Guidelines for Occupational Therapy in Critically Ill Patients

Introduction:

Critical care physicians and academics have started to think about how conventional approaches can result in long-term problems of critical disease over the past 20 years. Among patients with critical illnesses, delirium and bed rest are two prevalent symptoms that are major changeable warning signs for long-term cognitive impairment and ICUAW (intensive care unit acquired weakness). The ICU's best clinical practices currently advise handling patients with little to no sedation, increasing the proportion of awake patients. The modern intensive care unit (ICU) is where rehabilitation specialists like occupational therapists (OTs) have taken on a more prominent and crucial role in caring for previously unconscious patients with critical diseases since patients are more awake.

What Is Occupational Therapy?

Occupational therapy (OT) is a healthcare career. Establishing, recovering, or preserving the worthwhile activities or occupations of people, organizations, or communities requires assessment and intervention. Occupational therapists are medical professionals with training and education in enhancing mental and physical efficiency. Specialists in teaching, educating, and encouraging engagement in any activity that takes up a person's time are occupational therapists. Occupational therapists (OTs) and occupational therapy assistants (OTAs) make up this independent health profession, occasionally referred to as an associated health profession. Despite their varying duties, OTs and OTAs work with people who wish to improve their mental and/or physical health, illnesses, injuries, or impairments.

What Are the Occupational Therapy Interventions to Lower Delirium in Critically Ill Patients?

Up to half of patients with critical illnesses have delirium, an acute confusional state marked by inattention. Survivors' cognitive performance and impairment are related to how many days they spend in delirium. The need for nonpharmacologic therapies to lessen the burden of suffering associated with delirium has been reemphasized in light of numerous unsuccessful pharmacologic trials. Nursing-driven therapies are the hallmark of current non-pharmacologic interventions. However, recent research indicates that occupational therapy (OT)-specific therapies might potentially be beneficial in lowering delirium.

The following are part of the OT-specific protocol:

• Increasing a patient's alertness through polysensory stimulation using objects with various textures, fragrances, aromas, noises, tastes, or movements.

• Positioning to avoid edema and bedsores with devices and other modifications.

• Cognitive stimulation entails mental activities to stimulate language, problem-solving, perception of images, consciousness, speed of thought, and attention. For these cognitive exercises, patients are given notepads or electronic devices. Additionally, they are given access to card games, dominoes, memory exercises, and visual-spatial construction activities.

• Training in basic daily living skills, including tasks that mimic or replicate BADLs (basic activities of daily living, such as grooming, eating, and hygiene).

• Workouts for the upper extremities include gradated pinchers, thumb and finger workouts using putty, and arm and hand exercises utilizing resistance bands.

• Everyday family visits were encouraged.

What Occupational Therapy Interventions Are Used to Reduce Patients' Immobility?

The feasibility and safety of mobilization and rehabilitation have been shown in multiple randomized controlled trials and case-control studies over the past ten years, usually with the help of treatment teams made up of occupational therapy professionals and physiotherapists.

Patients treated with early mobility and rehabilitation have better muscle strength and the capacity to move around unassisted at hospital discharge than those treated with conventional care when these interventions start around the initial stages of critical condition (e.g., within one to three days). Furthermore, early mobility and rehabilitation interventions enhance additional results, such as decreasing the number of days on mechanical ventilation in the intensive care unit and boosting the number of days alive while out of the hospital.

Early mobility and rehabilitation, albeit primarily pursued to enhance muscle function and lessen physical limitations and impairments, may also impact transient brain dysfunction with severe illness.

What Are the Safety Guidelines for Performing Occupational Therapy in Critically Ill Patients?

Safety standards for early mobility in patients with life-threatening illnesses are as follows:

Cardiovascular System:

• Heartbeats per minute range from 60 to 130.

• The range of systolic blood pressure is 90 to 180 mm of mercury,

• The range of the mean arterial pressure is 60 to 100 millimeters of mercury.

Respiratory System:

• The respiratory rate ranges from 5 to 40 breaths per minute.

• SpO2 ≥ 88 % (saturation of peripheral oxygen).

• The tracheostomy or endotracheal tube airway is securely fastened.

Nervous System:

• Capable of opening eyes to voice.

• Additionally, none of the clinical symptoms listed below should be present:

  1. A new or noticeable arrhythmia.

  2. Chest pain accompanied by worry about myocardial ischemia.

  3. Spinal lesion or damage that is unstable.

  4. An unstable fracture.

  5. An uncontrolled or active gastrointestinal bleed.

Others:

Mobility workouts can be carried out with the following:

• Femoral vascular access devices, except femoral sheaths, in which hip mobilization is usually avoided.

• While receiving continuous renal replacement therapy.

• Injection of vasoactive drugs.

What Is the Protocol for Progressive Mobility in Occupational Therapy?

Progressive mobility treatments help patients proceed from passive range-of-motion exercises through more challenging exercises to independent ambulation utilizing the sit, stand, then walk method. The purpose of sessions for functional patients is to reach their maximal functional milestones as quickly as possible. Patients should first be examined for any safety issues that would prevent the safe performance of mobility exercises.

The kind of therapies that can be given can be determined by the patient's state of consciousness. Comatose patients lack the ability to engage in active interventions; as a result, they should be managed with passive range-of-motion exercises for all major joints, such as finger, wrist, elbow, knee, and ankle extension and flexion, shoulder flexion, hip flexion, abduction, and adduction, and ankle dorsiflexion and plantar flexion. Passive range of motion exercises can also be performed on individuals who can open their eyes to voice but cannot follow straightforward instructions. Passive range of motion exercises may prompt a patient to become more aware. If so, the workout can go on to the next workout.

Awake and composed patients are more amenable to a larger range of rehabilitation or mobility therapies. Patients should start with active or actively-assisted range-of-motion exercises in the semi-recumbent posture for all main joints. The patient can next advance, if able, to bed mobility activities (such as lateral rolling and supine to sitting), hanging one's feet off the side of the bed, postural training, and sitting balancing exercises. The patient can get training in daily living skills while standing or sitting, as appropriate, including eating or simulating eating, grooming, bathing, clothing, and using the restroom.

It is possible to undertake numerous repetitions of transfer training from a seated to a standing position and from a bed to a chair or commode (with appropriate technique changes). Before beginning standing exercises, the therapist should assess any conditions that would make standing risky (such as the patient's balance while seated, the strength of their lower extremities, and the lack of impulsive conduct).

Conclusion:

ICU occupational therapy is crucial to the medical team's holistic approach to treating patients and their families. The participation of sensory-motor integration with cognitive processing and graded motion reduces delirium. Improved patient awareness reduces the days spent on mechanical breathing, a key barrier in critical care. The performance of essential daily activities and instrumental duties like medication management develop from early mobility integration with functional activities. Occupational therapy reduces hospital readmissions. Early occupational therapy intervention can stop future disability, lessen sadness, stop the general weakening brought on by immobility, and help patients restore higher-level abilities for a functional reintegration into their surroundings.