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Is early mobility safe and feasible in the burn ICU? Considering the significant barriers such as pain, dressing changes, variable device securement, delicate position needs, etc., how can an ICU team continue to practice early mobility?

Episode Transcription

Kali Dayton 0:02
Audrey, welcome to the podcast. Thanks for joining us and all your great work and expertise. Can you introduce yourself?

Audrey O’neill, DPT 0:09
Yeah, thank you for having me. I am a physical therapist, working in Indianapolis, Indiana. I work for Eskenazi Health Hospital in a burn unit. I’m specifically dedicated to the burn unit there. So it’s a burn ICU. And what it looks like is it’s a 15 bed.

We call it “acuity adaptable”. So we can have patients who are intubated, sedated on CRRT, kind of at the most critical stages on our unit, as well as patients who are a little bit less acuity or even patients who we’d consider up adlib that we’re taking, we’re treating more as outpatient taking to our therapy gyms.

So we just have a really big variety of patients that we didn’t have on our unit. So that’s my primary focus. And I also do like some wound care and some outpatient therapy as well, just depending on our census, but I’m solely with burn patients.

Kali Dayton 1:08
And this is really exciting for me, because I have no experience with burn. I didn’t know that he had the constitution for it. So I have a lot of respect admiration for our burn ICUS out there. But as I’ve been in conferences, people have asked, “Well, what about burn?”

And I recognize that you have really unique demographic, such a variety of patients, and some of the really hard barriers to some of the methods that I would advocate for right. So when I found your study about early mobility in the burn ICU, I got excited. Tell us about your recent publication?

Audrey O’neill, DPT 1:45
Yeah, so basically, as a, I started in burn, seven years ago, and we had just started as a student, we had just rolled out this early mobilization protocol that we had made for our burn ICU. And as I was training and learning and I just had questions on, “Okay, how are we really using this? How effective are we being?”

It felt like we were running into the same barriers over and over when we were trying to mobilize patients. So I really just wanted to know, like, how we were using this and what our barriers were. So I started just retrospectively looking back at patient chart to see kind of our patients who were vented.

Where are we? When were we getting them out of bed? How are we getting them out of bed. And fortunately, we have very thorough documentation, which made it easier to look at kind of when we were documenting our barriers.

So it just turned into this multi-year thing where I had all this data, and just was able to turn it into a publication because like you said, there’s not a lot of resources and information out there.

Kali Dayton 2:58
Absolutely. And I recognize that there are some barriers, which we’ll get into. But also these are patients that can have prolonged ICU stay that are at high risk of delirium, and I see quite a weakness and all these long term repercussions. And so it the logic would tell you that early mobility would still be a top priority. What did you find in all these chart reviews?

Audrey O’neill, DPT 3:23
So with the and I will, I’ll go back and say that burn care in general is transitioning to where our typical, typically, burn therapists are in the ICU. But we’re doing a lot of passive interventions, we’re doing a lot of range of motion stretching, positioning, and those are treatments for patients and mobility has kind of been off the table because patients with large dressings and wounds are intimidating.

And it’s and like you said, the coordination is just very challenging. So, and unfortunately, our unit is has always been supportive and very progressive when it comes to early mobilization. So we have been doing it but we didn’t have an established protocol in place. So that was the rationale for the development of this protocol.

And basically, what I found was that, and I apologize, I don’t have it, I should have it right in front of me. But so our biggest barrier to mobilizing patients were the medical complications. So the initial week to two weeks, our patients are undergoing fluid resuscitation, which again is something unique to burn where just fluid is being moved out of the interstitial spaces and it can affect a lot of cardiac, lung, and kidney volume.

So we’re having to replace that and they can be in this really like delicate, delicate state. So patients are undergoing that. They’re undergoing multiple surgical debridement initially, so often they’re getting going in and out of the alar. So just that balance in that initial week to two week periods for some of our larger, more sedated burns that are that would be on a ventilator can be challenging.

So often we’re trying to combat that. But then also for our units, specifically, I found that femoral line was limiting our mobility with 21% of the time, which honestly, the benefit of this research was that it allowed me to take that data back to our physician and say, “Hey, this is limiting us.” So we’ve been able to change our practices.

Kali Dayton 5:38
And these are previous years, right? Because more current research shows that it is safe and feasible to mobilize patients with femoral lines. But before that research, that was a big concern in our community, right?

Audrey O’neill, DPT 5:52
And again, it is, yes, it’s a big concern in the ICU community, but for burns specifically. Generally, they’re more at risk for clot formation. And the security of the lines that are often sutured in place sometimes aren’t the best. So there’s just more challenges there.

And there’s not a lot of published data in the burn population, which is our burn position. Again, become a little bit more hesitant to that. Yeah. So and then also, so I guess, like looking for those were our larger barriers that I was able to put, like percentages behind as far as like the medical complications and hemodynamic instability along with our line limitations.

But in general, I found that sedation is a huge barrier for us, compared to some of the other studies because I guess what I looked at was mobility progression, like stages on mobility.

So how we were mobilizing the patients using the protocol, how many patients were we getting to the edge of the bed? How many patients were we standing? How many patients? Were we actively getting to a chair? How many were we walking?

You read the studies, and it’s all these patients that are like walking on vents all over the units and other ICUs. And we had, like six, within five years, that we were able to get into the hallway, which seems like huge achievements for us when it happened, but not to a regular frequency that seems to be out there and other populations. So just really looking at why.

And there’s other studies that I referenced in my article that showed like even intermittent use of intermittent use of sedation just really varies just how awake patients are and their ability to walk on event. And we’re our patients are undergoing dressing changes. So they have to get pain medicine and sedating meds and things for those procedures. So some of those barriers also influenced us as well.

Kali Dayton 7:55
Absolutely, yeah, that is a huge barrier. So how did for example, in those six cases, what made those six so different? What what helped the team at those times, navigate sedation or overcome those barriers?

Audrey O’neill, DPT 8:17
So I did in the in the paper, I did look at those specific patients that we walked and looked at kind of what the differences demographically, injury wise, like what age of patients kind of what the differences were. And a few of the patients were just what we consider inhalation injury, so they didn’t have any burns to their skin.

So it was just mostly they were on the in when a patient has an inhalation injury, and involves the epithelial tissue lining their respiratory tract, which can like fluff and cause extra mucus and inflammation. So they have to be on the vent for 72 plus hours just to manage that.

But they generally can be more awake so we can, we can secure their ET tube a little better because they’re not they don’t have facial burn. So we can keep them more awake. And then they can get out of bed and walk a little bit more. With sorry, with at least two of our patients. One was I believe in the 30% and one was 44% Burn, which is a pretty those are pretty large service areas.

And age, they could be younger, or just timing thing with coordination of staff. We never know I think we sometimes we get patients sitting on the edge of the bed and timing works great and we can stand and we can walk. Other times, just depending on their dressing change schedule. We might get them into bed, they might be more sedated and it’s unsafe to progress.

So I’m not sure necessarily, I didn’t look into….. or it’s just challenging just to determine on those larger burns like why they were okay. And others weren’t necessarily didn’t progress as far.

Kali Dayton 10:09
And how do you navigate pain management? Right? In the A to F bundle, a is for assess, manage pain is the number one, especially with burns. This is partially why I don’t know if I can handle burns that well, because…. with myself or my kids and we get burned, it’s, it’s terrible.

And so mobility in the settings of so much pain has to be really difficult. How do you navigate pain management so that you are not over sedated and can’t participate? But they’re adequately managed?

Audrey O’neill, DPT 10:42
So I think this can be a huge barrier or limited understanding between like, sometimes we’re if our nurses are titrating meds and it’s something that we’re working on or unit is:

Sometimes if the patient is more what seems to be more agitated on the vent, kind of assessing like, do they need more sedation? Or are they in pain and do they need more pain management?

When sometimes it’s easier just to titrate up the sedation meds, versus giving them their their regularly scheduled pain medicine. So for us, we just try to coordinate around the dressing changes.

So sometimes, if we know a patient’s going to be getting a lot more medication for a dressing change will come in first thing in the morning coordinate with the nurses before that, so that way we can be more successful, and they can participate in more on their mobility session.

Prior to that dressing change and do more active therapy there. And then depending we’ll do more dependent well with them to a cardiac chair or do something that maybe they wouldn’t need to participate as much. And that still gets them upright in the afternoon after the change.

Kali Dayton 11:50
That is so great. I love the way your team is working together that you’re aware of we have you work with wound care and the nurses and Artie like everyone is aware of what’s going on with that patient that day, and everyone sounds like respects your role. And the importance of early mobility.

Audrey O’neill, DPT 12:10
We’ve had, we have primarily two pts and two OTs, for that 15 bed unit. So we have a lot of staff to go around. And we are dedicated to the unit. And we only see the burn patients and just like our nurses are dedicated and only typically have burned patients. So we know each other we work a lot together. And it just and they it helps having that like just like team cohesiveness.

Kali Dayton 12:38
Absolutely. That’s astounding. I’m speculating that you have some longtime-ers like you have people there that aren’t just there for a few months, or aren’t just newly there. Like, though that is, like you said, their expertise, that’s their specialty, they’ve been there for a while they know each other.

That’s going to be an upcoming episode on team dynamics and how much that impacts the overall system. I think it’s really hard to coordinate with people that you don’t know, and that you don’t have relationships with and things like that. Because it I mean, these schedules with these patients, these procedures, it’s all very tenuous and variable.

So you have to work so closely with each other, which is, again, hard to do. I’ve been a travel nurse, and it’s hard for me to Vocera physical therapy when I don’t know who they are, you know, I don’t know how to find them.

I don’t there’s just your brain is working on so many other things. “I’m trying to find where the towels are. I can’t coordinate what I’m going to mobilize a patient right?” You have to have some stability, to be able to work on those other dynamics.

Why? How does your team feel about the A to F bundle? Kind of what is the culture and the focus in general?

Audrey O’neill, DPT 13:54
I would say that I think we are aware of the bundle, but I don’t know that it’s like, necessarily ingrained in practice. I think it’s something that we we know and as a general ICU setting, but unfortunately, I think it’s probably something that we could improve upon to kind of use more on a like protocol basis.

I mean, I think we we definitely do all of these things. Like you said, assessing for pain, spontaneous awake and breathing trials, we’re definitely coordinating those more.

So what happens generally is our our ICU team, surgical ICU team still runs our patients, ventilators and their setting. So and not our burn team. So that coordination some sometimes is like they’re not directly on our unit all the time. So they’re rounding at a certain time.

So it’s not necessarily scheduled. But But I won’t say that when the patient is on spontaneous, like, depending on how they’re doing, we’ll still progress them. And unless they’re planning to go towards extubation, soon, and then we won’t necessarily try to wear them out before. Before that we’ll kind of see what the team says and kind of see what happens.

Definitely, we’re trying to manage multiple things when we’re choosing sedation, for our patients, and some, some of it is just kind of what’s working best for the patient. But then also, our physicians have a lot against propofol, because it can just the way it kind of affects calorie counts and nutrition for our patients.

So that is sometimes a barrier that they’re coordinating with our pharmacy and our critical care staff. As far as, as far as delirium goes, I think for all of our patients, therapy plays a huge role in that.

And we’re trying to keep lights on and trying to keep patients like upright during the day, at least in chair mode. And even on our non intubated patients, I think if patients are at high risk of mobility, we’re in there all the time getting them up all the time.

And then with our family goes, we’re always we talked about early mobility this whole time, but kind of skipping over that, but trying to engage family as we can when we are mobilizing.

So like, I have a video that I can show later, but family recorded the video, and it’s as large burnt 20% year old or 20 year old kid, and he stands and he recognizes his girlfriend, and he wants to give her a hug.

So it’s I think sometimes family wants to be in the room, sometimes they don’t. So if they, if they want to be in the room, we can definitely encourage that and coordinate that. But if not, then sometimes we coordinate around.

Kali Dayton 16:59
That is difficult. I know I’ve never worked for an ICU. For any patient on a ventilator. It’s a startling sight for their families, it’s difficult, but then burns on top of it. That’s a different level of agony for the patient and the family. But how do you see families benefiting? They’re helping with the early mobility process?

Audrey O’neill, DPT 17:23
I think they can encourage patients to be awake more. So like if they’re like I can sit in front of a patient and talk to them. But they’re kind of like “Who the heck are you? And why are you in my face?” But if you have a family member who’s talking to them, often they’ll recognize their voice and like we’re trying to encourage patients to use their injured extremity.

So though, they’re want to reach for family members or kind of even try to hold their hands or something. So I think for families, it can be encouraging to see their loved ones doing real life activities that are not just lying in a bed, especially when they almost like can’t even recognize their loved one because of their injury and the dressings that are in place.

And then, but like you said, it can be scary and it can be intimidating for for family members to see just because they’re even scared to touch their their loved one at that point, let alone see them sitting up standing or doing anything active.

Kali Dayton 18:26
Right. And just out of my own curiosity, what do you see as far as family involvement and pain management? Does it impact the level of opioids given? I don’t know Do you know?

Audrey O’neill, DPT 18:39
Sometimes, sometimes we i i tried to avoid the the therapy sessions and the interventions that would involve a lot of pretty heavy like grimacing and like signs of pain with families there. But sometimes family can request more.

They feel like their loved one is uncomfortable for any reason, they might ask the nurse about pain meds, and our nurses are always checking and things are scheduled. And we they’re trying to stay on top of it as much as we can.

But we have conversations with family early on about kind of what we’re doing, why we’re doing it because they’ll come in and we’ll see them positioned and all these crazy positions and with the splints on and hip abduction, watch wedges holding their shoulders up or something strange.

And just explaining kind of that we want them to be able to use their burned extremities once they’re healed, and once they’re out of here and why the positioning and the stretching that we’re doing how that plays a role in the long term.

And they’re generally supportive of that because they talk about kind of what their loved ones hobbies were, what they would want to get back to. And so if we’re doing something that’s painful, generally, the family might chime in and encourage their loved ones saying If this is going to help you do this task later and kind of reminds me of that, too.

Kali Dayton 20:05
I love that. That has to be a such a difficult journey to be stuck in bed, and in so much pain, unable to move. It just sounds horrific, but your role, and moving that forward to getting them out of there and getting them back to their lives is pivotal.

And I love that you’re, you are part of the ICU team. You’re not just visiting the ICU, you are in the ICU, and you’re helping keep everyone focused on the overall goal and integrating the family even more into that journey. That is so key. And how do you feel like you work with nursing to manage sedation practices when it comes to early mobility?

Audrey O’neill, DPT 20:51
Like I said, the coordinating with kind of around when the nurses are going to need the sedating medicine to like do our therapy. Because our nurses are with the patients every day for weeks, months. And so they see what we do, and they can see the benefit and and they support our efforts.

So they and they know I guess we’re working together like we respect them and what they’re trying to do with their dressing changes and will often is that we know they need to do something will help.

Like we won’t just say like, “Okay, the patient’s had….we’re getting ready to mobilize them to but they’ve had a bowel movement in the bed. You go in there and take care of that. And we’ll be back to get them up later.”

No, we coordinate and we like help with those things. Their tasks, too. So they, they see that and appreciate it. And often we have some nurses who are in there participating in our mobilization sessions and are they’re doing linen changes while we’re standing or they’re doing…. so they’ll coordinate around that too.

But I think sometimes nurses are, if we have titrated sedation, they’re nervous to turn it down. If especially especially as the patient has been restless, but I think we’ve seen enough that sometimes patients are restless because they want to move, and they maybe have that pain and they don’t want to be stuck in the bed.

And so sometimes the nurses are like, “Yes, they’re itching to move! please go in there!” They’ll help titrate down their sedation, and we’ve had patients who are almost like completely sleeping in the bed, can’t get them to do anything. Sedation has titrated down and in five minutes they’re like dancing to Dr. Dre or something like that whenever we’re mobilizing them. So it can make a huge difference in our nurses see that. I love that.

Kali Dayton 22:18
there’s a saying in the Awake and Walking ICU, from a doctor Bill Benenati. He says “Walk when wild, walk when sluggish.” And that’s what you’ve just demonstrated that when they’re agitated, you mobilize them.

When they’re you said sleeping or they have hypoactive delirium, they’re kind of sluggish. It is amazing what happens during mobility. Patients that can barely open their eyes, you get them dangling, definitely they’re looking you in the eyes, they’re following commands, or dancing!

It is amazing what that stimulation can do and how much it helps with their delirium. And what are some of the risk factors that are especially high in your unit for the development of delirium?

Audrey O’neill, DPT 23:27
i Are we are very high as far as like the our unit in general as high risk for delirium. And again, even in our intubated patients and our non intubated patients. And a lot of times when our patients are extubated and are waking up more after their surgeries, they’re, they almost present somewhat like traumatic brain injuries just from the delirium in my persons, the cognitive deficits that they see initially.

And I would say just the the dressing changes the need for constant pain medication, multiple surgeries, that they’re undergoing periods of immobilization from not only are they stuck in bed longer, even if we’re trying our best to mobilize them as much as we can.

But we’re putting on splints and positioning. So they’re not really even able to, at times, like shift around and in bed the way a normal general ICU patient would be.

Kali Dayton 24:32
No, yeah, your risk factors are tremendous. Do you know what your delirium rates are?

Audrey O’neill, DPT 24:40
I do not actually, but we are we’re actually doing an internal study on that kind of right now too, because our hospital has a post ICU clinic that kind of manages our general ICU and we can send our burn patients to them as well.

But just outcomes anyone admitted to the ICU can follow up in this clinic, and they look for kind of those long term effects of the PICS syndrome and including delirium. And so we’re starting a, we’re looking at delirium at discharge and kind of how that’s progressing and outpatient initiate referrals for speech therapy, to work on cognitive tools.

Kali Dayton 25:27
I love it and the fact that there’s coordination between the post ICU clinic and the ICU, that they’re looking into what’s going on in the ICU and helping give you perspective on what happens after the ICU?

So as delirium, a frequent topic during rounds, between colleagues, is that something that people are really assessing for understanding, aware of concerned about?

Audrey O’neill, DPT 25:52
Yes, definitely. We, on our reunion, Burn Unit, we have multidisciplinary rounds three times a week, twice at patient bedside and the in the middle of the week on Wednesdays, we sit down in the conference room and go through all aspects of care.

So that’s something that we’re that the team is aware of, and assessing daily, and we’re bringing up that sometimes patients can we they maybe aren’t presenting as that they have cognitive deficits just during general assessment. But when we’re seeing them in therapy, and working longer with them, we’re seeing it more so. So we’ll bring up things that we’re seeing in our therapy sessions as well, during those conferences.

Kali Dayton 26:37
I love that. So as a nurse practitioner at the end of every shift, physical therapist comes in, or even just in the middle of the shift comes up, gives me an update, and everyone. And though I’ve done my own assessments, I’ve done all the rounds with everyone. Nurses have been talking to me, physical therapy always comes and brings this unique part of the overall picture assessment.

But their ability to identify delirium has astounded me. I’m like, “Well, I just saw a patient like two hours ago, I did a CAM”… “yeah but this gap it with his motor planning, or when I started doing more complex tasks. They really were slower than yesterday, something’s going on.”

Like it does that intuition that. But your assessment is different because you’re working so long and doing different kinds of tasks with them than I did as an NP or even as a nurse. So I think that’s really key that PTs be involved in that delirium assessment and intervention.

That’s a big part, I think we’re missing in a lot of ICUs. So it’s fun to hear your experiences with that. If you could wave a magical wand and have more patience, even during some of the higher acuity phases, mobilized. How would you approach that? It’s a tricky question.

If you could wave a magical wand and address some of these barriers? How would you? Do you think you could improve even more in early mobility, or get more patients doing more progressive mobility?

Audrey O’neill, DPT 28:20
I definitely think we could. I think, even though we are aggressive when it comes to mobility, and we do coordinate. Sometimes, we were still limited by staff constraints. And just overall timing.

And if we have multiple large burns on our unit, at the same time, they take a lot of resources. So it can be because even though mobility is a priority, the preventing the burn scar contractures is our number one priority.

So sometimes we have to devote more time to that than we necessarily kind of include in the mobility progression. So I definitely think having more staff more time more, would definitely help us improve kind of access to some of the patients as much as we would like to.

Kali Dayton 29:17
I love it. No, that’s a great that. Yeah, that’s a great answer. I think some of the most progressive teams I’ve interacted with are those that are looking for room for improvement.

Ironically, some of the teams that have the most dated protocols or practices are those that say, “We’re doing the best we can this is as good as it gets”, or “We’ve always done it this way, or this is the way it’s done.”

So I think just that mentality of saying there could be more done. And here are the barriers is a sign of a team and a clinician that is always striving to practice evidence based medicine. I’m sure that’s why your team is so progressive. It’s because we have great leaders like you. And what did you find in your public occasion, what was your conclusion? after scouring years of records?

Audrey O’neill, DPT 30:05
So our main conclusion was that it that were more limited than general ICU studies, that early mobility with burn patients is feasible, and it’s safe and it can be done, which is, again, that’s something that had been really looked at for specifically to find, like vented burn patients.

And that, again, again, we were just wanting to look at kind of how we were utilizing our protocol. So we were utilizing them. We were facing barriers, but we were just more limited. So I think we needed to look at more data. So I think we’re we’ve definitely changed our line protocol.

So we’re looking at how that has affected our mobility outcomes now and the patients we’ve been able to progress so and I can tell you, it’s led to a lot more active treatment with our patients with Lyme. So definitely excited to hopefully come out with that in the next in the next year.

Yeah, definitely, I think any performance improvement projects that a team can do, just looking back retrospectively reviewing your own work and your own charts is the best way to start.

Kali Dayton 31:18
That is such a powerful example. And the fact that you use this not just for publication, but for action, that you then change practices, and then you’re gonna reevaluate that is so powerful and as physical therapists, you are so needed in the ICU and you are saving lives. And thank you for your incredible example. And as you come up with more findings within the burn realm, please keep us posted. We’ll have you back on. Okay, perfect. Thank you. Thank you.

Transcribed by https://otter.ai

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