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When ICU-acquired weakness is not preventable, or we encounter a patient that has not received the ABCDEF bundle, how can we start the rehabilitation process? What approach can one lone clinician use for initiating recovery or preventing ICU-acquired weakness? Physiotherapist, Lucy Sutton, shares with us incredible insight into ICU rehabilitation.

Episode Transcription

Kali Dayton 0:01
Hello, and welcome back. This podcast has been primarily focused on preventing and at least minimizing harm, such as delirium and ICU acquired weakness. For most patients, it will always be better to have a focus of prehabilitation rather than rehabilitation. We know that the ABCDEF bundle greatly reduces the rates and severity of these conditions in our patients. The quicker we implemented the this approach to care, the less harm patients will suffer, and the less work it will be for healthcare providers in and after the ICU.

But what about when it’s not preventable? Or we as individual listeners work in an environment or are treating patients that have not had the ABCDEF bundle applied to the process of care? What can we do in the ICU for patients that have developed critical illness polyneuropathy? What can we as individuals do to help start treating ICU acquired weakness even when we don’t have the support of a team to start the laborious rehabilitation process? Lucy satin joins us now to help explore tools and methods of starting ICU rehabilitation.

Lucy, thank you so much for sharing your wisdom on this podcast. Do you mind introducing yourself?

Unknown Speaker 1:56
Hi, so I’m Lucy, I’m a physiotherapist from the UK. So I’d be a physical therapist in the United States. I’m a rehabilitation specialist in a small community hospital, which manages the rehabilitation of patients who have had inpatient stays, which mean their mobility is not at a sufficient level for them to be able to go home from hospital.

Kali Dayton 2:24
And I’m so excited to dive into this with you because I have repeatedly thought if the ICU community understood what rehabilitation really entailed what that was like for patients that would move us to do everything in our power to prevent ICU acquired a weakness and seeing the rehabilitation side. And what physiotherapist physical therapists do to rehumanize patients really changes as appreciation for movement especially during critical illness during kind of telling us what a physio intervention is.

Lucy Sutton 3:03
Okay, so I think this is like a really important topic, because there’s a lot of myths and misconceptions about what physio is, and obviously here, I’m sharing my opinion, and that’s come from my clinical experience and training in the UK. So there might be some differences nationwide, but like, you know, even across the nation, and internationally, really.

So in the UK, the physiotherapy scope of practice is encompasses four pillars of professional practice. So the first pillar is related to exercise movement and rehabilitation. The second would be related to manual therapy and therapeutic handling. The third is relating to the use of therapeutic technologies and the fourth is related to allied approaches.

And in the hospital setting, what that means is that physiotherapist are situated in the building prior merrily to assess someone’s mobility and functioning, and to prescribe them appropriate exercises to improve them ability and functioning, and to get them to a point where they are safe to go home and complete their activities of daily living. So that could be making sure that someone is able to wash their hair, make themselves a cup of tea, climb the stairs, get to and from the sharps. It could be anything like that.

There is also an element in the UK that physical therapy encompasses what’s traditionally considered, I think, respiratory therapy in the United States. So there’s an element that in the UK we also look at lung function, but that’s very much from the perspective of movement and mobility is the primary driver of optimal lung function. And while we do manual therapies to maybe improve that, so we could do vibrations and cupping, so where you pat your hands on someone’s chest in order to mobilize secretions of someone who is immobile.

A British trained physical therapists in my experience would generally prioritize Exercise and Movement, and only explore what we would call a passive therapy, if someone was no longer able to move and mobilize. And so really, the situation that we are in as physical therapists is that our professional scope of practice is related to the prescription of exercises that promotes a demand on the body that then requires the body to adapt over time.

So in the same way that if you wanted to build your ability to do a squat in the gym, your personal trainer might advise that you do sets and repetitions of a squat. In the gym, in order to build your strength to do it, a physical therapist in a hospital setting is completing a physical therapy intervention if they if they are providing exercises and breaking down and movements in order and doing repetitions and practice of that in order to improve their ability to do a functional task, like a sit to stand. And what a physical therapy intervention isn’t, is the movement of a patient from a bed to a chair, where there is no prerequisites problem that indicates that this is going to be a different thing that requires a specialist intervention, if that makes sense.

Kali Dayton 6:47
Absolutely, I think there’s a lot of conflict over that here in the States as well, that physical therapists job is to get them to a chair or to the commode or you know, those mobility things, which if patients are severely severely deconditioned. Those can be dangerous tasks. But that doesn’t mean that that is physical therapy. That’s not a physical therapy session. That’s not your main objective. So you spell Do you specifically address that, that your job is not just to get them to the chair. And there’s always all this joking or memes or not so funny memes about nurses being frustrated that physical therapists leave them in a chair.

Lucy Sutton 7:31
Yeah, I’ve seen. Yeah, and now, there’s an element, I suppose that in a specific setting, so a patient that’s got a severe critical illness, polymyopathy, and they’ve been hoisted into a specialist seat, or pat slid into a specialist seat that’s required the addition of supports under their lap, so like a wing support to help keep them upright, then moving someone in and out of that seat might be something that requires a professional that has a degree level intervention, ability, essentially, in moving and handling.

But the reality of the situation is, is we might do that, because that’s safe. But that still isn’t really a physical therapy intervention or physical therapy intervention for that patient, it might be spending time doing exercises on sitting balance or gaining control of the upper limb so that they could do reaching, grasping, sitting. And it might be that our intervention is better served, getting the patient from the bed, to sitting on the edge of the bed, and back to bed again, and then at a later date in the day, it might be better for the patient, once they’ve had a rest and then be hoisted out and spend some time in sitting.

And obviously, I think all of that is about the ideal world. And there is an element that we have to work across disciplines that we have to support colleagues that are less confident. But I think what I really wanted to do in this podcast is to maybe empower people who are working in a setting where they feel unsure whether it is safe for their patients to get out of bed.

They’ve maybe only works with patients that are habitually nursed in bed, so maybe like a cardiac ICU or a neuro ICU where there’s not really a mobility culture. And if they’re sat there, thinking, “Well, I’ve been listening to this podcast perhaps and I understand that mobility is actually a life saving intervention. I’ve tried bleeping the physical therapist because I feel that I need some support. I’ve not got three but I still my gut instinct is still that I want to get this patients out of bed, but I don’t know how to know that that is safe.”

So I think That, that’s probably a really important thing to talk about is what actually is a physical therapist assessing when they first come across a critically ill patient, or even a patient that’s ready to be discharged to the floor that’s been vented been slow to wean, that has now wanes and we’re looking at discharging them to the floor, we’re thinking that then they’re medically very stable. But still, the we exist in assistance we exist in, “I’ve tried bleeping physical therapy, they don’t have availability, or they’re not, they don’t have a KPI that requires them to come to the ICU. But I still want to get my patient out of bed. So how am I going to do that?”

Kali Dayton 10:43
Perfect, because I hear that from a lot of podcast listeners, especially the nurses, where they’re saying, “I understand. I see it now and it haunts me. I know, I look at my patients that I see them atrophying. And I am panicked, and I’m desperate to help them. But I can’t always do especially during this staffing crisis. I don’t always have the manpower available or the expertise available. So what can I do?” What kind of interventions can such a nurse do to help improve or slow down the process of developing or even expedite the process of recovering from ICU acquired weakness?

Lucy Sutton 11:23
Yeah, so I think tthis is maybe going to be easiest to cover if I thought through kind of the physical therapy mindset of how we would go and assess a patient from a mobility perspective and kind of the priority of treatment. So if I had a patient that was previously independently and now immobile, so they didn’t use walking aids is a very out of the blue illness that has led them to ICU.

So very typical for our COVID patients, right, they’re typically in ICU, they were younger patients that had developed ARDS. And I had had quite lengthy periods of time in ICU. So I think the first thing that is relevant is to actually have a good understanding of the patient’s history. So understand that they were previously independently mobile, maybe have a look back through and see how long they have been sedated what the weaning process was like if they have been weaned, or if they’re still ventilated, whether they’ve had paralytics, and things like that, because all of those things will give you good information about how much mobility is likely to be possible.

And especially in terms of the COVID weakness, if we’re talking specifically about critical illness polyneuropathy, there’s a big association between paralytics and whether someone ends up very, very weak. And so that will give you good information and look back and see what the providers have done that have been in work before you. And then I think it’s really key to go to the patient. So there’s a number of things that a physical therapist would assess a patient’s ability to do in bed before they even consider whether someone is suitable to be getting out of bed, or the process of how they would choose to get them out of bed. So from a physical physical therapy perspective, in order to be able to sit, you have to be able to move your body against gravity in bed, so you have to be able to roll, things like that would engage your core. And you have to be able to maybe lift your leg against gravity, so we call it a straight leg raise. Or to do like a glute bridge would be really important it to assess whether someone can sit to stand. So that would be with both of the knees bent, can they lift their bottom off of the bed. So as the nurse you’re in a great position to assess these things, doing bed bound activities of daily living. So seeing whether someone can perhaps wipe their own bottom after using a bedpan, and things like that, that all gives you good information about whether someone is suitable for sitting, standing and getting up. Because if someone can lift their bottom to get a bedpan underneath it, if they can use their hands to wipe themselves, is there a reason why they can’t use their hands to hold themselves on the edge of the bed, and why they can’t use their bottom in the same way to stand to a supportive aid. So those would be the things that I would consider as if someone can meet that criteria. So they can roll themselves in bed, maybe with assistance of one, they can lift their bottom and use a bedpan and they can maybe wipe their bottom after using it. That is a patient to me that I would have no carbs as a as a nurse as a respiratory therapist, as a doctor, as an advanced clinical practitioner. I’m thinking why is this patient still In bed, I tried to create physical therapy to do the referral, they’ve not come. But that evidently a strong enough to at least be sitting, if not trying standing, I suppose

Kali Dayton 15:13
would you recommend that we even throughout the chemo care from like day one, that a patient be involved in these kinds of activities? I really appreciate the way you walk in ICU, we say, Can you roll over, and they roll over the whole themselves? And now I’m seeing that was helping keep them able to do those things by involving them asking them to do it?

Lucy Sutton 15:35
Yeah, absolutely. And I think it’s really important to consider the impact of how and you know, we’re all working in a very stressed environment. So we might just want to think I’m just going to click them over and get get my care that’s working with me to wipe the bottom, and then I’m going to hold them back. And then I’m going to go to my other patients. But that the problem with that is, it might be quicker for your first instance.

But the problem with that approach is that if this patient is a long stay ICU patient, that then means that this patient is being forced in the future of being reliant on the assistance of two people for personal care in bed. So you can spend that little bit more time with them saying, well use your arm to reach over to the bed rail and pull yourself towards it. I know it’s uncomfortable. I know you’ve got these lines in and things like that. But this will help you get out of there. And I think that really comes down to that informed consent and acting in a patient’s best interests, kind of approach that actually it might be uncomfortable to roll in bed.

But if a patient had full knowledge of the fact that rolling in bed and participating in personal care tasks, not only is more dignified in the moment, but will allow them to have their independence in the future, with less difficulties, surely, we would involve them in that. And there would be very, very few patients, I think that would say actually, I would prefer to sit here kind of as a as an object that is cared for very few people want that. And I would probably suggest that those patients weren’t referrals to other mental health services as well, you know, but so I would absolutely recommend that activities of daily living, empower patients, when they’re in their most disempowered state. And they also were a time saving measure for someone who’s working in an ICU. That is very under pressure.

If a patient can brush their own hair, if they could do their own suctioning, if they could wipe their bottom themselves or, you know, wash under their arms and give themselves as best they can a washing bed, pull their own pants up if they need to. These are all things that are continuing to allow a patient to have independence and optimizing their chances of being able to walk and mobilize again in the future. And that is all cared that, in my opinion, someone could deliver in an ICU where there is a very strong anti-mobility culture. Because it’s, it would be very scary to be a professional in a setting where you are the only one who thinks these things. And there would be a lot of people looking at you and you will be in a position of potentially people will be concerned, “But what if I’m the only one doing this, and then my patient falls, I’m not acting in the same way as the other professionals.”

But in this setting of doing tasks in beds that are related to independence activities of daily living, you are still providing care that will fit with your organizational culture, and is quality care that is harm reducing. And I think that is what I would advise anybody. Because you are doing the best you can. And if harm reduction is where your organization is at, then I think there is pride to be taken in harm reducing care if you can’t provide perfect care, provide harm reducing care and take pride in that. Because slowly people will start to see and you’ll get more people bought on that will say well, actually, it’s much easier now that patients rolling independently. I’m going to try that with my patient. And once you’ve got that colleague, you’ve then got someone to say, “Hey, do you mind helping me sit my patient up? They go, what are you sure that’s okay. And you go well, actually, they’re rolling in bed. I’ve tried bleeping physical therapy, but I don’t have availability, but the rolling in bed. Let’s just try it. If it doesn’t work, we’ll put him back to bed.”

Kali Dayton 19:37
What’s the harm? Right? We’re just so fun. tracheal tube, but the harm rates are so low. I mean, a lot of studies, it’s less than 1%. Less than Yeah, just so so minimal, that we know the harm rate for leaving them there and not trying to even set them up is far greater than any of the risks of the unplanned excavations and you A lot of patients fail, you’ll be surprised that they can sit up. And if they’re not able to if they’re having weakness, or they’re being impulsive, like you said, the beds right there, they’re still on the bed laying back. It’s okay.

Lucy Sutton 20:14
Yeah. And I think it comes down to that experience, make risk assessment. So So it’s about that acknowledgement that, you know, whatever setting we’re trying to nurse and rehab people in. So you know, and I really want to in this podcast, so I don’t work in an ICU, I actually myself have quite limited ICU experience, I worked a little bit during COVID in the ICU, and did a placement as a student, and then spent some time working with some of my stroke patients that were in ICU. When I was on the temporary register, we went and we had a stroke patient, err.

So I’ve got very limited ICU experience. But I think these concerns are actually wider than just the ICU. You know, in rehab settings, we habitually whether it’s from the floor, or whether it’s from ICU, meet patients that have been quite functionally disabled by their stay in a hospital, they’ve been institutionalized. They remain in pajamas all day, there’s a big campaign in the UK, about pajama paralysis in a hospital, that patients aren’t getting dressed into their day clothes. And I think there are providers that within these settings that feel, “I don’t know what I can do to reduce this harm, because I cannot deliver the care that I want to deliver. So what’s the point of even trying?” – and I just want to reach out to these people to say, “There is a point in trying even if the patient does still require rehab stay, if they’ve got up and got into a chair with the nursing staff, that rehab stay will be massively reduced, it would go from, you know, weeks to months, down two days, two weeks, and that is valuable and much more acceptable to the majority of our patients.”

And actually, in truth, we are reducing the mortality of these patients, you know, there will be the very occasional patient that maybe falls to the ground, but those patients will be few and far between. But if all our patients were nursed in bed, every single day of their acute hospital stay, the majority of them would end up with chest infections, they would end up with kidney failure, they would end up with a whole host of medical problems, that would be avoided by mobility. So just want to reach out to people in any hospital setting, to have the confidence to say even if all it was my patient is independently rolling in bed, you have achieved a great thing and you have reduced their mortality.

Kali Dayton 22:37
Because what you’re seeing, especially with COVID, survivors, probably it’s this critical illness polyneuromyopathy where they have not and then cannot even lift a finger. How long does it take to rehabilitate from that point?

Lucy Sutton 22:51
So I think it’s important to state actually there and I’m just going to get a study that I was looking at before we started. So it’s important to say actually, that not every patient with a critical illness polyneuromyopathy will actually recover. So this study, just going to find the name was a study from 2008. On the long term outcomes in patients with critical illness polyneuromyopathy is a big multicenter study. And it showed that actually, in critical illness polyneuromyopathy, only two out of seven patients will recover. And I can send you the link to that study if you want after we’ve done this.

So that’s an important Yeah, so that I think is probably the first most important thing to state that where you have such severe muscular damage from this weakness. So you said you’ve got that kind of my that weakness which is more proximal than distal it can be both sensory and motor last season. But more commonly a lot of motor loss. There is there is it is the case that not every patient will recover with that. So you might have saved that patient’s life. And but the rest of their life may, if they don’t receive appropriate intervention may look like them in nursing bed, requiring a long term stay potentially for the rest of their life. In a nursing home facility, what the rest of their life looks like, if they don’t recover is going to be potentially rose every two hours on a high spec press relieving mattress needing full assistance to feed, they may even not recover a functional swallow.

So it’s a really dark picture really, that where that recovery is possible. That recovery in my experience, and it is limited I bet like I’ve only been qualified for a couple of years, but that recovery would be going from bed bound to a able to mobilize with a frame like a high gutter frame or something like that. So very supportive walking frame. And with assistance, I think that it’s usually in my experience a sort of six week process. And there will be exceptions to that there will be people that recover quicker, there will be people that recover slower, but you’re talking a process of someone being hoisted out into a chair, building up their sitting tolerance, doing exercises in bed, so doing repetitions and sets, lifting their leg straight, bending and extending their knees, bending and flexing their ankles, rolling onto their side, doing straight leg raises in sideline just like we would in like a legs bums and tums type exercise class.

And doing hours upon hours of those kinds of repetitions. And it’s also the difficulty of learning how to hold a fork again, how to hold their phone, again, how to press a button. All of those kinds of things, those fine motor skills, a lot of them may be permanently lost. And a lot of them these patients will continue to, they might get to a functional level of recovery in six to 12 weeks, that gets them home with care at home. But the ongoing recovery to you know, be able to live a life independently, likely will not happen. If it does happen. They’re very few and far between. We know a lot of ICU survivors never get back into employment or into education. And they don’t get back to their previous level of function if they were retired. So I think it’s it’s a dark, dark picture to your case is a little bit.

Kali Dayton 26:45
In my mind, I’m hearing the survivors talk about what it was like to get up for the first time it was like stepping on glass or how extremely exhausting it was.

Lucy Sutton 26:57
Yeah, and not so thing isn’t it? It’s so significant. Some of the neurological changes that there are sensation changes, and they see even, there’s even a sort of problem with the kind of things like a lot of people finding that their heart rate will raise. So they essentially with a lot of people have got COVID acquired parts like postural orthostatic tachycardia, where the heart rate races, the blood posts their feet, because their calf muscles are so weak, the calf muscles can’t pump the blood back up. And then they end up in a state of collapse. So they have a syncope and for the patient.

So another patients that were we’re very, very concerned about mobilizing, but they’re the patients that we need to somehow find a way of mobilizing. So I think that process can start in any setting. If that process is a patient being slid on a pat slide into a chair, if it’s a nurse saying. So kind of in terms of building that strength, I think it’s probably time to sort of move on to understanding how we scale exercises and what kind of things we can say to our patients and kind of trying to simplify the miss some of that what people assume is kind of that physiotherapy magic hands thing. So if, if you want to think about a particular muscle that you want to get stronger, there are a number of, in order to get it stronger, we have to do different types of contraction, for particular numbers of sets and repetitions.

So a muscle you can contract it and it stays the same length, you can contract it and it will lengthen and you will or you can contract it and it will shorten it. And in the human body, what you have is different groups of muscles, doing different types of contraction at the same time in order to hold the body in upright to step into move. So if you wanted to bend your knee, the muscles that cross from your hip to your leg will be shorting and contracting. But at the same time in order for that to happen the muscles behind your leg so in your hamstring and in your bottom will be contracting and lengthening, lengthening.

So they are eccentric contractions where you can tract and lengthen and they are concentric contractions where you can tract and shorten. And the other type of exercise that you could do would be an isometric contraction, which is where you can track and hold in the same position. So the one that we would all do to do that would be a plank in a gym. That would be an isometric hold on your transverter abs and all of those abdominal muscles. So if somebody is very, very weak, so I’m talking someone cannot lift their leg against gravity, it’s flopping it’s a flat sibling. The first thing that we need to just do is practice those repetitions of those contractures.

So some things that would be a great place to start would be as a provider, you can put your hand under their knee, and say, “Push my hand into the bed.” And when you do that, so the patient’s lying in supine on the bed, they’re contracting their muscles in their calf, in order to push down into the bed. And those are those calf muscles, your big muscles involved in holding your leg that’s not calf sorry, quads muscles, if you’re pushing your knee into bed, you’re working your quads, those are the big muscles that are going to primarily keep a person upright.

So if I was wanting to start anywhere on a patient that had a totally flaccid, very weak body, I would be starting at their quads and I would I will be saying push the knee into the bed. And even that by reconnecting the mind to the body. So all we have neuromuscular connection through our mind to our body. And that’s part of what’s lost in kind of this hospital acquired deconditioning. And this kind of critical illness polyneuromyopathy, that is specially what’s lost. But it’s also kind of lost three stroke and that kind of neurological damage as well. That’s good.

And to be even that process of thinking about it is about moving, it is going to actually start that process of rebuilding, where you see that a lot is in a patient that has a very flaccid on post stroke, a lot of patients have better movement of their weak side, if you bring that side into their vision. So they might have lost vision, or they might be inattentive to this side of the body. But if we bring that side into their vision, they are then able to have some small contractions. And what we can also do then is we can provide a stimulus to that. So if it’s someone’s leg, it might be a case of tapping the muscles that I want them to move. So it might be push this muscle into my hands or push, Can you feel my hands onto your knee? Yes, push your knee into my hands. And so they’re connecting it, they’re connecting the sensation, it’s all becoming integrated again.

And so in bed, we would then look at “Can you get back there with no resistance moving your ankles? Can you start, perhaps with a sliding sheet under the heel?” Can you start getting them to bring their heel towards their bottom? Again, even if you have to take some of the weight of the knee out. So the leg is very heavy, it’s going to be very flaccid, even if you had to physically hold some of the weights. And they’re just starting to contract to get that idea that that knee is designed to bend it’s designed to move and like a lot of us that have got experience of working in very sedation-heavy ICUs will have had experience of passive range of motion.

And this really is the same principle as a passive range of motion, but only the patient is awake. And what you’re essentially asking them to do is to join in. So even a patient that has a totally flaccid limb, you can pick up and move their knee in the same way you always have done for passive range of motion. And you could say to them, “Can you feel me moving your knee?” And they will often say “yes”. And then can you say, “Can you join in?” and over time. So you might have to do five repetitions and you’ll feel the muscles start to switch on. And the leg will go from a heavy blasted limb into a lead into a leg where they are taking some of the weight of it with their muscle strength. And it will become lighter in your hands. And it’s quite an amazing thing.

I’d encourage anyone to even you know, it’s a again, it’s a very safe intervention. These patients are in bed, they are safe. They are patients that you understand their medical history, you know, it’s safe to start moving them. This isn’t a leg that’s waiting for an operation. This is a patient that is you know, at the point where you think that you want to get them going again, whether that be on day of admission or whether it be day 50 They are in bed, they are safe, and you can pick up their leg and you can encourage them to start moving. So they’re doing these very small contractions and starting to take the weight of the limb.

So you’ve got those isometric contractions. So those things like putting your hands onto their knee and getting them to push their knee into the bed. We’ll call it a static quad. You could put a pillow onto their knee and get them to squeeze the pillow. Start working those quad muscles in there in a range. Get them to start doing things like so they might not they might be so weak that they can’t roll in bed but if you help them get there, get them over on their side. Can they then engage He wants some of their weight is taken. So we’re really thinking about gravity. And where we’re using gravity in these movements to either help us make the movement easier.

So getting them all in supine, where the majority of their body weight is taken by the bed, or whether we get them on their side. And they’re starting to act a bit more against gravity. And now we can move on. And over time, if someone could do static quads, if they could do in a range quads, you might say, tell them to try and straighten their leg, take a big breath in to feel their core, fill their core muscles, and say, say take big breath in, hold it, and then try and lift that leg off the bed and doing repetitions of that straight leg raise is going to be probably the best harm reduction that anyone anywhere working with a patient who is in bed can do in order to help a patient meet a goal of being able to stand and being able to walk.

So we’re just encouraging everyone to think back to the fundamental things that the human body is built to do. So we have central patterns of of different things that are fundamentally important to being human. So breathing is one of them. We know that when a heart pumps we have to take big breath in and that’s pumped all around our body that’s in the brain that’s deeply wired, we call it central pattern generation generated. And walking itself is also considered to be central pattern generated as is the urge to swim. So if you fall in a body of water, we haven’t, we have an instinctive urge to tread water, don’t we? What other things can I think about the instinct to put your hands out if you fall.

So in physical therapy, anyone that’s worked with pediatrics will have the experience of working with children with cerebral palsy that might have a heavy poetic side, that if you’re holding them holding a baby with cerebral palsy, you can provide a stimulus that makes their brain feel like they’re falling, then they will engage their hemiparetic side, to put themselves out to fall despite them having a weakness in that side. So it’s about that understanding that actually, we’re building up strength, and movement. And this is all stuff that our brains are hardwired to do above almost everything else.

So and about having that confidence that you know, this patient is very weak, it’s not appropriate at the moment. But when it is appropriate, it’s going to be obvious, because this patient will be able to roll they’ll be able to lift their bottom, there’ll be able to lift their legs, and we can sit them up, we can see that they’ve got sitting balanced, if it doesn’t work out, we can put them back to bed. But if they’re sat on the edge of the bed, and if they can lift their legs against gravity, if they can match, then they can stand, if they can stand that with minimal assistance, maybe the help of one or two, too afraid if they can stand they can walk. And it’s thinking about it in that stepwise way.

So I’m not getting a flaccid, telling everyone to get a flaccid very weak patient up. What I’m telling them is to think about what are the prerequisites to being able to move so if someone can’t lift their leg against gravity, they’re probably not suitable to be standing, because lifting their leg against gravity in bed is going to be easier than standing. But if they can’t lift their leg against gravity, rather than saying, “Well, I can’t do anything for that patient.”- If we’ve got time, we can encourage them to think about pushing their leg into the bed, we can explain to them that if you’re able to push your leg into the bed and have a goal of lifting your heel off the bed, then that’s going to be more reason for me to be able to bleep physical therapy again and say, “I’ve got a patient that’s ready to stand. I’ve been working with them. They weren’t able to straight leg raise a few days ago, they can now straight leg raise, they’re now rolling in bed, I really think they can stand I really need your help. ”

You know? And if if you’re don’t have time, or you don’t have the capacity, can you point me to someone who can is the occupational therapist free? Are they able to help me and and kind of taking it like that really, that actually if your patient isn’t meeting a criteria for a physical therapy referred there are things that you can do to get them there. And these things are say, you know, a patient is in bed, they are safe.

Kali Dayton 39:22
And the bed exercises I’m just thinking about family members that have reached out to me and their loved ones are in that very similar position where they’re so weak and maybe they’re waiting to go to LTACH they’re just not being rehabilitated and the family is desperate, willing to do whatever are those the kinds of tasks that we can teach family members that they continue while we’re not in the room?

Lucy Sutton 39:45
Absolutely. Absolutely. And I think that’s there’s an emotional thing that’s really understated there that you know to be doing exercises in bed with your loved one helps you feel in control of what is the situation where A lot of control has been taken away from you, you know, you might have been married to this person for 20 years, you’ve always been able to help them through every live crisis. And now you are reliant on somebody else to get them through that crisis. But actually, if that gives you some, that is a very valuable use of a family members time, if we’re going to advocate for visiting, if we can be saying that visiting is going to allow patients to be having bed exercises where they need prompting to do it, or where they need physical assistance to do those bed exercises.

It’s going to reduce their length of stay, then actually, it’s about that risk reward balance, isn’t it that that visitation isn’t without its risks during a pandemic, bringing more COVID onto a ward. But then we ask those questions over the fact we’re a COVID. Ward anyway. So what what is the harm of a potentially COVID positive patient coming to a COVID ward. And if we’re not a COVID Ward, can this risk be mitigated by asking people to test asking people to mask up and wear the same PPE that we’re wearing to come to work, if this is going to reduce this patient’s length of stay and lead to better outcomes, is the reward of that’s better than the risk of them potentially bringing an infectious disease onto the world.

And it’s not a decision for me to tell people how to make from a distance from my little community hospital. But it’s a decision that I think everybody has autonomous registered professionals can advocate that these are life saving interventions, that we potentially do not have the capacity to deliver them, because we’re potentially looking after for patients. And actually, it is critical to that patients stay that their family member can come and help them do bed exercises, and that is going to get them out of the ICU and free up that bed for the next patient. So that’s kind of the if I was arguing that as a professional, that is the phrasing that I would use. It’s it’s never about beds. It’s always about what’s best for the patient. But the reality is we exist in the system that we exist in this is better for the patient. And it has the added benefit of being financially a much better idea as well.

Kali Dayton 42:16
Absolutely. And Chris Perme back in episode 30, something and she mentioned that “Mobility is everyone’s job”, but she also, I can’t remember what she said. She said she gives patients assignments of using either resistant bands or doing leg raises as prevention, but things that the patient themselves can do when no one else is in the room. Because you can’t have someone working with them around the clock. But if they’re motivated, yeah, absolutely. Families can keep them on task. Families can say, Okay, raise your legs. Okay, we’re doing this. And when we educate families, then we have a whole nother workforce that’s available for just that patient to prevent that harm, as well as rehabilitate from it.

Lucy Sutton 42:59
Yeah, absolutely. I completely agree. And I think it’s also about that, that realism that if if this patient was previously independently mobiles, so they were maybe previously getting in their car driving to work, parking in a car park, walking three flights of stairs to get to their job, they would maybe after work, habitually go to the gym, or play golf, or go to the shops, this patient, their baseline mobility is probably walking between three and five miles in a day. So actually, even with a high level of critical illness, and you know, having been very sick, there is there is unlikely to be that much harm that is going to come to this patient by doing sets and repetitions of dices.

And actually, that it’s more likely that these exercises are going to be beneficial to them. And again, reiterating to family members that they can stop the exercise at any time, you could tell a family member that look if their heart rate goes above this, or their oxygen level drops to this, you can stop the exercises and come and find me I will be over there with this other patients. And so you can really safely net your intervention like that. It isn’t a case of me just telling people to just go and do exercises that they don’t know how to deliver. It’s a case of actually movements is normal for humans.

But we’re in a situation where we’re very frightened of it. being frightened is okay there is an element of risk. But that risk is safety nettle. If we’re in bed, we’re safe. From the edge of the bed, we can go back to bed, and we’re only going to mobilize people off the bed that we’re sure we’re going to be able to stand on those patients that can stand out are patients that can lift their bottom to get onto a bedpan and their patients that can lift their legs against gravity and those patients with assistance He’s going to be able to stand.

Kali Dayton 45:03
That was a great assessment tools. And your perspective of trying to rehabilitate these patients after the ICU is so valuable. I, I just repeatedly have thought that if all ICU clinicians rotated through the rehabilitation process, it would really impact how we approached an early ICU admission and what we were afraid of. Were so yeah,

Lucy Sutton 45:28
I yeah, I think it goes back. Yeah, it was so afraid of mobility. But actually, you know, I work in a rehab setting, I’ve got the same level of qualification as a physiotherapist or physical therapist, there’ll be we would be working in an ICU, we have done the same degree. And I think it’s really important to remember that perspective that actually and as a nurse as well, there are nurses in our tack or in rehab settings, that immobilizing these very weak patients, they might be hoisting them into a bed, they might be mobilizing them by using a standard like a Cyrus steady or a cricket or something that you can pull up to to stand and then sit back down again, they’re often nursing at really much higher ratios, then what we what ICU clinicians are nursing app, and they are managing it.

So there is a question that if they are managing it, and then managing the risk, we need to ask ourselves, if we step into an ice ICU, what is different about my location? So they might be ventilated. But is ventilation a reason not to mobilize them? I wouldn’t say so there might be certain circumstances, someone that’s got, you know, unstable intracranial pressure or something like that. We might not want to do that. They might be sedated. But we all our autonomous professionals that can ask questions about the validity of the sedation, and again, that sedation might be valid, they might not be able to oxygenate with mobility. But you could ask the question, why are they sedated? And the answer could be well, because they’re ventilated. So he could say, but those two always have to come together.

Kali Dayton 47:11
If we just ask that question. And that’s why I think LTACHs probably probably laughs at us and say, “We have patients intubated, sometimes on a higher ventilator settings, and what that patient is that in the ICU, and yeah, we’d have them hustle.”

Lucy Sutton 47:25
And these patients are sitting, they’re getting in a shower, they’re helping get themselves dressed, they’re stepping often, and they are rehabilitating on these like crazy ventilator settings, that actually we insert and organize organizational cultures, people are uncomfortable to mobilize people. And again, we’re as an individual, you can start a culture shift. But you have to be willing to work for I think, a long time, or you have to be very good at your people skills to get that buy in. But you can start a culture shift. But there’s a saying in the UK, “You cannot take on city hall”. So that’s that idea that actually the whole organization is against you. The chances of you changing the whole culture in one go like that into what you want is very small.

But these small changes of bringing family members to do bed exercises with patients to think actually, I’ve tried believe in physical therapy, but I can’t get through, they can’t get back to me. They don’t have time. They’ve told me don’t come and see this patient in four days time. That’s their KPI for their assessments. They’ve told me all of these things. And I’m still looking at a patient, that constraint leg race, they can sit on the edge of the bed. If this patient was in a&e, I would get them up. And I think that’s another that’s a I think, go thinking like that as well. From a physical therapy perspective. I often in rehab, my first thought is, “If I saw this patient in a&e, what would I do with them?”

So they’re in a&e? At the moment for me and rehab. They’re medically fit or they’re medically optimized in order to come to rehab. So if I had to get them home from hospital today, what would they need in order to go home? And those patients I think, “Well, they can straight leg raise, they can roll in bed, I’m gonna get them up. So they can sit on the edge of the bed. I’m going to put a frame in front of them and see if they can stand to the frame. If they can stand to the frame, can they wait shifts? So can they shift their weight weight from one leg to the other? Can they stand on one leg? If they can do all these things they can walk is they can walk the question is why are they still here? And why are they not at home?”

And I think it’s we’ve got a big move in the UK at the moment is what’s called “Home First”. So it’s a national strategy about delivering care in a home setting first so if a patient is so we we talk daily about what why a patient is still in hospital? Can their rehab or medical goals only be met by being in hospital? Could their general practitioner or family doctor manage their medical needs? Could they be looked after at home with carers bobbing in and out of the house? Could we have physical therapy go into their own home? So we’re asking those questions all the time. And I think internationally, that’s also a good standard to look at something. If this patient was in a&e, what would they need to get home today? Would I mobilize them? If I saw them in a&e? Knowing what I know about how he works? Would I do it? If the answer is yes, then you can do it in any other setting?

And if you were to get them home today, what would they need? And if you think well, actually, they’re still in hospital, which is a 24 hour care setting. But I am rolling them from side to side very easily by myself, they’re evidently participating in that, they’re evidently able to lift their legs up, because when I give them their trousers and tell them to pull them up, when I’m getting them dressed, they’re able to lift their bottom and pull their trousers up. So actually, if they can sit, if they can stand from a mobility perspective, they’re quite good. So they need to really be having medical reason to reside in hospital. You know, before I started thinking about, well, how are they getting out of here again, so that that whole kind of culture that thinks about discharge from point of admission.

Kali Dayton 51:24
That’s why this podcast is called “Walking home from the ICU”, because that is, that should be the ultimate goal. And one of the main barriers is because of the lack of mobility and weakness that develops because of it, you know, we can develop lots of medical complications while we’re, I say “rotting in bed”, and the to an LTACH or rehab. But primarily, it’s the care required because of the weakness. And so we all have that goal of having that patient walk home from the ICU from day one, that will influence yes to do whatever is in our power in that moment to preserve their muscle, their function, their brain.

And then if unavoidable circumstances that occurred in which they did develop that kind of deconditioning, and weakness, and critical illness piling on my apathy. You’ve given such good tools to how to start, yeah, on that rehabilitation journey, because every day that they’re they’re waiting for rehab, waiting for LTACH, waiting for their sepsis to resolve or whatever it is, more days and more increased risk of, of death. So an ICU may think, “that’s not my job, I’m just trying to save their life for the moment.”

Whereas you are pointing out that this is part of saving their lives. And so you’re catching them on the back end, trying to clean up the mess. But if we shared that information, that perspective, and that even that skill set–it is a skill set, ICU providers are not, we’re not trained to mobilize patients or to even talk to patients, you know, it’s just not part of the skill set that’s been in the culture of the ICU thus far. But that doesn’t mean that we can’t develop it. We are all qualified clinicians, and we’re malleable, we’re educated, we’re able to learn more. And as we do that, yeah, we’re gonna provide better care and have a totally different environment and outcomes for our patient and workload for ourselves.

Lucy Sutton 53:12
Yeah, absolutely. And I think that’s the thing is, it is an ICU or an acute Ward setting where a mobility culture is taken on by everybody is a setting that provides a lot less work to start. So I, I’ve been in rehab settings where all the patients have had Zimmer frames with trays on and they go and get their own lunch. So you know, so actually, you don’t have staff running around delivering lunches to every patient. You know, these patients can get themselves up and go to the toilet themselves. I would ask why they’re still in hospital.

But it might be that they’re waiting for care or for adult patients, or adaptations for home perhaps, or something like that. But if these patients are doing these things independently, so even if they’re rolling themselves onto a bedpan, that is only then taking one member of staff to put that bedpan onto their bottom, it’s not requiring one to roll them on one to see the bedpan. If they are able to pull their trousers up. It’s only requiring one member of staff to do their bed bath, because that’s required one person to do the bits that they can’t reach, and to get everything in place to a point that they can reach it, but then they’re able to do it themselves. So mobility is not only a life saving intervention, it is a time saving intervention. And quite frankly, it means you see your patients get better, which is a hell of a lot more fun coming into work.

Kali Dayton 54:39
Oh, absolutely. That’s been part of the moral injury, which we’re gonna have a whole episode on that and, and to how sedation of ability has played into a lot of the COVID burnout and the trauma that we’ve experienced from those bad outcomes. So, Lucy, thank you. Yeah, welcome knowledge. I’m so grateful for all your expertise and your support for the podcast and the IC community. Thanks for being Going with. Keep us posted on all your excursions to schedule a consultation and connect on social media, as well as find supportive resources including case studies ebook episode, transcripts and citations to research, please visit the website www dot Dayton ICU consulting.com

Transcribed by https://otter.ai

 

 

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