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When physical therapists are allowed to work at the top of their licenses, how do they save lives? What barriers prevent them from fully contributing their expertise during critical illness? How is mobility a life-saving intervention? ICU Physical Therapist experts, Kenny Venere, PT, DPT, and Kyle Ridgeway, PT, DPT, CCS share with us their experiences and insights.

Episode Transcription

Kali Dayton 0:00
This episode, let’s dive deep into the finer details of mobility and the best benefits it has on patients and their outcomes. Expert physical therapists join us to share their journeys to be able to practice at the top of their license and the ICU and what that means for patients during critical illness. We have Kyle and Kenny with this. Do you mind introducing yourself? Kenny, would you go first?

Kenny Venere, PT, DPT 1:00
Sure. My name is Kenny. I’m a physical therapist. I work in a 20 bed and MC you in New York City. So it’s been a very interesting few years, graduated from Northeastern University in 2014. So starting to feel a little old but

Kali Dayton 1:20
seasoned, seasoned,

Kenny Venere, PT, DPT 1:22
seasoned. Yeah, that’s a nice way to call it. That as old as Kyle.

Kali Dayton 1:28
And Kyle, will you tell us about yourself?

Kyle Ridgeway, PT, DPT, CCS 1:29
Sure. My name is Kyle Ridgeway, physical therapy clinical specialist at University of Colorado hospital. And then do a little work with the physical therapy program in the University of Colorado School of Medicine and the physical therapy school here at the University of Colorado want you to medical campus and undergraduate work was actually in neuroscience.

And I kind of came to this space in an interesting way. When I was in physical therapy school, I vowed to never step foot in the hospital. And I was definitely afraid of them. And now I’ve spent kind of the last 13 years of my life being kind of obsessed with critical and acute care, Physical Therapy and Rehabilitation. So you know, you can get here in a lot of different ways.

Kali Dayton 2:08
And you have been such a powerful voice on Twitter advocating for physical therapies role in place in the ICU. And I’m so excited to have both of you here coming from different specialties of ICU and different cultures with an ICU teams, I am excited to hear some very specific expertise from you guys. Throughout the podcast, we talk a lot about getting physical therapy and promptly and I want to dive deeper into why exactly what you have to offer the ICU team and how you drastically improve and change outcomes.

I think, habitually sometimes the role of physical therapist has been to do passive range of motion. And I think that comes from culturally a misunderstanding of what each level of mobility does during critical illness. So do you mind breaking it down for us each level level of mobility and how that impacts patient outcomes? And what we’re working in engaging during each level?

Kenny Venere, PT, DPT 3:09
Sure, I mean, I think I’ll, I’ll talk broadly about what I think the role of a physical therapist is in an ICU and then let Kyle get into the granular aspects of, you know, positioning levels of mobility and things like that, you know, it’s something he’s very passionate about and philosophical about. But overall, I think, when we look at the A to F bundle, and you know, quality improvement projects that have gone on in literature that’s been published on this, the uptake of it is it’s difficult point, prevalence is pretty low, the actual implementation of it is difficult.

And when we think about early mobility, and the role of a physical therapist, it’s arguably the most interdependent aspect of it, right? Because if someone is deeply sedated, they’re delirious. They’re essentially in a medically induced coma, there’s probably not a whole lot we can offer them that’s, that’s valuable. You can you can do passive range of motion and things like that. But, you know, the question is, does that actually impact outcomes that hospitals are interested in from a financial and administrative standpoint, does it impact patient centered outcomes in terms of quality of life, disability, dyspnea, pain, strength, etc.

And I think that can be argued that it might not. So I think what physical therapists offer in an ICU is their kind of causative antagonists for really meticulous supportive care very judicious use of analgesia and sedation, highlighting the presence of delirium and how to manage that and maybe a non pharmacological way A you know, we’re can sometimes be very quick to go for the hell doll pushes and restraints and things like that. So I think, bigger picture what physical therapists offer is trying to facilitate that meticulous supportive care, because without that, you’re not going to be getting the patient on a ventilator up, you’re not going to be having them walk in the hallway, you’re not going to have that person on ECMO, or CRT out of bed to chair if all of that other stuff is not already in place and laid down as a foundation.

Kali Dayton 5:35
And you bring in such a unique expertise to the bedside, understanding the neuromuscular system, and how that plays into survival. Yet, you need the rest of the team to understand what you bring in order for them to open the doors to allow you to come to your job. So Kyle, what do you bring to the table? Like practically? Why? How do you I mean, can you mentioned making nurses jobs easier by helping with delirium, decreasing the need for sedation, helping get patients out of the ICU sooner, things like that? Why do your interventions work towards those goals?

Kyle Ridgeway, PT, DPT, CCS 6:13
And that’s a great question. And I think it’s something that I’ve been pondering for close to a decade now. And if you depending on the day that you get me my answer might be a little bit different. But I think, generally speaking to Kenny’s points, a thing that I brought up before is, you know, we can’t rehab uracil minus four. So it kind of there’s this, there’s this barrier of entry into rehabilitation.

And generally speaking, what the physical therapist does is, and this is idealistic, of course, is becomes a part of the multidisciplinary team to ensure that our view of a patient’s organ systems and failure is not limited from the neck, to the abdomen, right that we get. And this includes our other therapy disciplines, our speech language pathologist or occupational therapist or physiatry. colleagues as well, is really looking head to toe and across systems of a patient and saying wait a second here, we need to be concerned about the impact of critical care and critical illness on the neuromuscular system, on the cognitive system.

And then more globally speaking, outside of the body system assessment is their current and future functional state, cognitively, and physically, their ability to return back to the community, to work to take on their social roles. And I think, for listeners who want to do a deep dive on this, you know, in rehabilitation, we have this constant construct called the ICF model, the International Classification of functioning disability.

And it’s a little bit of a flip if you’re used to kind of the system’s based organ based model of viewing a person because it takes into account activities, social roles, the environment, and I think foundationally philosophically, that’s what it feels, that’s what a physical therapist or rehab professional brings to the table. But specifically, as Kenny had mentioned, I think the power is, is that physical therapists are always in order to do their job to be able to assess a patient be able to treat them to be able to progress them are kind of Kenny said, we’re positive antagonists, we’re kind of like annoying, but annoying in a way that helps drive care forward.

And I’m fairly convinced that the integration of therapists into critical care if they are practicing at a high level, and good multidisciplinary team members, much of their power is actually nudging people and being annoying enough that we do all the right things for patients. And we don’t have to short of sight on the patient. Therapists are inherently longer term thinkers, because it’s like, okay, where’s the patient? Now? Where did they come from? And where are they trying to go to?

And that lens brings a different flavor to the critical care environment, which is rightfully so very in this moment, in the second, what needs to be done, what’s good, what’s not, how do we change the dose to approach things. And so I think that’s really where a lot of the power of physical therapy and critical care comes from. But if we dive into kind of what happens at the bedside, I like to break out the concept of positioning like what position is the patient in or statically, maintaining versus active mobility and how they may have gotten to that position. And so you know, if you see a patient up in a chair, that’s great. That’s a good thing, right? You got to mechanically ventilated critically ill patient up in a chair.

There’s not a lot of people out there who’s going to say that wasn’t a success, but to induce a former guest you had on, Heidi Engel. I didn’t go as obsessed with get a body against gravity and get weight bearing right. So it was that Kenny and I going in there and deadlifting and forklifting that patient over to the chair where they contributed nothing to that. Or did that patient just walk 250 feet around the unit now they’re sitting in the chair, right and result and position, completely the same to analysis. But the patient’s participation actively what they did is completely different.

So I just like to break those things apart is that there’s the act of mobility, a patient performs the highest level of mobility that they may attain depending on the scale or where you want to measure that. And then the position that they may be at, and all those things are highly, highly important. But I think there’s something to be said for each level of mobility. And I look at it like a staircase, we all go through a mobility staircase every single day going from supine to rolling to sitting at the edge of the bed, standing, walk into your bathroom, getting dressed, going to work going up and down stairs. Well, our critically ill patients may progress through those steps of mobility and performance of mobility at different speeds.

Or they may get stuck at certain levels of mobility. And we really need to look at those playing fields as opportunities to ask, why is the person stuck at this level of mobility? And what can we do not just as rehab professionals, but as an interdisciplinary team to help get them either to the next level of mobility successfully, or address either impairments or contributions to their, you know, not being able to get past a certain state? So I mean, the easy example,

is the patient who’s stuck in bed, they haven’t even mobilized to the edge of the bed. Well, is that a physiologic problem, right? I mean, I can understandably agree that the patient who’s on fit of 100%, and a peep of 47, probably doesn’t need to mobilize to the edge of the bed right this second. But maybe it’s a sedation issue, you know, if I think of that RASS of minus four, if the patient is physiologically stable, but hasn’t been awoken?

Well, we need to address that so that we can get to this next level of mobility. But then there’s all the neuromuscular cognitive sequelae that may contribute to their inability to progress, as well. So I’ll pause there for a sec, because I know we do want to jump into some specific impacts on respiratory physiology or respiratory benefits of mobility but just see if you are Kenny have reactions or want to sharpen that up.

Kali Dayton 12:06
No, I love where you’re headed. I, I just I’m thinking a lot of responses that I’ve gotten have been, we can’t do early mobility, because we don’t have enough lifts. And my response, at least coming from an MS ICU, COVID. ICU is, if you do it early, if you do it right, you don’t need to have a list. Um, if we do it promptly. And we do X actual active mobility, patients should maintain the function to be able to get themselves out of bed and like you said, do a lap around the unit and then sit in a chair. So I really appreciate that. That definition, I think getting into a chair is a really good initial step. But that shouldn’t be our ultimate goal, which I think needs to change in some of our definitions, early mobility.

Kenny Venere, PT, DPT 12:51
Yeah, I mean, I think you can get as granular as you want with him in terms of Kyle’s example of, you know, are they not getting to the edge of bed because they’re sedated, right? Like I think physical therapists can offer a unique perspective to a patient’s physiology, their pathophysiology. I think, Kyle and I joke about patients failing the PT test, right, so someone’s, you know, AFib RVR, as well control to at rest, and then all of a sudden, you sit them at the edge of the bed and their rates and you know, the 160s and the PA has to come in and maybe adjust their amnio drip and things like that.

I think you can get some interesting, maybe prognostic information from how people are performing during some of this stuff. You know, a patient who gets up in maybe walks or gets out of bed to chair and their their maps above 65. The whole time their blood pressure is solid, their respiratory rates, good. They don’t desaturate anything like that. And then the next day, you know, “they they kind of dipped down into the mid 80s there and we had to we had to bump up their Fi02” to “they got they got pretty hypotensive”.

I think that offers a lot of valuable information to our ICU team members because it gives a picture of how that patient’s physiology is tolerating demand demands that mimic real life activities demands that mimic what the patient is going to be doing on the floors because sometimes they look really great in the bed and they might go to the step down unit or they might go to the med surg floor and all of a sudden, you know, they go to the commode and they sink up highs or their their rate and rhythm gets really terrible. So I think we we uncover a lot of things that might be going on beneath the surface there that you don’t necessarily get when they are completely supine in NERT inactive.

Kali Dayton 14:54
I think something that the rest of the ICT needs to understand and appreciate is your expert He’s in your ability to assess patients, for these changes, and for their safety and their stability, I think there needs to be an increased level of trust. I think sometimes nurses are so afraid to mobilize patients on mechanical ventilation. And all they’ve really seen our physical therapists who in passive, passive range of motion, that they don’t appreciate their ability to assess whether or not a patient is physiologically stable enough to mobilize, and that they can assess and keep them safe each step of the process.

So instead of blocking the doorway, saying, I don’t think they should today, why not let the physical therapists go in, assess, give feedback, start initiating mobility and keep assessing, we need to be able to trust each other, to be able to progress and work towards that. But I think part of that is because we don’t understand what we’re working towards, we don’t understand what you can do, what you’re doing and why you’re doing it, and why it’s so important to do so quickly. And so therefore, it gets put on the back burner, and it has a lot of fear instilled into it.

And just, I think, a lot of lack of understanding and lack of trust. But I have so much respect for a physical therapist, I think you’re demonstrating that you are highly knowledgeable, extremely safe to handle patients, even as high acuity ease, and that you’re aware of any changes that happen and you know how to respond and defuse any kind of changes that could happen during mobility, which those occurrences are less than 1%. But nonetheless, you’re qualified to respond to those. And so I think physical therapists should be able to go in and do an assessment and be heard and have a say in whether or not a patient is appropriate to mobilize.

Kyle Ridgeway, PT, DPT, CCS 16:43
Yeah, I think what you’re speaking to is probably kind of the ground floor of anything that we do in critical care, which is, it’s a team sport, which is an easy thing to say, we need to have a multimillionaire disciplinary team, which is, you know, a great thing to sit at an administrative table and you know, come up with an action plan. But when we really get down into the work is something you mentioned is I think, just has to be there. And that’s trust, you know, trust is the foundation to high level teamwork.

And I think, something to explore here that I do want to bring up is that I am completely sensitive to a nurse who has either had a bad experience in the past with maybe a physical therapist, or maybe just trying to move a sick patient in general, or is a little skeptical, because they don’t have a relationship with this specific physical therapist. And I’m completely sensitive and understand that, that you know, as a bedside nurse, you know, you are the tollgate into the room, and You are the protector of that patient. And that is absolutely the role of the nurse.

And we should absolutely respect that. And I think the flip side of that is is that, you know, unfortunately, probably the range or the variance in training and skill set of a physical therapist in any given facility or especially across the country is so variable, that, that almost has to be assessed and as you know, unit to unit hospital to hospital, you know, around the country situation where you know, I can see two kind of opposite poles where you take a really expert, acute critical care physical therapist, and you put them with a, you know, a more novice nurse and the physical therapist is really coaching up training up that nurse and saying, hey, you know what?

“I know they’re on 70% and a peep of 12. But their ventilator settings have gotten better over the past day imaging works better labs are looking good. They’re off of their vasopressors I see their blood pressure is very stable ventilator synchrony, looks good saturations, blood gas looks great. I talked to the team earlier. And they do want to do a spontaneous awakening trial today. So why don’t I go in there with you and I’ll kind of show you what I’m going to assess. And we can kind of wake this patient up together. And I’m going to assess their strength and cognition in supine. And then if that looks good, we’ll sit them to the edge of the bed and see how it goes.”

So that’s an expert physical therapist helping kind of build trust and illustrate and explain and educate in real time. Now the flip side is also true and this is this is how I back in the day when I was not an expert was the expert ICU nurse saying Kyle Don’t worry about the systolic of 87 their map is that goal I promise you it’s okay. Why don’t we sit them up they’re strong you know that they’re okay I’m right here if we need to titrate their pressors just a little bit it’s all good okay, there’s no reason that you should not see this new oh you know, heart that this case example is a heart transplant that you shouldn’t see this heart transplant patient like come in let me explain this to you.

And so depending on the unit, you can kind of have different levels of expertise and but and the only reason I bring that up and I’m inducing kind of one of the the godmothers in our profession Chris perm here is she is very Are you very stringent about, you know, yes, we have good research to support the feasibility and potential impact of this stuff, we have good kind of program and research that shows that physical therapists can do this, they can do it at a high level. But then the but there is always in a highly trained, supportive, well functioning team.

And so the thing that I hear her bring up, and the joke I always use is, you don’t just take a physical therapist and have an army crawl under the current into an ICU bed and say, Go get some, we’ll see what happens. And the reason that I say that is, you know, you if you put the wrong physical therapist in the wrong unit at the wrong time, that can actually really burn a lot of trust and things. But the flip side of that is, is that sometimes, myself, my physical therapy colleagues, we need the training, and the support of the expert, critical care team to know, hey, you know what, it is safe. And we’re right here. What do you think?

Let’s try this, let me know what you think. And so that dialogue, that conversation, I think, is just vital, vitally important, and is really the predicate to anything that we’re going to do successfully and critical care. So that’s very much off the reservation, but I wanted to throw that out to the community and make sure that we address those important points.

Kali Dayton 21:14
Oh, is such an important point. And I think a lot of that culture is cultivated by knowledge and experience that comes from a nurse understanding that they desperately need physical therapy, and physical therapy, understanding that this is an ICU and that there are unstable patients and that they need to collaborate with nurses to know that everyone’s comfortable moving forward to that patient. What do you wish nurses or in the rest of the ICU team?

Physicians and PAs, NPs, nurses, RT’s What do you wish they understood about early mobility, the neuromuscular system, especially the muscles role in the respiratory system, during critical illness, what will help us fill that desperation for your presence and involvement during critical illness?

Kenny Venere, PT, DPT 22:02
I think one of the things that I always think about, you know, I’m fortunate in that I’m in a small hospital, that’s a part of a larger academic system. So we get to, we get to see some interesting stuff. But I also get to know pretty much all of my co workers, nurses, physicians, pas, on a relatively personal level, as opposed to a massive kind of academic hospital where there’s a lot of rotations of physicians and pas and nurses and things like that.

One of the things that I always, you know, think about is that I’m fortunate to be in a role where I get to follow a patient from their ICU stay to their their floor stay ultimately to their discharge. And I think what gets lost a lot of times in our ICU colleagues, is just how much their ICU stay affects everything that comes after. Because obviously, when when we have this critically ill patient, we’re concerned about mortality, right?

All of the the critical care trials, the big outcome is mortality, mortality, mortality, and that’s obviously important, right? But we have this idea of, you know, fates worse than death. And they’ve looked at stuff like this and thinking about JAMA Internal Medicine article that surveyed patients who survived serious illness and they looked at things like bowel and bladder, incontinence can’t get out of bed, I’m relying on a feeding tube or a breathing tube and stuff like that.

And, you know, over half of those those people surveyed described those certain things as a fate worse than death. And so I think if we were more conscious of what certain things that we do as critical care clinicians that we think are important, you know, keeping people really deeply sedated because it’s very uncomfortable to be on a, a ventilator, or not thinking of delirium as this this serious acute brain dysfunction but rather like a typical consequence of critical care and like pleasant confusion or hypoactive delirium being described as just someone sleeping.

I think if more critical care clinicians were stuck in the weeds thought to see what happens after that patient gets off the ventilator after 30 days where they were on a paralytic for 10 of it and they were deeply sedated and they were preowned. And they couldn’t run tube feeds for a while and they lost 20% of their body mass to see what happens a week after they leave the ICU 12 months after the ICU five years after that. I see you and we have good data that these people really suffer and I think if we had first hand experience with that, people would maybe be a little bit more calm. bunches judicious of certain things that we, we have reason to believe might mitigate some of that stuff down the line.

Kali Dayton 25:10
Yeah, you have such a unique perspective compared to a lot of the rest of the team that only stays in the ICU. And when you see patients like that you don’t see that they’re sleeping, you don’t see that they’re resting. It sounds like you have a sense of panic, you say, I know what comes after this. If we don’t get them up, this could mean days to weeks longer on the ventilator. And this could mean these long term effects. And I think I agree, if the rest of the team had shared that perspective, there would be a sense of panic and urgency to intervene and prevent that kind of harm. And Kyle, what do you wish they understood about your interventions, and how prevented a lot of this harm is?

Kyle Ridgeway, PT, DPT, CCS 25:47
You know, obviously, I agree with everything Kenny said. And I think the line that comes to mind is, you know, broaden your perspective and lengthen your time horizon. I mean, the hospital acute care, critical care would get so granularly focused on the here now, the next hour, the next minute, the next day, that we can get sucked into saving the life and forget about the life that we’re gonna send the patient to, in the next week, when they go to the floor, when they leave the hospital, potentially go to an LTACH or rehab facility, or for our patients who do who go back home.

You know, the data is fairly unequivocal at this point that patients don’t do well after critical illness. Physically, cognitively neuromuscular li it’s not a good situation. This is a this is a life changing life altering experience, not just acutely, but for months and years after patients leave the ICU. And, you know, obviously, we want to then think about what is the impact of the critical illness, not just on their life stabilizing organ systems, but on their neuromuscular system, their cognitive system, their cycle, their psychology, and their ability to function cognitively and physically.

But then also thinking about our environment and our interventions within critical care and how those may or may not impact those systems and those long term outcomes as well. Right, because what we can do physiologically is we need to give people the best supportive care and evidence based interventions to reverse their direct physiology and critical illness, right, that’s what we have to do. But outside of that, is we need to do everything we can to ensure that those interventions, in part the least amount of harm that they can, because they’re going to impart harm, you put an you put an ET tube in someone, you put it in me and 12 hours, you can biopsy my diaphragm, and it’s going to be different, right, you put someone deeply sedated, and keep them in bed, and you look at how the respiratory muscle system works, how their muscles work, it’s going to be different.

So let’s make decisions based upon that. But I think if we look at and I’ll hone in on the respiratory system a little bit is if we take a step back from the respiratory system, and we actually look at it from a neuromuscular standpoint, right, the diaphragm is a very, very important respiratory muscle. But then also, there are a lot of other trunk muscles that contribute to our respiratory system. Those muscles also work as postural muscles. So they also work to hold us upright against gravity.

And I think that’s a big important concept in my mind as if we want to attempt to mitigate potential harms that may come from critical illness. And from the treatment of it, and from especially being on mechanical ventilation, we want to try to ensure that we don’t lose any more strength than we need to in our respiratory muscle system. So that includes the diaphragm, but that includes our trunk. So therefore, hypothetically, you know, just having a patient sit at the side of the bed and have them hold themselves up against gravity, the first few times you see it from mechanically ventilated patient, it’s a fairly exciting thing, especially if you’re in an ICU that hasn’t done a lot of this.

You do this for some years and you’re singing whatever, we’re sitting at the side of the bed, you kind of forget, okay, we are but we’re doing a lot of different things here, neuromuscular early and physiologically that have the potential to be important. You’re forcing the patient to at least try to hold themselves up against gravity, you are obviously inherently changing v Q, you are changing where the bloods going and where the arrows go, you’re potentially helping with atelectasis and secretion mobilization. Right?

And then cognitively, you’re waking this patient up. So just that first step, I think is an important step to kind of get a gauge of where this patient is at. But it’s not to be under appreciated as far as what it can potentially do. A to help the patient along their kind of ventilator liberation, liberation from critical care journey, but also to give you good information to help make decisions to continue to progress them.

So if I think of kind of step one of getting that patient up to the side of the bed, there’s absolutely is value in that especially when we’re thinking about it from an active mobilization perspective, not just seven people, twisting someone to the side of the bed, four people behind them holding up one person holding their head up for them, not having the patient actively utilize their neuromuscular system, utilize their cognitive system and try to do something actively. So that’s where I would kind of start the assessment or the potential impact there is just right there at the sight of that.

Kali Dayton 30:28
Absolutely. And when we start promptly, we don’t need the seven people that initiate that. It takes maybe two if if that I’ve seen physical therapist, setting up COVID patients by themselves, because they’re doing it promptly, and the patients are still stable and intact, to do so safely. So I from a nursing perspective, I don’t think I really appreciated that, that I wasn’t trained to think that way about the respiratory system about mobility. I worked in ICU for many years, and I did those things, I set them up by walk them, but I didn’t understand in that moment,” okay, I’m decreasing their time on the ventilator, potentially by days. I’m making it so that they can get off the ventilator independently”-, I thought a lot about walking. Because I know that my mobility, my ability to walk is important to me. But even deeper than that, the ability to breathe, it’s been preserved by just dangling someone initially. That is powerful.

And if we understood that if we thought that way, if we had that urgency, okay. Here we have a COVID patient who has his high risks of having the path for a long time live in Toledo because of diet jam, for him dysfunction, we need to get physical therapy in here and start dangling them and moving them and engaging their respiratory muscles to prevent a tracheostomy, and extensive rehabilitation. If we thought about it, that way, you wouldn’t have to be annoying and pestering the team, they would be begging for you to come work with your their patients right away. So then how do we move forward after dangling? And what benefits? Do we have after the next step mobility?

Kenny Venere, PT, DPT 32:11
I mean, everyone’s going to be a little bit different, right? Based off of their prior level of function, their their critical illness and that kind of stuff. And it’s always a response dependent progression. So obviously, after dangling at the edge of bed, do you want to see are they able to to weight bear? Are they able to support themselves in standing when they do stand? And they have that increased orthostatic challenge? Are they able to maintain their their map and their blood pressure? Are they able to tolerate the increased respiratory demands?

Are they becoming more dis synchronous with the event because maybe they’re on a ventilator mode that doesn’t let them control their own flow as much and they’re trying to breathe against a closed expiratory valve or they’re triggering the vents so often that they’re getting this set tidal volume every time where they can actually exhale. So I think what what progressing their mobility and their activity does is it kind of it sets a ceiling for what can happen in those, you know, 23 hours of the day that they’re not with a physical therapist, but it also kind of helps combat some of the clinical inertia that can happen with weaning vent settings, weaning sedation, weaning pressors, because I think it’s a very powerful thing for providers and ICU clinicians and things like that to say,

” Oh, wow, that patient was on, you know, 70 and 12. And they’re, they’re sitting up at the edge of the bed. They’re SPO2’s 96, their heartbeats, perfect. They’re pulling good tidal volumes. They’re waving to me from the door, you know, maybe we can actually let’s let’s think about taking down there at fi02 and their PEEP today and seeing how they do. Lets, you know, their map was perfect while they were out of bed to chair and maybe we can come down on the levo a little bit…..” I think we, by demonstrating certain things and taxing people’s physiology, we can kind of facilitate that, that ICU liberation, that fan preparation and those those drip liberation.

Kali Dayton 34:18
Yeah, when it comes time to excavate a patient that has just walked 200 feet around the unit, at least, and they’re sitting up in a chair, and they’re right on the board, can we get the tube out? There, I’m gonna move ventilator settings, there was no finger crossing. During that extubation you know that they’re going to be strong enough to cough, protect their airway and independently breathe. There is a sense of confidence and security after seeing those physical milestones being met. So how do we get to that? How do we go from dangling to walking even on a ventilator?

Kyle Ridgeway, PT, DPT, CCS 34:56
Yeah, I’ll just break down kind of it again, you can Practice clinically, with different scales. There’s the ICU mobility scale, there’s the Johns Hopkins highest level mobility scale. In the research realm, there’s a lot of work now on accelerometers to kind of really quantify patient’s position and movement. But if I think of the levels of mobility from essentially, you’re in bed getting Q two turns, you’re in a chair position of a bed, you are sitting at the side of the bed, you are starting to initiate standing, which may include pivoting and getting over to a chair, you’re starting to initiate standing and stepping or marching.

And then you’re now actually ambulating. I think, looking at that stepwise progression for every patient helps you it seems like more complicated, but for me, it helps simplify the process, which is you don’t just go from laying in the bed to we’re on a portable ventilator, we got the wheelchair behind, we’re cruising down the hallway. But you have to go through all those steps. And each one of those steps is really in my mind is just intersection and the road to assess the patient’s physical capabilities in that position, their physiologic and cognitive response to that position, and their readiness to attempt the next level of mobility.

And really, at each one of those steps of mobility, there are things we can look at. And there are things that we can actually intervene on. And so I’m just going to take a minute and just kind of take you through my general approach to essentially every single patient that I see in a hospital, whether it takes me 32 seconds, or 32 minutes. So for me if I’m walking into a critical care room is step one is what position Am I encountering this patient on? And what physiology and iron Am I encountering? I’ve talked to the team, I’ve looked at the chart, but what’s their physiology right now? So we look at that picture and we see heart rate, blood pressure, respiratory rate, SPO, two, all that good stuff.

And then I put that into the context of okay, what am I seeing they’re in the context of the support that they need, what vasoactive? Are they potentially on? Is that the dosage that I looked at? Or talk to the nurse about? And what are they? What is their respiratory oxygen or ventilators support? I now have a hypothesis of okay, what looks good, what am I concerned about? Now I can look at the patient in the bed, and I can really start to intervene on let me wake them up. Let me see their cognition.

And let me test their strength or ability right here in bed, maybe that’s rolling them, maybe that’s asking them to move their limbs against gravity. At each step of the progression, we’re doing the exact same thing. All the persons are asked as minus one there unfortunately, can positive but they’re following commands. They respond okay to being awake. And my strength testing, respiratory rate comes up a little bit. But as co2 is fine, everything looks good. So we transition to the side of the bed. The process just starts all over.

What’s their physiology? What’s their cognition? And what’s their physical capability? are they holding themselves up on their own? Or am I really having to hold them like a limp noodle? And then I can test again, does this person have against gravity strength of able to kick their legs hold their trunk up, lift their arms, great, everything looks good here. They’re able to kick their legs against gravity, they actually took some resistance. I think we’re ready to try standing. We have one person on each side, we just stand from the bedside. And we’re not going anywhere. Right off the bat. We’re just standing there. Can the person bear weight? How much physical assistance they need to do it? What’s their physiologic cognitive and physical response to that? Well, the person stands for 227 minutes at the bedside, I think we’re ready to start trying to march in place a little bit and potentially get over to a chair.

And that progression just goes right forward into ambulating. I would say, in my mind, the stuck points happen at kind of those transitions, right? So we’re successful, kind of at the edge of the bed, but are we ready to get to the chair or successful over to the chair and getting into standing? Are we ready to initiate marching, stepping or even ambulating into the hallway. So my big thing that I always say, especially for folks who maybe are just starting out maybe logistical resources are especially human resources are a stretch, it’s hard to get two or three people to help you is and I may may not make some friends in the rehab world with this, but that’s okay is marching in place is absolutely just as good as walking.

And until someone can give me a mechanical physiologic reason that that’s not true. I’m doubling down on that statement. I tell it to patients all the time. In fact, and again, this is not data, but just experience. A lot of patients actually tell me that marching seems harder to them when walking. And I can see that they have to lift your you have to lift your feet higher, are often times making you do an out of fast cadence. Now, that’s not to undersell the psychological effects for the patient, the family team of getting out of the room of ambulating over ground, those type of things.

But if we’re thinking in a realistic, pragmatic way, if you’re working in a hospital, like every other hospital in the country that has staffing shortages, high rates of burnout, tons of COVID. It’s hard to deal with, Hey, you got to do the best with what you have. And that may be marching and ways and I want people to know that success, that is a great intervention. And that’s a good thing. But the other reason I bring it up is, is if you’re going to take someone on a road trip to do some walking, is it the juice worth the squeeze to you know, if your institution is like ours, if a patient’s transporting out of the room on a ventilator, you need an RT present, or someone else present, you probably need a nurse or a nurse’s assistant to help with IV polls, monitors, things like that a wheelchair follow. So let’s say it takes two or three people, you’re gonna have to set that situation opening up to break it down on the front and back end of that adventure.

Is the juice worth the squeeze? If the patient walks 14 steps one time, and that took 45 minutes? Maybe not saying it’s not. But what if you and one other person intermittently helping you could have stood the patient up seven separate times and done five bouts of marching in place for eight to 10 reps? So I kind of use marching as my road test to make decisions on should we get out of the room? If we are what’s it going to take?

How many people do we need, what type of equipment do we need, but that really working on those repeated sit to stands actually just statically standing and bearing your weight and marching in place. Those are the foundations to standing strength and function to being able to calculate. And those are things that are really actionable and quick to do. And those are things that can be done outside of therapy, because in a lot of ICUs, if this is first starting therapists are really oftentimes can be the drivers of mobility performance. But I can only be in a room what 30,60, maybe 90 minutes a day for a specific patient, a lot, a lot of hours outside of therapy, what’s actually pragmatic that other team members can perform.

And if you have a patient critical illness or not, ventilator or not, who can get up into a chair is up into a chair, maybe is working on kind of pre walking or walking with the therapist. But that’s going to be a really tough ask for a nurse or nurse’s assistant or a unit and a given period of time. That standing from the chair that doing three sets of stands in a row that standing for a minute, that marching eight steps, and then sitting down is a much easier hurdle to clear. And it’s absolutely still an effective and important intervention, neural muscularly and physically and functionally.

And so I really think one of the big missed opportunities for kind of increasing mobility or kind of a dosage of mobility would give folks is that standing, stepping, doing a few sit to stand standing in place marching in place kind of level, to build the foundation for successful and more easeful ambulation, but also to increase the patient’s activity and mobility and standing throughout a given day, in a way that’s pragmatic and is actually actionable and efficient.

Kali Dayton 42:55
And it reinforces Christiane Perme. She says that “mobility is everyone’s job”- that this is something that everyone can do, I mean, within their own feasibility, right. When you have extremely weak patient that’s probably not safe for nurses to be independently trying to get up in the middle of the night shift. But if you’ve been working with the patient, and they’ve stayed functional and able and safe to transfer to the chair themselves, that is absolutely within a nurse’s scope and the way can walk in ICU.

Historically, PT does the first two sessions of the day with the patients with the nurses involved but the night shift it just comes down to the rt tech and the art and then RN to walk and they’ll have these patients walking laps around the halls just the three of them without physical therapy but I think it’s because these patients become less complex, less unstable because it’s so prompt but that’s a question that I’ve received from some nurses is they’re trying to initiate this they don’t have all the support needed and they’re not comfortable in these patients probably aren’t safe to throw out of bed with just a nurse but they want to know I have a patient dangling at the side of the bed. What can I do to help them keep progressing within my own capacity in that moment? What kind of ideas do you have

Kenny Venere, PT, DPT 44:18
I mean, it’s hard every every unit is going to be different especially now right with with COVID and staffing shortages, nurses being ratios that they’re not super comfortable with a lot of times you’re just trying to keep your your head above water and I think the places that do this successfully are places that integrate it into routine care. So less so thinking of okay, I have to dangle this patient at the edge of the bed okay, I have to stand them up.

I have to get them out of bed to chair or to the commode but thinking about after I have to get my morning meds this morning. Let’s let’s sit this patient up at the edge of the bed so they can sit up and bring their pill cup to their their mouth or you know have to dangle during that to engage those postural muscles that Kyle talked about. And their cognition is challenged because they’re having to hold the pill cup and focus on it.

Or instead of opting for, you know, a passive roll on to a bedpan, let’s have this person stand up and bear some weight through their legs and get over to a commode and have to think about sitting up and engaging their trunk and maintaining that postural and hip control and then trying to participate in their their primary care and things like that. I think trying to find ways to integrate whatever small thing it is, throughout routine care is really the the key to success there.

Because, you know, like we’ve mentioned, patients work with a physical therapist for 10 minutes, 15 minutes, 20 minutes, 30 minutes, 90 minutes, whatever it is, but there’s a whole lot of other time during the day. And I think I would be, it would be hard to be pressed to tell me that the 15 to 90 minutes that the patient spends with a physical therapist is the driver of that massive magnitude of effect, you can see it’s it’s everything that happens after the fact and sometimes where the you know, we open the floodgates for that kind of stuff to happen, because we demonstrate that it can be safe, that it can be feasible, but it’s really everything that happens after that’s important.

Kyle Ridgeway, PT, DPT, CCS 46:36
Yeah, you guys have said some things that didn’t get me thinking if I can react to some of that. I think the the first thing Kenny, that you’re highlighting is a multidisciplinary approach to having goal directed mobility, as well as really talking about every moment is a moment to intervene with activity, mobility positioning, right, you want to integrate this into routine care. Because I think we have to be sensitive to the fact that, you know, every solution, every healthcare problem, and in any meeting anywhere is we’ll just have the nurses insert the blank right in there always asked to do more.

They’re stressed for time. And you got to make this stuff easy and actionable. And I think can you bring up some great illustrations and recommendations that say, let’s not just look at this as another to do on the task list of the day, let’s actually infuse this to our, into our entire approach to how we care for our patients, whereby every assessment, every trip into the room is an opportunity to impart some activity or mobility or repositioning or exercise, even if it’s for 30 seconds, even if it’s for a minute. You know, one of the things that I stole from Chris perm over the years is having patients do straight leg raises, and having to do 100 A day and the patient’s eyes always get a little bit wide, most of them.

And unlike I’ve done the math, that patient made me do it. If you’re awake for 10 hours, it’s 10 an hour, it’s one every six minutes, I think you can do it. Right. But that’s an easy intervention for a nurse or a CNA to integrate every time they go in there. Hey, Mr. Smith, let’s knock out five more of those straight leg kicks in the last few if we need to right. Now, that’s an ideal world. But I think one of the things that was brought up that I think is really important is you have a weak patient, or you’re not sure if your patient can stand or should stand or can’t walk, when there’s two things that we need to talk about or think about for every single patient.

And then we want to get to the point where we’ve operationalize this into our care. And that is, what’s this person’s potential to mobilize physiologically physically, right? Physiologically, there’s good guidance, we can talk about individual cases that that may be the easier one. But then it’s like, well, but how strong are they? How weak? Are they? Can they stand? Should they just sit? Can they stand and pivot and they take three steps to the chair five steps to commode they walk a mile, I can understand as a non rehabilitation professional.

Those are really hard questions. So we need to have some way to talk about their mobility potential and the need for physical assistance, as well as what is a realistic kind of mobility goal for this point in the day for this shift for this day. And for some patients that’s absolutely sitting on the side of the bed for other patients. That’s absolutely walking 250 feet. So if you’re a nurse, or you’re a non rehab provider, or someone who’s just starting out on this journey, you know, think about that mobility staircase that I brought up and start slow. And, and go slow.

So do the first step. Assess how the patient is doing and responding. And don’t be afraid to just do the next little step right so you don’t have to go from edge of bed to cartwheeling over to the chair. There’s a lot that can be done right there at the bedside. Okay, we’re not going to go anywhere. Let me get a second person and what Let’s just try to stand from the bed. Well, how much help Should I give? You just give them as much help as you are physically comfortable giving. And you see what the patient is able to do.

Oh, wow, they got three quarters of the way up, and then they sat down. I feel comfortable giving a little bit more help. Why don’t we try that? Again? I’m going to help them a little bit more. Let’s see if they stand up. Okay, they stood up. Let’s assess their response to that. See how they look. Let’s try to stand for a few seconds. Okay, great. They’re actually bearing some weight here. Well, now, right? Falls and mobility are always in constant tension. You don’t want to walk this patient away from the bedside. And we have a critically ill patient and fell face first and self extubated. That’s not going to look good. You don’t have to do that much.

Kali Dayton 50:40
That’s hasn’t happened, right? Yeah, you haven’t that that happen, right?

Kyle Ridgeway, PT, DPT, CCS 50:44
No, I haven’t. We’ve actually, as a general kind of rule, we have almost 10,000 data points of make you therapy. And there’s only been one extubation during therapy, so and that person didn’t have to be re intubated. So the customer’s always right

Kenny Venere, PT, DPT 50:56
and let the customer decide

Kyle Ridgeway, PT, DPT, CCS 50:59
you don’t have to get into that fear zone, you can just try to sidestep up the side of the bed, and maybe the the patient shows you, my goodness, they’re stepping really well. Let’s sit down, I think getting to a chair is completely feasible. Or maybe they don’t, you know, you’re really helping them the two of you. And their knees are buckling a little bit and you just know they can’t step that’s fine. The beds right behind now you can sit down right there at the bed. Reassess, make sure cognitions good. Physiology is good, they’ve recovered.

Okay, let’s just try it again. And you know, at this time, we’re not going to step why don’t we just stand, we’re just going to stand right there. And so really, the way that I look at it is you’re judiciously going up every step of the mobility staircase. And every step, you’re figuring out, how are they doing on this step? And are they ready for the next one? And if they’re not ready for the next one, in that moment, for whatever reason, you just stay in that step or that level? And you work within that level? And if that level, in that moment is standing at the bedside with two people assisting?

That’s fine. That doesn’t mean that that was a failure, or that you should stop. Why don’t you do three sets of standards? Why don’t you do four? Why don’t you do 10? You know, just repeat that level? That’s just like any other exercise, right? You know, if you can’t deadlift 225 pounds, you don’t just say, well, then that’s it for today. I guess I’ll just come back and try it tomorrow. Well, you figured out that you can deadlift.

And you did figure out that you can do 30 pounds four times and you do multiple sets of that you build your strength in that level, or in that task and try to progress your way forward. So I don’t know if that’s getting that kind of what you’re thinking about from like a you know, in the moment perspective for a nurse or for someone who’s just starting their journey is it

Kali Dayton 52:39
Revolutionists that are working so hard to make these strides, but sometimes feel frustrated that they don’t have all their mechanically ventilated patients of walking 1000 feet before they are excavated, I think it’s important to understand and appreciate the value of those little steps, because that is making a huge difference to their outcomes.

Sitting up, engaging the diaphragm helps them get excavated, being able to sit the sand helps them be ready to walk. Anything a nurse, or any professional does to work towards that has greatly contributed to saving the life and preserving a life worth living. So thank you so much for everything you guys bring to the table. Anything else you would add to the conversation that you’d want the IC community to know, to open mic?

Kyle Ridgeway, PT, DPT, CCS 53:31
You don’t want to give Kenny and you don’t want to give Kenny and I an open mic? You know you’re dead done on the hours of podcast material you might end up with here. But I’ll let me go first there.

Kenny Venere, PT, DPT 53:41
Yeah, I think it’s easy to go off the rails with Kyle here. So I’ll try to be brief, I think keep it in mind that, you know, these people when they survive the ICU, they have a very, very long road. And what you’re doing is trying to set them up for as much success down the road. And I think it’s what Dr. Washington who asked the question, are we creating survivors or victims of critical illness?

So I think when you keep that that 1000 foot view of what am I doing today that’s going to help or harm this person in two weeks and two months in two years is a very important thing to be conscious of. Because, you know, we know that these people are people who suffer when they leave the ICU when they leave the hospital when they reenter the community. If they do reenter that community. A lot of times they unfortunately end up being facility dependent. They have very little specialized follow up. There’s what Mike you know, probably less than 20 Post ICU clinics. I don’t know if that’s changed since you’re in Evan’s presentation a few years ago Kyle.

These are people that don’t have anywhere to go. And oftentimes, even if they had somewhere to go, they might not have the physical mental financial capability to get there. And so the onus is on us as critical care clinicians and people in hospitals to try to set these people up for as much success as possible at best, and trying to minimize harm, at worst, because they have a very difficult road.

Kyle Ridgeway, PT, DPT, CCS 55:34
Yeah, I think that that’s, that’s well, state of Guinea. And I would highlight that that’s those are very important things to think about. You know, I kind of think, after my time in critical care over the past decade or so, and especially after COVID, you know, critical cares is a funny double sided coin, there’s a lot of amazing outcomes and saves and, and in patient performance, that just blows you away on a day to day basis.

But, you know, it can’t be undersold, this is still critical care, you know, you’re we’re not, we’re not playing T ball here like this, there is a lot of bad that does happen could happen. And it’s gonna happen. And I kind of look at it from two perspectives, you know, for our rehabilitation professionals who are very used to trying to progress people to success, you’re going to work with people who end up dying, you are going to end up working with people who are profoundly impaired and don’t make a lot of progress, you’re going to have streaks where you don’t get a lot of good wins.

And you’re going to have streaks where you can do nothing wrong, and people just seem to really respond to your interventions. That’s kind of the game we’re playing. I think the flip side is is for folks who have backgrounds and critical cares, is take that long game approach and try to mitigate what you can mitigate and understand where the patient came from, where they are cognitively, physically and functionally. And what can we do to try to prevent any further downslide and start to reverse that trend and start to try to make some progress or address those issues.

And I think the last thing is and is there is a lot that can be done. But not everything can be prevented. And there’s a lot of this is also predicated on what type of ICU you work in. There’s folks that if you work in a super high acuity, medical ICU and no surgery patients, you are going to see a lot of folks with a lot of comorbidities, who may have physical functional impairment at baseline. And you may be dealing with a death rate that is remarkably different than if you work in a straight surgery ICU. Or if you work in a cardiothoracic ICU or a specialized ICU.

And just know that, again, you can only do what you can do, but not all of this is preventable. And the only reason I bring that up is, you know, my medical ICU team and us we hit a point where we struggled for a while because we got hit with a lot of bad outcomes. We were questioning, you know, well, we just need to get in there earlier. You know, when we were getting in there early on 84% of our patients with mechanical ventilation got PT while they were in the medical ICU.

And that was initiated on average within 33 hours of admission. Those are averages so there was plenty of people I can tell you we got in there on our 12 But still, there were some patients that weren’t getting better and I will never forget this gentleman. Day one five out of five strength we are working on standing I thought it was gonna be able to walk in a few days, day to struggling standing wasn’t really sure what was going on with him.

Day three, I think we saw him twice still struggling with standing day for three out of five strength examined by day 14 He had zero out of five strength in the worst case of ICU acquired weakness and critical illness, neuroma apathy I’ve ever seen in my career. No one did anything wrong. On that case, this guy was a RAS of minus one to zero the whole time, he was only camp positive one or two days, actively mobilizing actively working with rehabilitation, he won the reverse lottery.

And so what I would say is, it’s going to be hard, there’s going to be challenges, but do what you can do for those individual patients and for your population. And just know that at times, not everyone will respond. And that’s okay, we can’t have a mindset that we’re going to have 100% survival rate and 100% return to the community rate. But in the face of that there’s still a lot for all of us to do. And there’s definitely a lot if you’re a rehab professional that you can do, regardless of where you’re starting.

And again, you know, if you’re starting at a place where it’s deep sedation and that’s the norm and there’s no therapist in your unit. Hey, you know what, getting a few patients awake and getting people to let you start assessing people. That’s a win. You know, you’re not going to jump to the awakened walking ICU or a high level ICU overnight.

And you know, Kenny, on a different podcast can tell some stories of how he has a singular PT, drowning and COVID helping prone and supinate people all day because of staffing concerns, was able to start moving the needle on actually doing Some therapy and mobility in patients who are critically sick, and ICU that historically didn’t do a lot of that. And that was in during a damn pandemic. So just stay the course. Be judicious think about it and do your best. And I think that’s, that’s all we can say.

Kali Dayton 1:00:17
One of my favorite parts of doing this podcast and corresponding with all these people across the country and world, is the honor of meeting ice revolutionists. I’m speaking to an environment that I walked into. I didn’t do the hard work of creating it from the ground up and combating all the incredible barriers there are. But the people that are even during this COVID and staffing crisis that are so driven by compassion and passion, that are doing the extra work to make these changes, those are the people that I look up to that are my heroes. So I’ve had people reach out and say, “Oh, I’m so excited to talk to you.”

But in reality, I’m the one excited to talk to them, people like you can see that, in the middle of all of that, you’re still keeping that big perspective, and trying to keep medicine evidence based. And it is such an honor to speak to such seasoned physical therapists that are building the future of physical therapy and the ICU. And I hope, and I’m determined that your role will increasingly grow in the ICU, that your profession will be increasingly respected and acknowledged and utilized for every ICU patient. So thank you for building the future. And thanks for coming on and sharing your expertise. I appreciate it.

Kenny Venere, PT, DPT 1:01:37
I think that’s very kind and you know, that’s very lofty praise that I don’t know how I deserve it, it is but I will say thank you, for me in and for tile there and we appreciate the work you do. You’re a very fierce advocate for these kinds of things. And it’s even more powerful coming from someone outside of the the rehabilitation realm, you know, you give a platform not only to physical therapists and occupational therapists, speech therapists, physicians, but you know, patients and survivors of critical illness and that’s very valuable for people who have experienced these kinds of things to have a platform to share their their lived experience, and I think what you do is incredibly important and valuable. So we appreciate the opportunity.

Kali Dayton 1:02:29
Well, you embolden me. So everyone I talked to every survivor, every clinician, gives me more more reason to be more vocal and bold, so I’m happy to be the Hitman honored to be with you guys. Thanks so much. To schedule a consultation and connect on social media, as well as find supportive resources including case studies ebook episode, transcripts and citations to research. Please visit the website www.Dayton ICU consulting.com

Transcribed by https://otter.ai

 

 

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