Member Spotlight: Team Players in the ICU
August 7, 2020
Nancy Littke, PT
This month Physiotherapy Alberta shines our member spotlight on two physiotherapists who work in critical care in the province. Sara Yeo and Sharon Boitson share a full-time position on the Intensive Care Unit (ICU) at the Foothills Medical Center (FMC) in Calgary. I sat down (virtually) with Sara and Sharon to talk about their experiences as physiotherapists working in a busy ICU.
I was interested in how these members found themselves in this unique practice environment.
Sharon studied at the University of Manitoba. She remembers a one-hour lecture on critical care and thinking to herself “Wow, that sounds intense and scary. I don’t know why anyone would do that.” Little did she know that she would have the opportunity to work in ICU when she followed her heart to Calgary and started providing casual coverage at FMC on the critical care units. She discovered her passion and has been involved in providing physiotherapy to critically ill patients since 2002.
Sara started her journey while she was still studying at the University of Toronto. Two of her small group leaders where physiotherapists working on the St. Michael’s Hospital ICU team, and because of their mentorship and passion for critical care, Sara used her final placement to give ICU a try. She enjoyed it so much that she applied for a job on the ICU/CVICU/CCU team at St. Mike’s and worked there for 2 years before also following her heart to Calgary in 2007 where she immediately joined the ICU team at FMC.
Since 2012 these physiotherapists have shared a full-time position that allows them to continue to provide care in ICU, educate and orient new staff to the program and provide physiotherapy students with experience in this unique area of practice. Both women credit their ongoing love for this area to a strong program for ICU physiotherapists at the FMC, developed over the years by very experienced and passionate colleagues.
A passion realized
I asked Sara and Sharon to reflect on what has driven their passion for Critical Care. Both identified the huge variety in the caseload as a major factor. The FMC ICU treats medical, surgical, neurological, burns and trauma patients so they never know who they might see on any given day. This means there is always a lot to learn.
Multiple literature reviews for presentations, research and committee work have solidified their passionate belief in early mobility and the long-term impacts that ICU rehab can have on patients.
Both physiotherapists identified the tremendous feeling of fulfillment they experience when they help a patient who they thought may never leave the ICU walk off the unit and out of the hospital. They both vividly remember one such patient from early in their FMC careers. It seemed impossible that they could succeed in returning this patient to life outside the ICU. The individual had multiple co-morbidities and had minimal active movement when the physiotherapy team became involved. It initially took multiple people to work with the patient twice each day, but Sara and Sharon clearly remember the day the patient walked to the front desk of the unit, breathing comfortably and independently. This was one of those moments that revealed the impact physiotherapy could have.
The rapidly changing acuity and complexity of the patient population they treat may seem daunting at times but working with a strong team of physiotherapists and other professionals provides the ongoing support and resources needed to make the work less intimidating and ensure that patients are getting the best care available. Although the literature related to the role of physiotherapy and early mobilization in critical care is increasing, there is still not enough to cover all the situations encountered on the unit. The opportunity to consult with colleagues with many years of experience is a key strength of the FMC program.
The role of physiotherapy in the critical care environment
I asked Sara and Sharon to provide Physiotherapy Alberta members with some insight into the role of physiotherapists on a critical care team.
They feel that key roles for physiotherapists on the team are to both learn from and teach other professionals, and to be strong advocates for their patients. Working for up to a month or more with the same patient helps to develop strong therapeutic relationships and provides physiotherapists with unique insight into patient progressions or deteriorations which they can share with other team members who may be less familiar with the patient. This is particularly valuable with patients who cannot communicate easily.
They both discussed how valuable the holistic approach of physiotherapy is and how important it is to keep long term outcomes in mind even while patient survival is the priority. Sometimes physiotherapists may operate quietly in the background and other times they are collaborating with the team or performing intense co-treatments with respiratory therapists, nurses, families, and other rehab staff. Patient presentations range from being unresponsive to being ready for a discharge assessment. Interventions may be screening a newly admitted patient or may involve spending four hours a day providing care for another. This is particularly true for patients admitted with severe pneumonia or a new spinal cord injury. Physiotherapists may also attend rounds and share opinions on whether a patient is ready for extubation or clarify precautions and get clearance to provide treatment for less stable patients.
Ultimately, Sara and Sharon feel the role for physiotherapy in critical care is like a physiotherapist’s role on most units, focusing on early mobilization and strengthening, treating conditions amenable to physiotherapy, discharge planning and looking at long-term quality of life.
What is involved in training physiotherapists to provide care in the ICU?
Most physiotherapists learn on the job from colleagues in ICU and other units including neurology, burns and cardiorespiratory. The FMC has a formal 6-8-week orientation for new team members from all disciplines. Each new professional is buddied with a current therapist as they build their knowledge, comfort, and competence to assume their own caseload. Sara and Sharon help provide classroom sessions to physiotherapists and other health-care professionals at FMC once or twice a year on topics such as lab values, medications, diagnostic imaging, clinical reasoning, ventilators, ICU lines and the numerous populations and pathologies encountered in ICU, to ensure the continuing competence and knowledge of these clinicians.
Over 15 years of working in ICU, Sara and Sharon have come to realize that, although research is growing, there are still many gaps in knowledge and few courses readily available to support physiotherapists working in critical care. For this reason, they have joined the Provincial ICU Working Group to create robust orientation resources for ICU physiotherapists. Treatment decisions are rarely black and white in ICU due to the acuity and complexity of patients. The Working Group feels that one of the biggest challenges for clinicians working in critical care is dealing with a massive amount of information available regarding a patient and learning which pieces of data impact decision making and the risks of proceeding with or holding treatment. They feel it is very important for any physiotherapist to be able to justify why they are/are not performing certain treatments and to be able to discuss this with other professionals. The Working Group’s goal is to provide orientation tools to help physiotherapists working in critical care develop good clinical reasoning skills and feel confident making treatment decisions and consulting with the multidisciplinary teams.
Sara and Sharon believe the intensity of the orientation program and the support and mentoring available at FMC helps ICU physiotherapists build trust with the medical and nursing teams This allows physiotherapists a lot of latitude to make treatment decisions in the FMC ICU. They feel physiotherapists need to be mindful of this responsibility and strive to maintain this trust at all times.
Preparation to meet the needs of a pandemic
When asked about the preparation needed to meet the needs of a potential onslaught of critically ill patients with COVID-19, Sara described the planning that occurred on short notice by the Clinical Leaders and Allied Health management team, as well as the ICU team. This included identifying potential ICU physiotherapy staffing and prioritization needs if the unit goes from its usual 28 single patient rooms to a phase 4 surge capacity of 154 ICU beds in the facility. Unit physiotherapists researched what was known related to COVID 19 effects and impacts, proper PPE use, and the recommended use of proning as a fundamental intervention for COVID-19 patients. Sara collaborated with the ICU Provincial Working Group to ensure consistency around the province.
In the worst-case scenario, there is the potential that ward therapists could be pulled into ICU roles and required to work with more acutely ill patients than they normally would (e.g., proned or on paralytics). Quick refresher orientations were set up provincially for non-ICU physiotherapists, there was a push to link ICU therapists across the province with rural and small hospital physiotherapists to provide mentoring and resources and efforts made to ensure the Provincial Working Group’s ICU online orientation resources are readily available.
To minimize exposure to other acutely ill or immunocompromised patients, the ICU physiotherapy team has limited who sees COVID positive patients to decrease the risk of spread. To keep ICU beds open and readily available, there is a push to get other patients moving even sooner and to minimize their ICU length of stay.
Fortunately, to date the pandemic hasn’t hit FMC’s ICU as hard as it could have. So far, the overall patient numbers have been lower than those normally seen in the ICU, but the acuity of patients has been greater. Sara remembers the day the first patient who needed to be escalated to Extra-Corporeal Membrane Oxygenation (ECMO) due to COVID was transferred to the unit. She recalled feeling a palpable tension as the team awaited the patient’s imminent arrival. Sara felt that this was the main difference noticed in ICU to date – a sense of waiting for the other shoe to drop, and staff not knowing how bad it might get. It is with a great sense of relief that the unit has recently seen a reduction in the number of cases. However, the team continues to be prepared and hopes that Albertans will continue to work together to slow the spread, so ICUs across the province do not face another surge of cases.
Post-ICU rehabilitation and physiotherapy
Improved ICU survival rates in recent years has led to the realization that ICU survivors can have a shocking list of short and long-term side effects, not only physically but cognitively and emotionally, even years after their illness/injury. These side effects are referred to as Post Intensive Care Syndrome (PICS). Complications experienced by patients diagnosed with PICS are similar to those seen in patients with Acute Respiratory Distress Syndrome (ARDS) as both patient populations often require paralytics/heavy sedation while ventilated. These medications have been linked to ICU-acquired weakness (ICU-AW). Many seriously ill COVID patients present with ARDS-like symptoms and are at risk of developing ICU-AW and PICS due to the medications and other treatments required during their ICU stay.
Sara and Sharon identified that the goal while the patient is in the ICU is to reduce preventable complications by reducing secretions/atelectasis and ROM/immobility related complications, and to minimize loss of muscle mass and function. All these factors can impact the risk of the patient experiencing delirium, the discharge destination and the quality of life for patients post ICU admission. Reducing the extent of ICU acquired weakness and PICS also benefits physiotherapists working on medical units or with patients in the post ICU stage, as the patients are stronger and need less help to return to baseline.
Although some patients still leave ICU quite debilitated, Sara and Sharon have noted that the shift towards earlier and more frequent mobilization by all members of the ICU team has resulted in more patients being able to walk loops of the ICU with minimal assistance. They also said that, although there is no firm data to prove patients are leaving the ICU stronger, the team seems to be doing more stair assessments and Berg Balance Scales with patients than in the past.
When questioned further about the ongoing needs of patients experiencing complications related to PICS, Sara responded that this is difficult to describe as there can be many variables to the patient’s presentation. The hope is that these complications can be addressed by the inpatient team either in the ICU or on the medical care unit before discharge home.
Currently, there is little research related to the long-term needs of post-COVID patients following ICU admission but there is a great deal of research on ARDS patients. Sara strongly recommends that community physiotherapists and physiotherapists in sub-acute rehab centers or smaller hospitals utilize the resources found on the CPA or APTA (American Physical Therapy Association) websites to better understand the emerging evidence and develop appropriate treatment plans. The AHS Scientific Advisory Group has also released the COVID-19 Scientific Advisory Group Rapid Evidence Report which details many possible needs of patients post-COVID based on the current literature.
Sara’s hope is that physiotherapists on acute care wards can advocate for transfer to rehabilitation programs when patients are presenting with concerns that physiotherapists can address. At each step she encourages physiotherapists to take a holistic approach to patient assessment and treatment and to refer to other professionals where needed, considering quality of life, and seeking appropriate resources to support patients.