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Individuals and teams are transforming patient outcomes through the adaptation of the ABCDEF bundle. Hear a compilation of their inspiring successes in this episode!

Episode Transcription

The past few episodes have been heavy. Obviously we have to address the challenges we face and the damage being done to patients. Yet, we also need to focus on the incredible good we can and are doing!! This episode is dedicated to successes.

A few weeks ago, I was on-site for a gap analysis with a team. I was touring the unit to understand where they were at their culture, equipment, culture, beliefs, and sedation and mobility practices. I noticed a patient was on 50 mcg of propofol. He was a large man- probably over 300 lbs on a PEEP of 16 and 100%. The team told me he had overdosed on fentanyl and Xanax the day before and had been intubated overnight for severe aspiration pneumonia. He had been “agitated”, so they had to increase his sedation. Although the order was for a RASS of -3, he was a -5 at that point. “

In discussion with the team, we asked, “Why was he agitated?”. I suspected that he was potentially withdrawaling from opioids and/or benzoidazipines. I explained that it was valid to be concerned about his high ventilator settings, his behavior, and safety of the staff considering his size and drug history. Yet, if we kept him deeply sedated, he would quickly develop delirium and ICUAW, which would create more risk for him, and more risk and work for the staff when they had to care for him for days to weeks longer, use extensive equipment and personel to later try to mobilize him, and try to deal with confusion and agitation from delirium. His lungs would take much longer to get better and his settings would continue to remain high if we did not mobilize his secretions, allow his diaphragm to drop with being upright, and caused him to have diaphragm dysfunction under propofol.

We started scheduled oxycodone and klonipin down the feeding tube. Once that was absorbed, sedation was turned off around 3pm. He remained a RASS -5 for perhaps over 6 hours after that.

Had we not asked questions, he would have remained on 50mcg of proprofol until then next SAT in the morning. With his obesity, the propofol had already quickly accumulated in his adipose tissue, and so it would have taken far longer for him to metabolize that sedation if it had continued without reassessment.

The next day he was awake, writing on a clipboard, and ready to mobilize. On a PEEP 16, 100%, his sp02 was barely 90%, yet there was no real harm by seeing how he did. When he sat up, his anxiety improved and his saturations increased to 94%. I left them on a Friday morning, and he stay awake in the chair all weekend. He was extubated on Monday. This was a huge success for the team and eased their journey with this patient significantly. Those nurses that were nervous are now sharing this experience with all of their team.

I want to share with you incredible stories many of you have sent to me over Instagram over the years. There are a lot, so I will jump right into them.

“I was so proud of myself for starting something positive this morning. I’m in a COVID ICU that LOVES sedation. Patients comes in from the ED and was already on propofol, versed, and fentanyl. I moved her from the ER stretcher to my ICU bed and woke she woke up and started coughing. Iwas able to get that under control and coached her through everything. She had no clue what was even going on. She had an initial ABG with a pH of 7.1 and co2 of 101. Once she knew she had a breathing tube in and her arms had been restrained, she was so calm. I oriented her and told her that her family knew. I left with her on minimal sedation and threw the versed out. The doc would not give me precede, but it was a start. Day shift was able to talk with her and realize she didn’t need sedation. I hope it’s the start of a trend with this patient and someone doesn’t come in and sedate her. Fi02 100%, PEEP of 14. “

“I started a new unit today on a COVID ICU. I told my preceptor that I’m big on as little sedation as possible and walking patients even if vented. She responded that we aren’t able to do that with our folks. I had one extubated within 2 hrs who was previously “unresponsive” after the prop wnt off. The other made it into a chair around 1300. On of the PTs asked me if I had ever heard of a program called Walking Home From the ICU and that she highly recommended it. Thought you my like that part. “

“I had a patient the other day who wasn’t synchronous/double triggering with the vent. I had the perfect team that shift. The RT and PA worked with me. We DECREASED sedation and adjusted the vent for rthe patient, and guess what? He did amazing. Great volues. No restraints, talked him through everything I was doing. He ended up getting extubated on the next shift. Before that he was intubated for 5 days on and off prop, etc. I am continuing to feel stronger about advocating for less sedation on my unit. I know we haven’t talked in a while but I just wanted to let you know I’m still 100% in this movement for better ICU practice. “

Response to a post about communication- “I actually started doing this with a patient in ICU who.started waking up yesterday after a month! He really appreciated being heard and it was so good to understand him better. “

“Love listening to your podcast and learning! I wanted to keep propofol off on a patient that is intubated for respiratory failure tonight. He’s alert and following all commands, writing sentences, and typing on his phone. NP walks in and sees him writing sentences to me and says “He needs rest.” I stared that he was doing well off of propofol and was only requiring fentanyl for pain r/t recent chest tube placement. She said he needed to rest and to turn sedation up. I offered melatonin instead in hopes that we wouldn’t have to sedate. I’m not well versed in what you all succeed in, but I am learning. How do I offer my thoughts without coming across as a know-it-all all? “

“People do not like change or going against the norm/grain. Very sick patient on triple pressors, insulin drip at 65 u/hr. d20, d5 bicarb, and I have them off of sedation and following commands. I’ve oriented her and made her aware of everything. Melatonin ordered last night and awake this morning with lights and tv on morning news. Family at bedside and we are doing range of motion. I LOVE THIS!!! — A nurse walked in and said, “Why is she off sedation?” and before I could speak she said, “if I ever have a breathing tube, I better be sedated.” – baby steps. “

“I literally walked a patient 1,000ft the other day and the days previous note from PT said something along the lines of, “Patient receiving dialysis, will check back.” Never checked back. I walked him and literally his success cured his depression instantly. He was able to see he could actually do it. He had been super down and negative and BOOM- he was happy-go-lucky. “

“I love when I get patients were I can strut my stuff! We intubated a patient two nights ago that was already struggling with delirium. Intubated and bronch’d. After the bronch, I asked for precede. Weaned propofol and had him on 0.5 of precedex the past two shifts. Normal sleep cycle at night and lights on with the morning news. I educated family on your podcast and what my goal was. Gah, it feels good! Family was literally like, “wow, this is an amazing concept!” Every patient I get to do this with I always want to bring in your podcast. I’m not walking intubated patients yet, but I’ll get there one day!”

“One of our PTs. She came from an academic center where she worked only in critical care. She started with us just as COVID hit. Her mentality from day 1 was, “Let’s get them up!!” And with our ECMO pt, the biggest barrier was getting CT surgery’s approval. Once they felt like we could do it safely, they gave us the OK. It was MAGICAL seeing a patient sitting in the sun while on ECMO. OR doing laps with his entourage. We all felt so energized and full of purpose. Thank you so, so much for all you do! Know the amazing ripple effect you’re having. “

“When my intubated patients are awake, I have such an easy time understanding what they need. Whether it’s needing to use the bathroom, wanting to be suctioned, feeling anxious, etc. It’s always so much easier to communicate. When I first started diving deep into this, I started noticing that deliriuous/confused patients had such a difficult time understanding what was going on. Then I began realizing that patienst I was waking up after coworkers had “snowed” them, just need constant reassurance and re-orientation. Once they were awake and lucid, the confusion about why they couldn’t drink water, or why they had a breathing tube in became clearer. I often tell patients when I first wake them up not to get too stressed about having a hard time communicating at first. I tell them it can be really stressing not being able to clearly tell me what they want. I love involving family at this point because they know them best. Whether it’s using the whiteboard or picture board, once they are able to communicate, I notice anxiety and agitation decrease immediately. “

Another commenter said,
“Yes! Especially because they don’t understand how bad the “norm” is. One of my post rewarding moments was when a family member remembered me and said she was surprised the first day I met her and her husband saying “we are getting up today”. Other people who cared for this patient ended up following suit which was awesome! But it was an amazing feeling to be the first one. She was nervous (her husnbad was on ECMO, etc) but he did amazing. I have a post on that patient in my Instagram. His PT/OT at the rehab said they were shocked at how much he could already do! I watched him walk up stepts to the bus his family rented to take him back to Florida without assistance. And I was so happy. I know we still could have done even more with him- but we have to start somewhere. Our units is very stuck on sedation and immobility so that experience helped to solidify how important this is. Thank you for all your dedication and information. “

“Rounds this morning:
Attending: “We’ll keep her on the fentanyl drip for pain”
New Grad being converted to the ways of no sedation: “She hasn’t complained about pain for me, but you want what else works great for pain? ….tylenol.”
Now that she’s awake and can report that she isn’t in pain so when we back in, we wasted the fentanyl. I was like, “YAAAAAS GIRL. WAKE EM UP!” “

“Literally having an emotional breakdown in my car about this right now. My patient made an honest to God MIRACULOUS neuro recovery and we worked so hard to get her off sedation and sleeping last night. This morning I had her up on the side of the bed while on the vent and she was so grateful to be out of restraints she just hugged me and cried. Totally oriented, even using sign language to communicate. The first thing the day shift nurse says? “Oh my gosh, where are her restraints?”. I explained the situation and stressed the fact that she was ready to do an SBT. This conversation was at the bedside, with the patient (who was interacting with us). After I left, I realized I had forgotten something and went back only to find the nurse I gave report to pushing fentanyl and putting on restraints. My patient looked terrified, confused, and most of all, betrayed. I can’t get that image out of my head. I haven’t stopped crying.

I ended up getting a very trusted attending involved along with the nurse manager. I understand these are scary situations for nursing, and it’s pretty high risk, but woah. That was horrifying to watch. I’m also coming to realize that with these patients that I’m taking off sedation on the vent there’s kind of a “golden window of opportunity” to either extubate ot trach them before the ventilator complications start coming up. Which is what’s so upsetting to me. She was doing so good, and she wasn’t ready to walk by any means, but she’s a human being. She has rights. This is another one of those small community hospitals. And you know how skeptical I was about all this stuff starting out, I honestly felt like I was toeing the line of being hostile at first because the idea was so scary to me. But the research is there. And the first time you see a patient awake on the vent and just THRIVING, like…. You can SEE them healing? IT is SO magical. Ventilators with ALWAYS be necessary, but they don’t have to be permanent, ya know?”

“Context: My intensivist rounded at 2am one day and my patient said she wished she could play in the snow. So me, RT, and the tech walked her outside on the vent because HER ORDER SAID UP TO THE CHAIR ADVANCED AT TOLERATED, but when the intensivist came around and saw the empty bed he had a heart attack and thought she died and we had taken her to the morgue.

He found out what we were doing while we were making snowballs (I had a spare pair of half gloves, and she stayed in the doorway so her feet didn’t get cold) and he came running down and was like, “this is not what ‘advance as tolerated’ means” and my patient freaking GOT HIM with a snowball. Fiesty little old lady. Best night of my life. “

“Also MIND BLOWING WHAT HAPPENS WHEN YOU INTUBATE AND DON’T IMMEDIATELY SEDATE AFTERWARDS. Holy Dang. So much easier to have patients who don’t need to be reoriented after sedation than it is to wake them up from sedation. “

“My intubated ICU patient tried to tell us we should incorporate swimming into therapy. “Whats the worst that happens? I drown? I’ve got a snorkel built in!” “

“Also something I saw recently: Patient fond down in the street, awake, flailing, struggling to be sedated. I came to get report and I ask the patients what’s wrong and they point with their mitt at the meds and I was like, “alright, I’m going to let you write but don’t pull this tube” and all this poor patient wrote down was “RISPERDAL” all in caps and which point I said out loud, “OH SHOOT”. 12 hours later we had a calm unsedated patient. “

“My landyard may have all these drug n ames on it, but I’m super proud to say I didn’t use any of htem today! Instead, I weaned sedation and stood my vented patient out of bed! Mobilization > sedation. “

“My team just got out 3rd patient up to the chair! (77yo female, vent day 6, history of lung cancer with resection and current pneumonia). I had her the past 3 days. First day I worked n getting sedation off and controlling anxiety. Day two, sat at the edge of the bed but required max support to sit upright. Day three, could hold herself up right but quickly tired out and was able to remove restraints. Today I am off, but my coworker who is part of my small mobility group has her and got her up to the chair twice! Still intubated but each day tolerating longer SBTs! She says she can breathe better sitting up. Imagine that. “

“That patient got extubated today (after failing 4 breathing trials)!! We had her up to twice in chair yesterday but her weaning index was borderline and still having low tidal volumes, so our Dr thought she needed one more day. This morning my coworker got her up at shift change, they did her breathing trials, and the tube is gone all before morning rounds!!

Everything makes so much sense! She was able to clean her mouth and suction herself, use the bedside commode, pick music on her phone to listen to, Facetime family on her own and just wave/gesture to them, let us know her needs, etc. And she finally slept a full night sleep because we physically tired her out. Not chemically closed her eyes! “

“I also took care of another man who had been intubated/extubated 3 different times during the past month on our unit (next intubation would have guaranteed him a trach). Almost 500 lbs- took 4 of us to get him up to the chair on the first day (without PT) and by the next day was a strong 2 person assist! Everyone was so surprised to see him sitting up in a chair. Finally starting to feel like I can make a difference in peoples long term outcomes! “

“Today I was finally able intubated (day 11 on vent) patient stand at the bedside! “

“We seldom do sedation… except for ARDS lung protection or neurological symptoms control.”

“We have started a project in our ICU to work on mobility. WE have been mobilizing more and more patients on ventilators! It is so inspiring to see. I had a patient all week intubated, no sedation, no restraints. New diagnosis of myasthenia graves so very weak but able to stand up with PT/OT every day and sit edge of bed for 15 minutes. She was totally in control of her care still. She had push doses of fentanyl if she needed it but she decided when/if she wanted it. Incredible and so inspiring to know we are making a difference for these patients. I’m also precepting. “

“Critical care OT here! Had a patient that was intubated/sedated for 8 days, extubated, then 30 minutes later reintubated planning trach/PEG to LTACH. 2 doctors said “NO” to turning off sedation and therapy involvement. I finally found one that would hear me out. Day 1: sat edge of bed, O2 better than it had been. Day 3: Standing. Day 5: Walking to chair, extubated. Day 8: To regular floor walking 30 feet. Day 14: Discharge home. Family was eternally grateful. All it takes is one yes to change minds! “

Heidi Engle:
“A very good ICU rehab day- all 5 of my patients on ventilators out of bed, 4 of 5 walked down the hall with family assisting me. 5th patient on vent dancing in room with her daughter. Such a relief to have a2f bundle be family again. “

“I am a PT at a large level 1 trauma center in upstate NY with 8 adult ICUs. In 2015, we did our own early mobility trial with 1 PT designated to one of the MICUs and 1 PT designated o the SICU for one whole year. We had support from the director of adult critical care who educated the Mds and midlevels on the importance of early PT/mobility so we were able to get the necessary orders on patients more easily. The goal was to see every patient every day, if not twice a day if possible. Over the year we tracked data and our results aligned with the already established literature that early mobility decreased morbidity and mortality in our patients, decreased ICU length of stay and overall hospital length of stay, and ultimately we saved the hospital upwards of $820,000. This information was presented to the hospital budget committee and we were able to increase our budget to hire at least 5-6 additional PTs at that time to staff every ICU with their own PT! Since then, the hospital overall has appreciated our value and increased our budget incrementally such that our PT department has grown from 19 FTEs in 2015 to over 40 FTEs currently in 2022. We are significantly busier today than in 2015 but still, we are moving in the right direction.

Ny ICU started rounding with PT/OT, RT, nursing and an AP. It literally takes 15 minutes, we talk about how each patient is moving, our mobility goal for them that day, if they need therapy orders. It is a great way to build relationships and has already opened the doors to mobilizing more intubated patients than we have before! “

“New-ish grad PT here who’s more routinely covering the ICU at my midsized hospital. Mobilized my first intubated patient last week nad it was amazing. Big shout out to the nursing staff, RT, and the critical care AP who’s pushing for early mobilization and sedation weaning that’s going to facilitate me doing this more often!”

“In our 32 ICU beds over the last few weeks we have had only 1-2 patients on infusions, and this already is a great stride. We have had to bring in extra physical therapists into the ICU many days because we have never had this number of patients getting PT. Thank you for your engagement! “

“We are implementing small changes throughout our intensivist staff which are gaving ripple effects across our 4 hospitals that we staff. I’m on shift right now and we have 15 patients on service, 5 on the vent. Only 1 is sedated because he has been seizing. The other 3 are all awake and interacting with us, writing on paper for communication, able to move themselves, etc. We walked a patient on the vent last week and everyone jumped in without hesitation. We are making great strides. “

“Communication absolutely helps. Allowing people to express the more nuanced things they’re experiencing… one yesterday was able to write and tell me the reason she kept grabbing her ETT was because it was gagging her, but if she took off just a tiny bit of pressure it relieved the sensation. Her being able to express that relieved our anxiety and realize, “Oh, she’s not trying to self extubate) and helped us to know how to help her. I thought of all the ways it could have gone wrong without her ability to share that such as ending up restrained, sedated, etc. “

“We finally did it! After meetings and emails and sedation barriers and dated practices and pleading my case. We finally walked with a patient on a vent today! This is the message he wrote us “Thank you so much for being so good to me. I love you!” Our jobs can be so gratifying when we practice patient-centered, evidence-based care. “

“I’ve seen intubated patients ambulating successfully. It was incredible. At our rural ICU. AT the time it had received many cardiac awards. We had a truly incredible team from all different capacities. Case by case, we all know ambulating as soon as the patient is safe and stable is best. I say it every day at work, “If we’re not doing what’s best for our patients, what are we even doing?”

“Just wanted to say things came full circle. I ended up septic in the ICU after a cat bit, and on a vent after my surgical washout. I specifically requested to be kept awake and no one really knew what to do about that, but I explicitly stated before surgery that unless I was not tolerating the ventilator for some sort of pulm reason, that I shouldn’t be sedated. I requrested no benzos for induction because after seeing the results of immobility in ICU I was terrified. I almost made myself DNI because I didn’t trust the ICU not to sedate me. But I was ok!
Hot tips:
1. Don’t reposition the tube too far to the side when you’re switching position, that makes patients gag.
2. 30 degrees or higher isn’t enough. You still feel like you’re chocking.
3. ETT correct placement is KEY. Mine was a little too high at first nad it was MISERABLE.
4. They let me sleep on my side. I had a yankauer suction that I used myself but sleeping on my side helped SO much with keeping my hand elevated and also sleeping comfortably.”

“I love when I finally get my patient awake and calm enough to ask if they’re ok to be more awake and not sedated with the ETT (usually to prove a point to whoever is in the room with me). No one has said “no” yet and usually gives an enthusiastic
yes” nod. “

“Yes!! I show nurses how to help position vented patients on their side comfortably with pillows for sleep all the time! It makes such a difference in the quality of their sleep if they are normally a side or belly sleeper! And we all know how important quality sleep is for pain management and delirium prevention! The nurses are always so surprised in the different it can make! “

“How about the ER resident insisting my post arrest needed “propofol anesthesia for pain control”. Patient was following commands, off pressors when I stopped prop to do a neuro exam. Furthermore… patient shook her head “no” that she wasn’t in pain. Funny. The doc thought prop was for pain, that being intubated was more painful than seeing her family, and lastly… she had a nonrecoverable neuro infarct from the arrest. “

“We looked at 108 patients following a less than rubust protocol than the one you suggest and still decrease our ICU Length of stay from 5.7 days to 1.5 days. Yes- that’s a 75% decrease! “

“You best believe that on my non-ECMO patient day I helped OT and OT stand them. Then I got a gift of a solid CNA today. She’s standing with me and CNA just now, then we said, “F it.” I asked her if she could walk. She marched in place. We side stepped to the recliner. Swan, CRRT, all of it. She’s happy. And dang it, I’m happy. “

“Just love when I start my day at work by getting and agitated patient from getting zonked out with versed just by helping him sit up on the edge of the bed and stand up a few times and surprised the heck out of the medical team and nurses on how calm and reasonable he was after this. They were also shocked to see how easy it was for him to get up (he is a large man, so there were some assumptions that he couldn’t move well). We had a great education moment for everyone first thing this morning. “

“My patient went from high flow to 2L- great example of the power of all things mobility. He is on an LVAD. “

Team that has participated in webinars:
“Oh!! We have gone live with our ICU liberation and so far, we have had sedatino off for most of our vented patients. (It’s a msall sample size, we haven’t had many, but still, our patients have been soooo much more awake!) “

“I walked in the CTICU this morning and the overnight charge nurse excitedly told me that the nurses weaned off sedation on a patient day 3 of MV after heart transplant, fi02 100%, PEEP 12, sitting in chair off restraints! I think this is our first patient to be off sedation on this high of a setting. The patient is otherwise just chilling. “

“I just received a message from RN in our hospital telling me that she walked a ventilated patient in the room and she was so proud and happy telling me that I will be happy too. Even other nurses told her, “You’re crazy doing that!” The patient was so happy asking her to stay in the night to walk her. “

“Hi!! I feel like I have to share- I became an RN at the beginning of the pandemic and went straight into a MICU residency. It was not been part of unit culture you could say to get patients up and walking around, espeiclaly not intubated patients, since I’ve been there. I somehow stumbled upon your page at least a year ago now and always have it in the back of my mind. I have started bringin up early mobility plans everyday during rounds trying to normalize it as part of our conversation. I try to push myself everyday to do something with mobility that is out of my comfort zone. The other day, I had a patient who was on an SBT and having a particularly hard time, thrashing and shaking, not tracking well or following commands, pulling at restraints. YOUR voice (or posts, I guess) were in my head! I said, “If I give you a whiteboard, can you write and tell me what’s wrong?” She looked me dead in the eye and nodded, “yes”. Then she wrote the word “cold”. I got her a couple warm blankets and we extubated successfully only a few mintues later. My training taught me that restraints are the key to safety… but my patients keep showing me that movement and mobility are the key to progressing their care. This was such a special moment, even if it was small on the scale of everything you show on here. Just wanted you to know you inspire me and I look forward to a future of mobility in ICU care. “

To preface this one, there was a nurse on a unit that we worked with onsite. He hadn’t listened to the webinars beforehand, and was very concernend and doubtful when he suddenly had his patient on a PEEP 16/100% awake on the ventilator. The patient had baseline cognitive and hearing deficits, PTSD, and very poor coping mechanisms. Communication was difficult, and it took a lot of work and patience to write everything out for him to read and then try to read his writing. We got him to the chair and immediately his anxiety improved and vent setting went down to PEEP 10 and fi02 50%. This nurse was a culture leader, so we were worried that he would have a terrible experience with this exceptionally challenging patient. The next day, he came to us and said, “That was the hardest but the best shift I’ve ever had. I felt like I actually did something for my patient. I’m in. I’m all in.”

So then I get a text from one of their PTs:
“Kali, ___(that nurse) sent his intubated patient with an open belly to surgery with her sunglasses on and bagging herself! It was maybe one of the best parts of my day. “

“I kept thinking, “If all these people can get patients on ventilators out of bed, then why can’t I?” I went to work and got my first fentialtor patient on her feet not without a sling, and got to the chair. Woman in her 80’s who won’t have to be deconditioned after being on the vent for a prolonged period of time. It’s the most fulfilled I’ve ever felt in this job. I went home and bought stuff for the shower room at work to get people up to the shower with. This is super important work. “

SLP:
“Another win- after months of planning and pleading my case, placed what I think was the first in-line passy muir valve to ever be used in my hospital yesterday!! Patient told his wife he loved her after over 3 months on the vent. We all cried a little. “

“Come in to a patient on 35 of propofol for “agitation” today. Managed to work it down and then off. Got PT and RT together and sat edge of bed and stood! So much more fulfilling. The patient did really well and then asked to lay back down and take a nap. “

“Humble brag! Nursing and therapy together mobilized 3/3 of our appropriate and vented patients yesterday. It was awesome. “

“Interacting with family! Yesterday I dangled a patient who had been really lethargic but I had the family member sit directly in front of the patient and I was off to the side so the patient could primarily focus on their family member instead. Got a lot more out of them and much more alert! “

“I’m an OT and try to tailor EOB activities as best I can to be fun and also cognitively stimulating. I bring a deck of cards to play, if they are into arts, I will bring craft items, functional teaching activities, we also have a wii that we bring in sometimes to have patients play. The options are endless! All while working on sitting tolerance, balance, cognition, coordination, UE function, and more. We try to make ICU fun. “

“I’ve been following you for a year while earning my BSN. I just started my new grad ICU program and I’m so excited that I just found out today that my ICU is an Awake and Walking ICU! I could not be more thrilled!!”

“I have been working so hard with PT and OT on doing mobility on my intubated patients. The other day we had my intubated patient slow dance on the side of the bed with her husband. Brought tears to my eyes. “

“Admitted 6 days. Walking with PT. But only doing oral care in bed. Stood at sink. Brushed teeth. Washed face. Feels amazing. “Man I feel a bit like me today”. Made my day. One of my favorite things is the “problem patient” who really just needs someone to treat them like a person. Brush your teeth normally. Wash your hair. See some sunshine. Let me poop in a real potty. This patient who I got cause I’m a big stern male nurse is just tired of being a patient for over 30 days. Early mobility is a great way to help them feel normal. “

“The first thing I ask myself when I see a sedated patient, “Does this patient have an indication for sedation?” There are very few indications for sedation.”

“Just want to let you know, today we (OT, PT, RT, RN) walked a patient on the vent for the first time in our hospital. It was awesome. He danced. He gave hugs. His nurse was super stressed during it but at the ned of the day, I think she’s really glad we did it. The patient is excited to do it again tomorrow! “

“Today we had a patient with an open abdomen- intubated- walking on the unit! The hope and life this practice change has given my nursing staff has been the best cultural shift! We have our hiccuprs, but every day is a step forward. The best part- patients are getting better, length of stay is decreasing, HAPIs, VAPs, etc. are decreasing… it’s all for the greater good! “

“Had my first patient yesterday that made her own decision to stop treatment while on the ventilator. The family and medical team all listened to her and gave her space and time to write during the family meeting. Refreshing to see an intubated patient listened to and not deemed incapable of making their own choices. “

“I have had many patients who are awake and fully interactive on their ventilators. My favorite story is of a young man I’ve cared for on a ventilator he played classical piano while ventilated! “

“All my intubated patients mobilized oob today, all were seen by PT during SBT. All were successfully extubated within an hour after PT and passed their SBTs beautifully. Major win for our ICU. Our intensivists were so happy and in awe. Co-treated with RT for all of them. Took me 11 months to early this level of trust and respect from out ICU team. The nurses were stunned and were all talking about how amazing it was seeing this. They all told me afterwards they thought PT would agitate the patient more but it had the opposite effect and they were soooo happy. “

“Had a patient out of bed within 15 minutes of extubating today! The fellow was stunned. “

“Today my podmate had a patient who was trached and had been in the ICU sedated for 11 days. She was trying to wean his sedation for LTACH and he was “wigging out”. I went in the room because his vent was alarming and he weas trying so hard to get the mitt off his hand but was so weak and his eyes were still kind of rolled up from all thesedation. I reminded him why the restraints were on and reoriented him. He mouthed, “I won’t touch anything, please let me take it off.” I was surprised that he was so coherent but I was also nervous of the patient’s nurse because I already heard her telling family we would not remove restraints. I took the right write and mitt off and his BP dropped 50 points- 200 to 150. I gave him a pen and a whiteboard I keep in my locker. He couldn’t write but the motion and his family member allowed us to gifure out he was asking about his kids. I stayed in there for a while because I was nervous to leave the restraint off without the nurse. The nurse came in and saw he wasn’t messing with stuff and let him keep the restraints off. Honestly it made me sad, the whole situation. But I was glad from what I have learned from the podcast that I helped him anyways. And then the nurse changed her mind to keep the restraint off. “

“The other day the nurse came up to me and said I’d be so proud of her. I asked why. She said, “because I took my patient of of 50 of propofol and he’s awake on the vent on only fentanyl”. I couldn’t believe someone actually did something different after I talked with them about what I’ve been learning!! “

“I stood and did some steps in place with an intubated patient on A/C vent settings in a chair today for an hour!! I did it all by myself and she did great! I also bought a few whiteboards and gave her one. After she got back in bed with PT I went in the room and saw she wrote on her whiteboard, “I sat in the chair for an hour!!” She was so happy. I told her she was the first orally vented patient I had seen in my life stand and get in a regular chair. I barely had to help her. She was so happy she did a dance in the chair. I was so happy I ran around and told the whole unit! I also have gotten a lot of buy-in and now have a goal for our Medsurge ICU to become an Awake and Walking ICU by December 2024. All the hospital leaders are on board!”

“I have all our intensvisits a copy of Dr. Ely’s book. Few days ago one of the intensivists made a big announcement during ICU rounds and told the nurses they needed to be mobilizing their own patients and shouldn’t only rely on PT to do it. This week I’ve had several nurses come up to me asking for recommendations on how they can mobilize their patients alone. I saw so many ICU patients walking with their nurses this week in the halls. Made me so so happy. “

“I wanted to thank you so much for your content. My hospital is moving to Awake and Walking intubated (it’s apparently a slow process). I had a patient the last few days, intubated and on 7 of levo. I assessed him in the morning and turned off the prop and fentanyl, and was able to wean the levo off over the next hour. He asked to walk, which I was told I couldn’t because he was on levo prior to my shift. With a great PT, we sat him on the side of the bed. His sedation was off my entire shift. NOC shift got there, “educated” the patient and family that “being off sedation when intubated is harmful to the esophagus” and immediately put him back on sedation. Yesterday I again turned off sedation when I took over the patient, weaned off levo again, and the family thanked me profusely. I asked about extubation and the MD said it wouldn’t happen for 24 hrs because they wanted to do a TEE, but don’t do it on Sundays. The family was devastated. I educated them throughout the stay about the care I provided, (preventing VAPs, etc.) They asked the right questions, “So we are keeping him on the ventilator for 24 hrs only because it’s easier to do the TEE with the tube in place?” Yes.” – Aren’t you worried he will get pneumonia from being on the ventilator?” – the MD was pissed. Told the family it was because he was in a-fib and required pressors. I told the MD the pressors had been off for 4 hour and the last 2 days he only required pressors while on sedation, and his a-fib was diagnosed 8 months ago. RT backed me up and we advocated hard for the patient and family. 20 minutes later, we successfully extubated the patient. “

“I recently started in a new ICU, and they ALWAYS have a radio going at the nurses station. Not kitchy grocery store music, or things that come across us trying to be professional. Top 40, rap, country, you name it. I helps SO MCUH with my mental health at work, and I recently asked who chooses the music. It’s the patient. Each day, we we let the patient (or their families) from a different room pick the music. Why? So the patients haave hype music when we walk (or wheel) them around the nurses station. The attitude at this contract is, “even if they aren’t walking, get them our of bed and out of their rooms.” Whether it be just around the nurses station, to the waiting room, to the courtyard… whatever. Just change the scenery. Delirium is at an ALL LOW here. Anyway, after meeting so much resistance to mobility at my previous contract, I can’t tell you how good it is for my heart to be at this one. “

“One of my new nurses in the ICU that I’ve explained the mobility/sedation project to came and got me yesterday and tole md she got her vented patient up to the chair! She’s still in training so she was able to convince her preceptor to help her do it. It was awesome! People are really trying after I explain everything to them. “

“Our floor has “new ICU team (MDs and NPs)” One of the NP of the team introduced us to your Instagram account and yesterday for the first time, we got on of our vented patients up to the chair! “

“I was on the burn/trauma half of our unit this week, and I had a contract precaution lady. I had no one to help me move her with a lift, or slide her to the chair. When my attending asked why she wasn’t up in the chair, I told him that. He had a team of residents, fellows, and med student and still without hesitation, he was gowning up and said, “I’ll help. Let’s go” Kali, I cried. I had never felt more supported. He didn’t bat an eye. He wasn’t mad at me. He just identified a gap in support and took the initiative to fill it. “

“I took my vented patient outside today. We are palliatively extubating tomorrow. There were a lot of hoops to just through but we did it. The patient is awake and alert on the vent so I think it was therapeutic for them too. They saturated better too. “

After a brief onsite visit:
“We got an intubated patient up and walking. The nurse manager went up to the nurse and said, “let’s get this patient up and walking!” It took a village because we are not used to it. The patient did soooo good! Family was next to him cheering him up! We are meeting with the rest of the team tomorrow to see what we can do as a team to promote an awake and walking ICU. “

SLP:
“After 6+ months of work, we finally got our SLP, trach, vent protocol up and running! Auto consult on all trachs and starting to do in-line PMV placement. Our first patient was a CVICU PT status post 30 day intubation. Within one week he was wearing speaking valve all day and on a regular diet, asking me for a margarita! By week 2 he was decannulated. “

About a week ago, I was reached out to by a visionary trauma intensivist. She had the “classic” trauma patient with rib fractures and drug withdrawal. She was having a hard time getting the team to turn off the versed drip because he was “out of control”. He had an unclear history, but we started troubleshooting to try to manage his withdrawal and pain. They started klonipin down the feeding tube to cover for benzodiazepine withdrawal and manage anxiety, kept a fentanyl drip, started some Seroquel 50 BID, some other non-opiod pain management down the feeding tube, and gave him a champion RN. She was able to get his drip down and transition to precedex. She started communicating with him and figured out he needed to have a bowel movement, needed more dilaudid, etc. It would have been very helpful to have had an epidural for his rib fracture pain, but anesthesia was nervous. Yet shortly after, he was extubated. A huge success for this team!

Wherever you are at in your journey, count your successes. Celebrate them. Share them with us! We’re all in this together as the ICU revolutionists community. WE get to determine the future of our patients and critical care medicine.

Transcribed by https://otter.ai

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