Episode 115: Sedation By Race

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We know that prolonged sedation and immobility are lethal. We also know that there are significant racial disparities in outcomes in the ICU. How does race impact sedation practices? What role does sedation management play in racial inequality in critical care medicine? Dr. Thomas Valley shares with us his invaluable research into sedation by race.

Episode Transcription

Kali Dayton 0:00
We know that our health care system is riddled with inequality when it comes to race and care. This is one of the most important episodes on the podcast when it comes to humanity and equality and Critical Care Medicine. How does race impact sedation and mobility practices? We know that the more sedation and immobility, the more death and poor outcomes there are. Could this be one of the reasons why minorities have worse outcomes and the ICU? Dr. Valley joins us now to share his important research that dives into these key questions. Dr. Valley, thank you so much for coming on the podcast. Can you introduce yourself to us?

Dr. Tom Valley 0:39
Absolutely. My name is Tom Valley, I am an assistant professor in pulmonary critical care at the University of Michigan. I work primarily in our ICU at University of Michigan, as well as in the ICU at the VA. And Norbert, and I’m also a researcher. And my research focuses on trying to understand how we deliver care to critically ill patients and how we ensure that we’re providing the best possible care to all patients.

Kali Dayton 1:03
Excellent. And I reached out to you because I saw one of your recent publications, I think from this year looking into the correlation between race and sedation practices, and I was really excited because that’s something that I’ve wondered for a long time. What inspired you to evaluate sedation practices by race?

Dr. Tom Valley 1:27
Well, you know, I think it was it was very much motivated by my own experiences during COVID. In particular, you know, we we took care of a lot of really sick patients with COVID, especially early on, Michigan was hit pretty hard, in March, April, May of 2020. And we were taking care of really sick patients. And as a result of how sick they were, how little we knew about COVID at the time how scared we all were, you know, we were really sedating patients very heavily, right? We didn’t want people to self-extubate. We wanted to minimize the amount of time that nurses and physicians and respiratory therapists were in the room. We knew how long it would take to get into the room if someone did self excavate or had a problem. And so we were just sedating patients so much more heavily than we typically did.

And so when we looked back at that period of time, and we saw how high our mortality rate was, when there were papers coming out about how, you know, if a patient got intubated, it was essentially a death sentence early and COVID. It made me wonder whether it was really about mechanical ventilation, or whether it might have been some of the things that we were doing to those patients, as practical reasons. And then, in particular, when you look back in that time, there were specific groups of patients who were particularly prone to be hospitalized with severe COVID minoritized populations, marginalized populations. And so when you look at the huge mortality gaps early in COVID, between black and brown patients and white patients, not only did Black and Brown patients, perhaps, perhaps have more severe disease, but also we were providing care that was not necessarily standard of care, for practical reasons. Those things really motivated us to look into how do we deliver sedation, to sedation to critically ill patients, but during COVID, but also before COVID as well?

Kali Dayton 3:42
Yes, absolutely. You bring up so many important points, how much of our mortality was just because of COVID were directly related to mechanical ventilation. Or because of all this Aquila of deep sedation and mobility. Obviously, you’ve been aware of the repercussions with deep sedation and immobility. But I think a lot of the ICU community was not there had been movement from leaders from above to practice the ABCDEF bundle. But I think there’s this gap of education that most people do not understand the real risks related to those interventions. And so when it came down to a crisis, we ran back to it without even having the tools to do a risk versus benefit analysis and also for practical reasons that you’ve listed.

Dr. Tom Valley 4:30
And, and Kali, I think the struggle now is I think we had as a as an ICU community made a lot of progress in reducing the amount of deep sedation that we used. Pre COVID. Yeah, then COVID essentially normalized deep sedation again. So now we’re right back where we were before in the struggle to try to reduce deep sedation again.

Kali Dayton 4:54
Absolutely. I’ve had teams reach out to me for consulting the education teams that had participated in At 2018, A to F bundle study. But with a turnover in staff. We lost so many seasoned clinicians that understood that had participants participate in those studies had it perspective had that kind of maturity. And now we have all these new clinicians that came in during COVID. And, and reasonably. So that’s all that they know. So this is so multifactorial, but I really appreciate that you got on the Watchtower looked at the big picture and tried to figure out what are the other factors can contributing to these big this inequality? That’s right, and our process of care? And the outcomes that we’ve seen in our in our patients? Obviously, the minorities, have comorbidities have certain risk factors that make them at higher risk of being sick or having poor poor outcomes. But then in your study, what did you see about how they’re treated in the ICU?

Dr. Tom Valley 5:55
Yeah, so you know, we looked at patients pre COVID. So this, we actually looked at a randomized trial, we looked at the Rose trial, which was for neuromuscular blockade, several years ago, probably about five years ago when style study was actually going on. And so what we looked at was the controller, the usual care arm in that trial, and that trial was done in a major academic centers throughout the country. And and so in that control arm, we looked at, specifically, differences between Hispanic patients and non Hispanic patients. And we looked at the amount of sedation, the sedation depth that those individuals were sedated to so again, control arm, a gent most of these patients were not receiving paramedics, at some of the, you know, most kind of Premier academic institutions around the country, what we found that Hispanic patients spent about the equivalent about one more day, while mechanically ventilated, deeply sedated than non Hispanic patients. And what’s interesting is in that rose trial, there was only one subgroup that actually had a mortality difference. If you remember the word trial, it was looking at neuromuscular blockade, essentially a negative trial, right? There was no difference between the use of paralytics and not using paralytics. And it’s

Kali Dayton 7:15
It was discontinued pretty early, right?

Dr. Tom Valley 7:19
That’s right for because they didn’t think they were gonna find in fact, but there was one subgroup where there was a mortality difference, and that was in the Hispanic patient population. And so we hypothesized that perhaps that difference there, kind of like what we’ve talked about related to COVID might be related to how we were treating these folks, right, that we were providing care differently for these patients. And that’s what we found was that actually two kind of interesting things. One was that Hispanic patients were more likely to be deeply sedated. And two, that the hospital you’re at very much matters, right? That’s not surprising, but Hispanic patients tended to be at certain hospitals. And those hospitals tended to deeply sedate all their patients, more than other hospitals, but they still deeply sedated Hispanic patients even more than their other patients.

Kali Dayton 8:11
Oh, interesting. That is a good point, right? We see a lot of variation in sedation and mobility practices by hospital, even by team within the hospital. So if they’re already getting a shorter stick as far as being sent to the wrong hospital,

Dr. Tom Valley 8:26
that’s right. It really highlights how much like culture matters in the ICU, right? How you were trained, who you’re working with. Those are so key to how we deliver sedation, how we move people around how we provide them activity and exercise in the ICU. It’s very much a culture, right? You look at some hospitals out there that use very little deep sedation, because it’s ingrained in the way they deliver care, compared to other hospitals, right? And COVID is an example of how it totally flipped our hospital culture, right, our ICU culture, just overnight, we went from like, using very little deep sedation to like, max out date, everyone. Yeah, exactly. Knock everybody out entirely. And it just flipped our culture. And now we’re just struggling to change our culture, again,

Kali Dayton 9:10
Even within the same hospital system, I’ve seen. So I talk a lot about an “Awake and Walking ICU” on this podcast. A few miles down the road in the same hospital system, there is another hospital that has a bigger reputation and has a totally different process of care and different outcomes. And that was very obvious during COVID. And so we keep on coming back to “this is all about staffing ratios”. And that’s a big key part of this. But even within the same community, same staffing ratios, same mechanical ventilation protocols, same medication protocols. These two hospitals in particular had very different sedation and mobility practices. And it’s because of the culture despite all the same systemic structure that they have.

Dr. Tom Valley 9:55
That’s right.

Kali Dayton 9:56
And so then when you’re looking at these differences in practices and outcomes. Did you measure benzodiazepine use? Or was it just the level of sedation?

Dr. Tom Valley 10:07
Yeah, so we have the ability to look at benzodiazepine use. But when we get down to it, the study in the control arm only had about 50 Hispanic patients. And so it’s difficult to look at differences beyond just like level of sedation when you cut down to it, but certainly like, I would imagine that there are differences in the types of drugs we use for certain patients versus others. And certainly during COVID, right? That was the other thing we saw was, we were sedating patients so heavily, they tended to be younger. And as a result, we were using every sedative we could get our hands on. And so yeah, maybe that was a factor too. In terms of the mortality gap, we were using so much more benzodiazepine than we typically did in our ICU.

Kali Dayton 10:55
Which is painful, because we’ve known for now decades that it’s an independent predictor of mortality.

Dr. Tom Valley 10:59
That’s right. So many things we did early and COVID. Were just trying to keep our heads above water, right? And as a result, we weren’t providing what we considered standard of care for our ICU patients.

Kali Dayton 11:11
Absolutely. Yeah, that is extremely painful. And yet this isn’t to shame anyone this is, this was throughout our community, this was a very unique situation that we were in. Again, when you’re paddling, or when you’re just treading water, you can’t see the big picture. Now, we’re not treading water so much. But now we don’t have the culture and or even often the tool to see the big picture. So when you did this study, it was in different circumstances, right? Or it wasn’t,

Dr. Tom Valley 11:39
this was pre COVID. So this was kind of what life was like before COVID.

Kali Dayton 11:46
And did you measure language?

Dr. Tom Valley 11:49
So that’s a great question. This study did not have language, but that is what we hypothesized to be the mechanism for this difference, right? That, that perhaps clinicians have difficulty communing, communicating with Hispanic patients that perhaps we proceed. Language barriers might result in higher levels of anxiety, that then is perceived as perhaps maybe delirium that then is mis treated with sedatives, that, that our ability to document delirium, our ability to document levels of sedation, we’re, you know, we’re faced with barriers, when there are language differences between clinicians and patients, right, we’re busy at the bedside, we don’t always have time to get interpreters, particularly for routine assessments like cam or for rascals, that, as a result, when there is that language barrier, there are a lot of factors that might come into play that end up with us either overseeing patients or using sedation to treat things like pain, anxiety, and delirium.

Kali Dayton 13:01
And we don’t have the tools to communicate with them if they don’t speak or write English. In general, we have some tools now that are developed, but they’re not standardized in our hospitals. I speak Spanish, and I noticed a big difference in my assessment and my connection, I would receive patients and I’d get a report on them and some different assumptions that I’d go in and actually speak with them. And their level of understanding their needs were completely different than what was interpreted. So this makes perfect sense.

Dr. Tom Valley 13:33
One of my kind of most formative experiences during COVID When I as I speak of medical Spanish, and that I was trained in Miami and in Dallas. And so pragmatically, I kind of needed to pick up Spanish to be able to communicate with my patients and but at Michigan, I don’t have a lot of opportunities to, to use with my Spanish. But there was one patient in particular during COVID, here, Michigan, that I took care of who was Spanish speaking only, and I was the only one on our team at the time, who could speak Spanish with her. And obviously family weren’t allowed at the bedside at that time. This was very early in COVID. And, and she wasn’t yet intubated. But she did a whole heck of a lot better when she was pregnant, awake. And again, that was another one of those things that we didn’t do a whole lot of before COVID. But we were doing a lot at that time. But she had a lot of hip pain. And so she hated being on her belly.

And the only time she would do it would be when I would go into the room and be able to talk to her in Spanish about how important it was that she could lay on her belly for us at least for a couple hours. Because, you know, her oxygen saturation was you know, mid 80s When she was on her back in so she was really on the edge and that was the only way we could get her to do some away crony. But when I rotated off surface, you know, maybe she got sicker but A couple of days after I left service, she was intubated. And you know, maybe she just got sicker, or maybe we just couldn’t communicate her with her the same way. And as a result, those kind of borderline oxygen saturations led to her being intubated. So, absolutely being able to communicate matter so much with a critically ill patient population, who, at baseline are at such high risk for delirium. Now, you take away their ability to communicate, and take away their ability for failing to be at the bedside. You know, that’s a huge problem.

Kali Dayton 15:31
And there’s so much I mean, there’s a gap in medical literacy. There’s probably baseline mistrust. And then, I mean, I’ve, I tell them another upset about when I went to the orthodontist, and El Salvador. And I was pretty anxious. And I and things kind of went wrong, because I couldn’t communicate with them. That’s just with my teeth. That was a partner Tina, this isn’t that was not life or death. And so it’s kind of hard for me to hear about this and just understand,

Dr. Tom Valley 16:02
I mean, takeaway language takeaway, if you think about anybody who goes through an ICU, right, that is so scary, right? And then you take out the ability, like, you know, we as clinicians try to talk people through it, right? Like, hey, you know, I’m doing this, I’m doing that. It’s okay, you know, we’re here to take care of you, you take away the ability to do that. And it’s just us doing things to people, without them actually understanding what we’re doing. I mean, that’s so frightening. Regardless of, you know, medical literacy, regardless of anything, right, like, it is a frightening place for anyone to be take away our ability to communicate between patient and clinician. And it’s not surprising at all, that, that individuals who experienced a language barrier, have anxiety, have untreated pain, have delirium that’s either misdiagnosed or, or develop delirium. I mean, these language barriers are huge problems in our ICU.

Kali Dayton 17:01
It also exposes the gap that we have in our practices as far as how we treat delirium. Even with English speakers, no matter what ethnicity, whatever comes out of out of sedation, anxious, agitated, we’re not trained to assess what’s causing the agitation, we’re trained to mask it to turn it off, turn off note to turn off the psychomotor activity, thinking that we’re turning off the agitation or anxiety and treating it. So how much worse is that? How much more agitated are people when they have no idea what someone’s telling them? There’s no way to really communicate with them. But there’s also not really an expectation to communicate with them. It’s, it’s inhumane.

Dr. Tom Valley 17:44
That’s right. And, and, you know, I think we go about it in a good….I think we were trying to go about it in a good place, right? We think they look like they’re agitated, uncomfortable in pain. And so if we can turn off their motor activity, now, they no longer look like they’re agitated, uncomfortable, or in pain, even though their brains might be our perception of that is no longer there. And so we think they’re doing better, when in fact, you know, we’re probably harming those folks.

Kali Dayton 18:17
Absolutely. And that that’s deeply embedded into our ICU culture. And that so much of what this podcast is about, and this, this study just brings it to a head. We know that there are inequalities in our healthcare system. But this is this is some of the most obvious that I’ve really seen. It’s indisputable.

Dr. Tom Valley 18:36
And, you know, this gets around to, you know, we talked about culture, talked about resources, but like, it’s hard to be a clinician at the bedside, it’s hard to be a nurse at the bedside, and have someone who’s agitated and uncomfortable and in pain, and just sit there and be like, well, you know, like, you know, hold your hand. I’ll try to talk you through it. But that’s still just a very difficult place to be. We wish we had, you know, a medication that we could give that just takes it away. And so sedatives at least outwardly appear to be that type of medication.

Kali Dayton 19:11
Right? “It’s easy”

Dr. Tom Valley 19:13
it’s easy, it makes your life easier too

Kali Dayton 19:18
You don’t know when we don’t talk about the reality of delirium. We don’t talk about the short and long term repercussions. There’s no reason not to that they look more comfortable. They probably are, we assume that they’re more comfortable, and we don’t know. So this is all done in ignorance and with good intentions.

I just keep on thinking about this technology that we now have, it’s called the Vita talk. Have you heard of that? It’s, they initially created the letterboards that are in most ICUs. But now they’re software that loads onto any kind of tablet iPad. And it just has icons that patients can click with words with for phrases. But my favorite part is that it’s in 40 languages. Oh, wow. So the patient can you know, Spanish speaking patient can have in Spanish click on it, it reads it out in English. Oh, cool. The clinician can click on an English and it reads it in Spanish. That’s awesome. How else are we communicating with our non English speaking? Mechanical Engineer intubated on mechanical ventilation patients, right? How else? I mean, that just astounded me. I think I was in Salt Lake City, Utah, most people were Spanish speaking, if they were not English speaking, and that wasn’t really a barrier for me, but I’m thinking about some Mandarin, some different specific Islanders, older generations, I’m realizing that I kind of accepted the fact that it couldn’t talk to them. I really didn’t. I wasn’t panicked about being able to talk to them. I just went off their body language, their body cues, and and how unacceptable is that?

Dr. Tom Valley 20:55
Yeah. Especially when there are cultural differences where like, body cues don’t mean necessarily what we think they mean.

Kali Dayton 21:01
Yeah. No, absolutely. And even medical beliefs within those cultures really understand where they’re coming. That’s right. So cause anxiety, if they’re thinking, you know, we might put like a cool washcloth on their forehead, thinking that’s gonna help their fever. And then I think that that’s gonna make them sicker. But they can’t communicate that and I personally, I couldn’t communicate with those around me, I would, I would be extremely agitated, even if I didn’t have delirium. Even if I could talk.

Dr. Tom Valley 21:33
Yeah, yeah.

Kali Dayton 21:34
So what do we do with this study?

Dr. Tom Valley 21:37
So, you know, I think that that is, you’ve already outlined kind of one important step, which is to try to understand why this happens, right? Is it the language barrier? If it is, well, we’ve got interventions that we can, nicely tailored to that right, reduce those barriers so that clinicians have resources, like you just talked about where they can communicate more easily, right when, when a nurse is trying to go through their daily assessments quickly, right, like they don’t have time to wait for for a interpreter to come to the bedside or

Kali Dayton 22:09
an interpreter isn’t going to work for a patient that’s intubated?

Dr. Tom Valley 22:11
That’s right.

Kali Dayton 22:12
I mean, can they read the scribbles from the camera?

Dr. Tom Valley 22:16
Yeah, yeah. So like, there are interventions that need to be tailored to whatever the mechanism is for this finding. And so I think our key next step is to try to understand why this happens, right? Is it hospital culture, right? Is it just that Hispanic patients might be more likely to be hospitalized at hospitals and ICUs that are just heavies, additive use hospitals. But that’s a whole different intervention, right? It’s less about like language, and cultural differences, and more about aligning those hospitals and those ICUs care with what we believe to be best practices, understanding why do they heavily disobey all their patients, and then being able to get them to a place where they recognize and are able to change the way that they deliver care. So I think the key step is trying to understand why this happened. The next step is trying to eliminate, eliminate it from happening, right? Figure out why it’s happening, and then create interventions that can address those problems directly.

Kali Dayton 23:18
And unless we can identify the problem, we can’t fix it. So if we have people that are not English speaking, especially Hispanic population, apparently, we need to put that at top of our list, right? How do we, we need to recognize that they already have baseline risk factors that are making them more vulnerable to poor outcomes, they’re at a higher risk of mortality. We need to understand that deep sedation is an independent predictor of mortality. So why would you give lethal treatment to someone that’s already at high risk?

Dr. Tom Valley 23:50
That’s right. Yeah, I think sedation is easy to give. It’s hard to stop. But we know, I think most people know that. It’s not a good thing. But it’s just so easy to give, and so hard to stop that. It just takes a really just takes a lot of work to change practice.

Kali Dayton 24:11
And that scenario is a lot of work. When you start sedation, you give a patient delirium, and then you unmask it off sedation, even with an English speaking patient, that is a lot of work when they have delirium, coming from an “Awake and Walking ICU”, where they hardly ever start sedation. That is so much easier. So we just start from the very beginning and see the big picture anticipate what’s the common thinking that this patient develops delirium. It’s going to make things far more complicated.

And if they don’t have an indication for sedation, why not let them wake up after intubation? Give them a tool for communication. Let them dictate if they need something for pain, what they’re experiencing anxiety, help them participate in mobility and things that will prevent delirium that will make the process of care so Much easier for the patients and especially our clinicians. It’s really not a feasible or even fair scenario to expect nurses to keep a patient safe that cannot communicate with them can’t understand them and is experiencing delirium while on the ventilator that’s just not safe or feasible. But we have to change the whole process and rethink all of this. Yeah,

Dr. Tom Valley 25:25
I mean, it’s a dream, I think, to get to a place where we can have an “Awake ICU”, because we’re far from it. And I’d say most ICUs, most hospitals around the country are very far from there.

Kali Dayton 25:41
and we haven’t really, and this is a whole discussion, I’ve been having the podcast, but we haven’t really educated for that. That objective, we’ve implemented the AtoF bundle, even in the times of the most progress, we still did it as start sedation, turn it off sooner, at this subjective time, do sedation vacations, but turn it back on if they’re agitated. I think that’s very complicated. That should be that process should only be for when sedation is actually necessary when there’s an indication for sedation. But we never provided the tools to just not start sedation and just keep them awake and mobile.

Dr. Tom Valley 26:16
You know, one other interesting thing we found in our study, which isn’t surprising, interesting to me is that, remember, this was the control arm of that large randomized trial, big centers around the country. That control arm was they asked the control arm to specifically target lights addiction to not use deep sedation, right, this part of the trial 90% of the patients in the control arm received deep sedation at some point during the first five days of mechanical ventilation. Right, so 90% of patients in a randomized trial where they specifically ask people not to use deep sedation 90% of those patients still receive deep sedation.

Kali Dayton 26:58
So that was measured by RASS, Correct? That was measured?

Dr. Tom Valley 27:01
By RASS. Exactly

Kali Dayton 27:02
Which at least right now, I don’t know about back then, how accurate were the last assessments?

Dr. Tom Valley 27:09
Well, I would imagine these are probably the most accurate because it was part of the trial. Right? That’s true. And during training to us, right? So like probably better than how we typically do rest every day. And yet still, we can do it. Right? Even though that was like a main part that was a major motivator for this study was that prior studies, comparing neuromuscular blockade to deep sedation. So they’re like, Well, when we do it, we’re going to do neuro muscular gains to standard of care, which is like sedation, and they still couldn’t do it. So this is a huge problem. Not just, yeah, not just for, you know, my minoritized populations, this is a huge problem for everyone.

Kali Dayton 27:54
Absolutely, yep. That is, I mean, I, I almost feel like I’m just sitting there at the piano pushing one key the whole time. But I can’t move to the rest of the piece until we fix this problem. It’s almost when we know that A to F bundle decreases mortality by 68%. Why are we bothering with all the other interventions? Why are we just killing ourselves to to then clean up the mess that we create with deep sedation? When, when there’s just an easier way and more efficient way? People say, Well, we don’t have time for that we can’t really keep our patients awake or mobilizing because we’re just trying to save their lives in the moment. Sometimes that is true. But for the most part, it’s that is extremely ironic, that this is how we save lives, especially for our most vulnerable populations. This is what’s gonna make it Yeah,

Dr. Tom Valley 28:43
You know, it’s easy for us, easy for me to sit here and say, We need to make this change. But the fact is, when I get to the bedside, it’s really hard, right? It’s hard to, for me to remember and make sure hey, like, we should not be using deep sedation. It’s hard for me to convince the medical team, the nurses at the bedside that like this is the right thing to do that it’s going to be hard now, but it’s gonna be easier later. Especially when it’s just so easy for us to deliver sedation. When it’s so ingrained in our culture. It’s just, it’s a lot easier to talk about and to actually implement.

Kali Dayton 29:23
And that’s applicable to so many things in our lives. What are we actually doing that’s not productive, not the best or better ways to do? You know, we may know why, but it’s hard to change those auto responses. But I do get the sense that many do not know the why especially the nurses at the minors and training, never learned this. I didn’t really learn too much about delirium. Even after six years of ICU care, I didn’t really understand post ICU PTSD, precisely dementia. I didn’t understand the increased mortality of all of this, like I’ve learned a lot of that through doing my own Research. And so hopefully moving forward, we will learn from COVID.

Learn from studies like yours to really reflect on our practices and question why we do them not just that, it’s how it’s always been done. It’s just what we do. It’s convenient the moment at the travel nurse, I hated awakening trials, I thought that they were extremely laborious dangerous. And I was doing them at five o’clock in the morning and dark room with no support, I just didn’t know what we were working towards. I’d come from an awakened walk in ICU. And so none of that made sense, I still didn’t know the patient needed because they were too agitated and confused to tell me, and then I was trained to just turn sedation back on. So I just think that in our approach, understanding this information, evidence that you’ve provided, should empower us to step back and look at how do we avoid those scenarios?

How do we even avoid sedation vacations? How do we avoid delirium rather than to shorten the duration or decrease the severity, we can avoid a lot of it, we know that either bundle that delirium was decreased by 25 to 50%, even in a smaller dose of the A to F bundle. So we have so much room for improvement, but you’ve provided us with so much more of the why we’re in an era where we’re starting to really talk about these, this inequality in our system, especially in healthcare, this should be just another drop in the bucket, but a big drop in the bucket as to why we need to change.

Dr. Tom Valley 31:30
Absolutely, I mean, so much. You know, I think there are two ways to look at it. On one hand, there’s a lot we need to change, about how we deliver care in the ICU. On the other hand, you know, the things you mentioned, can make a huge difference, right? Like, because there’s so much to change, we have so many opportunities to improve care.

Kali Dayton 31:51
Absolutely. And I think that’s what people have really reaffirmed to me that matters to them. So when I go to conferences, and I started doing that, I felt really nervous thinking, here I’m addressing the group of people that have been through so much during the pandemic have been traumatized, and Hariom, saying, what we’re doing is not the best thing causing suffering and increasing mortality, that that’s a hard thing to say to people that have worked so hard and done so many good things. But they receive it so well. They’re filled with a sense of hope that what they had experienced, the trauma they’ve been through is not what they’re going to experience, they’re not going to have to take care of patients that way that there’s a better way in which they can fulfill the objectives of their careers just to save lives and alleviate human suffering. So even though your study shows some uncomfortable aspects of our system, it should fill us with hope and determination to change those things.

Dr. Tom Valley 32:49
That’s right. That’s right. There are ways that we can keep more people I’ve helped people live longer and feel better, we have opportunities ahead for us.

Kali Dayton 33:02
And in preparation for this, I was just thinking about this, that population that was studied this Spanish speaking population especially. And hold that up to post ICU syndrome. They are some of the last people that should that can really compensate for cognitive deficits, physical impairments, PTSD, they’re the least likely to have access to the resources to rehabilitate. A lot of times they don’t have the financial resources to compensate for loss of career. They’re just not going to be necessarily comfortable and talking about their trauma, things like that. These are especially vulnerable people, not just in the ICU, but after the ICU, and we have the power in large part to determine what the rest of their life looks like.

Dr. Tom Valley 33:48
Yeah, I think the post ICU space is a whole nother area where we know so little right like, post ICU programs tend to be at highly resource centers that tend to take care of certain groups of patients. And yet, we have a lot more data about how we practice and deliver care in an ICU, then about how we deliver care outside of an ICU and particularly for outpatients. And so the post ICU landscape is just ripe to try to better understand who we’re delivering care to how we’re delivering care, and what types of patients were missing, right? What types of patients are suffering silently, because they either don’t have access or aren’t referred, or don’t know about post ICU programs.

Kali Dayton 34:34
I cared for a patient that was admitted for an attempted suicide. And it was her third within a few months. And when I dug deeper, it turns out that she had been admitted for pseudo seizure into a different ICU, was deeply sedated and probably developed delirium and then got in that cycle of being sedated because she was delirious delirious because or intubated cuz she was sedated today because She’s intubated. So she was sedated for I think about two weeks. And her visitation was terrible. But no one really connected with her, told her what she might experience afterward. She had some baseline trauma that she relived the entire time. She was sedated. rape, kidnapping, hurricanes, I mean, she had lived a life. That all came back. But her new cognitive impairments made it so she couldn’t use her coping mechanisms. For it, she was now completely dependent on her son, she’s she was new to this country, didn’t have any other resources, no support. Besides her son, she didn’t want to be a burden to her son. She couldn’t drive a car anymore. She couldn’t do anything with her finances. So she just wanted to in her life because of that. And so in talking, I was able to tell her you have post ICU syndrome, this is all likely and because of that first ICU stay. And she had no idea she had no idea why she was the way she was. And I just wonder how many people like that are out there languishing without any kind of validation and kind of support?

Dr. Tom Valley 36:03
That’s such a powerful story. And I think it really highlights just normalizing the problem, right? Like that saying, Hey, we know that there’s this problem that people like you a lot of people like you face, right? It’s similar to how we’ve gone about talking about post COVID, right, and longhaul COVID. Just being able to tell people we understand, right? It’s not in your head, you’re not making this up. This is a real thing that a lot of other people go through after they leave the ICU. makes a world of difference, right? I would imagine it would be very easy to just say like, you know, like, I should be better, right? I’m out of the ICU, I’m at home, why aren’t I the way I was before all this happened? And so just being able to tell people, hey, there is this thing called post ICU syndrome. And that’s what you’re going through. And, and there are all these different domains within post ICU syndrome that called come together to explain the way the reasons why you feel the way you do.

Kali Dayton 37:06
And those groups that people, I’m in survivors that I know that are supported and connected, all in English. My podcast is I’m surprised how many survivors really dive into my podcast and find so much comfort and validation through this information. The most of it’s in English. I did one episode in Spanish, that was it. So there are no resources to tell them what they experienced. And so the family won’t know. And if Haley was there during COVID, how did they get there? Their experiences in Dilip delirium rectified to say, No, you weren’t sexually assaulted, right? They’re putting a Foley catheter, there’s no…. but then they get to live with that.

Dr. Tom Valley 37:48
Right. Right. It’s, it’s so challenging, you know, that, it gets back to some of the things that happened in the ICU and are in communication barriers that can that, you know, come up right, where we’re trying to say, I, you know, like, I’m putting my hand here, I’m about to insert, you know, a catheter, if you can’t communicate those things, then your mind fills in those blanks. And it’s not surprising that you feel like you were sexually assaulted during your ICU stay. And so it becomes increasingly challenging, as you get farther out to, to try to address those problems, particularly for groups that don’t have access to highly resourced post ICU programs or peer support groups, like you mentioned. I mean, it’s such a valuable experience and yet, I’m sure, tremendously underutilized.

Kali Dayton 38:45
Well, now my mind is really. But we, there’s so much more we can do. And I think we can’t really control what’s happened. And for many of us, it’s a little bit difficult to go and start Spanish speaking support groups. But moving forward, we have to look at this big picture, especially for our most vulnerable patients. I feel so deeply and passionately about that. So finding your study was extremely validating, to some of my concerns. It’s a question that I’ve always had. And it should be just another reason why we should expect and demand communication and ICU it is a basic human right. And those that do not speak English, of any race deserves that basic human right to be honored.

Dr. Tom Valley 39:32
Absolutely, absolutely.

Kali Dayton 39:34
Anything else you would share with the ICU community?

Dr. Tom Valley 39:36
No, I think I think this has been great, I think thank you for the opportunity to talk about this with you. I think we have so you know, I think it can be overwhelming in the ICU because we take care of such sick patients. And we’re constantly taking care of these really sick patients, but at the same time we have some such an opportunity to not only save their lives, but also improve their lives going forward that we work in a place where we have such room to improve in to improve people’s lives.

Kali Dayton 40:19
Absolutely. And we can prevent a lot of the sickness that happens on the road. That happens beyond the initial reason for admission. People always say, in response to this awaken, walk in ICU in Salt Lake, oh, well, your patients aren’t that sick. Even during COVID, when they were the same acuity, the same patients, the same community, everything was the same. They say, Well, your patients are that sick, they’re getting off the ventilator sooner. So they’re not that sick. But it’s because they prevent a lot of the secondary infections, all the repercussions. So we can make this a lot easier on our system too. And even in especially during that severe critical illness, we can still use more critical thinking and the bigger picture to ease the burden on everyone involved.

Dr. Tom Valley 41:03
That’s right. Yeah, I think it’s, it can be easy to kind of kick the can down the road in the ICU. But what happens is, as you kick the can down the road, it just keeps coming back at you faster. And so you know, if we can start if we can, if we can get to a place where we can just prevent these things that might might make our care easier upfront, but make it a lot harder down the road. Think it could make a huge impact on our patients.

Kali Dayton 41:35
Well, we know that the A2F bundle even in smaller doses, decreases readmission to the ICU by 46%. So there are so many ways in which we are making things harder on ourselves, but especially on our patients. So thank you so much for your work. Keep us keep us posted on future studies that you do, especially within this realm. I really appreciate it.

Dr. Tom Valley 41:58
Thanks, Kali, really appreciate you having me on.

Kali Dayton 42:00
Okay, I would be completely remiss if I failed to mention Vidatalk. At the end of such an important discussion, and episode 103 survivors. Even English speaking survivors shared the trauma and agony that they experienced in an after the ICU after being unable to communicate. Their testimonials will forever haunt me and have inspired my passion for Vida talk.

It is almost 2023. And most ICUs still have not standardized access to nonverbal communication for patients that cannot speak, write, and especially not in the language of the care team. This is completely inhumane. This should not be accepted by the ICU community. Vidatalk is the only technology that I’m aware of that offers nonverbal communication in over 40 languages in a way that is so much easier to use than writing, texting, or pointing to letters on a board.

It is an app that can load onto any tablet or iPad and provides easy communication with prompts customized to the ICU setting. Patients can point to the body and tell us the location of their pain type of pain, severity, pain, things like they need want to see their family they need to be suctioned etc. If the patient does not speak English or the language of the care team for example, they can select the word or phrase and their language and it will be read into the language of the clinician and can be done vice versa.

So like this, those that can see the video can see that the menu you see it- “Necesito aspiracion” – “I need to be suctioned”. It is so simple and intuitive to use. Those that are watching the video can see the various menus that are available. All the different options there can be options for drawing, texting, and lots of different menus with different prompts. If I were intubated I would demand be to talk, especially if it was too weak, or too confused to write or spell things out. Whenever anything new is introduced, the question is always how do we get our hospitals to pay for it?

This shouldn’t even be a discussion as a communication as a basic human right. And clearly it is inhumane to deprive our fellow men of their rights, as well as exacerbate racial disparities within our healthcare system. If we care about humanizing medicine, equality, inclusion and overall health equity, investing the Vita talk needs no further discussion. Yet that is not how our system works. Unfortunately, healthcare is a business. So let’s talk business. I think it is clear from this study that the ability to communicate influences sedation practices. Numerous studies show us that the deeper patients are sedated. The longer they stay on the ventilator the more complications like happy baps multiple infections and so on are developed. The longer they stay in step down on the medical floor and the more likely they are to discharge to a care facility. This all results in substantially higher healthcare costs.

So if we bring it back to that very moment, when a patient comes out agitated, maybe they’re trying to tell us that they need to write, that they’re in pain, that they’re hot, or whatever, and they cannot communicate that to us. And we decide to more deeply sedate them, we drive up their healthcare cost from that decision on. It’s also hard to know exactly how much one day in ICU costs. But the most exact number providing the research is an estimate about 3500 a day. But that was back from 2005. We know that that is much higher now. And especially as more care and interventions come into play.

There are multiple studies, repeatedly proving that the deeper the sedation, the longer the time of the ventilator and the ICU, and the higher the mortality. If we look at a recent study that evaluated COVID patients, we found that it compared those that had early light sedation to those that had early deep sedation, the difference between time on the ventilator was over four days, obviously, in favor of the light sedation group, the mortality rate was 18% lower in the light sedation group than the deep sedation group. And this didn’t even include mobility.

I am very convinced that by open the doors of communication, we will have patients that are more awake, but also more compliant and easier to mobilize. We can do better assessments before and during to help ensure their comfort, safety and participation in mobility that also decreases healthcare costs. So by having access to communication and the expectation and culture of using it to influence our sedation practices, that alone can drastically decrease healthcare costs, and investment and be to talk would be easily covered.

Yet on top of that, reimbursement agencies will cover for Vidatalk. There are multiple billable codes that can be used to charge insurance agencies and Medicare and Medicaid, which then turns Vita talk into a revenue generating intervention, the hospital can be reimbursed about $1,000 for each patient that is documented to have used Vidatalk. So what’s the excuse? This kind of technology is essential for humane care, human dignity, improved care and therefore lower healthcare costs, and then additionally makes the hospital money.

There are no excuses are treating patients differently by their race, language or ability to talk. It is 2022 we know better. We have better tools. Let’s do better. If you’re ready to humanize your ICU, please contact me. I would love to help your team overcome barriers to communication through improved sedation practices, as well as connect you with betta talk directly to do a free month trial. Most of you already have tons of devices from COVID laying around doing nothing. There’s nothing but benefit to be had by doing a trial and allowing your team to experience the ease and joy of human connection in the ICU.

Transcribed by https://otter.ai

Resources

http://maryland.ccproject.com/2022/02/21/valley-race-risk-and-structural-racism/

Dr. Tom Valley on Twitter: @tsvalley

Racial disparities in the ICU:

https://acrobat.adobe.com/link/review?uri=urn:aaid:scds:US:0eb6d168-0c55-350b-970a-471dcd19a2b0

https://pesquisa.bvsalud.org/global-literature-on-novel-coronavirus-2019-ncov/resource/pt/covidwho-1277372?fbclid=IwAR3Z9wWDWUVja_Vln5X59-hB4jl8p2jMb4YAQnviLWF_GaUR0iUnuYFxpNk

https://pubmed.ncbi.nlm.nih.gov/34636803/

https://www.atsjournals.org/doi/10.1164/rccm.202001-0116ED

Promoting Equity via Change in Practice for Respiratory Failure (PRECIPICE)

https://www.precipicestudy.org/

https://reporter.nih.gov/search/upKUlcC_8E6FHOGh_wRgzA/project-details/10365559