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After visiting the original Awake and Walking ICU, how did Dr. Brian Bellucci help bring these changes to his ICU? What is the physician’s role in supporting a team’s sedation and mobility practices? How can we increase physician buy-in? Dr. Bellucci shares with us his team’s journey to becoming an Awake and Walking ICU.

Episode Transcription

Kali Dayton 0:13
For any of us that have been trying to create, awaken walking ICUs we all appreciate the intricate complexities involved such as culture, team dynamics, tools, training, politics, resources, etc. Yet, when we zoom out and look at the reality of the situation, patients are suffering and dying from the effects of our habitual practices of automatically sedating and immobilizing immediately upon intubation. And in many ways, it is fairly simple.

We know how care should be. So what happens when a great team has strong leadership that is inspired by compassion, vision and collaboration. Dr. Bellucci joins us now to share his team’s journey to becoming an Awake and Walking ICU. Doctor Bellucci, welcome to the podcast. Can you introduce yourself to us?

Dr. Brian Bellucci 1:46
Yes. Hi. Brian Bellucci, a pulmonary critical care physician. I’m working primarily in Roseville, California.

Kali Dayton 1:54
Excellent. And what has been your experience with sedation mobility practices and what changed that?

Dr. Brian Bellucci 2:00
Typically, I had come from a place and places and training and when I first started practicing were, you know, conventional, critical care medicine was practiced and the conventional mindset of the ventilator be uncomfortable and, and being in the intensive care unit being uncomfortable was very prevalent. And I made my practice much like that for years, until I was actually influenced by a colleague of mine, Peter Murphy, who basically told me that, you know, doesn’t seem wrong doesn’t seem like a bad idea.

And let’s let you know, hear about other people who try different things. Of course, we’re influenced by Dr. Ely. And then of course, the podcast, you know, your podcast is with when I was really first introduced to. And Peter Murphy said, Well, let’s go visit a place that does this. And so I went with him to Salt Lake City, and just to get some input and experience from other people. But I think the bigger influence was the podcast and hearing the patient’s encounters and starting to do what, you know, Wes said in his book, you know, to re-engage with a human being in a bed and and it’s just it’s not a very human interaction when a patient is sedated and not interacting with you at all.

Kali Dayton 3:17
That’s powerful. I mean, you physically went to the Awake and Walking ICU. You saw what they were doing. But in the end, it was to the survivors that really, I guess pricked your heart and gave you your “why”.

Dr. Brian Bellucci 3:28
It was absolutely the stories, you know, from from the podcasts, from Wes, his book. I mean, it was really, really influential and everybody I tell it to, and relay it to and direct toward the book in the podcast. They universally feel the same way.

Kali Dayton 3:47
So how did that approach that impact your approach to patients? I mean, you have this awakening, your next shift. How does your business shift?

Dr. Brian Bellucci 3:57
Yeah, um, to me, it shifts to, you know, treating when you’re treating a patient like a person. You’re encouraged by the fact that you want them to participate in their care that you want them. You want to hear their input, you want them to know what they’re going through. You want to know what their goals are.

And then of course, you want to minimize their risk for post intensive care syndrome. To me, at the end of the day, hearing statistics about people’s personal lives and love lives and professional lives falling apart. That is very, very hard to to come to terms with that we had something to do with that. And so I have approached every patient, thinking that every drop of sedation, every minute that they’re lying in bed, I am taking away from that person’s livelihood. And that to me is what lights a fire.

Kali Dayton 4:53
Wow. We use the term “lung protective strategies” when we’re approaching mechanical ventilation. It sounds like you’re using a “life protecting strategy” when you’re approaching patients.

Dr. Brian Bellucci 5:06
That’s right. And so we’re focusing more on more than on just ventilator parameters and blood pressure parameters. We’re focusing on, you know, the patient’s life and their survivorship. That’s the the buzz term that we like to use.

Kali Dayton 5:23
Absolutely. And so you’re one lone physician, amongst this team. You went with Peter Murphy, who works with a different team. And then you come back to your team. And now you have this big job of changing the culture and the practices, what was your first step?

Dr. Brian Bellucci 5:39
Um, basically, you know, directly into the podcast. Letting them hear from patients, what survivorship means. Letting them know that, you know, it doesn’t end, you know, that their patient’s journey doesn’t end when they leave our four walls here.

I think, you know, just hearing that the first time, my colleagues hear that they’re moved by it, they’re agreeing, they’re hearing it. And they’re influenced to go to the podcast and listen to it. Early on, and you may remember, we did a, with my practice- we did a big group, basically discussion. We had Wes and we had you there. And it was about 20 of my colleagues.

And I think everyone walked away from that feeling, you know, that that the paradigm has to change. That critical care is not doing the right thing. And, you know, listening to someone like Dr. Peter Murphy, he says, “In a few years, what we’ve been doing will seem crazy and way wrong. And what we’re moving to will be the new standard.”

Kali Dayton 6:53
Yes, I loved in his episode, he gave multiple examples in which that’s happened throughout medicine. That it’s a field of evolution that I think someday we’ll look back and shudder at what we’ve standardized. And again, no one’s done this maliciously, no one’s….. most of us had no idea what we were doing to patients.

So this isn’t to demonize anyone, but just to have the vision of evolution that we’ll look back and we’ll really have a different perspective on where we’re currently at. So then, how did you lead the rest of your team? So you had physicians participating, but then you’ve got to get buy in from everyone else?

Dr. Brian Bellucci 7:26
Yeah, and the physicians, you know, that was pretty easy. We all universally, agree that “this is a good idea, a good option to trial and start”- and effectively it worked. When we moved on to the ICU staff, some slightly different approaches. But again, a lot of it was reiterating the stories.

I just find, like Wes says, you know, “The patient’s story is really what sells us, what motivates people.” So getting the stories, relaying them, send them to the podcast. Doing nursing education, presenting in their, in their conferences, that I actually have been doing, you know, dating back for a few years, and, and really focusing on delirium.

I always like to tell the nurses, you know, we have rounding checklists. And, you know, I get phone calls and messages about lots of things on the checklist, and they expect an answer to it. For example, I’ll get a call about hyperkalemia. They expect an answer, I’ll get a call about a ventilator, a respiratory parameter, and they’ll expect an answer, or a blood pressure, they have one a concrete answer.

But we would go through rounds, and they’d say “CAM positive”, and we move on. And it wasn’t like it wasn’t, “well, the patient’s CAM positive! You know, why aren’t we treating this?”

Like? Why are we treating brain failure like we’re treating circulatory failure? Like we’re treating respiratory failure? And kidney failure? We’re just glossing over and ignoring brain failure, which seems kind of backwards.

I mean, at the end of the day, will you survive the ICU, you survive a critical illness, one would think that, um, brain function would be at the top of the list. We would want, you know, all our cognitive faculties and abilities intact and as strong as possible. And we know ignoring delirium, you know, is a step away from that.

And so, making the nurses think about delirium, just like any other problem, even though it’s really probably more important than most other problems.

Kali Dayton 9:22
Right? If you’re trying to put it at the same level as an elevated, troponin or creatinine, you know, that they should respond to that with that urgency and and panic.

Dr. Brian Bellucci 9:31
And yet, that’s right! It’s more important than a troponin and creatinin and, you know, and an elevated pco2 on a blood gas.

It’s a it’s something that’s a very important thing. And so getting them in their rounds and in their daily tasks and you know, charting to realize that you’re not just filling in a value in an EMR when you’re filling in a CAM and a RASS.

That’s essentially a vital sign, you know. Essentially, it is critical to a patient’s meaningful survival. And you need to think about it that way your entire shift.

Kali Dayton 10:05
And so you’re addressing that during rounds. I’m getting excited because this is exactly what I’m wanting physicians to do. I do think…. I love nursing rounds led rounds, where they present the patient that go through the tools, but that is an opportunity for the physician to teach.

And I’ve seen rounds last two hours, I’ve seen rounds last 20 minutes for 30 patients, where they just gloss over. And there’s no way you could really understand or treat a patient as a human if you’re doing that kind of discussion with your team.

So as a physician, when you are notified if a CAM positive score, how do you approach and how do you manage and navigate that with your team in that moment?

Dr. Brian Bellucci 10:49
Yeah, it’s it’s basically like a scale, right? It’s a scale of things that we know are you know, helpful for delirium and things that are propagating and, and causing more delirium. It’s trying to take things, you know, from one side of the scale and make sure they’re on the good side and not on the bad side.

And so of course, it starts with, you know, in our case in our unit, since we were we are a minimal to no sedation ICU, the nurses right away know what to say, “Well, patient’s not on any sedation, or they’ll say the patient had to get this because of this.”

So right away, their mindset is, I have to explain why a patient has gotten 100 micrograms of fentanyl for an hour, and has gotten dexmedetomidine, you know, at the highest dose, that’s where they are prepared to explain that when it does come up.

Kali Dayton 11:40
Oh, that that’s a great application of this theory of the ABCDEF Bundle. C is choice of sedation and analgesia. And I think that’s been interpreted as “Which kind do you use? Because you’re going to use it automatically.”– But you have led your team to question, “Is there an indication? And if there’s an indication, what is it?”– and each rounds, it is, “Do they still have it? Do they have it?” and really discuss sedation. Not just how much sedation are they on, but why do they have sedation?

Dr. Brian Bellucci 12:10
Exactly right. I’ve tried to ingrain the term “dangerous behavior” into the nurses. Where “dangerous behavior” is really almost the only indication that we would like it for our patients to be sedated for “dangerous behavior.”

So if I so words, like, “oh, they looked uncomfortable.”– That’s not acceptable. You know, or, you know, “I was I was worried that they were going to pull their to tube out or pull their line out.” I don’t always find those acceptable answers in the rounds. And I expected that there’s some alternative way to to prevent those kinds of behaviors.

I think of “dangerous behavior”, like a patient who was going to hurt himself and jump out of the bed and, and harm on the staff. That’s dangerous behavior to me. We have good ways and better ways to prevent unplanned extubations than the chemical sedation.

Kali Dayton 13:07
Oh, I love that. And I think that’s why one of the reasons why it’s so important to really understand the RASS tool and to communicate that effectively. So to say ” A patient’s agitated”— what does that mean? Is that a RASS +1, or is that a RASS +4? – Because those merit very different interventions.

And so when I created in collaboration with other providers, and agitation toolkit, it was it RASS is zero to two, that’s when you can really do the therapeutic touch, communication, family at the bedside— family should always be there—- but assess the cause of it, right? You have time. Something is wrong, figure out what is wrong and fix that thing.

But if they’re at a + three or four, and you’re getting more into dangerous behavior, then you do need something else. And that’s when dexmedetomidine comes into play, fentanyl, things to get them closer to RASS of zero to one and then you can continue to use those other tools for agitation.

But yes, they should never just be allowed to be a RASS of three or four writhing in agitaion, danger to the clinicians or to themselves. But what do you do when someone calls you for agitation? Someone’s having problems? How do you support the team? Because you don’t want to just discontinue orders, and “no sedation” over text, right? What? How do you try…

Dr. Brian Bellucci 14:29
No, no, that’s very important. You know, first of all, a physical presence is very important. Because, you know, what does it look like if I’m telling you know the staff, “You guys handle it, you deal with it. If they’re agitated, you sit there and hold their hands and you prevent them from reaching?”

That’s not always a good leadership quality. I think number one presence is helpful. You know, for me for bras here, you know, stressing the importance to the family. It has And of such importance and a good key cornerstone to success is early autonomy in the ICU state to stress to the family, you know, what delirium means and how we combat it, and how they can help and our them helping hold in their hands can be helpful, and then supervising and sitting right at a bedside. That can be invaluable.

And it can give the nurse peace of mind as he or she does other tasks, that the family member is sitting there and making sure that that there’s no terribly unsafe behavior. But so showing up at the bedside, being present, communicating directly to the family. I make it a point to tell the family about delirium and, and how they can help. And then, having physical therapists that are comfortable with that kind of patients very important. And again, getting their comfort level up with agitated patients and ventilated patients is very helpful.

Picking the right patients at the beginning to help them learn and grow as therapists. Now, our therapists are so comfortable taking some of these patients who seem agitated, and as soon as they sit them up, or stand them up, the light switch goes on. I mean, I see it all the time.

Kali Dayton 16:11
Isn’t that magical? And that is the last thing people think, right? I had an experience where I had visited team on site that I didn’t do webinars beforehand, there was not a lot of context for the bedside clinicians as to why it was there as more of a gap analysis. And there’s a patient that was a massive plus one, maybe plus two floridly delirious, and, you know, I’m going into NP mode waiting to guide the team. And I couldn’t touch the patient because I wasn’t a provider there. And so I said, “Hey, do you think you’d benefit from sitting up?”— and he was intubated, and the nurses looked terrified. Which I understand that they didn’t have an opportunity to understand how or why especially to do that?

They said, “No! He’s not following commands! He can’t mobilize!” And then I heard them asking another nurse, “Can you can you go grab some Ativan for him?” And it was just what it was worst case scenarios in my mind. But they do need the opportunity to have easy wins, the quick sales, the successes, where they have actually witnessed and experienced the patient being awake, calm cooperative on the ventilator.

Otherwise, what I think most people have experienced, are awakening trials. And those rarely go well, right, they’ve only either had patients be still drowsy, comatose, which they may still prefer, or they come out thrashing. So how did you pick patients that you felt confident would allow your team the experience of having a patient be awake, communicative, and even mobile on the ventilator?

Dr. Brian Bellucci 17:37
Yeah, I mean, it’s picking by diagnosis is a big thing. So you know, a, someone withdrawing from a substance or intoxicated from a substance might not be the best patient at the beginning.

Kali Dayton 17:48
Not round one material.

Dr. Brian Bellucci 17:50
No, that might be someone who’s, you know, younger and larger and stronger and, and more at risk for some hyperactive kind of delirium. But choosing somebody who’s elderly, maybe and smaller and weaker, and with a with a non neurologic diagnosis, perhaps a post operative patient or COPD. That was really those are great patients actually, to start with, and but the group field and learn, practice communicating with somebody on an on a ventilator. And, you know, get the movement and get them standing and interacting with them.

Kali Dayton 18:30
How about timing in their admission?

Dr. Brian Bellucci 18:34
So yeah, I mean, honestly, for a patient like that, we would not long after RSI, wake them up. You know, it depends on the on the neuromuscular blockade that was used, but for the most part, within after an hour, we can have every patient wake him up right away

Kali Dayton 18:52
and communicate, that approach has impacted I mean, you’re talking about yours, call your unit, a no to minimal sedation in it. How has timing that approach or turning sedation off or not started, it impacted the success of having a minimal to no sedation unit?

Dr. Brian Bellucci 19:09
I think that the automaticity of it is becoming ingrained, and particularly a certain subset of the staff who’s very interested in very, very what’s the ambition? So there are subsets of us, particularly the daytime staff, that are very ambitious. And you know, as soon as the patient is wheeled up from the emergency department, they’re gonna get on it. Basically, immediately.

We’ve had many patients who were extubated very shortly after they arrived, actually, in the unit for that reason. I mean, thinking back eventually to fellowship and residency and early on in practice, how many times when I say, “Oh, patients should just stay intubated overnight.” So that meant that the patient said sedated overnight, and that meant that they’d have an SAT and SBT, you know, 20 hours later sometimes…

Kali Dayton 19:58
and they come out agitated and then we….

Dr. Brian Bellucci 19:59
and they come out agitated then it was a whole day of mobility. And I remember reading in Wes’ his book that, you know, when they did muscle biopsies on patients who were immobilized just for one day, the biopsy showed significant changes.

Kali Dayton 20:16
That amazing, I mean, just understand the physiology behind it. That really- the physiology should be a big part of our decision making. But we’re not commonly educated on what’s actually happening to all of our patients during that time. How has taking sedation off promptly, or not even starting to impacted your levels of agitation?

Dr. Brian Bellucci 20:38
Oh! Even more than agitation: delirium counts. We saw for the most part, we averaged a 50% decrease in our CAM positive rate. We have a lot more data to collect. And the data is not always super reliable because of the EMR. But the data we do have suggested that, and we’ve been anecdotally and walking around, I mean, for me to see a white bottle is very unusual. I mean, it’s very, very unusual for me to see a bottle of propofol in our hospital. And this is a 32 medical bed unit we have here. So very unusual to see propofol.

And interesting story early on. When we first started this in our our sort of go live was in over a year ago, it was in February or March of 2022. Very early on, like in the first week or two, we had a patient who had been in our surgical ICU and had conventional sedation. And when she got she ended up leaving that if that surgical ICU and ended up coming back needing medical ICU a week or two later.

And her and her husband said “We do not want to be want her to be intubated.” She was young, and she had a reversible fixable surgical problem. And I said, “Why?”. They said, “It was so difficult battling her agitation that we don’t want it.”

Kali Dayton 22:05
Wow.

Dr. Brian Bellucci 22:05
And I said well, you know, it’s it’s coincidental. It’s interesting, you’re coming here this time, because we are actually really going live with a no-sedation awake, active strategy in this unit. And they were like, “Yeah, let’s try it.” Then she ended up agreeing to be intubated. And we gave her no sedation at all. And she woke up. And afterwards, they said, how remarkably different it was being in one unit. And then coming to us two weeks later, and having a totally different experience.

Kali Dayton 22:36
Wow. I mean, just within weeks of each other, correct. I mean, an episode I think for three or four hours with the four time ARDS survivor, and she, after her first time, had paperwork drafted by an attorney protecting her against sedation, she’s a DNS. scary to think how variable the experiences outcomes are, but depending on the unit, even within the same hospital. That’s right. So you came back, you started having some easy wins, and then you launched this go live, we were said, we’re not going to start sedation unless there is a need for sedation. And you just did it!

Dr. Brian Bellucci 23:14
So the standard is, we expect that we’re going to be interacting with our patients, we accept that expectation that the patient is going to get up, they’re going to stand up on the ventilator, they’re going to do this. That’s just what the expectation is.

Kali Dayton 23:29
That is incredible. And how has this impacted the morale of your unit?

Dr. Brian Bellucci 23:36
Um, you know, morale, during COVID was obviously difficult. It was obviously, universally bad. Yeah. And I thought it was such an uplifting thing. It was we had some great stories we read, we recorded videos, we had a database of our patients, we had one gentleman who was playing his guitar, you know, on a ventilator sitting in a chair playing guitar with his family.

We had very early on, we had a lady whose family was just totally unsure of what to do. And when she was intubated on the ventilator on day two, we had kept her awake. And she made her decision. She said, “I don’t want to live like this anymore.” And the family was totally accepting of it.

Kali Dayton 24:22
Wow,

Dr. Brian Bellucci 24:23
Because she was able to communicate with them and write our messages and and now sometimes I’ll take videos of patients on their, on their phone, on their iPad, watching movies. So it’s just, I think we’re all excited by it that we want. We want to like document it,

Kali Dayton 24:41
Yeah! And you should, right? That’s part of the buy in and those are all things to be celebrated. This is really exemplary to the rest of the ICU community. And I think your role as a physician obviously has been incredibly impactful. What recommendations would you give to one: physicians that also want to bring this change, and two: clinicians that want to get more buy in from their physicians?

Dr. Brian Bellucci 25:07
Yeah. So number one is understanding, post-intensive care syndrome. And, you know, it’s hard for us to have our own experiences with post intensive care syndrome because as an attentiveness, we don’t always see the patients most of the time we don’t, once they leave here, we don’t hear from them, we don’t know about them.

So if you think that just doing general research and hearing experiences is not enough, maybe encouraging your own department to have some kind of outreach program, to hear about things and gather some small samples of data and to see what other patients are actually doing when they leave here, that’s one step.

Next step is to actually think of delirium, put it in this category in your mind, of organ failure, you know, treat it like any other organ failure, and habits and make sure that you have a strategy for it and plan for it. And that there’s an expectation of the staff, that they also have a plan for delirium because ignoring it and skipping it, and just just knowing it cannot be acceptable anymore.

Kali Dayton 26:14
And masking it, right? Responding to delirium with deliriogenic medications should not be standard practice that, you know, we were to do that with any other kind of diagnosis, it would be considered malpractice.

Dr. Brian Bellucci 26:28
Right? Right. So So step one, so number one was recognizing that post intensive care syndrome is a problem. Number two, recognizing the importance of handling delirium, the third step, I would say, is to choose appropriate patients at the beginning to build confidence and then make it the expectation that there should be an explanation as to why a patient is sedated and not moving, there should be a reason.

So it’s not a you know, it used to be in all the years I’ve done this before. You know, we would give a reason why patient wasn’t on sedation, “Oh, they got bradycardic. From they got bradycardic, from from propofol, so we stopped it. Oh, the bradycardia we got a fever from dexmedetomidine. So we stopped it.” But now, here, and, um, there’s there’s any, we need to explain why it’s there. And we expect it to not be there.

Kali Dayton 27:26
I love that. And that, that probably blows a lot of people’s minds, right? That is a culture to aspire to, but I, I just cling on to that hope in the vision that that is attainable. Know, that every clinician wants to do the right thing, and that we just need the tools to do the right thing. And you doing presentations with your nurses being at the bedside hands on, gave them the comfort to be open to that and to have those personal experiences. And then it resonated with every heart of each clinician as to why they’re doing it. And how is walking going on your unit.

Dr. Brian Bellucci 28:04
So I mentioned earlier that we take some videos at times of really good success stories. Where I think we’re to the point where, you know, at the beginning, when I was starting my career and in training, I mean, it would have been video worthy just for a patient on a ventilator to sit up. Like that would have been something that would be on a video, if they if they sat on the edge of the bed with the you know, the endotracheal tube hanging out of their mouth, that would have been video worthy.

But we’re at a point now where that’s I mean, that’s just expected. So a patient even standing up and taking steps in the room. That’s an expectation, it’s not even video worthy for us anymore. So we’re more interested in taking videos of, of things that are you know, better than that, like showing good cognitive stability and cognitive abilities. So that’s, like I mentioned earlier, you know, patients on their devices and shunt and showing pictures to our to the nurses of their family members, and playing a musical instrument and watching their videos and doing tasks that reading and you know, that’s that, to me is what drives us seeing videos and photo evidence of that. But that just goes to show the state of the mobility too, because it’s expected that our patients are going to be standing up.

Kali Dayton 29:17
No one makes a big deal out of it. No. So much of what you experienced when you went to the other awakened walk in ICU that Dr. Murphy’s laughs because they were questioning, “Why you were you guys there?” They didn’t understand what the big deal? You’re intensivists, you’ve worked in ICU- what makes ours different?

And that hopefully becomes the norm for anyone that especially starts their career in your ICU. It’ll be like when I started my career, right? We’ll know nothing else. At the end of the pandemic, when we had those higher volumes of patients that could not oxygenate with movement, they needed to be sedated. I remember nurse who had worked in that ICU for a year or two, but that was the only place she’d ever worked. She came and asked me, “What rate do I start propofol at and how do I titrate it?” – It just warmed my heart because that was just such an indication of where we had always been at and that ICU.

Dr. Brian Bellucci 30:09
Yeah. What’s interesting to me is I don’t just work in this sector. I’m, I work predominantly in our center here. But I also work in some remote ICU settings, like tele ICU, and I do occasionally travel to other intensive care units. And, you know, I see the difference is crazy. It’s incredible to see how just how different it is when people are doing the same old conventional sedation and SATs strategies.

And then when I it’s almost like, if I were to try to intervene on those the few days that I’m there, it feels like it would take so long to explain this to them and teach them because it’s such a, it’s such a cumulative, you know, process of learning for everybody. That for me to go there and in five days think that I could completely change them is wrong. So it just goes to it goes to show how involved this is and how cumulative it is and how much we’re learning experience on the fly as it is for a lot of the staff?

Kali Dayton 31:17
Absolutely. You’ve just captured my career for the last two years. Answering this question is how do you provide the tools to bring sustainable change, right? And that’s where I, at this point, you really won’t even go on site until I’ve done webinars with people because there’s so much to explain before you go and teach them “how” they have to understand the “why” and have a shift in perspective and insight.

Then they can be ready to digest the changes in logistics and the practice, but there’s a lot, there’s a lot. You do have to have your own experiences and have to understand why you’re changing these things. And that’s a lot to attempt when you’re just popping in and out of a unit.

Dr. Brian Bellucci 31:59
Yeah.

Kali Dayton 32:01
Kind of back to the question for clinicians, physical occupational therapists, RNs, that are hitting barriers with their physicians. How would you recommend that they get buy in from their medical directors or their leaders to invest in and really support changing these practices?

Dr. Brian Bellucci 32:20
Yeah, I think, you know, asking the physician leaders and practicing physicians in the unit, you know, what, what, what are our approaches to delirium, like, specifically, “what do I do about this delirious patient?” And expressing your worry about what delirium leads to and, and to express concerns about post intensive care syndrome. Say that, you know, “We need leaders, we need people who are going to, you know, want to be delirium champions.”

I like to use that word a lot around here. You know, people are “delirium champions”, and someone who’s a “delirium expert”, who is that person? You know, maybe maybe recommend choosing somebody to be that that delirium person who was a physician and a leader in the in the unit.

Kali Dayton 33:12
An ally, where they felt comfortable saying, “I have a situation, what do I do?” I like that.

Dr. Brian Bellucci 33:19
yeah. And refer them to to the podcast. Let them hear stories, and, you know, encourage them to, you know, to, you know, maybe try to set up a post intensive care outreach. Just to at least hear from individuals hear from patients, you know, what they’re experiencing, and, and then also, later on hospitalization and ask them actually. Encouraged physicians- ask the patient what their ICU stay was like. Ask the family what their ICU stay was like. What do they remember from it? That’s, if you’re asking if you’re asking the patients and families, then it’s also in your own mind.

Kali Dayton 33:56
Yeah, that’s great. Yeah, that makes it personal. It’s one thing to hear me tell stories about patients I’ve treated or patients that have been survivors that have been in other units, but just hear it this is what happened in our unit under our care with our process of care.

Dr. Brian Bellucci 34:10
Correct.

Kali Dayton 34:11
That’s haunting.

Dr. Brian Bellucci 34:14
It is!

Kali Dayton 34:14
I had a an acquaintance send me screenshots of some text messages where they were expressing concerns about a patient it was a nurse reaching out to their intensivist overnight. Saying, “This patient is agitated. They’re CAM positive, they have delirium, I see there are PRN Ativan orders. I’ve given it, I don’t think it’s working. And I don’t think it’s the best thing for the patient considering that they have delirium. Would you consider ordering physical and occupational therapy to work with this patient in the morning to help treat the delirium to get them mobilized?”

And the response for the physician was? “No, the patient needs more sedation. So the stalwart nurse said, but I understand that this Ativan is benzodiazipine and it’s going to worsen their delirium, and we’ll continue on the cycle. What else would you recommend I do?”

And the physician said, “Nope, they’re tachycardic and agitated, this means that they need more sedation.” That was the end of the conversation. What would you recommend to a nurse in that situation?

Dr. Brian Bellucci 35:15
Yeah, that’s, that’s difficult. And, you know, sometimes they sharing personal experiences with using benzodiazepines and similar patients can be helpful. Sometimes, you know, saying, oh, you know, maybe recommending an alternative agent at the beginning, while this position is growing, and suggesting something like dexmedetomidine might have been helpful.

You know, I’m still trying to educate our staff all the time about the pharmacologic agents. I have, you know, a lot of even colleagues, physician colleagues who who think that anti-psychotics Or, you know, they treat delirium, and they don’t, they don’t, they don’t fix delirium at all. They control agitation. But that comes at a cost.

Kali Dayton 35:59
They can still restrain them, and they can still be abused.

Dr. Brian Bellucci 36:03
That’s right. That’s right, that comes at a cost. So sometimes recommending, you know, or making a suggestion early on, can be helpful. And then asking that position, you know, “What, just out of curiosity, what strategies do you think, what other strategies do you have for mitigating and managing delirium?”

Sometimes you have to ask it respectfully and politely. But it may make them think about it, it may put it into their mind that, “Am I not taking delirium seriously enough?” And maybe, you know, working with that physician, and in the rounds, you know, focusing in on delirium when you’re rounding up the patient with that, you know, on all of his patients or patients, you know, talking about delirium all the time, that may help convince them. Because it did for me. I mean, you know, the more I thought about it, the more it helped me change my practice.

Kali Dayton 36:56
Absolutely. I hope that, you know, throughout the pandemic, we had to work so closely together. And as the newer generation, hopefully we’re phasing out of this hierarchy of our team structure. That we’re more collaborative, that we can all bring evidence to the table, and that nurses can speak up and say, “The evidence says that benzodiazepines cause delirium, delirium should not be treated with it”- that they can actually bring the evidence to the table and be respected.

Dr. Brian Bellucci 37:26
That’s right. And even benzodiazepines can affect mortality as we know.

Kali Dayton 37:31
Yeah! They’re an independent predictor of mortality!

Dr. Brian Bellucci 37:33
That’s right.

And I just want to share one other story. And a lot of it has to do with physicians and intensive care physicians and extubating and strategizing. I had a patient who was obese, large man and he was on a ventilator and he was awake, you know if he was on no sedation, is that fi02 was pretty high, though. So it was really a barrier checks debating him, I think he was, you know, in the 70 to 80% range.

And for me, I was hoping that later in the day, I’d be able to maybe get as if I were to down to 50 or 60 and extubate him to high flow nasal cannula. Because it’s ventilator parameters are good as we need parameters are good. He’s actually awake and following instruction. And he was maybe a little a little bit you know, agitated at times but manageable.

And I got called maybe three or four hours later after I decided to just leave him on the ventilator or not extubate him that he hadn’t extubated himself. And I come down to the unit and he’s breathing okay, saturating okay. We put a nasal cannula on and I think it was only seven or eight liters somehow after all that. And he managed you did okay. And I remember going to the nursing station and talking to the nurse who was in a very bad place because of the way you guys are trained.

Kali Dayton 40:00
Yeah! “If that happens, you are a failure, you’ll fail the patient, you’ve basically killed the patient. If an unplanned extubation happens on your watch. It’s all the nurse’s fault.”

Dr. Brian Bellucci 40:08
To me, my explanation to her was, “Consider the alternative. If we were practicing in a different place at a different time, the gentleman would have been resuscitated put back on propofol, he would have been completely snowed the whole night, another SAT would have happened the next day, he may have been agitated, he may have not been extubated because of the fi02 was high. And this would have gone on probably several days in a row until he may have he may have had tracheostomy done. So that fork in the road of us keeping him awake, and preventing delirium and preventing him from being sedated may have been a major fork in the road, in the right direction for him to get extubated, and walk out of the unit rather than end up, you know, treat content and sent off to a long term hospital.”

So I tried to explain to her that this was a better outcome. And, and that unplanned extubation is really need to be kind of rethought of, reconsidered.

Kali Dayton 41:09
And as a physician, taking that moment to educate, to support to provide that perspective is invaluable. Nurses just feel like their licenses are on the line. They’re just… someone’s waiting to just take them to court because of current events, right? They’re terrified. And that influences sedation practices.

So to say, “This physician supported me,” and now she has a better perspective of the real trajectory of the patient’s life. You know, she could have framed that as a complete failure. But hopefully, after your support and education, it was seen as the success that it was. It was successful to keep them awake, if he had been sedated the entire time and immobilized. And then he got his tube out, he probably would have had to be re-intubated.

He wouldn’t have had a functional diagram or been strong enough airway. So that was all success. And then he got the tube out because he didn’t have to have it out! What his doctor either “The customer’s usually right?”

Dr. Brian Bellucci 42:02
yeah. Right.

Kali Dayton 42:03
So if he’s trying to pause, pull out his own tube, he’s probably strong enough to breathe, which just kind of takes us back to the unplanned extubation episode, I think 123 I can’t remember. But check out the unplanned extubation episode for more on that. But this is a perfect example of how you are influencing the practice and culture of your team, by taking those moments to educate, to make sure that these things are sustainable throughout each nurse each clinician each day, even when you’re not there.

Dr. Brian Bellucci 42:32
That’s right. You know, if I were looking at that whole scenario, you know, the red light, the red X on O would just be for that one task of overseeing and making sure the patient doesn’t, you know, self extubate. But when you step back and look at the whole perspective of how this patient’s journey went, it ended up going the way it should have been and better for him.

Kali Dayton 42:54
Your approach saved his life. It saved his life.

Dr. Brian Bellucci 42:57
That’s right. And I’m confident in that.

Kali Dayton 43:00
bsolutely. And we see the A to F bundle that between the A to F group and the control group of deep sedation and immobility, that they had the same number of unplanned extubations. So it’s not like sedation really decreased unplanned extubations. But there was a 68%, improved mortality.

So unplanned extubation is not the worst or the most lethal event. There are far worse things that can happen to patients and we increase those risks with sedation, and we don’t necessarily decrease the risks of unplanned extubation.

Dr. Brian Bellucci 43:32
100% Absolutely.

Kali Dayton 43:34
Well, anything else you would share the ICU community?

Dr. Brian Bellucci 43:37
Um, you know, for me, as I’ve been stressing, I try to repeat it, you know, in the rounds in the room: “What are we doing about delirium?

and mention, you know, if a patient is on an infusion, that “Every drop of that infusion is, could be making that patient’s life worse. Every day, we’re not moving them. You know, everyday, we’re not moving that patient. We’re potentially making his or her life worse. And we didn’t sign up for this to make people’s lives worse.”

Kali Dayton 44:06
That is so powerful. Thank you. Thank you for the impact you’ve made on your team. And now the impact you’re making the other teams through this podcast Keep us posted when you get more data collection, let us know! I think a 50% reduction in delirium speaks pretty loudly but I look forward to even more updates. Thank you so much!

Dr. Brian Bellucci 44:21
Thank you, thank you for inspiring.

Transcribed by https://otter.ai

 

Resources

Every Deep Drawn Breath” by Dr. Wes Ely:
https://www.icudelirium.org/every-deep-drawn-breath

ABCDEF Bundle study:
https://pubmed.ncbi.nlm.nih.gov/30339549/

Unplanned extubations episode: https://daytonicuconsulting.com/walking-home-from-the-icu-podcast/walking-home-from-the-icu-episode-112-unplanned-extubations/

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