Alison Cassina, RN: Nursing Perspective on Mobility in the ICU

Welcome to another episode of the Mobility Minute Podcast - actually the 10th and final episode of Season 1. We've had some wonderful guests throughout the first season from traveling nurses to an ergonomics expert to a patient experiencing a blood clot and subsequent pulmonary embolism. We've covered a lot. Thank you to our listeners, guests, and those who may be listening for the first time. This podcast is a place for thoughtful discussion on patient mobility and how mobility factors into recovery.

Today, we speak with critical care nurse, Alison Cassina. In the ICU, mobility can fall down the priority list (and for good reason). Oftentimes bedside caregivers are unsure which direction to take when starting the rehabilitation journey for a patient. Critical care nurse, Alison Cassina knows this reality firsthand and has prioritized mobility for even the most acutely ill patients. She shares with us her team's approach to mobility with an ECMO patient who had to prove a certain standard of mobility before receiving a lung transplant.  

All of this and more on the Mobility Minute Podcast!

Transcript

0:06

Drew

Welcome to another episode of the Mobility Minute podcast. I'm your host, Drew Martin. today is actually our 10th and final episode from season one. We've had some wonderful guests throughout this first season from traveling nurses to an ergonomics expert and even a patient experiencing a blood clot and subsequent pulmonary embolism. We've really gotten to cover a lot and I want to thank our listeners also our guests and maybe those listening for the very first time to this podcast. It's really a place for a thoughtful discussion on patient mobility and how mobility factors into recovery. 

0:47

Drew

Today, we get to speak with critical care nurse Allison Cassina. In the intensive care unit, mobility can fall down the priority list, and for good reason. Oftentimes bedside caregivers are unsure which direction to take when starting the rehabilitation journey for a patient. Critical care nurse, Allison Cassina, knows this reality firsthand and has prioritized mobility for even the most acutely ill patients. In this episode, she shares with us her team's approach to mobility with an ECMO patient who had to prove a certain standard of mobility before receiving a lung transplant.  

All of this and more. Coming up next on the Mobility Minute podcast. 

1:30

Alison

My name is Alison Cassina. I am a cardiovascular ICU nurse. I've been a nurse for a little over eight years now in the critical care setting, specifically cardiovascular patients. Post-surgery from open-heart surgery, heart and lung transplant, and various other devices for cardiovascular complications. 

1:57

Drew

Sure. And how did you end up becoming a nurse? 

2:00

Alison

I always had an inclination towards the medical field. So I applied to nursing school one day. I figured if I got in I would see how it went. (I) went to nursing school, and it became a serious passion of mine and I started working out in the ICU. And it has been the only environment that I've known but it has been my passion since day one. And mobility happens to be one of those topics that go hand in hand with ICU patients. 

2:33

Drew

Just with the complexities of your job and being around other critical care nurses. Why do you think that mobility is so crucial for an ICU patient specifically? 

2:45

Alison

I think there are a number of reasons why mobility is important for ICU patients. Specifically, the patients that are entering into the healthcare realm now are patients who are much more acute than 10 years ago, let's say. Patients are coming in, and a lot of procedures are outpatient. So patients that you're taking care of and the ICU are extremely sick patients that require a higher level of care. So they come in sometimes in a debilitated state and you have to work even harder to get them back to a pre-sickness state so that they can go back home healthier than they entered into your setting. So I think that's part of one of the reasons why it's so important to hone in on mobility, and it goes hand in hand with so many other things that are important for patients. Specifically, delirium. That's one of the reasons why we target it so high in the ICU environment.

3:45

Drew

Right? And it seems like the ICU patient is the most sedentary type of patient. You know, they do not have a lot of opportunities for mobility milestones in terms of traditional walking and getting out of bed. What are some of the specific ICU mobility milestones that would be important for an ICU nurse to know? 

4:10

Alison

So I think that's true because out on the floor when the patient transitions, it's a little bit easier for them to walk. As ICU nurses, we're very controlling of our patients because of the high risk of falling. They have a lot of medications and they have a lot of lines and things. So they require help and assistance to get up. And so with their mobility milestones, we make sure that we are present for their activity levels, specifically post-surgically in the cardiovascular population. For instance, our patients have orders from the surgery team to at least sit up at the side of the bed on the same day that they had surgery. 

4:47

Alison

That's considering a number of factors considering that their hemodynamically stable - that they have gotten out of surgery within a reasonable timeframe to kind of arouse from anesthesia. But if they can do those things, it's important to go ahead and start early. Day two after surgery, it's important for them to get up early so we like to see our patients get up about four times a day. We work in a multidisciplinary approach with physical therapy and occupational therapy to make sure that our patients get up and move so we can also assess them and what their needs are. So physical therapy and occupational therapy work with us to walk the patients around the unit and make sure that we get them to regain their cardiovascular strength and endurance. 

5:34

Drew

Sure. And I guess executing a multidisciplinary approach to mobility. How do you communicate with the physical therapy staff and let them know where the patients at since you're around them more often than they are?

5:49

Alison

That's a great question. We work really, really well together. The physical therapy staff is in the unit for a fairly long amount of time so we see their faces regularly in our unit. We have a system where the patients have a designated physical therapist, so when they come in in the morning they will leave their contact information and their names so that we can set up a time frame because I think the other thing that's really important about mobility is not just telling patients that they have to do something, but also including in their plan of care so that they are part of their goals moving forward rather than just coming in and telling them, "Hey you're going to get up at two o'clock because this is the time that I'm free."

6:36

Alison

We try to coordinate and make sure that it's a good time for the patient. They've had enough rest so that they can perform well and make sure that the available people that are needed to mobilize that patient are available also. 

6:49

Drew

That totally makes sense. And that echoes the sentiment of an ICU nurse practitioner that I was talking to who's from out in Utah. Her ICU stresses Awake and Moving practices. They don't really sedate their patients as much. I'm not totally sure about their patient population as it compares to yours. She was talking about the importance of mobility from her standpoint and how sometimes patients will get to these certain milestones in the ICU. But once they leave the ICU, they have a high chance of possibly returning if they don't continue that mobility. So how can you have that communication both within your team in the ICU. But then as they're discharged to go to whatever unit they're going to, how do you keep that communication up so they know where they're at?

7:38

Alison

I think that is extremely important in two ways. One, we make sure that when we hand off our patients to the oncoming nurse to the respective unit they are going to transition to - whether that is a progressive level of care or a medical-surgical level of care that we also include the patient's mobility and what they have been doing. So they know what their baseline is what their progression is and what's expected of them. We also make sure that the physical therapist passes those milestones off to their transitioning physical therapist if they're not going to continue seeing the patient. In a multidisciplinary team approach, it's also important that the physicians, the nurse practitioners - all of the staff that rounds on these patients frequently - keep mobility in mind also to make sure the patient is transitioning in the appropriate time frame that they need to.

8:40

Drew

I heard a story about an ECMO patient where they had to justify how much mobility or their level of mobility before they could receive a transplant. Could you talk a little bit about that story? Is that a special case or is this something that you see very often?

9:00

Alison

It is. And specifically going back to that nurse practitioner that you had spoken to, that's kind of one of the things that we try to focus on for this patient population. Years and years ago, an ECMO patient would be somebody who would be extremely sick. You keep them down in the sense that you sedate them so they're not doing a whole lot and you let the machines help them recover. Their body can take over their functions again once they are ready to get to that point. So, (in) the current realm of health care and the acute care setting, we like to make sure that our patients are awake more often (and) that they are getting up and moving. We make sure that we don't sedate them too heavily so that they can be awake to participate in their care. And one of those things is mobility. 

9:52

Alison

So we have patients that get put on ECMO - which is extracorporeal membrane oxygenation - for various reasons. It could be a cardiopulmonary issue, it could be a respiratory issue. Some of these patients go on to be considered as candidacy for transplantation - either both lungs and heart or either of the two. Sometimes these patients are so sick (that) when they get placed on this ECMO support, part of our goal is to make sure that we can rehabilitate them and bring them to a point where they are optimized for their transplant. So patients are required to work with physical therapy to get up to the chair. So by awakening them we make sure that we can have them awake to participate in their care, explain to them kind of the process of what's going on. 

10:47

Alison

If we can take them off of the ventilation via the breathing tube, we attempt to do that and we can have these patients walk on ECMO support and get stronger and stronger to the point where they are optimized and their best level of health pre-transplant.

11:05

Drew

For that patient, was there hesitancy to get them overly aggressively moving or how did you determine what level the patient was able to perform in terms of walking? Because you know if the patient is very sick you don't want to just risk these other factors that can happen when you try to mobilize them. But how did you find that balance?

11:30

Alison

When the patient first gets put on ECMO, they are pretty sick so we do try to do a natural progression. We start off by trying to sit them at the side of the bed or sit them up in the bed and see how they are able to tolerate that. Mobility means a number of different things for a lot of patients and different statuses of their health condition, which is why it's difficult to quantify mobility, especially in the ICU. So for these patients at the beginning, they're very sick. So mobility might look like sitting on the side of the bed with physical therapy. And then we continue to try to make sure that we make mobility a priority for that day.

12:10

Alison

We work (on) other things around it so that we give it the appropriate level of time and importance that it needs. We make sure that we work in a multidisciplinary approach to have respiratory therapy, the nursing staff, and also physical and occupational therapists available. And we make slow steps to make sure that the patient continues to improve each day. We take into account their hemodynamic status to make sure that we're not doing something that is going to cause more harm than good. But, typically what we see in this patient population is they end up getting up to a chair and then from there they start walking and they walk a couple of steps one day and then they walk a little farther next day and they keep walking further and further and they optimize their status so that they are in a better position to be in a cardiopulmonary endurance state. 

13:06

Alison

And we make sure that we motivate these patients. A lot of these patients that are in these conditions can become very depressed also - from just being stuck in a room they can't get up on their own. They can't do a lot of things for themselves. So we kind of take away a lot of people's independence in the ICU, and that can be a very difficult thing when we talk about mobility too. So we make sure that we kind of parade them for all their little achievements And it's nice to see when they get farther and farther in the coming days.

13:40

Drew

Right!  And there is a sense from an outside perspective that an ICU nurse is just worried about keeping people alive, you know, and making sure that they progress and get out of the ICU is a challenge. And so mobility is not always prioritized in that sense because you know, you have so much going on. I thank you for the work that you've done. I think as an ICU nurse and someone that's strictly been in ICU, you have a unique perspective, just trying to help them get that start and get them motivated to keep going.

14:18

Alison

Yeah, I think the biggest point is that mobility in the ICU is something that - in today's world - is created by a culture change. A culture change of really nurses empowering each other, especially in that interdisciplinary approach to make sure that we're honing in on mobility as a goal of care for these patients. When they get up more often during the day and we spread out that mobility and not just work on them and make sure they get up. If they get up for three hours at one time rather than getting up one hour three times a day and we space it out, those patients are tired by the end of the day, they end up sleeping better when they sleep better, they have better sleep-wake cycles and they can be awake to participate in their care.

14:59

Alison

And it decreases their incidents of delirium also. So all the things kind of go hand in hand and it's really nice when they come back to you after. So specifically this ECMO patient population - like this patient who ended up getting a lung transplant after proving the ability to mobilize and get better. It's really nice when they come back and see you in street clothes and you see the endgame of all the work that was put in because we like to make sure that our patients are doing the best that they can, but you also want to make sure that the patients are not medically ready to transfer to a lower level of care but they can't because they're in a rehab state that requires a higher level of care. 

15:46

Alison

So we try to make sure we mobilize them early in the process so that when they are medically ready to transfer there also mobilized to a point where they can transfer to a lower level of care and continue their progression.

16:00

Drew

Thank you very much for joining us today on the podcast, Allison. Thank you for your time and your work in the ICU. It doesn't go unnoticed by us. So thank you very much.

16:21

Drew

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