Critical Care Occupational Therapist

Sharon Barker, James Cooke University Hospital

Before I begin it is probably best to start with what occupational therapy (OT) is. The Royal College of Occupational Therapy (RCOT) define it as ‘a science degree-based, health and social care profession, regulated by the Health and Care Professions Council’.

OT takes a “whole-person approach” to mental and physical health and wellbeing and enables individuals to achieve their full potential. Occupational therapists look for practical ways to support and empower people to recover or overcome barriers that prevent them from doing the things that matter to them.

Occupation matters refer to daily activities, such as getting washed and dressed, making and/or eating a meal, going to work, looking after family and children or even participating in your favourite hobby. They are the purposeful activities that allow individuals to be independent and have a sense of identity. Think about when you got up this morning, think about how you would have to cope or adapt if you could not lift your legs out of the bed or could not access the shower.

I am a Specialist Critical Care Occupational Therapist, which is a relatively new role within the profession and my trust, so even after 10 years as a qualified OT, I am still learning every day.

What does my role entail?

The main aim of my role is to provide assessment and rehabilitation in and after critical care to help people regain basic skills to look after themselves and return to the things they want or need to do. The role is extremely varied and is very much dependent on the patients I am supporting.

Currently I cover several critical care wards including:

  • the High Dependency Unit (HDU), which supports patients who need more detailed observations or interventions including support for single organ failure, post-operative care, and those ‘stepping down’ from level 3. This area usually has one nurse to care for two patients.
  • the Intensive Care Units (ICU), which supports patients requiring advanced respiratory support and/or support for at least two organ systems and is staffed with one-to-one nursing.
  • the Cardiothoracic Intensive Care Unit (CICU), which provides advanced care for patients who have undergone cardiothoracic surgery, critically ill cardiology patients and post cardiac arrest patients.

As you can imagine, my patients are often from all age ranges and have a range of physical, psychological, social, and environmental needs.

Today I did…

My day usually starts at around 8:15 with a therapy team meeting. This is an opportunity to meet with the physios, receive any critical care team updates/briefings, discuss any ongoing rehab cases, potential new cases and/or plan any joint therapy sessions, as well as discuss any training or service development opportunities. This usually lasts 15-30 minutes.

Next, I attended the inpatient OT team handover meeting to support with any issues that require senior support or specialist advice, as well as to feedback current cases open to OT in critical care and prepare for a seamless transition of care on step down to the ward environment. Dependant on the patient’s length of time in critical care and ongoing complexity of their needs, it may be appropriate for the senior inpatient’s OT to reach into critical care or for me to outreach to support on step down. This is also discussed and arranged within these meetings.

My final port of call before attending to patients was accessing Ward Watcher – a computer-based system which checks the location of my patients – and checking my inbox for any urgent emails or any meetings for the day.

Once I have made a loose plan, prioritising who I am going to see and when, I head up to the wards.

My morning rounds

First up is a lady who is currently on HDU. She was admitted for ventilatory support following post-operative complications after a tracheostomy. She is not yet ready for the special valve that will allow her to talk and as she has struggled to communicate, she is struggling emotionally with the overwhelming experience of being critically unwell which has resulted in anxiety, sleep disturbances and hallucinations.

I have been working with this lady to find alternative ways to communicate and increase her confidence, including arm and hand exercises to improve her ability to write. I have encouraged her to establish a routine and participate in daily activities including getting washed, brushing her hair and teeth, and eating her own meals using cutlery. I have also supported with anxiety management techniques and encouraged increased participation in physio sessions for early mobilisation to increase her activity tolerance. This morning was self-care and reorientation. Reorientation is a simple but essential intervention where a patient’s focus is directed to the current date and time as well as appropriate subjective information and is an important step in delirium prevention in critical care.

Next is another patient on HDU who requires support with his cognitive recovery following a road traffic accident. He is currently awaiting transfer to the trauma ward for further assessment/rehab and discharge planning.

This patient has been in critical care for a long time and is at greater risk of developing non-physical symptoms including delirium, loss of memory and problems with concentration and awareness. Through observations and assessments, we identified that this patient has reduced attention and delayed information processing so have put a daily plan in place which includes sitting in one of the ward chairs for short periods of time to build his core strength and sitting tolerance – a perfect opportunity to engage him in some cognitive stimulation activities.

It is important to make the activities meaningful and relevant to the patient, so we continue with a range of appropriate activities with short rest period built in to maximise his potential to benefit and engage with the activity. One of the core principles underpinning OT is client centred care, so it is important to always consider the patient’s perspective and involve them where possible, to keep them at the heart of what we do.

Time for lunch

Over lunch, I caught up on notes. Documentation one of the most time consuming and important parts of our job. Not only is this a legal requirement and professional standard, but it also allows us to track our patients’ progress, set realistic goals and support with rehab and their subsequent discharge planning.

My afternoon

Firstly, I met up with some of the physio team on ICU for a joint session with a patient who was admitted with Covid pneumonitis. This patient was sedated and ventilated for several days which can result in muscle weakness, joint pain, or stiffness, especially if they have been unwell for some time. This particular patient has ICU acquired weakness which is a common presentation and is usually symmetrical. It can also result in pain, or changes to sensitivity of temperature and sensation.

As today was the first time I had met this patient, I assessed them to see if they could communicate – either verbally, mouthing, gestures, blinking etc – if they followed instructions, made eye contact, if they could they move their limbs, signs of pain, and so on. This initial assessment will then form the basis of subsequent assessment and intervention. Tomorrow I will complete another joint assessment where I will focus specifically on their upper limb movements, sensation, and awareness.

This patient can communicate via nodding their head and has given consent to contact their family. As a result, I contacted their family to complete a ‘getting to know you’ questionnaire. This is an important part of the assessment process as it allows us to get to know the patient and supports with their rehab planning. In this type of call we find out what is important to the patient, what their home environment is like, important contacts, their usual activities, like / dislikes and what would their rehab goals be. This is often a therapeutic experience for the patient’s family and allows them to advocate for their family member whilst they are vulnerable and essentially, humanise them. These calls are very personal and should not be rushed.

I completed my day with more notes / admin, liaising with some of the therapists for updates on my other patients, updating EVOLVE – the hospital system for recording patient contact – and locking away my notes for the day. I usually try to include some service development projects within this time too, and then called it a day around 4:30.

A rewarding career

Hopefully, that is a glimpse into what OT can offer and it inspires others to learn more. OT is a challenging but rewarding career and I would highly recommend it to those interested in the field of care.