The role of the occupational therapist in the Intensive Care Unit: a systematic review

Bittencourt, Estéfanny da Silva; Moreira, Paula Silva; Paixão, Glenda Miranda da; Cardoso, Marcelo Marques

doi:10.1590/2526-8910.ctoAR2118

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Review Article • Cad. Bras. Ter. Ocup. 29 • 2021 • https://doi.org/10.1590/2526-8910.ctoAR2118 linkcopy

The role of the occupational therapist in the Intensive Care Unit: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction The participation of the occupational therapist (OT) in Intensive Care Units (ICU) is still discreet in Brazil, perhaps because of this, there is a little discussion of interventions and insertion of this professional in this area.

Objective To synthesize the actions of OT to restore function in adult patients admitted to the ICU most frequently described in the specialized literature.

Method Systematic review based on the PRISMA recommendation. The search for the studies was carried out on the Cochrane, PubMed, OTSeek, and PEDro platforms using the search terms “Occupational Therapy”, in the title or abstract, (AND) “Intensive Care Unit” (OR) “Critical Illness” (OR) “Critical Care”, in other parts of the text. English-language texts published in the last 20 years were included and texts that describe interventions in pediatric/neonatal ICU, psychiatric diseases, and review articles were excluded. Two independent researchers selected the articles and the agreement was submitted to Kappa analysis. The level of evidence and methodological quality of the included studies were assessed using the PEDro Scale and the Cochrane Collaboration Tool, respectively.

Results The main interventions were related to the training of Activities of Daily Living (ADLs) and tasks related to Instrumental Activities of Daily Living (IADLs). These private attributions of the profession occurred isolated or with physiotherapists. The sessions, excluding the contraindication criteria, took place early (24-48h).

Conclusion The findings show early mobilization interventions, followed by ADLs/IADLs training and it is also noted that the work of the occupational therapist in the ICU is under development. Studies on other effects of prolonged ICU stay should be conducted. PROSPERO record: CRD42020214615.

Keywords:
Intensive Care Units; Hospitals; Occupational Therapy; Activities of Daily Living; Rehabilitation

Platforms	Descriptor/	Boolean	Descriptor/	Filter	Quantity of Articles
Platforms	Filter	Boolean	Boolean	Filter	Quantity of Articles
Cochrane	Occupational Therapy (Abstract/ Title)	AND	Intensive Care Units OR Critical Illness OR Critical Care	All Fields	273	618
OTSeeker				All Fields	13
PEDro				Abstract/ Title	22
PubMed				All Fields	310

Studies	Risk of Bias
Studies	Generation of randomization sequence	Allocation confidentiality	Masking participants and team	Masking in outcome evaluation	Incomplete outcome data	Selective reporting of outcomes	Other sources of bias
Brummel et al. (2014)	Low	Low	High	High	Low	Low	Uncertain
Corcoran et al. (2017)	Uncertain	High	High	High	Uncertain	Low	Uncertain
Davis et al. (2013)	Uncertain	High	Uncertain	Uncertain	Uncertain	Low	Uncertain
Deluzio et al. (2018)	Uncertain	High	Uncertain	Uncertain	Uncertain	Uncertain	Uncertain
Fields et al. (2015)	Uncertain	High	Uncertain	Uncertain	Low	Uncertain	Uncertain
Hsu et al. (2020)	Uncertain	Uncertain	Uncertain	Uncertain	Low	Uncertain	Uncertain
Jolley et al. (2015)	Uncertain	Uncertain	Uncertain	Uncertain	Low	Uncertain	Uncertain
Jolley et al. (2017)	Uncertain	Uncertain	Uncertain	Uncertain	Low	Uncertain	Uncertain
Needham et al. (2010)	Uncertain	High	High	Uncertain	Uncertain	Uncertain	Uncertain
Pohlman et al. (2010)	Uncertain	Uncertain	Uncertain	Uncertain	Uncertain	Uncertain	Uncertain
Schweickert et al. (2009)	Low	Low	High	High	Low	Low	Uncertain
Sigler et al. (2016)	Uncertain	Uncertain	Uncertain	Uncertain	Uncertain	Uncertain	Uncertain
Titsworth et al. (2012)	Uncertain	High	Uncertain	Uncertain	Low	Uncertain	Uncertain
Wahab et al. (2016)	Uncertain	High	Uncertain	Uncertain	Low	Uncertain	Uncertain
Witcher et al. (2015)	Uncertain	High	Uncertain	Uncertain	Low	Low	Uncertain
Yataco et al. (2019)	Uncertain	Uncertain	Uncertain	Uncertain	Low	Low	Uncertain
Zanni et al. (2010)	Uncertain	Uncertain	Uncertain	Uncertain	Uncertain	Low	Uncertain

Authorship/ Year.	Objective	Study Design	(1) Different occupational therapist's roles from other professions.	Main results.	PEDro scale.
Authorship/ Year.	Objective	Study Design	(2) Other duties.	Main results.	PEDro scale.
Brummel et al. (2014)	Early and combined use of cognitive therapy.	Randomized.	(1) Yes.	Viable and safe, even under mechanical ventilation.	7/10
Brummel et al. (2014)	Early and combined use of cognitive therapy.	Randomized.	(2) Cognitive Therapy (Problem-solving; multi-step task execution).	Viable and safe, even under mechanical ventilation.	7/10
Corcoran et al. (2017)	Early mobilization in the ICU.	Prospective.	(1) No.	Viable with reduced hospitalization and ICU stay.	5/10
Corcoran et al. (2017)	Early mobilization in the ICU.	Prospective.	(2) Exercises in bed; Standing up; Ambulation.	Viable with reduced hospitalization and ICU stay.	5/10
Davis et al. (2013)	Feasibility of early mobilization in the ICU and functionality under mechanical ventilation.	Cohort.	(1) No.	Viable, safe, and well-tolerated under mechanical ventilation.	5/10
Davis et al. (2013)		Cohort.	(2) Decubitus change, sitting on the bed and the edge of the bed; Standing up; Sitting on the chair; Walking.		5/10
Deluzio et al. (2018)	Viability of the Cycloergometer in critical neurological patients.	Cohort.	(1) Yes.	Viable, safe and does not bring physiological, neurological, or cognitive changes.	4/10
Deluzio et al. (2018)		Cohort.	(2) Missing description.		4/10
Fields et al. (2015)	Early mobilization and associated adverse events.	Retrospective.	(1) Yes.	Safe and effective.	4/10
Fields et al. (2015)	Early mobilization and associated adverse events.	Retrospective.	(2) Missing description.	Safe and effective.	4/10
Hsu et al. (2020)	Level of recall, satisfaction, and benefits during mechanical ventilation.	Pilot Study.	(1) Yes.	Compromise of factual memory.	5/10
Hsu et al. (2020)		Pilot Study.	(2) Postural control; Equilibrium reaction; ROM; Sitting and standing up; Transferring to a chair and the bed; Ambulation.	Compromise of factual memory.	5/10
Jolley et al. (2015)	Early mobilization, mechanical ventilation, and associated care.	Transversal.	(1) No.	Wide use of early mobilization in the ICU: 95.7% without mechanical ventilation; and 76.6%, under mechanical ventilation.	5/10
Jolley et al. (2015)		Transversal.	(2) Weight transfer in the bed; Standing up; Walking; Transferring from bed to chair; and Ambulation.		5/10
Jolley et al. (2017)	Prevalence of mobilization in ICUs and progression of mobility.	Cohort.	(1) No.	Prevalence: 32% of patients in the ICU; 16% under mechanical ventilation; and 4% out of bed.	5/10
Jolley et al. (2017)		Cohort.	(2) ROM, passive; Sitting on the bed; Sitting on the edge of the bed; Standing up; Transferring of the chair to the standing position; Walking at the same point; Ambulation.		5/10
Needham et al. (2010)	Practices of sedation and analgesia in the ICU and functional mobilization.	Retrospective.	(1) No.	Deep sedation was not necessary and there was tolerance to mechanical ventilation. Viable, safe, and reduced hospitalization.	5/10
Needham et al. (2010)		Retrospective.	(2) Sitting on the bed; Sitting on the edge of the bed; Transferring from bed to chair; Transferring from sitting to standing; and Ambulation.		5/10
Pohlman et al. (2010)	Daily interruption of sedation and early mobilization.	Retrospective.	(1) No.	Viable and safe right after intubation (ICU).	5/10
Pohlman et al. (2010)	Daily interruption of sedation and early mobilization.	Retrospective.	(2) ROM (passive, assisted or active); Bed mobility; Sitting down; Standing up; Ambulation; Balance.	Viable and safe right after intubation (ICU).	5/10
Schweickert et al. (2009)	Early mobilization, interruption of sedation, and functional and psychiatric results.	Randomized.	(1) No.	Safe, well-tolerated, improving functional status, reducing symptoms associated with the ICU, and increasing weaning.	8/10
Schweickert et al. (2009)		Randomized.	(2) Movements (liabilities, assisted and active); Bed mobility (weight transfer, sitting on the bed); Balance; Standing, Sitting in a chair; Ambulation.		8/10
Sigler et al. (2016)	Implementation of an early mobilization program.	Cohort.	(1) No.	Simple, progressive mobilization, with modification of the analgesic and sedation regimen.	5/10
Sigler et al. (2016)	Implementation of an early mobilization program.	Cohort.	(2) Weight transfer in the bed; Sitting on the bed; ROM (passive, assisted, or active); Sitting on the edge of the bed; Standing up, turning, and sitting on a chair; Standing a few steps and sitting on a chair; Ambulation.		5/10
Titsworth et al. (2012)	Early mobilization in the neuro-intensive care unit.	Retrospective.	(1) No.	It does not harm the patient's critical condition and reduces the ICU stay.	5/10
Titsworth et al. (2012)	Early mobilization in the neuro-intensive care unit.	Retrospective.	(2) Sitting on the bed; Sitting on the edge of the bed; Getting out of bed; Walking to the bathroom; Exiting the room; Exercising.		5/10
Wahab et al. (2016)	Early mobilization in the ICU of a long-term hospital.	Retrospective.	(1) Yes.	Reduction in ICU stay and hospitalization.	5/10
Wahab et al. (2016)	Early mobilization in the ICU of a long-term hospital.	Retrospective.	(2) Missing description.	Reduction in ICU stay and hospitalization.	5/10
Witcher et al. (2015)	Early mobilization and sedation in neurological patients in the ICU.	Retrospective.	(1) No.	Reduced sedation, increased analgesia. It did not reduce the duration of mechanical ventilation or the length of hospital stay.	5/10
Witcher et al. (2015)		Retrospective.	(2) ROM (passive and active); Sitting down; Standing up; Walking.		5/10
Yataco et al. (2019)	Adverse mobilization events.	Retrospective.	(1) No.	Safety, feasible with low rates of adverse events.	5/10
Yataco et al. (2019)	Adverse mobilization events.	Retrospective.	(2) Transferring (from lying to sitting); Sitting on the edge of the bed; Standing up; Sitting on a chair; Ambulation.	Safety, feasible with low rates of adverse events.	5/10
Zanni et al. (2010)	Physiological effects and safety of rehabilitation in the ICU.	Cohort.	(1) No.	Safe, without significant physiological changes or adverse effects.	5/10
Zanni et al. (2010)		Cohort.	(2) ROM; Muscle strength; Occupation; Bed positioning; Sitting on the bed; Sitting on the edge of the bed; Transferring from seated to standing; Ambulation; Activities.		5/10

Authorship/ Year.	(1) ICU.	Contraindications.	Vital signs	Occupational therapist's roles in the ICU.
	(2) Sample.		(Monitoring/alert).
	(3) Ventilation.
	(4) Beginning.
Brummel et al. (2014)	(1) Medical; Surgical.	Missing description.	Missing description.	ADL training (dressing, bathroom), IADLs, or functional activities.
	(2) 87 patients.
	(3) Yes.
	(4) In 24 hours.
Corcoran et al. (2017)	(1) Medical; Surgical.	- Mobility and independent ADLs; - In palliative care; - Surgical indication; - Neurological disorders; - Disorders that impair mobility; - Mental state and level of consciousness; - Organ transplantation; - Risk pregnancy; - Postoperative of moderate to severe stroke; - Ventricular drainage device; - Low oxygen saturation; - Reduced chances of functional gains.	Missing description.	Not specified.
	(2) 443 patients.
	(3) Yes.
	(4) In 72 hours.
Davis et al. (2013)	(1) Medical; Surgical.	- Hemodynamic instability. - Neurological Disorder.	- Positive expiratory pressure:> 10cmH2O; - Respiratory rate: <5 or> 40 times/minute; - Oximetry: <88%; - Blood pressure: <65 or >110mmHg; - Heart rate: <40 or> 130bpm; - Suspension of vasoactive drugs for 2 hours.	Mentioning ADLs.
	(2) 10 patients.
	(3) Yes.
	(4) In 48 hours.
Deluzio et al. (2018)	(1) Neurological	- Systolic and diastolic blood pressure; - Average blood pressure; - Heart rate; - Oxygen saturation; and - Intracranial pressure.	- Hemodynamic parameters; - Patient's tolerance; - Attention during the task; - Signs of fatigue; and - Discomfort/pain.	Modality of unusual early mobilization of occupational therapists in Brazil.
	(2) 06 patients.
	(3) It is not clear.
	(4) It is not clear.
Fields et al. (2015)	(1) Cardiac.	- Hemodynamic instability.	- Active bleeding; - Accidental events; - Cardiac arrhythmia; - Discomfort; and - Intra-aortic balloon.	Bed mobility; Transfers; and Ambulation.
	(2) 366 patients.
	(3) It is not clear.
	(4) It is not clear.
Hsu et al. (2020)	(1) Medical; Surgical.	- Severely altered mental state; - High intracranial pressure; - Respiratory variables; - Active myocardial ischemia; - Hemodynamic instability; - Active bleeding; and - Open abdomen.	1) Monitoring: - Cardiovascular and respiratory signs; - Comfort level; and - Activity tolerance.	Self-care (facial hygiene, bathing), reading, writing, creating a schedule, and alternative communication.
	(3) 54 patients.
	(4) Yes.		2) Attention and Protection: - Endotracheal, nasogastric, and/or thoracic tubes; - Abdominal/ pelvic, urinary, and/or vascular catheters.
	(5) In 48 hours.
Jolley et al. (2015)	(1) Surgical; Trauma; Neurological; Cardiac.	Missing description.	Missing description	Not specified.
	(2) 47 hospitals.
	(3) Yes.
	(4) It is not clear.
Jolley et al. (2017)	(1) Surgical; Neurological.	Missing description	Missing description	Mentioning ADL.
	(2) 770 patients.
	(3) Yes.
	(4) In 48 hours.
Needham et al. (2010)	(1) Medical.	Missing description	Missing description	Not specified.
	(2) 57 patients
	(3) Yes.
	(4) It is not clear.
Pohlman et al. (2010)	(1) Medical.	- Hemodynamic variables; - Respiratory variables; - Oximetry; - Increases intracranial pressure; - Active bleeding; - Active myocardial ischemia; - Increased sedative (30 minutes).	1) Monitoring: - Heart rate; - Respiratory frequency; - Blood pressure; - Oximetry; - Fan asynchrony.	It describes ADLs: getting dressed, eating, organizing, bathroom and toilet.
	(2) 49 patients.
	(3) Yes.		2) Attention and Protection: - Vascular access catheters; - Enteric tubes; and - Endotracheal tubes.
	(4) In 72 hours.
Schweickert et al. (2009)	(1) Medical.	- Increased intracranial pressure; - Active bleeding; - Active myocardial ischemia; - Intermittent hemodialysis; - Agitation of the patient (administration of sedatives in the last 30 minutes); and - Respiratory variables.	1) Monitoring: - Hemodynamic variables; - Respiratory variables; - Oximetry; - Fan asynchrony; - Suffering of the patient.	It describes ADLs: Feeding, dressing, organizing, bathroom, and toilet.
	(2) 104 patients.
	(3) Yes.		2) Attention and Protection: - integrity of airway devices.
	(4) In 72 hours.		2) Attention and Protection: - integrity of airway devices.
Sigler et al. (2016)	(1) Medical.	Missing description	Missing description	It describes ADLs: going to the bathroom.
	(2) 32 patients.
	(3) Yes.
	(4) Few days.
Titsworth et al. (2012)	(1) Medical.	- Unstable spine; - Active AVE alerts; - Up to 24 hours after Tissue Plasminogen Activator (RTPA); - Endovascular intervention; - Increased intracranial pressure; - Active resuscitation; - Hemodynamic instability; - Hemodialysis; - Aggressive ventilation care; and - Palliative care.	Missing description	Not specified.
	(3) 170 patients.
	(4) Yes.
	(5) It is not clear.
Wahab et al. (2016)	(1) Neurological.	- Active coronary ischemia; - Arrhythmia; - Cardiac tamponade; - Respiratory variables; - Oximetry; - Heart rate <40 or> 130 bpm; - Hemodynamic variables; - Blood glucose <50 mg/dL; - Orthopedic contraindication; - Spinal cord injury (unstable); - Intracranial hypertension; and - Morbid obesity.	Monitoring: - Hemodynamic variables; and - Respiratory data; and - Oxygen saturation).	ADL training (Dressing, organizing, eating, bathroom and toilet).
	(2) 3,945 patients.
	(3) Yes.
	(4) In 24 hours.
Witcher et al. (2015)	(1) Medical; Cardiac; Surgical.	Missing description	Missing description	Not specified.
	(3) 68 patients.
	(4) Yes.
	(5) In 24 hours.
Yataco et al. (2019)	(1) Neurological.	- Presence or removal of femoral arterial introducer; - Hemodynamic variables; - Active bleeding; - Angioedema; - Intracranial pressure; - Neurosurgery; - Oximetry; - Accentuated diaphoresis; - Facial pallor; - Active bleeding.	Monitoring: - Intracranial pressure; - cerebral perfusion pressure; - Hemodynamic variables; - Oximetry; - Headache; - Nausea; and - Emesis.	Not specified.
	(2) 153 patients.
	(3) It is not clear.
	(4) Daily assessment.
Zanni et al. (2010)	(1) Neurological.	Missing description	1) Monitoring: - Hemodynamic variables; and - Oximetry.	It describes ADLs: (dressing up and bathroom).
	(2) 32 patients.		1) Monitoring: - Hemodynamic variables; and - Oximetry.
	(3) Yes.		2) Attention and Protection: - Venous and arterial catheters; and - Endotracheal tubes.
	(4) In 24 to 48 hours.

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Universidade Federal de São Carlos, Departamento de Terapia Ocupacional Rodovia Washington Luis, Km 235, Caixa Postal 676, CEP: , 13565-905, São Carlos, SP - Brasil, Tel.: 55-16-3361-8749 - São Carlos - SP - Brazil
E-mail: cadto@ufscar.br

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[TFN100] ⁽¹⁾
Differences between the occupational therapist and other professions - If there is a difference in the role of the occupational therapist in the ICU. (2) Other duties - Interventions classified as not specific to the occupational therapist, but they can be performed by the professional. Absent description - Absence of objective information in the text. ROM - Range of Motion.