acute & critical care rehabilitation

role of OT

• goal:

  • facilitate “early” mobilization/early engagement, functional independence, and discharge planning

  • prevent sequela of illness/injury

  • promote safety in basic ADLs/IADLs

  • identify d/c needs

  • mitigate/manage functional decline

• inpatient hospital units/wards, EDs, ICUs

many reasons for ICU admission

• neuro checks (q1) → client is receiving neurological assessment every 1 hr to monitor for cognitive changes (i.e acute brain injury)

• use of specific equipment

  • Roto bed (acute SCI, maitains spinal alignment)

  • continuous renal replacement therapy → prolonged dialysis

• mechanical ventilation

• specific drug/medication (i.e. vasopressors)

• mechanical circulatory support

• physiological decline (change in vital signs)

what is “early mobility”?

• catch phrase in ICU rehab → practice “early mobility”

• terribly defined

• “early” can differ from hospital to hospital

• is it safe?

  • the hospital/rehab center is NOT a nor -risk environment

  • practitioners must use clinical reasoning to determine when it is safe to do therapy

things to look for in pt chart

• new or revised orders (i.e. OT consult and follow-up treatment)

• dx and PMH

• precautions

  • may be listed as order (i.e. “on bedrest”)

• recent progress notes

• prior level of fx and social history

• recent lab results

• changes in meds and possible side effects

• significant changes in vital signs

frailty

“a state of increased vulnerability to adverse health outcomes”

• client’s with frailty don’t recover from adverse outcomes as quickly

evaluation and screening

• chart review

  • vital signs, medical history, medications, labs, precautions → safety first

• cognitive screening: orientation, attention, memory → important for pt participation/safety

  • person (check first, least likely to change), then place, time, situation last

• physical assessment

  • strength, ROM, sensation, etc

• ADL/IADL assessment

• in acute care need to “prioritize” certain patients

  • age, LOS, PMH, dx (stroke prioritized)

safety precautions

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decision-making

• are there any indications of medical procedures?

  • wait until after surgery for therapy

• are there restraints?

  • must put back on after therapy, can still do therapy

• does the pt appear anxious, distressed?

• does the pt look fatigued? → check breathing patterns

adaptive communication

• adapted quad bell

  • using tongue depressor as lever to push button

• sip and puff call bell (for clients woth very limited UE use)

• storyboard to communciate

  • consider visual deficits

common OT interventions

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environment

• maximize natural light (10 ft within window)

• location of light is key

• consider physical/sensory aspects:

  • monitors (light and noise)

  • IV pumps

  • smells

  • touch (healthcare providers, family members, etc)

    • where/how are we engaging in touch with patients)

family and caregiver support

• family is critically important to successful ICU outcomes

  • talk about familiar things, people, events

  • talk about person, place, day, date, time

  • bring in pictures from home

  • read aloud at bedside (caregiver)

  • ICU diaries

  • have caregiver bring in clothes from home instead of hospital gown

delirium

• hypo (low level arousal)

• hyper (agitated state)

  • better outcomes because they are moving more

• mixed

• factors

  • sleep/wake cycle → if they are sleeping at 2pm → OT should wake them and have them engage in activity

  • ICU diaries

  • calendar/clocks

  • lights

effect of early cognitive interventions on delirium

• after application of cognitive intervention → significant reduction in incidence, duration, and occurrence of delirium

  • cognitive training: repeated tasks, memory tasks, tasks resembling ADL

  • cognitive stimulation: orientation

  • cognitive rehab: memory aides, diaries, calendars

Richmond Agitation-Sedation Scale (RASS)

• can help assess for delirium

  • i.e. CAM ICU (confusion assessment method)

• score of +2 = agitated

• normal score is 0 = alert and calm

• positive numbers → agitated/alert

• negative numbers → drowsy/sedated

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transition to ward

• frequency of care decreases

• not due to a lack of progress

• changes in staffing frequency are possibly responsible

• d/c planning may play larger role

post intensive care syndrome (PICS)

• survival ≠ recovery

  • 80% of ICU survivors experience PICS, resulting in physical, cognitive, and psychological impairments

  • 50% are unable to return to work at 1-year

• ICU patients should have follow-up ≤ 4 weeks post d/c from hospital

• looks like:

  • muscle weakness

  • balance issues

  • thinking and memory

  • depression, anxiety

  • nightmares

• in pediatrics: developmental delays and learning difficulties