Episodes 186: The ICU Revolution at Mercy San Juan Medical Center Part 5- Respiratory Therapy
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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.

Okay, I'm excited for another incredible episode with more revolutionists from Mercy San Juan Dignity Health. But before we dive in, I want to share with you all that awake and walking ICUs have been nominated by nurse.org as the best nurse innovation. This really circles back to Polly Bailey and Louise Bestian, the episode 21, but is also a tribute to all ICU revolutionists. All of you out there that are leading the way to bring evidence-based,

life-saving and humanized care to your ICUs. Thank you so much for all you are doing and please go to the link in the show notes to vote and put Awaken Walking ICUs officially on the map. I am also nominated as Best Nurse Leader, which makes me laugh considering being told repeatedly five years ago that no one would ever listen to my silly podcast. Feel free to cast a vote in one or both categories, Nurse Innovation and Nurse Leader, and

It is everyone's win. So everyone jump in. The link is in the show notes. Okay, for this episode, be ready to take notes. Candice and Naila are model respiratory therapy leaders that have a lot to teach us about powerful RTs and their impact on bringing these huge changes to a big critical care department.

Candice and Naila, thank you so much for coming on the podcast. Can you guys introduce yourselves to us? So my name is Naila Capitula. I am the clinical specialist and supervisor at Mercy San Juan Medical Center. I'm Candice Wuschuk. I'm a supervisor of patient for respiratory therapy at Mercy San Juan. And I'm really excited to be talking about the role that you both have played in bringing your ICUs to almost to awake and walking ICU status, right? Yes.

In your facility, you have five ICUs and I have seen a spectrum of enthusiasm, we'll say for respiratory therapists. When I start training a team, I've seen respiratory therapists, understandably be very, very hesitant, folding their arms, saying absolutely no way we cannot do this. It's unsafe. We don't have the bandwidth, you know, all the excuses. Ironically, the team I'm thinking of, they then became some of the biggest advocates of this. I've seen other teams say, yeah, this is,

Fine, we'll play along. They don't necessarily lead this, but then there's you guys. So tell me what, when you first heard about this initiative coming down, what was your response and why? Well, initially here at Mercy San Juan, we, I mean, we've attempted this mobility program multiple times with no success. It was constant failure because we didn't get the nurses on board. We couldn't get RT and PT and OTK.

to communicate effectively to where that they could streamline. The issues weren't the patient. The issues weren't being concerned with the event. It was more communication aspect and the interdisciplinary education piece was missing. So once we got all that clarified, I think the webinars that you provided all of the staff

kind of answered a lot of the whys we were moving forward with this and clarified a lot because as a respiratory therapist, we don't learn a lot about this in school. We don't, we really don't. So we learn all of this in the hospital. Once you're in the ICUs with very, very sick patients. So they are skeptical. It's not, it's just, they want to be safe, right? So giving them the answers to all the whys was really important. Not everybody did them, but the people who did took an extreme amount of like the,

information from them and a lot of the information I didn't know. I attended a ton of the... What did you... The simulations? Simulations. Those were great. So getting everybody on board was pretty easy. They were more concerned about the staffing, which once we took that aspect away, it was... They were ready to go. So... Yeah. Let's talk about that. Even that alone. I mean, just starting off, meeting with all the leaders...

There was at the time was only you, Candice, and your manager, Chris. And you guys were like, yep, we're in. We're all in. Whatever needs to be done, we're going to get it done.

Yeah, in that time frame, our leadership was going through a little bit of a transition. We had two people leave the position. So I took on the entire. I mean, I remember I was sat there from 9 a.m. to 11 p.m. with your team and made sure that I was present with all the staff. I was asking them to be there. I felt like I needed to lead by example and be present for them as well. So I think I attended all of them the first week that you were here. But by doing that, I mean, it was...

huge with the buy-in with the staff because they really saw me doing it. If this is as important for my leaders here, then I feel like this is something that I need to be a part of, you know? So they asked appropriate questions. They were on board. And again, all the questions were about staffing. But it's super important as a leader to make sure you're present and visible to the staff and when we're moving forward with any kind of change. So.

I'd never experienced that before in all the trainings that I've done. To have RT leadership at every single simulation training, even playing the patient. You did a great job, by the way. Oh yeah, you ended up having COVID, but I don't think any of us got it or at least not had it. But it was just really impressive how involved you were and

It just sets precedence for the entire team, not just the RT department, but the rest of the disciplines to say, RT is going to help lead this. RT is important in this. And RT is bought in and they're going to do it. Because I've seen repeatedly that when a respiratory therapist says, yeah, let's do it. Let's get them up. Let's wake them up. Everyone else feels so much safer and willing to do it.

But we know how to work the machine that is essentially keeping your patient alive. So that holds a lot of weight in making people feel safe all the way around. So I think that's a lot. It was the PT, OT when we communicated with them. Yeah. Because they wanted to know more about the event. What are they looking for? What's important? What is an emergency? And what technically isn't? But how can I fix it? And that, they did a great job setting up that. Do you want to talk about that? Yeah. So I took about a week or so and we coordinated with PT and OT.

to come together and do like hour long trainings with them. And it was strictly respiratory, just what's the ET tube? What are the markings on that tube mean?

what's that thing holding the tube, um, suctioning if it was, so OT is not in their scope of practice, but for PT they can. So just training on even just suctioning and kind of, uh, I guess deescalating the intensity of what an intubated patient is like, or a ventilator or an airway, just kind of normalizing it more so that, um, if they, you know, as we,

grow in this program and doing this more regularly, they're able to feel more autonomous with the patients that are stable and able to kind of do what they can, even if they have like, because we have now mobility techs that help aid with, you know, if they need extra hands on deck for that.

And not necessarily taking that RT away from other patients and maybe delaying that mobility timeframe. So doing that education with PTOT, also just doing that kind of bridged a little bit of communication gaps. Yeah, it really did. I mean, you can see we did. I mean, I've worked here for five, six years now. I barely even had minimal words with Tom or Luke.

You know, so now we like really, we really know each other very well now. You know, so it's, we got really comfortable with talking to them and raising awareness of questions and asking the right things. Because I don't know if our staff was too concerned with PT and OT. They were very concerned with what we do. Yeah.

So we wanted to make sure we provided everything that we could to make them feel a little bit more comfortable. And I think that really- We loved it. Yeah, we did a little survey after and everybody was so appreciative of just getting that extra time, that knowledge of respiratory mechanics and ventilators and patients and stuff. We always want PT and OT to be working with these patients, but in reality, many of our PTs and OTs throughout the community have not received training on

mechanical mutilation, what the modes are, what the alarms are for, how to do inline suctioning. Can they or can they not do inline suctioning? But those are essential skills to make this feasible. You have to have an RT at the bedside every single time you sit a patient up. There is no way you will have enough RTs to do that. You have to build a communication skill sets of your colleagues and

That's why, I mean, I could have had someone from my team do that education for your PTs and OTs, but I wanted you guys to do it so that you would build those relationships so that when you work with them in the future, you know that they've received this education, you've checked them off on inline sectioning. They also know that they can come to you with questions and you're building this alliance between the two departments. Yeah. Yeah. No, it definitely made us a lot stronger as a team doing these mobility rounds.

Love it. And so with your team's concerns about staffing, how did you initially set out a plan to make them feel like this was going to be possible?

with the current workload? So we started initially with the simulations. We would staff one person over so that we can fully relieve somebody to attend these hourly rounds. And we were using that as we set a precedent, kind of like, this is what we plan to do. Like we're going to have a mobility respiratory therapist who's going to either relieve you from your duty so you can go mobilize your patient because you know them.

or we're going to have them learn the patient and then go do all the rounds of mobility. So at the beginning, it was very slow. They were not, they didn't, they didn't trust us that we were going to do that, but he made it very clear every day we had an extra person on. So they were, that's why we had such a great turnout with our teas because we had the coverage. Nursing doesn't always have that luxury of being able to have people back them up. They did on some nights, but some nights they weren't available because they

But I think they really gained the trust that we were going to do that for them. And that's what we've been doing. Then we eventually, the way we work at our department is we do it by points system and that allots, each point allots for a certain amount of time. So now when we know we're mobilizing patients or have the potential to mobilize somebody, we will give them additional points.

so that they are able to have the time to spend. And they know they can call Naila, myself, their lead, and if they're too wrapped up to be able to get to something, and we'll go alleviate them and they're able to do the mobility. So I think we've kind of got through that barrier by just proving to them that we are going to give them. And then we did talk about, you know, the

we do now have, but at the very beginning, we talked about staffing, um, the PTOT department with extra mobility techs for this specifically. And we now have three, um, employees who, I mean, they did, we did a great job establishing their workflow and how they rotate between the ICUs. Um,

to help with mobility, early mobility. So that's been really great. And I think the RTs, so all three of them rotated within our department as part of their orientation as well. Yeah, so they had orientation to the ICUs and just getting accustomed to vented patients or patients on BiPAP or high flow, very like high settings. So they got acclimated to that as well during their orientation. So they got to see face-to-face with a lot of the RT department and PTOT. So again,

like bridging that gap between communication and collaboration but also um the the staff like she candace had mentioned we had because we had a patient who we we ended up ambulating um on the ventilator down the hall in the icu and because the staffing was a little tight you know they weren't necessarily able to do it in that moment but leadership i went up there and you know just to like be

you know, a team player just went up there, me, Luke and the techs and the nursing that was at the bedside went and ambulated that patient on the ventilator. And it was such a great moment for even the ICU. Everybody was like, oh my gosh, is this really happening? Like, this is really happening. It was, it was cool to finally like have everybody see like, this is what we're doing this for. And it, but it did take like, I mean, that arc,

Me, myself, the nurse, Luke, who's the patient handling coach, and then Anna, mobility tech. So there was like, there's multiple hands on deck. So the staffing portion, I think we did a pretty good job here with making sure that there's availability for. A lot of the concern from the staffs were, I'll believe it when I see it. We talked about mobility tech in the simulations with you. We talked about, don't worry about staffing. Your leadership team is going to take care of that. Yeah.

And a lot of the feedback was, well, we'll believe it was big. We've tried this before and it never worked out. So the follow through and being consistent with what we were saying was huge here. I can only speak for our department, but we made sure we gave them the staff. We told them call leadership if we need help. Naila shows up immediately. Yeah. You know, so we told them they were getting mobility techs. They see them being trained by our team.

So that follow through showed them that we were committed to this. Now they know that they're bought in at this point. Right. So yeah, it was communication is huge. You know this and anything. But I felt with this,

program, it was huge. Yeah. And it sets such a precedence for the entire critical care department to see RTs changing their staffing model, accommodating the point system, having the mobility techs train with you guys. I don't think I've ever seen that before. Usually they're just like, just follow around the PT or whatever, but we really want to make sure that those mobility techs were helping lead this, that they were autonomous, that they were educated, prepared,

So to have them understand oxygen delivery, these high acuity patients by RTs, that RTs helped train mobility checks, it just brings in that stronger association between respiratory therapists and mobility, that it is part of your jurisdiction. And then as leaders to say, we're going to make this happen. We're going to make sure that you are staffed to be able to be trained, not just a few champions, but every single person is going to receive this training, will be at the training center,

And when you have patients that need help, especially initially, right? It was a huge lift. Like you described, Naila, that there were so many people involved in mobility session because it was a new skill to everybody, right? We weren't sure what was going on. And now, I mean, that was initially...

And you guys did smart rounds. You went patient to patient to patient with leaders of each discipline and ask questions like, why are they sedated? What's the indication for sedation? What's the rest level? What's their cam? Are we going to get them up? Are we not? And you went in and put hands on those patients. You got them up with them to show everybody this is not negotiable. This is life saving interventions that must be done. We're going to do it with you so that they could see it happen.

You are actually proving its feasibility to your team, but then you're teaching them how to do it so that they can do it independently later. So what have you seen? I mean, I know our last training was just a few months ago, but what have you seen as far as their skill set, the timing and the staff required to mobilize these patients?

I mean, even just this morning when I went into the ICU just to go around on a patient, I literally had to wait like 15 minutes for the RT to step out of the room because she was mobilizing the patient with PT and the tech. So, I mean, it's moving along. I think it kind of, at this point, it's the fine tuning of, you know, the patients that have

Like maybe their settings are just borderline and they're not quite sure if like, oh, I can just dangle them at the side or do I need RT and mobility tech at the bedside or more hands on deck kind of thing.

I mean, in the addition of the verticalization beds that, oh my goodness, there was a moment where I swear everybody was getting one. Like, I was like, holy moly, like this unit is just in and up, you know? And it was, it was really beautiful. It was great to see that being kind of normalized. It wasn't such a niche thing, you know? But again, not every patient is, it's not warranted for every patient. So there's like lulls, I think with that.

But I think for the most part, I mean, the improvement from the beginning. Oh, it's a total 180. Yeah. Part of our norm now. Yeah. It's normal. It's like,

we it's completely different than last year at this time yeah like I don't get called as much as I would have before now it's kind of in the workflow I would say even you know which like at the other facility I came from like it literally initially it was like rough but then the workflow it just was part of the workflow like you just knew you

You communicate with PT at your first round, like, hey, when's a good time? Okay, you want to do that? Okay, sure. Let me see what I can move around and just call me if anything. You know, the communication is better.

We also made some adjustments to our protocols where our staff, it's now you're able to put in an order for mobilization through our RTE valentreat. So if an RTE is going in and they can see like, hey, this patient needs to be up, they can put that order in. PT and OT don't have to do it. So we have obviously room for improvement there. We can definitely be

seeing a lot more patients but are ordering it for a lot more patients but having that as a tool has been great helping PT to recognize these patients that typically they aren't able to see so definitely increased amount of patients we see so yeah that's good yeah that is so great RTs are putting in PT and OT consultation orders yeah I mean I've never heard of that before

It's really, I mean, we're very protocol driven in this facility, which helps that be facilitated easier. So it's kind of built in within it, but then highlighting it specifically for mobility. For RTs to be thinking about that, you know, I think RTs and nurses, we're trained to look at certain organ systems and tasks that we're doing. So I think it's easy for RTs to fall into mobility.

I work with a ventilator instead of I work with patients. So to me, that just shows that our T's are looking at an entire person and the trajectory of their lives. And I think they've learned a lot about how that all connects into the pulmonary system. Yeah, they did. And that's, I was telling you, simulations were huge with the information that we took away from it. RAS and CAM, we don't get taught that. You know, and doing, I mean, they like can vouch for this. We started, it was just myself and Luke starting the smart rounds. Oh my gosh.

in the very beginning and it was tough. I mean, getting the feedback, the pushback from the nurses was not always positive, but we stayed consistent and then got the leadership from nursing on board and they started joining us and then it became more fluid. It was like, okay, they're coming around. Let's get our patient up. They were like ready with their stuff while they knew it was coming. And so they're like, oh, great, gosh, I need to figure it out. They were ready to report to

their leadership as well as you guys as leaders of the other departments. And I think if you were to go into any normal ICU right now and Candice as a respiratory therapist, if you were to say, so tell me about your patient, why are they sedated? They'd probably give you the middle finger and say, that's

That's not your... I did that today. They did. Yeah, you did. She just gave me a look. It wasn't the middle finger, but there was definitely a look. Communication has definitely improved with nurses because at first it was like, oh, why are you asking more rest and cam? We don't know anything about it until we're like, no, we've done our rest and cam assessments and we don't think they're at a negative two. We think they're more of a negative four. Why are we sedating them? You know, so having that open dialogue and understanding, like we...

Yes, we need to stay in our own lane, but remember we're on the same highway. You know what I'm saying? I love that. Because yes, we all do our different things and we all specialize.

in helping this patient differently. However, we're all after the same goal, right? So we need to keep that in mind. And so when we, I guess the nurses got a lot more education about how we were educated and what they do. They were like, oh, okay, well, I guess they do kind of know what they're doing. And doing that circulation training, had your team ever done training with PT, OT, RNs, physicians, everyone, CNAs, everyone together? No, not really. Yeah, not really.

Yeah, this is the first time we've had all disciplinaries actually in a training session together, right? Collaborating. Yeah, collaborating, talking to each other. What are your concerns? What are your concerns from your specialty, like meds versus vent versus getting up and EMAPs and all that stuff? So it's just, it's a lot of information, but working together was really helpful. It is. It's like doing multidisciplinary rounding without the pressure of actually like...

having the result of the patient like happening in your hand. It's beautiful. It's actually really, it was really nice to be a part of that because you do get to hear and every nurse has their own idea of what is possibly the right way to go. And RTs too. I mean, there's, you have protocols, but that's just a guideline. Otherwise you're using your critical thinking skills, trying to figure out what to do. Right. So NPT as well. So,

It was, the sims were great because it's like MBRs, but without the pressure of a patient, like a live patient. Yeah, and one of my objectives was to leave the entire team with the tools needed to critically think and work together collaboratively. Because it's really hard to prepare everyone for every single nuance and possible scenario that could happen in the ICU. Yeah, yeah. But I wanted you guys to be able to bring your experience

personal expertise to those discussions to be working towards the same goal. When historically we haven't had the same goal. We haven't had the same vision. We don't know what we're working towards or what these tools or letters of the bundle are for. But have you seen...

that objective achieved? Oh, yeah, I think so. I mean, it's going in the right direction. We're not fully there yet, but it's, it's still very new to us. Like it takes a lot, a long time to change this many people's mindsets, you know, what we're doing. But I think we're way better off than we were last year. I think,

ginger has given us this the statistics of like the medication being down this yeah like how much station we're giving has drastically changed so i think we're in the right direction there's always room for improvement but i think everybody's on board now we don't really have a lot of i think now it's issues it may may or not be mean may or may not be more of

depending on the physician, even that they're like, I feel like physicians can be kind of a barrier. Like today, for instance, the physician is the barrier. So I mean, there's just different cases every, every, like every week. I mean, it could be a day to day change where we're like mobilizing, mobilizing, and then a new physician comes on board. And it's just kind of like, oh, okay, I guess we're just gonna see, you know, it's hard to get to everyone every time. But

Generally, I think it's been amazing. But in that situation with today, questions are being asked. Yes. Why? Why are we doing this? Which is so much different than last year. It was like, oh, the doctor just said this. Now it's like, wait, why? They think a little bit harder and a little bit deeper, which is essentially what this program is, right? Let's think a little bit harder. We're not going to be able to.

and help everybody. I mean, we can't, it's close, but we can't do it for everybody, but at least we're asking the right person. We're advocating for that patient in the appropriate moments and making the changes that we can, you know? Yeah. And we, we actually, we didn't have really great physician involvement in the similar trainings or even the webinars, to be honest. And that was, that was really disappointing. And so I'm not surprised to hear that

there's variation because we're all a product of our training and our experiences. So it's hard to expect someone to really lead this and excel in it if they did not attend the training. But it's nice to know that there are layers of safety, that the rest of the entire team has gotten this training. They're having these experiences. They're developing this expertise. Then they're asking those questions and hopefully guiding those physicians. It would just how they manage these patients. Yeah.

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. Coming from your original, your first, I would say, coming from your last ICU...

where you actually worked with Dr. Bellucci, who I interviewed in episode 130. He talked about having visited LDS Hospital, seeing an awakened walking ICU, coming back to your unit. Yes. And then doing a rapid overall. So I want to share that experience of having a patient come to the hospital.

get sedation off everyone everybody get up and oh my gosh to make it happen versus a much more organized and thorough implementation oh gosh man when i i distinctly remember the shift when he came back i'm like who's this kaylee dayton like who is he talking about like i had no idea what that was or what your podcast was or whatnot but i remember him coming back and he was just like

he went gung-ho like all the way like okay guys no more sedation and I feel like

I mean, I don't think anybody was really a fan of that approach, but being able to see that, um, I guess implementation lack of a word, uh, versus how I kind of came in here at Mercy and one like halfway through your guys's program, uh, establishing that. Um, I actually, when I came on and I was like, wait, there's a whole, like, like

organization that implements this? I was like, wait, what? And for me, coming from kind of where Dr. Bellucci was like, hey, this is what we're doing. There wasn't, he, I think in the moments that he could educate why that's so important, most of that education went to nursing.

Cause they were the ones at the bedside doing the, um, the SATs and whatnot. So for the respiratory department, like for us, it was kind of just, there wasn't a whole lot of information given there. And we were, we just knew, Oh, they're not giving patient anymore and something we need to like figure it out. Like, okay. So I guess our patients are just, you know, there wasn't a whole lot of information to back up the why behind the change. But I mean,

There's different pluses and minuses because we had a lot of barriers, I believe, here with changing culture. And there was a lot of tiptoeing initially. I believe like, oh, we don't want to. But we also want to move forward. But we also don't want to like, you know, it was like a lot of I don't even know how to describe it. It was really scary.

We want to disrupt the system, but we don't want to upset people. Right. Right. Which is, I think looking at it now, kind of on this side of it, I think it's great how, where we're at, where we've come and how the collaboration has grown a lot over the, you know, at the previous facility with Dr. Pellucci. It was, it was good. You saw the value of it, but the, I don't even know how, the whys weren't answered. The whys weren't answered. There was,

There was just a lot of head-butting with disciplines before it became more of like, I mentioned like the workflow, like PT, OT, and RT, like we all became great friends. Like I still talk to them, like, and I've been here for almost a year now. Like you became so close because you had to, you didn't really have an option. Like, hey, there's no more sedation. Like, let's go and try to walk them or do something. Like we were walking patients on meds.

Actually, prior to Vellucci going, I think he continued, but when he came back, he was just like, this is it. We're done. We're changing it up. It's going to happen. And it was good. It was effective. But there was also a lot of nurses who left, actually, because they were like, I'm not doing this. Like, this doesn't make any sense. A lot of nurses quit, I remember, during that transition. And again, I think it's because they didn't know the why behind it. And it was always, you know, nighttime sedation. Oh, they're resting. Right.

But now we know exactly that that's the opposite. Right. But I don't know that they necessarily were given that information. And it's bad. Like, it's hard. Like, it could have just been a quick, you know, some education pieces, even some like education modules online or like webinar. But there was none of that. It was just I'm here. We're doing this. And I'm here.

Gosh, I love Dr. Belucci. Don't get me wrong. Like he was, and even now I highly, highly respect him. He's incredible. I think the approach could have been a little bit different. And I don't know if I'm the only one who feels that way, but. It's amazing what he's accomplished. I mean. Oh, incredible. Get to that point as a lone revolutionist and overall. And there is something to be said of.

pushing the team to just do it so they can actually experience it when you're just trying to manage awakening trials you never really get to the point where you see patients be awake free of delirium strong compliant walking on the ventilator so that's a lot to babysit so i mean i like it since that approach of like we're just going to do do it all the way so you can see the contrast

And it was like, yeah, like, cause a lot of those nurses, it wasn't necessarily, some of them left. They're like, I'm done. But others were actually let go because they just wouldn't, they were held accountable. And that, I think that part a little bit was difficult to find that bridge, that part here. Cause it was.

We don't want to push too hard because we know you have a lot going on, but we really need to change this. So that shift in culture took a lot longer. And I think it's still a work in progress. Whereas over there, hey, this is what we're doing. If you're not doing it, like, sorry. And there was, I think a few actually were just like let go because they weren't willing to change their culture.

their culture, like the way that they did their, their ABCD. Oh no. You know, it really should be standard of care. Yeah. And if we're like, no, I'm not going to do that vent bundle. I'm not going to do the oral care. Yeah. That would never fly for any RT or RN. Yeah. So we, I do like that. They saw it as imperative and non-negotiable and essential. I saw another team, um,

really put a lot of pressure on their charge nurses to lead this and oversee it and sat them down and said, if you're not going to assume this role, then you're not going to have this role. And one was demoted from being charge nurse, but it doesn't have to be personal, but this is what needs to happen for our patients. So that's, that's really hard. And that's where I would never want to be a manager of an apartment or any of that, because it's so hard to negotiate. But I,

I just wanted to kind of hear your perspective as someone that kind of got blindsided, didn't learn the why. I mean, a lot of those nurses, sorry, I didn't mean to interrupt, but I feel like a lot of those end results with those, the staff members, it could have been different if they had the why. I really feel like that could have been the change that would have been like, oh my gosh, totally. Because when I listened on some of those webinars and then the sims,

Oh my God, the nighttime. Oh, they're resting. I had never, ever heard that, that they're not actually resting and they're going through all these different episodes. You know, the PTSD post, like I did not know any of that. And I came from an ICU again, where we have been walking people on vents and early mobility for gosh, the last like five, six years that I was there. So to only now find that out, what?

That's what I felt too. I'm like, I had worked in an awake and walking ICU and I didn't know why we did it. So when I went to a normal ICU, I just did the normal thing. Yeah. And then I went back to my first ICU and I was like, finally, I was asking, why are we doing this? It just makes you feel insane that it's like trying to explain water to a fish. It's all around them. They're surrounded by it, but maybe they don't even know that it's water. Hilarium and isochord weakness. We don't actually see it for what it is. Yeah. And so it's,

Sounds like you both agree with me that understanding the why is the imperative first step. Yeah. And Naila, what has your role been as RT educator in rolling this out and now sustaining it?

I mean, just being a resource first and foremost for the staff, like, because I did come from the facility where we did a lot of that. So, and then with the education of the Y, with the symptoms and everything, just being a resource. Also, I mean, the education portion with PTOT. And then, yeah.

I did partake with the smart rounds for months. She got stuck doing it because I went on a week. And you know, you really saw the shift because I mean, it was consistently for probably the two months or so. We did it for initially two weeks, then it went to two more and then three more. So it was like almost two months. Yeah, I think two months straight of smart rounds that I was doing. And I really saw the change. And I think it's because nursing leadership

really started holding the staff accountable and making sure that, hey, why aren't your BMAT scores, which is our scoring for physical therapy to kind of know where they're at, what's their baseline, if, you know, and their RAS, all of that daily had to be updated. So just being able to see that and then coming back to my department and communicating with my staff, like, hey, are they communicating with you about their, you know, ability to mobilize if they're, you know,

slow on the V mat, you know, just doing that, bridging that part of it. Cause it's hard. It is hard with all the different disciplines to come together, collaborate and to like make a decision for a patient, like, Hey, we should do this. We should do that. But for the most part, I think just being a resource for them, if they're unable to do it, to be available to them, like, Hey, I can, I can pop in and do that. I, I love actually, I'm,

I'm not that long ago from bedside. So any moment I can go and do some kind of bedside anything, I'm just like, Oh, let me go. Let's go. Like, I'm all about it. So being a resource for them, and then just educating wherever I can, especially with the mobility techs, like during the orientation process, I was able to like incorporate them into the RT workflow so that they can see, you know, the ICU RT bedside work, you know, what the bed looks like and all that. So

I think that's probably been my biggest, I don't know, thing that I've been able to like give to the staff and then to this program. But otherwise it's been a full collaboration with everybody. And one of the big concerns that RTs usually have is ventilator dyssynchrony. We have to sedate our patients because we know that they're going to have ventilator dyssynchrony. When actually we know that sedation, especially deep sedation, increases and can cause ventilator dyssynchrony. So I just want to hear anecdotally,

Are you guys getting calls all the time saying, I can't synchronize with the ventilator, come help because we don't have sedation. I mean, today, today, I mean, I think that's a good question to ask our staff.

Yeah. Because we typically don't get assigned patients. They don't come to us and tell us that our patients are dysinfinite. We'd be happy to talk to them and see if they get their feedback on, hey, are you guys in this rapid? What are you guys doing? What are your steps to fix this? We typically, we don't see that many patients unless we round on them, but typically we don't round on the ones who are intubated. So,

I think that'd be a good question for the staff, but I know I don't hear it as often as I used to. Yeah. The issues, but. We did have a patient recently. We did like a whole lunch and learned with the RT staff and nursing where Dr. Bistrong, our medical director, he came in and we had like a case of patient like study. Yeah.

A case study? A case study. Jesus. A case study of a patient that we actually just had in our trauma ICU and the things we could have fixed, but they went into ARDS and it was, yeah. So in that sense, there was a lot of talk about sedation and dyssynchrony because, I mean, we are doing this early mobility. So there was a lack of sedation when it may have been warranted for specifically this patient.

And then later on, it ended up escalating more than it needed to if we had just kind of like treated the patient. Well, they were a trauma patient turned into medical pulmonary. It was a very complex situation. Yeah. But in that case, I kind of wish we would have collaborated more on the sedation and dyssynchrony because I think, I think, and that's where, again, the physician part comes into and their understanding of deep sedation and light sedation and

But otherwise, I think they've been, I mean, our staff is really good about trying to educate like on sedation with dyssynchrony and how if you deep sedate, I mean, you're also removing their drive to breathe. And now you're going to be having a harder time to ventilate your patients that they have no drive. So yeah.

Our RTs are pretty good. Yeah, they're pretty good. You guys do have incredible RTs. And even before we started this, your RTs had a lot of autonomy. They were on codes in the school. Oh, yeah. Oh, they still do. They love it. Yes, I know. I just love seeing an environment and a hospital system that allows them to practice at the top of their license. That made it a lot easier to...

hand this off to you to say, lead this. When you have an RT department that is not empowered, they don't see themselves as leaders. They're just the ones that only mess with the buttons or what the physicians tell them all the time on the ventilator. That's really hard to then say, you're going to help lead this. So I just feel like this was a really great puzzle to put together from my perspective with these great elements and to just let you guys shine. And I feel like that's what your RTs have done.

Any advice that you would give to the respiratory therapy world about helping lead the ABCF bundle in their units? I think what Candice said earlier was huge. Just you're leading your staff either. You present.

Take my example, embrace the change, understand that this is a critical part of the recovery process for these patients and that we need to get on board to do this. Remember why you went to RT school in the first place, right? To save lives. And this is what we're essentially we're doing and expediting that process when they're in the ICU. So embrace the change, educate yourself. I mean, you give all the right tools. I feel like webinars are huge for the staff.

So take the time to watch the webinars. I wish it would have been mandatory for our staff. We made it optional. So I wish they would have been mandatory because there was a lot of good information in there that was given to the staff before going into the simulations that they took away. Like, wow, I didn't know that this was this big, you know, so because we don't get taught this in our T-school. This is not something we go over. It's more nursing focused. Right.

Another thing that we did in our department, and I don't know if this is something other departments would want to do for theirs, but we have a, like a skills book that we use.

create every year for our staff and we were able to input all the data that you gave us, the graphs, anything that was a little specific to us. Yeah, we inputted it into a skills book for the staff so they always have something to reference if we're not here or if they don't, maybe it's been a while and they forgot what RAS is and all the other things.

It has a whole section on early mobility and I highlighted you in it and some of the success stories that you had online. So the staff always have that reference, which again, it just equips them. You just want to give them everything that they need or may need to do their job and do it well and to continue on. So I think that. Yeah, I think from a leadership, we can speak more from the leadership realm of what we do collectively.

collaborate with your colleagues, really get together, you know, make, identify, you know, weaknesses and opportunities for improvement and work towards a common goal.

for your department and that department to work together. I mean, that really helped with Tom and me and Luke and Chris and Mayla all sat down and really hammered out what we really wanted to get done. And we made it happen. Celebrating successes is huge. Knowing that what they did really worked and they were a part of this change. Seeing that, and like you said, like actually living it and then not just being a simulation, but watching it come to fruition, all the stuff you did, all the

Some things may not have worked, but some things might have. And seeing these successful patients, we took video of them. They were in a healing garden on a ventilator, like,

It was really cool to see. People really enjoyed that. Like I would hear them. They don't like to admit it, but they would think, oh, I took my patient outside today. You know, they really got excited about it. Not the cool thing to be excited about. Sorry, we're supposed to complain here. For God. But it became, you know, really exciting to know that they did something really good for this patient. I'm sure they went home. That was another one of my objectives is that.

they would be able to see that crossroads that patients were at. And that when they did these interventions and they took the right steps and had them awake and mobile, they could see in their minds the trajectory that they were putting them on to. Yeah. But they could feel like, okay, I'm saving their lives and giving them back lives worth living. Yeah. Part of their healing and their big, like their ability to get out of here and live their life. That's the coolest. Huge. Yeah. What's your plan to sustain this?

When you have turnover, new grads, new employees come in. Well, the new grads, we are...

really really tried to make sure our new grads specifically stay in the icu's um a lot of the night shifters don't get the opportunity to work with them as much as we want when it comes to mobility and unfortunately that's where all our newer staff go to is night shift but we do have a few per diems that have come on during the day and when they complete their training in the icu we try to ensure that they're going to be in the icu's a lot so they do get this training um

I also instructed more senior therapists who do this, do this a lot of people doing it to take them under their wing. Even if they don't have the AC, come with me, let's do this together. You know, let's figure out how we can get you comfortable doing it as well. So leading by example is huge. I think in any realm, like if you're a senior therapist, you need to, you know, feed our young. Yeah. Teach them what we should be doing and how to do it correctly.

And it lightens your load, right? If you're the only one that can mobilize a patient or is going to, then it's always going to fall down to you. But if you build up an arm and they can do it, when you're busy with one patient, you're going to have more help to catch your other patient. Right. Everyone's going to be more efficient. We're like twinning right now. One other thing I feel like we could have done better at, I always try to see what we could have done better was,

earlier collaboration with PTOT and nursing like set the goals of what we have and how we're going to go about doing this so we have more of the answers when we are in the simulations like oh we're going to work we already have education planned with PTOT instead of that was kind of we learned along the way like through simulations like maybe we need to do some simulations

education with PT and OT because they didn't know the difference between a suction catheter and an ET tube you know so so I think earlier education with the leadership team and clear like

what our goals are, how are we going to get there? And having that information when they express the concerns in the simulations would have been a little bit easier. I had no clue what questions they were going to come up with. But I think we did a good job getting everybody on board. And I think going forward, because I'm technically in the process of redoing our new hire orientation and all of that. So

I will be incorporating mobility and early mobility within that as a competency for them going forward. So that'll help just continue it on as we go forward. Again, that's a full project process, so it'll be a little while, but nevertheless, it's going to be highly highlighted within the orientation of any new hires. That I think will help again, sustain with the department because then the other staff members

It lightens the load again, you know, a little bit. And it sets the precedence that we are more Suzanne Juan. Here's the care that we give. You're going to work here. This is what we do. And we're going to teach you how to do it. We expect you to jump in. Yeah.

Thank you both so much for everything that you've done. You have saved lives for generations to come. Same to you, Julie. Are you kidding? I know. Well, thank you so much, guys. You're welcome. Yeah. Thank you so much. Yeah. It's been wonderful. It's been a journey. I mean, it's been great. I mean, everybody's benefited from it. Us nursing, PTOT, patients. Yeah. Just the number one bird. Yeah. Happy to be here.

Thank you. You need me to travel with you? I'm with you. Let's go. 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.