REHABILITATION FEATURE restoration of services , the team turned its focus to patients ’ aftercare in the community .
‘ We knew there was a gap in ongoing rehabilitation ,’ she says , ‘ and , in agreement with management , we felt well placed as providers , with our neurology background and mindset of longerterm rehabilitation . Due to service reconfiguration , we had the capacity to deliver this innovative practice and continuity of care .’
She adds : ‘ We had the opportunity to develop our pathway and referral criteria in the absence of any guidelines . We identified the need for a flexible length of input , due to the unknown recovery trajectory , and were fortunate to not be bound by timescales .
‘ Although there was a focus on virtual therapy , due to these patients having had the virus , and our understanding of their ongoing needs , we risk assessed that face-to-face rehabilitation was needed to maximise their functional recovery .’
The criteria were that people lived within the East Birmingham catchment area and that they had been treated on one of the trusts ICUs , having received either mechanical ventilation or Continuous Positive Airway Pressure ( CPAP ).
‘ We identified a caseload of approximately 60 patients who were initially telephone triaged to start evaluating individual level of need ,’ she says . ‘ Face-to-face assessment visits were then carried out , treatment plans discussed , and patient focused goals agreed .
‘ The group ’ s age range went from late 30s to early 70s , and most had been very high functioning and independent .’
The evolving occupational therapy role Clare reflects that her role has ‘ involved a holistic approach , encompassing physical , cognitive and psychological interventions to treat complications from both the virus and critical care itself ’.
She explains : ‘ Due to the unpredictability of the virus , realistic goal setting and determining long-term outcomes has been a challenge , however this reinforced the need for a functional approach .
‘ Many people had significant initial impairments , only being able to transfer or mobilise very short distances indoors , and stairs were unachievable for some . I have been working on their abilities within tasks such as personal care , meal preparation and housework , and many are now able to function independently within the home .’ She notes that ‘ evidence is emerging of prolonged fatigue and breathlessness and , for most of my patients , this has been significant ’.
In order to manage people ’ s activities of daily living Clare says she has needed to educate on the principles of pacing and grading , to support energy conservation . ‘ There have been common emotional responses of frustration and worry as to why their energy levels aren ’ t improving quickly and an eagerness to progress ,’ she says . ‘ More recently , vocational rehabilitation has become an element of my role for those who feel ready and are seeking the normality of resuming employment .’
She adds : ‘ The impact on the upper limb , thought to be due to proning and post-intensive care complications , has restricted movement functionally in a number of patients . Combined with trunkal weakness and breathlessness , the shoulder complex has been a challenge to treat .
‘ My role has been to support the functional use of the upper limb once the patient has gained sufficient muscle activity , linking in with the physiotherapists in the team .’
Flashbacks and vivid dreams of critical care have been significant for many of the patients , she says . ‘ I had not had prior exposure to this , and as a team we have received regular sessions with a hospital psychologist to gain clinical advice .
‘ I have learnt to focus on validation and normalising , by helping make links to critical care scenarios and the delirium they experienced . This then supports acceptance that they are an effect of critical care and should lessen in time .
‘ Disempowering the flashbacks and dreams and changing their relationship with them has also been important , discussing altering the emotional responses of frustration , anger and worry , to approaching them as non-threatening and with intrigue .’
The majority of Clare ’ s patients have ongoing cognitive difficulties . ‘[ They ] present differently , in part , from my usual stroke and acquired brain injury patients ,’ she says .
‘ The lack of an evidenced standardised cognitive screen has given me the opportunity to use my knowledge to creatively and effectively assess them using functional observation , remedial activities , and analysis through conversation , and also to identify common themes .
‘ Their abilities in tasks such as personal care and meal preparation are unaffected and they are all at an overall high level of functioning in their daily lives . However , many are experiencing altered attention , clarity of their thoughts and cognitive fatigue ; some commenting on a “ brain fogginess ”.
‘ There have been difficulties with executive skills , such as planning , organisation and flexible thinking , with one gentleman referring to himself as “ chaotic ”. A few have problems with formation and recall of new memories and word finding problems . This altered cognitive presentation is another element where cause and recovery is not yet clearly known .
‘ I have taught compensatory strategies , alongside carrying out remedial and function based rehabilitation . I have found it important to educate on cognitive fatigue to the same extent as physical , as it can create difficulties if not well managed .’
In addition , some of Clare ’ s patients developed anxiety , low mood and the signs of post-traumatic stress disorder . ‘ I have acknowledged my scope of practice and professional boundaries here , seeking education and guidance from the hospital psychologist and identifying a need for onward referral for some patients ,’ she stresses .
‘ My role has involved listening to their traumatic lived experience , emotions around their current self , and uncertainty of their recovery and the future . Many recall the conversation with the medical team , to which they consented to being ventilated ,
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