Heidi Engel has spent over 34 years in healthcare and has focused the last 11 years on ICU mobility. She leads physical therapy for a large academic healthcare center in San Francisco where she has been instrumental in establishing mobility initiatives. She has published work regarding the ICU liberation campaign and A to F bundle. As you hear in the upcoming session, she is very keen on the physiological impacts of walking and shares her perspectives on humanizing a critically ill patient. Family engagement is extremely important to Heidi’s ICU, and she believes patient and family buy-in is essential to the execution of critical care mobility.
We get into all these topics and more during our conversation so let’s get right into it…
“We look at the chart, but the chart just tells you this kind of a very foundational bit of knowledge and until you walk up to the patient’s room and you eyeball what they’re attached to what drips are running what their I. V. say what the monitor says, what the ventilator looks like and then what the person and the bed looks like and the family, when are they coming? Because I really want the family involved in my mobility session. I really rely on the family a tremendous amount.”
– Heidi Engel, Critical Care PT
Listen to the full podcast here.
Note: Podcast transcript below is a condensed version of the conversation generated using a combination of speech recognition software and human transcribers, and may contain errors. Please check the corresponding audio before quoting in print.
How do youdefine hospital patient mobility?
That the patient is out of bed. Ideally, the patient is walking. Far more of our patients walked into our hospital I think than we generally realize, and they don’t leave walking, which means we’ve done something to them to take away what I consider to be a survival skill.
Walking is not really an exercise. Walking is not a really complex task. Walking is something you were innately programmed to do because at age one you pulled yourself up on two feet and started to move across the room and that’s because it is a survival skill and therefore it’s clearly something that’s quite vital to our entire physiology.
You’re a healthcare veteran with over 34 years of experience. When did mobility become a priority for your hospital?
I started a project to try to create an ICU early mobility program in 2008. And at that time the inspiration for me was the one research article I could find on the topic which was from Intermountain Health in Salt Lake City, Utah. And it was an article published by Polly Bailey describing their respiratory care unit. And in it, they had a photo of the ventilated patient on really significantly high ventilator settings, and this patient was walking down the hall with the ventilator pushed next to them with a regular front wheel walker and looking incredibly normal and I did not even believe that was possible.
So I spoke to the experts we had at UCSF and we started our program which you know the thing about mobilizing patients and I believe this is true of mobilizing patients anywhere in the hospital. It’s a very inter-professional sport.
How do you communicate with this interdisciplinary team about a patient’s day-to-day mobility progression?
What the patient in the intensive care unit is capable of doing can change within the day and from day to day fairly significantly. Because we are a large teaching hospital, the rounding itself takes a very long time for the team so we do not as the physical therapist attend rounds because that would just be a lot of time that we are not working with patients. We do our own rounding, and we go to each bedside nurse and let them know we’re here.
It’s a pretty challenging environment to be able to line up the patient treatment sessions in their optimal window of time for everyone. You know, it’s in constant flux. This is why the physical therapist really has to be embedded in the intensive care unit.
Engel works with a patient in the ICU at UCSF Medical Center.
What is your process for dictating which patients to see and how do you engage family members in a patient’s mobility journey?
We look at the chart, but I always tell my students, you know, the chart just tells you this kind of a very foundational bit of knowledge, and until you walk up to the patient’s room and you eyeball what they’re attached to what drips are running what their I. V. say what the monitor says, what the ventilator looks like and then what the person and the bed looks like and the family when are they coming? Because I really want the family involved in my mobility session. I really rely on the family a tremendous amount. And so covid taking the family away from the bedside has been really a devastating blow to patient care and mobility in the intensive care unit.
What about line management? Does that factor into critical care mobility?
Yes, the equipment is exceptionally not mobility-friendly from the bed to the lift devices. Each is made by separate companies and therefore they aren’t (always) compatible with each other. There are cords, huge amounts of cords, and I. V. Lines attached to everything. For us, our rooms are very small. We have an older ICU so the physical size of the room has not changed at all – but the amount of equipment we’re putting in the room and the size of the bed have all grown so we’re also working in an incredibly tight space. And so yes logistically it can be very challenging.
In your opinion, how does sedation influence a patient’s readiness to mobilize?
What made your day easy today with the sedation will make your life as a clinician and certainly your patient’s long-term life far more difficult later. There’s a big payback for that time on sedation and it’s a payback that comes in the form of cognitive impairment, medical complications, rehospitalizations, longer lengths of stay and weakness, joint pain. I mean that’s a huge cost for making today look calmer and easier on the ventilator.
If you want to do things like preventing blood clots and oe of the best ways obviously to do that is to be up walking around. That’s more effective than laying in bed with sequential (devices) on your legs.
Heidi Engel, DPT, PT
So how can you bottle up that Kool-Aid of ICU early mobility and have people drink it when the easier today task is to continue that sedation instead of having their body continue to develop itself?
That is the question we have been at for quite a while now through the society of Critical Care medicine and the ICU Liberation campaign and the A-F bundle and all the work of Dale Needham at Johns Hopkins and the work of Dr. Wes Ely at Vanderbilt and all the work of the people at Intermountain Health; Terri Clements and Vickie Sperling and Polly Bailey. It just hasn’t been enough coming from a smattering of experts around the world. Thomas Strong has his research is all about a non-sedation ICU. So there are these smatterings of of of world leaders and experts who are trying to make the change, and I think we felt like we made a certain amount of progress in and now COVID has put a wrench in that.
I’ve come to believe honestly it’s going to need to be a patient/family revolution of sorts because I have been full-time in the ICU mobilizing patients for 11 years, and in my observation, who has helped the change move forward most? Patients and families.
How do you encourage family members to help patients in their mobility journey?
I set my patient up on the side of the bed and I have them facing their family member – not me. I do my best to get out of the way and put a chair in front of the patient who’s sitting on the edge of the bed. You’d be amazed even family members who you think are going to be kind of squeamish or not understand. They want to do this. And the patients certainly want to see them not me and certainly not the front of my shirt and an IV pole, right? So I try my best to as soon as we have the patient medically stabilized, I try my best to pretend my eyes are their eyes.
Especially if we if they were sedated and we are now trying to bring their brain back to reality. The sedated patient is hallucinating. The sedated patient is not sleeping. The sedated patient is usually having very traumatic dreams. And those are very real dreams for them.
One thing you touched on earlier was the physiological benefits of standing and how your breathing was different, laying down as opposed to standing up. What are some of those benefits for the ICU patient?
You open up a lot of lung spaces being upright and you cough a lot of secretions out – so you get a lot of lung clearance. Weight-bearing is the number one way to improve neuromuscular connections and strength in the legs. If you want to strengthen your legs you could do that exercise is forever. You could put them on a bed bicycle all day long and I promise you that will not translate to standing up on your legs.
So the compressive forces and the joints are really crucial for bone integrity, muscle integrity, neuromuscular stimulation. So we really depend on gravity and weight-bearing to help us stay upright beings. Then all the extensor muscles.
If you want to do things like preventing blood clots and one of the best ways obviously to do that is to be up walking around. That’s more effective than lying in bed with sequential (devices) on your legs.
What’s a take away you’d like to leave us with?
I think we (healthcare providers) are too good at imagining all the potential bad things or risks that could happen even though every single ounce of ICU early mobility research has shown that it’s an incredibly safe activity to do, particularly when you have a physical therapist involved.
But the patients and the families get this right away. We all recognize somewhere innately, just as we did when we were one year old that getting up and walking is a survival skill and, and it’s satisfying, we were made to move type of activity. I mean life is movement and movement is life and people understand it innately and, and so the rewards and the joys of watching patients and the family members just respond to that so positively – that is absolutely the reward.
Awesome. Thank you for your time today Heidi. I think we learned a lot from you, and taking some of your experience and bringing it to this podcast is the ultimate goal – So I appreciate your time!
Thank you, thank you so much for this opportunity and, and please design some more really beneficial mobility equipment!
Recovery Force, LLC has been selected for a showcase presentation during the 2021 American Heart Association Annual (Virtual) Scientific Sessions!
#AHA21 is the world-leading annual event for researchers, medical and healthcare professionals in science, prevention, and treatment of cardiovascular pathologies.
Recovery Force Health‘s live company showcase will take place on November 13th at 3:20pm EST.
Topics
Recovery Force Health (RF Health) is a digital health device company focused on data-driven, wearable, medical technology. The company has developed a cordless, lithium-ion powered, compression and mobility device for patients in the hospital and at home.
The MAC System is cleared as an FDA Class II device prescribed by healthcare professionals to stimulate blood flow in the lower extremities. By delivering therapeutic compression, the device assists prevention of deep vein thrombosis (DVT) in at-risk patients. The MAC System also monitors patient orientation and movement providing significant healthcare economic benefit by reducing costs associated with non-reimbursable hospital-acquired events.
What if a bedside caregiver could walk into any patient room and instead of reviewing a chart or asking the patient to recall how much they’ve moved today, they could look at the patient’s digital movement tracker and view up to a 48-hour history of objective data (bed-chair-steps) to answer that question? Would access to this patient data make it easier for hospital caregivers (nurses, patient techs, therapy services, etc.) to coordinate and execute mobility goals for patients? Could that data better guide clinical decisions relating to mobility progression for the caregiver or possibly even assist in transfer or discharge decisions?
The call to “Implement mobility early and often,” is used quite frequently – but what does that mean? Many organizations have made good attempts at developing mobility programs and protocols to answer this question, but we need good standards of practice to reference as these protocols and programs are being developed. We are off to a good start with efforts to improve healthcare outcomes through mobility and movement, however, I believe we are just at the beginning and have an exceedingly long way to go as we develop and implement these valuable and much-needed practices.
Let us consider some of the critical elements to include as we construct a mobility program. If it is to be a standardized part of care delivery, which disciplines will be responsible for leading the program? How will mobility orders be written into the care plan? Are there detailed descriptions for physicians to include in their orders? Which provider will be writing the orders for mobility, or might it be a hospitalist who determines what is required? Who is responsible for overseeing the execution of these mobility orders?
[pauses for breath]
A lot to consider, right?
Every program will need to begin with an assessment of the individual patient. From there, assessments will need to continue and evolve as the patient’s condition progresses. Patient-centered goals with objective metrics are critical to engagement, progress, and recovery. Acutely ill patient safety will need to be a key consideration – but a conservative view of safety should not in any way hinder the benefits achievable from getting a patient moving.
Technology can play a key role in facilitating mobilization. The selection of appropriate technology will help standardize practice and manage risk to both the patient and caregiver when engaged in early mobilization activities.
The MAC System by Recovery Force Health measures patient mobility and offers an easy-to-read interface on a patient’s lower limb. Mobility data empowers all bedside caregivers with the same critical metrics to understand a patient’s 48-hour progression.
When does early mobilization begin and end? I would say it begins as soon as the patient is placed in a hospital bed. With surface technology and other available medical devices, early in-bed mobilization can begin immediately. We will need to begin with what is thought to be the best prescription for the individual patient, but it will be important to measure what is taking place so that we can establish an evidence base on which to make prescriptions. Data collection capabilities are being built into medical devices and expanding the use of sensor technology in the healthcare environment. This allows us to now capture this crucial mobility data and drive clinical decisions. In my opinion, early mobilization shouldn’t end until the patient is back to their pre-hospitalization baseline, which means that there are several patients that will likely need prescriptive mobility even after going home.
This is just the very start of what needs to be considered – but we need to start somewhere. As we progress, it will be especially important to have a broad multidisciplinary perspective – but there’s no doubt that in today’s healthcare world, the synergy between technology and clinical practice will drive future improvement.
ABOUT THE AUTHOR
Dr. Guy Fragala Ph.D., PE, CSP, CSPHP
Dr. Fragala has many years of experience as a healthcare professional and is recognized as one of the pioneers of Safe Patient Handling and Mobility efforts in the United States. He has lectured throughout the world and is a recognized international expert in the application of ergonomics to the healthcare setting. Currently, he helps and supports a number of organizations, vendors, and facilities with their safe patient handling and mobility efforts. In 2012 he was awarded the National Advocacy Award for Improved Caregiver Safety and in 2017 awarded the Bernice Owen Safe Patient Handling and Mobility Research Award. His book entitled, Ergonomics: How to Contain On-the-Job Injuries in Healthcare, published by the Joint Commission on Accreditation of Healthcare Organizations, has influenced much of the work today related to healthcare ergonomics and safe patient handling and mobility programs.
In the ICU, mobility can fall down the priority list (and for good reason). Oftentimes bedside caregivers are unsure which direction to take when starting the rehabilitation journey for a patient. Critical care nurse, Alison Cassina knows this reality firsthand and has prioritized mobility for even the most acutely ill patients. She shares with us her team’s approach to mobility with an ECMO patient who had to prove a certain standard of mobility before receiving a lung transplant.
“I think the other thing that’s really important about mobility is not just telling patients that they have to do something, but also including in their plan of care so that they are part of their goals moving forward rather than just coming in and telling them, ‘Hey you’re going to get up at two o’clock because this is the time that I’m free.“
Alison Cassina, Critical Care RN
Listen to the full podcast here.
Note: Podcast transcript below is a condensed version of the conversation generated using a combination of speech recognition software and human transcribers, and may contain errors. Please check the corresponding audio before quoting in print.
Let the people know who you are!
My name is Alison Cassina. I am a cardiovascular ICU nurse. I’ve been a nurse for a little over eight years now in the critical care setting, specifically cardiovascular patients. Post-surgery from open-heart surgery, heart and lung transplant, and various other devices for cardiovascular complications.
I always had an inclination towards the medical field. So I applied to nursing school one day. I figured if I got in I would see how it went. (I) went to nursing school, and it became a serious passion of mine and I started working out in the ICU. And it has been the only environment that I’ve known but it has been my passion since day one. And mobility happens to be one of those topics that go hand in hand with ICU patients.
Just with the complexities of your job and being around other critical care nurses. Why do you think that mobility is so crucial for an ICU patient specifically?
I think there are a number of reasons why mobility is important for ICU patients. Specifically, the patients that are entering into the healthcare realm now are patients who are much more acute than 10 years ago, let’s say. Patients are coming in, and a lot of procedures are outpatient. So patients that you’re taking care of and the ICU are extremely sick patients that require a higher level of care.
(Patients) come in sometimes in a debilitated state and you have to work even harder to get them back to a pre-sickness state so that they can go back home healthier than they entered into your setting. So I think that’s part of one of the reasons why it’s so important to hone in on mobility, and it goes hand in hand with so many other things that are important for patients. Specifically, delirium. That’s one of the reasons why we target it so high in the ICU environment.
What are some of the specific ICU mobility milestones that would be important for an ICU nurse to know?
As ICU nurses, we’re very controlling of our patients because of the high risk of falling. They have a lot of medications and they have a lot of lines and things so they require help and assistance to get up. With their mobility milestones, we make sure that we are present for their activity levels, specifically post-surgically in the cardiovascular population. For instance, our patients have orders from the surgery team to at least sit up at the side of the bed on the same day that they had surgery.
That’s considering a number of factors considering that their hemodynamically stable – that they have gotten out of surgery within a reasonable timeframe to kind of arouse from anesthesia. But if they can do those things, it’s important to go ahead and start early.
Day two after surgery, it’s important for them to get up early so we like to see our patients get up about four times a day. We work in a multidisciplinary approach with physical therapy and occupational therapy to make sure that our patients get up and move so we can also assess them and what their needs are. So physical therapy and occupational therapy work with us to walk the patients around the unit and make sure that we get them to regain their cardiovascular strength and endurance.
Cassina has been a critical care nurse for over 8 years and works as a nurse trainer for her unit.
While executing a multidisciplinary approach to mobility, how do you communicate with the physical therapy staff and let them know where the patients at since you’re around them more often than they are?
That’s a great question. We work really, really well together. The physical therapy staff is in the unit for a fairly long amount of time so we see their faces regularly in our unit. We have a system where the patients have a designated physical therapist, so when they come in in the morning they will leave their contact information and their names so that we can set up a time frame because I think the other thing that’s really important about mobility is not just telling patients that they have to do something, but also including in their plan of care so that they are part of their goals moving forward rather than just coming in and telling them, “Hey you’re going to get up at two o’clock because this is the time that I’m free.”
We try to coordinate and make sure that it’s a good time for the patient. They’ve had enough rest so that they can perform well and make sure that the available people that are needed to mobilize that patient are available also.
That totally makes sense. And that echoes the sentiment of an ICU nurse practitioner that we spoke to from out in Utah. Her ICU stresses Awake and Moving practices, but once they leave the ICU, they have a high chance of possibly returning if they don’t continue that mobility. So how can you have that communication both within your team in the ICU and then how do you keep that communication up as they’re discharged to go to whatever unit they’re going to next?
I think that is extremely important in two ways. One, we make sure that when we hand off our patients to the oncoming nurse to the respective unit they are going to transition to that we also include the patient’s mobility and what they have been doing. So they know what their baseline is what their progression is and what’s expected of them. We also make sure that the physical therapist passes those milestones off to their transitioning physical therapist if they’re not going to continue seeing the patient. In a multidisciplinary team approach, it’s also important that the physicians, the nurse practitioners – all of the staff that rounds on these patients frequently – keep mobility in mind also to make sure the patient is transitioning in the appropriate time frame that they need to.
I heard a story about an ECMO patient (of yours) where they had to proven their level of mobility before they could receive a transplant. Could you talk a little bit about that story? Is that a special case or is this something that you see very often?
Years and years ago, an ECMO patient would be somebody who would be extremely sick. You keep them down in the sense that you sedate them so they’re not doing a whole lot and you let the machines help them recover. Their body can take over their functions again once they are ready to get to that point. So, (in) the current realm of healthcare and the acute care setting, we like to make sure that our patients are awake more often (and) that they are getting up and moving. We make sure that we don’t sedate them too heavily so that they can be awake to participate in their care. And one of those things is mobility.
So we have patients that get put on ECMO – which is extracorporeal membrane oxygenation – for various reasons. It could be a cardiopulmonary issue, it could be a respiratory issue. Some of these patients go on to be considered as candidacy for transplantation – either both lungs and heart or either of the two. Sometimes these patients are so sick (that) when they get placed on this ECMO support, part of our goal is to make sure that we can rehabilitate them and bring them to a point where they are optimized for their transplant. So patients are required to work with physical therapy to get up to the chair. So by awakening them we make sure that we can have them awake to participate in their care, explain to them kind of the process of what’s going on.
If we can take them off of the ventilation via the breathing tube, we attempt to do that and we can have these patients walk on ECMO support and get stronger and stronger to the point where they are optimized and their best level of health pre-transplant.
Mobility in the ICU is something that is created by a culture change of nurses empowering each other, especially in that interdisciplinary approach to make sure that we’re honing in on mobility as a goal of care for these patients.
allison cassina, rn
For that patient (type), was there hesitancy to get them overly aggressively moving or how did you determine what level the patient was able to perform in terms of walking? How did you find that balance?
When the patient first gets put on ECMO, they are pretty sick so we do try to do a natural progression. We start off by trying to sit them at the side of the bed or sit them up in the bed and see how they are able to tolerate that. Mobility means a number of different things for a lot of patients and different statuses of their health condition, which is why it’s difficult to quantify mobility, especially in the ICU.
For these patients at the beginning, they’re very sick. So mobility might look like sitting on the side of the bed with physical therapy. And then we continue to try to make sure that we make mobility a priority for that day.
We make sure that we work in a multidisciplinary approach to have respiratory therapy, the nursing staff, and also physical and occupational therapists available. And we make slow steps to make sure that the patient continues to improve each day. We take into account their hemodynamic status to make sure that we’re not doing something that is going to cause more harm than good. But, typically what we see in this patient population is they end up getting up to a chair and then from there they start walking and they walk a couple of steps one day and then they walk a little farther next day and they keep walking further and further and they optimize their status so that they are in a better position to be in a cardiopulmonary endurance state.
And we make sure that we motivate these patients. A lot of these patients that are in these conditions can become very depressed also – from just being stuck in a room they can’t get up on their own. They can’t do a lot of things for themselves. So we kind of take away a lot of people’s independence in the ICU, and that can be a very difficult thing when we talk about mobility too. So we make sure that we kind of parade them for all their little achievements And it’s nice to see when they get farther and farther in the coming days.
Right! And there may be a sense from an outside perspective that an ICU nurse is just worried about keeping people alive, you know, and making sure that they progress and get out of the ICU is a challenge. And so mobility is not always prioritized in that sense because you have so much going on.
Yeah, I think the biggest point is that mobility in the ICU is something that is created by a culture change of nurses empowering each other, especially in that interdisciplinary approach to make sure that we’re honing in on mobility as a goal of care for these patients. When they get up more often during the day and we spread out that mobility and not just work on them and make sure they get up. If they get up for three hours at one time rather than getting up one hour three times a day and we space it out, those patients are tired by the end of the day, they end up sleeping better when they sleep better, they have better sleep-wake cycles and they can be awake to participate in their care.
And it decreases their incidents of delirium also. So all the things kind of go hand in hand and it’s really nice when they come back to you after, specifically this ECMO patient population. This patient ended up getting a lung transplant after proving the ability to mobilize and get better, and it’s really nice when they come back and see you in street clothes and you see the endgame of all the work that was put in.
Thank you very much for joining us today on the podcast, Allison. Thank you for your time and your work in the ICU. It doesn’t go unnoticed by us. So thank you very much.
