Occupational Therapy EPA3 Identify, assess and treat patients therapeutically for delirium in critical care
This EPA is specific to patients admitted to the critical care units. The novice critical care OT will understand the mechanisms of delirium and its impact on rehabilitation, quality of life and its longer-term affect on recovery.
- Understand and demonstrate an awareness of delirium within CCU
- Understand and discuss the A-F Liberation Bundle and its evidence base
- Identify delirium and its subtypes
- Identify associated factors contributing to delirium i.e. pre-disposing, medications, environment
- Develop skills of assessment of delirium (verbal, non – verbal)
- Acknowledge environmental factors in the causation of delirium
- Demonstrate an awareness of secondary complications associated with delirium
- Implement a strategic delirium treatment plan including early mobilisation, sensory alterations and environmental changes
- Participate with MDT and family members in delirium prevention or treatment
Limitations
- This does not include assessment of patients intubated and sedated or are clinically unstable as per the Medical Team.
- This does not discuss referral/ screening processes for assessment/ treatment
- There will not be an in- depth review of pharmalogical management of delirium
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EPA reference
Scan this QR card code to access more information and guidance about this EPA:
EPA overview information
- Required knowledge
- C3Framework Shared AHP Competencies
- C3Framework OT Domains:
- Delirium Assessment and Treatment
Suggested resources:
- ICU steps.org website https://icusteps.org
- Dale Needham (Johns Hopkins University) presentation on Delirium within ICU
- https://www.sccm.org/Clinical-Resources/ICULiberation-Home/ABCDEF-Bundles
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5351776/
- https://www.youtube.com/watch?v=2cg1x4pxqcY
- Information to assess progression
- Senior supervision (informal)- verbal/ written feedback on resources review
- Observational sessions of assessment (2 sessions)
- Demonstration of skills session for treatment with senior (2 sessions)
- Clinical supervision
- MDT feedback on application and outcomes
- Supervision
- Full entrustment within 3 months of starting in Critical Care
- Documentation of self-assessment and senior sign- off through supervision
- Basis for formal entrustment decisions
An entrustment decision should be made by an experienced critical care OT after observing this EPA completed on more than one patient.
Use the EPA Completion Template (PDF, 88KB) for this.
| Self assessment | Senior assessment | |
|---|---|---|
Safety | ||
Infection Prevention and Control: | ||
Able to demonstrate knowledge of general infection control prevention and control including hand hygiene, aprons, masks and aseptic non-touch technique | ||
Patient Emergency Management: | ||
Has completed Basic Life Support Training as per local trust policy | ||
Describes how they would summon help in an emergency and locate crash bells | ||
Describes how to call a medical emergency call via switch | ||
Describes own role and expected contribution in medical emergency eg. Basic Life Support, providing assistance to MDT as able | ||
Patient ID: | ||
Demonstrates positive patient identification and awareness of allergies | ||
Monitoring Vital Signs: | ||
Demonstrates how to monitor vital signs (Temp, HR, SpO2, RR, blood pressure, MAP) | ||
Interprets observations in an ICU setting, considering trends and normal ranges for all (Temp, HR, SpO2, RR, blood pressure) | ||
Able to troubleshoot difficulties with taking vital signs eg. poor trace on pulse oximeter, missing ECG leads, positional sensitivity of arterial line | ||
Awareness of who to escalate concerns to in relation to patient safety with recognition of different levels of urgency and reporting to different staff members dependent on situation | ||
Orientation: | ||
Can describe the bed numbering, storage location of safety equipment, location of offices and other key areas within the critical care unit | ||
Can describe the shift patterns and handover process of other MDT members | ||
Able to identify key MDT members by their role, including critical care nurses, nurse in charge, consultant on call | ||
Demonstrates how to locate the local protocols and guidelines relevant to own role | ||
Has an awareness of key ICU meetings relevant to role e.g. MDT meetings, handovers, safety briefings, teaching sessions. | ||
Can identify standard ICU bedspace equipment and location of equipment necessary for role | ||
Communication | ||
Communication with patient: | ||
Describe barriers to communication in ICU including those associated with PPE, illness and ICU interventions. | ||
Awareness of communication aids with patients to overcome communication barriers i.e. PPE + oral intubation | ||
Communication with family + friends: | ||
Describe the support services available to help liaise with family including family support nurses, PALS, psychology services as appropriate. | ||
Describe barriers to communication with family and methods to improve this | ||
Knows importance of confidentiality and consent to share information with friends and family | ||
Communication with colleagues: | ||
Awareness of peer support and psychological support | ||
Documentation | ||
Local IT Training: | ||
Demonstrates how to access and document in patient records using local IT systems | ||
Demonstrates how to view results and imaging on local IT systems | ||
Moving and Handling | ||
Awareness of Falls prevention and who to escalate to if concerned regarding falls risks | ||
Compliant with Manual Handling training as per local trust policy. | ||
Non-technical skills | ||
Teamwork: | ||
Demonstrate working in an MDT by building and maintaining relationships with other professions | ||
Aware of the roles and responsibilities of other members of the MDT | ||
Clarifies, accepts and executes tasks delegated by the team leader | ||
Explains the importance of highlighting safety issues / concerns to a member of your team in a prompt manner | ||
Uses appropriate level of assertiveness for the clinical situation | ||
Demonstrates a logical and systematic handover using local format | ||
Outline how to escalate and to whom if there are patient / safety concerns | ||
Identify and respond to patient / staff safety issues appropriately | ||
Clinical Assessment and Basic Life Support | ||
Airway: | ||
Demonstrate ways to open up airway using simple manoeuvres (inc. repositioning, head tilt chin lift, jaw thrust) | ||
Demonstrates how to deliver manual ventilation using two person bag-valve-mask (BVM) technique | ||
Recognise and escalate airway compromise in a tracheostomised patient | ||
Mouth care: | ||
Demonstrates how to perform and document oral hygiene | ||
Oxygen: | ||
Knows the types of oxygen delivery system and their limitations (including reservoir mask, simple face mask, venturi system and nasal cannulae) | ||
Demonstrates how to deliver oxygen urgently (including reservoir mask, simple face mask, venturi system and nasal cannulae) | ||
Describe how to escalate or de-escalate oxygen therapy in a step wise manner eg. nasal cannulae to face mask. | ||
Lines and attachments: | ||
Recognise different lines and their location relevant to local population (eg arterial lines, central line, vas-cath) | ||
Nutrition: | ||
Identify enteral feeding tube in situ, whether it is connected to feed and whether the feed pump is running | ||
Knows to discuss plans with nursing staff prior to moving or reposition a patient with NG feed running | ||
Aware of events which can displace feeding tubes and to escalate accordingly | ||
Describes how to check enteral feeding length and escalates if tube length has changed | ||
Describe how to recognise dysphagia and an escalation plan including referral to SLT | ||
Demonstrates how to assist patients with eating and drinking | ||
Have an awareness of modified diets or thickened fluids in line with SLT recommendations | ||
Delirium: | ||
Demonstrate how to categorise neurological status using the AVPU scoring | ||
Describe factors that may cause or contribute to delirium | ||
Describes how to recognise delirium | ||
Demonstrates how to complete a CAM-ICU score | ||
Demonstrates an understanding of non-pharmacological management of delirium | ||
Demonstrates knowledge of the Mental Capacity Act, when capacity assessment is indicated, how to assess capacity and when specialist communication support is required eg. referral to SLT | ||
Pain: | ||
Demonstrates how to use pain faces or a similar visual analog scale | ||
Demonstrates an understanding on the impact of pain on patient presentation eg. agitation | ||
Demonstrates an understanding of the impact of pain medication on patient presentation eg. sedative effect | ||
Sedation: | ||
Demonstrates an understanding of RASS (or alternative sedation) scoring system | ||
Able to access and read using ICU drug charts | ||
Demonstrates an awareness of common ICU sedative medications | ||
Demonstrates a basic knowledge of common ICU medications and their role e.g. sedatives, vasopressors, inotropes | ||
| Self assessment | Senior assessment | |
|---|---|---|
Upper Limb Assessment | ||
MDT working | ||
To be able to feedback assessment to senior OT to implement appropriate intervention | ||
Delirium Assessment and Treatment | ||
Causes of delerium | ||
Demonstrate awareness of the factors that can contribute or cause delirium in an Critical Care | ||
Be able to discuss predisposing factors (gender, pre-existing cognitive impairment, age, auditory/visual impairment, alcohol/drug abuse, severe illness etc.) | ||
Show awareness of precipitating factors (analgesia, benzodiazepines, sepsis, pain, ventilation, hypoxia etc.) | ||
Describe how to recognise/diagnose delirium, including the common subtypes | ||
Be able to describe typical presentations of hyperactive delirium, hypoactive and mixed delirium | ||
Demonstrate basic knowledge of pharmalogical impacts on delirium | ||
Identifying typical medication forms that may impact such as benzodiazepines/antipsychotics and subsequent imbalances caused | ||
Demonstrate awareness of the ABCDEF Liberation Delirium bundle or PADIS guidelines | ||
Demonstrates the knowledge of early mobilisation, nutrition, activity engagement, sleep and family input in delirium management | ||
Delerium assessments | ||
Demonstrate knowledge of the RASS scores | ||
To be able to complete a CAM-ICU independently | ||
Delerium management | ||
Demonstrate how to feedback on results of assessment and recommendations to MDT, patient and family | ||
Demonstrate typical OT intervention and treatments of delirium | ||
Be able to complete a detailed social history capturing the wider needs of the patient including hobbies, likes/dislikes, occupations, personality, family dynamics etc. | ||
Complete and recommend daily orientation with delirious patient; to include use of orientation boards, pictures or verbal orientation strategies, use ‘framing’ to aid hallucinations/understanding of reality, insight building, education. | ||
Assess, commence and recommend early mobilisation, rehabilitation, routine and bed mobility | ||
Complete environment assessment and recommendations within scope of practice and skills. Consider light/ dark, windows, sounds and stimulation and work with MDT to support | ||
Sleep cycle – introduction of sleep hygiene strategies i.e. masks, reduce caffeine intake, exercise (if appropriate) or environmental changes to support sleep/wake cycle etc. | ||
Functional/cognitive activities alongside normal daily routine | ||
Partake in family, friend engagement/education of delirium and how they may participate in delirium management. Provide family/ friend education on delirium management | ||
MDT education on delirium and therapeutic role of activity | ||