The role and staffing of physiotherapy in critical care: a scoping review

Introduction

The National Guidelines for the Provision of Intensive Care Services (GPICS v2) (1) identify physiotherapy as one of the principle and most consistent therapy services for critical care. Historically, the aim of physiotherapy was to maintain bronchial hygiene for people who were intubated (2), and while this remains a key area, the focus is now towards early rehabilitation and on physical recovery (3, 4, 5).

GPICS (1) recommends that across the U.K., there should be access to, and provision of, for patients in critical care 24 hours a day, seven days per week (1) and may be achieved through the provision of out-of-hours or on-call services and weekend working. Additionally, GPICS recommend physiotherapist to patient ratios of one physiotherapist to every four patients (1). Furthermore, it suggests possible roles to be undertaken by physiotherapists working in critical care, including providing assessment and intervention for a range of acute and chronic respiratory pathologies, promoting early mobilisation and preventing deconditioning during periods of acute illness, in addition to providing specialist rehabilitation following critical illness or severe injury (1).

Whilst these guidelines have been invaluable in advising service standards, audit and future planning, there is limited evidence to either support or counter the recommendations made. Several authors have explored the minimum standards of clinical practice required within critical care (6, 7, 8). These studies identified the key assessment and treatment skills and knowledge required to work as a physiotherapist within critical care. Within the U.K., 107 items were deemed essential as a minimum standard of clinical practice and concluded that the findings may support training programmes in both higher education and the health service, to reduce variability in clinical practice (7). However, given the ‘minimum standards’ criteria of previous literature, these are unlikely to fully reflect the role of physiotherapy in critical care, nor do they allow guidance of required staffing numbers or structures.

There is a clear need for the role of physiotherapy within critical care to be better defined, both within the U.K. and internationally.

Based on the above, the objectives of this scoping review were to:

1. Map the volume and nature of evidence in relation to physiotherapy in critical care.
2. Describe the role of physiotherapy within critical care.
3. Describe recommended physiotherapy staffing ratios in critical care.

Methods

Review objectives and questions

The population, concept and context approach (9) was used to develop the search strategy, with the following criteria:

Objective

To identify the roles and required staffing for physiotherapy services within critical care.

Review questions

   1. What is the role of physiotherapy within critical care?

   2. What quantity of physiotherapy staffing is required within critical care?

Population

Physiotherapists and physiotherapy services within critical care units.

Concept

Literature that broadly describes either the role of the physiotherapist or makes recommendations on required staffing levels, including any attempt to increase physiotherapy staffing or involvement.

Context

All adult critical care units, including tertiary services, in any nation.

Eligibility criteria

Articles focused on adult critical care units, available in English language and published during or after 2009 were included. The review period was based on the publication of guidelines for rehabilitation after critical illness (3). All relevant clinical articles were included, and expert opinion papers, clinical guidelines and surveys were also eligible for inclusion. For systematic reviews, relevant research papers were extracted and added to the existing search titles following the same inclusion criteria. To ensure focus on roles and staffing, studies that investigated the effectiveness of physiotherapy interventions in critical care was excluded as were papers focusing on the interventions for single pathologies including COVID-19.

Search strategy

Searches were completed using MEDLINE, CINAHL, Cochrane Library and PEDro (Physiotherapy Evidence Database) databases for articles published from 1st January 2009–31st December 2021. The following terms were used: ‘intensive care unit’ or ‘critical care’ and ‘physical therapy’ or ‘physiotherapy’ or ‘physiotherapist’ or ‘mobilisation’ or ‘walking’ or ‘early ambulation’ or ‘therapeutic exercise’ or ‘rehabilitation’.

Types of study

All forms of study designs were eligible, including cohort observational studies (both prospective and retrospective), case control studies and opinion pieces. Additionally, service improvement projects and audits were included if available in full text.

Eligibility process

All titles identified were combined and duplicates removed. Titles and subsequently abstracts were reviewed by two of the research team, with any disagreements over inclusion discussed. Where consensus was not reached, a third researcher was utilised. Full text copies were obtained for the included articles, with those not freely available requested from the author through direct contact.

Data extraction and appraisal

Data extraction was performed using Joanna Briggs Institute (JBI) proformas relevant to each article (10). Extraction was completed by one member of the research team and checked for accuracy by another. Once data extraction was completed, only those deemed relevant to the objectives of the scoping review were critically appraised using the JBI methodology (9). Due to the widespread variation in research methodologies, participants and outcomes, a descriptive summary was completed.

Results

Searches performed

Initial searches identified 1331 articles published between January 2009–December 2021, reducing to 1099 after removal of duplicates. One systematic review was identified consisting of 85 primary papers, of which 43 were published prior to 2009 and a further 21 already included in the original searches. Therefore, a total of 1121 titles underwent review, of which 71 proceeded to abstract review and 28 full text papers were generated. Of these, six were excluded prior to critical appraisal (see Figure 1). Articles were most frequently excluded where they did not focus on either the role or recommended staffing for physiotherapists in critical care.

See Figure 1: Search and eligibility flowchart.

Data extraction

A detailed overview of data extracted for both the role of physiotherapy in critical care and physiotherapy staffing is provided in Appendices 1 and 2.

Quality of research

The quality of all the studies were assessed using JBI proformas. No randomised control trials or control trials were included, with the majority (n = 16) being survey-based studies. All the included studies had a clear rationale for completion. However, while some had clear research aims and explanations of methods, they frequently reported very low response rates (often <30%). The minimum standards studies in the U.K. (7) and Australia (6) recorded higher response rates (65% and 90% respectively) but this was achieved through targeted invitation and regular follow-up.

Surveys from two of the articles (11, 12) were completed by either nursing or medical staff members, with no input from physiotherapy staff and therefore generated a lack of clarity of roles and responsibilities. Additionally, three studies (13, 14) used scenario-based questions to review role and responsibilities, however the reviewers (Paul Twose, Vicky Newey and Una Jones) perceived that due to differences in practice across the world with regards to referral criteria and interventions, the results lacked generalisability to other nations or U.K. practice.

Of the non-survey-based studies, two utilised focus groups (8, 15), both of which had clear objectives and methodologies. Additionally, both utilised an appropriately sized and selected sample to ensure congruity between the research question and the results reported. Neither study reflected on the role of the researcher within the method and data analysis however, this was not felt to influence the rigour of the studies.

Sommers et al (16) utilised available evidence in making guidelines for 3 consensus topics for physiotherapy in critical care. There was a clear link between the recommendations made and the available evidence including a detailed approach to systematic review.

Of the remaining studies, 2 followed appropriate methodologies for the completion of a service evaluation (17) and quality improvement project (18). Both had appropriately detailed interventions and clarity regarding the use of routinely collected data. Additionally, the methodologies provide sufficient clarity to allow the studies to be reproduced in other health care settings. Conversely, the discussion by Pawlik (19) lacked some clarity on its purpose and its approach to gathering relevant evidence, and hence appears based on the author opinion and experience.

Summary of findings

Population and country of study

Participants included physical therapists, physiotherapists, and critical care directors (medical staff) with experience ranging from three months to greater than 20 years. By country, most of the publications originated from South Africa (n = 5, 21.7%) (8, 15, 20, 21, 22) or U.S.A. (n = 4, 17.4%) (13, 18, 19, 23).

Study methodology

The 22 included studies were predominantly survey based (n = 16,72.7%) with only two U.K. based studies (17, 19). Studies utilised a variety of distribution options, including circulation via membership groups (7, 13, 23, 24), direct contact in local hospitals and health establishments (6, 8, 12, 14, 15, 16, 20, 22, 25, 26, 27, 28, 29) or via senior medical clinicians (11, 19, 30).

The non-survey based studies were a mixture of focus group studies (n = 2) (8, 15), consensus guidelines (n = 1), a discussion paper (n = 1) (19), service evaluation (n = 1) (17), and quality improvement (n = 1) (18). Of these papers, none were U.K.-based.

Study findings

A detailed summary of the study findings can be found in Table 1.

Role of physiotherapy in critical care

The predominant themes from the studies were the role of physiotherapist in the provision of respiratory based interventions. These include management of a range of presentations including atelectasis, pneumonia and acute respiratory distress syndrome (25), and specific respiratory focused physiotherapy interventions, for example, airway clearance techniques and manual hyperventilation (12, 20, 26). Studies also discussed the role (or lack thereof) of physiotherapists in the adjustment of ventilator settings, weaning decisions and readiness for extubation (17, 22, 24). The studies focusing on the minimum standards of clinical practice identified broader roles for physiotherapists including the delivery of rehabilitation and the importance of physiotherapists working as part of the multi-disciplinary team (6, 7, 8, 15). Only Summers et al (30) focused purely on early mobilisation and based on a consensus process, developed protocols for treating patients in critical care.

Physiotherapy staffing in critical care

The studies reviewing physiotherapy staffing levels had significant variations in findings. Physiotherapy to patient ratios were reported between one physiotherapist to four patients (26), increasing to 1:50 (12). This variation occurred across counties but also within nations particularly between urban and rural settings, and different hospital settings for example, private versus public (22). There was also variation in the presence of physiotherapists within critical care with authors reporting only 11–40% of critical care units having physiotherapy presence daily (29). None of the studies attempted to suggest appropriate physiotherapy staffing but more reported on existing levels. Additionally, none of the studies discussed U.K.-based physiotherapy staffing levels.

Discussion

This scoping review, to the authors’ knowledge, is the first of its kind to review the evidence base for both the role and staffing levels for physiotherapy in critical care. However, based on the articles identified, it is not possible to form clear recommendations. The methodological quality and nature of studies reviewed mean that findings are not generalisable to physiotherapy practice across countries. The studies found were geographically dispersed across Africa, Europe, U.S.A., and Asia, further limiting generalisability to the U.K. This is particularly pertinent given the known variability in physiotherapy job titles and roles for example, physiotherapist, respiratory therapist, and physical therapist.

Role of physiotherapy in critical care

The role of physiotherapy in critical care is not clearly defined based on the evidence available in this scoping review. There is evidence that physiotherapists are involved in both respiratory management for example, airway clearance, positioning and delivery of on-call services, and a role within rehabilitation within the critical care. However, as most of the included studies had different aims and objectives, it is difficult to generalise the findings and hence define the role. Three studies reported on the minimum standards of practice for physiotherapists in critical care (6, 7, 8). Whilst these papers identified clear skills and knowledge required to work in critical care; these focus on the minimum level required by individuals rather than the overall responsibilities of a physiotherapy service. Furthermore, they are yet to be evaluated to determine the impact of defining these minimum standards on clinical practice or training programmes.

However, this scoping review has highlighted the presence of physiotherapists within critical care units internationally. Whilst the roles may differ from country to country, some fundamentals remain for example, combining both respiratory interventions and rehabilitation. There also appears to be greater similarity in the role of physiotherapy in particular countries, namely the U.K. (7), Australia (6), and South Africa (8, 20).

Physiotherapy staffing in critical care

Based on this scoping exercise, there is widespread variability in physiotherapy staffing within critical care, and the international nature of the studies included make recommendations challenging.

GPICS v2 (1) suggests a physiotherapist to patient ratio of 1:4 within U.K. critical care units, however it is relatively unknown if units are compliant with this suggestion. In 2016 the Critical Care Network National Nurse Leads (CC3N) (4) identified that many critical care units had limited access to AHPs although specific physiotherapy to patient ratios were not recorded (31).

Within this scoping exercise, international staffing ratios were reported in four studies, ranging from one physiotherapist to four beds (1:4) in Jordan (26) to 1:50 in Greece (12); with a theme of increased physiotherapists in the larger cities with teaching/academic hospitals compared to more rural areas (22). Barriers to perceived low staffing numbers included funding, lack of formal training, lack of role understanding and prioritisation of the service need (12, 26). Service provision varied as to whether physiotherapists were present on the unit only on weekdays or had an on-call service. Turkman et al (29) reported the complete absence of physiotherapy on-call services in Turkey versus 90% of respondents in Sri Lanka reporting the presence of an on-call service, of which 28% had overnight residence (25).

There was also variable reporting of static staff who were solely critical care based or those whose remit covered other clinical areas (24). Formal training and specific post qualification critical care training was difficult to clearly define with one study reporting a clear need for further formal training in respiratory physiotherapy (11).

Of the studies included, none were U.K.-based and therefore no assumptions can be made for the current U.K. physiotherapy workforce within critical care. As such it is not possible to generate any theories for appropriate workforce models beyond the recommendations of GPICS.

Limitations of scoping review

This scoping review utilised transparent methods throughout the entire process, ensuring a broad search of the literature. Eligibility of studies was ensured through a step-based approach to review, with all titles and abstracts being independently assessed by two researchers. Additionally, data extraction and appraisals adhered to JBI recommendations, with additional reviews completed by each researcher. The review was limited to 2009 onwards to reflect the timing of the publication of the guidelines for rehabilitation after critical illness and a likely shift in physiotherapy interventions towards delivery of rehabilitation.

As with all scoping reviews, there is the potential that not all available literature will have been captured, as well as some papers not being available to the research team at point of data extraction and appraisal. Specific papers known to the researchers, but not identified in the literature searches, were included at title eligibility phase. There are possible reasons for papers not being identified in the searches including specific journals not being included within databases or may reflect the search terms initially identified for use not capturing all aspects of physiotherapy practice within critical care. No new literature was included after this point.

Further research

Future research is needed to explore the role of physiotherapists working within critical care in the U.K. and to define the required physiotherapy staffing levels, as well as determine the impact of physiotherapy within the critical care environment. This will support future guidelines and service planning to ensure a value-based approach to physiotherapy provision and a focus on improving patient outcomes.

Conclusion

Based on this scoping exercise, there is currently a limited evidence base to support both physiotherapy staffing recommendations and role definition. Existing literature is often methodologically flawed in terms of responder bias and insufficient response rates. Furthermore, most of the available literature is based in healthcare systems outside of the U.K. However, throughout the literature there is clear evidence of physiotherapy involvement within critical care services, including the provision of on-call services. Furthermore, this scoping review has highlighted the increasing focus on delivering evidence-based practice and recognises the need for further research to provide greater role definition and to explore the impact of physiotherapy involvement.

Funding

No funding was allocated to the completion of this scoping review.

Conflict of interest

None of the authors have any declarations of conflict of interest.

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