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The Role Of The Occupational Therapy Practitioner: Pediatric Acute Care Virtual Conference

The Role Of The Occupational Therapy Practitioner: Pediatric Acute Care Virtual Conference
Cambria Hunter, MSGH, OTR/L
May 28, 2024

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Editor's note: This text-based course is a transcript of the webinar, The Role Of The Occupational Therapy Practitioner: Pediatric Acute Care Virtual Conference, presented by Cambria Hunter, MSGH, OTR/L.

Learning Outcomes

  • After this course, participants will be able to identify the role of occupational therapy on the interprofessional team in the acute care setting.
  • After this course, participants will be able to list skills required to work in the pediatric acute care setting.
  • After this course, participants will be able to compare and contrast different treatments/treatment approaches in various areas of acute care, including ICUs, mental health, inpatient rehab, ortho, and oncology.


  • Children have unique and specialized needs.
    • Late 1800’s hospitals created to exclusively meet the needs of children.
    • First hospital in America in Philadelphia – now over 200 providing exclusive care to meet needs of children.

(Dudgeon, 2020)

Hello everyone. I am glad you are here. Let's jump right into the topic.

We haven't always had children's hospitals. It wasn't until the late 1800s in Philadelphia, United States, that it was recognized that children have unique needs different from adults, leading to the establishment of the first children's hospital. In the past, children were often hospitalized for long stays with programs specializing in education and socialization. Currently, we have over 200 children's hospitals focusing on acute care onset problems, with much shorter stays.

  • Children receive care for a wide variety of conditions and diagnoses.
  • Most common reasons children require hospital care are gastrointestinal and respiratory problems.
  • Occupational therapy services are provided to children with multiple needs (Dudgeon, 2020 p.680):
    • Medical
    • Neurological
    • Musculoskeletal disorders
    • Mental health disorders
  • Higher frequency of OT services in acute care  > decreased readmission (Edelstein et al.,2021)
  • Consideration for pediatric acute care – may continue to be readmitted based on child’s medical status/diagnosis

(Dudgeon, 2020)

Children go to hospitals for various reasons and various conditions and diagnoses. The most common reasons are gastrointestinal and respiratory problems. About 25% of children and adolescents have chronic health conditions such as cerebral palsy or SMA, and these children are much more likely to experience respiratory conditions, especially during what we call RSV and flu season, leading to hospitalizations.

When working with pediatrics, we work across the development continuum, and they often need readmissions for various planned surgeries. Other diagnoses include general medical conditions, neurological disorders, musculoskeletal disorders, and mental health disorders, to name a few. Increased frequency of therapy services has been found to decrease readmission rates, according to a study in 2021. Children and youth without chronic conditions or a long-term plan of care who receive OT services while admitted can help decrease readmission rates and loss of functional abilities.

Different Acute Care Units

  • Intensive Care Unit (PICU, NICU, etc.)
  • General Acute Care Unit (tend to be designated by medical specialty)
  • Specialty Units (Cardiology, Orthopedics, Oncology, Burns, Palliative, etc.)

Every hospital will look slightly different regarding the types of acute care units they have. This is true for both adult and pediatric hospitals. For example, hospitals with a level one trauma center will have higher acuity patients and more advanced ICUs. Other specialized units that may not be found in every hospital include oncology, transplants, burn units, or inpatient rehab units. Here in Phoenix, for instance, one hospital handles all burn cases for adults and pediatrics. Depending on the hospital's resources and care teams, the specialties, the units, and staffing expertise will vary.

Evaluation in Pediatric Acute Care

  • Occupational therapy services initiated by physician order.
    • Collaborate and discuss with physician as needed to add specific elements to assessment and intervention activities.
      • Example: Working with a child with a TBI, OTP may advocate for other referrals to be placed, request orders for equipment, etc. (Dudgeon, 2020 p. 685-686)
  • Extensive chart review
    • Physician's order
    • Relevant medical notes (including relevant social history)
    • Activity precautions and limitations
    • Medications
    • Daily schedule
  • Collaboration with other members of interprofessional team as necessary
    • Referring provider & consulting providers
    • RN
    • PT, SLP
    • Psychology
    • Social Work
    • Child Life

(Dudgeon, 2020)

A physician's order is required for an evaluation in pediatric acute care OT. After obtaining this order, I will collaborate with the physician regarding the order itself and potentially request additional orders. For instance, if I see a trauma patient initially believed to have only orthopedic complications but then suspect they might have had a concussion or cognitive issues, I would suggest the physician order a speech therapy evaluation.

Depending on the patient's needs, I might also request that the physician write orders for DME equipment, such as a bath bench or outpatient OT services. Collaborating with the physician is crucial for ensuring comprehensive care. 

Before seeing the patient, I conduct a thorough chart review. This includes reviewing the physician's order for special instructions and examining all other orders to understand the patient's precautions and weight-bearing status. If the patient has an external ventricular drain (EVD), I need to know how long it needs clamped and any related limitations.

A detailed chart review is essential, especially for high-acuity patients. I look at the medications they are on and try to understand their daily schedule. Collaboration with other providers is also key. This involves coordinating with various healthcare team members to ensure all aspects of the patient's care are addressed and that we are collectively working towards the best outcomes for the patient.

  • Semi-structured interviews with patients and caregivers
    • Occupational profile
    • Identify prior & current levels of function
    • Identify inhibiting and supporting factors
    • Identify goals
  • Observation
    • Environment
    • Positioning
    • Participation
  • Physical assessment
    • MMT
    • Vision
    • Balance and coordination
  • Standardized Tests/Checklists
    • Utilized as appropriate based on each unique patient situation
    • Cognitive, developmental, endurance, etc.

(Walter et al., 2021; Dudgeon, 2020)

When I start my evaluation, I use a semi-structured interview with the patient and caregivers, depending on the child's age. I focus on the occupational profile, identifying prior and current levels of function and inhibiting and supporting factors. I work with the family to identify goals. For example, if the family wants the patient to walk again or aims to get them home, we will discuss the factors that brought the patient to the hospital and then break down the goals into manageable steps. This helps the family understand the tasks needed to achieve their broader objectives.

While conducting the semi-structured interview, I will observe the patient. This includes assessing the environment, monitoring lines and tubes, determining how to position the patient safely, and evaluating their current participation level. I will note how much they can participate and what might limit their involvement. These observations are crucial for my assessment.

Due to various constraints, it is rare to use standardized testing with pediatrics for physical assessment in acute care. For example, the presence of an IV in their hand or foot can alter how they perform tasks, making it difficult to adhere to standardization. Instead, I will focus on active versus passive range of motion, manual muscle testing, vision, balance, and coordination.

Not everything will be covered during the initial evaluation due to factors like the patient's ability, age, and medical fragility. Sometimes, checklists can be useful to ensure all critical areas are addressed. This approach allows for a comprehensive and flexible evaluation tailored to the specific needs and conditions of the pediatric patient.

  • High-quality clinical reasoning (Bailey et al., 2022)
  • Identify appropriate standardized assessments and checklists
  • Is it appropriate for the patient? (Developmentally, culturally, contextually)
  • May use portions of standardized assessment – will vary based on context
    • Pediatric Evaluation of Disability Inventory (PEDI-CAT)
    • Functional Independence Measure for Children (WEE-FIM)
    • Alberta Infant Motor Scale (AIMS)
    • Coma/Near Coma Scale (CNC)

It is important to have high-quality clinical reasoning, as noted by Bailey in 2022. The OTP needs to use clinical reasoning to determine what assessment or checklist is appropriate and how to adapt the assessment for the acute care patient. This involves modifying the evaluation based on the patient's current condition in the hospital. Clinical reasoning is also required to know when to end the evaluation, as it may not always be safe to continue. 

Sometimes, it may be unsafe to start the evaluation or treatment. For example, if a patient has just been extubated and is struggling to breathe, I may need to give them a day or several hours before continuing. Similarly, if the patient is heavily sedated and unable to cooperate or participate, this would skew the results, particularly in a cognitive screen.

Here are some assessments we might use in the acute care setting: the Pediatric Evaluation of Disability Inventory (PEDI), the WEE-FIM for inpatient rehab settings, the Alberta Infant Motor Scale (AIMS), and the Coma/Near Coma Scale (CNC). The CNC uses negative and positive stimuli to monitor subtle changes in the patient throughout the week. This can be challenging for families to observe, involving actions like pinching the ear or skin to see if the patient responds. While this might seem harsh, it may be the only stimuli the patient responds to. Families sometimes prefer to step out of the room during these evaluations. We don’t perform the CNC daily due to its difficulty for families; it is typically done several times weekly.

At Phoenix Children's Hospital, we use the Bailey and Dacey in Arizona. We've faced challenges discharging trach-vent babies because they require home health nursing services, which are only provided if a standardized test shows developmental disabilities. Consequently, our therapy team has been asked to administer these tests recently.

  • Utilize effective and appropriate screening
    • Vision screen
    • Cognitive screen
    • Motor control and coordination
    • Developmental skills
    • Delirium
    • Self and state regulation

Once you identify the appropriate screening tools, you'll administer them to the patient. Some of these tools are not standardized but useful for specific assessments. For a vision screen, you'll check if the patient can track in all directions with smooth pursuits. You'll look for signs of double or blurred vision and assess if their pupils are dilated. For concussion patients, you might measure the distance at which they see two fingers as you bring them closer, comparing this to age norms. You'll also observe if their eyes fatigue quickly, indicated by frequent blinking, difficulty keeping their eyes open or needing breaks.

For a cognitive screen, you'll determine if the patient can follow one-step or two-step directions or more complex instructions. You'll assess if they can plan and execute an ADL task they've always done, follow a simple recipe, or carry on a conversation while performing a movement activity. This provides insight into their cognitive functioning.

For motor control and coordination, you'll see if the patient can move from the bed to a chair and evaluate their static and dynamic balance in sitting and standing. You'll check if they can grasp a toothbrush to brush their teeth or if they lack motor control and coordination. For infants, you'll observe if they can grasp a toy, a developmental milestone.

Developmental skills should be assessed to ensure they are appropriate for the patient’s age. For example, you'll look at babies' tummy time performance and enjoyment. If they dislike tummy time, you’ll explore potential reasons, such as positioning issues. Sometimes, parents are hesitant to place infants on their tummies after a G-tube placement or cardiac surgery. However, after 24 hours post-G-tube placement, tummy time is usually safe, and after two weeks for cardiac babies, as long as the scar is healing well, with physician approval if earlier.

For delirium, you'll consider the patient’s sedation history, medications, and ICU duration. Infants might show signs of delirium through glossed-over eyes or a starry stare. You'll also assess self and state regulation, such as whether the baby can bring their hand to their mouth to calm down or if a TBI patient can avoid screaming when overstimulated. For mental health patients, you'll check if they can manage frustration without becoming aggressive.

Checklists will vary based on the patient’s age and diagnosis. For example, a neonatal infant will have different criteria compared to an older child with a TBI. A patient admitted for spinal fusion surgery doesn’t need cognitive testing unless there’s reason to believe cognition was affected. You'll use critical thinking to determine which checklists and tests are necessary, adapting your approach based on each patient's specific diagnoses and needs.

Intervention in Pediatric Acute Care

  • FOCUS is on
    • Preventing secondary disability
    • Restoring performance
  • Keep this in mind as we discuss intervention in various units

Intervention in pediatric acute care focuses on preventing secondary disability and restoring performance. It is crucial to prevent secondary disability when supporting developmental progression. For example, a neonate born prematurely requires proper positioning and sensory environment modifications to prevent secondary disabilities and promote normal development until they reach full-term age. This principle also applies to a six-month-old hospitalized long-term; we aim to prevent the loss of skills and restore performance to the six-month level while helping them achieve the next developmental milestones.

Prevention for all pediatric patients includes avoiding contractures due to lack of movement, which may involve splinting and range of motion exercises. Restoring performance is equally important for children and adolescents hospitalized with a loss of function. Focusing on these interventions can help our young patients maintain and regain their abilities, supporting their overall development and health.

Considerations for Evaluation and Intervention in Various Acute Care Units

  • OTP supports medical priorities and the child’s goals.
  • Crucial to understand the child’s diagnoses, potential precautions, implications of medical procedures, use of life support/equipment, and contraindications of positions/activities
  • Prevent secondary disability associated with prolonged bed rest and immobility (i.e., contractures, generalized weakness, decreased endurance, cardiopulmonary compromise
  • Prevent secondary disability associated with ICU stay – post-intensive care syndrome (PICS)

(Dudgeon, 2020, p.691; AOTA, 2023)

Let's now talk about the pediatric intensive care unit (PICU). PICU nurses are your best allies in any ICU. The nurse's goals for the patient might differ from yours based on the patient's medical status. Communicating with the nurse to understand their concerns and priorities is crucial. For instance, they might worry about a loose line, the patient's orthostatic status, or how well the patient slept last night. This information is vital for planning your therapy session effectively.

Children on continuous renal monitoring or heavy sedation will have limited stamina, which must be considered when planning treatment. They might not tolerate an extensive evaluation or long therapy sessions. For a child with an external ventricular drain (EVD), the EVD might only be clamped for 20 minutes, perhaps only once a day. Coordinating your timing to maximize movement or mobility activities during that window is essential.

Prevention in the ICU is key. For patients too sick to move themselves, positioning them upright rather than flat can help their bodies adjust to being upright, reducing orthostatic changes when they can move. This might involve raising the head of the bed or teaching families how to perform range-of-motion exercises or properly use a splint.

Post-intensive care syndrome (PICS) is a combination of cognitive, physical, and emotional symptoms that persist after discharge. As an OT, you might be the first to identify PICS during ADL and functional activities. Awareness of PICS allows you to educate the family and assist in the patient's home transition, ensuring a smoother recovery process.

  • Pediatric Intensive Care Unit
    • Occupational therapy professionals working in PICU settings have a unique perspective and can adapt to the PICU environment as appropriate to facilitate successful participation in play occupations.
      • Use of graded activities
      • Facilitate the child’s active participation
      • Positioning and orthotic recommendations to maintain skin and joint integrity
      • Delirium prevention

Over the last several years, there has been a significant push for early mobilization in the PICU. This mobilization is graded based on the patient's medical status, ability to participate, and developmental level.

The push for mobilization is partly due to the observation that patients who remain on respiratory assistance longer tend to have worse outcomes. Therapy can have a substantial impact in this regard. In the PICU, early mobilization might involve simple activities tailored to the child's condition. For a younger child, this could start with something as basic as batting a balloon in bed to work on arm movement against gravity. As the child progresses, the activity might be graded to having them sit on the edge of the bed to work on dynamic balance while batting the balloon. Further progression could involve standing, squatting, or walking to a chair while continuing the activity.

For sedated children, the focus can include splinting and positioning to prevent secondary disabilities. To help decrease delirium, the OTP can educate family and staff on maintaining a day-night cycle with lights on during the daytime and minimal interruptions at night. The family can also provide familiar items from home, such as pictures and favorite toys, to create a more comforting and less disorienting environment for the child. 

  • Neonatal Pediatric Intensive Care Unit
    • Occupational therapy professionals working in NICU settings are focused on both the prevention of secondary disability and development milestones.
      • Positioning
      • Regulation
      • Developmental activities
      • Family education

(Dudgeon, 2020, p.691; AOTA, 2023)

Moving on to the NICU, it's important to realize that gravity significantly affects premature babies without physiological flexion. One of the primary roles in the NICU is positioning. Prone positioning is beneficial for neonates, aiming to achieve physiological flexion with the knees and hips tucked underneath, promoting a nice curvature and flexion in the spine. The head should be turned about 45 degrees to clear the airway and promote good head formation, rather than a full 90-degree turn.

Proper positioning is crucial for promoting normal development as they approach full-term age. Several helpful positioning devices exist, such as Mölnlycke® Z-Flo™ Fluidized Positioners and Dandle Roo. Preemies with poor regulation are still developing their senses, and the OTP can assist with regulation by using containment techniques. This involves placing a hand at their feet and head, using positioning devices to get their hands to their mouth, and setting up the environment to limit noise, light, and other stimuli based on their corrected gestational age.

A significant part of OT in the NICU is providing family education on how to touch and hold the baby with appropriate sustained pressure. This includes holding their baby in kangaroo care, which is skin-to-skin contact, even with intubated babies, as long as they are stable. Additionally, neonatal touch and massage and participating in the infant's care through activities like a swaddled bath or a therapeutic diaper change are essential. 

For therapeutic diaper changes, especially with preemies, it’s important not to lift the bottom as most people do because this can increase pressure on their head, risking intraventricular hemorrhaging. Instead, focus on lower body trunk rotation, gently rotating the baby side to side during the diaper change.

Everything we do in the NICU aims to help the infants reach their developmental milestones and prepare them for greater success as they approach full-term age.

  • Cardiac Intensive Care Unit
    • Occupational therapy professionals working in CICU settings will incorporate both PICU and NICU strategies depending on the age of the patient.
      • Use of graded activities
      • Facilitate child’s active participation in play & ADLs
      • Positioning and orthotic recommendations to maintain skin and joint integrity
      • Delirium prevention

(Dudgeon, 2020, p.691; AOTA, 2023)

Considerations for our cardiac intensive care unit (CICU) are critical because the heart is vital to life. It's important to grade each patient's activities very carefully, as mistakes can be more life-threatening due to the involvement of this essential organ. For some cardiac babies, the extent of what I can do might be as simple as cradling their head in my hand. This might not seem significant, but it changes how they breathe since they are used to extending their head to open their airway. This can be very scary for the infant, and for me, it involves bringing their head into a more neutral alignment.

I may or may not be able to apply a little cervical traction on their neck, but even if all I can do is cradle their head, it's significant. By getting the head out of increased extension and into a more neutral position or even some flexion, I'm helping them tolerate breathing differently. This process involves constant monitoring to ensure their safety.

Delirium is another important consideration for our babies and kids in the CICU. Over-sedation can still occur today, as the medical team often aims to calm the baby or child. However, there might be other ways to achieve calmness, and this is where OT can play a crucial role in the cardiac unit. Besides managing sedation, OT can involve getting the baby into the parent's arms or moving a child to a chair, exploring alternative calming methods.

For young children and teens, even when intubated, we aim to mobilize them, get them upright in a chair, and engage them in normalized activities. This approach not only aids in their physical recovery but also supports their overall well-being by incorporating movement and familiar routines into their care plan.

  • General Acute Care Unit
    • Patients more medically stable compared to ICU
    • It is important to be familiar with various diagnoses and procedures across units (e.g., orthopedic, neuro, etc.).

(Dudgeon, 2020, p.691)

Evaluation in a general acute care setting involves understanding the needs of medically stable patients with fewer lines and tubes and less complexity. If you have ideas about tests you might use with these children or any tips and tricks that have worked for you, feel free to type them in the chat box. The general acute care floors are considered a step down from the ICU, meaning less complexity but still requiring careful monitoring.

Patients in the general acute care setting may have chest tubes or other types of lines that appear complex, and they can still experience orthostatic issues. Ortho patients after surgery might have a drop in blood pressure when getting up for the first time. While these patients are typically less critical than those in the ICU, they still require careful observation and monitoring.

Because they are more medically stable, you can usually observe more and perform more comprehensive evaluations with these patients. This setting allows for a broader range of assessments and interventions, helping to address their needs more effectively.

  • General Acute Care Unit: Orthopedic
    • Evaluation and intervention utilizing rehabilitative approach – providing compensatory techniques to restore occupational performance
    • May modify environment, and routines, or provide equipment

(Dudgeon, 2020)

On our orthopedic floors, problem-solving is key, especially with ortho patients, who require critical thinking skills and adaptability. For instance, if a patient is non-weight-bearing on their right lower extremity and left upper extremity, determining the appropriate ambulation device and teaching the families how to assist becomes challenging. Similarly, adapting showering techniques for a patient with a large freestanding tub that cannot accommodate a shower chair is another area where problem-solving is essential.

Timing therapy sessions with pain medications is crucial. Coordinating with the nurse is important to know when the pain medication will take effect. However, care must be taken with narcotics, as they can make the patient too sleepy to participate effectively in therapy. It is essential to educate the patient and family about the presence of pain during movement and reassure them that it will improve over time. We recently started an annual conference for spinal fusion patients to prepare families for the pain management process. Many families, especially those who have never experienced surgery or an accident, may not realize that some pain is inevitable, even with pain medications. They need to understand that movement can increase pain levels initially but will decrease with time and activity.

Setting daily goals for patients on the ortho floor is also important. For example, encourage them to get out of bed and sit in a chair for breakfast, lunch, and dinner or to mobilize to the bathroom and walk within their room a few times a day. For very orthostatic patients, simply elevating the head of the bed during the day can help reduce symptoms. The overall aim is to prepare these patients for discharge, ensuring they are ready and able to manage their daily activities at home.

  • Specialty Unit – Oncology
  • Children admitted with various types of cancer, immunodeficiency disorders, and blood disorders i.e., hemophilia
  • OTP working with patients and their families may encounter and provide services across a continuum of treatment
  • Important to coordinate therapy intervention with other medical interventions to enhance the benefit of therapy

(Dudgeon, 2020, p.691)

When working in oncology, it's important to understand the side effects of different chemotherapy medications and find the optimal time for the child to engage in age-appropriate play. Ideally, this would be when their chemo meds are not running through their IVs, although sometimes therapy sessions occur during chemotherapy. Flexibility is key, as some children do better in the early morning while others may be more active in the afternoon. 

Understanding the patient’s blood counts and knowing when they need to be isolated to their room or unit is also crucial. The nurse can provide guidance on this, and hospital policies regarding blood counts and isolation may vary.

Another important consideration is scheduling therapy around the patient's radiation schedule. In some cases, patients are transported to another facility for radiation. For example, at our pediatric facility, patients go to Mayo, which can take up to four hours, requiring careful planning to fit in therapy sessions around these trips.

Additionally, the OT's role may include working with the palliative care team to help the child find meaningful activities with their family at the end of life. This involves creating opportunities for the child to engage in activities that bring joy and comfort, ensuring quality of life during their final days.

  • Specialty Unit – Bone Marrow Transplant (In Oncology Unit)
  • Bone marrow transplant (BMT) – must be aware of the stage of treatment the child is in and adhere to any precautions identified by the medical team
  • Children receiving BMT experience “increased fatigue, decreased physical activity, and impaired social functioning” (Colman et al., 2020, p.2)
  • Profound impact on ADLs, play, leisure
  • A study completed by Colman et al. (2020, p.1) demonstrated a positive impact on strength, coordination, and independence for ADLs following OT intervention
    • Received OT 4-5x a week
    • OT services are offered in the morning as part of daily routine and planned around various medical needs
    • Participation in occupational therapy four to five times a week positively affects strength, coordination, and independence in ADLs for patients undergoing HCT. Again, trying to find the right schedule to work around their medical needs is always key.

Bone marrow transplants in the oncology unit typically occur in air-pressurized rooms. Regardless of the specific precautions, we wear gowns, masks, and gloves to protect the patients from germs. These patients are often fatigued, especially during and after the bone marrow transplant process, which can lead to deconditioning and decreased social functioning. Occupational therapy plays a crucial role in helping these patients regain strength and endurance, as noted by Coleman and colleagues in a 2020 study.

Coleman's study included 32 pediatric transplant patients and focused on interventions such as play and leisure engagement, upper extremity therapeutic exercises, fine motor activities, and ADL training. Strength, coordination, and daily living skills were documented prospectively to compare differences between patients seen by occupational therapy at high versus low frequency.

  • Inpatient Psych Unit
    • Occupational therapy practitioners working in inpatient psych will incorporate cognitive, behavioral, and psychosocial strategies and sensory integration approaches.
      • Sensory Diets
      • Facilitate child’s active participation & communication
      • Cognitive behavioral strategies
      • Assess triggers leading to IP stay

(Dudgeon, 2020, p.691; AOTA, 2023)

Inpatient psych units ideally have a full-time OT to run groups and provide ongoing cognitive behavioral and psychosocial strategies, along with sensory integration approaches. However, having a full-time OTP isn't always possible due to budgeting constraints. Nevertheless, OTs play a crucial role by conducting assessments and offering best practice guidelines for these kids during their hospitalization. At our hospital, we adopt more of a consultation approach.

We often use the Zones of Regulation with these kids to help them find socially appropriate coping strategies when upset. Our goal is to assist the child in understanding interoception, recognizing triggers before they escalate to the red zone, and finding ways to return to the green zone, which represents a calm state. Identifying the triggers that led to their hospitalization in the first place is a key part of our role. During our screenings, we consider factors such as visual motor integration, writing problems, visual acuity, core strength, and posture.

School can be particularly challenging for these children, so screening for these factors is crucial. Surprisingly, not every child who needs OT in schools or outpatient settings gets identified. Therefore, our role in identifying these triggers and providing recommendations is vital. For example, during my screenings, I often ask children if they have difficulty seeing the board when the teacher writes. They'll often admit they can't see well, and upon further probing, I discover their glasses are broken or lost. This conversation then extends to the social worker and nurse to find a solution for getting the child new glasses, which is essential for their attention and participation in school.

Additionally, sensory diets can help children focus and regulate. Sensory integration and understanding what the child is seeking or avoiding are critical. Implementing sensory diets in a meaningful context can greatly benefit the child in the inpatient psych unit and their home and school environments. This approach helps them modulate sensory input and maintain regulation across various settings.

Necessary Knowledge Base and Skills for Pediatric Acute Care

  • Clinical reasoning
  • Knowledge of lines/tubes/drains
  • Knowledge of various medical diagnoses & procedures and subsequent implications
  • Knowledge of child development

Strong clinical reasoning skills are essential in the pediatric acute care setting, enabling practitioners to think and adapt in real-time. It's crucial to read all the patient's physiological cues for stability and progression, knowing when to push and when to stop. For instance, a spinal fusion patient needs to be encouraged to move through their pain, as discussed earlier. Conversely, a cardiac baby who starts crying needs comfort, not pushing, due to their medical fragility and the strain crying places on their heart.

Understanding when to push and when to stop is vital and hinges on a thorough knowledge of the diagnosis. Equally important is knowledge about lines, tubes, and drains. Can the chest tube be removed from wall suction? Can the feeding tube be disconnected or stopped temporarily? Can the EVD be clamped to move your patient, and if so, is there a time limit for how long it can be clamped? When dealing with multiple tubes, you need to know which lines to prioritize for movement, whether certain tubes can be repositioned around the bed, and if there's enough slack to move the patient to the floor or a chair. Any leakage around a drain requires immediate nursing intervention before moving the patient.

Understanding diagnoses and procedures helps inform treatment plans. Can you see the patient before their procedure? After a procedure, is the patient alert and medically stable enough to be seen by the OTP? For example, a baby who has had a retinopathy exam or a child who has just been extubated might need several hours or even a day to recover before being ready for therapy. Flexibility is key in these situations.

Energy conservation techniques might need to be taught to the family for progressive diagnoses, while a diagnosis with an expected full recovery might require pushing the patient a bit more. Consideration of child development and cognitive ability to follow directions is also crucial. Young children often don't understand why they are in the hospital or why they need to push through pain to heal. Therefore, it's important to tailor your approach to their developmental level and cognitive capacity, ensuring that the therapy is appropriate and effective for each individual patient.

  • Play
  • Interpersonal skills & strong communication/collaboration
  • Knowledge of family-centered care
  • Parent/Caregiver coaching and collaboration with patients and families
  • Flexibility

Finding ways to motivate pediatric patients through play is essential. Engaging children in age-appropriate play activities can significantly improve their willingness to participate in therapy. For instance, if you need a child to build endurance and strength, you might get them to the edge of the bed and encourage them to reach across midline for their favorite toy while weight-bearing on the opposite arm. Activities like popping bubbles can also be highly engaging and beneficial.

For infants, facilitating reaching for a toy in midline with arms extended off the chest is a common strategy. Proper positioning of toys is crucial; for example, instead of placing a mobile at the top of the head, which encourages head extension, place it at the midline to promote head flexion and hand-to-midline activities. It’s also important to ensure infants reach for toys with their arms up against gravity rather than just resting on their chest.

Communication plays a vital role in pediatric therapy. For nonverbal infants or babies, the tone of your voice, gentle touch, and gradual preparation can convey reassurance. Older infants respond to your demeanor, voice, and touch, assessing whether you are someone they can trust. Calming your voice can help soothe them and reduce anxiety.

For older children and teenagers, direct communication is key. They need to hear from you, not just from their caregivers, about what you are doing and why. Being honest with them and explaining the importance of therapy can help them understand and accept treatment. Engaging the family to encourage participation can also be beneficial. Parents need to hear confidence in your voice to trust you and stay engaged in their child's care.

Family-centered care is the hallmark of children's hospitals, where families are encouraged to be an integral part of the care team. Involving families in the healing process can be as simple as facilitating a grasp reflex or performing passive range of motion stretches with a medically fragile infant. Families of children with special needs often have valuable insights into what helps their child participate, and incorporating their input can be crucial.

Families may feel guilty if they cannot always be present due to work or other commitments. Providing them simple tasks, like recording their voice or decorating the room with familiar objects, can help them stay connected and involved in their child's care. Empowering families to participate and remembering to be flexible in your approach is vital. Ultimately, it’s about the child’s needs and the family's involvement, not strictly adhering to your plan.

  • Understanding families' needs
    • Must recognize that families often cope with unexpected or traumatic events
    • Children and adolescents are faced with challenges to adapt to significant changes (physically, functionally, cognitively, etc.)
    • Recognize that family members have a short amount of time to learn many new things
    • Families function in different ways and have different ways of coping
    • Occupational therapy practitioners support families throughout the process – admission, throughout the hospital stay, discharge planning

Meeting your patients and their families where they are is crucial. Families are often under immense stress, dealing with challenging circumstances, such as the loss of a loved one in a motor vehicle collision or mourning a child's death while planning a funeral and managing the care of other hospitalized children. Seeing their child hospitalized adds to their stress, affecting their ability to retain information, and they may need you to repeat information frequently.

Being patient and sensitive to their needs is essential, ensuring clear communication with social workers and psychologists to provide comprehensive support. As part of the care team, occupational therapy practitioners play a vital role in supporting families throughout the admission process, the hospital stay, and discharge planning, offering hope and assistance daily and weekly.

This brings us to our parent coaching model.

  • Parent Coaching
    • Being family-centered is a cornerstone of pediatric hospitals (Dudgeon, 2020), but at times, it is challenging for occupational therapy practitioners to deliver.
    • High patient-to-staff ratio coupled with a focus on fast discharge at odds with family-centered care.
    • Coaching is a strengths-based approach that encapsulates family-centered care, “enhances outcomes for families and reduces pressure on hospital systems” (Lee et al., 2022, p.212)
    • Coaching empowers parents to reflect on the performance and needs of their child and problem solve and come to strategies and solutions.

(Lee et al., 2022)

Pediatric hospitals recognize that family-centered care is a cornerstone of their care approach. However, coaching can present challenges, such as the availability of the family during the occupational therapy practitioner's working hours and language barriers that might arise, especially when using interpreters or Zoom, which can hinder the context comprehension and retention of information. Differences in teaching styles and values between the family and the therapist, as well as time constraints due to high patient-to-staff ratios, are additional factors impacting the success of coaching.

Coaching involves occupational therapists demonstrating to the parent and child how to complete a skill, such as safely transferring from bed to chair within precautions and then having the parent return the demonstration while providing necessary verbal and physical cues to ensure the patient's safety. This strength-based approach encapsulates family-centered care, enhancing family outcomes and reducing pressure on hospital systems.

Coaching empowers parents and families to reflect on their child's performance and needs, enabling them to problem-solve and develop strategies and solutions. As the family becomes more comfortable and the patient becomes more medically stable, the goal is for the family to be independent by discharge, fully utilizing the coaching model.

  • Parent coaching – model utilized in Lee et al. (2022, p.213)
    • Joint planning
      • Collaboration between family and therapist on what to work on and how, during and between sessions
    • Observation
      • Therapist observes the family’s performance of a new skill in their natural environment to support problem-solving
    • Action/practice
      • Therapist demonstrates strategies to the family in action, then the family practices the strategies
      • **This step is often missed in acute care
    • Reflection
      • Open-ended questions from therapists to family to facilitate problem-solving
    • Feedback
      • Therapist shares professional knowledge with family

(Lee et al., 2022)

Here's the parent coaching model Lee utilizes, which includes five essential steps.

The first step is joint planning, where we collaborate with the family to identify achievable goals. We listen to the family's aspirations and break down these goals into manageable steps. For instance, if the goal is for the child to return to school but has a TBI and cannot sit up independently, the first task might be getting the child to follow a one-step command while sitting at the edge of the bed.

Observation is the next step. Since the hospital is not the family's natural environment, it requires critical thinking to determine the needs of the patient in their own home environment. We aim to practice as close to their home environment as possible and simulate it to determine the necessary adaptations for a successful discharge. For example, our pediatric hospitals might not have the same shower or bathroom configurations as their homes, but we can simulate and determine what adaptations they need. In the hospital, we have grab bars; if they don't have those at home, we need to find alternatives, such as a sink they can grab onto, a family member who can assist, or other strategies to ensure safety when getting on and off the toilet.

Action and practice are crucial steps, though often practiced the least. This step involves practicing the skills necessary for families to feel comfortable and confident.

Reflection is another vital step, yet it is not always adequately practiced. We must ask families for their input and ensure they understand the tasks. It’s important to engage in reflection to confirm their comprehension of our instructions.

Finally, it is essential to provide feedback to families in a nonjudgmental and caring manner. While we want patients to be safe, we also aim for families to become independent, as we won't go home with them.

Interprofessional Care Team

  • Interdisciplinary (interprofessional) care is common and mandated by most regulatory mechanisms (Dudgeon, 2020).
  • Children and families benefit from wide range of medical specialists and professionals.
  • Interdisciplinary medical teams are dynamic in nature.
  • The occupational therapy practitioner may be a member of many teams and collaborates and communicates with various medical professionals.

(Dudgeon, 2020)

Your interprofessional care team consists of various professionals, and it's common and often mandated by regulatory agencies such as JCAHO (The Joint Commission) and DNV (Det Norske Veritas). Occupational therapy practitioners, physical therapists, and speech-language pathologists are integral to this interdisciplinary team. The team includes respiratory therapists, nutritionists, child life specialists, developmental specialists, social workers, and case managers. Children and their families benefit from the expertise of this wide range of medical specialists and professionals, ensuring comprehensive care.

  • May need to continually define and redefine the role of occupational therapy
  • Develop understanding of how other members of the team compliment one another in provision of services to the child

(Dudgeon, 2020)

I like to joke and say sometimes it's a good day if they know what OT is in the hospital. But out in the community we know a lot of people don't know what OT is.

And so it's an opportunity for us every day in the hospital to educate people from medical professionals to our families what OT is. Sometimes our families that have some understanding what OT might be if their child receives OT on the outside, whether in school or outpatient. But that looks very different in the acute care setting. So again, it's another opportunity to educate our families what OT means in the acute care setting to try to help them get home developing an understanding of how members of our team can complement one another and provision for services to the child, again, to help them with discharge. We're all working together as one big team to try to help that child get well and discharge okay.

  • Occupational therapy practitioners may collaborate with other team members in “team efforts.”
    • OT and PT collaboratively decide on intervention to promote gross motor and fine motor skills, positioning, and transfers
    • OT and nursing collaborating to identify routines for ADLs and support training in special care routines such as toileting or maintenance of skin integrity
    • OT and psychology work together to identify the best routine and approach to support participation in therapy and meaningful daily activities

(Dudgeon, 2020)

Occupational therapy practitioners often collaborate with other team members to enhance patient care. For example, OT and PT may work together to develop interventions promoting gross and fine motor skills, positioning, and transfers. OT and nursing may collaborate to identify routines for ADLs and support training in special care routines such as toileting or maintaining skin integrity. 

In the PICU, nurses, and other interdisciplinary team members are vital in helping OTs keep patients safe. For a patient who is intubated or on ECMO, mobilization requires the collaboration of OT, PT, respiratory therapy, nursing, and the ECMO nurse to manage all lines. Physicians are sometimes involved, especially when mobilizing an ECMO patient for the first time. In the NICU, OTs perform four-handed care with nurses to regulate the baby and limit stress.

OTPs also work closely with psychology and child life specialists to determine the best routine and approach to support participation in therapy and meaningful daily activities. This includes coordinating schedules, using appropriate language, and supporting the child holistically when dealing with the loss of function or a loved one. For instance, it’s crucial for OTs to consult with psychology on what to say or not to say to a child who has lost a family member in an accident, ensuring that the approach is sensitive and supportive.


So, hopefully, you have gained a clear understanding of the following learning outcomes: 

First, identify occupational therapy's role on the interprofessional team in the acute care setting. OTs play a vital role in collaborating with various healthcare professionals to provide comprehensive care, ensuring the best possible outcomes for patients.

Second, recognizing the skills required to work in the pediatric acute care setting. These include clinical reasoning, understanding lines and tubes, developmental knowledge, and the ability to adapt interventions based on the patient's medical and developmental status.

Finally, comparing and contrasting treatments or treatment approaches in various acute care areas, including ICUs, mental health, inpatient rehab, ortho, and oncology. Each area requires a unique approach tailored to the specific needs of the patient population, emphasizing the flexibility and specialized knowledge necessary for effective OT practice in these settings.

Exam Poll

1)What are the most common reasons children require hospital care?

Gastrointestinal and respiratory problems are correct (B).

2)What is the focus of intervention in pediatric acute care?

It is a and b. It's both preventing secondary disabilities and restoring performance.

3)What is an example of a secondary disability?

All of these things are correct.

4)The parent coaching model includes ALL EXCEPT:

The parent coaching model looks at joint planning, observation, and reflection. Assessment is not part of the parent coaching model as that is done before.

5)What is a TRUE statement about the interprofessional care team in pediatric acute care?

The answer is b. The occupational therapy practitioner may be a member of many teams and collaborate and communicate with various medical professionals.


Bailey, A., Chenoweth, T., Fisher, Z., Joannides, M., Watters, S., Mazzucchelli, J., Taylor, S., & Harris, C. (2022). Identifying suitable cognitive assessments for children and adolescents with acquired brain injury for use by occupational therapists in acute and Subacute Hospital Contexts: A scoping review. Developmental Neurorehabilitation, 25(7), 485–500. https://doi.org/10.1080/17518423.2022.2099031

Critical care and occupational therapy practice across the lifespan. (2023). Am J Occup Ther, 77(3), 7713410220. doi: https://doi.org/10.5014/ajot.2023.77S3003

Colman, J., Casto, S. C., Wisner, E., Stanek, J. R., & Auletta, J. J. (2020). Improving occupational performance in pediatric hematopoietic cell transplant recipients. American Journal of Occupational Therapy, 74, 7405205020. https://doi.org/10.5014/ajot.2020.04054

Dudgeon, B. J. (2020). Hospital and pediatric rehabilitation services. In J.C. O’Brien & H. Kuhanwck (Eds.), Case-Smith’s occupational therapy for children and adolescents (pp. 680-701). Elsevier, inc. 

Edelstein, J., Walker, R., Middleton, A., Reistetter, T., Gary, K. W., & Reynolds, S. (2021). Higher frequency of acute occupational therapy services is associated with reduced hospital readmissions. American Journal of Occupational Therapy, 76, 7601180090. https://doi.org/10.5014/ajot.2022.04867

Lee, P. X., Wong, T. C., Ng, P. Y., Yuen, H. C., Pontre, I., Craig, J., Taylor, S., & Hatfield, M. (2022b). Coaching in an acute pediatric setting: A qualitative approach to understanding the perspectives of occupational therapists. Physical & Occupational Therapy In Pediatrics, 43(2), 212–227. https://doi.org/10.1080/01942638.2022.2131500

Walter, J. C., Coleman Casto, S. D., & Gates, E. (2021). Inpatient occupational therapy management for a pediatric patient with COVID-19 and multisystem inflammatory syndrome in children: A case report. The American Journal of Occupational Therapy, 75(Supplement_1). https://doi.org/10.5014/ajot.2021.049224


Hunter, C. (2024). The role of the occupational therapy practitioner: Pediatric acute care virtual conference. OccupationalTherapy.com, Article 5713. Available at www.occupationaltherapy.com.

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cambria hunter

Cambria Hunter, MSGH, OTR/L

Cambria Hunter is the acute care supervisor for occupational therapists, physical therapists, and speech therapists at Phoenix Children’s Hospital. She has experience in various areas of pediatric practice, both in the acute care and outpatient settings, and has specialized in medically fragile infants, including infants in the NICU and CVICU. She recently received her Master’s degree in Global Health from Northwestern University.

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