A day in the life of an occupational therapist: occupation centered practice within the critical care team

I’m an occupational therapist based in a tertiary cardiothoracic hospital. My role on ITU involves working with patients who are admitted needing surgical intervention or support for their heart and/or lungs, including those who are pre and post transplantation. Occupation-centred practice means the work I do each day varies hugely depending on the patients I meet and what is important to them, as well as their clinical presentation. The unique thing about OT on ICU is that we consider an individual’s occupations within the context of both their clinical presentation and the constraints of the critical care environment, and grade the task so it’s the right level for them to engage in. It can be challenging to find a way to adapt some occupations within such a medicalised environment, so we have to be a bit creative! 

My first patient of the day was admitted following an out of hospital cardiac arrest and is taking some time to wake up after sedation wean. It’s likely that he may have a hypoxic brain injury and unfortunately may be in a disorder of consciousness, so we are assessing his level of awareness using the Coma Recovery Scale and WHIM.

Today I am doing a joint session with the physiotherapy team, using the tilt table to see if being more upright will increase alertness and engagement. The patient manages this really well and demonstrates sustained eye opening for the first time, so we are able to use some personal photos brought in by his family to stimulate and sustain attention. I also spend some time with his family discussing his current function and consider carving out ways for them to feel involved in his current care, by supporting with passive range of motion, providing regular orientation and talking to him about normal things from home.

My next patient is a young woman who has recently had a heart transplant and a perioperative stroke and which has affected the use of her dominant hand. She has retained some gross motor function but is struggling with precision grips. As someone who previously enjoyed drawing as a way to relax, finding a way for her to establish a functional pen grip is important to her. We explore some different techniques and options for modifying the pen, as well as discussing her goals around self-care we want to work on over the next couple of weeks.

After our weekly MDT meeting where we discuss our patients’ progress and how we can best support them as a team, I head to see a patient waiting for transplant who is currently supported on an Impella. He is experiencing some sensory changes in his dominant hand following a nerve injury after the device was inserted. Although he’s about to do most of the things he needs to be able to do, he’s switching objects from his dominant to non-dominant hand as he’s worried about dropping things. We try out some wide grip cutlery and I go through some nerve glide exercises with him, to encourage him to use his dominant hand in normal movement patterns whilst feeding himself and encourage return of sensation in the affected hand. The cutlery works well and he’s keen to start using it. 

My last patient has been on the unit for several months with a number of medical complexities following LVAD implantation. We discuss his forthcoming step down to the ward and how he’s feeling about transitioning to an environment where he’ll need to press the call bell if he needs support rather than having a nurse at his bedside 24/7. He’s feeling a little uncertain but also eager to think about next steps and allowing himself to start thinking about the future, including return to work. I encourage him to break things down and consider the things he needs to achieve over the next days and weeks before going home, whilst also planning how we can work on his standing endurance and functional reaching which will support him both at home and in his work role.

One of the benefits of working in a small team and hospital is that we will continue to support these patients after they step down to the ward. It’s a real privilege to be able to take time to get to know what matters to people and then be able to use that knowledge to help support them through all the stages of their inpatient rehab journey. 

Helena Rampley

Senior Specialist Occupational Therapist, Harefield Hospital, Middlesex

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