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When we send patients to LTAC or SNF to relearn how to walk, what is that like? Susi Rimkus, DNP, shares with us her experience with rehabilitating rehabilitation.
Episode Transcription
Kali Dayton
Now that we’ve heard about the months it took for a patient like Jim, to be able to walk again, let’s look at what it took to get there. We’re going to explore prevention and treatment of severe deconditioning.
Susie Rimkus is a seasoned nurse practitioner in critical care. As a post acute care expert, she now gives us insight into barriers in maintaining and restoring function beyond hospital, she’s also going to give us guidance on how to change priorities to eliminate attack or rehabilitation for patients journeys, altogether.
Susi, thank you so much for joining us.
Susi
It’s so exciting. It’s such an honor to talk to you.
Kali Dayton
Can you give us a timeline of your career?
Susi
Thank you very much for having me. I got my bachelor’s degree, and a nursing and then I went to pursue my Master’s of Science in Nursing as a nurse practitioner. And then I did my Doctorate of Nursing Practice. So over almost three decades, over the 20 years, I work in critical care medicine. But now I’m working in Post Acute Care Medicine at respiratory units in a skilled nursing facilities for respiratory failure with tracheostomy and or mechanical ventilator patients.
Kali Dayton
And why are those patients coming to you? Why do they have tracheotomy, and what is what’s caused their persistent respiratory failure?
Susi
Well, the main reason why they come to me is because of the inability that they have to wean from mechanical ventilation from hospitalization, and from LTACH. And now they are at the SNF and respiratory unit. And that is coupled with severe deconditioning and delirium.
Kali Dayton
So these are patients that have had a critical illness. They’ve been in the ICU, correct?
Susi
Yes.
Kali Dayton
They were on ventilators,
Susi
yes.
Kali Dayton
intubated. And then you’re saying that the severe deconditioning, so probably from sedation and immobility, they then become ventilator dependent? And so do they still have active pneumonia going on? Or that so many of those acute or critical processes going on causing respiratory failure?
Susi
Um, most of them come free of infection, but very, you know, severe the deconditioning, is still oversedated, psychotic, in delirium, and unable to breathe down on their own. Very weak patients, but free of infection. Some do come with infection, believe it or not, yeah.
Kali Dayton
I think of, you know, at least an ICU and I think of respiratory failure. I start thinking of differentials like pulmonary hemorrhage, infection, all the different things that can happen. But this respiratory failure, this failure to be able to breathe is mostly at that point, from deconditioning. These are patients that cannot, what? do what? Hold their head up? They can’t take their own breath. Because they haven’t, in I don’t know, usually how long? How long has it been since they’ve been moved?
Susi
Well, it could be from two weeks, because like, I don’t know, if I told you about 40% of our patients come directly from the ICU to us. About 49% come fromLTACH, and 1% are from other skilled nursing facilities or even physician’s offices. So when they come to us, you know, the medical diagnosis, yes, they are sick and they severely the condition because they got pneumonia, but having being critical care medicine before and being post acute care. I can tell right now: uh uh. The patient doesn’t have pneumonia- but the patient is severely deconditioned, sedated, and encephalopathic .
Kali Dayton
So they’re coming to you and they still are under the influence of sedation. They still have delirium?
Susi
Exactly.
Kali Dayton
So they’re too delirious to even coordinate their body, and now they don’t have the strength to. Now that’s caused them to be dependent on a ventilator.
Susi
Yes, they are very weak. They don’t have any strength. They can’t breathe on their own.
Kali Dayton
So what is like, is that like for you, I know I mean, having done critical care for almost 30 years… You have seen, I know that you worked with Polly Bailey. So you’ve seen it both ways.
You’ve seen the path of sedation and immobility. And you’ve seen what it’s like to have patients in ICU awake and moving. So now that you’re doing LTACH and SNF you’re on the other side of it. What is it like for you to know that? Maybe this could have been prevented?
Susi
Oh, definitely, I would say 75% of the patients that I get that are in respiratory failure, they probably could have been prevented. You know, when I see the work that we have done in an ICU, and the work that I have, in a skilled nursing facility right now, it’s just showed to me that even though we have been doing this since 2006, the people around us like the medical society, the nurse practitioner, the staff, the nurses, the systems have not changed. Despite the literature, despite of the benefits that offer for the patients.
We assumed in our older days: “oh, let’s take care of the acute illness, sedated them, they are ‘too sick to walk’ “, and how much research do we have that proves that even if the patient has an acute illness, and you know, physically, he is strong, he has better outcomes than the patient that is weak, and is having an acute illness.
Yeah. So for me, is frustrating to see that nothing has changed. Independent of all the literature, all the studies, or all the good we did in our ICU. It’s just like that the medical community doesn’t adhere to that, and doesn’t change that practice.
Kali Dayton
Despite all the big pushes and talk that have been made about
Susi
And their outcomes!?! ICU patients going home, improving quality of life, able to breathe, decanulate, no ventilator- instead of going to a SNF. Why not go home?
Kali Dayton
Yet, we’re still stuck.
Susi
We’re still stuck on that. With our old practices.
Kali Dayton
Yeah, yeah. And so now you’ve transitioned to this role of “cleaning up the messes that we’ve made”.
Susi
Exactly.
Kali Dayton
And you already had this personal culture of being “awake and mobile” for your patients. So when you transitioned to an LTACH, what was that like trying to bring that focus into an LTACH?
Susi
It was as hard as it was to bring to our ICU. So I worked in three different ICUs in the same system. So the first ICU was not interested at all on this “awake, alert, mobile culture” where we would lighten up the sedation, make the patient’s awake and alert, and work on their physical strength. So we could extubate them, and prevent some short-term and long-term detrimental outcomes from this patients, you know, due to immobility and over sedation. Which most of the time is completely unnecessary, or over treated with sedation.
And it is the same argument I heard at that time. And then I went to another ICU, and we had new nurses, and believe it or not, they understood and engaged in that culture, and it did the work with them. Then I went to another ICU. There were older nurses, but with the group of nurse practitioners, and our leader, a physician, they all changed their practice to that way.
So now I’m starting again. But as you can see by my example, one ICU you didn’t work at all, they were not welcoming to those outcomes. Their mind-frame was “They are too sick”, “I’m not here to answer call lights”, “I’m here to take care of their illness and send them back”, so who is going to rehabilitate them? Some people still feel this way.
The second one because you’ve got the new nurses in a new unit, you know, the new nurses were anxious to receive education and teaching. So they went with it. The third group of the ICU, they are older nurses, but they welcomed the change as they started witnessing the ability of the patient to go home- to their loved ones. They started taking ownership for that.
So here I am starting a new culture. And I was trying to figure out is this group going to be the ones that didn’t want, the ones that wanted to be taught, or the ones that, even though have tons of experience in the past, decided to change their practice.
And the LTACH that I worked on… They didn’t want to. They did not want to. There were so many complaints from the physicians and they staff because they “didn’t have the resources”. That is exactly the same thing I hear. When I go to a Society of Critical Care Medicine conferences. They go, “oh, we can’t do that.”
You know, physicians and nurses come to the microphone. “Oh, we don’t have the resource.”, Oh, we don’t have the money.”, “Oh, we don’t have the time” or “we don’t have the staff” – it is the same thing. And so I just had to embark on that again.
But you know, I took for that. The LTACH was just one that did not catch on. Some SNFs decided to take it on. But then, because of so many complaints from family, patients, and the team, they decide to abort the culture. Yet, many SNFs embrace it.
And the SNF is a good place to do this culture too. Because the nurses, they are not valued most of the time. I don’t know if you know, but a physician by Medicare/ Medicaid, should see the patients once a month. I go there at least twice a week. So the nurses were craving to have somebody to teach to value there to help them help their patients. So they really embraced it. As you can see, I have vent units where I have 25 patients.
Kali Dayton
Okay, I gotta clarify. Oh, sorry. No, you’re good. Um, so an LTACH, we know that those can do ventilators. Yeah. And those, in my mind, I think LTACH was more for rehabilitation, and especially when they’re coming out the ICU.
Susi
Not really.
Kali Dayton
That they’re, they’re there to clean up the mess the ICU to rehabilitate them, get them strong mobile and decannulated. So you’re talking about ventilators on a SNF? How did that happen?
Susi
Yes. So what we did, we created and developed respiratory units in a SNF, where I could take care of this trach mechanically ventilated patients that are severely debilitaed, encephalopathic with delirium and psychosis. So the same thing I would do in an LTACH, I do in the SNF.
Kali Dayton
Yet, the nurses were more willing to do it than they were in the LTACH.
Susi
Yes.
Kali Dayton
And tell me about these patients that are coming to this SNF. I mean, that’s not the first place. I don’t think as ICU would think to send their trach’d, ventilator dependent patient to a SNF. So they must have been in an LTACH first?
Susi
Sometimes. Sometimes we have patients that comes straight from the ICU. For example, I have a hospital in town that will call me and tell me Susie, I have this kind of patient. Do you think you can take care of the patient? I said, Yeah, I think so. Is just like Post Acute Care Medicine in a SNF.
Kali Dayton
Wow.
Susi
And I did that because the LTACH did not welcome my culture. So I turn I SNF into an LTACH.
Kali Dayton
That’s amazing. So I’m just astounded that the LTACH was not interested in waking patients up and mobilizing them.
Susi
Yeah, they say they are, but they go too slow for our culture. Our culture dictates that the patient must do as much as they can do at any given time. We don’t do progressively. Oh today we are going to stand in the afternoon but tomorrow, we are going….
No. Today we are going to dangle, then in the afternoon or tomorrow we are going to stand. The next day/session, we are going to do one step. The next section we’re going to do three steps. The next session, we want you sitting up, then that… you know we take too long. If the patient says “oh I’m in pain”, they stop. No, you can’t do that. Is there pain? Let me know, and I’ll take care of the pain an hour before you come into therap. You have to- it is the patient and that body that needs to tell you when they cannot do it.
Kali Dayton
So this is all personalized, individualized for where the patients are considering what their baseline was, how long they been immobile….
Susi
Therapists go by their baseline activity, but I always remind them and educate them that we are there to do the extra mile. The patient need to do as much as they can do at any given time. And that means this and I have examples that:
Patients have not walked for eight years, eight, eight years, in a SNF, a trach patient. He just started walking last year, under our care. Yeah, it’s not because we are magical- it is because we do it. There is a difference between “Yeah, we do that…” most LTACHs, SNFs, and hospitals, they will tell you, “Oh, yeah, we walk and then we do the best”. They don’t. When they come to me, I can tell in terms of activity what they have done for the patient. Yeah.
Kali Dayton
And then how do you get that focus? I mean, these are patients that sometimes have a kind of written off by other therapists, other facilities, they’re just going to be stuck on the bed, they got critically ill. And that’s it for them. They’re stuck in the vent. So what is it about your perspective, your approach that actually gets these people decannulated?
Susi
So what I do, like I told the we meet with the family administration, the whole IDT team, and we, I tell them in this meeting, “This is the end of bucket. Nobody thinks that your loved one can go home. They think they are here to be here. That’s the house, we don’t want to have that we want to him to go home. And what we need to do is a lot of hard work.”
I do engage a family because in a SNF, you know, in any SN, the the mandates for therapy is very low. It is limited. I do have one SNF that has their private therapist, even patients that don’t have the money. They provide it. It’s interesting, but this this facility is owned by a nurse.
So yeah, so nurses know what that is. Yeah, so yeah, most of my patients are already done by the system and “nothing can be done with them”… but we prove them wrong. Because we have a patient that wants to go home, we have a family that wants to support them to go home, and we have a whole team that is there to treat and give the best in that time- Timely manner.
We cannot wait six months or a year he is going to be even more the deconditioned- it has to be right now. And that’s why we do it. That is the only difference. And it’s interesting that the people around the family the patient- let’s just say- they all have an ownership. Uou know, now this meeting is conducted without me present. Because they took it.
Kali Dayton
They get it.
Susi
Yeah, they get it. They engage- they witness. It’s not me telling them the beginning is me telling them and walking with them. But I’m a kind of a different provider too. You know, I’m five days we on-call. I see each facility two days a week. I engage in educating nurses, RTs, CNAs, speech therapists, any kind of therapist at the bedside. They have a question- I’m there. They need the help, but they are not controlling the patient. We work on a solution. So we work very close together. So the team that I have is phenomenal. In fact, to be honest, they really don’t need me there anymore. They just so they know how it feels. And they took ownership. They have seen the goodness that bring and they feel excited about just like me, I’m very excited.
Kali Dayton
You know, I’m such a believer of that, you know, we go to conferences and I say, well, “we can’t get our nurses to do that”. But I just truly believe that if nurses knew the “why”, and they knew, at least in ICU, that they could prevent suffering, prevent damage, give patients their lives back, they will get them up.
Susi
They need to try. They need to be open to try. Most of the people that I have problem is they don’t believe, but they are not open to trying. If you are open to trying, you will know and see for yourself.
Kali Dayton
Yeah. And I just blows my mind. These are people that were kind of written off like.. “they’re going to be such a machine the rest of their lives”. And also the fact that mobility waking up and moving and working hard. Yeah. Reversed these “irreversible conditions”.
Susi
Yes. And prevents complications too. That’s what they have just said the pneumonia. Why are you psychotic? Everything- it’s the drugs, but it’s also the environment. If you stay in a room, just look at the walls, – wouldn’t you be psychotic too?? I think so!!
Kali Dayton
Yeah! ..and looking at the big picture. And if we could just do that, to begin with, when they first get sick.
Susi
Oh, that would be a blessing. Then we wouldn’t then need SNF or anything. I don’t know if Polly mentioned to you, we did a study. And one of the ICUs … what year was that? On early, aggressive, not progressive mobility for respiratory failure patients. And it revealed that the patients can discharge from ICU to home 96% of the time, if they walk 200 feet or more.
The main difference seems to come down to the culture, the focus, and the approach to being awake and walking.
Yes! This is all about the culture. And that’s what I mean, it’s not me teaching them… it’s a culture change. And they have to be open to that.
Kali Dayton
And so what does that mean for meant for the decannulation rates for your patients having this approach, even months, almost a year after being left in bed to atrophy?
Susi
I know, So this is a consequence. So in the country, the rate of the calculation for SNF patients, but you have to think also, they probably can, I’m sure, I would say is 13.4%. That is the rate for decannulation in SNFs in general. We have 50 to 60%. Our readmission rate is 1 – 2%.
Kali Dayton
Wow,
Susi
Okay. Now, the length of stay is harder. It’s 120 days, because as you know, these patients come very debilitated. I have patients that have not been out of bed for 6 months.. Yeah, tell me about that. So it takes more days, but we do it.
Kali Dayton
Wow. I have to clarify. So about 13.4% On average, nationally,
Susi
nationally,
Kali Dayton
are decannulated. Meaning they’re able to get off of the ventilator and breathe on their own and how that darn hole in their throat closed up? Yes. So 13.4% On average. Yet your average, even with patients that haven’t walked for six months and even longer 50 to 60%?
Susi
50- 60%. That is I need to do a study. In fact, not a study. I have all the data. But I need to find someone I can give the data just to write the paper for me. Yeah, it’s beautiful what we are doing. It’s beautiful. I’m very happy.
Kali Dayton
So this process works.
Susi
Oh, definately. But that’s what I mean. I took a process and an ICU, took to an LTACH, and then I took it to a SNF in a specialized respiratory unit. And it works. Now the LTACH, I don’t have much experience because I only went to one. So I cannot answer about the others.
But I just want you to know that a lot of people say… but they don’t do it. If you go to my facilities you’re going to see…let me tell you. The facility that I used to work in and work now, before, they used to have a long-term facility and the patients are all in bed. You can come anytime of the day, they are 24/7, so I started waking them up.
We didn’t have a dining room because the vent/trach patients don’t go to the dining room. They can eat right? Oh my guys, we change that. Today, we have a dining room. Today, not only today, but for a couple of years, I now see the patients coming to the foyer. Can you imagine the happiness that I had? The nurses were so happy that you say, “Dr. Susie- look!. All the patients are here to say hi to you.”
Kali Dayton
They were up out of their beds.
Susi
up out of their beds, even those paraplegics, quadriplegic, those anoxic brain injuries, they do as most that they can do. Even if they can’t walk, they are up and about in creativity. In rooms, Activities, outings, going to the dinning room. You know, have a speech. I also do this: If the patient cannot, some patients, they don’t have a family support to take them home.
Even when you decannulate. I have a little grandma and the family told me: “If you decannulate her, I’ll take her home. It took a little bit but we decannulated her and they never took her home.” She went into a long term facility. So we do have those cases that sometimes they decannulate and they don’t go home… but the possibility was there. But you know, it has to do with the family.
That’s why now, I involve the family on that process. But it, you know, improves quality of life. Even if it is to stay in a wheelchair, at least you in a wheelchair- strong, moving in a power chair that you can move and do things. And then for those that cannot have, for example, decannulation, sometimes I happen anoxic brain injuries or traumatic brain injuries. What do we do, then I involve a speech therapist, to see if they can eat with the trach. It’s safer than being intubated. So we do that for them. And then they can live the life that they want in a wheelchair in a power chair, eating and being happy. Awake and alert, going to religious service, family reunions, to movies! Tell me about it!
Their living life. Not just wasting in bed!
YES! Got it? That’s what we do. First, we want to cure them to go home. Second, if we cannot cure it, do the best that they can and awake, alert, mobile, so they can go home. And those still that cannot go home with we maximize activity and quality of life to stay there or not.
Kali Dayton
That’s amazing.
Susi
Yeah, families are really happy. The satisfaction increase at the beginning is low. Family complains. Oh, my loved one is anxious. And I always say, “oh, we need to get him up.” And they say “Get him up? But just give medication to him!”, because that’s what that they have been given. Yeah, yeah.
So my nurse are outstanding. They at the beginning, I used to receive a call in the middle of the night, “Oh, the patient’s agitator, can I give something for him?” And I said, “Yes, get him up, put him in a chair and put him by you.” “Oh, okay.”
And then I had one patient than me and they are administrator of that unit. Everybody said they could not walk the patient. I grabbed the patient one side- he on another- and then we walked the patient up and down up in the body and the patient was doing the walk with us. Then he was agitated. So they want to send him to the hospital because SNF has different rules in hospital. They didn’t want to give anti-psychotics or anything so we just made him walk, put him in bed, and he slept so good with no medication. I’ll tell you Yeah.
Kali Dayton
And if we only had that perspective within the hospital.
Susi
Oh, tell me
Kali Dayton
We could put you out of business right?
Susi
Oh completly and and I’d be glad. I’d go completely for that. You know, when we are in an era that we talk about cutting costs, bad outcomes. I’m not talking about alive or dead. Because, I don’t think that is what we want for life. Oh, “I want to be alive but comatose.” No, we need to talk about the outcome.
What improved quality of life. That must be your outcome also. So, I don’t know why. People don’t do it. It could be the pressure from the people that are not used to doing that. But, yeah, that definitely would be a huge gain for the hospitals. No SNFs, no LTACHs, maybe you need some rehab depending the situation of the patient.
We’ll get rid of that, the patients will go back home, families or patients go back to work. If the patient cannot go back to work, so we help society, at least the family members care, because when a loved one is sick, what does family say? The miss work, they take leave of absence, because they have a family that…. everything would be much better.
Kali Dayton
If we did it from day one, the moment they rolled into the hospital.
Susi
It’s called priority. It’s not about resource. It’s not about money. It’s about priority. Nurses, physicians, staff needs to know where are the priorities in this patient. And you have to see: is awake alert mobile. Infections are going to decrease, decubitout ulcers are going to decrease. Psychosis will deccrease, delirium is going to decrease..
Kali Dayton
cognitive deficits….
Susi
YES. and… well-being and happiness to be able to go back where they belong. They don’t belong at the SNF, they don’t belong in an LTACH. They don’t belong in the hospital.
Kali Dayton
The right priorities, establishing a culture and practice within a multidisciplinary team to get patients their lives back. I hope that you’re out of business in 10 years.
Susi
Amen.
Transcribed by https://otter.ai
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