Value of OT in Acute COVID-19

Finally! We have some educational courses for COVID-10 patients and how Occupational Therapy can help with getting people better. It’s a little detour to our usual pediatric topics but I think this is an important conversation with the way our world is going. I don’t know about you, but the only way I can settle my nerves about the unknown is to learn more about it, make it less strange and more understandable. I have some parts of this particular blog for my fellow Occupational Therapists in acute care, but there’s good information for everyone. The information below is based on a great course I took called “The Value of Occupational Thearpy in the Acute Care Management of Patients with COVID-19,” if anyone else is interested. 

A little background

The virus is called Severe Acute Respiratory Syndrome Coronavirus 2 (SARS- Cov 2). Along with the same guidelines as HIV/AIDS; HIV is the virus that causes the AIDS disease, SARS-Cov-2 causes COVID-19. 

CDC Guidelines: Contact/droplet precautions except during aerosolizing procedures. Examples for when to take airborne precautions are; Tracheostomy, Intubation, CPR, High flow O2.

Illness Severity

Mild to moderate: 81% of patients have mild symptoms up to mild pneumonia

Severe: 14% with dyspnea (difficulty breathing), hypoxia (oxygen deprivation), or >50% lung involvement on imaging 

Critical: 5% includes those with respiratory failure, shock, or multiorgan system dysfunction

The clinical presentation for those going to the hospital include generalized weakness, dyspnea, delirium, upper extremity plexopathies, fatigue, anxiety. Other considerations include social isolation, occupational deprivation, stigma, and caregiver exposure/illness risk.

With increased survival rates of ICU admissions, patients are left with what is a new concept called Post-Intensive Care Syndrome. Basically in 2010, The Society of Critical Care Medicine found that with medical advancements there is an increase in survival rate of ICU patients However, those that were leaving the ICU were left with very profound neuromuscular physical deficits as well as psychological and cognitive deficits. Due to the pandemic and influx of critically ill patients, we can reflect some of the research for Post-Intensive Care Syndrome to understand how we can treat COVID-19 patients. 

Numbers

As we have heard on the news, the severity of COVID-19 cases have risk factors for neuromuscular impairments including; multiorgan failure, prolonged bed rest, possibly month long intubation and ICU stay. 85-95% of ICU survivors will experience persistent weakness at hospital discharge, possibly resulting in atrophy, sensory loss, foot drop. 

Regarding patients 1 year post ICU discharge; 50% experience deficits in ADL’s (ex: bathing, hygiene tasks, feeding, toileting, dressing activities), and 70% with deficits in IADL’s (ex: driving, cooking, cleaning, shopping). Other risk factors include increased need of caregiver support, less likely to go back to work. From a psychological perspective, 1 in 3 experience Depression, 60% experience PTSD. Younger age is correlated with higher rates of depression, anxiety, and post-traumatic stress syndrome, as well as with lower level of education. And importantly, that impairment in executive functioning is associated with higher rates of depression. 

Risk of Cognitive deficits secondary to prolonged periods of sedation, decreased memory due to hypoxia common with acute respiratory distress syndrome (a symptom with COVID-19). 

With an all hands on deck approach to stabilize the patient medically, and precautions for limited use of PPE, making patient isolation harder to keep track or assess delirium (confusion). 

Occupational Therapy Assessments

How can OT help? Recent article that showed in COVID-19 survivors that lower grip strength equated to higher rates of intubation, and it also correlated with respiratory muscle strength. -MMT or Dynamometer for measurement of strength 

Assessment for Physical Function

-ICU Mobility Scale is a zero to 10, Functional Status Score for the ICU, FSS-ICU (it has a really high 99% inter-rater reliability. It has five features including rolling, supine to sit transfer, sitting edge of bed, sit to stand transfer, and walking), AM-PAC for ADLs (6 ADLs with a scale of one to four grading level of independence), Katz Independence 10 of ADLs includes six ADLs (not great for scaling), Barthel (10 ADLs and mobility tasks including grading it from independent, needs help, and dependent. So here, you only get three ways to identify patient's progress, so not as sensitive but is supported by literature.)

Assessment for Delirium 

-CAM assessment method for ICU and the Intensive Care Delirium Screening Checklist are both high inter-rater reliability, high specificity (gold standard), Confusion Assessment Method – Severity (CAM-S), Intensive Care Delirium Screening Checklist (ICDSC), Brief Confusion Assessment Method (bCAM).

Cognition Assessments

-Richmond Agitation Sedation Scale (RASS), The Orientation Log (O-Log), Montreal Cognitive Assessment (MoCA)

Psychological Assessments

Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale – Revised (IES-R)

Intervention!

-Prone Positioning has been shown to improve gas exchange efficiency, increase perfusion and recruitment of dorsal lung, mobilizes secretion. Link: https://www.ficm.ac.uk/sites/default/files/prone_position_in_adult_critical_care_2019.pdf

Repositional strategy to mobilize the lungs, goal is to prolong or prevent intubation, can be done while conscious or when sedated with proper guidelines and precautions.

In order to prevent Brachial Plexopathy, proper prone positioning and nursing education is encouraged. Early Mobilization; the therapy team will assess and treat within safety limitations.

Teamwork; Co-treating with other healthcare professional and Cluster care is great for patient progression. Billing may take a back seat for the benefit of the patient. 

Delirium management:

Giving patients the tools they need to interact within their environment, regulating sensory input with hearing aids/dentures/glasses, modify environment; turning on lights, clock visible, collaboration with speech therapy for adaptive strategies, communication, reorientation strategies are all going to help regulate patients. 

Early mobility with engagement in ADL’s, modifications with DME (tools to help with activities of daily living) as needed, energy conservation. Preservation of independence and encouragement to continue doing activities will help with recovery. Your OT will also help patients learn breathing techniques, identify this is your breaking point in terms of safety for your fatigue level and then how to manage it. 

Management of Mental Health

We learned that deficits and executive functioning are independently linked with increased rates of depression (super important to address). Social engagement with facetimes, calls for those without smart devices can help patients in the ICU. Routines make cluster care easier but also helps patients with mental health. ICU Diaries are also used in OT for improving orientation, memory, psych component of mental health. Mindfulness breathing exercises have shown to reduce anxiety, and patients report improvement. 

Resources on

Facebook- COVIDRehab4OT Group (general COVID), COVID4CCOT Group (critical care) 

Royal College of Occupational Therapists: www.rcot.co.uk 

Hospital Elder Life Program www.hospitalelderlifeprogram.org § https://help.agscocare.org/products 

Johns Hopkins University: Everybody Moves Campaign 

Rehabilitative Care Alliance: http://rehabcarealliance.ca/

Resources

Alvarez, E.A., Garrido, M.A., Tobar, E.A., Prieto, S.A., Vergara, S.O., Briceno, C.D., & Gonzalez, F.J. (2017). Occupational therapy for delirium management in elderly patients without mechanical ventilation in an intensive care unit: A pilot randomized clinical trial. Journal of Critical Care, 37. § American Occupational Therapy Association (2020). The role of occupational therapy: Providing care in a pandemic. Retrieved May 13, 2020 from https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/News/2020/OT-Pandemic.aspx. § Bamford, P., Bentley, A., Dean, J., Whitemore, D., & Wilson-Baag, N. (n.d.). Guidance for Conscious Proning. Retrieved May 14, 2020, from https://www.ics.ac.uk/ICS/Pdfs/COVID-19/Guidance_for_conscious_proning.aspxCampbell, C. (2014). The role of occupational therapy in an early mobility program in the intensive care unit. Special Interest Section Quarterly: Physical Disabilities, 37(1). § Centers for Disease Control and Prevention (2020). Interim clinical guidance for management of patients with confirmed coronavirus disease (COVID-19). Retrieved May 13, 2020 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical- guidance-management-patients.html. § Clancy, O., Edington, T., Casarin, A., & Vizcaychipi, M.P. (2015). The psychological and neurocognitive consequences of critical illness. A pragmatic review of current evidence. Journal of the Intensive Care Society, 16(3), 226-233. § Costigan, F.A., Duffet, M., Harris, J.E., Baptiste, S., & Kho, M.F. (2019). Occupational therapy in the ICU: A scoping review of 221 documents. Critical Care Medicine, 47(12), 1014-1021. § Desai, S.V., Law, T.J., Needham, D.M. (2011). Long-term complications of critical care. Critical Care Medicine, 39(2). doi: 10.1097/CCM.0b013e3181fd66e5 § Esbrook, C., Jordan, K., Robinson, M., and Wilcox, J. (2020). Occupational therapy in hospitals & inpatient care: Responding to a pandemic. Retrieved from https://myaota.aota.org/shop_aota/product/OL8102 § Karnatovskaia, L.V., Johnson, M.M., Benzo, R.P., & Gajic, O. (2015). The spectrum of psychocognitive morbidity in the critically ill: A review of the literature and call for improvement. Journal of Critical Care, 30, 130-137. § Kho, M.E., Brooks, D., Namasivayam-MacDonald, A., Sandrar, R., & Vrkljan, B. (2020). Rehabilitation for patients with COVID- 19. Guidance for occupational therapists, physical therapists, speech-language pathologists and assistants. School of Rehabilitation, McMaster University. http://srs-mcmaster.ca/covid-19/ § Kofis, K., Roberson, S.W., Wilson, J.E., Pun, B.T., Ely, E.W., Jezowka, I., Jezierska, M., & Dabrowksi, W. (2020). COVID-19: What do we need to know about ICU delirium during the SARS-CoV-2 pandemic? Anesthesiology Intensive Therapy, 52(2). § Intensive Care Society (2019). Guidance: Prone Positioning in Adult Critical Care. Retrieved May 16, 2020, from https://ficm.ac.uk/sites/default/files/prone_position_in_adult_critical_care_2019.pdf 5/29/20 16 References continued § Parker, A., Sricharoenchai, T. & Needham, D.M. (2013). Early rehabilitation in the intensive care unit: Preventing physical and mental health impairments. Current Physical Medicine and Rehabilitation Reports, 1(4), 307-314. § Quick, T., & Brown, H. (2020). A Commentary on Prone Positioning Plexopathy during COVID 19 Pandemic. The Transient Journal of Trauma, Orthopaedics and the Coronavirus. Retrieved from https://www.boa.ac.uk/policy-engagement/journal-oftrauma-orthopaedics/journal-of-trauma-orthopaedics-and-coronavirus/a-commentary-on-prone-position-plexopathy.html § Schweickert, W.D., Pohlman, M.C., Pohlman, A.S., Nigos, C., Pawlik, A.J., Esbrook, C.L. … & Kress, J.P. (2009). Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomized controlled trial. Lancet, 373, 1874-1882. § Wilcox, M.E., Brummel, N.E., Archer, K., Ely, E.W., Jackson, J.C., & Hopkins, R.O. (2013). Cognitive dysfunction in ICU patients: Risk factors, predictors, and rehabilitation interventions. Critical Care Medicine, 41, S81-S98. § World Health Organization (2020). Infection prevention and control during health care when novel coronavirus infection is suspected. Retrieved from: https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when- novel-coronavirus-(ncov)-infection-is-suspected-20200125