Intubated Pt's Using Bedside Comodes

[EDrunnerRN]

Ok...a few days ago an ICU nurse, at my facility, stated that stable intubated patients on the Unit use bedside comodes. My first thought was you are joking, right?! No, she was serious! I don't pretend to be an ICU nurse or know the aspects of care that pertain to ICU nursing but in the ER I would NEVER place an intubated pt on a bedside comode for obvious reasons, they are not stable. Can any ICU nurses out there back up her statement? For some odd reason, I keep picturing an intubated patient on a bedside comode and find it HILARIOUS! I think I need to see this to believe it!!

[Biffbradford]

I agree. If they are strong enough to walk, but just cannot be weaned from the vent (paralyzed hemi-diaphram or whatever) - trach 'em!

[GreyGull]

Trauma centers with TBIs, SCIs and extensive facial injuries are very, very different and you know they will need a lengthy rehab and a trach to manage secretions. These patients are appropriate for a trach in 7 days or even during their first day in the hospital if they are in the OR. However, not every patient with a paralyzed hemi-diaphram needs a trach.

I can not imagine what the LTC facilities or the acute hospitals would be like if we trached every COPD, sepsis and ARDS patient. We've got too many patients now waiting for beds in the subacutes and SNFs. We feel lucky to have the ability to put an aggressive plan in place for some patients. I think the patients feel that way also. Sometimes the success of the patients depend on a "can do" attitude and a multidisciplinary effort.

But then, this is nothing new and it has been done for at least the 40 years I've been around the ICUs.

I'm not trying to being argumentative but showing there are other ways out there to get a patient on their feet again. We have the technology and the professionals who specialize in this so we might as well make good use of them if there is a benefit for the patient. Of course, not every patient will be a candidate for this. Just because you've never seen it might just mean your unit might have a different concept of success and a save or they have an adequate step down unit for all the trachs and vents.

[littleneoRN]

Trying to picture being awake enough to walk and not grossly uncomfortable and freaking out about being intubated. :)

[GreyGull]

Trying to picture being awake enough to walk and not grossly uncomfortable and freaking out about being intubated. :)

Do you keep all of your patients totally snowed and do no sedation vacations, weaning protocols (meds and vent), neuro checks, orientation etc? On modern ventilators, many patients are comfortable enough to not require much sedation once the initial event is over and they have stabilized. Even if trached, a patient can not go to a subacute on Propofol. The patient's comfort level and weaning success are proportional to the expertise of the care providers at the bedside.

[littleneoRN]

Well, I work in the NICU, so it's all different. Our patients receive fairly small amounts of sedation while ventilated, but they aren't up at the commode either. :) We RARELY use drips for sedation. A little prn Ativan, Fentanyl, Morphine, Versed...that's about it. Some kids have no sedation at all. I don't do adult ICU, so I'm not an expert there. But being awake enough be to oriented isn't the same as awake enough to be upright and walking... I was kind of just joking though...because my imagination of what it feels like to have a tube in my throat isn't very...good...

[ErinS, BSN, RN]

In my hospital system it is an EXPECTATION that pt's in the ICU that are recovering get up to the chair and ambulate as soon as possible. This is based on best practice. Our ICU's are also well staffed- 1 to 2 pt's per nurse with many RTs, CNAs, and PTs available for support. Intubation does not provide an exception to the rule. This has really decreased length of stay and improved outcomes. It may be a pain in the a$$ to ambulate a ventilated pt, but worth it when they walk back into the ICU in a few months fully recovered thanks to your hard work.

[NickiLaughs, ADN, BSN, RN]

I think it's fantastic. I've never had the opportunity to have a stable enough pt on a vent to do it, or seen it, but I would love to.

[tryingtohaveitall]

In my 21 years in the PICU, I have seen us do this once with a very stable CF patient who was doing a slow wean.

[ICURN2011]

We have a few chronic vent patients in our ICU and they sit on chairs-so a bedside commode could be a possibility. We are starting a new initiative to mobilize these patients sooner to prevent complications (pressure sores, muscle deconditioning etc)

[ChicagoICUNurse]

Are we talking orally intubated patient? It seems a little interested to me. I have used a cardiac chair for a "stable" orally intubated ICU patient on several occasions.

I must admit that I didn't read all the thread responses, but one thing pops into my mind regarding the airway. So if the patients extubates themself on the commode, what's the plan to handle that situation?? Then again, I work in neuro ICU and these patients are tubed for a reason.

[GreyGull]

Are we talking orally intubated patient? It seems a little interested to me. I have used a cardiac chair for a "stable" orally intubated ICU patient on several occasions.

I must admit that I didn't read all the thread responses, but one thing pops into my mind regarding the airway. So if the patients extubates themself on the commode, what's the plan to handle that situation?? Then again, I work in neuro ICU and these patients are tubed for a reason.

This truly is nothing that new and has been around for over 30 years that I've been in the ICUs. Commonsense should tell you this is not going to be practical to walk a patient who is immobile due to a TBI or CVA. Those patients may be trached and go to a subacute until they can go to an Acute rehab (if possible) where they may or may not walk again. Very, very different scenario than from a COPD exacerbation or ARDS recovery. This also is not something where a patient just graps his EVD and ventilator and trots over to the toilet. It takes a team effort with all disciplines. Sometimes just having a patient be weight bearing for a few seconds during that move to the cardiac chair can make a big difference in strengthening.

Of course you must be comfortable with airways and know how to test for security. I don't trust all the new commercial holders which we use in neuro ICU so there is nothing tight around the neck. I prefer over the ear with old fashioned tape the same as we did over 30 years ago without problems for moving patients. The patient must also be able to cooperate enough to where they are no longer in restraints and can understand the words "don't pull it out". These patients are also not on sedation or paralytics or HFOV to where if they did lose the tube, there is time to calmly get the patient back to bed or even give them a trial off the ventilator while the RRT and RN stands by to re-intubate if necessary. If you panic, the patient panics and increases their work of breathing. I recommend this only be done in an ICU with experienced and confident health care providers who can convey that confidence to the patient.

I sometimes find it safer than some of the scary moves on IFT ambulances or to CT Scan with 2 trees of pumps, a couple of chest tubes, a ventilator and a patient that just barely meets the size requirements for the sled.

I posted this link earlier.

UCSF

http://www.ucsfcme.com/2011/slides/MAN11002/32%20EngelEarly%20Mobilization.pdf

Johns Hopkins

http://www.hopkinsmedicine.org/dome/0711/top_story.cfm

Indepth detail and more references.

http://www.medscape.com/viewarticle/704498

[ChicagoICUNurse]

@GreyGull--thanks for the links!

I agree about the tube holders, too.