1. Occupational Therapy adding value to an Intensive Care Unit A pilot project : Sept 2016 - July 2017
Becca
OT – Royal Free London
Neuro background
12 month pilot project – need and impact of OT on our 34 bedded ICU
Rebecca Chewter
June 2017

2. Aims
Explore the role of Occupational Therapy (OT) in the Intensive Care Unit (ICU)
Identify drivers for change
Outline our developing service
Highlight the need for OT in ICU
Demonstrate the impact and value of OT in ICU
Aims of the session are to….

3. Why Occupational Therapy?
Skills
Holistic
Occupation
Function
Participation
Task analysis
Independence
Routine
Roles
Quality of life
Drivers for change
Rehabilitation After Critical Illness in Adults (NICE 2009)
Guidelines for Provision of Intensive Care Services (2015)
ICU is an emerging area for OT. We have lots to learn about the specialty but also have so much to offer as our bread and butter skills are very relevant to critical care.
We’re not necessarily fish out of water! and I didn’t feel as alien as I expected when I joined the team.
Our unique focus on occupation is very much needed
And we can address the physical, cognitive and psychosocial aspects of critical illness .
We can help restore a sense of routine and control by being person centred in what is so often a dehumanising environment
Where intervention with other professionals is usually about organs, numbers and machines.
We know we’re experts in task analysis and modification, so can break down tasks and finding solutions that enable the critically ill to participate in meaningful activities and roles
Which we know are so important to a person’s identity, recovery and quality of life
Two main pieces of legislation which are drivers for change –
NICE guidelines – updated and released this summer with RCOT contributions
GPICS OT per bed
Both recommend timely assessment, goal setting and rehab – emphasising the importance of meeting physical and non-physical functional needs

4. Literature Occupational Therapy in ICU:
Improves function at hospital discharge
Shortens episodes of delirium and reduces risk
Associated with reduced ICU and hospital length of stay, duration of mechanical ventilation and hospital costs
Schweickert et al (2009), Parker et al (2013), Alvarez et al (2016)
Evidence base for OT is growing as it’s an emerging area of research, particularly for the UK, but so far it shows that OT is safe, well tolerated,
and associated with better outcomes such as

5. The Royal Free Service 4 streams: Delirium monitoring & management
Disability management
Functional rehabilitation
Early discharge planning
Weaning round
Multi Disciplinary Meetings
Goal setting
The service we provide has 4 main streams which are:
4. So that’s with the view to starting this process in ICU, rather than waiting until the patient arrives on the ward, or even discharging directly from the unit on occasions.
I also contributes to our weekly weaning rounds, MDMs and goal setting

6. Results : so is there a need?
YES!
125 seen by OT
Full caseload
Waiting list
OT is definitely needed!
- Full caseload for duration of project
Seen 125 critical care patients – with another 32 identified as appropriate but not seen due to limited capacity, demonstrating unmet need.
Received referrals from most members of team who recognise the need
Many specialties have benefited from all 4 streams, but mostly liver, general medicine and cardiology due to the nature of our unit

7. What is the impact for patients?
50% returned home - 10% social care
14% inpatient rehab
5% placement
75% achieved rehab goals
100% maintenance goals
9 home from ICU!
Looking at patient progress…
75% achieved their rehab goals and secondary complications have been prevented in 100% of disability management cases
This demonstrates better functional outcomes using the goal attainment scale as a measure.
9 home from unit – following functional assessment, equipment provision, liaison with families and onward referrals
50% of my caseload could return home on hospital discharge – only 10% of those needed care, rest were supported by family or independent
14% inpatient rehab potentail
5% placement
Several repatriated, and rest sadly died, demonstrating complexity of patient group

8. What is the impact on teams?
handover increased efficiency & continuity of care
initial assessment & treatment plan in place… saved time on the ward
Greater focus on function... upper limb & cognition
more effective well-rounded goal setting
Good to humanise care
helps us to make more informed decisions
more person- centred
Early rehab is beneficial… can reduce length of stay…
Feedback from the unit has shown OT as part of the team helps to -
Humanise care
Identify cognitive impairments
Emotionally support patients and their families
Gather info and signpost
Set holistic goals
And focus more on daily activities and function in rehab
Feedback from other specialties and pathways has shown that OT in ICU has also made an impact on the wards
Reporting OT on ICU has helped ward staff build a rapport quicker
OT to OT hand over improved continuity of care and efficiency
ICU OT intervention saved them time, and in some cases seems to have reduced LOS
patients & families better emotionally supported
helped build rapport

9. Take home message OTs in ICU add value to:
Patients – earlier intervention, holistic care, positive outcomes
Families – practical and emotional support, education, signposting
Teams – decision making, communication, skill sharing, teaching
Governance – length of stay, objectives, guidelines, audit
Profession – role promotion and research
In summary, OT in ICU adds value to….
Patients as they receive…
Families as they now receive more…
Teams by supporting decision making and communication, as well as opportunity for skill sharing and teaching
Gov as length of stay, although multifactorial, seems to have been reduced, trust objectives and national guidelines better met,
Profession as it raises our profile and will hopefully contribute to future research
In the next couple of months I’ll be writing up the project as a quality improvement project and look to secure funding for a full time OT in ICU, which I’m excited to say is sounding likely.

10. References
Alvarez EA, Garrido MA, Tobar EA, Prieto SA, Vergara SO, Briceno CD. Occupational Therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomised clinical trial. Journal of critical care 2016;37:85-90
National Institute of Clinical Excellence (2009) Rehabilitation after critical illness in adults. Available from: nice.org.uk/guidance/cg83 [Accessed October 2016]
Parker A, Sricharoenchai T, Needham DM. Early Rehabilitation in the Intensive Care Unit: Preventing Physical and Mental Health Impairments Current Physical Medicine and Rehabilitation Reports. 2013;1(4)
Schweickert W, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, MacCalliser KE, Hall J, Kress JP. Early Physical and Occupational Therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009; 373,
The Faculty of Intensive Care Medicine & The Intensive Care Society (2015) Guidelines for the Provision of Intensive Care Services Available from: [Accessed October 2016]

11. Email: rebecca.chewter@nhs.net
Tel: Bleep 2492