Professionals should be knowledgeable of their ... Care PP... · Archivo PDFeducation Patient (Pt)...

Professionals should be knowledgeable of their institutions policies and procedures. This course will contain Florida Hospital established clinical practice guidelines associated with lab values, mobilization and intervention.

Clinical judgement should be based upon patient presentation, signs and symptoms, and communication with health care professionals to provide safe and effective care.

Identify information through the lens of each discipline when conducting a medical record review

Identify and understand the effects of lines and attachments

To understand lab values: How to provide safe intervention

To understand the positive and negative effects of medication on therapeutic intervention

To understand delirium: How it affects patient interaction and performance

Learn how to mobilize patient from supine to stride

To understand the importance of caregiver and staff education

Patient (Pt) has a resting Heart Rate of 150.

Pt has a femoral line, can you help them get out of bed?

Pt’s blood pressure (BP) is 205/110.

Pt has an arterial line, it is safe to perform grooming tasks and brush teeth?

Pt has a Doppler ultrasound ordered to rule out deep vein thrombosis (DVT) in the Lower Extremity. Pt is currently on Coumadin. Is therapy intervention appropriate?

Pt has an INR (international normalized ratio) of 4.

Pt with Respiratory Rate of 37 on vent with FiO2 of 75; PEEP of 10.

Handout!

https://www.youtube.com/watch?v=TFHP7WbICro

Cost Between 2000 and 2005, annual critical care medicine costs increased from $56.6

billion to $81.7 billion, representing 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of gross domestic product

Hospital stays that involved intensive care unit (ICU) services were two and half times more costly than other hospital stays

In 2011, 26.9 percent of hospital stays in 29 States involved ICU charges, accounting for 47.5 percent of aggregate total hospital charges

Hospitalization More than 5.7 million patients are admitted annually to intensive care units in the

United States

All acute care hospitals have at least one intensive care unit and approximately 55,000 critically ill patients are cared for each day

Cardiac, respiratory, and neurologic conditions dominated stays with high ICU utilization

Length of Stay

Intensive care unit length of stay (LOS) has been estimated at 3.8 days in the United States

Adherence to Surviving Sepsis Campaign performance bundles, early patient mobilization, use of high-intensity ICU physician staffing, and enhanced staff and family communication all improve LOS

From 2002 through 2009, ICU stays rose at three times the rate of general hospital stays without an increase in severity of illness

Delirium

Pressure ulcers

Malnutrition

Deconditioning

Weakness

Joint contractures

Isolation

Depression

EARLY INTERVENTION IS KEY!

Systemic• Acute respiratory failure (ARF)

• Acute kidney injury (AKI)

• Sepsis

Cardiac• Acute myocardial infarction (AMI)

• Myocardial Infarction (MI)

Neurological• Intracranial hemorrhage (ICH); Cerebral Vascular Accident (CVA)

• Progressive diseases (Parkinson’s ; amyotrophic lateral sclerosis)

Oncology• Leukemia

Post surgical• Liver, kidney, lung, or heart transplant

• Coronary artery bypass grafting (CABG)

• Mitral valve replacement (MVR); Aortic valve replacement (AVR)

Arterial lines (radial, brachial, femoral)

Central venous catheters

Intravenous catheters

Swan Ganz

Chest tubes

Feeding tubes: nasogastric (NG), percutaneous endoscopic gastrostomy (PEG) , gastro-jejunal (GJ), jejunal (J)

Drains (Jackson-Pratt; Hemovac; External Ventricular Drain)

Shunt

Electrocardiography (EKG) leads/Telemetry monitor

Foley catheter

Fecal management system (Flexi-Seal)

Sequential Compression Devices (SCD’s)

Nasal cannula

High flow nasal cannula

CPAP - Continuous positive airway pressure

BiPAP - Bilevel positive airway pressure

Mechanical Ventilator• Endotracheal tubes

Orotracheal - through the mouth

Nasotracheal - through the nose

• Tracheostomy tube -through trachea

T-piece

Why is patient in the hospital?

What series of events led to admission?• Surgery (Elective or Emergent)

• Cardiac

• Fever (Sepsis)

• Pulmonary

• Neurological Event

• Trauma

• Oncology

What is patients prior level of function?

What diagnostic tests have been completed?

Chest X-ray

Magnetic Resonance Imaging (MRI)

Magnetic Resonance Angiogram (MRA)

Computed Tomography Scan (CT)

Computed Tomography Angiography (CTA)

Electrocardiogram (EKG)

Venous Ultrasound and/or Arterial Doppler Scan

Electroencephalogram (EEG)

Ultrasound

Lumbar Puncture

Is Patient on oxygen?• Nasal cannula

• Heated high flow: added humidification will assist to overcome the negative impact of dry air on lung tissue

• BIPAP

• Mechanical Ventilator

What type of ventilator and settings?

Respiratory Rate:

• Number of breaths per minute that the Ventilator delivers

FiO2:

• Fraction of inspired oxygen or percentage of O2 delivered

Volume Control:

• Preset to deliver volume of O2 and air

PEEP:

• Positive end-expiratory pressure

• Increase oxygenation in either AC or SIMV mode

• Positive pressure applied at end of exhalation

Pressure Support:

• Used in SIMV, provides small amount of pressure during inspiration

Mode of Mechanical Ventilation

Assisted-Control (AC)

Synchronized Intermittent Mandatory Ventilation (SIMV)

Blood Pressure (BP)• 60/90 mmHg – 90/150 mmHg

Respiration Rate• 14-20 breaths/min

Heart Rate• 60-100 beats per minute

Temperature• 96.4 – 99.1 degrees Fahrenheit

What is mean arterial pressure (MAP)?

• Indication of blood perfusion

• 70-110mmHg

• Minimum 60 to nourish body

• DPx2+SP

3

MAP= Heart disease, Heart attack, stroke

MAP= possible sepsis

Antihypertensives

Anticonvulsants

Ca Channel blockers

Vasopressors (Pressors)

Diuretics

Paralytics

Anticoagulants

Narcotic analgesics

Analgesic sedatives

Opioid Analgesics • Fentanyl

• Morphine

• Meperidine

Benzodiazepines• Lorazepam

• Midazolam

• Diazepam

White blood cells (WBC)• Body ability to fight infections

• (4.4 - 10.5 x 103

mm3)

Platelets• Hemostasis – clotting

• (139 - 361x103mm

3)

Hemoglobin• Blood’s capacity to carry O2

• (12.6 - 16.7gm/dL males)

• (11.4 - 14.7gm/dL females)

Hematocrit: • Red Blood Cell (RBC)

• (36.9 – 48.5 % males)

• (34.3 – 45.5% females)

INR (International Normalized Ratio)• (0.8 - 1.2)

INR= Increased risk of bleeding

INR= Increased risk of clotting

Sodium (Na)• Determinant of extracellular fluid volume

• 136 - 145 MMOL/L

Potassium (K)• Important for function of excitable cells such as nerves,

muscles, and heart

• 3.5 - 5.0 MMOL/L

Calcium (Ca)

• Important for bone formation• 8.5 - 10.5 mg/dL

Chloride (Cl)

• Important for fluid balance and acid base status.• 98 – 110 MMOL/L

Blood Urea Nitrogen (BUN)• Elevates kidney function

• 5 - 25mg/dL

Serum Creatinine• Evaluates kidney function

• 0.6 - 1.20 mg/dL

Glucose• Measures blood glucose at time sample is obtained.

• 70 - 100 mg/dL

Measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery

pH

• 7.35-7.45

PaCO2- Partial Pressure Carbon Dioxide

• 35-45 mmHg

PaO2- Partial Pressure Oxygen

• 80-105 mmHg

HCO3- Bicarbonate

• 22-26mEq/L

O2 Saturation

• 92-100%

Respiratory Therapeutic Intervention ?

Endotracheal tube

Tracheostomy tube

O2 saturation: >90%<90%

Respiratory rate: <30bpm>30bpm

Ventilation: HFOVInverse ratioAMV

PEEP: <10cm H2O

Break

Occupational Therapy Assessment

Are there any orders that would impact therapy intervention?

Physician notes/Consults

Any recent or planned surgeries/procedures?

Where would you find “Weight Bearing” precautions?

Status Review • Mode of Ventilation

• Imaging

• Tubes and attachments

• Critical lab values

Handout!

Handout!

What does the patient look like? • Positioning

What equipment is in the room?• Line attachments

What are current vital signs?

Is the patient in pain?

Does the patient have any precautions?• Are there weight bearing precautions or range of motion

restrictions before you start mobilizing?

Borg Scale

MoCA: Montreal Cognitive Assessment

MMSE: Mini-Mental Status Examination

HADS: Hospital Anxiety and Depression Scale

RASS: Richmond Agitation and Sedation Scale

Pain Scale: Faces Pain Scale

Assessment of Pitting Edema

• The most common assessment of symptoms of breathlessness

Borg Scale

MoCA• Purpose: Measure of

cognition including orientation, short term memory, executive function, language, and attention

• Time: 10-12 minutes

MMSE

• Purpose: Assess problems with memory and other cognitive functions

• Time: 10 minutes

HADS• Purpose: Self-rating

scale to measure anxiety and depression a patient may be experiencing during their stay in the hospital

• 14 questions

• Time: >10 mins

RASS• Purpose: assess the patient’s level of sedation in the ICU

Pain Scale• Visual/Verbal Scale:

Assessment of Pitting Edema • Purpose: Subjective and qualitative measure of depth and rate

of pitting

Occupational Profile:Prior Level of Function Was the patient a caregiver to other people? Pets?

Did the patient drive?

Was the patient employed?

Was the patient attending school?

Did the patient perform household management tasks?

Did the patient attend religious services and activities?

What are the patients leisure activities? • Cook

• Gardener

• Singer

ST Assessments

Speech-language Evaluations (motor speech, language, cognition)

• Optimize functional communication

Swallow Evaluations (clinical bedside and instrumental evaluations)

• Optimize toleration of safest and least restrictive diets

Passy-Muir Speaking Valve and Voice Evaluations• Optimize functional communication

Pertinent Information

Prior level of functioning

Imaging

Lab values

Tubes, lines

Medications

Interdisciplinary consults/progress notes

Medical course

Recent admissions

Diet

Prior Level of Function

• Before admission, what was the patient’s most functional mode of communication?

• What technologies did the patient have available? (ie: glasses, dentures, communication device, etc)

• Has the patient had recent hospitalizations? Why?

• Does the patient have a history of requiring ST services? What for?

• What is the patient’s baseline diet?

• What modifications or assistance does the patient require during meals?

Imaging

• Infiltrates seen on a chest x-ray may reflect presence of aspiration pneumonia

• Infiltrates new or chronic? How do findings compare to prior radiographs?

• Location of infiltrates related to patient’s positioning

X-rays

• Important to identify presence and locations of neurologic injuries

• Locations of and types of neuro injuries/CVAs may indicate higher risks of cognitive-linguistic deficits, dysphagia/silent aspiration

CT/MRI

Lab Values

Leukocytosis (elevated WBC) can indicate developing infection, like pneumonia from aspiration, may be accompanied by fever

White blood cells (WBC)

Red Blood Cells (RBC), Hematocrit (HCT), Hemoglobin (Hgb)Red Blood Cell indices

Protein status indicator used to examine nutritional status; potential indicator of malnutrition

Pre-albumin lab values

Ammonia levels can indicate significant mental status changes; hypokalemia can cause weakness and fatigue r/t dysphagia; hypocalcemia can cause mental status changes, depression, extrapyramidal symptoms, neuromuscular irritability r/t dysphagia

Electrolytes

Tubes and Attachments

Tubes and Attachments

PICTURES

Medications

Central nervous system side effects• Decreased level of arousal

• Suppression of brainstem swallowing regulation

• Movement disorders

Peripheral nervous system side effects• Neuromuscular junction blockade

• Myopathy

• Oropharyngeal sensory impairments

• Disturbance of saliva production

Interdisciplinary Consults

ENT

GI

Internal medicine

General surgery

Neuro sx

Radiation oncology

Nutrition

Psychiatry

Medical Course Intubations (one vs. multiple, emergent,

complications)

Procedures?

Respiratory needs (weaned from bipap, requiring increased support, vent settings?)

NPO status (NPO due to concerns, GI issues, prolonged NPO?)

Current nutritional means (modified diets, tubes?)

Current cognitive state (alertness, delirium, sepsis?)

Vital signs (is the patient hemodynamically stable?)

Any reasons to defer the assessment? Is the consult contraindicated?

Clinical Presentation

What are nursing observations? What is current Patient condition and medical plans?

How does the patient present clinically?• Alert? Lethargic? Tachypneic? Agitated? Combative? Calm?

Screen cognition • Can Pt state Identification information? Pt oriented?

Following directions?

ST Assessment TypesSwallow Evaluations

Begin with clinical assessment at bedside, consists of:

• oral motor exam, liquid/food trials, if appropriate

• Determine if further evaluation via instrumental assessment is indicated

• VideofluoroscopicAssessment of Swallowing (VFSS)

• Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Speech Evaluations (communication, cognition)

Standardized and non-standardized assessments utilized

Often limited in ICU setting d/t fatigue, reduced endurance, severity of cognitive deficits, medical instability, environment

Swallow Assessments

PICTURES

Six potential mechanisms for the development of ICU-acquired swallowing disorders

Macht, M., Wimbish, T., Bodine, C., & Moss, M. (2013). ICU-acquired swallowing disorders. Critical care medicine, 41(10), 2396-2405.

Factors that can Impact Communication and/or Swallowing Postoperative dysphagia and dysphonia◦ Surgeries involving structures of the neck

Carotid endarterectomy

Cervical fusion

Thyroidectomy

◦ Posterior fossa and skull base

surgeries

◦ Cardiothoracic surgeries

Lung/heart transplantation

Lobectomy

CABG, AVR, MVR

Factors that Impact Both Communication and Swallowing

Tracheostomy• System now open: leak under the vocal

folds, loss of subglottic pressure

• Pressure present in the trachea below a closed glottis

• Loss of physiologic PEEP

• Sensory deprivation

• Reduced tone

Risk Factors for Potential Communication and Swallowing Disorders

Preexisting dysphagia

Cancer, surgery, or radiation to head, neck, and/or esophagus

Delirium, excessive sedation, and/or dementia

Stroke or neuromuscular disease

Longer durations of mechanical ventilation

Multiple intubations

Tracheostomy

Severe gastroesophageal reflux

Paralytics and/or critical illness polyneuromyopathy

Supine bed position

SepsisMacht, M., Wimbish, T., Bodine, C., & Moss, M. (2013). ICU-acquired swallowing disorders. Critical care medicine, 41(10), 2396-2405.

ASHA. Adult Dysphagia.

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA.2016;315(8):801–810. doi:10.1001/jama.2016.0287

C.G. Ravetti et al. Journal of Critical Care 30 (2015). 440.e7-440.e13

How Does Sepsis Impact Cognition?

Defined as “a life-threatening organ dysfunction caused by a dysregulated host response to infection”

Sepsis and septic shock both associated with increased mortality in hospitalized patients

Important to dx acute brain dysfunction to initiate tx

Structural brain alterations secondary to sepsis• Temporal coordination of neuronal responses is affected,

causes desynchronization between various interconnected brain regions

Rasulo, F. A., Bellelli, G., Ely, E. W., Morandi, A., Pandharipande, P., & Latronico, N. (2017). Journal of intensive care, 5(1), 23.Iwashyna, T. J., Ely, E. W., Smith, D. M., & Langa, K. M. (2010). Jama, 304(16), 1787-1794.

Damm T, Patel JJ. Long-term outcomes after critical illness: A Concise Clinical Review. PulmCCM Journal. 2015 Jan 28.

Lunch Break

Just 4 hours of immobility and disuse can initiate the process of decline in cell diameter,

number of muscle fibers, muscle mass, and endurance, particularly in LE.

Appleton, R., & Kinsella, J. (2012). Intensive care unit-acquired weakness. British Journal of Anesthesia, 1-5. doi:10.1093/bjaceaccp/mkr057

Consequences of Bed Rest and Immobility

How Mobility Decreases Ventilator Days

In a supine position, lung volumes are reduced

Risk of atelectasis and pneumonia increases

Muscles of respiration weaken rapidly

Knight, J. et al (2009) Effects of bedrest 1: cardiovascular,

respiratory and haematological systems. Nursing Times; 105: 21,

early online publication.

How Mobility Decreases Length Of Stay and Disability

Immobility can contribute to several complications that prolong hospital stay:

Best rest causes weakness

Bed rest causes long term disability

Bedrest causes pressure ulcers

Bedrest increases risk of DVT

Bed rest results in orthostatic hypotension

Wick, J.Y. (2011). Bedrest: Implications for the Aging Population. Retrieved from

http://www.pharmacytimes.com/publications/issue/2011/January2011/FeatureBedrest-0111

Early and Progressive Mobility *Levels of Therapy

1. Dangling

2. Standing at bedside

Early and Progressive Mobility *Levels of Therapy

3. Transfer to chair (active), includes standing without marching in place

4. Ambulation (marching in place, walking in room or hall)

*All may be done with assistance

Determining Readiness

How do you know if the patient is too sick for mobility?

We use the MOVE criteria

M: myocardial stability; no ongoing myocardial ischemia; no ventricular arrhythmias requiring initiation of IV

antiarrhythmic

O: oxygenation </= 0.8, PEEP </= 12

V: vasopressors; no increase dose of any vasopressor infusion for at least 2 hours

E: Pt engages upon verbal stimulation with staff (RASS of >/=

-3 or better to be successful

N: (New for Neuro Patients ONLY) neurologic stability (ICP < 20mm and no active seizures)

Mobility is Safe

Multiple research studies have been conducted on this topic in the past several years. A sample follows:

Of 498 patients, 1 adverse event (arterial line)1

Of 176 interventions, 2 adverse events (both hypotensive)2

Of 424 interventions, 1 adverse event (self extubation)3

1: Schweichert, W.D. & Hall, J. (2007). ICU-acquired weakness. Chest, 131 (5):1541-1549

2: Leditschke, A. et al. (Mar 2012). What are the barriers to mobilizing intensive care patients? Cardiopulm Phys Ther J., 23(1):26-29

3: Bourdin, G. et al. (Apr 2010). The feasibility of early physical activity in intensive care unit patients: a prospective observational one-center study. Respir Care. 55(4) 400-7

ABCDE Bundle

What is it?

Coordination between multiple disciplines

Management of critically ill patient

Goal: Prevent over sedation

Decrease immobility

Decrease development of delirium

ABCDE

Motomed

Physical Therapy Interventions

Positioning Exercises• Muscle strengthening• Breathing

Bed Mobility Activities• Rolling• Sitting edge of bed• Trunk control• Unsupported sitting• ADL • Turning side to side

PT intervention continued

Transfer from bed• Sit to stand

• Commode transfer

• Chair transfer

Gait• Pre-gait activities

• Weight shifting activities

• Stepping in place

• Gait training with walker

Stop, Look and Question

Symptomatic drop in BP

HR <50 or >130 for 5 minutes

RR <5 or >20 above baseline for 5 minutes

O2 sat <88% for 5 minutes with O2 supplement

Significant pain/distress

Profound fatigue

Pt requests to stop Bailey, P., Thomsen, G., Spuhler, V., Blair, R., Jewkes, J., Bezdjian, L., & ...Hopkins, R. (2007). Early activity is feasible and safe in respiratory failurepatients. Critical Care Medicine, 35(1), 139-145.

“Barriers?”

Fears based upon “what if?”

Illness severity

Sedation

Perceived lack of benefit

Equipment

Unit culture

How to Overcome Barriers

Education

Discussion

Training

Demonstration of How to Mobilize a Critically Ill Patient

VIDEO

Interventions ADL/IADL re-training• Toileting, grooming, dressing

Leisure participation • Play sports, garden

Social participation • Face to face interaction, phone call, text message

Relaxation/coping strategies• Deep breathing

Vision• High contrast colors

Cognition • Compensatory memory techniques

Interventions

Fall prevention and safety education• Preventative care to prevent risk of readmission

Edema management • Proper positioning, elevation extremities

Pain management• Proper positioning and use of external items

Bracing and splinting• Static or dynamic splints

Therapeutic exercises

Therapeutic activities

ICU Diary

Holistic, client-centered approach

Promotes: sensory integration through auditory and visual stimulation, cognitive engagement, reorientation, awareness to reality, fine-motor coordination.

A journal that can include notes from physicians, interdisciplinary staff in order to best communicate with patient and family in a chronological order

Identified for patients with: ICU length of stay grater than 48 hours, have experienced mechanical ventilation and sedation, who are experiencing or at high risk of delirium.

Goal of Interventions

Prevent social isolation

Increase quality of life

Improve occupational independence

Improve strength and range of motion

Promote psychological/spiritual health

Diagnosis: acute lung injury, COPD exacerbation, acute exacerbation of asthma, sepsis, hemorrhage

Acuity: in intervention group, patients received therapy 87% of days

Interventions: unresponsive patients PROM for all limbs, responsive A/AAROM, bed mobility activities, sitting balance activities and participation in ADLs and exercise, transfer training, pre-gait exercises, walking

Results: 59% of intervention group returned to independent functional status at hospital discharge compared to 35% of control group, shorter duration of delirium, and more ventilator-free days

Purpose: implement OT services in the ICU and report the awareness and perception of OT services by the ICU staff (including physicians, psychologists, nurses, social workers, STs, and PTs)

OT interventions: reception, coping, communication, functionality, and family involvement; weekly participation in clinical case discussions and contributing to the holistic vision of care

Results: the ICU team manifested an understanding of OT intervention possibilities and reports that OT can to the quality of care and more humanized care for pts

Intervention Illustration

Patient education

Lower body dressing

Toilet transfer

Grooming

Therapeutic exercises

VIDEO

Break

ICU Environment

VIDEO

Impact of Impaired Swallowing and Communication

Lack of participation in decision making, limited personal interaction• Motivation

• Misunderstandings

• Increased anxiety, increased likelihood of delirium

Over-medication and sedation• Increased likelihood of delirium

• Reduced mobility and positioning

• Increased risk for aspiration and subsequent complications

• Nutritional compromises

• Increased risk of reflux

• Dependent oral care

Dysphagia s/p Prolonged Orotracheal Intubation

ICU Delirium Prevalence 40-60% of Non-ventilated and 60-80% in

mechanically ventilated critical care patients

Results in hypoperfusion in frontal, temporal, and subcortical regions of the brain

Lasting cognitive deficits associated with reduced quality of life post discharge

Sedation and analgesia practices impact delirium; prevalent in ICU settings

Prevention strategies are more effective than treatment strategies

Fong, T. G., Tulebaev, S. R., & Inouye, S. K. (2009). Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews. Neurology, 5(4), 210–220.

Clinical Features of Delirium

Hyperactive

Features of restlessness, agitation, hypervigilance

Often experience hallucinations, delusions

Hypoactive

Most common in elderly patients

Lethargy, sedation

Respond slowly to questioning

Frequently overlooked, dx as having depression or dementia

Frequent reorientation

Cognitive stimulation

Early mobilization (PT, OT)

Timely removal of physical restraints

Vision and hearing assistive devices, if needed

Meeting needs for nutrition, fluids, and sleep

Modify environment• Noise

• Lighting

• Sleep/wake cycles

• Family presence

Fong, T. G., Tulebaev, S. R., & Inouye, S. K. (2009).

Communication in the intensive care unit is a necessity—not a luxury

ASHA 2010 Acute Care/AAC Garrett Baumann Downey

What are the benefits of using a “speaking” valve?

Restores• Communication of wants/needs, ability to express oneself

• Participation in care and therapy

• Improve patient cognitive and physiological status

• Reduce delirium and anxiety

• Laryngeal/pharyngeal sensation and tone

• Improve swallowing for secretion management and potentially PO

• Reduces tracheal secretions and need for suctioning

• Allows for coughing and clearance of material in the airway

• Physiological PEEP

• Reduces atelectasis, improves weaning from ventilator support

• Improves balance/support for sitting/dangling/ambulation

• Improve upper extremity force

• Improve bowel/bladder emptying

Therapy using PMV

ST/RT collaboration

Co-treating with PT/OT

Focus/goals• Pt/caregiver training

• Improve toleration

• Coordination of exhalation/voicing

• Speech/language/cognitive tx goals

• Using PMV to enhance swallow tx

• Resistive breathing training (ie: EMST)

• Oral motor exercises

• Laryngeal elevation exercises

• Oral sensory stimulation

VIDEO of in-line PMV placement

Second half of video starting at 1:44

References American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd

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Álvarez, E. A., Garrido, M. A., Tobar, E. A., Prieto, S. A., Vergara, S. O., Briceño, C. D., & González, 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, 85-90. doi:10.1016/j.jcrc.2016.09.002

Appleton, R., & Kinsella, J. (2012). Intensive care unit-acquired weakness. British Journal of Anesthesia, 1-5. doi:10.1093/bjaceaccp/mkr057

Arbaje AI, Wolff JL, YU Q, Powe NR, Anderson GF, Boult C. Postdischarge environmental and socioeconomic factors and the likelihood of early hospital readmission among community-dwelling Medicare beneficiaries. The Gerontologist. Aug 2008; 48(4):495-504.

Bailey, P., Thomsen, G., Spuhler, V., Blair, R., Jewkes, J., Bezdjian, L., & ... Hopkins, R. (2007). Early activity is feasible and safe in respiratory failure patients. Critical Care Medicine, 35(1), 139-145.

Bombarda, T. B., Lanza, A. L., Santos, C.A.V., & Joaquim, R.H.V.T. (2016). The occupational therapy in adult intensive care unit(ICU) and team perceptions. Cadernos De Terapia Ocupacional, 24(4), 827-835. doi:10.4322/0104-4931.ctoRE0861

DePalma G, Xu H, Covinsky KE, et al. Hospital readmission among older adults who return home with unmet need for ADL disability. The Gerontologist, June 2013;53(3):454-461.

Desai AS, Stevenson LW. Rehospitalization for heart failure: predict or prevent? Circulation. 2012; 126(4):501-506.

Evangelist, M., & Gartenberg, A. (2016). Toolkit for developing an occupational therapy program in the ICU. OT Practice, 1(1), 20.

Go AS, Mozaffarian D, Roger VL, et al. Heart Disease and stroke statics—2013 update: a report from the American Heart Association. Circulation. Jan 1 2013:127(1)e6-e245.

Haft, J. & Bartlett, R. (2016). Extracorporeal membrane oxygenation (ECMO) in adults. 2014 Intra-abdominal balloon pump. WebMD. <http://www.webmd.com/heart-disease/tc/intra-aortic-balloon-pump-topic-overview.>

Barrett, M., Smith, M., Elixhauser, A., Honigman, L., & Pines, J. (2014). HCUP Statistical brief #185: Utilization of intensive care services, 2011. Agency for Healthcare Research and Quality. Retrieved from https://hcup-us.ahrq.gov/reports/statbriefs/sb185-Hospital-Intensive-Care-Units-2011.jsp

References Götz, T., Günther, A., Witte, O. W., Brunkhorst, F. M., Seidel, G., & Hamzei, F. (2014). Long-term sequelae of severe sepsis:

cognitive impairment and structural brain alterations–an MRI study (LossCog MRI). BMC neurology, 14(1), 145.

Rasulo, F. A., Bellelli, G., Ely, E. W., Morandi, A., Pandharipande, P., & Latronico, N. (2017). Are you Ernest Shackleton, the polar explorer? Refining the criteria for delirium and brain dysfunction in sepsis. Journal of intensive care, 5(1), 23.

Patel, M. B., Morandi, A., & Pandharipande, P. P. (2015). What’s new in post-ICU cognitive impairment?. Intensive care medicine, 41(4), 708-711.

Maley, J. H., & Mikkelsen, M. E. (2016). Short-term gains with long-term consequences: the evolving story of sepsis survivorship. Clinics in chest medicine, 37(2), 367-380.

Sonneville, R., Verdonk, F., Rauturier, C., Klein, I. F., Wolff, M., Annane, D., ... & Sharshar, T. (2013). Understanding brain dysfunction in sepsis. Annals of intensive care, 3(1), 15.

Annane, D., & Sharshar, T. (2015). Cognitive decline after sepsis. The Lancet Respiratory Medicine, 3(1), 61-69.

Widmann, C. N., & Heneka, M. T. (2014). Long-term cerebral consequences of sepsis. The Lancet Neurology, 13(6), 630-636.

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