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Episode Transcription

Kali Dayton 0:00
Sure, good. Nancy, welcome to the podcast. Can you introduce yourself to us?

Nancy Mcgann 0:08
Yeah, sure. My name is Nancy McGann and I’m a physical therapist by background. I am the manager of caregiver safety or the partner mountain health and in the peach region. So the Colorado/Montana region of the organization. I’ve been in health care for 33 years, working in all areas of physical therapy, reaching outpatient, orthopedics, rehab, home health, kind of a whole gamut. My specialty, though, was outpatient, manual therapy and training to get to go back to manual jobs. And so that was what led me into caregiver safety and injury prevention. And for the last seven years, I’ve worked in the quality and safety department in my organization. So that is, led me to my, you know, combination of what I did ergonomics, as a physical therapist, that we want to keep everybody safe, not harm our patients and promote mobility. So that’s my biggest passion.

Kali Dayton 1:08
And I often am reached out to by PTs, nurses, nurse managers, directors within the ICU directly. So you have a very unique position and a seat on this whole system as far as the you’ve been able to bring the change that has happened at St. Joe’s. Maybe you came in from an angle of wanting to keep the clinicians safer. And then one thing led to another and it turned into this beautiful phenomenon of St. Joe’s becoming an Awake and Walking ICU. Tell us how that started for you.

Nancy Mcgann 1:47
so in our organization, we have an internal safety grants. And it’s, you know, for patient or caregiver safety. And in our organization, we call everyone caregivers. So for people that clean our hospitals and environmental services to our nurses, everyone is a caregiver. So, so with that, grants, we’ve had three mobility related grants. And so in 2020, we have an emulation grant. And that is for every patient in our hospitals- our acute care hospital.

And then in 2021, we had a pre-ambulation grants for and so those patients that aren’t treated with old walking, how do we maximize their mobility and healthcare? And so that kind of final frontier in the most complex area to really improve mobility is the ICU setting. It’s also the area that has the most evidence to show that it absolutely improves outcomes. And it also provides financial stewardship to your institutions.

It also enhances the joy of the work of our caregivers. So it is something that’s been around and evidence base for so many years yet is so uncommon in practice, but we kind of knew that that was the most complex. So that’s what we decided to wait till, you know, for that big focus and push for that, that three year, third year of our mobility work.

Kali Dayton 3:07
And because you are part of safe patient handling, you are in close contact with Margaret Arnold, who helps acute care LTACHs, SNFs, just throughout the continuum of care, increase their mobility. And very serendipitously, Margaret and I became in contact, she was cued into the podcast from Chris Perme. So she started listening to the podcast, that’s when we…. she and I started talking. So she’d already started working with your team. And she brought me in to come on site to St. Joe’s. And that’s when we took this momentum that you already had as far as increasing mobility in your ICU. And I came in and said, “Okay, now let’s take it to become an Awake and Walking ICU”. And I didn’t know how you guys were going to receive that. How was that initially perceived?

Nancy Mcgann 4:02
Well see, they were very ready for that, because we had already done some initial training. So Margaret and I have known each other for 15 years, we’ve been involved in for years and say patient handling and mobility. We’re both on the association of safe each and knowing professionals board. And I knew the consulting work she did with critical care. And I saw we did we hired her firm to help support us in this process so that we didn’t have to read that relays that have already been invented. And so with that, there has been when we write the grant project, we have looked at all her eight hospitals in the peaks region, and we were looking who’s the most ready for this.

And so, so they were very, very ready. Initially when we when we wrote the grants. There were a few hospitals in our system that had walked into patients in the past that was one of my key things like that they you know, that’s that’s, you know, a lot of people, if you say do I do have an ICU Early liberation, early mobility, those are the terms that float around, they say, “yes”. But then when you dive in, they really don’t understand what that means, which is why I really love the term “Awake and walking ICU”, because they kind of need to hear that it’s a plain language term, which is just much more impactful. And so, you know, even now, if it’s rehab driven, it’s not really early mobility. iF you know, they’re not walking an event to patients. It’s not early mobility. It’s not it’s not truly that. And so,

Kali Dayton 5:29
no, say that louder for those in the back. If they’re not walking patients, on ventilators…..

Nancy Mcgann 5:34
Yeah- it’s not not true ICU liberation, mobility, Awake and Walking ICU. So people have the best of intent. And but there’s still a knowledge gap. And even even with all the evidence from the frontline and the frontline leadership, there’s still a little bit of a knowledge gap there. Because there any mobility is mobility, right? But if you really are doing what’s right by your patients to your staff, for your, the financial implications of your institution, they need… you need to be walking most of your vented patients Now there might be so we know that came up, but the majority of them can be and should be.

And, you know, they so they so we had two sites very ready, we ended up going with St. Joe’s because of some more leadership turnover in one site, you know, post pandemic when we started this, of course, ICU turnover was massive. By the time we actually started at the Grand St. Joe’s, that turnover happened there. So we had all new leaders in there. But we had a very passionate CNO was now a regional CMO.

And then we had, we had enough to keep going with the project. But that was a barrier initially, because we had to kind of re educate that. But we have done that priority to you coming. And your inspirational podcasts. Honestly, were a big part of that and having people listen to what really goes on when someone’s sedated and understand that is enormous. Just last week, I was presenting to a leadership team on the project that we did at St. Joe’s, and one of the chief nursing officers for ambulatory care. So of course, critical care is not her background.

She was dumbfounded by what we were talking about when patients feeling like they’re being raped when they’re being categorized, they should feel like they’re being shot when their temperatures. She was like, “Wow, I just never knew that.” So. So sometimes that you know, that plain language again, people understand and also people being able to make end of life decisions, if they’re not going to leave your ICU and not having family have this burden to the rest of their life- “Did I make the right decision for my mom, no dad and a loved one?”

So, so I think they were they were very ready. And I think when people learn this, they all want to do it. It’s just super hard to achieve because of the complex nature and interdisciplinary mean. And so. So I think it’s easy to get across to people, the “why’s” but the “how’s” are variable.

Kali Dayton 8:04
Absolutely. And I love that you’re coming from all these angles, you are working at all the levels of decision making. The C suite, administrators, the nursing leaders, everyone. And there was already momentum going– because you’re right, everyone knows that early mobility, by now, should be a thing. But the definition of it, the approach to it, the end goal is so variable between disciplines, systems, hospitals, it’s just all over the place. So you came in and you said, “We are going to take this grant money and move this forward.”

And you brought in the “why”. You helped them understand….. They already were bought into early mobility, but to say, “Here’s why we need to go all the way. Here’s the harm that we’re preventing.” — not just “We’re just trying to save money, “- which is true. But you then hit the heart of it, and inspire everyone to really act and go all the way with it.

So once everyone had the “why” on board, now it was, “how are we gonna do this?”– Because it’s such a drastic change. And I was on site with Margaret a few months ago, and we were talking to this team, and they didn’t have very much preparation before he went there. The Medical Director even said, “You’re here with early mobility.com. But why are you talking about sedation?”

So when I came in, it was bringing them this piece of “Yes, we’re here for mobility. But let’s look at the big picture. We have to address sedation.” We’ve seen the team study that if we don’t talk about sedation and bring in that piece of it and understand like you said, what patients are experiencing- How do we approach early mobility? So it was so exciting for me to be a part of that to jump in and bring in this element. But what were your first steps to really setting up this movement?

Nancy Mcgann 9:57
So the first really is kind of that awareness, right? It’s understanding the why and doing enough training and determining leaders from each discipline. So we have PT, OT, speech, pharmacy, nursing, the physician leaders, you know, respiratory therapy, and we have process improvement as well on board.

So, so we really needed to get that entire team together to make this happen, you can have it driven, because there’s a therapist that’s very passionate about it. They can only go so far with that they can help, but they can’t really make it happen. If you don’t have the providers on board, because right if a patient’s overlies the data, no one’s mobilizing them, not possible. And so, so there’s so many pieces, and there’s some, you know, early struggles in the process, you know, when do you do awakening trials? When do you do breathing trials? How do you set people up for success? So you’re asking for a lot of change.

And again, we’re asking for that change from a group of healthcare professionals that truly took the burden of a pandemic, right? So there was some hesitation, but it’s like, “no, is this the right thing to do?” I did ask that. And “No, we need to move forward with this.” And what’s very interesting to me, in hindsight, and this is not something I anticipated. Was that that mass turnover we saw in critical care nationally. And both leadership and frontline. You know, that this work, although burdensome, initially, right? And saying, “Oh, it’s one more thing being thrown at us.” – brought back so much better teamwork, to their group, and joy in their work.

And that was when we did the first gap assessment at the hospital in February of 20. To 22, what year is it next? They, you know, pretty much everybody on that unit days, nights, nurses, everybody we talked to said, “Our patients are too sick, to be mobilized.” There was almost no one that didn’t didn’t mention that though. They had some patients they thought could. But for the most part, most were too sick.

In October 31 of 22, when you were there, we did the second gap assessment, nobody thought that. Literally nobody. And they were all talking about some hurdles of teamwork they needed to overcome early on. And they did so and how much better everything is because of this one program because it built a better team. And they were so excited that they had to learn to talk and communicate with vented patients. That they were getting feedback they had never gotten in their 10, 20 years of critical care nursing.

You could just see the joy that in this group of individuals that truly had post traumatic stress syndrome. So that was not a part of why I wrote the grant and any of the outcomes. But it was very apparent. And it’s still very apparent when you start having them tell their stories, how much joy that brings back to them, which is to me, helping to sustain our workforce. And this is a big thing.

Kali Dayton 13:04
And even just improved morale amongst the clinicians, has to improve care, and outcomes. And we know throughout this podcast, so many ways in which avoiding sedation and mobility, logically improve outcomes, decrease infection rates, things like that. But then down to those little details.

I just know myself, when my heart is there, when I’m present, when I’m looking forward to that shift, I approach everything differently. So if there was a way to capture the impact of staff morale, on their care, that’d be a really interesting study. But anecdotally, I believe it. I’ve personally experienced it. And it was really exciting to see that first visit on site, I could feel the defeat. The demoralization. They were honest that many, especially respiratory therapists, “We cannot do more. We are maxed out.”

And I just hung on to this personal experience, but also what we see in the research as far as this will make this an easier and more efficient process of care. And I just wanted them to experience what it was like to connect with patients and I just wanted to revive their spirits because it was very, very evident that they were willing, they were interested but they just couldn’t quite see what it was going to be like and we weren’t sure that it was going to work.

Then the second visit. We went at five in the morning to help with awakening trials, which made me nervous thinking, “okay, if they’re still doing awakening trials, standardized, that means that they haven’t really moved with the sedation piece.” But that was the exact opposite. We walked in there and almost every vented patient was awake, the very few that were not had valid indications for sedation, and I saw in rounds that they were discussing how they were going to navigate that when why the patient sedated when they’re gonna take sedation off it was just music to my ears.

On top of patients being communicative right now on their clipboards, I saw the excitement in the clinicians eyes. I saw the enthusiasm, they wanted to tell if they’re exciting stories, how they showered a patient. And we’ll have interviews with a lot of those clinicians in upcoming episodes. But that was an exciting byproduct of what we were working towards here. And what did you see in the data? I guess, what was your role in capturing the impact of these changes?

Nancy Mcgann 15:29
Yeah, so one thing that we strongly believe in, in our organization is that we have to have very good measures to drive process improvement, especially when I’m sitting here in a region office, right? Like, I’m not at the hospital, I obviously I go to the hospitals, but that’s not my role. And no, I don’t work in direct patient care or leadership or direct clinicians. So we need to do is have balancing measures of success that are accurate that our staff believe in than they know is, is coming, automated from the from what we use epic, or from any electronic health record, so that they can have confidence in the measure and try to achieve it.

And because if you don’t know how you’re doing, you can say, “Yeah, I have this.” Well, how do you know you have this? What are the measures? So we have a few different dashboards and we’re still evolving with them, they take a long time to really evolve and meaningful. And we are looking at multiple measures. So we look at our a RASS minus one to plus or the CAM ICU positive the number of days? What is there we use the bedside mobility assessment tool?

What was their big amount of time between the the ICU and discharge, and to the hospital discharge? We are looking at….what else do we have? We have length of stay in the ICU and they can say for the whole hospital, we are looking at pressure injuries, we’re looking at falls, to are we seeing falls because they’re usually more, and we’re not.

And so, so we have a dashboard, what we still need to do to make it more meaningful. And we have it for all eight of our hospitals is we need to remove those shortlinks of stain. Because we have there it’s watering our data, that’s not really the patient population that we’re focusing on with ICU liberation or ability, right?

We’re focusing on those patients that are not had had a coronary artery bypass graft, and we’re having ICU for 10 hours and moved on. Because that there were not detected anything’s can program. So we need to eliminate those shortly the state of relief seen our group and we’ll be doing some analysis on that. So our analysts are working on that right now. But what we can do is sort and see how we’re trending over time.

And we also are looking at our CMI keys adjusted length of stay. And we are seeing, once we, the St. Joe’s team felt like they were, you know, they’re still on 100%. There, they’re not fully Awake and Walking. But they’re close very close, they really felt like September is when they really started seeing a major change in their delivery of care, and their ICU. And we have seen financial or really benefits of CMI adjusted costs. That have been been very only a couple months, we have to look into lag as time goes on.

With that I’m very hesitant to say anything until I know I’m very confident that it’s reliable, valid. And again, it takes a while to evolve and our ambulation dashboards that we use, and it’s very, very valid and reliable data. And we’re definitely seeing improvements, more patients integrating in our ICUs. So so the bigger picture with data is, is you only measure data that’s going to drive the change. And you can’t just focus on one data point.

So what we did years ago, was focused on patient falls. And so we stopped moving our patients, because if they never left their bed, they weren’t going to fall. What that really does is physiologically increase the risk of falls, and also makes them deteriorate in every other way. And so we you know, we needed to have balancing measures.

So in our organization, our safe mobility, we always have a mobility measure out there called therapeutic ambulation. We also have a fall measure because we don’t want to see increased falls, why we’re increasing mobility. And then we also have a patient handling injury measure, because we also don’t want our caregivers injuring themselves normalizing our patients. And so when you have all three, you’re making sure you’re not doing harm and just looking at falls. So in the ICU, you don’t want to be so aggressive about reducing length of stay, that you’re not having as good outcomes in some of the patients safety measures and in readmission and things like that. So that’s where the dashboard analysis. You can’t just say, “Oh, we’re going to measure these three data points.”

We’re going to do a cups and chart audits and then we’re going to make a big change but it doesn’t work that way. And So you have to have big data come out to really see what’s going on, can’t just go around, do a sampling, and have it been truly impactful, there’s times to do that like to kick off the grabs, that’s what we did. But if you’re going to sustain a program then really has to be extracted from the health record and when meaningful, and so we’ve been on this journey for the ICU dashboard for eight months now or nine months. And I think we’re gonna need that another three months before we really have it set in running where people can go in and track the changes and share with their staff to drive the ratio.

Kali Dayton 20:37
And know that data is reliable. So tell me more about that. What were some of the barriers initially to ensuring that what you were collecting was accurate and, and actually, actually meaningful.

Nancy Mcgann 20:53
So a good example was 10 days. So you have to extract the bed base from a certain line and are in the health record. And then you have to have the denominator for that, right. And so the denominator can’t be every patient in the ICU, because not all of them are on but you also maybe don’t want to include those benefits to patients with short length of stay, like we talked about earlier. Because again, you want it to be indicative of the work you’re doing and the patient population, you’re impacting.

You also, if you have a patient that came in, from an oil tank, you don’t want their event date in there. Because again, that’s not who you’re impacting. So as you get the data and go back into the validate that the data state and moving properly, then you have to make sure you’re really measuring what you want to measure. And there were some things like we wanted to do seven of ours, that we just couldn’t do accurately, because the way it’s documented and pulled, it doesn’t work.

Kali Dayton 21:52
And what about delirium rates? How did you know? Or how did you get those to be accurate and reliable?

Nancy Mcgann 21:59
Right? So I told all of our other hospitals is, is that one thing that Margaret Arnold noted early on, was the three education needed on grass and canopy scoring. So if we looked at, you know, the data coming in, if it’s not reliable, even going into the health record as much, and this is pretty common, then you need to do the training on that. First, you got to see where the gaps are, and then start measuring. You know, another another example, with with the data over time is last January of 22, we still had a fair amount of COVID in our in our health care systems, right? And so some of our data looks like a great trendline.

But that was because we didn’t have any more. That’s because we got a lot less COVID patients, it wasn’t because of the work we did. So we had some hospitals looking at our dashboard saying, Hey, we’re doing great, I’m like, No, you’re not really because we would, then we need to have it. You need to annotate your dashboards and say, this is when we had a process change. This was an anomaly because we have it in flexibility patients. Just consider the context. Yes, you have to make context to your data. Or you might mislead people in what they’re doing.

Kali Dayton 23:09
And even COVID aside even time of the year. Oh, yeah, you’re going to have more respiratory more ARDS during the respiratory season during the winter, versus the summer. So we have to take everything with a grain of salt and look at the context in which that data was extracted. And was your team initially, when you started being more aware and more diligent with charting camp scores? It looks like the delirium rates went up, correct?

Nancy Mcgann 23:38
Sort of in Blips? Yeah. And some of that was was probably better analysis. Some of that was doing it more there were a lot of unable to assess, because so so it was a little bit of both of those things. And again, that’s that sometimes seeing a negative thing as a positive thing. Because you’re, you know, awareness brings on usually increase, we have we do a campaign for injury reduction very often to see more injuries initially, because people are, it’s awareness. It’s not that something’s changed. It’s the same kind of thing with that.

Kali Dayton 24:10
Yes. And I was in a meeting with a team talking about this discrepancy in raw scores. I think everyone in this podcast can probably nod their heads and say, I’ve seen that happen where it’s targeted at a negative two, but they’re really more of a negative four, negative five, right? So I had a team pull up their chart that just randomly went into a patient’s chart, and they found a charted RASS, I think of negative one, negative two, but the cam was “unable to assess”.

So I don’t know…. I wasn’t there. I didn’t see the patient, but we can safely suspect that maybe it wasn’t an accurate RASS. And then we don’t know what their CAM score as we don’t know if they have delirium. So you have to work out those kinks first before you can get a true baseline of where you’re at. But looking for that can to reveal the gaps in which we need to assess. So even though just because you have more documented delirium scores does not mean that the rates are going up, it just means that we’re now actually assessing for it.

Nancy Mcgann 25:12
Right. And that’s where the process improvement still was happening. So even though the data isn’t fully reliable, it’s still showing you where you need to make changes to improve your care with delivery of care delivery. So and that’s the whole thing with continuous practice improvement is, you know, it doesn’t have to be perfect at first and your data doesn’t have to be perfect, but it needs to drive the right change.

Kali Dayton 25:36
Absolutely. And, you know, we could have waited another five months to do this episode, and be able to have a grand finale, tada of the final changes and outcomes per your data. But you’re still in that process. And the reason I wanted you to come on it right now is that it’s important to show the process of getting there, I think people get overwhelmed. And there’s expectations of having it flipped around within a month. And also, we part, the journey is a big part of this, it’s not just the final product.

And I don’t think even when you have your data, it’s not going to be the final product yet. And I even seen the wake and walk in SEO, that they’re always trying to improve, always trying to do better. And that should be our our continual goal, we need to sell it celebrate our victories. And you already have victories to celebrate, you’re talking about staff morale, you’re talking about a notable decrease in time, the ICU time of the ventilator, much more ambulation. For patients on ventilators. And I’m assuming throughout the entire population, even those that are not on ventilators, do you see a change in the way that non-vented patients are cared for?

Nancy Mcgann 26:45
Yes, and so and they’re much more weight to have. The other interesting thing is like with Randy, the the St. Joe’s ICU has. And so when they when they are considering ECMO, and they’re considering anything else, they talk about how they’re going to integrate that and not have it avoid mobility. And some of the early ones, we had a patient who had mobility issues prior to admission to the ICU or someone who needed assistance with ambulation, prior to coming into the critical care unit, not an error, yes.

And this, this nurse, actually on her own, who is he was on ECMO, put him in a walking sling, and gotten to take a few steps to the chair and sit in the chair. Because, you know, he was someone that needed that assistance, but she was empowered. And that was a big win that she had been obviously she did it with PT and OT and respiratory first. But she felt like now all those new steps she could easily do with this with the sling, she didn’t need to go get other people. So so that full integration and that’s where that same patient handling people’s come in is when we have patients who are do have genuine mobility struggles that are in addition to not your patients like came and walk in like those, you can usually take them right off sedation to keep moving, you can get going together.

But for those that have a population, you know, using technology to get them to maximize their true mobility is is the other goal that came in. And that’s where kind of Margaret and I’ve been that same patient handling background came into this. But the facilitation and mobility throughout the continuum care without equipment, it’s huge for that lower level patient, right, that person who isn’t super able to ambulate safely.

What we’ve seen, kind of throughout our, our whole system with doing the mobility measures over the last three or four years now is that it’s just it’s a common thoughts in people’s minds. And our nurses especially understand now that if we mobilize patients, again, ICU and ICU early, and often it actually reduces our nurse for they don’t get the pressure injury, they don’t have muscle wasting and then need physical therapy, you know, they very often we would get a referral.

Because if we didn’t let a patient know that we caused them that immobility that arm. Now they needed rehab when they didn’t initially get in the hospital. And so with the ICU program, it’s even more profound. Because that muscle wasting with all the other processes of why someone’s in the ICU could be more pronounced. And their reserves, especially in older adults are not, you know, not we’re not there.

And so we take away 10% of their muscle mass. So they they will have to move it over a few days at a time. You really disabled that person and they may now be going to skilled nursing instead of home. You know so there’s there’s this whole component of getting the station off keeping them mobile, that improves our caregiver of safety because now they’re not going to get hurt moving handling those patients. And then for the ones who are immobile. Use the technology still take them off the patient and get them moving. And you know what, maybe you’ll have Sleep, we believe in a higher level of care. And they came in higher level of mobility, higher level of functioning.

Kali Dayton 30:05
Yes, I’ve seen it, I’ve seen it, people come in that aren’t unable to walk. And then they walk out the doors. It’s amazing. That’s not always the case. But there’s no way that would happen unless we had that kind of culture and process of care. And it sets a precedence to show, hey, we’ve walked patients on ECMO, we’ve passed by patients on ventilators with higher settings. So why not the rest of the hospital and that nurse getting the patient up on ECMO by herself, having a little confidence and comfort says so much about where your team has gone.

But even to the critical thinking, I think the standard process of thought is, that patient is weak at baseline, they’re on ECMO, it’s unsafe, it’s too much of a risk and hazard to mobilize them. But your nurse understood something different. She saw them at a higher risk of poor outcomes because of their baseline mobility, because they were more frail, she understood that she could save their lives and preserve their livelihood and their quality of life in that moment, because they were less likely to rehabilitate later, if she didn’t do it in that moment.

And that is extremely profound and mature, that as a mature clinician, to ensure that she does it safely has the right tools, utilizes those things, when it comes to equipment, equipment can be great. Sometimes we think we think that everyone has to utilize equipment, but I think that comes from having sedated patients, yes, and then trying to get them up. And then that’s when you do need a lift for every patient in every room and every situation. But, and because that’s been the culture, a lot of teams actually do have tons of equipment. And it sits in a closet and collects dust. Because that culture isn’t there.

Nancy Mcgann 31:54
Any equipment, if it’s in a closet isn’t going to be used, it needs to be above the head, especially in the ICU setting. So right to be easily acceptable flames need to be there. So some of that’s just a poorly setup program. And

Kali Dayton 32:06
The nurses need to know how to use it. Sometimes the physical therapists were like, Yeah, we have that. We can use it, but the nurses have no idea where it is what it does, they’re not comfortable with it. And you don’t want to be the one fumbling around with a patient. You don’t know how to use it. Yeah, that’s important. There’s no reason to learn how to use it, if you don’t have any ambitions of getting your patients up, or even touching the ones that are the most tenuous, or the most frail.

Nancy Mcgann 32:31
That nurse in that situation. Of course, she wouldn’t immobilize the more than a couple of steps will share by herself, right. But she, but she also didn’t have to go get another staff member and have them leave their patient to be a machine to help remove, she actually used the machine instead of a critical thinking nurse. And you know, when you interrupt someone to help you move the patients, and they’re in critical care, especially, and they’re leaving their patients to do that.

There’s potential harm that can come from that. So if you don’t need to do that, that it really improves quality of care in a more global way. You know, a lot of patient safety errors occur after interruption, someone’s going to deliver a message, they get interrupted, they forget their train of thought. And they get they’re human beings and they make an error. So the more we can reduce interruptions, the more you can reduce the number of staff that need to do things, the better.

As long as you keep in safety, if I’m very few ICU patients, or that are on events, or mobilizing just one person, obviously they’re on ECMO, but now it’s just a couple of steps to the chair, and she has that extra thing. And she, the patient has been already plotting and doing all that other stuff with a bigger team so

Kali Dayton 33:39
and nurses, what I’m finding when you get them hands on practicing these skills or doing them, they realize, “Oh, I know how to get a patient to a chair, I know how to pivot. This is so much like any other patient, they just have some extra cords, mature lines, machines connected. ” -that you need to be aware of be able to critically think and assess for stability during those interventions.

But when it comes down to their instinct and their skill set, they have a lot more than they realize. And once they do it, they realize it’s not so scary. And with the walking sling, that patient took their own steps. Yes, it’s it’s a sling, they had to put it on. But they didn’t just hoist them to the chair. They didn’t just, which I always think is more dangerous when you have to use a whole lift with ECMO.

That’s so much more that less control of where the lines are. You’re blocking visually blocking physically blocking those lines, not the lifts to a chair are banned. But to use that lift that technology to allow a patient to bear their own weight stand up, take their own steps, not just dangle in the air or just have a piece of equipment do the work for the patient. That was the objective and the nurse understood that and I think that’s important for nurses to know because that technology can also be abused, right we can think I got a patient with a chair with a lift, but there we go. on mobility check, they’re in a chair. But they’re mostly reclined in a recliner.

Nancy Mcgann 35:04
So in our organization, our nurses for seven years have been doing nursing driven mobility assessment called the BMAT. So we’ve empowered them to learn some very basic rehab kind of stuff, to know what their patients are safe and capable of doing. And then you only use the equipment based on that level in the way it’s meant to be used. So you’re actually using it to facilitate mobility, not some limit mobility.

Now, for a patient that truly is, you know, has is unable to get themselves to the edge of the bed at all, then it’s great to use the left and now they’re in the chair three times a day, or a patient that’s fatigued after rehab and use the left to get them back because there tends to indicate they can’t walk anymore back, you know that. So there’s it, you have to use all technology alternatives and healthcare at the right time. Pure wicks is another example. They can be a wonderful tool, they can also limit mobility and causing incontinence. Because our patients learn to go to the bathroom without you know, there’s so you know, again, yet it’s a great tool in certain circumstances.

So just like that the lifts need to be used at the right time in the right place that critical thinking. But we do need to train our nurses on that critical thinking because they mobilize patients and see patients more than rehab, and rehab in most acute care hospitals only see 50 to 60% of the patients. And so that other 40% Still need to move, or we’re going to deteriorate them or they’re in our care. And again, this has been beyond ICU, this is the entire hospital.

And we don’t want them to be admitted to the ICU because we immobilize them, and we don’t want them to have to go to skilled nursing or Sanur hospital wonder because we decommission them. And so it’s really proper use of programming that is important. And truly like said, If we stop sedation and most of our patients right away, and we get them right up, then no, you don’t be that quick.

For most patients, again, there’s some that are going to come in multiple sclerosis, they have other mobility issues. They had a surgery on their spine, you know, just before they have maybe cardiac arrest vor and they’re now they’re in the ICU, like I said, there’s times where you absolutely need that equipment. If you’re going to really maximally mobilize them, you won’t be able to without it.

Kali Dayton 37:23
And nurses are the masters that titration they titrate drips all the time, they critically think all the time. And it’s just empowering them and giving them the tools to titrate mobility per patient and the beam that really it’s it’s more for acute care floors. It has some elements that are not beneficial to the ICO. But what I saw at St. Joe’s is that they critically thought through that. So

Nancy Mcgann 37:50
I wouldn’t I don’t think I agree with you on that. So we’re being that, just like any assessment, whether any assessment we do in healthcare, really, and you need to critically think so that guides you. And it gives you a baseline for guidance. And if you don’t look and see if the patients have the quad straight to straight, safely standard before they stand, whether they’re in the ICU, a nursing home, frankly, home health care, and you ask them to stand and they fail, and now you’ve caused them fear, cause yourself fear, and then they don’t want to move anymore. And then they stop moving, and then they spiral and they come back from the hospital, or they go to freefall, and they fracture and we die. I mean, this is the real reality of immobility.

Kali Dayton 38:36
We don’t know, we don’t have to know what to expect, how to navigate that. The My only concern is that with a cognition element of it, it requires patients to cognitively engage and follow commands. So what I’ve seen with teams is that nurses often feel that that is part of the criteria to mobility is that patients have to be able to follow commands, do these things, touch my nose, shake my hand, you know all those things. Whereas in ICU, especially, if we really follow that to a tee without critically thinking, then we’re unable to use a tool, one of the main tools to treat delirium, so…

Nancy Mcgann 39:14
To add something to that. So we have in our epic documentation system BMAT contraindicated so in the critical care setting, if someone can’t do the BMAT, you do the old fashioned thing and you guess, right and clearly if they’re, if they have a RASS minus three, you know, there’s, they’re going to be a BMAT one because they’re there, they’re not able to follow commands because they’re been plowed out on drugs, right?

If they, if they have delirium or dementia, and they can’t follow commands, or they have a language barrier, or, you know, some other kinds of cognitive deficits that’s causing that. Then you’re you’re guessing and they might be a beam at three or two or one depending and you’re just going with the old fashioned get So we are nurses and throughout our organizations, we have patients and other tourists that can’t follow commands either more in the ICU. So we have a row where they, they write in and it’s contraindicated me, we didn’t do it.

But this is the mobility level, we’re guessing they have the equipment or no equipment are supposed to be so and that we’ve, again, been doing that for seven years in our organization, this isn’t new. We’ve been doing it for a very long time. So we integrate that inability to do to be met. Anyway.

Kali Dayton 40:31
I love that because we went on site again, the team didn’t have any preparation, there’s placed patient that was had a rash of one or two floridly delirious, and I made a suggestion to dangle them. And the nurses looked at me and Taryn said, but they can’t follow commands. Oh, wow. And I think that kind of comes back to the implementation of a b mat in that setting with out the critical thinking and the training, the support that your system has provided. And that’s where I, I’m glad we’re talking about it, because it’s one of those things to make sure that we do that appropriately. nurses need tools to know what to anticipate as far as are they safe to stand?

Or what? Do they need equipment? That process- something to cue demands in a systematic approach to it helps nurses feel so much safer and confident in approaching it. No one wants to guests all the time. stick their finger out in the wind right to see how do I feel this moment? But I just…. that’s my main but trepidation. Is that it? Could it become a barrier if we don’t provide the critical thinking tools.

I would never have thought that they would. There was just night and day difference between those two teams, right? Your application approach the BMAT nurses felt confident I could tell that they felt confident in assessing patients as they got going, getting them up. And they just were progressive getting the patient in a walking sling on their feet standing to the chair by themselves on ECMO. That surpasses…

Nancy Mcgann 41:57
Yeah, that’s and there’s not I that’s not common practice yet. But you know, it’s good to see it happening, really, with any safe patient handling and mobility program. You can’t set your staff up to fail. So and they’re very complex programs. So unless you’re going to really have the right onboarding, have the tools right there and available, have the swings right there and available, and people competent to use it and know when to use it by doing some kind of mobility assessment tool.

You know, I get calls and emails from colleagues across the country all the time. And they, they’re like, you know, no one uses the equipment, why should we buy it, and I said, Well, if you put two lifts on the floor, and someone has a patient, maybe once every six months that actually needs it, they’re never going to get it into their practice, if you don’t have the slings available, and they’re gonna need to call and get it, if you have a mobile, if they have to find that isn’t plugged in, and charged.

Again, you’re setting them up to fail. And so if you’re going to do it, you need to do it right. And you need to set up in the right way. And again, anytime you teach a new tool, we’ve got to remind people that no tool tells you what to do, it guides you in decision making. And the critical thinking is the key. And that’s the other reason to use these tools. And again, we want our, our clinicians CNAs. You know, PT, OT, rehab, in general cardiac rehab, our nurses, we want them for their brains, not to run.

And so and that’s, that’s where their real skill comes in, and their interpersonal relationships, their ability to communicate with patients. And so if we can use those tools in the appropriate manner, we actually do keep our staff with their patients and not as machines for people’s patients. But it has to be done the right way, like you said, because if it’s just Oh, yeah, I don’t really want to move this person.

So I’m just going to take a lift and stick them in the chair and check the box. So in our system, we’re we’re adding lower level documentation from the lowest level, the highest level of mobility. And when we do the analytics on that dashboard, that denominator would be those lower female levels. So the patient is a female to they will get passed on the dashboard of performing highest level mobility, if they just think with them. Or if they if they have to, they have to achieve what their maximum mobility is based on that. So that’s what proper measurement and that may be in a year from now we’ll have that dashboard to share with you. But

Kali Dayton 44:28
that’s Yeah, that’s great. I don’t think I held the guy I’ve seen in the research, much collection as far as here’s what they’re capable of doing. But here’s what we did. It’s assumed, but there’s not much accountability. So if you have a team that dangles patients across the board, and they check off that early mobility checkbox, but many of those patients could have been walking.

Did we really optimize that mobility or if they came in walking, we sedated them for five days and now we’re getting going again? Is that optimal? So I love, I love that approach. And you talked about very beginning that this is becoming quicker, or more efficient. Tell me more about that. What was it like your team? Initially? You said it was a lot more laborious initially.

Nancy Mcgann 45:14
Yeah. So I think, I think, Well, anytime you do something new, right, it takes longer even like if you commute to work, and your first day that you’re in a new job, it feels longer than after you’ve been doing it for three weeks. So there’s that perception because your brains working harder to do tasks also. But you’re fumbling at first, your whole nervous, your team communication isn’t as efficient.

You know, you might not have all the tools you need, you’re having, you know, I know one thing, a lot of ICU nurses have said to me, if a PT ot are coming in to mobilize my patients, and they’re new, I’m not I don’t trust them with those lines and drains. And frankly, as a PT myself, I wouldn’t trust me with those lighter drains, because I’ve never done critical care therapy, right. And so, so again, that training takes time and becoming competent at something isn’t, you know, we have we teach someone something or sign off a competency or competency takes time.

And so what competency comes efficiency, right? And anytime you do something a lot, you know, you buy a piece of furniture, and you put it together, it takes a really long time, if you have the company do it, they can do it in five minutes, because that’s the 30 of the time that those those, that group of individuals has made the furniture, it’s really the same kind of thing. And, and with that measurement piece, if you don’t document in your health record, though, how much that patient is capable of ambulating or capable of sitting or capable of standing or maybe not walking yet, you can’t really have good measures to drive process improvement.

So for our ambulation measures, we only include patients that are what we call our high BMAT 3 and BMAT four, because they’re physically capable of ambulating. We looked at our entire patient population, it would be a meaningless number, because it would depend on our census and how mobile those people are. And so if you’re not, if you’re measuring mobility without a denominator of their capability, if you’re not driving change, you might think you’re driving.

Kali Dayton 47:16
I love that. Absolutely. And we’re always talking about how this is customizable. This is you can’t optimize care unless you customize it. And so every patient is different, but you need to capture who is that patient? And did we do the best and optimize mobility for that patient. Most people, most humans walk but mostly, my daughter will never walk probably. But I would expect her to be mobilized. And so if someone just because she didn’t walk in the ICU during her ICU stay, which has been an ICU PT note, he worked with her, they didn’t walk her, but optimize and maximize mobility for her and she benefited from it. And that’s still an awakened walking approach. Exactly, yeah.

Nancy Mcgann 47:57
Not everyone’s capable of it and and maximizing their capability is going to still massively improve their health outcomes. And with some technology at a higher level, you can take a child with cerebral palsy and at least have them bear weight. And so we can do stuff. Now we couldn’t do when I was treating patients in the late 80s and 90s. You know, with this technology, we see stroke patients come so much further, because of their ability to safely be in certain positions that we couldn’t physically get them to before you couldn’t have someone do repetitive walking and hold them up in the air, that just wasn’t going to happen. So now that we can do that, we see much, much better outcomes. And as we all say, mobility truly is medicine. It truly is a treatment for mental health and physical health. And so that and whether you’re able to walk or not mobility tool.

Kali Dayton 48:55
Nancy, what have you guys seen as far as the financial benefits of making these changes on your team?

Nancy Mcgann 48:55
So we did a really thorough analysis, who worked with the finance department at St. Joseph Hospital, and then with some region, finance professionals. And, you know, there’s a lot of data and research out there about cost savings, but wanted to see if we can make it really precise and specific to our patients. And in this case, specifically at St. Joseph’s Hospital. And so what our Ruth decided, with a team of clinicians, and then a team of finance people, was to look at the last day of equipment costs in the ICU.

And we broke that up by vented patients and not vented patients. And then we looked at the key group, we wanted to focus just on the group were looking at impact by ICU, early mobility. So we excluded patients with a length of stay less than 1.5 days, because those tend to be your cardiac surgery, short stay, they’re getting up in mobile anyway, they’re just vented. So they’re, they’re in the ICU for a short time. So that’s not our patient population. We also excluded patients who passed in the ICU setting, feeling like that also may not be a group, we’re reducing length of stay, you know, medical circumstances are probably more profound than the mobility impact for that population. And so with the supply costs, we actually have it down to the patient level details, what’s all supplies built to that patient that are not reimbursed, which as we know, in healthcare are most supply.

And so what are our real costs, and then also, they hit a fancy formula for the unit supplies per day, based on what you buy for IV tubing and like general supply, so a very, very in depth and detailed financial analysis went into this. And with St. Joe’s, the six months prior to us fully implementing this in the six months after that, we saw a two day decrease in length of stay. And so what this analysis showed is that that decrease saved us anywhere from from 1.2 million to $1.8 million in supply costs. And the reason there’s a variation there is that we looked at two options. So one of them was with a patient was going to be in our hospital for 10 days, and four of those days were going to be in the ICU. And we ended up having them in ICU three days and nine days in the hospital, that that last day of supply cost in the ICU was all that mattered.

That was the real reduction in the cost to deliver that care. However, if when they left the ICU, the length of stay didn’t decrease. So though now again, that four days went to three in the ICU, but the length of stay stayed at 10. We subtracted the last day of supply costs at everywhere else they were in the hospital, whether it was the medical unit, the tele unit. And so we we took the difference between those. So that’s the difference between $1.2 million to $1.8 million is that over a year, then that would be over. So though, so if it were reducing the reduction, like this day was one day, that would have been the savings to the ICU over a year. But it was two days. And so we basically so in six months, we did what we estimated what happened in a year, which was the 1.2 to $1.8 million. So that is for six months.

Now I always say and Kali, you know, I’m like this, I’m very cautious. And very tentative. With data like this, I definitely want to see it even over a longer period of time. And we will be going back and doing deeper analysis. A patient level again to really see those trends. But you know, cautionary, it’s looking pretty amazing. And we also looked at the opportunity and all of our other ICU is based on that. And so we have each ICU and there is some very Asian and last day of class and all of our ICU. But you know, this doesn’t include also that we might need less PT and OT they might need less wound care. Our caregivers aren’t necessarily going to go home because we’d like what about staffing, they’re like, Well, you’re not going to necessarily be sending people home that precisely, but they’re able to deliver better care because they have the time to do that. We might have less patience and less time on the ventilator less things to worry about. Yep, exactly. So there’s that’s a that’s probably a minimum cost, not the total cost saving.

Right but it will pour into better outcomes which pours into better outcomes for better care if it goes into better outcomes and less healthcare costs overall for other patients as well. Yeah, I mean it lower it’s a win win, win it the whole mobility program and croute prove the quality of care for our patients, prove their outcome. Gives the joy back and work for our ICU. staff who had a horrible, horrible time during the pandemic, and provide stewardship and right now 66% of the hospitals, I believe I may may be a little off here in the United States ended in the red and 2022. So this is a huge issue with our staffing and things like that contract work, steal from the pandemic, leftover cost of living, like has gone up everywhere, obviously, is another impact.

So, so this is also a time it’s highly needed to have saved funds. And it’s so exciting to me, this has been the first within the first six months which, which I think is a time of growing pains when you’re still working out the kinks, figuring out your process, standardizing the practices, the education, the dynamics. So it’s not a completely flawless awaken walking approach, yet, but I mean, just those initial changes, those first steps of progress immediately resulted in healthcare savings.

There’s no excuse not to, right? This is a obvious return on investment. Yeah, how much do you estimate that the hospital invested into making these changes? So if we include the grant project, which was funded by our quality department, so not directly the hospital, it’s a system level grant that was funding that work. But let’s just even pretend that that was all paid for by the that particular hospital in that particular unit. And then if you add in all the training time, and everything like that, less than $100,000. So it’s been less than $100,000 to save, getting close to $2 million, maybe $1.8 million. And I am going to just assume or feel secure in estimating that that will continue to improve. No at 1.2 million. So just because of the six month differential, but yeah, but still pretty good. Right? Right. Exactly. So but very much. Great, great return on investment for anybody.

Kali Dayton 48:55
Yeah.

Nancy Mcgann 48:55
And then again, that doesn’t take into consideration the possible but likely improvement in retention, dynamic staffing, dynamics, morale. All of this will have a long term impact on your team, not just in the six months, but for years to come. Yes. And we actually are meeting with someone next week on our culture of safety survey results. And we’re going to look at the ICU there and see if we notice any changes in that. So more to come. Keep me posted. Thank you so much, Nancy.

Hopefully someday but the team that really is the team that did the day to day work. I mean, you know that’s where the hard stuff is done and and that really tedious work and then supporting our other hospitals in those interpersonal relationships between different teams and respecting each other for what they have. But yeah, one other thing with rehab is we leave our patients become the same we leave that nurse of that patient the whole day, everything’s thrown on that that relationship and that mutual respect and understanding for different roles. You know, that was the hard work team at St. Joe’s there that was really impacts them impact for patients. It impacts the whole community.

Kali Dayton 50:02
And stay tuned for episodes with the rehab department and RT. They have some really valuable insights. I loved what I saw there. I won’t give it away all the depths they have to offer but they’re there’s amazing stuff going on in your unit and we’re excited to learn from it. Thank you so much. Thanks for all you do. Because your your podcast goes up with a lot of our work. Well, you make it all worth it. Thank you. Thanks.

Transcribed by https://otter.ai

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