Occupational Therapy in the ICU: A Scoping Review of 221 Documents

Patient and family experiences of early cognitive rehabilitation in critical illness: A qualitative study protocol

BACKGROUND

Physical, mental and cognitive impairments are known severe adverse outcomes in critically ill patients who have beenadmitted to an intensive care unit (ICU). Early rehabilitation interventions such as lighter sedation and increased mobilization have improved patient outcomes, but evidence for early cognitive rehabilitation is sparse.

AIM

The study aims to describe the experiences of ICU survivors and their families regarding early cognitive stimulation as part of rehabilitation during and after ICU admission.

DESIGN

Our study has a qualitative, descriptive design using individual and dyad interviews as well as focus groups with ICU survivors and their families.

METHODS

Eligible participants are adult ICU survivors and families who are able to recall events during and after the ICU stay. We will use purposeful sampling in the outpatient clinic in the Department of Intensive Care at the Copenhagen University Hospital. We plan to conduct five individual patient interviews, four dyad interviews with patients and families, and two focus groups with patients. All interviews will follow a semi-structured interview guide based on the study objectives and input from a patient and public involvement (PPI) panel. We will use the framework method for analysis and invite the PPI panel to participate in the analysis process to strengthen the findings. Written informed consent will be obtained from all participants, and data will be anonymized before analyses.

RELEVANCE FOR CLINICAL PRACTICE

This study protocol provides a methodological framework to understand early cognitive rehabilitation from the perspectives of ICU survivors and their families. This study protocol presents one of the first studies to investigate the concept of early cognitive rehabilitation during critical illness from this perspective. The findings will facilitate a tailored approach to early rehabilitation to be investigated in further studies.

Intensive care unit acquired weakness and physical rehabilitation in the ICU

Approximately half of critically ill adults experience intensive care unit acquired weakness (ICUAW). Patients who develop ICUAW may have negative outcomes, including longer duration of mechanical ventilation, greater length of stay, and worse mobility, physical functioning, quality of life, and mortality. Early physical rehabilitation interventions have potential for improving ICUAW; however, randomized trials show inconsistent findings on the efficacy of these interventions. This review summarizes the latest evidence on the definition, diagnosis, epidemiology, pathophysiology, risks factors, implications, and management of ICUAW. It specifically highlights research gaps and challenges, with considerations for future research for physical rehabilitation interventions.

Occupational Therapy Interventions and Early Engagement for Patients in Intensive Care: A Systematic Review

IMPORTANCE

Patients in intensive care units (ICUs) experience complex functional, physical, and cognitive needs that affect their engagement in activities of daily living (ADLs). Occupational therapy practitioners are uniquely positioned to address these needs to optimize patients' functional recovery.

OBJECTIVE

To examine occupational therapy-specific interventions as they relate to early engagement for patients in the ICU.

DATA SOURCES

CINAHL, PubMed, ProQuest, OTseeker, and Cochrane Library databases.

STUDY SELECTION AND DATA COLLECTION

The Cochrane methodology was used to collect, evaluate, and analyze articles, then reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines for conducting a systematic review. Articles published from January 2012 to December 2021 evaluating adults who received occupational therapy interventions in ICUs with Level 1b, 2b, or 3b evidence were included.

FINDINGS

Nine articles met the inclusion criteria and the research objective. Findings showed moderate evidence for ADLs, physical rehabilitation, and cognitive interventions in promoting functional outcomes for patients in the ICU.

CONCLUSIONS AND RELEVANCE

This systematic review introduces the term early engagement to describe occupational therapy-specific interventions for patients recovering in the ICU and supports occupational therapy's role in this setting. Further research is needed to strengthen the evidence for occupational therapy-specific interventions and early engagement in the ICU. Plain-Language Summary: Patients in the intensive care unit experience complex needs that affect their participation in activities of daily living (ADLs). Current research demonstrates moderate evidence for early engagement with ADLs, physical rehabilitation, and cognitive interventions performed by occupational therapy practitioners. This systematic review introduces the term early engagement, which captures how occupational therapy practitioners provide holistic interventions for patients in the intensive care unit to promote patient well-being and functional recovery.

Speech-language pathologist involvement in the paediatric intensive care unit

PURPOSE

To measure the prevalence of speech-language pathologist (SLP) involvement and associated trends for critically ill children in United States (US) paediatric intensive care units (PICU) through secondary analysis of the Prevalence of Acute Rehab for Kids in the PICU (PARK-PICU) study data.

METHOD

A secondary analysis of cross-sectional point prevalence study conducted over 1 day in 82 US PICUs. Data collected included SLP presence, patients' age, length of stay, medical interventions, aetiology, admission data, Glasgow Coma Scale scores, staffing involvement, and family presence.

RESULT

Among 961 patients, 82 were visited by an SLP on the study day for a prevalence of 8.5%. Most visits were for children <3 years old. The odds of SLP involvement were lower for children who were 7-12 years old (vs. age 0-2; adjusted odds ratio [aOR] 0.28; 95% CI 0.1-0.8), were mechanically ventilated via endotracheal tube (vs. room air; aOR 0.02; 95% CI 0.005-0.11), or had mild or severe disability (mild vs. no disability; aOR 0.34; 95% CI 0.16-0.76 and severe vs. no disability; aOR 0.39; 95% CI 0.17-0.90). Concurrent physical and/or occupational therapy involvement was associated with higher odds of SLP involvement (aOR 3.6; 95% CI 2.1-6.4).

CONCLUSION

SLP involvement is infrequent in US PICUs. PICU teams should be educated about the scope of SLP practice, to support communication and oral feeding needs during early recovery from critical illness.

Effect of occupational therapy on the occurrence of delirium in critically ill patients: a systematic review and meta-analysis

Aim

Delirium poses a major challenge to global health care, yet there is currently a dearth of single effective interventions or medications. Particularly, addressing delirium induced by critical illness is a complex process. Occupational therapy is considered to have a high potential for use in the prevention of delirium, as it involves both cognitive training and training in ADL. To comprehensively analyze the effect of occupational therapy on delirium prevention, we evaluated the effects of occupational therapy vs. standard non-pharmacological prevention on incidence and duration of delirium, clinical outcomes and rehabilitation outcomes in critically ill patients.

Methods

The data sources, including PubMed/Medline, Web of Science, EMBASE, and Cochrane Library, were comprehensively searched from their inception until 15 October 2023. Following the PICOS principle, a systematic screening of literature was conducted to identify relevant studies. Subsequently, the quality assessment was performed to evaluate the risk of bias in the included literature. Finally, outcome measures from each study were extracted and comprehensive analysis was conducted using Review Manager 5.4.

Results

A total of four clinical trials met the selection criteria. The pooled analysis indicated no significant difference in the incidence and duration of delirium between the OT group and standard non-pharmacological interventions. A comprehensive analysis of clinical outcomes revealed that OT did not significantly reduce the length of hospital stay or ICU stay. Meanwhile, there was no significant difference in mortality rates between the two groups. It is noteworthy that although grip strength levels did not exhibit significant improvement following OT intervention, there were obvious enhancements observed in ADL and MMSE scores.

Conclusion

Although occupational therapy may not be the most effective in preventing delirium, it has been shown to significantly improve ADL and cognitive function among critically ill patients. Therefore, we contend that occupational therapy is a valuable component of a comprehensive multidisciplinary approach to managing delirium. In the future, high-quality researches are warranted to optimize the implementation of occupational therapy interventions for delirium prevention and further enhance their benefits for patients.

Critical care beyond organ support: the importance of geriatric rehabilitation

Very old critically ill patients pose a growing challenge for intensive care. Critical illness and the burden of treatment in the intensive care unit (ICU) can lead to a long-lasting decline of functional and cognitive abilities, especially in very old patients. Multi-complexity and increased vulnerability to stress in these patients may lead to new and worsening disabilities, requiring careful assessment, prevention and rehabilitation. The potential for rehabilitation, which is crucial for optimal functional outcomes, requires a systematic, multi-disciplinary approach and careful long-term planning during and following ICU care. We describe this process and provide recommendations and checklists for comprehensive and timely assessments in the context of transitioning patients from ICU to post-ICU and acute hospital care, and review the barriers to the provision of good functional outcomes.

Implementation and Mixed-Methods Assessment of an Early Mobility Interprofessional Education Simulation

INTRODUCTION

Extended periods of bed rest and mechanical ventilation (MV) have devastating effects on the body.

BACKGROUND

Early mobility (EM) for patients in respiratory failure is safe and feasible, and an interprofessional team is recommended. Using simulation to train EM skills improves student confidence. The purpose of this study was to enable health care student collaboration as an interprofessional team in providing safe management and monitoring during an EM simulation for a patient requiring MV.

METHODS

Nursing (n = 33), respiratory (n = 7), occupational (n = 24), and physical therapist students (n = 55) participated in an EM interprofessional education (IPE) simulation experience. A mixed-methods analytic approach was used with pre/post quantitative analysis of the Student Perceptions of Interprofessional Clinical Education-Revised, Version 2 instrument and qualitative analysis of students' guided reflection papers.

RESULTS

Pre/post surveys completion rate was 39.5% (n = 47). The Student Perceptions of Interprofessional Clinical Education-Revised, Version 2 instrument indicated a significant improvement (P = .037) in students' perceptions of interprofessional collaborative practice. Qualitative data showed a positive response to the EM simulation IPE. Themes reflected all 4 Interprofessional Education Collaborative competencies.

DISCUSSION

This study demonstrated improved perception of interprofessional collaborative practice and better understanding of the Interprofessional Education Collaborative competencies.

CONCLUSION

Students collaborated in the simulation-based IPE to provide EM for a patient requiring MV and reported perceived benefits of the experience.

Rehabilitation for adult patients undergoing extracorporeal membrane oxygenation

BACKGROUND AND PURPOSE

Current information on the latest rehabilitative practices is limited, with previous reviews only covering data up to October 2021, and some considering only patients on awake ECMO or with COVID-19. This review aims to present a concise overview of the latest findings on rehabilitation and highlight emerging trends for patients undergoing ECMO support.

METHODS

This integrative review was conducted by searching the National Library of Medicine - PubMed database. Two different search strings "extracorporeal membrane oxygenation" AND "rehabilitation" and "extracorporeal membrane oxygenation" AND "physiotherapy" were used to search the published literature. Articles that did not describe rehabilitation techniques, editorials, conference proceedings, letters to editor, reviews and research protocols were excluded. Studies conducted on pediatric populations were also excluded. The search process was completed in December 2023.

RESULTS

Thirteen articles were included in the final analysis. Eight hundred and thirty-nine patients aged between 27 and 63 years were included; 428 were men (51%). In 31% of the included studies, patients had COVID-19; nevertheless, rehabilitative activities did not differ from non-COVID-19 patients. In most studies, rehabilitation commenced within the first 48-96 h and consisted of progressive exercise and out-of-bed activities such as sitting, standing and walking.

CONCLUSION

Current practice focuses on rehabilitative protocols that incorporate exercise routines with progressive intensity, greater emphasis on out-of-bed activities, and a multidisciplinary approach to patient mobilization.

Prolonged Mechanical Ventilation, Weaning, and the Role of Tracheostomy

Depending on the definitional criteria used, approximately 5% to 10% of critical adults will require prolonged mechanical ventilation with longer-term outcomes that are worse than those ventilated for a shorter duration. Outcomes are affected by patient characteristics before critical illness and its severity but also by organizational characteristics and care models. Definitive trials of interventions to inform care activities, such as ventilator weaning, upper airway management, rehabilitation, and nutrition specific to the prolonged mechanical ventilation patient population, are lacking. A structured and individualized approach developed by the multiprofessional team in discussion with the patient and their family is warranted.

Early occupational therapy in mechanically ventilated patients improves functional status: Study protocol

Background

Experts suggest implementing measures that include analgesia, sedation, delirium prevention and early mobilization (ASDM) in patients undergoing mechanical ventilation (MV) to reduce complications. However, there is limited evidence of occupational therapy in these patients. The aim of the research is to compare functional independence in patients undergoing MV of an intensive and early occupational therapy protocol versus to standard ASDM strategy.

Method/Design

A prospective, multicenter, randomized clinical trial, with parallel groups (control and intervention groups). Participants will be hospitalized patients, over 18 years of age, admitted to the intensive care unit (ICU) and with the need of invasive MV. The intervention group will receive two daily 30-minute sessions of occupational therapy for 10 days. This study will research the effect of occupational therapy on functional independence, motor and cognitive status, evaluating at days 28 and 90.

Discussion

This work contributes to the theoretical and practical work of occupational therapists who work in the ICU. The implementation of protocols of occupational therapy in mechanically ventilated patients can contribute to the independence and functionality of patients.

Conclusion

Our research aims to contribute to the generation of systematized, organized, and feasible protocols that can be implemented in ICU.

Trial Registration

ClinicalTrials.gov NCT04819529.

Critical Care and Occupational Therapy Practice Across the Lifespan

This AOTA Position Statement defines the distinct role and value of occupational therapy practitioners in critical care settings across the lifespan. Occupational therapy practitioners are essential interprofessional team members who address the needs of critically ill individuals by implementing evidence-based critical care guidelines that aim to improve the quality of survivorship.

Implementing early rehabilitation and mobilisation for children in UK paediatric intensive care units: the PERMIT feasibility study

Background

Early rehabilitation and mobilisation encompass patient-tailored interventions, delivered within intensive care, but there are few studies in children and young people within paediatric intensive care units.

Objectives

To explore how healthcare professionals currently practise early rehabilitation and mobilisation using qualitative and quantitative approaches; co-design the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual of early rehabilitation and mobilisation interventions, with primary and secondary patient-centred outcomes; explore feasibility and acceptability of implementing the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual within three paediatric intensive care units.

Design

Mixed-methods feasibility with five interlinked studies (scoping review, survey, observational study, codesign workshops, feasibility study) in three phases.

Setting

United Kingdom paediatric intensive care units.

Participants

Children and young people aged 0-16 years remaining within paediatric intensive care on day 3, their parents/guardians and healthcare professionals.

Interventions

In Phase 3, unit-wide implementation of manualised early rehabilitation and mobilisation.

Main outcome measures

Phase 1 observational study: prevalence of any early rehabilitation and mobilisation on day 3. Phase 3 feasibility study: acceptability of early rehabilitation and mobilisation intervention; adverse events; acceptability of study design; acceptability of outcome measures.

Data sources

Searched Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PEDro, Open grey and Cochrane CENTRAL databases.

Review methods

Narrative synthesis.

Results

In the scoping review we identified 36 full-text reports evaluating rehabilitation initiated within 7 days of paediatric intensive care unit admission, outlining non-mobility and mobility early rehabilitation and mobilisation interventions from 24 to 72 hours and delivered twice daily. With the survey, 124/191 (65%) responded from 26/29 (90%) United Kingdom paediatric intensive care units; the majority considered early rehabilitation and mobilisation a priority. The observational study followed 169 patients from 15 units; prevalence of any early rehabilitation and mobilisation on day 3 was 95.3%. We then developed a manualised early rehabilitation and mobilisation intervention informed by current evidence, experience and theory. All three sites implemented the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual successfully, recruited to target (30 patients recruited) and followed up the patients until day 30 or discharge; 21/30 parents consented to complete additional outcome measures.

Limitations

The findings represent the views of National Health Service staff but may not be generalisable. We were unable to conduct workshops and interviews with children, young people and parents to support the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual development due to pandemic restrictions.

Conclusions

A randomised controlled trial is recommended to assess the effectiveness of the manualised early rehabilitation and mobilisation intervention.

Future work

A definitive cluster randomised trial of early rehabilitation and mobilisation in paediatric intensive care requires selection of outcome measure and health economic evaluation.

Study registration

The study is registered as PROSPERO CRD42019151050. The Phase 1 observational study is registered Clinicaltrials.gov NCT04110938 (Phase 1) (registered 1 October 2019) and the Phase 3 feasibility study is registered NCT04909762 (Phase 3) (registered 2 June 2021).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/21/06) and is published in full in Health Technology Assessment; Vol. 27, No. 27. See the NIHR Funding and Awards website for further award information.

Delirium Care by Intensive Care Unit Nurses: Focus Group Studies in a Medical Center of Southern Taiwan

OBJECTIVES

Studies have identified many nursing interventions that can prevent delirium and fall accidents in clinical patients, detect and treat delirium early to prevent functional decline in the patient, shorten hospitalization duration, and lower the death rate. This study aimed to explore delirium care by intensive care unit (ICU) nurses in a medical center of southern Taiwan.

METHODS

This study conducted 3 semistructured focus group interviews, each for a single medical ICU, involving groups of 6 to 8 nurses each. The nurses were recruited through purposive sampling. This research was approved by an institutional review board in the medical center of southern Taiwan from March 31, 2020, to January 30, 2021. The co-principal investigator described the purpose and process of this study to the participants before they provided their written informed consents. The interviews were conducted in the meeting room and were audiotape recorded. The recordings were transcribed and subject to content analysis to identify the themes of delirium care.

RESULTS

For nursing interventions of delirium, satisfying the patient's physical needs: comfort care, massages, and early rehabilitation; and psychological care: being presence, communication, and ensuring familial support were included. In terms of environmental interventions for delirium, providing reorientation, music, light, belongings with sentimental value, and audiovisual equipment were included. However, according to the recruited medical ICU nurses, these nonpharmacological interventions, although effective, do not have long-lasting effects. Finally, nurses reported themselves as having been attacked by patients with delirium. Thus, they all agreed that restraining patients with delirium may be necessary, but restraining is a double-edged sword for ICU delirium patients.

CONCLUSIONS

Research team suggests for future studies to extend their evidence-based findings of physical, psychological, and environmental care for ICU delirium patients toward integrating the efforts of various health care professionals.

Effect of early mobilisation on long-term cognitive impairment in critical illness in the USA: a randomised controlled trial

BACKGROUND

Patients who have received mechanical ventilation can have prolonged cognitive impairment for which there is no known treatment. We aimed to establish whether early mobilisation could reduce the rates of cognitive impairment and other aspects of disability 1 year after critical illness.

METHODS

In this single-centre, parallel, randomised controlled trial, patients admitted to the adult medical-surgical intensive-care unit (ICU), at the University of Chicago (IL, USA), were recruited. Inclusion criteria were adult patients (aged ≥18 years) who were functionally independent and mechanically ventilated at baseline and within the first 96 h of mechanical ventilation, and expected to continue for at least 24 h. Patients were randomly assigned (1:1) via computer-generated permuted balanced block randomisation to early physical and occupational therapy (early mobilisation) or usual care. An investigator designated each assignment in consecutively numbered, sealed, opaque envelopes; they had no further involvement in the trial. Only the assessors were masked to group assignment. The primary outcome was cognitive impairment 1 year after hospital discharge, measured with a Montreal Cognitive Assessment. Patients were assessed for cognitive impairment, neuromuscular weakness, institution-free days, functional independence, and quality of life at hospital discharge and 1 year. Analysis was by intention to treat. This trial was registered with ClinicalTrials.gov, number NCT01777035, and is now completed.

FINDINGS

Between Aug 11, 2011, and Oct 24, 2019, 1222 patients were screened, 200 were enrolled (usual care n=100, intervention n=100), and one patient withdrew from the study in each group; thus 99 patients in each group were included in the intention-to-treat analysis (113 [57%] men and 85 [43%] women). 65 (88%) of 74 in the usual care group and 62 (89%) of 70 in the intervention group underwent testing for cognitive impairment at 1 year. The rate of cognitive impairment at 1 year with early mobilisation was 24% (24 of 99 patients) compared with 43% (43 of 99) with usual care (absolute difference -19·2%, 95% CI -32·1 to -6·3%; p=0·0043). Cognitive impairment was lower at hospital discharge in the intervention group (53 [54%] 99 patients vs 68 [69%] 99 patients; -15·2%, -28·6 to -1·7; p=0·029). At 1 year, the intervention group had fewer ICU-acquired weaknesses (none [0%] of 99 patients vs 14 [14%] of 99 patients; -14·1%; -21·0 to -7·3; p=0·0001) and higher physical component scores on quality-of-life testing than did the usual care group (median 52·4 [IQR 45·3-56·8] vs median 41·1 [31·8-49·4]; p<0·0001). There was no difference in the rates of functional independence (64 [65%] of 99 patients vs 61 [62%] of 99 patients; 3%, -10·4 to 16·5%; p=0·66) or mental component scores (median 55·9 [50·2-58·9] vs median 55·2 [49·5-59·7]; p=0·98) between the intervention and usual care groups at 1 year. Seven adverse events (haemodynamic changes [n=3], arterial catheter removal [n=1], rectal tube dislodgement [n=1], and respiratory distress [n=2]) were reported in six (6%) of 99 patients in the intervention group and in none of the patients in the usual care group (p=0·029).

INTERPRETATION

Early mobilisation might be the first known intervention to improve long-term cognitive impairment in ICU survivors after mechanical ventilation. These findings clearly emphasise the importance of avoiding delays in initiating mobilisation. However, the increased adverse events in the intervention group warrants further investigation to replicate these findings.

FUNDING

None.

Individualized Goal Setting for Pediatric Intensive Care Unit-Based Rehabilitation Using the Canadian Occupational Performance Measure

The Canadian Occupational Performance Measure (COPM) is a client-centered outcome measure that facilitates the prioritization of individualized interventions. Given the rising emphasis on individualized intervention in pediatric intensive care units (PICUs), this cross-sectional study aimed to explore caregivers' perspectives on their children's functional goals within PICUs. From 1 September 2020 to 26 June 2022, caregivers of 41 children aged 1-18 years completed the COPM within 48 h of PICU admission. The study also explored the clinical variables predicting a high number of occupational performance goals (≥4/5). Out of 190 goals proposed by caregivers, 87 (45.8%) pertained to occupational performance, while 103 (54.2%) were related to personal factors. Among the occupational performance goals, the majority were associated with functional mobility (55; 28.9%), followed by personal care (29; 15.2%) and quiet recreation (3; 1.6%). Among personal goals, physiological factors (68; 35.8%) were most common, followed by physical factors (35; 18.4%). We found caregiver anxiety, measured by the State-Trait Anxiety Inventory-State, to be a significant predictor of the number of occupational performance goals. These findings underscore the importance of caregiver psychological assessment in the PICU to facilitate personalized goal setting and improve rehabilitation outcomes.

Functional and cognitive rehabilitation interventions during intensive care admission: A protocol for a systematic integrative review

BACKGROUND

Long-term cognitive impairment occurs in up to 60% of intensive care unit (ICU) survivors. Early use of functional and cognitive rehabilitation interventions, while patients are still in ICU, may reduce cognitive decline. We aim to describe the functional and cognitive interventions used during the ICU stay, the healthcare professionals providing interventions, and the potential impact on functional and cognitive rehabilitation.

METHOD

In this integrative systematic review, we will include empirical qualitative, quantitative, mixed- and multiple-methods studies assessing the use of functional and cognitive rehabilitation provided in ICU. We will identify studies in relevant electronic databases from 2012 to 2022, which will be screened for eligibility by at least two reviewers. Literature reported as narrative reviews and editorials will be excluded. We will assess the impact of interventions evaluating a cognitive and functional function, quality of life, and all-cause mortality at 6-12 months after ICU discharge. The Revised Cochrane risk-of-bias Tool will be used for assessing risk of bias in clinical trials. For observational studies, we will use the National Institutes of Health Quality Assessment tool for Observational Cohort and Cross-Sectional Studies. Furthermore, we will use the critical appraisal skills programme for qualitative studies and the mixed methods appraisal tool for mixed methods studies. We will construct four matrices, including results describing which ICU patients and healthcare professionals were engaged in rehabilitation, which interventions were included in early rehabilitation in ICU, the potential impact on patient outcomes of rehabilitation interventions provided in ICU and a narrative synthesis of themes. A summary of the main results will be reported using modified GRADE methodology.

IMPACT

This integrative review will inform the feasibility randomised clinical trial testing the development of a complex intervention targeting functional and cognitive rehabilitation for patients in ICU.

Effectiveness of active occupational therapy in patients with acute stroke: A propensity score-weighted retrospective study

Background and purpose

The effects of therapy and patient characteristics on rehabilitation outcomes in patients with acute stroke are unclear. We investigated the effects of intensive occupational therapy (OT) on patients with acute stroke.

Methods

We performed a retrospective cohort study using the 2005-2016 Japan Rehabilitation Database, from which we identified patients with stroke (n = 10,270) who were admitted to acute care hospitals (n = 37). We defined active OT (AOT) and non-AOT as OT intervention times (total intervention time/length of hospital stay) longer or shorter than the daily physical therapy intervention time, respectively. The outcomes assessed were the Functional Independence Measure (FIM) and National Institutes of Health Stroke Scale (NIHSS) scores, duration of hospitalization, and rate of discharge. Propensity scores and inverse probability of treatment weighting analyses adjusted for patient characteristics were performed to investigate the effects of AOT on patient outcomes.

Results

We enrolled 3,501 patients (1,938 and 1,563 patients in the AOT and non-AOT groups, respectively) in the study. After inverse probability of treatment weighting, the AOT group had a shorter length of hospitalization (95% confidence interval: -3.7, -1.3, p < 0.001), and the FIM (95% confidence interval: 2.0, 5.7, p < 0.001) and NIHSS (95% confidence interval; 0.3, 1.1, p < 0.001) scores improved significantly. Subgroup analysis showed that lower NHISS scores for aphasia, gaze, and neglect and lower overall NIHSS and FIM scores on admission led to a greater increase in FIM scores in the AOT group.

Conclusions

AOT improved the limitations in performing activities of daily living (ADL) and physical function in patients with acute stroke and reduced the length of hospitalization. Additionally, subgroup analysis suggested that the increase in FIM score was greater in patients with severe limitations in performing ADLs and worse cognitive impairment, such as neglect, on admission.

Occupational therapy in a private adult Intensive Care Unit (ICU): an experience report

Abstract Introduction The treatment of critically ill patients has gained prominence in recent years. The health demands of these patients are specific and require hospitalization in intensive care unit (ICU), confirming the need for a specialized, qualified, and multidisciplinary team as recommended by resolution RDC No. 7 of 2010, which addresses the need for the presence of an occupational therapist in ICUs. Objective This study aims to report the experiences of the first year of an occupational therapist in the adult general ICU in a private high-complexity tertiary hospital located in the city of São Paulo, and to reflect on this field of action. Method This is an experience report conducted through the analysis of medical records and occupational therapeutic assessment for later reading of the existing literature. Results The identification of occupational therapeutic interventions involves the use of assistive technology, reception actions, and (re)habilitation of occupations in the ICU environment. Conclusion Occupational therapy has been gaining ground in the context of adult general intensive care unit, where the demonstration of real occupational therapy actions has led to the recognition, by high hospital management, of these approaches with critical patients and the role of this profession in the multiprofessional team.

Terapia ocupacional em unidade de terapia intensiva (UTI) adulto privada: relato de experiências

Resumo Introdução O tratamento de pacientes críticos tem ganhado notoriedade nos últimos anos. As demandas de saúde desses pacientes são específicas e requerem internação em unidade de terapia intensiva (UTI), confirmando a necessidade de equipe multiprofissional especializada e qualificada, como preconiza a resolução RDC nº 7 de 2010, a qual aborda a necessidade da presença de terapeuta ocupacional nas UTIs. Objetivo Este estudo visa relatar as vivências do primeiro ano de atuação de uma terapeuta ocupacional na UTI geral adulto de um hospital privado de nível terciário de alta complexidade localizado na cidade de São Paulo e refletir sobre este campo de atuação. Método Trata-se de um relato de experiência realizado através da análise de prontuário e avaliação terapêutica ocupacional para posterior leitura da literatura existente. Resultados A identificação das intervenções terapêuticas ocupacionais perpassa por uso de tecnologia assistiva, ações de acolhimento e (re)habilitação das ocupações no ambiente de UTI. Conclusão A terapia ocupacional vem ganhando espaço no contexto de unidade de terapia intensiva geral adulta, onde a demonstração das reais ações terapêuticas ocupacionais ocasionou o reconhecimento, pela alta gestão hospitalar, dessas condutas junto ao paciente crítico e do papel dessa profissão na equipe multiprofissional.

Occupational therapist-guided cognitive interventions in critically ill patients: a feasibility randomized controlled trial

PURPOSE

Intensive care unit (ICU) delirium is a common complication of critical illness requiring a multimodal approach to management. We assessed the feasibility of a novel occupational therapist (OT)-guided cognitive intervention protocol, titrated according to sedation level, in critically ill patients.

METHODS

Patients aged ≥ 18 yr admitted to a medical/surgical ICU were randomized to the standard delirium prevention protocol or to the OT-guided cognitive intervention protocol in addition to standard of care. The target enrolment number was N = 112. Due to the COVID-19 pandemic, the study enrolment period was truncated. The primary outcome was feasibility of the intervention as measured by the proportion of eligible cognitive interventions delivered by the OT. Secondary outcomes included feasibility of goal session length (20 min), participant clinical outcomes (delirium prevalence and duration, cognitive status, functional status, quality of life, and ICU length of stay), and a description of methodological challenges and solutions for future research.

RESULTS

Seventy patients were enrolled and 69 patients were included in the final analysis. The majority of OT-guided sessions (110/137; 80%) were completed. The mean (standard deviation [SD]) number of sessions per patient was 4.1 (3.8). The goal session length was achieved (mean [SD], 19.8 [3.1] min), with few sessions (8/110; 7%) terminated early per patient request.

CONCLUSION

This novel OT-guided cognitive intervention protocol is feasible in medical/surgical ICU patients. A larger randomized controlled trial is required to determine the impact of such a protocol on delirium prevalence or duration.

STUDY REGISTRATION

www.

CLINICALTRIALS

gov (NCT03604809); registered 18 June 2018.

Occupational therapy in pulmonary rehabilitation programs: A scoping review

Pulmonary rehabilitation (PR) is a multidisciplinary intervention forming the cornerstone of chronic respiratory disease management, improving individuals' exercise capacities and abilities to complete activities of daily living (ADLs). Although the occupational therapy (OT) scope of practice focuses on similar outcomes as PR, the tasks/roles and benefit of including OT in PR has not been reviewed. This scoping review synthesized the i) tasks/roles, ii) recommendations of guidelines, iii) prevalence and iv) effects of OT as part of PR programs. Searching of four databases (MEDLINE, EMBASE, CINAHL and Cochrane), OT association websites, and hand searching was performed, and 51 records were included. The OT tasks/roles most reported include teaching energy conservation techniques (n = 23), addressing ADLs (n = 17), and assisting with breathlessness management (n = 10). Using the Canadian Model of Occupational Performance and Engagement these tasks/roles were grouped into person (n = 16 unique tasks/roles), occupation (n = 6 tasks/roles), environment (n = 5 tasks/roles), and other (n = 3 tasks/roles) domains and were endorsed by two available practice guidelines addressing OT in PR programs. From 13 PR surveys across four continents, 17-92% of PR programs included OT. Inclusion of OT in PR resulted in positive effects on ADLs, pulmonary function, dyspnea, quality of life, and mortality. Although an increasing number of PR programs include occupational therapists in their multidisciplinary teams, there is a paucity of original studies and guidelines reporting on the tasks/roles and benefits of OT in PR. Further research is needed to clearly define the tasks/roles of OT in multidisciplinary PR teams and contributions to enhancing patient outcomes.

Occupational therapy service provision in adult intensive care units in Australia: A survey of workload practices, interventions and barriers

INTRODUCTION

Occupational therapy practice within intensive care units (ICUs) is limited with respect to published research evidence and guidelines regarding scope of practice. An understanding of the current level of service provision, feasibility of services in ICUs and training and development needs of occupational therapists is required to enable consistent best practice and promote the occupational therapy profile. This study aimed to explore occupational therapy practice within ICUs in Australia including the barriers and enablers to practice perceived by occupational therapists.

METHODS

In this cross-sectional study, a national customised online survey was completed by registered occupational therapists who provide services in intensive care settings in Australia. Recruitment was from July to September 2019 through Occupational Therapy Australia and other professional networks and interest groups.

RESULTS

The survey was completed by 43 respondents. The majority were experienced therapists from Queensland with greater than 10-years post-qualification and working in a tertiary hospital setting. The most common length of time spent working in the ICU was 0-2 h per week. Formal and informal self-care measures, cognitive screens and physical outcome measures were commonly used. Bed-based grooming retraining, pressure care management, functional upper limb retraining and passive ranging were the most frequent interventions provided on a daily basis. Perceived barriers to occupational therapy service provision in ICU included lack of funding for staffing, competing workload demands, lack of occupational therapy role delineation and scope of practice and lack of published evidence and training.

CONCLUSION

Occupational therapy services in intensive care settings in Australia are limited. Published practice guidelines, further research, applications for service funding and ongoing education of the ICU multidisciplinary team regarding the scope of occupational therapy practice are recommended to promote the development of occupational therapy services in ICU.

Case study research: Building the occupational therapy evidence base one case at a time

BACKGROUND

There is growing recognition in healthcare that evidence from randomised controlled trials may not be appropriate to answer the full spectrum of practice-based questions and a more pluralistic approach is needed.

AIM

To consider the use of case study research in contributing to the occupational therapy evidence base.

MATERIAL AND METHODS

A critical discussion of the current state of evidence-based practice in occupational therapy and exploration of a viable approach to case study research is used.

RESULTS

Case study research can capture the context and complexity of occupational therapy practice. Cases can then be pooled to make a substantial contribution to the evidence base.

CONCLUSIONS

Occupational therapists should consider the use of case study research to produce practice related, meaningful research. Journal editorial boards need to be mindful of the value of high-quality case study research when considering publication priorities in occupational therapy literature.

SIGNIFICANCE

Highlights a changing landscape in the literature about how best to conduct research in health and social care, particularly for complex interventions and describes a pragmatic approach to case study research for occupational therapy.

Virtual Reality-Based Early Neurocognitive Stimulation in Critically Ill Patients: A Pilot Randomized Clinical Trial

This study focuses on the application of a non-immersive virtual reality (VR)-based neurocognitive intervention in critically ill patients. Our aim was to assess the feasibility of direct outcome measures to detect the impact of this digital therapy on patients’ cognitive and emotional outcomes. Seventy-two mechanically ventilated adult patients were randomly assigned to the “treatment as usual” (TAU, n = 38) or the “early neurocognitive stimulation” (ENRIC, n = 34) groups. All patients received standard intensive care unit (ICU) care. Patients in the ENRIC group also received adjuvant neurocognitive stimulation during the ICU stay. Outcome measures were a full neuropsychological battery and two mental health questionnaires. A total of 42 patients (21 ENRIC) completed assessment one month after ICU discharge, and 24 (10 ENRIC) one year later. At one-month follow-up, ENRIC patients had better working memory scores (p = 0.009, d = 0.363) and showed up to 50% less non-specific anxiety (11.8% vs. 21.1%) and depression (5.9% vs. 10.5%) than TAU patients. A general linear model of repeated measures reported a main effect of group, but not of time or group–time interaction, on working memory, with ENRIC patients outperforming TAU patients (p = 0.008, η_p² = 0.282). Our results suggest that non-immersive VR-based neurocognitive stimulation may help improve short-term working memory outcomes in survivors of critical illness. Moreover, this advantage could be maintained in the long term. An efficacy trial in a larger sample of participants is feasible and must be conducted.

Experiences and effectiveness of occupational therapy interventions delivered in the acute setting: a mixed methods systematic review protocol

OBJECTIVE

The objective of this review is to synthesize and integrate the best available evidence on the experiences and effectiveness of occupational therapy interventions delivered in the acute setting.

INTRODUCTION

Occupational therapy is a client-centered health profession promoting health and well-being through occupation. In acute hospital settings, occupational therapy interventions are provided to patients to maximize function, prevent readmission, and promote safe discharge. Recent studies have demonstrated that occupational therapy has modified its practice in acute settings to include advocacy, team facilitation, and rapid clinical reasoning. This review will investigate not only the effectiveness of occupational therapy interventions, but also the experiences of patients, caregivers, and clinicians in the acute setting.

INCLUSION CRITERIA

This review will consider qualitative, quantitative, and mixed methods studies on the experiences and effectiveness of occupational therapy interventions delivered in acute settings. For the qualitative component, the experiences of patients and caregivers receiving any occupational therapy intervention, and clinicians directly or indirectly involved in delivering occupational therapy interventions, will be investigated. For the quantitative component, occupational therapy interventions will be compared with non-occupational therapy interventions, no intervention, wait-list, or other inactive or active (usual care) control interventions. Patient outcomes will include impairment, activities of daily living, psychological outcomes, and quality of life, while health system outcomes will include health care utilization and patient flow.

METHODS

The databases to be searched include CINAHL, Cochrane Controlled Trials Register, MEDLINE (Ovid), OT Seeker, PsycINFO (Ovid), and Scopus. Study selection, critical appraisal, data extraction, and data synthesis and integration will utilize the JBI segregated approach to mixed methods systematic reviews.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020206363.

The Role of Occupational Therapy in Pulmonary Rehabilitation Programs: Protocol for a Scoping Review

BACKGROUND

Chronic respiratory diseases are highly prevalent and compromise an individual's ability to perform activities of daily living (ADLs) and participate in meaningful life roles. Pulmonary rehabilitation (PR) is a well-established intervention aimed at restoring an individual's exercise capacity and improving their ability to complete their ADLs. Occupational therapists help individuals engage in meaningful "occupations," improving their health and well-being. Given the concordance in the aims of PR and the occupational therapy (OT) scope of practice, occupational therapists appear to be well suited as key players in PR programs. However, the benefits of adding OT to PR programs have been sparsely reported in the literature and the role of OT in PR has never been synthesized or reported in national and international guidelines.

OBJECTIVE

The aim of this review is to explore the role of OT in PR programs, the current guideline recommendations for the inclusion of OT in PR programs, the estimated prevalence of OT in PR programs, and the reported or anticipated effects of OT interventions in PR programs.

METHODS

The review will be conducted following the Joanna Briggs Institute (JBI) methodology for scoping reviews. A comprehensive search will be undertaken in the Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, and CINAHL (EBSCO) to identify and retrieve relevant literature published in English, French, or Portuguese. Gray literature on international OT association websites will also be identified, including position statements and guidelines relevant to PR programs. All literature published since the establishment of the effectiveness of PR for chronic respiratory disease in 1994 that explores OT in PR programs for these patients will be included. Search results will be exported to Covidence for title, abstract, and full-text screening by two independent reviewers. Data will be extracted by two independent reviewers using a pilot-tested template including the following: the number of PR programs including OT (specifically from surveys), the purpose of the study, the study design, patient characteristics, respiratory conditions included, PR components, OT role, outcomes, and results. Findings will be presented using a narrative summary, supplemented by figures and/or tables. Key themes will be displayed in an infographic or schematic.

RESULTS

The study was initiated in January 2021 and registered with the Open Science Framework (OSF) in February 2021, prior to title and abstract screening. Data collection and analysis and drafting of the manuscript will occur throughout 2021, with expected publication in 2022.

CONCLUSIONS

The results of this scoping review will help health care professionals improve patient care by broadening their understanding and awareness of the role of OT in PR programs. This role clarification may help to inform program development and clinical decision making and will serve to optimize the delivery of multidisciplinary care for patients in PR programs, ultimately improving patient outcomes.

TRIAL REGISTRATION

OSF Registries ZH63W; https://osf.io/zh63w.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/30244.

Occupational Therapy: Essential to Critical Care Rehabilitation

The coronavirus disease 2019 (COVID-19) pandemic reshaped the health care landscape, leading to the reassignment of essential health care workers to critical areas and widespread furloughs of providers deemed nonessential, including occupational therapy practitioners. Although multidisciplinary critical care teams often include occupational therapy practitioners, efforts to define, measure, and disseminate occupational therapy's unique contributions to critical care outcomes have been overlooked. This editorial provides recommendations to improve the occupational therapy profession's readiness to meet society's current and future pandemic needs. We propose a three-pronged strategy to strengthen occupational therapy clinical practice, education, and advocacy to illuminate the distinct value of occupational therapy in critical care.

A comparison of standard occupational therapy versus early enhanced occupation-based therapy in a medical/surgical intensive care unit: study protocol for a single site feasibility trial (EFFORT-ICU)

BACKGROUND

Admissions to intensive care units (ICUs) are increasing due to an ageing population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care.

METHODS

This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60-min sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed.

DISCUSSION

This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268 ; prospectively registered on 13 March 2018/ https://www.anzctr.org.au Trial funding: Metro South Health Research Support Scheme Postgraduate Scholarship.

A atuação do terapeuta ocupacional em Unidade de Terapia Intensiva: uma revisão sistemática

Resumo Introdução A participação do terapeuta ocupacional (TO) em Unidades de Terapia Intensiva (UTI) ainda é discreta no Brasil, talvez, por isso, haja pouca discussão das intervenções e inserção do profissional nessa área. Objetivo Sintetizar as atuações do TO para restabelecimento da função em pacientes adultos internados na UTI mais frequentemente descritas na literatura especializada. Método Revisão Sistemática baseada na recomendação PRISMA. A busca dos estudos foi realizada nas plataformas Cochrane, PubMed, OTSeek e PEDro, utilizando os termos de busca “Occupational Therapy”, no título ou resumo, (AND) “Intensive Care Unit” (OR) “Critical Illness” (OR) “Critical Care”, em outras partes do texto. Foram incluídos textos em língua inglesa e publicados nos últimos 20 anos. Excluiu-se textos que abordavam UTI pediátrica/neonatal, doenças psiquiátricas e artigos de revisão. Dois pesquisadores independentes selecionaram os artigos e a concordância foi submetida à análise Kappa. O nível de evidência e a qualidade metodológica dos estudos incluídos foram avaliados pela Escala PEDro e pela Ferramenta de Colaboração Cochrane, respectivamente. Resultados As principais intervenções foram relativas ao treino de Atividades de Vida Diária (AVDs) e tarefas relacionadas às Atividades Instrumentais de Vida Diária (AIVDs). Essas atribuições privativas da profissão ocorreram isoladamente ou com fisioterapeutas. As sessões, excluídos os critérios de contraindicação, aconteceram precocemente (24-48h). Conclusão Os achados evidenciam intervenções de mobilização precoce, seguidas por práticas de treino de AVDs/ AIVDs. Ademais, é notado que a atuação do terapeuta ocupacional na UTI está em elaboração. Estudos sobre outros efeitos da internação prolongada na UTI devem ser conduzidos. Registro PROSPERO: CRD42020214615.