The implementation of an intensity regulated exercise programme in coronary artery bypass graft surgery patients: A pilot randomised controlled trial

AIM: To determine the safety and effect of an intensity regulated exercise programme, compared to a structured usual care mobilisation protocol, on the functional capacity of patients following coronary artery bypass graft (CABG) surgery, at discharge and 10 - 14 days after discharge. METHODS: Single centre, double-blinded, randomised controlled trial at a private hospital in Cape Town, South Africa. Subjects in the exercise group performed an intensity regulated exercise programme, while subjects in the control group were encouraged to mobilise out of bed. Both programmes were implemented within 24 hours after extubation following uncomplicated CABG surgery. Functional capacity was tested by means of the Six-Minute Walk Test (6MWT) at discharge and 10 - 14 days after discharge. RESULTS: Eligible patients (n=38) were randomly allocated to an exercise group (n=17) or a control group (n=21). The functional capacity of subjects in the exercise group was signifi cantly higher than that of the control group at hospital discharge, mean difference 103.10 meters (95%CI 23.39 - 182.81) (p=0.01). The exercise group did not further improve after hospital discharge (p=0.3) whereas the control group showed a signifi cant improvement (p<0.01) in walking distance over time. The mean difference in 6MWD at the second test was 44.89 meters (95%CI -84.33 - 174.10) (p=0.47). CONCLUSION: An intensity regulated exercise programme leads to higher levels of functional capacity on discharge and should be encouraged in the in-patient phase of cardiac rehabilitation following CABG surgery

Public sector physiotherapists’ organisation and profile: Implications for intensive care service

Background: Physiotherapists are essential in the management of hospitalised patients. The way in which a physiotherapy service is offered in intensive care units (ICUs) can affect ICU patient outcomes. Objectives: To provide a clear picture of the organisation and structure of physiotherapy departments, the number and types of ICUs requiring physiotherapy services and the profile of physiotherapists working in South African public-sector central, regional and tertiary hospitals that house Level I–IV ICUs. Method: Cross-sectional survey design using SurveyMonkey, analysed descriptively. Results: One hundred and seventy units (the majority Level I, functioning as mixed [37%, n = 58] and neonatal [22%, n = 37] units) are serviced by 66 physiotherapy departments. The majority of physiotherapists (61.5%, n = 265) were younger than 30 years, had a bachelor’s degree (95.1%, n = 408) and were employed in production Level I and community service posts (51%, n = 217) with a physiotherapy-to-hospital-bed ratio of 1:69. Conclusion: Insight into the organisational structure of physiotherapy departments and physiotherapists working in public-sector hospitals with ICU facilities in South Africa was provided. It is evident that physiotherapists employed within this sector are young and early in their career development. The large number of ICUs functioning within these hospitals and high bed-to-physiotherapist ratio is concerning, highlighting the high burden of care within this sector and the possible effect on physiotherapy services in the ICUs. Clinical implications: A high burden of care is placed on public-sector hospital-based physiotherapists. The number of senior-level posts within this sector raises concern. It is not clear how the current staffing levels, physiotherapist profile and structure of hospital-based physiotherapy departments affect patient outcomes

The way in which a physiotherapy service is structured can improve patient outcome from a surgical intensive care : a controlled clinical trial

The original publication is available at http://ccforum.com/Publication of this article was funded by the Stellenbosch University Open Access Fund.Introduction: The physiological basis of physiotherapeutic interventions used in intensive care has been established. We must determine the optimal service approach that will result in improved patient outcome. The aim of this article is to report on the estimated effect of providing a physiotherapy service consisting of an exclusively allocated physiotherapist providing evidence-based/protocol care, compared with usual care on patient outcomes. Methods: An exploratory, controlled, pragmatic, sequential-time-block clinical trial was conducted in the surgical unit of a tertiary hospital in South Africa. Protocol care (3 weeks) and usual care (3 weeks) was provided consecutively for two 6-week intervention periods. Each intervention period was followed by a washout period. The physiotherapy care provided was based on the unit admission date. Data were analyzed with Statistica in consultation with a statistician. Where indicated, relative risks with 95% confidence intervals (CIs) are reported. Significant differences between groups or across time are reported at the alpha level of 0.05. All reported P values are two-sided. Results: Data of 193 admissions were analyzed. No difference was noted between the two patient groups at baseline. Patients admitted to the unit during protocol care were less likely to be intubated after unit admission (RR, 0.16; 95% CI, 0.07 to 0.71; RRR, 0.84; NNT, 5.02; P = 0.005) or to fail an extubation (RR, 0.23; 95% CI, 0.05 to 0.98; RRR, 0.77; NNT, 6.95; P = 0.04). The mean difference in the cumulative daily unit TISS-28 score during the two intervention periods was 1.99 (95% CI, 0.65 to 3.35) TISS-28 units (P = 0.04). Protocol-care patients were discharged from the hospital 4 days earlier than usual-care patients (P = 0.05). A tendency noted for more patients to reach independence in the transfers (P = 0.07) and mobility (P = 0.09) categories of the Barthel Index. Conclusions A physiotherapy service approach that includes an exclusively allocated physiotherapist providing evidence-based/protocol care that addresses pulmonary dysfunction and promotes early mobility improves patient outcome. This could be a more cost-effective service approach to care than is usual care. This information can now be considered by administrators in the management of scarce physiotherapy resources and by researchers in the planning of a multicenter randomized controlled trial. Trial registration PACTR201206000389290Publishers' Versio

The development of a clinical management algorithm for early physical activity and mobilization of critically ill patients : synthesis of evidence and expert opinion and its translation into practice

The original publication is available at http://cre.sagepub.com/content/early/2011/04/15/0269215510397677Includes bibliographyObjective: To facilitate knowledge synthesis and implementation of evidence supporting early physical activity and mobilization of adult patients in the intensive care unit and its translation into practice, we developed an evidence-based clinical management algorithm. Methods: Twenty-eight draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n¼7) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus – semi-interquartile range <0.5 – were collated into the algorithm. Results: The draft algorithm statements were edited and six additional statements were formulated. The 34 statements related to assessment and treatment were grouped into three categories. Category A included statements for unconscious critically ill patients; Category B included statements for stable and cooperative critically ill patients, and Category C included statements related to stable patients with prolonged critical illness. While panellists reached consensus on the ratings of 94% (32/34) of the algorithm statements, only 50% (17/34) of the statements were rated essential.Medical Research Council of South AfricaPost-prin

Reaching consensus on the physiotherapeutic management of patients following upper abdominal surgery: a pragmatic approach to interpret equivocal evidence

BACKGROUND:Postoperative pulmonary complications remain the most significant cause of morbidity following open upper abdominal surgery despite advances in perioperative care. However, due to the poor quality primary research uncertainty surrounding the value of prophylactic physiotherapy intervention in the management of patients following abdominal surgery persists. The Delphi process has been proposed as a pragmatic methodology to guide clinical practice when evidence is equivocal. METHODS: The objective was to develop a clinical management algorithm for the post operative management of abdominal surgery patients. Eleven draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n = 5) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus-semi-interquartile range (SIQR) < 0.5-were collated into the algorithm. RESULTS: The five panelists allocated to the abdominal surgery Delphi panel were from Australia, Canada, Sweden, and South Africa. The 11 draft algorithm statements were edited and 5 additional statements were formulated. The panel reached consensus on the rating of all statements. Four statements were rated essential. CONCLUSION: An expert Delphi panel interpreted the equivocal evidence for the physiotherapeutic management of patients following upper abdominal surgery. Through a process of consensus a clinical management algorithm was formulated. This algorithm can now be used by clinicians to guide clinical practice in this population

Mammal responses to global changes in human activity vary by trophic group and landscape

Wildlife must adapt to human presence to survive in the Anthropocene, so it is critical to understand species responses to humans in different contexts. We used camera trapping as a lens to view mammal responses to changes in human activity during the COVID-19 pandemic. Across 163 species sampled in 102 projects around the world, changes in the amount and timing of animal activity varied widely. Under higher human activity, mammals were less active in undeveloped areas but unexpectedly more active in developed areas while exhibiting greater nocturnality. Carnivores were most sensitive, showing the strongest decreases in activity and greatest increases in nocturnality. Wildlife managers must consider how habituation and uneven sensitivity across species may cause fundamental differences in human–wildlife interactions along gradients of human influence.Peer reviewe

Risk factors for Coronavirus disease 2019 (Covid-19) death in a population cohort study from the Western Cape province, South Africa

Risk factors for coronavirus disease 2019 (COVID-19) death in sub-Saharan Africa and the effects of human immunodeficiency virus (HIV) and tuberculosis on COVID-19 outcomes are unknown. We conducted a population cohort study using linked data from adults attending public-sector health facilities in the Western Cape, South Africa. We used Cox proportional hazards models, adjusted for age, sex, location, and comorbidities, to examine the associations between HIV, tuberculosis, and COVID-19 death from 1 March to 9 June 2020 among (1) public-sector “active patients” (≥1 visit in the 3 years before March 2020); (2) laboratory-diagnosed COVID-19 cases; and (3) hospitalized COVID-19 cases. We calculated the standardized mortality ratio (SMR) for COVID-19, comparing adults living with and without HIV using modeled population estimates.Among 3 460 932 patients (16% living with HIV), 22 308 were diagnosed with COVID-19, of whom 625 died. COVID19 death was associated with male sex, increasing age, diabetes, hypertension, and chronic kidney disease. HIV was associated with COVID-19 mortality (adjusted hazard ratio [aHR], 2.14; 95% confidence interval [CI], 1.70–2.70), with similar risks across strata of viral loads and immunosuppression. Current and previous diagnoses of tuberculosis were associated with COVID-19 death (aHR, 2.70 [95% CI, 1.81–4.04] and 1.51 [95% CI, 1.18–1.93], respectively). The SMR for COVID-19 death associated with HIV was 2.39 (95% CI, 1.96–2.86); population attributable fraction 8.5% (95% CI, 6.1–11.1)

The implementation and evaluation of a best practice physiotherapy protocol in a surgical ICU

BibliographyThesis (PhD ( Interdisciplinary Health))--University of Stellenbosch, 2010.BibliographyENGLISH ABSTRACT: Introduction: It is increasingly being recognized that how intensive care services are delivered may have a greater impact on patient outcome than the individual therapies. Uncertainty regarding the optimal physiotherapy service provision model in a surgical intensive care unit (ICU) exists. Methodology: The aims of this study were to 1) develop an evidence-based physiotherapy protocol; 2) validate the content of the protocol; and 3) conduct an explorative intervention trial to compare usual care to the estimated effects of providing a physiotherapy service guided by an evidence-based physiotherapy protocol by a dedicated physiotherapist. A systematic review process was used to synthesize the evidence in eight subject areas. The GRADE system was used to formulate best practice recommendations and algorithm statements. Forty-two experts from a variety of disciplines were invited to participate in a Delphi process. Finally, the evidence-based physiotherapy protocol was implemented in a surgical ICU over four three-week intervention periods by a group of research therapists. The outcomes measured included ventilator time, ventilation proportions, failed extubation proportions, length of ICU and hospital stay, mortality, functional capacity, functional ability and cost (using nursing workload as proxy). Results: Fifty-three research reports in eight subject areas were identified, 23 draft best-practice recommendations and 198 algorithm statements were formulated. The draft protocol consisted of five clinical management algorithms. Fifteen international research experts and twelve national academics in the field of critical care agreed to participate in the Delphi process. Consensus was reached on the formulation of 87% (20/23) recommendations and the rating of 66% (130/198) statements. The risk of an adverse event during the protocol care intervention period was 6:1000 treatment sessions (p=0.34). Patients admitted to the unit during the protocol care intervention period were less likely to be intubated (RR 0.16 95%CI 0.07 – 0.71; RRR 0.84 NNT 5.02; p=0.005) or fail extubation (RR 0.23 95%CI 0.05 – 0.98; RRR =0.77 NNT 6.95; p=0.04). The mean difference in the daily unit TISS-28 score between the two condition periods was 1.99 95%CI 0.65 – 3.35 (p=0.04). Patients managed by the protocol tended to remain in the hospital for a shorter time after unit discharge (p=0.05). There was no difference in the time spent on the ventilator (p=0.50), mortality (p=0.52) or in the six minute walk distance (p=0.65). In addition there was no difference in the proportion of patients who reached independence in any of the Barthel Index activities measured within 48 hours of discharge from the unit. Conclusions: The use of an evidence-based physiotherapy protocol for the comprehensive physiotherapeutic management of patients in a surgical ICU was feasible and safe. The preliminary results of this study suggest that a physiotherapy service, which is guided by an evidence-based protocol and offered by a dedicated unit therapist, has the potential to lower the cost of ICU care and facilitate the functional recovery of patients after unit discharge. This information can now be considered by administrators to optimize the physiotherapy service provided in ICU.AFRIKAANSE OPSOMMING: Inleiding: Daar word toenemend erken dat die wyse waarop dienste gelewer word, ‘n groter impak mag hê op die uitkoms van pasiënte as die spesifieke modaliteite in gebruik. Onsekerheid heers tans oor die optimale fisioterapie diens model om te volg in ‘n chirurgiese intensiewe sorg eenheid (ISE). Metodologie: The doel van hierdie projek was om 1) ‘n bewysgesteunde protokol te ontwikkel; 2) die geldigheid van die protokol te bevestig; en 3) om deur middel van ‘n eksploratiewe studie die uitkoms van pasiënte te vergelyk wanneer die fisioterapie diens gelewer word aan die hand van die bewysgesteunde protokol deur ‘n toegewyde fisioterapeut, teenoor wanneer die gewone fisioterapie diens gelewer word. Die empiriese bewyse in agt onderwerp areas is gesintetiseer na afloop van ‘n sistematiese literatuur oorsig proses. Die GRADE sisteem is gebruik om beste praktyk aanbevelings en algoritme stellings te formuleer. Twee en veertig kundige persone van verskeie disiplines is genooi om deel te neem aan die Delphi proses om die geldigheid van die protokol te bevestig. Uiteindelik is die geldige bewysgesteunde protokol oor ‘n tydperk van vier drie weke intervensie periodes deur ‘n groep navorsings terapeute in ‘n chirurgiese ISE geïmplementeer. Die tyd wat pasiënte geventileer is, die proporsie pasiënte wat geïntubeer en geherintubeer is in die tydperk, die lengte van ISE en hospitaal verblyf, mortaliteit, funksionele kapasiteit asook funksionele vaardigheid en koste (deur die verpleeg werkslading te gebruik as ‘n indikasie van koste) is gemeet. Resultate: Drie en vyftig navorsings verslae in agt onderwerp areas is geïdentifiseer, 23 konsep aanbevelings en 198 algoritme stellings is geformuleer. Die konsep protokol het uit vyf algoritmes bestaan. Vyftien internasionale en twaalf nasionale kundiges het die uitnodiging aanvaar om aan die delphi proses deel te neem. Konsensus is bereik vir die formulering van 87% (20/23) van die aanbevelings en die gradering van 66% (130/198) van die algoritme stellings. Die risiko vir ‘n ongunstige episode tydens die protokol intervensie periode was 6:1000 sessies (p=0.34). Pasiënte wat tydens die protokol intervensie periode tot die eenheid toegelaat is was minder geneig om geïntubeer te word (RR 0.16 95%CI 0.07 – 0.71; RRR 0.84 NNT 5.02; p=0.005) of om ‘n ekstubasie te faal (RR 0.23 95%CI 0.05 – 0.98; RRR =0.77 NNT 6.95; p=0.04). Die gemiddelde verskil in die daaglikse eenheid TISS-28 telling tussen die twee intervensie periodes was 1.99 95%CI 0.65 – 3.35 (p=0.04). Patiente wat tydens die protokol intervensie periode behandel is was geneig om vinniger uit die hospitaal ontslaan te word nadat hul uit die eenheid ontslaan is (p=0.05). Daar was geen verskil in die ventilasie tyd, (p=0.50) die mortaliteit (p=0.52) of die afstand wat pasiente in ses minute kon aflê binne 48 uur na ontslag uit die eenheid (p=0.65) nie. Daar was ook geen verskil in die proporsie pasiente wat onafhanklikheid bereik het in enige van die kategorieë van die Barthell Index instrument nie. Gevolgtrekking: Die gebruik van die protokol vir die omvattende hantering van pasiënte in ‘n chirurgiese eenheid is haalbaar en veilig. Die voorlopige resultate van hierdie studie dui daarop dat wanneer ‘n fisioterapie diens in ‘n chirurgiese ISE gelewer word aan die hand van ‘n bewysgesteunde protokol deur ‘n toegewyde fisioterapeut dit die potensiaal het om ISE koste te verminder en die funksionele herstel van pasiente na ontslag uit die eenheid te fasiliteer. Hierdie inligting kan nou deur administrateurs oorweeg word om ‘n optimale fisioterapie diens in ‘n chirurgiese ISE te verseker

The profile of a surgical ICU in a public sector tertiary hospital in South Africa

Thesis (MScFisio)--University of Stellenbosch, 2004.ENGLISH ABSTRACT: Objective: To describe the baseline data of a surgical ICU in South Africa before the implementation of an evidence-based physiotherapy practice protocol. Design: Prospective cohort observational study Setting: Ten-bed closed surgical unit in a university affiliated tertiary hospital. Patients: All adult ICU admissions from 16 June - 30 September 2003. Measurements: The patient’s clinical data including demographic information, admission diagnosis, surgery classification and co-morbidities were recorded on admission to the unit. APACHE II score was calculated. The physiotherapy techniques, positions and functional activities used, the frequency and duration of physiotherapy treatment sessions, the provision of after-hours service and the diagnosis of pulmonary complications were also recorded daily. The time of mechanical ventilation was calculated and the number of re-intubations documented. The ICU length of stay or mortality was recorded. Results: 160 patients were admitted. Patients were 49 +/- 19.95 years of age. The mean APACHE II score was 12.3 +/ 7.19 and a 12.3% mortality was observed. Thirty seven percent of patients were admitted to the unit following elective surgery. Patients stayed in the unit for 5.94 +/- 6.55 days. Hypertension was the most frequent co-morbidity found in this cohort (42%), and 21% of patients tested, tested positive for HIV. Co-morbidities had no significant association with ICU LOS or mortality. Nine hundred and twenty seven physiotherapy records were obtained. Students were responsible for 39% (n=366) of treatment sessions, the unit therapist for 34% (n=311) and the on-call therapists for 27% (n=250). Despite routine daily physiotherapy for all patients in the unit, 39% (n=62) developed excessive secretions, 30% (n=48) of patients developed pneumonia and 27% (n=43) of patients were diagnosed with basal atelectasis. Nineteen patients (12%) died in the ICU. Patients spent a mean of 5.94 (SD 6.55) days in the unit. One hundred patients (63%) were ventilated. Almost a third of ventilated patients (31%) were intubated more than once. The patients spent a mean time of 3.8 days (SD 6.30) on the ventilator every time they were re-intubated. The development of pulmonary complications significantly increased the time on the ventilator and the LOS. Conclusions: This baseline study of a surgical ICU presents a picture of a unit providing care comparable to first world environments. The picture of the physiotherapy service provided in this unit is of a “traditional” service based neither on the available evidence regarding the prevention or management of pulmonary complications, nor on the incorporation of early rehabilitation into the management of mechanically ventilated adult patients in ICU.AFRIKAANSE OPSOMMING: Doel: Om die basis lyn van ‘n chirurgiese intensiewe sorg eenheid in Suid Afrika te beskryf voor die implementering van ‘n bewysgesteunde fisioterapie protokol in die eenheid. Studie struktuur: Prospektiewe kohort observerende studie. Eenheid: Tien bed geslote eenheid in ‘n tertiêre opleidingshospitaal. Pasiënte: Alle volwasse pasiënte opgeneem in die eenheid tussen 16 Junie en 30 September 2003. Meetings: Demografiese data, diagnose met opname, chirurgie klassifikasie en ko-morbiditeite is aangeteken by opname. APACHE II is bereken. Die fisioterapie tegnieke, pasiënt posisies en funksionele aktiwiteite gebruik in behandelingssessies, die frekwensie en duur van behandelingssessies, die verskaffing van na-ure diens aan die eenheid asook die komplikasies gediagnoseer is daagliks aangeteken. Die tyd wat pasiënte geventileer is asook die aantal kere geher-intubeer is bereken. Die tydsduur van eenheid verblyf asook mortaliteit is aangeteken. Results: 160 pasiënte is opgeneem, met ‘n gemiddelde ouderdom van 49 +/- 19.95. Die gemiddelde APACHE II telling was 12.3 +/ 7.19 en die mortaliteit was 12.3%. Sewe en dertig persent van pasiënte is opgeneem na elektiewe chirurgie. Pasiënte bly in die eenheid gemiddeld vir 5.94 +/- 6.55 dae. Hipertensie was die mees algemene ko-morbiditeit (42%), en 21% van die pasiënte wat getoets is, het positief getoets vir HIV. Ko-morbiditeite het geen beduidende verband getoon met die tyd in die eenheid of mortaliteit nie. 927 Fisioterapie rekords is aangeteken. Studente was verantwoordelik vir 39% (n=366) van die behandelingssessies, die eenheid terapeut vir 34% (n=311) en die op-roep fisioterapeute vir 27% (n=250). Ten spyte van daaglikse roetine fisioterapie behandeling van alle pasiënte in die eenheid het 39% (n=62) oormatige sekresies ontwikkel, 30% (n=48) is met pneumonie gediagnoseer en 27% (n=43) met basale atelektase. Negentien pasiënte (12%) is dood in die eenheid. Die tydsduur van eenheid verblyf was 5.94 (SD 6.55) dae. Een honderd pasiënte (63%) is geventileer. Byna een derde (31%) van pasiënte is geher-intubeer. Met elke her-intubasie het die pasiënte gemiddeld 3.8 (SD 6.30) dae langer op die ventilator gebly. Pulmonale komplikasies het beide die tydsduur in die eenheid as op die ventilator betekenisvol verleng. Gevolgtrekkings: Hierdie basislyn studie beskryf ‘n eenheid waar pasiënte mediese sorg ontvang soortgelyk aan eerste wêreld lande. Die fisioterapeutiese diens wat gelewer word is egter nie gebasseer op die nuutste bewyse in die literatuur nie. Nog, in die voorkoming of in die behandeling van pulmonale komplikasies, nog in die vroëere inkorporasie van rehabilitasie in die hantering van volwasse pasiënte in ‘n intensiewe sorg eenheid

Mapping of a curriculum renewal journey : lessons learned

CITATION: Hanekom, S. 2014. Mapping of a curriculum renewal journey: Lessons learned. African Journal of Health Professions Education, 6(2):178, doi:10.7196/ajhpe.527.The original publication is available at http://www.ajhpe.org.zaA curriculum is described as an expression of educational ideas in practice.[1] It is a living document which should be adaptable to a changing environment. When faced with specific contextual challenges that required curriculum renewal, we took a phronetic approach. The process was predominantly based on craft knowledge and relied in most part on the insightfulness of staff. The curriculum renewal provided a unique opportunity to evaluate both the content and the mode of delivery. In this edition of AJHPE we share the valuable lessons learned along the journey of curriculum renewal. We started with the end in mind by defining the profile of the Stellenbosch University physiotherapy graduate (Table 1).http://www.ajhpe.org.za/index.php/ajhpe/article/view/527Publisher's versio