Episode 187: The ICU Revolution at Mercy San Juan Medical Center - Part 6 with Ginger Manss
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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 had innumerable revolutionists reach out to me to talk about how to get their teams even bought in to the idea of having patients awake and mobile. There is so much a bedside clinician can do to help their own patients and to bring awareness throughout the team. Yet setting a team-wide standard still requires strong leadership from leadership of each discipline of rehab, respiratory therapy, nursing and medical director, as well as the director of critical care and

executive leadership team. I have spoken to directors of critical care about Awaken Walking ICUs and their eyes get huge. And I can tell they are overwhelmed by trying to even fathom leading such a big change, a totally new process of care, team dynamics, and skills that they have never personally done, let alone taken leadership of. They are already so burdened with so many other tasks, initiatives, audits, hiring, et cetera, such a huge

transformation is more than they can often even think about. This episode, I'm excited for you to listen to Dr. Ginger Mon's talk about her role as a new critical care director, how she did her own research, sought out expert help, used the evidence and financial proof to build a bridge between the needs of bedside clinicians and patients,

and the executive leadership team. She exemplifies a leader that is driven by compassion and vision and opened the way for my team to come in and provide the tools and support to make these changes possible in her five ICUs. Ginger, welcome to the podcast. I am so excited to dissect your leadership at Safety, Duty, Health Mercy San Juan. Can you introduce yourself to us, please? Sure. I am Dr. Ginger Manns. I am

I'm really the Senior Director for Critical Care here at Mercy San Juan. I've been doing this for about two and a half years.

Long career, I'm almost getting ready to retire, but I became an LBN at the age of 19 and an RN at the age of 20. I've done a lot of different specialties, including oncology, critical care, cardiac telemetry, quality. And one full job I had was really focused on patient engagement. So this project was really goes along with patient engagement.

I have also been a chief nursing officer for a federally qualified health center. So went a few years in the ambulatory world. So I have a lot of different leadership experience, but I really love what I love about critical care nurses is they're so focused on the patients. Yeah. And that's just really high level nursing, but it's amazing to bring in

such a spectrum of experience into a very niche, little isolated world. Because I feel like critical care is usually very territorial or like you just stay there. And tell me more about the role of a critical care director. Sure. At Dignity Health Mercy San Juan, I do have oversight of five ICUs. We have 56 beds. I see my role, really, I quote Gary Chapman, to take care of the people who take care of

who take care of the people. Dr. Chapman had written a book about radical loving care, and that's really a core precept here at Mercy San Juan. But I see my role, I really am very into patient rounds,

and say prayers with patients if that's appropriate. I make sure I check in with every single day and night staff that I come across and ask them how they're doing, what can I do to help support them in their role. Haley, you and I talk. I'm not a critical care nurse by training, but it's that love of leadership and the love of our patients and staff that keeps me at work. And that was so impressive to me when I first went to Dignity Health Mercy San Juan in August.

of 2022. In August of 2023, you were giving me a tour of the unit, but I just tagged along while you went room to room to each patient and you introduced yourself. And when it was appropriate, you prayed for them. You shared a scripture. Like it was really sweet that you were again, very focused on the patients and the patient care. And even though you were fairly new in your role, you already knew your clinicians really well. It was fun for me to watch and learn about leadership from you. And I also thought it was so brave of you

I think for any director to take on a huge initiative like this to transform some of the pillars of our culture and our practice is daunting. I think that I've felt from many leaders that I've talked with, whether it's medical directors, CNOs, or critical care directors in general, their eyes just get big and they

feel the weight of the magnitude of this kind of change and what that's going to take as a leader to push that forward. And I was especially in awe that ICU wasn't even your main thing. You didn't spend 25 years being an ICU nurse. And it's easy for someone to say, I've done balloon pumps for 25 years. I'm going to be the director of a CV ICU and make sure they have good balloon pump protocols. But for you to come in and say, not my expertise,

But this needs to happen for the patients and for clinicians. And as a critical care director, I'm going to make it happen. Ginger, it blows my mind. I just think it's so brave. And I also have always said that people that come in with a fresh perspective, like new grads, people coming from other specialties can be so powerful in the ICU because you don't necessarily have the clouded vision like those that have done it for so long.

You don't just assume that patients are going to be sedated because you treated sedated patients for the last 20 years. You've had experiences in oncology and inpatient and outpatient and interacting with patients in a different way that a lot of critical care clinicians have not. So to bring that in, to build that bridge as a leader and to bring in patient experience

It just blows my mind. And so what made you brave enough and willing to take on such a huge initiative? Well, when I was hired, probably in every single interview that I had, somebody mentioned the Awaken Walking. I knew it was a big ask for me.

come in. We started, so I started, I'm pretty methodical. I started with understanding the ADAP bundle and looked at what we were doing, what counted for points in the ADAP bundle. We did education with the staff, worked with Gina Flakes, a critical care educator, and the managers to make sure we signed everybody off on what the ADAP bundle was and what the timeframes were. We did improve

Those scores from about the 60th percentile to the 70th percentile in the first year.

And then I still remember Dr. Murphy calling me one day and saying, we are harming patients. We have to get this program started. We'll get no pressure. So I remember I called you, Kaylee, and we had a conversation. And this was in the summer of 23 and brought you to assess where we were. And we had really some pretty awesome pockets of success. The Russell ICU, which is the heavy medical unit, it had some lovely stories of patients on ventilators outside enjoying the sunshine.

But it wasn't consistent and it wasn't interdisciplinary, multidisciplinary. And I think that was our biggest learning in all of that early talk.

I did sit down and read Wesley's book, Every Deep Dawn Best, twice. The first time I perused different chapters and stuff, and then I just read it from start to finish and marked pages and really got excited about the whole project. So I think that got us motivated to get the project off the ground. So as a critical care director, you could be totally bought in. You didn't have to necessarily know how to make these changes.

So you were willing to bring in help from outside parties myself. But then there's a whole huge barrier of how do you get executive leadership buy-in? So how did you make that case to the ELT? Because I think that's where a lot of teams get hung up and don't get to excel.

Well, I think one of the things that as a leader, I am very much into evidence-based practice and it's taking the evidence-based practice that makes sense at the bedside and finding a way to quantify it. And we all know ICU care is very, very costly.

And as I was looking through the literature, it's OK, well, if we can reduce delirium this many times, how much can we say if we can reduce this many times, how much can I save? And my team and I actually sat down and tried to put numbers on it. We kind of have a joke about it because I had this audacious goal of saving six million dollars.

And I put that to, okay, well, what are we going to spend to save $6 million? And, you know, the contract for the consultants, I wanted to buy new chairs, mobility techs, an idea that we had that was going to be important to this project that,

multidisciplinary collaboration. So I quantified that. And I did take a proposal to the executive leadership team saying, this is what it's going to cost, $350,000, but I'm going to give you $6 million back. And they all laughed at me. But it made people sit up and look. And we looked at the literature and

And I did have to make a proposal, not just to the executive team, but I had to take that also to the regional dignity health team to get buy-in from both levels. And they did approve it as a trial project. But since we've been so successful, there's no talk about it being a trial. Like it's just going to be the standard. Absolutely. I know there was concern. People were saying, well, they might give us mobility techs now, but they could take them away later. But I just can't imagine that happening overnight.

Because even within the first few months, you've already seen hundreds of thousands of dollars of savings. I mean, you've already at least doubled what the hospital put into it, right? Correct. And what are you measuring for those savings? So you're doing a special study, right? Yes, we have a couple of different things that we're doing. Through Common Spirit Health, we have a fantastic dashboard that gives us stuff like mean ICU days and

percentage of patients greater than seven days, mean days on event. It helps us to look at that within our own hospital, within our system, and compare ourselves year to year. So we have a lot of data coming through. That just shows one snapshot. As we sat down and we are looking at the A to F bundle, the choice of sedation doesn't always tell you whether they're on sedation or not. So we wanted to

device and I put together with my quality team a special study. And it was real time asking the nursing chip manager, okay, are they out of bed? Are they on restraints? What's their sedation? What's their cam? What's their rats? And we did rolled out this study in the middle of 2023 to get some baseline data about

If patients are eligible for mobility, are they dangling? Are they in a chair? Are they absolutely walking? So trying to capture that data real time. And we have that study ongoing as a longitudinal study that's within our own system, our own hospital.

That was really helpful for me to have that conversation with the executive leadership team to say, here's the amount of mobility actually happening in your ICU. That is a common gap is that our ability to track mobility as far as how often it's happening, what kind of mobility, if they're ambulating, how far are they ambulating, that doesn't easily sink into an EHR dashboard. So it's nice that you would already been looking at that and you could show what was actually happening because by the end of that presentation, when I'm showing mobility,

the costs of failing to mobilize patients, cost benefits, the savings of mobilizing patients, and then what's actually happening in their hospital. It all just clicked. I could just see the CFO being like, oh, shoot. And I think really sparked their interest. So you as a leader to have gathered that data, already be pulling that together was really helpful to even guide that conversation. And that's oftentimes one of the gaps.

Even getting that kind of executive leadership buy-in is not even knowing what is actually going on in our units. Because we can anecdotally say, we hardly ever mobilize our patients. They're often sedated. They're deeply sedated. It's all very subjective. So we've got to have numbers. We have to measure it. And so as a leader, that's amazing that you, even before I ever got involved, you were already trying to quantify the gap. Right. Thank you. And what other... So you got the buy-in.

you we got to get started as a leader what other barriers did you hit along the way one thing I just want to say it's not just one leader that does this this is absolutely a team and I have been so blessed to have not only a great nursing team a great respiratory therapy team and a great rehab team and strong physicians so all of us coming together to to work on things and as

As I was driving in for work the other day, I was thinking about how change is hard and how do you help people for change? And there's a lot of theories about change, but one that I like, I don't know if you're familiar with it, but it's by two brothers, Chip and Dan Heath. You know that one? I don't. They wrote a book called Switch probably a dozen years ago or something, but it's about a, they have a really wonderful analogy that just resonates with me and a writer who

on an elephant on a crooked path and the writer is kind of that mental aspect of this is the change I want to have happen but if you don't have the elephant going the way you want to go you're never going to make it or if you have branches in the path you're never going to make it so

How the Heath Brothers talk about is that educate the mind, but you motivate the heart. You get that passion from the staff and you have champions in each unit and not just in each unit, in each specialty. We had wonderful champions in respiratory therapy with Candice and Nela. And we had wonderful champions in rehab therapy with Tom and Luke. And we had wonderful nursing and physician champions. So you get...

the people to motivate each other and to build that passion. And then the last part of the analogy is the crooked path. How do you straighten the path? How do you get rid of barriers? How do you give them the resources to do what you want to do to make this change happen? And I see that and you mentioned the mobility tax and

We did not get the mobility techs at the beginning of this project. And part of it was we were trying to figure out how if they were going to be in nursing or if they're going to be CNAs or mobility techs. And we did come on to mobility techs centered through the rehab services department where they count their IVUs and everything because the worry in a big hospital is

Oh, we have a CNA here. You know what? We need this sitter. Let's pull them to do that. Oh, we need this. Let's pull them to do that. And by putting it in the mobility tech fashion, it helped keep them out of that scoop of everybody else. Probably shouldn't say that. I did. But the other part is how to, by the fact that we didn't get these people started until after the consultation was done and everybody had that education, I wanted the nurses to own it.

Because even though it's multidisciplinary, the people who are at the bedside 24-7 are the RNs. And they needed to own this and be the pivot point and have the additional resources with rehab and respiratory and mobility tech. So I think that's another thing that I think works well with change. I think it's so nice to have the Highest Up leadership be a nurse and you can speak nurse and you understand...

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.

nurses to have the nurses be leading and advocating this maybe I'm biased I know I'm biased but I do love having nurses lead this and having the rest of the team come in and support we talked to the trauma team and they felt initially that they would be very left alone in it that initially it was just turn sedation off and everyone else walks away and it's they're left to deal with it but

starting the patient and the whole team off on the right path of we're not even going to start sedation unless we have to. We're going to prevent delirium and the whole team is going to be playing their part. Really empowered the nurses to take leadership, to take ownership. And so it's fun to listen to them talk about being the advocates for this now and protecting their patients from maybe visiting physicians that

aren't playing by the same rules. It's really cool to watch that shift. I know that as a leader, you probably took a lot of heat, especially initially. Like who is this ginger coming in and like making these big changes? And she doesn't know critical care and she's never done this before. She's just bought drinking the Kool-Aid. But for you, I think we have a few barriers with the nursing union. I think in doing it differently, I would say we should have gotten our nurse union reps on board earlier.

We had some worries about our protocol with early mobility and how we define that. And are we going to get everybody with an open belly out of bed? And how are we going to do that? And it's going to put nurses at risk. And I think that's one learning that I have from this. That was one barrier. And then we also had some pushback about using the verticalization beds. Well, we have to sit and watch them for 20 minutes. How are we going to do that? And how are we going to staff for that? We have a one-to-one. And so...

I think having the union representatives on board early would have helped. Honestly, once we took it to the union and we showed the evidence-based practice, totally bought on it, that this is the right thing for a patient. And for patients who aren't even strong enough to dangle, if we can get them in a vertical position, that's going to really help drop that diagram and help us get them extubated earlier. And so I think that was a big warning that I had with this.

And I as well, because I had never worked for the hospital that was part of a union. And so that's one of my takeaways as well. I can now approach it saying we're going to get the union involved right away and make sure that everyone's on the same page and up to date and that we're not blindsiding anyone because anything new is scary. From the union perspective, what's good for the patients and good for the nurses, it's totally, this is the kind of thing that we want to work together on and make it

Because if you can get patients up earlier, you're not getting them out of bed when they're five days laying in bed. And it's harder to do that. So definitely, I think that was a great learning for me. And some of your nurses did a really good job scouring the hospital policies and making sure word for word that this was not going against policy. That's something that I look at beforehand to say, what are their policies and protocols? And then when I'm teaching, I'm like, this is within your policies and protocols. But a lot of times they say that they don't think that it is.

When what in reality what's happening is that it is oftentimes part of the hospital policy and protocol that they're not practicing. So where they're afraid of going against policy and being vulnerable to legal problems and things like that. It's ironic that what they're currently doing, the current practices, oftentimes the deeper sedation, failing to

screen their patients for delirium, failing to mobilize them is actually more of a legal liability and is going against hospital policy and protocol. But when we culturally have this accepted norm, we think that those cultural practices are policy. It was interesting to go through that with your team and figure out what's the actual, yeah, what actually needs to change in these protocols or is this just a perception? Or do we need to build a protocol to make sure that we know what we're doing?

I think another barrier that I think is sometimes there's so many competing priorities in health care that taking your foot off the gas. And we have Joint Commission over here and CDPH over here and everything. So how do we keep this going? And we have put some things in place for sustainability and accountability and with our rounds and making sure that we are

sharing what we're doing. And I mentioned it before the podcast, even these podcasts and going out and helping other hospitals. And we made a video to share and be excited about. And those are different ways to keep that momentum going and keep this, have it be an embedded change in the culture. Yes. And tell me about that video. What inspired that and how did you execute that?

Oh, I am so proud of that video. It's definitely a project of love. My managers and educator and I were sitting around the table one day and we were talking about how can we take these stories and make people excited? And we thought about this one patient that we had in Russell ICU. His name was Tang. And could we get him on video? Oh, what about this patient? We just brainstormed and it came together. Actually, we just got it produced and we started it in August of 2023. So it was a 15 month long project.

We interviewed a couple of physicians, a nurse champion, and six patients and families, primarily about what felt to be in delirium, early mobility or late mobility, and that family engagement and staff engagement. We had a couple of glitches along the way. Our first videographer, we taped about 10 hours worth of sessions, and then she was unable to complete

project. So we had to start from scratch. Luckily, I knew a guy who was really good at videos. His name is Bill Dodge and he worked for corporate dignity health and invited him and got approval from his boss and his boss's boss. And we sat and reviewed all 10 hours of the taping. It gave us chills. The power of the testimonies of some of these patients

got it down to about an hour and 50 minutes and we knew that was way too long so we just kept editing it down and then Bill had the thought we need to make it a story arc we need to have the bigger picture so I sat down and wrote a script and I'm not a writer but I just wrote a script and Dr. Bariccio one of our physicians who hadn't been interviewed said the story from start to finish so it

It is a 19-minute video. We have it on a private YouTube now, and I've sent it to all of our patients and have gotten wonderful responses. And my favorite was Tangs, who I asked if he might be willing to sit down and talk with you, Kaylee. And he said, yes, but they're expecting their second child. This is a young gentleman who nearly died, who nearly needed a lung transplant during COVID, who is now...

more than awake and watching, but is thriving and succeeding. And it's been wonderful and chilling to share that story. He was one of the first patients to really be awake and mobile on a ventilator in Russell. Right. And

Your team's heroism totally set him off on a different trajectory for his life. And that was a great example. And we always talked about him in simulation training. How was this video received for your current staff and how will you use it for future staff members? We started at the September staff meeting and there was probably, we have 180 staff, so probably 120 of them saw it then. They loved it. The chats were just, oh, I didn't even recognize Adam until I saw his toenails.

Oh my gosh, that's Joel. I took care. He was one of our first COVID patients. And it was just pretty, pretty wonderful. And I think now that we have it on the YouTube and can share it more readily, it's been fun because we didn't use any paid actors. It's all our nurses and therapists and techs in the video. And they had a lot of fun with that. So we're keeping it as we are bringing new staff on board. We do have the requirement for them to have to see webinars.

that you and your team created, but not, I don't want them doing it on pathways while they're doing the dishes. We are having them do that in a group together, stopping the tape, talking about things and making it real and making it live for people. So having that, and then we're also showing this video at our education for all of our new staff.

I love it. We'll put the link into the show notes so that everyone can go in and watch Dignity Health video. It's beautiful. And it was fun for me to watch some of your charge nurses play the patient and see them just be so involved in this. Those are some of the key leaders to have taking stewardship of this. How many patients, even just this year, will pass through your whole critical care department?

Well, I mean, when we did our baseline study, our volume was about 4,300. In looking at, we have done some pretty good. I do have some results for our first five months of our project from May 1st to September 30th. And our annualized volume this year, looking at what we've done in the last five months, is going to be about 6,200 patients.

So a lot of people to be impacted by this. I don't want initiative, this transformation. I don't like to call it a project because that sounds so short term. But these changes that you have led

That's a lot of souls to impact within just the first year. And this is not something that's just going to go away. Yeah. And one of the things that I shared at our National Common Spirit Health Critical Care Team is we have seen a decrease in our mean ICU days. Not a lot, but 5.1. We've seen a less percentage of patients greater.

In the ICU, greater than seven days. The mean days on a vent is about similar, but one really cool statistic is our number of patients who went from ICU vent to trach. In our baseline period in FY23, it was 4.1% of all of our patients. In this first five months, it's 3.4%.

So that 0.7% drop when you analyze it on 6,000 patients is 26 lives that have not gone from vent to trach. And so that is changing the trajectory of these people. I'd love to see if you could also measure grade missions during this next year.

You could see what percentage of your current patients end up coming back to the hospital. Oh, readmissions. That's beautiful. Yes. You might hit your 6 million with those costs, especially. Yes, maybe. We've also seen a 2.1% drop in mortality. Wow. These five months compared to the whole year. And that's, again, within the first few months. And what I see is it takes about six months to really get momentum going and to really excel. Also, I think it's important to note that

You guys had initial series of webinars back in 21. By the time I showed up, you guys were lightly sedating your patients for the most part, using very little benzodiazepines.

And we're doing some mobility. Now, a lot of your patients are off sedation and doing a lot more mobility. So your baseline wasn't quite as extreme as other teams because you guys had already started making so much headway. And still, again, it just reinforces that this is a dose dependent. That's the more you strive for awake and doing their highest level of mobility, the more you can impact their outcomes and the cost savings. Do you have an estimate of what you saved in those first five months?

Yes, I worked with our finance department and we looked at our ICU variable cost per patient day and took again the FY23 data and these five months and we decreased that by $123 per patient.

But if you multiply that times 6,200 patients, that's a cost savings annualized for one year of $766,000. So we did get 100% return, more than 100% return on our investment for the first five months. And moving forward, we're not going to be buying more recliners. A lot of the stuff we already have going, the only ongoing cost really is the mobility checks and they are worth their weight in gold.

Absolutely. And you haven't even hit the most expensive part of the year, which is respiratory season, where you can really change the trajectory of the time. You have a lot of your summer problems, but the winter is when you really have patients end up there for a long time, depending on how we care for them.

It's so early. It's main to see that kind of outcome and those kind of numbers even early, early on in the game. But you guys will wrap your study up when? The plan is to go through the end of June 2025. So we want to do full year to full year comparisons. Okay, wonderful. Well, Ginger, any last thoughts for critical care directors and how they can approach making this kind of transformation? Think, put your heart in it. Think about that analogy with the elephant and get that brainwashing

passion going. I've done a lot of cool things in my career, but this has been something that has been

multi-dimensionality of seeing it in the patient, seeing the change in the staff, seeing the change in the leadership team. I feel like I've been a nurse for 42 years and I've been blessed to help drive this transformation here and just want to see it keep moving and keep sustaining. And if anybody would like to sit down and talk with somebody who's been there, done it, I'd be very happy to offer my services in my retirement.

Yes, and congratulations on your retirement. This is really going out with a bang. This is a good note to end on. Even though I've already got plans, you're going to be busy doing hobby kind of presentations and things, right? But thank you so much for everything that you've done and happy retirement.

Well, thank you very much for allowing me to share my small part in this wonderful story. So I appreciate your leadership and vision in taking this nationwide because we want every ICU to be awake and walking. You guys have set the standard. Thanks, Ginger. Thank you.

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