The Critical Role of Occupational Therapy in the Intensive Care Unit
Occupational therapy has a unique and important role in the intensive care unit (ICU). A history of OT in the ICU, the environment, specialized equipment, diagnoses, and the importance of OT’s contribution in the ICU, as well as evaluation and intervention, will be covered in this article. Early treatment proposes the opportunity to decrease ICU length of stay (LOS), hospital LOS, and readmission rates (Deng et al., 2020; Falkenstein et al., 2020).
The Role of Occupational Therapy in the Intensive Care Unit
In the United States, admissions to the intensive care unit (ICU) are 4.1 million a year for people over the age of 18 with a high rate of survival (Weinreich et al., 2017). Patients are admitted initially for critical injury, surgery, or disease in the ICU due to medical instability. Care is multifaceted, offering specialized nursing, surgeons, and physicians 24 hours a day (Clark, 2017).
The ICU Environment
The intensive care unit is a highly specialized area for the treatment of life-threatening conditions. The medical team operates equipment to monitor the patient’s vital signs and bodily functions. Each room has a specialized patient bed set up with multiple system hook ups, a curtain for privacy and rooms have a curtained bathroom plus an area for the family member(s) to participate or observe (Clark, 2017).
Diagnoses Typically Seen in the ICU
Life-threatening conditions admitted to the critical care unit include (in order of typical occurrence):
1. Pulmonary conditions requiring mechanical ventilation
2. Cardiac disorders telemetry closely monitors
3. Post-surgical complications with respiratory or cardiac involvement
4. Systemic infections are treated with an inflammatory response causing cardiopulmonary compromise.
5. Neurologically based conditions include, cardiovascular accidents, traumatic brain injuries, and spinal cord injuries (Clark, 2017)
Monitoring Vital Signs in the ICU
Vital signs are closely monitored with these invasive and non-invasive devices:
- Urinals and hats for output measurement
- Telemetry with imaging
- Blood pressure instruments with sphygmomanometers
- Pulse oximetry
- Oral or axillary temperature gauges
- Foley catheters or rectal tubes for output,
- Central lines and pulmonary catheters,
- Intracranial pressure gauges with extra ventricular drains or bolts, and
- Blood pressure with arterial lines (Clark, 2017, p.117).
OT’s Role in Reducing ICU-Acquired Weakness
Critically ill patients have commonly experienced general weakness (ICU-acquired weakness) created by mechanical ventilation more significant than five days and the immobilization in the ICU (Clark, 2017). Some studies relate the critical illness immobility to a neurological myopathy if muscles are affected or polyneuropathy if sensory innervation is limited.
According to Clark (2017), “ICU-acquired weakness is a generalized weakness developed during critical illness for which there is no explanation except the critical illness itself” (p.125). Occupational therapy is an essential component with early mobilization to prevent patients from acquiring ICU-acquired weakness (Falkenstein et al., 2020).
Occupational Therapy and ICU Delirium
Like ICU-acquired weakness, ICU delirium can result from acute cognitive disruption from altering states of alertness, medications, sleep cycle disturbances, and loss of natural light. The occurrence of delirium in the ICU is 30-60%, with 80% of those incidences are from those who received mechanical ventilation (Deng et al., 2020).
Delirium can increase hospital length of stay, readmissions, and mortality. OT is truly unique in offering early treatment, including cognitive processing, early sensory integration, and functional performance of daily activities while also addressing early mobilization.
The History of Occupational Therapy in the Intensive Care Unit
Occupational therapy (OT) and physical therapy (PT) are components of the medical rehabilitation team and grouped as one profession in the literature. Solely recorded OT has been in the ICU since 2005 (Weinreich et al., 2017). This study suggests this profession has been in the ICU since the early 1900s but only recognized with physical therapy (PT).
Evidence indicates OT is a feasible, safe, and valuable component to the medical team in critical care. The authors promote further research solely for occupational therapy evidence-based practice (Weinreich et al., 2017). OT education in physical, psychological, and social sciences place the therapist in a distinct role for the patient and family care in the ICU (Clark, 2017).
The intensive care environment with multiple tubes and monitors is challenging to manage initially. Constant alarms sounding and lights flashing to monitor all the critical care patients’ vital signs can be difficult for the new therapist Clark (2017). Experienced therapists suggest collaboration with the patient’s nurse is vital because they know what the team priorities are to monitor specific to the individual at that time.
Recommendations are any referred service and team collaboration, consult the nurse first on the patient’s status, and how much activity the patient can tolerate Clark (2017). The nurse also knows the current team objective to progress the patient, or they communicate if a treatment session is contra-indicated. Team collaboration is essential in the ICU due to the patient’s critical state and the specialized equipment (Clark, 2017).
Occupational Therapy Evaluation in the ICU
The traditional occupational therapy process involves assessment, treatment planning, goal setting, and intervention with performance-based measurements documented for comparison. Risk factors affecting critical care are the patient’s medical stability, cognitive skills, restrictions of the vital parameters, activity prescription, and the attached lines.
The OT evaluation at the primary level, according to Clark (2017), “Therapists collect the following data: Vital signs before, during and after the session; Cognition and vision; Range of motion; and, Basic activities of daily living; noting the position of the patients and attached lines, tubes and drains” (p. 125).
If the family is present, it helps determine the set-up of the patient’s home, relationships, and prior level of function for daily living activities—cognition, delirium, and pain assessments.
Goal Strategizing and Occupational Therapy Intervention
In the ICU, goals are short term to show progression in therapy (Clark, 2017). For example, the patient attempts to keep their eyes open for 60 seconds after scanning to determine an object’s location. The completion of an entire activity in one session is often more activity than the patient can tolerate; therefore, attending to a portion may be the initial focus then build-up to the entire task. Patient increased activity tolerance can be another goal set, for instance, the mobility advance to sitting tolerance with the bed at sit mode, with no dizziness for a certain amount of time (Falkenstein et al., 2020).
Findings to prevent delirium also place OT at the forefront with incorporating family participation (Deng et al., 2020). This study’s findings indicate family participation has positive effects on patient recovery with reinforcement by the family.
OT educates the family to assist management for instance, decreasing patient agitation with a familiar voice. The relative increases patient awareness, short-and long-term recall for cognitive processing by sharing past event memories. Improved awareness increases patient motivation to participate in functional activities, such as, pursed lip breathing or self-feeding. These tasks require the endurance and strength to sit upright for therapy progression and thought processing with sensory input Deng et al. (2020).
Prescribed exercise programs support the early movement, cognitive processing, and functional activities to progress the patient toward daily living’s (ADLs). Family education in medical literacy increases family confidence in care-giving and psychological support for patient healing Deng et al. (2020); Falkenstein et al. (2017).
The Early Mobility Program (EMP) is a multi-disciplinary project promoting team collaboration for critical care. The program develops daily mobilization standards with a mobility scale that recognizes activity tolerance parameters, increased team communication, and focusing on the patient. Due to increased team involvement, nursing participates at levels 1 and 2, which require less mobility and build up patient endurance for upright positions. This progression allows patient participation in PT and OT to increase patient skills for gait and functional ADLs. The EMP has positive team-building components for patient-centered care (Falkenstein et al., 2020).
Occupational therapy in the ICU has exclusive education as a vital component to the medical team to approach the patient and their family holistically. The involvement of sensory-motor integration with cognitive processing and graded motion minimize delirium. Improved patient awareness decreases the length of days on mechanical ventilation, one of the significant barriers in critical care.
Incorporation of early mobility with functional activities evolves into the performance of necessary activities of daily living and eventual instrumental tasks such as medication management. OT has evidence of decreased hospital readmissions (Rogers et al., 2017).
Early OT intervention can prevent future debilitation, minimize depression, prevent the overall weakness associated with immobilization, and regain higher-level skills for functional return to the community. Increased occupational therapy is a cost-effective service for patient-centered care and return of investment for the organization.
Clark, K. (2017). Intensive care unit. In Smith-Gabai, H., and Holm, S. E. (Eds.), Occupational Therapy in Acute Care (2nd ed., Chapter 9). Occupational Therapy Association Press.
Deng, L.-X., Cao, L., Zhang, L.-N., Peng, X.-B., & Zhang, L. (2020). Non-pharmacological interventions to reduce the incidence and duration of delirium in critically ill patients: A systematic review and network meta-analysis. Journal of Critical Care, 60, 241–248. https://doi.org/10.1016/j.jcrc.2020.08.019
Falkenstein, B. A., Skalowski, C. K., Lodwase, K. D., Moore, M., Olowski, B. F., & Rojavin, Y. (2020). The economic and clinical impact of an early mobility program in the trauma intensive care unit: A quality improvement project. Journal of Trauma Nursing, 27(1), 29-36, https://doi.10.1097/JTN.0000000000000479
Rogers, A.T., Bai, G., Lavin, R. A., & Anderson, G. F. (2017). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review, 74(6), 668-686. https://doi.org/10.1177/1077558716666981
Smith, K., Day, M., Muir, S., & Dahl-Popolizio, S. (2020). Developing Tailored Program Proposals for Occupational Therapy in Primary Care. The Open Journal of Occupational Therapy, 8(1), 1-13. https://doi.org/10.15453/2168-6408.1630
Weinreich, M., Herman, J., Dickason, S., & Mayo, H. (2017). Occupational Therapy in the intensive care unit: A systematic review. Occupational Therapy in Healthcare, 31(3), 205-213, https://doi.org/10.1080/07380577.2017.1340690