Heidi Engel, PT, DPT: Family Engagement in the Intensive Care Unit

Welcome to the mobility minute podcast. This is our first episode of season 2 and we are super excited to kick off a new season with even more content on hospital patient mobility. We have an awesome lineup of clinicians, academics, and other key stakeholders dedicated to patient outcomes.

I am your host Drew Martin – but our focus today is on critical care physical therapy. Our guest Heidi Engel, PT, DPT has spent over 34 years in healthcare and has focused the last 11 years on ICU mobility. She leads physical therapy for a large academic healthcare center in San Francisco where she has been instrumental in establishing mobility initiatives. Heidi has published work regarding the ICU liberation campaign and A to F bundle. As you hear in the upcoming session, she is very keen on the physiological impacts of walking and shares her perspectives on humanizing a critically ill patient. Family engagement is extremely important to Heidi’s ICU, and she believes patient and family buy-in is essential to the execution of critical care mobility.

We get into all these topics and more during our conversation so let’s get right into it…

Transcript

D. Martin

00:00:04 - 00:01:02

Hello everyone. Welcome to the Mobility Minute podcast. This is our first episode of season two and we are super excited to kick off a new season with even more content on hospital patient mobility. We have an awesome lineup of clinicians, academics, and other key stakeholders dedicated to patient outcomes. I'm your host Drew Martin - but our focus today is on critical care physical therapy. Our guest Heidi Engel has spent over 34 years in health care and has focused the last 11 years in the ICU. She leads physical therapy for a large academic health care center in San Francisco, where she's been instrumental in establishing mobility initiatives. Heidi has published work regarding the ICU liberation campaign and the A-F bundle, and as you'll hear in the upcoming session, she is keen on the physiological impacts that walking can have on patients, and she shares her perspectives on humanizing a critically ill patient. 

D. Martin

00:01:03 - 00:01:21

Family engagement is extremely important to Heidi's ICU and she believes patient and family buy-in is essential to the execution of critical care mobility. We get into all these topics and more during our conversation. So, let's get right into it. 

D. Martin

00:01:21 - 00:01:53

Thank you for joining us today on the mobility minute podcast. Want to get into critical care ICU mobility and what you found to be successful as someone that works in that field and then overall what PTs role is in helping to humanize an ICU patient in terms of their mobility. So thank you for joining us today. What is your definition of mobility? Um in terms of the patients that you see and then overall in the hospital, how would you define certain mobility-related events.

H. Engel

00:01:53 - 00:02:52

That the patient is out of bed. Ideally the patient is walking. Far more of our patients walked into our hospital I think than we generally realize, and they don't leave walking, which means we've done something to them to take away what I consider to be a survival skill, right? Walking is not really an exercise. Walking is not a really complex task. Walking is something you were innately programmed to do because at age one you pulled yourself up on two feet and started to move across the room and that's because it is a survival skill and therefore it's clearly something that's quite vital to our entire physiology. So, I have long said let's please stop talking about ICU early mobility or hospital mobility, and let's start talking about walking. 

D. Martin

00:02:52 - 00:03:26

Thank you. And I think a lot of people define mobility differently obviously through their lens, you know, as a nurse you might say, "oh mobility is just having the patient, you know, move their legs up and down" or certain embed mobility task might seem more significant than someone like you who sees the value in getting out of the bed. So when did this mobility initiative start to manifest itself in your hospital system? Was it when you first started or has it progressed as you've gone along?

H. Engel

00:03:26 - 00:04:29

In terms of what's happened in our intensive care unit. I started a project to try to create an ICU early mobility program in 2008. And at that time the inspiration for me was the one research article I could find on the topic which was from Intermountain Health in Salt Lake City, Utah. And it was an article published by Polly Bailey describing their respiratory care unit. And in it they had a photo of the ventilated patient on really significantly high ventilator settings, and this patient was walking down the hall with the ventilator pushed next to them with a regular front wheel walker and looking incredibly normal and I did not even believe that was possible. So when I saw this photo in that article I thought I don't I don't understand. 

H. Engel

00:04:29 - 00:05:17

I've never seen a patient do this. And if they can why aren't we doing this for them? Because any time I had received a physical therapy referral for one of my patients or followed one of my patients from the floor into the ICU, I had no idea what I should be doing with them. They looked sedated and attached to a lot of equipment. I had no idea of what it was really for or did and I would just leave the ICU and leave them there until they were coming out of the ICU again. So I spoke to the experts we had at UCSF and we started our program which you know the thing about mobilizing patients and I believe this is true of mobilizing patients anywhere in the hospital. It's a very inter-professional sport.

H. Engel

00:05:17 - 00:06:09

it's really not about a physical therapist being consulted or showing up to the bedside particularly with the complexity of the patient population anywhere in the hospital these days. So we had to form an inter-professional group, we had to have a respiratory therapy representative, a nursing representative, a physician representative, PT/O.T. And then in order to really make the program successful, we also needed administrative support. So we really benefited a lot from a person who was a financial administrative above us all in pay grade person who could do things like help us purchase equipment, help us hire staff - simply for the purpose of helping people get out of bed and move down the hall. 

D. Martin

00:06:09 - 00:06:41

And it sounds like communication amongst the different stakeholders for mobility is crucial. You talked about establishing some of the frameworks for that communication to flow from nursing leaders or from PT leaders such as yourself. But what does the day to day, communication about a patient's mobility status look like? What do you guys kind of prioritize to communicate to the nurse or do the nurses communicate to the pt about what the patient is capable of doing? 

H. Engel

00:06:41 - 00:07:30

So what the patient in the intensive care unit is capable of doing can change within the day and from day to day fairly significantly. What we do is in the morning. So our rounds because we are a large teaching hospital. The rounding itself takes a very long time for the team. And so we do not as the physical therapist attend rounds because that would just be a lot of time that we are not working with patients. We're talking about patients and it takes too many hours. So we do our own rounding, we go to each bedside nurse and let them know we're here and try to find out if the patient has any procedures, dialysis, if they had a bad night. 

H. Engel

00:07:30 - 00:08:09

Do they have sedation running? And is that going to be turned off? Can we turn that off? Can we turn the sedation off? This is a frequent question from our team. Then we touch base with the respiratory therapist for the ventilated patients in particular. And then we try our best to set appointment times to work with the patient based on what seems like the optimal time for the nurse, the respiratory therapist, my schedule, the patient optimization. 

H. Engel

00:08:09 - 00:08:55

It's a pretty challenging environment to be able to line up the patient treatment sessions in their optimal window of time for everyone. You know, it's in constant flux. This is why the physical therapist really has to be embedded in the intensive care unit. They can't wander in and out from the floor, It doesn't work very well. So we do our individual rounds and then we find out who really needs us the most today and we try our best to make sure that we aren't going to leave that day without that patient getting out of bed. 

H. Engel

00:08:55 - 00:09:44

And then we look at the medical record, we look at the chart, but I always tell my students, you know, the chart just tells you this kind of a very foundational bit of knowledge and until you walk up to the patient's room and you eyeball what they're attached to what drips are running what their I. V. say what the monitor says, what the ventilator looks like and then what the person and the bed looks like and the family, when are they coming? Because I really want the family involved in my mobility session. I really rely on the family a tremendous amount. And so covid taking the family away from the bedside has been really a devastating blow to patient care and mobility in the intensive care unit. 

H. Engel

00:09:44 - 00:10:39

And then once I looked at them, I can tell almost immediately. "Great, this is gonna be good. Let's do that 12:30 is a good time for everyone. Let's go!" Or else, "Oh no they look terrible. What are we gonna do about this? So after that then we just start going. One of the most important people that we have working with us is the ICU mobility tech or mobility aid. So we have an aide who is dedicated to the physical and occupational therapists only and he can go in the room and untangle all the lines. Set up the chair, rearrange the furniture, get the socks put on the patient. So there's a huge amount of tasks that you don't need a graduate degree to complete these tasks.

H. Engel

00:10:39 - 00:11:19

 And yet they're very important tasks - they have to be done. I can't get the patient out of bed unless all of their lines are slapped in the direction the person is going. Not where the person is but where the person is going. So the IV pole has to be on the same side of the bed as to where the patient is going. So maybe over by the ventilator because the patient's going to turn towards the ventilator not away from the ventilator. So all that has to be pulled around on the side of the bed before you even start moving the patient. And that could be 10 minutes of untangling, reconnecting, moving furniture. So when we train people, they can do that which saves me a lot of time.

H. Engel

00:11:19 - 00:11:28

I can be with another patient by myself while our mobility tech is rearranging all the equipment prior to me coming into the room. 

D. Martin

00:11:28 - 00:11:50

Tell me if I'm wrong. But that seems to be one of the biggest challenges in mobility in the ICU. Is getting all of those lines, the line management, figuring out how to get the patient up in the first place. So do you think that's a big reason why a lot of these initiatives haven't really taken off to help get the patient out of bed in the ICU? 

H. Engel

00:11:50 - 00:12:56

Yes, the equipment is exceptionally not mobility-friendly from the bed to the lift devices. They're all made by separate companies and therefore they aren't made to be compatible with each other. There are cords, huge amounts of chords, and I. V. Lines attached to everything. For us, our rooms are very small. We have an older ICU so the physical size of the room has not changed at all - but the amount of equipment we're putting in the room and the size of the bed have all grown so we're also working in an incredibly tight space. And so yes logistically it can be very challenging. The logistical challenges are I think everywhere which are sedation, sedation, and sedation and turning that off instead of down so the patient can participate and so they aren't delirious.

H. Engel

00:12:56 - 00:14:05

Managing the ventilators so that the ventilator adapts to the patient rather than us forcing the patient to adapt to the ventilator settings. So when we mobilize patients we do not mobilize them on the same ventilator settings as when they are lying in bed resting because you do not breathe the same way lying down into the bed as you do standing up on your feet, especially if you're deconditioned, especially if your lungs are compromised. So I need the respiratory therapist there to adjust the ventilator for the patient while the patient is moving. And again the sedation piece is also about adapting the ventilator to the patient instead of vice-versa. And so I'll give you a quick example of this. We recently have someone (not covid but ARDS) She's very sick,  asthma baseline. Um on top of new pneumonia, on top of some other things including pulmonary hypertension.

H. Engel

00:14:05 - 00:14:38

This patient is on pressure control which we don't typically see. We usually have a volume control setting for patients who require to be on a set rate respiratory setting. And I was curious. I didn't really understand. She didn't have even the characteristics of someone we typically set on pressure control ventilation and she did very well. She was left on pressure control during us mobilizing her. But I left the room. And I asked the physician 

H. Engel

00:14:38 - 00:15:47

"Just out of curiosity why is she on pressure controls? She looks fine. But we don't usually see that." And in fact typically when we mobilize patients we make sure they're on pressure support so that they're initiating their own breaths and setting their own respiratory rate for every breath. And he said, "Well, she was sort of agitated and dyssynchronous on the volume control and we wanted to be able to reduce the sedation enough that she could be awake and getting out of bed. So we tried we just tried pressure control and see if it works better for her. And it did." So that's the type of thinking that that really requires successful mobilization. Like alright look the ventilator is not working for this patient rather than sedating them so that we force the patient to be so inactive that they then tolerate the ventilator. What if we kept trying to switch the ventilator to allow the patient to be awake and mobile and out of bed like they need to be?

H. Engel

00:15:47 - 00:16:33

That's a very tricky part. There are no guidelines. There's no expert consensus. I have been dying for someone to create an expert consensus on that topic. There's huge variation in practice. But the bottom line is you know it's far easier and less stressful when you're not accustomed to doing it all the time to then just turn on sedation. But, what made your day easy today with the sedation will make your life as a clinician and certainly your patient's long-term life far more difficult later.

H. Engel

00:16:33 - 00:16:59

There's a big payback for that time on sedation and it's a payback that comes in the form of cognitive impairment, medical complications, rehospitalizations, longer lengths of stay and weakness, joint pain. I mean that's a huge cost for making today look calmer and easier on the ventilator. 

D. Martin

00:16:59 - 00:17:28

Yeah, that makes total sense and it seems like there are long-term implications too if you do the flip side and you get patients out of bed and walking. Hhow do you bottle that up and have people drink it? You know the kool-aid of mobility for the ICU patient when obviously the easier today task is to continue that sedation instead of having their body continue to develop itself. 

H. Engel

00:17:28 - 00:18:27

That is the question we have been at for quite a while now through the society of Critical Care medicine and the ICU Liberation campaign and the A-F bundle and all the work of Dale Needham at Johns Hopkins and the work of Dr. Wes Ely at Vanderbilt and all the work of the people at Intermountain Health; Terri Clements and Vickie Sperling and Polly Bailey. It just hasn't been enough coming from a smattering of experts around the world. Thomas Strong has his research is all about a non-sedation ICU. So there are these smatterings of of of world leaders and experts who are trying to make the change and I think all of us have felt the struggle and COVID has made it worse.

H. Engel

00:18:27 - 00:19:16

So I think we felt like we made a certain amount of progress in and now COVID has put a wrench in that. And so I've come to believe honestly it's going to need to be like a patient family revolution of sorts because it's anecdotal obviously but I have been full time in the ICU mobilizing patients um for 11 years and in my observation who has helped the change move forward most? Patients and families. 

H. Engel

00:19:16 - 00:20:08

I can give lectures I can you know create PowerPoint presentations. We can do data collections. We can have committee meetings. We can have leaders in our institutions say gosh this is really what we need to do. And I don't think any of that compares with just this site of excited family members seeing the patient awake and interactive and looking lively or patient themselves looking really like a regular person even though they're attached to all that equipment. You know it really does something for your heart and your soul because you feel like, "oh yes this is what I should be doing. This is what our patients should be looking like. This is showing me that the outcome we're hoping for them is possible."

D. Martin

00:20:08 - 00:20:29

Right? And that ideal setting you have the family involved and you can give them tasks to maybe help the patient reach their goals. So outside of this whole covid situation where you might not have that family member engagement, how do you take advantage of that normally as a PT to be able to give them you know the tools they need to help the patient succeed. 

H. Engel

00:20:29 - 00:21:13

I set my patient up on the side of the bed and I have them facing their family member - not me. I do my best to get out of the way and put a chair in front of the patient who's sitting on the edge of the bed. And I have if you know almost you'd be amazed even family members who you think are going to be kind of squeamish or not understand. They want to do this. And the patients certainly want to see them not me and certainly not the front of my shirt and an IV pole, right? So I try my best to as soon as we have the lines clear as soon as we have the patient medically stabilized. I try my best to pretend my eyes are their eyes. 

H. Engel

00:21:13 - 00:21:58

So right now where is this patient's gaze? Are they staring at the floor? Are they staring at a ventilator? Are they staring at IV pole? That's not what I want them to see. Especially if we if they were sedated and we are now trying to bring their brain back to reality. The sedated patient is hallucinating. The sedated patient is not sleeping. The sedated patient is usually having very traumatic dreams. And those are very real dreams for them. You see you can read the descriptions over and over and over and over again. You know they thought they were being harmed. They thought they were being held, hostage. They thought they were drowning. They thought there were people in the room trying to do harmful things to them. 

H. Engel

00:21:58 - 00:23:01

One patient, we had I can give us an example. He was a very highly educated college instructor. So obviously he knew reality very well and he had been awake and walking around our ICU but he also had been very agitated a lot. And they had received sedation and after he left the ICU And we interviewed him. He said, "I was so sure I was part of a medical experimentation camp out on Alcatraz Island. And I was so sure that was real that after I was discharged for me I see when I was out on the floor, the volunteers brought me a laptop and I googled medical experimentation camp out on Alcatraz because I swore that's where I had just been." And that's not an uncommon type of experience. So if I can get, you know, 

H. Engel

00:23:01 - 00:23:11

reality to sink in when I know that patients are often having these sorts of experiences. The family members, the person is going to do it.

D. Martin

00:23:11 - 00:23:35

And that empathy for the patient is crucial, right? To know that they might have things going on in their head. They might not feel as confident in that ability as you might as a PT of, you know, we feel like you can achieve these statuses in your mobility, but they might need some encouragement there or it might be dealing with a whole host of things.

H. Engel

00:23:35 - 00:24:14

They are scared who would not be scared. And so we have to yes, help them through their anxiety. Help them through their fear. And you don't know me, but you do know, you know, the person sitting in front of you holding your hand, telling you it's gonna be okay, you're going to do okay. And you know, also by doing that. Typically the family member uh tells the patient to trust me and trust my voice and that establishes a much better relationship when I come back the next day for that same patient. 

H. Engel

00:24:14 - 00:24:38

They're like, "Okay, it's her, it's her who brought me my family, it's her who, you know, rubbed my back, it's her who combed my hair and you know, it's her that reminded me what reality is that's fine. I'm on board, I will like let's do this, I will not pull out my ET tube and we will get up and get moving."

D. Martin

00:24:38 - 00:25:23

Right. And those temporary relationships that you build with your caregiver, I'm sure are it takes a while to establish that trust, and it's not just her coming to move me, but they (start to) know your name - At some point, there has to be some sort of connection where they trust you um in order to help them do what's best for them. So that's crucial. 

One thing you touched on earlier was the physiological benefits of standing and how your breathing was different, laying down as opposed to standing up. What are some of those benefits of not just standing and walking, but even being in a chair or as opposed to laying down on your back? What are some of those benefits as you kind of meet those mobility goals? 

H. Engel

00:25:23 - 00:26:19

So better aeration of the lung, You open up a lot of lung spaces being upright, you open up a lot of long areas. You cough a lot of secretions out - so you get a lot of lung clearance. Weight-bearing is the number one way to improve neuromuscular connections and strength in the legs. If you want to strengthen your legs you could do that exercise is forever. You could put them on a bed bicycle all day long and I promise you that will not translate to standing up on your legs. So the compressive forces and the joints are really crucial for bone integrity, muscle integrity, neuromuscular stimulation. So we really depend on gravity and weight-bearing to help us stay upright beings. Then all the extensor muscles. 

H. Engel

00:26:19 - 00:26:54

So think about it - all the muscles you are lying on you are in the act of lying on them inhibiting them. So all the muscles that run up and down your spine. All the muscles. All the hip extensors that that keep your hips straight and tall when you stand and especially the muscle fibers that are the long-term postural muscles. So I'm explaining to people all the time that they've lost that endurance quality in their postural muscles. And so there you sit them on the edge of the bed and they're just limp. 

H. Engel

00:26:54 - 00:27:26

They have no ability to hold their posture up tall or else they're doing it but they're doing it as an active activity whereas the whole rest of us are keeping our trunk straight and upright all day long without even thinking about it. That's what the muscles are designed to do. But they've lost all that. So the more you can preserve that, the better off you are, it's much easier to preserve the muscle integrity than it is to regain it after you've lost it.

H. Engel

00:27:26 - 00:27:58

Being critically ill (plus) all the medications you receive are catabolic medications. The condition of the critically ill put you in a hyper-catabolic state. So you're wasting skeletal muscle, you're just burning it off in order to save yourself and stimulate your immune system. Then you had all the in addition of being in bed and the lack of brain input because of sedation and delirium and everything else. And pretty soon you don't have much muscle left. 

D. Martin

00:27:58 - 00:28:06

and yeah that degradation happens pretty quickly too. It's what like  within 48 hours of being admitted or something along those lines?

H. Engel

00:28:06 - 00:28:33

For the diaphragm, within 48 hours for part of the rectus femoris muscle, the big quadricep muscle that starts happening in a couple of days. Yes, and then just you know if you want to do things like preventing blood clots and one of the best ways obviously to do that is to be up walking around um that's more effective than lying in bed with sequential (devices) on your legs. 

D. Martin

00:28:33 - 00:29:29

Yeah, definitely. It's a preventative measure but the ultimate goal is to get the patient up, right? And to have their body do it themselves. You know a little bit about our background, I think we're really focused on mobility and getting that message out there, but the importance is that it's not just one thing that mobility affects. It's based on whatever the hospital patients dealing with at that time, Mobility can help a lot of them. So one last thing before we go, I appreciate your time today and I appreciate your insight into everything PT-related how you kind of go about promoting early mobility in your hospital and getting out of bed. What is that feeling you get when you know that a patient has gotten back to their pre-hospital state and you know, maybe they come back and see you? You see them at their sickest state, but when, when you see them recover fully, what is that feeling like? 

H. Engel

00:29:29 - 00:30:09

It's indescribable. It's so rewarding and fulfilling, especially for our patients who stayed in the intensive care unit for a long time and we didn't even, we were not sure that they would even survive their ICU stay. To hear the things they get back to doing. And again, this is why I think it's going to be a revolution of, of patients and family members because they get it far faster and I think with far more depth than what I've seen my colleagues in health care across the board understand.

H. Engel

00:30:09 - 00:31:03

I think we (healthcare providers) are too good at imagining all the potential bad things or risks that could happen even though every single ounce of ICU early mobility research has shown that it's an incredibly safe activity to do, particularly when you have a physical therapist involved. But the patients and the families get this right away. We all recognize somewhere innately, just as we did when we were one year old that getting up and walking is a survival skill and, and it's satisfying, we were made to move type of activity. I mean life is movement and movement is life and people understand it innately and, and so the rewards and the joys of watching patients and the family members just respond to that so positively - that is absolutely the reward. 

D. Martin

00:31:03 - 00:31:18

Awesome. Really well put, thank you for your time today Heidi. Incredible insight, I think we learned a lot from you, and taking some of your experience and bottling into this podcast is the ultimate goal. So I appreciate your time and would love to keep in contact. 

H. Engel

00:31:18 - 00:31:27

Thank you, thank you so much for this opportunity and, and please design some more really beneficial mobility equipment. 

D. Martin

00:31:27 - 00:31:34

We'll try our best. 

D. Martin

00:31:34 - 00:31:44

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