Introduction
The European Society of Intensive Care Medicine recommends the presence of a specialist physiotherapist, available every five beds, seven days a week in the high complexity Intensive Care Unit. However, in Chile the adherence of adult Intensive Care Units to this recommendation is unknown.

Objective
To describe the organizational characteristics and the physiotherapist availability in adult Intensive Care Units in Chile, and according to the adherence to international recommendations, inform health decision-makers.

Methods
Observational study based on a telephone survey. All adult Intensive Care Units institutions of high complexity, private hospitals and teaching health centers in Chile were eligible (n = 74). The primary outcome measures were the proportion of institutions with physiotherapist availability 24 hours a day and seven days a week (24/7 physiotherapist), a maximum caseload per physiotherapist of five patients and the presence of a specialist physiotherapist.

Results
Response rate was 86.5%, with 59% of responding units being public and 83% offering level III care. 70% of the adult Intensive Care Units in Chile have 24/7 physiotherapist (87% of the public and 46% of the private sector). 41% of the centers had a maximum caseload per physiotherapist of five patients during the day on weekdays. This number decreased on weekends and during night shifts. 23% of the Intensive Care Units had a specialist physiotherapist, being more common in the private sector (31%).

Conclusions
In Chilean adult ICU, 24/7 physiotherapist availability is high, the prevalence of physiotherapists with specialist training is low. Future efforts should focus on promoting the uptake of specialist training.

Authors: Nadine Aranis[1], Jorge Molina[2], Jaime Leppe[2], Ana Cristina Castro-Ávila[2,3], Carolina Fu[4], Catalina Merino-Osorio[2]

Filiación:
[1] Physical Medicine and Rehabilitation Service, Clínica Alemana de Santiago, Santiago, Chile
[2] School of Physical Therapy, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
[3] Department of Health Sciences, University of York, Heslington, York, United Kingdom
[4] Departament of Physical Therapy, Speech and Occupational Therapy, Faculty of Medicine -Universidade São Paulo, São Paulo, Brasil

E-mail: catalinamerino@udd.cl

Correspondencia a:
[1] School of Physical Therapy
Facultad de Medicina
Clínica Alemana Universidad del Desarrollo
Las Condes
Santiago de Chile

Citación: Aranis N, Molina J, Leppe J, Castro-Ávila AC, Fu C, Merino-Osorio C. Characteristics of physiotherapy staffing levels and caseload: a cross-sectional survey of Chilean adult Intensive Care Units. Medwave 2019;19(1):e7576 doi: 10.5867/medwave.2019.01.7576

Fecha de envío: 6/11/2018

Fecha de aceptación: 21/1/2019

Fecha de publicación: 26/2/2019

Origen: not commissioned

Tipo de revisión: external peer review by three external, double-blind reviewers

Ficha PubMed

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1. Gobierno de Chile, Ministerio de Salud, Subsecretaría de Redes Asistenciales M. Nivel de Complejidad en Atención Cerrada. Santiago, Chile: MINSAL; 2012.
2. Gobierno de Chile, Ministerio de Salud. Criterios clasificación según nivel de complejidad de establecimientos hospitalarios; 2013 [on line]. | Link |
3. Saez E. Guías 2004 de organización y funcionamiento de unidades de pacientes críticos. Rev Chil Med Intensiva. 2004;19(4):209-23. | Link |
4. Valentin A, Ferdinande P; ESICM Working Group on Quality Improvement. Recommendations on basic requirements for intensive care units: structural and organizational aspects. Intensive Care Med. 2011 Oct;37(10):1575-87. | CrossRef | PubMed |
5. Danbury C, Gould T, Baudouin S, Berry A, Bolton S, Borthwick M, et al. Guidelines for Provision of Intensive Care Services. Intensive Care Society; 2015. [on line]. | Link |
6. Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013 Jun;41(6):1543-54. | CrossRef | PubMed |
7. Castro AA, Calil SR, Freitas SA, Oliveira AB, Porto EF. Chest physiotherapy effectiveness to reduce hospitalization and mechanical ventilation length of stay, pulmonary infection rate and mortality in ICU patients. Respir Med. 2013 Jan;107(1):68-74. | CrossRef | PubMed |
8. Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012 Mar;23(1):5-13. | PubMed |
9. Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011 Apr 7;364(14):1293-304. | CrossRef | PubMed |
10. Herridge MS, Cheung AM, Tansey CM, Matte-Martyn A, Diaz-Granados N, Al-Saidi F, et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. 2003 Feb 20;348(8):683-93. | CrossRef | PubMed |
11. Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA. Interventions to improve the physical function of ICU survivors: a systematic review. Chest. 2013 Nov;144 (5):1469-1480. | CrossRef | PubMed |
12. Castro-Avila AC, Serón P, Fan E, Gaete M, Mickan S. Effect of Early Rehabilitation during Intensive Care Unit Stay on Functional Status: Systematic Review and Meta-Analysis. PLoS One. 2015 Jul 1;10(7):e0130722. | CrossRef | PubMed |
13. Skinner EH, Berney S, Warrillow S, Denehy L. Rehabilitation and exercise prescription in Australian intensive care units. Physiotherapy. 2008 Sep;94(3):220-9. | CrossRef |
14. Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M, et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med. 2008 Jul;34(7):1188-99. | CrossRef | PubMed |
15. Merino-Osorio C, Castro-Ávila AC, Arias-Gutiérrez R, Arriagada MJ, Villanueva C, Leppe J, et al. Effects of 24-hours/day versus business hours physical therapy intervention in adult intensive care unit patients: a systematic review. Int Phys Med Rehabil J. 2018;3(1):100-6. | CrossRef |
16. Haines TP, Bowles KA, Mitchell D, O'Brien L, Markham D, Plumb S, et al. Impact of disinvestment from weekend allied health services across acute medical and surgical wards: 2 stepped-wedge cluster randomised controlled trials. PLoS Med. 2017 Oct 31;14(10):e1002412. | CrossRef | PubMed |
17. Mills E, Hume V, Stiller K. Increased allied health services to general and acute medical units decreases length of stay: comparison with a historical cohort. Aust Health Rev. 2018 Jun;42(3):327-333. | CrossRef | PubMed |
18. Intensive Care Society. Core Standards for Intensive Care Units. Core Stand Intensive Care Units. 2013;1:1-27. | Link |
19. Wright SE, Thomas K, Watson G, Baker C, Bryant A, Chadwick TJ, et al. Intensive versus standard physical rehabilitation therapy in the critically ill (EPICC): a multicentre, parallel-group, randomised controlled trial. Thorax. 2018 Mar;73(3):213-221. | CrossRef | PubMed |
20. Johnson AM, Henning AN, Morris PE, Tezanos AGV, Dupont-Versteegden EE. Timing and Amount of Physical Therapy Treatment are Associated with Length of Stay in the Cardiothoracic ICU. Sci Rep. 2017 Dec 14;7(1):17591. | CrossRef | PubMed |
21. Stone SA. Staffing levels: give us a tool for optimum staffing levels. 2018. csp.org.uk [on line]. | Link |
22. Allied Health Professions the Workforce and the Services They Provide. 2017;(March). | Link |
23. Cartmill L, Comans TA, Clark MJ, Ash S, Sheppard L. Using staffing ratios for workforce planning: Evidence on nine allied health professions. Hum Resour Health. 2012;10:1-8. | Link |
24. Skinner EH, Haines KJ, Berney S, Warrillow S, Harrold M, Denehy L. Usual Care Physiotherapy During Acute Hospitalization in Subjects Admitted to the ICU: An Observational Cohort Study. Respir Care. 2015 Oct;60(10):1476-85. | CrossRef | PubMed |
25. Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, et al. Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany. Crit Care Med. 2014 May;42(5):1178-86. | CrossRef | PubMed |
26. Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas PJ, et al. Intensive care unit mobility practices in Australia and New Zealand: a point prevalence study. Crit Care Resusc. 2013 Dec;15(4):260-5. | PubMed |
27. Berney SC, Rose JW, Bernhardt J, Denehy L. Prospective observation of physical activity in critically ill patients who were intubated for more than 48 hours. J Crit Care. 2015 Aug;30(4):658-63. | CrossRef | PubMed |
28. Connolly BA, Mortimore JL, Douiri A, Rose JW, Hart N, Berney SC. Low Levels of Physical Activity During Critical Illness and Weaning: The Evidence-Reality Gap. J Intensive Care Med. 2017 Jan 1:885066617716377. | CrossRef | PubMed |
29. Grammatopoulou E, Charmpas TN, Strati EG, Nikolaos T, Evagelodimou A, Vlassia Belimpasaki, Skordilis EK. The scope of physiotherapy services provided in public ICUs in Greece: A pilot study. Physiother Theory Pract. 2017 Feb;33(2):138-146. | CrossRef | PubMed |
30. Norrenberg M, Vincent JL. A profile of European intensive care unit physiotherapists. European Society of Intensive Care Medicine. Intensive Care Med. 2000 Jul;26(7):988-94. | CrossRef | PubMed |
31. Campbell L, Bunston R, Colangelo S, Kim D, Nargi J, Hill K, et al. The provision of weekend physiotherapy services in tertiary-care hospitals in Canada. Physiother Can. 2010 Fall;62(4):347-54. | CrossRef | PubMed |
32. Griffiths P, Ball J, Murrells T, Jones S, Rafferty AM. Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study. BMJ Open. 2016 Feb 9;6(2):e008751. | CrossRef | PubMed |
33. National Quality Board. An improvement resource for urgent and emergency. 2017;(November). | Link |
34. Haupt MT, Bekes CE, Brilli RJ, Carl LC, Gray AW, Jastremski MS, et al. Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care. Crit Care Med. 2003 Nov;31(11):2677-83. | CrossRef | PubMed |
35. Fisher ME, Aristone MN, Young KK, Waechter LE, Landry MD, Taylor LA, et al. Physiotherapy Models of Service Delivery, Staffing, and Caseloads: A Profile of Level I Trauma Centres across Canada. Physiother Can. 2012 Fall;64(4):377-85. | CrossRef | PubMed |

Gobierno de Chile, Ministerio de Salud, Subsecretaría de Redes Asistenciales M. Nivel de Complejidad en Atención Cerrada. Santiago, Chile: MINSAL; 2012.

Gobierno de Chile, Ministerio de Salud. Criterios clasificación según nivel de complejidad de establecimientos hospitalarios; 2013 [on line]. | Link |

Saez E. Guías 2004 de organización y funcionamiento de unidades de pacientes críticos. Rev Chil Med Intensiva. 2004;19(4):209-23. | Link |

Valentin A, Ferdinande P; ESICM Working Group on Quality Improvement. Recommendations on basic requirements for intensive care units: structural and organizational aspects. Intensive Care Med. 2011 Oct;37(10):1575-87. | CrossRef | PubMed |

Danbury C, Gould T, Baudouin S, Berry A, Bolton S, Borthwick M, et al. Guidelines for Provision of Intensive Care Services. Intensive Care Society; 2015. [on line]. | Link |

Kayambu G, Boots R, Paratz J. Physical therapy for the critically ill in the ICU: a systematic review and meta-analysis. Crit Care Med. 2013 Jun;41(6):1543-54. | CrossRef | PubMed |

Castro AA, Calil SR, Freitas SA, Oliveira AB, Porto EF. Chest physiotherapy effectiveness to reduce hospitalization and mechanical ventilation length of stay, pulmonary infection rate and mortality in ICU patients. Respir Med. 2013 Jan;107(1):68-74. | CrossRef | PubMed |

Adler J, Malone D. Early mobilization in the intensive care unit: a systematic review. Cardiopulm Phys Ther J. 2012 Mar;23(1):5-13. | PubMed |

Herridge MS, Tansey CM, Matté A, Tomlinson G, Diaz-Granados N, Cooper A, et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med. 2011 Apr 7;364(14):1293-304. | CrossRef | PubMed |

Herridge MS, Cheung AM, Tansey CM, Matte-Martyn A, Diaz-Granados N, Al-Saidi F, et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med. 2003 Feb 20;348(8):683-93. | CrossRef | PubMed |

Calvo-Ayala E, Khan BA, Farber MO, Ely EW, Boustani MA. Interventions to improve the physical function of ICU survivors: a systematic review. Chest. 2013 Nov;144 (5):1469-1480. | CrossRef | PubMed |

Castro-Avila AC, Serón P, Fan E, Gaete M, Mickan S. Effect of Early Rehabilitation during Intensive Care Unit Stay on Functional Status: Systematic Review and Meta-Analysis. PLoS One. 2015 Jul 1;10(7):e0130722. | CrossRef | PubMed |

Skinner EH, Berney S, Warrillow S, Denehy L. Rehabilitation and exercise prescription in Australian intensive care units. Physiotherapy. 2008 Sep;94(3):220-9. | CrossRef |

Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M, et al. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med. 2008 Jul;34(7):1188-99. | CrossRef | PubMed |

Merino-Osorio C, Castro-Ávila AC, Arias-Gutiérrez R, Arriagada MJ, Villanueva C, Leppe J, et al. Effects of 24-hours/day versus business hours physical therapy intervention in adult intensive care unit patients: a systematic review. Int Phys Med Rehabil J. 2018;3(1):100-6. | CrossRef |

Haines TP, Bowles KA, Mitchell D, O'Brien L, Markham D, Plumb S, et al. Impact of disinvestment from weekend allied health services across acute medical and surgical wards: 2 stepped-wedge cluster randomised controlled trials. PLoS Med. 2017 Oct 31;14(10):e1002412. | CrossRef | PubMed |

Mills E, Hume V, Stiller K. Increased allied health services to general and acute medical units decreases length of stay: comparison with a historical cohort. Aust Health Rev. 2018 Jun;42(3):327-333. | CrossRef | PubMed |

Intensive Care Society. Core Standards for Intensive Care Units. Core Stand Intensive Care Units. 2013;1:1-27. | Link |

Wright SE, Thomas K, Watson G, Baker C, Bryant A, Chadwick TJ, et al. Intensive versus standard physical rehabilitation therapy in the critically ill (EPICC): a multicentre, parallel-group, randomised controlled trial. Thorax. 2018 Mar;73(3):213-221. | CrossRef | PubMed |

Johnson AM, Henning AN, Morris PE, Tezanos AGV, Dupont-Versteegden EE. Timing and Amount of Physical Therapy Treatment are Associated with Length of Stay in the Cardiothoracic ICU. Sci Rep. 2017 Dec 14;7(1):17591. | CrossRef | PubMed |

Stone SA. Staffing levels: give us a tool for optimum staffing levels. 2018. csp.org.uk [on line]. | Link |

Allied Health Professions the Workforce and the Services They Provide. 2017;(March). | Link |

Cartmill L, Comans TA, Clark MJ, Ash S, Sheppard L. Using staffing ratios for workforce planning: Evidence on nine allied health professions. Hum Resour Health. 2012;10:1-8. | Link |

Skinner EH, Haines KJ, Berney S, Warrillow S, Harrold M, Denehy L. Usual Care Physiotherapy During Acute Hospitalization in Subjects Admitted to the ICU: An Observational Cohort Study. Respir Care. 2015 Oct;60(10):1476-85. | CrossRef | PubMed |

Nydahl P, Ruhl AP, Bartoszek G, Dubb R, Filipovic S, Flohr HJ, et al. Early mobilization of mechanically ventilated patients: a 1-day point-prevalence study in Germany. Crit Care Med. 2014 May;42(5):1178-86. | CrossRef | PubMed |

Berney SC, Harrold M, Webb SA, Seppelt I, Patman S, Thomas PJ, et al. Intensive care unit mobility practices in Australia and New Zealand: a point prevalence study. Crit Care Resusc. 2013 Dec;15(4):260-5. | PubMed |

Berney SC, Rose JW, Bernhardt J, Denehy L. Prospective observation of physical activity in critically ill patients who were intubated for more than 48 hours. J Crit Care. 2015 Aug;30(4):658-63. | CrossRef | PubMed |

Connolly BA, Mortimore JL, Douiri A, Rose JW, Hart N, Berney SC. Low Levels of Physical Activity During Critical Illness and Weaning: The Evidence-Reality Gap. J Intensive Care Med. 2017 Jan 1:885066617716377. | CrossRef | PubMed |

Grammatopoulou E, Charmpas TN, Strati EG, Nikolaos T, Evagelodimou A, Vlassia Belimpasaki, Skordilis EK. The scope of physiotherapy services provided in public ICUs in Greece: A pilot study. Physiother Theory Pract. 2017 Feb;33(2):138-146. | CrossRef | PubMed |

Norrenberg M, Vincent JL. A profile of European intensive care unit physiotherapists. European Society of Intensive Care Medicine. Intensive Care Med. 2000 Jul;26(7):988-94. | CrossRef | PubMed |

Campbell L, Bunston R, Colangelo S, Kim D, Nargi J, Hill K, et al. The provision of weekend physiotherapy services in tertiary-care hospitals in Canada. Physiother Can. 2010 Fall;62(4):347-54. | CrossRef | PubMed |

Griffiths P, Ball J, Murrells T, Jones S, Rafferty AM. Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study. BMJ Open. 2016 Feb 9;6(2):e008751. | CrossRef | PubMed |

National Quality Board. An improvement resource for urgent and emergency. 2017;(November). | Link |

Haupt MT, Bekes CE, Brilli RJ, Carl LC, Gray AW, Jastremski MS, et al. Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care. Crit Care Med. 2003 Nov;31(11):2677-83. | CrossRef | PubMed |

Fisher ME, Aristone MN, Young KK, Waechter LE, Landry MD, Taylor LA, et al. Physiotherapy Models of Service Delivery, Staffing, and Caseloads: A Profile of Level I Trauma Centres across Canada. Physiother Can. 2012 Fall;64(4):377-85. | CrossRef | PubMed |