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The normality of delirium in the ICU is often mistaken for benign. What does it really mean to “assess, prevent, and treat delirium”? Are we treating a positive CAM score with the same urgency as a positive tropinin? If we are automatically starting deliriogenic medications on every patient immediately upon intubation, are we truly practicing the “D” of the ABCDEF Bundle? Dr. Adrian Austin shares with us the full picture of the “D” of the ABCDEF bundle. John W. Devlin, PharmD, BCCCP, MCCM, FCCP joins us in this episode to share his expertise on best sedation and analgesia practices in the ICU.

Episode Transcription

To quote the creators of the ABCDEF bundle, the bundle’s mission is to “produce patients who are more awake, cognitively engaged, and physically active…… facilitate patient autonomy and the ability to express unmet physical, emotional, and spiritual needs. ”

If we zoom out more, The main objective of this approach is to prevent and treat delirium and ICU-acquired weakness.

What I am seeing in teams that I’m working with is that they may have some understanding of delirium, but many do not know how to properly perform a CAM test. Nurses have told me, “Despite working here for 18+ months, this is the first time I’ve really been taught how to do this test, let alone why”.

There is a lot of documentation of “unable to assess” for intubated patients. Some seasoned nurses have told me they thought CAM was not appropriate for intubated patients, and that’s why they chart “unable to assess”. Often times, this unable to assess is charted along side a RASS -1, or -2, but the reality is the RASS is much deeper, and that is why they cannot perform a CAM test. Their patients are rendered unable to engage and show their true brain function. This means that many to most of their patients can be suffering from acute brain failure without any detection, diagnosis, let alone treatment.

As John Devlin said last episode, a patient being deeply sedated without an indication should be a NEVER event, as it’s even more dangerous than line and device removals.

Our teams can be working so hard to treat all sorts of other organ dysfunction, but simultaneously and inadvertently causing, exacerbating, and/or prolonging, acute brain dysfunction.

Ultimately, the CAM screening tool should be considered as important as a tropinin level or creatinine. It is 1 of only 2 validated tests that can detect delirium with accuracy.

Considering that delirum doubles the risk of dying in the hopsital, it is alarming to find some ICU teams still have not implemented the CAM tool and others are not frequently using it and especially not discussing it in rounds.

I have been in contact with a physical therapist that left an Awake and Walking CVICU and moved to a idfferent part of the country. She has been dumbfounded to find how behind her new hosptial is far behind in modern sedation and mobility practices.

She has been told, “We practice the ABCDEF bundle. We rolled it out a year ago.”- and yet almost everyone is deeply sedated and they have not implemented standardized CAM screening in their ICUs.

The D of the ABCDEF bundle is for delirium- ASSESS, prevent, and treat delirium.

I will forever repeat, the ABCDEF bundle is NOT just SAT and SBT documentation. It is NOT an on/off switch for sedation. If our teams do not fear delirium more than unplanned extubations and treat CAM scores like a daily creatinine, then we have not yet acheived an ABCDEF bundle culture and mastery.

This episode, Dr. Austin joins us to dive deeper into the D and guide us to evaluate whether or not our teams are truly practicing the D of the bundle.

 

 

Kali Dayton 0:02
Dr. Austin, thank you so much for coming on the podcast. Can you introduce yourself to our audience?

Dr. Adrian Austin 0:07
Hey, I’m Adrian Austin. I’m a geriatrician, pulmonologist and intensivist at work at UNC Chapel Hill in North Carolina. And I’m a delirium researcher.

Kali Dayton 0:18
I’m so excited to have you on, we’re doing each episode for the next two months is dedicated to each element of the ABCDEF bundle. So today, we’re gonna be really diving into delirium. But I wanted to start from the very beginning. I know a lot of my listeners obviously know what delirium is, we hear the word all the time in the ICU, but I think it’s helpful to before we get into the details of it to zoom out again, and talk about what is delirium.

Dr. Adrian Austin 0:47
Delirium is a term with 1000 names. The older term with acute brain failure, which was very dramatic. There’s a term that’s thrown around by CMS that’s encephalopathy, or toxic metabolic encephalopathy. We is geriatricians. And as delirium researchers like delirium, it’s an acute change in mentation, an acute state of confusion. That’s defined by inattention.

So something happens to a person, and then they have a change in their mental state, which is defined by inattention. And it can wax and wane or fluctuate, or whatever you want to say it. But that inattention piece is key. So one of the key things is it’s not disorientation, I know we are trained as physicians, nurses, therapists to assess for orientation, which doesn’t tell you a whole lot about whether somebody is delirious or not. That’s an independent association. In assessment, so yeah, that’s what delirium is, it’s incredibly prevalent.

Kali Dayton 2:05
That’s interesting, because I am seeing that sometimes. Because we use it so often we see it so often, we assume that we know how to screen for it. And think sometimes we’re not doing the full cam assessment, we’re not doing the save a heart. We’re just saying, “Okay, well, they follow commands, so they must not be delirious.”

When I see myself, patients can be following commands, so they can tell you where they’re at. But you go to do save a heart, and they’re all over the place, they just lose, lose attention. So it’s one of the key features. And that’s why we have these validated screening tools like the cam ICU, so that we can really catch those nuanced features of delirium, because I’ve had patients say, when I asked them, “Can rocks float on water?” and they’ll say, “Depends on how salidic the water is”. Right when they go to SAVEAHAART, and by the end, they’re off in another world, they’re not really squeezing your hand appropriately.

Dr. Adrian Austin 3:00
And I think that speaks to the fluctuating nature of delirium. Another way I describe it is it’s really easy to disorient a person and then reorient them. In our hospital. Like many large academic hospitals, there’s multiple different buildings. And if you come in the middle of the night, in the emergency department, and then let’s say go to one of our wards and didn’t have a decompensation, it gets shipped up to our ICU.

You will, there’s a very real chance you have been in three different buildings throughout the hospital within a short amount of time. Probably changed the day, but you rolled over a midnight. So you could already not know exactly where you are or what the day specifically is, and so be, quote, unquote, disoriented. But it can be easy. If somebody was not delirious to reorient. You say, “Well, you’re in X building, and today’s actually Tuesday, the 25th or today’s actually Monday, the 27th.”

So you try that with a person who’s inattentive and you can correct them, you know, ask them to do a save a heart or days, the week backwards, you could say, well, no, this is how you would do that test. They’re not going to retain that delirium will preclude them from being able to retain that. But just very different parts of the brain that are affected and not functioning depending on whether it’s malaria versus some other end.

Kali Dayton 4:37
And since we’re talking to the ABCDEF bundle, D is for assess, prevent, and treat. And I think we all assume that that’s what we’re doing. But I think we need to understand what that really means. What are the tools to prevent and treat delirium.

Dr. Adrian Austin 4:57
That’s a $6 million question. Preventing delirium, we have firmer data for ways to prevent delirium. It’s good humans. Mystic care is the core principles. And what I would say is good geriatric care, minimizing offending medications, avoiding benzodiazepines, or medications that are strongly anticholinergic like Datron ag remain Benadryl being the big offender.

Getting people up out of bed, putting their feet on the floor, getting them moving, removing devices that are unnecessary bladder catheters, central lines, arterial loads, these things that we commonly use in the ICU, to stabilize people acutely and to monitor them and assist in their care. As soon as we can get them out. Not only does that risk, reduce the risk of a potential infection for indwelling devices, but makes mobilization easier and also independently helps reduce the risk of delirium.

Trying to maintain a good sleep wake cycle, having the family around engaging people during the day, allowing them to rest at night, just creating a more home like environment, instead of the sterile ICU environment are the ways to prevent delirium. When it comes to treatment, there is no good medicine, proven medical treatment, no pharmacologic treatment. For delirium, there have been many large trials, studying various medications for delirium, they’ve all been negative.

The largest one would be the, or the largest one until recently was the mind USA study, which combined or compared a typical antipsychotic have appeared all versus an atypical antipsychotic, which surprised own versus placebo, as an intervention for delirium. And that was a completely negative trial. So we don’t have a proven single agent for the treatment of delirium. Prevention is key. And it comes down to less medications, if anything.

Kali Dayton 7:20
And I think there are some studies that show benefits to the same methods for prevention, as that can be used for treatment.

Dr. Adrian Austin 7:28
That’s correct. But non pharmacologic treatments can be used for treatment as well, the data isn’t as strong for treatment, as it is for prevention. But the great thing about the sort of what I call humanistic Bumble is it’s not harmful. So at the very least, you’re not making people worse. And if it gives you benefit, even that, if that benefit is small, it’s better than what we standardly do. But

Kali Dayton 7:59
yeah, I appreciate a lot of these trials, we are looking at the rate of delirium, like how often it occurs. But including a lot of our trials, as well as the duration. So within within some of these trials, looking at mobility and the impact, and just A to F bundle in general, we see that not only with the rate lower, but oftentimes the duration was lower as well, which as well, which implies that we were able to treat delirium with these approaches as well, because we’re always going to have delirium.

It’s always going to be something that patients show up with on admission, there are so many risk factors within the ICU no matter how well you humanize the ICU. Yet, we absolutely have certain elements ingrained into our culture into our practices into our routine that cause delirium. So when we hear teams say, oh, yeah, we practice A to F bundle.

But they automatically start sedation and everyone that’s intubated. There may be giving some enthusiasm pushes. In my mind, when you give sedation, you’re taking away a lot of those tools to prevent delirium. They’re not getting they cannot get real sleep. They’re not able to mobilize. They’re not able to connect with their families. They’re not getting agents that cause delirium. So what are your thoughts about how we should approach management of sedation when we really are trying to practice the D which is to assess prevent and treat delirium?

Dr. Adrian Austin 9:28
I think a less is more approach is warranted. I’ve been thinking about this a lot lately, too, because we have a lot of experience with sedation and delirium during COVID which is brought this issue back to the forefront

when it comes to sedation, light sedation or minimal sedation is superior to deep sedation for our patients that think well supported with the evidence because it facilitates engagement and with reality, it reduces PTSD and allows people to get up and move which the more you move, the easier it is to get people off the ventilator and ultimately out of the hospital.

A no sedation or incredibly light sedation after induction for mechanical ventilation after you intubate somebody and place them on a ventilator, a minimalistic approach to sedation, I think, should be the paradigm we’re following. Unfortunately, it is not. Now with COVID, we really saw some deep sedation practices, because we were trying to maintain a mechanical ventilation principle that we is well evidence supported, is supported by strong evidence, and that’s low tidal volume, mechanical ventilation for ARDS.

The problem is, it’s not a very comfortable mode of ventilation. So it can require a lot of sedation for patients to tolerate that, particularly if they’re young, and they have a strong drive to breathe in it in excess of what the ventilators providing that was our experience time and time again during COVID. So I’ve been thinking recently, there’s likely some point of diminishing returns where the effects of sedation will outweigh the positive benefits of low tidal volume ventilation in certain patients.

This is a realize heretical to pulmonologist myself, being a pulmonologist. But, uh, I don’t think I’m the only one who’s talking about this. I heard Margaret herridge bring this up at a conference a few months ago. I don’t know, it’s an interesting thought. There’s no good guy point for that right now. But in general, my practice has been to allow people to wake up after intubation.

And if they are, you know, agitated, which I don’t really like that term, it’s not descriptive, if they’re having a behavior that is harmful to themselves or to others, usually to themselves, which the trying to self excavate wouldn’t be the behavior, then you can give some sedation, because, and I prefer low dose sort of intermittent opiates for that. I would imagine I don’t have the conscious experience of being on a ventilator myself, I can imagine that as a noxious stimuli and some occasional opiates can reduce that it can be helped for patients.

Like so many things in medicine, I think there’s a U shaped curve, where too little will lead to agitation because people are in distress in too much they over sedate, and you got to find a sweet spot. And that’s sort of what my research is focusing on is finding the sweet spot for opiates to keep people comfortable and involved and minimally delirious. Currently, I think it is fair to say we greatly err on the side of too much.

Kali Dayton 13:17
And I love the way you’re bringing the focus to sedation use as the parameter needs to be that can they still engage with their environment, mobilize, communicate, be autonomous. You know, I talked about an awakened walk in ICO. And I think sometimes it’s perceived as a no sedation unit. It’s, it’s not, we use sedation when there is an indication for sedation.

Sometimes an indication for sedation is a wrath of three or four. And I’m hearing the word agitation be used very arbitrarily. And sometimes they’re, they’re using it. I mean, I’ve been on units where I’m hearing that word be used. And I’m seeing it the patient simultaneously and the patient looks like a RAS of one, maybe two occasionally, right? The Restless, they look uncomfortable, we can treat those things.

We need to figure out what’s causing it, we can treat that, but we’re using agitation to describe restlessness and discomfort when agitation is in the literature defined by a RAS of three or four. Those are dangerous behaviors, that’s when you really have actual risks. And you might need some sedation. But when you use that, does that warrant a massive negative two, negative three? Or can we use sedation to achieve what you’re describing? Being awake, calm, communicative, autonomous, mobile, that really should be for most patients, the sedation level that we’re looking for, and all of that so that we can actually use the tools to prevent and treat delirium, otherwise, we’re giving delirium and then we’re masking it with sedation and we’re making it impossible to prevent or treat it.

But I think sometimes from a nursing side, I personally did I appreciate the risks associated with delirium. I knew what it was I could diagnosis diagnose it, I could use a camera really effectively. I was I hated it, because it made my job so much harder. But I wasn’t really panicked about it. I think the lack of panic about delirium influences our sedation practices. So why should we really concerned about delirium on top of all the other things that are happening in the ICU?

Dr. Adrian Austin 15:28
Sure, it’s funny. It says an aside what you brought up that my 15 Second overview of delirium, the history of delirium research is we define what it what it is, and its prevalence. And then we said, oh, we knew it was prevalent. Should we care? It’s bad. And now we’re at the what do we do about it phase? It’s talking about why is it bad? So delirium, yes, and no. and duration of delirium are two different exposures.

Ooh, two different ways to think about delirium. So if you have any delirium versus no delirium, and the more delirium you have, every day of delirium confers an additional risk of pretty much any outcome that we’ve measured being worse. And so you can measure a concrete outcomes at different time periods like mortality, ICU mortality, hospital mortality, six month a year, mortality two years, things that ICU physicians were interested in duration of mechanical ventilation, and then downstream from that, that leads to longer on the bit long in the ICU, longer duration of hospitalization.

All these things are worse, if you’re delirious, then things that are a little bit harder to track, but are, I would say, incredibly important for our patients and their families, our ability to go home versus to a nursing skilled nursing facility or inpatient rehab facility or Eltech. Ability to return to Prower functional status, to participate with PT, it’s really difficult to dissipate with PT, in the inpatient, and certainly the outpatient setting, if you’re delirious, it’s hard to engage delirious patients harder, I should say. And then, one of the things that got me interested in this field is the ability to return your prior cognitive function.

Go back to work, to resume the things that bring our patients joy, and value in their lives are all affected, if you’re delirious. It is one of our mentors is taught me and she’s got a great slide going through the Comparative Literature, it’s the equivalent of having an acute MI of the brain, if we look at at outcomes, like carries the equally poor outcomes compared to having acute MI, it’s just a catastrophic injury to the body. And that’s independent of just severity of illness. It is an additional risk factor or an insult to the body.

Kali Dayton 18:32
And you mentioned, you know, the terminology, acute brain failure has been extreme, which I totally understand that perspective. I also appreciate that terminology, because it helps us at least from a nursing side, it helps understand the urgency of what’s going on. Because in the ICU, we’re very we’re hyper focused on kidneys, liver, lungs, you know, these single organ systems.

And if we have an elevated troponin, boom, we’re on it. If we have an elevated BUN or creatinine, we’re on it, right. But when we have a positive camp score, we’re like, Well, yeah, they’re in the ICU. So you know, and we can’t deal with their agitation. So we have to sedate them more because there have delirium is sometimes the more the prospective, because we don’t appreciate it as the MRI of the brain.

We don’t appreciate it as this is an organ dysfunction, slash failure. I mean, we are having brain damage actively occurring. And I think that’s one of the barriers to really mastering the D is that we don’t appreciate the urgency of it. I appreciate it. Dr. E. Lee’s studies in 2014, at for every one day of delirium, there’s a 10% increased risk of death.

I mean, if we really talked about at the bedside it would, I perceived that it would shift our decision making that we would be much more urgent about treating this, quote, acute brain failure. I know we probably never standardized that terminology. You know, I think we’re probably more towards them. encephalopathy per CMS, documentation, reimbursement and things like that. But if we could even just culturally understand that this is a medical emergency, not just an annoying thing that just happens to almost everybody, and we can’t do much about it. I think it would change how we reacted to it, and how we started off a patient’s course in the ICU.

Dr. Adrian Austin 20:26
I completely agree. I see it as as an emergency. I think delirium has a an advertising problem. Yeah, and that, and the American delirium society, which I’m a member, and does a good job in helping with that, and helping have a sort of a central warehouse for people with an interest in delirium to do to function. But yeah, it doesn’t carry the same dread within clinicians as an acute MI or acute renal failure, where I would say it’s equally as deleterious. It’s another organ system that has failed.

Kali Dayton 21:21
Somebody mentioned that abs that delirium associate is associated with worse outcomes than any other organ failure. Now, I didn’t see a study to support that. But that was just what was mentioned, I thought that was at least a very interesting thought.

Dr. Adrian Austin 21:36
I’m not sure about that. I don’t know the evidence behind that statement. It’s as bad I would say is, is are the other organ failures way to do encounter in the ICU for a long term outcomes. If your brain doesn’t function, when you leave the ICU, the rest of the body is not going to function? Well, you have to have your brain to engage in life.

Kali Dayton 22:03
And delirium increases the risks of long term cognitive impairments by 120 times. And yet, we’re arbitrarily giving neuro toxic medications essentially, or delay or agentic medications without really questioning whether or not they’re necessary. We’re not oftentimes really trying to minimize it. And I don’t think it’s a common perspective to really be sedated with a goal of having patients be more of a wrath of zero so that they can mobilize, right? And if we’re not doing that, are we really practicing the ABCDEF bundle?

Dr. Adrian Austin 22:38
I would say we’re not. And I would say that prior to sort of 2018 2019, at least my experience, where I work, and also from talking colleagues, to colleagues and other institutions that we culturally, were doing a better job of practicing lighter sedation and achieving that rasam, hopefully, zero realistically, usually negative one, maybe negative two, and that’s okay.

You can engage people that are lightly sedated, it’s harder for them to not be sedated at all, but it’s incremental steps in many ways. But I, we took a big step back during COVID, because of the deep sedation practices initially, because we were trying to avoid as clinicians going into into the hot zone, pre vaccine. And when we were in PPE, critical shortages. I mean, there were other competing things that sort of forced our hand on that, realizing that we were balancing risk and benefits. And then, as can happen within medicine, things became culturally ingrained, and they just carried over. And now we’re back to where we were, I think, a decade ago with a lot of our sedation practices.

Kali Dayton 24:04
I think that’s an accurate assessment to this, what I’m seeing throughout the country. And the A fo has culturally morphed into this mandate of charting SAT, SBT, CAM, and RASS and it’s more of a mandatory “on off switch” for the sedation. So when they say “We practice the bundle, we’ve got it covered,” meaning that it’s in their charging system, and yes, they may be doing sa t every day.

But those SATs are done with trying to sedation off unmask the delirium, turn sedation back on. So if we’re automatically starting sedation on everyone without asking, we’re not necessarily really practicing the bundle if we’re sedating the point that they can’t really achieve the goal of the bundle, which is I mean, Dr. Brenda Pun said in her article, “it’s to have patients that are awake, cognitively engaged, physically active and communicative and autonomous, to express their needs.”

So if we’re sedating to have patients on unable to do that we’re not practicing the bundle. But what if What about mobility? If we’re not mobilizing patients, when they really should be mobilized their patients that obviously cannot mobilize? But if we’re not practicing early mobility, are we really mastering the D of the bundle?

Dr. Adrian Austin 25:18
I would say, No, we’re not one of the mind blowing things I’ve observed time and time again, during doing inpatient, geriatric wards, so this is the non ICU wards. But it’s the geriatric medical approach that I’ve received during my geriatric training was the change in people’s psyche, and mentation, that putting their feet on the ground or standing them up can have…. you take patients who are delirious or agitated…

You know, I’m taking care of the patient patient with baseline dementia, who’s having some psychosis, getting them up, opening the blinds, and just have having them stand with assistance. Is, is a game changer. I mean, it can really shift people’s perspectives and bring them back to reality. It’s just that simple act of putting someone’s feet on the floor and getting them out of bed. It’s still, when I observe it still, in older adults in the non ICU setting. It’s so stark, where it can be that it sort of blows one’s mind.

Kali Dayton 26:36
I just, I don’t know how to make that louder for the people in the back. You know, it’s one of the things that it doesn’t make sense to most people that have practice for a long time in a certain way. If you’re just used to automatically sedated in response to signs of discomfort, and even agitation. It’s hard for them to believe that patients can and should be mobilized when they’re having these episodes.

And I’m not talking about getting people out of bed when they’re RASS of three or four. In those cases, I think it’s perfectly appropriate to give them some precedex, to get them to a more appropriate RASS of zero, maybe plus one, maybe negative one, then to mobilize them so we can really treat the delirium.

So we’re using things like precedex, I think sometimes sub optimally, because we’re not then actually treating the delirium, we’re still using it to mask it. But I see it as an opportunity to then mobilize them actually communicate, engage with their family actually treat the delirium and get them out of it. Otherwise, press X becomes a long term plan, and it, they still are having prolonged episodes of delirium.

But you have to see it for yourself, you have to see the patient that thinks they’re in Mars, suddenly start to make eye contact, follow commands even write on a clipboard. So you can see it profoundly even in psych wards, on the acute care floors, and especially in the ICU, it can be extremely dramatic. And that’s what I’m hearing from listeners from teams that I’m working with. They’re astounded by the difference in the impact it makes and how much easier it makes the rest of their shift.

And the rest of the hospitalization by making that decision in that moment to treat the delirium to actually get them up deal with the agitation through mobility. I worry about teams, obviously, the bundle has a lot to implement all at once. I appreciate that. I also see difficulty in only addressing sedation. So if they say, Well, we’re just going to avoid sedation, or we’re just going to lighten sedation, and then we’ll get to the mobility stuff later. Because in my mind, as a nurse as a nurse practitioner, that’s, that’s gonna be really difficult for my job, because delirium is going to happen, you know, unavoidably for many of our patients.

But if we don’t have mobility available, how do we then react? How do we respond? How do we keep patients safe during delirium? If we can’t wear them out, if we can’t get them less than the severity, at least with mobility, then we really get stuck with Okay, now we’ve got a patient that is getting agitated now we are stuck, sedating them. And then once that sedation starts, it’s easy to sneak into deeper and deeper sedation, especially when we don’t we don’t have the goal of mobilizing them. So if we’re not mobilizing our patients, are we practicing the bundle? Are we even?

Dr. Adrian Austin 29:23
I would say no, I mean, it’s all works together.

Kali Dayton 29:27
And then the F is another element. Right? We know that family is so powerful. So what are your thoughts about family visitation family, the family role in the ICU, especially when it comes to the to the D part of the bundle?

Dr. Adrian Austin 29:43
The evidence for family isn’t as strong as some of the other elements. There is a recent meta analysis examining this that shows that families are involved in is beneficial for reduction of delirium. It’s not going to harm the patient. And I would argue, I think it’s a very easy argument to make, that it is part of good humanistic care and of caring for the patient and their family because the families eat is equally is important.

Patients who have families that are involved will do better after they leave the hot ICU environment, because they’re going to be the caregivers, usually. Usually they are. And if a patient has a family member that wants to be involved, but they are certainly in my mind, much, much more fortunate that some of our patients who don’t, which is something we observe as well, my own speaking from my own experience.

So our unit here is an open unit. Meaning that families can come by, we asked them to sort of limit it during our shift change times, you know, for a couple of hours during our two shift changes, but certainly make exceptions but otherwise, family can come and go as they please. My grandfather, it was very near and dear to me passed away in an ICU and in a rural part of the country.

And I went in knowing that he was going to pass away imminently expecting that open ICU and being told that I was gonna have to wait till visitation time to see him, you know, and I’d flown across the country and driven multiple hours and like, wait, what, it was a really sterile cold environment. And we pretty immediately moved into an inpatient hospice facility primarily, so we could be close to him, and vice versa. And that was just got, you know, it just reinforced. I think the the way we can provide empathy for patients and their families who are dealing with complex, life altering situations about preserving that those relationships that are important for, for our patients, and for all of us as humans.

Kali Dayton 32:07
Absolutely, I similar experiences with migrant two of my grandma’s during COVID. And it felt really inhumane. And they both suffered delirium during their stays, no one is familiar to them. There’s no grounding, presence, voice for them. And it was it was absolutely horrific, and it felt inhumane. I do think some of those studies when they’re conflicting, I think sedation is should be part of the consideration and those family studies, if patients are deeply sedated. how impactful can family be? What are your thoughts?

Dr. Adrian Austin 32:46
I don’t think they’re going to be harmed, the family involvement would be harmful. I think that’s it unless the family members actively hidden, they’re trying to arm someone, which could be because we’ve all seen it tongue in cheek. But barring that, having a loved one around is not going to harm someone, and would probably allow for less sedation. If you wake up in an environment you’re unfamiliar with, you’re probably going to be distressed, in a familiar face can be very calming, a familiar voice can be incredibly calming, and bring people back to reality.

Kali Dayton 33:29
I think there was a fairly recent study showing that family visitation, decreased sedation use in the ICU. And if I find it, I will put it in the links of this into the transcription of this episode, because that’s, I think, one of the one of the findings in a fairly recent study that I found, and it makes sense that I think we’ve all seen it and we also saw the opposite during COVID Ellis family that they’re the more we ended up sedating patients partially because of necessity, when you have low staffing ratios. You have all these crisis, right?

The family can be kind of sitters, in some cases, right? They help keep patients engaged, interactive, that can be key in communicating with our patients, all these things that ultimately prevent and treat delirium. I love that your unit is open visitation. That’s the same with the unit that I come from, I think teams that fully practice the AF bundle if they’re really proactive about delirium. They don’t kick families out after seven. They understand that this is part of humanistic care that overall improves outcomes and as part of being humane caregivers, anything else you would share with the ICU community?

Dr. Adrian Austin 34:46
we have to sedate our patients less. And to quote Dale Needham, the brain bones connected to the body bone, the more that we can do to minimize delirium. The more we can do to help our patients return to their lives and hopefully, hopefully thrive after their ICU experience.

Kali Dayton 35:10
Absolutely. Thank you so much, Dr. Austin. I appreciate all you’re doing for the community, all your research and everything you’re doing boots on the ground with your patients there. Thank you so much. Thanks.

Transcribed by https://otter.ai

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