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When all you’ve ever known is walking patients on ventilators, what is it like to enter a time machine and go back to sedation and immobility? What did Tara learn taking care of COVID19 patients outside of her “Awake and Walking ICU”? She shares with us her reaffirmed empowerment to change patients’ outcomes through evidence-based practice.

 

Episode Transcription

Kali Dayton 0:29
Hey, everybody, I am hearing from listeners that they are woken, moved, inspired and simultaneously weighed down by the podcast. They report that now it is hard to go back to work and see all of the sedated patients on the unit now knowing what they are really experiencing and what their journeys will be like, I am touched by the depth of compassion and tenderness of all of you.

I do this podcast because I know human suffering matters so deeply to you get this podcast is not meant to inflict shame or guilt. Yes, we have to face the reality of where we are at and the harm we are doing. As Dr. Edna said, “You cannot correct what you are not willing to confront.” Yes, if you have a soul, it will hurt to see patients perspectives. Yet, embrace that pain, but use it to turn your vision forward to what can and should be. Use this indignation to inspire others and bring change.

I have seen many comments on social media saying, “I would love to work in this ICU!”. Of course, I am biased but the team members of the Awake and Walking ICU are exemplary. But I have the deepest conviction that the standard of care is replicable in any team that is willing to change to save lives. We need pioneers in ICU around the world that have this perspective of patient care to create their own awake and walking ICU exactly where they currently are. This is not about any specific hospital, it is about a process of care outcomes and standard of care should not vary so drastically between hospitals, And yet they do.

Tara nurse from the “Awake and Walking ICU” shares with us what she learned while taking a travel contract outside of her home ICU. Tara, thanks so much for coming on with us and being willing to share your insights with us. Can you tell us about your background?

Tara 2:28
Yeah, so I’ve worked in the awaken walking ICU for about five years now as a nurse, and I recently took a travel contract as a nurse during COVID. Two. So I’ve had experience in an awakened walking ICU and then an all in an ICU that uses more sedation, and most patients are up and moving either.

Kali Dayton 2:50
So what was it like? Especially did you start your critical care experience in the awake and walking ICU? I did. I started there as a new grad. Yep, same here, or that was my first critical care job. And so that became normal. And so what what is it like to work in an Awake and Walking ICU?

Tara 3:10
Um, it’s, I feel like, you get to build a lot stronger relationships with patients because they’re awake, they’re moving, and you’re able to help them through a really difficult time in their life. And like opposed to working with patients who are sedated. Like I feel like it’s kind of easy to lose the humanity in that situation, because it feels more like you’re taking care of somebody hooked up to machines versus when someone’s not sedated.

You can interact with them, you know them, you know, what they’re going through, they can share their emotions in their thoughts. So I feel like it’s actually really strengthens my ability to be compassionate and care for others, and relate to what they’re going through with patients and stuff like that, like within an Awake and Walking ICU. I feel like your teamwork becomes so much stronger, because you’re all like, it takes a lot of teamwork to get patients up and moving. So I feel like your relationship with your co workers becomes a lot stronger because you rely on each other to improve patient outcomes.

Kali Dayton 4:10
Yeah, that’s a really good point. Yeah, it’s not one person can bring all of this change or maintain this culture. And that’s what I love about this ICU is everyone has the same vision. Everyone’s going to get their patients up, and they’re all going to help you get yours up. And so that was that is the standard in the wake and walking ICU. Right? How often have you had sedated patients in that ICU?

Tara 4:36
Um, before COVID, I would say, oh, goodness, like, once every couple of months. I take not more than 10 patients every year prior and for a very unique exceptions, right? Yes, it’s usually with with ARDS is what it was before,

Kali Dayton 4:55
Once they were prone and paralyzed. Right. Yeah. So how has it been with COVID? How often are you having patients be awake at some point on the ventilator?

Tara 5:05
I feel like all patients are awake at some point on the ventilator. Now, we do use more sedation at this point just because we are having more ARDS patients. But compared to like what I was working with on my travel assignment, we’re not sedating nearly as much as other facilities.

Kali Dayton 5:25
Were you there with Kenneth Hurwitz?

Tara 5:28
Yes, I was.

Kali Dayton 5:29
So we interviewed him a couple episodes ago. And he talked about, he doesn’t remember. But he was awake for the six days on the ventilator, and was prone and paralyzed and was down for about eight days. And then immediately once he could tolerate being supine, was back on his feet, and was extubated four days later.

Is that kind of the process that you’re seeing with patients there where they’re awake, up until that point, and then once they had to be paralyzed? They’re sedated. And then once they can be supine? They’re back rolling?

Tara 6:01
Yes, that’s actually …I had a patient this weekend. That’s exactly that patient story. They were up and walking on the ventilator for the two days that they were intubated. And then when the time came that they need to be prolonged and sedated. They did that for two days. And then as soon as we could supinate them, they were up and moving again. And then at this point, when I had them, they were like a one person assist in the room, they were almost independent, they hadn’t lost much muscle strength at all, they were just ready to go.

Kali Dayton 6:37
You know, it’s really hard. I mean, we know by research that when patients are sedated, that they lose all this muscle and their time on the ventilator is so much longer. And our, our process, it’s different even than the ABCDEF bundle. We’re a lot more aggressive with mobility. And so it’s really hard to know how much longer with a patient like that be on the ventilator? And how different their outcomes be? Because we know they’re definitely improved, drastically improved. We can the research validates it, but it doesn’t accurately reflect the magnitude of difference. It makes to have people mobilize that aggressively. Did that patient discharged home?

Tara 7:20
I believe at this point, they’re still hospitalized, just because they’re so on the ventilator. And it was just a few days ago.

Kali Dayton 7:28
So one person assist while on the ventilator?

Tara 7:30
Yes.

Kali Dayton 7:33
I just want our listeners to hear that- a one person assist. Because here I get this question all the time. Well, how many people does it take to get these people up? And I tried to reiterate the point that not that many if we catch them early. Meaning if we don’t sedate them, leave them to rot for a few weeks, then we don’t need all the lifts all the people, it’s not this huge fall risk. So you’re saying even this person had been prone and paralyzed for two days, they still were able to be one person assist after that?

Tara 8:03
Yes. And when I say one person assist, it was more of like, I was just in the room watching their ET tube and the cords while he moved around. If he hadn’t been intubated, I would have just like he would have been able to move completely by himself.

Kali Dayton 8:19
That is so great. And and he wasn’t restrained?

Tara 8:23
No, he was not.

Kali Dayton 8:24
And that’s a question I’ve gotten as well is how do you know when a patient is safe to be unrestrained.

Tara 8:32
So in my experience, what I’ve done is I make sure that the patient is completely alert and oriented, and communicative. So there’s no delirium going on. They’re very with it. They’re familiar with this, like, like the scenario in ICU and what’s going on. And I think patient education on the ET tube, and on central lines aren’t lines, anything else that the patient has been just really reinforcing what the lines there for how we need to take care of it, how to keep the patient safe, so not pulling on the ET tube, not pulling on any of your other lines, and just really setting boundaries with those things.

I think after a few days of education at that point, you can kind of evaluate if the patient’s going to be compliant with those things, and if they’re okay, to be unrestrained. And I think like when I think back to what I’ve done in the past, like, I’ll watch how the patient does while we’re doing mobility.

So if we’re dangling, I’ll watch if the patient goes for any of their lines at all. Or if we’re up and walking, I’ll see if the patient is going for anything and see if they’re following what I’ve taught them. And then sometimes I’ll just sit in the room with them for a while or while I’m like scanning medications or something. They’ll let them just be unrestrained and like do some range of motion with their arms in the bed. And then if they’re following what I’ve taught them, they’re not pulling it anything Then I’ll leave a man restrained.

And then if when they go back to sleep, if they take a nap if they go to bed for the night, usually the first night or two, I’ll leave them loosely restrained. So there’s not tired that restraints is tight. And then after a few nights, I’ve just let them be unrestrained. And they’ve done fine. I haven’t had any patients self extubate when I’ve done that.

Kali Dayton 10:26
Yeah, that’s a really good point. Not that it never happens. But the research also shows that self extubation has a strong correlation with sedation. And by sedation, I think delirium right? The sedation makes them get delirious and that’s when they get so scary as people think, well, not of my patients could be unrestrained, which if they’re delirious, they shouldn’t be. But you’re explaining this process where you are constantly assessing for delirium, and you’re preventing it. And that’s what allows them to be safe. Do you feel like they protect their tube as well?

Tara 11:03
I do. I’ve actually had some patients that I’m like, that’s the first night taking care of them. They’ll write notes to me, and they’ll say, be careful with my two. Like, they’re just so worried about it. And they’ll watch it carefully, just to make sure that I’m as careful with it as they are.

Kali Dayton 11:19
Wow. And are they scared?

Tara 11:24
Of being intubated? Or of that? Yeah,

Kali Dayton 11:26
Do they seem like they’re traumatized, or tense or the entire the whole time being on a ventilator and awake?

Tara 11:33
No, I think, I think, like taking patients that have been sedated and bringing them back, they’re kind of like a little, they feel confused. They don’t really know what’s going on, versus if a patient is awake. And they’ve been, like, they know they’ve been integrated the whole time. They’re used to it, they’re able to use, like the reasoning skills and being able to cope with having the tube in.

Kali Dayton 11:58
Yeah, yeah, beautifully put. And so spending five years in that kind of environment and taking care of patients in that way. What was it like to go as a travel nurse to a totally different environment and culture and standard of care?

Tara 12:15
Well, I was, I was a little nervous it but so I was going to wait bigger facility, like a teaching hospital that has a, like a big reputation. So I was, I was kind of curious to see how they would do with mobility and how the culture would be with it. And, and I like compared to like an awake and walking ICU and walking into this, it was just kind of, it was crazy to me how many people were sedated.

And then on top of that, how many patients ended up like with the trach, and a peg, and it was, it was just a complete culture shock for me to go from what I thought was the standard of awakened walking to a lot more people going to LTACHs and SNFs on discharge instead of being able to go back home.

Kali Dayton 13:07
And this is a facility that has a reputation for mobility, right?

Tara 13:11
Yes.

Kali Dayton 13:14
And produces a lot of really good research. And do you feel like the acuity of the patients were so much more severe that they would warrant sedation? Like, if they were in the “Awake and walking ICU”, would they still hit that threshold of max out on the ventilator settings couldn’t oxygenate with movement and therefore needed to be prone to paralyzed? Or do you feel like sedation was being put on much more liberally?

Tara 13:41
I think the sedation was put on a lot more liberally.

Kali Dayton 13:45
What did that feel like?

Tara 13:48
It felt… unnecessary, I guess is the way to say it. And it kind of felt like we were damaging patient outcomes. And I know the other people I was working with didn’t view it that way. But coming from an awake and walking ICU, to putting someone on sedation and then not being able to move them…. it was it was really hard because I knew how much we were damaging the outcomes.

Kali Dayton 14:15
And you’re used to watching people walk out of our ICU to the floor and walk themselves out the doors later to go home. And so what was going through your mind when you’re watching people get trached and pegged and be totally flacid in bed and have to go to LTACH?

Tara 14:33
It was it was kind of sad like I would I would go home and I would just it was just a complete culture shock for me. I just it just made me realize how much more important like an awake and walking ICU and how much we need to share that message with other ICUs and make that a standard of care.

Kali Dayton 14:57
I know that as a nurse I kind of thought Polly and Louise were so neurotic- which they are. Then I was a travel nurse. And I became neurotic too. So how do you think this has impacted your perspective of the big picture of critical care?

Tara 15:11
So I think it’s made me more neurotic with my patients as well. Because like, you just hear stories from patients in it like, like being sedated and not being able to move for days, they’re not able to go back to their jobs, they’re not able to go home independently. Versus if they’re awake and walking the entire time, they can almost return back to their normal life, like they’re going to some patients to return home with some deficits. But it’s just like, the difference in outcomes is amazing.

Kali Dayton 15:44
Yeah, and I like that word “neurotic”. It just makes you a really powerful advocate, when that’s how you see it, right. And our older nurses that have done this for 30 years, they’re so hardcore, I just didn’t do some amazing things. And they started to seem more and more sane to me as I saw what what the other outcomes could be if we don’t do what we do. And any specific stories or cases that you saw while you were there that impacted you.

Tara 16:21
So I was there I did ICU float pool, a lot of it ended up being in like the COVID icu just because that’s what there was a lot of at the time. So I had one patient specifically, that really stood out to me. When I had him he was on high flow. I had him for three nights in a row, and I dangled him every night. So at that point, he was strong enough to dangle with just my help, he probably could have walked, but I didn’t like none of my coworkers are available to help. And I don’t think any of them would really want to help just because that sounds bad. I don’t think they had the same push for mobility that I did. It wasn’t on their top priorities.

Kali Dayton 17:03
And maybe they wouldn’t be comfortable in high flow. And the episode previous to this, we hear from a tech that wanted to move people in high flow, but the whole unit had set the standard that no one could get out of bed if they were on high flow.

Tara 17:16
Yeah. And like coming from the awake and walking ICU to this one that everyone on high flow was was moving. It was just, it was crazy. But I would I dangled with this patient a few nights, three nights in a row and he had baseline dementia. So he was, he was I think at that point, he was already a little bit delirious, too, just because he hadn’t slept for a few nights.

But after I would help him dangle those nights, he’d like burn enough energy to finally go back to like, get some good rest for a few hours. And then so I had him those three nights in a row, I ended up caring for him in another unit A few weeks later. So at that point, he’d actually been intubated for a week in the ICU because of COVID. And then he had transferred out to another ICU. And he when I cared for him at that point, he wasn’t able to move his he wasn’t able to lift his arm or his legs or his head at all. And he was very, very delirious completely disoriented, and it was just watching how, like being sedated and immobilized for one week, the effects that had on that patient, it was shocking.

Kali Dayton 18:37
And it’s kind of haunting even to hear even though I wasn’t there at haunts me, really reminded me of a patient that we got, and there we can work in ICU that had been at another facility and had been deeply sedated for 10 days. He had baseline dementia. And so when it came to us, it was the perspective is totally different. Where it was he has dementia, so he we better take off the sedation, we better wake them up and move him.

And I’m hearing about people on high flow being on precedex. And I wonder if it’s that kind of patient that you took where he has dementia, he’s probably delirious, he probably was a lot of work to take care of right, probably move over place a little bit of a safety risk, right. So the inclination is he’s not behaving can take care of them unless he’s at least lightly sedated, even on high flow, but you allowed him to get real sleep.

But his outcomes are going to be so much harder recovering from delirium with baseline dementia is I don’t know that there isn’t really much of a recovery. And so that definitely changed his quality of life drastically for some of the demented have delirium. And I think if we all had that perspective that you did where he’s agitated, he’s uncomfortable. He’s confused. He hasn’t slept. So your answer was to move him to make him use his muscles, so he would actually rest. Did that make your shift easier after you did that?

Tara 20:11
It did. Before we would dangle, he was always pulling on his HiFlo pulling on his IVs. And then, once we were done dangling, I felt like he burned enough energy to actually relax and get some, get some good rest for a few hours. And then it would, it would start up again a little later. But I think that was just being in the ICU like you’re getting woken up every couple hours is so hard.

Kali Dayton 20:39
Yeah, you’re kind of reminds me of my approach with my toddler, right? She’s, she’s not listening to me, she’s all over the place. So I make her go and run it out.

Tara 20:49
Yes, that’s actually the same approach I use as my daughter. If she’s been a wild woman, we go for a couple walks, and then and then she takes a nap, and we’re good.

Kali Dayton 21:00
And it makes your life as a parent easier. And I think as nurses, it can make her shift so much easier to wear people out, as well as safer. So I think yeah, that’s a very powerful example. Anything else that you saw?

Tara 21:18
There was another patient I saw that also had COVID. That’s a lot of what I worked with there, right. Um, but when I had him, he’d been hospitalized for almost three months. And at that point, he was already trached and pegged. But he was ventilator dependent and had been pretty much sedated for the whole month, but whole hospitalization for the three months, and had been on and off a few times.

But he just wasn’t like he wasn’t compliant with the vent, he would have coughing fits these, like lots of desaturations. So they just put the sedation back on. So when I took care of him, he could barely wiggle his fingers or toes. And it was, it was just really sad compared to coming from the awakened walking ICU, where we have patients that have been hospitalized for like a month at a time with COVID. But those patients were still mobile, and they were they hadn’t been sedated the entire time. So it was it was just shocking to see the difference in how COVID was being managed specifically, but also just ARDS and the standards and different cultures.

Kali Dayton 22:33
Yeah, this is a really unique time where we are all across the world, we’re treating the same disease. Granted, our baseline demographics and health status of our demographics is different from region to region. But we now have like the same disease process to compare outcomes with. And last time I checked the Awake of Walking ICU, the length of stay was 6 days shorter than all of the neighboring hospitals in that area.

Tara 23:04
That’s crazy. I didn’t know that. That’s, that’s actually…

Kali Dayton 23:09
You can see why now. Right?

Tara 23:11
Yes.

Kali Dayton 23:12
So how much does that impact hospitalization costs? Again, quality of life? Discharge disposition? How often are you guys sending patients to LTACHs after COVID?

Tara 23:25
Very rarely,

Kali Dayton 23:26
Have you seen anyone go yet?

Tara 23:29
Um, we had one patient, that should have gone to an LTACH, But there were a lot of complicating factors. But throughout the whole year of COVID, I think the one patient I’ve seen that’s pretty crazy compared to other places where there’s a lot more patients going out to LTACHs.

Kali Dayton 23:50
You had to think about it, you had to reflect on that one patient throughout all your time. And elsewhere, it’s just assumed, right? If you come to the ICU, you’re going to LTACH. So can even compared to hospitals in that same region, and they’re good hospitals doing good things. But this element is this culture changes outcomes drastically. And I appreciate your perspective on that.

Now that you’ve seen it both ways, and you went to a good hospital with a good reputation, and yet, maybe not the strongest mobility culture. And on Instagram I was taught kind of did a quiz with the followers. And we talked about how the first study that came out was from Polly Bailey, your nurse practitioner, right and then your unit published a study that showed that walking them until they’re safe and feasible. That was first published in 2007. After they had already been doing this process for years, and here we are in 2021 and You can go to any other facility and be shocked by the culture and the standard of care and outcomes.

Tara 25:05
So I actually, for my bachelor’s degree actually wrote a paper on the mobility protocol, specifically related to like related to Polly’s paper. And it was just crazy because my professor wrote to me, she’s like, “This papers like a few years old, and I’ve never heard of this.” And I was like, “Well, it’s a standard here. We do it all the time.” But it was it was really interesting to share that perspective with all my my classmates.

Kali Dayton 25:35
Yeah, I was astonished at some of the answers when I asked- Does sedation prevent or cause PTSD? Do benzodiazipines prevent or create more self-extubations and about 25 to 35% of the answers were wrong, which actually is better than expected. But it’s still a little bit disheartening that we have so much misinformation, and so many myths in our community still. Yet everyone wants to do the right thing. And once we disseminate this powerful research that’s been going on for decades, then things will start to change. And hopefully, just as you go to a hospital, and you can expect the same antibiotics to be given a certain base of pressors to be standard standardize, someday, or mobility will also be standardized, and there won’t be any more huge shocks, hopefully.

Tara 26:25
hopefully, yeah.

Kali Dayton 26:27
What anything else you would share the ICU community?

Tara 26:31
Um, I think I just, I just want to tell the other nurses out there who work in ICUs, just how important mobilization is, and how drastic of an effect it can have on patient outcomes. like. Especially on their ability to be able to return home someday and be able to go back to work, it’s just laying in bed for weeks at a time, it’s so hard to recover from versus if you’re up and moving. During all of that. It’s just I know, for me, if I was hospitalized, I’d want to be up and moving, started, be able to come home, go back to work, take care of my little girl. And I think if I had those things taken away from me, it would be horrible. And I just feel so much compassion for patients who have gone through that.

What I want to share it just, I just really wish that an Awake and Walking ICU would become the standard everywhere. And I do understand like how difficult changing a culture can be in other units. And people will look at mobility and say, “well, that’s just another thing I have to do on my shift. I don’t have time for that.” But if you put in the effort and keep your patient moving, when they can already move when they are admitted, then you’re it’s not going to be as hard to move them the rest of the time, it becomes easier because you don’t have to take four or five people to just get them in a lift and up to a chair. It’s just 30 moving, they don’t lose any of that function. They’re just, it just makes it so much easier.

Kali Dayton 28:06
I love it. And you do it. You’ve done it for years. And so when anyone tries to dispute whether or not it’s possible or doable, you have a powerful testimonial to that and I’m so grateful that you’re willing to share that with us.

Transcribed by https://otter.ai

 

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