencing factors was implemented in China. The retest reliability was 0.92 and expert validity was 0.96 of the questionnaire. There were 3 563 respondents in 31 provinces, municipalities and autonomous regions which eliminated 357 unqualified questionnaires, including 173 respondents from neonatal or pediatric ICU, 89 respondents whose working time was less than 6 months, and 95 invalid respondents, and then there were finally 3 206 valid questionnaires and the response rate were 90.0%. Those 3 206 respondents included 616 doctors (19.2%), 2 371 nurses (74.0%), 129 respiratory therapists (4.0%), 51 physiotherapist (1.6%) and 39 dietitians (1.2%). The mean age was (30.7±6.3) years old. Most of them had bachelor's degree (65.9%), master and above was 14.1%. Associate senior physician and above was 8.0%; ICU working time was (5.94±4.50) years. In clinical practice, only 26.5% of the ICU medical staffs confirmed that they had treated or taken care for ICU-AW patients; 52.9% of medical staffs evaluated ICU-AW only based on clinical experience, and only 12.3% used ICU-AW assessment tools. The majority of respondents believed that ICU-AW knowledge training should be performed (81.8%), ICU-AW assessment should be as important as other complications (pressure sore, infected ventilator associated pneumonia, etc., 75.1%), and ICU-AW assessment should be part of daily treatment and care activities (61.2%). However, only 10.2% of respondents had received ICU-AW related knowledge training, and 42.7% respondents believed that their ICU-AW related knowledge could not meet clinical needs. Only 18.7% respondents would actively assess whether patients suffered from ICU-AW or not, and 42.3% respondents thought that ICU-AW should be assessed every day, and the assessment tools were also inconsistent. There were 44.0% respondents considered the Medical Research Council Muscle score (MRC-score) scale was the optimal tool for diagnosing ICU-AW, the following were neuro-electrophysiological examination (17.2%) and manual muscle strength (MMT, 11.1%). The main cause of the ICU-AW assessment barriers was the lack of ICU-AW related knowledge (88.1%), and the following were lack of ICU-AW assessment guidelines (76.5%), patients' cognitive impairment or limited understanding ability (84.6%), unable to cooperate with the assessment due to critical illness (83.0%), and inadequate attention to ICU-AW assessment by the department (77.5%). The current status of ICU-AW assessment were unsatisfying in China, and the main barriers were lack of skills and knowledge.

Associations between Intensive care unit acquired weakness with post-extubation dysphagia and other clinical outcomes-a cohort study in critically ill respiratory patients.

BackgroundThailand is a rapidly aging society, which places high demand on home health care services for the elderly. The shortage of health care workforce in rural areas is a crucial obstacle to the delivery of adequate home health care services. The appropriate skill-mix between multidisciplinary health team and care givers (CGs) is an attractive solution for improving home health care services in rural Thailand. This study assessed the potential of trained CGs to provide home health care services and projected what the optimal mix for a multidisciplinary home health care team in rural Thailand would be in 2030.MethodsEleven pilot districts in Thailand were recruited for the study. Secondary data were collected along with surveys of home health care providers. A total of 130 care managers (nurses) and 351 care givers (CG) were recruited for the survey. Workload, skill-mix potential, and acceptance of care givers were assessed in the surveys. The results from secondary data and the survey were used to project the health workforce requirements in 2030.ResultsIt is projected that in 2030 the number of elderly living in rural areas will be 7,156,700 (27% of the projected rural population). Of this, 20.3% will be home-bound, 1.1% will be bed-ridden and 1.6% will need rehabilitation. The main members of the multidisciplinary health workforce involved in home health care were nurses, doctors, and physiotherapists. The home health care services that were provided by the multidisciplinary health workforce included patient assessment, development of a care plan and case conference, home visits, and teaching and supervision of CGs. The CGs were village health volunteers trained to carry out regular home visits to patients. The CGs provided assistance with the activities of daily living, basic health services, moral support to patients and relatives, and surveillance of the home environment during home visits. CGs were well accepted by both the health professionals and the patients. Projections showed that 16,094 nurses, 1,542 doctors, 1,022 physiotherapists and 50,148 CGs will be required in 2030 to meet the needs of the dependent elderly for home health care in rural Thailand.ConclusionWith the increased need for home health care services in the future, appropriate team work between the members of the multidisciplinary health team and the CGs in the community is the appropriate solution for likely shortages of health professional workforce.

Intensive care unit-acquired weakness (ICU-AW) is associated with poorer outcome of critically ill patients. Microcirculatory changes and altered vascular permeability of skeletal muscles might contribute to the pathogenesis of ICU-AW. Muscular ultrasound (MUS) displays increased muscle echogenicity, although its pathogenesis is uncertain. We investigated the combined measurement of serum and ultrasound markers to assess ICU-AW and clinical patient outcome. Fifteen patients and five healthy controls were longitudinally assessed for signs of ICU-AW at study days 3 and 10 using a muscle strength sum score. The definition of ICU-AW was based on decreased muscle strength assessed by the muscular research council-sum score. Ultrasound echogenicity of extremity muscles was assessed using a standardized protocol. Serum markers of inflammation and endothelial damage were measured. The 3-month outcome was assessed on the modified Rankin scale. ICU-AW was present in eight patients, and seven patients and the control subjects did not develop ICU-AW. The global muscle echogenicity score (GME) differed significantly between controls and patients (mean GME, 1.1 ± 0.06 vs. 2.3 ± 0.41; p = 0.001). Mean GME values significantly decreased in patients without ICU-AW from assessment 1 (2.30 ± 0.48) to assessment 2 (2.06 ± 0.45; p = 0.027), which was not observed in patients with ICU-AW. Serum levels of syndecan-1 at day 3 significantly correlated with higher GME values at day 10 (r = 0.63, p = 0.012). Furthermore, the patients' GME significantly correlated with mRS at day 100 (r = 0.67, p = 0.013). The combined use of muscular ultrasound and inflammatory biomarkers might be helpful to diagnose ICU-AW and to predict long-term outcome in critical illness.