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When Dr. Mikita Fuchita heard about an Awake and Walking ICU, he had to see it with his own eyes. After visiting the Awake and Walking ICU, how did Dr. Fuchita embark on bringing his colleagues together to update their sedation and mobility practices? He shares his personal conversion and his team’s journey with us in this episode.

Episode Transcription

Kali Dayton 0:02
Okay, let’s be honest, if you’ve worked in normal ICUs, the concept of an awake and walking ICU. sounds insane. When you first heard of patients being awake while intubated, you likely connected that to the only experience most ICU clinicians have with patients being off sedation, which is when sedation is turned off after days, two weeks of sedation.

I’ve noticed that there is an expectation for physicians to understand and lead best sedation and mobility practices. Yet, in reality, they are equally left in the dark on the truth of sedation and immobility. We are all a product of our experiences and training. In order for physicians to lead these changes and take stewardship over ensuring best evidence based practices. They too need the education, training, support and expertise to change their own perspectives and practices.

I have been honored to be in touch with Dr. Mikita Fuchita over the years. He is one of the earliest podcast listeners and an exemplary ICU revolutionist I’m excited to have him share his insights and journey in this episode.

Dr. Mikita Fuchita 0:09
Yeah. Hi, my name is Mikita Fuchita. I’m an anesthesiologist in Denver. Originally from Tokyo, I went to medical school in Japan, and came over for residency in Indiana University. And I started my critical care fellowship in 2020. And spend that year in 2021, doing clinical research. And I’m currently finishing my cardiothoracic anesthesia fellowship at University of Colorado.

Kali Dayton 0:41
And during your training in the ICU, what kind of sedation and mobility practices were you taught? Or what was instilled into your training?

Dr. Mikita Fuchita 0:50
Yeah, so it kind of goes back to my internship year. So I graduated medical school 2013. And I spent two years during internship. And I still remember there and working in different hospital in Japan, and then Indiana and Colorado.

The standard of practice has always been some sort of continuous steady sedation for mechanically ventilated patients. So I’ve been trained to essentially sedate patients. And over time, I’ve learned about SAT, SBT. How sedation is actually harming patients.

Kali Dayton 1:29
How did you become exposed to that information? What opened your mind to the concept of an Awake and Walking ICU?

Dr. Mikita Fuchita 1:37
Yeah, so I did my literature review, I just wanted to learn about what’s actually out there in literature about sedation. This is in preparation, before going to fellowship? Because I guess I’m a little perfectionistic in that sense. Then I learned that, you know, “Oh, wow. There’s even a study about no sedation from Dr. Strom, in Denmark in 2010. And that was a replicated as a multicenter trial in I guess 2019, 2020.”

And so that’s, I had an understanding from the literature that sedation can harm patients that if you can minimize isolation, the patient’s outcomes are better. And I think it was around 2019. I was watching some videos on SCCM website. And I somehow stumbled upon a video by Heidi Engel.

So Heidi, and go as you we all know, very well. So woman, strong woman, a physical therapist, and she was giving a lecture on early mobility, and she had lots of videos. So it was a recorded webinar that I was able to download, because I was a member. And she was talking about her practice of keeping patients awake, and ambulating those patients.

And the recording was, I think, from 2015, or 16. But that was the one of the biggest breakthrough of my life. First of all, no offense to anyone, but I’ve, I’ve been used to listening to lectures from physicians. So I hearing something very profound from a physical therapist that brought a lot of insight was, you know, one surprise, in a good way.

And kind of opened my mind to the idea of ambulating patients with a mechanical ventilator. But my personal practice in training, I was, I was never exposed to a patient who was ambulating on the ventilator. So, you know, in my mind, I was thinking, “Oh, this is UCSF, you know, the top, you know, hospital in the United States. It’s an exception.”

And another breakthrough happened when I listened to your podcast, Kali, so this is kind of the beginning of our relationship. So it was 2021. around February, I was midway through my critical care fellowship. And you were, I was going through a podcast known to the anesthesia community, the ACCRAC, and you were a guest speaker on that.

And that was the second shock that I experienced, and I was like, wow, not only mobilizing patients, but like keeping them those with no sedation. And so that was when the reality kind of shattered and I’ve got myself very curious. It makes sense to me what you talked about in the past. asked, because I knew that, you know, not had the knowledge from the literature. So it clicked with me.

And that’s one of the other reasons that sparked a lot of interests. But I still have lots of skepticism. So as a, as a member, the first thing I did was I emailed you and say, “Kali, I want to see this with my eyes so that I can see with my own eyes and determine if this is real, and if this is worth believing.” and so that’s what happened.

Kali Dayton 5:35
So I sent you to the Awake and Walking ICU. You’re in Denver, they were in Salt Lake. So you just jumped on a plane and went, and you had a really great visit with Polly and Louis, the nurse practitioners that really founded that ICU and that process of care. What was that like for you to tour the unit and to see with your own eyes?

Dr. Mikita Fuchita 5:57
Yeah, so I still remember the biggest impression that I had, my first impression was that every staff member in that ICU was kind of nonchalant about their practice. Like, they didn’t….. They didn’t seem aware that their practice was very different from other ICUs. So Brandy, took me, you know, around the unit, she was kind of like my tour guide.

And she brought me into the unit, and I saw some nurses kind of shooting and breathe, drinking coffee at the nursing station. And I was like, “Okay, maybe there’s no sick patients in this unit” And Brandy will like walk them around the unit. And that’s when I realized, “Oh, wow, there actually intubated patients,” and saw that there was no sedation going on.

And I think every patient that I saw, I think there were like three patients. And if I were to have like a 60% 70%, PEEP of 12. But everyone was in chair. And some of them were on the iPhone, you know, texting. And that was like, “Wow, I’ve entered a different world.”

And so what I noticed was that that was the the standard, that was the norm. So no one question, or did wasn’t didn’t seem aware that their practice pattern was very different from other ICs that I’ve, you know, been exposed to. And they’re questioning while it’s visiting. Like, what?

Kali Dayton 7:47
“You’re an intensivist, you’ve worked in ICUs. Why are you here?” Yeah.

Dr. Mikita Fuchita 7:51
This is another ICU, I guess, in a community hospital? Maybe not? Right? Not quite an academic hospital either. So that was that was the impression I still remember.

Kali Dayton 8:05
And what was it like to walk away with that? I think there’s, it’s from what I hear from listeners is, there’s a moment when everything clicks, when you realize that what you’ve been taught what you’ve always done, what you’re used to, is not necessarily the best thing for patients.

And now you can’t a vision of what could and should be. And that’s kind of a heavy weight. I think I’ve heard from podcast listeners, it’s a little bit hard for them to listen to the podcast, and then start their shift, and look around and see what’s happening. So what was that like for you to step away from that? And then what was your next step?

Dr. Mikita Fuchita 8:44
Yeah, so clearly, I’ll back up a little bit and say that I was still skeptical. To some degree. I bought into the idea after seeing patients awake, and you know, actually ambulating. And I think it was Polly, who taught who told me that, “Hey Mikita, If you want to try this at your own institution, you want to bring it back, I have one suggestion for you.”

And she said, “It’s much easier to not start sedation than to wean sedation that’s been infused in for three, four days.”

Because if you’ve let them been, you know, kind of get marinated with a propofol, fentanyl, whatever the sedation, you’re depriving them of regular sleep, increasing the chance of, you know, hallucination, delirium.

And so, that was the advice. She said, “If you’re ever involved in patients who you have the opportunity to be at the bedside, from the moment they’re getting intubated, try not to start sedation.”

So that’s what she said. And so you know, I needed to convince As myself because I want it to spread, I want to bring it back to my institution. But then before I could talk to other people that that that might be the best practice, I really wanted to convince myself that you actually works.

So basically, it was an experiment for me. So I was involved in intubation on five patients where I had the opportunity to go through this together. So first patient was an ARDS patient, who had to be on BiPAP for the previous two, three days on, you know, fio2 of 100%, high pressure settings, and finally getting worn out and you know, worked up breathing 30 times per minute.

And so I approached her and said, “Hey, if so, you know, first of all, you need to get the breathing tube, I’m sorry about your lungs are still need some time to recover. We need to get your breathing tube and ventilator machine.”

And I basically gave them the option to stay off of sedation. And how I phrased it is, “You know, the literature, you know, if you look at this the research, we know that if you use sedation to a degree of comatose, unconsciousness, it not only increases length of stay, mechanical ventilation, duration, mortality, but also like long term quality of life, cognitive function.

And so, I will still give you medication for comfort, but not to degree of unconsciousness. That way you can tell us what you need, you can interact with your family members will give you, you know, whiteboard who communicate by if you’re really anxious about it, if you don’t like the idea of being awake, then we can do the you know, what, what’s the standard of practice to give sedation so that you’re unconscious while you’re intubated?

And this patient said, “Sure, I’ll give it a try!” And so I kind of prepared her tha, “It’s still going to be uncomfortable. No one wants to be intubated. But they’ll like that, I will guide it her through.”

and I also mentioned that she’s going to have restraints in her arms. Just because it’s natural for patients to reach out to tips and lines that are usually not there and that kind of pressure. So I would, I decided to use propofol. I think I use succinylcholine just making sure there’s no contraindication and it would intubate.

And I just sat there until she woke up. Because you know, 15 minutes has elapsed, and she’s starting to show some, you know, recovery, smart thing is breathing. In the nurse, this bedside nurse brought in propofol and fentanyl without me putting the orders in.

Kali Dayton 13:12
Right.

Dr. Mikita Fuchita 13:13
And instead. “So Dr. Fuchita, what would you like to start at?” So I said, “No, I talked about you know, trying to stay more awake with minimal sedation. So I want to see how she wakes up.”

And she would be like, “Oh, so you want to just do fentanyl then, you know, and so let’s just wait.” I really needed to push back on what she was trying to do.

Kali Dayton 13:42
Or walk her through it, right?

Dr. Mikita Fuchita 13:44
Yeah. 30 minutes passed and the patient has finally started to wake up. And Kali, that gets what she she did? The first thing she did was she winked at me! She smiled and she winked at me. As if she saw my nervousness and saying, “Oh, this is a piece of cake.”

And so at that moment, I realized it was as if I just completed a case for colonoscopy. So in colonoscopy, we give propofol sedation in oftentimes, when we’re involved as anesthesiologist, and give it as an infusion. Let them wake up in you know, 10,20 minutes.

And a lot of the patients said, “oh, so when are you getting the procedure started?” So a lot of the patients wake up with not much memory about the procedure. They just the unconsciousness begins the moment we get proper form, and the memory usually is not there if we did the job correctly, I guess.

So that patient, the first patient reminded me of colonoscopy, when we get sedation, let them wake up, they’re back normal. The only difference for her this patient was that she had breathing tube. But she was prepared.

So so she was able to tolerate it much easier than I had anticipated. But it also made sense to me because only exposed to medication was propofol and succinylcholine. I might have given some fentanyl too. So I picked I repeated that for other patients in by the way is dispersed patients that offer sedation for the next four or five days. And the nurse,

Kali Dayton 15:41
How did your nurses respond to that? Were they nervous when they come on shift to get their assignment, see their patient awake?

Dr. Mikita Fuchita 15:47
So the first nurse was still kind of skeptical. But I explained about your podcast, I mentioned about your podcast, you know, “There’s a hospital that actually, this is a standard of care.” And she was like, “Wow!”

I don’t think she was completely bought in. But as a rounding team, I would visit this patient every day, right? And I was going even more frequently because I was nervous like you wanted to you wanted. And so I spent a lot of time talking to different nurses that took a turn to care for this patient.

And I was surprised. But just by seeing the patients being okay. Acting like a normal person. And communicating with the family at the bedside. They seem to get it. They seem to kind of flip also much easier than I thought to accept it.

Kali Dayton 16:49
In so that resonates with the nursing model, and the nursing heart. Yeah. They just need to actually experience it themselves. And then it clicks. And then I think from there, they need to understand that that can be the norm. I think there’s still some feelings of I’ve had a patient away from the ventilator they were okay. But that was that one patient that was the exception.

Dr. Mikita Fuchita 17:13
Yeah, so the second patient I want to talk about, you know, it was a, she was intubated for bronchoscopy. But she had a high oxygenation requirement. So the team decided to leave her intubated overnight. But I did the same consent, and she, you know, agree to stay off of sedation.

But when I went back home around like by by pm, I was very nervous. Because I, when I maybe I left around seven, because I remember talking to the makeshift makeshift nurse coming on, and I explained what what’s going on, because that was completely out of the norm.

Kali Dayton 17:59
Night shift might have certain expectations, right?

Dr. Mikita Fuchita 18:02
Yeah. So she was asking that they shift nurse as they were signing out, “Why is this patient off sedation? So should we start some propofol?”

And I was like, “oh, no, no, she actually agreed to stay off sedation.” And so I just mentioned that I just didn’t want to be pushy, or, you know, the controlling of what they think is best for the patient. But I was very nervous, right?

So when I woke up in the morning, you know, five 6am The first thing I did was open My Computer and check, check if the patient had started sedation overnight. And to my surprise, there was no documentation of the trip. And then Kali, I I almost cried. I think I actually cried.

I was like, “Wow, like, that does actually happened. It worked. It worked!” And then first thing I did when I arrived at the hospital is to go to this patient’s bedside. And I caught this nightshift nurse still at the bedside, they’re about to give it on site now. And what I noticed was that a patient was who we left with our restraints was off restraints. So they decided to take off the restraints themselves. Yeah, I asked the nurse like, “Oh, she’s off restraints,” and I kind of made a statement. And she was like, “Oh, yes, she she looked appropriate. So we just took it off and she’s been fine.”

Kali Dayton 19:39
They’re just falling back into their nursing instinct. Yeah, it really do get it. They know how to, they know how to do the best thing for patients. They just need the opportunity.

Dr. Mikita Fuchita 19:49
So, you know, obviously this approach was is not scalable, because I had I was spending lots of time at the bedside, committed and advocating for, you know, minimum is no sedation and we have patients that I use the low dose press of x, because I’ll be like texting Polly, Louise, while I’m trying to do this, like, just now gagging like what should I do?

And they have all the tips and tricks. So, but these were five patients, you know, similar story that I just needed to prove myself. So the next thing I did was I asked you to come over for work, or lecture to give give a ground except, right? So that’s, that’s when, how our project kind of started?

Kali Dayton 20:41
And what’s the impact? Like how I think a lot of people struggle with how do I convince the rest of my team? Right? It’s I’m one person, I have all this insight, a lot of podcast listeners have listened to a lot of podcast episodes, but maybe their colleagues haven’t. So what’s the value of having an outside party, or just a formalized presentation of this concept, rather than trying to explain to it, explain it to each person one by one at the bedside?

Dr. Mikita Fuchita 21:12
That’s the tough part, right? Initially, I spent quite a bit of time trying to talk about your podcasts, try to sneak in that. Geez,

Kali Dayton 21:27
the plan, I put put a plug in. And that’s what the way made the podcast, so that someone in your position, or anyone could say, Hey, I’m not crazy. This really works. Check out the podcast. So you don’t have to do all the work of having to repeat it and try to explain it. Because it’s, it’s a lot, there’s a lot to explain a lot to convince. So what if I could even just from sharing the podcast? What impact did that make on your colleagues?

Dr. Mikita Fuchita 21:53
Well, they get it, they listened to it. And they’ll come back to me and say, Wow, this is this is cool. But I think as a nurse, like one individual nurse that listened to the podcast, got inspired and clicked. But that’s still a different practice than what their ICU is used to do doing. So you might have that new idea about keeping light sedation or no sedation.

Like if you look at the patient next door with different nurse taking care of care of them, is to see a different standard, like order the social norm. So I think it’s hard for them to speak up as an individual nurse. And so I think that’s where the moral distress come comes in. When you think that the best care is might be different, different, and you’re unable to provide that because of the structure that they’re in the culture that they’re in. And I certainly experienced that a lot. And I had to learn how to deal with it.

Kali Dayton 23:10
How did you deal with it? Because that is I hear that from listeners, it’s a hard thing when you understand that you can’t unsee the harm anymore. When you get the real insight into what’s going on, and then you’re facing that every shift. How do you cope with that?

Dr. Mikita Fuchita 23:27
I need to reframe my thinking, to some some extent, the one thing that we did as a quality initiative. So just to kind of back up a little bit after I got you on for the lecture. Three people approached me and became a team member, you now know them. Alexis Galen Lake and we slowly expanded our team to a multidisciplinary model. Now we have nurses, respiratory therapists, pharmacist all passionate about your vision, and how we can do better. So I forgot my train of thoughts.

Kali Dayton 24:14
Um, how do you cope with a moral injury? And then what do you do with it?

Dr. Mikita Fuchita 24:18
Yeah, so the as a quality initiative, we, we became curious, like, what’s the mental model? About sedation? Why do we give sedation and what do people think the clinicians think? How it’s affecting patients outcome? So we basically surveyed try to serve every individual that routinely work in this ICU.

I work in cardiothoracic ICU. And so there happens to be 130 or so clinical staff up. In most of the nurses like 60% or so, respiratory therapist, APPs, physicians, PT OT, speech therapists, pharmacist, not missing anyone but… dieticians? Actually, there’s only one dietitian.

But But anyway, yeah, anyways, we surveyed and we’ve got a response rate of like 80%. And what we found was that, in this survey, the first question that we asked was, do you think? Or is it surveys? I think we phrased it as my isolation practice is making a difference in patients outcomes.

And we had a Likert scale response options. So strongly agree, agree neutral disagree, strongly disagree. And what we found that across different disciplines, like 97 98% of respondents either strongly agree or agree, saying that how they’re practicing sedation is important for patients outcomes.

But when we look through the results, questions like sedation helps alleviate psychological stress, or, you know, decreases anxiety, depression, PTSD, among patients who are mechanically ventilated. There was a differences in the response pattern based off of the discipline. So for our ICU, but whatever the reason, it was physicians and PTO T, that said, “No, sedation does not help with those psychological conditions”, but nurses and respiratory therapists, especially had this belief system, where they found it was helping them.

And so what I noticed was that everyone in our ICU, is trying to do the best for their patients. But they have different background knowledge and training about how things work. Maybe physicians tend to lead read more literature, I don’t know what mechanisms of the differences. And for physical therapists, maybe they have more longitudinal, you know, feedback of how the patients do after you know, even post ICU discharge.

Sure. So that’s my hypothesis, like why they have that, you know, literature or perspectives that that is in line with literature. So, I, so I’m going back, sorry, but long story short, going back to your original question about how do I deal with this moral distress is that I respect their perspectives, and try to be understanding, so that as

Kali Dayton 28:08
You start, yeah, you start to dig into what are the roots of this?

Dr. Mikita Fuchita 28:13
Yeah, that’s right. So, you know, because we all want to do the best for a patient’s life, we don’t have the same vision or belief as to how sedation is impacting their patients. No wonder there’s this agreement, oftentimes that the rounding, right, yeah.

Kali Dayton 28:35
It’s hard to when you’re just doing rounds to say, as a physician to say, take the sedation off. That’s it, or the discussion to the order, or they just give a command, but there’s no unified front as to why we’re doing those things. And I’ve seen teams that I’ve consulted with that have maybe tried to have more, I see liberation movements in the past that have not either succeeded or haven’t stuck. I do see a big gap in education and the culture has persisted.

Dr. Mikita Fuchita 29:06
Yeah. And I was gonna say something, but I forgot.

Kali Dayton 29:13
So you, you sent out these surveys, you were able to expose some of the core beliefs that dictate your station practices. I did a webinar just a big introduction webinar with your team. And you immediately had people respond and say, I want to be part of the the group. What was the course of action for your group of champions? And what do you call that group?

Dr. Mikita Fuchita 29:41
Oh, yeah, we call this group. Alex just came up with this. It’s a sore so AR, which is the abbreviation for sedation off awake and rehabilitating? I think which is a brilliant.

Kali Dayton 29:56
I love it. No, I mean, I like that bar more than I see liver ration, it’s just much more specific, it gives a vision and a goal that you’re working towards.

Dr. Mikita Fuchita 30:05
Yeah, so, you know, to be very open about everything at the webinars, we have, we struggle with participation, because it was not a part of their core curriculum or onboarding process for nurses. So we have to, like actively advertise your lecture. And those that watched it, I think we have, you know, 10 people for each webinar, right.

And which was, you know, I was a little bit disappointed, but, but those people who listened to it had some interest, right, there’s a selection bias of those that volunteer to use their time to participate. But that, I think, at least for those that, you know, was exposed to your webinars believed in what what you’re talking about. And because it’s a truth that you share with how they manage patients without sedation in the the hospital in Utah.

So, it’s hard to measure, like, how much impact your webinars had. But maybe there, there was some conversation that started because of one person, one person that, you know, attended that webinar. So it’s hard to kind of point out to what worked and what didn’t work, but you know, it definitely has some positive influence.

And as our initiative, we have serendipitously decided to use like positive reinforcement, as a measure to engage more people, and to create a new narrative narrative, especially among nurses and respiratory therapists, because those are the population that we identified, that, you know, we need to introduce to a new idea, right?

So what we started to do is when a nurse was able to wean sedation through a regular SAT, or it was able to keep sedation minimum to off, to allow them to communicate, and bring bring in family and treat them more humanized way. I sent an email to this provider or a nurse and said, “Hey, you’re doing great job, thank you for being open to, you know, keeping managing patients with breathing tubes without sedation, what you’re actually doing is evidence based medicine, or practice, and it’s actually impacting directly impacting patient’s outcome for the better, you’re saving lives. Thank you for doing this.”

You know, I see see that email to the nursing manager in the nursing Educator of the unit. And that’s, I think that’s how kind of the buying started, probably because I got a response from the nursing educators saying that hey, Makita, this is amazing. It’s, it’s, it feels, I don’t know, what that works is to us. But it’s great that this nursing lead practice, is making a difference in patients outcomes, and that this is a collaborative effort. And so I was like, Oh, this is a positive response.

Kali Dayton 33:56
So often, my experience is not often that nurses get a private email from a physician, commending them on their work. That is a huge thing for the morale. And this is, I’m gonna say early 2022 That you were working on this starting up,

Dr. Mikita Fuchita 34:14
over like, yeah, mid 2022.

Kali Dayton 34:17
So, you know, just coming fresh off of the pandemic. Everyone’s demoralized, burnt out, morale is low, and you’re taking the time to commend each individual person that’s doing the right thing. That is exemplary. That is leadership. That truly is.

Dr. Mikita Fuchita 34:37
Are you talking about me? Yeah, I’m talking

Kali Dayton 34:39
about you know, yes. Because I, you know, physicians can say yes, I support this process, but they’re not really involved a lot of times because they it’s kind of seen as seen as a nurse, RT, PT kind of thing, but that’s how you support the process. That’s how you get by and you’re at the bedside, you’re helping the nurses pray. access these things, bringing the tools and then having communication and helping build them up and have confidence. That is all leadership.

Dr. Mikita Fuchita 35:08
And I trusted this ICU, because I’ve, you know, worked in different institutions. And I just get this feeling that University of Colorado, like, when they say they’re doing the best for the patients, that patient comes first, if you’d like they actually mean it. And for the most part, they believe in that and actually show it with actions.

So when I, when I’m sending emails like this, and you that they appreciate it, because that’s their core value set. Yeah. And also had great leadership within the unit. But Dr. Sullivan, you’ve met? Yeah, made leadership. That’s a completely supporting my kind of crazy idea, so to speak, right? And, yeah, so it’s not without the support, that I’m able to even send these emails as a fellow. Right. And so

Kali Dayton 36:06
I give props to your team just wouldn’t during my visit there, there was such a good vibe on the unit, I could just tell that there were some really good core structures, teamworks routines that you had in place that facilitated this extra level of excellence, I would say, and, and everyone just seemed to like each other and work well together. And I think that is underrated. When it comes to succeeding tip create an awakened walking ICU.

Dr. Mikita Fuchita 36:35
I agree. Like there’s something about teamwork, right. This is a team effort in ICU. And having that trusting relationship, as a baseline foundation really has been probably the key to success so far that we’ve had someone has an idea for better patient care. You know, there’s slower adopters, but oftentimes, it’s met with some positive response, like, Oh, that’s a great, great idea. We should try it. How can we try it? How can I help, right.

Kali Dayton 37:09
And I even saw visual cues in your, on your unit, I saw posters, with celebrations of patients pictures of patients, tell me, tell me more about that other celebratory theme that you had going on.

Dr. Mikita Fuchita 37:23
So as a team, we decided to kind of leverage this opportunity of like nursing recognition, recognizing nurses, in awarding them, like, you know, celebrating these successes, small successes. So we formalized that, because we started getting emails from different bedside providers, like APTs, and some, like nursing colleagues telling us that, “oh, this nurse, nurse a was able to ambulate this patient, you know, within 24 hours of surgery,” or, you know, “Nurse B, was able to wean sedation or, you know, was able to deal with delirium without relying on sedation.”

And we’re like, “oh, we should is completely leverage this opportunity.” So we created this monthly recognition award called the winners award winner of the month award, like in about the greening, sedation, and we also even made a logo or mascot of this sausage guy. Dog, a hot dog. Yeah. We kind of stole this idea from a group. Next, next, next door neighbor, at the Children’s Hospital, there was a similar initiative that was working on similar topic. And that’s how they celebrated these successes with wieners. Because it makes it kind of more fun.

Kali Dayton 38:51
And it’s funny. Yeah, I like it.

Dr. Mikita Fuchita 38:54
And so we would make this certificate, like, legitimate, like looking certificate with signatures from the ICU, leadership, nurses, nursing leadership, even that a CMO of the hospital. Yeah, and we’ll recognize formally and then hand these certificate in front of everyone and celebrate it. And we’ll take pictures and I would kind of summarize it into a single page flyer, or poster kind of describing the snippets of what kind of accomplishments this nurse did and how that affected patient’s outcome. And we decided to place it in the restroom because restroom is…

Kali Dayton 39:49
you got time.

Dr. Mikita Fuchita 39:49
Yeah, exactly. And so I think that’s how we slowly but think Yeah, introducing this new new concept, new narrative that if you’re able to somehow minimize sedation, it’s better for the patient. And the more more nurses that saw, I think, the more convincing became by.

But… we’re not there yet. We’re not anywhere close to no sedation, or the awakened walk in ICU. But we still hear these anecdotes of incredible success. For example, two months ago, when I walked into the ICU at 7am, one of the nurses grabbed me and said, “Mikita, come check out 229. There is a patient who’s intubated and off sedation.” I was like, “wow, that’s, that’s great!”

Kali Dayton 40:53
You had nothing to do with that. I mean, you didn’t physically have to dictate that, right?

Dr. Mikita Fuchita 40:57
That’s overnight nurse and a CNA. And when I walked there, not only that patient was off sedation, he was sitting in chair off restraints. And when I looked at the ventilator machine fit was 100%. And people 12 or 14, something that I never expected would happen. Because, you know, as the expert guideline says, if someone’s if I were to use greater than what is it like 60% 50%, you’re not advised to do SBT or SAT.

Kali Dayton 41:35
In some of the guidelines, like, you know, the evidence is so conflicting. And also the studies, the research that studies, ventilator settings is so weak. But we’ve set you know, standardized guidelines. On other on the settings that were just used during the studies.

Dr. Mikita Fuchita 41:54
I guess he was an expert consensus to be more accurate. But anyhow,

Kali Dayton 42:00
I’ll link that in the in the podcast episode. I know what you’re talking about. Yeah. So it wasn’t even a study that consensus was just a group of people that got together chatted about what they felt was a safe and appropriate parameter to set. And then they published it. Yeah.

And that’s what then was used to create policies in our hospitals. But again, it was not a study, it was just a powwow, I would say, between experts, very credible, very knowledgeable experts that were going off of their own experiences, and, and just discussing in, in the setting of a lack of evidence, right, they were just coming up with a consensus,

Dr. Mikita Fuchita 42:37
Right. And so what happened with this particular patient was they were in sedation to off mobilize to a chair, off restraints. Now the patient’s communicating with our whiteboard. And by 234 PM, the oxygen requirement had have gone down to 50%. And then the following day, it was extubated to nasal cannula.

And so now that we know the cause and effect, you know, unless we can have a virtual parallel world, you can’t really say if it’s the mobility, the help with it, but pretty convincing, based on like anecdotes that I’ve keep hearing, some patients response to mobilizing, mobilization to upgrade, and there’s, you know, physiologic rationale to support that, just like how some patients responded to proning. In the COVID pandemic.

Well, some patients didn’t. And some patients may have, you know, worsening oxygenation from mobility. Right. So I guess the point is, like, you never know, if mobilization or you don’t currently know, how to predict patients that might respond favorably favorably immobilization versus those who may not. And I think, until you try, right, so I think unfortunately, currently, we just have to try it in order to see if it works or not.

But if you’re, you know, skillful enough as a team to safely conduct this, you know, mobilization even at a higher oxygenation levels. Then if there’s any signs of no optimization, deterioration, raishin, you can just say, okay, that’s not working, let’s stop, let’s get him rested. But, you know, that’s what, you know, the LDS hospital does, right. They try it and if it’s not working, and when it gets to, you know, maximum ventilator setting and still hypoxic, then you yourself, right. Yeah.

Kali Dayton 44:57
And that how does how does this impact your culture and the morale these little moments that keep on accumulating. What changes? Have you seen?

Dr. Mikita Fuchita 45:07
I guess that’s one of the outcomes. Right? So nursing, making this initiative for, you know, taking the initiative to make this happen without specific guidance. That’s obviously that’s the outcome and impact it’s had so far. And I think we actually repeated a survey just recently, to see if there has been any changes to the mental model was right, towards sedation. And, first of all, what we noticed was, it was like a doubling of podcast listeners over the months.

Kali Dayton 45:48
In your initial survey you looked at you compare the answers from those that had and those that had not listened to the to the podcast, correct? Yeah. So there is a growing interest in participation in the podcast, meaning that nurses and clinicians independently were doing their homework.

Dr. Mikita Fuchita 46:05
Yeah, so they’re interested now, at least some of them, some of them are listening to podcasts, like routinely basis. And, and, yeah, we’ve saw a shift in those responding to questions like, “I would prefer to be sedated. If I were mechanically ventilated.”- at baseline, there were like, upwards of 80% of nurses and respiratory therapists that sang strongly agree or agree. And that’s dropped by I think, like, 15%. And that’s a tough question, though. You know, I don’t know if I would say strongly disagree. Yeah, I want to be comfortable, right? Yeah.

Kali Dayton 46:54
Because it can be so circumstantial to exam especially when you’re asking clinicians that have done awaking trials for years. When they’ve come out of sedation, thrashing, agitated, you can see the discomfort that burns in your mind. Right, like, I still, I can still, even though I have years, and nobody can walk, can I see my experiences doing those awakening trials, and getting patients outside facilities?

If that’s all I knew, it would take a lot to convince me otherwise, that this really could be the standard at this, that I, I myself could be awakened comfortable on the ventilator? If that’s most of what my experience is based off of.

Dr. Mikita Fuchita 47:33
Right, totally. So it’s a tough question and understand either way, you know, someone response positive or the negatively about specific question about the fact that we are seeing shifts in the response patterns. I take it as, as a slight change in the culture. And kind of anecdotally, you know, patients like this happen with mobilizing, you know, meaning sedation. And I think our general approach is shifting to favor minimal to low sedation when possible.

Kali Dayton 48:11
Yeah, I saw that when I was at the bedside, I saw you guys doing great work. And I loved hearing in rounds, especially your your pas, were really running rounds in a way in which you were discussing and considering cam RAS sedation, delirium ability that was asleep, those were all just part of the systematic approach to discussing each patient at the bedside. And I saw a lot of power and influence, just with how you ran your rounds process.

Dr. Mikita Fuchita 48:39
Yeah, so that’s something you know, kudos to the medical director and the leadership of BP and nurses that establish that culture of collaboration and open discussions. Yeah, so.

Kali Dayton 48:59
Yeah, we talked about your let’s move to simulation training. I visited with Jenna Hightower, who’s a physical therapist from Mayo Clinic. She works elsewhere now. But she’s an eco extraordinaire. She can make the dead walk, I swear. She’s amazing. And so we came in, visited your team, we got to participate in rounds, weigh in on some of the discussions got to really see how you guys are doing and how to give some some insights into how to take it to the next level.

But we did simulation training. And you were so great to play the patient. You were such a good sport. Your university Colorado has an incredible Sims lab. And it looked so realistic. We had even an ECMO machine, your perfusionist attended. We invited people from all the disciplines and we didn’t have a number of sessions with your team. But also we invited all the other ICUs in the hospital. And I really wanted to hear one, what it was like for you to play the patient and to what kind of feedback and what kind of impact did that they make on your team? And even the hospital?

Dr. Mikita Fuchita 50:12
Yeah. So just to kind of explain to the listeners that a little bit, this was a voluntary participation simulation training that we organized with the QI team, with the help of you, Kaylee, and then Jenna. And we had a 16 participants, overall, different backgrounds, nurses RTP to T, ABP. And I think we had one critical care fellow,

Kali Dayton 50:40
from your team.

Dr. Mikita Fuchita 50:42
From our team, yep. I guess one of the challenges with doing something like this was, you know, getting the financial support, I guess, because all these people who participated was like self motivated people who wanted to learn more. Some people coming in from home, when they’re, they’re off work to get exposure to this simulations session. Right? They were.

Yeah. And so that’s just like, no background, but those people that participated. No, we had two case scenarios that we, you know, drafted together a script, so to speak. And we would start with a patient, which was me. And I trusted that you’re going to be a great facilitator, along with Jenna.

So I decided to play the role of the patient, how we had set up was I would wear the hospital gown, or half the arm strings on the simulation room, and I have to holster on my cheeks, to secure a breathing tube that was kind of chopped with a scissors. So that I looked like I was chewing on a straw. But from from distance, it was looked as if I was actually intubated. Right.

And we had that circuit connected to the ventilator machine, which we know we kept turned off, but we will have a high fidelity monitor at the back of the room, where the control person could, you know, change as the simulation, the scenario went along. So for me, I, I went into this role, just because there was no one else that could have wanted to do it.

So that’s the only reason I had to do it. But aside from thinking, Okay, I gotta be realistic, because, you know, the fidelity matters in simulation. But what I noticed was, his one thing is just having the eye level, to the rest of the people in the room. So initially, I, we started out the scenario with me laying flat in the, in the, in the bed, so that they did, and my arms are restrained, and I have my glasses off.

But when you know, you prompt the participants, and you elevate the head of the bed, to the point that that things that I’m seeing is not just the ceiling, but also the other providers in the room, just gravitational effect, somehow had an effect on my connection with the rest of the surrounding environment. So that was a huge you know, for me playing that role a learning for me that simply sit in them up the patient’s up, might have some positive effect on reorienting. So when you’re trying to reorient patients who were sedated or doing SAT. You know, I would probably start considering that more often. Hopefully I don’t.

Kali Dayton 54:06
Absolutely. When I played a patient in it another setting. My level of vulnerability changed by my position. So I felt very vulnerable, especially with people hovering over as I really got into character. I realized how, how scary that must be, especially when you don’t know what’s going on. But even if you do or hovering over you, you are in a very dependent, vulnerable position. When you get up. You feel just more in control.

Dr. Mikita Fuchita 54:35
And another thing along the same line was those providers, the participants who were talking to me and try to communicate with me that meant a lot. You know, it kind of feels like warm and fuzzy things. But as a person being that, you know, just playing that role, someone actually trying to know Giving me reassuring words that you’re okay. I’m okay. In explaining the situation and surrounding environment, but I’m intubated I can talk, that they’re there to help me that reassurance?

Well, it’s calming, even, you know, in the scenario when I was just playing the role, and especially like, you know, physical touch from the physical therapists who was trying to dangle me at the bedside, and looking me into the eyes, you know, just checking my orientation. And I was like, okay, this person is trying to help me is the feeling that I had the kind of relief that I mean, the right hands kind of feeling. That was another find no finding and learning.

Kali Dayton 55:47
Yeah, someone refer to those things as soft skills. Those are things that we don’t formally get training on. When not usually educated, it kind of comes down to experience intuition, but we should receive formal training. If those things can help calm a patient down and keep sedation, often those approaches those soft skills. help save lives. That’s right. Yeah, it’s warm. It’s fuzzy. It feels good. But it also is just hardcore, lifesaving, which is something that I did not appreciate until I started this exploration, right.

And they experienced that as well playing the patient, that it’s indescribable how much that means to you. And that’s also what I hear from survivors. So that sort of setting, they got to actually practice that. An ideal world, I would love for everyone to rotate and play the patient, right? Because it’s, it is a perspective you don’t get unless you are a patient. What kind of feedback did you hear from your team as far as their takeaways from that experience?

Dr. Mikita Fuchita 56:49
Oh, they wanted more time. They wanted to read more, you know, understandably so because, you know, we went into discussions. Everyone had lots of questions, right? So we had a 9090 minutes session, started out with like a 15, minute introduction, pre assessment. And then each case, it’s ran like, 20 minutes, 25 minutes.

And, yeah, it was, I guess it was just not enough time. But I said, like 90 minutes, thinking that they want to get out the most with like, smallest amount and shortest amount of time. But they’re, you know, self selected motivated people who wanted more. And so that was the biggest theme. And one of the nurses that participated, email me back a week later saying, “I actually practice this, the things that I learned in the simulation session and you worked!” and that she was, you know, starting to talk about it with her peers. So that was very strong, too.

Kali Dayton 57:53
I take different approaches with teams, I love simulation lab, it’s so quiet. It’s a really consecrated area and space for that learning. But one of the barriers that it’s hard to bring people with on their day off, it’s far away from the ICU. So if you were to Pete bring people from that were on shift, if you were to cover their patients, it’s a long ways to travel, if there’s some barriers with that. What I’ve seen with other teams is using an ICU room on the unit, and rotating through people that are on shift, having a resource, RT, resource RN, come in and cover so that they can step away for an hour.

And so there are pros and cons to both approaches. Right? I really loved having that. Just sacred space and complete focus, right. They just knew what they were going into. I also saw we invited clinicians from all over the hospital. And so there was your team. And I think most of those people that came had already participated in the webinars, right, the same? Probably half of them. Yeah.

Okay. In the presentation, I just could do a brief overview. And for many, it seemed like it was revealed, they seemed, maybe from what they’d already been practicing the bedside, they seem to already have the hang of it. What I had worried about and I think happened a little bit was when the other teams came, they hadn’t had much exposure to this approach before. So it was just, it was shocking. It was a lot. It was just a completely new concept. Mostly right.

They came because they were interested, they were open to it, but they still had not received thorough education before being expected to apply the principles at the bedside in a scenario. But they still did really well. And we had intensivists attend, who I’m still in contact with email there. They they’ve inspired me to develop some more tools to help their team and what did you experience as a patient the contrast and those that had some experience or just between the different teams?

Dr. Mikita Fuchita 59:51
Hmm. Well, the general approach is for I guess, yeah, always actually similar. Because like, I think maybe there’s also a select self selection bias. participated, perhaps knew that reorienting was an evidence based approach to managing agitation. Right? It’s there’s actually data around that.

But I think those that really was exposed to your webinars, and had that patient perspectives, and I think the big, I think that’s the key, like those were actually talking to me. You know, thinking that I understood things. So when they reassured me, I could tell from their tone of voice, that they actually meant what they said, and when they saying, oh, Makita, I’m here to help you. I’m the nurse taking care of you. And, yeah, if that makes sense, but

Kali Dayton 1:00:58
ya know, and I saw, I think there are a selection bias, because I mean, I think most clinicians are good and willing to talk to patients. I just think that those people came on the time off, because they’re really progressive and innovative and wanting to lead these changes. And when we did two briefings after the sessions, and what I was hearing from a lot of the other ICUs was excitement.

They were catching the vision. And then the big question was, well, how do we get the rest of our team on board? Will this will this process? Will this education be available for the rest of our teams? Right? Because I mean, again, you walk out with this perspective, these tools, and then it does require a whole team. So what advice would you give to close things off? What advice would you give to those that attended, and those that are just listening? How do you get the rest of your team on board?

Dr. Mikita Fuchita 1:01:49
Now, it’s scary to have opinion, that’s, you know, going against the, you know, standard occurring, you know, practice, and I’m still am a little scared to talk about, like, Oh, no sedation, maybe can be default, you know, can be the standard of practicing next few years. And when I say that I, you know, with some, you know, there’s no data yet. So it’s hard,

Kali Dayton 1:02:16
though, you know, A to F trial where they thought that outcomes improved, depending on how much they how well they avoided sedation, how will they mobilize patients, but we still have a lot more exploring and capturing to do and the evidence,

Dr. Mikita Fuchita 1:02:30
because that’s, you know, for some clinicians, you know, that worried about, you know, what about low tidal volume ventilation, or, you know, minimally invasive or protective lung ventilation, able to comply with that with a weak ambulating, you know, a patient’s?

And I don’t have an answer to that, and maybe what’s, what’s the risks and benefit of, you know, potentially breaching that principle, versus, you know, keeping them awake, and taking away all the adverse consequences of sedation and immobility. And I argue that sedation in order to suppress respiratory drive to a point that you’re completely compliant with the protected lung ventilation and six CC’s per KG, with lower respiratory rate, you really have to hammer with sedation, you got to get them to negative three, four, or five, even paralyzed to achieve that.

And in some, there are some data that says, patients who are deeply sedated in the mechanical stress is actually it’s not different, if not, could be more. And I recently learned about this phenomenon called reverse triggering of mechanical ventilation, where deeper the patient’s sedated, the more the double triggering kind of waveform of the ventilator occurs, causing more injurious breathing patterns.

So there’s a lot, you know, obviously a lot to explore what’s the best practices, and if you can, you know, keep the low tidal volume ventilation while keeping the patient’s awake. That’s ideal, right? So that’s something that I want to be careful about when implementing this because I’ve heard of a lot of concerns around this topic. And to get your question about how to do this, I think I think just, you know, it’s scary, but also start talking about it.

There are people out there, that thinking the same way you do. So you will be surprised. The like minded people who just unable to speak up, because it’s scary to go against the norm. But then once you becomes two people that think alike, and now you’re your team, and next moment, it becomes three people, and our case became, you know, a team of 10. And now there’s no buying from the nursing leadership.

And now they’re starting to talk about coming up with a, what is the operation guideline? Not guideline, I forget what they call it, but basically, policy or protocol, protocol, I guess, yeah, protocol to mobilize a patient’s when they have vascular accessing the groin, because anecdotally, we’ve considered that as a contraindication, when they have, you know, the alysus, Catherine, the femoral vein, or, you know, baleine.

Kali Dayton 1:05:59
And I really addressed that during simulation training,

Dr. Mikita Fuchita 1:06:02
vv ECMO via ECMO. But the recent literature is actually supporting, mobilizing those patients, if you do it with caution with safety, you know, checklist, with skilled individual who’s able to, you know, you know, who knows what to look out for, for safety events, then you can successfully do it, and that can change their patients outcomes. So, you know, I think, just starting from you, too, to answer your question, just speak up, there’s someone that resonate with your idea.

And then you become a team, and it just can be slow. But as long as the things that you’re talking about, sounds like sound, right? It sounds a legitimate. And, you know, you can use the storytelling from your podcast, what really motivated me was listening to the ICU survivors.

Because I’ve always thought of, you know, keeping patients alive was, if I’m able to keep someone alive, then that success as an ICU provider, and never occurred to me that 50% of them suffer from, you know, pics cost intensive care syndrome. So, you know, I think you can also use your, you know, podcast, the voice of the patient survivors. As a feedback, right, and use that to inspire people, I guess.

Kali Dayton 1:07:41
Yeah, that was the objective of the podcasts is to have backup for those lone voices to find validation reinforcement to help convince the colleagues of those revolutionists, and this group was growing, podcasts is growing. And, as you’ve experienced, going to these conferences, in this last year, when you meet those fellow ICU revolutionists, those lone pioneers, that bond is pretty special, right?

People that can understand what you’ve been going through what you’ve been working on that share those passions and interests and even just the vision that this will someday be standardized, that awaken walk in ICUs will be the future norm. But it will require those of us that today, and now that understand the reality of these practices to lead the change, and that is scary. But your example is so inspiring Dr. Fuchita. I appreciate everything that you’ve shared, anything else that you would leave with the ICU community?

Dr. Mikita Fuchita 1:08:34
Okay, I just want to thank you for everything that you’re doing your commitment, and how you’re bringing all the members around the world, right, really, as a team and as a community to support each other and doing this in a bold way. You’re You’re such a, you know, inspiration for many of us. And so thank you for all that you do.

Kali Dayton 1:08:56
I wouldn’t have the courage to do it and wouldn’t be continuing this project. If it wasn’t for the buy in and the support of those that are on the boots, boots on the ground, and they’re individualized to us bringing this change. You guys reminded me of why we’re doing this give me hope for the future. So thanks for all you’re doing. And we’ll put citations to these everything that we’ve mentioned on the transcript on the website. Thanks so much.

Dr. Mikita Fuchita 1:09:19
Awesome. Thanks so much.

Transcribed by https://otter.ai

 

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