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.
