SUBSCRIBE TO THE PODCAST

Episode Transcription

[00:00:00] This is the Walking Home from the ICU podcast. I’m Kali Dayton, a nurse practitioner and ICU consultant. I help teams create awake and walking ICUs through evidence-based sedation and mobility practices. By hearing from survivors, clinicians, and researchers, we’ll explore how to give ICU patients the best chance to walk out of the ICU and go home to survive and thrive.

Welcome to the ICU revolution.[00:01:00] 

All right. Let’s talk about awake and walking ICUs. But what’s in it for nurses? Throughout this podcast, we have primarily explored the research and testimonials on how automatic sedation and immobility causes life-threatening and life-altering damage to patients. Yet, there is this persistent perception of, well, sedation’s easier and safer for nurses, as if to say that sedation and immobility are better for the nurses.

But is that true? Is that the reality? We know from the research that delirium is one of the largest psychological burdens for nurses, in addition to the moral injury from terminal care that directly relates to patients being stripped of their autonomy when sedated. Yet, I don’t think nurses have been allowed to really dissect and explore the reality and personal price of these normal practices they’ve been born into and that have been [00:02:00] unquestioned.

So I wanted to learn directly from them, nurses who weren’t necessarily already podcast listeners and revolutionists, nurses working in pretty normal ICUs with the traditional sedation and immobility culture. In an AACN symposium, I asked them questions and received their anonymous responses via their cell phones during the presentation that was actually more like group therapy.

About four different hospitals were represented in the group of participants. Here’s what I asked, and here is what they shared First question. What are the challenges in caring for patients with hyperactive delirium? Their responses? Pulling out lines needing to be replaced, missing meds. Our other patient safety, time, difficult to manage, exhaustion, safety, and safety What are your instinctive feelings when you receive a patient with hyperactive delirium?

Their [00:03:00] answers: harder to give best care, dread, frustration, anxiety, eye roll, stress. Who carries the burden of managing hyperactive delirium on your unit? The patients, other patients, family, sitters, everyone, nurses, everyone, nurse, nursing. What is in your toolbox to manage patients with hyperactive delirium?

Mobilizing, appropriate alarm parameters, meds, no naps, lights on in the daytime, try to manage sleep-wake cycles, look for what’s causing delirium, low sodium, patient’s family if around or willing to help, physically holding patients, redirection, palliative consultation, sitters to help reorient, prosthetics, and my favorite answer, more delirium-inducing strategies.

Is hypoactive delirium easier to manage? [00:04:00] Their responses: harder to extubate, makes my job feel pointless, easier than hyperactive, yes, many times under-recognized, yes, turn, water, feed. We don’t know how to manage it. How many people does it take to turn or boost a two hundred-plus-pound patient? Depends on how they are positioned in their sling, how wiggly they are.

There’s always poop. How many lines, drains, poop? Two with lift, two, two to three, two with an AirTap, two, two, three, two. What percentage of intubated patients can turn or boost themselves? One hundred percent of participants answered zero to twenty-five percent. When I asked them by raise of hands if in their unit the answer was closer to zero than twenty-five percent, everyone raised their hands.

Next question: What kind of outcomes do patients with delirium have? Their answers: neglect, suicidal [00:05:00] ideation, PTSD, longer total hospital course, not something the patients would agree to if they were properly educated beforehand, brain fog at discharge, confusion and time loss, extended stays, longer length of stay.

How do these outcomes impact you as a nurse? I disrupt my stretch on purpose, one on, one off, so you don’t have the same patients. You can do anything when it’s only one shift. I wouldn’t tolerate it if it was my family. Makes me forever want to be a DNR. Bothers me because I know we contributed to it by not implementing strategies to avoid it in the first place.

Burnout, jaded, anger, opposite of fulfillment, tired, decreased job satisfaction, existentialism. Who makes decisions for the patient when they have delirium? It feels like nurses’ hands are tied to make necessary changes. Doctors. Not enough nurses. Too much without proper [00:06:00] training and medical education, without time and resources.

Survival mode. The DPC team. The team, hopefully. How does this impact you as a nurse when your patients cannot make their own decisions? Just another Tuesday. I appreciate it when doctors are aggressive in discontinuing delirium-inducing orders and educating in rounds about it rather than focusing on the dis- disease process alone.

Uncomfortable. Poor patient education causes poor patient outcomes. Moral injury. Absolutely. Families want things without understanding the repercussions How does self-extubation impact you? Chronic stress leading to my own health issues. Feel fault. Guilt for having to unnecessarily restrain. Next patient gets tighter restraints.

Treated like we failed by leadership. Imposter syndrome amplified. Panic. Feel like you failed. I take it as a personal failure. More paperwork. Take it personally. [00:07:00] Do you get in trouble if your patient self-extubates? I’m my own worst critic. You feel bad about yourself that it happened. In trouble with my own standards and mental peace.

Made fun of. Fired once for a self-extubation. Situationally dependent, but not typically. Just a side eye. You get shamed. No and no. In what ways does delirium increase your workload? Busy shift, less breaks. In the delirium patient’s room longer. Heavy. Makes patient seem like they should be one-to-one, unintentionally takes priority over sicker patient.

Longer ICU stay. Stress out nurses. Difficult to manage full assignment. Other issues more likely to be neglected. Kills staff retention. Keeps me from the other patient. It decreases my work quality. How does ICU-acquired weakness increase your workload? Difficult to extubate, skin breakdown, increased work-related injury, need more [00:08:00] help/equipment to mobilize, full care patient, more physical stress on my body.

How does ICU-acquired weakness impact your team’s resources and dynamics? Higher risk of physical injury for caregivers. Laziness because we can’t keep up, so we give up. Survival mode becomes culture. Takes up more resources. More muscle necessary, less ability to care for others. Strain on resources and time.

Strains the system. How easy is it for patients with delirium and/or ICU-acquired weakness to communicate? Scribbles. Not. Lol. With proper tools, maybe not as hard as we think. How does this impact you as a nurse when your patients cannot communicate? Did we give them a fair chance to write/spell/point before we wrote them off?

Increases patient anxiety. Impatient. I give up. Cannot communicate. Frustration for both parties. Frustrated What are the risks of [00:09:00] unplanned extubation for patients with ICU-acquired weakness? Maybe they didn’t need the tube anymore. Maybe it’s good they self-extubated. Doctor hates you and your reputation is destroyed.

Airway decompensation, death, and DC to JC. How much do you love awakening trials for extubation then? I can’t tell if it’s how I weaned the sedation or something else that caused them failed SAT. Satisfying. It is an art, but not everyone is an artist. Butt pucker. It’s necessary. 10 out of 10. I love it.

Always sweating a little. Zero out of 10. Do you administer gravity as a standard part of your shift? 100% answered no. When does the mobility usually happen on your unit? 38% said after extubation, 38% said close to extubation, 25% said we wait for PT and OT. What is it like to [00:10:00] mobilize a patient after days to weeks in the ICU and in bed?

Astronaut who never got to go to space. Not sure. They’re in an LTAC by then. So much weakness. Floppy fish. Unpredictable. More challenging for all involved. Dangerous. Sling them up. Does your team initiate the ABCDEF bundle for prehabilitation or rehabilitation? 17% said prehabilitation, 83% said rehabilitation.

Then I shared a real case study with a patient who weighed six hundred and fifty pounds upon arrival to the ICU who was intubated, and I asked the participants, “How will caring for Dan impact your ICU team?” They answered, “You already know it will take more help to do turns and cleans. We need more support with turning and cleaning.

Takes a team, and hopefully everyone has a little extra time. More than two people to do [00:11:00] almost anything. Inappropriate jokes about Dan at the nurse’s station. Lift team to help with turns. Heavy care.” What kind of risks and outcomes do you assume will occur in Dan’s course? Doctors will neglect Dan also.

He will need respiratory support. My back. His quality of life is done for. Everything will be a challenge and Murphy’s Law will rule. The newer nurse will be assigned to Dan because he’s, quote, “lower acuity, pressure injury.” What comes to mind when you hear the word delirium? Hyper/hypo. Restraints. Incident reports.

Socially acceptable unethical torture. Under-recognized. Procidex. Stress. Violent and violence. Have you ever been assaulted by a patient? 100% of participants said yes. In those events, was the patient or patients [00:12:00] clear-minded without delirium? 11% said yes, 89% said no

If you’ve been listening to this podcast, you’re likely convinced that sedation and mobility practices in the ICU need to change. The ICU community is facing incredible difficulty with the trauma from the pandemic, staffing crisis, and burnout. We cannot afford to continue practices that result in poor patient outcomes, more time in the ICU, higher healthcare costs, and greater workload for the ICU team.

Yet the prospect of changing decades of beliefs, practices, and culture across all disciplines of the ICU is a daunting task. How does this transformation start? It can begin with a consultation with me to discuss your team’s current practices, barriers, and to formulate a plan to help your ICU become an awake and walking ICU.

I help teams master the ABCDEF bundle through education, [00:13:00] consulting, simulation training, and bedside support. Let’s work together to move your team into the future of evidence-based ICU care. Click the link in the show notes of this episode to find out more.

These answers share a totally different story than our sedation memes and especially decisions at the bedside. We are all impacted by this myth in our own scope of the revolution, and in many ways, it is totally understandable why the majority of ICU clinicians feel that sedation is easier. Patients don’t move.

They don’t use the call light. They don’t resist treatments, et cetera. Yet there is a lot of additional harm and burden happening to nurses that looms over our community as an invisible ball and chain. Yet the familiarity makes it [00:14:00] invisible. Here’s an example from a team I trained. I asked them for a few case studies of normal intubated patients that are so routine and normal that no one on the team would find questionable or significant I then dissected their journeys and the impact of their sedation, delirium, and mobility management on the patient outcomes and even staff workload.

Here is one of the examples. Diane was a 54-year-old patient with a history of methamphetamine use. She was 103 pounds at baseline, washed marijuana for work, and lived in a trailer with friends. She arrived to the ED with hypoxia and shortness of breath and was a RASS of +1 and requested to be intubated.

She was intubated for sepsis and pneumonia, and when she rolled into the ICU, she was already sedated on propofol 30 and fentanyl 75 and on a little bit of norepinephrine and vasopressin. She was on a PEEP of 10 and FiO2 of 50% on the ventilator. Her RASS was documented as a negative 2, but she was not taking any spontaneous breaths.

She should have had [00:15:00] sedation off upon arrival to the ICU, given tools to communicate, and walking around on day one. Instead, she remained sedated with no questions asked. On day two, she was on a PEEP of 8 and 50% with levophed and vasopressin drips very minimal and perhaps only still running because of the propofol that probably didn’t even need to be running.

She should have been extubated, walking and preparing for transfer to the floor that afternoon or the next day. Instead, she did not receive an SAT, probably because of the vasopressors excluding her from an SBT and the perception that there was no need to do an SAT so soon after intubation and when she’s not ready for SBT.

Yet the screen on the charting looked compliant. Yay for a good dashboard, right? On day three, they do an SAT, and she emerges with a RASS of +1, and sedation is resumed, and an SBT is failed. And this continues daily until she gets a ventilator-associated pneumonia on day seven [00:16:00] and finally gets extubated on day 10.

And now she is super weak and has hyperactive delirium, so they keep Precedex going with Haldol PRN doses. She doesn’t get on her feet until day 12 and then discharges herself home on day 13 with severe cognitive impairments, stage III pressure injury, and barely able to use a walker. So obviously, this was a devastating journey for Diane, but what about the nurses?

We could say that they kept her sedated for their own convenience. But how convenient was this? Just because tasks like oral care, turning, boosting, restraints, grabbing, double-checking, hanging, and documenting propofol and fentanyl, emptying the Foley, et cetera, are familiar, comfortable, and absolute muscle memory for nurses does not mean that this isn’t still work with a silent impact chiseling away at their souls.

Sedation is seen as the easy quick fix, but it [00:17:00] doesn’t look that way when we zoom out right here. For example, the PRN Versed pushes on her MAR led to grand 24-hour totals ranging from 8 milligrams to 32 milligrams in 24 hours. When her meth nap wore off and her delirium raged before she was too weak to fight, she received 32 milligrams of 2 milligram pushes.

That means that between two nurses, the Pyxis was accessed, Versed was grabbed, scanned, drawn up, and given 16 times in 24 hours In this podcast, we say the quiet things out loud. There is a burden of being the dump station of the health system and society as a whole. When the housing crisis, food scarcity, poverty, and the drug problems rage in an area, the ICU gets blasted with the worst of it.

I’m constantly told, “We can’t do this here. We have polysubstance abusers.” But from my experience, [00:18:00] that makes it even more important to have a strong system to prevent and treat delirium to minimize the rate, severity, and duration of delirium in patients just like Diane that come to us with so many risk factors, like that drug use, baseline psychopathologies, poor coping mechanisms, trauma, poor family support, malnutrition, poor access to supportive post-ICU care, et cetera.

But even for the team themselves, when these patients develop delirium and ICU-acquired weakness, it becomes everyone’s problem. It has been so fulfilling for me to follow up on these exact teams who were suffering from this population and to hear them say, “Of course, they’re still here. They still come to us, but they don’t get as bad.

They’re not as dangerous, hard, or stressful to manage, and they don’t stay nearly as long.” She should’ve been extubated day two had she been promptly awake and mobile. Maybe she wouldn’t have even developed delirium. But if she had, it would’ve been so much easier [00:19:00] to mobilize her out of it while she could still move her own body early on.

Then she would’ve been out of the ICU and unlikely to return. Instead, here is my estimated total of extra time, staff, and workload just for the nurses in Diane’s journey under the convenience of sedation and immobility. They did 42 extra oral cares, 84 extra turns, 168 extra hourly documentation of vital signs, 84 extra restraint assessments and documentations, 70 extra PRN suctioning about 10 times per f- 24 hours, seven extra baths, 42 extra PRN reposition and boosting, 14 full assessment and documentations, 18 extra propofol bottle changes, 14.8 extra fentanyl bag changes, 84 extra RASS documentations, double-checking controlled [00:20:00] substances.

And four extra SATs. It sounds insane when we write it out on paper, right? Yet this is a display of human nature. For example, I have a six, almost seven-year-old in a wheelchair. We have been lifting her 54-pound body into her complicated medical car seat and breaking down her 60-pound wheelchair to stow in the back of our car for many years.

It’s routine, muscle memory, et cetera, but is it convenient? Is it safe for our bodies? Is it sustainable? We were blessed to get a wheelchair van with a slick ramp that comes out so she can stay in her chair and wheel into the van, and then we do have to strap down the four-point access on her chair. So it’s been an adjustment.

There are steps. It requires a change in routine, more thought involved, but ultimately, less time, strain, and inconvenience for us, and is truly so much better for her and our whole family. I found my [00:21:00] dear husband choosing to take the old SUV out when he would take our kids for outings. I asked him why he didn’t take the wheelchair van, and he said that the SUV was easier.

This reveals such human nature that we can see in the ICU. It’s not easier, it’s familiar. Now, a few months in and he zooms her into the new van, straps her down in record time. The adjustment has been made, and now the full convenience is realized. Making this transition in routine and tools has allowed for a more sustainable, safer, and enjoyable new norm for our family.

This is what I’m hearing from nurses when their whole team buys in, and they get to have patients awake and mobile promptly. I’m talking 50%-plus of intubated patients totally off of all sedation two hours after intubation as a unit-wide standard. They have told me, quote, “I thought this was gonna be so much extra work, but now I would so much rather have a patient awake after intubation [00:22:00] than delirious without an endotracheal tube.”

Or quote, “No way I would ever want to go back to how we were doing it before.” They enjoy a 50% reduction in delirium, patients’ ability to easily text or write so they actually know what they want and need, all leading to a drastic reduction in patient agitation, fear, violence, and nurses’ stress. They appreciate that patients are much more likely to be able to turn or boost themselves, get themselves to the edge of the bed or chair, and even walk without so much demand on the team.

They especially note the surprise and joy they’ve experienced with the transformation in patients successfully extubating, walking out the doors, and in their own knowledge of the harm they have protected them from by keeping them awake and mobile. They love seeing their patients survive and thrive.

They have greater joy and satisfaction in their work. Yes, there is still work involved, but it is work that is worthwhile. Nurses [00:23:00] aren’t afraid of work, but they want to know that what they do matters, makes an impact, and is for patient benefit. And it sounds like with current culture and practices, they lack that kind of confidence, reassurance, and joy

Now circling back to Dan, the 650-pound patient arriving to the ICU intubated for fluid overload among many other acute and chronic conditions. Fortunately, he was admitted to a newly budding awake and walking ICU that now has more tools to apply to his care that could keep him and his nurses safe. They had him off of sedation two hours after intubation.

His hypercarbia rendered him unresponsive, but they had him on a verticalization bed hours after arrival to the ICU. When his CO2 improved, he woke up standing and intubated in his verticalization bed. Instead of spending the dreaded weeks completely [00:24:00] dependent on the team and equipment for turns, boosts, total care, ending up with pressure injuries, infections, hospital injuries, trach, PAC and LTAC placement, Dan was extubated three days later and walked out of the ICU.

He continued to have 100 pounds diuresed while on the step-down unit. I saw that step-down unit. They did not have ceiling lifts nor Hoyers capable of accommodating for Dan. Running through that narrow window of opportunity to preserve his ability to move himself protected multiple teams in and out of the hospital.

So yes, this absolutely saved the life of Dan and innumerable current and future patients. But make no mistake, this protects nurses as well. If we are not using transformation towards awake and walking ICUs in our advocacy for improvements in safe staffing, workplace violence, workplace environment, moral injury, burnout, and staff retention, [00:25:00] then we are not playing one of our biggest cards to leverage for these imperative changes.

I want to conclude with the powerful testimonials of other nurses that have done it both ways. Had patients fully awake and mobile promptly, and those that have known the sedation and immobility conveyor belt. Go listen to episodes 76, 114, 185, and the YouTube video shared in the show notes. Let’s join together to change the narrative of sedation being convenient to exposing the harm of these unquestioned norms on patients and nurses[00:26:00] 

To schedule a consultation for your ICU as well as find supportive resources such as the free ebook, case studies, episode, citations, and transcripts, please check out the website.

Transcribed by https://otter.ai

SUBSCRIBE TO THE PODCAST