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What is it like for one lone ICU clinician to truly understand the risks of sedation and immobility? What it is like for them to try to implement interventions like awakening trials that have been supported by decades of research? How does lack of support and success increase moral injury, burnout, and the loss of expert and compassionate clinicians? “Kara” joins us to share her journey as an ICU pharmacist and revolutionist.
Episode Transcription
Kali Dayton 0:13
Awakening and breathing trials are not new. They were the very first elements of the ABCDEF bundle that started in the 1990’s and early 2000’s.
Go back to Episode 150 To listen to Dr. Wes Ely talk about how this all started at least 28 years ago, in 1996, Dr. Ely did the first breathing trial study in which they did routine screening, then shut the vent off for two hours. They found a 1.5 day decrease in time on the ventilator.
And 2000 Dr. JP Kress published an awakening and breathing trial study, he found a 2.4 day decrease in time of the ventilator and a 3.2 day decrease in time in the ICU. And 2008 Dr. Girard repeated this SAT SBT study and found a three day decrease in time of the ventilator and time in the ICU. They found that patients that had dailey SATs and SBTs were more likely to be alive one year after discharge.
For every seven patients that received daily SATs and SBTs. One life was saved. So at the beginning, it was SBTs than in the early 2000s SATs and SBTs later the ABC bundle then it became the ABCDEF bundle in 2014.
Now, in 2024, true revolutionists will agree that SATs and SBTs should not be the focus of the ABCDEF bundle for most patients, we should be evolved enough to be questioning whether or not to even start or continue sedation as we know better than to treat the bundle as an on and off switch for sedation as a standard, we should be mobilizing all patients possible and truly minimizing or avoiding sedation.
Nonetheless, we see that from these studies, daily SATs and SBTs absolutely save lives and improve outcomes compared to continually running sedation without a break by this point in 2020. For every single patient that has sedation running and does not have a rare exclusion criteria such as elevated ICP, Status Epilepticus, or neuromuscular blockade agents should have their sedation shut off enough to be able to do a breathing trial every single day.
If we are not at least doing daily SATs and SBTs. We are not providing standard of care, not giving patients the best chance to survive and are even causing many patients to die. Now as a nurse, admittedly, I hated SATs, doing them at 5am. Without a team that was ready to support me and keeping patients safe and working through the agitation.
It was stressful and it didn’t feel productive awakening trials should be done with a goal of mobilizing patients, unless there’s an actual physiological instability that necessitates the resumption of deep sedation, as it is expertise for all patients that are sedated should be standardized and integrated into routine cares, just as non negotiable as daily Bed Bath and am labs.
But now in 2024. How are we doing? Where are we at with this? What is it like to try to roll out these programs and teams that still do not have standardized as it has an expertise? I’m excited to have a new friend share her experience. As a pharmacist. Her journey reaffirms the struggles of innumerable revolutionists that have reached out to me with the same frustrations and sorrows. Over the past few years. Her name and voice has been changed to protect her from retaliation. “Karen”, thank you so much for coming on the podcast. Can you introduce yourself to us?
“Karen”, PharmD 4:08
Yes, so, I am a former clinical care clinical specialist. I trained at two major academic medical centers. After my after I finished my PharmD degree. I did one year of residency in a general pharmacy practice residency and my second year was a specialty residency in critical care, at which point I started practicing in critical care at a smaller hospital, not not a huge major academic medical center, but I was there for over 10 years. Wow.
Kali Dayton 4:41
So, you were deeply ingrained in the critical care world. And the reason I bring you on is because you had mentioned to me that you had tried to launch an LSAT protocol and had a lot of really relevant experiences that I think a lot of people listening to the podcast will be able to relate to. But what inspired you I mean And when did you launch this protocol and what led you to do that or to try to do it.
“Karen”, PharmD 5:06
So our hospital had some unofficial versions floating around of, you know, spontaneous awakening trial protocols that were never really didn’t have never really went through the right channels for approval, there was never a cohesive rollout. So I was in a multi hospital health system, as well. So that that also factors into things. As if anyone knows who worked within a system, it’s, it’s a little bit more difficult to get things done, because you have to get agreement from all the sites that are involved.
So you know, we have various hospitals of various protocols. And that went on probably for the first seven ish years. And it was actually, during COVID, during during the pandemic, we were COVID unit that I realized, you know, we need a official protocol for this. There also was at the time they were trying to do a trial, I’m not going to mention the specifics of it. But the trial was being run by respiratory therapy, and they needed to do an SBT as part of their research study.
But we had no SAT. So you can’t really do the SBT without people doing the SAT first. So I got involved, I you know, run a protocol and decided I was going to take it to the official channels, this was like in the very end of 2020. And it went, you know, I had, I had some obstacles getting knocked on. A lot of pushback came from, from nursing really wanted to not turn off the sedation, they are bringing pre existing, you know, protocols that were unofficial, that were floating around had really complicated titration recommendations, like turn it off 50%, then an hour later do this, like it was very hard to follow, I think for nursing and, and as far as I know, there’s no data for what, what those protocols contain either.
So I did eventually, you know, through citing studies, and just being very kind of, you know, I harped on this, that I thought it was really important that we try and turn the sedation off as part of our SAT. That’s very standard practice.
Kali Dayton 7:15
And the early SAT SBT studies that have been replicated.
“Karen”, PharmD 7:19
Exactly right. So and then we I was able to get it through and it went live, I think in January of 21, January or February.
Kali Dayton 7:28
And how did it go?
“Karen”, PharmD 7:30
So, you know, there was a lot of barriers to implementation, I would say, there was an educational presentation that we made us a system about the ABCDE bundle ABCDEF bundle. And it was for whatever reason that I am sure there was reasoning behind this that but I still don’t truly understand they didn’t make it mandatory for nursing to watch, which I think I think it eventually became mandatory, perhaps the following year.
But when it was launched, it wasn’t made mandatory, which I which was very frustrating to me, because I think it was a great tool. And it wasn’t, you know, it wasn’t being used wasn’t being utilized. So that was tough. I tried to do a lot of education myself at our hospital, in small groups. And I know we have a nurse educator whose job it is just to do our subject nursing education. So he you help to with that.
So education, I would say it was one issue. We also had to build all of our SAT exclusion criteria in our EMR, and we had that book. So you know, that takes time to do as well. And we we did eventually get all that built in there. But then even so people will still get the exclusion criteria wrong. So you constantly would hear well, they’re on a presser so we can’t do the SAT. And so I would say you know that actually that’s a team actually get the patient off the presser, which, which it often did. Oftentimes, that is the outcome, though.
Kali Dayton 9:02
So, during COVID A lot of these patients were on pressors. But only because they were on sedation. Yes. I mean, I rarely saw COVID patients on pressors because they were rarely sedated. Yeah, so absolutely can take sedation off because your oppressor and can’t take the pressure off presser off because you have sedation, you’re just chasing your tail for how many days straight?
“Karen”, PharmD 9:25
Exactly. And that was a huge thing I heard over and over again. So I think we finally I got to the point after I able to dispel that as you know, as a myth. Another issue that we faced was was the incorrect documentation of the RASS to begin with. So we would have people documenting the RASS as negative one which you know, is like negative one or negative two or zero which is technically you know, lightly sedated.
And the patient was not they were actually RASS negative three, negative four when I started digging in and asking the questions Have, that was another interesting, you know, our, our protocol said, if the patient’s already awake, you don’t have to do that as a team because the patient’s already awake. So if you know you’re documenting massive negative two, then the SAT wouldn’t be getting done because that was, you know, that was an indication that the patient was already awake. So that was another issue we face.
Kali Dayton 10:23
Episodes 134 and 156. Support this, this is these are from nurses that have done audits, or that have entered the ICU with a fresh perspective and are seeing these the same phenomenon of this really inaccurate, subjective interpretation of the RASS. And they both face a lot of I want to say persecution, a lot of pushback for raising these flags. So one of them was a nursing student that did an audit for her Capstone.
And she presented this information to the nurses. And a number of nurses stood up and walked out of the room, as they were so fitted and this was she was sharing objective data, she was comparing what was prescribed what was charted and what was objectively observed at the bedside and found that 58% were inaccurate. And 68% of those, I think were at least two points, or more off of what was charted.
So negative two would have been negative for which doubles the risk of dying. So she shared that nurses got offended and left. Another one was, she’s a very seasoned med surg nurse, she really studied up on this stuff as she endured critical care. And her military nurse was getting mad at her for charting Eros negative four. And what they know knows there, why did you chart that take that off if they’re negative one, and she says,
“Am I misunderstanding? I’ve watched YouTube videos, I’ve, I’m looking at this chart, it is not a negative one.” And it was just this constant thing where she was almost being pushed into this culture of lie about it. And I don’t know if the mentoring nurse really saw it that way. But that’s how she proceeded have, as don’t follow the chart, don’t go objectively, go with what was previously charted, or what I’m telling you to chart.
Let’s say you’re saying that that’s that was one of the big barriers is that if they were within this range, there’s no need for an SAT. But they weren’t actually in that range. That was just what was being charted. absolutely terrified, terrified, considering that isn’t a predict independent predictor of death?
“Karen”, PharmD 12:28
Absolutely. It is. And, you know, seeing that over and over it, just it’s it’s so difficult to watch. We also would have a lot of people, you know, well, there was high, even though that was not one of our exclusion criteria, or exclusion criteria was a P F ratio under 150, which is actually more conservative than other SAT protocols that use a cutoff of 100.
Kali Dayton 12:53
So the ironic thing about that is, we have a Polly Bailey study in 2007, where it showed it was safe and feasible, to mobilize and usually walk patients with a medium P F ratio of 89. And as a team criteria requiring to be a fruit ratio, I mean, we you just, you don’t state for ventilator settings.
“Karen”, PharmD 13:12
So when I proposed when I proposed the SAT, originally, I had, I had proposed that PF ratio of less than 100. And the pulmonologists didn’t, they wanted me to increase it to 150. So, so we did that, but we still didn’t matter because we still would get pushed back. And it wasn’t just from nursing, that, you know, they’re in a high P, they can’t tolerate it. I had physician saying, “If I’m ever on the ventilator, Don’t wake me up!”
When I would bring it up on rounds. I had, you know, physicians, were not championing this. So I would have, you know, them say, “Well, they’re going to be out for it, we’re gonna they’re gonna be down for a few days anyway, so we don’t need to wake them up.
And I would say, “That is actually all the more reason to wake someone up, if you anticipate a longer ventilator, you know, duration, because the longer they’re on the ventilator more deconditioned they’re gonna get, the more sedated they are.” So that was another issue that we had. I had nurses just straight up refuse to turn sedation off just I’m not doing it, even though the patient wasn’t sad candidate. So that was another barrier that I encountered.
Kali Dayton 14:16
And so there’s very, there’s variable, if not, across the board, little position support. As a pharmacist. Nurses weren’t necessarily responding to your either recommendations and ventilation invitations. Sounds like a lot of this is rooted in not understanding the risks of sedation, not a lot of the misinformation about sedation being sleep humane, safer necessary. It’s going to improve acute respiratory failure, which is the exact opposite of reality, which I think a lot of people are can totally relate to.
This is something that is a very common thread through every team that I’ve worked with every team I worked in, and everyone that I’ve talked to, you have an alias, we’ve changed your voice. And yet, this could be anyone, any pharmacist sharing this. These are common practices, common myths that are in our ICU. I’m also astounded by the misunderstanding of the pharmacist role. Did you feel like nurses were territorial sedation and didn’t want to hear it from a pharmacist?
“Karen”, PharmD 15:28
Yeah, I have a pretty wild story about that. I was sitting in my office one day and I ended direct one of the directors of nursing for the hospital, knocked on my door. And she came in and said, so the director of the ICU, the medical director, he came to my office today and said that you’re talking about sedation too much on rounds, that, you know, it’s got to stop that you’re just it’s, you know, he’s just taking up too much time.
And then she went and proceeded to give me every reason why they couldn’t be told that the nurses didn’t want to sedation off because we’re coming off of a pandemic wave. Because nurses don’t want to get injured, which I completely understand. I was friends with all the nurses, I did not want them to get injured either. And there’s a safe way to do these things. She just keeps giving me reasons why.
And I said, I pointed to Wes Ely’s book on my shelf, And I said, “Have you read this? Because I would highly recommend that you read this. “And she before she was a director of nursing, she was a critical care nurse. And then she was a critical care nurse manager, which was very, very upsetting to me.
That was actually that was actually the day I started looking, I started I said I can’t I can’t do this anymore. If I don’t have any support or leadership, I have to get out of this job. I cannot watch this anymore. Yeah, that is heartbreaking. It was It was awful.
Kali Dayton 16:38
But it still kind of makes sense to me. I don’t think a nurse from any other discipline would have been as bold or felt as strongly as she did. She’s coming from years of experience of treating delirious patients sedated patients fall in a lot of the same mentality, the same practices and falling into the same gap in education. So now having this new authority without the right foundational knowledge.
It makes sense to me why she felt so threatened and defensive on behalf of nurses. And yet, as a loan, I say your revolutionist you were very alone and being so concerned about delirium, increasing mortality from sedation, what would happen as patients during and after the ICU from the sedation being the only one to feel that way. Not just feel that way. And it’s not just about feelings. It’s about knowledge, you know, what’s happening? It’s hard once you know you can’t unknow it. You can’t not try.
“Karen”, PharmD 17:37
Absolutely. And another issue was, once we had in our EMR once we had these, these things built, we could look at data, right? So we could look and see how what percent of the time are our nurses completing the SATs screen. So I would sit in these meetings and the percentages, I’d say that my hospital was the best out of all four because of me, because I would harp on it. So the percentages were not good, right? They’re not good.
So and then when that came up, oh, the reasoning was, “Oh, they’re just they’re doing it. They’re just not documenting it.” And I would have to speak up and say, “Actually, I can tell you that I’m on rounds every day asking you about it. And it’s not being done until I asked it to be done. And then even then sometimes it’s not getting done”
So it was kind of trying to minimize the problem and almost turn a blind eye it is to not to not see what’s really happening each day in the unit. And I said during that meeting, you know, I said we are harming people, by overstating them and not doing the sap the SPI not doing the bundle. And people do not like that. I said that. We tell you people do not like that.
Kali Dayton 18:42
And I commend you for being so bold. Certainly, you have to be tactful and careful and cautious. But sometimes when we are so fixated on being gentle that we we avoid saying truth.
“Karen”, PharmD 20:00
Yeah, I couldn’t I just couldn’t keep it in anymore. And that’s, that’s my personality.
Kali Dayton 20:06
But as a patient advocate as well, I think when it comes to can and SHOULD pharmacists be talking about this? Absolutely, I think about how involved and autonomous and bold you guys are about antibiotic stewardship, you would never let us give an extra gram of vancomycin because we felt like it, right. And yet, when our RASS scores are off, when we’re giving more sedation than what’s prescribed, that’s outside of current scope, that’s malpractice. That’s lethal.
And that should be part of pharmacy stewardship, the rest is the trough of sedation, you would never look at a lab value knowing that it was off and be like, “Well, it’s okay. Like the labs probably just, you know, just probably that one lab tech, it’ll be fine.” Next time, you know, you’d be like, “no, what, how did this happen? How do we fix this process to make sure that we have reliable lab values, because this is toxic to the kidneys? This is dangerous. We have to know what Vancomycin level these patients are at.”
We have to have a draw at a certain time, you are very structured and regimented in those protocols. Why are we not the same with sedation, we know that it is an independent predictor of delirium, mortality, long term cognitive deficits, it traumatizes and injures people, if not kills them. And yet, because culturally it’s so normalized, you become the bad guy for speaking up about it.
“Karen”, PharmD 21:28
Exactly. It was. It’s hard, you know, it’s hard to see they talked about you talked about moral injury. It’s hard to there’s so many other things that happen in the hospital, but this was a big, a big one to watch happen and have very little control over.
Kali Dayton 21:42
And yeah, let’s talk about that more of as your, from your perspective, as a pharmacist, because I know my perspective as a nurse and nurse practitioner, we’re having to deal with these patients that are delirious and having to actually treat the ICU acquired weakness and things like that. I think pharmacists, sometimes I think we don’t understand your relationship with patients and how much this can impact your moral injury. What did you see? And how did that change your career?
“Karen”, PharmD 22:08
So you know, over sedation, we so much delirium, I feel like I would see from patients who were the longer people are sedated, the harder they can be to wake up. And when they do wake up, I think the more likely they are to be, you know, how to have delirium, whether it be hyperactive or hypo active. But we would see the prolonged vent days. You know, and then that it’s just a cascade of issues that can happen, you get an alias because you can’t move because you’re too sedated. And then you have to get an NG to put in and then you know, it’s just like one thing after the other, just cascades of events that could have possibly been prevented.
And I do want to say that I do recognize there are times patients need deep sedation. Yeah, there are there are times that that is appropriate. And I was very, I felt that I was pretty understanding of that too, during this whole process. But when there was a case where I felt that it wasn’t necessary, I really would try to speak up because of those adverse outcomes that you do that I would see from from this.
Kali Dayton 23:10
And to be told that you were talking about it too much, that that wasn’t a good use of time at rounds. I mean, the objective of multidisciplinary rounds to collaborate, formulate a plan of care and make sure that everyone’s on the same page, make sure that we’re aligning our interventions with evidence that I’ll make sure that we set patients up to succeed in the long run, as well as during that one shift. That all seems very relevant to sedation practices.
“Karen”, PharmD 23:38
Yeah, and, you know, the, the physician, and he said that his round his rounds on 18 ICU patients would be like an hour and a half. So it’s not like, we didn’t have time, we had time, we had time to talk about it, in my opinion. And I think, you know, we don’t have time to not talk about it, it’s so important.
And I feel like the attention, we didn’t really get attention from administration until we started talking about cost, how doing the SAT can actually improve costs, because you’re going to have less patience on the vet on, you know, you’re gonna have shorter event times shorter ICU status, you’re gonna decrease costs, I think that’s when people really started to get interested, which is a sad state of affairs, in my opinion, because the real reason to do it is not money. It’s it’s to, you know, improve patients lives.
Kali Dayton 24:20
To save lives! It’s, I mean, we do so much in the ICU to patients, and we really try to do it for patients. But some of these interventions become become the exact thing that kills patients. And I don’t, I think that is a really hard reality to swallow. So for you to bring that up. And to put it that way, it can sound very offensive, and yet, it is the reality of it. And so it’s hard so I think I have found success with getting buy in from executive leadership teams by bringing the financial picture.
You know, I started this podcast talking to all about patients, their suffering, their death, even like the clinician moral injury, things like that. But what actually got me in the doors and bought in that our staffing, equipment training, things like that for teams is talking about the money, which is, which is incredible. But as a clinician, what really impacts you and drives you to show up to work every day is to be able to save lives.
And I think that’s a really big part of our burnout and our loss of seasoned clinicians is that were depriving our teams of having that success. And I don’t think even those that don’t know that this is impacting their burnout. It does. But especially once you know, once you know what it’s like for the patient, once you’ve read and read Dr. Ely’s book, you’ve heard this podcast, and you’ve seen it for yourself the bedside? How do you keep doing what we’ve always done? But when you can’t change it? What do you do?
And so how did how did that go for you when you hit that crossroad of I have my clinical leaders are pressing down on me, my executive leaders are pressing down on me. My colleagues aren’t listening to me. I don’t see I’m continuing to see harm to my to the patients. How did that impact your journey after 10 years of Critical Care Medicine, all the expertise and the wisdom and the contributions that you brought to the table? Where are you at now?
“Karen”, PharmD 26:11
So I will say that things that things were slowly getting better in our unit. You know, we had a lot of ICU as everyone I think did after COVID. During COVID, we had a lot of turnover. So we did have a lot of new nurses. And when those newer nurses came in, I feel like most of them were more willing to listen, and to kind of learn the data and maybe learned in their training, I’m not sure. But things did get better. But they definitely definitely remain difficult. I just, you know, I think I felt so just defeated. And it was it was just so tiring.
And I wasn’t getting that. It was like, especially during COVID was so difficult because people were not getting off the ventilators. They weren’t going on the ventilator. And I mean, we had a list of people that got off the ventilator. And it was like seven people long. And it was just terrible. All of those things combined, you know, like seeing the other ways we failed the ABCDEF bundle, we closed visiting hours, we had as everyone did, we have no visitors we used to have.
So our former nurse manager, pre COVID, she managed to get completely open visiting hours for ICU and she fought for that tooth and nail through her whole career. And right before she retired, she was able to get that done. And then COVID completely reversed it. And even after the restrictions ended, we still didn’t like family and unrestricted. So there was still these restrictions on family. And I still saw, you know, early mobility wasn’t happening as much as I could, because we didn’t have enough staff, and we didn’t have buy in from some of the physicians.
And exactly, that’s just the most important part. So they can do early mobility. So I mean, all those things just kind of added up and along with you know, a million other little, you know, the kind of like death by 1000 paper cuts situation of seeing all the little teeny tiny things that were happening that we just want the best they could have been. It just led me to want to do some try something else. And
Kali Dayton 28:10
I think I mean, you’re not the only one I heard, have to leave Critical Care Medicine. And it kills me because I can understand when you dedicate your entire career you did your residency and fellowship and this and 10 years dedicated to mastering your your skill. I wish leadership understood not just the financial loss or patient care, the financial loss and losing expert clinicians.
And not just expertise, but just compassion, the fact that you would work so hard to roll out a whole protocol. I mean, you weren’t there just to clock in and clock out. You were there to save lives and you were willing to do the extra work to do it. But because they weren’t supporting that they lost you. They’ve lost lives. They lost so much money by failing to practice the bundle.
“Karen”, PharmD 28:57
I mean, we had I just just a little bit on early mobility, because I would be interested to hear your response we had so there was a tweet, I think it was a 2022 New England journal article that basically said early mobility doesn’t save lives, but increases risk of adverse events. Well, there was a lot of things. So we had a physician who would quote that all the time. And to me, I mean, there’s first of all, you’re not only worried about saving a life, like are you I think it’s just there’s also the other outcomes like quality of life, ability to function, ability to maintain your IQ.
There’s just so many other things that go along with it. And in addition, I mean, that meta analysis, I believe it was, was it a meta analysis or just to study but anyway, the difference between early mobility and not early mobility was so few minutes, I think it was like 10 minute difference, or I don’t have the exact numbers memorized, but I would just like to hear your opinion on that.
Kali Dayton 29:50
Yeah, absolutely. I’m looking for the exact episode number but it’s called diving deep into the team study. So it was positive England Journal of Medicine and 20 Very into 22, I think it was a really well funded study. And you’re right there were there’s very little difference between the control intervention group. So they’re about 12 minutes difference in duration, duration of mobility. So the control group was probably doing a much higher level of mobility than what your team does. They were mobilizing patients within six days after intubation.
But the median RASS during those six days was negative to negative three. So patients were still sedated, they did a brief sounds like they did a brief break, and sedation to mobilize and then they were re sedated. And so this was still not a full mastered a specific bundle. Yeah, you’ll have to hear the whole episode and the discussion as far as what levels of mobility were done, it was. So the conclusion said that there was not a difference in mortality or time a time alive in the hospital and out of the hospital, for these for these patients. But again, there was not much contrast.
So if you’d done maybe your unit, compare them to even the control group, there would probably be a difference in mortality. But you’re right, mortality is not our only shouldn’t be our only metric that we’re measuring. We should be looking at delirium rates, long term PTSD, cognitive impairments, things like that well after the ICU as well.
But also, I think we could see I mean, the conclusion I would draw from that study is now we know that 12 minutes of extra time mobilizing was not enough to adequately rehabilitate patients after six days of moderate to deep sedation. That’s the conclusion I get from it. But what your position was saying is very common from what I’m hearing as far as the misinterpretation that we’ve had from that study.
“Now, we know that early mobility does nothing. I’ve heard that now we know that it’s too high risk. All these things are absolute misinterpretation.” So you have to hear Carol Hodgson, say, that was not the finding of the study. That was not the objective of the study. That’s not we measured. She’s still a huge mobility advocate. So that study, it’s like anyone that wanted to validate their failure to practice the bundle, was able to twist that that those last two sentences with the conclusion to validate what they’re doing or not doing, but that was not, that’s not an accurate interpretation of the study. Those are my thoughts on it.
“Karen”, PharmD 32:10
I actually, you know, that was brought up during a system wide critical care meeting like they like a subcommittee, you know, it was one of those committee meetings. And I was when when it got brought up, I was taxing the system director of Critical Care Medicine being like, well, the difference in the two groups was only this and I was trying, because I wanted him to know that, you know, there were some issues with that study, and that we shouldn’t be talking about it in that way.
Kali Dayton 32:37
It’s really important to read the study before using it to determine practices, and also weighed against decades of research. I mean, that was a dozen 22. But 2007, we had a study coming out saying the adverse event rate from allies and patients with a PF ratio of median at nine was 0.6%. But I think the difference in that study was that they were mobilized shortly after intubation. So we we definitely decondition we destabilize patients with prolonged sedation. So yeah, I think it is a lot more high risk to then rehabilitate them after letting them lose almost 40% of their muscle mass in a week.
“Karen”, PharmD 33:17
Yes. So we would always we would do that. I feel like we would do that as well, where we would wait too long, I feel like and then it’s harder to do the mobility, and then it’s not really mobility. So I would say on rounds, well, at least we’re doing late mobility here. And because we’re not doing early mobility, you know, if it’s if we’ve waited so long, where, where it’s no longer that early, I mean, you know, it is good still that we were doing it.
Kali Dayton 33:39
I love where you put that because that’s how I see it as well, I think and even the research is seen as if it’s done in the ICU at some point anytime before they leave. It’s early mobility, but early subjective mobility, subjective past range of motion can be continued, like six days after intubation can be early mobility, but, but to be able to, and we don’t have a very like, specific timeframe as far as in this window.
It’s early in this window. It’s late, but I don’t think you’re wrong. And I think calling it late mobility helps reinforce we may have missed an important window of opportunity to make this easier, safer, we could have creaky blood hated them prevented a lot of harm. Now as a pharmacist, that’s hard. I’m sure you had people throwing daggers at your way saying your pharmacist stay in your lane. Where are you talking about mobility? But yeah, yeah, we’ve got to get over that. Definitely.
“Karen”, PharmD 34:29
It is it is everyone on the teams job I feel like to to think about the bundle as a bundle. And you know, I never claimed to be an expert in early mobility, but one thing I do know is that you can’t do any kind of mobility if you are not awake.
Kali Dayton 34:46
Yeah, we see in studies that mobility helps decrease the resuscitation. Yeah, so that’s under your wheelhouse. Delirium as part of your wheelhouse, so that is that is under your umbrella. So I think it is reasonable for farmers to say how about we mobilize them, let’s do an SAT to mobilize them not just turn this session on and off, we should be the city to get to mobility. And therefore prevent and treat delirium and then address their agitation and anxiety and therefore, avoid resuming sedation.
So it’s very relevant. That’s something that pharmacists absolutely can and should be bringing up. I’ve heard dieticians bring up mobility, for the bowels and for Yeah, so let’s all use and post servation and things like that, like everyone has some skin in the game, some reason wireless mobility is relevant to getting the job done. Definitely, definitely. One thing else you would share it the ICU community, this has been, I think, very relatable for many people.
“Karen”, PharmD 35:46
I mean, you know, tell you people that are still in there, keep fighting the good fight. And, you know, don’t give up, even if you’re the only person saying these things out loud, you know, the more the more you speak up about it, hopefully the more people will become educated about the issues and be able to improve patient outcomes.
Kali Dayton 36:05
There’s a whole community. You’re not alone, you may feel alone in your facility. But this has inspired me to get the ice revolutionist support groups back going going on. Again, I’m doing those every month and life got busy and crazy. But we do need to get those going again, because I appreciate the support from all the revolutionists out there. But this is remind me of how lonely of a journey it can be when you don’t have people sharing your same perspective and vision.
“Karen”, PharmD 36:32
Yeah, that’s very true. Those groups will be very helpful, I think to to walk people.
Kali Dayton 36:39
Well, thank you for everything that you’ve done. I know that, you know, didn’t go exactly how you want it to, but I’m sure that you made a huge impact and saved lives with the difference that you made there much.
“Karen”, PharmD 36:49
Thank you and thank you for having me. Thanks, Kara. And for all the work that you do you do such great work as well. Thank you so much.
Kali Dayton 36:55
Well, it’s the community that’s really driving this. Thanks.
Transcribed by https://otter.ai
Resources
Bailey, P., Thomsen, G. E., Spuhler, V. J., Blair, R., Jewkes, J., Bezdjian, L., Veale, K., Rodriquez, L., & Hopkins, R. O. (2007). Early activity is feasible and safe in respiratory failure patients. Critical care medicine, 35(1), 139–145.
Balas, M. C., Vasilevskis, E. E., Olsen, K. M., Schmid, K. K., Shostrom, V., Cohen, M. Z., Peitz, G., Gannon, D. E., Sisson, J., Sullivan, J., Stothert, J. C., Lazure, J., Nuss, S. L., Jawa, R. S., Freihaut, F., Ely, E. W., & Burke, W. J. (2014). Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Critical care medicine, 42(5), 1024–1036.
Ely, E. W., Baker, A. M., Dunagan, D. P., Burke, H. L., Smith, A. C., Kelly, P. T., Johnson, M. M., Browder, R. W., Bowton, D. L., & Haponik, E. F. (1996). Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. The New England journal of medicine, 335(25), 1864–1869.
Girard, T. D., Kress, J. P., Fuchs, B. D., Thomason, J. W., Schweickert, W. D., Pun, B. T., Taichman, D. B., Dunn, J. G., Pohlman, A. S., Kinniry, P. A., Jackson, J. C., Canonico, A. E., Light, R. W., Shintani, A. K., Thompson, J. L., Gordon, S. M., Hall, J. B., Dittus, R. S., Bernard, G. R., & Ely, E. W. (2008). Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet (London, England), 371(9607), 126–134.
Kress, J. P., Pohlman, A. S., O’Connor, M. F., & Hall, J. B. (2000). Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. The New England journal of medicine, 342(20), 1471–1477.
Every Deep Drawn Breath by Dr. Wes Ely: https://www.icudelirium.org/every-deep-drawn-breath
Episode 117 on the TEAM trial: https://daytonicuconsulting.com/walking-home-from-the-icu-podcast/walking-home-from-the-icu-episode-117-diving-deep-into-the-teams-study/
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