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Critically ill cardiovascular patients can be very high-risk and high-acuity patients with numerous devices and multiorgan failure. How and when can we safely initiate early mobility? What role should physical and occupational therapy play in the CVICU? Jenna Hightower, PT, DPT, CCS shares her incredible expertise and ground-breaking work in early mobility in the CVICU.

Episode Transcription

Kali Dayton 0:04
Throughout the ICU community, there is a justifiable pattern of heightened hesitation and fear in regards to mobility when invasive devices are present. Cardiovascular ICU patients often have the highest risk and the most numerous devices such as such as intra aortic balloon pumps, impella devices, left ventricular assist devices, external pacemakers, Extracorporeal Membrane Oxygenation, mechanical ventilation swans, ganz catheters, central lines, CRRT and so on.

These catheters can coexist in different locations such as femoral arteries that make us so nervous to mobilize. Obviously, these are high acuity and high risk patients that are vulnerable to very poor outcomes.

We know that adding in delirium and ICU acquired weakness to their long list of complications and organ failures can be lethal. We know that early mobility can be a life saving intervention yet, how do we navigate how to safely manage sedation and early mobility? With all these devices and comorbidities?

Jenna Hightower joins us now to dive deep and early mobility in the CV ICU. Jenna, thank you so much for coming on the podcast. Can you tell us about yourself?

Jenna Hightower, PT, DPT, CCS 2:00
Yeah, so I’ve been a PT for about five years now, which is kind of hard to believe. And I did a residency right out of school in critical care and cardiopulmonary physical therapy, to be able to sit for boards. So I’m now a board certified cardiovascular and pulmonary specialist and physical therapy for about three years now. So I primarily work in critical care, and have been a critical care physical therapists ever since I got out of school for five years. I mostly work in cvicu. But I also work a little bit in NICU. But my special passion is working with patients on mechanical circulatory support. My patients pre and post heart and lung transplant. That’s where I have my most interest, but also most experience, I would say,

Kali Dayton 2:50
What drew you to that specialty?

Jenna Hightower, PT, DPT, CCS 2:54
Well, in school, I actually went into school with an open mind not knowing really what I wanted to do, but I always loved acute care when I was in school. And then in school, I met my mentor Dr. Ellen Hilligus, who was kind of a trailblazer in the cardiopulm world as far as education. And she invited me to do residency under her and so she kind of lit that passion and really grew, grew my passion for cardio pom and really, ICU and critical care.

Kali Dayton 3:26
And when you started mobilizing patients on high support on mechanical ventilation and ECMO and Elbaz and all of these really invasive and life sustaining devices, were you scared?Did that intimidate you?

Jenna Hightower, PT, DPT, CCS 3:43
Absolutely. Absolutely terrified, actually. But I’ve actually always been taught that it’s, and I totally agree with this concept, that it’s always good to have a healthy fear in the ICU. You know, these are really sick patients. So it’s always good to maintain that healthy fear, but also to not let it scare you too far away from it. But always keeping you on your toes. And being aware is what I mean by that healthy fear, never becoming too comfortable. Which is really easy to do when you’re in it all day, every day, it becomes routine and comfortable. And that’s where mistakes can happen.

So maintaining healthy fear is super important. But you know, getting past that point is you just keep learning you do your research, you keep getting your hands dirty and and learning from other people. But I think the biggest thing that helped me kind of get over that hump of the fear is the multidisciplinary team. It’s a team sport in the ICU, and having the support and, and helping support other members of the ICU team is really you know, how you get the job done with these patients.

Kali Dayton 4:57
And why is it so important to mobilize them? I know we should have some trepidation, understanding how sick they are and the risks of moving with certain devices. At the same time, why should we also be nervous and scared about leaving them in bed with these specific diagnoses and devices?

Jenna Hightower, PT, DPT, CCS 5:20
Right. So with mobility, you know, it’s that risk versus benefit ratio. You know, the benefits just far outweigh the risks, you know, when you leave a patient in bed, they just deteriorate almost immediately. It happens fast, but then the time that it takes to get all of that back, takes days upon days and months, even, especially patients that are left in bed for weeks at a time. I mean, I’ve, I’ve worked with patients, all ends of the spectrum.

So you know, the patients that get sent to our hospital, from other hospitals that have been sedated for weeks, and they can barely move their fingers when I start with them, you know, to the patients that we get started with right away. And just the difference in how those patients do and the how much faster they get off support is just, I mean, you can’t even compare them to each other.

It’s just very important that you you mobilize these patients because they’re very sick. But also a lot of patients on mechanical circulatory support, it’s a bridge to transplant, sometimes it’s a bridge to recovery. But in my experience, a lot of times it’s bridge to transplant, and you can’t go into a transplant surgery week, you’re not going to do well.

You know, I mean, outcomes show that, you know, if you’re weak going into surgery, then your outcomes post surgery, your risk for complications, your hospital length of stay your ICU length of stay your ventilator time, you’re most likely to need a tracheostomy, a feeding tube, all of these complications that can happen, your stroke risk is higher. So it’s so important that we, you know, are very aggressive with these patients so that they can have the best outcomes possible.

At the hospitals that I’ve worked at, you are not a candidate for transplant surgery unless you can stand from a chair. And, and even sometimes they will say being able to walk is the best outcomes we can. But sometimes there is extenuating circumstances and emergent need for transplant. But if if you can’t stand, then the frailty index is just too high. And you’re not going to do well, so you don’t get listed.

Kali Dayton 7:31
Yeah, that’s a great motivator. I mean, it is literally life or death.

Jenna Hightower, PT, DPT, CCS 7:35
Yes.

Kali Dayton 7:36
And so I think in some units and cultures, it’s imagined that early mobility is “lethal”.

Jenna Hightower, PT, DPT, CCS 7:43
Yeah.

Kali Dayton 7:44
But you see it as life saving- it is the only chance to even survive. And that’s not even considering the quality of life that you’re preserving or restoring.

Jenna Hightower, PT, DPT, CCS 7:53
Right.

Kali Dayton 7:54
So when patients are so sick, they have such high acuities, they have multiple devices…. Give us some examples of how you know when a patient is appropriate or is not appropriate for early mobility. Then kind of how to advance the levels of mobility. And I know obviously, we all know that this is very case dependent, very customized. But what are some thresholds or examples that you can give of how to determine safety for patients?

Jenna Hightower, PT, DPT, CCS 8:22
Yeah, absolutely. So whenever I’m mentoring other therapists, or other clinicians, I always say there’s never a black and white answer. It’s all gray area. And it just it depends on each patient, every patient is different. And even the same patient can change moment to moment. But you’re looking at the whole clinical picture. So your big ones are: Are they able to awake, be awake and participate with you?-which is very important.

Can they be calm?- but sometimes there are moments where moving helps them calm down, or just getting out of bed helps them calm down. Sometimes they’re just very uncomfortable on bed, and they need to move.

But hemodynamic stability is very important. And that doesn’t necessarily mean if they’re on pressors or not, it’s just are – you titrating up? Are you coming down on pressors? Are they on max doses? Do we have wiggle room just in case we need it? Which is where that multidisciplinary team comes into play.

And same thing with the ventilator. You know, have they been stable? What are their blood gases look like at the levels that they’re at? How do they do tolerating just rolling in bed with nursing staff?

And I usually start slow. You know, especially with ECMO, I usually raised the head of the bed up first, you know, assess as you go, how they’re doing, how their hemodynamics are. Depending on the cannulation like if it’s a femoral cannulated patient I will you ever been there hip up in bed just to see if that particular patient is sensitive to hip flexion but most of the time we don’t have issues. I mean, it rarely happens, but sometimes you’ll have float issues. and just kind of going slowly along the way.

And if they tolerate each piece, then we advance more, if they don’t, we kind of take a step back and work in the range that we can. And then you’re always trying to advance. You’re always trying to get better. But you just kind of have to gauge that, you know, on the patients. And also, it depends on their baseline mobility level. So what are they like, at baseline when they’re healthy? Are they normally standing and walking? Or are they normally sitting in a wheelchair or a chair most of the day? So you kind of gauge what you’re going to do based on all of those factors as a whole.

Kali Dayton 10:34
when you get these patients from outside facilities that have been sedated and immobilized for so long…. How do you even start?

Jenna Hightower, PT, DPT, CCS 10:42
Yeah. Yeah, I mean, I have several case studies that I have, from patients where we started with them just can barely wiggle their fingers. And then they don’t get better on ECMO. So they need a transplant. And a lot of these were from COVID. But you just start where you can. So you, you do what you can you do what they can tolerate, you start slow, raise that head of the bed up. And even that sometimes for those patients is a lot. I started out with, like gravity eliminated exercises, to move in the planes that they can.

And I usually engage family members. If there isn’t family members than engaged nursing staff into small doses more frequently throughout the day. So that we can work towards that. When they’re ready for it usually a transition them to like a tilt hospital bed, so that they can get that graded weight bearing multiple times a day. And that makes the world of difference in being able to tolerate upright and tolerate strength. And then usually about two to three weeks of that I can progress them off the tilt bed and start actual assisted standing from the edge of the bed and things like that. But it does take a lot more time when they start out extremely weak. But we have had a lot of success with it.

Kali Dayton 12:00
And tell me about the tilt beds, I know that you’ve mentioned before, in our conversations that you have nurses doing the tilt bed. What are the benefits of it? And also, how do you get the whole team engaged? Granted, you’re coming in to an environment in which there are already engaged? But yes, what recommendations can you give as far as using the tilt bed with those kinds of patients?

Jenna Hightower, PT, DPT, CCS 12:23
Right. I was introduced to the tilt bed during residency, and we used it a lot with patients with femoral balloon pumps. And I shared a citation with you of a mentor of mine, started walking patients with femoral balloon bought femoral balloon pumps, using the tilt bed, which is just incredible, because traditionally, those patients are on bed rest. And he published some research saying that, you know, they had done over 300 ambulation sessions with no adverse events with femoral balloon pumps, which is just incredible. And those patients at this particular hospital are waiting for heart transplant. So you can imagine the the outcomes that that changes. Which is just incredible, because then they can tilt to eat, tilt during the day, but also just staying ambulatory is just super, super important.

Kali Dayton 13:19
I love when people bust myths!

Jenna Hightower, PT, DPT, CCS 13:23
and he has a specific protocol. But you know, they say with balloon pumps, you can’t flex your hip past 30 degrees because your risk of aortic dissection, dissection or pump migration is very high. But with ambulation, you actually don’t flex your hip past about 20 degrees. So it’s considered feasible and safe to do it is what his research proves. And so other hospitals around the country have started doing this as well, utilizing the tilt bed.

But that’s just one use. But I brought it in my hospital for…we would have a lot of patients from outside hospitals. You know, we’re a quaternary care hospital. And we get a lot of patients that needed transplant or want to be worked up for transplant, or just were too sick for these smaller hospitals to manage. And they come to us very debilitated.

And so the tilt bed is just a great tool to kind of bridge that and accelerate that rehab process. And so that’s kind of how I justified it to our team. But I mean, there’s all kinds of benefits just like your benefits of mobilizing, you know, you’re improving their level of alertness and consciousness. sensory stimulation, you’re stimulating proprioception touched your vestibular apearance.

It helps with delirium being in upright, you’re reducing your aspiration risk, your risk for ventilator associated pneumonia, you’re improving lung lung volumes and alveolar recruitment upright because you’re dropping that diaphragm down, improving the ability for the lungs to expand, changing that heart position off your left lower lobe, to improve VQ matching, you have a better pressure gradient improve create PF ratios, but then also the benefits of axial loading through that graded weight bearing, being able to slowly titrate their ability to bear their own weight, again, muscle activation and strengthening through that, and then the in that you’re retraining autonomics and improving stimulation of bear receptors and decreasing your risk of vasopalegia.

So just I mean, all kinds of benefits from just being upright, our bodies are just not made to be flat, and the tilt beds just a great tool, one for those patients that are very, very weak that we can’t mobilize traditionally, but to for for those programs out there that want somewhere to get started, where they’re scared to start somewhere as far as mobility, it’s a great stepping stone. And that’s what I use it at, at my facilities, we really weren’t mobilizing a lot of ECMO when I started there. And it was a stepping stool of like, okay, this is a safe way to do this. And then once we get comfortable with that and realize how safe it is, we can go from there. And it got to a point where we were mobilizing strong patients on ECMO with the tilt bed, and it’s like— “This patient’s strong. like, Why are we limiting them to just to tilt bed” you know?, and now we walk patients orally intubated, on ECMO down the hallway from femorally cannulated, no limits, but obviously, it’s patient dependent.

Kali Dayton 16:22
And why do you see some hypotension when you start to change the position of patients, especially when they’re on these devices. When they’re so deconditioned tell us about what happens that affects the dynamic stability.

Jenna Hightower, PT, DPT, CCS 16:36
So when you’re you’ve been supine for a long time, you you get vasopalegia, you lose that vein, basal tone in your in your extremities. And especially when you’re very weak, you’re even more at risk for that, because you don’t have that muscle strength and muscle pumping to help that venous return. Also, just depending on what, you know, the pathophysiology of the patient is, you know, sepsis, and all that can increase your risk for vasopalegia and whatnot, as well.

Kali Dayton 17:06
So as you’re advancing with a tilt bed, you’re constantly monitoring for hemodynamics. And what do you see over time with how they tolerate it, because I think sometimes people worry if they sit them up, and they become hypotensive, or vagal down, they don’t know what where to go from there. How do you gradually improve their hemodynamics to be able to tolerate being totally upright and then weight bearing?

Jenna Hightower, PT, DPT, CCS 17:30
right, so we just start slow. So I usually start out at like 20 to 30 degrees, which doesn’t seem like much, but when they’re there, it’s it’s pretty good amount and just assessing as you go. And that’s where that multidisciplinary team comes in. Like sometimes our nurses in real time will titrate, pressors, and inodrips to help the patient tolerate so that we can get over that hump, so that we can start doing mobility.

Same thing, sometimes the the PA or the nurse practitioner or even the physician will be in the room to help monitor those things. And then patients on ECMO sometimes will have either the nurse ECMO specialist or the perfusionist, right there in the room to help titrate their circuit settings to help them tolerate because at the end of the day, mobility is the goal, we’ve just seen the outcomes of how important it is that that’s where that multidisciplinary team is so important. Because even if we have to give them a little extra support, we want to be able to support that mobility and support the ability for the patient to get stronger, because at the end of the day, that’s how they get off.

Kali Dayton 18:34
That’s so similar to my experiences in MSICU with mechanical ventilation, we think in the community that they’re on mechanical ventilation that is threshold that they cannot mobilize. Whereas in a culture with strong early mobility practices, those devices, those interventions are seen as supportive to enable mobility. And that sounds like what you guys do, the vasopressors, the ECMO, the mechanical ventilation is all to enable them to support the not just to survive, but to walk and in order to be independent and functional.

Jenna Hightower, PT, DPT, CCS 19:09
Right? Especially, for example, our patients that are awaiting for lung transplant on ECMO, the doctors will often titrate up them up to 100% FTO2 to on the circuit and 100% Fi02 on the ventilator to help them support mobility to be able to tolerate walking. Even though they may only be at 50% at rest. But you know, on that 50%, they can only tolerate walking 50 feet, whereas if they’re on 100%, they can walk, you know, over 400 feet or 500 feet. So just the ability to support them to do that because that’s where the outcomes are.

Kali Dayton 19:47
Oh, I love it. And then what about patients that start out in your unit? From day one with different devices? How do you approach that? What do you usually see as far as their capacity? Again, you mentioned, when you started using the tilt table that became the inclination is to just use the tilt table, but you were limiting patients. So how do you make sure you’re meeting patients where they’re at, and encouraging them to progress or at least even preserve their function?

Jenna Hightower, PT, DPT, CCS 20:14
So it depends on the patient. You can see such a wide variety of pathophysiology in CVICU. So we’ll start with LVADs. You know, research and mobility for LVADs has has been out for years on years that post op day one, if they’re stable, if their chest is closed, hemodynamically stable and awake— they’re moving. That’s where your outcomes are.

And obviously, you have certain precautions, that, you know, they have sternal precautions, and you want to make sure your drive line’s anchored and things like that. No signs of bleeding, but you’re just monitoring along the way. But really no, no limitations in our unit with patients that have undergone an LVAD.

And then next would probably be the impella, which is like a percutaneous LVAD. And at our facility, they mostly implant those axillary so that patients can be very mobile. And a lot of times those patients, when they come to us, they really aren’t tolerating a whole lot, because they’re in cardiogenic shock, you know, they got to a point where they needed added support. So usually they’re on a couple inodrips, and then supported by the LVAD, or the the impella.

And just routine precautions for those patients are they can’t lift their elbow, either shoulder flexion, or abduction past 90 degrees, but really, we try to keep them around 45 degrees, no heavy lifting, or anything pushing, pulling with that arm, just for risk of dislodgement, which whichever side that it’s in, but we keep them actually training their biceps, biceps and hand muscles throughout that just limited shoulder mobility.

But a lot of times those patients, they get like a little competition going in on the unit. And by the time they’ve accepted an organ for them, they’re walking miles per day on the unit, and doing strength training and power training, you know, being one of the best predictors after a sternotomy for success and mortality is being able to stand from a chair without using your hands.

And so we really drill that in them and get that that power back that you lose when you are in multi-system organ failure. And they feel good because they’ve got that support, finally, so we maximise on that. And it’s really cool that they, you know, have are able to support each other on the unit, a lot of the guys will, you know, knock on the door of another patient and say, Hey, ready to get your walk in. And of course, nursing has to walk with them, because they are there to manage the machine and make sure that they’re being safe and monitoring their vital signs always they’re always on portable monitor. But, you know, when I started there three years ago, we didn’t mobilize these patients. And then it came to the point of asking why not? So it just takes somebody being there asking those questions: why not? And now, I mean, just huge success with these patients with impella.

Kali Dayton 23:11
What have you seen for their discharge disposition over the last few years?

Jenna Hightower, PT, DPT, CCS 23:16
Yeah, they go home. Yeah, absolutely. Unless they have some sort of complication, after transplant, such as tamponade, or, or any kind of complication that can happen with transplant or stroke or things like that, you know, they go home probably 90% of the time instead of rehab.

Kali Dayton 23:33
Just speculating, I don’t even know what’s what’s the national average, what’s usually expected for LVAD patients or impella patients?

Jenna Hightower, PT, DPT, CCS 23:40
You know, I don’t even know, I don’t know that a lot of centers do a lot of impellas. Because there’s no research out yet supporting bridge to transplant. So it’s, it’s all new in the field. So stay tuned.

Kali Dayton 23:56
Yeah, I know, it’d be interesting to go back into the data there. Yeah, you know, three years ago, what those mortality, discharge disposition, kind of rates were and where it’s at now. That’s really interesting.

Jenna Hightower, PT, DPT, CCS 24:09
And same thing with balloon pump. I mean, with that hip restriction and impellers. The same way, if it’s inserted morally, you’re not supposed to flex past 30 degrees, because you don’t want to have risk of pump migration, or whatnot. But we have found ways around that. And just, I can only imagine what the difference is as far as ICU length of stay and discharge disposition in patients with femoral balloon pumps at a hospital that doesn’t mobilize because they’re on strict bed rest. I mean, they can’t even sit up in bed.

Kali Dayton 24:39
And if they’re waiting for transplant, how long can that be? How long can that take?

Jenna Hightower, PT, DPT, CCS 24:44
I mean, it could take months. I mean, we’ve had patients in the hospital with impellas waiting for three months.

Kali Dayton 24:51
How do you not lose your mind, let alone the rest of your body?

Jenna Hightower, PT, DPT, CCS 24:55
Right, right. And I mean, patients within impella, like we take them down to the gym, we take them outside, you know, we let them participate in food truck Friday, like, you know, just things that make such a difference. And, you know, through COVID, you know, there’s a visitor limits limitation. But, you know, we would take these patients outside to where more family members could see them in a safe distance space, you know, and that just makes the world of difference. Just being able to sit out in the sunshine makes such a difference. Because you do you go stir crazy, especially being in the same room, sometimes we even switch their rooms, like we’ll just move on rooms just to give them different thing to look at.

Kali Dayton 25:37
That so interesting. Preserving that will to live such a life sustaining intervention,

Jenna Hightower, PT, DPT, CCS 25:43
yes,

Kali Dayton 25:44
and so unique for every patient. But I think we’ve all seen what that looks like when patients lose their will to live.

Jenna Hightower, PT, DPT, CCS 25:50
Yes.

Kali Dayton 25:50
And I can see that quickly happening. If you’re stuck reclined in a bed for months, I would personally struggle so much,

Jenna Hightower, PT, DPT, CCS 26:00
not to mention the risk for skin breakdown. And, you know, if patients get a sacral ulcer, they get delisted. You know, you don’t qualify for transplant because its risk of infection. So, you know, it’s, it’s just so important.

Kali Dayton 26:16
And it’s ironic, because keeping them in bed was theoretically the approach to saving their lives. But you’re taking away their opportunity to have any organ and to actually survive.

Jenna Hightower, PT, DPT, CCS 26:26
Right.

Kali Dayton 26:28
And so, what are the sedation practices like in that unit? And how do sedation practices impact your role as a physical therapy?

Jenna Hightower, PT, DPT, CCS 26:38
Well, I think, you know, as most hospitals, we still have some room to go as far as sedation practices, usually, if they are pre transplant, absolutely trying to get them awake as soon as possible because because that is their their life or death chance to be able to be awake and participate in mobility and get strong enough for transplant.

Often just depends on the transplant. Sometimes they’ll give them a day on sedation, to let their organs rest and see if they’re gonna have any signs for for bleeding and need to return to the OR and things like that. Especially lung transplants, they usually let them rest on the vent for a day. But most of the time, in CVICU, they’re they’re trying to wake up as soon as possible. And if they failed, SAT, SBT, you know, they’re trying again 12 hours later.

So just really trying to minimize sedation as much as possible. I think it depends how sick the patient really is, like, if it’s a totally different ballgame. If the patient was on high flow in the ICU walking that they needed to calculate for ECMO, than somebody who crashes and burns and is in multi-system organ failure that gets cannulated for ECMO. It just depends on their global picture on how soon they’re able to wake them up from a stability standpoint, because sometimes the patients with multi system organ failure, it takes them a little bit to get them hemodynamically stable once they’ve cannulated.

But you know, the patients that that they calculate for ECMO, especially pre lung transplant, or heart transplant, they wake them up immediately, because they want them if they’re able to be off the ventilator while they’re on ECMO. Obviously, that’s ideal. So a lot of patients are either on high flow or regular nasal cannula while they’re on ECMO.

Kali Dayton 28:28
And for patients that have been sedated for a period of time that have delirium, what has been your role, or what would you recommend be your role and the awakening trials?

Jenna Hightower, PT, DPT, CCS 28:38
Well, a lot of times, I mean, I’ll go to the nurse and they’ll say, “oh, they can’t wake up, you know, they’re not calm enough, blah, blah, blah.” And I’m like, “Okay, well, let’s try, let’s try while I’m in here”, or “wean sedation I’ll be back in 20, 30 minutes, and we’ll try moving around a little bit and calming them down.”

We use GET TO KNOW ME boards in our facility where the family members fill it out, or the nurse will call family members to have it filled out and it’s you know, what name do you go by? What’s your interests, your hobbies, your favorite food, your favorite music, TV shows, movies? What are your accomplishments in life? What are things that stress you out? What are things that make you happy?

And so when I’m trying to kind of talk someone down when they’re waking up from sedation, I’ll use a lot of that, to help that familiar environment. And if family members are in the room, absolutely having them talk to the patient as well so that they can wake up calmly and reorient them to their situation, so that they can start participating. And most of the time when you use all of those tools and strategies, it works.

And sometimes there is the other end of the spectrum where the patient has hypoactive delirium whether we’re awake but you know not really home yet. You And that’s where the stimulation is key, really continuing to stimulate them with those familiar things, having them up, right moving their, their limbs, repositioning them often helps stimulate to come out of that delirium as well. So therapy definitely can be a key factor in decreasing delirium and managing delirium, but also helping change those sedation practices. Because sometimes, oftentimes not not that I’m trying to diss nursing or anything, there have been a lot that they have to manage. So if a patient is waking up and trying to pull everything, and they’re in the room by themselves, you know, it’s a lot to manage. So changing that practice is hard to do. But so worth it if you’re persistent.

Kali Dayton 30:49
Absolutely. And sounds like your, your unit has had a lot of changes throughout the years. Who was asking those questions? You said, you know, sometimes these things don’t change until someone asks, “why not? What if?”- who was asking us questions, and how has the culture started to morph as far as what mobility you’re doing, and then how has that impacted sedation practices?

Jenna Hightower, PT, DPT, CCS 31:09
A lot of it was our therapy team. We have had some champion nurses that have seen excellent outcomes with, you know, exceptional patients that we’ve had. You know, good scenarios with. And they see the difference that that makes, and then they become a champion.

Same thing with some of our intensivists in the ICU, they, they see the outcomes that we can have, like during COVID, you know, if they would calculate early and wake up early, you know, that was our best outcomes. So that was a key game changer, I think, because we were having so much volume that we couldn’t afford to let people sit in a room for months on end, because they’ve been sedated. You know, we had to get them up and get them out.

So I think COVID was a key player in that. But I think our therapy team, during COVID was present always on the unit. And that makes such a difference, building those relationships, proving to those doctors that what you know, and, and what you can do, is really important, because a lot of times, you know, physicians think Oh, therapy just walks patients down the hallway, they don’t know anything. So being able to really prove your worth. And being present and building those relationships.

And everything in the ICU is based on trust. Like if I walk into the ICU, and you don’t know me, and you don’t know what I know, you’re not touching my patient. So you know, building that trust and relationships is so important. And that’s where I just nail home, the, you know, multidisciplinary team and having a strong multidisciplinary team is so important. And that’s really how our sedation practice has changed. Because it’s everybody’s job, not just one.

Kali Dayton 32:58
Absolutely. And for teams that have never done a lot of this, and they’re extremely intimidated by the thought of mobilizing patients with all of these devices, What recommendations would you give them? How do you start?

Jenna Hightower, PT, DPT, CCS 33:16
Do your research learn about it. So physical therapy and occupational therapy, we don’t, we don’t get to learn about critical care in school. Most programs have minimal acute care, education. So there’s a lot to learn. But if you learn the device and learn the pathophysiology, then you can justify the right intervention at the right time for the right patient. And also, you know, if I’m looking at this patient, and I’m thinking, “Okay, if I start to mobilize them, and I know the possibilities of how they could start to decompensate, and then what I have to do to fix that.”- that is the best way to approach that. And that goes for your whole multidisciplinary team and and being on the same page.

And that communication is so important. Also being present and asking questions and starting small, because it is scary, but also you want to make sure you have good safety protocols. It took a lot of a lot of time building these protocols and making sure we practice them. And asking, asking the why not question continuously being persistent is is the biggest way to start. You know, getting some headway on this stuff. But it takes time and it takes persistence, but it is so worth it once you get going. But just remember it takes a village like that’s my key point takes a village. Everyone has to be involved. Yes.

Kali Dayton 34:52
And then you recently published an article. Tell us about some of your recent work.

Jenna Hightower, PT, DPT, CCS 35:00
Yeah, so one of my OT counterparts, Lydia Sarah, she, I actually have to give her all the credit for this article. She and I were worked very closely on our COVID task force when COVID first started on kind of building the protocols for our department, how could we be best serve these patients and have the best outcomes? She was the one there with me every day, kind of pushing some of these points– “why can’t we wait this patient out? Why can’t we get involved?”

And actually, you know, one of the first patients we mobilize, which we talked about in this article is, you know, we mobilized him, three or four days after he got cannulated, by femoral cannulation, vv ECMO, orally intubated, and mobilized him, kept him moving, kept delirium at bay, and he walked out of the hospital three days after he got to cannulated.

That’s just unheard of. And, you know, we got to talking and we’re like, “We should really look at these outcomes, we should look at what we’re doing.” And she started looking at some of the research and realize that there’s really not anything for the role of occupational therapy in the ICU, especially with ECMO patients. And there’s not a whole lot of research out there.

And, and, you know, what, what she was doing was so important in managing that delirium and managing, you know, that risk of neurocognitive decline is so high with these patients. So, you know, she was really nailing down the self care and making them feel like a person, also assisting in in room functional mobility. You know, we were trying to adapt these rooms since the patient was isolated in a room, how can we make this room most comfortable for the patient to kind of combat that delirium?

I mean, we had checklists on the wall for nurses and whatnot. To integrate these, we had handouts for exercises that they could do since we couldn’t really walk them in the hallway. So those were kind of the big roles that we had. And we put this in a paper and looked at our outcomes. And we looked at the patients that we we saw, you know, while they were still cannulated, for ECMO, and then patients that we didn’t get consulted until after or the patient was sedated the whole time they were on ECMO.

And some of the differences we saw were, we saw a significant higher ampac score. So six click mobility score, were significantly higher in the early mobility group that are the ECMO group. Most of them are there, I think length of stay in the, the ECMO group was longer, but that’s because their cannulation times were higher. So they’re on ECMO longer, and then our outcomes with these patients, so they’re time to first sit to stand in time to walking was much faster in the ECMO group, the ECMO mobility group than the other.

But the goal of the article was to, to kind of empower occupational therapists to really drive their role in the ICU, because I think there can be some gray area sometimes between PT OT, but to really nail home their their role in delirium, and cognition. And even I myself before all of this didn’t know the skills that occupational therapists have in improving patient’s cognition, because you know, when patients are sedated, or how much cognition a patient can lose from ICU delirium. It is wild, and they just have tools on tools on tools to help. So that was our our big goal from this article, but I have to give her all the credit. She’s fantastic.

Kali Dayton 38:36
That is so exciting. And the link is included in the blog with the transcript on my website. Anything else you would share the ICU community

Jenna Hightower, PT, DPT, CCS 38:43
Be persistent. I mean, we were doing some amazing things. But we have so much room for growth, especially across the country. And you just have to keep being persistent. And even though the risk of burnout is high, when you just get shut down and shut down and shut down. But gosh, the benefit, they’re so worth it. That’s my little go give them encouragement, but also use your resources. I mean, we’re, we’re, we’re here for you. I mean, I’m always happy to answer a phone call or answer an email or give people tools to help them out. Because what are we doing if we’re not sharing our knowledge?

Kali Dayton 39:22
Absolutely. And I think there’s going to be really important place for you with all this consulting and team sharing and webinars and everything. I think you are a just a treasure mine of experiences and knowledge. And thank you for sharing that with us. And I’ll include Jenna’s information for anyone that has any further questions.

Jenna Hightower, PT, DPT, CCS 39:42
Absolutely.

Kali Dayton 39:43
Thanks so much, Jenna.

Transcribed by https://otter.ai

 

 

References

Chen, et al. (2021) Safety and feasibility of an early mobilization protocol for patients with femoral intra-aortic balloon pumps as bridge to heart transplant. ASAIO Journal, 68(5). https://pubmed.ncbi.nlm.nih.gov/34380951/

Keshavamurthy, et al. (2021). Ambulatory extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation. Indian Journal of Thoracic and Cardiovascular Surgery, 37. https://link.springer.com/article/10.1007/s12055-021-01210-4

McGarrigle, J., & Caunt, J. (2016). Physical therapist-led ambulatory rehabilitation for patients receiving ventrimag short-term ventricular assist device support: retrospective case series. Physical Therapy and Rehabilitation Journal, 96(12). https://academic.oup.com/ptj/article/96/12/1865/2866288

Pasrija, et al. (2019). Ambulation with femoral arterial cannulation can be safely performed on venoarterial extracorporeal membrane oxygenation. Annuls Thoracic Surgery, 107(5). https://pubmed.ncbi.nlm.nih.gov/30508528/

Perme, et al. (2006). Early mobilization of lvad patients who require prolonged mechanical ventilation. Texas Heart Institute, 33(2). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1524705/ Shoemaker, et al. (2014). Early ambulation as a predictor of length of stay and discharge to home following lvad implantation. The Journal of Heart and Lung Transplantation, 33(4). https://www.jhltonline.org/article/S1053-2498(14)00562-2/fulltext

Jenna Hightower’s publications:

https://sphmjournal.com/wp-content/uploads/April2022SpecialIssueEM.pdf

https://www.us.elsevierhealth.com/essentials-of-cardiopulmonary-physical-therapy-9780323722124.html?

 

 

 

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