Episode 181: Physician Insights at CHEST
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This is the Walking Home from the ICU podcast. I'm Kaylee Dayton, a nurse practitioner and ICU consultant. I help teams create awake and walking ICUs through evidence-based sedation and mobility practices. By hearing from survivors, clinicians, and researchers, we'll explore how to give ICU patients the best chance to walk out of the ICU and go home to survive and thrive. Welcome to the ICU revolution.

Physicians hold a lot of power in the ICU. They are extremely educated, smart, and expert in so many high-level assessments, diagnostics, procedures, and management of complex and critically ill patients. They have the final say and write the mandatory orders that are rarely questioned. I've seen their incredible influence to revolutionize the ICU, like in the example of Dr. Makita Fuchida in episode 133, and in the example of Dr.

Dr. Brian Bellucci in episode 130, Dr. Terry Clemmer in

Episode two, who gave a yielding support to Polly Bailey in the 1990s when she created the Awaken Walking ICU process. Just last episode, we learned from Dr. Jahidul Alam about his physician leadership in his ICU in Bangladesh. I've also seen the opposite in which physicians prevent their teams from being able to update their practices. Throughout my consulting journey, I have seen physicians really step up to engage in trainings and help take lead.

I've also seen others that seem to not recognize the importance of the ABCDEF bundle. There is a perception of the bundle still being the ABCs of the early 2000s and just for awakening and breathing trials to check for intubation. There is sometimes a sense of this is an RN and rehab thing. I already know about all of this. I don't need the training. Then when they come on shift and find patients fully awake, sitting up and even walking, they panic.

We have had incidences in some of these ICUs we've trained in which physicians that did not engage in training come in and say things like, quote, why aren't they sedated? Why are they up? This is insane. I trained a team this year in which one of their awesome attendings that was on was really happy to engage in the revolution. Yet during rounds, his endorsement and leadership of early mobility was to, quote, sling them to the chair on every patient. He needed more clarity about

about what early mobility really is. We are all a product of our education, training, and experiences.

I really doubt that I would have questioned sedation and immobility if I hadn't started in an awake and walking ICU. I recently attended the CHESS conference to present with Dr. Del Needham, Dr. Wes Ely, and Heidi Engel. While I was there, I tried to understand the physician's focus and perception of caring for patients on mechanical ventilation. I wanted to know, as an organization primarily comprised of physicians with a heavy focus on critical care medicine, do they put equal emphasis on getting the endotracheal tube

out as putting it in. It was disheartening to see that classes dedicated to management of patients on mechanical ventilation and another on ventilator dyssynchrony were so full there was standing room only and there was little to no mention of sedation, mobility, and delirium management. Even in the class polls, increased sedation was a commonly selected answer for a response to ventilator dyssynchrony. So I set out to hear it from physicians personally. I

I followed the same model of spontaneous interviews in the hallway, like in episode 172 with nurses at NTI. I tried to select a range of ages and demographics to make sure I captured resident, fellow, fairly new attending, and very seasoned attending perspective of how the ABCDEF bundle is going in their ICU. As medical residents going into critical care,

What are your thoughts about walking intubated patients on mechanical ventilation? And you can be honest. I think when you start training early on, it's quite challenging because you're not very comfortable with mechanical ventilation. And so if there's any issues with complications, you don't feel very comfortable managing those complications. And so you're looking for help. But as you get more experience with managing these patients on the floor or in the ICU, you feel you're comfortable walking them and moving them around.

We don't do that at our institution, but I've seen it at other institutions. And I think for me, it would be quite challenging if we had to. I definitely want a lot of like support and like guidance on what to do. Yeah, I'll kind of echo what he says. I think one of the big things I see in general is multidisciplinary. So I think the big thing, at least we do the jump with our system, is getting a little new culture of care providers involved. And that includes physical therapy, social therapy, we're going to drive this.

If we have the support, I think it's important because obviously mobility, health, frailty decreases. And I'm hoping mobility will help hopefully wean ventilation sooner than later. But I don't think it's done as frequently. The same reasons he said is very challenging. Specifically, if you're running a busy unit and you have other patients to also manage and you may not have enough patients to check in at 2 to 3 p.m. as opposed to 7 a.m.

Tell me about your education going into critical care. Have you guys learned about the ABCDEF bundle? No, we have not. Maybe in a different capacity. I don't recognize the term. ICU liberation? Yeah. What have you been taught about it? ICU liberation in the sense of weaning patients. Just help me wait until you understand. What is ICU liberation?

If I had to guess, because I probably haven't heard the term directly, either has to do with two things. One is patients who are on some type of ventilation, non-invasive or invasive, and helping them get mobilized, get better, and get downgraded to force. Okay, you're not wrong. What have you guys learned about early mobility?

and delirium and sedation management in the ICU in your formal education. I have medical students now as residents going into critical care. In terms of like sedation, we're often taught the side effects, how to manage these patients while they're on sedatives or analgesics. We often try to wean sedation as much as possible. I see delirium, hospital delirium is very common. We often go on an everyday basis. I think we are taught to reinforce throughout the ICU really to make sure that our patients

are being weaned as much as possible, the more the better most of the time. And so it's something that we often focus on and we often teach incoming residents as well. In terms of formal education, we do have formal education as well. I've actually worked on our modules to help do analgesia and sedation modules to help our new residents, especially interns who are coming into the ICU on just basics of which patient deserves which anesthesia or which sedatives are best for certain scenarios, how to manage them, what are the side effects.

and different case-based learning for them to help practice with the sedations before they're actually in the ICU and have to manage that. After you intubate a patient, what are you taught to do after intubation? Or is it before intubation? How do you prepare a patient to be intubated? What do you do after in terms of sedation management? In any specific sedation management, I think the big thing we do well is...

huddling before and after an intubation, having a game plan. I think it depends on the patient and everything is patient-centered and individualistic approach. So if we expect the patient has been aggravated, it depends on what they're being intubated for as well. But if they need sedation, right? We know what sedatives to reach for through the education and the models that my colleague has given us. But also in the sense of, are there risks for some extubations? Or...

Are they, if they're already intubated, are we intubating them for like a full hour period? They're in status and they're just going to resolve when we're going to turn it off, turn off the phenobarb and they're going to wake up and they'll be fine. We want to keep them in the light sedation mode so we can do that quick on half a quick extubation. So I think every patient is individualistic. I think the one thing we do well is making sure we're all on the same page pre and post and that evolves naturally.

not just residents, but Moll's fellows and Moll's attendings and Moll's respiratory therapy. A patient is probably going to be intubated for a while, a few days at least, and they're arrested plus one on the ventilator and they still have delirium.

How do you manage that patient? What are the interventions to treat that delirium? That's a good question. Well, I know the one thing you would often do for delirium, which you shouldn't do, well, not for delirium, for agitation, you should not do when delirium is like benzene, right? So I think it depends how agitated they are. Obviously, if they're intubated and their rats want, they're awake. It's something you can go back to the root of delirium and kind of reorient and kind of just talk to them because it'll be different if they wake up, they'll go from negative 301 and they are like,

oh my god there's something in my mouth right versus they are already aware they recall that moment and they're just now like okay i'm ready to come out i think it's important assessing a patient are they actually ready if they're RAS one as long as the rest depending on what the rest of their clinical picture looks like maybe it's time to just take it out maybe but what if they still are on like a heap of content well lungs aren't ready and

Yeah, we're doing the waking trial and the comedoracipus one and they have delirium. Do you restart the laryngogenic meds like propofol? I think it depends on the patient, right? Like you're mentioning that this patient isn't ready. And so we weigh all the options. And so, yes, some of these things do have side effects and it's a risk versus benefit, right? If we ask about this patient and there's a risk that they're re-intimidated, right? There's a risk of other things. So you have to weigh your options on what would be best for the patient. Again,

The tube is not going to be like a bowl for these patients. And so we also have to understand that some of these are going to be for their better benefit. And then you can, instead of doing just continuous sedation, you can do intervals. You can do, you can work with your nursing staff to really find what sedatives work best. If you can do PRNs instead of continuous. And I think there's different modalities of different. I don't know if one patient's model would fit in every patient. So it's really a discussion, I think, and depends on the patient. Has it ever been part of your training to respond to

delirium, some anxiety, RASA plus one, plus two, with mobility. Has it been part of your training to consider getting that patient up and mobilized? No. And I think a lot of that is talking back to her with initial questions. We feel, do we have the resources to do it? The answer is probably yes. But I think there's a lot of other factors. We ourselves, as we said at our institution, we don't.

While for any of these I haven't seen, walking is good for student mobility. We do have intubated teachers doing physical therapy at times, depending on RAS or any of the next initiatives. But in that specific scenario you mentioned, RAS 1, I think they did major delirium through mobility. Is that something that first you're going to see?

It's fair to expect physicians to believe that they've kind of initiated it. They've never seen it. They haven't been trained to do it. They don't know how to do it. So, so you know, we're physicians where you're trying to acclimate to the environment and learn better.

basics of critical care, are you comfortable in then being the leaders if they're to fight physicians to lead this? I think everyone has different backgrounds. And so obviously in medicine, we have multiple disciplines. We work with the specialties. I think it's important to have someone who is specialized in this aspect. And I think there are physical therapists, there's certain hospitals that do have models that do incorporate this.

I think to ask like a resident like myself to come in and do this would be overwhelming, challenging and half a man's sleep. So I wouldn't come to look at it, but if I was given like proper training, given the opportunity to learn and have like support, I think it's important. And that would be like where and being able to take on this challenge just to come out of like medical school or just to come out of residency and be put in an ICU and expect to do that. That would be very fair to the patient, to the resident.

Absolutely. So should it be part of standardized medical education to really learn how to mobilize patients, manage their anxiety, agitation, delirium with proper tools so that you can lead a team like you're expected to? Absolutely. I think the biggest thing about this initiative, I think everyone should feel comfortable taking on an initiative and they feel healthy about it. Now that I'm learning about walking into bed with patients, something I've maybe seen on Instagram, but I'll be positive I maybe never, right?

have my mind turning back. Why don't we do it? Why don't we do it that often? And that initiative of mass curiosity should lead to some type of newer implementation intervention in terms of should there be for life? Because you're absolutely right. But I think also everything we work on nowadays, everything's institution based, right? I think everything, whether that's, whether that's a cost, whether that's a money thing, whether that's a resource thing,

But if there's initiative and there's curiosity, I mean, you can get somebody in the hospital system to do some type of educational intervention and kind of get all the residents on board because we all here learn. Specifically, as putting their fellows, even more so, right? Because we may be working at a solution now that doesn't walk into beta-biz and doesn't do mobility for delirium or BRASA plus one. We may match or go elsewhere that does, right? And

In that place, they're probably getting education and ruler that way. But what about the residents of that program? I agree. We're all products of our experience and training. Yes. And so no pressure. But I really believe in the next generation of clinicians to be open-minded, malleable, and bring evidence to the table to overcome what we've always done with what should wait. Thank you so much. Thank you.

As a fellow in critical care, what are your thoughts about walking and debating patients on mechanical ventilation in the ICU? In favor of it as a practice from what I've learned in terms of its potential for benefit, but have no personal experience with it yet at any institutions I've worked at. And how many institutions have you been at? In my fellowship, I've rotated thus far in three hospitals for ICU.

You've learned about it in your formal education. So has this been part of your medical education? It's been reviewed in some of my clinical lectures and training. Yeah. But yeah, I would say it is part of my formal education. And was it taught in a way that it's a key part of managing patients on mechanical ventilation? I would not say it as a key part, no. Kind of as like a next step ancillary thing, but not as one of the key features of the management. And what's the timing of educating? Is it like a rehabilitation measure?

I think it was in the context more in terms of not rehabilitation, but like outcome, time in hospital, disposition from the ICU.

That was the context of this, it was disgusting. A nice idea that shows benefits, but any practical logistical education on how to do it? None. When to do it? Similarly, none. I'd be like the limitation is not practically told of logistically how to do this. And more specifically, what kind of patient is a good selection for this?

So just early mobility in general, but not what kind of other baby. Not which patient, inclusion, exclusion criteria. Exactly. None of that. Right. What I've received this far. When the critical care community says...

our physicians won't let us or they need to take lead, they need to take charge. Is it fair to expect that of you? Especially once you become an attending, you suddenly lead this initiative in your ICU or wherever you land. I mean, ultimately it should be something, but personally I just need more exposure to training. But ultimately it is fair that the physician should meet that or certainly not be an obstacle to that. Definitely not.

Do you feel like physicians need and deserve more formalized education and more in-depth training? Absolutely. Absolutely. Tell me about what delirium education has been during your education. Certainly, personally, I've had a lot more education in delirium identification and in management. In internal medicine training, we do a lot of that too. So in hospital medicine, internal medicine training.

Definitely much more covered than mobility. Do you know how to do a CAM ICU? I've done them. I'd Google it again. But it's not a part of your assessment. No, I do. I review sometimes. I would say not every time. Sometimes it's nursing that does like the ICUs or the CAM ICs for her. But I do delay assessments. Yeah. And let's say a patient is on a PIPA 10, 60%, and they're a RASA plus one, and they're

They seem to be delirious. So the nurse says the patient is CAM positive. Okay. But they're concerned about this RASA plus one. What do you do? What are your interventions to treat that delirium? Any approach to delirium for me is always looking for any kind of factor in the hospital that's like causing an altered mental state, an infection.

Vent to synchrony in this ventilated patient would be something I look forward to. And then after trying to optimize everything, would consider if there was issues like a safety issue for the patient or something like that, increasing sedation. But otherwise, we just try to optimize all the variables around it as much as possible to improve the delirium. Would mobility ever cross your mind as an intervention to treat their delirium? Now that you say it?

Yes, but prior to that prompt, I can't say it would. I would think of all these other environmental things, family to bedside and day-night optimization and all these other things. But I can't say that I would have thought mobility and mobility

Now that you, with that prompt, I'd absolutely. But culturally, the nurse is going to be inclined to resume sedation. You even mentioned maybe resuming sedation. If there was like, yes. If there was like, there were, the learning was progressive where there was like safety issues, pulling in lines for two or something like that. So more of a RASA plus three or plus four. Yes, if they were going up in the wrong direction. But if they weren't going in the wrong direction, then no, no sedation without RASA plus one. That's hard to manage as a nurse, right? You turn your back, you don't know when it's going to escalate. 100%.

But does it make sense to give deliriodenic medication in response to delirium? Oh, never. No, it's done so frequently, but no, it does not make sense. But culturally, that's how you're trained to accept. Yeah, yeah. So it's a common practice for sure. Any suggestions that you would give for the medical community on how to better prepare on incoming positions on how to be leaders in early mobility? I guess putting it always in context with just all the other core measures that we do for patients in terms of

benchmarks that we want to hit with everyone like viewing it as one of those would then give it more standing more focus so i think like keeping it in a context that this is like a benchmark thank you so much absolutely uh intubated break or intubated like intubated uh intubated orally yeah okay well if it were me it won't be comfortable

But I see the point in why they're trying to do it. It depends on how sick the patient is, meaning what is their oxygen demands, how much metabolic work they're going to be doing, walking. If they're intubated for and they're on the process of recovery, then maybe something can be considered, but it's going to be uncomfortable walking them with an ET tube. Maybe if they're at trach or on ECMO, that makes perfect sense, but I'm not sure about

PT tube and walking. And you do transplant, rehabilitation.

prior to transplant. Some transplant units are very aggressive with mobilizing their intubated patients for transplant. What have you experienced? So in our center, we are a walking ECMO center. So for our patients who are ECMO-based to transplant, we make it a point to make sure they walk every single day. And we vouch for our physical therapy team, and they've done such a great job with our ICU patients, making sure they're at bedside every day.

The time is blocked off. We avoid any disruptions in PT time. So it's super important to walk our patients who are waiting on the transplant list. Excellent. And if they're only on mechanical ventilation, then it's more of a gray zone. Correct. But if they're tricked, we will still try to do range of motion exercises when they're in bed.

And if it's maybe someone with severe ARDS, by the time they get to ECMO, they've usually been sedated and immobilized, and then we're rehabilitating them, correct? Yeah, we still try to make sure they're able to set foot on ground and walk a few steps. So it's very painful the first few days, but we try to make sure because it's hard to advocate for a patient who is not able to walk. So we try to get them there before they can still be on the list and be rehabilitating.

We've had accidents with patients with ECMO cannulas, with cannula breakage or bleeding from the cannula site while we are trying to wake patients up and walk them. But that should not be something that would stop anyone from walking patients on ECMO. I think there's a way to deal with complications. Oh, that makes me so nervous. That's everyone's worst fear, right? Is that something happens with the cannula device and that is their lifeline. So why wouldn't you just scrap the program if something happens? Why do you still...

keep trying? Well, because of the benefits of having these patients awake and seeing the progress they're making is so important. It's important to their well-being. It's important to their family, their caregivers, and also our confidence in our team that we can handle complications. And we have a full supporting team at the time. So, you know, complications happen if you don't extubate enough patients.

you won't have reintubation. So that shouldn't stop you from extubating patients. I think of it the same way with walking intubated patients. Hey, as residents applying for your fellowship in critical care, what are your thoughts and feelings about walking intubated patients? Oh, major fan. Early mobilization is very important to weaning that ventilator. I've been at a couple of different hospitals where

There's been implemented mobilization protocols, challenging because it's time intensive, labor intensive, requires a lot of coordination. But ultimately, we're combating that critical illness myopathy. We're getting out of bed.

We're stretching those lungs as best we can and even combating some of those secondary factors that prolong your intubation, like medications, delirium, all those extra pieces. Okay. Did you learn this in medical school or did you learn this from working on site with those kind of teams, with that kind of culture? Partially with teams in that kind of culture. And I have a background of ICU chargers for a lot of years before I went to medical school. So I'm well-versed in a lot of those areas.

essentially just from past experiences. Yes, that's a very different perspective. And our friend here, what's your perspective? We worked in critical care before. As a resident, I've been the upper level on our ICU many times. And I think that I agree with him. Early mobilization, the earlier you can ambulate people, the better they do. Not just even from a cardiovascular standpoint, but the GI tract and

Everything works better when you can move patients. The only thing that I would have challenges with, I'm at a community-based center. And so having resources is usually the biggest limitation for these things, not just resources of things, but of people. And how do you encourage the hospital systems to invest in those resources? There has to be some type of benefit. So I think emphasizing that shorter duration of stay in the ICU is huge.

And we all know the sooner you can get people to an ambulatory state, this is post-op, this is whether they've been in the hospital for whatever situation, the sooner they move, the better. And the sooner you can get them off the train,

often being intubated off mechanical ventilation, the sooner you can get them out of the ICU. That's a big motivating factor for community-based programs that rely on that income to keep patients moving and to keep the hospital afloat. So what do you do if now you go into your fellowship and you're going into an ICU that has barely heard of these concepts? They have their patients deeply sedated. No one's being mobilized.

What do you do as now a physician, ethically and then even logistically? How are you going to lead that? I think the important piece is to understand that whatever culture you end up in, there's always room for growth and change. That being said, growth and change can be challenging in areas that are already well-structured and have an organizational pattern in place. The big thing is really bringing to the forefront that

As physicians, along with all our colleagues, the RTs, nurses, the nurse practitioners, the pharmacists, our goal is doing the best care that we can for the patient. And if we're not willing to stretch and make that a possibility, are we really doing what we can to

to ensure that they have the best outcomes and get the tubes out, get them out of the ICU, get them out of the hospital and get them back to their families and the rest of their lives. Having been a nurse, it's in your wheelhouse, just go in and start moving the patients, right? You're just used to that, but good luck to you both in your fellowship. What are your thoughts and feelings about walking intubated patients on mechanical ventilation in the ICU, getting them up and walking? Number one, we have to see why the patient needs mechanical ventilation.

This and that, you start treating the underlying problem and you see how can you get him or her off the mechanical ventilation first. If they are acutely ill, let's say the ventilator settings are still maybe a peep of 10 and 60 percent, and they may not be able to get off the ventilator in the next few days. How do you feel about walking them then? Maybe with a simple pneumonia, we'll say.

Okay, again, you treat the underlying cause and we'll see what's the prognosis of that. Usually we'll try to keep them the least number of days, mechanical ventilation. And if you're able to get them off that, get them off the bed quick.

And this way they can start moving and build up. There's a few things how to get off that. Number one, what's the cardiac standpoint? Are they in failure? They're not in failure. What's the status? Secondly, you have to get them off the bed. You have to check some blood work as magnesium, TSH to make sure that they're fine. So the diaphragm will work. That's how we look at things.

And you try to use non-invasive to get them off mechanical inhibition. So you have to look overall in the patient. Oh, he's intubated. Why? Let's treat the underlying cause. Let's see, are we feeding the patient or not? Because often enough,

Patient in ICU, they will be very concerned about treating the problem. They're not feeding them. They're not getting them off the bed. And this are the baseline ABCs in medicine. Get them off the bed, feed them, let them move.

and try to put them on seat in between so they can breathe out in their own. That can give you an idea what's the next step. So has it been your practice to primarily initiate mobility once they're off the ventilator? That's definite because we know a patient in bed will increase the risk for DVT and PE. So you need to work to prevent that from happening and you make sure the muscles are working because if for

If for some reason they are on steroids, they can get steroid myopathy. Get them off steroid quicker by treating the underlying condition. Absolutely. Have you ever had intubated patients mobilizing while still on the ventilator with endotracheal tube? Mobilizing?

When they are in a condition that needed to be in tube, they are not able to move much. So you have, if you tube them, make sure you sedate them. So they will be the machine. Mechanical relation will work with them, not fighting, trying to pull the tube, not doing this. And you have to work like as a team.

What I mean by that, you have to work as well with physical therapy. They need to be there. You need to lighten the sedation so they can breathe.

And you give them a chance to breathe on their own. Thank you so much. If you've been listening to this podcast, you're likely convinced that sedation and mobility practices in the ICU need to change. The ICU community is facing incredible difficulty with the trauma from the pandemic, staffing crisis, and burnout.

We cannot afford to continue practices that result in poor patient outcomes, more time in the ICU, higher healthcare costs, and greater workload for the ICU team. Yet the prospect of changing decades of beliefs, practices, and culture across all disciplines of the ICU is a daunting task. How does this transformation start?

It can begin with a consultation with me to discuss your team's current practices, barriers, and to formulate a plan to help your ICU become an awake and walking ICU. I help teams master the ABCDEF bundle through education, consulting, simulation training, and bedside support. Let's work together to move your team into the future of evidence-based ICU care. Click the link in the show notes of this episode to find out more.

Actually, it's something that I have experienced in our ICUs. I think it's great for patients if we can get them to that point. I think it improves ventilation days, ICU length of stay. So honestly, it is something that I wish we were more proactive about it. I don't see that much. We did it a lot more before COVID. And I think we have gone backwards and regressed. But from a setting that I come from, I just think that the resources are probably not there or

providers, the multidisciplinary team, they're not experienced in it. And the physical therapists that have that experience are really, there's many particularly ill patients. And how do you implement a program like that? And I come from a small, smaller size, non-teaching background.

community hospital. But you would be totally on board doing it if the team was doing it with you. Exactly. 100%. And I think there's a lot of improvements and there's data to support how beneficial it is. Perfect.

So one of the moments of patients that sticks out is we actually had a patient that he was young, he was intubated for a very long time. And we got him to the point of he sat in the chair, he was intubated and he worked. He had his laptop out and he really did work his work there. So that was a memorable moment of how much if you start this early enough and continue it,

And I think post-extubation and post-ICU, I think there's a lot of benefits from it. How do you feel about walking intubated patients in the ICU? I think it's important. And is this part of your practice? Yes. Yes. How does your team get there? It's teamwork, collaborative. And what's your role as a physician? Well, I'm a medical director, so I help set up protocols and workflows. Perfect. And how long has your team practiced this way? Eight, 10 years.

And was it preserved during COVID? The walking, no. But the proning, we had proning teams. And when you think of who should be the proners, which patients get prone the most? In the operating room, those people get spine surgery. So the anesthesiologists and the OR nurses are the experts. So they became the proning teams. And it's the same way with physical therapy and bedside nurses. You have to create teamwork. It's all teamwork in critical care. Love it. So what kind of ICU do you run? 34 of them.

Okay. Amongst those 34 ICUs, what percentage are sedated? Depends on the type of ICU also. Right. Let's say med-surg ICU. Okay. That's great. And how soon are patients mobilized generally? When they're clinically able. Perfect answer. Thank you so much. What are your thoughts and impressions about walking intubated patients? Walking intubated patients? I haven't done it myself. I know there are more people doing it and

I would be interested if there's enough support in the hospital. Let's say you have a physical therapist and a nurse coming to you and saying, got a patient on pneumonia, let's say. And keep on saying PIPA 10 and 60%. Can we get him up and walk him? They were just debated this morning. What would you say? I would like to see him doing a little more activities before deciding to walk him out of the bed.

Let's say he was walking yesterday and got intubated this morning and he's awake, riding on a clipboard. Well, even then, I would like to see him at least getting out of the bed, maybe mobilized to the chair, taking a few steps with multiple physical therapists before deciding to walk him out of the room.

Perfect. Doing it progressively and seeing how he does. I think so. Just honestly, would you be nervous? I think to a certain extent, but I mean, I think as long as there's enough support to, you know, work with the patient, I think I'll be reasonably comfortable. And how long have you practiced in critical care? 12 years. 12 years. And if your hospital administrator said, Dr. So-and-so, lead this, make it happen, do it. We know it decreases costs, just go do it.

How would you feel about that? What would you say to that? I mean, I wouldn't be necessarily pressured by the hospital administration. I mean, as long as we can find the good evidence and find enough support to do the patient care, then I think, I mean, I wouldn't be necessarily pressured by it yet. Good. And what would you need to be able to lead this in your team? I think, of course, you need to educate the staff, show them the evidence, give them the example of other situations.

systems and do one patient at a time and see what the outcome is within the hospital and see if there's improvement in an outcome to convince other people like this. So the right support and training, you'd be okay with it? I think so. Thank you so much. So what are your feelings and thoughts about walking intubated patients on mechanical ventilation? Like someone is intubated but walking. Yeah. I think I'm not very surprised because I think it's too

Actually, it won't. It's the place. So I think it always has a good effect. In the future, I think it's coming. And have you done this in your practice? Well, I haven't done yet, but I think I read it in Google when I thought about it. It was a long time ago, so I don't recall what I read and how I all this information I know.

But when I read about it, when I thought about it, I felt that it's doable. And I was hopeful for the future, but most likely I'm the same as this. So it's logical to you, right? Yeah, it is. What would it take for you to be able to lead this in your team to make it common? Maybe, well, the big part is the education, right? And the other part is the science. Yeah, well, you have to do that. And if we are able to do that, I think that

maybe fish hunt doesn't need to be done you can go home and now if there's any complications or anything patterns are produced that

need to be addressed and who's gonna who's gonna do that right so there's lots of things that has to be in place before we do something like like crazy thing like that right i think it's doable yeah i think it's doable we just need education a good system and innovation you don't have to have like

I mean, portable ventilation. Got to have the right equipment. Yeah, right. Processes. I'm going to bring another question on you. How accurate are your RAS scores right now in your ICU? So I'm assuming you order like a zero to negative two, right? For your sedation. Now you're laughing. What's actually happening when you go to assess your patient? So it's very subjective. And also who is doing it. It varies. And so it's like,

I do something or a nurse does something it can get different because a nurse is significant over time. I'm not in the business of a snapshot. So maybe I'm not the best guy to titrate sedation. They're doing it. But again, with the nursing staff, everyone has their different views on it. It's quite impossible to get that skill and act the same. So that's hard. So let's say, I mean, Russ...

Negative one, negative two, negative three. Their spots will respond to voice. Do your patients usually, when they're sedated, do they respond to voice? Well, no. No, maybe not all the stuff like that. So now you're going from like somewhere in a light, moderate sedation, now they're deeply sedated, right? So yeah, so it varies. I have seen that variation.

And as a physician, and honestly, this is anonymous, right? What is your response to that? Do you feel safe to raise those concerns or to try to guide those things? Or is it kind of like, well, that's the nurse's thing. The nurse is taking care of them. The nurse is going to do what the nurse does. Yes. And I think

When we raise this question, after we, I don't want to use the word carefully. We're working together. Right. If I just go in and raise all these questions, you know, I might sound independent. I might sound like that other person who is thinking out of their head.

There are so many angles and so many times, right? So I think when the team dynamics is better, then of course pushing off is better. So I think the relationship between the team members, whether it's a physician, a nurse, a staff, or a CMS, there is a good communication relationship, I think. Then you can raise the questions.

have a good outcome. You can have a sit down. You can sit down and talk to them and pray, this is my vision, what do you think? You can pitch in and we can start small and make it bigger. So it needs the right environment in order for a physician to say, hey, you were giving too much sedation. But if a nurse were to give an extra gram of angliosin, the pharmacist's physician would speak up and be like, whoa, whoa, whoa. That's how it was ordered.

When it comes to sedation, we're giving more sedation than is ordered, but it's still very touchy to approach that topic. Yes, it is. We don't want our patients to suffer. And then the ventriloquism of dysentery. I know we're not talking about that. It's relevant. Yeah, yeah. So ventriloquism of dysentery, it's not, you know, I feel like if someone goes to the bedside, look at them like grass, right?

and try to adjust the pent-heel to a different core seated in the patient. Maybe that's a better activity.

And there is residents, there are fellows, even just with therapists, they have their input. So everyone views things different. I think that's not why you're choosing the sedation. Any other needs, we can just try to see if there's any other things we can do to help the patient. I love that because as an NP, I obviously have an RN perspective as well. And it takes the entire team. Just because the nurses are one, breaking up the sedation,

Does that mean it's all on them? So we need the entire team to create an environment where we can say, hey, can I go in with you as I turn down the sedation? I just need to see what's going on with the ventilator. Let me adjust the things. Let me help you.

So we did that. Thank you. What are your thoughts, impressions, and experiences with walking intubated patients on mechanical ventilation? Experiences-wise, we don't do it. I think we have limitations in experience and resources. I think it's a good idea. It's a very small population that probably could do it, but I think it's a good idea in that population. And what's your specialty of ICU? Medical ICU. I'm biased, but I come from a high-acuity medical surgical ICU, and most patients

We're mobilized, but it's understanding what's real inclusion, exclusion criteria. What are your thoughts? My thoughts is patients that would qualify would benefit from it. It's the resource limitation that's keeping it from happening at our institution. What would it take to make this happen at the common process of care in your ICU? Respiratory, PT, all those things.

What are the things called that you use to push the patients in the thoracic walker, right? All the resources. And if your executive leadership team knew that this could decrease their costs by 30%, do you think then they might be interested? I'm not sure. I think because it does take upfront resources, which like we don't have a lot of physical therapy resources available for ICU patients. So those upfront resources, I don't know if they'd be willing to

And then it's just tough time right now. We also have that long-term plan, right? Do they know that if they spend thousands, they could save millions annually for years to come? It doesn't affect this year's budget. That's the problem. Right. We're just looking at the hair now. We can roll our eyes at them, but we did that in the ICU too, right? I'm just trying to get through my shift this next hour. Do you think that you're, or do you know if your RAS scores are accurate in your ICU?

I'm assuming you order RAS as Zerodin negative. Is that really the parameter in which your patients are sedated? It's a good question. It's a safe place. I honestly don't know systematically if it's accurate. So we actually just went to a RAS. We used to use the SAS. It's a little different, so we're trying to get used to it. But I don't know. I don't know if they're right. I think they generally are, I would say. And we do daily awakening trials, and I think that's gotten pretty good in the last couple of years. I don't know if they're meeting their target RAS all the time.

So are your patients responsive to voice when you assess them? Yes, we check them all the time, you know, so we go in on rounds. And if they're not, I say, please do an SAT. Excellent. And what does your team do? And how would you support them as a physician if they do the SAT and the patient comes out at a RAS says plus one?

What's the normal response? If you do an S-A, normal response is keep going. Do an SBT and see if you can get an X-ray. If they're RASA plus one and they fail their SBT, what's then the next normal course of action? Continue the same care. So keep them awake from oxidation. Are they doing, are they fine? Well, they're RASA plus one. So fine is very subjective. I think RASA plus one is fine. Is that fine on your unit? Are your nurses comfortable with RASA plus one? Do they know how to treat RASA plus one?

Are we talking night nurses or day nurses? Okay. Tell me about that. There's a difference, right? Night nurses, they'll use more resources to keep a person asleep. And the day team reverses that. And are physicians present at the bedside doing rounds at night like they are during the day? Sometimes. Physicians are present, but not as present because at night there's only one physician for...

both of our medical ICUs in our institution. And you're doing consults in the ED and the floors. So we're not rounding on the bedside on all the patients at night. What about CAM screening? Is that accurately and consistently happening? You walk down the halls and you hear S-A? Is that what you hear? It is happening consistently. It's documented. It's happening. And I think it is accurate. So, yeah.

Yeah, I don't hear it. I don't know. We're not in the unit the whole time. We're rounding around the hospital. But you feel confident? Yes. Yeah. Because I think when I see it, and it seems accurate to my assessment, even though I may not do the whole CAM ICU assessment, but I think it is accurate. As physicians, how do you help your team take it to the next level of keeping patients awake, communicative, autonomous, and mobile per the ADEF bundle? What do you understand to be your role? I think one is we focus on which drugs we're using. Right.

Probofol over Versed. That's a big one. Keep the Versed away because we know you turn the Probofol off, you're going to wake up. I think if it's not happening, just understanding why it's not happening. So from getting the point of view of the nurses or other providers, what's the concern? Why is the RAS minus three? Or why not get an SH? There's usually a reason. So if we can understand that, we can deal with it.

And as physicians, you feel like you're in an environment in which you're safe to ask, why are they negative three? Yes. Absolutely. Great. Thank you so much. You're welcome. So as a resident, what are your thoughts, impressions, and experiences with walking intubated patients on mechanical ventilation? Walking intubated patients? Walking intubated patients? I think that's a great idea. Yeah, yeah. Decreased ICU weakness. I think that's the biggest thing.

Have you seen it in the ICUs that you've been in thus far? So unfortunately, our hospital, because we have a lower staff, we weren't able to do that thus far. I know a lot of our attendees who come from bigger programs do recommend it. And a lot of nursing staff who comes from different academic hospitals do recommend it. But unfortunately, because of our staff members, we weren't able to do that.

we are trying to push for that. As a fellow, what is your experience and insights into walking patients that are intubated on mechanical ventilation? I don't think I've ever seen a patient walking on a mechanical ventilation. Have you learned anything about it? I mean, your face looks like your face looks confused, shocked. I wouldn't say it's confused. I think it's very challenging to move and have patients who are intubated and on a ventilator to walk. We do that with tracheostomy.

patient on a tray on the ventilator. We have them walk with a platform or with a walker, it depends on their muscle strength. But a patient who is intubated, I think that would be a very big challenge, risking losing the airway. And basically that would mean death. Yeah. What would you guess the rate of unplanned extubation is during mobility and even during walking? I don't have that number up top of my head. So I

Would you be surprised to hear it's less than even 0.6%? That would be surprising, but I would imagine it's doable, but it would need a lot of training and it's labor intensive. So it's not something that I think we can do, at least like nowadays, that we can generalize to all ICUs and expect them to walk the patients. Absolutely. We're not trained and prepared for it in most ICUs.

What about if a nurse came to you and wanted to get her patients sitting up, their patients sitting up at the side of the bed, maybe walk into the chair while intubated? What would be your thoughts about that? If they're trained to it and if they have all the precautions, I'm for it. How do you feel like things are going in? You've worked in three different ICUs and according to your observations, how accurate are the RAS scores? So you might order a RAS that's aversion negative. Have you noticed that's usually...

the level of RAS that patients are at with sedated or is it common to have them more deeply sedated? So far, I would say mostly accurate. We do have those swings, especially when the patients get agitated or the synchronous with the ventilator. So we have push sedation. So they get pushed over to like more than like minus three or minus four, but we come back on that. So I would say it's mostly accurate, but there are like the outliers.

Thank you so much. What are your thoughts and experiences with walking intubated patients on mechanical ventilation? So we haven't done it. Only patients, if they have a tracheostomy, we could consider doing it. But if they're intubated with an ET tube, it's unlikely that we've done it.

And why is that? I just say safety of the patient and inability to make sure that the tube doesn't get dislodged. And some of them are not going to be conscious enough to do it or weak. If they're weak, now they're alert, awake and already eating tube, that's a rare patient.

And how do you feel like ABCDF bundle compliance is on your unit right now? Pretty good. We have a EMR that has it part of the system for the ICU care. So that's what we do. Excellent. And what kind of RAS score do you usually order when you prescribe sedation on patients?

normal patient? Most of them are going to be minus three or something that they can be aroused from, but we always discontinue sedation usually by morning hours and then restart as necessary. And do you feel like your RAS scores are accurate? Do you feel like what you order is what is performed with patients? Yeah, I think the nurses follow through around every day and look at it. If it didn't seem to follow, then we'll tell them.

Thank you so much. How do you feel or what have you experienced with walking intubated patients on mechanical ventilation? It's very resource intensive, but I think it's good for the patients. Do they do it on your unit? And because it's resource intensive, any other barriers? I guess it's culture to getting all the nursing and physical therapy and back to resources and staffing. If like Russ scores are accurate on your unit, what do you order for Russ? We always try to keep them not

do sedated, obviously, but it's very hard. Overnight, nurses have to do whatever they want to just give these patients deeply sedated. So it takes all day long to wake them up. Absolutely. As an intensivist, do you feel like you're able to speak up, guide them, or is it a tough thing to navigate or to bring up with the nurses? Resources, again, is a problem.

How do you feel like your team is doing with the ABCDEF bundle? Reasonably well. Again, the mobilization is tough, the weaning down sedation is tough. Thank you so much. So my portable microphone stopped working during an interview with a seasoned physician that expressed concerns about the safety and feasibility of walking intubated patients. He reported that most of his patients were unresponsive to voice and that delirium was not consistently checked or discussed.

Then when I asked him how the ABCDEF bundle was going in his unit, he said, quote, pretty good. This is the call to chest, ATS, medical programs, fellowship programs. Let's give physicians the education and tools they need.

to be effective leaders in creating awake and walking ICUs. Help them see the ABCDEF bundle as more than just the ABC bundle from the early 2000s. We need to be way past just focusing on daily awakening and breathing trials. They need to see being awake and mobile as just as important as which antibiotics to give, which ventilator settings to order, and what kind or how much fluid to order. They need to see early mobility as a treatment

for acute respiratory failure and a measure to prevent and treat delirium and ice-acquired weakness. They need to understand that providing mobility as soon as possible prevents many tracheostomies rather than wait for a tracheostomy to then start mobility as rehabilitation on the back end. Placing an endotracheal tube is a very important skill, but getting it out as soon as possible with the least damage possible should be a top priority because

Because if their critical illness doesn't kill them, sedation and immobility just might do it. We need intensivists to be educated on what awakened walking ICUs are and how to lead teams to create and sustain them. This needs to be nursing driven, but physician led. If physicians are not spot in, it won't happen. When physicians expect most patients to be awake, communicative, autonomous, and mobile, and when they know how to make that happen,

and order that with as much flexibility as an antibiotic, it will get done. To schedule a consultation for your ICU, as well as find supportive resources, such as the free ebook, case studies, episode citations, and transcripts, please check out the website, www.daytonicuconsulting.com.