Today we speak with Heidi Engel, PT, DPT.

Heidi Engel 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. She 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…

“We look at the chart, but 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.”

- Heidi Engel, Critical Care PT

Listen to the full podcast here.

Note: Podcast transcript below is a condensed version of the conversation generated using a combination of speech recognition software and human transcribers, and may contain errors. Please check the corresponding audio before quoting in print.

How do you define hospital patient mobility?

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.

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.

You’re a healthcare veteran with over 34 years of experience. When did mobility become a priority for your hospital?

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 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.

How do you communicate with this interdisciplinary team about a patient’s day-to-day mobility progression?

What the patient in the intensive care unit is capable of doing can change within the day and from day to day fairly significantly. Because we are a large teaching hospital, the rounding itself takes a very long time for the team 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 do our own rounding, and we go to each bedside nurse and let them know we're here.

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.

Engel works with a patient in the ICU at UCSF Medical Center .

What is your process for dictating which patients to see and how do you engage family members in a patient’s mobility journey?

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.

What about line management? Does that factor into critical care mobility?

Yes, the equipment is exceptionally not mobility-friendly from the bed to the lift devices. Each is made by separate companies and therefore they aren't (always) compatible with each other. There are cords, huge amounts of cords, 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.

In your opinion, how does sedation influence a patient’s readiness to mobilize?

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. 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.

So how can you bottle up that Kool-Aid of ICU early mobility and have people drink it when the easier today task is to continue that sedation instead of having their body continue to develop itself?

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 we felt like we made a certain amount of progress in and now COVID has put a wrench in that.

I've come to believe honestly it's going to need to be a patient/family revolution of sorts because I have been full-time in the ICU mobilizing patients for 11 years, and in my observation, who has helped the change move forward most? Patients and families.

How do you encourage family members to help patients in their mobility journey?

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. 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 patient medically stabilized, I try my best to pretend my eyes are their eyes.

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.

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 for the ICU patient?

You open up a lot of lung spaces being upright and 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.

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. That's more effective than lying in bed with sequential (devices) on your legs.

What’s a take away you’d like to leave us with?

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.

Awesome. Thank you for your time today Heidi. I think we learned a lot from you, and taking some of your experience and bringing it to this podcast is the ultimate goal - So I appreciate your time!

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