Introduction of a structured approach to cognitive rehabilitation for critical care patients

Aim:

To provide cognitive assessment and rehabilitation for patients who are critically ill. The main focus is for the patients who are long-term patients on the critical care unit who are at greater risk of cognitive dysfunction both in the short and long-term.

Objectives:

• To introduce cognitive assessments to patients
• To provide delivery of cognitive rehabilitation for patients
• To implement a structural approach to cognitive assessment, rehabilitation and management
• To consistently meet the NICE guidelines, (CG83, 2009) and the intensive care society standards (ICS, 2013), to "deliver 45 minutes of each indicated therapy 5 days a week".

The Critical Care unit at Nottingham University Hospitals, NHS Trust, City Campus is a 17 bedded flexible Level 2&3 unit. The main specialities covered by this unit are Cardio-Thoracic Surgery, Gastro-Intestinal Surgery, Urological Surgery, Haematology, Burns and Respiratory Medicine. Approximately 1000 patients are admitted to the unit per year and approximately 200 stay ≥ 5 days.

Prior to this project, the occupational therapy (OT) input to critical care patients was minimal. No routine visits were made to patients and OT’s were only involved in supplying foot drop splints at the request of nursing or physiotherapy staff. There is an increasing evidence base describing the cognitive impairments survivors of critical illness face and reports of these impairments suggest patients can experience them for years post critical illness.

Snapshot ‘service evaluations’ revealed a service gap by demonstrating that there was a demand to provide cognitive rehabilitation to patients, particularly to those who were delirious, sleep deprived and agitated or were at risk by having a length of stay ≥5 days.

This project was implemented to provide a structured approach to delivering cognitive rehabilitation to critical care patients at high risk of developing the long-term non-physical symptoms such as loss of memory, attention deficits, sequencing problems, apathy and low self-esteem. The service is provided by one Band 7 OT whole time equivalent, 1 Band 6 OT whole time equivalent and two full-time Band 4 therapy support workers.

To improve efficiency, patients are assessed by a registered member of the OT team and prescribed a cognitive therapy rehabilitation programme, this is then delivered by the therapy support workers. This enables the registered staff to be freed up to treat more complex patients. The project introduced rehab time lines, developed a structured approach to assessing patients and provided individually prescribed cognitive rehabilitation interventions to critical care patients. Stakeholders were involved by funding the project and quarterly reports.

Patients and carers gave us feedback and this is why the rehabilitation timeline was implemented as their feedback was that they found it useful to aid memory and build insight.

An Advanced Practitioner OT was recruited with a clinical interest and experience in critical illness rehabilitation.

The advanced practitioner led the process of integrating an occupational therapy service to provide rehabilitation on the critical care unit.

A consistent occupational therapy service, specifically for cognitive assessment and rehabilitation to meet the NICE and ICS guidelines was commenced.

Band 4 therapy support workers were trained to perform cognitive assessments and deliver cognitive rehabilitation techniques. For example, completing a bespoke "bed side cognitive assessment". This includes completing an observation of the patient's cognitive interactions such as localising to sound, visual tracking, level of alertness, following commands and response to attention.

Following the bed side assessment, validated assessment tools such as the CAM ICU and the Montreal Cognitive Assessment (MoCA) are used, when appropriate, to provide a baseline measure of the patient's cognitive function.

Appropriate cognitive interventions are identified for the specific needs of the patient. This ranges from the spectrum of a patient being delirious to those who have reduced attention and mild memory issues.

Having a presence on the long term ward round was a platform to promote and increase awareness of cognitive dysfunction and the role an occupational therapist provides.

Challenges we have faced include;

• Unprotected registered occupational therapist time to the critical care area
• Changing the perceptions of the multi-professional team of the role of occupational therapy in the critical care setting.
• A lack of awareness of the role and the benefits OTs bring to non-physical critical care rehabilitation.
• There is a lack of primary evidence for the management of cognitive dysfunction specific to occupational therapy in critically ill patients. Therefore, our interventions are based on more established patient groups such as stroke and head injury.

The aims and objectives of the project were met as patients are receiving cognitive assessment and rehabilitation on a consistent basis for critically ill patients.

As a result we are more consistently meeting the NICE and ICS guidelines.

 The objectives met:

• Patients consistently receive cognitive assessments whilst on critical care.
• Cognitive rehabilitation is provided on a patient specific need as part of their rehabilitation process, including when they are transferred to the ward.
• A structural approach has been established, which has had its challenges given the pressures on the acute wards. However, a flexible approach to maximising resources and a team re-structure has enabled an increased level of registered occupational therapy time to be utilised with critical care patients.
• Due to a lack of resources we focus our cognitive rehabilitation for patients who have a stay of 10 days or more, or who present with severe cognitive dysfunction.
• Fluctuating cognitive condition of critically ill patients can affect carry over which can impact all aspects of the rehabilitation pathway.
• Environmental challenges we face are typical of the critical care setting for example; medical and nursing interventions being prioritised over cognitive rehabilitation.
• Using charitable funds to provide equipment, for example, 9 hole peg test, iPad and holder. 

Please see attached file for our outcome measures regarding the FIM and FAM to demonstrate improvement in cognitive function following occupational therapy interventions.

• To ensure registered occupational therapy time is protected to allow for training and consistent service delivery of cognitive assessment and rehabilitation in critical care.
• Team restructure to free up registered OTs to support therapy support workers to deliver the service.
• Create a written protocol to provide a structured approach for cognitive assessments and interventions and how to implement them.
• Always look to evolve and develop the service, to continue to meet the needs of the patient, in order to optimise short and long term cognitive function.
• More standardised cognitive assessments have been identified to fit with patient group, for example; o-log and the Trust's "cognitive assessment booklet".
• Using outcome measures is important to identify patients’ cognitive function. Furthermore, outcome measures highlight the benefit of cognitive rehabilitation for critically ill patients. See attached FIM and FAM information.
• Greater understanding of role of occupational therapy within this setting enabled more appropriate referrals and greater support with ensuring interventions were continued during out of hours, for example, orientation of the CAM-ICU. This therefore reinforces the delivery of cognitive rehabilitation.
• Use of every day resources and patients personal belongings, for example; Trust documentation 'About Me', photographs, pets, get well cards, writing boards, orientation boards, visits outside, magazines, use of iPad and phone, all can be used in cognitive rehabilitation (these are cost effective methods to engage patients in cognitive tasks).