I am a nurse leader responsible for improving practices across the intensive care units of a large health system. As an experienced ICU nurse, I know the culture that most often exists in ICUs is one that promotes and accepts over-sedation that often causes unintended harm. While reviewing the literature to better align our liberation practices with the best evidence, one of our bedside nurses discovered Walking Home From The ICU. The combination of poignant stories from ICU survivors with the expertise of some of ICU Liberation’s leading experts became the impetus for a system-wide evidence-based practice improvement project aimed at changing analgesia and sedation management in our ICUs.
After initially being inspired by Kali’s podcast and the incredible stories it provides, we saw an opportunity for more. We brought Kali in to present a webinar to almost 100 of our critical care team members, including nurses, APPs, physicians, and respiratory therapists. Kali’s presentation struck a needed balance between evidence-based practice information and inspiring stories, highlighting real patients who benefited from a practice that is often very different from what occurs in most ICUs today. The webinar was very well-received by all who attended, and the lessons learned have continued to be referenced by our team members as we strive to create an Awake and Walking ICU culture.
Kali offers a refreshing perspective on critical care, and she supports it with a wealth of knowledge garnered from years as a bedside nurse and advanced practice provider. Kali knows how to speak to clinicians because she is one, and she’s still very connected to the daily lived experiences of those on the frontline of critical care. I believe anyone working in critical care will find inspiration in Walking Home From The ICU to change the harmful culture of sedation in their practice. I would even go so far as to recommend the podcast as required listening for all ICU team members, whether experienced clinicians or new residents and nurses. When additional support is needed, I encourage clinical leaders to utilize Kali’s expertise and experiences to further inspire and motivate their teams. Time spent working with Kali is an investment that will pay dividends in the positive impact it has on the lives of the patients we serve.
Patrick Bradley, MSN, RN, CCRN
Virginia, USA
When patients are so ill that they require a ventilator in the ICU, the antiquated approach of heavy sedation and immobilization should be avoided in order to help prevent the immense burden of physical and cognitive disabilities suffered during survival. To understand this better, listen to Walking Home From The ICU. You will see what ICU consultant Kali Dayton provides to your team.
Her training will catalyze changes in your practice to improve outcomes, decrease costs, and allow your patients to return to their full lives. Learn to love your job again as you embrace whole person care instead of caring for inert sedated bodies. Kali is leading ICU teams to become Awake and Walking ICUs through true mastery of the ABCDEF Bundle.
I endorse her mission and look forward to the standardization of this evidence-based approach in ICUs all over the world.
Dr. Wes Ely, author of "Every Deep Drawn Breath," leading founder of the ABCDEF Bundle and ICU CAM delirium screening tool, and Professor of Medicine in the Division of Allergy, Pulmonary, and Critical Care Medicine at Vanderbilt University Medical Center
The service Dayton ICU Consulting provided was exceptional and above expectations.
As an ICU medical director, I have had to unlearn what has been taught to us over the years and what we thought was right. When I started listening to Kali’s Walking Home From The ICU podcast, I felt profound sadness and guilt for what we have done to other human beings while thinking what we’re doing is right.
I have changed my practice and we had Dayton ICU Consulting at our hospital in each of our intensive care units for multiple sessions. It was eye-opening for the staff, especially the bedside RNs.
We have developed significant momentum, especially in our surgical and trauma ICUs where staff that were nonbelievers are now champions of this movement. We have even done videos of patients’ experiences and plan to use them as education for new hires.
I am very excited about where we have come from and expect great things, and I cannot thank Kali Dayton and our staff enough for helping us improve ICU care and experiences for our patients.
Lawrence Bistrong, MD, FCCP
As an RN in the Medical-Surgical ICU at the hospital I work at, I began my interest in ICU Liberation through an Evidence-Based Practice project.
While I was initially grabbed by what the literature has to say about over-sedation and patient outcomes, it wasn’t until I discovered Kali’s Walking Home From The ICU podcast that a culture of sedationless ICU care sounded tangible. The group I worked with on the project was both inspired, devastated, and intrigued by the stories Kali illuminates on the podcast, and we were able to bring her to our hospital for a virtual Zoom Webinar, where she presented on the practices in the Awake and Walking ICU.
This webinar was an incredible way to draw attention toward this necessary culture shift as Kali shared stories of patients awake and mobile in the ICU despite the complexity of their illness. The webinar inspired our final draft for the new practice guideline on analgesia and sedation management in the ICU, and since then we have seen intubated COVID patients playing tic tac toe on the door with staff members on the other side, taking laps around the unit, performing their own oral care using a hand mirror, and most importantly, keeping their autonomy and integrity while fighting to leave the ICU to resume the life they had before coming in.
While no change is instant, the webinar was a necessary catalyst for changing the culture at our hospital system, and because of it we are seeing improvements in our practices and culture every day.
Nora Raher, BSN, RN, MSICU
Virginia, USA
I stumbled upon Kali’s podcast midway through my anesthesia critical care fellowship in February 2021. At our institution, I got the impression that patients in the ICU either got better on their own or had a prolonged and complicated course to LTAC or death. In her podcast, Kali explained that LTAC was rarely the outcome for patients in the Awake and Walking ICU in Salt Lake City.
Their ICU survivors hardly ever got trached, PEGed, or sent to LTAC, and literally walked out of the hospital in condition as close to their previous health as they could be. Although the concept of using no sedation on ventilated patients was completely foreign to me, it made sense based on what I had read in the literature. I devoured all of the episodes from the beginning, many of them bringing tears and regret for my ignorance, followed by inspiration and hope in later episodes. Listening to her podcast has been one of the most profound experiences in my short, eight-year career in medicine.
After discovering the no sedation, early mobility practice at the Awake and Walking ICU, my focus shifted to bringing it to my own institution. I visited Salt Lake City in March to witness it with my own eyes. Since then, I’ve been in touch closely with Kali and Louise to learn the practical approaches to sedation wean and sedation avoidance for newly intubated patients in the ICU.
Implementation has been challenged by pushback at the bedside, but knowing how most patients can be off sedation and comfortable allowed me to advocate for the patients. So far, four patients were successfully kept off of sedation after getting intubated, and two of them immediately smiled at me as they woke up from induction meds. Kali and the members of the Awake and Walking ICU have decades of experience in this approach.
Some institutions such as Johns Hopkins have implemented this as their hospital-wide QI project. If you are interested in improving patients’ lives beyond survival, I highly recommend listening to the podcast and reaching out to Kali for further guidance. If this concept is new to you, as it was for me, it will broaden your perspectives in taking care of your ICU patients, and perhaps renew the sense of purpose in your everyday practice.
Mikita Fuchita, MD
Colorado, USA
Dayton ICU Consulting team came to our unit for 4 days, and they did in-person training for over 100 staff members, and spoke with many on our Leadership team. The transformation of the staff after the consulting team was remarkable.
The consulting team pushed us to look outside of our comfort zone in a way that someone from within our team could not achieve. They have firsthand knowledge of what to do, and how to do it and they walked side by side with us while they showing us how to do it. Many of the staff who were very ambivalent prior to the in-person training are now the biggest advocate of implementing the change.
Kali and her team have the knowledge and the skills to help make change happen.
Roni Kelsey, BSN, ICU Liberation Leader, PeaceHealth
Bellingham, WA
Before Kali, our hospital struggled with overly-sedated patients and lack of early mobility. Despite multiple efforts to change the culture, we were at a standstill. In one hour, Kali was able to ignite a flurry of conversations regarding her experience with the Awake and Walking ICU and this immediately led to a change in clinical practice.
Patients with less sedation and other neurotoxic medications are spending fewer days on the ventilator. If you are considering starting an ICU early mobility program at your hospital, your first step needs to be to consult with Kali and absorb as much information as you can!
Matthew McClain, DPT
Florida, USA
Kali Dayton’s consultancy energized our ICU to adopt the very latest evidence-based therapies to identify, prevent, and treat delirium with the ultimate goal being to eliminate preventable delirium by leveraging lessons shared by Kali to get our ICU patients awake, mobile, and walking.
The advice and tier-one support by Dayton ICU Consulting is a critical component of any ICU leader who wants to do better and make the greatest impact possible for patients so that they survive the ICU and go home to continue their livelihoods free of post-intensive care syndrome or PTSD.
Kali offers a powerful vector to ensure ICU care is state of the art.
Brian Delmonaco, MD, FACEP, Medical Director, Pulmonology and Critical Care Medicine, Samaritan Health Services
Over the last few years I have become aware of the PICS (post-intensive care syndrome) condition and the very serious negative impact that it has on our ICU survivors. I have become much more aware of the potential negative impact of anxiety, depression, PTSD and cognitive dysfunction. Many patients whom we consider saves in the sense they leave the ICU alive have many issues that most people would consider far from a successful experience. Their lives are often dramatically changed in a very negative fashion.
I am a professor of medicine and have been an ICU director for over forty years. What I find very disturbing in my own experience and that of many other intensivists is that this outcome is generally considered acceptable; the patient survived and will get better with time. We have little access to these patients and almost zero information about their condition unless they are unfortunate enough to return to our ICUs. Very few of us have a PICS clinic where we would have a chance to better understand the challenges that some of our patients encounter, and there are very few systems in place to provide feedback to us as ICU clinicians. Therefore, we are blissfully ignorant of the many challenges that a substantial number of our survivors encounter. This is a major problem. The vast majority of ICU survivors and their families will experience cognitive, emotional and physical symptoms which often have devastating impacts on their lives. At this time, with PICS clinics being a rarity, there is no reasonable mechanism for intensivists to have a solid perspective on the frequency and severity of this condition.
How patients and their families are treated in the ICU often has a major impact on how the patient and families survive post discharge. It is generally agreed that most sedation infusions, particularly benzodiazepines, frequently have higher incidences of delirium and post-discharge dysfunction. There are a few hospitals in this country where sedative infusions are rarely used and the incidence of the complications described above are dramatically decreased. I have visited one of these hospitals and was amazed to see how effectively patients on maximum ventilator support can be managed, even walking without sedative infusions. In an effort to explore this treatment option in greater detail I have identified Kali Dayton. She is a nurse practitioner who has practiced in this Awake and Walking ICU for many years and is an amazing source of information on this topic. After extensive discussion with many colleagues, administration and many others, and reviewing the major potential benefits of the program for our patients, we have decided to introduce this program into our hospital.
As you would anticipate, this is a major culture shock for all ICU providers at all levels, including physicians, nurses, physical therapists, and respiratory therapists. We have reached out to Kali Dayton to help with the educational process and provide amazing information for all of the ICU providers, particularly our nurses who clearly anticipate that this program will result in a major culture change. Kali presented a series of webinars which have been fantastic to bring all providers up to a high level of understanding, and to demonstrate that this process is not nearly as challenging as most people initially anticipated.
Since Kali has experienced the Awake and Walking ICU for many years, she is an invaluable source of information and encouragement to all levels of providers who have appropriate concerns as to how challenging this might be. Our clinicians, particularly the nurses, as well as respiratory and physical therapists, have been very impressed with the webinars. This program involves a steep learning curve and culture shock for most providers, as it is counterintuitive and not consistent with the experience of most ICU providers. However, the harm that we have unknowingly caused our patients demands that we must ask ourselves, ‘Is this the best we can do?’
The Mayo Clinic recently reported that the mechanical order set no longer includes mandatory use of sedative medications. Light sedation with a goal of an RASS score of 0 to -2 is the goal. Without any reservation, I heartily recommend the assistance of Kali Dayton if you are interested in exploring this radically new approach to ICU patient care. This program is a major challenge at many levels. Having someone on your side who has walked the walk, to help in the training of all your staff is an amazing benefit.
I am confident that just like at the Mayo Clinic, the Awake and Walking ICU will be standard practice in the next two to five years. At a very selfish level, there is a high probability that all of us will spend some time in the ICU. I suspect we would strongly demand that the care we or our families receive be at the cutting edge, particularly as it relates to decreasing post-discharge cognitive dysfunction, in addition to anxiety, depression and PTSD. I wish you every success as you try to upgrade the quality of ICU care in your community.
Peter J. Murphy, MD, FCCP, MRCPI, BSc
The Walking Home From The ICU podcast has been transformational in helping to change the culture in the small community ICU where I work. I am an occupational therapist and have wanted to implement early mobility in our facility for several years now. It wasn’t until I started listening to this podcast that this “want” became more than that. It became a “must.”
The podcast has made it so easy to share the passion I have gained. The stories of the patients and the knowledge of practitioners sharing their clinical practice advice are so valuable.
Kali Dayton has shared with our team her knowledge through a video format as well. She was able to answer nursing related questions that I, as an OT, haven’t been able to answer. She is professional and willing to share her knowledge and passion in order to make changes in the ICU community around the world.
She is inspiring and gives me the courage to keep pressing on to make these best practices a reality in my community.
Kristie Porter, OT
Arizona, USA
