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How did the ABCDEF bundle come to be and what is its true objective? What barriers are causing the ICU community to fall short of full compliance with the bundle and what is the future of the ABCDEF bundle? Michele Balas, PhD, RN shares with us her insights as one of the founders of the ABCDEF bundle.
Episode Transcription
Kali Dayton 0:00
Hmm. Michelle, thank you so much for coming on the podcast. I’m excited. I’ve seen your name all over the research for years. I don’t know how we haven’t met before. But this is really exciting. Can you introduce yourself to the listeners?
Michele Balas, PhD, RN 0:14
Absolutely. Equally thrilled, thrilled to meet you. My name is Michelle ballasts. I am currently the Associate Dean of Research at the University of Nebraska Medical Center College of Nursing, relatively new to that role, great opportunity, working with some really fantastic young nurse scientists and established investigators who are aiming to change the world. So I’m thrilled to be here. Well, you
Kali Dayton 0:38
have done so much incredible work in the ABCDEF bundle realm. I see liberation projects. How did that even start?
Michele Balas, PhD, RN 0:50
Well, that’s a great question. We spoke a little bit before the podcast, but I’m gonna have to say that a lot of my work was influenced by my everyday clinical practice, I was a nurse in a surgical trauma intensive care unit. And I was working in a unit that I’m going to say was kind of like nirvana or heaven, if you think about it. So this was probably this was in the 90s. And at the time, we had eight amazing clinical nurse specialists by the name of Joanne Phillips, and aren’t normal practice was really heavily influenced by her.
So in those days, we already had the culture of getting people up and walking. And if you didn’t get your patient out of bed that day, she was kind of in your face and what I perceived to be a good way asking why but more importantly, asking, how could she help? Right? So she was one of those leaders that just didn’t expect the nurses to get the patients out of bed, she would be there physically to help us, you know, walk the walk. So she was amazing.
That I say it was like a Nirvana because the nurses that I worked with, were all just super fantastic and skilled in their own way, we had a great group of complementary skills. And it was a fantastic practice environment, or respiratory therapists, physicians would go out to eat, you know, breakfast after night shift and things like that was a great interprofessional team. So I was very lucky that my early days of practice took place in an ICU that was very patient focused.
Kali Dayton 2:25
I don’t know what comes first, the great environment that leads to early mobility or the early mobility that leads to an environment whether you bond with each other.
Michele Balas, PhD, RN 2:34
Yeah, well, back then there wasn’t really any evidence supporting what we were doing. I mean, early mobility wasn’t a thing. It was just kind of one of those like, Doug moments, like, is it better to keep a patient in bed and not mobilize them get the pressure sores and all of the, you know, complications that come with bedrest. I mean, we knew bedrest is bad.
For decades, right? bed rest is bad for every single part of your body. And, you know, I think a little bit of it has been tempered by to that we were it was a surgical ICU so that then surgeons kind of expected that their patients were up and walking as soon as possible.
Kali Dayton 3:15
Right. But in the 90s, that’s when we most of the ICU community started to really adapt this deep sedation and immobility for everyone on a ventilator for any reason.
Michele Balas, PhD, RN 3:26
Yeah, because the orange trials, right, low tidal volume, low tidal volume did a lot, right? Because those patients, you know that those studies that were We were part of those clinical trials, required patients to have neuromuscular blockade, which then necessitates sedation, and adequate pain management. Yep.
Kali Dayton 3:45
And we never, we still haven’t really compared patients being awake with low tidal volumes settings, versus being paralyzed and sedated on low tidal volume setting. So that’s a whole nother ARDS discussion down the road. But that is where, you know, the ARDS research is what really hit us off to this wildfire effect.
Of “Quick, sedate everyone on ventilator for any reason, no questions asked.” Now, here we are in 2023. And it’s still been a problem that we’re facing. But then how did we start to evolve from there as far as the different guidelines and the research that you’ve been involved with?
Michele Balas, PhD, RN 4:23
Well, the evolution has actually been pretty interesting to watch. I mean, I think probably in several other podcasts, you’ve covered how it started with cress in the shutting off sedation and then demonstrating that that was effective that patients were able to be on the ventilator without sedation. No, we even back in the 90s. We weren’t doing it to be mean. We weren’t sedating people to be mean.
In fact, I was on Twitter yesterday and my head almost exploded. It almost explodes every day on Twitter for a number of reasons. But I saw somebody comment on one of West’s e Lee’s questions about deep sedation. saying that you know that this is going to come back and haunt you guys, the people that are saying, you know, to minimize sedation, because all these patients were going to get PTSD and things like that we were doing the right thing.
I remember being a nurse saying that “If I’m ever in here, and I’m ever in a car accident, and I’m the second, if you don’t sedate me, and I die, I’m gonna come back and haunt you!”- like it was ingrained in our soul that the proper thing to do was to sedate people. That historical context. And that belief that still is present today with many well meaning ICU clinicians that’s really, really hard to break.
Kali Dayton 5:39
Absolutely. And we started getting more research more data showing the harm of those things. So how did the ABC of Fidel come to be How did your team create this protocol to address those problems and change this approach?
Michele Balas, PhD, RN 5:54
My life has been guided by serendipity. I mean, I had the blessing of working wet with Wes Ely, even in my PhD program, you know, this random nurses going to school emails, the biggest guru in ICU research, and you know, could you help me? And he said, Yes. So one of the big takeaway points that I’ve learned in my life is that if somebody comes and is really passionate about a topic, say yes, to help them, you know, the reason that I do this work, and then I’ve committed my work to this was all based on a patient’s story.
And it was not so much early mobility related, but it was something that literally changed my life. And I think about almost daily, we were caring for a relatively young woman who was brought to ICU, really, really sick after a motor vehicle crash. I mean, she was really sick. She had liver lacerations, broken ribs, went into severe ARDS, like really sick on admission. And at the time, she was also like 20 weeks pregnant. And so back then, you know, the thing that we had to do is really focus on helping the mom survive her injuries.
And that was the best chance for the baby to be able to survive. So we were able to get her through kind of the acute phase of illness. And then one day, kind of almost out of the blue. She had a really active husband who’d come and visit her family. They hated leaving her back then we had restricted ICU visitation. Like how antiquated is that notion, you know, we made the family members leave the bedside, leave their loved ones when they’re dying.
But out of the blue one night, she she got really super confused. So she started like, pulling out her lines and tubes was like trying to kick pull, and she was really on high vent settings at that point. And we were afraid that you know, if she pulled out her lines and tubes, she she wouldn’t be able to live. So we did what we thought was again, best practice back then we heavily sedated or right, we gave her every PRN that was on her list.
So she got her benzo she got all of her opioid she got her probably Benadryl. God forbid if people are still using Benadryl for sleep. But she also got really high doses of how though, like really high doses Now again, this is in the 90s. So this is when we were pushing five milligrams, five milligrams, five milligrams until the patient went down. Again, back then that was kind of normal practice.
Kali Dayton 8:22
We didn’t know.
Michele Balas, PhD, RN 8:23
We didn’t know. Um, next day came in to take care of her and I walked in to do my report. And you know, the nurse told me how terrible or night was. And I touched your hand and never felt something so hot in my life. took your temperature 106 Seven, took a test, you know, ICU nurse that can’t be right to get again, 100 and 680. My God. So you know, I called for help pull back the covers, and didn’t cheat deliver her baby in the bed. The baby was there. Right between her legs. We call the OB it was too late. baby died.
So we had again, kind of focus on taking care of the mom. It’s something that I’ll never forget. We don’t know what happened. We don’t know if maybe her agitation the night before was her trying to tell us she was going into labor. She couldn’t tell us right? She was ventilated. her wrists were restrained. We used to think wrist restraints were good. And that would protect people from harm. We know that’s not true to you know, we didn’t give her a way to communicate. Could she have told us you know, maybe she was going into labor and that’s why she was getting so wiggy we just assumed she was agitated.
You know, like patients become in the ICU sometimes rarely, but sometimes. You know, maybe that’s what she was trying to tell us. We don’t know my intuition to this day. Nobody will ever change my mind. idea in the situation probably likely to come about from all the health all that we gave her right neuro malignant syndrome from the halidol. Everybody says it’s rare never happened. Well, I’ve seen it four or five times. But yeah, “never happens”.
So that’s why I actually went back to my, to get my PhD, I never wanted another person who was confused to be treated the way we treated her again, with our best intentions in mind, we did everything that we thought was right back, then calm her down, keep her comfortable, protect her airway restrainer. And I’ve just committed that we would never, that would never happen again, particularly with older adults, who are my passion and my love of life. I love this sweet, confused, older adult that many, you know, many people find, honestly, challenging to care for.
So that’s kind of why I did that. And it’s still what guides my research is, and how I got involved with the ABCDE bundle. So the bundle was thrown out there theoretically, just based on all of the great randomized control trials that we had that supported all these interventions. Why not put them all together? Right? What would happen if we put them all together? We didn’t know what would happen if we put them all together the ABCD and E. So I worked with my team was the first to test what would happen if you put the bundle into everyday care. We did that at The Nebraska Medical Center.
And we found really great results. Since that time, like my takeaway is every study that’s ever been done on the bundle, has found extremely consistent results extremely consistent. I challenge people when I speak, to show me a study where the ABCDE bundle doesn’t benefit patients. It’s consistent mortality length, well length of stay, you know, ICU length of stay, what does that matter?
That just depends on beds in the med surg area. But improving delirium, improving coma, getting people off the ventilator earlier, getting people home, as opposed to a new institutionalization, every single outcome improves consistently. We’ve also demonstrated the more you get the better, right, right,?
Kali Dayton 12:17
The 2019 study, looking at the bundle across over 15,000 patients and facilities, I just have to share those results. They found that seven day mortality decreased by 68%. readmissions decreased by 46%. Coma, delirium decreased by 25 to 50%, patients were 36% more likely to go home restraint use decreased by 60%. Mechanical ventilation decreased. I mean, those are incredible outcomes. But if you look at compliance, the 100% compliance only hit at 8%, only 8% of those patients had 100% compliance, only 12% of those 15,000 Plus patients are on their feet bearing weight. But they found that it was dose dependent, the closer the carob got to an awakened walking ICU approach, the better outcomes were so those statistics so they’re impressive and exciting. That’s an average. With all of those combined,
Michele Balas, PhD, RN 13:20
So we did publish a paper on that. I mean, these sites that were in the ICU liberation collaborative: top notch. Again, the most motivated ICUs in the country, they’re taking all this time treasure and talent and investing it into the ABCDE bundle, we want to do the right thing. On a positive day in my positive friends are always like we tripled it, right?
We tripled ABCDE F bundle performance. That’s Fanta and it’s great, right? Because we know what it does to patient outcomes. And those are all I think, in those 68 ICUs, we only got to 12% compliance, you know, adherence to the ABCDE bundle. So there are great opportunities for improvement. You know, what’s interesting is, again, hundreds probably now, due to cost to Kelly did a great review not too long ago about all of the challenges, we know it’s hard to do this, right? These people that say just just do it, it’s the right thing. We have to do it for their patient. They’re not speaking reality, Kali. It’s hard.
Kali Dayton 14:26
When you’re deeply rooted. And these cultural practices, I think, once people haven’t mastered they had that skill set, they’re comfortable with it. It’s it’s not that hard. It’s about you know, the difficulty is not doesn’t far surpass what we’re doing as a norm. It’s getting there that is so hard that transition is where the challenge lies.
Michele Balas, PhD, RN 14:47
Yeah. So we’re actually looking now so again, we know hundreds, you know, hundreds of studies supporting the individual bundle elements and how great they all are all the studies shown the ABCDE bundle works now Our study showing it works, but nobody’s using it. So our research that we’re doing now we just were so blessed just got a grant from the National Heart and Lung, NHLBI, and the National Institute of Nursing Research. How cool is this? I could die.
Now, this is my dream study. So we know these things work. We know nobody does them. Well, not nobody, but there’s some great performing ICUs like we know we’ve practicing. How can we help clinicians do it? What strategies work we know the barriers, right? We know the barriers, you need physical bodies to mobilize patients, nobody will tell me different. And mainly, that always involves a nurse, Kali, right? We know that. The nurses are intimately involved .
Kali Dayton 15:45
They’re the linchpin,
Michele Balas, PhD, RN 15:46
Almost every single bundle element. So in this study, how cool is this, we are going to test two different implementation strategies, we’re gonna have units that are randomized to either get this dashboard that’s displayed in the ICU. So everybody, patients, families, other ICU clinicians, whatever will know, this dashboard will be there, and they’ll have the ABCDEF.
And they’ll know whether or not those elements were received in the last 24 hours. So did the patient get up and walking, right, we’ll have it set up in a way. So for the early mobility, red will be green. They’ll do their safety screens, if they pass their safety screens, they’ll get them up and moving in bed, out of bed, right? So it’ll be green, yellow, red, whether or not they received it that day. That’s one arm. So half of the units are gonna get this visual reminder, please, please, please, please, please do these things.
This is where we are as a unit, oh, what’s going on here, maybe the nurses could help here, the respiratory therapists couldn’t do this. The other arm ready, all right, is gonna get an extra nurse. And this nurse is going to act kind of like your CNS. And my CNS did in the past almost as an ABCDEF bundle facilitator. She’s not going to have an assignment. Right? She’s going to be there to help the whole ICU as needed to get these patients the ABCDEF bundle.
Kali Dayton 17:23
You know, I have a team that I worked with, that I trained, they kind of beat you to it. Because they were as they were working through this, they found the gaps. They also started seeing the financial benefit, they were able to justify getting an ICU liberation nurse. Oh, that would be this published? No, I want them to publish it, I hope the last couple of months, but those that is the only purpose is to go around saying, “Where are they out with a bundle? What do you need? Why aren’t they up? Let’s get up. Let’s get this sedation off.”
I mean, they’re there just for that. And they they rotate through. So everyone gets the experience of looking at the whole unit? Oh, fantastic. I know. And they they come up with on their own. That wasn’t my idea. But they were able to justify that because of the progress that they’ve already made. Yeah. To say, to go all the way this is what we need. And this is financially very justifiable, huge return on investment.
But I think that’s, that’s perfect. So that’s, that was one of my roles as a nurse practitioner, is to oversee that to look at the big picture. And that was in a team that already had a process very established that everyone had that skill, we still needed that oversight. So especially those that are really, you know, in the in the trenches of working on this, that is very, very bad. What a great resource and excited to see the evidence from that.
Michele Balas, PhD, RN 18:41
Yeah, I mean, you have to have equity codes and research, right? We don’t know which one’s going to work better, right? I don’t want to cheat, but I kind of have my assumption on my hypothesis of which one will work better. I think both will be better than usual care. And so this study is going to help us see, you know, you know, all the great work that’s been done by the past by leaders in the field, you know, outline these barriers and facilitators, were taking those barriers and facilitators, moving beyond that, we don’t need to know what inhibits us anymore, we know that we know the problems.
Now let’s test strategies to see if we can overcome that. So congratulations to the team that’s done that I’m more than willing to help them if they want to get that work out there. But I think we’ll have finally some evidence and see, you know, the effect that it has on patient outcomes and the fact that it hasn’t been to adoption, hopefully it’ll help get the safe effective practice into everyday ICU care.
Kali Dayton 19:38
So exciting and and I think it was doing more. Let’s talk about what the objective of all this is, what is the objective of the ABCDEF bundle because I worked with one of those first rollout teams in 2016. As a travel nurse, I It wasn’t part of the formal training but what I got at the bedside was okay at five in the morning. We have to do this really annoying thing where you turn on sedation you crash you turn back on. That’s what I, that’s what I caught of the bundle, right?
So I think as I’m working with teams, I’m seeing this gap where we’re not understanding the objective of it, we’re seeing it as a task list. These are mandated things in the charting system, which you can work around in 10 different ways, right? Yeah. So what is the actual objective of the ABCDEF bundle?
Michele Balas, PhD, RN 20:23
In my opinion, the objective is to obviously help people survive. But it’s so much more than that. It’s having patients while they’re in the ICU, being a week, engaged, able to interact with their family, able to communicate with the ICU providers. In my example, Hey, you know, I’m having contractions. Hey, I’m having pain, Hey, I forgot my dog, my dog is home at home alone, and nobody’s caring for it.
And that’s why I’m quote unquote, agitate agitated, awake, and be able to interact, whether or not I mean, some people are gonna die. Wouldn’t it be better to be at least able to communicate to your family, to your loved ones, what your needs were what you’re sorry about what you wish you could have done, how much you love somebody, if I’m laying in bed, you know, I don’t want to just pass slowly, I want to be able to tell my kids, I love you, I’m proud of you.
So giving them that opportunity. But more importantly, we don’t want all these people justice survived the ICU to have the worst life ever later. Right? We want them to go back to work. We want them to have healthy family relationships, to be engaged in their community, to be able to partake in the things that they like. And if we’re not harming them in the ICU with practices that we know harm people. That’s a great step forward to empowering them to be healthier later, we want healthy people later.
And it’s hard when we’re doing the, you know, minute by minute routines to get past, you know, the patient that’s coding in room two, I mean, we still are priorities, the patient that’s coding in room two, but to bring it back to that, you know, it’s just as important that the patient that’s getting a little bit better that we help them maintain their muscle mass maintain their brain, so that they could have a high functioning life later on. It’s hard to think in the long term, particularly if the ICU providers are never provided with what happens to their patients in the long term.
Kali Dayton 22:36
Right. And I when Wes talks about how the acronym came to be just that it was it was something catchy did adapt it to write, you’re gonna have all these different elements cues, and you’re trying to figure out something to help people remember and organize it right. But those those of us downwind have taken it as a very sequential thing, right? So you can automatically start state patients, you have to give them opioids, then you’re gonna do breathing trials down the road. And that was never the objective is to still sedate people. I feel like we’re holding on so tight participation in mobility, and still trying to walk and move forward. But
Michele Balas, PhD, RN 23:14
That’s based in science, your statements based in science, when we look at that ICU liberation collaborative, guess what the three hardest things were to do? Guess what the hardest was to do? Mobilize the Yeah, the least performed.
Kali Dayton 23:27
Right? Because we didn’t get to the rest. Because we create so much difficulty when we start sedation, we cause delirium, then it’s hard to peel off sedation and focus, how can we get to the mobility side? And we make this really complicated. I mean, I appreciate the dashboards and everything. But I liked what Dr. Ely said in a webinar just recently, he said, when we’re looking at the bundle, we just need to ask three questions when we’re looking at compliance.
Are they awake? Are they out of the bed? Where’s the family? Are they awake? Or they have the bed? Where’s the family? And so I have a picture of a card on a highway with a road sign, and the car is the bundle. The road is icy liberation, the destination on that road sign said says awake and walking ICUs love that, that that’s what we’re working towards. That is the vision and when we finally have a clear vision, then we can optimize the tools that we’ve been given.
Michele Balas, PhD, RN 24:23
Yeah, and I like Heidi Engles approach too, right? She always she would be at these meetings together. And she’s like, we’re not supposed to start with the eight. We’re not supposed to start with the eight. I mean, we have to start somewhere. So that sticky message is important. That’s why sometimes I get a little nervous if we call it different names at this point, right? But here they’re here not. But if she always challenged us to think what if you think II first does make sense, right? If you think e first, you can’t do e without the without shutting off the sedation, or at least having the patient awake so at least that triggers that awake. All right, great strategy.
Kali Dayton 25:03
If we have to go sequentially, let’s do F to A. So family, if our goal is to have them engaged, really connecting, communicative, engaged with family, then we’re not going to sedate them. And then they’re going to be ready for mobility. And then we’re going to be managing sedation with the sea appropriately. And then we really are going to be preventing and treating delirium. So I think if we have to go in a very specific order, if we’re still needing to do a conveyor belt approach, let’s start from the bottom up.
Michele Balas, PhD, RN 25:34
I agree, but not all patients are going to have family, some family will have challenges getting in, I think that’ll vary. I think there’s disparities and health. I mean, if you’re talking to somebody that’s in ICU from a rural community might not be there every day. I also worry about burdening families. I was always about what the families do you know, if they want to help with mobility, why not? And what one of my other what really wise mentors puts out, like, you know, how we got to consider where the families are, as well.
I mean, this is normal to us seeing people on the ventilator and stuff is normal to us. How much stress and burden do we want to put on the families to be involved with care that we should we should be providing that is in our scope of practice, which is another interesting thing, that probably a whole other podcast, we could talk about those structural and organizational things that stopped us from doing it.
And until we get to the root cause, and, you know, put our big boy pants on and talk about some of the challenges nurses are facing on a daily basis that are structural, it’s going to be hard. So I’m going to steal I think, in my head kind of go with Ingo philosophy with think of the E. But yeah, that f is tough. You know, it’s tough to define, it’s tough to measure. And it’s probably, again, the most important part. They’re not our patients, they’re their families.
Kali Dayton 26:57
Right, and they are the experts on them. But again, every family has different levels of capacity, comfort, its intuition to know how to involve the families at the right level for them. We also have institutional barriers. So we have now very restricted visitation hours, I’ve seen nine to seven, in some facilities. I mean, would you kick out a respiratory therapist at seven o’clock at night? It’s insane. So then that’s a clinician, what can they do? How do they they’re now….
Michele Balas, PhD, RN 27:26
Where did they get the idea that it’s okay for us to restrict families from seeing their loved ones like that. That’s that’s the, like, where did we where did we organizationally think that that was okay, that there OUR patients, not their families.?
Kali Dayton 27:40
COVID. But but then we learned in COVID, that was inhumane?
Michele Balas, PhD, RN 27:45
Yes.
Kali Dayton 27:46
And then we did, we still didn’t fully go back to where we had been from the previous A to F bundle rollouts, we had really moved towards open ICUs, we went back 100 miles, and now we’re only back. We’ve only come 50 miles since then. So…
Michele Balas, PhD, RN 28:00
It may be a blessing like you’re putting up right, because it showed us the barbarity of restricting family visitation, or your family members dying. Let’s stop you from seeing them. I’m not talking about COVID. I understand the complexities there. That’s not easy. And I’m not blaming hospitals for restricting family visitors in a time that we didn’t know what was gonna happen. Right? We didn’t know. Right? They get a pass. We don’t get a pass that we were doing it before. And we’re still doing it now.
Kali Dayton 28:30
We know very well. Now the evidence supports that which, you know, we’re doing episodes on each element of the bundle. So f will really hit hard the evidence that supports full family visitation involvement. But from a family perspective, what a families knew about the bundle, they knew that their loved one had would have a 68% chance, greater chance of being alive in seven days. If the bundle was being applied. Is this a liability for teams? If we don’t comply with a bundle? Should this be considered standard of care?
Michele Balas, PhD, RN 28:59
Oh, by far, yes. It should not. I’m not saying that yes to liability. Because again, there’s structural things that stop us from doing it. So I don’t think liability I think I love your idea, telling the family or giving the family pamphlets about why we’re doing stuff. What a great idea, right? Fantastic idea.
Kali Dayton 29:17
I have a podcast for families. It’s called “Walking You Through the ICU”, so that the clinicians don’t have to sit there and try to explain delirium, I record weakness, it’s a lot takes a lot of time. So my goal is to just give them that podcast where it’s succinct and catered for them where they’re at.
Michele Balas, PhD, RN 29:33
That’s fantastic. We also have an early stage investigator here who’s working on an app to help with family engagement that will hopefully be coming down the pipe very soon, but yeah, absolutely. 100% Yes. Should be considered standard of care. Um, yes, there should be. We have a responsibility to do the bundle is the best we can in terms of liability. I mean, I’m not a lawyer. I can’t to speak to that, but I know that there’s challenges that make it very, very hard to do the best care.
Kali Dayton 30:05
And I only bring that up because we, there’s so much hesitation to apply with the ply or comply with a bundle, because they’re afraid of liability. But if we understood how this could look on paper, right, but it has been proven to be life saving. And if we fail to comply with it, could there be down the road as the public understands more? Could we be held accountable for failing to provide the standard of care? Yeah,
Michele Balas, PhD, RN 30:31
I mean, that’s fascinating, right? Particularly with the E. So everybody’s worrying that their patients are going to fall and get this terrible thing patients are going to fall, it’s going to happen, they’re going to follow the walk in them or not walking them, they’re going to pull out tubes, where did they restrain non restraint? It’s interesting, because if you think and we’re gonna have to deal with this with our grant, like, okay, what are the potential adverse events, right? of early mobility, the adverse events are really more likely to occur in the patients that aren’t getting the early mobility.
So I think that’s kind of what you’re talking about, meaning there is more harm that’s going to occur if they’re not mobilized. So if anything, the liability risk should be on keeping them in bed. That’s the liability. That’s where you’re going to run out of its liability risk, or I actually jet. It’s definitely the isogenic risk, right? We know there’s more harm keeping people in bed. But how do you describe that everybody thinks is the fall is the bad thing as opposed to the pressure ulcer as opposed to the deconditioning as opposed to the cognitive impairment that’s coming from deep sedation and immobility and things like that? So changing that from a liability perspective is interesting.
Kali Dayton 31:46
No, absolutely. No, we just need to understand that this is how you save lives. Yes. And that, if we’re not doing that, we’re not giving patients the best chance to survive and thrive. So Michelle, thank you so much for your decades of dedication to this and the hard work and your name is all over the research. And you have saved lives that you will never touch, which is amazing.
Michele Balas, PhD, RN 32:07
They just say the same thing to you with. As I said before doing things like the podcast, you’re doing such a service to the ICU community, and more importantly, particularly if you’re doing this for the families, oh my god, think of the millions of families and people that you will never touch or see that you’re changing with this. So I’m so happy that you’re brought into my life. And please, please commit to keep doing this important work.
Kali Dayton 32:32
Absolutely. No, there’s a whole movement happening. There’s a cute group of ice revolutionists that are joining the ranks. No. I love that I like them happening. So yep, awakened walking ICUs are the future of critical care medicine. We will master the ABCDEF bundle you will see it in your lifetime. So thank you so much.
Unknown Speaker 32:51
I am convinced
Transcribed by https://otter.ai
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