Occupational therapy in the ICU - CIUSSS du Centre-Ouest ...

OCCUPATIONAL THERAPY IN THE ICUCLINICAL PLACEMENT 2B PROJECT

ANNIE PETTORELLI, SCHOOL OF PHYSICAL AND OCCUPATIONAL THERAPY, MCGILL UNIVERSITY

SUPERVISED BY JOELLE BÉRUBÉ DUFOUR

JEWISH GENERAL HOSPITAL, PHYSICAL MEDICINE

FEBRUARY 22, 2017

LEVELS OF CRITICAL CARE

Critical Care Programme: AHP and HCS Advisory Group, The Role of Healthcare Professionals within Critical Care Services, June 2002 (http://www.ukcpa.org.uk/ukcpadocuments/5.pdf)

LEVEL 3 CRITICAL CARE –ROLE OF OT

Prevent complications and overcome/adjust to the physiological effects of organ system failure

Positioning to prevent contractures, joint deformity, and pain

Orthosis fabrication

PROM exercises

Advising and teaching nursing staff techniques for positioning and handling

Assess for and provide appropriate seating, including WCs

Pressure sore prevention through the provision and management of appropriate pressure relieving devices

Improve ROM, power, and control through activities and exercises



Facilitate Pt to overcome and adjust to the psychological impact of organ system failure and loss of function

Provide reassurance and support to Pt and carers

Assist Pt and carers in understanding Pt’s condition and cope effectively

Explore and assist Pt and carers in adjusting to the potential changes in relationships

Assist Pt to reduce stress factors and develop coping strategies, e.g. anxiety management, relaxation techniques

Help Pt and family plan for the future

Overcome the effects of cognitive and perceptual dysfunction through retraining and the use of compensatory techniques



Begin the process which enables Pts to take control of their life, adapt to loss of function, and maximize their

ability to carry out everyday tasks

Assessment and training in basic self-care activities, e. g. eating, toileting, grooming

Advise on energy conservation and fatigue management techniques

Assessment and facilitation for the provision of equipment and adaptations to the environment to aid ADLs

To assist the Pt in the their management of a meaningful lifestyle including at a basic level, sensory stimulation and providing

meaningful activity while in hospital and at a higher level, engagement in leisure pursuits and work

Provide information to enable Pt and carers to access appropriate resources



Interventions include all those in level 3 and in addition

Review and grading and treatment, e. g. providing orthoses to prevent contractures for night use only if Pt is more active

during the day

Education and recommendations on ADL management and post surgery precautions


EQUIPMENT

https://www.chestercountyhospital.org/patient-and-visitor-information/patient-information/visiting-the-critical-care-unit-ccu/ccu-equipment

CHART REVIEW

Ventilation

First line options

Standard nasal cannula: low flow oxygen, 1-6 L/min

Venturi mask: high flow enriched oxygen, provides fraction of inspired oxygen (FiO2) 24-40%

Second line options

Simple face mask: FiO2 40-60%

Reservoir cannula: improves oxygen delivery efficiency

High flow humidified oxygen: nasal or transtracheal, deliver oxygen comfortably from 30-60 L/min

Non-invasive ventilation

Continuous positive airway ventilation: provides continuous positive pressure (CPAP)

Bi-level positive airway ventilation: provides pressure on inspiration and expiration (BiPAP)

Invasive ventilation

Mechanical ventilation: non-weaning (continuous) vs weaning modes (spontaneous)

Trach colllar weaning mode ventilation: consult RT before session.

Evangelist, M., Gartenberg, A. (2016). VITALS: A toolkit for developing an occupational therapy program in the ICU, Rusk Rehabilitation, NYU Langone Medical Center. Presented at the 5th Annual Johns Hopkins Critical Care

Rehabilitation Conference, Baltimore, MD.

CHART REVIEW

Activity orders

Bed rest: may be indicated with new DVT or PE, cerebrospinal fluid leak, or internal bleed

Imaging

Chest X-ray (CXR): identifies pulmonary edema or atelectasis

Ultrasound: e. g. to rule out deep vein thrombosis (DVT)

MRI: e. g. identifying new brain bleed

Computed Tomography (CT): e. g. to identify pulmonary embolism (PE)

Lab results

Hemoglobin <7 and hematocrit <24: consider therapy in bed only, plans for transfusion, norms for specific patients or diagnoses

Potassium <5: consider therapy in bed only, assess trend, check recent EKG, read cardio note

Sodium <130 or >150: consider therapy in bed only, assess trend, check recent EKG, read cardio note, and assess changes in mental status



MANAGING TUBES, LINES, AND DRAINS

Central venous line (CVL): ensure dressing is secure

Arterial line (ART line): avoid joint flexion at insertion site

Venous and arterial femoral catheters: okay for out-of-bed activity, avoid prolonged hip flexion

Femoral hemodialysis catheter: okay for out-of-bed activity once catheter has been in place for 24 hrs

Femoral intra-aortic balloon pump (IABP): no out-of-bed activity

Pulmonary artery catheter (i.e. swan-ganz): okay for out-of-bed activity, use caution with UE ROM

Transvenous or epicardial pacemaker: okay for out-of-bed activity with stable underlying rhythm, out-of-bed contraindicated with dependent rhythm

Post-pacemaker insertion restrictions: no shoulder flex past 90 degrees, no lifting, pulling, or pushing on affected side for 4 weeks

Extracorporeal membrane oxygenation (ECMO): okay for in-bed activities. If not single bicaval, defer out of bed

Continuous renal replacement therapy (CRRT): okay for out-of-bed activity

Endotracheal tube (ETT): okay for out-of-bed

Tracheostomy tube: okay for out of bed. Notify RN immediately if loosened or dislodged during session

Pigtail in place: no WC self-propelsion



CONTRAINDICATIONS TO INITIATING OT IN THE ICU

Mean arterial pressure <65, >110, normal MAP = 70-90 mmHg

Systolic BP >180 mmHg, >20% decrease in SBP/DBP; orthostatic hypotension

Heart rate <40, >130 beats/min, >20% decrease in resting HR

Respiratory rate <5, >40 breaths/min

Pulse oximetry <88%, >4% decrease

High sedation level, RASS ≤-3

Pt agitation requiring increased sedative administration in the last 30 mins, RASS >2

Evidence of elevated intracranial pressure

Active gastrointestinal blood loss

Active myocardial ischemia

Patient-ventilator asynchrony

Patient c/o intolerable DOE

Insecure airway (device)

Patient refusal

Adler, J. & Malone D. (2012). Early mobilization in the Intensive Care Unit: A systematic review. Cardiopulmonary Physical Therapy Journal, 23(1), 5-13.

Pohlman, M. C. et al. (2010). Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med 38, 2089-2094.

MENTAL STATUS ASSESSMENTS IN THE ICU

Richmond Agitation Sedation Scale (RASS)*

Measures agitation and sedation and is the first step of administering the CAM-ICU. Often used with patients on mechanical

ventilation to help determine the adequate level of sedative medication.

Confusion Assessment Method for the ICU (CAM-ICU)*

Delirium screening tool for use in the ICU.

Rancho Los Amigos Level of Cognitive Functioning

System by which the level of head trauma and response, based on cognitive and behavioural presentations, can be classified.

It designates eight levels of functioning

Glasgow Coma Scale

A standardized system used to assess the level of consciousness of patients with acute brain injury. Findings are used to

guide initial decision making and monitor trends in responsiveness.

* Most often used at the JGH ICU.

RASS

Ely, E.W., Truman, B., Shintani, A., Thomason, J. W., Wheeler, A. P., Gordon, S. et al. (2003). Monitoring sedation status over time in ICU patients: the reliability and validity of the Richmond Agitation Sedation Scale (RASS).

JAMA 2003, 289, 2983-2991.

Sessler, C. N., Gosnell, M., Grap, M.J., Brophy, G.T., O'Neal, P. V., Keane, K. A. et al. (2002). The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med,166, 1338-1344.

ASSESSING CONSCIOUSNESS USING THE CAM-ICU: LINKING LEVEL

OF CONSCIOUSNESS & DELIRIUM MONITORING

Step 1: Level of consciousness -RASS

Inouye, et. al. (1990). Ann Intern Med, 113, 941-948

http://www.icudelirium.org/docs/CAM_ICU_training.pdf

ASSESSING CONSCIOUSNESS USING THE CAM-ICU: LINKING LEVEL

OF CONSCIOUSNESS & DELIRIUM MONITORING

Step 2: Content of consciousness – CAM-ICU


CAM-ICU WORKSHEET


CAM-ICU FLOWSHEET


OT FOR DELIRIUM MANAGEMENT IN THE ICU

Refer to Pt by first name

Reorientation, including delivering information about time, date, location, and reason for hospitalization

Correction of sensory deficits (hearing aids, glasses)

Modification of environment

Replacing physical restraints with supervision whenever possible

Installing clock and calendar in Pt room

Sleep protocols including dimming lights, promotion of quiet and calm environment

Ask family to bring familiar items, family photos

Polysensory stimulation

Cognitive stimulation targeting visual perception, memory, attention, problem solving

cards, dominoes, memory and visuospatial construction games, pattern recognition, forward and reverse digit spans, etc.

Encourage family participation

Alvarez, E. A., et al. (2017). Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial. Journal of Critical Care, 37, 85-90.

Brummel, N. E., Jackson, J. C., & Girard, T. D. (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, Physical Therapy, 92(12), 1580-1592.

POST-INTENSIVE CARE SYNDROME

Physical Psychological Cognitive Social

Muscle weakness

Fatigue

Weight loss

Joint pain/stiffness

Impaired mobility

Anxiety

Depression

PTSD

Amnesia

Confusion

Delirium

Cognitive impairment

Reduced social

participation

Isolation from

family/friends

Health & well-being of

others

Late return to work

Adapted from: Ramsay, P., Walsh, T., Donaghty, E., & Hope, D. (2016). Development and evaluation of a novel health resource to support patients and families after ICU, Edinburgh Napier University, 5th Annual Johns Hopkins

Critical Care Rehabilitation Conference, Baltimore, MD.

ROLE OF OT IN THE ICU

OT/PT should be initiated as soon as possible in the ICU

3 main issues contribute to the need for OT services in the ICU

Immobility and prolonged bed rest

Sensory deprivation and stress

Prolonged mechanical ventilation

Important consideration: Pts in ICU are commonly completely dependent

Affleck, A. T., et al. (1986). Providing occupational therapy in an intensive care unit. Am J Occup Ther 40, 323-32

ROLE OF OT AT THE JGH ICU

Evaluation of functional abilities

Setting appropriate goals with multidisciplinary team to promote autonomy and prevent further functional deterioration

Decrease time of rehab in acute care, facilitate process of rehab application once transferred to floor

Modifying the environment, providing/fabricating adaptations to facilitate Pt. care, function, and promote autonomy

Positioning for comfort or prevention of pressure ulcer formation or progression

Restraint alternatives

Orthoses

Trach collar patients: if 24 hr trial done, OT/PT to see for mobilization

Collaborate with SLP to facilitate communication

Pt unable to undergo N ax due to decreased motor skills, OT consulted to provide adaptations: pencil grasp, positioning

Consultation/education with family/staff re promotion of autonomy

Importance of ADL participation

Exercise

Other recommended activities that optimize the rehabilitative process

Attend multi-disciplinary rounds every Tuesday 1:30-3 pm

FUNCTIONAL STATUS SCORE FOR THE ICU (FSS-ICU)

Assessment to evaluate Pt’s physical function in the ICU setting

Five functional tasks

Rolling

Supine to sit

EOB sitting

Sit to stand

Walking/WC mobility

Scoring

Each task evaluated using an 8 point ordinal scale that ranges from 0 (unable to perform) to 7 (complete independence)

Total score ranges from 0-35

Psychometric properties range from fair to excellent

Ragavan, V., Greenwood, K., & Bibi, K. (2016). The functional status score for the intensive care unit scale: Is it reliable in the intensive care unit? Can it be used to determine discharge placement? Journal of Acute Care

Physical Therapy, 7(3), 93-100

Huang, M., et al. (2016). Functional status score for the intensive care unit (FSS-ICU): An international clinimetric analysis of validity, responsiveness and minimal important difference Critical Care Medicine, In Press

Parry, S., et al. (2015). Functional outcomes in ICU -what should we be using? An observational study. Critical Care, 19,127.

FSS-ICU POCKET CARD

FSS-ICU ADMINISTRATION AND SCORING

Evaluator may assist with managing medical equipment

Scoring should be based on only one evaluator, with the exception of walking/WC mobility task

Cannot use a lifting device

Scoring based on what was observed in the testing session

If Pt. does not perform task for any other reason besides weakness use the following method of scoring:

If ≤ 2 items were not performed, use the mean score from the completed items to complete the score for the 1 or 2 items

not performed

If > 2 items were not performed, only the completed tasks can be scored and a total FSS-ICU cannot be calculated.

EARLY MOBILIZATION IN THE ICU: SYSTEMATIC REVIEWS

Measures

Patient safety

Feasibility

Functional outcomes

Interventions

Functional mobility

Supine-sit

EOB sitting

Standing

Transfers

Ambulation

ADL training


MOBILITY PROTOCOLS

Lichtenstein, A. H., Escalon, M. X., Delgato, A., & Posner, E., (2016). Rehabilitation in the intensive care unit at Mount Sinai: A quality improvement project. Department of Rehabilitation Medicine, Icahn School of Medicine at

Mount Sinai, New York, NY. Presented at the 5th Annual Johns Hopkins Critical Care Rehabilitation Conference, Baltimore, MD.

DAILY MOBILITY ASSESSMENT AND TREATMENT

Engel, H. J., et al. (2013). ICU early mobilization: from recommendation to implementation at three medical centers. Crit Care Med 41, S69-S80.

EARLY MOBILIZATION IN THE ICU: SYSTEMATIC REVIEWS

Outcomes

Strength/ROM

Increased UE and LE strength, as measured by MMT and dynamometry

Mobility

Higher FIM scores

Higher Barthel Index scores post-tx

Mobilization milestones reached quicker (e.g. day to first OOB)

Increased score 6MWT

QoL

Seldom measured in ICU

Decreased LOS in ICU and hospital

Increased chance of returning to baseline functioning, decreased need for post-acute care services

Higher scores on the Short Form (36) Health Survey, Physical Functioning (PF) subscore at D/C

Decreased duration of mechanical ventilation in Pts with acute respiratory failure

No serious adverse medical consequences

Mobilization of critically ill, but stable Pts in the ICU can be done safely with minimal risk to Pt (including mechanically ventilated patients)

Corcoran, J. R., et al. (2016). Early rehabilitation in the medical and surgical intensive care units for patients with and without mechanical ventilation: An interprofessional performance improvement project. American Academy

of Physical Medicine and Rehabiliation, 1-7.

Lai, C. C. et al. (2016). Early mobilization reduces duration of mechanical ventilation and intensive care unit stay in patients in acute respiratory failure. Arch Phsy Med Rehabil. doi: 10.1016/j.apmr.2016.11.007.


BARRIERS TO EARLY MOBILITY

Lack of leadership

Lack of staffing and equipment

Lack of knowledge and training

Lack of physical referrals

Over-sedation

Delirium

Pt. hemodynamic tolerance of activity

Safety

Engel, H. J. et al. (2013). ICU early mobilization: from recommendation to implementation at three medical centers. Crit Care Med 41, S69-S80.

OCCUPATION BASED INTERVENTIONS IN THE ICU

Seated self-care activities for patients with femoral arterial line

Out of bed → chair transfer for patient with swan-ganz catheter

Occupational profile assessment for patient while receiving CRRT

Standing grooming at sink-side for patient with multiple chest tubes and pacing wires

Pre-LVAD assessment for patient with IABP

Near visual acuity

Grip and pinch strength

Cognitive assessment

Hands-on practice

Cognitive screening for ICU-acquired delirium using the CAM-ICU

Early mobilization for patients on mechanical ventilation (including collaboration with Respiratory Therapist)



IMPORTANT CONSIDERATIONS

Value of interdisciplinary communication

Joint sessions with physiotherapy

Meaningfulness

Critical care physicians may not be aware of the value of OT and the literature to support improved outcomes –

often we must advocate for patients

THANK YOU FOR YOUR ATTENTION!

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