Episode 154: E- EARLY Mobility with Heidi Engel

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What is EARLY mobility? Why is it so vital that the ICU community advance past passive range of motion for intubated patients? What are the main barriers that prevent us from mastering the E of the ABCDEF bundle? If we’re not doing highest level of mobility for most of our patients, are we truly practicing the ABCDEF bundle? Heidi Engel, DPT, joins us now to clear the air about early mobility.

Episode Transcription

Kali Dayton 0:22
For years, early mobility has been a hot and controversial topic. Even recently, I was told by a physician that their physical therapist will only do passive range of motion for intubated patients, and that anything beyond that is too intensive and dangerous. Yes, in 2023. That was said.

iI feels like early mobility is often glazed over as a “Yeah, for some few select patients in our wildest dreams. But for now, we’re just going to work on daily awakening trials.”

When that is the mentality and approach, our teams of patients end up missing out on the incredible benefits of the full ABCDE F bundle the rest of the elements in the bundle stay beyond our reach when we are not aspiring to do the highest level of mobility on most of our patients.

Heidi Engel joins us now to clear the air on what early mobility is, and how it is supposed to be utilized in the ABCDEF bundle. Heidi welcome back to the podcast. This is your third episode here on the podcast. But will you introduce yourself again?

Heidi Engel 1:47
Hi, I’m Heidi Engel. I’m a physical therapist at UCSF Medical Center in San Francisco, California. And I have been working in the intensive care unit, mostly medical ICU, but also surgical and cardiac and neuro ICUs at our institution for a good solid 15 years full time.

Prior to that I was creating our ICU mobility collaborative at UCSF, our interprofessional group. Because this is never a physical therapy project. This is always an interprofessional teams sport, which is part of why I love what I do. And I was a founding member of the ICU liberation committee for the Society of Critical Care Medicine. So I’ve been a pioneer of promoting the A to F bundle.

Kali Dayton 2:40
I consider you one of the main experts on all things ICU early mobility. And that’s why you’re here to talk about the E of the ABCDEF bundle, which is early mobility and or exercise. It’s listed in different ways. Let’s just cover what is early mobility.

Heidi Engel 2:58
Early mobility is having a patient in the intensive care unit no matter what type of equipment they happen to be on, whether it be ET tube, mechanical ventilation, or ECMO, or balloon pumps, or you name it of what we can provide to people in the intensive care unit. CRRT, nitric oxide, so the equipment is not the barrier in the early mobility definition.

The objective is to have your patient who walked into the hospital and was admitted into the ICU for some reason to walk out of the hospital. And because there is a profound amount of weakness and cognitive and psychological changes that happen as a result of having to be in an intensive care unit on all that life saving equipment and with the life saving medications.

It is really easy for people to lose their abilities to get up and walk around to engage in their job and perform their work activities. So really, mobility is at the soonest opportunity you can you want your patient to be awake and able to participate in their own care through an ability to communicate and an ability to get up and walk around because walking is a normal survival skill. it’s for most people, not an exercise per se.

Kali Dayton 4:33
Talk to us about the highest level of mobility. Why is that important? And how do you determine that

Heidi Engel 4:38
Highest level of mobility is important because you know, there’s a wealth of physiologic research not necessarily in the world of critical care, but certainly in the world of cancer care. So if you want to say okay, yes, exercise physiology principles need to be applied to people to prevent cardiovascular disease or to help them recover from chronic lung disease.

But those people aren’t very sick, you can then switch gears and look at the oncology world. So in the oncology world, there’s been a wealth of exercise research demonstrating people who are very sick and actively going through chemotherapy have the same responses that healthy people have to activity that induces a anaerobic response of some sort to what you were doing.

So some elevated heart rate, some elevated respiratory rate within the setting of activity. Best case scenario is activity involves weight bearing on the legs, because we all know, intuitively, that it is the large skeletal muscle in your legs that facilitate better functioning of your heart and lungs.

Right? I always tell my, my family members and the patients, you know, when you want your heart and lungs to work better, and to be stronger, you don’t sit on the edge of the bed with a closed pin on your nose you and take nice breaths, you stand up and run up the hill, because it’s the messaging and the signaling of those large skeletal muscles, and the weight bearing on your legs that actually facilitates a lot of physiologic normality, and a beneficial exercise response.

And we haven’t done this well in the critically ill patient population, per se, but we’ve done it incredibly well, in people in in cancer research. So hospitalized patients, patients undergoing stem cell transplants, people having chemotherapy, Exercise seems to be the very beneficial medication for anyone at any phase of their lifetime, even when they’re very sick.

Kali Dayton 6:58
I think highest level of mobility is really important to be bringing into this conversation because early mobility has had such a ambiguous connotation or definition throughout the history of early mobility. So let’s talk about a little bit of maybe the history of how early mobility came to be and why we are where we are as far as having so many different interpretations and applications of early mobility.

Heidi Engel 7:22
Okay, well, history of it. For me started with I previously was floor PT working with liver transplant patients and hematologic oncology patients. And those patients would end up in the ICU at some point. And I would follow them into the ICU and go into this foreign scary place and look around and go the nurse and say, I haven’t ordered to see this patient for physical therapy.

And the nurse would say, “I don’t know why they’re on a ventilator.” And I’d say, “Yeah, I don’t I don’t know why either.” And I would walk out and that was probably 2007. And finally, at one point, and I have to say that the thing that has helped me be on this path for as long as it has, as I have is how much the patients and the families love mobility.

They love mobility more than we do. They have been the driving force for me, they have been the guiding light that has shown to me that I really need to keep doing this and that it’s so important. And so I had a patient end up in the ICU, I had no ICU experience, because I’d always been told passive range of motion is what you do in in the ICU setting.

And I was like, “Well, do I need to do passive range of motion as a physical therapist? Can a nurse do passive range of motion? I have other patients to go see out on the floor.” And that was my ICU experience.

So finally, I had a patient who was on a ventilator really wanted to get up out of bed, he was a nurse, his family were a bunch of nurses. They were from a different country. Maybe that made the difference. I have no idea why they were so adamant that he needed to be up out of bed, even though he was on a ventilator. And the nurse said this crazy, he can’t do that he’s on a ventilator.

And I kept looking at him and he was awake. And I said, “Do you want to get up out of bed?” and he would vigorously nod as hard and he looked strong enough and his family was eager to help me and so we just did it. And after we just did that I thought, “Well wait, is this what we should be doing for everyone? Like why?” Because he looked great!

Kali Dayton 9:40
Why could he do that and the 99.9% of the rest of our patients can’t do that?

Heidi Engel 9:47
Yeah. So I started to do some research. And there was nothing practically there was a study by Pete Morris. And it was a lot of bed level activity. But then there was Holley, Bailey’s 2007 article in critical care medicine describing how these very sick patients on ventilators are getting up and walking down the hall. You know, Pa freshers have 100 Apache scores of 26. And she’s got pictures, she’s got pictures in this article, I have these people just walking down the hall on a ventilator.

And I had a student of the time and I looked at the article, and I said, “I didn’t even know this was possible! How is this even possible? I thought there’s no way you can walk in the ventilator. Why? wait!” It just like, sent sparks off in my head to say, “Wait, why are why aren’t we doing this? If this is possible, why aren’t we doing this for every patient, everyone needs to….. like walking is….to me, walking and breathing and eating and drinking. These are foundational things humans do.”

So that was the start of the journey. I was connected to Dale Needham, who is now the world’s leader and expert on ICU all things ICU, early mobility and rehab, they were just starting their program at Johns Hopkins.

He was incredibly generous with sharing a lot of information with me about the program they were starting. I went to see what Polly Bailey did, she was extraordinarily generous. And then she said, “This is the hardest thing you’ll ever do in your life.” And I was a little scared because I felt like she knew a lot.

Kali Dayton 11:32
And she’d been fighting this or, you know, moving the needle on this for at that point, probably 15 years.

Heidi Engel 11:39
Yeah. Okay, around that brings us, you know, that was around 2010. In 2013, they, the Society of Critical Care Medicine published the updated PAD guidelines with Julie Barr, who you had a great interview with on your podcast. She was the lead author of the pain agitation, delirium guidelines.

And what happened between each of them five years, right, a clinical practice guideline is taking all the evidence and making recommendations to clinicians based on what all the evidence everywhere says it’s a huge undertaking.

So what between when they started the development of the PAD guidelines in 2008. And the publication of it in 2013, five years it took mobility had become a bit of a thing Hopkins was starting, we were starting Pete Morris, his article was out there and more schweickert study was published in Lancet 2009, the Australians had been making a lot in, you know, presentations on how they mobilized their patients in the ICU there.

So there was a lot coming together. But because it wasn’t anyone’s radar in 2008, when they created the group for the PAD guidelines. The there was no mention of mobility. So this is a 52 page guideline. There is one sentence two sentences, I think that describe mobility. And it essentially says for the delirium part, we recommend, you know, early mobility as a potential treatment for delirium, not it.

That’s how the whole thing that the PAD guidelines in 2013 could say about mobility. But thanks to the wonderful committee that that group was founded upon Julie bar was Ely, they appreciated that.

“We really missed early mobility in this, how do we want to address that now that we’re going to be trying to help people adopt these guidelines?” So society Critical Care Medicine created this I still operation committee, and decided to use the A to F bundle as the toolkit to help the PAD guidelines, meaning the evidence that’s out there be put into practice. It’s just a toolkit.

And they wanted mobility to be a part of that. That is the E of the bundle, even though the PAD guidelines didn’t specifically mention it. So I had been floating around enough with the Institute for Healthcare Improvement and a bit with the Society of Critical Care Medicine, that they asked me to be part of that committee to help make mobility something that that everyone thought about in regards to the peg guidelines.

Kali Dayton 14:35
Then we had the big study published in 2019, showing incredible outcomes. What do we see about actual implementation of early mobility?

Heidi Engel 14:46
What I found with the ICU liberation initiative? And that’s what you’re describing. So we went from a committee of let’s turn the 2013 PAD guidelines in To practice, how can we do that we had a grant funding, we had cyber Critical Care Medicine backing, we created this collaborative of 60, different ICUs, who applied to the Society of Critical Care Medicine to be part of this program to receive a lot of training and mentoring and education.

And we asked them to do data collection, to have a project manager and interdisciplinary team, and to do randomized data collection to see how well they implemented the bundle through this whole year and a half project. And what we found is folks really tended to apply the bundle as if you were going point by point through the alphabet.

So what’s of great compliance with the A, the B was better than ever, the seeing is getting better the D sort of the E, you know, honestly, not so much. I was I was personally a little stunned when the the raw data came back. And we looked at how early mobility had been defined. So because it was so friendly, based in that level activity, there was passive range of motion, and the definition seemed to be a lot of dead level activity.

Kali Dayton 16:28
So only 12% were actually out of bed bearing weight, only 5% of those were actually taking steps in the hall.

Heidi Engel 16:35
And that was that was anytime during their ICU stay. And that included both ventilated and non ventilated patients. Okay, so that’s what I consider quite low level activity for if you’re looking at your entire ICU population, because we all have non vented patients in the ICU. Right, right. Yeah.

Kali Dayton 16:59
For everybody, right? Anyone can develop delirium, anyone can develop ICU, quite a weakness. It’s not just about the ventilators. But we know that it’s been sedated expedites the development, device acquired weakness, and it’s much harder to walk down the hall after being sedate and immobilized. Once you’re excavated, if you get excavated, right, it decreases the chances of being successfully excavated.

So obviously, we made really good strides in the right direction. But I love how you bring up how this was the first element of the bundle, because we were very fixated on going sequentially, in alphabetical order, we still missed a lot of opportunities to optimize outcomes.

But we found in that study that outcomes were dose dependent, the closer they got to being awake, and walking, the better their outcomes were. And that’s not just because of acuity, people will bring that up all the time. Well, of course, if patients are well enough to be awakened walking, they’re gonna do their acuity is not as high, they’re gonna do better, which is not necessarily what we’re talking about.

We’re talking about patients that are walking during critical illness. And despite their acuity, they do better because of the interventions, right. So now here we are in 2023. And there’s still a lot of turmoil when it comes to early mobility, we still have passive range of motion being accepted as part of early mobility, we have lots of fear regarding early mobility.

We know from Peter Nydahl’s meta analysis that with over 14,000, in activity sessions, diversity event rate was point 6%. But now we have newer studies coming out, well, no, a new study coming out. I not to make it plural. It was just the one. Let’s just talk about the TEAM trial. Let’s just put it out there.

Let’s talk about the TEAM study, because I’m finding every team that I’ve worked with, since that study, come out came out almost every discussion I have with anybody, anybody that wants to validate what they’re doing as far as low level mobility or no mobility brings up the team study, as their validation that it is too risky, what they’re doing is the optimal care. What do we know from the team study? As far as is this really so dangerous?

Heidi Engel 19:15
What do we do we know from the TEAM study? Well, first, I think I need to clarify that if you asked me for what I believe is the correct definition of early mobility. I fully believe in what you have said in your more than 150 episodes of your podcast at this point, which is awake and walking is the standards that we should aim for can every single patient every time be awake and walking no matter what the equipment?

No, but can a vast majority of the patience in your ICU? I would say “yes”. I would challenge everyone everywhere to make that the definition of early mobility, but the awake part has to be part of the picture and when I am when I talk about the awake part and this will get us to the team chyle when I talk about the awake part as someone who is probably mobilize everyone on every kind of medication known to man, and seeing the impact of that.

I have to say that we have to stop believing that RASS zero or RASS minus one to zero and awake are the same thing. Because they’re not. I can have people in bed, eyes open nodding their head cam, I see you negative, but propofol was turned off an hour ago, for example. A propofol drip was on all night long, as was some fentanyl, the propofol has come off to allow the patient to be awake.

It’s been an hour, so everyone’s quite sure it’s left their system, which it has not right. It sits in their adipose tissue, it’s a lipophilic drug. And depending on how much they received over how much time it’s continuing to feed into their bloodstream. So they’ve had their brain has adapted to it. Our brains really want to be awake and walking, our brains want this your brain craves to not be sedated lying in bed, no matter how sick you are.

So the protocol is off, everyone sees their eyes open or can ICU negative, great recalling the wake. However, what I watch, when we start moving that awake person is coordinating the movement of walking, having the cardiopulmonary tolerance and aerobic capacity for good walking without becoming tachycardic, or having a fib especially when they’ve had baseline a fib, or having a hypertensive episode or hypotensive episode of some sort.

It, it’s really hard to achieve that level of mobility with that drugs scenario. So I, I feel very strongly and this is after years and years and years of mobilizing people, that it’s not, it’s not accurate to call someone awake, who has been pretty deeply sedated for days, or even hour, just hours and hours overnight. And then today, you turn the drug off, making them capable of very basic low level interaction and eyes open all the time, you’re calling that awake, and you want to walk them down the hall.

It’s really hard to do that. You can do it sometimes. But it’s messy, and it’s ugly, and it doesn’t work very well. And the patients who have been allowed to have the sedation turned off and stay off and actually let it let them metabolize it. So which to me can take days depending on how long it’s been. So even though the propofol is a short acting drug, it really does stay in their system in impact their brain, their functional capability, their coordination, their balance and and very much so their cardiopulmonary response, right?

We know these drugs work on everyone’s baroreceptors. So why are we thinking it’s unusual, if we’re trying to help these patients stand up and get out of bed, we turn the promo fall off, but they still hemodynamically look like like they’re exerting super hard, you know, it’s the drug, it’s the drug. It hasn’t really left the patient!

Kali Dayton 24:13
And that’s, you know, an awake and walking and ICU that I worked in, we mobilized patients, oftentimes, you know, hours after intubation, at least within the first 24 hours, usually within 12 hours.

I mean, it was really prompt that we were mobilizing them, and they rarely ever had propofol running right after intubation. There had to be extremely good reason like seizures, intracranial hypertension, there had to be an indication for that sedation.

And so patients remained so intact cognitively physically, I mean, propofol is mitochondrial toxin, it has talked to the muscles, so you don’t just you can’t just give it for four to six days and then expect those muscles to be able to fire and function even if you have not lost large volume of mass which is probable if you’ve had it running for that long, you’re going to lose mass, right? But you also lose function. So we destabilize our patients with sedation.

Heidi Engel 25:10
Yes. So getting back to the TEAM trial. Number one, I want to say, this is an incredible study, right? This is an incredible feat that Carol Hodgson and the ANZIC group have pulled off. They did something we were absolutely craving in the world of critical care and ICU, early mobility in particular, they had a huge large study, you know, an n of over 700 patients 50 Different ICUs around the world. And it’s a very distinct protocol to follow, that really encouraged people to help patients get up and move out of bed as soon as possible.

And again, this study was 10 years in the making, right? So between 2012, and let’s face it, that’s now getting you back before the PAD guidelines were even published, right? So none of us are really knowing much about mobility, or even doing it very much at the points where we’re putting this study together and designing it, we might be asking different questions today than we were ready to ask five and 10 years ago. So this study is a brilliant undertaking, it has a lot of data in it more data than any other mobility study ever.

t’s published in a medical journal of the highest impact of all the medical journals, New England Journal of Medicine. And so it’s not a study, we can discount, or I would ever recommend discounting. But I think when you drill down into all that data, particularly the the supplemental part of the article, which isn’t the main published part, you really have to go someplace else and and go through all the supplemental tables.

When you drill down through all of that data, I personally have a different narrative I draw from that data, then I think the author’s did. And so to me, their narrative has been a little controversial. Because their narrative is, look, we had an intervention group that got more intensive mobility. And we had a control group, which got what we’re calling a good level of mobility.

And this is the only difference between the two groups, and therefore anything we saw that didn’t create a positive outcome or anything we saw that was an adverse event, it can only be due to the mobility because everything else was controlled for. So you know, you know, the ICU, you know, this and there’s nothing in this study that talks about sedation at all. It’s it’s a big black box in this study. We don’t know what drugs people receive. We don’t know how long they received it.

We don’t know in what pattern they received it, we can guess. Those of us like you Kali, who work in a lot of different ICUs or talk to a lot of different people who do work in ICUs. can see that it’s very standard practice for a drug to go off from Fall goes off during the day, goes back on at night, that we have learned to call sedation, sleep and rest. And that sleep and rest is really not the same at all right?

So to me the narrative of the team trial is hmm nobody really achieved a whole lot of out of bed walking down the hall particularly early in their stay within the first week. Honestly, the majority of people were doing bed and bed level activity. And, to me, that’s a low level because I want folks awake and walking before they lose their ability to walk.

The other thing about the teen trial is, there’s a lot made about the adverse event rate was higher in the intensive mobility group. And again, because their narrative is well, the only we controlled for everything else. And the only difference between these two groups is the the level of mobility, so it must be the mobility is the problem. I’m, I’m not sure that the mobility is the problem, if we make sense, if you look again, at at the all the factors that play into what mobility is in the ICU.

So to me, the narrative of this study is we’re continuing to attempt to do everything. While we also sedate our patients, and maybe that’s not working out, as optimally as it should, that what we need is a TEAM study 2.0, where the intervention is, your patient’s going to be awake and walking, which means once the drug is off it, it stays off, because sleep and sedation are not the same thing. And because a patient needs rest in the form of sleep, in order to be able to have the wherewithal to get up and walk down the hall the next day, and sedation makes all of that too challenging for everyone, or impossible.

Kali Dayton 31:48
I mean, sedation prevents sleep. It disrupts the brain there’s there’s not real sleep. They don’t go through the full REM cycles, under sedation. And we saw in the team’s trial trial that they were at a RASS of negative three for four to six days before starting mobility.

And when I see that RASS negative three, I’m not sure if I really believe that. Granted, this was in Australia, maybe they have impeccable RASS scores. But we see in Brazil, and here in the states that 50 to 70% of our RASS scores are inaccurate. That they are likely more deeply sedated than we’re actually charting.

So when I say negative three, I really wonder, “I don’t know that negative three easily becomes a negative four and negative five”, and that exacerbates the harm happening to our patients while they’re sedated. So nonetheless, without looking through the supplemental tables and understanding the methodology and asking these questions, you know, many of us, it’s easy to just go through the abstract, find the last two sentences at the conclusion, and their say and say, “Aha, see? Early mobility is dangerous, and it does nothing.”

And that’s what I’m hearing from people, which is obviously really concerning. And it’s creating a whole new barrier to really practicing the ABCDEF bundle. I see the initial steps of the bundle as tools to enable the E part and the F part of the bundle and the C and the D, right?

But we don’t have them awake, we can’t mobilize them, but we should be waking them up to mobilize them and not as a “holiday, break, interruption”- but to have them awake and able to mobilize throughout their time in the ICU.

Heidi Engel 33:32
It’s not just mobilize, Kali, but, but communicate. So, you know, I can tell you a quick story of a patient that I had recently who walked into an outpatient sports medicine procedure. As a 30 year old with a torn Achilles tendon needing surgery. He went into the outpatient sports medicine, Achilles tendon repair had a massive anaphylactic reaction to one of the drugs he had to receive needed intubation for airway protection, and then woke up the next day in our ICU.

So imagine how confused and distraught he was to come out of his Achilles tendon outpatient procedure and find a tube down his throat in an intensive care unit when he had no previous medical history. So none of none of this is anything anywhere near familiar to him in the world. And so what is his reaction to being woken up a little bit?

He is panicked. When he panics, his heart rate gets very fast. His respiratory rate gets very fast. He’s having trouble synchronizing his breathing with the ventilator even though it’s a pressure support ventilation setting. His wife is there and She sees monitors and machines beeping and going crazy and him looking very distraught. And she obviously thinks something’s wrong. And the nurse says, I know how to fix this and turns propofol on to help him “rest”.

Kali Dayton 35:17
And technically, all of that meets a “failed awakening trial criteria.”

Heidi Engel 35:21
Yes. exactly. In a 30 year olds with the airway protection receiving steroids to bring down the anaphylactic swelling is airway, right? Like no, nothing, nothing crazy going on here. Right?

Kali Dayton 35:35
But if you sedated and receiving steroids and immobilized Oh, yes, a 30 year old is going to turn into the physical capacity of an 89 year old very fast.

Heidi Engel 35:45
Yes. And something weird happens in hospital settings where everyone is happy when anyone of any age or background who can get up independently and titled down a hall with a front wheel. Walker is called independent, and we’re all good with that. But I leave that aside. So I asked the nurse on this particular patient, what’s the appropriate fall for and she said, This is what happens when we turn it off.

He gets agitated and crazy. So he you know, I can give him a dosage of propofol that helps him keep his eyes awake. So he’s technically aroused, minus one to zero. But on a protocol drip and young people do that, right. They metabolize, they’ve got good healthy organs, they metabolize the drugs, their drive to be awake is huge. You can have people awake on propofol drips.

And I amazed at how much staff were very happy about that. Like, this is great. You know, and I’ve had this same for a very long time. Okay, but you don’t understand this drug is not your little glass of Chardonnay at the end of the day, like this is not all toxic. Yeah, it’s not this little relaxation tool for the family member is confused. She says “yeah, like, let him Let him rest. He needs rest.”

And so we spoke to her and said, “You know, but there are a lot of potential side effects to other organ systems in his body. If we let him rest on this drug propofol, even though his eyes are open.” and she said, like, “What organ systems?” and this is someone who is in a very intellectual career, and I said, “Well, his brain” and she was stuneed and we’re like, “What do you mean his brain?” And and I said, “yeah, it causes, you know, long term cognitive impairment, it increases psychological trauma over time. It’s not really the kind of thing you want to rest on.”

And she said, “Well then gonna turn it off!” Which we, which we did, because I guarantee you to the nurse, it’s so you know, “we’ll do this, I’ll get the respiratory therapist, we’ll get him up moving.” She’s like, well, “It’s okay. It’s okay, he can write on a clipboard.” Now we have a 30 year old with a very high intellectual capacity, scribbling the most basic illegible sentence on a clipboard because he has a RASS of zero.

But this is what his brain function capability is.

Kali Dayton 38:22
It’s propofol handwriting.

Heidi Engel 38:23
It’s propofol handwriting. And again, we are so adapted to this drug being a good thing, a compassionate thing, arresting a calming down thing, that we’re willing to accept that she’s like, See, he can run on the clipboard, and I was like, I don’t like that doesn’t seem like his writing, I don’t know, his baseline, we turned off the drug, we got him up, we walked down the hall.

And we sat him back in the chair. And now he’s able to text on his phone and communicate by typing with his fingers. And he can write now the full paragraphs on the clipboard that are legible. So there’s a certain amount of what are we willing to accept? And what is our understanding of what propofol does and doesn’t do when we’re also discussing what isn’t?

What is the level of mobility that that our patients should engage in? And what is intensive mobility versus what is, you know, good, we can accept this level of mobility and and I think we just haven’t developed the standard of awaken walking sufficiently in the ICU to really see all the profound benefits it can have. And that’s why as you know, I have said, I feel like we got the bundle a little bit wrong, and it should be the F to A bundle.

Because in order to have, you know, that wife was incredibly happy and able to communicate with her husband, and they were able to discuss what really happened to him. And she was thrilled to see him walk, she was thrilled to stand and look out the window at the view with him, she was thrilled to understand that seeing all this to Herman, he wasn’t going to stay in the ICU, he was going to just go home a walking person.

So but in order to make that happen, we had to do all the other elements, right. And we had to do all the other elements to the highest extent, we couldn’t except that well, yeah, the protocols on or the press text is on, but their eyes are open, and they can kind of scribble something on a clipboard, therefore, they’re good to go. Like, let’s just keep them chill on this drug, while you also do everything else.

Kali Dayton 40:59
And it’s easy when it’s hanging there to sneak back up overnight. And later on. I mean, it’s just, it’s really hard to have that be an option just there. And that’s a great example of how those initial elements of the bundle and powered the E and the F. And the E and F made the other the initial elements of the bundle, easier and more feasible.

I see this happening teams where they say “We’re just going to focus on SATs and SBTs, our charting is improving or having compliance. And we’ll start with that, and we’ll do mobility later.” I see such a challenge to that, because mobility enables patients to be awake, free of delirium, calm treats, their anxiety keeps your brain intact.

All of those things keep patients safer, makes it easier for the staff, I think that makes it less likely that they end up being sedated to control the agitation. So when you only focus on the initial bundle, you’ll really never probably get to the end. But you also can’t fully master the initial elements that bundle without the E and F. So I love the F to A approach.

It makes sense to me. If we’re really focusing on families being communicative engage interacting with the patients that will guide our sedation practices, and then you can finally get to the E. What are the main barriers to real true early mobility throughout the ice community right now,

Heidi Engel 42:26
I think a misunderstanding of how vital being upright and mobile is to the physiologic normalization of patient’s lungs and diaphragm start to adapt to their new positive pressure. Lying without the force of gravity horizontal positioning situation within 24 hours, doesn’t take days takes even less than 24 hours. But let’s just call it a day.

Within a day of being intubated, your body is now adapting less if we have sent you in a spaceship into outer space, and started reversing the way you normally breathe. And so your body does this mal adaption really, and things start functioning abnormally. So in order to actually ideally help lungs, you position someone fully upright, and not smashing the back surface area of their lungs by lying supine, or even having a bed placed in a chair position.

I think we’re afraid of mobility, I think I’ve watched fear of mobility be something that that prohibits mobility over and over and over again. And it’s, it’s almost one of the biggest areas to have to tackle is the fear. Now the problem with the fear is we treat our fear with sedation and we treat you know, sedation gives us a ton of control and predictability over our patients. Right.

So a sedated patient looks calm numbers look great. We don’t worry about them pulling anything out we don’t worry about them doing anything unsafe. We don’t really worry about them hemodynamically so much sedation really gives us us The providers a sensation of of our own comfort and that we have rested and the medicines are getting the machines are going to help this patient and then as the medicines machines help the patient will slowly take this away but for today, numbers look great. Patients looking sweet in bed they look eyes close, like they’re just having a nice nap. I’m familiar it’s

Kali Dayton 44:47
again controlled. It’s predictable. Yes.

Heidi Engel 44:51
Yes. So if if I come along and I’m like no, no, no, turn that drug off and let’s get this person out of bed. You know Oh, it’s like, wow, that is a big, messy, potentially risky, dangerous thing. Why, and the problem is I have seen over and over and over again is we were it, it actually is harder and I probably doesn’t work well as is reflected in the team trial, when we’re doing it this halfway approach, when we’re trying to both sedate our patients and mobilize our patients, because I’m asked to do this all the time.

And it’s really hard, it’s a much more challenging job for me. And it’s not as productive. The patient, getting them to be able to focus coordinate, understand. It is my patients I have, and we do this routinely with our lung transplant patient population, people are waiting for lungs. That particular team at my institution, shuts the sedation off immediately and never allows it to go back on and insist that those patients get up and walk down the hall are the first couple of days difficult.

Yes, I think day one is never going to be not difficult. For the most part, our activating investment on day one gets you so much. It’s the return on your investment of doing this hard thing this one time and making sure that sedation is fully off. And that this patient is writing a right a writing test is the perfect thing to me, maybe the next bundle could be and the way you know if you’re complied with this bundle is your patient can write a complete sentence on a clipboard. And and it makes sense and the handwriting is legible.

Kali Dayton 46:45
Lance Patek says that the same perhaps should be communication. I’m trying to get teams to make this part of the rounding is how is the patient communicating to reinforce it, that should be our expectation. And that everyone be wanting patients to communicate, knowing how they communicate, making that a huge focus, because that again, will inspire and guide our sedation practices.

Heidi Engel 47:08
Or C for “patient control”. Believe it or not, when we allow our patients to guide their own care, they do so much better. They don’t get agitated, they they’re cooperative, they’re helpful, they’re appreciative. They’re, you know, so much comes together so well. People, I believe, resist this way we treat them, which is to just completely disempowered them, right. We’re we’re tying their hands to bedrails. We don’t allow them to talk, they think they should be able to eat and drink.

And obviously, that’s not something we can possibly give them that they will understand for going that when they can understand it in the context of their illness. So I see us having a future world where the ICU liberation 2.0 is the F to A bundle. And early mobility is described as awakened walking down the hall.

And that the the, the lessons of the team child are perhaps mobility isn’t as easily achieved or well achieved in terms of walking quickly before you lose your ability to walk. So within a day or two of intubation, when we’re also still providing a lot of sedation through the remainder of the day.

I mean, if it a lot of a lot of the ideas I have about how to to mobilize it or exercise patients in the ICU setting comes one from I said oncology research I read, but also exercise physiology research that I read, and I’m ready for this study that takes healthy participants puts them in a propofol drip at night gets them up during the day has them exercise and the control group is the group that didn’t have any propofol on at night, healthy people.

And let’s see the impact of what exactly that protocol is doing and your ability to coordinate your motion tolerate activity the next day, because I will bet money, I will bet money that we still have a lot to learn about how these drugs are really negatively impacting the functional capability, as you said, a mitochondrial toxin. Now your muscles have been starved, literally starved all night long. And tomorrow you’re gonna get up and walk around on them. And

Kali Dayton 49:56
We’ve seen the team study and in other mobility studies that the main barriers are sedation and agitation.

Heidi Engel 50:02
The WEAN study that we in trial that was just published in Lancet, a high though the one that has the forest plot with the it shows clearly that the greatest, the greatest barrier is sedation. And I, again, I think it is because we have missed defined what the student is capable of versus what harm it does, I think we have routinely seen it as an a nice way to help you relax and get through the trauma of your ICU stay.

And it doesn’t turn out to be true. But we don’t have a robust enough counter messaging, or demonstration of awakened walking ICUs everywhere to tell people that this drug has more harm than benefits. And it’s not just protocol, right? We’re also talking I mean, I people say, well, we’ll just leave my precedent strips all the time because their eyes are opening on precedents. I’ve had so many patients knees buckle on the precedents strip, partway down the hall versus when there’s no precedents.

Obviously fentanyl drips have also their own. So I think we have to start learning to trust the human body better and the and the will to live. You know, Wes has his thing about people need to know their why to live. And they have to be awake, right? What’s really said that one of your previous episodes, they have to know their why to live in, they have to be given an opportunity to to strive for their why to live.

And again, I come from the oncology world I see the power of that is profound. Do I have a large multicenter trial to demonstrate it? No, I was, I have so much experience, and I have so much faith in the people who become our patients, once once you connect with them as people, and I’ve heard this from your other participants, as well. So I feel like I’m preaching to the choir, or else I’m just repeating similar messaging, but it is ever so true.

On the other side of your machines, in your drips, there are people with amazing lives and incredible stories, and you’re depriving them of those lives and those stories when you have them lying in bed as as an inert body that needs to have certain numbers and values hid in the in their day. And I and I would I would add one more. You have an episode where you interview the nurse who started the ECMO program in Texas.

Kali Dayton 52:43
They proved mortality by 30%.

Heidi Engel 52:46
Yes, and just lets you know, her story also is really fantastic. In that she she also describes multiple times in her interview with you how much that when the nursing staff saw their patients become people and got to know them as people that there was there was a healing connection, right? There was a bond and a healing connection that really, you can’t quantify that. And it is it is genuine

Kali Dayton 53:19
in Episode 118.

Heidi Engel 53:22
Yeah, you can’t, you can’t provide that to, to a half awake person or eyes, just opening your eyes should not be a standard of, of how we perceive like we’ve done the right thing by a patient, and

Kali Dayton 53:39
I’ve seen with team that we’ve worked with that that’s a key part of sustaining these programs, ICU liberation. I mean, if when we only see this as awakening and breathing trials will never get there, we’ll never have that human connection. We’ll never…. I mean, there’s such a humanization of walking, of being upright, sitting on the side of the bed bearing your own weight right in the clipboard.

That is the vision that our clinicians need to have when we’re talking about the ABCDEF bundle of what’s just SATs as PTS we will never really get to know our patients and never enjoy watching them walk out the doors. And not every patient can walk even at baseline. But we’re doing we’re preserving their baseline function. And by doing that we’re preserving their humanity.

And when we talk about the risks of early mobility, we need to really look at what are we talking about and hold it up against the risks of not practicing early mobility. That’s I think what we’re really lacking in our discussions we’re seeing with teams trial, seven times greater risk, but again, are those how many of those patients how many of those events were different the same patients? How much of that was observational bias? How much that was from the destabilization from sedation and mobility for four to six days. And the poly Bailey study. Their median PF ratio was eight benign, these were sick patients and their adverse event rate was 0.6%.

Heidi Engel 55:06
Yeah, because they were promptly walking. Yeah, there is some…. I’m gonna make sure I don’t screw up the lead author’s name here. There is a meta analysis in 2020 by Petra Waldauf

Kali Dayton 55:22
I’ll put it in the transcript.

Heidi Engel 55:25
It’s a meta analysis of early mobility studies, and they had a no adverse event rate in that meta analysis. It also showed that the in dead the bed bikes and neuro esteem in bed that people want to do, did not did not have the better outcomes that just physically getting up and moving out of bed in a, you know, functional way did so.

There’s definitely more than one study out there on early mobility, it has been shown to be honestly an incredibly safe intervention. I will put my early mobility intervention up against almost anything else we do in the ICU. Let’s look at CLABSI rates, right? Well, what’s the risk of putting in a central line? There’s a risk of infection introduction, we know this for real, it’s trapped right?

Kali Dayton 56:25
Now we know that there’s a risk. Once I showed a 300% increase in early mobility decreased, all hospital acquired infections by 60%.

Heidi Engel 56:35
Right, we have lar Ferrante study about how decrease ventilator associated pneumonia is by mobilizing patient about a bed we have by 40% study about long term cognitive improvement in the group that mobilized within 24 hours to 48 hours after intubation. Right. So there are the benefits far outweigh the risk. There’s nothing we ever do in the ICU that has really zero risk, genuinely. But my concern is we still think sedation needs to be part of the whole package.

And the sedation makes mobility so much riskier than my people who are awake, my people who are awake, where the sedation is off, and it’s really staying off. You know, day one is a little hard. Day two is a little hard. Day three, I walk in, in the morning, I go to their room, I’m waving, they’re waving back, they’re smiling, they’re writing on the clipboard, when are we walking? You know, they know the routine, they get up?

How’s your you know? How’s it going at home? How’s the dog doing? You know, we have this exchange and interaction. It’s all very normal and routine. And there’s four pillars of all human health, right? It is exercise, nutrition, sleep. But then number four, pillar one, and this is in every kind of wellness research ever done anywhere. The fourth one is social engagement and interaction. We humans need that. And that is healing. And you cannot do that if you’re sedated and hallucinating at night. And I’m shutting it off for a couple hours during the day.

Kali Dayton 58:20
I was surprised to hear from survivors, that part of their trauma is the isolation. Yeah. And it made me think when else do we ever not talk to other humans, and have human touch and real human connection? Other than solitary confinement, which drives people to insanity? Right. So are we putting patients into solitary confinement when we sedate them?

Or is it an all of it just plays into this whole picture of dehumanization? Yeah. And that’s what we’re liberating patients from, not just the ventilator, I’m just I just came from a meeting and it sounded like this ICU liberation was just for SATs SBTs. To get him off the ventilator. That was it that’s extended the discussion. We’re liberating them from critical illness, from the ventilator from sedation, from the bed, or liberating them from a future of disability, and isolation, and ramifications of sedation and immobility.

We’re freeing them from all of that. And when that’s our focus, then the E finally becomes a key priority as a life saving intervention. Not just an afterthought, if you get to it. It’s part of saving lives as a whole.

Heidi Engel 59:35
Yeah. And people want to stay breathing. So once they understand that they need that ET tube, you know, the patients who are kept awake, we’re getting them up to walk down the hall and they’re like holding the ET tube for us, you know, while we’re rearranging other equipment, or they’re telling us exactly where to move it so it’s more comfortable for them.

My patients with the on off sedation strategy can’t really Project and communicate well in that way, my way patients are again, getting back to the lack of social isolation. Walking in the hall is so important, not just standing up next to the bed and trying to march in place, which was the highest level of activity achieved in the teen trial. Walking down the hall is so important. You know, they walk down the hall, they see the nurse they had last week they smile and wave the nurse interacts with them, “How’re you doing, you look great. It’s great to see you out your room.”

They look out our window, we have the fantastic view of San Francisco Bay, we talk about what landmarks they can see we look at the trees in the park and the people in the you know, you realize the normal world is out there waiting for you. So awaken walking needs to be the new standard of what we call early mobility.

And and I think what I hear you expressing by some of your recent experiences from what we’ve heard about the teen child, from what we know COVID did to us that the definition is actually getting smaller and smaller and tighter and tighter into this world of well, let’s just do a couple things in the bed, a certain the sedation on and off, because we know that there’s evidence saying that’s a good thing to do.

But I think we’re really missing the big picture here. The patients need to be able to be awake, communicating, and participating in their own care. I once had a conversation with Bill Schweikert, who’s our hero of early mobility from his Lancer 2009 randomized control trial that demonstrated starting mobility on day one instead of day seven, really gave you less delirium, better functional mobility, more likely to discharge home, right? That was a big study that put us all in the excited position of wanting early mobility to be part of the bundle. I once had a conversation with him where he said, “My dream is that all of our patients are either up in a chair are readily to patients, or they are suited up to standing in a standing bed or in a combilizer. And they are awake and participating in their own rounds.”

So he wants his ET tube, ventilated patients participating around, maybe that has to be the new standard, because obviously, you need to be awake enough to understand what they’re talking about and to write in your opinion about what they’re saying about you and your care. So again, empowering II for empowering the patients who participated in their own care.

Kali Dayton 1:02:44
I love that. Absolutely. I think this will be really unique, a unique perspective for many that listen to this podcast or to this episode. Specifically, I’m already thinking of people that I wasn’t want to send this out to. Because again, the definition is on the fritz.

Heidi Engel 1:03:04
If I had not seen it myself, I mean, I saw it in probably Billy’s ICU in the wake of walking ICU. I seen it in our own ICU with our patients who are on ventilators for weeks waiting for a lung transplant. They initially have a hard time walking couple days later they realized walking is part of the routine. They communicate fully, but that’s because they’ve had no sedation running night or day. They’ve just learned to to make that adaption for their own benefit. So I have had patients where I’ve seen it do such magic.

And I have also patients who have this switch flip, sedation, oxidation, oxidation, oxidation of n, and yes, their eyes are open. Yes, there was zero in the sedation off phase of the day. But mobilizing them is so so so so challenging. There can negative but they still lack a lot of things that normal mobility should be able to provide to them. And there we are, we are denying them those benefits.

Kali Dayton 1:04:21
Everyone nursing from a nursing perspective, for so many patients is difficult to get them from sedated took Ross to zero. I can’t imagine wanting to do that every day. It’s just challenging. So this is and then spent takes a lot more of your time and your effort with lower reward. Yeah, to have to then try to work through that sedation and that, that cloud every day, every time with that with patients. So this is really also about making our process more efficient and more effective for our teams as well as our patients.

Heidi Engel 1:04:55
Yes. Oh, absolutely. You know, yep. The first day or To it could be a bit of a wild ride to help this person get through their sedation mean, they’ve been on if they’ve come in from an outside hospital, they’d be on sedation on time. Are they going to get tech at Kartik? Yep. And they’re going to get to Kipnuk? Yep. Are you going to have to, you know, help tuck them down from their help find other ways to ride that wave? Yeah, because otherwise, you’re going to be doing this every single day. And it’s painful. It’s so painful Wakka moly process to have the sedation go on and off and on and off. And yeah. And

Kali Dayton 1:05:34
the week mark, and I see when we got patients from outside facilities, and we were having to work through that process. Everyone was both were willing to do it, because it’s the best thing for the patient, right. But also, we wish that we could turn back the clock and have gotten them on day one. Because we knew that it would not be that difficult, that this whole scenario could have been prevented likely, had we done our full weight walking approach never started sedation, they would not be that delirious, they would not maybe have ever developed elearning, and they wouldn’t be so weak, it wouldn’t be so difficult to monitor that patient, then try to rehabilitate them, everything got harder. Because of the perceived convenient route of sedation or mobility, it did not make it easier.

And so everyone was really upset also just to see the patients suffer, and be as scared and confused and debilitated as they were that’s really hard to swallow when you’ve seen the alternative. And so that’s hopefully the perspective that our patients our community will have in the future is to say, here’s the outcome that I want for my patient. I’ve seen that possible. I’ve seen it happen. And this is why we’re doing this and we’re gonna do it all the way. I do. Thank you so much for everything that you’ve shared. We’re gonna keep tapping into your reservoir of knowledge. Heidi comes with me on site to train teams. So we’re, uh, we’re working collaboratively and we’re excited to bring this to more ICUs thank you so much.

Heidi Engel 1:06:54
Thank you, Kelly. It’s always a pleasure to talk to you. Please keep doing all the great things you’re doing and thank you so much for having me today.

Kali Dayton 1:07:01
Thank you.

Transcribed by https://otter.ai