Working with COVID patients in the ICU and acute care

A Q&A with the Baylor University Medical Center Therapy COVID Team

Texas Woman’s School of Occupational Therapy alumni Chris Villarreal, OTR, MOT ‘17 and Blaire Sanders, OTR, MOT ’18, along with Hailey Booth, OTR, MOT, Evan Duft, OTR, MOT, and Kelsey Novosad, PT, DPT, serve on the Baylor University Medical Center Therapy COVID Team. TWU Dallas Adjunct Instructor Sarah Borsh, OTR, OTD, who works for Baylor, moderated this Q&A with the team members to provide an inside look at the fight against COVID-19.

Q: How has your role changed since volunteering for the COVID-19 Therapy Team?

A: The role of an Acute Care OT as a whole has had to rapidly adjust to this novel COVID-19 viral infection and its impact on not just our patients, but hospital policy and protocols, and pandemic response-based societal changes. As occupational therapists, we have had to look at both the paucity of recent COVID-19 literature that is being published regularly by our medical and therapy colleagues around the world, and the existing literature regarding similar respiratory distress syndromes, in forming customized therapeutic intervention plans for our patients with COVID-19. While COVID-19 primarily impacts pulmonary function and consequent respiratory activity tolerance during functional mobility and ADLs, there is a myriad of sequelae, ranging from long-term cognitive changes to persistent musculoskeletal weakness which are impacting task performance. OTs are addressing the psychosocial stressors that are impacting patients’ motivation, self-efficacy, general levels of participation with therapy sessions and ability to discharge. Acute Care OTs are assisting with complex discharge needs, as many patients are unable to discharge home with family given an inability to self-isolate when they get home if they are discharged as COVID Positive, and they cannot go to a post-acute inpatient facility if they have not tested COVID Negative. In some of these complex situations, patients may remain in the hospital for weeks until they test negative, with Acute Care OTs performing lengthy plans of care for these patients throughout the course of their stay, which are more consistent with an inpatient rehabilitation facility.

Q: When someone progresses from the ICU to step-down unit, what do interventions look like at this critical stage?

A: Even though the patient has progressed from the ICU, these patients often have ongoing medical and vital signs instability, with persistent oxygen desaturation, orthostatic hypotension and tachycardia impacting activity tolerance. Therapeutic interventions may focus on decreasing this fatigue with both specialized endurance exercises and exertional ADL tasks and supplemented with energy conservation and work simplification training and education. A key component to success upon discharge is good or at least adequate pulmonary function, so specialized breathing exercises targeted at increasing the respiratory expansion which was so severely limited by this restrictive lung disease pathology are performed extensively during therapy sessions. Many of these patients who were in the ICU have weakness from prolonged immobilization, but they also have proximal upper- and lower-extremity weakness from being on prolonged high-dose steroids. Strengthening programs are initiated in collaboration with the Physical Therapy team to ensure the patient has functional strength to perform both transfers and mobility, but also, the inherent reach, grasp and object manipulation required to perform ADLs. Prolonged hypoxemia, such as that which occurs with more critical presentations of COVID-19, can result in cognitive impairment. We are most commonly seeing executive skill dysfunction, with patients having decreased attention to tasks, delayed processing, short- and long-term memory deficits and difficulty with complex problem solving. OTs incorporate functional cognitive training during the primary ADL and IADL task training to facilitate recovery.

Q: How are you able to provide support for a patient’s mental health during this tough recovery?

A: Patients are dealing with obvious fear and anxiety that comes from having a potentially life threatening viral infection, but also the mental and emotional distress that comes from occupational disruption and deprivation, and the social isolation which comes from not being allowed family or friends to visit. We provide activities of interest for patients to complete in the room, such games or puzzles, and encourage interactions with loved ones via their own personal electronic devices or devices made available by the hospital. In therapy sessions, OTs utilize therapeutic use of self, active listening and coping strategies, and holistic approaches to meeting social, psychological and emotional needs. It’s not uncommon for OTs to form close personal but professional bonds with patients given that the therapists are often the ones spending the most direct patient care time with patients and helping them regain their functional independence.

Q: Could you tell us more about the Words of Encouragement Group?

A: While as OTs we do our best to encourage our patients who are suffering from the psychological and emotional impacts of their current health situation, it occurred to us that perhaps the best source of encouragement would be fellow patients who are having or have had the same experiences as them.

The Words of Encouragement Group was created to meet that need. It is an anonymous peer-based patient support group for patients with COVID-19. It allows patients to anonymously share words of encouragement with other patients who may be experiencing secondary mental health and psychosocial impacts of both their illness and often complex hospital stay. Patients who are in the recovery stage of their illness verbally consent to participate with the program and then provide words of inspiration and motivation for other patients with COVID-19. They are transcribed by the OT via an electronic device, absent any patient identifiers to maintain compliance with the Health Insurance Portability and Accountability Act (HIPAA), and then shared with a patient who would benefit from positive affirmations and has also consented to participate with the group.

We have had a powerful response from our patients, who may become emotional, break down into tears and eagerly await new words of encouragement from their peers in subsequent sessions. As these recipients recover, they then provide words of encouragement to newly admitted patients.

Q: Is there an example you can share?

“Hello. I’m 21 years old, and I’m a COVID-19 survivor. I know you’re thinking about a lot right now—trust me, I know the feeling. You’re thinking about every possible outcome of your situation and your head is probably giving you dark thoughts. Please try to avoid this, you’re only scared because you think you’re battling this new thing alone. You’re not. I promise you, if there was a beacon for every person that is outside of these walls right now praying for you to recover, the night sky would be illuminated.

I’ll be honest with you, I accepted the fact that I might not make it and even wrote goodbye letters to my parents and told my mom where to find them if anything were to happen to me. That’s how scared I was. It’s going to be okay. Don’t ask if you’re going to die because you’re not. Ask when you’ll be sent home. You’re not alone. I am with you! You are going to beat this!”

– Former patient and COVID-19 survivor