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Moving in the MICU
The hospital’s sickest patients are benefiting from less sedation and more physical rehabilitation therapy.

Some of the staff from Nelson 6, this year's winners of a Best Practice Award are, left to right, Lynn Desrosiers, Monica Darland, Sharon Owens, Tina Cafeo, Deb Sedlander, Stephanie Meredith, Betty Stewart and Susan Rush.
Nurse Lauren Waleryszak (left) and physical therapists Kenroy Greenidge and Jennifer Zanni help a patient into a wheelchair on the MICU. Getting patients on ventilators out of bed has reduced length of stay on the unit. It also prevents pressure ulcers.

For years, Roy Brower had heard about the unusual goings-on in the intensive care unit at LDS Hospital in Salt Lake City. There, patients didn't lie in bed day and night under heavy sedation; they were up and walking the halls with ventilators, an idea so at odds with routine ICU practice that some consider it impossible.

Brower was so doubtful, in fact, that he took a trip to Utah to see for himself. "I asked the nurse manager and nurse practitioner, ‘What do you do with a patient who's on a ventilator and delirious and squirming in bed who looks like he's going to pull something out?'" recalls Brower, director of Hopkins' medical intensive care unit. "Without hesitation they said, ‘It's time to get moving. He's got all this extra energy he doesn't know what to do with, so let's go in there and help him do something useful.' I was stunned by this response."

It was with those possibilities in mind that Brower and intensivist Dale Needham introduced their quality-improvement project to the MICU last spring. They decided to see how their patients, most of whom suffer from multiple organ failure and are on mechanical ventilators, would tolerate less sedation so they could begin rehabilitation therapy earlier during their treatment on the unit.

As mortality in ICUs has gone down in the last 20 to 30 years, there is a growing number of ICU survivors with debilitating weakness and depression after discharge from the hospital, lasting weeks, months and sometimes even years. Needham and Brower wanted to do something about these residual neuromuscular and neuropsychiatric problems. "We believe that if these patients can get more rehab therapy, then they might have better outcomes," says Needham.

First the pair had to overcome some barriers, not the least of which was their unit's own sedation practices. "Our belief was that when you're very sick, when you have this breathing tube that goes from your mouth through your throat into your trachea, that it's very uncomfortable and you'd be best left heavily sedated," says Needham. "But there's some evidence showing that's not the case." Now MICU patients no longer get over-sedated with continuous infusions of sedatives automatically upon admission. The amount of sedation has now been reduced to an "as needed" basis.

Carrying out the project required that a like-minded team be on board. In addition to having to adjust to the new sedation practice, nurses needed to re-learn elementary tasks like how to use wheelchairs and how to properly bend when lifting patients. Respiratory therapists found themselves working with different ventilators to allow patients to walk. Meanwhile, dedicated physical and occupational therapists, whose presence in the MICU had been minimal, were assigned to the unit for the duration of the four-month pilot.

The MICU patients started with small accomplishments, such as sitting up at the side of the bed, and progressed to such activities as getting into a chair or taking steps around the unit. Some stable ventilated patients even ventured out of the MICU into the hospital's outside courtyard, accompanied by a MICU team that kept the complicated monitoring equipment in motion. The scene often generated stares from staff and visitors alike. Such feats can be "a motivating thing in a unit where we do see a lot of death and tragedy," says physical therapist Jennifer Zanni. "All the nurses are cheering and excited. It's great for everyone, not just the patients."

Another new experience for the unit is having patients on ventilators communicate with staff. To do so, patients point to letter boards or write down what they need. "It was quite a culture shock to try to understand what they wanted at first, but I think as a unit we've grown," says MICU nurse Lauren Waleryszak. It's also more important than ever that staff communicate with patients. "If the patients are awake, I need to let them know what's going on in the room, that I'm going to turn them," Waleryszak continues. "It's elevated the caring level on the unit."

Nurses, who normally are responsible for two ICU patients at a time, were naturally concerned not only about patient comfort but also about safety. "We did get some questions before starting to do this," says Brower. "We said, ‘We know there are going to be some patients we need to sedate. But give it a try. Let's see if we can do this.' Our nurses got on board quickly. We had an incredibly rapid culture change."

For their part, patients seem to take the chance to get out of bed in stride. One patient told Zanni, "It felt great to get up and stretch my legs." The exercise also tires patients enough that they take naps afterwards, without the aid of sedatives.

Needham and Brower realize that because the initiative was designed as a QI project to directly help patients in the MICU and not a randomized, controlled trial, they need to do a more rigorous assessment in the future to have broadly applicable results. But there are indications already that the steps they've taken have directly benefited MICU patients through reduced time on ventilators and in the ICU and may reduce the percentage of patients who need inpatient rehab.

The project has also inspired many of those involved. "When I left school, I wouldn't have guessed I would have ended up focusing most of my attention on critical care," says Zanni. "Like everyone else, I wanted to do sports medicine. This is the most important thing I've been part of in my career. We've done so much that's beneficial. But in the back of my head, I have all these ideas for things we can still do to improve."

—Mary Ellen Miller



Johns Hopkins Medicine

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