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When Brenna’s ICU set out to become an “Awake and Walking ICU”, Brenna, OTR/L, accepted the challenge. She shares with us her journey to leading her team to have the skills and culture to optimize mobility during critical illness.

Episode Transcription

Kali Dayton 0:13
A few years ago, I spoke at a conference and I will never forget the group of OTs that approached me after my presentation, they were filled with emotion and thanked me for giving ot a shout out in the presentation, I was taken aback by how significant that was to them.

To me it was, “Of course, I’m going to mention OT when talking about preventing and treating delirium in the ICU, and drastically changing patient outcomes!”

But they explained to me how dismissed they had been throughout their careers, and frustrated by the persistent barriers such as sedation and culture that made bringing their expertise to the patient so difficult.

So with those valiant pioneers that OTS in mind, I am so excited for this episode that is dedicated to showing how ot can be a huge leader in the ICU and drastically change culture and save lives.

Brenna, welcome to the podcast. Can you introduce yourself to us?

Brenna Seitz, OTR/L 1:45
Yeah, I’m Brenna Seitz. I’m an occupational therapist. I work at St. Joseph Hospital in Denver. I’ve been an OT for four years, and only working at St. Joe’s. And in the last year, I’ve become the ICU specialist for the physical medicine and rehabilitation department. S

o I kind of increased communication between the ICU team members, trained the PM&R members on becoming competent and treating ICU patients and just working on a lot of extra projects up there.

Kali Dayton 2:16
So you’re four years into your career. And I’ve asked a lot of nurses and physicians, what was your training as far as early mobility in the ICU? But I haven’t really dived into what that was like for occupational or physical therapist. What is your training? Before all of this development happened? How were you trained? Or what was your exposure, starting your career?

Brenna Seitz, OTR/L 2:43
Yeah, in school, it was just the basics of here are what some of the lines are, here are some things you can do in the ICU, I really started getting interested in it, though, when I was a student on my fieldwork.

So I went to a really big hospital had a lot of ICUs. And that’s where I got my first exposure to hear what LVADs are and ECMO and CRRT and what OT can actually do with those patients.

So that kind of sparked my interests. And I’m like, “Okay, I need to learn more about this. And I can get involved.” And then starting out as a new OT, I had a lot of pts and I had one PT and OT who were really, really competent in ICU and were really passionate about mobility and what we could be doing.

So I shadowed them and worked with them. And like really tried to teach myself more about the lines and what we were doing and how I could kind of improve the care for the patients up in the ICU. But nothing super formally ICU.

Kali Dayton 3:45
So you had some peer modeling. You had some like lofty visions and dreams of what you could be doing. A lot of this is self-taught then.

Brenna Seitz, OTR/L 3:55
Yeah, it is takes a lot of CEUs and just spent time researching and reading journal articles and teaching myself.

Kali Dayton 4:03
Amazing. And what were some of the barriers, so maybe you’re taking the CEUs, you had these ideas, but how, how, how did you approach this? Or how did you? What was the like trying to even get in to apply these at the bedside?

Brenna Seitz, OTR/L 4:19
At first, it was really hard. I mean, I’m a new practitioner too. So that kind of made it harder to feel like I had the ability to discuss things with the nurses and doctors and other therapists. Our ICU also had a big sedation culture and still does to some extent, but it’s something we’re all working on and trying to learn more about. So I had a little bit of fear but and worry like oh no, am I gonna hurt these patients, but having a pure modeling and co workers who showed me that it was safe and okay, it really helped.

Also, I started right before Work COVID. So we suddenly had a lot of intubated patients, a lot of patients who were coming out of sedation, very weak, needed, PT and OT, and they kind of didn’t have any other options of what they could be doing with those patients. So the doctors and nurses kind of let us just see what we could do to offer. So it was kind of a lot of trial by fire being thrown into these rooms and having to figure out what worked and what didn’t work.

Kali Dayton 5:25
Oh, that’s an interesting point. Having to be immersed into the back end, into the damage that was happening during COVID. That had an extremely enlightening and sobering to realize what happens during sedation. ICU acquired weakness really is like, that is a crash course. And that’s a heavy burden. I think that’s something that I think many, if not most occupational physical therapists can really relate to that in some ICUs.

They were kicked out initially. But everyone’s sent in on the back end to go clean up or go try to fix what already happened. And when an episode 126 I think we had Nancy McGee talk about this initiative that’s been happening.

So it was 127. There’s an issue that’s been happening on your unit, and which Margaret Arnold from earlymobility.com. And I teamed up to work with your team and move this forward. And you were just right at the forefront, you were just one of the main leaders, we showed up on-site, and you already had so much momentum going and you took a huge leadership role. What did that mean to you to have this initiative rollout in your unit?

Brenna Seitz, OTR/L 6:41
I felt very excited to be able to take this on. From my own personal experience watching patients were I’d go into a room and help them wake up and see kind of what delirium actually look like. And these patients, I knew what it needed to change.

And I was very happy that our hospital was chosen to be able to kind of advance mobility and increase like awakening and humanity of ICUs. It was just really, really wonderful. I’m sorry, it was just, I love it. I think seeing people like actually get up and do things and do ADLs. And wake up and watching people come out of delirium has been the best thing for our unit. Seeing the successes has been really wonderful.

Kali Dayton 7:39
Yeah, your team has had really exciting progress. So we went in, I think of him last summer. And we did this a little bit different than how I usually would do it. We had a few champions meet together. And we did kind of crash course on site simulation training. And I like to do it with almost every person possible throughout the unit. But with your unit, it was just a few champions. But how did even that helped get buy in to support you and what you were working towards? Yeah,

Brenna Seitz, OTR/L 8:17
I having the on site training and having everyone come together as a team really solidified that team culture and our ICU. Before we were definitely working in silos, where OTs came in and do did their thing RTS came in and did their treatment nurses were there to kind of help if they needed to.

But having everyone sit down in a room and actually go through the same training, get on the same page about why we’re doing what we’re doing. And get the same kind of training the same education and being able to model discussions in simulation training. Like here’s how, the best way to ask to lighten sedation or here’s a safer way to move somebody and getting everybody on the same page to mobilize a patient. And putting the patient at the center, I think was invaluable for that.

Kali Dayton 9:05
And I loved watching you lead this, I loved watching you jump in, especially when we came back at the end of October. And you guys had made a lot of progress. And you already had so many success stories. And then I got to just spend the day with you and watch how you worked with people. Because not every clinician on your team received the same education.

It really came down to you as champions to disseminate this and to model this and to try to teach your team members how to do this and watching you come into the room as an OT with so much confidence and tact and just you’re really strategic and saying do you call these the nurse or the RT saying, “Here’s what we’re gonna do? Let’s do it.”

You just jumped and made things happen. It was just it was a beautifully orchestrated production that you as an OT really led and you made everyone else feel really comfortable. So tell me more about how you’ve trained your colleagues to be You profession in this process of care?

Brenna Seitz, OTR/L 10:03
Yeah, as far as the PT and OTs and I included speech in our training as well, just because I feel like having everybody from PMR is very important. Yeah. I know, especially speech they can do so much with communication and cognition that I think leaving them out is always a mistake.

Kali Dayton 10:21
100%

Brenna Seitz, OTR/L 10:23
Yeah, so I trained them specifically, I made lions and leads competency trainings, taught them the same things we talked about with delirium, showed them other episodes of your podcast, and just had everybody sit down and kind of learn why we were doing mobility.

And then a lot of having them shadow me or when we had new, new hires, training them up in the ICU, they would shadow me or PT, they felt comfortable. We had a few PT champions as well. And they would come up and shadow us and watch us interact, watch us do rounds where we ask the nurses “Why, or why not?”

Like, “Can we work with your patients?” and just kind of getting them immersed and seeing us be confident up there, “I think helped them feel more comfortable asking as well. And I’m always available for any of the PM&R staff to, if they’re like, “I don’t really know what to do with this patient, or these lines are kind of scary,”- I always take time out of my day to go teach them about it in real time and show them how we can be safe and moving those patients appropriately.

Kali Dayton 11:25
And that that kind of experience being able to shadow and follow a more experienced competent clinician and to learn in real time with real patients. That is invaluable. And that’s really great that the system supported that, that they didn’t have to just take their own patient low and and keep on trying to bushwhack their way through this experience.

But they could, but they were allowed to take that time, they were paid to train with you. And that is a huge return on investment for them to gain those own skills for themselves. And not just be told or given a checklist without the proper training and support. And then I saw the way you worked with nurses, how have you helped nurses feel comfortable with your involvement?

Brenna Seitz, OTR/L 12:13
Yeah, that took a lot of time to build the trust. But I think once you have trust, being able to have discussions and kind of question some of the decisions in a nice and respectful way, obviously, but I just started with not asking, “Can I work with your patients?” it was more “Could we try to do some ADLs today in bed? Can we try to sit on the edge of the bed?”

and being very specific and what I wanted to do and explaining why that was what I wanted to do with them. So instead of them worrying that I’m just going to get their patient who’s been pretty agitated out of bed and leave them in a chair and just be gone for the rest of the day, I tried to make it a team approach.

I’m also including the nurses in my treatment sessions. So I’ve been really trying not to cooperate with PT as much, but to include the nurses with mobility so they can see that it’s safe and easy and get more comfortable with it themselves. And that’s really helped in our department to a lot of nurses move patients before therapy even gets there.

They’re walking patients outside of therapy sessions and really feeling more comfortable themselves, which I’d like to think is at least a little bit from them watching us and being part of included in our mobility sessions.

Kali Dayton 13:25
100% So my experience is an RN in an Awake and Walking ICU is PT helps with two mobility sessions, OT treats separately. And then a night we have another mobility session with just RT, RN, CNA, and/or family. And I never questioned that.

So then looking back and trying to dissect how do I help teams implement this? I had asked myself, “Why was I as an a nurse, so comfortable with that? Why was I okay with that?” –Because I worked day and night shifts. And I worked….. I was with PT during the day, subconsciously learning those skills because I was just helping.

And that helped me feel and be competent at night without PT there. And it’s just part of the culture. And so then I learned watching PT work with delirious agitated patients at night, I wasn’t left on my own without those tools, I could then use those tools to treat that agitation that delirium and facilitate real sleep. So I love that approach.

And I think that is what needs to be happening. We’ll do later on an episode about PT and OT co-treating in the ICU because I think that’s happening a lot. And it’s because we’re not learning how to really work with the rest of our colleagues.

But as Chris Perry says, “Mobility is everyone’s job”, but we can’t fulfill our jobs if we don’t have that training. So that’s what I loved watching as you were teaching them. Why to do it, when to do it. Right. I saw patients that were agitated and are weak and the nurses were like, they wouldn’t probably have done this on their own. But you’re showing them how feasible it is and techniques to do it. What has been the feedback with just even what have you observed from the nurse as you’ve seen them walking patients on their own? What else?

Brenna Seitz, OTR/L 15:08
I have found a lot of RTS and RNs are calling me and asking, why haven’t they moved yet? Why aren’t we walking them? Why is this not happening. And sometimes it’s for good reasons that they’re too weak to be walking, but we’re still working with them in other ways. And we talked about that. But I love when other disciplines are calling me and asking, and I’m not the one pushing to mobilize the patients.

So that’s been a really fun change for me and physicians as well. They’ve also been calling and saying, so tomorrow, you’re gonna mobilize a segment patient, and today, we’re taking this person outside. And it’s really become a whole team approach. Instead of me feeling like I’m going in there, trying to force everybody to be on my side.

Kali Dayton 15:51
That makes me emotional. I’m just trying to imagine what that’s like other OTs and PTs that I’ve talked to that have been fighting for this for so long. What that makes them feel, to hear that and to envision that. If you could go back and tell yourself two years ago, what would come or what this would happen? What would What do you wish that yourself two years ago, had known and understood?

Brenna Seitz, OTR/L 16:21
To just keep advocating for each patient and not give up with it? I feel like sometimes I’d get discouraged when I’d be told no, you can’t know they’re not following commands know, they’re sick. And just knowing that like, we’re going towards the right direction, and that how much more comfortable and confident I would feel, after getting through and working through some of those really complicated, tough patients that maybe we didn’t make the right decisions, mobility wise, and maybe we pushed a little too hard or didn’t push enough. And just seeing the really good outcomes that we have that it would be worth kind of all those tough discussions with nurses and other staff members.

Kali Dayton 17:02
Oh, that is powerful, that sometimes those experiences that we’re tempted to call failures, or to then project into other situations to say, Oh, that one patient had a syncopal episode. Therefore, mobility is just, you know, it’s not appropriate, it’s unsafe, and to shut the whole project down. But you utilize that to learn, and to build your expertise and thinking and other elements of our careers. When we started proning trading areas in general, I mean, we were always learning from the things that didn’t go so well.

And that’s what I’m trying to help teams capture is that this is a process that I might come on site with my team, and we might know bring in his ailments, we might even help work through some of those powerful and complicated situations. But then we leave and you still have to keep that learning process going. But you’re you’re getting towards the top of the mountain, right, where you’re sleeping, the clouds are partying, you’re, you’re catching your breath again, and looking back how much you’ve learned and who you’ve become as a clinician. Now, tell me about those individual patients, what are some of the success stories that you’ve really enjoyed?

Brenna Seitz, OTR/L 18:16
There’s quite a few. Um, once you get patients more awakened, you learn more about them as individuals, I mean, all staff members like that, but especially OTs, that’s kind of what we do. It’s making an occupational profile learning about individuals and how to get them back to their daily life and their quality of life that they want. So some of them for me were one patient who was there for a very long time and was intubated, she couldn’t get a trach just because it was difficult. And I’m talking like a month, month and a half, with an ET tube.

And she was pretty mobile. But they she all she wanted was a shower, and we hadn’t showered somebody with an 82. Before, some of the nurses don’t even know that we have a shower in our ICU. So I knew it was going to be a challenge. But the collaboration with our tea was great. She was made me feel comfortable. And the physician said it was fine. So we took her in and got her a shower after months of being in the ICU. And she absolutely loved that. And just made her feel more like herself again. So that was one really big win, I think that I might have,

Kali Dayton 19:26
if you do it, I or someone else i someone’s got to do a study, somehow capturing the impact of showers during critical illness and mechanical ventilation. Because now you’ve seen it, I’ve seen it they walk out or sometimes we’ll out a totally different person. And that’s got to improve their will to live their delirium and their overall outcomes. It’s just it makes sense. And as an occupational therapist, I mean that’s you’re thinking through that all the sensory stimulation all these things that I as a nurse practitioner was not really even thinking about. I just knew that was a hygiene thing, dignity thing. But there’s so much more to it. What are some of your speculate speculations about the benefits of showering in the ICU?

Brenna Seitz, OTR/L 20:09
Well, I mean, just as part of your routine, like most of us shower every day, every other day, not once a month, bed baths are not quite the same. So just from a mental health side, there’s a lot, also how much you have to move your body to be able to stand long enough to shower to be able to sit in, reach all the parts of your body, like reach down to your legs, and wash your hair and just have to move so many different muscles while you’re showering, that it’s a great exercise, regardless of like, instead of like just walking, maybe you’re walking like to the shower, then you’re standing and showering the whole time with rest breaks for sitting and then walking back or wheeling yourself and your wheelchair, it’s just so much more activity, you can pack into something that’s meaningful and beneficial for your mental health.

Kali Dayton 20:53
And this is why we have occupational and physical therapists in the ICU, because that’s not Those aren’t things that I would intuitively think about as coming from a nursing side. How did your counterparts respond to that? I mean, it made you feel comfortable. How do the RN respond? Before maybe after?

Brenna Seitz, OTR/L 21:12
They were definitely nervous. It was a lot of talking through like, how are we going to do this safely? I mean, we had a handheld showerhead. So it made it easier that we’re not going to just like, have her stand with your mouth, like up towards the water and all that then that’s what they were worried about. And we’re like, what if something goes wrong. So we tested all of like the emergency features up there, and like just to make sure that if something did happen, we’d have a backup plan.

And then we’re like, well, this patient is relatively stable as far as an ICU patient goes. So we feel comfortable trying and just kind of see and we’re like, we have a time limit and set a lot of boundaries. And like, if her like saturations got to lower to this amount, we’re gonna just be done. And everyone was on board with that. So I think having those parameters really helped, but it was definitely nerve wracking.

But then, when they saw that she was fine. They were like, “Oh, this is okay, like that.” I’ve had a few other nurses asked like, “Oh, can we shower this patient?” not necessarily vented, but they realized we had a shower, and they’re like, “Hmm, I think this person could probably shower today.” And like this kind of trying to incorporate it more, there’s definitely still some fear. But I mean, on other units, we shower patients with tricks like not that we have a lot of them in our ICU, but that happens. And I feel like that’s kind of paving the way to like, let us try to do it a little bit more when they’re ready.

Kali Dayton 22:31
And that kind of collaboration, communication, critical thinking, that’s probably not taught in school. Some of it I’m like, not even sure how we would teach it right. So that’s something that comes with experience and developing those relationships with your colleagues. On that note to relationships with their colleagues, how has this impacted your relationship and just the overall dynamics within the team amongst the disciplines? If you’ve been listening to this podcast, you’re likely convinced that sedation and mobility practices in the ICU need to change.

Brenna Seitz, OTR/L 23:03
I think there’s a lot more respect for what each discipline does. Now. It’s also a lot more fun. Like when I go up and do rounds I can socialize while the nurses and they like really like just talk about our days and a lot more just like it’s more familiar. And there’s a lot of trust and a lot of respect. And we’re willing to kind of joke around and just like that kind of dynamic makes it really wonderful to be up there. It makes my job more fun. I’m not fighting every single day the nurses aren’t getting frustrated with me being up there. It’s just a nice environment. We’re all working to get the patients better. And that just really proves all of our like job quality.

Kali Dayton 24:44
And how do you anticipate that impacting retention during this really difficult time?

Brenna Seitz, OTR/L 24:50
I’d like to think that it would keep people around a little bit longer when you’re having a job that you enjoy doing that you feel like it’s benefiting patients and yourself and it’s more fun that environment and it’s not as stressful. And I also just think seeing more patients awake and less that are heavily sedated and heavily, like, just so agitated that they can’t do anything. Because if we can stop that, then your patients are easier to work with, you can communicate with them better. And it just that part of your job gets easier to cause caring for delirious patients is not easy.

Kali Dayton 25:22
Yeah, once that he showed that delirium is part of the significant psychological burden on nurses. It’s really, really difficult to be with someone that that’s that uncomfortable, that unstable, unreliable, for 12 hours straight plus, it’s really difficult. So yeah, I would love to see some studies, I’m always throwing out ideas for research, because people are always looking for more studies to do time to navigate the impact on retention, when we improve this process of care. Okay, what other stories do you have? What other successes,

Brenna Seitz, OTR/L 25:57
yes, this is multiple patients. But one of my favorite things that has come with people being more awake, or even patients who are delirious, has been involving family members. But specifically, once we get patients standing or sitting for the first time, letting their family come and hug them. And I pretty much cry every single time it happens. But it’s been really wonderful because the family, I tried to help them be less scared about all the lines that the family member has, and just really try to connect with their family member. And it just makes me so happy when they can come in and hug them.

Kali Dayton 26:33
There’s so many things on this podcast that have made me just look back and question. Things that I could have done better things I wish I’d known. That’s an idea that I wish I’d had. I think we’re just as me, especially as a nurse, I was just so task oriented, right? We’re just to go through the steps whipping through we got to get this session with, you know, cranked out but why not? Why not hug and we know, the psychological benefits, the physiological benefits of a hug. One thing that I was really taken aback by with survivors perspective, is that how isolated they felt during their medically induced comas.

Which is crazy to think because oftentimes they do have them at the bedside, they have clinicians at the bedside, all that they’re never really physically alone, but they don’t have a real connection. And what else do we go with days to weeks out talking to someone without touching someone? I mean, that’s what we use for torture, during war. That’s what we, that sends people into psychosis. That’s what we do, knowingly to our patients. So you’re taking that to a whole new extreme saying, talk, communicate, touch, and hug. That is so powerful, and how, how did the families and the patients respond to that?

Brenna Seitz, OTR/L 27:54
They almost always cry too. I think they just love getting the permission to touch their family member, especially the ones that really don’t seem that stable. They’re like they have they’re easy to but they have all the lines, they have a swan, they have everything attached to them. And it’s just like the permission to like, let them like, show their love to their family member that they just, I think really appreciate because you can tell they’re scared the first time and then they go away. And they’re like, oh, I can just hug them. And it’s I’m not pulling anything out. I’m not hurting them, like I’m helping them and then their family member will smile or cry. And I think it just has let them have like a really personal connection that is missing a lot.

Kali Dayton 28:33
And you just think for the family’s perspective. You don’t know what the relationship with the scenario was before that most critical illness comes unexpectedly. And you know, how much your heart pines to be able to hold that person and have that connection? Because you don’t know if that’s last opportunity. And that’s one of my big beefs about unnecessarily medically these comas is that we deprive them of that connection, those touches that could be some of their last opportunities.

My daughter was in the PICU and anytime she’s in the hospital, I when she was especially smaller, she’s four now but she was started when she’s about 816 months old. I slept in the crib with her. I don’t know if that’s normal. I people kind of some nurses gave me more looks than others, but it just felt normal. It’s anything we can do to normalize that situation. And for me that brought me comfort to have her close by. I’ve had family members sleeping in the bed with a patient and some nurses are gonna say just totally cringe at that, right. But think of it’s your spouse, especially when they’re on the way out when they are dying when they are terminal. Why not? There now that’s not always feasible. That’s not always appropriate, but why not? When it’s when it’s okay. Okay, what else?

Brenna Seitz, OTR/L 29:53
Yeah, some of the most fun learning experiences have been with our ECMO patients. They’re typically younger patients who come in we’re very independent before, some of these were even during COVID. But so like before we started really pushing for mobility. But thankfully, our physicians that run the ECMO program are very involved in have been advocates for mobility for a long time. So we had a few that were both very young, and they’re like, Alright, you’re getting them up, like, you’re gonna make it happen. And I was like, “Okay, well, we have to decrease their sedation just a little bit, because they can’t even open their eyes right now. But once we got that all settled and figured out, we’re able to stand them up and sit them on the side of the bed”– and just watching the collaboration from the whole team, because that takes a lot of people involved.

It takes respiratory, the perfusionists, the nurses, it takes a lot of people. But we got some people up, they started following commands, they went from very delirious, to sitting up following commands, being able to brush their teeth, being able to just engage with the environment and like, follow commands tell us if they were having pain. And the two patients I’m thinking of right now, both ended up one went to rehab for a short time, but then went home and went back to his job and was working and doing all everything he was doing before and the other one ended up walking home. Like she went to the regular floor first. But she left the hospital went home, because we were able to move her and keep her strong.

Kali Dayton 31:19
And in Episode 118, one team showed a 30% reduction in mortality among their at COVID ECMO patients. I mean, I think from a nurse perspective, I would just see OTs, brushing their teeth, helping them brush their teeth, right? It didn’t seem that profound. But that is literally saving lives, decreased mortality by 30%, we look at that machine. And yes, obviously has a role in sustaining their life and saving their life. But there’s so much more to it, and you just bring in this extra element. And that literally saves lives. That never gets old to me, never gets old to me. I love it. Especially since that was like kind of at the beginning of this initiative. You were really breaking down barriers. And then from your perspective, you’re probably like we can do with ECMO patients, why can’t we do with other patients that are mechanical ventilation? And those are just all building blocks to your expertise and to the team’s success? What else?

Brenna Seitz, OTR/L 32:18
Yeah, I think the why not is like the question you asked is kind of how I go about my day most of the time. So like, we’ll have patients that are like not following commands, arrest of negative five, they’re off sedation, that they’re just not waking up. And I just say, why can’t I try? Like, why can’t I sit them up? Why can’t I do this, our hospital has a lot of safe patient handling equipment. So we have all the ceiling lifts we could ever want. So I can put somebody in a sling and sit them up and just see. And I’ve been so surprised with how people wake up just being upright and being given a chance to be awake. Instead of raise your hand or open your eyes and just leaving it at that with like sitting them up and turning on music and helping them kind of like sway back and forth to it or helping them like like turn on lights and have their family member talk to them while they’re upright.

And it’s just crazy how much more weak somebody can get. And suddenly they’re following commands some of the nurses, it always makes me laugh. They’re like your magic. How did you make that happen? And I’m like, Well, I just gave them a chance I do have maybe more time than the nurses do to take that like time to sit them up and do that. But then they see that they wake up and I’m like, Oh, they are getting a little better they are like in there and they can kind of see them more as a human than to

Kali Dayton 33:38
It’s amazing. It’s one of those things that you wouldn’t I don’t think I would have taken this approach had I not just been trained with it or seen it because it wouldn’t have made sense to me and so I don’t blame people for not turning to mobility what a patient can barely open their eyes it’s not my favorite to try to mobilize someone that’s a resonated too. Right? It does require more effort quipment you know, time but I love Dr. betta naughty from LDS hospital. He says walk when wild walk when sluggish.

And that’s exactly what you’re doing. You’re mobilizing when they’re sluggish. And that’s I do like how your team is utilizing the GMAT. I worry about the mean that because of the perceived requirement to follow commands, but you guys critically think through that you identify Can I file commands that they can then we’re going to need some reinforcement, right? But that doesn’t stop the mobility. But the myth in the nursing world is they can’t follow commands, therefore they can’t mobilize but that is not what your team is doing. And I really appreciate that. And you show in the nurses again, pure modeling, you’re setting the precedents. They’re going to say okay, that happened in that scenario. What about my other patients, and they’re going to lean back on those experiences that they had with you? How many what else you’ve done with a sling? I love what you did with a walking sling and some of your delay areas patients that are agitated.

Brenna Seitz, OTR/L 35:01
Yeah, so we’ve had a few, they typically are more of like the withdrawal patients, but just anyone who has hyperactive delirium. And they’re not really following commands. Maybe they’re not quite hitting or punching people, but they’re moving around and they just will not sit still, like a wrath of western style. Yeah, exactly

Kali Dayton 35:21
right, sometimes three or four. That’s what I say bring in a lot of pain, like, we do need to tame on down. But But nurses especially get really nervous with the rest of zero, plus two when a patient’s delirious,

Brenna Seitz, OTR/L 35:33
Especially because they look uncomfortable, you don’t really know what they’re thinking. And you can always redirect them well. So I put them in a walking sling. And we just sit up or stand and I let them do what they’re going to do. Because they can’t fall I can manage their to where I had the nurse managing their all their lines. And we just see what they can do. I’ve had people suddenly stand up and start walking across the room. And I’m like, Oh, I guess you really just wanted to move. Or they’ll start kind of being with it enough to say, “Oh, I really have to go the bathroom or I was just my shoulder really hurt.”

Or like you can kind of get that with yes, no questions like, Are you in pain, like is it here. And then once they’re sitting up, they just like, look more relaxed, and then they’re up moving, and then you put them back down? They’re exhausted, there’s out and they stop moving. And you’re like, Oh, I guess you just had so much energy, we just needed to do something. And suddenly they’re relaxed and better. And the nurses like, “oh, okay,” and they’ve even gotten some of the patients up themselves, or they’re called me and be like, “can we please do a second session? Like, they’re up moving again? Can we try again, just to see if it helps before, we have to give them a bunch of sedation.”

Kali Dayton 36:37
I love that. Yep, rinse and repeat. Right? They’re gonna get real sleep, but they’re going to come out and they’re still delirious, they could still be somewhat restless. So why not? Right. And when talk about a sling, I think we always think about these things from the big, what are they called the other things that go from the chair to the bed, it’s a very passive thing. And you wind up putting them in a recliner with the with the legs up, and they end up basically in the same position in the chair as they were in the bed. That is not the approach you’re taking. You are having them bear their own weight as much as they can.

But there’s a safety net when someone’s really delirious, you don’t know what they’re gonna do, but you want to wear them out. But I think that is ingenious. Just let them stand there and work it out. I don’t know if anyone listening, it has written horses, I grew up with horses. And when they were really naughty, like I had a horse that just was like, he remind me of a five year old, like he just whatever he could get away with, he would try to get away with. And when I couldn’t get him to just be obedient, I guess or like, or you just been compliant. He could be really rough on my siblings. So I get on him and I’d run eights. And we were just just just to wear him out. It wasn’t like a bit abusive or harsh thing, it was just, we’re just going to wear you out. And that’s how I keep on thinking and with some of these patients, I’m just going to wear you out just to get that extra energy out that angst that agitation, that really anxiety and then you can just calm down, and it’s easier for everybody. And so the nurses keep calling you for it, huh? What a shift.

Brenna Seitz, OTR/L 38:13
Oh yeah. Especially like even the ones that can’t like bear their weight, and we sit them up on the side of the bed will still use those chairs, things but I take the slack off, I make them hold their head up and hold their weight up. So even though it might be a passive thing for some people, I make it active as much as they can do because some patients only can hold their head up. And that’s what we’re working on. But I just kind of meet them where they’re at and just see what I can do to wear them out.

Kali Dayton 38:37
Yes, and that’s what when we are learning these equipment, we need to keep that focus on making the patient do as much as they can. And you know, nurses are gonna play that’s really valuable for the muscles and all those things. But as a nurse, I’ll tell you what, I really appreciate them being so tired and sleeping afterwards, right? Especially if they’re kind of wiggly, I’m worried about the lines and tubes being dislodged when I’m my back is turned, if I know that they’re going to get so sleepy and worn out and they’re not going to mess with their tubes. I’m all about it. I think that’s a really good buy in for nurses and another tool that they need to have up their sleeve.

Otherwise, I think it’s really hard when we’ve historically sometimes will say well, we’re just gonna, we’re just gonna focus on sedation first. And we’ll worry about mobility later. And in my mind, with my experience, you can’t try to go without sedation, if you don’t have mobility in place, because you’re going to have delirium anytime you’re bed bound, you’re at high risk of be delirious on top of all the other risk factors in the ICU. So if you don’t have that tool to really treat the delirium and prevent delirium, your team cannot really thrive on being minimal to no sedation. So they have to go hand in hand and that’s totally what your brain as you bring in these tools. They’re not so dependent on sedation anymore, and they don’t even really want to maybe as much any more. What else would you share with that? The IT community in general, even just occupational therapist, I think you’re such a good example of the power of your discipline.

Brenna Seitz, OTR/L 40:13
Yeah, a few things. So one, just helping people through spontaneous breathing trials and awakening trials, that has been a really big shift. And one that I feel like OTS can have a very big role in if you kind of put yourself in the position to have that role. So do you put yourself out there daily? Yeah. So I asked why did they fail their daily wakening trial this morning? Can we do another one? So even in the past couple of days, I’ve gone up to nurses and said, Can we just do under sedation, if I want to work with them like, is like, you already tried it this morning. Like, let’s just try it again, while I’m here, and just see what happens.

And nurses like, “I guess I’ll turn it off at this time, like you can be here, like 5-10 minutes later.” “Sure.” And then we like work together. I had somebody that ended up staying off her station for six hours after I worked with her. And just because we sat there we sat up, we like tried to get her to open her eyes, she started following a few commands, and then got so worn out. But she stayed off for sedation for six hours. Also, with like breathing trials, I’ve had patients that like, get so anxious or so just, they’re lethargic, and they can’t or delirious, and can’t initiate breaths and start breathing.

So we’ll sit up and try to engage them in exercise, which is gonna try to make them breathe a little bit more anyway. But then we can talk to them and wake them up and say,” Alright, you need to breathe now, like, let’s sit up, have good posture, really good, like lung volumes, and then talk them through it.” And we’ve ended up getting people extubated from doing just from sitting up, they’re actually in a good posture. They’re not slumped in the bed trying to breathe. And they’ve ended up being able to be excavated, because we can prove that they’re following commands and able to breathe on their own.

Kali Dayton 41:58
I hear that from therapists time and time again. And I think there’s well, we’ll get into breathing trials and in the future episode, but that’s a really important principle, we think, no, we can’t mobilize them, because we’re going to do a breathing trial. But it’s that is how we pass breathing trials. That’s how we prepare them. And if they can’t sustain work of breathing while they’re mobilizing, they’re probably not going to be safe to excavate anyway. So it’s a really good way to prepare the patient, as well as test them to see are they going to be safe? Love it. What else? Yeah, better. I’m taking notes here.

Brenna Seitz, OTR/L 42:33
Also just kind of recognizing the really big role that ot has it can spend so much from just the sensory interventions that you can ride somebody that is barely responding, and can they respond to pain? Can they respond to like a toothbrush in their mouth or cold washcloth? And then can they open their eyes and track all the way up to? Can they do their laundry? Can they feed their pets? Can they do all this, there’s so much that ot can do that it’s not limited to let standing up goat stand up and go into the bathroom?

Like there’s so much that you can go in and do and it can be cognition based, it can be, like helping them with like, getting back to doing a hobby that they like, there’s just so much so many avenues you can go with ot that, try not to pin yourself into one specific role that I’m the person that goes goes in and helps them brush their teeth every single day. That’s great, too. But what else can you do for some of the other patients that maybe they’re not ready for that? Or maybe they can brush their teeth? Fine? Like, how do you push them even more? And I think just recognizing how big ot scope of practices and explaining that to your nurses and advocating for trying to go in and not just do passive range of motion or just do like oral hygiene or whatever, and really kind of being creative? Yes,

Kali Dayton 43:51
yes, I want OTS to feel their power to know the role that they play and the power that they have to save lives and change outcomes and help the rest of the team. You’ve given so many important tools. I’m just thinking back to my first in person conference. I’m gonna say it was two years ago, a year and a half ago, it was big. It was a trauma conference. And it was combined with all the disciplines, right.

And I don’t, I didn’t stick it on occupational therapy. But I definitely gave a plug into there. I think it was talking about delirium and saying get your physical and occupational therapist and there it was something really brief. But afterward, a group of like seven occupational therapists came up to me with tears in their eyes, saying thank you so much for the shout out. And these were some of them I could tell they had been in their careers for maybe 20 plus years. And I still felt so unseen, under appreciated under util underutilized. So, you are exemplifying the future of occupational therapy. That you are an intricate part of it. Critical Care Team and that you’re not to be shoved out during a pandemic. You’re not just on the back end. You should be in there shortly after admission and helping prevent harm as well as treating that when it happens. Thank you so much Brenna.

Brenna Seitz, OTR/L 45:26
Yeah, thanks for having me.

Transcribed by https://otter.ai

 

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