On Monday, RN Jessie Buffenmeyer and myself were talking about wanting to get our long stay patient D outside. D has been hospitalized with us for the last 80 days and before coming here was in a hospital in Montana since the middle of August 2023 with an anoxic brain injury from a severe hypoglycemic event. We have struggled to get to know D and his care preferences due to his expressive aphasia and to manage his intermittent aggressive behaviors throughout his stay. He is in a Posey bed to give him more freedom in his movement and turning safely in bed but usually remains curled up in a tight ball with a pillow over his head and his eyes closed. Jessie and I were commenting on how difficult it must be to have not been outside for such an extended period of time.

Our unit secretary, Janet Fischer, chimed in on the conversation and how nice the weather was that day. We discussed the feasibility of taking him outside due to his unpredictable behaviors and made the decision that an EMS litter was the safest transportation mode to get him outside. Janet called Life Lion and spoke with Laurel Morrison, Supervisor to request an EMS litter to borrow. Janet explained the reasoning for the request and emphasized how much we felt this would improve the patient's care and behaviors. Laurel asked to speak to Jessie, who also gave the reasoning and continued to request the litter. Due to the lack of training on the litter, Life Lion was unable to provide one for us to use.

However, Laurel asked if nursing would be willing to accompany an EMS crew outside if she sent a litter to the unit for the EMS to use, we absolutely agreed.

Jessie and I prepped D for his trip outside when we were notified of their coming to the unit. We did all of his care, dressed him and told him about what was happening. When asked if he wanted to go outside, D nodded yes. When Life Lion arrived to the unit, we were struggling with D with 4 staff members to get a blood sugar check; Jessie and I became nervous to how he would cooperate with leaving on the litter. The Life Lion crew of Jeffrey Gewertz and Derek Selestok brought the litter in, greeting D with positivity and telling him how nice it was outside. D calmed down and was able to be moved over to the litter without incident. D curled up in his usual ball on the trip outside the North Entrance. Once we got outside, D opened his eyes and squinted into the sun. We all commented about the breeze and warmth he was feeling. We rolled him over to the grass and unstrapped him. We asked if he wanted to sit up and put his feet in the grass, D again nodded yes. Jessie and I helped him sit up and he placed his feet in the grass, flexing his toes and feeling the cool grass. He was looking around with his eyes open. He laid back down on the litter and, for the first time in his 80-day admission, stretched his legs out and lay relaxed with his arms gently resting on his chest, flexing his toes. Tears rolled down D's face as he lay outside with us. We allowed him to lie and be in the sun for about 15 minutes before taking him back inside. On the walk in, we asked D if he wanted to go back outside another day, D again nodded yes. Jeff and Derek asked Jessie and I if we were working on Tuesday because they were back and would be willing to come do this again; all of us commenting how emotional we were seeing the change in D and how much this meant to him.

While we were out of the room, Janet ordered a new, clean Posey bed and arranged with housekeeping to deep clean his room and mop the floor. We returned D to his room and told him we would take him outside again.

On Tuesday, PT and OT came to work with D in the morning. D stood with PT and OT, for the first time in 55 days. PT and OT attempts since then have resulted in D being aggressive or unwilling to participate. His primary RN for that day was Lindsey Mellott. I spoke with Lindsey in the morning to discuss his outdoor trip the day before and asked if she would be willing to take him out again, she happily agreed. During his care at 1100, I asked D if he wanted to go back outside again today, he nodded yes but this time began to sob cry and curl into a ball while shaking his head yes. I called the dispatch center and again spoke with Laurel who stated they were currently busy with 9-1-1 calls but "knows the crew from yesterday is more than willing to come back if they are able to between calls for their special assignment". Laurel called back in an hour and let us know Jeff and Derek were on their way up. Lindsey was checking D's blood sugar prior to their arrival, which usually is a struggle because he hates finger sticks and occasionally results in needing multiple staff to assist along with security. Security was in the hallway but Lindsey told D the litter was coming to take him outside and he willingly gave a finger to be pricked for his blood sugar. Jeff and Derek arrived, we easily moved D over to the litter for his trip outside. Lindsey brought nail files and an electric trimmer with us in case D would be willing to let us provide some care to him outside. Our Capstone student Avery Barley; who will be joining the unit as a GN in July and was our Extern last summer; came with us. Once outside, D again agreed to sit and put his feet in the grass. He was wearing socks due to working with therapy, so as I removed the socks, I told Jeff and Derek that he stood with therapy today for the first time in 50 plus days. Jeff and Derek both praised D and D shook his head yes that he stood. He sat again and flexed his toes in the grass. D's fingernails were about 2 inches long and very dirty and a safety risk. I attempted to file his nails but due to the length and dirt, were unable to make any progress on the length. Jeff gave me clippers and I asked D's permission to trim his nails, D nodded yes. D laid back on the litter, again with his legs straight and relaxed while he let me cut all of his nails. Taking the chance, I asked him if he would let us shave his unkempt face, D nodded yes. Avery took great time and care to shave his face and neck and leave him with a nice goatee. Lindsey asked D if he wanted to see a picture of himself to see how he looked, D nodded yes in agreement and Lindsey took a (secure) TigerText picture to show him. In the picture, D is sitting up and smiling as he can. I used the trimmer to cut the long, matted hair at the back of his neck the best I could. Due to the long, matted nature of his hair, I am exploring the options for bringing a Barber to the hospital to give him a professional haircut due to D nodding yes that he always had short, shaped hair. We kept D outside for about 30 minutes before returning him to the unit, clean shaven and looking like a new person. Again, when we were outside, Jeff and Derek were engaging with D, encouraging him to follow their voices to look in different directions, sit up, and flex his toes. On our way back in, D said (what we all believe to have heard) "thanks". In his 80 days as a patient, I have only heard 2-3 sounds when interacting with staff.

I plan to continue to take D outside and incorporate therapy services in our trips to see how his participation changes or improves. This is a wonderful example of teamwork and going above and beyond for a patient; being outside is something we all take for granted, and we all believe this has a possibility of improving D's care plan and participation.