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Having technology to increases access to VT is a big first step towards giving all patient early and routine doses of gravity. In this episode, Heather M. Fudala, PhD, RN, CCRP, Audrey Roberson, PhD, RN, CPAN, NPD-BC, Elisa Winn, MSN, RN, AMB-BC, CWON, and Alice Peay, DPT, PT, MS join us to share lessons learned during their verticalization therapy study.

Episode Transcription

[00:00:00] This is the walking home from the ICU Podcast. I’m Kelly 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, we’ll 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.

The next few episodes will be dedicated to implementation and logistics of verticalization therapy. We are going to hear from clinical leaders, researchers, bedside clinicians, and even survivors about the power of verticalization therapy. If you haven’t [00:01:00] listened to episode 158, please stop and go back and do that.

It provides foundational knowledge of the incredible benefits of being verticalized experts. Walk us through their research and the case studies of these benefits by each body system. Without that knowledge of the why. The next few episodes may not make the most sense to you. Another key part of the foundation is the deep understanding of the dangers of bedrest.

I have noticed that any clinician can reir to you that yes, bedrest is bad. Yet I have been noticing that when I share slides and information at conferences about the value of gravity for the human body. Phones come out, eyes get big, and I can see light bulbs going off. So let’s make sure we are all on the same page about gravity.

Gravity is essential for survival of the human body, but we don’t appreciate it as such, since it is a constant force in our lives, and most of us have only known [00:02:00] gravity, right? The only times a human body goes prolonged times without gravity is obviously during prolonged space travel, but also during bed rest.

We noticed in the 1960s and seventies that these young, athletic and healthy astronauts would return to earth after a few weeks and be unable to walk. It had a significant decrease in muscle mass and bone density matter loss with orthotic hypertension, cardiac deconditioning, and insulin resistance.

That’s when that sound familiar in the 1980s of researchers such as Joe Navar. Look her up. Joan Barco. Her work is amazing and she’s an absolute delight person. She found a way to research the impact of prolonged space travel without having to go to space. She was able to take robust and healthy study participants and put them on bedrest and studied the molecular to the systematic damage.

Of being in a microgravity environment. She [00:03:00] has over 200 publications. Seriously. Ola Corrupt, a more recent study from 2016, took a group of healthy 23-year-old young men and put them on bedrest for a week. So, you know, they were eating normally. They were shifting their weight in bed, able to lift their limbs against gravity, et cetera.

Just they couldn’t get out of bed. They were just hanging out. After that week, they had a 1.4 kilogram or 3.08 pound lean muscle loss. A 5% increase in insulin resistance. Okay? So that’s really dangerous. That’s crazy, right? How quickly things change when we’re in microgravity. So what about our frail aging chronically ill and medically complex patients at baseline who are admitted to the ICUs battling critical illness, and now have catabolism, hypermetabolism inflammatory processes, et cetera.

What do we do? We deprive them of gravity and oftentimes give them sedative that are toxic to the muscles and take away their [00:04:00] ability to even contract a muscle while essentially stripping them out to a space like environment while in bed. This is wild, right? Like deep, you see it, right? It’s, it doesn’t make sense, and yet it’s it accepted as the norm.

It’s even defined as safe, and yet it is so unsafe. It is so dangerous. This is why verticalization therapy should be accessible in all ICUs as a standard for patients that cannot easily or even possibly access gravity without it. We need these tools to provide early, frequent, and higher doses of gravity throughout critical illness.

It can be key for their survival. More and more research is being done to capture the magnitude of benefit of verticalization beds. I was so excited to see a study about verticalization therapy listed on the cover of the American Journal of Critical Care. When I pulled it out of the mailbox that I feverishly flipped straight to that page number, I got even more excited to see that it was studying the benefits of VT [00:05:00] or verticalization therapy during acute respiratory failure, and then was shocked to find what was.

Listed in the abstract, so I’m just gonna read the abstract essentially, right, so it summarizes that this was a convenient sample of adult patients and the medical respiratory intensive care unit at a metastatic urban academic medical center. Received up to two verticalization therapy sessions daily for a goal of 30 to 120 minutes each.

The result said. The study aimed to enroll 15 participants, but suspended recruitment after six. Because of clinical team concerns that some participants were experiencing hypotension and decreases in oxygen saturations during verticalization, as well as lack of adequate nursing staff time. Most participants tolerated verticalization therapy, but one participant’s initial verticalization therapy session was stopped at 30 degrees.

’cause of hypertension and desaturation unit lapped nursing staff [00:06:00] needed to consistently verticalize participants. The conclusion says the small number of participants limits interpretation of study findings. Future studies should consider baseline critical illness severity, and a slower rate of verticalization.

Although it is unclear whether verticalization therapy decreases demands on physicians, advanced practice providers, and respiratory therapists. It clearly increased nursing workload in this study, so this made it sound like using verticalization beds with these patients was dangerous and laborious, which is very different than what I am hearing and what I’ve seen with teams that use these exact beds for these exact patients as a norm.

If we’ve learned anything from this podcast, hopefully it is to look beyond the abstract, read the entire article, and even hunt down the researchers and authors. Of that study. I am so glad that they were willing to join us on this podcast and for the invaluable insights that they shared. There are so much captured in this [00:07:00] study that expose common barriers, implementation challenges, and important lessons.

Any team trying to master BT needs to hear. I can go first. My name’s Alyssa Wyn. I’m the nurse manager for the wound care team at BC Medical Center, SI Heather, and I am the program Director for Nursing Research and Innovation at the VC Health System, Shelly Orr. I’m the director of Clinical Research operations for BCU Health System.

I’m Alice p. I’m a physical therapist and currently the Director of Rehab Services at VCU Medical Center. I’m Dr. Audrey Robertson, and at the time of the study I was the nurse manager of the medical respiratory ICU where the study was done. I am currently a clinical assistant professor at the School of Nursing at VCU.

Great. Thank you so much for joining us on this episode. When I saw your study come out, it really called my attention Verticalization is. Kind of a new upcoming [00:08:00] innovation intervention. Uh, from my perspective, I see teams throughout the country starting to implement verticalization, and I see it done in different ways.

I see different levels of engagement. I had a lot of questions about how the study was done, what the findings were. So first up to start with what even inspired you to start this study? Who started this? Why were you interested in studying this specific question? And then we’ll talk about how it went. I think I can probably speak to that.

Interesting. Coming from a wound care team perspective. So wound care team at VCU Medical Center oversee specialty bed rental. And so we had this verticalization therapy available, but we were using it here and there in little pockets, and I’ll speak a little more specifically to that, but it was isolated to mainly our cardiac population, even though our rep had been letting us know, gosh, you guys could be using this for so [00:09:00] much more.

So at the start of COVID wound care team, we were gearing up for an increase in wounds. Hospital-acquired pressure injuries from. Prone positioning or device related injuries from more ventilated patients, potentially less time spent in patient rooms. Because remember, COVID, it was so new we were trying to navigate it.

How much time can we spend in the room? How much time should we spend in the room? So maybe having less hands on time with the patient could have been contributed to hospital card pressure injuries, and then of course, COVID related skin changes. So we were really anticipating a lot more business in that area of skin issues.

So. Because we had had some experience with verticalization in the cardiac population and it had favorable outcomes. We wondered if that had a place with our respiratory failure patients as well. So that kind of prompted us looking at COVID and respiratory failure as our population for verticalization.

And I think knowing that Proning [00:10:00] was a tool that had been used and the belief was that proning is so labor intensive and difficult to accomplish that, was this another mechanism by which to get better? Oxygenation and profusion without needing to figure out how to put somebody prone and keep them prone and comfortable.

And so what was the question of this study that you were investigating? I think at first we were wondering could verticalization therapy take place, a proning? And unfortunately, our anesthesia partner, who’s wonderful, was not able to be on this call today, but his thought was proning is proning. It’s really a gold standard, and there’s nothing that’s gonna take the place of proning.

But we kind of shifted our thought process to maybe VT will not take the place of proning, but if we initiated verticalization therapy earlier on, could we actually prevent the need for cloning or intubation in some of these patients experiencing respiratory failure? And I think that also with proning, you don’t get the added benefits of weightbearing through the [00:11:00] lower extremities like you can with verticalization.

So I think that it’s a double win, not just for the oxygenation, but for the hospital acquired weakness that can come with laying supine or prone. A study was being done in France about at the same time, or maybe was published in 2022, I believe, showing that. Verticalization did improve VQ mismatch almost equally, as much as protein, if not more.

Do you know which study I’m talking about? Yeah. We only, that study was published after our study had ended, so that was one of the things. February we’re looking at when we looked, did our analysis and looking at potential future corrections. That particular spending was able to do a lot more quantity measurements than ours was.

Ours was not. We had very little funding. We did have funding, but it was a low amount of funding for this particular study. He has since published an article recently in [00:12:00] 2024 where he explains a little bit more about what would during that, and I noted in his 2024 article, he did mention a lot of the same problems that we encountered that he had not.

Specifically mentioned in his initial publications, so that was interesting. As you were embarking on the study of doing it, what were some of the challenges and barriers? I kinda wanna talk about maybe the context of the culture and the environment in which this was being rolled out in verticalization being used in primarily the cardiovascular ICU, but it was new to this respiratory population.

What was the culture of the ICU at the time as far as. Sedation and mobility new things, COVID iss a hard time to start something new. So paint for us a picture of the environment at that time. And then what kind of challenges did you face? I’ll start with just the culture of mobility and I’ve worked here for 34 or five years [00:13:00] and the culture of mobility is necessary and needed.

Audrey and I connected way back. When she was starting her doctoral program, the murky was an early adopter of culture mobility, and our ICUs are actually farther ahead than our floors as far as sustainability with the culture of mobility. So I think that the Merky was the right place from a culture of mobility perspective.

And then I’ll let the others talk about the sedation and all of those things. But we do have a robust A to F bundle steering committee that we work through all of the letters together. Alice is correct. We have always talked about mobility, and it’s been. Something that we hold near and dear to our patient population because we are talking about patients who usually have chronic diseases who are usually intubated, who we really have to focus on that part of their plan.

And so prior to this study, while we were mobilizing our patients, it was, it was not something that was considered necessarily routine in our patient population. It wasn’t something that was discussed [00:14:00] routinely in our rounds. And so I think some of that had to do with, it was some intimidation of emulating patients with tubes and lines and things like that, and is, you know, fairly validated in the literature as well.

And so partnering with the physical therapy partners, they were great champions for not just their knowledge base and helping to teach and train our staff. But also walking the walk along with nursing so that we could understand some of the dynamics of what maybe a patient can tolerate as far as their mobility.

So prior to the study, this had started with physical therapy for some time. I think one of the outcomes that was really monumental was that partnership with PT and nursing. So that we could ensure that we were assessing our patients together and identifying patients upfront, whether they were gonna be in this study or get verticalization therapy [00:15:00] or if we were able to mobilize them even more independently than that, you know, um, that the culture I think at DCU and in the maq as a whole for mobility and doing what’s best for our patients is amazing.

I think some of the challenges that we had are really more inherent to the fact that this was a study, right? So unlike our prior use within the, within our cardiac patients of it was integrated into clinical care and people were able to adjust and do what they needed to do because it was a study, it was set up with very precise intervention, right?

Very precise measures. And that in itself, I think makes it more challenging. And one of the things that we noted is the need for the ability to be a little bit more flexible, right? So I think many of us on this call are ICU nurses by background, and we really appreciate the beautiful algorithm that we developed and the very precise, if the numbers of this, you do this, and if there’s this, you do that.

Um, but what we really learned was that even though, again, [00:16:00] inherently for research, a lot of times that’s necessary, right? So that you can actually control the data that you get and ensure that it’s valid. That doesn’t necessarily work as well with something like this where all of our patients really are different and their needs are different, right?

So there’s some patients who do have respiratory issues, so you can lay flat and they can tolerate that. There are other patients who cannot tolerate that at all. Right? So having some flexibility, I think within that. We’ve learned was really important. Right, which is challenging within a study as a whole.

The other thing is the manpower that it took to do this, right. So I think if you go back to some of the things we were talking about with proning, as Alyssa said, and Bashaw says P proning is P proning. It’s amazing manpower that it takes to do that is incredibly difficult. So I think one of the great things about BT is that it definitely takes less resources, but the reality is, again, because this was a study and there was data to be gathered, it did take more manpower than it would’ve just in a general clinical setting.

Right? So [00:17:00] ideally, a nurse would be able to perform BT sessions themself right in the room with the patient, have that flexibility of stopping and making sure the patient’s stable before they go up more. In this case, it really took two nurses because we needed someone to be able to adjust the bed. You know how the room is, all these things, but we needed somebody to record data, to record vitals and things like that.

As the incremental changes were done, having two nurses pulled away from other patients, and because we did verticalize relatively quickly, it did pull them away from their other patients, which is, can be challenging as we all know. So I would say that staffing, although we know that this was much. Easier on staffing than something like pruning is.

It still was more challenging than what we thought because of likely more due to the fact that it was a study rather than just being integrated into clinical care. You, I would tag learn about. I think some of the things that I really learned from this particular experience was, first of all, I wanna say the [00:18:00] culture and mobility and the GUE is phenomenal.

I think we’re unusual in that regard. I think that there. Is not a lot. Um, there’s not a lot of clinical nurse apprehension or barriers, you know, going to a patient, like for example, I think like we had been doing that previously and there had been experience with the verticalization barrier on the unit prior to this.

It just hadn’t been used in respiratory failure Patient. The nurses were familiar, somewhat familiar with the bed. I wouldn’t say that most of the patients were being verticalized or gotten home, but it was not unusual, useful to have a patient intubated that you would get and put in a chair or verticalization for some other problems.

But I think that for us, the study design really hammered us. Like we really, this study was really designed as a quantitative design with some pretty strict constraints around the verticalization process. And the exclusion criteria and the criteria to stop a verticalization session. And I think that the reason we did that was out of concern for [00:19:00] safety.

We really wanted to make sure that since this was the first time we were doing this in a respiratory failure patients, we wanted to make sure that it was safe. However, I think what we learned is that a pragmatic trial would’ve been a lot better where the nurse had independent flexibility based on their patient conditions.

Zero. My think. I think if we were to redesign it, I wouldn’t do it that way. One of the huge barriers for us was the criteria we set around stopping a verticalization session related to the patient’s staff. So we said the patient had the increased presser demand. If they had an increased presser demand of greater than 20%, or their map decreased by greater than 20% for five minutes, we stopped the verticalization session.

And the reality is that what that effectively did was it meant that patients on low dose vasopressors were not considered for the study because you have a patient on five micrograms or less ILI bed and [00:20:00] going up one would take them up, would mean you had to stop the verticalization session and being on 10, you could really only go up to.

So I think for us, if we were to redesign it, we would not potentially be so conservative on those numbers. And I did know that the BU shot study in the 2024 publication Alls General mentioned the decrease in hetic was a significant thing that happened with them, and that increased VA of suppressive support was needed.

And so I think we would probably work to do that. We really ended up not being able to recruit a lot of patients that I think would’ve done well in study otherwise. Yeah, that was so interesting. That really helps because that’s one of the things that I noticed is that. Many of these sessions were discontinued and I didn’t anticipate that, and that’s not often what I see at the bedside.

And it made me also wonder if the hemodynamics had to do with the timing in which it was initiated. That was one of my other questions was what do we know about the timing from admission [00:21:00] or intubation until patients who are verticalized ’cause you know, sarcopenia, you know, really contribute to that ortho hypotension.

And in cardiovascular ICUs, the irony is a lot of times they’ll increase the VA suppressors or inotropes or give midodrine prior to verticalization because they anticipate that fluid shift. So I can imagine in that setting where this is different and we’re much more conservative and worried about those interventions such as VA suppressors and a respiratory ICU, if maybe that played into hesitation, but that makes sense.

That was already built into the parameters of the study. They couldn’t wait. You know, it was five minutes passed, not coming back up. We have to lay them back down, but maybe that wasn’t necessary. Maybe we lost some opportunities. And another question was timing. What was the timing of implementation of verticalization therapy?

We attempted to have patients within the first 24 hours of admissions in the ICU. We did not [00:22:00] actively enroll participants on the weekend, so we allowed up to 72 hours to capture patients on Monday who had been admitted over the weekend. So they were pretty quickly. Um, identified and met the criteria and we did do the first verticalization session within like the first day.

Soon they signed that our verticalization session. I didn’t think world, our owls were really into that strict control we had around the, our, the reason I think that was a mistake. I mean, it’s great in a scientific worlds of design a study like that because when you’re really trying to figure out exactly what’s contributing to different factors, like that’s a great way to do it.

In a real world, when you go to translate research into the real world, you run into these issues. And I think knowing what we do now, I think work flexible trial would’ve been much better option with that change in hemodynamics, what percentage of these patients had sepsis and were interventions such as impression stocks used prior to verticalization to [00:23:00] help?

Prevent or compensate for that, those changes in hemodynamics. So I can tell you that all patients, it’s just part of our care, standard of care for our patients who are not mobilizing to have either some compression hoses like, uh, sequential compression devices or. Impression, hoses, stockings on. So that would’ve been standard of care.

So even with the protocol, we would’ve maintained standard of care. I try to look really quick to give you an answer on that percentage that had set most primary diagnosis. Let’s risk I, my other question with the hemodynamic changes was what percentage of these patients were on sedatives such as propofol?

For example, in my week walking COVID unit, the minority of patients were on vasopressors period. Because the minority of patients were on propofol. So my, my gray was, was their propofol present? Did that contribute to the hedy [00:24:00] instability? And then you have a fluid shift on top of it with verticalization.

What was the setting and what was the context of sedation? I would say probably, I could look for probably, maybe a small majority of these patients were on sedation. I think did have some patients who were on the protocol who weren’t sedated, said they would’ve not been on any sedation. But I think the ones that were sedated and particularly our COVID patients, um, would have been sedated, I think.

That’s one of the other things. It’s kind of like that elephant in the room for this study that impacted it was because this was during COVID, it was during our second week surge. Right. And there was still rationing, A PPE, there still wasn’t readily available ppe. There was still anxiety about how to manage COVID patient and either not all of our patients had COVID.

There were a large number of COVID patients on the unit, so that really increased the overall kind of anxiety and the workflow [00:25:00] was really changed during that time, which is not necessarily the case anymore. So our COVID patients, for sure, I think would had been sedated because that a lot of them were, were sedated and or paralyzed because of the COVID process and the implant and noncompliance of the ventilation.

I would’ve to that being. Outside of that, our goal really is to not use sedation the way we did at one point in time. Right? So I think if we were talking about this 15, 20 years ago, that would’ve been a very different answer. But we really now are truly only heavily sedating patients who need it from a physiological standpoint.

Right. That they’re, they’re more unstable if we’re not able to sedate them. Um, so I do think there are some patients, as Heather described, you know, COVID patients that were particularly sick. But for the most part, outside of that, the patients were on very little to no sedation, you know, pain control definitely.

But true sedation. Very little. Yeah. But I do think that one participant that we had the [00:26:00] hemodynamic decrease in that caused the anxiety was s date wasn’t, I think was a combination and the, I hope they were right. Yeah. And I like, I love that you brought up the word anxiety. I don’t know if that was used.

In the study or the writeup of the study, but that is a board that I face all the time, training teams at the bedside, bringing in verticalization therapy. There’s a lot of anxiety, and that’s obviously the perfect word for COVID in general, and I’ve seen great protocols, great tools. For example, safe patient handling tools.

We know that they’re effective. They work, they gather dust. And there’s a lot of anxiety in using them and using them on high acuity patients. So the trend continues with verticalization therapy. And so as I was reading this, I was just trying to imagine during COVID resources are spread thin. You’ve got this intervention that is [00:27:00] kind of known to the unit, but it’s new as far as a normal practice for these certain patients, high acuity patients.

I see a lot of anxiety with patients with higher ventilator settings. A lot of anxiety with COVID so that the study screamed to me anxiety, and I was just so eager to talk to you guys about how that plays into what happens at the bedside. When I saw that these sessions were discontinued early, my assumption was, oh, those nurses were really anxious.

And that’s normal when you are doing something new again, very sick patients, times of the essence, you gotta go and so. There’s a certain level of comfort that comes with mobility in general, right? When I talk about case studies of my own patients that I treated, I’m like, yeah, the patient’s on a PPA of 18, a hundred percent walking around and people that wet themselves, and then when I’m trying to move teams to mobilize a patient on a PPA 10 and 70%, they’re like, they’re anxious, right?

That [00:28:00] happens. I think thinking back to when you’re starting your career and you’re doing anything new. You are so anxious now, a year or two later doing those same tasks, same skills. You do it with your eyes closed, and that’s what I see happen with these teams that have trained is later on, they’re like, no, we were nervous about that.

It was fine. We never cared. You know? I’m like, no, you were, it was hard, right? It took 30 minutes to get someone to the chair that was intubated, and now you do it within five. But at the time it was hard. So it’s validating to hear that. That’s what I see all the time with bringing in this new tool of these verticalization beds.

I see teams that have used it for a long time. They’re like, not a big deal. We just get upstanding. We do, and they have this expertise and they have protocols, but they also have this experience that helps them navigate and customize and personalize how they’re using it for each patient, and they’re not ed to see a fluid shift.

They can recognize. When they [00:29:00] actually really need to discontinue it versus we’re gonna give them a minute to compensate. We’re gonna actually turn up the vasopressors and I think they’re gonna be okay. I think one of the things with regard to anxiety that I don’t wanna lose focus on, and I think all of us can speak to it, is during this study or, and I’m sure maybe many other studies during the time of CO.

During a time where there were such concerns. So the medical respiratory ICU was also considered like ground zero for COVID. So it had been determined by our organization that all of the patients for COVID would come to the medical, respiratory ICU. This was very early as COVID was underway in Virginia.

So in March when we started screening for patients, it was thought that all these patients would come to the medical respiratory ICU. So you have anxiety there. Then of course there was also things such as that many units went through was having enough supplies and the complexity of some of these patients that were developing COVID, the [00:30:00] illnesses that they were experiencing, and these were patients that were relatively healthy that needed to actually be admitted to an ICU.

There was also anxiety personally from team members, right, because of the unknown and what to expect and their loved ones as well. The other piece I don’t wanna lose sight of is the new hires. And so macu is an ICU that, um, we hire new grads in our ICU. So we had people who were not able to stay connected in their clinical rotations because of the COVID pandemic, and so had to have an alteration in their learning during that time.

And during the time we were during the study, some of them had graduated and had joined the MACU team and again. That was also an impactful time. So while we had a great deal of experienced staff and kudos to our team because our turnover actually had decreased during this time, so we didn’t have the attrition that we would’ve normally [00:31:00] had previously.

People were staying in the macu and kudos to the VCU Health system because we didn’t furlough team members during this time. We were granted permission very generously. I might add. To increase our staffing in order to support the safety of our patients and promote their outcomes. All of this, and there’s so much more, but you get the idea, right, that all of this is really impacting what we can do and impacting the learning at the bedside and such.

So it was really important that we really stayed focused with the training that was available to us because it wasn’t uncommon for us to have a. More novice nurse caring for these patients and having a more experienced nurse to help support that transition for the patients. And we’re really working through not just the therapy and the study, but also working through just our basic care delivery for these patients [00:32:00] during a horrific time.

Mm-hmm. In so many ways, this COVID timeline is perfect. I mean, you have so many patients that you can enroll in the study. But in reality, I am just, I’m overwhelmed by imagining doing a study at that time, and I think even just knowing that at the bedside when we’re doing this, it’s for a study. It makes it feel high pressure or it makes it feel experimental.

If you’ve been listening to this podcast, you are 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 [00:33:00] 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 ICUI help teams master the A-B-C-D-E-F 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.

Is this safe? Is it not? We’re seeing it as safe. We’re seeing if we can do it. Whereas in a normal setting, it’s like we have more time and flexibility to educate them more thoroughly on why they’re doing it. It’s more we can make it more of a routine thing rather than this high pressure experiment. So I wondered if that played into the high anxiety that was present.

Sure, and it’s interesting, all of this, we think about the coronary IU. Like we said, it’s a standard of care. They’re verticalizing. [00:34:00] Patients two to three times a day. Patients that are awaiting LVAD placement or patients that are awaiting heart transplant. And it’s just, it’s very routine. And I think if I recall correctly, the providers are what pushed this.

Like, we’ve heard about this verticalization therapy. This is what we want our patients to receive. And so there was that added level of support where me, like they said such a. Strong culture for early mobility. I remember approaching some of the attendings to get permission to enroll a specific patient in the study.

They were like, no, we don’t wanna discourage the patient from getting outta bed. I was like, well, if they can sit on the edge of the bed, if they can get up to the chair, they’re not appropriate for the study. We’re trying to verticalize people who are not at that point. So that we can improve organ function and decrease delirium and improve deconditioning.

And so that was a little bit of a culture shift for the unit. And I think we had one patient that did not recover well. After one verticalization therapy session, [00:35:00] the map dropped. We couldn’t get it back, and at that point. Like you’ve said, that anxiety set in and then when you would approach about the next patient, it was like, eh, I don’t think this patient’s appropriate.

So I’m sure that fear and on top of COVID and everything that was going on on the unit every day was just a lot during that time. I think as a study team, we became more cautious about who we enrolled after that as well, because we didn’t wanna reinforce that anxiety that had happened and just as a point, like it took us.

Less than two weeks to enroll the first four participants. And it took us over four months to enroll the last two. So that one event really had a pretty significant impact on the clinical team and also the study team in terms of tightening down our processes a little bit because we didn’t want veterans to have an additional experience that was similar to that.

So for the last few, we made sure that there was a study team member available, right to be [00:36:00] there. And so like that fourth patient. We had because of the team on Variety, had already been familiar with the verticalization bag by the fourth patient, and they understood the protocol. We really were a little more hands off for that particular participant.

And then also because they were a COVID patient. There’s all that added complexity of like the pump is outside the room, but the ventilators outside the room and the people who are verticalizing are inside the room and the door is closed and you’re trying to hear if this patient needs to be stabilized.

Across the door. The study team was really like allowing the clinical team to do their thing, and I sometimes wonder if we had maybe not been more interactive at that time, if it would’ve delayed some of their anxiety. I guess we’ll never know the answer to that, but I think for us, the COVID time experience and the anxiety around that, definitely leading into how this particular study and the context is so important, I think.

We’re all guilty of just looking through an abstract of a study and being like, it didn’t do anything. It didn’t work, right? [00:37:00] But understanding all of these things that we’re discussing helps us glean so many things at it. Not just that someone could say, well, verticalization doesn’t work for key respiratory failure patients.

That was what kinda made me panic. I’m like, well, that’s not what I expected. And looking into it more, I saw some things that led to more questions, and so it’s so nice to have you guys on to give context. I think everyone can relate to the circumstances that you’re describing. And I feel the same way when I am getting teams to mobilize patients for the first time, even though I’ve done it so many times and I wouldn’t normally have anxiety with the patients that we’re choosing, the fact that we’re in a new setting and that the team is so anxious and that it has to go well that first time.

Otherwise, we’re creating more barriers, more psychological distress, trying to get this going the rest of the time. So I feel that. You have to have a go. Well, those first few times, if it doesn’t, that will spread like wildfire throughout the team and it will [00:38:00] paint the intervention for potentially years to come.

And I wanna bring back one of Audrey’s points because it’s a very ting point, and I think it already is worth mentioning a second time some of these new graduate nurses that we had working in the mEq at that time. Because of the clinical experience being so altered, they came into the ME review not really having a lot of experience with hands-on patient.

So even to like turn a patient and Aruba patient was a completely foreign experience to them. And we’ve never really seen that, at least in rare history of healthcare in our country, maybe outside of Ebola, which was very limited in scope, like we really didn’t see. We haven’t seen a situation where clinicals were interrupted to that extent and where education was really interrupted.

And I think it made a difference too. They were already anxious that observation, let EL on additional tasks on top of it, or a n new piece of equipment. And even in normal circumstances with very seasoned teams [00:39:00] and just thinking about a team that I trained at, their nurses were remarkably seasoned post COVID.

We’re always dealing with this spectrum of education. But this team had retained a lot of nurses. They had were very seasoned that they owned their practice and they still required a lot of education on verticalization therapy. There was still a lot of anxiety, so I can only imagine as a new clinician where everything is scary, daunting, overwhelming, and a reasonably so.

Those new grads that were thrown into COVID are my heroes. The kind of courage that it takes to just do that is so admirable. There was a lot of news happening right at that time, so it’s a new study, a new way of managing your patient outside the room. The pumps outside the room, ventilators, monitoring outside the room, different supplies, because this was also a time where we had supply management issues.

Across the country, and so the supply you used last [00:40:00] month may be different from the supply you’re using this month. So just acclimating to that, there was just this constant learning that was going on at a rampant speed in order to ensure, again, the safety of our patients. And so I go back and give kudos to.

Museum health system because we, this was a yeoman’s job with providers and engineers and just some our supply department to just ensure that we have what we needed. But we were constantly learning. During this time, we learning PPE, donning and doffing, and it just was a constant churn. And so when we talk about that anxiety, we’re not even to forget the study, right?

Because it’s just anxiety and how to basically care for my patient. In an ICU setting and being able to identify the newness of caring for these patients during this very horrific period of time where things were just constantly [00:41:00] changing all the time. And I’ve noticed that with verticalization therapy implementation, even in normal calmer circumstances, this really requires thorough education of all disciplines.

And that is something I see missing. Across the board is it’s like, here’s a stew bed, here are the buttons, and here are the benefits. But it’s very brief. When I train teams, I actually require them to have a verticalization bed available, implemented, because it’s one of the puzzle pieces. But I paint the picture of the entire puzzle that we’re building so they see where it fits and where it goes.

I’ve also seen teams that don’t have the puzzle being built. They don’t necessarily understand the value of mobility weight bearing, the pulmonary benefits of being upright. They’re very comfortable and acclimated to patients being supine and would rather have them that way. When I train teams, I’m like, here’s the dangers of that, and they’re panicked and they’re eager [00:42:00] to get patients upright and getting all these benefits, but then they find, oh, these patients are more complex.

These patients have more barriers. And then I can say, and for that you have verticalization beds. That’s where that fits in. Alice, what was it like to try to educate your brand new patients? Yeah, I think, again, I think Shelly said it well, that this, you know, being a study kind of hindered because in the cardiac ICU, we started mobilizing our ECMO patients who are femoral cannulated and all of our Impala femoral cannulate people.

I mean, it’s automatic PT doesn’t even have to weigh in. These people are on a verticalization bed. But what we found is that we’re an academic medical center. We have receptive people. Do new ideas and we have to kind of push. But you know, with our ECMO patients that were f firmly cannulated, what it showed was we could verticalize them, step them off, walk them down the hall.

It showed everybody that mobility was not harmful necessarily. But now we have the conversations of the providers are thinking, [00:43:00] let’s. But there are access up in the neck so that we can sit and stand and move in a normal pattern. So the evolution of mobility with verticalization has really driven better clinical care, I believe, and thinking through all the p, all the parts.

And there are patients that have to be femoral cannulated, but now we have a tool that doesn’t hinder them like it did, you know, years ago. So I think that. People just, they need to see it. I think we have room to grow. I’m proud to work on a team that is forward thinking, but it is one step at a time. We have new learners that are like, what do you mean you wanna stand and walk?

My patient that’s got all these lines, tubes, drains and leads. But I think that it’s just the slow, steady slog. And I think, as Shelly said, the research portion of it might’ve hindered some of the natural evolution. I think too, the um. The particular attending provider arm or a few that Alyssa had talked about when we first approached during the study on the [00:44:00] unit was very much, well, the patient can sit on the bed or can sit in the chair.

Right? They, they need to do that and they’ll be verticalized. And I, in some reason, I wish we maybe had pushed a little harder because I think there’s real, and again, it’s different. Being verticalized is different than sitting in a chair. And so I think that that’s definitely something I would do differently.

There’s health study or encourage additional people to look at, really engage with those providers and get buy-in from them. That verticalization is another tool. It’s not in place. We’re not replacing sitting in a chair, but we’re providing extra localization. Admittedly, I was kind of that same party when I first heard about these verticalization beds, and a lot of it was my own bias from my own experiences.

Right? 2012 to 2020, working in a wake and walking ICU. It was kind of the wild west. We barely used any, like we use a basic walker. A lot of that had to do with our patients being awake in a while right away. But it also is because we were up to [00:45:00] date with a lot of the equipment that we have now. So when I heard about this, I was like, well, you just get up and move them.

And I thought we wouldn’t really use that. And now I look back to certain patients that were having seizures, certain patients that came from outside facilities that had been sedated. Im mobilized. We did sit the bed, the side of the bed and sometimes they were like era negative four and we’re sweating under PPE and we are like doing all the work for them.

And I look back and I’m like, no, absolutely. We would’ve loved to have had a better tool that required less people. We could do it more frequently. And now I’ve shifted to looking at the context of these teams, their comfort level. They’re not gonna get a patient that’s four and can’t even lift their own head up to the side of the bed.

That plays a lot of skill, a lot of people, and a lot of accountability from leadership. But maybe in person can stand that patient up with the right tool. Then I also started looking at patients that can briefly stand at the bedside and it takes three people and it’s the whole thing. [00:46:00] What if we could get them standing bearing weight longer, more frequently with less people?

So I’ve fallen in love with these tools because I see how much it could enhance. You know, we can walk in, I see you approach, and it doesn’t replace things. But it helps build that bridge to get there. But it does require, again, education from everybody. And the providers especially need this kind of education.

We assume that they’re gonna take stewardship of it, that they’re gonna know what it does, why we’re doing it, how to use it, who to use it with. That’s not the case. Everyone needs the opportunity to learn. So where is your team at now? Years later. How is verticalization therapy going in your unit and what recommendations would you have for teams starting out with verticalization therapy?

I think what I would say is two or three things real quickly. One, I think the ongoing skill, communication and collaboration is a must with your interprofessional team. I talked earlier, Alice and I partner, this was years ago. I don’t wanna [00:47:00] date us, but this was. Sometime ago. But the point is that is just so key to have those relationships so that you can lean on each other, have that dialogue and identify again what is the best thing for the patient.

And we’ve talked about in Meki, we think that inter collaboration is really part of our strength. Second thing though is, I think you hit a little bit on it, Kaylee, is just, we had the benefit of having one of the verticalization beds on the unit available for training purposes. And I know a number of people, Alyssa included, had come over to help support our team.

That was learning because again, you’re talking about a team of 120 some team members, and so, and one day you’re not getting everybody through. So. Even if I taught someone, it was gonna be important to reinforce that over time, because who knows when you would be having a patient that you would need to use that therapy on.

So just reinforcement of their knowledge of their clinical practice. The hands on ICU nurses are very tactile learners, so having that [00:48:00] available. And then the last thing I think is just being really authentic with our bedside leaders and being able to have open conversations with our patients and families so that they understand the benefits of these innovative strategies that are available for their loved one or for themselves, and how it can optimize their plan of care.

So those would be the three things I would say moving forward that I think would be very beneficial for including. Such innovative strategies, but also including our patients and families for outcomes. Yeah, I think as far as the research study piece goes, I think a different design would be an absolute must.

It really needs to be a pragmatic design that’s able to be tailored to the use of a particular patient. I think for scientific reasons, I still would love to see, uh, stratify participants using like a critical illness severity tool. Like the Apache or the Silva and potentially providing different guidelines around those.

I did. What was interesting to me was, is we started to see [00:49:00] some hemodynamic instability at around 30 degrees, and that was also reported in Hans study is more recent publication indicate that’s where they saw it as well. So I think, and it was only for certain patients. I think it was the more ill patients that that really seemed to start to happen.

That has really always been a curiosity to me from a scientific perspective, is we really didn’t see in ME’S participants even within those five minutes of compensatory heart rate or breathing rate. So they would desat and they were, the blood pressure would drop, but we didn’t see that pump. Um, so for me, I’m very curious as to like why we didn’t see that.

Like what would go on with them from a physiological standpoint that prevented that from happening. Those are things that I think I would really like to see different moving forward, and I would encourage if there was additional trials, I would encourage those kinds of, that pragmatic design, the critical illness [00:50:00] stratification, and then just kind of the personalized approach, which is really what we should be doing is them planning care should be individualized to our patient that we’re taking care of.

Well, thank you so much. This has been so beneficial. I know that there are a lot of questions about. Implementation of verticalization therapy and studied like this. If again, someone just looks at the abstract, that may deter them from using it. But this has brought so much insight and so many gems of knowledge and bias that I also love that it was nursing led study.

Obviously, our rehab colleagues get in love ization therapy, but this needs to be nursing led because we’re the ones at the bedside. Really having the opportunity to do it frequently and also things about agitation management. I could go on and on. It’s really an useful tool for nurses. And so you guys have set a standard of nurses being invested in investigating this new therapy and this being nursing owned and collaborating with your [00:51:00] colleagues, love having Alice here and her expertise, and I’m sure she’s so excited to have had.

Nurse is engaging in this because rehab gets lonely being the only ones to care about mobility and being upright and weightbearing. So thank you so much for all that you’ve done for the community. Please keep us posted on your, for other studies, any other research that you put out. Thank you for having such a proactive and progressive unit and for owning this.

Thank you so much. Thanks for having us. Yeah, and thank you, Kaylee, for the platform. This is great and wonderful. So thank you for what you’re doing as well. To get this information out there, and thank you for the opportunity to expound on this a little bit, because when you’re limited by word count in journals, you don’t really get a chance to paint the full picture.

And so I think pinging this full picture could better inform everyone, hopefully increase like the culture of mobility across the country because it’s just really like, I hate that we say this is a negative study. [00:52:00] To other studies, what do I see so many positive about? I see this capturing so many of the things that I see at the bedside, but no one’s talking about.

So thank you for allowing us to learn from this. This is exactly what needs to happen. Thank you. It was not a negative study. It was definitely a positive study because it will help set the tone moving forward. So the knowledge we gained was good. Exactly. Thank you so much for sharing it. Thank you. Thank you.

Bye. So, in conclusion that this was not a negative study, but instead one that captured the challenges of COVID overall. My final takeaways are verticalization therapy needs to be implemented in an environment in which bedside clinicians are terrified of the dangers of depriving patients of gravity and are eager and comfortable in providing gravity through multiple means, including verticalization technology.

This requires teams to be thoroughly trained on the harms of bedrest and the many benefits, implications, and indications for verticalization therapy. Bed [00:53:00] clinicians need to have flexible protocols that allow for transient changes and vital signs that reflect the normal physiological changes during verticalization, such as changes in blood pressure during the initial fluid shift.

They also need to have critical thinking to be able to identify when patients need more time to adjust to this change in position. Or when they are showing dangerous intolerance, they also need to be able to implement more support to possibly facilitate that dose of gravity, such as compression stockings, Mediterranean, increase in vassopressors, et cetera.

I’ve seen that verticalization therapy best thrived in an environment that sees these tools as important and routine as a ventilator or an antibiotic. All disciplines are on the same page about when to provide these treatments and are involved in administering early and frequent doses of gravity. And a variety of patients for a variety of reasons.

Remote patients, especially when confidence and competency are established among the team, verticalization therapy should only require one clinician. This study [00:54:00] utilized at least two nurses at a time, which was an incredible feat during COVID. Stay tuned for the next few episodes with teams that have made gravity dosing a routine treatment even in their patients with the highest acuity.

And most challenging mobility barriers.

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, www.daytonicuconsulting.com.

Transcribed by https://otter.ai

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