Abstract
The coronavirus disease 2019 (COVID-19) pandemic reshaped the health care landscape, leading to the reassignment of essential health care workers to critical areas and widespread furloughs of providers deemed nonessential, including occupational therapy practitioners. Although multidisciplinary critical care teams often include occupational therapy practitioners, efforts to define, measure, and disseminate occupational therapy’s unique contributions to critical care outcomes have been overlooked. This editorial provides recommendations to improve the occupational therapy profession’s readiness to meet society’s current and future pandemic needs. We propose a three-pronged strategy to strengthen occupational therapy clinical practice, education, and advocacy to illuminate the distinct value of occupational therapy in critical care.
As health systems in the United States braced for the onslaught of coronavirus disease 2019 (COVID-19) cases in 2020, hospitals canceled elective surgeries, reassigned essential health care workers to critical areas such as emergency departments and intensive care units, and furloughed or laid off nonessential staff. For the 28% of U.S. occupational therapy practitioners working in hospitals, the COVID-19 pandemic called into question the essential nature of occupational therapy in acute and critical care settings (American Occupational Therapy Association [AOTA], 2020).
Without a well-delineated position outlining occupational therapy’s unique and essential role in these medically complex settings, many occupational therapy practitioners experienced job insecurity during the COVID-19 pandemic (Esbrook et al., 2020). Ironically, this was happening as some occupational therapy practitioners across the country, particularly in larger centers with well-established multidisciplinary care teams, were already applying best-practice guidelines to patients with COVID-19. Given the unprecedented number of people in the United States recovering from COVID-19 and new waves of infections on the horizon, rehabilitation and survivorship will be central themes in the medical community going forward. The time is right for the occupational therapy community to better define and communicate its role.
This editorial emerged from informal discussions among occupational therapy practitioners exchanging ideas from the frontline and seeking ways to improve care and disseminate current practices to the occupational therapy community. Here, we examine the profession’s public health emergency readiness. We propose a three-pronged strategy to improve occupational therapy’s capacity to meet society’s pandemic needs in critical care settings and call on professional occupational therapy organizations and their members to
Strengthen evidence-based clinical practice,
Enhance entry-level and postprofessional training, and
Promote awareness of occupational therapy practitioners’ impact on value-based health care.
Evidence-Based Clinical Practice
Historically, the role of occupational therapy in hospital-based acute care has been largely accepted, given patients’ need to relearn basic activities of daily living after illness, injury, or surgery. Advances in modern medicine now allow patients to survive life-threatening conditions that were once deadly; this has resulted in increased medical complexity and fragility of patients receiving occupational therapy in acute care settings (Lilly et al., 2017).
Occupational therapy practitioners in acute care have made dramatic shifts to keep up with these changing patterns, such as providing earlier care to patients who have undergone invasive, life-sustaining medical therapies (Schweickert et al., 2009). However, availability of rigorous, evidence-based guidelines specific to occupational therapy practice in critical care settings is limited. Efforts toward knowledge mobilization have been made with recent clinical and research publications in OT Practice and the American Journal of Occupational Therapy (Affleck et al., 1986; Carter Smith et al., 2020; Dinglas et al., 2013), as well as publication of Smith-Gabai and Holm’s (2017) textbook Occupational Therapy in Acute Care (2nd ed.). However, most research on critical care recovery and rehabilitation is published in medical and rehabilitation journals not specific to occupational therapy.
Physician champions, recognizing occupational therapy practitioners’ unique contribution to critical care rehabilitation, have aided the profession by systematically including occupational therapy in early rehabilitation clinical trials and practice guidelines (Devlin et al., 2018; Schweickert et al., 2009). Notably, the Society of Critical Care Medicine’s ICU Liberation Bundle is a multidisciplinary road map that has been widely adopted and contains elements of care that strategically improve long-term outcomes of adult intensive care unit survivors (Devlin et al., 2018). However, reliance on research investigating multidisciplinary rehabilitation in critical care has left the full scope of occupational therapy interventions poorly defined (Costigan et al., 2019). As a result, variations in utilization and occupational therapy care delivery exist across U.S. hospitals (Prohaska et al., 2019).
Occupational therapy practitioners working in critical care settings lack a platform for regular discussion and knowledge mobilization in their own field. Currently, research examining critical care outcomes is driven by professions other than occupational therapy (e.g., medicine, physical therapy, nursing), and original research focused specifically on the impact of occupational therapy interventions in these care environments is lacking. As a result, existing research endeavors do not reflect the breadth or depth of occupational therapy’s contributions to enhance recovery across physical, cognitive, and psychological domains (Costigan et al., 2019).
To ensure the viability of occupational therapy’s professional role in this unique and rapidly evolving area of practice, we offer the following recommendations:
Define the occupational therapy scope of practice in critical care settings.
Coordinate efforts to define, measure, and disseminate the distinct impacts of occupational therapy on patient-centered outcomes, health system outcomes, and health care utilization.
Develop special interest sections for critical care practitioners to facilitate collaboration.
Education and Postprofessional Training
To better address society’s rehabilitation needs during situations such as the COVID-19 pandemic, students and clinicians alike need education on the core foundations of critical care practice. Although current educational standards prepare students for generalist hospital-based practice, there is currently no specific language in the Accreditation Council for Occupational Therapy Education (ACOTE®; 2018) standards addressing critical care rehabilitation. Although some may argue that critical care is a specialty area of practice, the recent pandemic has seen practitioners of all levels of experience being forced to assume critical care roles. In preparation for future pandemics or other health care crises, entry-level practitioners need to be aware of the knowledge and competencies required in critical care settings. These skills may include safe management of invasive lines to enable successful participation in mobilization and meaningful activity as well as in situ clinical reasoning regarding hemodynamic responses to therapy intervention (Carter Smith et al., 2020; Mejia-Downs et al., 2015).
In addition to entry-level competencies, experienced practitioners have also faced a heightened need for advanced education in critical care skills and resources specific to COVID-19. Recognizing this need and opportunity for growth, AOTA has hosted several educational courses and developed various online resources, including tool kits and a fellowship directory. The 2018 Adult Rehabilitation Specialty Conference in Los Angeles included a preconference institute titled “Advancing Occupational Therapy Practice in Critical Care.” Throughout 2020, AOTA hosted a continuing education webinar series addressing the COVID-19 pandemic, the last of which was titled “Occupational Therapy for COVID-19: Treatment and Recovery Trajectories—Clinical Updates” (Margetis et al., 2020) and brought together the authors of this editorial to help accelerate progress on these issues.
In addition, AOTA coordinates, through its Fellowship Program, a directory of postprofessional training programs, including several physical rehabilitation, acute care, and critical care fellowships that offer clinicians additional training in this specialty area of practice. Taken together with the availability of AOTA conference presentations, OT Practice articles, and online resources available through AOTA’s website, the profession has made strides in providing more educational opportunities for students and clinicians interested in critical care. To bolster the available educational offerings, we provide the following recommendations:
Incentivize increased development of geographically diverse AOTA-sponsored fellowships that provide critical care training.
Create a national consortium of fellowship sites to bolster interfacility harmonization of training.
For professional occupational therapy organizations (e.g., AOTA) and practitioners with extensive critical care experience, host routine preconference institutes and comprehensive critical care continuing education courses for clinicians and students.
Create an exam-based specialty certification for critical care rehabilitation
Advocacy and Collaboration
Although many robust hospital-based occupational therapy departments exist across the nation, many health systems lack occupational therapy representation in leadership roles. This lack of representation of occupational therapy at the highest levels of health care means that other professionals may define the scope of, and control access to, occupational therapy services in critical care settings. Nationwide advocacy efforts should aim to transform institutional perceptions of occupational therapy practitioners from routine and nonessential rehabilitation personnel to critical components of the multidisciplinary health care team. A statement from AOTA delineating the scope of occupational therapy in critical care settings, reviewing areas of contribution by practitioners, addressing barriers to access to services, and identifying strategic research priorities is a crucial next step for the occupational therapy profession. To support this effort, the profession needs more original research focused on interventions specific to occupational therapy and the development of best-practice guidelines for occupational therapy practitioners in critical care settings (Costigan et al., 2019).
In the current era of instability and financial uncertainty, occupational therapy services are also vulnerable as a result of occupational therapy’s lack of robust revenue generation capacity in the hospital environment. As a result, the profession relies on health care policy research to characterize the impact of occupational therapy services on key performance indicators (e.g., readmission rates) of value-based health care. For example, the study by Rogers et al. (2016), which demonstrated that occupational therapy was the only spending category that reduced hospital readmissions, has frequently been cited. In addition, Pritchard et al. (2019) reviewed changes to the U.S. health care landscape, outlining the significant role that occupational therapy practitioners can play in safe community discharges, decreasing lengths of stay, and protecting patients from hospital-acquired conditions. Occupational therapy practitioners in management and leadership roles should proactively share these data with hospital administrators to solidify the profession’s role in critical care settings and public health emergencies.
Ongoing investment in advocacy efforts at both the national and the state levels through lobbying and political action committees is necessary to ensure the occupational therapy profession’s ubiquity in hospital-based practice. To that end, AOTA routinely nominates subject matter experts to advise national bodies on policy development, including the American Medical Association and Centers for Medicare & Medicaid Services; subsequent dissemination of these efforts will enhance advocacy at the local level. Given the critical role advocacy plays in promoting the profession, we offer the following recommendations:
Expand the literature supporting the impact of occupational therapy interventions on value-based health care and critical care outcomes.
Foster collaborative partnerships between occupational therapy hospital departments and clinical outcomes researchers.
Expand lobbying opportunities to elevate the visibility of occupational therapy practitioners in critical care settings.
Conclusion
The COVID-19 crisis has provided opportunities to highlight essential occupational therapy contributions in critical care settings. In the early chaotic months of 2020, the importance of early occupational therapy for critically ill patients was often overlooked. As the world continues to face this pandemic, rehabilitation and survivorship have become central themes as the medical community struggles to return patients to their occupational roles and routines. Occupational therapy practitioners specializing in critical care rehabilitation have illustrated the profession’s essential role in the COVID-19 pandemic by proactively applying best-practice guidelines to COVID-19 patient populations and incorporating the profession’s holistic patient-centered lens (British Society of Rehabilitation Medicine, 2020; Devlin et al., 2020). AOTA and the profession at large have the opportunity to create a joint venture among researchers, educators, and clinicians to invest in this important area of practice, further solidifying occupational therapy’s capacity to influence thousands of lives amid this, and future, public health crises.
Acknowledgments
John Margetis and Jamie Wilcox contributed equally to this work and are considered co–first authors.
