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Occupational Therapy in Acute Care: Liver Transplant

Disclosure

I have no relevant financial relationships with any companies related to the content of this course.

Molly Murphy, OTD, OTR/L

• 4th generation Bay Area native
• Cal Poly San Luis Obispo (2005), Earth Sciences, BS
• Washington University in St Louis (2014), OTD
• Productive aging
• Fall prevention and aging-in-place
• Medication management
• Occupational therapist since 2015
• Skilled Nursing Facility
• Acute Rehabilitation
• Acute Care
• Currently UCSF Liver and Kidney Transplant since May 2017

Goals and Objectives

• Define Occupation and Occupational Therapy (OT)
• Understand the role of the Occupational Therapist as a member of

the multidisciplinary Liver Transplant Team

• Understand common assessments, interventions, discharge

recommendations for patients that are pre- and post-liver transplant

• Identify when to consult an occupational therapist for your patients
• Provide practical clinical suggestions and ideas to help enhance

patient care and empower your patients to live their lives (with a new liver!) to the fullest

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What is an occupation?

“Occupation is the everyday…the things people need to, want, or are expected to do everyday” (Polatajko, 2007)

• Occupations give meaning to our lives
• Create our identity
• Define our life roles and responsibilities

Areas of Occupation

Activities of Daily Living (ADLs)

• Bathing
• Dressing
• Toileting and toilet hygiene
• Swallowing/Eating
• Self-Feeding
• Functional mobility
• Personal device care
• Personal hygiene and grooming
• Sexual activity

Instrumental Activities of Daily Living (IADLs)

• Care of others
• Care of pets
• Child rearing
• Communication management
• Driving and community mobility
• Financial Management
• Health management and maintenance
• Home establishment and management
• Meal preparation and cleanup
• Religious and spiritual activities and

expression

• Safety and emergency maintenance
• Shopping

Rest and Sleep

• Rest
• Sleep Preparation
• Sleep Participation

Education

• Formal education participation
• Informal education needs, interests and

participation

Work

• Employment interests and

pursuits

• Job performance
• Employment seeking and acquisition
• Retirement preparation and adjustment
• Volunteer exploration and participation

Leisure

• Leisure exploration
• Leisure participation

Social Participation

• Community
• Family
• Peer, friend

Benefits of Occupations

• Reduce the risk for disability and enhance the recovery process

from an ADL disability (Mendes de Leon et al, 2003)

• Social and productive activities are as protective as physical activity

in lowering the risk for mortality (Glass et al, 1999)

• Protects against cognitive decline and depressive symptoms

(Bassuk et al, 1999)

• Restriction for participation causes physiological deterioration,

leading to the loss of ability to perform competently in daily life (Kielhofner, 1992)

Occupational Therapy

American Occupational Therapy Association (AOTA)

• OT is the only profession that helps people across the lifespan to do the things they

want and need to do through the therapeutic use of daily activities.

• OT practitioners enable people of all ages to live life to its fullest by helping them

promote health, and prevent—or live better with—injury, illness, or disability.

• OT is inherently patient-centered, holistic, dynamic, and optimistic

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Person-Environment-Occupation-Performance (PEOP) Model

PERSO

N

ENVIRONMENT OCCUPATION PERFORMANCE

OCCUPATIONAL PERFORMANCE AND PARTICIPATION

Spiritual Psychological Cognitive Physiological Neurobehavioral Sensorimotor Biomechanical (Intrinsic Factors) (Extrinsic Factors) Social Supports Social Capital and Economic Systems Culture and Values Built Environment and Technology Natural Environment Well-Being Quality of Life

Acute Care Considerations

• Limited time with patients, short length of stay
• Simultaneous evaluations, interventions, discharge planning
• Quality metrics and cost reduction
• Medical instability
• Environmental limitations
• Appropriateness of referral
• Care protocols and activity precautions
• Infection control
• Need for flexibility
• Lines, tubes, monitors
• Productivity

Occupational Therapy and Liver Transplant

Stages of Liver Transplant

(Scott, 2011)

• **Occupational therapy services likely not indicated

STAGE # COMMON SYMPTOMS PARTICIPATION

• 1. Decline in health

Self-awareness that something is “wrong”

• Fatigue
• Gastrointestinal

problems

• Puritis
• Ascites
• Decreased initiative
• Mental health

(depression, anxiety, denial, fear, frustration)

• Likely no impact on

performance of ADLs and IADLs

• 2. Organ failure

Loss of capacity Diagnosis Validation: something is wrong

• Chance of some decline

in meaningful

• ccupations

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Stages of Liver Transplant

(Scott, 2011)

STAGE # MENTAL HEALTH PHYSICAL HEALTH PARTICIPATION

• 3. Referral to

transplant team

Fear, uncertainty, denial, search for information

• High stress,

frustration, fear

• Need for staying

healthy, yet sick enough for transplant

• Stigmatization
• “Patient role”
• Lab fluctuations

determine eligibility

• Laxatives for HE
• Frequent BMs
• Restricted

travel

• Skin integrity
• Accidents
• Increased fatigue
• Malnutrition
• Muscle loss
• Water retention
• Skin breakdown
• Back pain
• Abdominal

distension

• Shortness of breath
• Impaired balance
• Loss of ability to

participate in roles begins

• 4. Waiting for the

call

Loss of control Anxiety, fear Loss of capacity and role strain

• Encephalopathy

(HE) causes forgetfulness, confusion, stress, slowed processing, impaired safety

• Exacerbation of

underlying disorders (depression, adjustment, anxiety)

• Decreased

ADLs, IADLs, mobility

• Travel planning

is impacted to stay close to hospital

• Family education

needs

Pre-Transplant Occupational Therapy Evaluation

• Gather an occupational profile: WHO is the patient?
• Patient-centered short-term and long-term goals: WHAT motivates the patient?
• Environment: home set-up/barriers, access to durable medical equipment
• Assessments:
• KATZ Index of Independence in Activities of Daily Living (ADL)
• Lawton Instrumental Activities of Daily Living (IADL) Scale
• The Occupational Therapy Pretransplant Historical Interview (OT-PHI)
• Structured interview of self-awareness, initiative, coping, support, limitation
• Role Checklist
• Self-reported roles performed in past, present, and planned in future + Value associated with role
• Functional cognition
• MoCA, EFPT, Menu Task, heath literacy, medication management
• Discharge options and planning: home, home health, placement, community

resources

Pre-Liver Transplant ADL and IADL participation

(Samoylova et al, 2016)

• >50% unable to participate in one or more ADL/IADLs
• Patients with cirrhosis have functional disability > 80 y/o adult
• ADL and IADL disability is significantly associated with wait-list

mortality

• Most common ADL impairments: incontinence and transferring
• Most common IADL impairments: shopping, food preparation
• Predictors of waitlist mortality:
• Toileting
• Transferring
• Housekeeping
• Laundry
• 17% are dependent for medication management

Pre-Transplant Occupational Therapy Interventions

• Fatigue management
• Energy conservation
• Memory strategies
• Coping and adjustment
• Pain management
• Transfer training
• ADL re-training
• ADL/IADL adaptation
• Communication strategies
• Balance for ADLs
• Sequencing
• Functional Cognition
• Planning for transplant
• Personal goal-setting
• Awareness training and education
• Caregiver education
• Adaptive equipment
• Durable medical equipment
• Home environment safety
• Social support and isolation
• Home exercise programs
• Delirium management
• Breathing techniques
• Relaxation and stress management
• Skin integrity
• Medication management
• Incontinence planning

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Incontinence Management Strategies

• Normalize the discussion
• Create a culture of continence promotion
• Prevent, anticipate, prompt
• Provide privacy when safety is not a concern
• Set-up environment BEFORE the need for voiding
• Check for broken equipment
• Habit training with timed voiding schedules
• Protective undergarments (disposable underwear, pads)
• Patient and family education in self-monitoring to recognize patterns

around medication and meals.

• Encourage out of bed toileting, urinals from bed-level are not normal
• Assess home environment needs, modifications, attitudes

Stages of Liver Transplant

(Scott, 2011)

STAGE # MENTAL HEALTH PHYSICAL HEALTH PARTICIPATION

• 5. Transplant

surgery

Thankfulness, anxiety about survival, fear of future

• Cognition and mood

swings due to medications

• Loss of decision-

making to medical team

• Delirium
• Abdominal

guidelines

• Wound

management and healing

• Pain
• Fatigue
• Reduced activity

tolerance

• Activity

modifications for ADLs and IADLs

• Caregiver training

for self-care and cognition

• Medication

management

Post-Transplant Occupational Therapy Interventions

• Abdominal guidelines and activity

modification

• Bed mobility
• Compensatory strategies for ADLs
• Adaptive equipment (AE)
• Durable Medical Equipment (DME)
• Energy conservation
• Pacing
• Safe progression of activity
• Assistive device training
• Fall prevention
• Fine motor coordination
• Delirium prevention and

management

• Family education and training
• Building post-transplant habits
• Education and encouragement for

self-care ADLs vs defaulting to caregiver

• ADL training
• Lower body dressing/bathing
• Bathing
• Toileting
• Grooming
• Potential dialysis education (new
• ccupational role)

Delirium Prevention and Management

• Person factors:
• Physical
• Early mobilization
• Address toileting independence
• Offer drinks during/after OT
• Work with nursing and family on

encouraging food and hydration

• Cognition
• Orient and explain goal of OT
• Stimulate cognition and socializing
• Education to family
• Visit, talk, orient, bring personal items
• Sensory
• Use personal devices and glasses
• lighting
• Reduce visual distractions
• Environment Factors:
• Minimize interruptions at night
• Orientation information in view
• All needs within reach
• Glasses, call light
• Safety signage
• Move near nursing station
• Fall prevention
• Occupational Factors
• Interview patient/family on meaningful

activities, habits, routines

• Give patient choices
• Perform daily activities
• Meaningful work and leisure
• Encourage socialization with family

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Promoting Patient Sleep Hygiene

Goal: Promote optimal sleep performance Interdisciplinary team approach

• Educate patients on sleep

expectations while in hospital

• Pain management
• Medication
• Positioning
• Anxiety and depression
• Reduced caffeine in PM
• Increase daytime activity, mobility
• Balance diet and food choices
• Planning for nighttime voids:
• Void before bed
• Bed mobility, log rolling
• Toilet transfers re-training
• Modify environment
• Noise, temperature, lighting,

technology

• Establish a “normal” bedtime routine

while staying in hospital

• Coping skills and stress

management

• Eye masks, ear plugs
• Communicate sleep preferences

with night shift RNs

• Avoid daytime napping ‘

Discharge planning

• PEOP Model as a Framework
• What is the patient’s level of function? What environment will support participation?
• Pre-Transplant
• Generally back to home with either family assist OR Home Health if “homebound”
• OT is not considered a stand-alone therapy, must also have Physical Therapy needs
• Occasional need for placement if poor function, but will impact liver transplant waitlist
• Post-Transplant
• Preferred discharge: home with either family assist OR Home Health if “homebound”
• Placement if level of function will not be supported by environment, less ideal
• SNF: <3 hours a therapy a day
• Acute Rehab: >3 hours of therapy a day
• Long-term: Outpatient OT or PT
• Return to normal functioning, community integration, work, IADLs
• Physical therapy for core strength after abdominal guidelines lifted

Referrals to Occupational Therapy

• ADL impairments and limitations
• Safety awareness
• Cognitive impairments and mental health
• Medication management barriers and compliance
• Patient and family education
• OTs are NOT just for “safe discharge” planning
• To reduce risk of hospital readmissions (Rogers et al, 2016)
• Timing of referral
• Delayed referral to OT (and PT) can result in longer length of stays
• Discharge depends on patient and family readiness and

cooperation (Toledo et al, 2013)

Occupational Therapy Pioneer Ideas and Recommendations

• Coming soon in Fall/Winter 2019: Trial acute care liver transplant

wellness groups lead by an occupational therapist

• More research is needed for efficacy of occupational therapy in liver

transplant

• Consider occupational therapy referrals in outpatient clinics
• With increased survival rates, many have problems with fatigue,

return to valued roles and work, adjustment to new routines to prevent rejections, poor social functioning

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References

• Bajaj, J. S., Wade, J. B., Gibson, D. P., Heuman, D. M., Thacker, L. R., Sterling, R. K., ... & Bell, D. E. (2011). The multi-dimensional burden of cirrhosis

• Bassuk, S. S., Glass, T. A., & Berkman, L. F. (1999). Social disengagement and incident cognitive decline in community-dwelling elderly persons. Annals
• f internal medicine, 131(3), 165-173.
• Elliott, C., & Newton, J. (2009). Occupational therapy in chronic liver disease: a gap in service delivery. British Journal of Occupational Therapy, 72(3),

• Glass, T. A., De Leon, C. M., Marottoli, R. A., & Berkman, L. F. (1999). Population based study of social and productive activities as predictors of survival

• Iwarsson, S., Isacsson, Ǻ., Persson, D., & Scherstén, B. (1998). Occupation and survival: A 25-year follow-up study of an aging population. American

• Kuehn, B. M. (2010). Delirium often not recognized or treated despite serious long-term consequences. JAMA, 304(4), 389-395.
• Lai, J. C., Feng, S., Terrault, N. A., Lizaola, B., Hayssen, H., & Covinsky, K. (2014). Frailty predicts waitlist mortality in liver transplant
• candidates. American journal of transplantation, 14(8), 1870-1879.
• Mendes de Leon, C. F., Glass, T. A., & Berkman, L. F. (2003). Social engagement and disability in a community population of older adults: the New

• Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2017). Higher hospital spending on occupational therapy is associated with lower readmission
• rates. Medical Care Research and Review, 74(6), 668-686.
• Samoylova, M. L., Covinsky, K. E., Haftek, M., Kuo, S., Roberts, J. P., & Lai, J. C. (2017). Disability in patients with end‐stage liver disease: Results from

• Scott, P. J. (2011). Occupational therapy services to enable liver patients to thrive following transplantation. Occupational therapy in health care, 25(4),

• Scott, P. J. (2010). Participation in valued roles post-liver transplant. British Journal of Occupational Therapy, 73(11), 517-523.
• Smith-Gabai, H., & Holm, S. E. (Eds.). (2011). Occupational therapy in acute care. Bethesda: American Occupational Therapy Association.
• Toledo, A. H., Carroll, T., Arnold, E., Tulu, Z., Caffey, T., Kearns, L. E., & Gerber, D. A. (2013). Reducing liver transplant length of stay: a Lean Six Sigma
• approach. Progress in transplantation, 23(4), 350-364.