Episode 185: The ICU Revolution at Mercy San Juan Medical Center- Part 4 with the Trauma ICU RNs
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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.

Throughout the years, I have repeatedly circled back to a moment I had with a medical director in 2019. When I told him about the awakened walking ICU I worked in, he scoffed and said,

Yeah, I've heard about stuff like that, but you'll never get our nurses to do that. I have carried that deep in my chest for the past five years. I wanted to say, how can you know that? Have you taught them the why and how? Have you been a true leader and provided support and the opportunity to do this? This was one of the big stepping stones that inspired me to create a consulting program because clearly he didn't know nurses like we know them. It is absolutely not that nurses don't

won't keep patients awake and mobile. It's that they have not been given the proper education, training, team dynamics, leadership, and support to develop that skill set, culture, and to experience their own successes. Few modules copying pastes from PowerPoint slides from 2014 is not really giving nurses a great opportunity to do this. Nurses aren't hesitant because they won't

do it. They're afraid to do it. I have repeatedly seen that nurses will do just about anything for the benefit of their patients when given a proper chance. This episode exposes the true heart of nurses, especially our quote, tough trauma nurses that make me so proud to carry the title of nurse. This is the episode I wish I could send back to that medical director as a direct response to his statement.

Until you've given nurses a proper chance to learn the why and how, do not tell me that nurses won't keep their patients awake and mobile.

Okay, everyone, I'm so excited to be finally doing an episode with the trauma ICU at Mercy San Juan. Can you guys introduce yourself? Let's start with Amber. Go, Adrienne and Jessica. Yeah, my name is Amber. I've been at Mercy San Juan for about 17 years. My background is all critical care and primarily neuro and neuro and trauma. And I am one of the shift supervisors or nurse shift managers for the trauma ICU.

I'm Adrienne. I've been a nurse for almost 15 years now. I worked in med-surg for the first third of it or so. I've been in trauma for the last, I think, eight years or so. I'm Jessica. I have only been in the trauma ICU for six years now, but I have been a nurse for about 15 years as well, just like Adrienne. I worked in tele-med-surg for...

three and a half years and went to the medical ICU and then transferred over to San Juan and have been there ever since. This is one of the things that I loved about working with your hospital and your critical care department, and especially your ICUs, that there were nurses with a lot of experience. Right now, the average years of experience for nurses in the ICU was 2.6 years. So to come to your hospital and have eight plus years of experience was so exciting for me because you've got the basics down and beyond, right? You guys are really experienced nurses.

and experienced in what your ICU was used to doing. So let's talk about up until this past year, what were the sedation and mobility practices in your ICU? It was just the norm. If they were on a ventilator, they had...

sedation and pain and analgesia, like everybody was on fentanyl and propofol or fentanyl and Berset. That's just what they were on when they were intubated. It was pretty rare. I would always question when I come on and they were not on a sedation medication, like a continuous sedation infusion. And it was always like, well, they've been on propofol for a couple of days. It might be time to switch them to Berset type of thing instead of

They've been on group ball. Like, how about we get them off of sedation? I was just going to say that something that we never questioned either. I always felt like even when I went to the medical ICU and continued my journey into trauma, it was something that was okay. They're intubated. So they automatically have to be sedated. And so there was always an infusion of some sort, regardless, like what Adrian said, propofol, fentanyl, Versed. It was always something that was just, it was like an automatic,

Okay, yes, box checked. Now they're sedated. And now we have to figure out what to do with them once it's time to wean them off the vent and wake them up. So it was never just always a given that they were going to be sedated. And Amber, did you say you have 15 years of experience? Actually, 23 in nursing, and I've been at San Juan for 17. So yeah.

And it's funny that I feel like one of the older nurses, I guess you could say, or more experienced to be. And I've worked at a couple of different facilities. I've obviously been at San Juan the longest, but even just looking at the cultural changes over the decades, I remember when I lived and worked on the East Coast 20 years ago, patients with spleen and liver injuries and things like that, that we were worried about bleeding, we kept in bed for 14 days.

And you know what? They got up and they still bled. And just watching as technology has given us the tools. I was coming in at the time where smart pumps were just coming in and

doing drips by hand, but everybody, and not just Versed and Fentanyl, people were on Ativan drips. You don't ever see that anymore. It's been exciting and fun to see the changes over the years. And as technology has come along and research has come along, how much more we've learned and how much more we've grown and changed. And I think for the patient's benefit,

the outcomes have got to be, and I don't have all the information statistics. I'm sure they're out there too, but how much better they are off overall and the survivability rate. Absolutely. And you guys have such a strong team of all these friends, clinicians, and you had been doing mobility with your patients that were not vented, right? You already had a pretty strong mobility culture. It was already a focus, right? Probably because of your

trauma surgeons and their focus. I think some of our younger trauma surgeons that with technology changing, we started even in the last couple of years before we started mobilizing patients on ventilators, we started to see less and less of continuous drips and more and more of like, let's put on a fentanyl drip and try Versed pushes. And I remember just even that was like, oh, that's barbaric. And that's

so cruel and these patients are going to be miserable. But you know what? It worked. And we started with webinars with you guys back in 2021 during COVID. You guys were one of the first teams that I did a webinar series with. And so it was a little uncomfortable even for me during the heat of COVID to be saying, I know everyone's doing their best, but let's consider what we're actually doing. And what were your perceptions? That's probably about the time that you started doing more analgo sedation.

I know Dr. Coates was really trying to push this in your unit. And as bedside nurses, having very brief webinar series, being in the heat of COVID, how was that received? How did you guys really feel about that? This is a safe place to be totally honest.

Not great. We felt like we were kind of being asked to do more with less. And the experiences that I think we had previously, everybody had this mindset that yes, less sedation is better, less time on the ventilator is better. Obviously,

duh, obviously, like not any new information. And I know that we did have some doctors that would try to implement it, but it wasn't, it wasn't very streamlined process. So it was more like, well, I'm just going to discontinue these medications and good luck type of thing. So we had

that were self-ex debating or nurses that got smacked a couple of times or people falling out of bed. Although the intent was obviously very good. We're trying to do best practices. It was not the most streamlined. That's a great word. It's not very well received, I think, from the nursing staff because we just felt like you just took away the tools that we had to keep this patient safe and keep us safe. And so I think the pushback kind of came into play.

Where it's like, yeah, everybody's trying to do what's best for the patient, but we still have to be safe in this situation. And I think that's just where we were at with that. Yeah, I think there wasn't a lot of practical implementation available to you. Not just about not giving sedation. It's what you do instead. And also, when do you give sedation? And how do you do that safely? So there were a lot of practical tools that were lacking. And I think

There needs to be physician leadership, but to be honest, physicians have never been bedside nurses. The vast majority of them, right? So then how do they guide nursing practices and the nursing approach to managing these patients, right? So as I turn off sedation and walk away or to DC it on the EMR, it's not practical, especially when you guys have not had the chance to learn the other tools and have the whole team support on how to make this feasible.

And you probably started off initially trying to take it off sooner, right? Start in sedation and then take it off on the back end, right? And then try to mobilize them. So 2024 comes around. Your hospital has my team and I come in and do full training in preparation for that. Again, this is a safe place. I wouldn't be doing what I'm doing. Tell me honestly, before we came on site, how excited were you for us to come?

It's okay. I know we were not that excited. We still were coming from that place of, okay, they're asking us to do again more with less. Like this is, we're not going to have the support that we need to implement this appropriately. And we were like, okay, we'll see how this works for them. But there were not a whole lot of positive thoughts about how well this was going to work.

Well, I don't think it was only that. I also feel like because of our patient population being so dynamic and how it is not as streamlined as a medical arts patient or somebody who has overdosed, who's on the vent that we're now waking up

It creates a whole different ballgame of, okay, we have this patient who came in and was positive for meth, cocaine, was drunk. We have to worry about them going through withdrawal. We now have a TBI on top of everything else. And oh, by the way, they can only do weight bearing as tolerated on one leg. They can't use this arm. And oh, there gets a front on top of it. So how can we make sure that we are safe?

that they are safe, that we are able to mobilize them without having them freak out by being awake on the vent and self-extubate, which could create a whole other cascade of problems for them in the long run. But also, what are the medications and the tools that we're going to be able to use with our physicians that they can actually see are actually being effective?

And the other thing I have, when I came to trauma, I felt very confused about is our trauma docs are only on for 24 hours and then a new physician will come on. So you have multiple physicians with their own personal practices of how things should be handled. And so it would change. And so we never would get some consistency with what is working for these patients. How long do we wait for them to have it be effective before we tweak this med or that med? So I think it was just like, all right, how is this going to work with all these patients?

different personalities and making sure that it's effective for everybody because it was a big pause moment. And is this going to work? Yeah. I was really worried about it being very black and white with no gray area that it was going to be like, no sedation for anybody, no restraints for anybody, that type of thing. And I was worried that they were going to take away a lot of nursing judgment, but I think the doctors have been really receptive when we've come back to them and said, Hey, this isn't working. They do need a

a little bit of something. What should we try? Can we do a little bit of Dex? Can we do a little bit of this? Yeah, there are a lot more medications like that that seem to be, they're a lot more open to that than I guess I thought that they were going to be. And I think coming from a provider perspective, when you trust your nurses to understand the risk versus benefits of these interventions, when you trust that your nurses want the patients to be awake and mobile,

then those recommendations are received very respectfully. Like I know Jessica's going to get her patients out of bed every chance possible. And if she says that this isn't safe and this isn't possible, that I absolutely respect that because having worked with nurses in an awake and walking ICU and then having float nurses come in and travel nurses,

I realized how much I relied on nursing judgment. As an NP, I have 13 to 16 patients that I'm managing and I need their judgment. When they come in with these recommendations, I need to be able to trust them that I had

Ativan drip. Amber, you talked about that being a thing of the past, but this is 2020. And one was asking for the Ativan drip for a patient that was a RASA plus one. I just learned that some nurses, I don't even have to ask. Absolutely, whatever you need. You need dexmedetomidine drip, I trust you. I'm also going to go see the patient, but I'm going to order that before I even leave this office. So you have to build up that trust and that culture. And coming from a normal background where it was totally forward to even have someone awake on the ventilator

They needed to know that's within your wheelhouse, your skillset and your goals as well so that everyone can have those educated and productive conversations. I remember we trained the surgical ICU first and then trained trauma the next month. And as I was in training the SICU and doing simulation training there, I'm sad that Dan's not on this call. He was supposed to be. We love Dan. Yeah. Tough looking guy. Pop his head around the corner. I just knew he was from trauma. Yeah.

I knew he was a trauma nurse and I was like, I'm training Siki, but I think trauma is fine. I think they're trying to figure out what's going on with simulation training and filling the heads out. Which is totally reasonable. I would probably do the same. And he pulled me to the side afterwards and he's like, listen, before you came, I had a lot of words about and for you. He said, we've been saying for months who the H died and made Kaylee queen. And I thought that was so funny. And he's like, but you know what? After...

Seeing what's going on here and how, what this is really about, I get it and I'm bought in. And I know like everyone had their own journey of being bought in, but I thought that was so fair. I mean, that you were concerned, hesitant, maybe a little judgmental, but that's normal. But also being open to, if it's best for the patients, I'm willing to try it, but let's make sure that we do this safely. And what difference did it make to have

depth training versus the previous approach of just take it off and deal with it. How did that change your comfort level and how you approached this initiative? I think that from previously practicing with everybody who's intubated gets sedated, it also gave me a pause for, okay, what am I doing for their long-term brain effect on top of it? Because they're already stressed. Their body is in that fight or flight response anyways. And

us giving all these extra medications on top of it, what am I doing? They're

trying to be a functioning member of society, just like I am. So when they're back to their baseline, what is that going to look like? And how is that going to change for them? If we're just constantly pushing for said, if we're constantly giving these heavy, you know, how is that going to affect their long-term life after they leave the ICU? Because we don't see them a lot of times after their injuries have resolved and they're transferred out of the hospital, unless they come back to see us and we don't know what they've gone through. And

after we had a patient that was a nurse previously and he was like I was so foggy and I was trying to get back to where I was and I was thinking that all these things were happening and he is a healthcare provider as well and so having his perspective was like this

this is very interesting. How are we going to make sure that we don't create more of a problem long term? And the more I had talked to you, the more I had realized, okay, wait a minute, we need to do something. And that and Adrian and I really, our first patient that I did the case study on for you. That was I feel like the snowball effect for everybody else to be like, all right, if we can do this with one patient, what's stopping us from doing this with other patients?

And tell us more about that scenario. It's in December, right? Before? Yeah. This is before you came and we were all in. Okay. Well, Kaylee's coming. We have to be thinking about this. We have to be open because like you said, stranger danger, who's this person coming in? That's going to come to our house. And yeah,

throw all these things out there. Like we do our things our way and that's how it's always been. But it was like, okay, this person is here. And it was a very long journey for him, unfortunately, but got intubated, was on the vent after coding. And it was after being in a car accident and it was like, okay, well, let's multimodal him. Let's not start him on a continuous infusion. Let's see what he does. What's his brain doing underneath? Let's make sure his pain is under control. And Liz was the first person that got him to sit on the edge of bed. And then it was like, all right, well,

18-0, if you need to see him, let's all do the things. And then it was, all right, he's writing to us on the whiteboard. He is still restrained at this point because we were still really cautious of, can we take him out of restraints while he's intubated? I am very fearful that he is going to self-extubate. And then we got him dialed in pain med wise. And then it was like, oh, look it,

he's sitting on the edge of the bed and he's still vented oh look it now he's in the chair oh look now he's on the portable vent walking down the hallway and he was on the vent for quite some time self-extubating and god bless him after he self-extubated he didn't last very long and he was trying to put his breathing tube back in on his own and that did not that did not work very well

And then he got reintubated and we had untied him and he was like, are you going to do that again? He just shook his head. No, I'm, I will be fine. I will be good. So he had his phone and he would be in bed or in the chair texting on his phone or writing things down and unrestrained. He was just hanging out and then he finally got him off the vent and off to the floor he went. So it was the epiphany, the aha moment, as people would say that kind of was the catalyst for us being like, all right,

If he can do it, but I also kept calling him our unicorn because it was totally the unicorn because it was the perfect timing and the perfect scenario with the perfect patient who, like you just described earlier, he wasn't your...

homeless patient that has schizophrenia and mental problems and then also substance use disorders and things like that. This was a normal, functional, everyday kind of guy. So I think that definitely was the turning point for us. And even so, and the change was really uncomfortable and really scary, especially just

From my standpoint and standing back on the sidelines, when you guys are at the bedside, seeing this patient walk down the hall on a vent is just flippant weird. It's just weird. But also that unicorn patient,

He showed us all the things that could go wrong. He self-extubated, which was, I think, everyone's biggest fear. It's like, oh my God, they're either going to hurt themselves, hurt somebody else, or they're going to be a detriment by ripping out the tube. I don't think he hurt anybody else and hopefully not himself. But we dealt with so many of those things in that first case that I think, I mean, we all know that change is hard and it's scary. But he gave us that confidence, I think, that allowed us to

to plow through that and move forward with our other patients. And well, if we could, like you said, Jess, if we did it with him, then why can't we do it with others? You know? Yeah. I was so upset that he self-extubated because delirium is the main risk factor for that. It increases the risk of self-extubation by 11.6 times. Keep them clear. And they're far less likely to do that. And what does he do when he's perfectly clear? Clear.

Oh, yeah. Oh, yeah. But there is a benefit to having the worst case scenario happen. Right. That's the worst case scenario in our minds. When now that I've done this for so long, I'm like, yeah, for most patients, the worst case scenario is probably more delirium isoquat a weakness and all the downwind effects that happen that end up likely killing them. So you guys saw that and he was awake enough.

to breathe so that's safer than maybe him dislodging a tube while being turned and being yeah but he still needed mechanical ventilation so he was re-intubated but it wasn't like the hot emergency that everyone expects like the sudden arrest but it was still a bad deal but i was so proud of you guys for continuing to keep him awake communicate with him

and not restrain him, I would have had trust issues, right? That's reasonable. But you had that, again, that nursing instinct and that humanity to say, we good, bro? Are we on the same page here? And let him be part of his journey again. Because if you had restrained him, it would probably drive him insane. There was a brief period after he ended up getting re-intubated where he was briefly restrained. And then the night shift nurse took them off again because she wanted to make sure he was awake enough post-intubation

to make sure that he understood what had happened. And my thing was like, kudos to night shift for not jumping on the boat of instantly starting continuous infusion for him because of him extubating. I think that that also had a huge impact on how night shift perceives what awakeness is too for patients because it's so different day and nights are so completely different shifts. And I know that sometimes some people have a harder time understanding the

the long-term goal for some of these people, for our patients. And that was definitely like, okay, look, there's another moment where people are understanding, okay, well, he's awake and talking, communicating with us. Why would we jump to putting him on a continuous infusion when he clearly didn't need it the first time? So I thought that was really...

a profound moment to not just automatically go back to old past practices and old habits. Absolutely. Go night shift. And I think you bring up a good point. Their definition of wakefulness, because we could say aroused negative one, they open their eyes to voice that's wakeful, but are they able to write on a clipboard and text like he was able to so that their goal was to let him keep communicating his needs and

That is true wakefulness. Heidi Ingle always says, let's scrap the RAS and just say the clipboard test. Can they write on a clipboard? And that's what they did. And so early on, we hadn't even done a lot of the practical training that we did on site. And they didn't have PT and OT there to hold their hands through navigating these things, but they just did it.

Obviously set the entire team up, all the shifts to follow benefited from that decision that night. And now what about your more difficult patients, the normal patients now? Has this skill set changed the way you approach even those patients?

I think so. I think we're a lot more proactive on a lot of the Seroquel Zyprexa's that we know that we're going to need some pharmaceutical tools for these patients, the Presidextra, but it's nice that we don't automatically just go to smacking them down with a bunch of propofol or Versed or even a continuous, like continuous fentanyl infusions are not even a thing in our unit anymore. And we have broken people. We have people with legitimate pain.

So it's interesting to just see, we had this surgeon not that long ago that doesn't work with us that often. And I remember I came on and I was break relief and I'm like,

why is this patient on a Versed drip? They're on fentanyl and Versed. Why are they on this? They're like, oh, well, he's intubated. I didn't know. No, no, no, no, no. Why are we doing this? And he was going off shift. And so the very first thing that the new surgeon did was discontinue and try to get him back on something. Cause it wasn't even a patient that was wild and crazy. It was just like that surgeon's past practices come into the forefront. And it was like, Jodi, I

I'm so proud because I feel like nurses are the first line of defense, right? There's a whole other layer of expertise and critical thinking that happens on our side as nurses. And for Adrienne to come in and to flip the tables and say, not on my patient. Adrienne, that makes my heart sore because people were saying, Adrienne's really hesitant about this. Watch out, she might eat you alive. But the second I met you, I was like, oh, I'm not afraid of her.

Yeah. Well, I'm like, once she knows what this is about and she feels confident, she's going to own this. And so when I came back months later, I think I was in the medical ICU and I went in to visit. He pulled me in down the hall and you're like, what about this patient? And he was unstable pelvis. He was smashed up. And I was like, you can't mobilize him, obviously. But you had him awake. You had his pain controlled. You were doing everything possible for him. And then you're like, okay, got to go. And you went to the surgical ICU to help them mobilize one of their patients.

It was just like my prophecy was fulfilled. That Adrian would become the captain of the ship. But that speaks to so much to who you are and that you really do want the best for your patients. So once you learned the why and you learned the how, no one has to babysit you on this. You're the one monitoring the surgeons on this.

It's just become such a change from why to why not? Is there any reason why we can't do this? And it's just a change in how we started thinking about our patients and how we really

provide movement as medicine for them. It's really just a change in the culture. And even that patient that was not appropriate for mobility at that time, I later saw a picture of him standing in a verticalization bed. Oh, that's right. Tell me more about that. That was me. That was mine. Yeah, no, we ended up thinking, okay,

Are we able to get him? He was, he had a pelvic fracture. One of his arms was broken. He had a really bad spine injury that they were going to say he was not up for. It was either a clamshell. Yeah. He ended up having to get a clamshell brace. So we put him on a verticalization bed and he did really, really well with it. He was so excited to be not laying flat. He was so excited to be sitting up. My little baby,

bait of carrot dangling the carrot for him he was like jonesing for a pepsi and i was like i will get you that pepsi if you do this and so we did it and i had dan run to the cafeteria and get him said pepsi so when he was up that 45 degrees for the first time he was just elated and then later on ot and pt had come to see him and i was like he has not been outside in two weeks

can you please go get the bariatric chair so we can take him outside? So all of the teams assembled at the right time. He was my only patient. So we rolled him outside and did OT outside with him. He washed his face outside, brushed his teeth outside. He was so excited to just be

just be outside and away from the four walls of his room. I don't remember a time where I was like, oh man, I can't imagine not being away from this area. This is the one space that they're in 24 seven. I didn't think about that until it was like, all right, let's take them outside and not only getting them away from the rooms and getting them that natural fresh air and that's

sunshine, what it does for their spirit and their ability to engage and want to push harder to get better to get out of there. And he was so excited. I remember him, I had taken a picture of him, we have a brag board at work. So anybody who has been in ICU for a long period of time, and we take them outside for the first time, we take pictures of them outside, and we put it on our brag board. So his buddies hadn't come to see him yet. So I printed two pictures, and I put them in his room. So he could see them as little motivational tactics of

Like I need to do this so I can go back outside so I can get back to what I used to be doing. And he was so stoked. One of his kids took a picture of the picture and put it on his Facebook and was like, yeah, bragging about how he finally got to go outside. And it was just, that was really cool. And he was so excited. He was just so grateful that

people took the time to do the things that make him feel normal and make him feel more human to go to be grateful for going outside, which I think everybody in our department makes sure that they do. I don't know how many times our staff is like, all right, 1045, I'm going outside with this person. We'll be back. Please watch my other patient. We all rotate of, all right, I'm going outside today. We'll be back shortly. And we talk to the trauma doc. So we go outside unmonitored and we go and we come back and then...

They take a little nap and get that good brain sleep and good mindful sleep. And it's just they're a totally different person once they wake up from that little nap and all the work that they put in. So it's just that's nice to see. That's nice to see. And that's the kind of stuff that I don't even touch on when I'm doing this simulation training, because we're talking about the basics. Right. Still talking about the why and to talk about some of the logistics.

That's like a wake and walk in ICU 301. 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.

We're still working on a 101, but that's the kind of stuff that I've seen and I've done in an awakened walk in ICU. We used to go to the helipad. I don't know if that's allowed anymore. We've done a kiddie pool with sand with someone that was intubated for a long time, those kinds of things. But

If I mentioned that back in February when I was training you guys, when you're so overwhelmed and just thinking, how do we have the staff to do this? How is this possible? We don't have time for that. You already had your guns drawn. Right. If I'd mentioned taking them outside. But the cool thing is that I've seen this with numerous teams now. I don't have to mention it. Once those doors open to humanized care, that's who you is.

caregivers are as healthcare workers, as nurses, that's your instinct. We're just opening the doors to let you guys

Provide the care that you want to. People start showering and debating patients. They take them outside. It's so amazing to see, learn so much about who you are by how you care for your patients now. So you talk about humanizing things and personalizing it. And all I can think of is 45. Now he's been there for months. It's been very tenuous. He's had a lot of surgeries. He's been on and off the vent. He's been in ARDS. He was definitely up and walking on the vent.

And Jess, you kill me, man, because he's a huge Niners fan, right? And what started with the king crown? So one day it was rather slow at work. And our trauma docs had been joking about how she needed a crown and all these things. And I had just been given a box of decorations and supplies for helping spruce up stuff in the unit. And so I went on my lunch break and I made her a crown and I made her a cape. And so then...

He saw it and he wanted a crown too. So I made him a crown. So every time he walks in the hallway, he has his blanket on and he wears a crown.

I think he has a scepter now he does yeah oh yeah it's great down the hall now like this guy does dreams coming off of him that's been on and off the vent that we're trying to motivate him kick him in the butt to get up and it's a lot of sisterly love but yeah like yeah 15 sisters in the unit that are all like no get up oh we're getting talking and then he doesn't want to and we're like you can wear your crown all right

Okay. So we think about trauma. I see you think about the big accidents, the broken bones, the gnarly stuff, the hot emergencies, right? Like the big sexy stuff. Yeah. But I could tell there's a lot of pride in being bad A with soft skills. With this understanding, do you see how you're saving lives with these little things? I think for some of us, it's, it just comes as like second nature. It's like, why would you not

celebrate your patient's birthday and sing happy birthday to them when it's their birthday. It's getting things for the department for

For when people are bored and they don't have family. Oh, I know this sounds really silly, but I have some coloring crayons and some coloring books. Would you like some of this stuff to take your mind off of these things or encouraging family members to bring their guitar for the patient to play while they're in the hospital? And Adrian talked to one of our patient's dads and they were like, oh, no, we don't want to bother you with this. It's like, no, bring it. Let him play.

do what he loves to do because at the end of the day, they're not just a diagnosis. They're not just a trauma activation. They're people. And I think that's the one thing that the more we have really opened our eyes to the

reducing the sedation and really seeing how people interact with us in their time of vulnerability. It also brings us the focus of they're human too. They have a name, they have a family, they have all these things that are happening before their lives are completely turned upside down because of whatever accident or

that had happened to them that brought them to us. And so I think that's something that our staff, my coworkers, I love them dearly because they really push that to people. Like have your kids draw pictures and leave them here for them to look at. Bring the photos of them as people. And I think that really helps drive that piece home is just remembering that they're human. How does this work with the workload? I'm assuming you guys have seen drastic decrease in delirium, length of stay, time in the ventilator. So just anecdotally, just from your perspective as

That's nurses. How do you feel like the workload is when you're dealing with patients that have delirium versus doing these extra things for them? It can be difficult. I will say that it's a lot easier when you only have one patient at the time. I know. I mean, obviously, that's not a feasible thing to do. But I do notice that a lot more happens when you like you're the open bed nurse.

you don't have another patient, but it's also been helpful with the mobility techs that we've gotten. They come through and it's like, oh, you're here. Let's do this. Let's check this box, get this patient up, get them in the chair for the morning, and then you can move on to, oh, you're here for my next one too. Okay, cool. Done type of thing. So that definitely helps. And I think

Honestly, a lot of it is just changing the mentality, not like, well, am I going to get them up today? It's like, no, I'm going to get them up. I'll get them up at this time and then I'll get them up at this time type of thing. Instead of being like, I don't really want to. I have all these other things to do. It's something more like this, like a med pass. It's not an optional thing. It's not a well, if I have time for it, it's like a no, I'm this is part of the this is part of the stuff.

where am I going to work it in? Like Jessica said, mobility is medicine. And I feel like if it ends up on the nurse's brain and your report sheet and your schedule, you're going to get it done. Those mobility techs didn't get hired until six months after we trained, something like that. But the nice thing is you guys were already doing so much of it on your own that you knew exactly where to fit in. You're so much more efficient rather than if they had to come by and be like,

maybe if sedation was still being a barrier, it wouldn't be very useful. But you're there. And as nurses, you are mobilizing your patients, even vented, right? Mm-hmm. They're up in the chair waiting for PT and OT, usually. Yeah, PT and OT will come by now and they'll be like, oh, you already got them up. And I'm like, I'm working away for you. Yes, now you can go do the actual therapy. Go do that. Yeah. You're not a chair to bed service. Yeah. Over the weekend, we had a patient, Adrian had,

had a patient in 40 and I was charged that day and we were both like, all right, what time do you want to do this? Like, all right, let's do this. PT and OT hadn't even seen the patient yet. And I was like, all right, make sure RT is there. And that's all that we did. And it was the first time that he had been able to sit up on the edge of the bed and he did fairly well, all things considered. It was just really, I like the initiative that all of us are taking. And it's a lot of people that are like, all right, hey, RT is here. Can we sit him on the edge of the bed? Okay, we'll wait for PT to come do the other stuff because...

They're exhausted now after just sitting up, but at least we can get the ball rolling and we can explain to the family how this is normal practice for what they can anticipate while their loved one is in the hospital. I really like how it tends to become a snowball effect and it builds on it. Even though they're intubated and have 11 rib fractures and they're delirious. We just sat them edge of bed yesterday. So I'm going to add a minimum sit them edge of bed. Maybe we can stand. Maybe tomorrow they can take a few steps. So it's like very much, it just moves.

the bar a little bit further each day. So we're not going to go backwards. Like you sat edge of bed yesterday, you're going to sit edge of bed today, plus some, it's going to just keep going. And Jessica, you alluded to this a little bit. How does this change the rest of your shift?

behavior wise, how easy these patients are to manage when you've done those things with them. I feel like it just benefits them so much more for the good. Even that patient, Adrian and I, because she had him, she was the primary nurse. And then I had him the next day as the primary nurse. And it was just like she said, it's the snowball effect where once you start something, you can't stop it. And it creates so much more of a better environment for your patient because then you see them start to engage and you see them start to

immersed again out of whatever fog or whatever. Because this guy was very complicated, multiple rib fractures, TBI, scapula fracture, bilateral chest tube. He was very, very broken. And to see him perk up and be like, oh, okay, and actually make that good engaging eye contact and not have those crazy delirious eyes that I know everybody can relate to when they see that dissociated look. And then one day he just finally perked

perked up and he was like, oh, that's my daughter over there, looked at her and waved at her. And then it was me cracking jokes with him the next day being like, you're killing me, Smalls. And he's sitting there just like with a funny shit-eating grin on his face because he's understanding what you're saying and knowing that, okay, he's participating now. So what is our next step to make sure

we can keep this going. And then they sleep. I mean, after Adrian and I sat on the edge of the bed, he took like a two hour nap. And it was just like, this is actual restful sleep. And that is, I think the one thing that

We never give our patients is restful, mindful sleep. And that delirious factor, I feel like overall, from what I've seen personally, has reduced dramatically in our department with having the mobility and everybody being on the same page about less sedation and more rest.

activity. Yeah. We've noticed that too. If patients are starting to get more and more amped up or riled up and it's like, man, do I have to go up on their Resodex? Do they need more stuff? And they're just so fidgety in the bed. And Jess is great at being like, let's get them up. Let's get them up, wear them out a little bit, see if that helps. And 90% of the time it does. And it's like, oh, okay. And then it benefits everybody. It benefits us because they're resting and it benefits them because we know that

we exhausted them to whatever capacity that they could tolerate at that time. So then we know that they're going to be able to do a little bit more and be hopefully more participatory. And then the one thing I've definitely noticed, and I don't know if you guys can agree to this or not, I feel like our patients are being vented for shorter periods of time, the more we're starting to mobilize them. I know Gina had said some statistics that our numbers had improved really dramatically in trauma ICU. And I can't remember what they were specifically. But she said that

ever since we had been really more aware of what we're doing with our patients, that mortality has gone down or some ICU, which is that proof is in the pudding right there. And it's really nice to see that even if I'm primary nurse and I'm going to go on break and like Jeanette or Liz or any of our nursing staff is like, I'm like, hey, PT is coming. Can you? Yep, sure. I got it. And it's just,

Nice to know that the ball's not going to get dropped depending on who is taking over for you. It's just going to keep going in the positive direction, knowing that you're going to have the continuity to keep these patients safe.

going in the right direction when it comes to mobility. And Jessica, you were one of the first to be willing to try this, right? And so you were in, if you were the break nurse, you'd like sneak in and sit up at open abdomen. That was not me. No, that was not my credit. That was, that goes to Jeanette full height. That, that was all her. I had done it the day before because she was my patient and I was like, all right, Jodi, like you,

you want to mobilize her? You want to do this? And she was like, yep, let's do it. And the stars, I say, align for that patient specifically because we had an occupational therapist who was so game to do it and also spoke the same language as the patient because her primary language was not English. And then we had a physical therapist who was also, yes, let's do this. So I felt like it was just, how could you not do it? And in that situation, particularly that poor family,

Those that patient and her husband had been in a car accident and her husband was at another hospital, but he was intubated and sedated. And so the family member who was coming to see her specifically was like, why is she awake? He's like, why should she not be awake? So she was unrestrained while the family was there and writing in their language. And I'm very much with it, very much participating. And then.

We got her up and we sat her up and she always sat up on the side of the bed for five minutes, got her back to bed. But yeah, that patient was going to go to surgery to close her belly the next day. And before she went to the OR, I had told her,

She'd be coming the next day. I was like, she's going to go to OR. Please make sure you mobilize her before she goes operating room. And that was Jeanette. She did that. She continued. Like Adrienne had mentioned, we have to continue this where everybody is able to help the process keep going. And she did fairly well. So that was exciting to see. Yeah. And tell me about the contrast between being some of the few champions, some of the first people that are willing to try this out.

And now having a coach in the whole team where it doesn't matter who's on, it's going to get done and it's being done shift to shift. Because compare that to, I think a lot of listeners are not in that kind of environment. And maybe they're a lone visionary revolutionist and they maybe get their patient up during the day and then they get sedated at night. Or their physical therapist coming in trying to beg for awakening trials. So when everyone is doing this, the RTs are already looking, who's vented? Who's going to get up?

When it's going, how does that impact your workload? You know, having been...

Trying to go against the tide to now being able to ride the tide with everybody. I just feel like it's just part of what we do. I feel like it's just ingrained in, okay, well, what's my day going to look like? Sure, I have to give meds. Sure, somebody is going to need to be cleaned up. Something's going to happen. Some tube feeding is going to get everywhere. Whatever it is, what it is. It's like, okay, well, also, what time are we going to mobilize? It's not an afterthought of what the care and the trajectory of my day is going to be. It's just already ingrained in what I'm going to do. Yeah.

And sometimes PT will come see other patients and then I'll say, hey, this person needs to be mobilized. They have to be there first time. What timeframe can you, OT and I all work together so we can always just like

streamline things for the first time before we start adding multiple levels of therapy for these patients. And then we can figure out what works best for them at whatever level of mobility they're at for that period of time. But I just feel like it's second nature now for a lot of us to be like, oh, okay, we're mobilizing this patient today. All right. Can you please just keep an eye on my other patient? They should be fine. Don't worry about them. Or, okay, I'm taking my patient who's getting a little squirrely outside. Can you please watch them? I'll be back in five minutes. It's just very much second nature for

our practice now as a trauma EC, which is so different from when I first started. So I think that in itself, it's crazy. Yeah. Can you imagine if they were sedated overnight and now you're coming in during day shift and cleaning up the sedation, cleaning up the delirium, mobilizing for the first time every single time, how exhausting that would be. It's like a hamster wheel. Their speaker is saying, yes, that's my life. Uh-huh. Yeah. It's like a hamster wheel. It's just like the continued cycle of

Going back to practices that don't make sense, I feel like, because there would be times where we'd be like, oh, yeah, we've done X, Y, and Z during the day. And then we're going to hopefully SET them again in the morning. Please don't do X, Y, and Z. And then things change over the night. And then you're like, okay, well, I got to dig myself out of this hole again. But the one thing I do have to say is that night shift, I feel like they were almost... They were very cautious. But then they also changed their ideas on things based off of certain individuals and how they...

practiced because I feel like there were some people on my shift they're like okay well I guess we're gonna do this then they wouldn't outwardly say that but just in the way that they people I would follow specifically oh yeah we didn't do x y and z or we tried x y and z families come in they're still not calm we did go we did add prosthetics but we got we're doing fentanyl pushes or we added some cerical and it was you know gabapentin oxy we've done all the things and it

But they're awake and they're participatory. So it's definitely a culture change, I feel like, for both shifts. And it's something that as much as I thought was going to be get pushback, I definitely feel like it's much more embraced and just a cultural norm now for our department. Also, harder to start sedation on someone that's awake and writing on a clipboard than it is to sneak sedation up on someone that's already aroused negative one, negative two.

Well, that even is like true for, we had a new tips nurse have a nice lovely exchange with one of our anesthesiologists because the patient was going to go to OR for surgery and they're on the vent wide awake, just sitting there with their arms crossed, legs crossed. Like why isn't he sedated? And the anesthesiologist just thought it was completely inappropriate that we weren't sedating them. And it was like, why? He is awake. He's participatory. He's

not fighting the vent. Like we just couldn't get them off the vent quite yet. And they just thought that it was the most out of this world experience to go in and see them like that. And you have a new nurse to the ICU and then you've got our veteran nurses that are backing her and barking. No, this is what we're doing. Get used to it. If you need to go talk to somebody, go talk to the chief of trauma and figure out

what the new thing to expect in the TICU is going to be. So yeah, I love it. And how have you sustained this with this high census that you've been fighting once everything exploded? I would say the biggest challenge, yeah, with the census and the biggest challenge and staffing in general, I will say we've struggled from the staffing side of things and it's getting better, but it also meant that we've had a lot of float nurses, a lot of travelers, a lot of those that aren't ingrained or comfortable or familiar with

that culture change that now seems second nature to us. And I've seen, I don't want to say backslides, but they aren't as, pushy is not the right word. They aren't as assertive in saying, no, it's not if we're getting up, it's when we're getting up. Because again, going back to

our friend in 45 where, you know, if you don't push him yesterday, Jess, he'll lay in the bed because he's had a lot of complications. He's had a lot of setbacks. And I think a lot of it is mental too, that he's just frustrated and downtrodden and frustrated.

But at the same time, we all know that he's going to feel better getting up. The day before you had him yesterday was a float nurse. And she's like, well, I'm just going to let him rest today. And it's like, yes, we know he needs rest. And we need to look at each individual that way too. But he can get up in a chair and he can rest in the chair. Or he can get up and walk for 10 minutes and go back and take a nap. He'll still get his rest, but he doesn't need to lay in the bed all day. So changing that culture of those that are coming into the units

for a temporary period of time, whether it's a travel contract or a float from another hospital or whatever, I would say is probably one of the challenges now because for our core staff, it has become second nature. So it's now trying to spread the word further to the anesthesiologists, to the hospitalists, all of that, that, no, this is how we do it here. And here, let me help you. It's not a matter of if, it's a matter of just when. Yeah, it's hard to capture the importance or the impact of

A team that understands the why, the how, and now has experience and a skill set in it. It almost doesn't feel fair to have someone come in and expect that of them. That's been my question for years, right? How do we make this change without actual training and support and then experience? And it impacts the entire team, right? So...

You don't have a unified front for messaging for this certain patient. He gets the slide one day, but one day that could be 2% muscle mass. Then you guys get to come in and make up the difference. Yeah. And we'll start that all over again, all the psychology behind it. So really, I would like to see us someday having this a standardized education for all critical care nurses. Anyone that works in the ICU should understand delirium, sedation and mobility management.

as absolute standard of care. And you guys are setting that precedence, I think. And so with the census climbing in the last few months, how have you maintained these practices, even with all the fluctuating staff? And how would this have been had you not had these practices in place? Because we use examples in your simulation training of your own patients

That spent probably one of them was two to three weeks extra in the ICU from delirium and ICU-acquired weakness. If that was more common now, how could your team sustain the current census that

But then how do you maintain the census doing this approach now? I also feel like it really depends on what your patients come in for because a lot of our patients really have had some of them we have not been able to mobilize because we've actually need to have them on continuous infusions because they are so broken. Adrienne and I had a patient that coded not too long ago who was prone and it was a CRT, cannulated for ECMO. Like it was just a really big there. It

It has also given us pause to know that there are times where sedation continues infusion is okay and not to be afraid to do it, but also to remember that it's not the end all tell all world. At some point, whenever they are able, we can turn it off and do other things with it. I think that's one of the biggest things that we were more hesitant about with this whole awake and walking process when it first initially started, because we just thought like Adrian had mentioned, we just thought everybody was going to get no sedation and it's,

That would just be completely overwhelming for the whole staff to try and deal with and really deplete our energy reserves and trying to keep patients in bed and just have them not be squirming all over the place. We keep going back to 45. He was intubated briefly again, and he was in the reclaimed video games while vented. It's just the funniest thing. You walk by and you're like, oh, hey, what's up? And he's still in there playing his Xbox and he's

Where now it's like, okay, that's the cultural norm, whereas people coming in would see that would be just completely out of their mind to see that. But I feel like we are still doing a really good job of knowing what's appropriate and what's not appropriate. Even yesterday, we have a patient who was intubated and the nurse was weaning the sedation down and he was awake, writing on the whiteboard, talking to his family. And it's still, even though the census is so high, we're still making sure patients that are in our department are really still looked after in that sense where we're not

that sedation is appropriate for what their injuries are at that point. It's just been, and we've had some long-termers and we live a small ICU too. We only have an eight-bed ICU and we've got four fence right now. The caseload is very heavy. There is no soft assignment. Everybody is super busy, super sick. So I think that just

Just remembering that we have to take one step at a time with these patients and then just to keep going forward and keeping the consistency of moving patients that are intubated. It's the best thing for them. And I think that we've all seen how well it benefits them. Mark, in the skill set that you guys have developed this past year,

to maintain these practices with this caseload and the high acuities. It's amazing to me. Watching you guys along this journey has been so fulfilling. And I also noticed that with your patients, you have a very diverse population. Jessica, you mentioned you guys had like 10 languages represented in your ICU within the first few months. Patients that were intubated, nonverbal, different languages. And so we know that

Patients that do not speak the language of their caregivers are twice as likely to be restrained. Hispanics are five times more likely to be deeply sedated. How do you feel like

Having them awake and mobile has impacted your ability to provide equitable and inclusive care for them. We have good language tools. And I think that coming from a place of trying to really be more interactive with your patients that are intubated, it's just one more tool now that we have the video language person that's on the other side of the iPad that we can put right up to them and be like, oh, that's what you needed.

It's just one more tool in the bag. Well, yeah, I go back to our little lady that was in 40 that was intubated and she did not speak English. She, it was either Cantonese or Mandarin or something. I can't remember what it was specifically. We would use the interpreter, the language line and the, she would,

listen to what they're saying in response and she would sit there and she would write down the responses to everything and then hold it up so the interpreter could see what she needed and then they would translate to us what she needed and then we would clarify things so that was it was a lengthy process obviously but it was the best way to communicate with her when family wasn't there because she had her faculties about her no problem but it definitely brings another element of how can we support these patients when they don't understand what we're saying even the other patient that

We took care of the open abdomen who spoke Hindi and her daughter was there and just writing all the things down and helping translate that way. It was that I know family is so important if we're able to have them there. That is something that we do with the caveat of making sure that it doesn't overwhelm the patient because sometimes that can make things, they get frustrated. They can't express themselves as helpful, but sometimes we have to pause just to make sure that it's safe for them at the same time. Yeah, absolutely. I just,

Your whole journey has fascinated me, your relation, the whole community that you serve. I'm so proud of everything that you have been through and what you guys are accomplishing. What last words of advice, what advice would you give to teams that are starting out in this journey and other trauma issues? Just try it. You'll be surprised. I'm still, I'm like,

I don't know if this will work, but let's just try it. Let's try to sit edge of bed. What's the worst that's going to happen? Like we're just going to lay back down or they can't do it. And then I'm always surprised where it's like, oh, you did a lot better than I thought you were going to be. Okay. You want to try to stand up, try to push it a little further. So just try it. No, I think having somebody as a resource that has done it before,

With new teams implementing it, to have somebody with experience to encourage them, I think, would be a great opportunity. I think we were extremely fortunate to have a core group of staff that, even though there were doubts, even though there were questions of whether or not it was safe, they were willing to try. And that was huge. Having the training obviously helped. But having somebody there that's done it before in real time would

would be ideal if there is some way that we could magically make that happen. That's my future model is to leave a trial nurse there to be able to be there hands-on and over a period of time to work with all the different nuances and the complications that come up. I absolutely agree. I think that also, we also, you have to trust that

it's okay to have doubt. It's okay to be fearful of the change because all of us, we were very cautious of, okay, is this really going to work? Is this going to be something that we're going to be able to continuously implement for our patients? And the more people that started understanding it and started doing it, the more it trickled down to everybody just saying, okay, yeah, if they're doing it, then why can't I do it? And I think that has been the

The best response we've had nurses who have said, oh, yeah, I've done this before. This isn't new to me. This is something that we've done in other hospitals or I've done when I was a nurse in another country. Like this is something that we've already done. So it wasn't completely unfamiliar for people, but it was just also something that was not really practiced. And I think that just.

pulling the trigger and just doing it. Like Adrienne said, just try it because you never know what you're going to get. And then the responses that you do get afterwards, I think that those are the most fulfilling when you know that you've done something and you have helped that person exponentially be able to leave the ICU a lot sooner, despite all that they've been through is probably the most rewarding aspect of it all. Thank you guys so much for everything that you've done. And I look forward to continuing to learn from you guys and your new expertise and

having other teams continue to learn from you as well. 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.