SUBSCRIBE TO THE PODCAST

Episode Transcription

Kali Dayton 0:05
This is a special episode as part of a pod crawl, where big nursing podcasts are getting together to co host episodes that dive deep into delirium. We include “Up My Nursing Game”, “Fresh RN”, “Cup of Nurses”, “How to Not Kill Your Patient”, “Rapid Response RN”, and “Good Nurse Bad Nurse”. Even if you’re not a nurse, please check out their episodes on delirium to get full insight into the impact of delirium in the ED, med surg floor, and RN perspective in the ICU. I co-hosted this episode with Tina from “Good Nurse, Bad Nurse”. Let’s jump into my discussion with her.

Tina 1:24
So this is a story of Yvette Hunter. She was a registered nurse in Lexington, Kentucky. And this is a very fresh story. It’s actually it was just in the news a couple months ago. So Yvette Hunter was she’s 52 years old. She was a registered nurse, as I said since since 2018, so relatively new registered nurse, however, she had been an LPN, a licensed practical nurse, which little side note, there are nurses, they’re still nurses. And yeah, so that always drives me nuts.

Kali Dayton 1:56
Absolutely.

Tina 1:56
They are nurses, and they do, depending on what state you’re in, they do almost the exact same thing as registered nurses, even at the bedside, believe it or not, I worked alongside them. And they’re absolutely amazing. And they are underappreciated and underpaid. But anyway, I so I cannot ever say anything about LPN without saying, yeah, it’s just a market. It drives me crazy, such an injustice. But she had been an LPN since 2007. So she was definitely inexperienced nurse without a doubt. So don’t be thinking, “Oh, new grad, well, relatively new.”

I mean, I think it takes years and years and years to get really to where you’re seasoned. She’d been there. She was employed by Baptist Health, Lexington, and on April the 30th, in 2022. As I said, this is pretty recent. She was assigned to the direct care of a 97 year old James Morris Morris was a World War Two and Korean War veteran, amazing, absolutely amazing, had been admitted after a fall and slip injury. He was reportedly restless and it’s spent the previous night in a recliner in the hallway, instead of his room, the 97 year old patient became agitated and aggressive, according to nurse hunters account of what happened. So I just want you to think about this. I’m not sure what kind of facility this is, I feel like it might be some sort of skilled nursing facility like maybe a higher level of care?

Kali Dayton 3:22
Sounds like it.

Tina 3:25
That’s the feeling I had, okay. And so I have worked in facilities with geriatric patients who have a tendency to wander off and you know, we had we would put put them, you know, at the nurse’s station, so that there will always be somebody there to watch over them to make sure they’re not going to hurt themselves. Maybe give them something to do give them a little pile of washcloths, and they’ll sit there and fold them and just talk to them, whatever. And so I that’s sort of what I picture here, like, yeah, to try to keep an eye on him.

So documentation from the Kentucky Board of Nursing says that nurse hunters sought to restrain Morris, due to his distressed state, but according to investigators, no one actually witnessed her using restraints. So that’s a little bit of a discrepancy. I think initially, maybe in the first investigators report, they said she was trying to actually physically restrain him using sedation or some sedative type medications, to relax somebody and keep them from getting up and keep them from moving.

Well, that is restraint. So she reportedly asked for Ativan or Lorazepam to help alleviate some of his distress to calm him down. And hopefully she had in her mind, she’s thinking, not hurt himself that she was afraid, you know that he was gonna get up and hurt himself. So the on duty physician and nurse practitioner both denied her request for Lorazepam. Now prosecutors have said that her next course of action was considered maltreatment. The facility where the patient was at has referred to it as a medical discrepancy. So you guys can decide, but I know where I fall on this pretty firmly, around 7:27am, she allegedly withdrew a two milligram vial of Lorazepam from the Omni cell.

And for those of you that don’t know, that’s just this big cabinet that’s computerized and pecs is accurate dose, all those things, you have to a lot of times use your fingerprint or whatever the sign in, it keeps track of absolutely everything that goes in and comes out, then they know who took it out. And they know what kind of thing get all kinds of information from these things. So she pulled this, not out of his because he didn’t have it ordered, but a different patient.

So in her mind, she’s thinking, “oh, so the doctor and the nurse practitioner won’t give me this, I really feel like this patient needs this. I’m so afraid he’s gonna hurt himself. And so I know this other patient has it, I’ll pull it out of theirs. Use it for him.” And I don’t know what in the world, she thought she was going to just don’t. It doesn’t make a whole lot of sense to me to do to do this anyway. But I don’t even know how she thought she’s gonna get away with it.

About five minutes later, she set off his alarm, his chair alarm, but trying to get up and in this can be frustrating. Like I said, I worked in a facility, it was a behavioral health unit for geriatric patients. And it would be it would be really, really frustrating and scary to take care of people who are constantly trying to get up. And these people are so fragile and unstable. And you’re so scared, they’re gonna hurt themselves. And it’s scary as a nurse that you’re responsible for these patients. So I totally get it. I don’t want to minimize that at all. Or pretend like oh, well, you know, we get it.

We understand as nurses, why a nurse would be concerned about this patient and be trying to think of ways to help minimize the risk of them hurting themselves. So multiple members of the hospital staff came to the alarm as what usually happens, you know, your chair alarm already goes running, right? Hopefully, that’s what happens, including this nurse. Now, while they’re in there, she gives the patient something with a three to five mil milliliter syringe, put something into his IV. She does this right in front of everybody. She’s just, you know, puts it right into his IV. And then somebody who one of her colleagues said, what was that? What did you just give him? And she said, “Well, it’s something special.”

So she was a little, a little ambiguous. Well, he very quickly became sedated. And after he was put back in the bed, her colleagues I once again, what did you What did you give him? Exactly, and she just kind of doubled down on that something special. About 30 minutes later, another nurse discovered Morris struggling to breathe and found that his oxygen saturation equipment was disconnected. Once the equipment was plugged back in his oxygen level was reading at an unsettling 76%. So according to the documentation, the charge nurse was then brought in a consultant and then that nurse advise that the medication that was administered through the IV was what caused the patient’s decline in other words, she’s looking at this going, “It had to have been something.”

You don’t don’t go from his state what he was doing all up and trying to get up to comatose. You literally watch somebody put something in their in their IV? Absolutely. There’s no indication they go to look at the chart. Okay. Surely if she she gave him medicine, it’s going to be charted right because you don’t do anything without charting it. You would never give a patient medication and Uncharted. So there’s nothing there. There’s nowhere anywhere on the patient’s chart that indicates that you know, there’s anything order that would explain his respiratory distress, his poor oxygen, poor oxygenation, his mental decline, nothing.

And so a respiratory therapist is called in to to give a breathing treatment and they found the respiratory therapist found food, like food bolus, so there was a neck food stuck in his throat. So he apparently eventually developed pneumonia as a result of aspirating on the food that he was eating. Because apparently, he was fed after he was given the Lorazepam and they were thinking, okay, he’s sitting there kind of sedated and and not able to really, you know, chew up his food and swallow it really good and drink a drink and have it all go down. And so it just sort of got lodged there. And then he wasn’t able to breathe adequately didn’t have good oxygenation. So they put him on hospice care on May 3, and two days later, he unfortunately died.

So now, before this incident, he was reportedly doing well, and so well that he was going to be released from this or to a rehab facility. So the nurse was terminated from her position on April 30, the day of the incident. on or about May 5, the Kentucky Board of Nursing received a complaint from Baptist Health saying that Hunter’s employment was terminated for a suspected quote, medical discrepancy. So, the board investigated that concern and determined that 100 had disarmed and lowered the oxygen monitoring system several times, because she was tired of it going off. I mean, this is another thing that I have experienced a lot of times in the hospital dealing with patients who’ve like real fidgety, and they have the little Sp02 probe on their finger. And the thing just get, maybe they’re just like, maybe they’re playing with it or whatever, but it just gets off. And it’s not it’s reading, it’s not reading at all, or it’s reading 60 out of the room.

Kali Dayton 11:10
It’s exhausting.

Tina 11:12
It is exhausting. It is absolutely exhausting. But if they have it on, they have it on for a reason, if it’s ordered, you know, to monitor their oxygen saturation. And so no matter how frustrating, you have to just be diligent about it, you have to just keep, you know, replace the Oh, to try to get creative about, you know, alternative places to put it although there’s some controversy about that. And, you know, the accuracy, I think of some some of those options, but at any rate, you can’t just turn off the machine. I mean, you just can’t if there’s an order given by provider that the patient has to be monitored. Their O2 has to be monitored, the 02 has to be monitored. I mean, you just you’re gonna get in so much trouble if something happens. It’s a huge liability. I mean,

Kali Dayton 11:58
Did she lose her license?

Tina 11:59
at the time, in a released order of suspension from the Kentucky Board of Nursing, she allegedly admitted to administering medication without an order, and subsequently feeding the patient. So, okay, so she’s what she’s admitting to. She’s admitting to administering a not just any medication without an order, but a controlled substance without an order. And not only without an order, but going against specifically had asked for it was told “no”, and then just defiantly,

Kali Dayton 12:31
It’s even worse than I thought it was. I didn’t realize she had asked and that her request for an order was denied.

Tina 12:37
then ended up once the medication was given, fed the patient. And so the whole thing is just a complete mess. The order says that Hunter intentionally falsified paperwork to indicate that the Lorem the Lorazepam was quote, not given that would have been on the other patient. So what she did is she, yeah, she went to into the other patient’s chart and just put, not given.

Kali Dayton 13:03
So it doesn’t look like she’s diverting drugs, right? I see… I mean, obviously, there’s so much wrong with this. The easy bites are not given a medication without an order, taken off the oxygen probe, false documentation, things like that. Most obviously, I can see that. But if we zoom out more, it this falls in line with a lot of systemic problems that I see. As a nurse, worked in the as an RN for ICU seven years…. I of course, I heard the word of delirium a lot. I probably could have identified it in that patient, right. But I was not panicked about it.

I didn’t know about the drugs that I was giving. I didn’t know what they do to patients. I think there’s a big gap in education. Now, from my perspective, being obsessed with delirium, I’m seeing a 97 year old that’s at high risk of delirium. And we don’t know why he was agitated. Was he in pain from his broken hip? Ativan wouldn’t treat that. That would just mask it. Was he sundowning? Did he have dementia? Did he have some sort of infection, UTI developing? Was this acute delirium?

The treatments for delirium are that it presents mobility and real sleep. But when you give something like a benzodiazepine, especially that disrupts the brain activity so severely, it blocks REM cycle. You make it so that they cannot sleep, you are depriving them of sleep, which is one of the reasons, or ways in which benzodiazipines and many sedatives in general, cause delirium. So if he was, let’s say, he was just having only acute delirium, and we’re going to a benzodiazepine, we’re going to exacerbate that delirium or masking agitation. We’re not treating it necessarily.

Even further out 97 year old probably has altered renal function to some degree, which benzodiaizpines are cleared through the kidneys. We also have a contraindication for benzodiazepines, Lorazepam, especially, according to the BEERS criteria, which tells us which should and should not give geriatrics, Lorazepam is top on that list and medications we should not give geriatrics. Even with normal healthy patients, it has an increased risk of mortality, increased risk of delirium.

What I didn’t know was that for every one milligram of Lorazepam, there is a 20% increased risk of delirium. And no one told me that right when we’re running into these medications, because we’re trying to just defuse that situation, we think we’re trying to work keeping the patient safe, right? Because we’re keeping them in, in a chair. We want them to be “comfortable”. And when they are sedated, they look comfortable, they look like they’re sleeping. And so we pat ourselves on the back and we say, “good job”.

And then when we’re told no, we get frustrated thinking that these providers are heartless, they’re clueless as to what the nurses going through, which is sometimes can be the case. But when I see these memes, laughing 0.25 mg of Ativan, they’re frustrated, they’re not getting a bigger order. I think they don’t really realize what the price is for that two milligram bolus. Because you may have the patient look more comfortable for those few hours. But that’s going to metabolize out and in a few hours when that wears off. How do they come out? Tina, you know, we’ve all seen it!

You just lock them into this roller coaster of highs and lows with the Ativan and we see that especially with alcohol withdrawal, that’s why CIWA protocol with Lorazepam is on its way out. That is an antiquated protocol that does not help outcomes for the most part. A lot of times it’s because of this benzodiazipine-induced delirium that it causes that just causes this roller coaster that’s really hard for nurses to deal with. So then you just run back here with, “Okay, Ativan worked a few hours ago, I’m just gonna give that again, problem fixed. ” – and we only see our shifts.

We have this very narrow focus. And so we see how they respond in this few hours. They look more comfortable, we’ve done a good job, we’ve kept their patients safe wink wink, because we’ve kept them in bed and …zooming out again, I think a lot of this has to do with the culture of liability for nurses. When falls happen when unplanned extubations happen, it’s all on the nurse. They’re so afraid of losing their licenses. And because we have this system that doesn’t support nurses, we drive them into this hard spot where they’re like, “I just had this situation, I just need to keep them safe for my shift.”

Tina 17:20
Instead of the system, looking at the bigger picture saying, “How can we keep the patients safe for now, but also set them up to be able to survive and thrive?” But the nurses like, “Just as long as they’re, they don’t fall on my shift. I don’t care about anything else.”— They don’t say that. They don’t think that they think that, but that’s what we’re trained to feel. “I just need to keep them in the bed for my shift, I want to clock out then it’s not my patient on my problem.” Because they don’t know what happens after.

A lot of times as nurses we learn through our experiences. And so we have a patient who’s agitated where they have a milligram or half a milligram of Ativan, it’s ordered, we administer a half a milligram of Ativan and we see them get calm, we’re able to go on with our shift. The patient doesn’t fall everything is great. Now we just learned through that experience that Ativan works. So what we don’t get to see- what you’re taught– the consequences of that later on down the road, unless we are doing things to educate ourselves.

And so this is this is why. This sort of thing, what you’re talking about with the benzodiazepines and the effects of them, and why we don’t give them, why they should not be given. That needs to be explained at some point. Nurses need to understand why we’re giving what we’re giving, and why we are not giving what we think we should be given. You know, and I just, I think that sometimes, some doctors and nurse practitioners are kind of like, there’s just thinking, “Well, it’s not really my job to educate the nurse, and I don’t have time,”– they have so many patients themselves a lot of times way too many. So it’s just like, “No, I’m not gonna do it,” and then move on, instead of taking an extra minute or two to just explain very briefly, why it is not appropriate.

I’ve had really good doctors and nurse practitioners, I’ve done that for me before about other things like why wouldn’t we give lasix or fluid overloaded or, you know, whatever? And then once it’s explained to me, I’m just like, “Oh, why should I didn’t know that? Okay. It’s because I didn’t go to nurse practitioner school. I didn’t go to medical school.” But I learned that through proper education, instead of just, “Well, I know, I gave Lasix, and it helped them to get the fluid off”, you know, but you learn things as a nurse, about your interventions.

And a lot of times, though, there’s so much so much more that we don’t learn. And I mean, it’s it’s the medical side of it. It just, it’s a whole nother step for it’s a whole nother universe, you know, and we can learn those things as we go. But what we don’t need to do is think that we know more than the providers. Think that we know more because of our personal life and giving this for so many years. And it always does this or always says that. It’s so tempting to do that to think that because of my personal anecdotal experience, I know more than this doctor or nurse practitioner that doesn’t want to give this particular medication. And I think that that’s probably what happened, she was just like, there could be no reason, clearly, what the reason that the doctor and the nurse practitioner both did not want that patient to have Ativan is exactly what happened to that patient at night.

Kali Dayton 21:59
And I think what should happen in those moments, because agitation is real. It can be emergency, what we don’t realize is that delirium is an emergency. And we prepare our nurses with tools and education and training for other emergencies that are far less likely to happen. But not for delirium, which happens in up to 80% of ICU patients, but throughout the continuum of care, we don’t really educate nurses about what delirium is. And don’t give them a sense of urgency that it delirium is a medical emergency. It’s in the past been called acute brain failure, now for billing and stuff, they’re not wanting to call it that.

But it is a sign of brain dysfunction, it is a symptom that something is going wrong with the brain. And the brain matters. It’s an important Oregon, and so we don’t feel urgent about it, because we’re so used to it. It’s so normal, oh, they’re confused, they’re sick, of course, they’re gonna get confused. But it’s more than just confusion, what we need to train our nurses to understand is that these symptoms are likely to turn into chronic thing.

So patients that have delirium in the hospital, at least, are at 120 times greater risk of long term cognitive impairment. And this means that they have a hard time remembering things processing executive function, they can’t oftentimes go back to their jobs because they don’t have the same cognitive capacity. One survivor told me, he can’t drive anymore, he was in his 40s, when he was discharged from the ICU, he could not drive anymore, because he doesn’t have the same response time. He’s not safe to drive because he can’t think quickly enough to drive. So those cognitive impairments aren’t just forgetting the word here and there. It can be, or it can be severe impairments.

That makes it really hard for them to have the same relationships, the same identity, the same profession, the same financial situation, it has a huge impact. But we as nurses are not taught that. So we see this confusion, we see agitation, and we want to just make them still, “rested”, so that they’re “safe”. But we’re not thinking about their long term safety, because we’re not given the tools to think through that. And we think “We just going to keep them alive during our shift.”, right? But we don’t see delirium, and we don’t panic with a sense of “Wow, this delirium could double the risks of dying in the hospital, triple the risks of dying six months after discharge.” Or we’ve got to get this patient out of delirium because for every one day to learn there’s a 10% increased risk of death.”

We’re not given that information to make decisions based off of the evidence right? What we culturally learn is, “They’re agitated, sedate them.” And that’s not malicious on anyone’s part. That’s because we want to keep them comfortable. What we don’t especially realize is what it’s like for many patients, when they are delirious and especially sedated, is that they’re not sleeping. Again, to clarify, sedation is not sleep. Benzodiazepines didn’t set it up like propofol, they disrupt brain activity so they cannot sleep.

So you know, in war, sleep deprivation is called torture. But in the ICU, it’s called standard of care. And I know that sounds harsh, but that’s where masking delirium, we’re exacerbating and prolonging delirium and often causing delirium with those sedatives. When they’re not sleeping, for whatever reason, the brain seems to more often than not go into the deepest, darkest, most morbid, gruesome, graphic realities that are far worse in the ICU.

So survivors have told me about thinking that they are kidnapped, that their children are kidnapped, they’re watching babies burned, they’re watching their loved ones be torn apart with their insides gushing out on repeat for days to weeks. So from our side, we sedate them, their eyes are closed, they’re not moving, we call it “sleep”, we tell the families are sleeping. We feel like we are sparing them the trauma of the ICU. But we don’t realize that underneath, we’re actually keeping them locked into a cycle that is going to cause long lasting psychological scarring.

And so when we take off sedation and the ICU oftentimes they come out thrashing, and they’re agitated. And we have assumed that that was just endotracheal tube. And so we want to spare them awareness of the endotracheal tube. So what do we do we run right back to the sedation. And so I think systemically, we need to have better education. Nurses need to know what they’re looking at so that they can be eager to assess it. They can identify it. They can know the risks of these medications. But especially, they need to have the tools to treat it. So a provide over the phone saying “no, no Lorazepam, bye. ” — that’s not adequate. That’s not supporting your nurses. That’s not helping patients.

Rather, providers need to come to the bedside, especially in the ICU, I feel like. Or anywhere, really, to the bedside, say “You asking for Lorazepam gives me a sign that something’s going wrong, that we’re having an emergency. What’s really going? This patient has delirium. What could be causing delirium? Are they had they been sleeping? What do they need to sleep better? How they’ve been mobilized? Do they have any infection?”

I mean, this is a sign of something going wrong. But we can totally mask it and miss what’s going on underneath. So we need to support nurses and going through that critical thinking process. And say, when we identify that it’s delirium. We need to say okay, we need to especially avoid sedatives. So you don’t treat an infection with bacteria. So training delirium with sedatives, is very much along the same lines. But what can we do? We can’t let a patient just be trying to crawl out of bed and be thrashing and agitated and or trying to hurt the staff.

We know that delirium increases workplace violence, and makes sense at conferences. I’ve asked “Who here has been assaulted by a patient?”– and I, myself even raise my hand. And I said, “Put your hand down if those patients were completely oriented, and free of delirium” – and I don’t think it’s really seen hands go down. So delirium is one of those huge risk factors. So it’s a risk to everyone involved. Patients have falls in the ICU, 75% of them have delirium. Delirium makes the risk of unplanned excavations 11 times higher.

So we’re concerned about those events, but we’re not really treating the root cause of it. So in that moment, the providers, the nurses the therapist ever needs to join in to say “This is a medical emergency, this is life threatening. This can change the trajectory of their hospital admission and their whole lives. This will double the nursing hours required for care, we know that it doubles the nursing hours required for care.” — so to say, “I don’t have time to treat delirium.” That may be true in that moment, but look at the big picture. The system needs to say, “This is going to be a huge thing. This will increase hospitalization by about seven days, at least seven to 10 days.”– So it’s worth investing in mobility in that moment.

Changing visitation restrictions, get the family and their family presence for more than two hours a day decreases the rate of delirium by 85% Maybe, no 88%. Get the family in there, communicate with the patient try to figure out what to do need, what’s causing the agitation Mobilize them, wear them out and then let them get real sleep uninterrupted by sedation, and then rinse and repeat. That’s how we make a systemic change. And we really support our nurses not just to say, “Wow, that Lorazepam situation. She shouldn’t have given a medication without an order.” but to say, “What was really happening?” She was in a crisis. Yes, it wasn’t a good decision. But what influenced her decision?

Tina 30:25
Right. And she absolutely just went so far out of bounds that it’s really unthinkable. I think, to most nurses, I think most nurses are seeing this going, I totally can understand how she was feeling and the frustration but to get to go to pulling a demand that was ordered for someone else and giving a man that was not ordered. I can’t it’s so hard for my mind to even understand. And the board said that she was unfit to continue practicing nursing. So they they didn’t even feel that she was redeemable. As far as just for education or just a suspension.

Kali Dayton 31:04
Something similar happens in the ICU at least. I see memes talking about joking about how RASS orders are subjective, sedation orders are determined by the nurse, right? Jokes about nursing boluses, things like that. I have a survivor friend, that’s a lawyer. And he said “This is…. if something were to happen, this is completely against it, this is absolute evidence that they are consciously practicing gets their licenses.” So RASS orders are what determine the level of sedation, right? Or measures the efficacy of our sedation. What depth of sedation they’re at right?

To give more sedation to state beyond the prescribed RASS level is giving medication without an order, you’re giving extra doses of sedation, we never would give an extra milligram of vancomycin, especially without an order, and especially if the trough said it was at a therapeutic level. Because we know that that’s never toxic. We know that it’s dangerous, but we totally disregard that when it comes to sedation. And that’s a cultural thing. No one’s really mean to do that. I think also that comes down to are we training our nurses on the RASS- do they really know how to accurately assess the RASS? So when we chart a certain RASS, but the patient in reality is lower RASS or different RASS that’s could be considered false documentation. So I worry about nurses being vulnerable and liable for over sedation, practicing outside of their license, their scope of practice, false documentation, all these things, because culturally, they’re immersed in that process of care that teaches them to do that.

Tina 32:43
Yes, we are all at risk. I feel like working in hospitals, working in direct patient care, we are all at risk whether it’s just making a specific decision like this with that was obviously it’s a it’s just playing out against the law is just actually just, there’s no other way to say it. She was it was wrong. It was it was illegal. It was unethical and everything every sense of the word. They actually turned it over to the Kentucky Attorney General’s Office on July the seventh and then believe this or not, she had obtained a new position as a travel nurse at the University of Kentucky General Chandler hospital through an external agency. It’s so unbelievable.

She was indicted on August 22. For one count of murder, her bond was initially set at 100,000. However, her attorney was able to successfully request the bond to be lowered to 50,000. She’s not required to wear an ankle monitor due to no criminal history and not being considered a flight risk. And according to the death certificate, his cause of death was listed as pneumonia. So now her legal team is saying during their court testimony that it’s really unprecedented for somebody to be locked up in jail and charged with murder for a death that was ruled in natural natural by natural causes by medical examiner, her defense team saying that this patient suffered from several significant conditions that contributed to his death.

They have to have a defense right they have to put on something and I feel like this is probably the best the best are going to do. It still feels like grasping at straws to me. her legal team said also that before the Commonwealth indicted her for murder, they neglected to consult with a medical examiner, nor did they seek to do any toxicology to determine the levels of Lorazepam or any other substance in the patient system at the time of death. The thing is, I don’t think it would have mattered because she admitted that she did it. She gave the Lorazepam it was not ordered period. I mean, the whole progression of everything. The fact that he was so agitated and so awake and so mobile and moving around and then went to being completely calm to the point that he couldn’t even eat, and it got stuck in his throat.

Kali Dayton 34:49
He couldn’t protect his airway. He couldn’t coordinate his swallow. I just imagine that he was reclined in bed so medication aside, but critical thinking for nurse– feeding the patient with an altered mental status that who’s somewhat obtunded?

Tina 35:03
Yeah, And I think that it’s tempting sometimes for people to want, especially when you’re having to feed patients, and they have had more patients than they probably can really safely care for. And they get in a hurry, and they’re just sitting there, you know, just trying to feed a patient who’s obviously sleepy. It is so unsafe, it’s so dangerous. And you’re just risking so much by doing that, obviously, that’s what happened here.

Kali Dayton 35:27
And I think, again, that probably comes down to education, too. And culture because I ever telemedicine, I popped it on rooms, and I see patients are almost completely reclined on high flow and nurses serving food into their mouth, and they’re barely opening their eyes. So it’s a cultural thing. I wouldn’t say that this is just one nurse completely going against everything she’s ever learned or experienced. It should be part of our education and our culture. But I see obviously, her errors, which we’re going to get into medication giving them medication against order, especially controlled substance, obviously. But there’s a lot more to it that I think we can and should learn from.

Tina 35:59
Yeah, and the fact that, you know, she is out of jail right now. But she is going her trial set for June the 12th. And is scheduled to last for about four days. But I know that there are probably people out there screaming at the radio right now going. You know, there’s a staffing problem, I guarantee you she had way too many patients, and I totally understand that. But I know you guys know that it does not matter if you have accepted that patient load. And I say this with the utmost respect for every nurse because I, I, I’m a I worked the bedside and worked in ICU worked. I was a travel nurse, I’ve done it all I’ve seen.

I’ve been handed unsafe assignments, and I’ve accepted unsafe assignments many times, not really even understanding when I was doing it what what I really was risking that I really don’t think that I understood it. And I don’t think that a lot of nurses understand what you’re actually risking when you accept these unsafe assignments. And that that’s the thing. She accepted this assignment. And so even if she it was an unsafe assignment, if she had way too many patients, and she somehow in her mind justified giving this medication, there is nothing that’s going to justify giving a patient a medication that wasn’t ordered, ordered for them absolutely period, there’s just end of story there is no, it is never, ever justified a patient a medication that isn’t ordered for them.

And that’s it think I know that there are people that want to have compassion for her because of that whole nurse patient ratio problem. But we have got to start thinking about what we are signing up for working at the bedside. And the thing is, if you walk onto if you took a job, you said if you pay me $30 an hour, whatever it is, if you pay me $30 an hour, I will come and I will take care of patients for you. And the doctor, and the hospital says okay, we’ll give you $30 An hour if you come and take care of our patients. And they say, “Okay, well, how many patients am I going to get at a time?” “You’re probably going to get…. we want it to be ideally” —so and that’s how they always start out— “Well, ideally, on this progressive care unit, you should have three, some days we have to flex up.” You know they. And so you agree you agree to that right up front.

And sometimes maybe they’re a little dishonest, maybe they’re just like, “oh, it’s three to one. We don’t… oh Yeah, we would never go over that.” And then next thing, you know, you’re handed four, and five. And so when you do it, when you agree to take money to take care of patients, and you and your mind, know that it’s unsafe and use, can you agree to go ahead and say, “Well, I know it’s unsafe, but I’m gonna go ahead and take care of these patients anyway.”- You are agreeing to it. You are saying that you are okay with it. And you really are. And it’s it’s what I had to learn myself, I had to accept that for myself at some point, and I had to go, you know, I’m taking responsibility for these people. This is on me. And if we as nurses continue to do this and continue to take unsafe, unsafe patient loads, if we just continue to do it, I think they’re gonna just keep locking us up, because this this case deserve to be prosecuted the way it was, she absolutely gave something that was absolutely illegal. But there are some nurses that it’s inexcusable. And there there are some people that are that we make just good faith errors, we just make a mistake. And sometimes it is due to inadequate patient ratio ratios.

Kali Dayton 39:34
I would also like to see systems support nurses and a process of care and the system that gives them the tools and the access to actually treat delirium, and not just run in the heat of the moment to throw sedation at it. I think sometimes physicians will order out of PRN just because I don’t want to get those calls all the time. And so this is not just on nursing, but when that tool is available and nurses just keep throwing it out there without having tools to critically think through the scenario nor access to people to help with mobility, family, you know, we put on these big restrictions. We’ve set nurses up to be in that moment of desperation. It’s kind of the way I see it. And nurses are the gatekeepers of delirium in so many ways. They have the power to completely turn this around. They just need to have the opportunity education and tools.

Tina 40:18
well, to actually get more nurses are going to have to really put their foot down and demand safety in these hospitals. They’re just going to have to, if that means walking away from your job, and finding a hospital or finding, you know, a place of employment that that does, they do exist, they are out there, believe it or not, we’re just we’re gonna have to do that we absolutely are going to have to do that.

I think that kind of brings us to a point where we can kind of get into our good nurse portion of the purpose the story because I’m really excited about this person you guys. This sounds so innovative. It sounds so like this just came along. This is something new this walking home from the ICU or awake and walking in the ICU. It sounds so impossible. But This started a long time ago. Tell everyone about the good nurse this week.

Kali Dayton 43:02
Yeah, this story just exemplifies the power of nursing. There really about two nurses. So Polly Bailey was a nurse and the shock trauma ICU in Salt Lake City, Utah. This is in the 90s when we were really starting to deeply sedate everyone that was really rooted in experimented with treating ARDS before that patients want and weren’t as sick then weren’t able to keep patients with sick lungs alive for very long. So patients dually had tracheostomies, they were on the ventilators, they were awake and walking.

But in the 90s, they started to be able to treat ARDS. But they had stiffened tracheal tubes, archaic ventilators, they were using big volumes, high peeps. So it was really uncomfortable for patients, there’s no way they could really synchronize with the ventilator. And so that’s when they started bringing up medications from the OR into the ICU. And using that to help patients synchronize the ventilator during ARDS. And they immediately noticed that they actually did better they synchronized better and they looked more comfortable and it made them quote, “sleep”. So that looks good for the moment. But they didn’t have data to say what happens to these patients over time or long term of what happens after the hospital.

Now we know that very few of those patients survived and those that did were severely maimed. But because of that perception that we have just for that little glimpse in the ICU of them being sleeping and comfortable in the ventilator. Those medications, those benzodiazepines, barbiturates, opioids, those are to sneak into how we care for patients on the ventilator for other diagnoses not just for ARDS. Polly Bailey followed out a survivor who ended up going was from her hometown, so she would visit the survivors and young mom in her 30s and she saw what it was like at home and this is really before rehab. So they basically scooped them out of the chairs, put them in the car, and that was when Polly watched this young woman, mother of I think three or four spend months and months even up to a year trying to get up the stairs.

Her husband is having to do the bedpan with her, she was psychologically and cognitively destroyed. And so she went back to her medical director and said, “What are we doing here? Is this the life that we’re saving patients for? Because this isn’t right, this isn’t worth it.” She proposed that they try to avoid those conditions of delirium and ICU acquired weakness, but they knew very little about it. There wasn’t what we have now, decades of research. This is a complete experiment.

And imagine this is the 90’s. Polly is a female RN, you’re shaking your head, you understand millennials and down. I think we don’t appreciate what Polly Bailey’s did for nurses and for women in our profession. So just appreciate what that was like for her to say, “You know what? I know no one’s ever done this before. There’s nothing about in the research that I can find, but I’m just gonna throw it out there. Let’s keep patients awake and walk them.” But Terry Clemmer, he’s on my episode number two, he trusted nursing instinct. And so he let Polly wake patients up and mobilize them on the ventilator. And they quickly notice that it changed outcomes entirely.

So they started to do that with more and more patients, the hospital started a new ICU, and they let Polly be in charge of hiring and training the nurses. And she’s basically said, “Welcome to the ICU. Here’s who we are, here’s how we do it.”– and stopped even sedating patients. And she just made a total culture shift. And Louise Bezdjian was one of those early nurses in that short term ICU that was open to trying it out with her, saw the impact, said “I’m in.”– So those two still, Luis Bezdjian just retired last year, but that became nurse practitioners. They were basically working as NPs before that was really a roll and run in this ICU.

And so even during COVID, they led probably the only “Awake and Walking COVID unit” in the world. They just stuck to what they knew. And they they were the first to put out a study showing that it was safe and feasible to walk patients on ventilators during acute respiratory failure with really sick lungs. That was in 2007 that they published that study. Here we are to 2023 in the same situation, but the lives that they have saved and the quality of life that they have given back to patients is immeasurable throughout the decades that they’ve done this.

So they were my mentors in the ICU. They’re my inspiration. And I want nurses to know the power that they have to not only save lives, but give patients the ability to thrive after the hospital. But so much of that is rooted in how we prevent and treat delirium. And so when nurses, I just constantly felt that when nurses really understand what delirium is what it’s about, there’s no way that they’re going to let things continue them on on the way they are. But until nurses know nothing can change.

Tina 47:32
I’m curious to know if there was a study or some way of knowing how the COVID patients did in the awake and walking ICUs versus all the others. In every COVID ICU and I’ve worked at multiple COVID ICUs. And every one that I’ve worked in, once they went on the ventilator, it was very unlikely that we’re going to come off,

Kali Dayton 47:52
I do know that their mortality rates were less than half of the other COVID units within the same hospital system, same community, same staffing ratios, everything the same except for their sedation or mobility practices. Formal study needs to be published, there’s a lot of politics behind it. As you can imagine, it’s a little exposing. But we’ll get there with that, because we definitely need to publish that. But everything within the rest of the research supports this approach that we put in the show notes that ABCDE F bundle showed that this was dose dependent.

And if you look- I can even give you the graphs, the less he was used. The more patients were mobilized, the more family was involved, the more the delirium rates went down, the more all other outcomes improved 68% decrease in mortality. And that was dose dependent— that was with a spectrum of compliance. So the more you comply with the ABCDEFF bundle, which is extremely evidence-based. To get to a an awake and walking approach, the better your outcomes are. And a lot of that even a lot of that research was inspired by Polly Bailey. She shook the medical community and especially the early mobility studies that have come since then, were rooted in one nurse asking “Why, why not? What if?”

Tina 48:59
I love Polly Bailey she is I’m such a huge fan and Louise Bezdjian is that her name? As well. I mean, what trailblazers and I I’m so proud of them. I’m so thankful for them for doing this. And for the people that love I’m sure the lives that were saved because of this. I know that it’s this is like turning around the Titanic.

Now those of you who are CVICU nurses, I know that you understand this a little bit. I know you kind of get this because what do we we do it we have to do it. They they when patients come out of open heart surgery, what do what are we doing? We’re trying to get them out of the bed and into into the chair and walking around with their chest tubes and they’re all of their, their lines and all the things that are coming out of every orifice. I feel like it’s not that big of a jump from getting a patient out of the bed with an Artline under your own arterial line and a swan ganz catheter and the two different you know eight trams for for free chest tubes. And walking them.

You guys know we do this and we hook them all up with their oxygen tank and everything, you know, we do this and they walk down. It’s literally one more tube. It’s just going, it’s helping them breathe. And I feel like there’s nurses out there going, This is insane. These people have lost their mind, there’s no way. I feel like I’m so excited about it, instead of thinking about it from a nurses perspective, instead of thinking about you working in the ICU, and having to deal with a patient who’s completely awake and alert with the with their tube down their throat, and you’re scared to death that they’re going to pull it out. Don’t think of it.

Think about it from the patient’s perspective, if you were the patient, what would you want? And it sounds like from what Kelly described these patients, she’s basically telling us stories that she is first had heard firsthand, from people who’ve experienced this, think about the horror that these people are experiencing that they’ve told you that experience, would you want to be experiencing that and have the long term psychological scarring, the psychological effects, the PTSD, the things you’re going to have to deal with later on down the road? It’s not worth it.

Kali Dayton 51:08
And what nurses are probably thinking is they’re imagining awakening trials and everyone all the time. And they’re gonna say, Ah, no, I’m not doing that. And what I insist is, absolutely, you can’t do that that’s not feasible. That’s not safe for anyone to do all these awakening trials. The point is that we asked after each intubation, Does this patient have an indication for sedation? Is it really worth the risks of all these repercussions of sedation, to sedate them, and then try to take that off later, because that’s when we get patients coming out thrashing, agitated and terror and agony.

At five o’clock in the morning, and when one nurse is alone with them, it’s just not sustainable and it’s not safe. And oftentimes, it’s not effective. What we’re working towards is asking those questions right after intubation and letting them wake up. And it’s like coming out of colonoscopy, but oftentimes with less induction meds and even colonoscopy and reorienting them, and hopefully we had a chance to talk to them beforehand. If not, we introduced this new to saying, “Hey, you’re an ICU, you’re intubated. This is helping you breathe”- Give them a mirror, let them touch their tube, their face.

Get them up right away, normalize the situation unless there’s a contraindication to mobility, which are few, walking, sitting and those things normalize your breathing pattern with a ventilator, it helps you feel more control less panicked, let them communicate, that helps decrease the panic. It’s just putting this little effort in the first hour to two by days, two weeks less on the ventilator. And a lot of that comes down to delirium we as nurses should be terrified of delirium, even just from our perspective, because it is so much work and risk and it’s heartbreaking.

And so when we avoid delirium, we make everyone’s journey through the ICU and throughout the hospital and even Eltechs and sniffs much better. And that awake can walk and Polly Bailey’s ICU 98% of their survivors discharged home from the hospital from a 2012 collection. They compared it to an outside facility, st patients 46% discharged home. Same patients, same hospital system. So that’s how much of a difference nurses especially can make and preventing delirium and changing where they go after the ICU.

So Tina, thank you so much for supporting nurses, for believing in them, for moving this along. I don’t know if a data collection from 2012 show that in Polly’s ICU 98% discharge home from the hospital versus 46% in an outside facility. That’s how much of a difference nurses can make in that moment. And a lot of that comes down to delirium, preventing delirium, keeping patients mobilized. And that’s where good nurses become great and actual experts and giving patients the ability to survive and thrive.

Tina 53:41
And I know there are a lot of nurses out there listening to this, who want to be those excellent nurses who, who do have open minds and who are willing to accept you know, even if it goes completely against everything they think they know and have learned and experienced, who are willing to just maybe consider that there could be a different way of doing something that’s better for everybody concerned, is there somewhere they can go to help get some of this information like actually get have access to some of this research you’re talking about

on my website, www.daytonicuconsulting.com. They go to the Resources tab. There’s a category for clinicians. That is to a podcast but it is organized by topics. So go to the delirium tab, you’ll find testimonials from survivors, clinicians, and there are citations for each transcription of each episode. So find the topic. Go to the bottom there are the citations. There’s also usually citations to the Johns Hopkins library that has over 3,000 studies supporting this also organized by topics. So it’s a rabbit hole, jump in start digging. It’s insane. There’s so much behind this. It just needs to reach the bedside and I think it’d be nurses to do it. We’re an evidence based discipline.

Yes. Absolutely. This needs to be some research jump in there. Do a research project You know how impressed your your doctors around you and your other colleagues would be if you jumped in and got actually were did a research project about this and got this changed in your ICU. This would be life changing for so many people. So I encourage you to do that. Give me send me an email, you can send me an email at Tina at gunners, matters.com. And let me know if you do work in an ICU or you actually let people get out of the bed while we’re still in a ventilator walk around.

Let me know, do you have your patients always sedated if they’re on a ventilator is usually people will hear my podcast and they’ll send me an email. And they’ll just be like, “Hey, I heard your podcast, I just wanna let you know, we’re doing this. And we’re doing that.” So I’d love to hear from you. If you have a story to tell me or an experience. And if you have any concerns about it, I don’t I this is you. We have to have conversations before things change. So tell me your perspective. Let me know what you’re thinking. You know, don’t get mad. Don’t get mad at us. We’re just trying.

Kali Dayton 55:53
Any objection you have, I’m happy to provide discussion, evidence, resources, case studies, other clinicians that can help you work through that. That’s how we make progress is finding the gaps and the barriers. So, again, Tina, thank you so much. I appreciate it. This has been wonderful.

Tina 56:09
Thank you for coming onto the podcast. Thanks for having me on your podcast. I’m so excited about this whole pod curl. It’s gonna be so insightful and we’re gonna learn so much that whole week. remind anybody where they can find you on Add replay. So

Kali Dayton 56:22
stay tuned. ICU consulting, is my social media handle? And then Dayton ICU consulting.com is my website and my podcast is walking home from the ICU.

Tina 56:34
All right. And of course, you know, obviously my as I said at the beginning podcast is Good Nurse Bad Nurse podcast, you can find me good nurse, bad nurse on all social media sites and you can send me an email at Tina at good or spenders.com and I like to end my podcast by saying even if you’re a bad girl or a bad boy, be a good nurse.

Kali Dayton 58:03
To schedule a consultation for your ICU, as well as find supportive resources such as the free ebook case studies, Episode citations and transcripts, please check out the website www dot Dayton ICU consulting.com

Transcribed by https://otter.ai

 

References

BEERS Criteria

1mg of Lorazepam increases risk of delirium by 20%:
Pandharipande, P., et al. (2006). Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology, 104(1).

Benzodiazepines prevent REM sleep:
Weinhouse, G., & Watson, P. (2011). Sedation and sleep disturbances in the icu. Anesthesiology Clinic, 29(4).

Weinhouse, G., Schwab, R. (2006). Sleep in the critically ill patient. Sleep, 29(5).

Yaffe, K., & Boustani, M. (2014).Benzodiazipines and risk of alzheimer’s disease. British Medical Journal, 349.

Patients with delirium are at 120 times greater risk of long-term neurocognitive deficits:
Girard, T., et al. (2010). Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Critical Care Medicine, 38(7).

Delirium doubles the risk of dying during admission:
Ely, W., et al. (2004). Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. Journal of American Medicine Association, 291(14).

Delirium increases workplace violence:
Jakobsson, J., Axelsson, M., & Ormon, K. (2020). The face of workplace violence: experiences of healthcare professionals in surgical hospital wards. Nursing Research and Practice.

Delirium increases falls:
Meier, et al. (2017). Incidence, correlates and outcomes associated with falls in the intensive care unit: a retrospective cohort study. Critical Care and Resuscitation: Journal of the Australasian Academy of Critical Care Medicine, 19(4).

Delirium increases unplanned extubations:
Kwon, E., & Choi, K. (2017). Case-control study on risk factors of unplanned extubation based on patient safety model in critically ill patients with mechanical ventilation. Asian Nursing Research, 11(1).

Episode 21: Polly Bailey Episode.

Polly Bailey Study:
Baily, P., Thomsen, G., Spuhler, V., Blair, R., Jewkes, J., Bezdjian, L., Veale, K., Rodriguez, L., & Hopkins, R. (2007). Early activity is feasible and safe in respiratory failure patients. Critical Care Medicine, 35(1), 149-145. Retrieved from

Episode 2: Dr. Terry Clemmer Episode.

ABCDEF Bundle study.

SUBSCRIBE TO THE PODCAST