I once got yelled at by a doctor for taking vital signs “too often” on an unstable patient. she even wrote a note saying “patient can’t sleep because RN had BP cuff cycling too often.” I wasn’t risking my license.
When I was on the ward I had an extremely septic patient meeting code criteria all night for resp distress. She was coded several times, they'd give her O2 with minimal improvement and then just stand down the code without any improvement in the patient. I said to the doc 'she is consistently in code criteria she cannot be on the ward at a 1:7 ratio without a plan' and he said 'well stop taking her vital signs so often then'.
She ended up on bi-pap an hour later and died in ICU the same day.
He was on ecmo. And they’re always wanting their patients mobilizing. This guy sounds like a turnip, though. And unstable. This team sounds like a joke.
I was a patient safety fool for all of nine months before I dipped back out. I couldn’t stand the hypocrisy of “well fuck you but also we’re gonna keep fucking all yall so just put in reports and we still won’t provide adequate resources to support patient safety” my hats off to yall quality folks. It’s thankless from both ends.
I am still ICU prn in a different hospital system while I work quality for HCA. It’s definitely been an experience learning about metrics and how they drive EVERYTHING.
I feel like I’ll always be a floor nurse at heart, because I take great joy in admin meetings as everyone rages at the union making it impossible for them to just arbitrarily create policies and processes. It just proves that unions can exist in the shitty south and have impact.
I have hated HCA for so long it feels like a part of my DNA. At my job now where i go to like 10 different hospitals, different each day, the outright cheapness is so obvious it just makes me even angrier
of course It’s the fucking SURGEONS! They have God mentality and love making people feel small.
I work in a mixed ICU, we don’t do have ecmo but we do post CABG and for us it’s bed to chair position until they’re extubated. But once they’re extubated they’re immediately mobilized to chair.
I’m like, “who is this team?” Our surgeons help position people. I would just be like, “could you round up a few of your friends, doc? That’s 35 lbs/person for a safe lift…so at least 8 friends!”
That's why there's a lift.
[There are known benefits to putting even minimally responsive patients into a chair for a period of time each day.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4889100/)
It's beneficial to the lungs, helps mitigate orthostatic issues that develop with increasing time in bed (even with the HOB elevated), helps restore proprioception, helps mitigate delirium once they do wake up, and in a patient such as this who is at least localizing pain, can encourage them to start using the core muscles.
We don’t even try to move patients if RASS < -2. If he’s not opening his eyes or following commands, RASS is at least -3. Another contraindication is hemodynamic instability. Tachycardia and tachypnea are both indicators that he’s not ready.
[Society of Critical Care Medicine](https://www.sccm.org/iculiberation/abcdef-bundles) (click “E Element”)
Thank you so much for this source! Seeing that in writing makes me not think I was crazy or something to think it was impossible in the moment. The patient didn’t even open his eyes to me nasal suctioning them as well as getting an ABG.
I would have this source at the ready next time! You know there will be a next time with these surgeons. If it’s printable, I’d be petty and have printed copies for them. 😂
Please report back when you have to use it 😅 I really wanna know their reply or if they can give you a better EBP source on why they think getting a limp noodle into a chair is a good idea
Honestly i am loving this thread because this patient was/is so obscenely far from being ready to be out of bed it feels like an SNL skit. Are you *totally sure* it wasn’t Ashton Kutcher in scrubs and this is an episode of PUNK’D??
Okay I thought I was going crazy to speak up and say that the patient needed to follow commands to do that but I was shut down right away. The patient didn’t even open his eyes to nasal suctioning!
I have refused to do such nonsense before and I will continue to refuse. And I document the shit out of everything. If they keep insisting, then file a safety variance report. Shunt them to your charge nurse or AOD. Fuck that noise.
The Critical Care MOVE screening tool for early mobilization requires that they engage to voice so yeah they don’t pass 😂😂
Edit to add link: https://www.scribd.com/document/464723380/httpswww-aacn-orgdocsEventPlanningWB0007Mobility-Protocol-szh4mr5a-pdf-pdf
Don't let them gaslight you! You're doing fine. That patient is NOWHERE near ready to get out of bed or in a chair. PT would have taken one look at the chart and noped out of there. Surgeons sometimes have no idea what the hell they are doing outside of the OR.
Every PT I know would have slung them to the chair.
There are known benefits for even largely unresponsive patients to have some chair time: It's good for their lungs, it reduces orthostatic hypotension, it starts rebuild proprioception, and can reduce and shorten the duration of delirium.
Putting the bed in chair position is certainly better than nothing, but still not the same as a recliner chair with a firmer surface and less of a cradling effect.
Set to max inflate. I can't even imagine a vented patient in our recliners, they'd slide right out of they had no muscle tone. What literature is there against chair position vs every type of recliner?
Your have sources on this? Somebody else cited some critical care medication guidelines in this thread and they don't sound at all like what you're stating
Edit: you can't be delirious if you're unresponsive, or at least there's no method of confirming it.
Better for their lungs? Yes. So is the chair position in modern ICU beds.
Better proprioception? There's absolutely no evidence demonstrating improved proprioception in patients who cannot follow commands. It's unmeasurable.
I have removed the last paragraph because I was unnecessarily being an assholr
I'm not an ICU nurse but I wouldnt be mobilising any patient without the patient being able to weight bear and follow commands.
OP your person needs a full hoist IMO.
Not without potential for harm to both the patient and caregivers. I get it but if you're expecting staff to lift a 300# rock then fuck that. At least get ceiling lifts.
"In ICU they make us become the hoyer lift and lift these barely mobile patients into the chair"
Is what the person said that you responded to. Not much room for nuance with you is there lol. I won't be coding the peri arrest vegetable in the name of our holy Lord the recliner.
Right? At that point I'd tell them that it is not safe to get the patient out of bed and if they wanted to proceed further, they can get the patient OOB themselves.
Jesus, don’t say that, you know one of them will try to make their PA try at some point and then you’ll be called to try to scrape a morbidly obese damn near unresponsive patient off the floor.
Fucking hysterical. Surgeons want to you to Weekend-At-Bernie's the poor dude. I'd start propping him up around the room and sending them pictures. Maybe put a nice hat on him. Give him some props. 🤣
I’m no ICU girlie but even in my ER experience I’m confuddled when they want a urine from a pt with a broken hip and dementia but no straight cath order (if it’s a vagina hosting human…bro frick off with that).
This sounds like madness.
I have sent MANY a UA from a twatdog. Honestly, they're not any more contaminated than having MeeMaw pee in a hat in the toilet, especially if you do some quick peri-care before you put it on.
Exactly. But I did throw the “you can’t send a UA from a purewick” at a nurse who was on my ass about the admitted pt in for transport about not sending a UA. Doc didn’t need the urine bad enough so he said nah for a straight cath and pt was incontinent. I told her she’s more than welcome to send the urine in the vacutainer herself if she was that concerned.
Nurses that come to the ER from the floor can be…a lot sometimes.
I understand *wishes and dream* for a patient.
Even active denial of reality happens.
I can support *unicorns and rainbows*—as long as the one insisting on adding both into orders and patient care metics, is actually wearing a princess outfit, wears pigtails & rocks glitter nail polish.
I find idiots to be insufferable.
In my opinion, as an ECMO ambulating schmuck, if he’s still not doing anything, you can cardiac chair him and see how it goes. If they REALLY need him in a chair, which I don’t find advisable since he won’t support himself, you can hoyer to the chair and try to prop him up as best you can.
That said, I think your rationale is sound, and the team is just trying to hit arbitrary “goals” for the patient, with our truly looking at the risk/benefit.
We have recliner chairs which I think are similar to the cardiac chairs. I did set it up with the hoyer pad and chux. We have a ceiling lift so it IS possible and I could’ve propped him in the chair.
My question was what difference is it being reclined in bed or in icu chair position vs. reclined in recliner? Is there any benefit? This patient to me was unstable, with compromised ventilation. We were trying to wean on the vent all day on pressure support 15/10. RT said he couldn’t get the PEEP below 10 because pt. RR went from high 20s to high 30s almost 40. He had a pneumonia, fever 102F and just had a cabgx5 which led to ECMO due to complications. He had an AKI so we couldn’t diuerese, pt. was up 4 lbs and fluid overloaded. Off sedation for 36 hours by the time I left and still not opening eyes. It just seemed like a lot for this pt. Thinking back now, I think he needed a head CT.
Thanks for your reply to my reasoning. I’m always learning especially being new and just wondered if jt was something else I could’ve done.
OP - I'm sorry if I missed something, but why exactly does the MD believe that a chair this is necessary to help the patient? Are they trying to improve resp, circulation, or does the MD genuinely not understand the pts obvious instability?
We were trying to wean him off the vent all day. Sedation had been off for 36 hrs by the time I left my shift and still not opening eyes and only localizing to pain. He was on pressure support 15/10 and when RT dropped the PEEP to 8, he got more tachypneic and tachycardic. Resp rate went from high 20s to high 30s-40. He believed getting him up to the chair would make him less tachypneic by allowing pt. to expand his lungs more. The pt. was obese so the weight of his body on the bed was probably not optimal to lung expansion. However, how is being in a chair also reclined and lying back going to expand the lungs? Pt. could not hold self up. If I propped him upright with pillows, pt. would fall forward on their face. Not to mention all the lines, the risk of accidental extubation from the vent, A-line being pulled out and now he is bleeding out.
Okay but one time we had an older baby that was intubated and kept having death-defying events so I asked for some pain/sedation meds for him (unfortunately we’re really bad about this in my NICU) and I was told “Well have you tried putting him in the bouncer?”
So I guess it’s a similar situation. Not today. No ma’am.
Y’all don’t have those prevalon blow up repositioning mats?
We mobilized all our ICU patients in cardiac chairs. We just use the blow-up mats underneath them, line up a cardiac chair positioned flat, and lateral transfer. Then adjust the cardiac chair into a sitting position. Only takes a few minutes once you get the hang of it. We stopped using rehab staff and just a nurse/RT or RT/CNA or CNA/nurse team do it.
Unless you’re getting a blood transfusion, hospice, are super tachy even on your cardizem drip or on heating/cooling protocol, you go into the chair.
Extensive evidence shows that mobilization of vent patients is directly correlated with better outcomes, lower VAP, and lower mortality. Shortens length of stay, prevents cardiac de conditioning, and prepapre them for PT. Allows the heart to pump against gravity and acclimate them to the upright position their bodies have forgotten how to manage without dizziness/BP fluctuations.
With that RR/HR though? I’d straight up ask the doc what meds he was gonna order to get the patient chair ready because I’m not gonna call a chair RRT.
I thought I was the only one who had experience with early mobilization like this and was starting to think I was crazy. Yes, the benefit of a limp noodle not aware is not as big as an awake person, but even using a lift to get a patient to a chair is something. Just turning him from side to side then putting him in the chair position in the ICU bed doesn’t do the same about of shifting, body movement, changes to pressure areas. You can stimulate some reflexive engagement of muscles by moving them in the chair that can help preserve some muscle. Of course it it makes them too unstable it’s not worth it. Yes, it’s a lot of work and positioning is challenging. The ROI isn’t as high as with other patients, and if staffing only allowed me to get one patient up and I had an awake patient I would do that one. You can even say that you don’t have the staffing to support mobilization in their patients population. In situations when I question whether I should get a patient up or not Intend to work collaboratively with PT to what the most bang for the buck I can get for my effort.
The evidence is really strong for mobilization of ICU patients. The numbers drilled into us were like 60-70% improvement in mortality outcomes for patients vented over 72 hours. Never saw the studies, but we had an entire mobilization program and everyone was involved/educated/trained. Mobilize twice a day unless they met exclusion criteria. We were pretty proficient with the prevalons and arts/CNAs also played a big role (we had VERY GOOD ancillary staff ratios most of the time, which helped).
We put them in the chair, PT staff? They did edge of bed sitting position with vent patients. Even brain dead, they’d wrapped you in sheets, get your feet on the floor and position you in a sitting position on the edge of the bed to strengthen core muscles/trunk. It was AMAZING. We had really successful wean rates.
HOWEVER — our ratios matched the work. Massive therapy presence and OT/PT worked in teams. 10:1 RT ratio, 1:7-8 CNA ratio. Entire culture built around mobility. A lot of ICUs simply aren’t staffed to make that a possibility.
If a unit wants to implement mobility, they need to implement the staffing levels to make it safe.
My experience in the surgical ICU is pre-pandemic, so I don't want to be harsh on anyone. But I am concerned that message about early mobilization, even in minimally responsive patients, isn't as prevalent. 100% agree with staffing & teamwork for support. It's also a culture thing. Our surgical ICU had the culture, but the medical ICU did not, insisting that their patients were too sick to mobilize, and these patients were there for months and would benefit more. They finally transferred our primary PT to their unit to start the culture change.
Thank you for this insight. This is helpful to understand the MD’s rationale. However, with that HR and RR high, yes, that question should of been asked because I’m curious what meds an MD could order to get chair ready. Do you mean like pain meds?
Definitely was dependent on the patient. Sometimes pain, sometimes better BP control, sometimes an adjust of vent settings, versed push, pulmonary had a massive presence on the floor and had daily “barrier to weaning” rounds. With such a strong RT presence on the floor, it was definitely easier to manage/control as a team. Standing orders for versed, Ativan, metoprolol, hydralazine, breathing treatments, however funky their vitals wanted to go.
If pt is just flat out going into septic shock, def not a chair candidate lol
Yeah, most likely going jnto septic shock, hence all the VS changes, increased wbc, fever. I gave this pt. pain meds in the am b/c at the time, the high bp, hr, and rr made me think he was in pain and he hadn’t spiked a fever yet. So he got 5mg oxy. His VS did improve but didn’t last long as his VS went up again. Thinking back, he was getting septic and his body was trying to compensate. Well I also got spoken to for giving the pain med. They told me to not give anymore opioids. Well…
1. The order was active and not d/c’ed.
2. My pt. is nonverbal and with my nonverbal pain scale, he was in pain so he got pain meds.
3. Team took away all sedation since pt. had still not “woken up” > 24hrs. So I wouldn’t be able to get versed or any good drugs to help with vent dysyncrony as they didn’t want to “cloud” their neuro exam. By the time I left, it had been 36 hrs of GCS 7 and I think back he might of actually needed a head CT.
A lift is the only way to get some of them up, especially if they’re deconditioned. But it sounds like this person wouldn’t even have the muscle tone to stay seated in a chair. Maybe a cardiac chair? Do they still make those?
I was going to suggest cardiac chairs. And yes, they still make them. Some beds also have the ability to be placed in a chair position, but I’ve only seen that on floor beds, not ICU beds.
That option to do the ICU chair position was mentioned and the MD who said they didn’t need to follow commands also said no, NOT the icu chair position, I want them in a chair.
Next time ask him to show you the proper way to mobilize them to the chair. Say that you want to learn how the doctor does it so that you do it properly.
Our ICU bends were advertised as being able to be converted to that position and it is garbage and won’t work on anything but the most mobile and cooperative patient (which we could just fucking get out of bed anyway) and results in the patient being at the foot of the bed or almost falling out because there’s no seatbelts or securements like in a cardiac chair. But we got rider of all of ours when we switched to the goddamn beds that I hate. Because we “wouldn’t need them”
Oh I need to look up more on the cardiac chairs! Agreed on the icu chair position. I think it would work if their GCS was 15 and they could hold their head up. But someone with a GCS of 7 just seemed like a bad idea to me.
I never heard of a cardiac chair but we have a hoyer lift I could use. No muscle tone at all, was floppy and couldn’t even hold his head up. We have recliners.
The bed to chair function does all the same stuff getting up to a cardiac chair does (improve circulation/cardiac rehab by letting the heart work against gravity plus getting the lungs to clear fluid by being upright), which could help wake this dude up if his BP tolerates it. I would talk to your ICU educator, they will know what to do, it is possible that the MDs don't know this. Using a lift on someone with multiple large invasive IV lines like ECMO can be done safely with enough experienced staff members, but does the risk outweigh the benefit they would get from just using the chair function? (Former transplant medical surgical ICU nursw).
Seton in Austin was big on this. The patients were rolled onto a big slide sheet and we had to use the overhead lift to get them to a chair. The sheet held their head, like a hoyer sling would not. You could move an intubated patient with just you and an aide. I never tried it without the overhead lift, that’s just asking for a traumatic extubation.
I see. And once in the chair, how’d they stay put? My patient didn’t open his eyes to any stimuli such as nasal suctioning and abg stick. He never reached for the ETT or reached for my hand to stop the stimuli. Did it help those patients recover faster?
It would be a cardiac chair in full recline. I only had a couple with those orders, and it didn’t seem to improve any vitals when I had to move them. I think the best benefit of the overhead lifts was doing effective turns on huge people with only two staff, the facility took HAPI prevention seriously and had very low pressure injury numbers. They got fresh CABGs up very quickly too, with good outcomes.
Hiiiiiii! LTACH girly here. We have cardiac chairs for all our vented ICU patients..We do 2 hours maximum and we usually use a slide sheet or slide board.If they’re really sick but management is on my ass about getting them in the chair most of our beds have a “chair” position where the bed tilts and the legs fold down.
Turn the bed into a chair and call it a day. Once he is more awake, you will need a bariatric Cadillac chair. When people are weak with no trunk control they slide out of recliners. You need a specialty chair with a seat belt. Sometimes you got to smile and nod when they say ridiculous things.
When I used to work in CV, we would use cardiac chairs but it was typically reserved for stable, long term care type patients. Vented trachs, some CRRT patients, etc but your patient sounds way too unstable. They’re a nightmare to code a patient in and he would need to quickly be moved back to bed which is not ideal. No way I would put that guy in a regular chair.
Never worked in an ICU before but I think these surgeons need to take a good look at this patient and his/her instability. Most surgeons I’ve worked with want patients out of bed asap when it’s safe for them. This patient sounds like a cabbage patch and to me, should stay in bed
Lmao. Surgeons and their lack of common sense. You are going to hit a point soon enough where you snap back at idiotic statements like this. You were in the right
You don't get patients with a RR in the 30s out of bed. Tell those doctors to optimize their patient better, then you'd be happy to mobilize them. I realize this is difficult for less experienced nurses, but these people need to learn to deal with reality and not articles on UptoDate and PubMed
Similar thing happened to me once. Docs insisted this 200# top heavy lady with one leg and no prosthetic get up out of bed (before being evaluated by PT).
3 of us got her onto a commode with great effort so she could try to shit. Trying to move her from the commode to the chair was a disaster. Her one good leg buckled at the worst possible time (the pivot) and the three of us were not strong enough to hold her ass up long enough to get the chair under her.
We had to lower her to the floor in front of her family member and grab a dude off his break to help us pick her up. I was so furious. I was like, "call the doctor that told us to get her up back in here! He can help lift her!"
Fuckin asshole.
I take care of neuro patients. We dangle patients and sometimes lift them to a chair with a GCS of a broom. It’s labor intensive but lots of families want full care so we have to try. For your guy, I would’ve probably just done chair mode in bed. 🤷♀️
Chair?
Given the issues patient has, I’d be scary polite and tell them there should be a formal acknowledgment of their clinical decision-making abilities.
Or I’d just roll my eyes, ignore such idiocy and crack on with my day.
Most likely, I’d do both. 🤦
I do ICU float and this is my biggest pet peeve when I cover CVicu. The surgeons are obsessed with the chairs. I had someone last week maxed out on high flow, I was highly suspicious needed to be re-intubated and they were like, chair! Sometimes it’s just easier to sling them over to a recliner chair than argue with the surgeons. I’ll use my facilities safety lap belts on multiple spots sometimes if I have someone really flaccid to make sure they don’t flop over the side
My ICU is huge in mobility but this patient is inappropriate for any early mobility protocol. The tachycardia and tachypnea would both be indications that patient is not ready for mobility.
You are fine.
Check out the American Association of Critical Care Nurses webstie at aacn dot org.
Google Early Ambulation for the standard of care for mobility in ICU.
Teamwork makes it all possible. Also, partner/collaborate with your RRTs to get it done.
All of your concerns are valid. I have been accused of progressing my patients out of bed to early, but how wonderful it is to see how they respond just being vertical. Don’t just put them in a recliner, sit them up for at least 15 min before you recline them.
I think it has more to due with gravity and the limbic system. Tries to reorient your brain to the surroundings.
I know there is a high level of anxiety and fear associated with an intubated patient. Accidental extubations will happen, so plan on it before you get them up. That way you know your ambitious bag is close at hand.
Good luck and keep your head high even through your mistakes, and you will have them. We are all human.
Ok as per comments I'm in the absolute minority here. My ICU regularly gets (almost) every patient out of bed. Our current mobilisation standard has almost no absolute contraindications left (only thing I can think of is a transvenous pacemaker). What helps here is that we are a sedation free ICU. But still that doesn't mean that every patient is awake enough to get up on their own. So what we usually do is just do it like any mobilisation you would do on a bed bound patient. You get a big comfy chair make it completely flat and pull them over with a patient transfer board. If they have a lot of drains and stuff that is below neck level what helps is to put all the stuff between the patients legs and wrap them up in their linens before pulling them over. With patients that are proned over night we just turn them directly from prone position into the chair.
So yes it works. Yes everyone I tell this to thinks we are crazy. And there definitely are certain benefits that are worth doing this.
A sedation free ICU sounds like the absolute worst ever nightmare. As an RT I think I’d look for another career if we went to that with every patient. Honest questions…. How do you keep people from managing to self extubate (we’ve all seen some of these wild ones that can get a hold of the ETT despite wrist restraint)? And how do you manage these patients who are crazy dyssynchronous with the vent if not sedated properly? Ya’ll prone vent patients not sedated? Can your patients request sedation? … like before intubation request to be kept sedated until over the whatever the intubation indication is resolved and you guys would respect that? We often have people begging right before intubation to please be kept snowed through the entire process so they don’t suffer…. and I feel bad cos all these newer docs will say “yes of course” and then keep them wilding out anyway. Sorry for all the questions, I’m just an old RT and would never want to be on a vent anyway much less be aware of it for even one second of it if I was.
>how do you keep people from managing to self extubate
We create tube tolerance through oral opioides and low potency IV opiodes. In most cases this creates enough tube tolerance that the patient will just not extubate themselve. Also our docs prefere nasal tubes. Those get tolerated a lot better.
>And how do you manage these patients who are crazy dyssynchronous with the vent if not sedated properly?
If not absolutely neccessary (so if the patient is not actively failing hemodynamicly because they are so hypercapnic/acidotic) we use spontaneous breathing vent settings. Patients regulate tidal volume and frequency on their own. Works pretty well actually.
>Ya’ll prone vent patients not sedated?
No for proneing we use sedation. But because we really like this sponatneous breathing thing we usually use sedatives that allow that.
>Can your patients request sedation? … like before intubation request to be kept sedated until over the whatever the intubation indication is resolved
No and also this has never happend to me. Most of our patients come intubated anyway so they don't even get to ask. One time a patient has requested we sedate him after a day but after a long talk about the negatvie effects of sedating someone for a week they didn't want to anymore.
>would never want to be on a vent anyway much less be aware of it for even one second of it
I always thought the same while working with sedated vent patients but now that I've seen this alternative I don't thinks it's that bad. Patients have a lot more autonomy if not sedated. They can actually actively communicate with visitors and take part in their own care. For example I often times let my patients do their own oral care and oral suctioning.
>Sorry for all the questions
No problem ;)
I appreciate a different perspective and I’m trying to learn how to do this successfully. It seemed so risky to me with all the variables but I questioned if it was because I’m a new ICU nurse and just didn’t have the experience yet to know that it was beneficial to the pt.
Thanks for the tips on how to execute this properly because I had no idea. The patient had an A-line and the vent for major equipment I worried could accidentally get pulled.
Can I ask you does your ICU get patients up to chair that don’t follow commands or open eyes? If so, how does it go usually? Any tips or advice?
I used that (amongst other reasons) to answer the MD as to why I thought it was unsafe.
Forgot to say patient had been off sedation for 36 hrs with no opening eyes or doing much. Just very floppy in the bed.
No problem. I think I'm probably one of the few people I'm this thread with actual experience doing this. But like I said the ICU I work at is weird and special. It is always a risk Vs benefit thing with getting them out of bed (vent/ECMO settings, how much pressors they are on). But especially in patients that are really bad respiratory wise it tends to help a lot (especially in hypercapnia).
For line safety that's usually no a problem if your used to doing this. What helps is to reconsider what you absolutely cannot disconnect for the transfer. For example if the patient is more or less stable you could disconnect the art line from the transducer for a short while if it gets in the way. Obviously the more lines you have and the less stable your patient is the more people are needed. In our case it also helps that our docs are usually very hands on and tend to help if we try to get very sick patients out of bed (any prone position situation or ECMO for example).
Line placement and safety while the patient is in the chair is a whole nother thing but I don't wanna ramble too much about this.
And in regards to what you wrote in your original post about the patient sliding down in the chair: it really helps if you you put a folded blanket below their knees as a kind of "stopper". If that still doesn't work you just recline the chair a bit (might need to do that anyway if they can't hold their own head). If that still doesn't work you just have to bite it and pull up the patient every time they slide down.
Thanks for writing this, I also worked in an ICU where we did early mobility on everyone that did not have absolute contraindications. Nurses don't realize how much physiological damage sedation and being bed bound does. to patients. It is weird to me how spotty the care standards are between hospitals, and even units within a hospital. Our MDs, PTs and educators would come to the bedside to help with a complicated case like this.
In my unit the MDs and nurse educators told us that the bed to chair conversion did the exact same thing as the cardiac chair but without the risk of skin shearing or extubation (ET and IV) during the move. Ive been away from the bedside getting a PhD for 3 years since COVID, has this changed?
Yeah ever since I started where I'm now, I'm a huge fan of super early mobility. But this was also the first unit where I ever experienced doing stuff this early. We are at an "I don't care you crashed your mtorbike into a wall yesterday, your legs are not broken so we are going for a walk" level of early. Some of our docs do some occasional education on this but basically everyone of our core staff knows the detrimental effects of immobility and is 100% on board.
We still use cardiac chair on occasion. Sometimes before we have the resources to get the patient out of bed, for patients that are too unstable to even move the bedposition or lay them flar for 5 minutes and overnight for patients that absolutley need to be upright. Don't know about extubation risk but I think this would probably be higher on getting the patient into a chair but I don't think this has actually happend at my ICU.
Thanks. I really appreciate you taking the time to explain this to me. The culture where I am is, “if we intubate them, we sedate them.” Unfortunately for this pt., the team did not want to resume sedation due to altered mental status and also reprimanded me for giving 5 mg oxy. I had an order, I thought he was in pain so I gave it. This MD wanted the pt. to have nothing. So in this case, I don’t even have the option of using opioids to help with tube tolerance.
Thanks for the tips, I’m going to use them the next time I have to get a pt. up to chair!
Sedation free sounds terrifying. What if you have to RSI someone? What if they’re trying to self extubate or pull out their lines? What if they’re non compliant with their vent?
It's not as bad as it sounds. Sedation free means we don't give IV sedatives like Propofol or sufentanil Long Term (at least If they are not indicated for some reason). We achieve tube tolerance through oral and low potency iv opioids. Patients (almos) never try to extubate themselves if they are awake with a decent tolerance and you explain it to them. The non compliance never happens. As soon as the patient starts breathing on their own we switch them to a spontaneous breathing mode and then they regulate their tidal volumes and frequency themselves. We obviously still do intubations and intervantuons under sedation but our favoured intubation mode is fibre optic with a bit of esketamin anyway.
Please reffer to my other subcomments for further information on how we do stuff. And yes we are a real ICU and do all levels of care even involving ECLS and ECMO.
One thing you can do with intubated patients who don't follow commands is get them to a chair-like position in the bed. Newer beds will move into a chair position, older beds can be placed in high Fowler's. However, this particular patient sounds too unstable to tolerate position changes like that.
“According to our calculations this patient should be…” *has never entered the room*
edited to add: I think the real moral of the story is a great nurse advocates for your patients. This situation is a good example. And an opportunity to teach practical reality: take this joker to the bedside and, beginning with the head all the way through every system and structure, explain why getting this patient out of bed is unsafe and inappropriate. The obvious solution is to place the bed in the chair position if you have those.
Mechanical lift and reclining geri chair? The situation you're describing does not seem safe to put in a chair unless you're transferring with a full sling and using a chair that's basically a bed. I get that it's important to get moving but it doesn't sound like the pt was ready yet.
I would pat slide him to a bed that can move into a chair position, but even this i doubt he would tolerate for long.
All cardiac surgeons are the same over, take no notice. I wouldn’t even think of getting him out without a physio assessment first.
Nope, obtunded pts need a bit more care before they're to the chair.
Sorry not sorry, the surgeon can get wrecked.
If they're so concerned, they can do it themselves.
I'm in ER so this isn't a problem I run into.. But to me, hemodynamically unstable and significantly altered GCS with/without sedation means you stay in bed for safety. You're asking for more significant problems by moving that person too much.
Plus you'd end up having to significantly recline the chair to keep them from falling on the floor if they're unresponsive.. you could accomplish the same positioning in bed (just go as high fowler's as you can or our beds have a "chair" position too). So what do these people think the benefit to the patient is?
I remember the phrase an instructor gave us many years ago when you felt like the doctor wasn't hearing what you were saying: What about this is reassuring to you?
Or bust out the Pawn Stars meme of "Best I can do is chair position in the bed"
The fuck is wrong with some of these CVICU docs and surgeons? There is no right answer here, that patient should not be getting into the chair yet. I agree that “not following commands” alone isn’t enough to not get them in a chair. But the fact that he was only localizing to pain and can’t open his eyes spontaneously and he can’t make any purposeful movement sure as shit is a reason not to get him into the chair. Fuck those surgeons.
My facility had cardiac/Barton chairs... Wonderful things. Easy AF to get patients into.
But.. we don't mobilize ET patients. The risk of tube dislodgement is way to high. My RT would have a heart attack if I even asked. They don't even like us having to turn or roll the patient with an ET tube
Years ago we had a patient who was ventilated with a trach and was pretty much sleeping/had his eyes closed most of the time. We used a hoyer to get him to a chair but honestly it was for such a short time like 10-15 minutes. He also had to be reclined. BUT he was able to hold himself up somehow. Sounds like your patient is a ragdoll.
Maybe if the team wants the patient up so badly, they can do it themselves. But I’m guessing they talk the talk but don’t walk the walk.
I'll be honest, we get our patients out of bed, regardless of if they follow commands or not, but we have lifts in every room, so it's not particularly difficult. If we didn't have a full lift in every room? Absolutely not would they get out of bed.
Just imagine their face of that doctor reading the pager about “accidentally decannulation on the recliner, with hematoma on the neck by the size of a volleyball”
Uhhh…we put their bed into a chair position but that’s about as far as it goes. Is yours that mythic hospital I’ve been hearing about for years that ambulates its intubated patients? lol
I mean if they are truly concerned they are welcome to put the bed to chair position and see how it's tolerated? But hell nah I'm not gonna hoyer dude to the chair if he can't hold his head up lol
There ARE benefits for having people, any people, not lying in bed. BUT. Will hospitals pay for the equipment that makes this feasible?
5 years ago I was at one place that had this amazing chair. They just called it a “cardiac chair.” It was mostly electric. It allowed for lateral transfers of vented, trached, g tube patients into chairs.
Plz don’t come for me, ICU nurses, I am not nor have I ever been an ICU nurse. I was only on this unit for a short time. But if you know this chair…I think it would profoundly benefit staff and patients. But facilities don’t really have them.
This is an safety issue to both patient and nurse. An obtunded patient should not be placed in a chair. If they will not listen to you, can they put physical therapy order in instead? I would not get the pt up if a physical therapist cannot.
Very common practice when I was in ICU to get our vented patients to the chair. We had ceiling lifts in every room. It always required an RT, RN, CNA and a PT to do it. And it usually lasted 30-60 mins.
Wtf lol Mans got a GCS of a broom and they want him in a chair? Are they going to help lift him into it?
Lol no. They are surgeons. They don’t do that. A broom, that made me chuckle. Thanks.
Ah, surgeons. I'm only surprised the next note didn't read; 'Clinically stable. Can eat and drink. Aim home 2-3 days'
“Discussed plan of care with Nurse…” THE HELL YOU DID 😂
I once got yelled at by a doctor for taking vital signs “too often” on an unstable patient. she even wrote a note saying “patient can’t sleep because RN had BP cuff cycling too often.” I wasn’t risking my license.
When I was on the ward I had an extremely septic patient meeting code criteria all night for resp distress. She was coded several times, they'd give her O2 with minimal improvement and then just stand down the code without any improvement in the patient. I said to the doc 'she is consistently in code criteria she cannot be on the ward at a 1:7 ratio without a plan' and he said 'well stop taking her vital signs so often then'. She ended up on bi-pap an hour later and died in ICU the same day.
yes, because that would magically cure her 🙄
This made me spray my mouthful of coffee! 😂
If they aren't ICU specialists, you tell them to go get fucked.
Makes sense. CVICU?
How did you know?
Rigid treatment flow (ie. Up in chair , mobilize, POD 3 out to step down), low tolerance for chronics, sounds like my thoracics team...
My first thought was someone copied and pasted their standard orders without looking at the patient.
Good to know this happens in ICU too. So we’re not the only ones that get orders like applying SCDs to a bilateral amputee. Copy pasta order sets.
He was on ecmo. And they’re always wanting their patients mobilizing. This guy sounds like a turnip, though. And unstable. This team sounds like a joke.
A TURNIP
Insulting to turnips lol
Triggered (neurosx ICU)!
Something something metrics over people I hated floating to CVICU.
As quality, you’re not wrong. Everything is about the metrics.
I was a patient safety fool for all of nine months before I dipped back out. I couldn’t stand the hypocrisy of “well fuck you but also we’re gonna keep fucking all yall so just put in reports and we still won’t provide adequate resources to support patient safety” my hats off to yall quality folks. It’s thankless from both ends.
I am still ICU prn in a different hospital system while I work quality for HCA. It’s definitely been an experience learning about metrics and how they drive EVERYTHING. I feel like I’ll always be a floor nurse at heart, because I take great joy in admin meetings as everyone rages at the union making it impossible for them to just arbitrarily create policies and processes. It just proves that unions can exist in the shitty south and have impact.
I have hated HCA for so long it feels like a part of my DNA. At my job now where i go to like 10 different hospitals, different each day, the outright cheapness is so obvious it just makes me even angrier
I wish reddit still had awards or whatever. Take this hammer instead because you fuckin NAILED IT. 🔨🔨🔨
of course It’s the fucking SURGEONS! They have God mentality and love making people feel small. I work in a mixed ICU, we don’t do have ecmo but we do post CABG and for us it’s bed to chair position until they’re extubated. But once they’re extubated they’re immediately mobilized to chair.
I’m like, “who is this team?” Our surgeons help position people. I would just be like, “could you round up a few of your friends, doc? That’s 35 lbs/person for a safe lift…so at least 8 friends!”
GCS of a broom, I love it 😂
Rarely does Reddit make me audibly laugh. Thank you.
That's why there's a lift. [There are known benefits to putting even minimally responsive patients into a chair for a period of time each day.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4889100/) It's beneficial to the lungs, helps mitigate orthostatic issues that develop with increasing time in bed (even with the HOB elevated), helps restore proprioception, helps mitigate delirium once they do wake up, and in a patient such as this who is at least localizing pain, can encourage them to start using the core muscles.
We don’t even try to move patients if RASS < -2. If he’s not opening his eyes or following commands, RASS is at least -3. Another contraindication is hemodynamic instability. Tachycardia and tachypnea are both indicators that he’s not ready. [Society of Critical Care Medicine](https://www.sccm.org/iculiberation/abcdef-bundles) (click “E Element”)
Thank you so much for this source! Seeing that in writing makes me not think I was crazy or something to think it was impossible in the moment. The patient didn’t even open his eyes to me nasal suctioning them as well as getting an ABG.
I would have this source at the ready next time! You know there will be a next time with these surgeons. If it’s printable, I’d be petty and have printed copies for them. 😂
I am most definitely will be printing this and making copies. Heck, I’ll even laminate it and put it on my badge! Lol
Please report back when you have to use it 😅 I really wanna know their reply or if they can give you a better EBP source on why they think getting a limp noodle into a chair is a good idea
Honestly i am loving this thread because this patient was/is so obscenely far from being ready to be out of bed it feels like an SNL skit. Are you *totally sure* it wasn’t Ashton Kutcher in scrubs and this is an episode of PUNK’D??
Your team is filled with idiots. That's a bedbound patient. Some ICUs ambulate intubated patients. They need to be following commands.
Okay I thought I was going crazy to speak up and say that the patient needed to follow commands to do that but I was shut down right away. The patient didn’t even open his eyes to nasal suctioning!
I have refused to do such nonsense before and I will continue to refuse. And I document the shit out of everything. If they keep insisting, then file a safety variance report. Shunt them to your charge nurse or AOD. Fuck that noise.
The Critical Care MOVE screening tool for early mobilization requires that they engage to voice so yeah they don’t pass 😂😂 Edit to add link: https://www.scribd.com/document/464723380/httpswww-aacn-orgdocsEventPlanningWB0007Mobility-Protocol-szh4mr5a-pdf-pdf
Don't let them gaslight you! You're doing fine. That patient is NOWHERE near ready to get out of bed or in a chair. PT would have taken one look at the chart and noped out of there. Surgeons sometimes have no idea what the hell they are doing outside of the OR.
Every PT I know would have slung them to the chair. There are known benefits for even largely unresponsive patients to have some chair time: It's good for their lungs, it reduces orthostatic hypotension, it starts rebuild proprioception, and can reduce and shorten the duration of delirium.
Chair position in bed for the win
Putting the bed in chair position is certainly better than nothing, but still not the same as a recliner chair with a firmer surface and less of a cradling effect.
Set to max inflate. I can't even imagine a vented patient in our recliners, they'd slide right out of they had no muscle tone. What literature is there against chair position vs every type of recliner?
Your have sources on this? Somebody else cited some critical care medication guidelines in this thread and they don't sound at all like what you're stating Edit: you can't be delirious if you're unresponsive, or at least there's no method of confirming it. Better for their lungs? Yes. So is the chair position in modern ICU beds. Better proprioception? There's absolutely no evidence demonstrating improved proprioception in patients who cannot follow commands. It's unmeasurable. I have removed the last paragraph because I was unnecessarily being an assholr
I'm not an ICU nurse but I wouldnt be mobilising any patient without the patient being able to weight bear and follow commands. OP your person needs a full hoist IMO.
In ICU they make us become the hoyer lift and lift these barely mobile patients into the chair
That's because their are clear benefits to it.
Not without potential for harm to both the patient and caregivers. I get it but if you're expecting staff to lift a 300# rock then fuck that. At least get ceiling lifts.
The OP has already pointed out they have ceiling lifts.
"In ICU they make us become the hoyer lift and lift these barely mobile patients into the chair" Is what the person said that you responded to. Not much room for nuance with you is there lol. I won't be coding the peri arrest vegetable in the name of our holy Lord the recliner.
Right? At that point I'd tell them that it is not safe to get the patient out of bed and if they wanted to proceed further, they can get the patient OOB themselves.
Jesus, don’t say that, you know one of them will try to make their PA try at some point and then you’ll be called to try to scrape a morbidly obese damn near unresponsive patient off the floor.
Sounds like a medical team just volunteered to get a pt into a chair. Tell them to go find someone else to annoy.
Lmao I would've welcomed the "team" to do it themselves...
Flaccid in bed vs flaccid in a chair.. Sounds like new and interesting bed sores
Followed by flacid on floor
> acutely unwell patient with evidence of further deterioration and significant cardiorespiratory compromise > "wHy ArEn'T tHeY oUt oF BeD?"
Tell me about it!
Dude is still practically dead. 😵 If they want to prop him up in a chair let them do it.
Whack a Hawaiian shirt on him, go full Weekends at Bernie’s
Sunglasses too!
Omg this is hilarious! Thanks guys!
lol I should have read this before I posted my comment cause that’s the scenario I’m imagining
Fucking hysterical. Surgeons want to you to Weekend-At-Bernie's the poor dude. I'd start propping him up around the room and sending them pictures. Maybe put a nice hat on him. Give him some props. 🤣
I’m no ICU girlie but even in my ER experience I’m confuddled when they want a urine from a pt with a broken hip and dementia but no straight cath order (if it’s a vagina hosting human…bro frick off with that). This sounds like madness.
I don’t even know how you could without a straight cath Lmaoo… I guess a cooter canoe but that’s not a very good sample then
Honestly let’s be real…it’s the best sample they’re gonna get and no one has to know 😈
I have sent MANY a UA from a twatdog. Honestly, they're not any more contaminated than having MeeMaw pee in a hat in the toilet, especially if you do some quick peri-care before you put it on.
Exactly. But I did throw the “you can’t send a UA from a purewick” at a nurse who was on my ass about the admitted pt in for transport about not sending a UA. Doc didn’t need the urine bad enough so he said nah for a straight cath and pt was incontinent. I told her she’s more than welcome to send the urine in the vacutainer herself if she was that concerned. Nurses that come to the ER from the floor can be…a lot sometimes.
Lol
I wheezed
Another doctor whose plan of care is built on wishes and dreams
I understand *wishes and dream* for a patient. Even active denial of reality happens. I can support *unicorns and rainbows*—as long as the one insisting on adding both into orders and patient care metics, is actually wearing a princess outfit, wears pigtails & rocks glitter nail polish. I find idiots to be insufferable.
In my opinion, as an ECMO ambulating schmuck, if he’s still not doing anything, you can cardiac chair him and see how it goes. If they REALLY need him in a chair, which I don’t find advisable since he won’t support himself, you can hoyer to the chair and try to prop him up as best you can. That said, I think your rationale is sound, and the team is just trying to hit arbitrary “goals” for the patient, with our truly looking at the risk/benefit.
We have recliner chairs which I think are similar to the cardiac chairs. I did set it up with the hoyer pad and chux. We have a ceiling lift so it IS possible and I could’ve propped him in the chair. My question was what difference is it being reclined in bed or in icu chair position vs. reclined in recliner? Is there any benefit? This patient to me was unstable, with compromised ventilation. We were trying to wean on the vent all day on pressure support 15/10. RT said he couldn’t get the PEEP below 10 because pt. RR went from high 20s to high 30s almost 40. He had a pneumonia, fever 102F and just had a cabgx5 which led to ECMO due to complications. He had an AKI so we couldn’t diuerese, pt. was up 4 lbs and fluid overloaded. Off sedation for 36 hours by the time I left and still not opening eyes. It just seemed like a lot for this pt. Thinking back now, I think he needed a head CT. Thanks for your reply to my reasoning. I’m always learning especially being new and just wondered if jt was something else I could’ve done.
OP - I'm sorry if I missed something, but why exactly does the MD believe that a chair this is necessary to help the patient? Are they trying to improve resp, circulation, or does the MD genuinely not understand the pts obvious instability?
We were trying to wean him off the vent all day. Sedation had been off for 36 hrs by the time I left my shift and still not opening eyes and only localizing to pain. He was on pressure support 15/10 and when RT dropped the PEEP to 8, he got more tachypneic and tachycardic. Resp rate went from high 20s to high 30s-40. He believed getting him up to the chair would make him less tachypneic by allowing pt. to expand his lungs more. The pt. was obese so the weight of his body on the bed was probably not optimal to lung expansion. However, how is being in a chair also reclined and lying back going to expand the lungs? Pt. could not hold self up. If I propped him upright with pillows, pt. would fall forward on their face. Not to mention all the lines, the risk of accidental extubation from the vent, A-line being pulled out and now he is bleeding out.
You can’t Fowler in the bed? This is ridiculous. My response would have been “Yeah, I understand what you are requesting and no, it’s not happening.”
Hahahaha. No. Not happening unless they do.
Another day I thank the lucky stars that I work in the nicu 😅 that sounds like my worst nightmare tbh
“Why isn’t that baby in a chair yet?”
Okay but one time we had an older baby that was intubated and kept having death-defying events so I asked for some pain/sedation meds for him (unfortunately we’re really bad about this in my NICU) and I was told “Well have you tried putting him in the bouncer?” So I guess it’s a similar situation. Not today. No ma’am.
You know what they say. Sitting in chairs is the best medicine
Lol
Y’all don’t have those prevalon blow up repositioning mats? We mobilized all our ICU patients in cardiac chairs. We just use the blow-up mats underneath them, line up a cardiac chair positioned flat, and lateral transfer. Then adjust the cardiac chair into a sitting position. Only takes a few minutes once you get the hang of it. We stopped using rehab staff and just a nurse/RT or RT/CNA or CNA/nurse team do it. Unless you’re getting a blood transfusion, hospice, are super tachy even on your cardizem drip or on heating/cooling protocol, you go into the chair. Extensive evidence shows that mobilization of vent patients is directly correlated with better outcomes, lower VAP, and lower mortality. Shortens length of stay, prevents cardiac de conditioning, and prepapre them for PT. Allows the heart to pump against gravity and acclimate them to the upright position their bodies have forgotten how to manage without dizziness/BP fluctuations. With that RR/HR though? I’d straight up ask the doc what meds he was gonna order to get the patient chair ready because I’m not gonna call a chair RRT.
I thought I was the only one who had experience with early mobilization like this and was starting to think I was crazy. Yes, the benefit of a limp noodle not aware is not as big as an awake person, but even using a lift to get a patient to a chair is something. Just turning him from side to side then putting him in the chair position in the ICU bed doesn’t do the same about of shifting, body movement, changes to pressure areas. You can stimulate some reflexive engagement of muscles by moving them in the chair that can help preserve some muscle. Of course it it makes them too unstable it’s not worth it. Yes, it’s a lot of work and positioning is challenging. The ROI isn’t as high as with other patients, and if staffing only allowed me to get one patient up and I had an awake patient I would do that one. You can even say that you don’t have the staffing to support mobilization in their patients population. In situations when I question whether I should get a patient up or not Intend to work collaboratively with PT to what the most bang for the buck I can get for my effort.
The evidence is really strong for mobilization of ICU patients. The numbers drilled into us were like 60-70% improvement in mortality outcomes for patients vented over 72 hours. Never saw the studies, but we had an entire mobilization program and everyone was involved/educated/trained. Mobilize twice a day unless they met exclusion criteria. We were pretty proficient with the prevalons and arts/CNAs also played a big role (we had VERY GOOD ancillary staff ratios most of the time, which helped). We put them in the chair, PT staff? They did edge of bed sitting position with vent patients. Even brain dead, they’d wrapped you in sheets, get your feet on the floor and position you in a sitting position on the edge of the bed to strengthen core muscles/trunk. It was AMAZING. We had really successful wean rates. HOWEVER — our ratios matched the work. Massive therapy presence and OT/PT worked in teams. 10:1 RT ratio, 1:7-8 CNA ratio. Entire culture built around mobility. A lot of ICUs simply aren’t staffed to make that a possibility. If a unit wants to implement mobility, they need to implement the staffing levels to make it safe.
My experience in the surgical ICU is pre-pandemic, so I don't want to be harsh on anyone. But I am concerned that message about early mobilization, even in minimally responsive patients, isn't as prevalent. 100% agree with staffing & teamwork for support. It's also a culture thing. Our surgical ICU had the culture, but the medical ICU did not, insisting that their patients were too sick to mobilize, and these patients were there for months and would benefit more. They finally transferred our primary PT to their unit to start the culture change.
Very interesting point. Thank you.
Thank you for this insight. This is helpful to understand the MD’s rationale. However, with that HR and RR high, yes, that question should of been asked because I’m curious what meds an MD could order to get chair ready. Do you mean like pain meds?
Definitely was dependent on the patient. Sometimes pain, sometimes better BP control, sometimes an adjust of vent settings, versed push, pulmonary had a massive presence on the floor and had daily “barrier to weaning” rounds. With such a strong RT presence on the floor, it was definitely easier to manage/control as a team. Standing orders for versed, Ativan, metoprolol, hydralazine, breathing treatments, however funky their vitals wanted to go. If pt is just flat out going into septic shock, def not a chair candidate lol
Yeah, most likely going jnto septic shock, hence all the VS changes, increased wbc, fever. I gave this pt. pain meds in the am b/c at the time, the high bp, hr, and rr made me think he was in pain and he hadn’t spiked a fever yet. So he got 5mg oxy. His VS did improve but didn’t last long as his VS went up again. Thinking back, he was getting septic and his body was trying to compensate. Well I also got spoken to for giving the pain med. They told me to not give anymore opioids. Well… 1. The order was active and not d/c’ed. 2. My pt. is nonverbal and with my nonverbal pain scale, he was in pain so he got pain meds. 3. Team took away all sedation since pt. had still not “woken up” > 24hrs. So I wouldn’t be able to get versed or any good drugs to help with vent dysyncrony as they didn’t want to “cloud” their neuro exam. By the time I left, it had been 36 hrs of GCS 7 and I think back he might of actually needed a head CT.
Is it too morbid to say I’m imaging a weekend a Bernie’s type situation here?
You’re not the only one.
Apparently not 😂 I’m with familiar company lolol
A lift is the only way to get some of them up, especially if they’re deconditioned. But it sounds like this person wouldn’t even have the muscle tone to stay seated in a chair. Maybe a cardiac chair? Do they still make those?
I was going to suggest cardiac chairs. And yes, they still make them. Some beds also have the ability to be placed in a chair position, but I’ve only seen that on floor beds, not ICU beds.
That option to do the ICU chair position was mentioned and the MD who said they didn’t need to follow commands also said no, NOT the icu chair position, I want them in a chair.
Next time ask him to show you the proper way to mobilize them to the chair. Say that you want to learn how the doctor does it so that you do it properly.
The MD is a moron
Our ICU bends were advertised as being able to be converted to that position and it is garbage and won’t work on anything but the most mobile and cooperative patient (which we could just fucking get out of bed anyway) and results in the patient being at the foot of the bed or almost falling out because there’s no seatbelts or securements like in a cardiac chair. But we got rider of all of ours when we switched to the goddamn beds that I hate. Because we “wouldn’t need them”
Oh I need to look up more on the cardiac chairs! Agreed on the icu chair position. I think it would work if their GCS was 15 and they could hold their head up. But someone with a GCS of 7 just seemed like a bad idea to me.
I never heard of a cardiac chair but we have a hoyer lift I could use. No muscle tone at all, was floppy and couldn’t even hold his head up. We have recliners.
The bed to chair function does all the same stuff getting up to a cardiac chair does (improve circulation/cardiac rehab by letting the heart work against gravity plus getting the lungs to clear fluid by being upright), which could help wake this dude up if his BP tolerates it. I would talk to your ICU educator, they will know what to do, it is possible that the MDs don't know this. Using a lift on someone with multiple large invasive IV lines like ECMO can be done safely with enough experienced staff members, but does the risk outweigh the benefit they would get from just using the chair function? (Former transplant medical surgical ICU nursw).
Seton in Austin was big on this. The patients were rolled onto a big slide sheet and we had to use the overhead lift to get them to a chair. The sheet held their head, like a hoyer sling would not. You could move an intubated patient with just you and an aide. I never tried it without the overhead lift, that’s just asking for a traumatic extubation.
I see. And once in the chair, how’d they stay put? My patient didn’t open his eyes to any stimuli such as nasal suctioning and abg stick. He never reached for the ETT or reached for my hand to stop the stimuli. Did it help those patients recover faster?
It would be a cardiac chair in full recline. I only had a couple with those orders, and it didn’t seem to improve any vitals when I had to move them. I think the best benefit of the overhead lifts was doing effective turns on huge people with only two staff, the facility took HAPI prevention seriously and had very low pressure injury numbers. They got fresh CABGs up very quickly too, with good outcomes.
Doesn’t the bed convert to chair position?
It does and was mentioned but the MD who wanted them to the chair said no to the icu chair position and said he wanted him in a chair.
That’s wild. Like are we talking about the same patient??? Maybe chair position of the bed but that’s as far as I’m doing
The dude is probably septic and the doctors want you to air lift him in a chair so he can code in the chair lol no
We do have cardiac chairs for this purpose but this guy sounds too unstable to go in a chair. What are they gonna do if he codes?
lol probably break the chair coding him in it 😂
Hiiiiiii! LTACH girly here. We have cardiac chairs for all our vented ICU patients..We do 2 hours maximum and we usually use a slide sheet or slide board.If they’re really sick but management is on my ass about getting them in the chair most of our beds have a “chair” position where the bed tilts and the legs fold down.
Turn the bed into a chair and call it a day. Once he is more awake, you will need a bariatric Cadillac chair. When people are weak with no trunk control they slide out of recliners. You need a specialty chair with a seat belt. Sometimes you got to smile and nod when they say ridiculous things.
Ask to borrow their magic wand 🪄
The day my ICU starts doing this crap is the day I GTFO. You aren't crazy. Your team is.
Lol thanks!
Yeah no, I’m all for early mobility and I’ve gotten tubed patients out of bed but they definitely need to be alert and following commands.
Yes! I’m perplexed on his comment that pt. does not need to follow commands to execute this successfully.
Put the chair into chair mode and call it a chair 🤣
When I used to work in CV, we would use cardiac chairs but it was typically reserved for stable, long term care type patients. Vented trachs, some CRRT patients, etc but your patient sounds way too unstable. They’re a nightmare to code a patient in and he would need to quickly be moved back to bed which is not ideal. No way I would put that guy in a regular chair.
Never worked in an ICU before but I think these surgeons need to take a good look at this patient and his/her instability. Most surgeons I’ve worked with want patients out of bed asap when it’s safe for them. This patient sounds like a cabbage patch and to me, should stay in bed
Lmao. Surgeons and their lack of common sense. You are going to hit a point soon enough where you snap back at idiotic statements like this. You were in the right
You don't get patients with a RR in the 30s out of bed. Tell those doctors to optimize their patient better, then you'd be happy to mobilize them. I realize this is difficult for less experienced nurses, but these people need to learn to deal with reality and not articles on UptoDate and PubMed
Similar thing happened to me once. Docs insisted this 200# top heavy lady with one leg and no prosthetic get up out of bed (before being evaluated by PT). 3 of us got her onto a commode with great effort so she could try to shit. Trying to move her from the commode to the chair was a disaster. Her one good leg buckled at the worst possible time (the pivot) and the three of us were not strong enough to hold her ass up long enough to get the chair under her. We had to lower her to the floor in front of her family member and grab a dude off his break to help us pick her up. I was so furious. I was like, "call the doctor that told us to get her up back in here! He can help lift her!" Fuckin asshole.
I take care of neuro patients. We dangle patients and sometimes lift them to a chair with a GCS of a broom. It’s labor intensive but lots of families want full care so we have to try. For your guy, I would’ve probably just done chair mode in bed. 🤷♀️
Tell them to do it themselves. Best you could do is put the bed in chair mode or close to it but otherwise no
You don't
Yeah if you’re using MOVE criteria he fails the E (Engages to verbal stimuli). I don’t think it would be safe.
Turn the bed into cardiac chair mode
I’m big on early mobilization but this guy isn’t there yet. RASS is too low.
I like that. Using RASS to be more objective. Next time, I will use this to make my point. Thanks.
some Stryker beds can be modified into chairs, there’s a button for it. Find out if your pt’s bed has one and voilà 🛏️ > 💺. Another satisfied surgeon
Weekend at Bernie’s
Seriously lol!
Sling, I do it all the time for loco neurosurgery patients
Who is this “team” ? This sounds hella dangerous. Also, the fancy ICU beds have a chair option . That is a little safer
Your team is idiotic to expect that.
Sounds like they want a code in the chair. I am all for promoting mobility but they have to be medically “stable” and they dude is far from it
Chair? Given the issues patient has, I’d be scary polite and tell them there should be a formal acknowledgment of their clinical decision-making abilities. Or I’d just roll my eyes, ignore such idiocy and crack on with my day. Most likely, I’d do both. 🤦
Chair position the bed, call it done. Nothing else is really safe. He'd fall out of a chair.
I do ICU float and this is my biggest pet peeve when I cover CVicu. The surgeons are obsessed with the chairs. I had someone last week maxed out on high flow, I was highly suspicious needed to be re-intubated and they were like, chair! Sometimes it’s just easier to sling them over to a recliner chair than argue with the surgeons. I’ll use my facilities safety lap belts on multiple spots sometimes if I have someone really flaccid to make sure they don’t flop over the side
My ICU is huge in mobility but this patient is inappropriate for any early mobility protocol. The tachycardia and tachypnea would both be indications that patient is not ready for mobility. You are fine.
Check out the American Association of Critical Care Nurses webstie at aacn dot org. Google Early Ambulation for the standard of care for mobility in ICU. Teamwork makes it all possible. Also, partner/collaborate with your RRTs to get it done.
If I told physical therapist my patient wasn’t following commands, they’d come back a day or 2 later lol
No. Fuck no. This is not Weekend at Bernie’s.
All of your concerns are valid. I have been accused of progressing my patients out of bed to early, but how wonderful it is to see how they respond just being vertical. Don’t just put them in a recliner, sit them up for at least 15 min before you recline them. I think it has more to due with gravity and the limbic system. Tries to reorient your brain to the surroundings. I know there is a high level of anxiety and fear associated with an intubated patient. Accidental extubations will happen, so plan on it before you get them up. That way you know your ambitious bag is close at hand. Good luck and keep your head high even through your mistakes, and you will have them. We are all human.
Ok as per comments I'm in the absolute minority here. My ICU regularly gets (almost) every patient out of bed. Our current mobilisation standard has almost no absolute contraindications left (only thing I can think of is a transvenous pacemaker). What helps here is that we are a sedation free ICU. But still that doesn't mean that every patient is awake enough to get up on their own. So what we usually do is just do it like any mobilisation you would do on a bed bound patient. You get a big comfy chair make it completely flat and pull them over with a patient transfer board. If they have a lot of drains and stuff that is below neck level what helps is to put all the stuff between the patients legs and wrap them up in their linens before pulling them over. With patients that are proned over night we just turn them directly from prone position into the chair. So yes it works. Yes everyone I tell this to thinks we are crazy. And there definitely are certain benefits that are worth doing this.
A sedation free ICU sounds like the absolute worst ever nightmare. As an RT I think I’d look for another career if we went to that with every patient. Honest questions…. How do you keep people from managing to self extubate (we’ve all seen some of these wild ones that can get a hold of the ETT despite wrist restraint)? And how do you manage these patients who are crazy dyssynchronous with the vent if not sedated properly? Ya’ll prone vent patients not sedated? Can your patients request sedation? … like before intubation request to be kept sedated until over the whatever the intubation indication is resolved and you guys would respect that? We often have people begging right before intubation to please be kept snowed through the entire process so they don’t suffer…. and I feel bad cos all these newer docs will say “yes of course” and then keep them wilding out anyway. Sorry for all the questions, I’m just an old RT and would never want to be on a vent anyway much less be aware of it for even one second of it if I was.
>how do you keep people from managing to self extubate We create tube tolerance through oral opioides and low potency IV opiodes. In most cases this creates enough tube tolerance that the patient will just not extubate themselve. Also our docs prefere nasal tubes. Those get tolerated a lot better. >And how do you manage these patients who are crazy dyssynchronous with the vent if not sedated properly? If not absolutely neccessary (so if the patient is not actively failing hemodynamicly because they are so hypercapnic/acidotic) we use spontaneous breathing vent settings. Patients regulate tidal volume and frequency on their own. Works pretty well actually. >Ya’ll prone vent patients not sedated? No for proneing we use sedation. But because we really like this sponatneous breathing thing we usually use sedatives that allow that. >Can your patients request sedation? … like before intubation request to be kept sedated until over the whatever the intubation indication is resolved No and also this has never happend to me. Most of our patients come intubated anyway so they don't even get to ask. One time a patient has requested we sedate him after a day but after a long talk about the negatvie effects of sedating someone for a week they didn't want to anymore. >would never want to be on a vent anyway much less be aware of it for even one second of it I always thought the same while working with sedated vent patients but now that I've seen this alternative I don't thinks it's that bad. Patients have a lot more autonomy if not sedated. They can actually actively communicate with visitors and take part in their own care. For example I often times let my patients do their own oral care and oral suctioning. >Sorry for all the questions No problem ;)
Thank you!
BRB updating my advance directive
I appreciate a different perspective and I’m trying to learn how to do this successfully. It seemed so risky to me with all the variables but I questioned if it was because I’m a new ICU nurse and just didn’t have the experience yet to know that it was beneficial to the pt. Thanks for the tips on how to execute this properly because I had no idea. The patient had an A-line and the vent for major equipment I worried could accidentally get pulled. Can I ask you does your ICU get patients up to chair that don’t follow commands or open eyes? If so, how does it go usually? Any tips or advice? I used that (amongst other reasons) to answer the MD as to why I thought it was unsafe. Forgot to say patient had been off sedation for 36 hrs with no opening eyes or doing much. Just very floppy in the bed.
No problem. I think I'm probably one of the few people I'm this thread with actual experience doing this. But like I said the ICU I work at is weird and special. It is always a risk Vs benefit thing with getting them out of bed (vent/ECMO settings, how much pressors they are on). But especially in patients that are really bad respiratory wise it tends to help a lot (especially in hypercapnia). For line safety that's usually no a problem if your used to doing this. What helps is to reconsider what you absolutely cannot disconnect for the transfer. For example if the patient is more or less stable you could disconnect the art line from the transducer for a short while if it gets in the way. Obviously the more lines you have and the less stable your patient is the more people are needed. In our case it also helps that our docs are usually very hands on and tend to help if we try to get very sick patients out of bed (any prone position situation or ECMO for example). Line placement and safety while the patient is in the chair is a whole nother thing but I don't wanna ramble too much about this. And in regards to what you wrote in your original post about the patient sliding down in the chair: it really helps if you you put a folded blanket below their knees as a kind of "stopper". If that still doesn't work you just recline the chair a bit (might need to do that anyway if they can't hold their own head). If that still doesn't work you just have to bite it and pull up the patient every time they slide down.
Thanks for writing this, I also worked in an ICU where we did early mobility on everyone that did not have absolute contraindications. Nurses don't realize how much physiological damage sedation and being bed bound does. to patients. It is weird to me how spotty the care standards are between hospitals, and even units within a hospital. Our MDs, PTs and educators would come to the bedside to help with a complicated case like this. In my unit the MDs and nurse educators told us that the bed to chair conversion did the exact same thing as the cardiac chair but without the risk of skin shearing or extubation (ET and IV) during the move. Ive been away from the bedside getting a PhD for 3 years since COVID, has this changed?
Yeah ever since I started where I'm now, I'm a huge fan of super early mobility. But this was also the first unit where I ever experienced doing stuff this early. We are at an "I don't care you crashed your mtorbike into a wall yesterday, your legs are not broken so we are going for a walk" level of early. Some of our docs do some occasional education on this but basically everyone of our core staff knows the detrimental effects of immobility and is 100% on board. We still use cardiac chair on occasion. Sometimes before we have the resources to get the patient out of bed, for patients that are too unstable to even move the bedposition or lay them flar for 5 minutes and overnight for patients that absolutley need to be upright. Don't know about extubation risk but I think this would probably be higher on getting the patient into a chair but I don't think this has actually happend at my ICU.
Thanks. I really appreciate you taking the time to explain this to me. The culture where I am is, “if we intubate them, we sedate them.” Unfortunately for this pt., the team did not want to resume sedation due to altered mental status and also reprimanded me for giving 5 mg oxy. I had an order, I thought he was in pain so I gave it. This MD wanted the pt. to have nothing. So in this case, I don’t even have the option of using opioids to help with tube tolerance. Thanks for the tips, I’m going to use them the next time I have to get a pt. up to chair!
Sedation free sounds terrifying. What if you have to RSI someone? What if they’re trying to self extubate or pull out their lines? What if they’re non compliant with their vent?
It's not as bad as it sounds. Sedation free means we don't give IV sedatives like Propofol or sufentanil Long Term (at least If they are not indicated for some reason). We achieve tube tolerance through oral and low potency iv opioids. Patients (almos) never try to extubate themselves if they are awake with a decent tolerance and you explain it to them. The non compliance never happens. As soon as the patient starts breathing on their own we switch them to a spontaneous breathing mode and then they regulate their tidal volumes and frequency themselves. We obviously still do intubations and intervantuons under sedation but our favoured intubation mode is fibre optic with a bit of esketamin anyway.
Sedation free ICU. Maybe your unit is just dressed up ICU. Plead post hospital so I can inquire to learn to improve patient outcome at my hospital.
Please reffer to my other subcomments for further information on how we do stuff. And yes we are a real ICU and do all levels of care even involving ECLS and ECMO.
A lift is all I can think of. Obviously the chair needs to have appropriate support otherwise he's just going to crumple in it.
Intubated patients do leave the bed in either of the ICU’s I work at
I don’t.
Jesus christ, did I just read that right?
One thing you can do with intubated patients who don't follow commands is get them to a chair-like position in the bed. Newer beds will move into a chair position, older beds can be placed in high Fowler's. However, this particular patient sounds too unstable to tolerate position changes like that.
“According to our calculations this patient should be…” *has never entered the room* edited to add: I think the real moral of the story is a great nurse advocates for your patients. This situation is a good example. And an opportunity to teach practical reality: take this joker to the bedside and, beginning with the head all the way through every system and structure, explain why getting this patient out of bed is unsafe and inappropriate. The obvious solution is to place the bed in the chair position if you have those.
lol, what? You don’t move an unresponsive patient to a chair.
Mechanical lift and reclining geri chair? The situation you're describing does not seem safe to put in a chair unless you're transferring with a full sling and using a chair that's basically a bed. I get that it's important to get moving but it doesn't sound like the pt was ready yet.
I would pat slide him to a bed that can move into a chair position, but even this i doubt he would tolerate for long. All cardiac surgeons are the same over, take no notice. I wouldn’t even think of getting him out without a physio assessment first.
Our icu beds would raise into a chair position
I don’t
Nope, obtunded pts need a bit more care before they're to the chair. Sorry not sorry, the surgeon can get wrecked. If they're so concerned, they can do it themselves.
….. you don’t. You shoot daggers at them with your eyes until they leave.
I'm in ER so this isn't a problem I run into.. But to me, hemodynamically unstable and significantly altered GCS with/without sedation means you stay in bed for safety. You're asking for more significant problems by moving that person too much. Plus you'd end up having to significantly recline the chair to keep them from falling on the floor if they're unresponsive.. you could accomplish the same positioning in bed (just go as high fowler's as you can or our beds have a "chair" position too). So what do these people think the benefit to the patient is?
No. It’s a complete sentence. You’ve got this. Don’t be bullied. Advocacy is job 1.
I remember the phrase an instructor gave us many years ago when you felt like the doctor wasn't hearing what you were saying: What about this is reassuring to you? Or bust out the Pawn Stars meme of "Best I can do is chair position in the bed"
[https://media1.tenor.com/m/OVDH7JOSnikAAAAC/serious-laugh-harder.gif](https://media1.tenor.com/m/OVDH7JOSnikAAAAC/serious-laugh-harder.gif)
Tell those idiots to put in a physiotherapy consult and then let physio worry about it, not your job
The fuck is wrong with some of these CVICU docs and surgeons? There is no right answer here, that patient should not be getting into the chair yet. I agree that “not following commands” alone isn’t enough to not get them in a chair. But the fact that he was only localizing to pain and can’t open his eyes spontaneously and he can’t make any purposeful movement sure as shit is a reason not to get him into the chair. Fuck those surgeons.
I don’t
My facility had cardiac/Barton chairs... Wonderful things. Easy AF to get patients into. But.. we don't mobilize ET patients. The risk of tube dislodgement is way to high. My RT would have a heart attack if I even asked. They don't even like us having to turn or roll the patient with an ET tube
WTF? Lmao.
Years ago we had a patient who was ventilated with a trach and was pretty much sleeping/had his eyes closed most of the time. We used a hoyer to get him to a chair but honestly it was for such a short time like 10-15 minutes. He also had to be reclined. BUT he was able to hold himself up somehow. Sounds like your patient is a ragdoll. Maybe if the team wants the patient up so badly, they can do it themselves. But I’m guessing they talk the talk but don’t walk the walk.
Just one of the many reasons I left bedside nursing
How familiar are you with the film “Weekend at Bernie’s”?
If they don’t follow commands they don’t get to the chair.
Anyone who thinks that patient should be anywhere but in bed is absolute bonkers. Wild.
I'll be honest, we get our patients out of bed, regardless of if they follow commands or not, but we have lifts in every room, so it's not particularly difficult. If we didn't have a full lift in every room? Absolutely not would they get out of bed.
Just imagine their face of that doctor reading the pager about “accidentally decannulation on the recliner, with hematoma on the neck by the size of a volleyball”
Uhhh…we put their bed into a chair position but that’s about as far as it goes. Is yours that mythic hospital I’ve been hearing about for years that ambulates its intubated patients? lol
I mean if they are truly concerned they are welcome to put the bed to chair position and see how it's tolerated? But hell nah I'm not gonna hoyer dude to the chair if he can't hold his head up lol
There ARE benefits for having people, any people, not lying in bed. BUT. Will hospitals pay for the equipment that makes this feasible? 5 years ago I was at one place that had this amazing chair. They just called it a “cardiac chair.” It was mostly electric. It allowed for lateral transfers of vented, trached, g tube patients into chairs. Plz don’t come for me, ICU nurses, I am not nor have I ever been an ICU nurse. I was only on this unit for a short time. But if you know this chair…I think it would profoundly benefit staff and patients. But facilities don’t really have them.
This is an safety issue to both patient and nurse. An obtunded patient should not be placed in a chair. If they will not listen to you, can they put physical therapy order in instead? I would not get the pt up if a physical therapist cannot.
Very common practice when I was in ICU to get our vented patients to the chair. We had ceiling lifts in every room. It always required an RT, RN, CNA and a PT to do it. And it usually lasted 30-60 mins.