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When post-intubation wait times increased during the COVID19 crisis, Julie, an ED nurse, took “saving lives in the ED” to a whole new level. She shares with us what communication and patient autonomy mean to her and how she is applying that to how she cares for patients in the ED. One nurse can make a ripple effect throughout an entire hospital system.

Episode Transcription

Kali Dayton 0:38
Okay, let’s talk about those first few hours and days after intubation. There is so much going on for most patients that have a new need for ventilator support. And we can easily become consumed with all the necessary steps and tasks to stabilize them. Yet, the choice to sedate or not state, which sedative we use and how deeply we sedate a patient is an impactful part of stabilizing preventing harm and determining the future for our patients. even and especially at the beginning.

A few studies throughout the years have reaffirmed the same conclusion that early deep sedation is an independent predictor of delayed extubation and increased mortality. One study showed that deep sedation, which is arrest lower than negative three, occurred in 76% of patients within four hours after intubation, and 68% were still deeply sedated 48 hours after intubation, the study did not go beyond the initial 48 hours. This showed a direct impact on mortality. So what does this mean for us? Who can we allow to wake up right after intubation?

I would suggest that most patients can, with some clearly defined exceptions, such as Intracranial Hypertension Status Epilepticus, open abdomen, many TBI and spinal cord injuries, the inability to option it with movement from cardiogenic shock, or the most severe of ARDS, and so forth. Yet, we all must understand that mechanical ventilation is not an independent indicator for sedation, especially deep sedation, even initially, this is why we must ask questions each time such as:

Does this patient have an indication for sedation?

Is it worth the huge list of risks including delirium, ICU acquired a weakness and death to sedate them right now?

Are we sedating them because it is essential and there are other risks that outweigh the risks of sedation?

Or are we doing this out of habit and inclination to keep them still quiet and voiceless and then deal with them later?

Do we all understand this will create more complications and work for us in the long run?

Have we told the family the risks involved and do they understand that we are increasing their chances of dying by automatically giving sedation without an indication?

In the awakened walking ICU, almost everyone is allowed to wake up right after intubation. paralytics are rarely used for intubation, and if they are used, it is with minimal dosing. Often half what others use then both doses of propofol are given at the end of the procedure. Then patients are allowed to wake up and tell us what they need.

This is to do a true assessment, prevent delirium, allow patients to have their autonomy in their care, and ensure that they are safe, comfortable and have the best chance to survive and thrive. And truth. This approach by avoiding sedation and prompt mobility makes the care so much easier for everyone and drastically flips patient outcomes culturally, the ICU community has accepted the approach to deeply sedate now, get them situated and then think about lightening things later when their critical and acute conditions a result yet the studies show that when we do this, we are not giving our patients the best chance to survive, let alone thrive.

Those first few hours and days can define the course of an ICU stay, hospitalization, and a life this podcast isn’t focused on the ICU, but I was approached by an ER nurse that gave me new insight. As stay times in the ER changed during COVID. This ER nurse found an opportunity to take saving lives to a whole new level. I’m excited to have Julie tell you all about it. Julie, thank you so much for coming on the podcast. Do you mind introducing yourself?

Julie, RN 4:55
Sure. My name is Julie. I’m a nurse at Indian for Colorado, I’m an ER nurse and I work at a hospital called Lutheran hospital. And it’s a level two Trauma Center. Awesome.

Kali Dayton 5:07
And how did you even come across this concept of letting patients wake up after intubation?

Julie, RN 5:16
Yeah, so I did a project on innovation and sedation protocols or EDI. And I was talking, I presented this poster at our poster annual poster fair that we have. And one of our trauma specialists came up and said, Hey, do you know about awakened whacking ICUs and I was like, I kind of heard about them a little bit in the literature. But I was focusing on sedation practices in the IDI. And there’s I mean, there’s a lot of talk in the literature about rare scores and getting patients to different risk scores in the IDI for them to transition to the ICU, but I didn’t really focus on the ICU stuff. And so my friend, Stephanie was like, “You need to listen to this podcast.”

And it was actually your podcast. So she sent me the link to the one where you interviewed the doctor from Denmark. And I kind of went down the rabbit hole. And of course, I was like, Oh, my God, this is incredible. Like, of course, why wouldn’t you do this? And so initially, this project that I had taken on for my department, as part of my clinical ladder work, was just to work with our doctors to put into place a sedation protocol. But when I started learning more about waking, walking ICUs, I went to our Chief Medical Director and looked at him I went, what do you think of letting us wake up the patient? And he looked at me, he goes, “Why would we do that?”

I was like, “well, there’s a school research. And so they started talking about it. And then I heard aware that our hospital is going to be an ‘awake walking hospital’, we’re on a three year transition path to being an awakened walking ICUs in our hospitals like, so it turns out our ICUs are doing this, why don’t we support them?” He’s like, “cool, do it. Let’s have a meeting. Let’s sit down with one of our pharmacists, and let’s figure out what we want to do.” And I was like, “Alright, let’s do it.” And there it went.

Kali Dayton 6:55
With that, and a lot of people are trying to process the concept of the ED getting involved in this. I have never worked the ER. And so I’ve done as I’ve been doing presentations, people have asked, “Well, what about the ED?” And I myself thought, “Yeah, what about it?” I do know that for a while ED was sending patients that we were just shaking their heads like they would be intubated because they were GCS of three and yet they’d come up sedated.

And or they just be on such heavy benzodiazepines. I mean, this is there must have been a new provider, something in the ER, because that hospital sent us for so long. But we had to open up communication between the departments to say, when you give them this huge onslaught of benzodiazepines, and makes it more difficult for us. And then they started coming up off of sedation. And I don’t know if they were just turn off sedation right before they came up. Or they’re letting them wake up right afterward. But it made me really think about the interaction between the ER and ICU. And things have changed recently, in the ER, as far as how long you actually have these patients for right. You can’t just to them and send them up. What does that been like? Especially during COVID?

Julie, RN 8:08
Yeah, so I actually can’t speak to it. It’s like pre-COVID Because I was one of those weird nurses. I was like, “Oh, look, there’s a pandemic. Let’s go for my nice push inpatient job and pediatric hospital to an ER, an adult ED”, yeah, reasonable, very strange transition, I was wanting to work er, and then my life took some weird turns, and it just opened itself up and turned out to be a really good thing.

So when I came, it was after the alpha wave, and I came out of orientations, just as Delta was hitting United States. So I was learning to animate patients when we were holding for for six, eight hours, sometimes these ICU patients. I mean, it was intense. And we’ve not seen before in the EDS, like, all my friends are telling you that there needs to be like, you’d have them for maybe an hour, and then they’d be up on the unit. So we, quite honestly, we’re learning as we were going and not to not to make it sound like we didn’t know how to manage these patients. But it was new to us. And it was new to our providers, and it was new to nursing. Your life is interesting. Within innovative patient, a lot of times we just don’t know a ton about them.

Like I’ve had patients where we literally don’t even know their name, we just get this story from EMS, and they’re acutely ill. And we have to intubate them because their instead of seizure, and we don’t know, either instead of seizure or what their history is, or anything else. And we’re like, okay, let’s do our best to keep them stable, without any medical history, just the labs in front of us and what they look like and then go from there.

Kali Dayton 9:39
slapping on some band aids….

Julie, RN 9:41
yeah. Yeah, I can be very shocked and approach honestly, because that’s all the patient gives us. And then other times we have like their entire medical history because we treat them at our hospital and we treat them in our clinic so we know absolutely everything about them. So it’s a very much a big range. So that can vary. I think because we don’t always know exactly what’s going on with the patient, the doctors are very much having to look physically what’s in front of them and go based off of minimal information and make big choices for these patients. And that can make things challenging for them.

Kali Dayton 10:14
Especially when you have to quickly intubate them. And they’re sedated. Yeah, family still hasn’t been contacted. There’s known to speak for them, and they then cannot speak for themselves.

Julie, RN 10:27
Yeah. And sometimes we don’t get the option of asking them, Hey, do you want to be intubated, they’re crashing on us. Or they’ve already crashed. And we’re getting them into data from EMS. And we don’t know what triggered, or what they looked like before they were inundated. We just have to trust our partners in the field that they’re making the right choices for our patients, and move forward from there.

Kali Dayton 10:47
No, absolutely. Emergency Medicine is such a unique and incredible skill set. And the focus that obviously, I mean, reasonably so is keeping them live for that moment. A lot of this podcast is how do we stabilize them and look at the big picture, and keep them stable throughout critical illness and yet prepare them for the lives ahead. And that you took this very personally when you heard about this humane approach to intubated patients. And even though you could have easily said, “I’m just going to ship him off, not gonna be my patient, not my problem, right?” What inspired you or why, why did you take this extra step to change this process of care?

Julie, RN 11:31
Because I don’t think anybody gets into nursing that wanting to do the best for their patient, or medicine. Like, if there’s another option that’s better out there, I think we should try it. And I am so grateful. As to where I ended up, I had a wonderful job before working in pediatrics, and I love working with kids and transitioning to adults was terrifying for me. But I ended up in this amazing department with the most supportive management I’ve ever had in my life and surrounded by incredible doctors and nurses that are all just super into doing the best for their patients.

Like it’s it astounds me every time I talk to somebody about different projects that are going on. So I’m surrounded by this amazing culture of change and process and doing good for our patients. It’s feels very natural to just say, how can we do this better. And for me, in particular, I had a very challenging innovation with a COVID patient early on in my eight year career. And when I was working on my clinical ladder work, I approached my educator and said, What should I do a pop project on? And she’s like, think about some of the worst things you’ve experienced here and how you can make it better. And I was like, okay, so I kind of rolled around and then decided I thought about that experience. I was like that was miserable.

Like that was the worst, some of the worst hours of my nursing career ever. I felt like I couldn’t keep this patient stable. He was bucking the event, he was breathing over the vent. I had maxed out on propofol and its pressures were dropping and his oxygen status was dropping even intubated, I couldn’t get him above 90%, which in Denver, our goal is 88. And because of our altitude, so our numbers are a little bit lower for people that didn’t think of that. But I could barely keep them above 90. At one point, I could barely keep them above 80. Like we were talking about proning him in the ER it was it was terrible. I, I was working with one of our best pharmacists and doctors trying to get medications on board to help support him.

And my just like, I felt like we were all banging your head against the wall trying to help this man. And he ended up paralyzed and prone in the ICU pretty quickly after it took him up. Like they were ready with the medications to paralyze and put him upstairs because it was the last option on the table. And so I thought about that a lot. And I was like, there has to be another way. Like that was terrible. It’s not like nobody was trying. It was just terrible. And so that led me into the research of looking at other sedation practices, and then down this rabbit hole. And so when we started talking or excited looking, seeing the literature, listening to you, and then going into the literature about awaken walking, I’m like, “why don’t we just help our ICU counterparts if I can start waking them up? If I have a patient that’s stable enough that we’re having the conversation about innovating them before we intubate them in the ED and I can slowly talk to them about waking them up afterwards and get them set up for better look in the ICU and a better outcome in general. Why shouldn’t I do that?” Like, and one to one with them in our ER. All of our intubated patients are 1:1 in the ER. So why can’t I help my ICU friends and give them a better spot to start with upstairs?

Kali Dayton 14:39
Oh, that is so powerful, because really, I mean, even if some comes up on propofol, they’ve been on propofol for 30 minutes, even a few hours. It’s it’s really not that big of a deal to let them come out of propofol. But when you are trying to transition an ICU culture, and they’re overwhelmed, they’re burnt out and I have to do one And they’re not maybe as prepared to let patients wake up. That is such a powerful position for you to say, I’m going to set them up for success. I’m going to bring up a patient that is already awake, oriented acclimated to the tube. So then they can take it from there. So what was that like the first time you did that, or even other times that you’ve done it?

Julie, RN 15:22
So this project is still very much in its infancy. And where I am right now is I have approval from our medical director in our lead pharmacist, forestation protocol. Now I’m working on getting our ICU folks to build it out for us so that I can introduce it to all the other doctors and nurses. So everyone just kind of knows my rumor mill stories of this, but I’ve done this with a couple of different patients.

Now. The first patient that I took up, it was very early in the process also for ICU switching over to the wake and walking so our nurses up there. We’re just starting to hear about it themselves. So the nurse when I called and gave report because we already are the calls ahead and gives reports. My old hospital was not just had patients here. Yeah, when I came here, I was like, Oh, we do report Okay. As it should be, what a novel concept. I call it my said, “Hey, she’s awake, and she’s got a RASS of minus two. And she went and the nurse went, “Oh,” and I was like, “She’s totally comfortable.”

Our protocol that was decided on this. We are still on have our patients on propofol but they’re also on a fentanyl drip. And so I had her titrated up on the fentanyl drip for physiological comfort. And then it’s still on a light propofol drip, just to kind of help balance things out as she was coming out of her RSI drugs as well. And, and the nurse was like, “Okay,” and I was like, “She can follow directions. She can tell me that she’s not in pain. And she understands she has two tubes in her throat. One is the ventilator and one’s the orogastric tube and she is not pulling them. She’s not restrained. She’s in bed, and I’m chillin next to her. And she’s kind of half dozing, half waking up and can communicate with me.”

I’m she’s like, “Oh, okay. All right.” And I got out to the room and we started transitioning and our ICU is wonderful when they need us in the room. There’s a crew that meets the nurse and the RT that bring the patient off. So we there’s usually like five or six of us in the room to transition that patient over to the much more comfortable bed and get them situated. And so I looked at this patient went “Okay, cross, your arms are about to move you over.” And there’s another nurse in the room that said, “She’s awake! There’s an eye open!”- that the nurse was taking her and I went, “Yep, she’s like, and she can follow directions. And it’s okay, she’s comfortable.”

And we transition are over and I I do this trick with the ones that identity I have a passion for sign language. So before I intubate, or the doctors intubate, if are stable enough, I teach them how to sign yes and no. And signing yes and no. Yes. It’s just a fist that you shake up and down. Like you’re nodding your head. And no is like you’re cracking your fingers like a duck. And I’m like, “even if all you can do is stick out your fingers or make a fist, I’ll know that yes or no.”

And so I taught the nurses upstairs that as well. And I looked at her, using her name, and said, “Are you comfortable in this new bed?”- and she made a fist and I was like, “great. Are you in any pain?” And she put out her fingers? “No. Okay, everybody good. I’m out.” And they were like, “Okay, bye.” I don’t really know what happened to her. Because that’s the nature of ER life. You give the patient up and hope that they do well, and move on. But that was my first experience. And since then it’s only gotten better. Now when I take them upstairs and they’re awake. The other people they’re more like, “Cool. They’re awake.”

Kali Dayton 18:49
What impacted the culture? And I’ve repeatedly said, I think when it comes to this, “Seeing is believing”, so you’re just giving them the opportunity to see. I mean, it’s hard to validate sedating someone when they’re already saying, “I’m fine. I’m comfortable, don’t sedate me.”— You’re giving them their autonomy right away. The concept of someone being awake on the ventilator is usually immediately imagine someone thrashing, biting, trying to pull out their breathing too, because that’s what we see when we do sedation vacations in the ICU.

And patients that have been sedated and are delirious. So you’re allowing them this obligatory insight into here is a calm, awake, alert patient that is free of delirium, and autonomous and it sounds like it just resonates with the nursing soul, right? The ethics of nursing. It doesn’t take much convincing after they see that. And I love that you teach them a simple sign language. And that just goes to prove that they retained that. They were Yeah. sedated came out and they remembered that and utilized it. And now the rest of the team gets to continue that and hopefully they’ll have other tools for communication but you immediately You’ve treated them as a human even during the critical illness in the ER. And you’re setting them up to have that kind of humane journey in the ICU. That is so powerful. And what kind of feedback have you heard from the ICU, or from nurses that you’ve exposed to this process?

Julie, RN 20:17
So from the ICU, just from a handoff, I feel like there is a shift in the culture up there. And they’re like, that’s really cool. Like literally the last one I took out, there was one of the people in the room that was helping transition and I told the patient, we’re going to get you ready to cross or to go into the bed, so cross your arms, and I can still see her face. She does, “She’s awake. So cool. Thanks for doing that.” And got her over. What I think is super interesting, too, is I hear all these stories about like these thrashing terrible, delirious patients, I haven’t had that experience at all with any of mine.

And I think it’s just because even one that we had that was a status seizure patient that had gotten benzos and ended up intubated, I was really surprised when she started waking up, and I was like, You’re, you’re waking up, and I like right above her, and you’re in the hospital, you have a tube down your throat and sort of walking her through everything that was going on. And she woke up fine. And without thrashing or biting as soon as long as I was able to stay with her and keep talking her through, I was like, “You’re in a safe place. You know, you don’t remember what happened, we’re gonna walk you through it, just hold my hand, hold my hand for the moment. And I’ll walk you through what’s going on.”

And that one ended up being really powerful. That was one of the cases where we didn’t know her name even. And I wasn’t able to, she never woke up enough for me to like, give her a pen and paper to get her name. But I later heard through the grapevine that she was able to write down her name, and you’re able to get history turned out that she had been, we just were told that she was seizing outside our liquor store. So we were just treating her for seizures, turns out she was assaulted, and ended up with multiple internal injuries that we had no clue about. Because all we have what was in front of us. And because we were able to, or because I would like to say, because I let her wake up. And she was able to communicate, they were able to get that story much faster than they would have had otherwise.

Kali Dayton 22:17
Oh, absolutely. I wonder all the time? How are we getting full history full information, especially those patients that I mean, the “Awake and Walking ICU” is by a homeless shelter, and a drug park. And so there are lots of people that come in, identified. And our goal is to identify them and who better to defend themselves. I mean, I’ve had people that, you know, they’re telepathic, for different kinds of reasons. We look in their wallet, we get a card and ID. But once they come to, and they can tell us who they are. It’s not the ID that was a fake ID. So that was helpful to us, we couldn’t find family off of a fake ID and things like that. So also, pain is such a huge vital sign and it tells us so much. They’re having an internal bleeding, abdominal pain, you can’t get that from someone that is just comatose. So I’m sure that totally changed her trajectory because you allowed her to wake up. So that is such a powerful example. And how has the perception been in the ER, or any? Is anyone else getting comfortable with this?

Julie, RN 23:22
So I, I have some friends that are trying it. And they kind of know what to do. But part of it is they’re waiting for the rollout and the actual education because we’ll do some education for everyone with it. When I first started talking about that people were like, “Excuse me? What? You know, there’s no way if I’m intubated, I want to be sedated.” And I was like, “Really? Do you want to? Do you want to trust your family to make the right choices? Because how many times do we see families change the choices that the patient has made? ”

And they would stay at me and be like, “Oh, I hadn’t thought about that.” And I was like, and “If your pain can be controlled? Do you care? Wouldn’t you rather have a voice and what’s going on with you? I mean, you’re medical, when would you rather know what’s going on with you?” And they’re like, “Oh, yeah.”—And as soon as I say that, they’re like,” Okay, what, what else? Tell me more.” So I tell them more about the research. And they’re like, “I haven’t met anybody yet. It’s been like, no, that’s still too crazy”. Everyone’s like, “Okay, let’s try it. Tell me what to do. Like, let me know when we’re ready.” And when we’re doing this, and when I have all the tools teach me how to do it. Everyone’s incredibly curious about it, and willing to try.

Kali Dayton 24:31
That’s so validating. And I remember years ago talking to a medical director about this. And he said, “Oh, well, we good luck. We can’t get our nurses do that. They’ll never do that.” Oh, and that gets me so angry. It still makes my blood boil years later. It’s not our culture at all. Oh, and I was thinking, “Obviously you don’t know nurses don’t know the heart of nurses. They don’t sedate patients just because we want to torture them. It’s because we don’t know what we’re really doing to them. We’ve been uninformed and unsupported in these changes. And once we understand the big picture, watch out nurses are going to overhaul this process like you’re doing.”

One of the questions that often, well, not often, but a few times I’ve received from teams when I’ve been doing webinars with them is, “What do you say to them when they wake up?”- That is a genuine concern, because it’s such a new process to communicate with patients that are intubated. This seems to be innate for you. So what recommendations would you give it sounds like you’ve been doing the right thing? And how do you you’ve given them tools for communication? And how do you know what to ask them, or how to calm them down?

Julie, RN 25:41
Well, either not freaking out on me, because I haven’t had that experience. The only times I’ve had patients that have been really struggling and the ones that I’ve tried to kept them super sedated, or they’ve been bucking the vent really hard. And I think those are though they were early in my career, and also in peak delta and COVID. And those patients are coming in with saturations and like the 50 percents and their hunger drive is or their air hunger drive was so deep that I don’t, I don’t know that anything else helped them at that point had been hypoxic and had been hypoxic and possibly hypoxic for days, and just they’re, they’re worse. So ill.

So I think there’s a subset that we’re always going to struggle with. But the ones that are all of my experiences and waking up patients, it’s because they’re coming out of sedation, and because I do keep the propofol going for them. I mean, there’s so talking with our medical director and our one of our lead pharmacists that because we’re doing so many interventions in the IDI, the decision was to keep propofol available for all of our patients like we’re realigning bones and casting and suturing and all these other things that we would typically do consciously patients for so keeping propofol going for them that we can also do boluses, and give them a little bit of conscious sedation to help them manage through these more invasive things as we stabilize them to get them up to the ICUs has a benefit for us. So all my patients that I’ve woken up, have propofol still on board that they’re usually very low rates, like we can titrate a protocol up to 50.

And I don’t think I’ve ever gone past 10 Since I started doing this, and I just titrate up their fentanyl instead. And we can bolus off our pumps both fentanyl and propofol. So I can just kind of control everything internally off of my pumps and not have to do anything too crazy, like running to my Omni cell and finding other nurses and getting the waste and leaving my patients that’s waking up by themselves can do it all right next to them. So that’s really helpful, because I’m never leaving their side, and I can let them slowly wake up. So for instance, some of our doctors love atomic date, and some of our doctors love succinylcholine.

The ones that get succs are gonna be coming out of that, not even by the time that they’re finished securing intubation device, so that might give it some extra propofol to because they’re, we’re still doing major interventions, I still have to shove another tube down their throat for their OG, like I still have to do some invasive things with them. So I can very carefully control them coming out of their sedation, and get their pain under control. And focus on that. And I think once I get their pain under control, and their discomfort with this whole situation, pulling them off the protocols really easy. And I just slowly back off of it for like the next half an hour to the hour that I have them and then let them make up little by little. And I’ll tell them “Do you want to sleep a little bit more? Do you want to go back? Are you uncomfortable?” And if they tell me “yes”, I’ll give them a little bit more propofol or I’ll give him a bolus to let them relax a little bit more. And then we’ll kind of just I’ll just work with them and let them tell me what they need and then haven’t had any issues with them. Really buckling and trying to pull anything out because I’m giving them the option of what they want.

Kali Dayton 29:00
Oh, so and you’re really applying that PADIS guidelines. But yeah, I’ll go sedation and I know I knock on propofol all the time. And I’m really talking about when it’s given for days to weeks. Oh yeah, sure. And it’s a great medication for procedures for sued for surgery and things like that. That’s really what it’s meant for. And that’s where it has the most benefit. So, yeah, while you have it there and you’re doing those procedures that no one should have to be fully conscious through. That’s a great because that’s not going to induce high levels of delirium or create difficulty in removing later and to do it in such a way in which the patient gets to navigate and dictate what they want and what they need. That is the ABCDEF bundle. So not consultation, but in reality the “Awake and Walking ICU” isn’t always a sedationless ICU If needed, we can give it and we give it for those purposes for to meet those goals and humanize the process, but also to in a way that it doesn’t create a barrier, or increase their likelihood of dying. So these aren’t just bad medications, you can learn how to use them appropriately. And I think you said a really good example of that, that that is an appropriate time you’re continuing to do interventions and procedures. Use it, you’ve got an airway. And still, even during those procedures, you’re not deeply sedating them.

Julie, RN 30:31
Yeah, no, I’m just trying to bring them down enough. So they’re not as aware of it, and able to mitigate or manage their way through it, and not fight us as we’re going through. It

Kali Dayton 30:43
was just perfect. And it kind of question of: Why does someone with pneumonia that’s not getting a limb casted have to be at a RASS of -4?

Julie, RN 30:51
yeah, yeah. And I think the other really big thing that I’ve been noticing, too, with communication and learning how to communicate with these patients is you have to be very direct and very simple with all of your questions with them. Because especially initially, as a coming out, they basically only have yes and no in their brain. And they’re not going to want to be communicating a lot more. So very pointed questions. And when they tell me they’re in pain, I’ll start like touching them in their body. “Does it hurt up here? Does it hurt down here?”- and we’ll play like a game of warmer and cooler until I can figure out where it’s hurting for them, and then go from there. Because then I can also communicate with our doctor, hey, I innovated them, hey, they’re on offense, rip of this, they’re still in pain, and they’re seeing the belly hurts. Like, where did that come from? And the doctors are like, where did that come from? And they come back into the room and they reassess them and try and figure out what’s going on next and go from there.

Kali Dayton 31:43
Oh yeah. I’ve always been a how do you do that as a neuro exam, but the full assessment if someone’s not participating in the exam?

Julie, RN 31:51
Yeah. I mean, that’s been the hardest part for me transitioning into ED and transitioning into these intubated patients and sedated patients. Because I don’t know how to assess these people. Like I am used to kids, but they’re awake kids and kids can’t always telling you how they’re feeling. So like, young kids kind of give me the tool of like, really looking at the physiological state? It was so strange to just stare at this, like fully sedated adult and be like, “how do I know what’s really going on? I don’t. I know your vital signs. And I know I can listen to your lungs and your bowels can feel your pulses and look at your skin color. But what’s really going on with you?” Like one of the reasons why I liked switching to adults is I could ask them questions. Can you fully? Tell I’m like, I can’t do that with you. But you’re an adult. That feels really strange.

Kali Dayton 32:41
And I think the differences in the ICU, it’s so normal that we’ve stopped questioning that. “Well, they’re intubated. So therefore, that this is all I’m gonna get.” Yeah, where are you as you’re coming in with fairly new eyes coming from peds and coming from inpatient? Er, is new intubation is new. You’re actually critically thinking through it and saying, “This isn’t a full assessment until I hear it from them? Or could I get more out of them?” And I love that you innately reorient them. And probably many times you’re, you’re an ER you the intubated, here’s what we talked about, and reminding them and I think I imagine that that brings a lot of the peace and the comfort and the trust that you’re experiencing from patients because you’re informing them and taking that time.

Julie, RN 33:29
I hope so. I’m not on their side. But I hope so.

Kali Dayton 33:33
Right there have been intubate it’s a lot of my sense has come from survivors themselves. Those who didn’t have this process of candles that did and they appreciated being formed in episode three, with Susan east, the three times ARDS survivor. She said that one of the reasons after her first time with Arias, she had documents drafted with her attorney, protecting her gets sedation was because she wanted to have her autonomy. She loved her family, but didn’t fully trust them to make those decisions. And so even in subsequent times with a ventilator, she was had ARDS two more times after that. At one point, they want to do a bronchoscopy. And her family was saying, “no.” And she’s like, “hi, right here, I’m awake, give me the paperwork, and she signed it.” But it makes my head hurt as well that he didn’t talk to her about it, though she was awake that was probably really unique for the team and only happened because that was her Advanced Directive. Sure, it probably still hadn’t crossed their mind to get authorization from the patient herself. But that should be the norm. Yeah, that’s in that we have to go to outside sources for authorization, but the patient should be able to navigate their own care even during critical illness for the most part.

Julie, RN 33:33
Yeah, I think that part that struck me the most about learning about being awake on a ventilator was that like that? For me personally, that was the key moment. I was like They can make their own autonomous decisions. Yeah, of course, I’m gonna want that for them. Like, that’s just an obvious thing that I think that everybody who’s sick would want for themselves. And I love families, and I love how much they care about their family members. But the number of times I’ve seen DNR is revoked or changed, because in that moment, that acute fear of losing your loved one over took all their good judgment.

Kali Dayton 35:31
And I think patient autonomy is one of the nursing ethics, right? I can’t remember exactly the clause or the wording, but it’s part of our nursing ethics is to allow patients to be informed and autonomous.

Julie, RN 35:41
Yeah, and I think that’s the biggest thing for me, like I try and look at my nursing philosophy is I’m going to treat every patient how I would want to be treated if I was in this situation. And that’s just kind of how I keep my personal sanity going. And so the idea of me being so out of it, that I can’t make my own choices in my own health is very scary for me. So I, I try as much as possible to keep that going for my patients. And so waking them up as part of that, and letting them start making choices. And if their choice is that they want to go back to sleep, and that’s their choice.

Kali Dayton 36:17
No, I mean, means back to sedation, I guess. No police? No, they should have have a choice. And I remember that was being challenged to me. When I started the podcast. I was saying give patients a choice. But then I realized, people started asking me “Well, do you let your patients choose?” I thought, “no, I guess I don’t, we just will say when you are in after intubation, you’ll wake up and then we’ll keep talking about this.” And so I went out to, I don’t know, maybe two dozen of these patients were intubated and made it sort of making the thing to say, “Would you like to be sedated right now?”

Every single one said “no”. And they even looked at me like I was crazy or wrote on the board. “Why?” And I’m like, I just thought I would ask, “I don’t know”. But I still think it is important to say “this is an option”. But when we do that, and especially when we do informed consent for like any procedure for intubation, whether it’s we’re informing the patient or the family, we need to include sedation as part of that. But we have to include the risks involved. Otherwise, it’s not a true informed consent. But we’re not doing that because we ourselves don’t understand the risks. We don’t understand the options, and then we don’t provide that kind of transparency, and the options to our patients. So I have a whole episode on that. But I just along those lines of autonomy, we have to be transparent and honest about the options and the risks involved in either side.

Julie, RN 37:43
Yeah, I will admit, though, every the times that I’ve been able to tell them that we’re, or we’ve talked to them about their innovation, and then I told them, hey, I’m gonna wake you up afterwards. And there’s gonna be tubes down your throat. This is how you say yes, and no, I haven’t really given them the choice of waking up. But once they’re awake, I will look at them and go, “Okay, you’re awake? Are you in pain?” and then we deal with their pain first. “Okay, I can give you drugs to make you feel more sedated. If you’re needing more comfort? Do you need that comfort?” And then we’ll go from there. And the three that I’ve had that have been in that situation, none of them have said “yes. But I’m open.”

Kali Dayton 38:21
It is a lot to say, “Here you are in the verge of death, we could do the thing that could definitely increase your risks of death that we could give you delirium, which could traumatize you and or double your risks of death….”- It seems like a lot to explain that in the moment when they’re already having whatever instability that certain is a breath hypoxia, that’s requiring intubation. So I personally haven’t found a moment where it felt right to say here all the risks involved unless maybe pull the patients that are on high flow for a long time.

And we say, “you know, down the road, you could need to be intubated here, your choices, things like that.” But absolutely, once once they’re intubated, and they’re awake, and they can compare – “how am I doing now?” And what I prefer these risks? I don’t know, I don’t know exactly when the right time is. But I do think that, I don’t know it just it also feels weird to give an option of we could set you up for much more trauma, disability and death if you’d like. What do you do? It isn’t kind of intuitive. Even if there isn’t an option, if someone absolutely require sedation, we should be telling families that “this could cause delirium. And here’s what that could look like.” And to prepare them –not to freak them out, but to help them be prepared to help their loved one rehabilitate and be part of that process and to help us get them out of sedation. Because it could be difficult when they do have delirium. So there’s a lot of education on all the team members, that means Yeah, but yeah, and part of that,

Julie, RN 39:43
yeah, and I don’t think we ever get that option in the ICU like we’re not we’re never innovating people on a slow roll. Right. That doesn’t really happen. We’re always innovating people in an acute situation and we’re just meeting them like the I don’t think I’ve ever had a patient that we intubated that we had been sitting in our ear for more than 45 minutes.

Kali Dayton 40:04
Right, no that’s true. That, yeah, that’s just not the time to be chit chatting,

Julie, RN 40:09
ya know,

Kali Dayton 40:10
Once they’re stabilize, you’re already taking that opportunity to say, what do you need?

Julie, RN 40:15
Yeah, but I think once we can give them the autonomy to start making choices than we should, that’s just part of any medical process, or Doc, I mean, our doctors are doing it as well, they’re I was giving our patients their choices.

Kali Dayton 40:28
So and maybe that’s a perspective that can be shared. It’s almost like you’re seeing the ventilator as enabling them to be stabilized, to communicate, to be comfortable to make decisions.

Julie, RN 40:40
Yeah.

Kali Dayton 40:41
Whereas we’ve been seeing the ventilator as this door that you go through, you shut it. And that’s it, they don’t get to be human anymore, because they walked that door and needed to be on the ventilator. Yeah, you’re flipping that you’re changing that in the ER, and then the ICU. And I think that is so powerful. And it keeps saying one clinician can start breaking down these barriers, it’s going to take the whole team, but you’re chipping away at it already. And I just am so grateful for your powerful example, initiative and testimonial, is there anything else that you would share with the ER and ICU community?

Julie, RN 41:14
I think the ER and as you can be, I mean, we work so closely together in completely different ways. But in the end, I feel like we’re just such partners. And I wish there was more communication, I recognize that what’s going on in my hospital in my hospital systems a bit unique because we are transitioning to wake in walking. So it’s easy for the IDI to transition with him. But if there’s our ICUs out there that are awakened walking, and you’re haven’t partnered with your ad, reach out to them, and talk to your doctors and your nursing leadership and see if you can have them start helping you because it we are in a spot where we can start helping you.

And I think you I think ICUs be really pleasantly surprised that II II these are filled with incredibly intelligent nurses and doctors that want to do the best for their patients, and are happy to partner and set things up. Because that’s inherently what we’re doing. For every unit, we’re trying to get the patient, stable and pet for whatever, wherever they’re landing in our hospitals. That’s our end goal for all our patients. And so what we have to do to help make that happen. Absolutely happily do. And then. Yeah, I think that’s the biggest thing. So if you’re if you’re working in a hospital where you’re waking patients up in the ICU, talk to the ICU, see if they can partner with you, they you might be really pleasantly surprised that they would happily do it.

Kali Dayton 42:39
And maybe I had done the same thing make the same assumption as people do. When I assumed that the IDI wouldn’t really be interested in it. Yeah. And then now I’ve interviewed someone for EMS, and now an IDI nurse. And that just proves that in every facet of our system, there are caring people that are willing and anxious to make whatever impact they can’t at the patient survival. That’s what you’re doing at nurse, but now you’ve found another way to contribute to their ultimate success. And you’re all over it. And that is probably a shared mentality and willingness that we just have to tap into and connect with.

Julie, RN 43:15
I mean, literally the conversation between me and my chief. I was eating lunch, and he was walking through the lounge to his office. And I was like, “Hey, I need to set up a meeting with you.” And he goes, “Oh, what about and was like, I told them a little bit. The project has awakened walking ICUs. And just stared at me. And as I told them a little bit like, “okay, yeah, that’s fascinating. I’m gonna go look that up.” And yeah, we’re meeting. And it was so it was so immediate. But his immediate response is, “oh, people do tha?”- because we don’t live in that world. And then as soon as I told him about it, he goes, “Oh, I’m looking that up.” And he was immediately on board.

It was such an easy thing. So I, the initial response might just be, “hey, we don’t know about this.”

Kali Dayton 43:57
Exactly.

Julie, RN 43:59
But at least from in within our system, the response is, “Yeah, I don’t know about that. Oh, that’s really cool. Oh, yeah. Let’s totally support our partners. And doing this. We’re on board.” And I mean, our protocols do have limitations, like there. The first step in this protocol we’re building is: what RASS? Or do you want the patient because there are patients that need to be sedated for neuroprotective reasons for other reasons. And so our doctors will make that choice. And then it’s us as nurses to to honor the choices of our doctors, because they’re the drivers of that those things. And then from there, they pick their medication profiles for these patients. And even the orders that we’re hoping to have built it automatically defaults to a RAS of minus two. And then if they want to change it, they have to make a comment as to how long they want that patient at a deeper RASS level.

Kali Dayton 44:50
That could allow for lighter rest as well.

Julie, RN 44:54
Yeah, it can. So we picked a rest of mine as to what are the other things that I’m not sure I see. You kind of put So now there’s actually a really great research going on. Dr. Freeman at Vanderbilt is doing a lot of research on intubation protocols in the ED setting, because most of the intubation research is being done in the ICU setting. So he’s doing research in the ED setting, and specifically in analgo-sedation. So the protocol that we’re going to end up following is very much off of one of his protocols that he published on.

And his research shows that big just because of the time constraints that we typically have patients, a RASS of minus two to minus one is more realistic for us, we’re not going to get them to a zero. They’re just walking, hopefully not going to be with us that long. And especially now in kind of this more stable COVID world, like we’re seeing our holding times go down. And there’s a lot of research to that shows that holding any patient in the ER for more than four to six hours starts impacting their morbidity and mortality, whether it’s like a patient going through a med surg, or an ICU, it doesn’t matter. We as ER nurses just can’t provide the best care for these patients, because we’re always changing our focus based on the acuity of our other patients. And you could at any moment has, like four patients that are all going to be discharged to the street, or you can have four ICU patients or any mix there. And because that’s what our ratio is four to one.

Kali Dayton 46:22
And the point isn’t to create an ICU. Er, yeah.

Julie, RN 46:26
So there’s the role. Yeah. So the realistic is research showing that the kind of realistic number for Ed nurses to and doctors to aim for is arrest at minus two. And hopefully at that point, they’re going up to that ICU. Now, if they get stuck down with us for longer than we can have a discussion with our doctor. And we in this protocol, we even have the option of we don’t use precedents in our year, very much. It’s very rare. And I don’t know a lot of ers that use precedents? I know it’s a question that I asked. The response was just unfamiliar.

Yeah. And our pharmacist is this pharmacists I’ve been working with is one of the smartest men I’ve ever met. He’s, I don’t know how he holds this much information about drugs in his brain. And his response was, let’s do it. I’m open to putting it on the order set. And our chief was like, all right, but let’s have conversations when we do it. And so I think if we are starting to hold the patient for longer, and they are mostly off their project, we can already talk we can talk about switching the precedents instead. But we have to learn how to do that in our ER. So our pharmacists, like when you’re when we’re ready to do education, I will sit down and do education of all the nurses about how precedents works, and how we titrate it and how we do everything. And he’s ready to stand by your side and teach us so.

Kali Dayton 47:53
Oh, that’s so exciting. I’m a personal fan of precedex, even though in the “Awake and Walking ICU”, it’s still rarely used. So really your first go to Oh, yeah. And if it’s used, it’s often you know, if they have a high RASS for using it to get them to a RASS of zero, hardly ever deeper, but can go deeper. That’s why we see some of these other studies that comes aren’t that different, because they still got them to a deep like a negative two, with precedents, but nonetheless has lower rate of delirium or less brain disruption, the outcomes are different. So even if you’re setting them up on a precedex strip, and that’s, for whatever reason continued in the ICU, you’ve still improved an outcome just because you didn’t have midazolam or propofol. Yeah, so I’m a fan.

I think that’s, that’s an exciting update as well. When in the “Awake and walking ICU”, usually patients are fully awake, not on anything right after intubation, and then we go from there and see what they need. And that works really well. But I think even what you’re doing is even arrest, too, and having but it sounds like if they’re doing hand signals that they’re probably a little bit of lighter wrath, at least at some point. And showing ICU nurses that that is what they’re capable of, and having them expect that and want that you’re changing outcomes significantly. Julia, I’m so proud of you. And like that. That is the power of nursing there. And I’m just excited to hear your updates Keep us posted. Let me know. And I’ll keep sharing on social media, any cool stories that you have, Sheriff, this is so powerful, and I appreciate everything that you’ve shared, and you’re doing for your hospital system, and the community in general.

Julie, RN 49:24
I am just really excited to be in a hospital system that’s so supportive, and in a department that is so supportive. I mean, even my doctors, like when I innovate, because we don’t have the protocol set up. I just tell them what I want. And they’re like, cool, we’ll do it. And I’ll look at them and be like you “you’re okay with me waking this one up”. And they’ll be like, “sure, yeah, do it.”

Kali Dayton 49:46
That’s how the “Awake and Walking ICU” started as the nurse saying, “what if we did this?”- and this was back in the 90s of Polly Bailey going her medical director and he says, he thought that well, that sounds crazy. But he trusted nursing instinct. And that’s what we need to work together. are with us trusting each other working together to achieve these goals and just sticking with what we know, or this hierarchy that does nobody any good. Yeah,

Julie, RN 50:08
we very much don’t have that in our er, I love that the partnership that we have. And we’ll just continue to say how grateful I am to all the support that they’ve given me in this project and continue to give me as I continue to kind of roll it out. And I’m really excited to see you are our department goals and our hospital system as a whole goes with it because I think we can provide really great we do provide really great care and we’re just continuing to step forward in that for our patients, and the most educated way that we can.

Kali Dayton 50:40
Not so powerful. Well, thank you so much. Appreciate it. Yeah, thank you to schedule a consultation and connect on social media, as well as find supportive resources including case studies, ebook episode, transcripts and citations to research. Please visit the website www dot Dayton ICU consulting.com

Transcribed by https://otter.ai

 

References
Early deep sedation is an independent predictor of increased mortality:

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0176012

https://pubmed.ncbi.nlm.nih.gov/22859526/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4435917/

Moy, Hawnwan P. MD1; Olvera, David BA, FP-C, NRP, CMTE2; Nayman, B. Daniel MBA, NRP, CCP-C, FP-C3; Pappal, Ryan D. BS, NRP4; Hayes, Jane M. MPH4; Mohr, Nicholas M. MD, MS5; Kollef, Marin H. MD6; Palmer, Christopher M. MD, FCCM7; Ablordeppey, Enyo MD, MPH7; Faine, Brett PharmD, MS8; Roberts, Brian W. MD, MSc9; Fuller, Brian M. MD, MSCI7 The AIR-SED Study: A Multicenter Cohort Study of SEDation Practices, Deep Sedation, and Coma Among Mechanically Ventilated AIR Transport Patients, Critical Care Explorations: December 2021 – Volume 3 – Issue 12 – p e0597
doi: 10.1097/CCE.0000000000000597

Delirium recognition, prevention, and treatment in the ED:

Sangil Lee, Michael Gottlieb, Paul Mulhausen, Jason Wilbur, Heather S. Reisinger, Jin H. Han, Ryan Carnahan,
Recognition, prevention, and treatment of delirium in emergency department: An evidence-based narrative review,
The American Journal of Emergency Medicine, Volume 38, Issue 2, 2020, Pages 349-357, ISSN 0735-6757. https://doi.org/10.1016/j.ajem.2019.158454.

Tools for helping with ETT comfort:

Checklist for endotracheal tube tolerance

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