SUBSCRIBE TO THE PODCAST

Let’s talk about delirium severity. Does the severity of delirium vary by ICU specialties or by ICU treatment? What role does sedation play in delirium severity? What role does race play in delirium severity? Dr. Damaris Ortiz shares with us key findings from her important research.

Episode Transcription

Kali Dayton 0:00
Yeah. Dr. Ortiz, welcome to the podcast. Can you introduce yourself to us?

Dr. Damaris Ortiz 0:07
Thank you. Thanks for having me. So I’m Damaris Ortiz. I’m a trauma surgeon, and I’m a critical care intensivist at IU Health and at Eskenazi hospital. And I’m also a researcher and I do research in delirium as well as the biopsychosocial factors related to violent injury. One of my other roles is as the medical director of the hospital based violence intervention program, prescription for help at Eskenazi hospital. And I’m also assistant professor of surgery at IU School of Medicine.

Kali Dayton 0:43
That’s it? You’ve been really boring lately. No, that’s amazing, your experience, your preparation, and then your interests have been really impactful within your hospital system. And I’m excited to talk about some of the recent research that you’ve come out with recently. You actually reached out to me in response to my interview with Dr. Valley about sedation by race. And you had more to add to that conversation. So let’s talk about your recent study that was really revealing of some of this disparity within our sedation practices.

Dr. Damaris Ortiz 1:21
Sure. So this study was published in Scientific Reports last year, um, it’s called delirium severity does not differ between medical and surgical intensive care units after adjusting for medication use. And it’s actually a secondary analysis of two parallel randomized control trials that were done at IU Health. With data from 3d of our intensive care units, by a pulmonologist Dr. Barbara Khan, who is excellent and also does delirium research.

And there’s a whole group of us here at IU that have been continuing that delirium research. So what we did was, we took 474 of those patients from those ICUs and compared the delirium severity between the medical ICU patients and the surgical ICU patients. And what I was thinking was, most of the studies that are out there on delirium currently, group, all those patients together, making you insecure, are lumped together or for the surgical ICU patients, they’re grouped just by specific surgery, like a cardiac ICU, or certain types of surgeries.

And I feel like in medicine, a lot of us think or have a perception that our patient populations are all different from each other. And they’ve got these unique factors that make them different or react differently to the way that we’re treating them or whatever protocols we use. And so that was really the question that came to my mind was, are they actually different? And I really, I thought that they were.

Kali Dayton 3:06
Between medical and surgical, right?

Dr. Damaris Ortiz 3:08
Between medical and surgical. Exactly. Yeah, exactly. So taking that data, we looked at their delirium severity scores within the first seven days of their hospitalization, or discharge, or Sharik came first. And then we also wanted to look at how they expressed their delirium to see if there was a difference in that. And so we did that by looking at their core features of delirium. So the four features acute onset fluctuating course inattention, number two, and number three is altered level of consciousness. And then number four, disorganized thinking.

And because of the way that we score, the delirium severity score, using the CAM ICU7, which was developed by Babara Khan, they use the cam ICU, which is already the the delirium assessment and ICU and then the RASS. And so using the average scores from that we were able to determine how patients were expressing their delirium. And that has not been studied before either. And we’re really just curious to see if there are differences in that as well.

Kali Dayton 4:21
Because we know there are different types of delirium, different features of delirium, but we hadn’t fully gone that far as to say, who has what, and how does rest play into that? Right. And so what did you find?

Dr. Damaris Ortiz 4:39
So the make you patients, as we suspected, were older, they were more likely to be female. They were more acutely ill based on their Apache scores. They had more medical comorbidities, they had worse baseline cognition. They had worse baseline functional status. I thought for sure, the MICU patients, because of all that, were going to have worse delirium severity.

When we looked at the univariate analysis without adjusting for any other factors, the SICU patients, the surgical patients, actually had worse delirium severity, which is very surprising. So then we looked at the data a little closer, we looked at the medications that were given. So we were able to document how many, how much benzos they were getting, opioids, propofol, any sedation, and then also psychotropic medications. Either at all or also by daily dose.

And so we factor that in, and after we factored in the medications, as well as other factors like their age, sex, race, acute illness, and we adjusted for all those things. There was actually no difference between the delirium severity between the medical ICU patients and the surgical ICU patients. So that that was also surprising.

Kali Dayton 6:16
Right? Before we didn’t really have anything to say, patients, at least between these two specialties have the same risks and rates of delirium, not the same risks, per se, but they might have different risks, but they had the same weight into what rate of delirium is developed. But between those two different ICUs, the surgical ICU had a higher rate of delirium. And why was that?

Dr. Damaris Ortiz 6:44
Yeah, and so looking at it, it’s because the medications that were being used. So all the patients in the surgical ICU were receiving more doses of benzos, and opioids in particular. And they also initially had lower RASS scores, which correlates with more sedation.

And so the really interesting thing about that is that taking all of that away, taking the medications away that we give, even though the medical patients had all of these predisposing risk factors for delirium, it and even the playing field. If that makes sense, the medications were a bigger factor than even those innate factors.

Kali Dayton 7:38
Which makes so much sense. But that is astounding. That’s a breakthrough finding, right? We assume that patients are older, sicker, they have all these other risk factors for delirium, their rates are going to be higher. But they were in an ICU that gave less sedation, compared to an ICU that had probably more stable patients, just surgical patients, which can still be sick, right?

But they’re often younger patients that don’t have these such high risks for delirium, per se. But they were receiving deliriogenic medications. So they had a higher rate of delirium. So your chances of delirium did not depend on who you were before going into the ICU. It depended on or what brought you to the ICU. It depended on which ICU you ended up in.

Dr. Damaris Ortiz 8:24
Exactly, exactly. And so I was definitely surprised by that. And I do want to clarify that all the patients in the study had had delirium. And so we were really looking at delirium severity. And we use factors that we know that have been associated in the literature with delirium onset, because that’s the literature that we have. But delirium severity has been studied less.

But it’s important because every, every just one number increase on the delirium severity scale is associated with a 47% increase in risk of mortality in the hospital, and 20% decrease in the chance of going home at the time of discharge. So having to go to a nursing home or rehab. And so it’s even just that small difference is actually a huge clinical difference.

So the research is getting a little more focused and nuanced, because it’s not just about do you have delirium or don’t you? What what’s the risk for getting delirium? It’s now delirium as a spectrum, and the severity of it and the presentation of it and how we can change that as as medical practitioners.

Kali Dayton 9:53
Okay, this has me so excited because for years, it’s been hard for me to our articulate and express the difference in treating delirium in an Awake and Walking ICU, versus in a outside hospital. I worked in 11 Other ICUs. So I definitely saw some delirium in the Awake and Walking ICU. It’s a med surg, ICU, all those risk factors. There’s a detox unit down the hall, there’s a drug park on the corner. We were referral center for all sorts of liver failures and sepsis. And so, definitely, delirium happens not at the same rate as the other ICUs, where I worked at.

Not just the rate, but the severity. And so being on this journey, I’m trying to dissect what I experienced and what I witnessed. I think part of it was because we have tools in that Awake and Walking ICU to treat delirium. So if someone is confused, agitated, we don’t just sedate them for that. We get them up, we get family there, we try to emerge them from that. We try to wear them out so they get real sleep.

So now, looking back at that, I didn’t appreciate that as a nurse, it was just kind of a routine and habit that we did. We had a system that caught these patients, and had the resources to pull them out of it. But when I was working as a nurse at other units, I was often getting patients that had been sedated now I’m doing the awakening trial.

The level of agitation they came out with was so rarely seen in that Awake and Walking ICU- and the duration of it! We know that for every one day delirium, there’s a 10% increased risk of death. And I just did not see delirium, go on for weeks, like I’m seeing and hearing with patients at other hospitals, but they’re continuing to get his medications. We’re… you know- we are treating delirium with deliriogenic medications.

Dr. Damaris Ortiz 11:47
Right,

Kali Dayton 11:48
So likely that surgical ICU, they had higher severity, and probably a longer duration. I don’t know if that was measured in the study? The duration?

Dr. Damaris Ortiz 12:00
Duration, you know, I’d have to look back honestly at that, but I don’t think that there was a difference…. for the surgical and MICU, Sorry, we did not look at duration. We did not.

Kali Dayton 12:10
Well, we Two episodes ago, we talked with Dr. Anozie about using Ativan during alcohol withdrawal, and then setting patients up for benzo induced delirium. But that severity is so much higher. And so you’re on this roller coaster. So I’m wondering, in the study, at that’s perhaps capturing this phenomenon of treating delirium, the agitation from delirium with a deleriogenic medication and it escalates, it gets higher as they get more agitated.

Survivors will tell you, and this is where it starts making even more sense of what it’s like to have delirium then to emerge from sedation and be re-sedated. And the panic just escalates. They go deeper into their delirium, but they also had some sort of awareness, and it all played into their delirium and the terror when they’re submerged back into it. Then the next time they come out, with next awakening trial, they’re even more desperate to get out of that scenario. And so that’s my theory as to maybe why this severity was worse when medications were given more.

Dr. Damaris Ortiz 13:23
Yeah, um, you know, I’ve heard a few episodes with survivors speaking about that. And it scares me because we don’t, we don’t know. Because we are not communicating with them, or unable to communicate with them. And they’re feeling and experiencing these things, but we’re not seeing it on the outside. And I know that the culture in most hospital systems is sedation is for the patient’s comfort.

It’s not like we’re trying to hurt them or harm them. They’re trying to help. But there’s this mismatch between what the patient is actually experiencing and what we think they’re experiencing. And I say “we” as like the general medical community. Because of course, we want to put patient comfort and patient safety first.

And I have not heard such poignant stories from patients who have been sedated and you know, have lived through an ICU experience and to hear them talk about how traumatized they are. And and even that, a specific story about like, knowing that they were waking up and then being put back down on the sedation and how scared they were. That breaks my heart.

I feel like part of the importance of this study was that it it provides some evidence that we do have more control over this then maybe we thought like I, I feel like a lot of times during rounds with trainees, when people talk about a patient being delirious, it’s kind of like, “Oh, yeah, they’re delirious, but they’re old, they had surgery, like, they have all these risk factors. And, and that’s unavoidable.”- kind of a thing. But it’s not. This is a preventable thing.

Kali Dayton 15:28
And it’s a treatable thing.

Dr. Damaris Ortiz 15:30
Yes.

Kali Dayton 15:31
I’m always comparing my perspective who I was as a nurse, your 10 years ago as a new nurse than who I was. I mean, in an Awake and Walking ICU then how I practiced, how I approached patient care outside of that ICU- that culture. Then as a learning nurse practitioner, and now as I guess somewhat of an expert on this, right? I’ve done this podcast for three years, I’ve been immersed, I feel so much more educated in all the different perspectives and the reality of what’s going on.

And it completely changes how I see patients. Now, when I’m on-site, and I see patients that are delirious. I hear the survivors voices in my head. But when I compare that to how I would have viewed that beforehand, I would have said, “Oh, yeah, they’re just confused. They’re just, they’re wearing me out. They’re kind of annoying. I just got it, we got to tie those restraints tighter.”- you know, I didn’t, I just didn’t have any tools to really empathize with them. I had no idea.

No one taught me I didn’t have access to survivors, the patient couldn’t say, “Hey, I actually am worried about my kids being kidnapped right now.”

Dr. Damaris Ortiz 16:40
Yeah.

Kali Dayton 16:40
I had no idea. So there, we can’t expect the clinicians to treat them differently, or to know differently or to truly empathize when they have no access to that education. So as an intensivist, in that moment, how are you guiding that change?

Dr. Damaris Ortiz 16:57
So I’m definitely known as the attending who will turn off all the drugs, when I’m around. The fentanyl drips are all off. The sedation is all off. Because I want to extubate people as soon as possible. And I ask them for an indication for sedation.

And I do think that that is new territory for a lot of people. Not just the trainees, but the nursing staff as well. You know, I did train an institution, as a fellow, I was at UT Houston. And they were ahead of the times with their pain management and sedation strategies, as well. And so my mind was already there.

And then I started listening to your podcast, and it just solidified all those practices that I want patients to be awake, but comfortable. And so that’s, that’s how I tend to express it now, when I talk to also patient families. They’re also concerned that they might be uncomfortable, and sometimes they will request for me to sedate them more because they look uncomfortable, or they’re shifting around in bed.

Taking the time to explain that I want them awake so that they can interact with us. And so that I can communicate about the care plan, but still keep them comfortable. I think it’s helpful. And it just also teaching the staff and the trainees about why I care about this so much. I think that helps too. Because otherwise it’s just “Oh, she’s the crazy attending that doesn’t like medications.”– I’m like, “no, no, it’s not about that!”

Kali Dayton 18:40
There are memes about doctors like you. There are lots of memes about it.

Dr. Damaris Ortiz 18:43
Yeah,

Kali Dayton 18:43
It’s okay. I’ve inspired some memes to it’s the worst thing. But I actually learn a lot from memes, because I see meme saying, basically “Turn sedation off, peace out.”– And the patient’s a hot mess.

And I don’t think that’s about us specifically, Right? But I think that is a valid point. How do we approach this from all the different aspects, right? Are we providing our teams with the “why”— which you’re doing- check! Which, I love that. That’s when I’m on-site working with all the different disciplines. I’m telling the physicians don’t just tell them what to do, Tell them “why” and collaborate with them. Help them understand what we’re working towards. And they will bring ideas into how to get there and how to do that safely.

Don’t just…. because I think we go to medical conferences, and we hear “sedation is bad, it’s dangerous” the outcomes are obvious, the research is compelling. But we don’t necessarily have tools to know how to do it otherwise, or when patients are agitated when they come out thrashing. I don’t think it’s part of intensivist training to know what to do with that. But we know that logically we can say, “Well, it doesn’t make sense to give a deleriogenic medication during delirium.” But then, how can you as an intensivist bring in the other disciplines to really treat that and make it a more successful experience for everybody?

Dr. Damaris Ortiz 20:08
Um, bringing in other disciplines, I think. I mean, really, I think just having multidisciplinary rounds is really helpful. I do think that we have just a staff shortage, which has affected improving this significantly, especially since the COVID, when we were trying not to go into patient rooms. And now we don’t have a lot of nursing staff. We don’t have a lot of physical therapists. And I think that that has impacted us quite a bit. So while I think it would be great to have more staff, physical therapists working with patients every day for a significant amount of time to keep them mobile, to keep them up to keep them engaged in their care and able to suction and the cells and things like that. We just don’t have the manpower right now.

Kali Dayton 21:10
Do you see even with these changes in sedation practices, an impact on the severity of delirium, and maybe the rates of delirium?

Dr. Damaris Ortiz 21:21
I don’t know. I don’t know yet. I honestly think this study needs to be redone, or a similar study done. This is older data. And so potentially sedation practices have already changed. Since the time this was done fancy initial studies, I would like to think that as surgical intensivist, that we’ve improved in the last few years, to not even just awake and breathing trials, but more of a titration of sedation, which is what I’ve moved to, and the ability to excavate really, at any time of day, as long as resources are available at your hospital. It’s not like, I know that everyone wants to be extubated before 11am, usually, but sometimes they’re not ready until you know, the afternoon. And that’s okay to you. I think, anecdotally, I would say that less days on the ventilator, certainly, with less sedation, or no sedation, limited sedation.

Kali Dayton 22:35
I think that’s a pretty easy and quick one to see right away. Even if you’re not tracking your data, you can see patients and you realize- “This could have gone a totally different way.” When taking the observation or decreasing in that moment, that really changed their trajectory.

And then that’s one of the first things that’s easiest to track that shows up the data that’s much more reliable than some of our subjective RASS and CAM scores. But so in the future study, we need to be measuring severity of delirium, and seeing how our practices impact the severity of delirium.

So throwing that out there for all the researchers out there, people reached out to me asking for projects or ideas, add that one to the list. I love it. What else did you find in the study? What was an incidental finding?

Dr. Damaris Ortiz 23:21
Um, so we looked at for the core features of delirium, after taking all the variables into account and removing the coma scores. So coma scores, meaning when a patient is like RASS, negative four and negative five, we consider that they’re in a coma. And so you can’t really do a CAM. And so we did two analyses, one with making those patients as an automatic CAM score of seven or highest severity. And then with those just completely removed, so

Kali Dayton 24:00
Can I just say that that is awesome. I, that’s one of my big questions. So I’m looking at delirium, —and you’re nodding your head,—- but I’m looking at delirium studies. And they’re given a certain percentage, but I looked at the methodology and see that were a RASS of negative four, negative five. But when they’re looking at duration of, and rate of delirium, they’re only looking at when they could do a CAM score.

But that sometimes didn’t happen. They didn’t lighten sedation to at least negative three until a week or two after intubation. So I don’t trust those results at all, because I have no idea what patients are going through the first two weeks of being intubated.

So I appreciate that you would go on a conservative scale and say, let’s just assume, considering the risks of delirium, that if they are receiving that much sedation to be negative four, negative five on the RASS scale, let’s just count it as having delirium because it’s most likely happening.

Dr. Damaris Ortiz 24:55
Right? Right. And you just can’t detect it because you can’t do the CAM, you can’t communicate.

Kali Dayton 25:02
Sorry I keep interrupting. I mean, I tried to tell teams, the CAM is the creatinine of the brain. For nurses, especially that clicks, like, oh, because you know, those am labs, you’re gonna be looking at that creating you looking for renal failure, but we’re not that systematic about assessing for the brain, depending on our culture. So how often do we go days to weeks without checking renal function? But yet, we’re doing that with the brain when we deeply sedate patients? And sometimes that has to be, there are some situations which that is unavoidable.

Dr. Damaris Ortiz 25:35
Yeah,

Kali Dayton 25:36
but those are the exceptions.

Dr. Damaris Ortiz 25:38
Right? Exactly. And I will say that at our hospitals, I’ve been impressed by the consistency with which it gets measured, at least daily. And, and I think that just has been a push from the researchers that, you know, have started this research 20 years ago by Recon, Molasses, Donnie was my mentor. And we have others doing more research in this area. And so I think, just that culture is starting to really permitted in the ICUs. And so I appreciate that we even have this data to look at, really, because they did a good job.

Kali Dayton 26:21
That is that is not always the norm. When I’m working with teams and saying, “:et’s get baseline rates of delirium.” That’s not always reliable. So sometimes when we start really looking into the data and pushing this, it looks like the learning rates have gone up. But usually, it’s because we’re just now starting to consistently track it, which is fine, I mean, but to take that bump and data with a grain of salt and understand this is actually an improvement that we are seeing more delirium means that we’re actually checking for delirium. Now that we have a baseline, a reliable baseline, now we can assess the impact of our interventions, but you already have a team that cares about that about it, that’s aware of it. So that’s already a huge step in the right direction.

Dr. Damaris Ortiz 27:07
Exactly, exactly. So looking at that, looking at those core features between one through four, the only only features three, which was the altered level of consciousness, which is represented by the RASS score, like we talked about, was significant. And it was associated with being in the surgical ICU. It was also associated with a patient’s identifying as black, activities of daily living, and then the daily doses of the benzos and the opioids. So that was, the association with the medications was not surprising. But the association with identifying as Black was definitely a surprising finding. And it wasn’t one that I have seen in any other study.

Kali Dayton 27:55
Nor have I suddenly reached out I had immediately I had questions for you. I thought maybe, maybe you already understood the why. But I, I don’t. Obviously, baseline risk factors can be involved if there are higher risks, rates of diabetes, cardiovascular disease, things like that, which we know because this in those populations, but were you able to dissect the studies and see, did we treat those patients differently? Dr. Valley, we speculated from his study that Hispanics at higher rates have received more sedation, because there was probably a communication barrier.

Dr. Damaris Ortiz 28:39
Yeah,

Kali Dayton 28:39
but what would that be for our, our black population?

Dr. Damaris Ortiz 28:44
You know, I’m really I’m not sure and, and most, most of the patients in this study identified as either white or black. We have very little Hispanic patients, Asian patients, and it was about 50 was like 44%. Black. So we had a good amount of people. And looking at the literature, I was trying to see if there had been any reports of racial or ethnic differences with delirium.

And that really hasn’t been described. There’s been some studies, but there have been very mixed results. And so nothing that I could really definitively point to I do know that can I talk about this in a discussion that there’s been studies on the effect of sedation, particularly purple fall, and anesthesia, or morphine, even on patients of other races, compared to white and from different countries as well?

And they have noticed some differences and for example, onset like the amount of medication needed for induction, and how long the sedation lasts, and then also the effect of opioids. But there’s no data to definitively say that there’s any clear like underlying or inherent difference that would affect the delirium severity. So then, of course, the other question is, did they receive more medications? Or, and I don’t know, there’s no way to really look at that.

Kali Dayton 30:30
They’re not able to go and go back and compare the dosages given at the duration given?

Dr. Damaris Ortiz 30:37
I guess potentially could if we looked at those specific patients, and then the doses and then compare between the two, but we have not done that analysis. I would say that, because it’s older data, it shouldn’t be… it should be redone. And compared between the two, I’d be really interested to see,

Kali Dayton 31:00
Add that to the list as well! Because this is really important, we either, I’m sure, there are many possible reasons for this. I worry about blacks being at a higher risk of delirium period. I also obviously worry about them being treated differently. If there’s some bias that’s influencing sedation practices, we have got to identify that either those we have to identify and make sure that everyone’s being treated the same.

But especially if they’re at higher risk, if they’re more vulnerable to delirium, we need to know that so that we can act accordingly. We should be protecting all of our patients from delirium. But it is important to know upon admission, if someone has is at higher risk so that we are at higher guard for it. And I worry about certain populations having less access to rehabilitative services.

So they develop these life threatening, and then life altering conditions like ICU acquired weakness and delirium. Do they have the family support? Do they have the financial means Do they have the access throughout the system to be able to get the cognitive, the psychological support and therapy that they need to have any chance of going back to their normal lives?

And so what does that mean if a patient that already has disparities in the system, develop delirium, now, they have post-ICU PTSD, Post ICU dementia, if they already have are from a low lower income demographic, and they lose their jobs, and the family, what happens? Who’s catching them? And these are important questions in my mind, that we need to be assessing to say, “Now, we have no doubt that delirium is a huge concern. We know that there’s disparity within our healthcare system. We need to be piecing this together to figure out, I guess, how differently are we treating patients? Or how different are their outcomes? And why is that?”

Dr. Damaris Ortiz 33:07
Right? Yeah, and I think, right now, we really don’t know. But I think that we gotta follow the data and look deeper and do our studies and figure it out. Like you’re saying, if there’s a modifiable reason for this association, we can’t say that there’s any cause and effect with this study. Then it’s, it’s worth looking into.

Kali Dayton 33:37
Okay, delirium researchers. I would almost put that one above all else, right. I feel really concerned about it. What else? You had, you invited me to a really great meeting in your system, where it sounds like it’s a routine process where people bring up questions, problems, and everyone collaborates and how to solve them. Tell us about your recent presentation.

Dr. Damaris Ortiz 34:02
Yes, so you were at an Innovation Forum. And these are sponsored through the Center for Health, Innovation and Implementation Science at IU. Dr. Bustani, who I mentioned is my mentor is the founder, the founding director, and they offer a graduate course, actually, in innovation implementation science, which I’ve been through. And this is part of the process.

He’s now has this whole cohort of change conductors that are looking to change the way that we practice medicine. And so we have these innovation forums where you can bring a clinical question or problem and bring it to the group and it’s moderated and everyone participates and bringing their ideas and solutions in a judgment free positive environment where everyone gets a voice and and then everyone gets sent the discussion at the end and can use it as they wish. So the question that I brought was how do we improve communication with intubated patients in ICU, and that was inspired by your podcast by one of the episodes, and

Kali Dayton 35:34
103. Episode 103, I’ll throw that out there.

Dr. Damaris Ortiz 35:38
Everyone listen to that. It’s really good. Yeah. And so I thought it was very good discussion. And I was really glad that you were there and to provide your insight and expertise. So

Kali Dayton 35:51
I was really excited that that’s the topic that you chose. That you’re advocating, you’re trying to bring everyone into discussion. And I was thrilled by the response that was found. There was a lot of curiosity, there was excitement. There’s also a sense of shock. Like we’ve been doing critical care medicine, we’ve had patients on ventilators for decades now. We don’t have a way to communicate with them. And maybe a mix of “oh, we should communicate with patients on the ventilator!”

I think there was, I’m sure there’s a lot going on from people that have done critical care for a long time. It is a novel concept to many that we should expect patients to be able to communicate on the ventilator. Obviously, that’s because of our sedation culture, that’s not on anyone. No one’s trying to be inhumane or insensitive. But it’s just what how we’re trained in how we’re raised in the ICU, to expect patients to be comatose.

So I think you sparked a lot of thoughts and a lot of curiosity to say that the expectation, we’re going to have patients that are going to be awake, that is that should be the norm. And we should expect them to communicate. Now, what are the tools? And people had really great ideas? And it was, it was an inspiring process? I was honored to be a part of that.

Dr. Damaris Ortiz 37:11
Yeah, that’s awesome. And I don’t know if other institutions have those type of forums. But I will say that, since during that graduate certificate I’ve done, I’ve participated in several, and I’ve presented several problems at them. And they’re always helpful. It generates such good discussion. And because people from other disciplines, specialties. And, you know, sometimes they’re, they’re not medical people, they have completely outside perspectives to bring to the conversation that I wouldn’t, you know, maybe wouldn’t have thought of otherwise. So it just seemed that to me, at your institution.

Kali Dayton 37:55
Yes, absolutely. And if you have will put more information to that program, and any information you have about that process within the system. Let’s include that in the transcription On this episode, as well as citations to all the really powerful studies that you’ve mentioned, as well as your study. This being in that meeting just made me zoom out and think about the power of asking questions.

I think about the only reason that an Awake and Walking ICU exists and has existed for over 25 years, is because a nurse asked “why? Why not? What if?” and the impact that you’ve made even that discussion, you didn’t just come out and say, “Here’s how we’re going to communicate with our patients.” You asked a question that changed perspectives. And that is how we’re going to change process of care.

You asking at the bedside, “Does this patient have an indication for sedation?” is something so powerful about that, that probably has a bigger impact than saying, “This patient doesn’t need to be sedated!”– you lead them through thinking through and it opens it up for feedback, it changes the culture, the tone of the discussion, and I think that’s how we’re going to have people gain their own understanding and knowledge rather than just being told.

So you are such a good example of leaders within Critical Care Medicine, and I’m excited for what you do and any future studies you have coming out. Please share them with us anything else you would share with the ICU community?

Dr. Damaris Ortiz 39:30
Oh, I just thought that this is something that I think we can all actually do something about. And I think my dream now is to actually be a part of and see an Awake and Walking ICU. I’ve actually never seen that before…

Kali Dayton 39:51
I can set you up with a tour! They do it all the time. I’m happy to send you there. Absolutely.

Dr. Damaris Ortiz 39:55
So yeah, thank you for having me.

Kali Dayton 39:57
Thank you.

Transcribed by https://otter.ai

 

Resources

CAM ICU 7: The CAM-ICU-7 Delirium Severity Scale: A Novel Delirium Severity Instrument for Use in the Intensive Care Unit

1 number increase in delirium severity = 47% increase in risk of mortality in the hospital, and 20% decrease in the chance of going home at the time of discharge: The association of delirium severity with patient and health system outcomes in hospitalised patients: a systematic review.

1 day of delirium = 10% increased risk of death
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)

Indiana university center for innovation and implementation science.

Delirium severity does not differ between medical and surgical intensive care units after adjusting for medication use

SUBSCRIBE TO THE PODCAST