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By Bai-Ou He, Occupational Therapist Practising in London, UK (Band 6)
Occupational therapists (OTs) have a key role on neurosurgery wards. Neurosurgery covers operations on the central nervous system (brain and spinal cord) and the peripheral nervous system, which can involve any area of the body. More specifically, OTs support with neurological assessments, rehabilitation and hospital discharges. The wards are fast-paced and there is a lot of multidisciplinary team (MDT) working involved. Working on a neurosurgery ward has particularly increased my knowledge of anatomy, medications and cognitive assessment skills...
My typical morning includes around 10 ‘snoozes’ and some frantically put together porridge! I leave early to attend the 8am morning meeting with the MDT. The meeting includes: doctors, nurses, bed managers and therapists. We go through each patient on the ward and update on their medical status. New patients awaiting surgery will also be discussed and brain scans shown. The main role for therapists at this meeting is to identify if patients are safe for therapy intervention or if they are on certain restrictions. For example, some patients will be placed on bed rest to reduce chances of vasospasms and further bleeding in the brain, or they may have specific spinal precautions post-spinal surgery. In addition, I update the team on which patients are safe for discharge home from a functional perspective and those who are likely to need further rehabilitation.
At 9am, the ward therapy team meet for a handover and allocation of patients. We sit and prioritise patients and arrange joint sessions with the physiotherapists (US: physical therapists). Those who are likely to be discharged sooner are prioritised, as the ward needs beds for the many patients waiting for their surgery.
First, I see a young man in his thirties. He has had neurosurgery to debulk a brain tumour.
It is day 1 post-operation, so I am keen to review his function. I complete a full neuro assessment. I start with seeing how he is feeling and some orientation questions, in order to get a sense of his mood and cognition. I then assess his range, strength and balance. I want to ensure that, since surgery, he doesn’t have any new onset of limb weakness and that he is still able to coordinate movement smoothly. I also review his sensation, identifying any new changes to touch, any onset of pain and if his vision is the same.
I observe his function whilst he gets out of bed and walks to bathroom to use the toilet. He presents with no physical or cognitive deficits since surgery. However, through our discussion, he appears more anxious about the next stages of treatment and his employment. He and his family are aware of his tumour and are keen to find more support services. I provide him with an information pack, which signposts the local and national charity support they are entitled to. I also inform the medical team regarding his concerns about treatment.
Next, I meet with the physiotherapist and we review a woman in her sixties, who has had a large subarachnoid haemorrhage.
Since her brain bleed she has presented with low awareness and arousal. From yesterday’s assessment, the rehabilitation assistant has brought us the appropriate tilt-in-space chair. We hoist her into the chair to review her seating; it is hoped that the seated position will also increase her alertness and reduce her muscles from deconditioning from lying in bed. I then complete a standardised low-level cognitive assessment, which can help track any functional changes. This will be done over a period of days, as per guidelines. We ensure her mobility chart is updated to ‘full hoist’ and nurses are aware of her positioning needs. Subsequently, we ask the rehabilitation assistant to complete some passive range on her limbs to reduce contractures. It is agreed that we should arrange a family session for the coming week to optimise therapy. Patients tend to respond better with familiar voices, objects and smells. It would also be good to arrange a joint session with her speech and language therapist (US: speech-language pathologist), to identify if there are any ways we can support her communication.
I telephone her family to arrange the joint session and provide an update of her current function. The family have lots of questions, so we decide a meeting with the wider team would also be useful. We want to ensure the family’s well-being is addressed; it will be a challenging time and we want them to be included in decision making.
At 12:15pm there is a ward 'huddle.' Since things can change quickly, we update the nurse in charge on who we have assessed safe for discharge and any concerns we have. I then document the patients I’ve seen from the morning and make any appropriate referrals. Lunch is at 1pm and we all head to the therapy staff room for some time away from the ward.
After lunch I check in with my Band 5 OT (UK - qualifying grade), to see how they are managing with their caseload. I ask if there is anyone she would like me to see with her. The therapy team encourage us to support one another and are big advocates of joint sessions. I find it's a great way to bounce ideas off each other and share knowledge. I also have a quick check of emails and any continued professional development (CPD) tasks that need to be done.
I will then see a few more patients in the afternoon, including a fifty-year-old man, who had a fall leading to a subdural haematoma.
The neurosurgeons completed a craniotomy to remove the blood. He has been presenting on the ward with confusion and reduced short term memory. I take him to the kitchen and ask him complete a hot drink task to assess his cognition. He struggles to recall where the coffee is and what the order was. He then leaves the tap running. Once the coffee is made, he is unable to orientate back to his bedside independently. More worryingly, he is unaware of any deficits. I noted that he lives alone and has limited social support. With all factors considered, it is assessed that he would benefit from in-patient rehabilitation, with focus on complex cognitive rehabilitation.
He is recommended for further OT interventions, to help him identify strategies to build and manage his short term memory deficits and to gain more insight into his current function.
I spend some time calling his local rehabilitation units to check he is a suitable candidate. Once this is confirmed, I complete the appropriate referral form. It is useful to note that this OT role includes a lot of interaction with external services, such as community neuro therapy teams and social services, in order to identify the best pathway for a person. Before I finish the session, I update the ward on his risk factors, due to his reduced cognition. I inform the nurses that he benefits from supervision and verbal prompts for his daily activity tasks, such as showering and going to the toilet.
Today I finish at 4pm. So in the last hour I spend time making plans for the next day, replying to emails (that I probably should have done earlier) and ensuring all my documentation has been completed.
It has been a busy day, but it is always interesting and manageable, thanks to my hardworking and superb NHS colleagues!