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Standardized sedation and immobility are rooted in a gap in education. What is the power of a nurse educator in transforming knowledge, culture, and practice in the ICU? Jeana Flakes, MSN, RN shares how she helped lead the ICU Revolution as a nurse educator at Mercy San Juan Medical Center.

Episode Transcription

Kali Dayton 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. You I am thrilled to start a series of weekly episodes with the incredible team at Mercy San Juan Medical Center. Mercy San Juan is a level two trauma hospital in Sacramento, California with five ICUs neuro trauma, surgical, medical and cardiovascular in episode 123 one of their medical directors, Dr Peter Murphy, shared his astounding conversion after nearly 50 years of medical practice when he learned about awaken walking ICUs and even visited LDS hospital himself. For years, he pushed and pushed at Mercy, San Juan, my team and I had the incredible honor of training those five ICUs at Marcia San Juan this year, the next seven episodes or so will be with some of the key players in these ICUs that have dedicated so much time, effort, blood, sweat and tears to bringing a radical transformation to their critical care department. I am beyond proud of the progress they have made, and excited to share their journey with you. This episode, we will start with Gina flakes, the nurse educator who was a shining star in this evolution. Gina, welcome to the podcast. So excited to have you on. Gina and I have been friends for years, and it’s such a treat to be able to formally interview you as a podcast guest. Will you introduce yourself to us?

Gina flakes 2:07
Okay? My name is Gina flakes. I’m an educator here at Mercy San Juan Medical Center in Carmichael, California, which is a suburb outside of Sacramento, for people that don’t live out in this area. And I’ve been an ICU nurse since 2001 so 23 years. The first half of my career was spent in a surgical ICU. It was a six bed, small surgical ICU, but we saw a wide variety of different patients, high acuity patients, lots of vented patients. And then I went into the trauma ICU, and I was there for 10 years. And then I’ve been doing the Critical Care Education position for about four years now, started in critical

Kali Dayton 2:44
care medicine, 2000 Oh, one. I mean, you were really in some of the big advancements in technology and capacity within ICU. But also know that that time was very deeply rooted already in deep sedation and in mobility. So what was your experience early on in your career, and what was it like, and how did you get exposed to a new approach to critical care?

Gina flakes 3:08
I think I saw it probably when it was almost the worst. It was that I know of, just even through research and things like that. It was when the pendulum swung to where we were really deeply, heavily sedating patients. And it was even before they started researching like propofol syndrome and issues they were having with paralytics and long term muscle mass loss and things that came from those medications. And we would have patients on propofol literally at 100 mic Max, like we would go through a bottle an hour just think, you know, and wouldn’t blink an eye at that, and we would say, Okay, we think they’re finally ready to start weaning them from the ventilator, and it would take three days for them to wake up. And of course, they were like a wet noodle, right? Because they hadn’t been moving, and it would turn them but they weren’t really mobilizing, or we weren’t waking them up. We weren’t even doing spontaneous awakening trials then. So then the whole thing with the propofol came through, how many long term effects people were having. So then it was like, people can only be on propofol for three days, and we can only go to 60 mics. And so there started to be some limits. Then the spontaneous awakening trials started to get into the picture, and that became a pretty standard practice, the awakening and breathing trials, I think that part of the A through F bundle, we did pretty well for many years, but it stopped there, in a sense, like we didn’t really take it any further. We didn’t really look at the other elements of the bundle, and that part got built in, and we were doing it, but the patients were still not mobilizing, and they weren’t really getting out of bed, and we were still using sedation pretty regularly with vented patients. Now it was the standard they get vented among sedation because we wanted them to be quote unquote comfortable and sleeping, and all the things that cause terrible things to happen to our patients, things that we know. Now looking back, I think how many patients we probably put into delirium. Them, and that we caused all these terrible things to happen to them because of what we did, but we just didn’t really know any different, right? And so I think that’s where a lot of the for me, a lot of the motivation comes from, is righting the wrongs of all the years of over sedation. And I mean, I definitely was really good at it. It’s an easy thing to be good at.

Kali Dayton 5:23
And so what was the first exposure that you had to this different approach?

Gina flakes 5:30
Well, when I was in the trauma ICU, there was a lot of doctors coming out of UC Davis, and they were young, and they were up on the research, and they had the energy to fight about us old nurses that were stuck in our ways, and they were like, This is not the way to do things, and this is not appropriate, and sedation is harmful, and all these things. And I it was such a foreign concept to me, and I sat down with a doctor, and it’s the middle of the night, so I worked night shift, and we’re having this like back and forth debate about sedation. And finally he just looks at me and he goes, Okay, you don’t believe me. Go ahead and find me some research

Kali Dayton 6:06
and show me different. I was like, Alright, fine, I can do that.

Gina flakes 6:12
But I was telling all my co workers, I’m going to prove it. I’m going to show them. And I did my due diligence and dug into the research and looked for everything, and basically found out that I was completely wrong, and I had the ground to stand on. And I kept telling everybody, okay, I’m still looking but it’s not looking good, but I had to pedal and basically be like, Okay, I guess you’re right. I was definitely the one that would probably fight it the most, and so I think in part, that helped me when it came time to roll it out here, that I knew what I was up against. I was up against people like myself that were going to fight it and that weren’t going to be okay with the changes. And we’re going to understand the why, and we’re going to need to see it and feel it and touch it and smell it before they

Kali Dayton 7:01
Yeah. But understandable. I think that’s human nature. Also, when you’re experienced, you trust your experiences, and so it’s hard to be open to a new experience. So it’s also hard to say and accept what you have just said, that we harmed patients. That takes a lot of humility, but I’ve harmed patients. We all have, and we just did not know the prime probably the biggest culprit, because I had worked in an awakening walking ICU, and I still got sucked into the culture of the ICU. I just kept thinking, I remember as a traveler, I’m like, Well, it can’t be that bad, if everyone’s doing it right. If it was really harmful, they wouldn’t do it. So it’s hard to be just that aware of it’s harmful, and yet we do it even years after the fact. Tell me what your experience was with Dr e Lee’s book. Every deep, drawn breath.

Gina flakes 7:50
That definitely was the start of my perspective changes. I read the book. One of the doctors that I work with here was a huge advocate for this awaken walking. He had went to your hospital and saw what you guys were doing and came back just in a blaze, like we are going to do this, no matter what, kicking doors down, literally and

Kali Dayton 8:11
a little bit much for your team. No one’s ready for that, right?

Gina flakes 8:14
I appreciate his passion. Let’s just see. So, yeah, so he was like, I want to do a book club. And so he brought it to us, and I read it, which I don’t typically read for leisure. So it wasn’t really my nature to read, but I was like, hooked on this book once I started reading it, because it was almost like I was sitting down with him at dinner, and he was just telling me all his amazing stories and his journey. And it was fascinating to me. And so I just, I literally couldn’t stop. I just couldn’t wait to get another hour of time to sit down and open this book and and so it really left an impression on me, and I really appreciate the fact that he didn’t accept the norms. And then he looked at the practice and went, This is not right. We’re not doing something right, and what can we do differently? And I’m fascinated with people like him that look at the world and think there’s a different way to do this, and I’m going to figure it out, and they do right like he did. He figured out a better way. And that definitely left an impression on me, and it helped open my eyes to what happens to my patients when they leave the ice. I never really saw that part of it. We would go, okay, they’re great. They survived, and they went to the floor, and that was the end of our experience with them. We really, very rarely would have patients maybe come back and visit, or we would get an update, maybe from the floor nurse that we transferred to. Oh, how did so and so do when they left. And so we never really saw anything beyond that. We didn’t know all the long term effects that people were dealing with when they left the ICU. And I think hearing that from him, in his perspective of seeing the patients, when they come into the office and they’re like, completely dysfunctional because they had an ICU stay, it was really eye opening. Mean, and in my own way, in my mind, years being an ICU nurse for so many years, I had my own theories of what happened. I was like, it’s probably lack of oxygen, and they probably have a little bit of a noxia. There’s little micro clocks that go into their brain, and that’s why people don’t function the same way afterwards. And I didn’t make the association to these things like delirium and sedation and immobility hospital acquired

Kali Dayton 10:21
like a result of our interventions, right?

Gina flakes 10:24
I just looked at it as like part of the pathology. If you have an ICU stay, this is going to be your outcomes. This is what happens as a result, not realizing that, no, there’s a different path. Like we have a different we can create a different story. Basically, we can write a different story. And so that really opened my eyes. And then we worked with you closely, and we did the webinars in 21 and I was like, blown away when I heard all the different statistics and all the science behind it and the amount of research that’s gone into it. And so for me, I was like, getting to be like, Doctor Murphy, I’m just going to call it out, because that’s who it was. And I was ready to kick down the doors. And I was like, Okay, wait, this is not acceptable. Like, we can’t just close our eyes anymore to this. And we had another doctor do a talk, Dr Coates, and she’s another one that’s been a big advocate, and she talked about, like, the Santa Claus moment, where once you know you can’t not know, right? Like you can’t pretend like you don’t know. And so I think that’s the way it was for me, is that there was like, Okay, I can’t really go backwards now and pretend like this isn’t real. So I was willing to put the time and the effort in, and I think that’s the one piece that is hard because people get discouraged, and this has been over three year journey of trying to get this thing off the ground and really get some traction and movement. And it’s been very much like a collaborative effort where we’ve had the critical care directors, the doctors, both of our main doctors that are in critical care, Dr Bucha, Dr B strong. They were another ones that were like, right at it from the beginning, and they were right along with the war path. And like, this has to happen, the revolution. Yeah, exactly. It’s like, literally, that’s almost like what it felt like. And I think that helped drive the change is that they had belief in it, and they kept pushing it and pushing it because they knew that we were harming patients with what we were doing. But it is difficult, from a physician standpoint, to change nursing culture, so I think that’s where you need somebody in between. That’s where my role was communicating to the nurses why it matters to you. Then there’s the ELT portion of it, where you need your executive leadership team to back it and fund it and give you the resources that you need to do it. So you need somebody to speak their language also. So I think being in a role like mine is almost like an interpreter, or like a mediator, as I say, like when you sit down with a lawyer, because it’s like, you need somebody in the middle that can say, Okay, let me take this information and translate it into your language so that you understand why it’s important, and then I’m going to translate it into your language so you can see why it’s important. So that’s what I think

Kali Dayton 13:15
we always talk about. This is a gap in education. We keep saying that because it is you were not educated on this as a new nurse, but that’s back in 2001 but education didn’t hit your hospital until you basically brought it right. And you are one person in charge of education for five units in a very large and busy hospital and very different ICUs. You’ve got surgical, trauma, medical, cardiovascular and neuro, those are very different specialties. That’s a lot of very specialized education for many, many nurses, hundreds of nurses, that’s a lot. Now this is a new concept to you. You were bought in, but how do you get become the expert on something you’ve never done? How do you then radically transform the nursing education and then the culture on something so new that was a lot of responsibility. You were such a huge part of making those webinars happen back in 2021 but it was 2021 and we were in the thick of COVID. You guys were one of my first teams that I did a full webinar series with trying to figure out, how do I lay a foundation of knowledge and provider? And you were really receptive, but it was just a lot of information during a challenging and basically impossible time in critical care medicine. So then, what kind of pressure was that on? On you as a new revolutionist, as a nursing educator, as someone trying to manage five units of education during COVID and now trying to bring in this huge new change with all the passion you had, what kind of barriers did you face?

Gina flakes 14:50
Well, honestly, the barriers are endless. I feel like you could come up with a million reasons why you shouldn’t, wouldn’t, couldn’t. It was hard. There was a lot. But. I really knew that at the at my core, that this was the right thing to do. And so I wanted to keep pushing forward and look at what options we had. And of course, the doctors were still like, you need to make this happen.

Kali Dayton 15:13
You’re the nursing educator. Go ahead, educate the nurses. Uh huh, get

Gina flakes 15:17
the message through. And so I did take each nurse, basically one on one, and I sat down with them, and I said, Tell me what your takeaways were from the webinars. First of all, did you watch them? Because they were like, we feel like people didn’t really watch them, because it was via zoom and then a recording. And it’s so hard to really know how much people are taking in when they’re in that platform, and they’re going to basically get out of it, what they put into it, essentially, right? So I sat down with each person, one on one. Okay, tell me, did you watch the webinars? Number one, if so, what were your takeaways? And I would ask them the questions, and what did you think about it? And first I would get I haven’t watched it, or, yeah, I kind of watched it, but I didn’t, really didn’t. I just don’t even think it’s possible to implement something like that here. We don’t have the resources. We have patients like we still have our COVID patients, and we have to keep the doors closed, and we had them sedated because we were worried they’re going to extubate themselves and all these things.

Kali Dayton 16:23
So I heard all the reasons why we couldn’t, basically, and like, law, all the different things that people didn’t agree with.

Gina flakes 16:25
There was some people that were like, Yeah, well, we’ve moved patients on vents before. And I was like, Yeah, but when was the last time you’ve done it? Maybe you did it, like, five years ago or something, one time. But I don’t see patients getting up and moving on ventilators. Like, I’ve been in this position for a while now, I haven’t seen it, and they’re like, well, it’s just not a new concept. No, it’s not, but we’re not doing it. So, I mean, that’s not helpful. What can we do? Let’s talk about what we can do instead of what we are what we can’t. Let’s start limiting sedation. Let’s start trying to get people moving. Let’s just start something like one patient a day. I was like, just the simplest thing, one patient a day per unit, let’s get them up. Let’s do something. And then we were getting a lot of like, kind of heat from the upper leadership saying, we’re really not seeing a lot of change. We provided these resources for you, and we’re really not seeing a lot happening. And it was like, okay, part of the issue was we didn’t really have a way to track what was happening and what wasn’t happening. And I think once the dashboard came through with common spirit, that helped some, because then we at least had data. And we said, we could say, Okay, here’s our data, then our next step was, all right, we have data. Let’s look at what it is and how we’re being graded. In a sense, what are pulling out of our charts and putting on this dashboard? And so we dove into all the different parameters, what they were, what the definitions were, exactly what they were pulling from the chart, and what part of the chart they were pulling from, and then went and did another education. And literally, it was like, again, almost one on one or small groups with each one of the nurses.

Kali Dayton 18:06
I’ve sat down with each of them so many times, so I think now down the hall and they’re hiding,

Gina flakes 18:13
but we went through and we made sure, okay, maybe it’s just they’re not documenting things correctly. Maybe it’s just a documentation thing. Things are happening that we’re not aware of, but they’re not documenting it properly. So let’s talk to them about it. And so we did this whole other education, literally on just these are the elements of the A through F, and here’s how you document them. Here’s what we’re graded on. These are the goals. And made sure everybody knew those things, hey, and circle back again, see where we’re at. And basically, like, nothing changed, like it was still just so stagnant. Then we got a new director in, and that’s when ginger came in and was like, Okay, let’s look at trying to get a consultant to come in and do some work. And she was able to put the numbers together where we were able to get the resources to do that. And I think that’s where the Drive Agent really came from. Was like, Okay, now we have buy in from all levels, because she was able to communicate the financial gains and the return on investment to the upper leadership, and then that allowed us to get the resources we needed with the consulting simulation, all that stuff. When you guys came and hung out with us for a few months,

Kali Dayton 19:25
which was so fun for me, it was a big buy in consulting for five teams. To me, I felt like was a lot, right? But really, when your CFO looked at my estimate, his eyebrows raised, and this is after I presented all the financial information, the return on investment, he said, This is it. I always wanted to grab the paper back and put some more zeroes, right, but I was like, Yeah, you were to spend 1000s to save millions. It’s that simple. And they were like, done. And I but I did explain to them, I will be doing a gap analysis you. I will probably be identifying more things that the teams need. You need to have your checkbook open to. Turn around to the people right behind you, those clinical leaders, and say, What do you need to be successful? Right? You want this return on investment. If you want to decrease your financial legal liability, you have to support your clinical leadership. But it’s like those doors open and we could finally roll our sleeves up and figure out, what are the barriers, and what are we actually going to do about them, right? And you were so busy with this, Gina, I don’t think people on site really understood how much this consumed your life. We did webinars again, because there was a lot of turnover. We did webinars cater to each ICU individually, right? Neuro has different needs than surgical ICU, and you were the one organizing those webinars with me, rocking who attended, who did not have helping people sign up. Making it mandated was really, really important. What would you say about that? Because some teams in the past haven’t mandated the webinars, and I don’t think people really understood how important they were. What would you say to that, and how do you recommend or give advice to improving attendance?

Gina flakes 20:57
I would have preferred that we had more people on the live webinars, because we didn’t have as many people, which then, in turn, they weren’t able to ask the questions, which then I just ended up having to do that in the after, which is fine, but I think it was just more powerful coming from your end, because you have all the pieces and all the information just off the cuff. And I would have preferred that, but we recorded them and then have them in our learning management system where we could assign it. So then if they didn’t attend, they were given that assignment. And so they either had to go to the live webinar or watch it on the learning management and I think that you really you’re going to invest that much into something, and if you really want to lay the foundation of knowledge with your staff like it needs to be required, I just don’t think that is something that should be optional, because you’re just not going to get the buy in from the staff if they don’t know the theory behind it. I

Kali Dayton 21:55
noticed an impact. The majority of your clinicians had watched the webinars, and there’s a huge contrast into that minority that didn’t when they first came into simulation training. You could feel it in the body language those that knew what we were working towards, though they were nervous, they weren’t sure how it was going to be executed, but when they understood the why, it changed their ability to engage in the simulation training and their openness to it. What did you notice about the impact of understanding the why and having that foundation laid? I really

Gina flakes 22:28
think that it’s it was a huge part of it. And I think too, like with the webinars and then being able to see the stories of people that have gone through situations like delirium and the post effects, and we didn’t require anybody to read the book or anything like that, which I we encouraged it. We actually gave away free books to people to try to get the message out, but I think at minimum, they needed to see those webinars to really get the foundation of the theory behind it and the why behind it. Because if you don’t have that piece, you’re not going to have the passion behind the change, because it is a big change, and upfront, it’s a lot of work, right? Once it’s moving the patients are easier to take care of. They’re they do better, they’re they’re healthier, they get out of ICU, like all those things that we’re working towards. But that initial change is it feels really daunting for staff. And so I think if you don’t have the why behind it, that motivation to do it is just not there. So I feel like they have to have that or it’s just not going to things aren’t going to move and change the way that we’re hoping otherwise. And I’ve talked to nursing educators that

Kali Dayton 23:33
are revolutionists. They’re excited about this, but they’re also so overwhelmed they may not have five ICUs that they’re over like you do. Even still, it’s a big role, a big responsibility. There’s so many much to cover, as far as skills and competencies and skills labs and so many things. This is a big change. It needs and deserves a lot of investment of time to thoroughly and properly educate the clinicians. I also worry that when it’s just nursing in charge of education, team members don’t get the same education, such as the physicians, nurses will then have this ethical dilemma of now the sedation is being ordered, and the physician doesn’t want me to move them, but now I know better, and I learned these things, and so the entire team has to be involved and on the same page as The nurses. So how has having the other disciplines involved in the education enhanced or impacted the nursing education? I

Gina flakes 24:27
also think too, like when we first rolled that out, that was one piece that I feel like we didn’t include it. We didn’t include respiratory therapy and we didn’t include rehab. Of course, our physician leaders had their background that they had done the research, and they had their knowledge base and whatnot, because obviously they were part of the Drive Agent for this, like the change agent. But I feel like having all the disciplines was really key in the success, because I learned a lot about how they function and their routines, and I feel like they. The same, like on our end, they learned a lot more about what our role is in the care, because we never had a problem working together. Like our teams always worked well together, the respiratory and the rehab and the nursing, but we didn’t always communicate well, and we worked in silos next to each other, like even in the same room, essentially. But we’re not really like talking about what you’re doing and what I’m doing and why you’re doing it, and what time you’re doing it, and when it was just like, Oh, I’m going to get your patient and work with the patient for PT, okay, great. And that was the end of the conversation. Or we’re going to do your SATs and SBTs, okay, cool. And then we would coordinate, obviously, with sedation and things like that, for the awakening trials. But I feel like after this whole initiative and like that, they were included in the training, and they came to the simulations, and we all did it together, that we became a full team. Like it wasn’t just we’re all taking care of the same patient now, it was like we’re all a team together now going in, looking at what we can do for the patient, and it’s really been cool to see that transition and really see how we can maximize what we can do, because I think as a group, we’re much more effective than we were when we were siloed, because like now, we all come together and say, Okay, what Are we going to do with this patient today? Oh, they’re going to get up all right, restore. We need you here at this time. PT, we’ll have you here at this time and this map. If

Kali Dayton 26:29
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.

Gina flakes 27:37
The other piece that came out of all of this, and they started after you left was the mobility tech. We’ve got three mobility techs now, so like one for each pod within our ICUs, and they are now assisting too. They’re going around and seeing who needs to mobilize and helping with the coordination of the team. So I think having all those pieces together has made such a big difference. And now I walk the halls and I see patients up today, a patient was sitting on a ventilator watching a movie with his significant other, and I was like, there it is. There it is. This. Is it? This is where we wanted to be. And it wasn’t odd, and it wasn’t a big deal, and it wasn’t something that everybody was like, we can’t do that. And it was just done, you know? And I see patients wander in the halls on ventilators, and I see, like, it’s just so amazing. I walk around and every patient I see, I still celebrate a little bit inside, and I cheer them on, and they’re like, you know, this is the norm now, you’re crazy. And I go, just let me celebrate the wins. Okay, well, this

Kali Dayton 28:43
is why I’m doing these interviews, even just a few months after we did the training, because I’ve seen that within six months to a year, people forget to celebrate because it becomes so normalized and so much easier that it’s not this huge effort and this novel thing that I don’t want them to ever lose the magic of it, right? Don’t forget where you’ve come from and the impact that you’re making with these, quote, little things you are saving and preserving lives in a way that you were not doing a year ago. So it’s worth celebrating. So I’m glad, as an educator, that you’re keeping them aware of the good that they’re doing, not just what lack they yet, but what they’re accomplishing it each day, because it’s easy being the routine and onto the next task, right? Well, looking at, wow, we’ve created. And

Gina flakes 29:32
I think in leadership, a lot of times, we’re always looking at, like, what people aren’t doing, right? Like, a lot of the focus is, you didn’t do your compliance training today. It’s due, and so I try to stay away from always focusing on that and also celebrating when they do the right things, right encouraging that behavior, because it’s truly making a difference. And I’m not the one doing the work, right? I mean, yeah, I organized the education, and I helped get all everybody in the classes and did. The tracking. You do all those things, but and, well,

Kali Dayton 30:02
you do a lot of the heat, and you took a lot of the heat. Let’s not forget that part, right, when you roll this out and everyone’s scared you have a target on your forehead, and you took it.

Gina flakes 30:13
I did. I did. I did, because I knew that it was important, and I understood where they were coming from. But yeah, I did get a lot of heat. There was a lot of pushback when they say blood, sweat and tears, like literally, it was all of those things. And it’s not easy to inflict this type of change on a group that is so deeply rooted in one type of practice, and we are unique, I think because, from what I’ve heard from different people that travel the nation and reps and different things that I work with, we have a uniquely experienced staff. We have a lot of long term people that have been here, that have been here 15 years, 20 years, 3040, years. Some people, we just had a couple people retire that had been here almost 40 years. And so it’s like, we have a very experienced staff. So it wasn’t like a bunch of newbie, new grads that are easy to influence and change. These are people that like their their heels are dug in. They knew their stuff, yeah. And so I had to come correct, essentially ashamed of them with it, and make sure I had all my ducks in a row, so that when they challenged me with this and that and whatever, I was able to defend it. And even, like, when the union was like, we don’t agree with the practices, and we need to understand why, and you’re putting our nurses at risk for losing their license. And I’m like, No, this is the right thing to do, and there’s plenty of research to support that. This is the right thing for our patients. There’s nothing that these nurses are doing that is unsafe or is going to put them at risk for any kind of problems moving.

Kali Dayton 31:52
I wish I’d had episode 179 out during that training already, the one with Maggie Ortiz, because they don’t understand the liability that their nurses are exposed to when they don’t practice the ABCDF bundle. But because it was such a change, there’s a lot of fear, and it brings up a lot of COVID trauma, any kind of politics or drama that’s happened in the past, everything comes up to surface. So it a lot of pressure, and you guys sift through it, deal with it. But how’s that healed? Are you guys all friends again? Oh yeah, we never, we’re

Gina flakes 32:23
like a family. You got to have your arguments. And maybe they, I think they didn’t talk to me, maybe for a minute a little bit, but they’re back, because you

Kali Dayton 32:29
have such great people like, Yeah, it’s fun to watch some of the biggest barriers, I guess, the most people that were so opposed and so passionate with that passion and being for it and making it change those really experienced, super expert nurses now influencing and leading the rest. And that is exactly what I dreamed of happening. And so it’s really fulfilling to watch them do that.

Gina flakes 32:54
It’s happening. And I think too, I just was so almost calm about it, because it was so the right thing to do. So for me, I could look them in the eye and say, I know you’re upset right now. And I know this seems really weird, but it’s what has to happen. And this is what the direction we’re moving. And one day you’re going to look at me and you’re going to say, Okay, I understand right now you can’t stand me, and you’re upset with me, and you think I’m trying to do things that are going to cause you harm, or your patients harm, but I’m telling you this with a straight face in your eyeballs, this is what it is, and this is what direction we’re moving, and it has to happen. Like there’s no other option. This is not optional. Like there’s no turning back, essentially. And that’s where I think me believing in it helped. Because I think if I didn’t have that truth, like that belief in my core, I wouldn’t have the passion behind it to look at my staff in the face and say, No, we’re going to do this. If I didn’t really believe that it was the right thing to do, then there’s no reason for me to push it, like it would be really hard, like I’ve had initiatives like that where they’ve said, you need to do this. And I’m like, okay, and I’m trying to find the reason behind the why, and if I can’t find the reason behind it, and I’m presenting it to staff, they’re like, this is crap. I don’t know how to say you’re right or you’re wrong, because I don’t really believe it myself, right?

Kali Dayton 34:23
Oh, this is one of those things. This

Gina flakes 34:24
wasn’t that at all. This was like the total opposite. And I think that was a lot of it, why I was able to drive it so hard and take the heat and deal with the drama and go to the meetings and explain it to whoever I need to explain it to and literally, I’m like, screaming it from the rooftops, even my my kids, my husband, my mom, they all know like, Okay,

Kali Dayton 34:49
we get it. So it is an initiative that consumes your life and your soul for a while. Yeah, and that’s something i i try to make clear to those that I start this journey with. Of you as leadership, this is going to take a lot from you. It will give you so much in return. And what have you experienced, as far as the reward,

Gina flakes 35:07
I think, like I said, just even walking the halls and seeing these things in motion, the wheels in motion, is so rewarding to me. And literally, it’s the thing that kind of gets you coming back to work every day. Okay, I gotta see this thing through. I’ve got to see the other end. I’ve got to see the other side of it. And also too, because we do have a dashboard and we have a way to track our data, we are seeing changes within our data.

Kali Dayton 35:40
For instance, we’ve had a decrease in mortality of 2.2% our last training was four months ago, right? Yeah. And

Gina flakes 35:44
this isn’t even all the data yet, because it comes out like at the end of the month. So we don’t even have September in there yet. Oh, wow.

Kali Dayton 35:50
And we’re not even into respiratory season, where we have the sickest and highest acuity patients,

Gina flakes 35:55
yeah. So we’re already seeing that, and we see approximately, like 4000 patients a year. So when we do the math, that’s about 80 patients that are not that are surviving ICU and going on to live their life with their families, right? So, like I can that

Kali Dayton 36:10
doesn’t even capture the contrast in preservation of quality of life. There’s just literal life and death.

Gina flakes 36:17
That’s brutality, right? I see these patients moving and up in chairs, and I know that they’re gonna do better because they’re not weak little wobbly noodles when they leave here. So I see that part of it too, and it’s so hard to measure, like muscle preservation, right? Like muscle preservation, so there’s not really a like, a value that goes along with that, but also too, like, the mental aspect of delirium is another piece that’s like, really difficult to measure. We have our cam, but how do we really know how it affects the patients when they leave here and their quality? It is that’ll those are difficult to measure. But in incidental, just findings and stuff, you see the quality in the patients. You see the patients when they’re awake, they get up, they move, they get out of here, and they’re better off, like you see it, that’s so evident. But we’ve had some other things, like a decrease in length of stay. We’ve already seen some decreases, and I think that we will see more, because our decrease in length of stay is only minimal right now, but even at a minimal level of days decrease in length of stay, and when I calculate that, it comes out to almost a million dollar savings in a year. So if you and that’s just a minimal, itty bitty, tiny, little slice of a change, but yet this massive, like return on investment, and it’s not considered

Kali Dayton 37:37
rain, like the time of the ventilator. It’s not considered readmissions, like there’s so many other financial AAPIs, HAIs,

Gina flakes 37:44
right, exactly. So we’re already seeing a lot of benefit there, even in just these little minor changes. But that’s with also too, like, a lot of things working against us, outside, things that we can’t control. Like, we’ve had a really major cut start case management, and we’ve had some long term patients like our SNF availability in this area is difficult, so sometimes we’re holding patients for weeks that need sniff placement, which is skilled nursing facility. I don’t know if people know what that means, but and that can sometimes really hold our patients and make our numbers look like they’re not as good, but we don’t know really, like we’re not scrubbing that stuff out. We’re just looking at this global thing, even with all those challenges, we’re still seeing these benefits really early on. And so our big thing right now is really pushing for the sustainability of the program. And how can we continue this momentum? Because we don’t want it to fizzle, right? And I do think it’s becoming a part of the norm. There’s still things that we find. Like, can you explain to me why this patient’s on sedation, and if the staff’s not able to give us a really good reason, we’ll go, Okay, why don’t we try working on getting rid of that? Like, I don’t know that they need that, and see how they do. And even, like, today, there’s a patient that was confused and hollering and things like that. And I’m like, let’s open the blinds. Let’s get them sitting up. Can they move and mobilize? That might help? Because it sounds like they’re trying to go down that delirium road. Little things like that come up, and you just have to continue to push the narrative and make sure people are moving the right direction, encourage the wins right? I celebrate

Kali Dayton 39:18
now. They have the tools, and they understand what you’re talking about. When you bring that up exactly, gap analysis, and I make those suggestions, and they look at me like, I’m insane, right? So much to explain as to why. So when you just bring in those reminders, they’re like, oh, yeah, those tools that I have, they’re applied to this situation now, yeah, and it’s still, we’re only a few months out, so it takes a while to become experts in this, but now they’re able to be guided. What’s your plan for nursing education moving forward, we know that staff turns over. I hope this improves retention in staff, but when new nurses come, what’s your role? Well, we

Gina flakes 39:56
are still doing daily rounds, and I think that that will continue. Because the mobility techs and nursing leadership, respiratory leadership and rehab all come together and look at all the patients daily, and look at the mobility practices and station and all that. That’s our smart rounds. They still go around and check everybody and make sure we’re moving the right direction on patients. I think that’s important, that daily kind of oversight, because that’s a constant reminder that this is what we’re doing, and this is why and all of that. Now when new people come in, they have the videos assigned to them, and they’re required to watch them as part of their like onboarding. Right now, I’m trying something out with the some new hires that we brought in from the med search area into the ICU. It’s our transition and practice nurses. And I’m going to do a live showing of the webinar and then do like, where you stop it and talk midway or at the conclusion, where we discuss what are your thoughts. Let’s talk about what you think about what we just watched, or whatever, and maybe even stop at certain pivotal moments and say, Okay, I really want to drive this piece home with you. Did you hear what was said during this part and see if that’s a little bit more effective way to kind of drive that message home. Because these are our new training nurses. I want them to really, really have it in them when they start. So that was something. I was like, I’m going to try this out with this group and see how it goes. And so I’m hoping that they will just jump right on board and it’ll be part of their normal practice. They won’t know any different because they’re new coming in.

Kali Dayton 41:32
So,

Gina flakes 41:33
you know, it’s going to continue to be a progress the process. I know there are things that we are going to encounter, and there’s going to be challenging patients, and there’s going to be things that come up. But I think if you just continually look at, what can we do better with each patient, every patient we look at, okay, can we move them a little more can we keep them a little more awake? Maybe we can take the restraints off when the family’s in the room. Let’s look at little techniques. Anything we can do that’s going to help benefit them, even if it’s just a little micro movement. I think those are the things you have to do every day and look at and like I said, and I’m not the one at the bedside doing the work, but I think you do need to have somebody in a leadership role that oversees the bigger picture. And I think having all of our leadership is on board helps, because there’s constantly that push, okay, let’s keep going. We’re doing good. Let’s keep going. Let’s keep this happening. That makes a big difference, because people will, I think, intuitively, just fall into their old habits. If you don’t have that momentum going, but and we have such a motivated team when it’s it’s a full team that’s motivated. It’s not just the nursing education, it’s the management, it’s the upper executive leadership, it’s the physician leadership, respiratory leadership, rehab leadership, everybody is equally motivated to make it work. And I think that’s where the big piece, like, why this time it’s so different, is that all the pieces are there, like every all the pieces of the puzzle are there, and we’re all moving the same direction, versus one doctor coming in and saying, No, this has to happen.

Kali Dayton 43:18
You wouldn’t be here if Dr Murphy hadn’t come in like a hurricane, right? But it’s also a lot of pressure on the educators to be like here, overhaul your protocol, systems, processes, culture, education, knowledge of everybody.

Gina flakes 43:31
It was too much.

Kali Dayton 43:32
You already have five ICUs, but I’m so glad that there’s a strong revolutionist in the position of a nurse educator. We’re also going to be talking with your RT and your rehab departments about the education that’s happened, but you are such a powerful revolutionist, and I’m so honored to have watched you help lead this initiative, and you have just changed 1000s and millions of lives for years to come through magnifying your role as a nurse educator. So thank you so much, Gina. You’re so sweet. Everybody. Take notes on Gina, thanks so much for being the podcast you know.

Gina flakes 44:04
Thank you. I appreciate the opportunity.

Kali Dayton 44:28
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Transcribed by https://otter.ai

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