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What role do respiratory therapists play in creating Awake and Walking ICUs? How did Candace Wistrich, RRT, BSRT and Nelya Kapitula, RRT, BSRT lead their respiratory therapy department to move the revolution forward? They join us now to share their team’s journey!

Episode Transcription

Nelya Kapitula, RRT, BSRT 0:00
Candace and Nelya, thank you so much for coming on the podcast. Can you guys introduce yourselves to us?

My name is Neila capitula. I am the clinical specialist and supervisor at Mercy San Juan Medical Center.

Candace Wistrich, RRT, BSRT 0:12
I’m Candice Wistrich. I’m a supervisor of day shift for Respiratory Therapy at Mercy San Juan.

Kali Dayton 0:16
I’m really excited to be talking about the role that you both have played in bringing your ICUs to almost to awaken, walking ICU status right in your facility. You have five ICUs. And I have seen a spectrum of enthusiasm. We’ll say, for respiratory therapists. When I start training a team, I’ve seen respiratory therapists understandably be very, very hesitant, folding their arm, saying, “Absolutely, no way. We cannot do this. It’s unsafe. We don’t have the bandwidth.” All the excuses.

Ironically, the team I’m thinking of, they then became some of the biggest advocates of this. I’ve seen other teams say, “Yeah, this is fine. We’ll play along.” They don’t necessarily lead this. But then there’s you guys. So tell me what, when you first heard about this initiative coming down, what was your response and why?

Candace Wistrich, RRT, BSRT 1:07
Initially here at Mercy, Scene one, we’ve attempted this mobility program multiple times with no success. It was constant being there because we didn’t get the nurses on board. We couldn’t get RT, PT and OT to communicate effectively to where that they could streamline. The issues weren’t the patient. The issues weren’t being concerned with event. It was more the communication aspect and interdisciplinary education piece was missing.

So once we got all that clarified, I think the webinars that you provided, a lot of the staff answered a lot of the whys we were moving forward with this, and clarified a lot, because as a respiratory therapist, we don’t learn a lot about this in school. We don’t, we really don’t. So we learn all of this in the hospital once you’re in the ICUs with very, very sick patients. So they are skeptical. It’s just they want to be safe, right? So giving them the answers to all the whys was really important.

Not everybody did them, but the people who did to go to an extreme amount of like information from them, and a lot of the information I didn’t know, but I attended a ton of the simulations. Those are great. So getting everybody on board was pretty easy. They were more concerned about this staffing, which, once we took that aspect away, they were ready to go.,

Kali Dayton 2:15
So yeah, let’s talk about that, even that alone. I mean, just starting off meeting with all the leaders there was at the time, was only you Candace and your manager, Chris and you guys were like, “Yep, we’re in. We’re all in. Whatever needs to be done. We’re gonna get it done. ”

Candace Wistrich, RRT, BSRT 2:31
Yeah, in that time frame, our leadership was going through a little bit of a transition. We had two people leave the position. I took on the entire I remember I was sat there from 9am to 11pm with your team and make sure that I was present with all the staff. If I was asking them to be there, I felt like I needed to leave by example and be present for them as well. So I think I attended all of them the first week they were here. But by doing that, it was huge with the buy in with the staff, because they really saw me doing it.

If this is just important, where my leaders here, then I feel like this is something that I need to be a part of. So they have to pro question they were on board. And again, all the questions were about staffing. But it’s super important as a leader to make sure you’re invisible to the staff and when we’re moving forward any kind of change.

Kali Dayton 3:17
Yeah, I’d never experienced that before in all the trainings that I’ve done to have RT leadership at every single simulation training, even playing the patient. You did a greatjob, by the way, oh yeah, you ended up having COVID, but I don’t think any of us got it, or at least.

It was just really impressive how involved you were, and it just set this precedence for the entire team, not just the RT department, but the rest of the disciplines, to say, “RT is going to help lead this. RT is important in this, and RT is bought in, and they’re going to do it.” Because I’ve seen repeatedly that when a respiratory therapist says, “Yeah, let’s do it. Let’s get them up. Let’s wake them up, everyone else feels so much safer and willing to do it.”

Candace Wistrich, RRT, BSRT 4:03
Well, we know how to work the machine that is essentially keeping your patient alive, so that holds a lot of weight in making people safe all the way around. So I think that’s a lot it was the PTO team. We communicate with them, yeah, when they wanted to know more about the what are they looking for? What’s important, what is an emergency and what technically isn’t. But how can I fix it?

Every job setting up that if you want to talk, yeah, so I took a about a week or so, and coordinated with PT and OT to come together and do hour long trainings with them. And it was strictly respiratory. Just, what’s the ET two? What are the markings on that to be? What’s that thing holding the two suctioning, if there was so OT is not in their scope for practice or PT, they can so just training on even just suctioning and escalating the intensity of what an intubated patient is like, or a ventilator or an ear wig, just normalizing it more so that, say, as we grow in this program.

And doing this more regularly, they’re able to feel more autonomous with the patients that are stable and able to do what they can, even if they have now mobility techs that help eight with they need extra hands on deck for that, and not necessarily taking that RT away from other patients and maybe delaying that mobility time frame. So doing that education with PT, OT, also just doing that bridge, a little bit of communication.

Yeah, I really did. You can see we did. I worked here for five, six years. Now I barely even had minimal words with Tom or Luke. So now we like really, we really know each other very well. Now we got really comfortable with talking to them and raising awareness of questions and asking the right things, because I don’t know if our staff was too concerned with PT and OT and they were very concerned with what we do, so we wanted to make sure we provided everything that we could to make them feel a little bit more comfortable. And I think that really

Nelya Kapitula, RRT, BSRT 5:51
was they loved it. Yeah, we did a little survey after and everybody was so appreciative of just getting that extra time that knowledge of respiratory mechanics and ventilators.

Kali Dayton 6:03
We we always want PT and OT to be working with these patients, but in reality, many of our PTs and OTs throughout the community have not received training on mechanical ventilation, what the modes are, what the alarms are for, how to do inline suctioning. Can they or can they not do inline suctioning? But that those are essential skills to make this feasible. If you have to have an RT at the bedside every single time you set a patient up, there is no way you will have enough RTs to do that. You have to build a communication skill sets of your colleagues, and that’s why I could have had someone from my team do that education for your PTs and OTs by wanted to you guys to do it so that you would build those relationships, so that when you work with them in the future, they’ve received this education. You’ve checked them off in inline sectioning, they also know that they can come to you with questions, and you’re building this alliance between the two departments.

Candace Wistrich, RRT, BSRT 6:58
Yeah, no. Definitely made us a lot stronger as a team doing these mobility rounds of it.

Kali Dayton 7:02
And so with your team’s concerns about staffing, how did you initially set out a plan to make them feel like this is going to be possible?

Candace Wistrich, RRT, BSRT 7:11
We started initially with the simulations, we would staff one person over so that we can fully release somebody to attend these hourly rounds, and we were using that, as we said at present, this is what we plan to do. We are going to have a mobility respiratory therapist who’s going to either relieve you from your duty so you can go mobilize your patient because you know them, or we’re going to have them learn the patient and then go do all the rounds. At the beginning, it was very slow.

They didn’t trust us that we were going to do that, but we made it very clear every day we had an extra person on so they were that’s why we had such a great turnout with an artist. That’s because we had the coverage. Nursing doesn’t always have that luxury of being able to have people back them up. They did on some nights and some nights they weren’t available. So I think they really gained the trust that we were going to do that for them, and that’s what we’ve been doing. Then we eventually, the way we work at our department is we do it by points system, and that a lot each point a lot for a certain amount of time.

So now, when we know we’re mobilizing patients or have the potential to mobilize somebody, we will give them additional points so that they are able to have the time to spend and they know they can call Nayla myself their lead, and if they’re too wrapped up to be able to get to something, and we’ll go alleviate them, and they’re able to do mobilities. I think we through that barrier by just proving to them that we already get the staff.

Nelya Kapitula, RRT, BSRT 8:29
And then at the very beginning, we talked about staffing the PT OTA department with extra mobility text for this specifically, and we now have three. They did a great job establishing their workflow and how they rotate between the ICUs to help with mobility, early mobility. So that’s been really great. And I think RTS, so all three of them rotated within our department as part of their orientation as well. Yeah. So they had orientation to the ICUs, but just getting accustomed to vented patients or patients on BIPAP or high flow, very like high setting.

So they got acclimated to that as well during their orientation. So they got to see face to face with a lot of the RT department you have PT. OT, so again, bridging that gap between communication and collaboration, we had a patient who we ended up ambulating on the ventilator down the hall in the ICU, and because of staffing, it was a little tight. They weren’t necessarily able to do it in that moment, but leadership, I went up there and just to be a team player, just went up there me and Luke and the tech the nursing that was at the bedside went to the angulated outpatient on the ventilator. And it was such a great moment for even the ICU.

Everybody was like, Oh my gosh. Is this really happening? This is really happening. It was cool to finally have everybody see this is what we’re doing this for, and it but it did take that RT, me, my myself, the nurse, Luke, the patient handling coach and a mobility tech. So there was like, oh, there’s multiple hands on deck. So the staffing portion, I think we did a pretty good job here, yeah, making sure that. If there’s availability.

Candace Wistrich, RRT, BSRT 9:38
A lot of the concern from the staffs were, I’ll believe it when I see it. I talked about mobility tech in the simulations with you. Talked about, don’t worry about staffing, or your leadership team is going to take care of that. And a lot of the feedback was globally big. We tried this before and it never worked out. So the follow through and being consistent with what we were saying. Was huge here. I can only speak for our department, but we made sure we gave them the staffing. We told them, call leadership if you need help. Nayla shows up immediately. Yeah. So we told them they were getting mobility checks. They see them being trained by RT, so that follow through showed them that we were committed to this. Now they know that they’re bought in at this point, right? So, yeah, it was communication is huge, just in anything. But I felt in the program, it was huge,

Kali Dayton 10:47
It set such a precedence for the entire critical care department to see RTS changing their staffing model, accommodating the point system, having the mobility techs train with you guys. I don’t think I’ve ever seen that before. Usually they’re just like, just all around the PT or whatever, but we really want to make sure that those mobility techs were helping lead this, that they were autonomous, that they were educated, prepared.

So to have them understand oxygen delivery with these high acuity patients by RTS, that RTS helped train mobility techs, it just brings in that stronger association between respiratory therapists and mobility that it is part of your jurisdiction. And then as leaders to say, “We’re going to make this happen. We’re going to make sure that you are staffed to be able to be trained, not just a few champions, but every single person is going to receive this training, we’ll be at the training. And when you have patients that need help…”, especially initially, right? It was a huge lift.

Like you described Nelya that there were so many people involved in a mobility session, because it was a new skill to everybody, right? We weren’t sure what what was going on. And now, I mean, that was initially, and you guys did smart rounds. You went patient to patient to patient with leaders of each discipline, and now questions like, “Why are they sedated? What’s indication for sedation? What’s the RASS level? What’s their cam? Are we going to get them up? Are we not?”

And you went in and put hands on those patients. You got them up with them to show everybody. This is not negotiable. This is life saving interventions that must be done. We’re going to do it with you so that they could see it happen. You were actually proving its feasibility to your team, but then you’re teaching them how to do it so that they can do it independently later. So what have you seen? I know our last training was just a few months ago, but what have you seen as far as their skill set, the timing and the staff required to mobilize these patients.

Nelya Kapitula, RRT, BSRT 12:41
Even just this morning, when I went into the ICU just to go around on a patient, I literally had to wait 15 minutes for the RT to step out of the room, because she was doing mobilize. She was mobilizing the patient with PT and the tech. So it’s moving along. I think at this point it’s the fine tuning of the patients that have.

Maybe their settings are just kind of borderline, and they’re not quite sure if, oh, I can just table them at the side, or do I need RT and mobility check at the bedside, or more hands on deck kind of thing. And then the addition of the verticalization bed that, oh my goodness, there was a moment where I where everybody was getting one, yeah, like, holy moly. Unit is just in and out, you know. And it was really beautiful, actually. It was great to see that being normalized. It wasn’t such a niche in, you know. But again, not every patient is. It’s not more different for every patient. So there’s, like, old, I think, with that, but I think for the most part, the agreement from the beginning, oh, yeah, part of our normal, yeah, like, it’s normal.

Candace Wistrich, RRT, BSRT 13:39
It’s like, we completely different than last year at this time,

Nelya Kapitula, RRT, BSRT 13:43
Yeah, like, I don’t get called as much as I would have been before, which at the other facility I came from. Like, it literally, initially it was, like, rough, but then the workflow, it just was part of the workflow. You communicate with PT at your first round. Hey, when’s a good time you? Oh, okay, you want to do that? Okay, sure. Let me see what I can move around and just call me if anything. The communication is better.

They also make some adjustments to our protocols. Where our staff it’s now are you’re able to put in an order for mobilization through our RTE valent treat. So if an RT is going in and they can see, hey, this patient needs to be up, they can put that order in 18 OT, don’t do it, so they I’m we, we have, obviously room for improvement there. We can definitely be seeing a lot more patients, but are ordering it for a lot more patients. But having that as a tool has been great in helping PT ot recognize these patients that typically they aren’t able to see. So it’s a pretty increased amount of patients we see. So yeah,

Kali Dayton 14:40
That is so great. RTS are putting in PT ot consultation orders. I mean, I’ve never heard of that before. We’re very protocol driven in this facility, which helps that be facilitated easier. So it built in within it, but then highlighting it specifically for mobility, for RTS to be thinking. Got that. I think RTS and nurses were trained to look at certain organ systems and tasks that we’re doing, so I think it’s easy for RTS to fall into I work with a ventilator. I work with patients, so to me, that just shows that RTS are looking at an entire person and the trajectory of their lives. And I think they’ve learned a lot about how that all connects into the pulmonary system.

Candace Wistrich, RRT, BSRT 15:25
Yeah, they did, and that simulations were huge with the information that we did away from it RASS and CAM, we don’t get taught that. We started. It was just myself and Luke starting the smart rounds in the very beginning. And it was tough, like getting the feedback pushed back from the nurses. Was not always positive, but we stayed consistent. And then got the leadership nursing on board, and they started joining us. And then it became more fluid. It was like, okay, they’re coming around ready to get our patient up. They were like, ready for their stuff while they knew it was coming. And so they’re like, “Oh, great gosh, I need to figure it out.” Yeah,

Kali Dayton 15:59
They were ready to report to their leadership as well as you guys as leaders at the other departments. Yeah, right. And I think if you were to go into any normal ICU right now, and Candace as a respiratory therapist, if you were to say so, tell me about your patient, why are they sedated? They’d probably give you the middle finger.

Candace Wistrich, RRT, BSRT 16:16
Yeah, communication is definitely like, “Oh, why are you asking?” We don’t know anything about it until we’re like, No, we’ve done the RASS and CAM assessment, so we don’t think they’re at a negative two. “We think they’re more of a negative four. Why? Why are we sedating?”

Having that open dialog and understanding, yes, we need to stay in our own lane, but remember, we’re on the same highway. You’re saying that kind I love that, that because, yes, we all do wear different things, and we all specialize in helping this patient differently. However, we’re all after the same goal. Yeah, right, so we need to keep that in mind. And so against, the nurses got a lot more education about how we were educated and what they do. They were like, oh, okay, well, I guess they do know what they’re doing.

Kali Dayton 16:54
And doing that circulation training. Had your team ever done training with PT, OT, RNs, physicians, everyone, CNAs, everyone, together?

Candace Wistrich, RRT, BSRT 17:04
Yeah, this is the first time we’ve had all disciplinaries actually in a training session together, right? So, collaborating, yeah, collaborating, talking to each other. “Why? What are your concerns? What are your concerns from your specialty? like men’s versus men, versus getting up and BMATs and all that stuff. So it’s a lot of information, yeah, but working together was really helpful.

Nelya Kapitula, RRT, BSRT 17:24
It’s like doing multi disciplinary rounding without the pressure of actually having the result of the patient let counts in your hand and beautiful. It’s actually really, it was really nice to be a part of that, because you do get to hear and every nurse has their own idea of what is possibly the right way to go and RTS too. You have protocols, but that’s just a guideline. Otherwise, you’re using your critical thinking skills trying to figure out what to do, right? and PT as well. So the Sims were great because like MDRs, but without the pressure of a patient, like a live patient, yeah.

Kali Dayton 17:54
One of my objectives was to leave the entire team with the tools needed to critically think and work together collaboratively, because it’s really hard to prepare everyone for every single nuance and possible scenario that could happen in the ICU. Yeah, but I wanted you guys to be able to bring your personal expertise to those discussions, to be working towards the same goal, when historically, we haven’t had the same goal. We haven’t had the same vision. We don’t know what we’re working towards or what these tools or letters of the bundle are for. But have you seen that objective achieved?

Candace Wistrich, RRT, BSRT 18:30
Oh yeah, I think so. It’s going in the right direction. We’re not fully there yet, but it’s been. It’s still very new to us. It takes a long, a long time to change this many equal mindset of what we’re doing, but I think we’re way better off than we were last year. I think Ginger has given us the statistics of medication being down the city, yeah, like, how much Station we’re giving has drastically changed. So I think we’re in the right direction.

There’s always room for improvement, but I think everybody’s on board now. We don’t really have a lot of I think now it’s issues may or may not be more depending on the physician, even that they’re like, physicians can be a barrier, like today, for instance, the physician is the barrier. There’s just different pieces. Every week. It could be a day to day change where we’re, like, mobilizing, mobilizing, and then a new physician comes on board, and it’s just like, “oh, okay, I guess we’re just gonna…” it’s hard to get to everyone every time, but generally, I think, but in that situation where tonight, questions are being asked, yeah, “Why? Why are we doing this?” which is so much different than last year, it was like, “Oh, the doctor just said that, yeah, I’m walking away.”

Now it’s like, “Wait, why? “Yeah, we think a little bit harder and a little bit deeper, which is essentially what this program is, right? Let’s think a little bit harder. We’re not going to be able to help everybody. I mean, yeah, can’t close, but we can’t do it for everybody, but at least we’re acting right.

Nelya Kapitula, RRT, BSRT 19:52
We’re advocating for that patient in the appropriate moments and making the changes that we can. Yeah, yeah.

Kali Dayton 20:00
We didn’t have really great position involvement in the simulation trainings or even the webinars, to be honest, that was really disappointing. And so I’m not surprised to hear that there’s variation, because we’re all a product of our training and our experiences. So it’s hard to expect someone to really lead this and excel in it if they did not attend the training, but it’s nice to know that there are layers of safety that the rest of the entire team has gotten this training.

They’re having these experiences, they’re developing this expertise, then they’re asking those questions and hopefully guiding those physicians with just how they manage these patients. And Nayla, you have a special experience from your last ICU where, yeah, you actually worked with Dr Bellucci, who I interviewed in episode 130 he talked about having visited LDS hospital, seeing an awake walking ICU coming back to your unit, yes, and then doing the rapid overall. So I care that experience having get sedation off everyone, Everybody get up and family to make it happen, versus a much more organized and thorough implementation.

Nelya Kapitula, RRT, BSRT 21:07
Oh gosh, man, I distinctly remember the shift when he came back. I’m like, “Who this? Kali Dayton, who was he talking about?” I had no idea what I was or what your podcast was, or whatnot, but I remember him coming back, and he went gung ho all the way, like, okay, guys number sedation. And I feel like, I mean, I don’t think anybody was really a fan of non approach, but being able to see that implementation versus how I came in here at Mercy San Juan, like, halfway through your guidance program when I came on and I was like, “Wait, there’s a little organization right in the middle that implements this. I was like, wait, what?”

And for me, coming from where Dr Belluucci was like, “Hey, this is what we’re doing,” there wasn’t he, I think, in the moment that he could educate why that’s so important. Most of that education went to nursing because they were the ones at the bedside doing the SATs and whatnot. So for the respiratory department, for us, there wasn’t a whole lot of information given there. We just knew, “Oh, they’re not giving sedation anymore. It’s something we need to figure it out.” Like, okay, there wasn’t a whole lot of information to back up the why behind the change.

There’s different pluses and minuses, because we had a lot of barriers, I believe here with changing culture, and it was, there’s a lot of tiptoeing initially, I believe, like, Oh, we don’t want to, but we also want to look forward. I don’t even know how to describe it. It was really kind.

Kali Dayton 22:36
We want to disrupt the system, but we don’t want to upset people.

Nelya Kapitula, RRT, BSRT 22:40
Right, which is, I think looking at it now, on this side of it, I think it’s great how where we’re at and where we’ve come and how the collaboration has grown a lot at the previous it was good. You saw the value of it. But how are you not the whys weren’t the whys weren’t answered. There was just a lot of head letting with disciplines before it became more of the workflow. Like, PT, OT and RT, like, we all became great.

Like, I still to them, and I’ve been here for almost a year now. You became so close because you had to, you didn’t really have an option. Like, hey there, there’s no more sedation. Like, let’s go and try to walk them, or do something. Like, we were walking patients on men, actually, prior to Baluchi going, I think in singing. But when he came back, he was just like, This is it. We’re done. We’re JD, that happened, and it was good. It was effective. But there was also a lot of nurses who left, actually, because they were like, I’m not doing this. This doesn’t make any sense.

A lot of nurses quit, I remember during that transition, and again, I think it’s because they didn’t know the why behind it, and it was always nighttime sedation. “Oh, they just, they’re resting” when now we know exactly that. That’s the opposite, right? But I don’t know that they necessarily were given that information. And it’s sad, it’s hard. It could have just been some education pieces, even some like education modules online or like webinar, but there was none of that. It was just, I’m here. We’re doing this. And, and, gosh, I love Dr Belucci. Don’t get me wrong, like he was, and even now, I highly, highly respect him. He’s an incredible I think the approach could have been a little bit different. And I don’t know if I’m the only one who felt that way.

Kali Dayton 24:16
It’s amazing what he’s accomplished. I mean,

Nelya Kapitula, RRT, BSRT 24:18
Oh, incredible, yeah

Kali Dayton 24:20
To get to that point as a lone revolutionist, and overall, yeah, and there is something to be said of pushing the team to just do it. So yeah, actually experience it when you’re just trying to manage awakening trials. You never really get to the point where you see patients be awake, free of delirium, strong, compliant, walking on the ventilator. So, yeah, that’s a lot to babysit. So I like this inside approach of, we’re just going to do it all the way, so you can see the contrast, the difference.

Nelya Kapitula, RRT, BSRT 24:48
And it was like, Yeah, because a lot of those nurses, it wasn’t necessarily. Some of them left because they’re like, but others were actually let go because they just wouldn’t. They were held accountable. I think. Part a little bit be difficult to find that bridge that part here, because we don’t want to push too hard, because we know you have a lot going on, but we really need to change this. So that shift in culture took a lot longer, and I think it’s still a work in progress, whereas over there, hey, this is what we’re doing. If you’re not doing it, sorry. And there was, I think a few actually were just like, let go, because they weren’t willing to change their culture, like the way that they did their their ABCDEF bundle.

Kali Dayton 25:27
It really should be standard of care, yeah, yeah. And if we’re like, “No, I’m not gonna do that vent bundle. I’m not gonna do the oral care”– that would never fly for any RT or RN,

Nelya Kapitula, RRT, BSRT 25:38
yeah.

Kali Dayton 25:39
So I do like that. They saw it as imperative and non-negotiable and essential. I saw another team really put a lot of pressure on their charged nurses to lead this and oversee it, and sat them down and said, “If you’re not going to assume this role, then you’re not going to have this role.” And one was demoted from being charged nurse. But it doesn’t have to be personal, but this is what needs to happen for our patients. So that’s really hard, and that’s where I would never want to be a manager of a department or any of that, because it’s so hard to negotiate. But I just wanted to hear your perspective as someone that kind of got blindsided, didn’t learn the why.

Nelya Kapitula, RRT, BSRT 26:15
I feel like a lot of those end results with those that staff members could have been different if they had the why, and really feel like that could have been the change. That would have been like, “Oh my gosh, totally.” Because when I listened on some of those webinars, and then the sims, oh my god, the night time, “oh, they’re resting,”

I had never, ever heard that that they’re not actually resting, and they’re going through all these different episode the PTSD posts like, I did not know any of that. And I came from an ICU again, where we have been watching people on vents and early mobility for the last five, six years that I was there, so to only now find that out, what? How?

Kali Dayton 26:53
That’s how I felt, too. I’m like, I had worked in a wake and walk in ICU, and I didn’t know why we did it. So when I went to a normal ICU, I just did the normal thing, yeah. And then I went back to my first ICU. And finally I was asking, “Why are we doing this?” It just makes you feel insane that it’s like trying to explain water to a fish. It’s all around them. They’re surrounded by it, but maybe they don’t even know that it’s water. Delirium and ICU-acquired weakness. We don’t actually see it for what it is.

Nelya Kapitula, RRT, BSRT 27:19
Yeah, yeah.

Kali Dayton 27:20
And so it sounds like you both agree with me that understanding the why is the imperative first step.

Candace Wistrich, RRT, BSRT 27:27
Yeah, of any change, but specifically Yeah.

Kali Dayton 27:30
And Nelya,, what has your role been as RT educator, in rolling this out and now sustaining it?

Nelya Kapitula, RRT, BSRT 27:36
Just being a resource first and foremost for the staff, because I did come from the facility where we did a lot of that, and with the education of the why, with the symptoms and everything just being a resource, also the education portions with PT OT, and then I did partake with the smart rounds for months, she got stuck me because I went on, yeah, she and you really saw the shift, because I was consistently almost two months, yeah, I think two months, yeah, I think two months straight of smart rounds that I was doing, and you I really saw the change.

I think it’s because nursing leadership really started holding the staff accountable and making sure that, Hey, why are your BMAT scores and their RASS all of that daily had to be updated. So just being able to see that, and then coming back to my department and communicating with my staff like, hey, are they communicating with you about their ability to to mobilize if they’re low on being that, just doing that, bridging that part of it, because it’s hard.

It is hard with all the different disciplines to come together, collaborate, make a decision for a patient, like, “Hey, we should do this. We should do that.” But for the most part, they just being a resource for them. If they’re not able to do it, be available to them. Like, hey, pop in and do that.

I love actually, I’m not that long ago from bedside, so any moment I can go and do some kind of bed sign, anything, I’m just like, “let me go. Let’s go.!” I’m all about it being a resource for them, and then just educating wherever I can, especially the mobility techs.

During the orientation process, I was able to incorporate them into the RT workflow so that they can see the ICU, RT ed side work, what the bed looks like, and all that. So I think that’s probably been my biggest thing that I’ve been able to give to the staff and to this program. But otherwise it’s been a full collaboration day.

Kali Dayton 29:18
One of the big concerns that RTS usually have is ventilator dysnchrony. “We have to sedate our patients because we know that they’re going to have ventilator dysnchrony”, When actually we know that sedation, especially deep sedation, increases and can cause ventilator dysnchrony. So I just want to hear anecdotally, are you guys getting called all the time saying, I keep synchronized with the ventilator? Come help, because we don’t have sedation.

Candace Wistrich, RRT, BSRT 29:42
I mean, today, today, and I mean, I think that’s a good question to ask our staff, yeah, because we typically don’t get assigned patients. They don’t come to us and tell us our patients and be happy to talk to them. And so you get their feedback. Are you guys dropping? What are you guys doing? What are your steps to fix? We typically tap any patients must be round on them, but typically don’t round on the oneswho are intubated. So I think that’d be a good question for the staff, but I know I don’t hear it as often as it used to. Yeah, the issues.

Nelya Kapitula, RRT, BSRT 30:11
We did have a patient recently. We did like a whole lunch and learn with the RT tap in nursing where Doctor Bistrong, our medical director, and we have our trauma patiemt that we actually just had in our trauma ICU, and the things we couldn’t fix because they went into arts, and it was, yeah. So in that sense, there was a lot of talk about sedation, and distinct me, because we are doing this early mobility, so there was a lack of sedation when it may have been warranted. For specifically this patient, they were trauma patient turned into medical pulmonary.

It was a very complex, complex situation, yeah, but in that case, I wish we would have collaborated more on the sedation into synchrony, because, I think, and that’s where, again, the physician part comes into and their understanding of deep sedation and sedation, but otherwise, I think they’ve been our staff was really good about, yeah, trying to educate quality sedation with Disney and how, if you deep sedate, you’re also removing our drive debris, then now you’re going to be having a harder time to ventilate your patient because they have no drive so our our teeth. Our teeth are pretty Yeah, they’re pretty good, pretty great.

Kali Dayton 31:18
You guys do have incredible RTs. And even before we started this, your RTS had a lot of autonomy. They were on COVID. Oh, yeah. Oh, they still do. They love it. Yes, I know. I just love seeing an environment and a hospital system that allows them to practice at the top of their license. That made it a lot easier to hand this off to you to say, lead this. When you have an RT department that is not empowered. They don’t see themselves as leaders. They’re just the ones that only mess with the buttons according to what the physicians tell them all the time on the ventilator.

That’s really hard to then say you’re going to help lead this. So I just feel like this was a really great puzzle to put together, from my perspective, with these great elements and to just let you guys shine. And I feel like that’s what your RTS have done. Any advice that you would give to the respiratory therapy world about helping lead the ABCDEFbundle in their units.

Nelya Kapitula, RRT, BSRT 32:12
What Candace said earlier was huge. If you’re leading your staff, be there.

Candace Wistrich, RRT, BSRT 32:16
yeah, lead by example. Embrace the change. Understand that this is a critical part in the recovery process with patient and that we need to get on board to do this. Remember why you got in school, why you went to RT in the first place, right to save life, and this is what we’re essentially we’re doing and expediting the process when they’re in the place. So embrace the change. Educate yourself. You give all the right tools.

I feel like the webinars are huge staff, so take the time to watch the webinars. I wish it would have been mandatory for our staff. We made it optional. So I wish they were mandatory, because there was a lot of good information in there that was given to the staff before going into the simulations that they took away. Wow. I didn’t know if this big, because we don’t get taught this in RT school. This is not something we go over. It’s more nursing focused, right?

Nelya Kapitula, RRT, BSRT 33:05
Another thing that we did in our department, and I don’t know if this is something other departments would want to do for theirs, but we have a skills book that we create every year for our staff, and we’re able to input all the data that you gave us, the graphs, the anything that was specific to us, yeah, and put it in into a skills book for the staff, so they always have something to reference if we’re not here or if you don’t like maybe it’s been a while, and then you forgot what RASS is. And, oh yeah, I have a whole section on early mobility, and I highlighted you in it and some of the success stories that you had online. So the staff always have that to reference, which, again, it just equips them. You just want to give them everything that they need, or may need, to do their job and do it well and to continue on,

Candace Wistrich, RRT, BSRT 33:55
I think from a leadership because we can speak more from the leadership realm of what we do. Collaborate with your colleagues really get together, identify weaknesses and opportunities for improvement, and work towards a common goal for your department and that department to work together that really helped with Tom and me and Luke and Chris and Nayla, all sat down and really hammered out what we really wanted to get done, and they made it happen.

Celebrating successes is huge, knowing that what they did really worked, and they were part of this change, seeing that, and like you said, like actually living it, and then not just being a simulation, but watching it come to fruition. All the stuff you did, all the some things may not have worked, but something might have. And seeing these success patients, we took video of them. They were healing garden on a ventilator. Like it was really cool to see. People really enjoyed that. Like I would hear them. They don’t like to admit it, but they would, oh, “I took my patient outside,” they really got excited about it. It wasn’t the cool thing to be excited about.

Kali Dayton 34:53
Oh yeah, we’re supposed to be complaining here. I forgot!

Candace Wistrich, RRT, BSRT 34:57
but it became, you know, really exciting. To know that they did something really good.

Kali Dayton 35:04
That was another one of my objectives, is that they would be able to see that crossroads that patients were at, and that when they did these interventions and they took the right steps and had them awake and mobile, they could see in their minds the trajectory that they were putting them onto,

Nelya Kapitula, RRT, BSRT 35:18
yeah,

Kali Dayton 35:19
That they could feel like, okay, I’m saving their lives and getting the best lives worth living.

Nelya Kapitula, RRT, BSRT 35:23
Yeah, yeah. One part of their healing and their big like, their ability to get out of here and live their life, Yeah,

Candace Wistrich, RRT, BSRT 35:29
huge, yep.

Kali Dayton 35:31
What’s your plan to sustain this? When you have turnover, new grads, new employees come in?

Candace Wistrich, RRT, BSRT 35:37
Well, the new grads. We really tried to make sure our new grads specifically stay in the ICUs. A lot of the night shifters don’t get the opportunity to work with them as much as we want when it comes to mobility, and unfortunately, that’s where all our newer staff go to is night shift. But we do have a few per diems that have come on during the day, and when they complete their training in the ICU, we try to ensure that they’re going to be I also instructed more senior therapists who do this, do this a lot for comfortable doing it, to take them under their wing, “Come with me. Let’s do this together. Let’s figure out how we can get you comfortable doing it as well.”

So leading by example is huge. I think that any realm like if you’re a senior therapist, you need to feed our young, teach them what we should be doing and how to do it correctly,

Kali Dayton 36:20
And it lightens your load, right? If there’s only one that can mobilize a patient or is going to then it’s always going to fall down to you. But if you build up an arm and they can do it when you’re busy with one patient, you’re going to have more help to catch your other patient, right?

Candace Wistrich, RRT, BSRT 36:36
One other thing I feel like we could have done better at. They always try to see what we could have done better. Was earlier collaboration with PT OT and nursing set the goals of what we have and how we’re going to go about doing this. So we have more of the answers when we are in the simulations. Like, “Oh, we’re going to work. We already have education plan with PT OT” – instead of that was we learned along the way, like, third simulation, like, “Maybe we need to do education with PT and OT” because they didn’t know the difference between infection catheter.

And so I think earlier education with the leadership team and clear what our goals are, what are how are we going to get there? And having that information when they express the concerns in the simulations would have been a little bit easier, because I had no flu questions they were going to come up with. But I think we did a good job getting everybody on board. And I think going forward, I’m technically the process of redoing our new hire orientation and all of that, I will be incorporating early mobility within that as a competency for them, so that’ll help continue it on as we go forward again.

That’s a full project process, so it’ll be a little while, but nevertheless, it’s going to be highly highlighted within the orientation of any new hires that I think will help, again, sustain with the department, because then the other staff members enlighten them out again a little bit, and

Kali Dayton 37:56
it sets the precedence that we are. Marcy San Juan, here’s the care that we give if you’re going to work here, this is what we do, and we’re going to teach you how to do it. We expect you to jump in. Yeah, thank you both so much for everything that you’ve done. You have saved lives for generations to come.

Nelya Kapitula, RRT, BSRT 38:12
Thanks to you Kali, you kidding?

Candace Wistrich, RRT, BSRT 38:15
I know!

Kali Dayton 38:16
Well, thank you so much, guys. You’re welcome. Yeah, thank you so much. Yeah, it’s been wonderful.

Transcribed by https://otter.ai

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