Occupational Therapy News OTnews April 2019 | Page 17

CRITICAL CARE FEATURE
C
ritical care is provided for patients with acute life-
threatening injuries and illnesses who require organ
support and monitoring by highly specialised staff.
Critical care includes intensive care units (ICU),
ventilator weaning units (VWU) and high dependency units (HDU).
Growing evidence highlights the impact on patients and their
families of a critical care admission, termed post-intensive care
syndrome (PICS).
A recent UK study found that ICU and VWU patients were
inactive for 96 to 100 per cent of the day (Connolly et al 2017).
Occupational therapists recognise the value of occupation in
promoting health and therefore the impact of occupational
deprivation in critical care (Howell 1999) as contributory to PICS.
Evidence and the occupational therapy role
Historically, occupational therapists have had little presence in
critical care, despite the role being discussed in literature for 20
years (Howell 1999). The evidence for early rehabilitation includes
occupational therapy (Schweickert et al 2009; Corcoran et al
2017), however it is rare for critical care units to have full funding
for occupational therapy provision. High quality evidence for
occupational therapy within critical care is required.
Occupational therapists can help to foster an enabling
environment by promoting engagement in everyday activities with
families, nursing staff and other therapy professionals. Patients are
assisted by occupational therapists to re-engage with physical and
social environments through interventions to increase familiar sensory
input, alertness and awareness. This helps them to regain access to
meaningful occupations.
Interventions completed by occupational therapists within Guy’s
and St Thomas’ Hospitals critical care units include:
• information gathering: gaining a holistic picture of the person
prior to critical care admission;

• goal setting: person-centred goals, coming from the patients’
wishes or communication with the family, related to occupations
that are important to them;
• personal care: daily activity practice (grooming, washing,
dressing, showering and make up application) and grading tasks
(starting with hand over hand and building up to independence);
• family Involvement: encouragement to participate in all the
above;

• sensory stimulation: familiar sounds, music, family voices,
touch, objects and different materials;

• cognitive stimulation: re-orientation regularly by the whole
team; whiteboards are used for orientation and familiar photos;
recognition and use of everyday objects; memory rehabilitation;
higher level cognitive reha-bilitation, using games such as cards,
board games and word searches; and completing patient diaries
for use after discharge;

• upper limb: 24-hour positioning using blankets, thermoplastic
splints/casting, ensuring full range in dif-ferent positions;
stretching and oedema massage if required; and rehabilitation
through occupations;
•
seating and positioning: specialist assessment for 24-hour
positioning recommendations and assessment and provision of
specialist seating; and

• communication: Working with speech and language therapists
– compensatory/adaptive strategies to improve communication
and use of technology.
Life after critical care
The impact of PICS reaches far beyond the hospital stay and
the bearing on re-engagement in occupations is now also being
recognised. Instrumental activities of daily living have been
reviewed in the critical care population, but a recent systematic
review (Hopkins et al 2017) suggested that risk factors for
reduction in occupational performance need to be explored.
The return to work rate is poor, with only 55 per cent of
previously working individuals returning to work one year after
discharge (Myhren 2010). This has a negative impact financially on
patients, families and the state (Griffiths et al 2013). This reduces
their access to occupations further, which can affect their physical
and mental health.
Guy’s and St. Thomas’ Hospitals Critical Care Recovery Clinic
(NICE 2017a) has been fully commissioned since August 2016.
The clinic runs fortnightly and provides a comprehensive follow-up
at three months post-discharge (NICE 2017b).
The team includes a consultant, nurse, healthcare assistant,
occupational therapist, physiotherapist, psychologist and
psychiatrist, as well as access to a dietician, speech and language
therapist and pharmacist.
Occupational therapists complete a full initial assessment jointly
with the clinic physiotherapist. This is to gather information from
the patient and their families relating to their daily occupations,
returning to previous roles, return to basic activities of daily living,
domestic tasks, community activities and return to work or
education.
Many patients, particularly those who have had extracorporeal
membrane oxygenation (ECMO), are young and have families, so
these roles are important to focus on.
Service evaluation
From September 2016, a 12-month prospective service evaluation
(Firshman et al 2018) was completed by the clinic occupational
therapists: 76 per cent of the patients required occupational therapy
intervention; and 59 per cent required advice, including fatigue
management, returning to work, cognitive strategies, environmental
adaptation, financial signposting and driving advice.
Education and resources were provided during the
appointments, alongside signposting to other services for benefits
advice, legal rights (including employer obligations and sick pay)
and returning to work.
Letters of support were also provided for applications for
benefits, blue badges, and to assist employers with managing
phased return to work; just under half of patients (46 per cent) were
referred to community rehabilitation teams, vocational rehabilitation,
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