Occupational Therapy in the ICU: An Interview with an ICU OT

I’m excited to showcase My OT Spot’s first interview with an Intensive Care Unit (ICU) Occupational Therapist, Abby Lefkove, OTR/L. Occupational therapy in the ICU is a subset of acute care that entails working with medically fragile patients and their families while they are in the ICU.

In this interview, Abby tells us about what a typical occupational therapist in the ICU’s job looks like, along with recommendations for those who are interested in working in the ICU or are about to start an ICU rotation.

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Tell us a bit about your background. 

My name is Abby Lefkove and I’ve been an OT for several years at a community-based hospital in Decatur, GA, where I started in acute care. I moved into the ICU about a year ago and I’m now primarily in the ICU, depending on our census. I also have a passion for adaptive rock climbing.

What typical diagnoses do you see in the ICU?

Our ICU is very mixed. We have a lot of patients in respiratory distress or failure, COPD or CHF exacerbation, along with severe sepsis with organ failure. We also see patients following a myocardial infarction or those who have had a major surgery and need ICU monitoring. Every stroke patient given TPA comes to the ICU for monitoring.

A lot of the neurosurgical interventions like the patients post-craniotomy will come to the ICU and they’ll usually spend a day or so. People with carotid endarterectomies will also come to us.

We also see a good amount of people detoxing and a fair amount of people who have transferred back from our LTACH that have gotten sicker.

Patients may also transfer down because of a drip, like a Cardizem, Levophed, or insulin drip. These patients can be higher level and look like a floor patient except for the fact that they have something unstable about them. We also have a lot of patients with encephalopathy. Overall, we have a BIG mix of diagnoses.

What types of OT interventions do you typically do as an ICU OT? 

It can depend. For patients who are awake/alert, I like to push their mobility as much as I can whether it’s get to a chair, walk to the toilet, wash up at the sink, like you would in the rest of acute care. That is for people who are more stable and can tolerate it.

For patients who are less stable, I’ll usually keep interventions at bed level in chair position or at edge of bed. For patients on a ventilator who I know are awake and able to, I try to get them to a chair or get them on a bedside commode. I may also do a simple bath at the edge of the bed, work on improving their range of motion, get their stimulation up, and make sure they don’t lose strength while in the hospital.

What types of interventions do you do with lower level patients?

For lower level patients, I’ll try to get them to follow basic commands if they are awake. I start with very simple therapeutic exercise, i.e. trying to include a little core control, stay midline in chair position, and/or try to reach forward some and pull their back off the bed to prepare for moving during ADLs.

I also work with rolling, oftentimes with the patient care techs if the patient needs to do a bed bath and be alert for that. I also provide a lot of education with the PCTs and caregivers on how to appropriately handle neuro patients. I do see a lot of people still pulling on patient’s arms and educate them to try to stop that.

And then sometimes I’ll bring a simple communication board to work on pointing to different things, especially on vented or trached patients who aren’t capped and can’t talk.

I really like to make moving a priority. Patients in the ICU are going to get so much out of moving even if they sit at the edge of the bed for 5 minutes. This activity is very stimulating and makes all of their muscles work so much.

What would you tell a new OT grad or student who is going to be in the ICU?

First off, you want to be really strong on the medical floors first because you need the foundation of what is acute care and what are the goals in acute care.

So is the goal for the patient to get into placement, go home, get back to rehab or is it to get through something new that’s happened in life? And then in the ICU your understanding of lab values, surgical procedures, precautions, tests, imaging and pulmonary status are REALLY important.

Pulmonology is probably the biggest area to learn more about that’s going to be really helpful for vent-dependent patients who can be in any ICU. This is regardless of the specialty, whether its medical, surgical, neuro, or cardiovascular. That’s going to be a driving force, if someone is vent-dependent. You also need to know with the settings what you can push and when you have to dial it back, and how occupational therapy fits into everything else they have going on.

In the ICU, do you provide a good amount of family education?

All of the time, if they’re there. It can be kind of a “read the situation if they’re there” and if the family is willing to accept it. Not everyone is willing to accept it.

I’ll do a lot of education with neuro patients, like educating their family on having them attend to their inattentive side, talking to them to try to stimulate them and help to make them aware of what’s going on. I’ll talk to caregivers about keeping the lights on when it’s daytime and turning the lights off when it’s nighttime.

Discussing the rehab process early is also important. I’ll talk to the families about what the process is going to look like, and I’ll start the rehab conversation early. I might say something like “I know your mom is very sick and is in the ICU, but she’s getting better day by day and eventually we’d like to send her to rehab.”

Conversely, if a patient is going downhill, the family might be interested in going home with hospice instead of a rehab facility. They want their family member to have a peaceful death at home. I’ll still talk to the family about letting their family member do as much as they want at home because even though people are really ill, they still might have things they want to do. It’s not just about laying in the bed. It’s allowing them to still have meaning in their life to what’s important.

I had a conversation like that with a woman the other day who bounced in and out of rehab, went back home then back into the hospital due to abnormal lab values. I asked her what her ultimate goal was, and it was “I want to be able to cook my cornbread.” So I broke down the steps of what she would need to do and the family could just not wrap their head around it. It took a lot to explain that this is what brings this woman fulfillment, and who cares if she can put on her pants and use a toilet as long as she’s doing something that she wants to do.

Do you find yourself using any equipment in the ICU?

I’m usually pretty minimalist. I use my gait belt depending on whether or not the patient has chest tubes, a central line, or just too much stuff going on. The cardiac chair is really important along with the Sara Stedy.

I also incorporate bedside commodes, walker, or the cardiac/platform walker, if the patient doesn’t have very strong arms to bear down on a traditional walker. Rarely do I bring in the hip kit in the ICU.

If the patient needs a built up utensil, I’ll show the nurses how to build the plastic utensils up with tape to an appropriate size for the person so they can better feed themselves. I encourage patients to keep the hard plastic cups from their tray if they have a hard time with the styrofoam or soft plastic cups.

What typical lines and tubes do you typically see while working with patients?

We see peripheral IVs, central venous catheters, PICC lines, vas-caths, chest ports, nasogastic tubes, radial arteral lines, orogastric tubes, endotracheal tubes. We also see tracheostomies, foley catheters, condom catheters, rectal tubes, rectal pouches, and ostomies. Big abdominal surgeries will have drainage to suction.

Patients might have tubes and ports from every direction, so it’s important to learn what these are before starting in the ICU.

[For more information, be sure to check out this article from University of Wisconsin titled “Equipment you may see in the ICU” and this PowerPoint: “Lines, Tubes, and Drains to Recognize, Evaluate and Treat.”] 

Do you have any final tips for a new ICU occupational therapist?

When in doubt, don’t do it. Be conservative.

It’s okay to be aggressive with interventions in the ICU if you’re comfortable in the setting, but if you’re not, then absolutely be conservative and you will not potentially be doing harm.

And along with being familiar with the lines and tubes, be sure to learn what the vital signs mean on the monitor and to understand the trends in vitals. Once you get comfortable in the setting, don’t be afraid to try new things!

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I want to give Abby a huge thanks for giving such a great rundown of what working in the ICU is like for OTs. If you’re an OT interested in working in the ICU, I hope this gave you a good starting point of what to expect.

For more on interventions in the ICU and the general acute care setting, also be sure to check out our e-book available now: Occupational Therapy Intervention In Acute Care.