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!
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.
Dr. Pavon is a researcher and associate professor at Duke University and works with the Durham VA for geriatrics. During our conversation, we get into the importance of mobility measurement. Dr. Pavon’s research revolves around using accelerometer data to measure mobility in the hospital, and one of the key takeaways from our conversation stems around the best way to use objective data in order to improve clinical practice. Just like many things in life, it is often hard to improve on something until you measure it, and that’s something that Dr. Pavon’s research has really highlighted.
“I think the main reason why I feel it’s important to objectively measure mobility through something like wearable devices is that it gives more awareness to the provider about whether the patient is actually moving or not moving. The converse is also true – a provider might assume that the patient is moving more than they are.”
– Dr. Juliessa Pavon, MD
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.
Hi Dr. Pavon! As we do with all of our guests – let us know what your overall definition of mobility in the hospital is and then bring us back to your original research on this topic in 2018.
Well, thank you very much for the opportunity to be here, and I’m very excited to talk to you about mobility, especially mobility in the hospital because what we’ve seen is that patients spend a lot of their time in the bed while they’re hospitalized.
We’ve seen other research support that over 90% of a patient’s hospital stay is spent in bed, and that was very striking to me. (For us) the majority of our rounds are spent talking to patients over their bed and very little seeing them up in the chair, or even up and walking around in the hallways.
That only became more evident as we (started) to see the impact immobility has on hospital outcomes. I would certainly define mobility in the hospital as an activity that takes the patient from a lying position, even up to a sitting position that would still count as mobility. Mobility from the bed to the chair certainly counts – but walking activity outside of the room into the hallway is really where we want to see mobility (eventually) happen.
We ask that question because you can talk to 10 people, and you might get 10 different answers on what mobility in the hospital should look like.
What led you to notice these gaps in how mobility was being addressed in your system, and how were you able to take that into your research to start finding these accelerometer-based ways of measuring mobility?
I think part of what happened is that in talking to patients we would certainly ask, “Have you gotten out of bed today?” And a very simple answer sometimes is yes, but other times it’s no. Even with the yes, that still doesn’t say enough.
We’d then follow up with the question, “Well, how much walking were you able to do?” for instance, or, “How much time did you spend in the chair?” And again, generally, answers are very vague. Some patients can’t really recall the amount of time that they spend up in the chair or walking. And we thought knowing those details was still a very important part of their recovery process to actually know how much time someone is spending out of bed or walking.
We would then dig into the chart to try to find out from a PT note, for instance, or a nursing note. It became difficult to consistently find that (mobility) information in the chart, and so there was this awareness of the need for some objective measure of mobility. We found that one objective way of measuring mobility certainly is with the use of wearable devices.
And I guess the hospital patient is unique in the fact that their gait speed is going to be slower. They’re typically not as quick to move. And we know that accelerometers in consumer-grade technology are not 100% accurate all the time. So how did you go about validating this tool for the hospital patients specifically?
You bring up a good point about how mobility in the hospital is very different from mobility in the outpatient setting. There’s more of a shuffling gait in a lot of our inpatients too so we did want to look for monitors that had taken some of those features into account.
And the striking part we found is that the median number of steps that patients were taking during their hospitalization was a little bit under 1300 steps a day. And certainly, that speaks to the minimal amount of mobility that is occurring in the hospital with a range from 200 steps to 6000 steps a day. But that also was consistent with what other literature has shown around mobility in the hospital.
Hospital-acquired disability (HAD) refers to functional loss acquired during hospitalization. According to Dr. Pavon, a key contributor to HAD is patient immobility. Dr. Pavon’s research defined HAD as having one or more of the following: 1) A new ADL deficit from the Katz Activities of Daily Living Scale 2) A decline of 4 or more points from baseline to discharge in the functional component of the abbreviated Late-Life Function and Disability Instrument (LL-FDI) 3) Discharge to a skilled nursing facility (SNF) determined by chart review or telephone follow-up In the following graphic – average refers to the median total daily step count, which was 1456 steps per day.
Right! And going back to your 2018 article about pharmacologic VTE intervention and relating it back to mobility. Where in your research did you find this connection between VTE prevention and mobility?
That was a unique study that (compared) wearable mobility data with someone’s EHR data. We placed monitors on patients’ ankles and wrists and then had that monitor in place during the duration of their hospital stay for up to seven days. Then, we looked at the patient record to see what type of VTE Prophylaxis orders they had been receiving during that time. So we were looking at the start date for the VTE prophylaxis and the end date.
And what we found was that even for the patients that were moving the most in the hospital – that 4,000-5,000 steps a day range – their length of time with pharmacological VTE prophylaxis was just as long as the person that was moving with the fewest number of steps a day.
And that is not what we would have wanted to see because the guidelines certainly recommend that for patients who have mobility – VTE prophylaxis can be shortened. We would have wanted to see that those with the highest number of step counts would have had the shortest days in prophylaxis use.
NOTE: VTE prophylaxis was anything related to the heparins or, the Lovenox medications, pharmacological VTE prophylaxis as well as mechanical VTE prophylaxis. The study mostly looked at pharmacological intervention but sequential compression device orders were also considered.
And that makes sense – as a patient starts to walk and their calf pumps the blood back up to their heart for them, they don’t necessarily need to rely on that pharmacological intervention and blood-thinning drugs. So how does the typical patient get assessed for their pharmacological VTE intervention and when do they decide to wane them off that drug?
The guidelines do vary around whether a patient is a general medical patient versus a surgical patient – but overall there is a recommendation to use VTE prophylaxis especially when someone is medically ill and always and surgically ill as well. And the main recommendation is around pharmacological VTE prophylaxis.
There are recommendations to risk stratify using scores such as the Padua or the Caprini risk stratification score as well. And that’s where mechanical VTE prophylaxis becomes very important because there are a good number of patients who have a risk for bleeding, especially post-surgery.
So what is the importance behind mobility measurement even for the most various of patient types? Why is it important to measure mobility?
I think the main reason why I feel it’s important to objectively measure mobility through something like wearable devices is that it gives more awareness to the provider about whether the patient is actually moving or not moving. The converse is also true – a provider might assume that the patient is moving more than they are.
(During our research) we interviewed providers and patients in terms of what type of information they would want about their mobility. And there was a lot of interest in knowing certainly the step counts but also the amount of time that someone spent out of bed and moving as well.
That was my next question of what metrics were important to you guys. Finding a standardized way to measure mobility is so crucial, but then understanding what’s going to be important for the caregiver is the other half, right?
The literature is consistent around thresholds for the number of steps that someone should take in order to prevent functional decline in the hospital, and that threshold is somewhere around 1100 steps a day. So I would say step count is still one of those metrics and then also a position and time spent in that position out of bed.
Some patients might not fully make it out of the bed and into the chair – but there is still a difference between laying down flat and at least spending some time sitting up in the chair. Making that distinction is a difficult piece for some of these wearable devices.
The literature is consistent around thresholds for the number of steps that someone should take in order to prevent functional decline in the hospital, and that threshold is somewhere around 1100 steps a day.
dr. juliessa pavon, MD
So, what’s the follow-up with these findings through the research? Are you just going to strap accelerometers on every patient just to see what they’re up to?
I think what we’ve learned the most through this work is that even if we were to strap an accelerometer on every patient and that data was available, there’s still a lot that needs to be understood on how the end user would use that data.
So how would the physician change their clinical management, knowing how much the patient is moving? How would it change nursing workflow? How would it change PT/OT workflow? And when we did start to do a deeper dive into understanding that we found that there was a big impact on the culture of mobility.
There is still such a big drive to minimize mobility because of this ‘falls never event.’ That is a federal quality mandate in the hospital where the goal is to have no (patient) falls in the hospital. That mandate is driving a lot of the culture you see around mobility. So even if patients and providers would know how much they were walking, would it really change the nurse being willing to move the patient out of bed if there’s still all this concern around falls as a never event.
What we’re realizing is that we’re focusing on implementing a redesign of mobility in the hospital with the focus of changing some of that culture around mobility. I would say that’s the main next step and then using objective mobility within those types of interventions that are being developed to promote mobility in the hospital.
It seems to me that patient mobility is like a lot of things in life where if you don’t measure it it’s hard to change. The underlying reasons why hospital patients are often immobile are known – they’re very ill in a lot of cases. But truly how do you change something unless you have an idea of what is going on in the first place? Or am I missing something?
That’s right. A big part of the culture change is around documenting mobility. So even without having a widespread objective measure of mobility, at least there is this idea that some standardization needs to occur.
That decision must be within the institution to make it (happen). For example – are we going to measure mobility through steps? Are we going to measure it through time out of bed? All of those discussions definitely need to occur. But for sure, even just documenting something that in a standardized way is really part of the culture change.
You mention finding only 52% of older patients had any type of walking documented in the EHR. So what does that tell you? Obviously, that’s not to the level of which it should be. Is that correct?
The first three days of being in the hospital, very few patients have any data around mobility because it’s usually around day 3 when PT and OT are consulted – and only then do you start to get documentation of mobility. So for the first three days, when it’s a very critical period of a patient’s hospital stay, there’s very little information about mobility.
And once those three days pass, only around 50% of the older adult population receive a PT or OT consultation. This becomes very challenging for the providers to make clinical decisions around their hospital care because minimal mobility can contribute to delirium, it can contribute to a longer length of stay, to functional decline in the hospital, and then requiring a higher level of care after discharge. So that’s why that becomes very critical that for three days essentially providers are kind of driving with blinders on.
Yeah, exactly. That is a scary situation considering those are some of the most critical days in the hospital that there is essentially no data that is currently collected.
That’s why I definitely like a lot of the work that your group is doing around trying to capture mobility in an objective way throughout the hospital by using medical devices. Because certainly, one way of capturing objective mobility is through devices that patients are already having to wear.
And then the low-hanging fruit would be a culture change around documentation. So for instance, there’s a big focus in our institution in having nursing participate in some of that documentation around mobility and being able to screen for mobility using a bedside mobility assessment tool. There are also other tools like an AMPAC that other institutions are using – but having that be part of the structured daily workup for a patient is incredibly valuable.
Dian has been a thought leader in pneumonia prevention in the hospital, and her work has highlighted hospital-acquired pneumonia, the #1 hospital-acquired infection, as an underrepresented problem in hospitals across the country. During our conversation, we talk about the importance of mobility when it comes to preventing pneumonia in the hospital and some of the simple steps that bedside caregivers can take in order to improve outcomes.
“Given all the new information, we understand the critical importance of mobility in the hospital. Up as often as possible, up as early as possible, and maintaining activity is one of the most essential things nurses can do.”
-Dian Baker Ph.D., RN, APRN-BC
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.
Hi Dian – Thanks for joining us today. I want to start by talking a little bit about preventative measures in general such as routine oral care and mobility and how these help prevent adverse events.
There are several parts to a nurse’s daily job in the acute care setting that interface with the prevention of secondary complications. We consider these aspects of fundamental care to be essential nursing procedures and interventions. And perhaps amongst the most important of those is mobility.
Mobility is tied to improving outcomes in several different areas, including prevention of non-ventilated, hospital-acquired pneumonia, gastric mobility, prevention of deep vein thrombosis, overall health, less muscle disintegration, maintaining a patient’s strength and well-being. The other important intervention that nurses do on a daily basis to help prevent non-ventilator hospital-acquired pneumonia is preventing the oral microbiome from building up germs by daily oral care.
So the connection between mobility and fundamental care and other types of fundamental care, such as oral care all work together to protect patients in hospitals from non-ventilator, hospital-acquired pneumonia.
So you say, protect patients, which I find really interesting. What are some of the physiological benefits of mobility that directly affect hospital-acquired pneumonia prevention?
There are several physiological processes that help us prevent pneumonia. So in our lungs, full expansion helps us prevent pneumonia. Having good ciliary action, the little hairs that kind of keep brushing up dirt and things forward, help us prevent pneumonia.
General mobility helps us prevent pneumonia because it allows for greater lung expansion. It moves the fluids around in the lung and encourages us to deep breathe and cough, which we all do several times a day. I would say it’s all part of lung hygiene. Lung hygiene and the ability to perform those necessary functions are directly tied to your mobility.
Even just sitting up. Everyone knows when they get up in the morning, the first thing you do is just take a nice big breath of air, you expand your lungs, you kind of get them ready for the day. Very often you might cough a little bit and just wake them up and get them going and the more that you do that, the healthier your lungs are going to be less likely you are to get pneumonia.
I listened to a previous podcast that you have done where you reference the great divide in terms of oral care’s relationship with the rest of the body. Can you talk a little bit about that?
Yes, we actually study the mouth, and who takes care of the mouth belongs to a whole different profession and that’s the dental profession. And so when patients come into the hospital were often not thinking about looking in their mouths, assessing their mouth, making sure that oral hygiene is maintained because it’s been psychologically and professionally separated from us, which has created a great divide.
And therefore when patients are in the acute care setting, little to no priority is given to the absolute physiological health reasons to maintain the oral microbiome and to prevent germs from growing in the mouth. We tend to think of it as a nicety, not a necessity for the patient’s well-being.
And that great divide continues today, although there have been several groups that are moving toward what we call oral-systemic health and trying to reunite this great divide and to get us more focused on thinking of oral care is actually a therapeutic intervention, much in the same way we would think of mobility as a therapeutic intervention.
They (Kaiser Permanente) rearranged their workflow, they got patients up out of bed first thing before a lot of other activities took place because it became prioritized.
They knocked back their NV-HAP rates significantly, also reduced their antibiotic usage for patients, all of which are very positive outcomes. All directly related to priority with mobility.
DIAN BAKER, PH.D., RN, APRN-BC
Right. So do you see a similar divide when it comes to the importance of mobility and uh the execution of mobility in the hospital?
Yes, very much so. We think that mobility is something we can do when it’s convenient and that what does it hurt if somebody’s in bed for a few days and that’s an incorrect assumption on the part of all of us.
Given all the new information, we understand the critical importance of mobility in the hospital. Up as often as possible, up as early as possible, and maintaining activity is one of the most essential things nurses can do.
Nurses just like the rest of us are constrained by time and even more so in many cases. How do you see oral care and mobility become either prioritized or deprioritized, and what leads to that?
Well, first and foremost, nurses need to be educated about the importance of oral care. Again, seeing it as a therapeutic intervention rather than something nice or simply a comfort care. The same thing with mobility, it’s not the last thing you’re going to do if you can get around to it, it should be the first thing that you should do.
The constraint of time requires sometimes reorganizing the team and how the team works together. It involves getting patients and families involved in their care, and it involves education for the patients and families. Quite often for the patient care technicians or nurses aides that are also caring for the patient and working with other team members that have a role in mobility such as a physical therapist. By working all together, realigning our priorities, we will find a way.
I have a great example of that from Kaiser Permanente in northern California where they put mobility as a priority on the unit. They rearranged their workflow, they got patients up out of bed first thing you know before a lot of other activities took place because it became prioritized. They knocked back their NV-HAP rates significantly, also reduced their antibiotic usage for patients, all of which are very positive outcomes. All directly related to priority with mobility.
Yes, that’s a great example of how successful mobility initiatives can be in the hospital. So thank you for sharing that. And I find it interesting because we know that there are all these benefits for mobilizing patients, but there has to be a reason why patients aren’t being mobilized in the first place. As a nursing educator yourself, do you see a fear of falls being instilled in young nurses? And how does that contribute to immobility?
Yes, I think I think there are several barriers that allow us to have mobility is less of a priority. Certainly one is time, right? And we talked about teamwork and the importance of that. The other is the emphasis on fall prevention. You cannot go into a hospital today and not see warning signs about falls, patients wearing yellow socks, and signs above the bed.
All those things would send a pretty direct message to any nurse in the field and especially new nurses into practice. (Nurses find themselves saying) “Oh, the most important thing I have to do here is to make sure my patient doesn’t fall and it feels like getting them up and out of bed would increase that risk.”
But it doesn’t. We know from numerous studies that mobility programs do not increase fall risk and in fact, there is fairly suggestive evidence that it does exactly the opposite.
Maintaining the patient’s strength, getting them up, setting up good communication techniques so patients get assistance when they need to get out of bed are all things that not only prevent falls, but you get all the advantages of mobility with it.
Exactly and not just the fear falls, but also the unknown of whether a patient is ready to mobilize or not. You can ask them questions and try to feel out the situation and based on the physical therapy consult, you have a lot of factors there. When it comes down to it, you want the patient to be ready to mobilize. So how do you know that?
Good assessment technique, communicating clearly with the patient and the family, using a standardized mobility readiness framework, assessing the patient frequently every four hours, and then minimizing those things and activities that take away from mobility time.
So for example, a patient can be off to therapeutic things like going to X-ray or having tests and procedures, or they gotta wait for the lab person to come in. Reorganizing the day and putting mobility as a priority will also help with all of that. So you’re kind of knocking down those barriers and you know, if you will excuses.
Right. Because if there is clarity around that mobility status and readiness to mobilize, then you can take a lot of the question marks out of it. I wanted to also talk a little bit about family member engagement. I know you mentioned that briefly, Can you talk a little bit more about the importance of family member engagement in all of this?
Most family members want something to do. They’ve come to the hospital to visit their loved one for exactly that reason. They’re there to be comfort, support, and help. By engaging them in a partnership and asking them what they would like to do what they’re comfortable doing and then taking the time to teach them.
I can remember one time working with a family, a patient had just come out of surgery. It was a very large surgery that had been over six hours and the wife was there and (the patient) was very drowsy. It was time for his oral care and he just didn’t want to do it. He didn’t want to sit up in bed – didn’t want to move. He just felt so down and out, and I’m talking with his wife about how to talk through those feelings and emotions. And then her offer of I’m here to help you. I will help you brush your teeth.
As the nurse, I was able to show her the technique to use a suction toothbrush. And then we went through the passive range of motion for all of his limbs and talked about the importance of turning in position and building up his strength. All the while doing reflective listening and teaching with both the wife and the husband.
It wasn’t long afterward, he was sitting up and brushing his own teeth. He had good passive range of motion when he wasn’t able to get out of bed. So he was prepared for when he could get out of bed. And those types of engagements with the family are one of the beautiful joys of nursing.
When did your research on the effects of pneumonia in the hospital begin? It seems as though you’ve really prioritized spreading awareness about the importance of pneumonia prevention and doing a lot of research to help continue that conversation on a nationwide scale. Can you talk a little bit about that?
Several things happened about the same time in my career about 10 years ago, and I was invited to partner with two different hospital systems in northern California. And at that time the CDC had just put out very strong advisories that hospitals had to be held accountable for hospital-acquired infections. But in looking over the data, what the hospitals found was that their number one hospital-acquired infection wasn’t on the list that was being required by the CDC. And that number one hospital-acquired infection was non-ventilator hospital-acquired pneumonia. It felt, at that time, like a huge ‘aha.’ There’s this hidden infection, hospitals aren’t aware of it, no one is doing anything about it specifically, and it’s not being required to be monitored like the other ones. And yet it’s the number one or number two hospital-acquired infection in every hospital we looked at.
Ultimately we did a national study with 21 hospitals across the country and found the same thing. It was like opening Pandora’s box and our group decided that we were going to persist study and pursue this until we have the opportunity to bring to national attention this problem.
It’s now the 11th year into this journey, and I’m proud to say that one of my colleagues Dr. Shannon Munro with the Veteran’s hospital system is leading a national effort called ‘No HAP’, which has partnerships from the CDC, AHRQ, The Joint Commission, American Hospital Association, American Dental Association, and multiple academic institutes. Groups have partnered together to get this on the national radar. So it’s been a long but rewarding journey. And I think we’re not too far away from every hospital having to talk about oral care and mobility as a priority in terms of nursing care to prevent pneumonia.
Well, we thank you for the work that you’ve put in and that you’ve been able to uncover some of these key issues in the hospital. If you could, for our listeners – detail the difference between non-ventilator-acquired pneumonia and ventilator-acquired pneumonia. And talk a little bit about how the two are differentiated in the hospital.
So great question. And a lot of people do ask about the distinction. In fact – when we first started talking about non-ventilator hospital-acquired pneumonia, people were confused. They just kept assuming that we were talking about ventilator because that was so much the priority for everyone. And it became a priority because the CDC issued that requirement that hospitals had to and must monitor and pay attention to hospital-acquired infections. But as I mentioned before, NV-HAP was not on that list.
First of all – hospital-acquired means something that you get after you’ve been in the hospital for 48 hours. For non-ventilator – it means that there’s never been that device or that tube put down into the lungs, which greatly increases the risk of pneumonia.
It makes sense – you’re taking a tube through that germy mouth and putting it into the lungs. It’s easy to see why ventilator-acquired pneumonia could occur. But the thought that patients were getting pneumonia not being on a ventilator wasn’t really well established or very well studied, especially among non surgical patients. And so our difference is calling attention to the information from our study that non-ventilator hospital-acquired pneumonia occurs on every unit in the hospital, including maternity.
There is a risk for all age groups and all patients to some extent. Certainly some patients are more at risk than others. Elderly, frail, oncology patients, but they’re not the sole risk. In our study, 50% of the patients were under 65 and so it’s it was like this hidden alert. So just trying to create that general awareness and seeing people to distinguish between envy. HaP and ventilator acquired pneumonia I think is an important one. It’s not just the ventilator that creates risk.
Well, Dian, I want to thank you for your time today. We appreciate your expertise on pneumonia in the hospital and willingness to share with our listeners some of the impacts that preventative measures such as mobility and oral care can have on improving pneumonia outcomes in the hospital. So thank you very much.
Brueilly’s background in education and physical therapy clinical practice came full circle when he was diagnosed with a saddle pulmonary embolism in January of 2019. In this episode – we detail Kevin’s lessons from going through this scary situation and how his focus has since shifted to bringing awareness and research around post-op recovery and mobility.
I think his story is something that we can all take something from and learn a little bit about what the risk factors are for DVT and how mobility ties into this whole story.
“I think the biggest misconception I had before doing any research was that a DVT was a small thing, you know, the size of a dime or something like that. But DVT is really when they break and they pulled and flow into the pulmonary vasculature. The really dangerous ones are really long like feet and inches long.”
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.
Kevin Brueilly’s clinical background as a physical therapist began at Mayo Clinic in Jacksonville Florida in the 1990s. As a young professional. He was always questioning norms at his hospital, a trait that eventually led him towards a path and research and academia later in his career. One of his early observations as a clinician was the hands-off approach to patients diagnosed with deep vein thrombosis or DVT. The norm at the time was to keep DVT patients in bed and discourage movement at any level in order to let the body heal.
Now, Kevin knew through his training that this physiologically didn’t make any sense, and began to look into this seemingly widespread problem. Along with other doctors at his hospital and his medical director at the time, he put together an informal clinical practice guideline at his hospital to address this.
Since then, Brueilly has gone on to receive his Ph.D. in education and is responsible for starting physical therapy programs at numerous academic institutions. His combined experience as a clinician and educator came full circle with his own personal battle with blood clots in 2019, Brueilly describes the sense of anxiety he felt in the days leading up to his eventual diagnosis.
It was alarming. It was in the wintertime, right after Christmas break, and I had been somewhat sedentary, but I wouldn’t say I was sedentary. Typical Christmas break, watching football, you know. I remember laying on the couch, watching a couple of games, one day back to back, and thinking man, “this is the least I’ve walked in any day in my life I think.”
That’s very possibly where I contracted it, but who knows. Leading up to that incident that day, for about two or three days before, I do recall having some calf irritation. I wouldn’t say pain, but it was like an Achilles tendon strain. That’s what it felt like. And I remember having some shortness of breath and nausea, but that’s about all I remember. My wife was giving me a honey-do list one time on Saturday.
She noticed that I was breathing heavily, and she said, “do you know do you need to go to the doctor?” I said, “no, no I don’t think I need to go to the doctor.” But at that point, I recognized I was breathing heavier than I normally do. And even that day I remember pulling up the Wells Criteria for DVT and scoring myself and finding out that I didn’t meet the threshold of DVT being likely, but it did cross my mind.
So, that was a Saturday.
On Tuesday morning, driving to work, I started to have a real heavy unproductive cough. It was not the light, pollen asthmatic allergy kind of cough. This was a cough where you’re trying to cough something up but I wasn’t able to. And this is on my way to work at 7:00. AM. And as I came into the office that morning I had about a maybe 100 yard walked from my vehicle to my office and I just remember what a challenge it was to take that walk.
That must have been such an overwhelming feeling. What were some of the symptoms that you were experiencing at that time and what did you think that it could have been?
(I was) sweating profusely, and I could hear myself obviously breathing heavily and wheezing with the breathing. And I thought, “you dummy, you’ve let yourself get pneumonia from laying around watching football.” That’s exactly what I thought.
So I went out and sought out one of the faculty members and asked them if they could get me a thermometer to take my temperature. I took my temperature and was normal. So I’m like, okay, something else going on.
I went and laid down for a few minutes and almost immediately after I laid down, I could not get enough air. I laid there for five or 10 minutes just struggling and decide I’ve got to get up. This is getting worse. And I got up, and went to the faculty member again and said, “can you give me a pulse oximeter?” And they did and what got me on it, but the battery was dead.
So I said, “I don’t feel well. I think I need a ride over to the emergency department.” That’s probably the best decision I made. I stumbled into the emergency department and they quickly brought me back and diagnosed me with a DVT and PE.
Kevin Brueilly, recovers in the ICU at the Augusta University Medical Center, GA. He recalls being in disbelief at his saddle pulmonary embolism diagnosis although he felt quite calm knowing he was receiving excellent care.
Thank you for sharing that story. I think it really shows that this could happen to anyone. When they told you that obviously were probably surprised. But, with your background and understanding of what that meant, what was the first thing that went through your head there?
It’s actually comical now that I think about it, but my first response to the dock, when he told me you have a pulmonary embolism, I said, “I can’t have a PE.” And he said, “why?” I said, “because I haven’t felt anything, and I haven’t experienced any of the symptoms.” He started going through the symptoms and I’m like, “Okay, yeah, you’re right. I do.”
(Chuckles)
About that time, the spiral CT results came back and it confirmed a saddle pulmonary embolism. He said, “by the way, it is a saddle pulmonary embolism. Both your pulmonary arteries are blocked.” And I remember responding to him saying, “that’s impossible, I’m still alive!” And he said, “I know.”
I remember at that point, the respiratory therapist in the room said they had exhausted all their options, and the next option was a ventilator. This was a very busy time in the hospital. Covid wasn’t there yet, but for some reason, there were a lot of ventilators in use. She said they had one clean ventilator in the hospital, and that she was going to take that with me to my treatment room so that in case I needed it, I would have it available. So it was very surprising and it really took me back.
The doctor said, “by the way, it is a saddle pulmonary embolism. Both your pulmonary arteries are blocked.”
…and I remember responding to him saying, “that’s impossible, I’m still alive.”
kevin brueilly, pt, ph.d.
I’m sure that’s a really scary situation to come out of. Um, And how did you start to look at your rehab? And it seems like you almost became a research subject of your own in a way. Can you kind of outline how that process all went down?
Basically, I used myself as a research subject, but it’s not really my intention when I did it. It was more of understanding what’s going on and making myself better sooner. So I am not going to allow myself to lay in bed for days and then try to get better. I am going to work through this and I’m going to make sure that I stay the best that I can be and not have some kind of long-term disability or problem as a result of this.
What I saw in the hospital and what really made me want to learn more about mobility and particularly mobility after blood clots was how debilitating bed rest is. Just look at anyone after surgery, after injury, after illness, after (almost) any condition. After a day or two in bed, it requires more than a day or two to get them back on their feet.
Particularly that ICU-acquired weakness was multiplying the number of days. I’ve had enough experience in my professional life that when this hit me in my personal life, it gave me a new understanding and a new appreciation that I could drawback on that.
First of all, I’m glad you’re able to recover from this situation and you’re able to kind of take what you’ve learned from that situation and bring it straight into your research. I think that’s very telling of how personal this got for you.
How did you take, what had happened to you and bring it into your research and can you talk a little bit from your physical therapy background of why these mobility milestones and getting up out of bed is so important?
The reason that we don’t want people lying all the time is the pulmonary alveolar and gas exchange, but just as important as the fact that when you’re upright, your heart has to work against gravity. So it’s giving your body more of a challenge to push that blood up to your head and keep your brain perfused and the rest of your body. So it’s actually a therapeutic effect to get a patient from lying to sitting. You know, even the smallest amount of upright puts a tax on the heart and allows the heart to have to work harder in order to maintain that equilibrium.
That’s why, you know, when we faint, we fall and that’s a safety mechanism so that we continue to get blood to your brain because if we stopped moving and never went down then you know, potentially would not give blood to our brain. And if you lose blood to your brain, it doesn’t take long at all for brain death to occur.
Thoughts of my rehabilitation revolved around the rehabilitation of my own physiological self to build my strength back and to combat the effects of lying in a bed in intensive care for two days when I could not move because that ecosystem catheter was in my venus system through my heart and into my lungs. And so I couldn’t move around because that was all attached to a pump that was basically saving my life to break the clot. All I could do (in the ICU) was lie on my back and do isometric exercises with my other leg and my arms and my core and things like that. But I couldn’t get up. So that was the one thing that I really wanted to do was get up out of that bed and test my system and make sure that I was moving and maintaining what I had so I didn’t lose anymore and then focus on gaining that strength back.
I remembered again what I had looked up in my days as a clinician that as long as I’m anticoagulated, that clot is attached to the endothelial wall, it’s not going to propagate and it’s not likely to move. So I made myself get up out of bed almost immediately when I got to that hospital room and they had removed that cannula from my leg and I just started going through short bouts of exercise to my level of tolerance until I got home. And then I continued it.
Yeah, and that’s the important thing is continuing that exercise and continuing to progress in your mobility is important for recovery. What do you think are some of the common misconceptions about DVT s and pulmonary embolism that you might have had before it happened to you?
Well, first of all, “t couldn’t happen to me.” I was in that, you know, I denied it. I’ve been a physical therapist for close to 30 years, and I’ve caught patients that had DVTs and got them help and potentially saved them from having a PE. But, for whatever reason, I decided it didn’t happen to me or couldn’t happen to me.
I think another (misconception) is that DVT requires a lot of risk factors when really it doesn’t. Blood clots happen to everybody every day. Even healthy people throw pulmonary emboli, but they’re microscopic into their lungs and it’s when they start getting larger as when the problem occurs. So it does happen to everyone.
I think the biggest misconception I had before I started doing any research was that a DVT was a small thing, you know, the size of a dime or something like that. But when DVTs break and they flow into the pulmonary vasculature, the really dangerous ones are really long like feet and inches long!
The PE that we believe that I threw went from the length of my knee to my hip, and I’m 6-feet tall. So that’s you know 20-24in long and this is a blood clot, probably the size of a pencil or larger. That’s a lot of solid material to go up into your lungs and just start bawling up, and that’s what shuts off your blood flow. And that kind of gave me the confirmation that this was a big caliber clot that started from my knee and went to wherever it ended.
Most of my reading has taught me that DVTs don’t occur to people that move period. It’s just not likely if you’re up and moving around regularly, you’re probably not going to get a DVT and thus you’re not going to get a pulmonary embolism. So that was the first thing in my mind as I’m getting out of this bed. Even though I knew I was anticoagulated, that (the clot) was not going to grow, I just knew that I wanted to get up and I didn’t want to have the effects of immobility jump on me and have a long rehab because I need to get back to doing what I want to do. I just have too many things to do to not be healthy.
Wow, I think those are some powerful messages and maybe some things that people don’t consider when they think about DVTs and PE.
I also want to get your thoughts as a physical therapist and someone that’s been in the hospital. What are the best ways to motivate a patient to be mobile from your perspective?
I mean someone in the hospital, it’s obvious you have to weigh the risks and benefits of getting them up. What’s their condition and what’s occurring. But for someone who doesn’t have active pathology at the time, it really is a mindset. I don’t know how many people have an Apple Watch, but I got one about six months ago, and it gives me my score at the end of the day, if, how many times I’ve been up on my feet and how much movement I’ve made and how much exercise I’ve had. And it’s a really good reminder to tell myself, “hey, you met your goals today or you didn’t meet your goals today and tomorrow you got to do better.”
What we sow today we reap tomorrow, not only in the vegetable market but also in our health. That’s what I try to teach my patients is that your lifestyle today is what you’re gonna be looking back on 10 and 20 and 30 years from now saying, “I wish I should have done it or could have done it differently.” Adopting an up-and-moving lifestyle is certainly something that we would want everyone to adopt that is able to do it.
That’s very true. And something that we want to encourage people to continue to do with this podcast. So thank you again for your research and your time today. I think it’s a good reminder that even people who know the risk factors of DVT and immobility are still at risk so thank you for documenting that and making it a part of your research.
My whole thought and publishing it was If I can save one person out there that recognizes it and goes and gets treatment and doesn’t have to go through what I did then the effort was worth it.
Thank you for your work and thanks for joining us today on the Mobility Minute podcast. We appreciate your time and talking with us today.
