Patient Management and Prioritization in the ICU: A Model for Consideration

Occupational Therapy’s Distinct Value in the Intensive Care Unit (ICU)

Many might pose the question “What is occupational therapy’s (OT’s) distinct value in the ICU setting?” OT plays an important role in facilitating early mobilization, restoring function, preventing further decline, and coordinating care—including transition and discharge planning.

OT offers a unique perspective and focuses on a holistic view, in which many factors can influence the success of a patient’s recovery and rehabilitation process. “OT practitioners believe that intervention provided for people with physical disabilities should extend beyond a focus on recovery of physical skills and address the person’s engagement, or active participation, in occupation” (American Occupational Therapy Association, 2008). OT uses a systematic process of client-centered evaluation, intervention, and task modification to facilitate progress toward performance-based goals. This process begins by identifying activities the client needs and/or wants to do, as well as analyzing pre-hospitalization role and determining the supportive abilities or barriers to participating in those activities/roles.

In the critical care setting, OT practitioners perform a variety of skilled evaluations and interventions, which are essential to long-term patient wellness post-ICU discharge. The following are some examples of OT interventions in the ICU setting:

  • Evaluate the need for splints and other positioning devices to preserve joint integrity and decrease risk for skin breakdown due to prolonged pressure from bed rest;
  • Perform bedside evaluations to promote safety with eating and swallowing;
  • Train families and caregivers to assist with range-of-motion exercises, safe transfers and mobility, and skin checks;
  • Educate patients on post-surgical protocols, including appropriate weight bearing and other post-surgical precautions during activities of daily living (ADLs);
  • Teach compensatory strategies/techniques and use of adaptive equipment for maximizing independence with ADL function (i.e. teaching hemi-dressing technique after stroke to improve independence with upper extremity dressing, educating energy conservation techniques during ADL performance while patient is on the ventilator, teaching the use of a adaptive feeding utensils to improve feeding independence of a patient with poor grip strength after prolonged bed rest in the ICU);
  • Develop exercise programs and instruct patients, family members, and caregivers in how to use the programs during their ICU stay;
  • Fabricate or provide assistive devices and train patients in their use to promote healing and maximize independence;
  • Teach specific techniques for safety during functional mobility;
  • Teach stress management techniques and the development of coping skills;
  • Evaluate and treat ICU-acquired neurological-cognitive impairment (executive functioning, memory, and attention) to improve functional occupation-based outcomes;
  • Recommend home safety modifications and durable medical equipment during discharge planning.

In addition, OT practitioners understand the interplay between the patient’s needs, abilities, and environment, which assists with the patient’s successful transition to the home, community, or next level of care. OT programs in the ICU can alleviate some of the problems of isolation, sensory and occupational deprivation, and cognitive inactivity, which are risks to long-term wellness. ADL programs, including bed mobility, functional transfers to the commode or toilet, sitting tolerance, and light hygiene can restore a sense of daily routine and personal independence. These programs can also include relaxation techniques in combination with reality-orienting programs to provide organized, patterned stimulation and to develop an increased sense of control. These individualized programs can use client-centered, meaningful tasks to promote cognitive and motor recovery in patients (Affleck, Lieberman, Polon, & Rohrkemper, 1986; AOTA, 2014; Brummel et al., 2012; Brummel et al., 2013; Foreman, J., 2005; Hogan-Kelley, D., 2007; Schweickert et al., 2009).

Acquired Physical and Cognitive Impairment in the ICU

Patients who experience critical illness in ICUs are likely to acquire long-term physical and cognitive impairments, which affect the patient’s ability to function autonomously after discharge from the hospital. Due to bed rest and prolonged immobilization as well as increased use of sedation, patients can develop ICU-acquired weakness and motor/sensory neuromyopathy; sensory deprivation and stress; increased ventilator-dependent days; development of secondary medical complications, such as blood clots, pneumonia, and pressure ulcers; and acute brain dysfunction, manifesting as either delirium or coma. Therefore, occupational therapy has value in this setting and can assist in minimizing these complications.

Long-term physical impairment affects between 25% and 60% of ICU survivors. In addition to physical dysfunction, long-term cognitive impairment can be observed in one half to three fourths or more of ICU survivors. More specifically, delirium – defined as an acute change in mental status and fluctuating course of inattention and disorganized thinking – affects 60% to 80% of patients who are mechanically ventilated and is associated with several adverse outcomes including: prolonged mechanical ventilation, delayed hospital discharge, an increased risk of mortality, and long-term cognitive impairment (Brummel et al., 2012; Brummel et al., 2013; Mendez-Tellez, Nusr, Feldman, and Needham, 2012). Since many patients experience cognitive impairment in addition to physical complications when in the ICU, occupational therapy—in addition to physical therapy—should be incorporated into ICU programs and research studies.

Benefits of Early Rehabilitation in the ICU

Whole-body rehabilitation programs in the ICU—consisting of interruption of daily sedation combined with physical and occupational therapy in the earliest days of critical illness—are safe and well tolerated and result in better functional outcomes at hospital discharge, a shortening of delirium duration, fewer days on the ventilator compared to standard care, and decreased risk of mortality and re-hospitalization (Brummel et al., 2012; Brummel et al., 2013; Mendez-Tellez, Nusr, Feldman, and Needham, 2012).

These early rehabilitation programs demonstrate cost-saving data. One study outlined a length of stay reduction of 22% in the ICU and 19% reduction for the floor patients with a cost-savings of $817, 836. In this study a financial model projects that investment in an ICU early rehabilitation program can generate net financial savings for U.S. hospitals. The projected net cost of implementing an ICU early rehabilitation program is modest relative to the substantial improvements in patient outcomes and cost-saving measures related to decreased length of stays, reduced number of days on the ventilator, and a decreased rate of re-hospitalizations (Lord et al., 2013).

A Peek into the ICUs at the University of Colorado Hospital

The OT department at the University of Colorado Hospital (UCH) strives to advocate for OT services in its six ICUs—neurological (24 beds), medical (24 beds), surgical (10 beds), cardiothoracic (17 beds), burn/trauma (9 beds), and cardiac (12 beds). The OT department recognizes the potential for overlap of services with other disciplines, particularly physical and speech therapy; however, OT is able to differentiate their role among other disciplines and highlight the distinct value of their services to patients and other health care personnel through sound clinical reasoning, appropriate timing of intervention, and occupation-based intervention tailored to patient and family. OT at UCH focuses on any functional deficit that will improve with OT intervention, such as ADL retraining; cognitive, vision, and sensory screening/assessment/treatment; upper extremity splinting, and establishment of routine to maximize functional independence.

When deciding which patients to treat in the ICU setting, the OTs developed an ICU triage system to improve the focus of OT, improve consistency among practitioners, and increase efficiency. The following characteristics have been identified as important for consideration when prioritizing ICU patients:

  • Acute rehabilitation candidacy;
  • Patients who are pending discharge;
  • Ventricular assistive device candidates (VAD) who need pre and post-VAD placement screening for identification of possible brachioplexus injuries, cognitive impairment, and UE dysfunction to determine if the patient will be able to manage the VAD post-operatively;
  • Patients after lung transplant (screening for possible radial nerve injury);
  • Patients with neurological and orthopedic issues (need to be acknowledged, screened, and charted on within 36 hours of initial OT order);
  • Patients with forearm free flaps, for splinting and follow-up
  • Patients with prolonged time on the ventilator (>3 days), general prolonged ICU stay (>3 days), or with greater than three chronic conditions (Hobbs, Boysen, McGarry, Thompson, & Nordrum, 2010).

The OTs at UCH evaluate patients status post coronary artery bypass grafts, aortic valve replacements, mitral valve replacements, video-assisted thoracic surgery, and Whipple procedure on post-operative day two as through practice based evidence it was determined these patients were mostly limited by post-operative pain, cognitive issues related to pain medication with subsequent difficulty remembering precautions instructed on post-operative day one, and numerous lines/tubes limiting what the OT could do on the first day after surgery (i.e. Swan Ganz Cathetor). Therefore, these patients were better suited to be evaluated and treated on post-operative day two.

When determining type of treatment the OT will facilitate in the ICUs at UCH, the Richmond Agitation Sedation Scale (RASS) is used as a guide for treatment. Each level of the RASS scale correlates to a specific treatment regimen. For example, if the patient has a RASS score of -3 or -2, which is moderate to light sedation and movement and eye opening to voice, the OT may perform guided active range of motion/active assist range of motion, ADL retraining (i.e. basic grooming) in bed to chair position, and initiate cognitive re-training (i.e. call light training, basic card game to improve attention, etc.). In addition, if patient scores a 0 or +1 on RASS scale, which is alert and calm or restless, the OT focus may be ADLs in bathroom seated or standing; instrumental activities of daily living (IADLs), such as medication management, financial management, self-care strategies; OT functional cognitive screen (Cognistat, Montreal Cognitive Screen, or Allen’s Cognitive Level Screen), and cognitive behavioral retraining (Ely et al., 2003; Sesslar et al., 2002).

UCH has established an ICU Progressive Mobility Program for nurses to assist with mobilization of patients. The nurses are responsible for following this protocol to determine at which level their patient should be mobilizing, such as positioning patient in chair mode in bed, sitting edge of bed, transferring to chair, and ambulating around room/unit. The nurses are provided with inclusion criteria for mobilization, including neurologic, respiratory, and cardiac stability as well as exclusion criteria including but not limited to unstable intracranial pressure (ICP) or presence of femoral sheaths (Perme & Chandrashekar, 2009; Timmerman, R.A., 2007) . The progressive mobility program allows OTs and PTs to focus on treatment beyond the scope of routine mobilization of each patient.

To maximize safety during OT intervention, UCH has recently developed an ICU competency program for new staff members. Ideally, the OTs will mentor a trainee for approximately three months and be available to answer any ICU-related questions. The ICU therapists (PTs and OTs) have developed an ICU Skills Check List so that the trainee has to identify each line (i.e. standard monitoring, tubes, ICP monitoring, cardiac support devices, oxygen delivery devices, and mechanical ventilation). The trainee also has to understand hemodynamic monitoring, delirium/sedation monitoring, and common medications used in the ICU.

Conclusion

It is encouraged to consider use of the ICU program at UCH as a model for the development of both early rehabilitation programs and patient management. OT has a distinct and valuable role in the ICU setting – facilitating minimization of physical and cognitive impairment as well as optimization of overall functional patient outcomes, while reducing institutional financial burden. It is essential that OTs advocate for their role in early ICU intervention programs in their respective hospitals in order to ensure that the value of OT is not overlooked; and more importantly, so that patients receive comprehensive, quality care as they begin their journey to recovery.

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About the Author

Melissa Sixta, OTD, OTR/L is an occupational therapist at the University of Colorado Hospital (UCH), which is a 568-bed teaching hospital in Aurora, CO. Melissa graduated with her Doctorate in Occupational Therapy at Creighton University in Omaha, NE in 2009. She has experience working in acute care, sub acute and acute rehabilitation, and outpatient therapy. Melissa is currently the Student Program Coordinator at UCH. She is also the Public Policy Chair and Board Member for Occupational Therapy Association of Colorado (OTAC). In 2013 she was on the Legislative Committee of which contributed to passage of licensure for occupational therapy practitioners in Colorado. She is published in the Journal of Neurotherapy, OT Practice, and has contributed to a chapter in OT Manager.

References

  1. American Occupational Therapy Association. (2008). Occupational therapy’s role in acute care. Retrieved from aota.org.
  2. Affleck, A.T., Lieberman, S., Polon, J., & Rohrkemper., K. (1986). Providing occupational therapy in the intensive care unit. AJOT. 40(5). 323-332.
  3. Brummel, N.E., Girard, T.D., Ely, E.W., Pandharipande, P.P., Morandi, A., Hughes, C.G., Jackson, C.G. (2013). Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: The activity and cognitive therapy in ICU trial. Intensive Care Medicine.
  4. Brummel, N.E., Jackson, J.C., Girard, T.D., Pandharipande, P.P., Schiro, E., Work, B., … Ely., W. (2012). A combined early cognitive and physical rehabilitation program for people who are critically ill: The activity and cognitive therapy in the intensive care unit (ACT-ICU) trial. PT Journal. 92(12); 1-13.
  5. Ely, E.W., Truman, B., Shintani, A., Thomason, J.W., Wheeler, A.P., & Gordon, S. (2003). Monitoring sedation over time in ICU patients: The reliability and validity of the Richmond agitation sedation scale (RASS). JAMA. 289; 2983-2991.
  6. Foreman, J. (2005). Occupational therapists’ roles in intensive care. OT Now. 15-18.
  7. Hobbs, J., Boysen, J., McGarry, K., Thompson, J., & Nordrum, J. (2010). Development of a unique triage system for acute care physical therapy and occupational therapy services: An administrative case report. Physical Therapy. 90; 1519-1529.
  8. Hogan-Kelley, D. (2007). Occupational therapy frames of reference for treatment in the ICU. Retreived from aota.org.
  9. Lord, R.K., Mayhew, C.R., Korupolu, R., Mantheiy, E.C., Friedman, M.A., Palmer, J.B., & Needham, D.M. (2013). ICU early physical rehabilitation programs: A financial modeling of cost savings. Critical Care Medicine. 41(3); 717-724.
  10. Mendez-Tellez, P.A., Nusr, R., Feldman, D. & Needham, D.M. (2012) Early rehabilitation in the ICU: A review for the neurohospitalist. The Neurohospitalist. 2(3); 96-105.
  11. Perme, C., Chandrashekar, R. (2009). Early mobility and walking program for patients in intensive care units: creating a standard of care, AJCC, 18(3); 212-21.
  12. Sessler, C.N., Gosnell, M., Grap, M.J., Brophy, G.T., O’Neal, P.V., & Keane, K. A. (2002). The Richmond agitation-sedation scale: Validity and reliability in adult intensive care patients. American Journal of Respiratory Critical Care Medicine. 166; 1338-1344.
  13. Schweickert, W.D., Pohlman, M.C., Pohlman, A., Nigos, C., Pawlik, A.J., Esbrook, C.L., Kress, J.P. (2009). The Lancet. 373 (9678); 1874-1882.
  14. Timmerman, R.A. (2007). A mobility protocol for critically ill adults. Dimens Crit Care Nurs, 26(5); 175-9.

 

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3 responses to “Patient Management and Prioritization in the ICU: A Model for Consideration”

  1. Amy says :

    Where is the linked RASS tool that was discussed? Thank you.

    Liked by 1 person

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