The evidence is pretty clear that the involvement of an integrated team that includes OT helps patients in the ICU get better faster!
Impact of ICU on the patient
Patients who are in the ICU experience many negative outcomes: delirium, polyneurophathy, myopathy, and sleep pattern disturbances. 1,2,3
In addition, extended bedrest (even without an ICU stay) has been found to have consequence on every body system2,3. Many of these difficulties are agreeable to OT intervention4.
- Cardiac: reduced cardiac output
- Hematologic: reduced blood volume and transport of O2
- Respiratory: decreased muscular endurance for breathing
- Gastrointestinal: Decreased intestinal mobility leading to constipation and decreased appetite (and, decreased appetite leads to a decrease in activity level)
- Gastrourinary: Increased risk of UTI due to a decrease in filtration rate
- Endocrine: Abnormal hormonal responses
- Musculoskeletal: Overall muscle weakness
- Neurologic: Increased risk for delirium and psychological distress (increase in rate of depression and anxiety)
- Integumentary: Increased risk for skin breakdown
Interdisciplinary management of the ICU patient
The ABCDEF bundle is an evidence-based approach to dealing with patients in the ICU5,6,7. It is comprehensive and holistic and provides a model for an interdisciplinary approach to care. It can be used to justify OT services. What does it stand for?
A: Assessment and management of pain (everyone’s job, all the time!)
B: Spontaneous awakening and breathing trials
C: Choice of analgesia and sedation
D: Delirium assessment (see below!)
E: Early mobility and exercise
F: Family engagement and empowerment
The ABCDEF bundle has been rolled out in many hospitals and hospital systems and evidence suggests that it is effective at producing better outcomes with ICU patients than traditional care. The “D”’ opens a door for OT practitioners to demonstrate their skills in working with clients with cognitive impairments!
See my previous blog on cognitive assessments used in acute care for some ideas on how to assess ICU patients for cognition.
Specific occupational therapy interventions for delirium and the ICU patient8,9
- Intensive care unit diaries: Documenting the sequence of events throughout a patient’s ICU stay allows a patient to re-orient quicker and prevent development of delirium and shorten the duration of delirium.
- Polysensory stimulation: Using different types of sensory stimulation to calm clients in the ICU (soothing, preferred music, massaging lotion into the skin, etc).
- Positioning: Provide positioning for pressure relief and social interaction; working on tolerance in functional semi-seated positions for improved engagement.
- Cognitive stimulation: Can range from simple orientation tasks to reading the newspaper and working on word puzzles. The aim is to prevent boredom and secondary psychosocial responses from the ICU. OT can also include teaching clients how to use the call button and when/how to safely move.
- Basic activities of daily living: Facilitating normal routines by participating, as able, in upper extremity grooming, hygiene, and ADL tasks.
- Upper extremity function: Therapeutic exercise to facilitate increased range of motion and strength to improve bed mobility, ADLs, and transfers.
- Family training and daily visits by trained family members: Family can be used as adjuncts to therapy by carrying over therapeutic exercise programs, sensory stimulation, and cognitive stimulation.
Getting OT referrals in the ICU for delirium management
Some facilities are generating OT referrals with all patients admitted to the ICU as one strategy to prevent delirium (and reduce length of stay). OT can monitor patients for changes in cognition and alert medical staff to any change. In addition, OT can intervene promptly when and if delirium sets in.
Many facilities already use the CAM-ICU to assess for delirium. Those who are CAM-ICU positive (indicative of delirium) may be referred for occupational therapy.
Some occupational therapy departments are using RASS scores (the Richmond Agitation Sedation Scale) as an indicator for therapy and timing of activities – for example, a RASS score between +1 and -1 would let the OT know that a patient may be appropriate to participate in ADLs out of bed or IADLs such as medication management or finances. While those at -3 to -2 might be more appropriate for active assisted range of motion, cognitive retraining, and basic ADLs in bed.
- Ball Sanders, C. (2015). Preventing secondary complications in trauma patients with implementation of a multidisciplinary mobilization team. Journal of Trauma in Nursing, 22(3), 170-175.
- Smith-Gabai, H. (ed.) (2011). Occupational Therapy in Acute Care. Rockville, MD: American Occupational Therapy Association.
- Paz, J.C. & West, M.P. (2013). Acute Care Handbook for Physical Therapists – E-Book (Kindle Locations 13265-13266). Elsevier Health Sciences. Kindle Edition.
- American Occupational Therapy Association (2014). Occupational therapy practice framework: Domain and process (3rd ed). American Journal of Occupational Therapy, 68 (Suppl. 1), S1–S48.
- Costa, D. K., White, M. R., Ginier, E., Manojlovich, M., Govindan, S., Iwashyna, T. J., & Sales, A. E. (2017). Identifying Barriers to Delivering the Awakening and Breathing Coordination, Delirium, and Early Exercise/Mobility Bundle to Minimize Adverse Outcomes for Mechanically Ventilated Patients: A Systematic Review. Chest, 152(2), 304–311. https://doi.org/10.1016/j.chest.2017.03.054
- Miller, M. A., Govindan, S., Watson, S. R., Hyzy, R. C., & Iwashyna, T. J. (2015). ABCDE, but in that order? A cross-sectional survey of Michigan intensive care unit sedation, delirium, and early mobility practices. Annals of the American Thoracic Society, 12(7), 1066–1071 https://doi.org/10.1513/AnnalsATS.201501-066OC
- Morandi, A., Piva, S., Ely, E. W., Myatra, S. N., Salluh, J. I. F., Amare, D., … Latronico, N. (2017). Worldwide Survey of the “Assessing Pain, Both Spontaneous Awakening and Breathing Trials, Choice of Drugs, Delirium Monitoring/Management, Early Exercise/Mobility, and Family Empowerment” (ABCDEF) Bundle. Critical Care Medicine, 1. https://doi.org/10.1097/CCM.0000000000002640
- Álvarez, E., Garrido, M., Tobar, E., Prieto, S., Vergara, S. Briceño, C., & Gonález, F. (2017). Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial. Journal of Critical Care, 37, 85-90.
- Beg, M. Scruth, E., & Liu, V. (2016). Developing a framework for implementing intensive care unit diaries: A focused review of the literature. Australian Critical Care, 29, 224-234.
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