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What specific approaches help rally the troops to bring change to the ICU? How have other PICU teams cultivated a rich culture of mobility? When an interdisciplinary approach becomes the culture of the PICU, what happens to patient outcomes? Erin Gates, DPT and Sara Eilerman, DPT share with us the PICU UP! culture and practices they have led their team to develop.
Episode Transcription
Kali Dayton 0:29
All right, in case you were still doubting whether or not children can or should be spared from deep sedation and immobility. Today, we have Aaron gates and Sarah Ellerman. For a pediatric physical therapist from a team in Ohio. We are so grateful for incredible pediatric teams that are willing to dream and work so hard to improve outcomes for our children. Sarah, Erin, I am so excited to have you guys on will you introduce yourself?
Erin Gates, DPT 0:57
Yes, I am. Erin. I am a pediatric physical therapist and I have been in the field now for about eight years. And I’m here with my partner Sarah.
Sara Eilerman 1:09
And I’m Farah and I am also a pediatric physical therapist and I have worked in the hospital for 12 years.
Kali Dayton 1:17
And so tell me about kind of what specialty you guys work in and what your role in the ICU team is.
Erin 1:25
We are both pretty passionate about working in our ICUs. We both work in our regular PICU as well as our specific cardiothoracic ICU. And our role within the early mobilization team is working as physical therapists to help coordinate early mobility throughout the day.
Kali Dayton 1:44
And so what was the culture? Like, let’s say at the beginning of your careers, you guys have been doing this for a while? What was it like before and what evolution have you witnessed throughout the years?
Sara Eilerman 1:54
So before we started our early mobility program, a lot of our patients I think, like the same as in a lot of other institutions are patients were sedated and in bed when they were in the ICU. And therapy was really just range of motion and positioning. And then once patients were out of the ICU is when we really started moving. Since we have started our early mobility program, there have been many more patients who are getting up and moving now while they’re still in the ICU.
Kali Dayton 2:27
How does this come about? What brought the change?
Erin Gates, DPT 2:31
We were noticing a change in the landscape of the adult literature. So we were seeing a lot of this early mobility success, both, you know, hearing it anecdotally through people that we knew in the field, as well as reading it in the literature. So for us, we thought, you know, why not? Why not in peds, we see these kids, and we’re seeing this prolonged length of stays.
And we’re seeing how hard it is to rehab them back and the deconditioning. And, you know, we’re recommending inpatient rehab for them or even outpatient therapies. So we’re like, you know, why can’t we start this earlier, like in adults? So we thought at that point to, you know, can we get a champion behind us? Can we get physician support?
What we were able to do, you know, we were able to show that literature specifically to our cardiothoracic ICU, they were really progressive. And they were ready to jump on board with us. So we got a physician champion. And we worked on establishing some guidelines, and we really put it forward to try to make it culture and that CICU first to create some buy in.
And we were we were there for a year we got we were very successful. We got kids moving early and often. And nurses were kind of taking that over being able to facilitate mobility outside of therapy times, which was great. And at the end of all of that we got some great outcomes.
You know, we got shorter ICU length of stay shorter overall length of stay shorter time intubated, and we were seeing a decrease in our outpatient therapy referrals, which was great. So we were able to kind of mitigate those effects of bedrest, while they were here with us. So that way, we didn’t have to necessarily get them referred as outpatients, which was wonderful.
Kali Dayton 4:03
That is so powerful, and how are you tracking your data?
Erin Gates, DPT 4:08
Well, we have a lot of data coming in, we actually as therapists ourselves, we fill in our flow sheets, every time we see a patient, as well as we have just our conglomerate of data hospital wide, that we’re able to access through our IRB that we have.
And then we also are able to just kind of look at general nursing data. So our patients moving outside of therapy times they track that every hour or every two hours depending on the ICU. So that way we can see the kids are actually getting up during those times not not just in therapy.
Kali Dayton 4:38
And what what facilitated or what sparked that nursing buy-in?
Sara Eilerman 4:41
I feel like that was probably one of our biggest challenges was to really show them the evidence and the changes we were making. Like Erin said, our CT ICU was much more progressive than our normal pediatric ICU and those nurses were very on board with let’s get up let’s get moving.
Then we’re going to do developmental activities during the day, we’re going to let parents be involved in holds and do kangaroo care. So I think once we got nurses on board in the cardiothoracic ICU, we could really show our nurses in the PICU, this can be done and it can be safe.
We started sending out like a weekly email with like, early mobility wins and calling out like the great things we were doing putting pictures in when parents said it was okay. And I think those stories, and really hearing like what could be successful and what was going well was super helpful, and making our whole program successful.
Kali Dayton 5:35
I like that. Like specific stories, real life application, not just these big, broad concepts with no educational support as to how to do it. So on that note, what kind of case studies could you give us or what success stories have made your jaws drop?
Erin Gates, DPT 5:53
We had a lot of good success stories, a lot of really individual wins when you are in a room with a patient. And you know, we’re sitting them up, well intubated, and we get grandma on FaceTime, and she’s able to sing her favorite song to a patient.
Or, you know, we are sitting up or getting to mom’s lap and able to do someone’s hair, you know, a toddler’s hair and get them into those pigtails that we want to get done. Because they’ve been on bed rest for a few days. Or those big wins when we’re getting these babies up to parents arms, specifically to mom’s arms, as soon as she gets to the hospital for the first time. Those are some of our really, really big wins for our little ones.
Sara Eilerman 6:33
I think, for some are more critical patients eating even like letting parents hold babies who are on ECMO, who are on like these higher levels of support. So it’s really hard, I think, for parents to feel involved with those patients. So as long as they can hold and cuddle or even lay beside them, and then I think those are big wins for parents. And it’s important that they feel more involved and that they can still be a parent, even when their child was really sick.
Kali Dayton 6:59
Absolutely, I’m kind of in and out of the hospital with my daughter all the time right now. I sleep in the crib with her. And I just I get emotional, just trying to think of her being on a ventilator and not even like opening your eyes or connecting with me, that would be super traumatizing for me.
Even when she’s sick, and she’s not herself. We just miss her being herself. So I’m sure it’s extremely therapeutic for everyone involved. But especially for kids, when the kids go days without being held or touched or cuddled or hearing voices, how have your sedation practices changed in order to facilitate that kind of connection?
Erin Gates, DPT 7:37
That’s a great question. And as, as the program is continuing to evolve, we definitely see some more changes and some more progressive sedation changes, it still is kind of dependent. Sometimes we’re have some kids that are definitely really awake or you know, at least able to participate. And then there’s still those some kids that they definitely want to use some sedation for safety, but for these kids that we can, you know, talk to and say, “hey, you know, you have that tube in your mouth, let’s make sure we don’t pull that.”
Parents are at bedside and we can interact with them. It’s been really, really successful to keep them awake, especially when they can see the kid is calm and clean and able to communicate. You know, recently I had a little one who was communicating via signing. And to continue that communication. You know, Mom asked, you know, “Can we decrease that sedation?”- and it happened and that little one was able to stay awake and communicate via signing the entire time. And that was wonderful and super cathartic for mom and super cathartic for the little one, which was great.
Kali Dayton 8:36
I know the adults when you went down sedation, you see this crazy agitation and just pure terror. Do you see that in kids as well, when I’ve been sedated and you take on sedation? Does delirium look the same like that with kids?
Sara Eilerman 8:48
I think for a lot of our kids, yes, it kind of does look the same. I think where it’s better for us, though, is that kids find a lot of comfort, especially for the little ones being held by their parents. So being then being able to get up and even just something as simple as being held in the chair for two hours seems to do wonders for our kids who are kind of coming off at sedation or having a little bit of delirium.
But like, like mom and dad are something that’s very constant and that is just super calming for them. They can keep them in a safe space and kind of try to work through some of that coming off of sedation.
Erin Gates, DPT 9:22
One of our most important things with early mobilization when we start to educate families, you know, when we first get in those rooms is delirium prevention and providing reorientation and familiar items from home and working on that from the beginning step one.
So that way we can have parents feel autonomous, to get up to that bedside and say, you know, you are safe. I am here with you here is Blinky, or here is your favorite stuffed animal. And that just provides that extra little bit of cramming to have those parents they’re unable to do that, which is really great.
Kali Dayton 9:53
Yeah, and there’s so many, obviously parallels to adults. When they’re under sedation survivors. We talked about the feelings of isolation and loneliness and fear and just lack of connection. And I just, it mortifies me to think of kids exploring that experiencing that for prolonged amounts of time.
And that’s got to be a huge catalyst for PTSD, no matter how vivid or explicit, their hallucinations are just those feelings of isolation are really damaging to kids. How often do you have parents advocating to have sedation decreased, or having nurses be eager to get sedation off?
Sara Eilerman 10:31
I feel like more recently, we’ve had more parents asking not to use as much sedation so that the children are more awake and are able to participate more in play and communication and things of that nature. I definitely feel like over the past year or so we’ve seen more parents advocating for that.
Kali Dayton 10:48
From the education?
Sara Eilerman 10:51
I like to think yes, education that we provide. But we also know that there’s so much more research out there, even if it is mostly in adults, and everybody likes to look things up on Google. So maybe parents are even kind of doing a little bit of their own research to when seeing what’s best for their child while they’re in this critical state. That’s great.
Erin Gates, DPT 11:12
Yeah, in the beginning with our especially for our little ones we really tried to advocate for when we go in and see these little ones during care times. So those are the times we know they get the most agitated and the most frustrated when they’re getting on swaddled.
So we really try to educate those families on you know, you can be that calming force during care times you can provide this containment opportunity or you know, this way to keep them calm, and keep them involved in their child’s care in a safe way. But still, then we see that possible decrease in sedation, because they won’t have to give that extra bolus during that care time.
You know, do can we have a parent or a therapist keep them calm during that time? And that has been a really successful thing that we’ve seen for really, really young ones.
Kali Dayton 11:52
And boy, I just…. the exchange is so impactful. And just imagining trading off actually human connection connection for sedation is really exchanging a nonpharmacological option for post ICU dementia in a child.
I mean, you, the parents, I’m sure they don’t really understand the role that they’re playing, but they are potentially sparing their children post ICU, dementia post ICU, PTSD. I mean, that is huge for my daughter, who her cognitive function is her strongest function, right? Are you going to measure cognitive outcomes? Or what do you have down the pipeline?
Erin Gates, DPT 12:29
That’s a great question. We actually are working in our post ICU clinic right now. And originally, we were just collecting those fine and gross motor outcomes to see longitudinally, what is occurring with these kiddos that have come out of our ICU.
And now more recently, within the past six months have started to collect cognitive outcomes. So on our Bailey developmental screening test, we are looking at, you know, what is happening gross motor, fine motor, and now cognitive to see that impact and trying to get these kids as much therapy as early on and as often to try to, you know, mitigate anything that is happening long term for them.
Kali Dayton 13:03
And even if you haven’t had anything analyzed, are there any trends that you’re seeing?
Erin Gates, DPT 13:07
I haven’t seen any trends yet, just because it’s been so it’s such a short amount of time, but I am, you know, just anecdotally seeing things from especially prior to initiating or we are early mobilization, really becoming culture. We were seeing these kids that you know, needed follow up and needed, you know, how to decrease in significant decrease in speech, like, I can remember when little kiddo who definitely required a lot more sedation, or was using quite a bit of sedation.
And, had significant speech delay, and no longer was was using any words about, you know, three, four months after leaving our ICU. And so that was just such a profound story that really made us all be like, you know, we really need to mobilize more, we really need to get these kids to decrease the sedation and get them more active and participating in all of this.
Kali Dayton 13:55
Has that become part of your discussion amongst all members or disciplines at the team as far as, hey, let’s we have stations so we prevent these consequences. Is that part of the culture now part of the discussion? Is everyone aware of this?
Sara Eilerman 14:10
I think everybody’s becoming more aware of it. I think it’s been discussed much more during rounds and at the bedside for patients, I definitely think there’s always room to improve and always room to get better when it comes to helping prevent delirium in these patients.
Kali Dayton 14:28
I just always wonder if we’re really doing an adequate risk versus benefit measurement, when we don’t include all the long term repercussions. And so I’m always curious what teams are discussing when they’re discussing sedation, you know, if we increase it now, if we don’t decrease it today, what could that mean later?
I think if all members of the team understood everyone would be on board with being aggressive and getting that sedation off. What other kiddos have you seen what other success stories as far as kids that are awake, calm, walking on the ventilator or playing on the ventilator? Whatever the capacity is.
Erin Gates, DPT 15:03
I think a lot of the success that we do see is getting our kiddos with whether they’re on BIPAP or intubated and getting down to the play mat. You know, bringing in one of those typical therapy benches that you would see in a PT session and allowing them the opportunity to work on you know, sitting at the bench or pulling to stand at the bench.
Or, you know, we’re but we’re right next to the bedside next to the vent, so they can stay nice and safe, but, and then having the opportunities to have toys around them to explore and feel like just a typical play environment for them feels like a big win. We tend to utilize that a lot specifically with our toddlers. And it’s been really successful.
Kali Dayton 15:40
I think most people couldn’t even imagine that. Right, I’m sure you got some crazy looks when you propose this.
Erin Gates, DPT 15:48
Absolutely. Yeah.
Kali Dayton 15:49
A lot of terror and doubt?
Erin Gates, DPT 15:52
Yeah, I think the first step was even asking for play mats for our ICUs was just a big shock at first.
Kali Dayton 16:01
Why would you need to play mat, right?
Sara Eilerman 16:05
I think it takes a while for people to realize that like kids are still kids, even when they’re in the ICU, like they want to play, they want to have fun. If their bodies move, then they can get better rest to later. Like we all know that when we have our kids at home. So even though kids are sick, there’s still kids, and they still want to move and play and have fun.
Kali Dayton 16:25
That’s a huge coping mechanism. Right? That they need a distraction from everything that’s going on. And if they’re just laying in bed, one and delirium and having terrible hallucinations. That’s one thing, but also they’re awake, and they’re just staring at the wall and other machines and the strangers.
Like who doesn’t need a good distraction? And if you get to be on their phones, texting or watching a movie, or whatever, on the ventilator kids to be able to do their kid stuff.
Sara Eilerman 16:49
Yes, absolutely.
Kali Dayton 16:53
That’s amazing. And the first time you walked a kid on a ventilator, what was that like?
Sara Eilerman 16:58
It’s amazing to have a patient who is just got a transplant, or has been in the hospital for a while and just show them that like, even though I have this tube in my mouth, like I can still get to the edge of the bed, and I can still stand and I can do squats and I can walk down the hall.
And you know, they always get you know, an applause from the other nurses and the other physicians in the hallway, because everybody is so excited about it. So I think it’s super motivating for our patients to be able to do that.
Kali Dayton 17:25
And how has that changed that your personal fulfillment in your career, and even just the tone in the team?
Erin Gates, DPT 17:32
I think it’s given us a lot of gratification. I mean, when you can leave those rooms and you’ve seen a smile on you know, not only the kiddos face, because you know you change the course of their day, but also seeing those parents, and how you’ve allowed them the opportunity to see their kid be a kid, and give them kind of a little bit of control and such an out of control environments to give them some autonomy there.
It’s such a big game changer, and makes you feel like wow, I made a difference today. This is huge. So not only like just personal gratification in our career, but you know, seeing the growth of our program, you know, we’ve gotten a lot of acknowledgment from you know, being able to do national presentations to teach others and show that this is possible. This is a big deal. And we can do this we can change the game and peds and let these kids, let them play and let them move and do all the kids things they want to do.
Kali Dayton 18:24
Sounds like this is a future of pediatric critical care.
Erin Gates, DPT 18:29
We would like to believe so yeah.
Kali Dayton 18:32
What were you gonna say?
Sara Eilerman 18:33
I’m just gonna say in addition to what Erin said, like we love presenting and sharing everything we’re doing, but there’s nothing better than being in a room and helping a patient move who’s intubated or on ECMO?
And the parents say like, “oh, this is the first time they smiled since they’ve been here.” Like there’s nothing better than a therapist to hear that during the day like, “oh, they’re smiling like this is the best!” even though they’re working hard and even though they’re doing something that’s completely new for our staff, that’s always the best outcome.
Kali Dayton 19:03
Okay, this is why I couldn’t do pediatrics. I cry at everything. And this is hitting a spot because my daughter has had neurological changes this past week and then the past few days she started to improve. And after spending, you know, week wondering if she would be herself again, not knowing what was going on with her.
But to see her smile. It just bathed your soul with relief. Yeah, and I’m sure and I know actually parents come out with PTSD. I’ve had moments with my own daughter I had to back her she got all over said and didn’t do well with it and it whole long story, but it was I was I had to pack my own child so that was really scary. And when I passed by that room, it wasn’t in a pre op room.
We’ve had surgery since when I passed by it it just despair comes back to me. It’s an it’s a trigger. And so I just relate to that so much of seeing your child smile and having that glimmer of hope or just that connection to just knowing that they’re still there. And I imagine that’s even more so now on a ventilator, and they’re, you know, not medical, and they think that they’re, they’re fearing that their child is dying, when they get to see them smile, they get to know that they’re still there, and they’re still their child like that. I think any parent can appreciate how important that is.
Erin Gates, DPT 20:29
And that’s our goal, you know, we don’t want to the parents to feel like they’re losing their child through any of this and in making sure that they can stay, you know, as awake as they can, and alert as they can and have, you know, a normal day playing and interacting, and then, you know, a normal night’s sleep, that’s our, that’s our big goal to try to, you know, decrease that delirium, decrease that deconditioning and get these kids back to being kids as soon as possible.
Kali Dayton 20:53
And back to being themselves, they shouldn’t have brain injuries after an infection or after, you know, other complications. They shouldn’t lose the potential for the rest of their lives, because of a few weeks or a few days in the ICU. That’s a huge Well, anything else you would share with teams that want to make this change? Since this is so cutting edge in the pediatric world.
Erin Gates, DPT 21:24
is they just keep remember, you know, let kids be kids, kids are still kids, it can happen, we can make this change, you know, give it a chance. And you know, kids are, they can be reasonable, you can talk to them about, you know, what we expected them and you know, keep them engaged in toys and keep them right interacting with their families, and it is possible, and we can get these kids to move and stay awake and be safe and have success.
Kali Dayton 21:54
And I’m putting you guys on the spot. But if a pediatric ICU team wants to start this and wants to have, let’s say a webinar or presentation, would you guys be interested in doing that?
Erin 22:05
Absolutely. Always are.
Kali Dayton 22:08
Okay, well, if it’s okay, well put your contact information on the blog, any pediatric studies that are out there that you guys enjoy or appreciate and what is to keep everyone connected, so everyone can get on the same page and move forward?
Erin 22:21
That’s great. The the biggest network, we can have success with our peds, PT and acute care. I mean, that is the best thing ever. It’s such a niche. And so there’s such a need for us to all get together and work together to be successful.
Kali Dayton 22:35
Absolutely. And I think especially pediatric providers get into it because they love kids and they want to get their lives back to them. And so I think you’re gonna find a lot of people are eager to make these changes. So thanks so much, ladies.
Transcribed by https://otter.ai
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