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What do physicians understand of the ABCDEF bundle? What are their perceptions of early mobility? How are their teams practicing the ABCDEF bundle in their own units? What do physicians need to be able to lead an Awake and Walking ICU approach in their units? I interviewed physicians while attending the CHEST conference to find answers to these questions.

Episode Transcription

Kali Dayton 1 0:00
This is the walking home from the ICU Podcast. I’m Kali Dayton, a nurse practitioner and ICU consultant. I help teams create awake and walking ICUs through evidence based sedation and mobility practices by hearing from survivors, clinicians and researchers will explore how to give ICU patients the best chance to walk out of the ICU and go home to survive and thrive. Welcome to the ICU revolution. Physicians hold a lot of power in the ICU. They are extremely educated, smart and expert in so many high level assessments, diagnostics, procedures and management of complex and critically ill patients, they have the final say and write the mandatory orders that are rarely questioned. I’ve seen their incredible influence to revolutionize the ICU, like in the example of Dr Makita fuchida In episode 133 Dr Brian Baluchi in episode 130 Dr Terry Clemmer in episode two, who gave unyielding support to Polly Bailey in the 1990s when she created the awakened walking ICU process. Just last episode, we learned from Dr jahidul alam about his physician leadership in his ICU in Bangladesh. I’ve also seen the opposite, in which physicians prevent their teams from being able to update their practices. Throughout my consulting journey, I have seen physicians really step up to engage in trainings and help take lead. I’ve also seen others that seem to not recognize the importance of the ABCDEF bundle. There is a perception of the bundle still being the ABCs of the early 2000s and just for awakening and breathing trials to check for intubation, there is sometimes a sense of, this is an RN and rehab thing. I already know about all of this. I don’t need the training. Then when they come on shift and find patients fully awake, sitting up and even walking, they panic. We have had incidences, and some of these ICUs we’ve trained in which physicians that did not engage in training come in and say things like, quote, why aren’t they sedated? Why are they up? This is insane. I trained a team this year in which one of their awesome attendings that was on was really happy to engage in the revolution. Yet during rounds, his endorsement and leadership of early mobility was to, quote, sling them to the chair on every patient, he needed more clarity about what early mobility really is. We are all a product of our education, training and experiences. I really doubt that I would have questioned sedation and immobility if I hadn’t started in an awake and walking ICU. I recently attended the chess conference to present with Dr del Needham, Dr Wes Ely and Heidi Engel. While I was there, I tried to understand the physician focus and perception of caring for patients on mechanical ventilation. I wanted to know as an organization primarily comprised of physicians, the heavy focus on critical care medicine, do they put equal emphasis on getting the endotracheal tube out as putting it in? It was disheartening to see that classes dedicated to management of patients on mechanical ventilation and another on ventilator dyssynchrony or so full there was standing room only and there was little to no mention of sedation, mobility and delirium management. Even in the class polls, increased sedation was a commonly selected answer for a response to ventilator dyssynchrony. So I set out to hear it from physicians personally. I followed the same model of spontaneous interviews in the hallway, like in episode 172 with nurses at NTI. I tried to select a range of ages and demographics to make sure I captured resident fellow, fairly new attending and very seasoned attending, perspective of how the ABCDEF bundle is going in their ICU as medical residents going into critical care. What are your thoughts about walking intubated patients on mechanical ventilation? And you can be honest,

Physician 4:14
I think when you start trading early on, it’s quite challenging because you’re not very comfortable with mechanical ventilation. And so if there’s any issues with complications, you don’t feel very comfortable managing those complications, and so you’re looking for help. But as you get more experience with managing these patients on the floor hiring the ICU, you feel they’re comfortable walking them and moving them around. We don’t do that our institution, but I’ve seen that other institutions, and I think for me, it would be quite challenging if we had to definitely want a lot of like support and like guidance on get to do. Yeah, I’ll kind of like what he says. I think one of the big things I see in general is multi discipline, right? So I think the big thing at least we do the jump with our system is getting full of care providers involved, and that includes physical therapy, social therapy. To drive this if we have the support, I think it’s important, because obviously mobility, I’ll just frailty decreases, and I’m hoping mobility will help, hopefully wean mentally sooner than later, but I don’t think it’s done as freaking independent about the same reasons, he said, is very challenging. Specifically, if you’re running a busy unit, and you have other patients to also manage, and you may not have enough things to tap in, like two, 3pm, as opposed to seven, eight.

Kali Dayton 5:28
Tell me about your education going into critical care. Have you guys learned about the ABCDEF bundle?

Physician 5:34
No, we have not. Maybe in a different capacity. I don’t recognize a term. At least I see liberation. Yeah, you’ve heard of Yeah. What have you been taught about it? ICU liberation in the sense of, like weaning, patients strong, just

Kali Dayton 5:49
having what you understand. What is ICU liberation?

Physician 5:52
If I had to guess, because I probably haven’t had to turn directly, I would say either. Has to do with two things. One is patients who are on some type of ventilation, not invasive or invasive, and helping them get mobilized, get better and get downgraded to force. Okay, you’re

Kali Dayton 6:06
not wrong. What have you guys learned about early mobility and delirium and sedation management in the ICU, in your formal education at medical students now as residents going into critical

Physician 6:19
care in terms of like sedation, we’re often taught the side effects, how to manage these patients while they’re on cellulitis or analgesics. We often try to wean sedation as much as possible. I see delirium, hospital delirium is very common. We often go on an everyday basis. I think we are taught and to reinforce throughout the ICU, really, to make sure that our patients are being weaned as much as possible, the more like a better most of the time. And so it’s something that we often focus on, and we often teach incoming residents as well. In terms of formal education, we do have formal education as well. I’ve actually worked on our modules to help do energy using sedation modules to help our new residents, especially interns, who are coming into the ICU on just basics of each patient deserves which are which sedatives are best for certain scenarios. How to manage them? What are the side effects and different case problem based learning for them to help practice with the sedations before they’re actually in the ICU and have to manage that after

Kali Dayton 7:13
you activate a patient. What are you taught to do after debation, or isn’t before intubation? How do you prepare a patient to be intubated? What do after in terms of sedation management,

Physician 7:23
if any specific sedation is, I think the big thing we do well is modeling before and after an intubation, having a game plan, right? I think it depends on the patient, and everything is patient centered and individualistic approach. So if we expect the patient has been aggravated, they’re being depends on what they’re being intubated for as well. But if they need deep sedation, right? We know what sedatives they reach for through the education and the maglisa, my colleagues. But also in the sense of, are there risk for sub excavation, or are they if they’re already intubated, we intubating them for like, a solar period. They’re in status, and we think they’re just going to resolve when we’re going to turn it off, turn off the phenobarb, and they’re gonna wake up and they’ll be fine. We want to keep them in the light sedation mode so we can do that quick on profit, quick extubation. So I think every patient is individualistic, but I think the one thing we do while is making sure we’re all on the same page, pre impulse, and that involves not just residents and most fellows and multi settings and malls, respiratory therapy,

Kali Dayton 8:18
what a patient is probably going to be intimated for a while, a few days at least, and they’re arrested, plus one on the ventilator, and they still have delirium. How do you manage that patient? What are the interventions to treat that delirium? That’s

Physician 8:32
a big question. Well, I know the one thing you would often do for Delian, which you shouldn’t do, we’re not for delirium, for agitation only you should not do in delirium, is like benzene, right? So I think it depends how aggregated they are. Obviously, they’re intubated and they’re rats one, they’re awake, but something you can go back to the YouTube literally, kind of reorient and kind of just talk or do, because if they it’ll be different. If they wake up, they’re both negative one, and they are like, Oh my God, there’s something in my mouth, right? Versus they are already aware, they recall that moment, and they’re just now like, Okay, I’m ready to first to come out. I think it’s important assessing your patient. Are they actually ready? If the rest won as long as the rest, depending on what the rest of their clinical picture looks like, maybe it’s time to just take it

Kali Dayton 9:13
out, maybe. But what if they still are on the heap of content? Well, lungs aren’t ready. And, yeah, we’re doing the awakening trial, and the comedores a plus one, and they have delirium. Do you restart the larogetic nets like propofol? I

Physician 9:29
think it depends on the patient, right? Like you’re mentioning that this patient isn’t ready, and so we weigh all the options. And so yes, some of these things do have side effects, and it’s a risk versus benefit, right? We have to move this patient, and there’s a risk that they’re reinterpreted, right? There’s a risk of other things. So you have to rate your options on what would be best for the patient. Again, the tube is not going to be like comfortable these patients, and so we’ll also have to understand that some of these are going to be for their benefits and manage their pain. You can, instead of doing just continuous addition, you can do intervals. You can do you do work with your nursing staff through. Really find what standard is work best if you can do prns instead of continuous. And I think there’s different modalities or different I don’t know if one patient model would fit in every patient. So it’s really a discussion, I think, and depends on the patient. Has

Kali Dayton 10:13
that ever been part of your training to respond to delirium, some anxiety? Rasa plus one plus two with mobility. Has it been part of your training to consider getting that patient up and mobilize? No,

Physician 10:26
and I think a lot of that is talking back to her within his questions. We feel, do we have the resources to do it? The answer is probably yes. But I think there’s a lot of other factors we ourselves. And as you said at our institution, we don’t walk around decide and see it walking into student mobility. We do have interpretations through physical therapy at times, depending on Rasta, but in that specific scenario, in Ras one activated major delirium through mobility is not something perceived as a

Kali Dayton 10:59
third to expect physicians to believe that they’ve kind of initiative that they’ve never seen it? Have been trained to do it, they don’t know how to do it. So certain you were physicians where you’re trying to climb it to the environment and learn basic the critical care. Are you comfortable and then being the leader? Is it fair to expect physicians to lead this? I

Physician 11:18
think everyone has different backgrounds, and so obviously in medicine, we have multiple disciplines. We work with the special fees. I think it’s important to someone who is specialized of this aspect, and I can hear our physical therapists. There are certain hospitals that do have models that do incorporate this. I think that asks like a resident like myself to come in and do this would be overwhelming, challenging and happy about sleeping, so I would come to look. But if I was given like, proper training, given the opportunity to learn and have like support, I think it’s important, and I would be like, where and be with, Okay, on this challenge, just to come out of like metas, just to come out of residency and be put in an ICU, and expect to do that, very fair to the patient, add to the resident?

Kali Dayton 12:02
Absolutely. So should it be part of standardized medical education to really learn how to mobilize patients, manage their anxiety, adaptation, delirium, with proper tools that you can lead a team like you’re expected

Speaker 3 12:15
to meet? Absolutely. I think the biggest thing about this initiative, I think everyone should feel comfortable taking on an initiative, and they feel confident about it right now that I’m learning about walking into beneficial something I’ve maybe seen on Instagram, but maybe never right have my mind training like, why don’t we do it? Why don’t we do it that often? And that initiative of magic should lead to some type of new implementation, intervention, in terms of, said there be for my division? Absolutely. But I think it also, everything we work on nowadays, everything’s institution based, right? I think everything, whether that’s whether that’s a cost marketing, whether that’s a resource, but if there’s initiative and there’s curiosity, you can get somebody in the hospital system to do some type of educational intervention and kind of get all the residents on board, because we all hear specifically as putting their fellows even more so, right? Because we may be working at a solution now that doesn’t walk into big investment, doesn’t do mobility for delirium or browser plus one, we may match or go elsewhere that does right? And in that place, they’re probably getting education, and we’ll learn that way. But

Kali Dayton 13:19
what about the resolution I drink? We’re all products of our experience and training, yes and so no pressure. But I really believe in the next dinners with clinicians to be open minded, malleable, and bring the evidence to the table to overcome what we’ve always done with what should we thank you so much. Thank you. As a fellow in critical care. What are your thoughts about walking and debated patients on mechanical ventilation in the ICU

Physician 13:45
in favor of it as a practice, from what I’ve learned in terms of its potential for benefit, but have no personal experience with it, yeah, at any institutions I

Kali Dayton 13:53
worked at. And how many institutions have you been at in my fellowship, I’ve rotated thus far in three hospitals for ICU.

Physician 14:01
You’ve learned about it in your formal education.

Kali Dayton 14:02
So has this been part of your medical education? It’s been reviewed into my clinical lectures and training.

Physician 14:07
Yeah, but yeah, I would say this part of my formal

Kali Dayton 14:12
education, and was it taught in a way that it’s a key part of now do patients on mechanical methylation?

Physician 14:18
I would not say there’s a key part, though, kind of as like a next step, ancillary thing, but not as one of the key features of the management and

Kali Dayton 14:28
what’s the timing of educated as like a rehabilitation measure.

Physician 14:32
I think it was in the context more in terms not rehabilitation, but like outcome, I’m in hospital disposition from the IC. That was my context of this. It was disgusting,

Kali Dayton 14:47
a nice idea that shows benefits, but any practical logistical education on how to do it, none, when to do it

Physician 14:56
similarly, none. That’d be like. The limitation is not practically. Hold of logistically, how to do this, and more specifically, what kind of patient is a good selection for this?

Kali Dayton 15:06
So just parallel mobility in general, but not what kind of exactly, not which patient inclusion, exclusion criteria,

Physician 15:14
exactly, none of that would I receive this right? So

Kali Dayton 15:17
in the critical care community, says our physicians won’t let us or they need to take lead. They need to take charge. Is it fair to expect that of you? But so once you become an attendee, you suddenly lead this initiative in your IC or wherever you land.

Physician 15:32
I mean, ultimately it should be something, but personally, I just need more exposure to training in it. But ultimately, it’s fair that the physician should be that, or certainly not be an obstacle to that, and definitely not. Do

Kali Dayton 15:48
you feel like physicians need and deserve more formalized education and more in depth training? Absolutely, absolutely, yeah, tell me about what delirium education has been during your education, certainly,

Physician 16:01
personally, I’ve had a lot more education in delirium identification and then management. In internal medicine training, we do a lot of that too. So in hospital medicine, internal medicine definitely much more covered than mobility. Do you know how to do a cam? I see you. I’ve done them the time. I’d google it again, but I’ve got a part of your assessment? No, I do. I want review sometimes, I would say not, every time. Sometimes it’s nursing those like the ICS or the KC score, but I do delayed assessments, yeah,

Kali Dayton 16:30
and let’s say a patient is on a paper 10 60% and they’re a rasa plus one, and they seem to be delirious. That nurse says the patient is cam positive, okay, but they’re concerned about this rasa plus one. What you do? What are your interventions to treat that delirium

Physician 16:53
at any particular for me, is always looking for any kind of factor in the hospital that’s like causing an altered mental state, an infection vent to synchrony in this ventilated patient would be something I look forward to. And then, after trying to optimize everything, would consider if there was issues, like terms of a safety issue for the patient, or something like that, increasing sedation. But otherwise, would just try to optimize all the variables around it as much as possible to improve the delirium.

Kali Dayton 17:21
Would mobility ever cross your mind as an intervention to treat their delirium? Now

Physician 17:25
that you say it, yes, but prior to that prompt, I can’t say it would. I would think of all these other environmental things, family to bedside and day night, like optimization and all these other things. But I can’t say that I would have thought mobility. And now that you would that prompted Absolutely, but culturally, the nurse is

Kali Dayton 17:43
going to be inclined to resume sedation. You haven’t mentioned maybe resume and sedation.

Physician 17:47
Maybe, if there was, like, there the learning was progressive point where there’s like, safety issues, pulling it lions or tube

Kali Dayton 17:54
or something like that. So more of a rasa, plus three or plus four. Yeah. So

Physician 17:57
they were going up in the wrong direction, but if they weren’t going in the wrong direction, then, no, no, no, sedation, plus one.

Kali Dayton 18:03
That’s hard to manage as a nurse, right? You turn your back, you don’t know what it’s gonna escalate 100% but does it make sense to give deliriogenic medication in response to delirium?

Physician 18:14
Oh, never know. No, it’s done so frequently, but no, it

Kali Dayton 18:17
does not make sense. But culturally, that’s how you’re trained to accept, yeah, yeah. So it’s a common practice, for sure. Any suggestions that you would give for the medical community on how to better prepare, on incoming positions, on how to be leaders in early mobility,

Physician 18:32
I guess putting it always in context with just all the other core measures that we do for patients, in terms of benchmarks that we want to hit with everyone, like viewing it as one of those would then give it more standing, more focus. So I think like keeping it in the context of this is like a benchmarkation. Thank you so much. Absolutely integrated, break or integrated? Like, integrated, integrated, orally, yeah, okay. Well, if it were me, it won’t be comfortable, but I see the point in why they’re trying to do it. It depends on how sick the patient is, meaning, what is their oxygen demands, how much metabolic work they’re going to be doing walking, if they’re intubated for and they’re on the process of recovery, then maybe something can be considered, but it’s going to be uncomfortable walking them with an ET tube. Maybe, if they’re treated or on ECMO, that makes perfect sense, but I’m not sure about ET tube and walking and you do transplant rehabilitation prior to transplant, some transplant units are very aggressive with mobilizing their intubated patients for transplant. What have you experienced? So in our center, we are in walking ECMO center. So for our patients who are ECMO bridge to transplant, we make it a point to make sure they walk every single day, and we vouch for our physical therapy team, and they’ve done such a great job with ICU. Patients making sure they’re at bedside every day. The time is dropped off, we avoid any disruptions and PT time. So it’s super important to walk our patients who are waiting on the transplant list, excellent.

Kali Dayton 20:11
And if they’re only on mechanical ventilation, then it’s more of a gray zone,

Physician 20:15
correct? But if they’re trach, we will still try to do range of motion exercises when they’re in bed, and

Kali Dayton 20:22
if it’s maybe someone with the severe aid, yes, by the time they get to ECMO, they’ve usually been sedated, immobilized, and then we’re rehabilitating them, correct?

Physician 20:31
Yeah, we still try to make sure they’re able to set foot on ground and walk a few steps, so it’s very painful the first few days, but we try to make sure because it’s hard to advocate for a patient who is not able to walk, so we try to get them there before they can still be on the list and be rehabilitating. We’ve had accidents with patients with ECMO cannulas, with cannula breakage or bleeding from the cannula side, while we are trying to make patients up and walk them. But that should not be something that would stop anyone from walking patients on ECMO. I think there’s a way to deal with complications. Oh,

Kali Dayton 21:06
that makes me so nervous. That’s everyone’s worst fear, right? Is that something happens with the canyon the device, and that is their lifeline. So why wouldn’t you just scrap the program if something happens? Why do you still keep trying? Well,

Physician 21:19
because of the benefits of having these patients awake and seeing the progress they’re making is so important. It’s important to their well being, it’s important to their family, their caregivers, and also it’s our confidence in our team that we can handle complications, and we have a full supporting team at the time. So you know, complications happen. If you don’t extubate enough patients, you won’t have the intubation so that shouldn’t stop you from extubating patients. I think of it the same way with walking at more patients. Hey, as

Kali Dayton 21:48
residents applying for your fellowship in critical care, what are your thoughts and feelings about walking intubated patients?

Physician 21:54
Oh, major fan. Early mobilization is very important to wean a ventilator, been at a couple different hospitals where there’s been implemented mobilization protocols challenging because it’s time intensive, labor intensive, whereas a lot of coordination. But ultimately, we’re combating that critical illness, myopathy, we’re getting out of bed, we’re stretching those lungs as best we can, and even combating some of those secondary factors that prolong your intubation, like medications, delirium, all those extra pieces.

Kali Dayton 22:28
Okay, did you learn this in medical school, or you go, did you learn this from working on site with those kind of teams, with that kind of culture,

Physician 22:35
partially with teams in that kind of culture, and I have a background ICU charge nurse for a lot of years before I went to medical school, so I’m well versed in a lot of those techniques, essentially just from past experiences. Yes, that’s

Kali Dayton 22:49
a very different perspective. And our friend here, what’s your perspective? We worked in critical care before as a resident, I’ve been the upper level on our ICU many times. And I think the I agree with him, early mobilization, the earlier you can ambulate people, the better they do, not just even from a part of that cardiovascular standpoint, but the GI tract. Everything works better when you can move patients. The only thing that I would have challenges with, I’m at a community based center, and so having resources is usually the biggest limitation for these things, not just resources of things, but of people. And how do you encourage the hospital systems to invest in those resources? There has to be some type of benefit. So I think emphasizing that shorter duration of stay in the ICU is huge. And we all know, the sooner you can get people to an ambulatory state. This is post op. This is whether they’ve been in the hospital for whatever situation. The sooner they move, the better I’m and the sooner you can get them off of the awesome being intubated, off of mechanical ventilation, the sooner you can get them out of the ICU. That’s a big motivating factor for community based programs that rely on that income to keep patients moving and to keep the hospital afloat. So what do you do if now you go into your fellowship and you’re going into an ICU that has barely heard of these concepts, they have their patients deeply sedated. No one’s being mobilized. What do you do as now a physician, ethically and then even logistically? How are you going to lead that?

Physician 24:27
I think the important piece is to understand whatever culture you end up in, there’s always room for growth and change. That being said, growth and change can be challenging in areas that are already well structured and have an organizational pattern in place. The big thing is really bringing to the forefront that as physicians, along with all of our colleagues, the RTS nurses, the nurse practitioners, the pharmacists, our goal is doing the best care that we can. In for the patient, and if we’re not willing to stretch and make that a possibility, are we really doing what we can to ensure that they have the best outcomes and get the tubes out, get them out of the ICU, get them out of the hospital, and get them back to their families and the rest of their lives,

Kali Dayton 25:18
having been a nurse, it’s in your wheelhouse, just go in and start moving the patients right. You’re just used to that. But good luck to you both in your fellowship. What are your thoughts and feelings about walking intubated patients on mechanical ventilation in the ICU, getting them up and walking?

Physician 25:34
Number one, we have to see why the patient need mechanical ventilation this and that you start treating the underlying problem, and you see, how can you get him or her of the mechanical ventilation? First, they

Kali Dayton 25:48
are acutely ill. Let’s say ventilator settings are still maybe a peep of 10 and 60% and they may not be able to get off the ventilator in the next few days. How do you feel about walking them then maybe with a simple amount, you will say,

Physician 26:02
Okay, again, you treat the underlying cause, and we’ll see what’s the prognosis of that. Usually we try to keep them the least number of days, the kind of calculation. And if you’re able to get them off that, get them off the bed quick, and this way they can start moving and build up. There’s a few things how to get off there. Number one was the cardiac standpoint, are they in failure? They’re not in failure. What’s the status? Secondly, you have to get them off the bed. You have to check some blood work as magnesium TSH to make sure that they are fine. So the diaphragm will work. That’s how we look at things. And you try to use non invasive to get them off mechanical Bucha. So you have to look overall in the patient, oh, he’s two of these intubated. Watch this street underlying cause. Let’s see, are we feeding the patient? Not because often enough patient in Ico, they will be very concerned about treating the problem. They’re not feeding them. I’m not getting them off the bed. And this are the best line ABCs in medicine, get them off the bed, feed them, let them move and try to put them on seat in between so they can breathe out in their own deck. And give you an idea what’s the next step.

Kali Dayton 27:34
So has it been your practice to primarily initiate mobility once they’re off the ventilator? That’s definite,

Physician 27:40
because we know patient bed will increase the rest for DVT and PE so you need to work prevent that from happening, and you make sure the muscles are working, because if, for some reason, they are on steroids, they can get straight myopathy, get them off steroid quicker by treating the underlying condition. Absolutely. Have you ever had intubated patients mobilizing while still on the ventilator with endotracheal tube mobilizing when they are or in a condition that needed to be in tube, they are not able to move much. So you have, if you tube them, make sure you sedate them so they will be the machine, the mechanical volition will work with them, not fighting, trying to pull the tube, not doing this. And you have to work like as a team. What I mean by that? You have to work as well with physical therapy. They need to be there. You need to lighten the sedation so they can breathe, and you give them chance to breathe in their own thank you so much.

Kali Dayton 28:51
And if you’ve been listening to this podcast, you’re likely convinced that sedation and mobility practices in the ICU need to change. The ICU community is facing incredible difficulty with the trauma from the pandemic, staffing crisis and burnout. We cannot afford to continue practices that result in poor patient outcomes, more time in the ICU, higher healthcare costs and greater workload for the ICU team, yet the prospect of changing decades of beliefs, practices and culture across all disciplines of the ICU is a daunting task. How does this transformation start? It can begin with a consultation with me to discuss your team’s current practices barriers, and to formulate a plan to help your ICU become an awake and walking ICU. I help teams master the ABCDEF bundle through education, consulting, simulation, training and bedside support. Let’s work together to move your team into the future of evidence based ICU care. Click the link in the show notes of this episode to find out more. Actually, it’s something that I have

Physician 29:59
because. Parents in our ICUs. I think it’s great for patients, if we can get them to that point. I think it improves ventilation, days, ICU, length of stay. So honestly, it is something that I wish we were more proactive about it. I don’t see that much we did it a lot more before COVID, and I think we have gone backwards and regressed. But from a setting that I come from, I just think that the resources are probably not there, or providers, the multidisciplinary team, they’re not experienced in it, and the physical therapists that have that experience are really there’s many particularly ill patients. And how do you implement a program like that. And I come from a small, smaller size, non teaching, community hospital,

Kali Dayton 30:45
but you would be totally on board doing it if the team was doing it with you

Physician 30:49
exactly under percent. And I think there’s a lot of improvements, and there’s data to support how beneficial it is. So one of the moments of patients that sixth house is we actually had a patient that he was young, he was intubated for, so for a very long time, and we got him to the point of he sat in the chair, he was intubated, and he worked. He had his laptop out, and he really did work, his work there. So that was a memorable note. How much if you start this early enough and continue it, and I think post extubation and post ICU, I think there’s a lot of benefits from

Kali Dayton 31:26
How do you feel about walking intubated patients in the ICU? I think it’s important. And is this part of your practice? Yes,

Physician 31:33
yes.

Kali Dayton 31:34
How does your team get there?

Physician 31:36
It’s teamwork, collaborative. What’s

Kali Dayton 31:38
your role as a physician?

Physician 31:39
Well, I’m a medical director, so I help set up protocols in the workflows

Kali Dayton 31:44
perfect. And how do you have how long is your team practice this way, 810, years. And was it preserved during COVID?

Physician 31:51
The walking? No, but the proning. We had proning teams. And when you think of who should be the proners, which patients get prone the most in the operating room, those people get spine surgery, so the anesthesiologist and the Omar nurses are the experts, so they became the pruning teams. And it’s the same way with physical therapy and bedside nurses. You have to create teamwork. It’s all teamwork and critical care.

Kali Dayton 32:14
Love it. So what kind of ICU Do you run 34 of them? Okay, amongst those 34 ICUs? What percentage are sedated

Physician 32:22
depends on the type of ICU also,

Kali Dayton 32:24
right? Let’s say med surg ICU. Okay, that’s great. And how soon are patients mobilized, generally,

Physician 32:32
when they’re clinically able?

Kali Dayton 32:33
Perfect answer. Thank you so much. What are your thoughts and impressions about walking intubated patient?

Physician 32:40
Walking into baby patient. I haven’t done it myself. I know there are more people doing it, and I’ll be interested if there’s a enough support in the hospital.

Kali Dayton 32:52
Let’s say you have a physical therapist and a nurse coming to you and saying, got a patient on a pneumonia. Let’s say I keep on saying, PIPA, 10 and 80 60% can we get them up and walk them? They were just debated this morning. What would you say?

Physician 33:06
I would like to see him doing a little more activities before deciding to walk him out of the bed. Okay,

Kali Dayton 33:14
let’s say he was walking yesterday and got intubated this morning, and he’s awake right on a clipboard.

Physician 33:20
More even then, I would like to see him at least getting out of the bed, maybe mobilized to the chair, taking few steps with multiple physical therapists before deciding to walk him out of

Kali Dayton 33:32
the room. Perfect, doing it progressively, and seeing how he does. Just honestly, would you be nervous,

Physician 33:37
I think, to certain extent. But I mean, I think as soon as there’s enough support to, you know, walk with the patient. I think I’ll be reasonably comfortable.

Kali Dayton 33:44
And how long have you practiced in critical care? 12 years, 12 years. And if your hospital administrator said, Dr so and so, lead this. Make it happen. Do it. We don’t decrease this cost. Just go do it. How would you feel about that? What would you say to I

Physician 34:02
mean, I wouldn’t be necessarily pressured by the Osprey administration. I mean, as soon as we can find the good evidence and find enough support to do the patient care, then I think, I mean, I wouldn’t be necessarily pressured by that good

Kali Dayton 34:13
and what would you need to be able to lead this in your team? I think, of

Physician 34:17
course, you need to educate the staff, show them the evidence, give them the example of other systems, and do one patient at a time, and see what the outcome is within the hospital, and see if there’s improvement in an outcome to convince other people, I guess so. The right support and training, you’d be okay with it. I think so.

Kali Dayton 34:35
Thank you so much. So what are your feelings and thoughts about walking intubated patients on mechanical ventilation,

Physician 34:41
like someone is independent of walking. Yeah, I think, I think I’m not very surprised, because I think it’s too actually play standard. So I think those has COVID in the future. I think it’s coming. And have you done this in your. Practice. Well, I haven’t done yet, but that about it, and I think I can go through when I thought about it, I it was a long time ago, so I don’t recall what I did and how I all this information. I know, but when I read about it, when I thought about it, I felt that it’s doable, and I had very like, I was hopeful for the future, but most like the

Kali Dayton 35:27
same this. So it’s logical to you, right? Like it is, what would it take for you to be able to lead this in your team, to make it common?

Physician 35:36
Maybe? Well, the big part is the education, right? And the other part is the science do that, and if we are able to do that, maybe, and how, if there is any implications of anything patterns up, which we need to be addressed, and who is gonna, who’s gonna do that, right? So there’s lots of things that has to be in place before we do something, like, like, crazy thing, like, right? I think it’s doable. Yeah, I think it’s doable. We just need education, a good system and innovation. You don’t have to have, like, very important, the right

Kali Dayton 36:24
equipment processes. I’m gonna bring another question on you. How accurate are your RAS scores right now in your ICU? So I’m assuming you order like a zero to negative two, right? There’s sedation. Now you’re laughing. What’s actually happening when you go to assess your patient. So it’s very

Physician 36:41
supportive. And also who is doing good barriers? And so it’s like, I do something, or a nurse does something. It can get different, because nurses significant snapshot, yeah, so maybe I’m not the best guy to titrate sedation. They are doing it. But again, you know, the Narsing staff, everyone has that different perspective. It’s quite impossible to to get that like scale and neck. So let’s say

Kali Dayton 37:14
I mean Russ, negative one, negative two, negative three. They’re supposed to respond to voice, do your patients usually, when they’re sedated, do they respond the voice, well, well, no,

Physician 37:28
maybe not all

Kali Dayton 37:30
the stuff. So now you’re going from like somewhere in a light, moderate sedation. Now they’re deeply sedated, right?

Physician 37:37
So yeah, so I it’s it varies. I have seen that variation. And

Kali Dayton 37:43
you as physician, and honestly, this is, this is anonymous, right? What is your response to that? Do you feel safe to raise those concerns or to try to guide those things? Or is it kind of like, well, that’s the nurses thing. The nurse is taking care of them. The nurse is going to do what

Physician 37:57
the nurse says. Yes. And I think when we raise this question after we I don’t want to lose the word carefully, we’re working together, right? If I just go and raise all these questions, you know, I might sound independent. I might sound like that. The other person who’s thinking, there’s so many angles that good times, right? So I think when the team dynamics is better, now, of course, pushing out and better. So I think the relationship between the team members, as a member physician, international staff, that is a good communication. I think then you can raise these questions and have a good outcome. You can have a sit down. You can you can sit down and talk to them. And this is my views. Everyone can

Kali Dayton 38:48
pitch in, and we can no we can start small, maybe like a bigger so it needs the environment in order for a physician to say, hey, you were giving too much sedation. But if a nurse would give an extra gram of ancill, the pharmacist, physician would speak up and be like, whoa, whoa, whoa. That’s how it was ordered. When it comes to sedation, we’re giving more sedation than is ordered, but it’s still very touchy to approach that topic. Yes, it is.

Physician 39:21
We don’t want our and then the like ventilator of dysentery. I know we’re not talking about that, but yeah, yeah. So when the synchronous, certain it’s not, you know, I feel like if someone goes to the bedside, look at the like grass, right, and try to adjust the Panther before seated in the patient. Maybe that’s better actively. And there is residents, there are fellows, right? Even just with therapists, right? They have their input. So everyone use things different. But I think, I think that that’s not why you’re increasing the solution. Adjust something. Or any other things we can just try to see if there’s any other things we can do to help the patient.

Kali Dayton 40:05
I love that, because as an MP, I obviously have an RN perspective as well, and it takes the entire team just because the nurses are one breaking up the sedation, does that mean it’s all on them? So we need the entire team food environment where we can say, Hey, can I go in with you as we turn down the sedation. I just think this is what going on for ventilator. Let me adjust the things. Let me help you. So we did that. I love Thank you. What are your thoughts, impressions and experiences with walking intubated patients on my chemical ventilation? Experiences

Physician 40:35
wise, we don’t do we don’t do it. I think we have limitations and experience and resources. I think it’s a good idea. It’s a very small population that probably could do it, but I think it’s a good idea in that population. And what’s your specialty of ICU, medical ICU.

Kali Dayton 40:50
I’m biased, but I come from a high acuity medical, surgical ICU, and most patients were mobilized, but it’s understanding what’s real, inclusion, exclusion, criteria. What are your thoughts? My

Physician 41:02
thoughts is, patients that would qualify would benefit from it. It’s the resource limitation that’s keeping it from happening at

Kali Dayton 41:08
our institution. And what would it take to make this happen at the common process of care in your ICU, respiratory dt, all the what

Physician 41:18
are the things called the US to which the patients in the thoracic Walker, right? All the resources, and

Kali Dayton 41:23
if your executive leadership team knew that this could decrease their cost by 30% do you think then they might be interested?

Physician 41:31
I’m not sure. I think, because it does take upfront resources, which, like, we don’t have a lot of physical therapy resources available for ICU patients. For those upfront resources. I don’t know if they’d be willing to spend them. It’s just tough time right now. We also have

Kali Dayton 41:45
that long term plan, right? Do they know that if they spend 1000s, they could save millions annually for years to come? Doesn’t affect this year’s budget? That’s the problem, right? We’re just looking at the hair, and now we can roll our eyes at them, but we did that in the ICU too, right? And start to get through my shift this next hour. Do you think that you’re or you know if your RAS scores are accurate in your ICU are I’m assuming you order RASS as they are to negative. Is that really the parameter in which your patients are sedated?

Physician 42:14
It’s a good question. I don’t it’s a safe place. I honestly don’t know systematically if it’s accurate. So we actually just went to arrest. We used to use the SAS, but it’s always different, so we’re trying to get used to it. But I don’t know. I don’t know if they’re, I think they generally are, I would say, and we do daily awakening trials, and I think that’s gotten pretty good the last couple years. I don’t know if they’re meeting their target RASS all the time. So

Kali Dayton 42:38
are your patients responsive to voice when you assess them,

Physician 42:41
yes, we check them all the time, you know. So we go in on rounds, and if they’re not, I say, please do an essay. Excellent.

Kali Dayton 42:47
And what does your team do? And how would you support them as a physician? If they do the SAT and the patient comes out at a RAS says, plus one, what’s the normal response if

Physician 42:59
you do an essay? Normal responses. Keep going, um, do an SBT and see if you can get it next paper

Kali Dayton 43:06
at the rasa plus one, and they fail their SBT. What’s the next normal course of

Physician 43:10
action? Continue the same care. So keep them awake. Them off sedation. Are they doing? Are they fine? Are they well, they’re

Kali Dayton 43:16
rasa plus one. So fine is very subjective. I think rasa one plus one is fine. Is that fine on your unit? Are your nurses comfortable with a recipe? Plus one? Do they know how to treat eresa plus one? Are we talking nine nurses or day nurses?

Physician 43:27
Okay, tell me about that. There’s a difference, right? Nine nurses, they’ll use more resources to keep a person asleep, and the day team reverses that.

Kali Dayton 43:37
And are physicians present at the bedside, doing rounds at night like they are during the day. Sometimes,

Physician 43:42
yeah, physicians are present, but not as present, because at night, there’s only one physician for both of our medical ICUs in our institution, and you’re doing consults in the ED in the floors and coats, so we’re not rounding on the bedside, on all the patients at night. What about

Kali Dayton 43:57
cam screen? Is that accurately and consistently happening. You walk down the halls and you hear s a oh, here it

Physician 44:05
is, happening consistently, as documented as happening, and I think it is accurate. Um, so, yeah, yeah, I don’t hear it. I don’t know, because I’m not we’re not in the unit the whole time. We’re rounding around the hospital. So, but you feel like, confident, yes, yeah, because I think when I see it and it seems accurate to my assessment, even though I may get not do the whole cam ICU assessment, but I think it is accurate

Kali Dayton 44:26
as physicians, how do you help your team take it to the next level of keeping patients awake, communicative, autonomous and mobile, per the adaf bundle, what do you understand to be rule? Well, I think one

Physician 44:35
is we focus on which drugs we’re using, propofol over burst. That’s a big one, right? Keep the burst away, because we know you turn the profile off, you’re going to wake up, I think, if it’s not happening, just understanding why it’s not happening. So from like getting the point of view of the nurses or other providers, and what’s the concern? Why is the rest minus three? Or why not get an sh? There’s usually a reason. So if we can understand that, or we can deal with it, so.

Kali Dayton 45:00
And as physicians, you feel like you’re in an environment when which you’re safe to ask, why are they negative? Three?

Physician 45:04
Yes,

Kali Dayton 45:05
absolutely great. Thank you so much. So as a resident, what are your thoughts, impressions and experiences with walking, intubated patients on mechanical ventilation?

Physician 45:19
Walking, intuitive, interesting idea. Yeah, decreased ICU weakness. I think that’s the biggest thing.

Kali Dayton 45:26
Have you seen it and the ICS that you’ve been in this far? So unfortunately, our hospital, because we have lower staff, we weren’t able to do that thus far. I know a lot of our attendees who come from bigger programs to recommend it, and a lot of nursing staff who comes from different academic hospitals. Do you recommend it? But

Physician 45:44
unfortunately, because of our staff members, we weren’t able to do that. We

Kali Dayton 45:47
are trying to push for that. As a fellow, what is your experience and insights into walking patients that are intubated on mechanical ventilation?

Physician 45:56
Don’t think I’ve ever seen a patient walking on the mechanical Have you learned anything

Kali Dayton 45:59
about it? I mean, your face looks like face looks confused, shocked. I

Physician 46:05
wouldn’t say it’s confused. I think it’s very challenging to move and have patients are intubated and on a ventilator to walk. We do that with tracheostomy, basically on a tree, on the ventilator. We have walk with a platform or with a walker, depends on their muscle strength, but a patient who is intubated, I think that would be a very big challenge, risking losing the airway. And basically that would mean that, yeah, what? What

Kali Dayton 46:34
would you guess the rate of unplanned extubation is during mobility, and even during walking,

Physician 46:42
I don’t have that number up top of my head. So I

Kali Dayton 46:44
would you be surprised to hear it’s less than even point 6% that would

Physician 46:48
be surprising, but I would imagine it’s doable, but it would need a lot of training, and it’s labor intensive, so it’s not something that I think we can do, at least like nowadays, that we can generalize all ICUs and expect them to walk the patients. Absolutely, we’re

Kali Dayton 47:05
not trained and prepared for it. In most ICUs. What about if a nurse came to you and wanted to get her patients sitting up? There are patients sitting up at the side of the bed, maybe walk into the chair while intubated. What would be your thoughts about that,

Physician 47:18
if they’re trained to it, and if they have all the precautions I’m for it, how do you

Kali Dayton 47:22
feel like things are going in? You’ve worked in three different ICUs and according to your observations, how accurate are the RAS scores? So you might order rasher negative. Have you noticed that’s usually the level of RAS that patients are at with sedated or is it common to have them more deeply sedated?

Speaker 9 47:39
So far, I would say mostly accurate. We do have those swings, especially when the patients get agitated or the synchronous with the ventilator. So we have push so they should say they get pushed over to like more than like minus three, minus four, but we come back on that. So I would say it’s mostly accurate, but there are like the outliers.

Kali Dayton 48:00
Thank you so much. What are your thoughts and experiences with walking intubated patients on mechanical ventilation?

Physician 48:07
So we haven’t done it. Only patients, if they have a cast, we we could consider doing it, but if they are intubated with the ET tube, it’s unlikely that we’ve done it. And why is that? I just say, safety of the patient and inability to make sure that the tube doesn’t get dislodged, and some of them are not going to be anxious enough to do it, or weak if they’re weak now, they’re alert, awake and hard reading ET tube, that’s a rare patient.

Kali Dayton 48:32
And how do you feel like ABCDF bundle compliance is on your unit right now? Pretty good.

Physician 48:38
We have a PMR that has it part of the system for the ICU care. So that’s what we do. Excellent.

Kali Dayton 48:44
And what kind of RAS score do you usually order when you prescribe sedation on normal patient? Most

Physician 48:51
of them are going to be minus three or something that they can be aroused from. But we always discontinue sedation, usually by morning hours, and then we start as necessary.

Kali Dayton 49:01
And do you feel like your RAS scores are accurate? You feel like what you order is what is performed with patients? Yeah, I

Physician 49:08
think the nurses follow through around every day and look at it. If it didn’t seem to follow, then we’ll tell them. Thank

Kali Dayton 49:13
you so much. How do you feel? Or what have you experienced with walking intubated patients on mechanical ventilation is

Physician 49:18
very resource intensive, but I think is good for the patients. Do they do it on your unit? And because it’s resource intensive, any other barriers? I guess it’s culture to getting all the nursing and physical therapy and back to resources and staffing.

Kali Dayton 49:33
If like, Russ scores are accurate on your unit, what do you order for us? We always

Physician 49:40
try to keep them not too sedated, obviously, but it’s very hard overnight nursing staff do whatever they want to just keep these patients deeply sedated. So it takes all day long to wake them up absolutely

Kali Dayton 49:50
as an intensivist, do you feel like you’re able to speak up, guide them, or is a tough thing to navigate or to bring up nurses we

Physician 49:59
used to. Courses. Again,

Kali Dayton 50:00
it’s a problem. How do you feel like your team is doing with the ABCDEF bundle? Reasonably well, again, the

Unknown Speaker 50:06
mobilization of stuff we need down sedation and stuff.

Kali Dayton 50:09
Thank you so much. So my portable microphone stopped working during an interview with a seasoned physician that expressed concerns about the safety and feasibility of walking intubated patients. He reported that most of his patients were unresponsive to voice and that delirium was not consistently checked or discussed. Then when I asked him how the ABCDEF bundle was going in his unit, he said, quote, pretty good. This is the call to chest ATS medical programs, fellowship programs, let’s give physicians the education and tools they need to be effective leaders in creating awake and walking ICUs help them see the ABCDEF bundle as more than just the ABC bundle from the early 2000s we need to be way past just focusing on daily awakening and breathing trials. They need to see being awake and mobile as just important as which antibiotic to give, which ventilator settings to order, and what kind or how much food to order, they need to see early mobility as a treatment for acute respiratory failure and a measure to prevent and treat delirium and ice acquired weakness. They need to understand that providing mobility as soon as possible prevents many tracheostomies, rather than wait for a tracheostomy to then start mobility as rehabilitation on the back end, placing an endotracheal tube is a very important skill, but getting it out as soon as possible with the least damage possible should be a top priority, because If their critical illness doesn’t kill them. Sedation and immobility just might do it. We need intensivists to be educated on what awakened walking ICUs are and how to lead teams to create and sustain them. This needs to be nursing driven, but physician LED. If physicians are not bought in, it won’t happen when physicians expect most patients to be awake, communicative, autonomous and mobile, and when they know how to make that happen, and order that with as much flexibility as an antibiotic, it will get done foreign. To schedule a consultation for your ICU as well as find supportive resources such as the free ebook case studies, Episode citations and transcripts, please check out the website

Transcribed by https://otter.ai

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