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Although the ABCDEF bundle does not solely rest on the shoulders of nurses, their leadership is KEY. Andrea Silva, BSN, RN shares with his her journey to revolutionizing care in her ICU as an assistant nurse manager.

Episode Transcription

Kali Dayton 0:00
Kali, this is the walking home from the ICU Podcast. I’m Kali Dayton, a nurse practitioner and ICU consultant. I help teams create awake and walking ICUs through evidence based sedation and mobility practices by hearing from survivors, clinicians and researchers will explore how to give ICU patients the best chance to walk out of the ICU and go home to survive and thrive. Welcome to the ICU revolution Andrea. Last episode, we heard about the impact a nurse can make by finding ways to support, teach and guide his colleagues to improve compliance with the ABCDEF bundle. This episode, I’m really excited to interview Andrea Silva, whose leadership helped empower Michael and others and allow them the opportunity to learn and apply the evidence into their own patient care. Andrea, welcome to the podcast I am thrilled to have you on. Can you introduce yourself to us?

Andrea Silva 1:15
Yes. Hi everyone. My name is Andrea, Silva, and I’m the Critical Care Clinic coordinator at Luther Medical Center in Denver.

Kali Dayton 1:23
How did we get connected? Where was your team at before starting this revolution?

Andrea Silva 1:28
First of all, thank you for having me. It’s an honor to be here with you, and I’m so excited about this. So we have been doing the weekend walking ICU for about a year now. September. It’s a year which is so exciting. To tell you, a little bit of background from our ICU. We have a general ICU and neuro ICU. So we run two ICUs at Lutheran. We’re Level Trauma two and a couple years ago, I remember my former manager saying, Andrea, my goal is to walk our intubated patients in the hallway. And I was like, Are you crazy? Your ICU patients? Shortly after, I think he presented in one of the trauma conferences, and we had a few of our nurses, I think this was like, around in 2022 and a couple of our nurses, ICU nurses, went to this conference, and they came back to us to leadership in ICU, and they’re like, oh my gosh, we met this nurse, Katie Dayton, and she did a wonderful presentation about awaken walk in ICU. Can we look into that? Like, okay, sure. And we invited you a few months after to one of our staff meetings, and you came and talked to us about the wake and walking ICU and promoting early mobility in the ICU. At this time, we were already doing some work with early mobility in our ICU. We were not doing anything with sedation. It was just early mobility after extubation was just up to the chair, so we were not seeing a lot of changes to the outcomes. They were pretty much the same, but we didn’t know. And then Wendy, our director for physical therapy applied program, and she was able to get you back in here with us, and we did coaching you came around and saw our culture, we were using a lot of sedation, and everyone was deeply sedated and immobilized. And I even remember one of our providers, when he first came to this hospital, he was like, Oh my gosh, you guys are using a lot of sedation on this patients. And we’re like, What are you talking about? This is what they need to sleep. They need to be delicitated. They’re super sick. And even I was one of those nurses too, like they need to rest. You guys don’t understand the ICU. We understand the ICU because we work in the ICU. Well, let me tell you that around that time too, when you came to see us, one of my nurses gave us Dr West elat book, and I was reading that book, and I started listening to your podcast, and I was like, wow, this is so amazing. This is so beautiful. So this is how everything started. We had already been doing a lot of work with early mobility, but couldn’t even see a lot of changes to our outcomes until we really went live with a full awake and walking ICU in implementing the eighth bundle in our team.

Kali Dayton 4:33
There’s a lot in that that I don’t even remember and that I didn’t know. I mean, it makes sense that your previous perspective was normal, that this is sleep, this is humane, this is necessary, the more the better, and that’s absolutely not to your fault. I love how open you were to it, that we were shocked when it was first proposed, when nurses came back to you, you said, Okay, let’s look into it. Let’s try and. And then you were open to learning more, receiving more. And so for you personally, you read Dr e Lee’s book, you’re listening to the podcast, you saw how beautiful it was. But then what was that like? I’m always interested in what it’s like for people that have practiced it a certain way. Then I call it the Santa Claus effect, something you realize the reality of what you’ve been doing. How do you bear that as a revolutionist, to have this awakening and then go on the unit?

Andrea Silva 5:29
Yeah, it’s a great question. So to be honest, I still remember there were times that, as we’re whole to a certain level of early mobility in the ICU, even before we went live with this, right? And there was like, a very now, like, oh my gosh, very low. I mean that we have to do early mobility. And I remember my director coming like, Hey, what’s going on with early mobility? I see you. And this was my answer, hey, they’re really sick. They need to rest. They need to sleep. So when I started reading that book, it just opened my eyes. It really did. Oh, my God, what are we doing? And then listening to your podcast. And I’m not kidding like I would listen to your podcast. I sometimes I drive almost an hour to get to work. It will be one podcast on my way to home, another podcast and my way to work, just to start learning. And I follow you on Instagram and looking at those research articles, and I was like, Oh my God, there’s so much out there that we didn’t even know, that I didn’t even know. And to your point, it’s no one’s fault. This is just the way we were trained and given this a try when you were here with us, and we had that one patient who was super sedated, on that, on everything that he could have been on max out, on Triple four, I think he was even on Versa trip and fentanyl trip. And you were like, This is what we can do to treat the cause instead of just covering it with sedation. And I trusted you, and I start seeing the outcomes with my own eyes.

Kali Dayton 7:02
I was like, this works this. I mean, it’s talking about that patient. Because I was there doing a gap analysis with early mobility.com, Margaret Arnold, and so I was tagging along with her, and so we were there just to see what was going on, what the needs were. So no one knows who I am, besides you and a few others, correct. No one’s heard the podcast besides you and a few others. So that’s a hard place for me to be in, because I can’t just stand there with a clipboard and take notes when these are real people in the bed. They’re patients that are suffering exactly what I’m combating, right? So I give your team so much credit, because it’s a hard position me as a consultant. I don’t think your attending was new. This was his first week in that ICU. He didn’t know me at all. And so here I am, and I see this man that’s probably 300 to 350 pounds, and I see propofol runners and debate, and I’m asking, Why is he in debate? And they say because he overdosed fentanyl and probably Xanax. He had aspiration pneumonia, and he had been intubated overnight because of worsening respiratory failure. And so I say, Okay, but why has he sedated? And they look at me like I’m insane, and they say, because he’s sick, because he’s intubated, and he had high ventilator settings, I think, a paper of 16 and 90% and even at that, he was saturating 92 91% so these good nurses were like, look at his saturations. Look at his ventilator settings. Who are you? Don’t you know about the ICU? Of course, he has to be sedated. And so it was a hard position to say, Okay, but why is he on 50 micrograms of propofol? Or bariatric patients, that’s going to be huge concern. And they said, because he was agitated overnight. So then that’s where we walked through this process of, okay, but why was he agitated? They said, well, because he’s intubated, so we had to give him a bunch of our said, pushes and crank up the propofol. And I said, Okay, he’s just on propofol, but if he’s withdrawn from Xanax and fentanyl, then he’s not getting any opioids. He’s probably withdrawing. So I found your attending, and I said, Hi, my name is Kaylee Dayton. I don’t work here. I’m a consultant, but I got some ideas, and so he was so nice to just go with it. We did oxycodone and Klonopin down the feeding tube, and then about an hour later, we took everything off, and nothing happened, because he was just still sedated with the propofol running through his system, settled into the adipose tissue, so six hours later, he comes out, and he’s grumpy being on the side rails. Yet they don’t deeply sedate him. They let that ride overnight, and then the next morning, everyone went in there and got him up the side of the bed. And I remember everyone was so nervous. We were there, right? And at that point, I think he was saturating like 90 89% laying their supine. I knew this could go either way. He could desaturate, or he could saturate better in a better position. So powerful and speaks a lot to your team, and you were there being a great leader, your. OTs, your PTS were on board, and so the nurses kind of had to go with it. Sat him up, and the saturations went up to 93 94% and you could just see you remember the anxiety, the angst in him just dissipated. We got a clipboard. He said he wanted to get to the chair. He set himself up, got himself to the chair, and everyone was just amazed. What a bizarre experience for your team who has never experienced anyone really being awake, communicating, let alone mobile, on the ventilator, and now we have a patient on very high ventilator settings who’s morbidly obese getting himself to the chair. So I left that Friday, that very first day that he got up, I had to fly out, and I said, Okay, take good care of him. Don’t derail this and you guys kept it going. So he sat up in the chair most of the day. Didn’t walk around the halls again, very new to your team. I think he definitely could have walked around the halls, but now you would do that, but back then, the fact that you guys kept him awake unrestrained, ended up in a chair. Huge experience. By Monday, he was extubated walking around the halls. How different that would have gone for a patient with severe respiratory failure. He probably would have developed ARDS. There was even talk about proning and paralyzing him because of the ventilator settings. And yet, shortly after he was sitting up in the chair, weren’t you guys able to start weaning down those settings? We were and so that was one of the big experiences, I think, for your team, to see that in action and see such a contrast in outcomes that you can trust patients, but it wasn’t a night and day difference for your team, right? There was still a lot to do. So those people that saw that for what one patient doesn’t mean that the entire team is now converted and ready to do this as a standard, correct. So there was a lot of work to do. So we came and like we talked with Michael last episode, this is Michael’s team. He was on board with this, but we had to do education, and this was a very abbreviated version of the training process that I usually provide for teams. And with that comes a lot of challenges, where my goal is usually to train every member of the team. I stay there for four days and camp out, and we do night and day. But for years we I came back for one day with Margaret Arnold, and we did two different simulation trainings. There were four hours each. So it was thorough. It was great. But what portion of your team between those two? ICUs attended those trainings? So it was

Andrea Silva 12:19
very little. It was very little because I remember we didn’t have that much notice when put it to out to the team. So that was one. So we had to make up for that, right? Because we cannot make it mandatory if that’s such a short time. Hey guys, whoever’s available, please come and join us, because this is the way we’re going. So we offered more education, the staff meetings, to make up for that, but as even in the staff meetings, not everyone comes to all the staff meetings. So we did have a lot of portion of our caregivers join or come to the staff meeting. We also offer the webinars that you that we have regarding webinars, but not everyone listens to the webinars, right? So that was a huge learning for us, because we should have made it mandatory since day one. So we had to play a lot of catch up in our end. Some people we had their buy in, and some people we didn’t. So it was a lot of catching up and training. And it’s not easy. It’s not easy to change the culture. This is a culture that in mobility and deep dissipation. It’s been going on for years. This is the way we’re trained, and it’s no one’s fault. And I believe in nursing. I believe in my team. I believe that I have the best team ever, and our nurses are really caring. And I think it was they were scared. It’s not because not wanting to try it. They were scared of not having what they needed. Like, in their mind was like, I need a lot of resources. I need. What if my patient self extubates and I’m responsible for that? What if my something happens to my patients? So I think the pushback that we got initially, it was not because they didn’t want to do it is because they were scared to do it, and especially if you didn’t attend the staff meeting or the one on one coaching that you offer. Can you imagine, it was a lot, right? It was a lot. It’s a big change. So to all those teams listening to this podcast, obviously, make it mandatory. We learned our lesson, and we didn’t know, right? We didn’t know because we have never done it before. Make it mandatory, make sure everyone hears the same information. Because nursing and nurses, they want to do the right thing for the patients, and that’s why they’re nurses. They’re here. They want to help someone. This education is not just for the nurses.

Kali Dayton 14:41
The nurses bought in, it will not happen. It’s not all on them. I know that I attended a meeting with your respiratory therapist and try to catch them up as well. What about your physicians? Did you see a difference between those that attended those trainings and those that did not? In my nurses? Yep.

Andrea Silva 14:59
And. In your team as a whole? Yes, I think those who attended your one on one coaching felt a little bit more comfortable, right? They were still scared, because they have never done it before, but I think they had that knowledge. Same ones that went to the staff meeting compared to the one that didn’t go to any of those, they were lost, and they didn’t know why. Yeah, they didn’t know why. They didn’t understand the why. All they wanted to know is why. How is this going to change? If I’m keeping my patients safe, he’s not going to be safe anymore because he’s not on sedation and he’s intubated and he’s sick. It was not they don’t want to do this on purpose. They were just scared. And you’re right, this is not just nursing. There’s a whole team approach. This is providers, RT, PT and OT, obviously nursing, and it’s everyone involved, right? Like, we’re here for this patient, and how can we make this happen? How can we implement this? Providers? I can tell you that some providers, they were, they’re all about mobility and minimize sensation. But there were some like, what are we doing? What are we doing? I remember because we we did a lot of one on one too, like, even myself and Scott, we were out there on the unit. Okay, this patient is perfect. Let’s Can we turn off sedation? He’s agitated. But why is he agitated? You talk to the patient, I did, but he’s still agitated. Okay, we give it another try. I’m going to be there with you. Let’s turn off oscillation 18 otter, right here, and here, let’s give it a try to this patient. You know what that patient wanted, get up to the bathroom and go home. That’s what he was asking for.

Kali Dayton 16:43
And I remember, for this specific patient, one of the providers like, oh Andrea, are we sure we want to do this?

Andrea Silva 16:45
Do you trust me? Do you trust me? Yes, I do, but I’m not used to this. Hey, he’s doing okay. He’s stable. We’re going to start slow. We’re going to set him up the edge of the bed and then stand him up, and then we’ll go slow. PT, and OT, two nurses are here in the room. Let’s give it a try. If he doesn’t do well, we’ll stop right away and reassess. Okay, okay, that patient did beautifully. I still remember that the nurse already had decks ready. On the other hand, to go. We didn’t even need decks anymore, because you trust the why, the why, this is the why. The next day, the patient was extubated in this and transferred to the unit. The next day, we walked that day, we got him up to the chair, we got him up to the commode, and he was fine. So it was a lot of a lot of coaching, one on one, coaching with our team, telling them, like, Hey guys, this is okay. Let’s give it a try with our providers. Can we stop sedation? And what else can we do? He’s agitated, but what else can we do? Why is he agitated? How can we treat the agitation instead of just going up on sedation? Can we treat the pain first? We learn to treat the pain first. Instead of just going sedation on sedation, he’s tachycardic. He Why is he tachycardic? Let’s find the why. Let’s treat cause, utilizing sedation to treat everything that’s going on. So it was a change of mindset, not just for it was for everyone around and I can tell it took time. It was not from one day to the next. It took time for our nurses, because to your point, one day you have one nurse who experienced this, and then with one day specific patient, then the next day another nurse. So it took time for everyone to see this process and for providers to see oh, this makes a difference. Are we perfect right now? We’re not. There’s still room for growth, but we’re better than we’re a year ago, and we were seeing amazing results and outcomes in our patient population.

Kali Dayton 18:53
And those changes really wouldn’t have happened if nursing leadership hadn’t taken such an involved role in this, I was really touched by your personal investment. Listed the podcast to and from work. You also went to my website, looked at the citations, you printed off those studies, you highlighted them, you put them in a binder, so when physicians had questions, hang ups, you are ready to use the evidence to guide those conversations like, which study? Okay, which topic? What are you concerned about? I’ve got a study for that, and you would have meetings with the physicians. You would sit them down and say, here’s where we’re at. Here’s where we need to head, even pointing out specific things about their notes here I love I hope this is okay to tell but for you to say, Hey, I see that you documented that the patient is sedated and comfortable. How do you know that patient was comfortable? Just the level of accountability that you brought to the team, and in this way where, obviously, not everyone was thrilled with it, you weren’t everyone’s favorite person for a while, and with just knowing you, I know you did it in a way where you were trying to be loving, gentle. And yet you are backing down because you knew the why. You knew that patients were being harmed, and you weren’t willing to allow that to happen in order to spare the feelings of others, and you push them to the point where they had to experience success, and that’s a really hard point to get to. So yes, my normal process I entrain everybody in the team, is the goal that the webinars are mandated, the simulation training is mandated. I say for days. We do day and night simulation training so that every member of the team has at least been exposed to the why. They’ve been prompted and guided through critically thinking through different scenarios and applying it. But then even with that knowledge set, you still have to have your own personal experiences with it, and I have just learned that that doesn’t happen unless there is someone, hopefully a team of people. It shouldn’t just all just come down Andrea going room to room and saying, Why is this patient sedated? What do they need? Why aren’t they being mobilized? What do you need to mobilize them really asking those questions for each specific patient. This is not like, Hey, we’re going to switch the IVs in our unit. Now. This is the only tool that’s available, and everyone’s just going to do it. It doesn’t work that way. This is so much more sensitive. It’s such a deeper change. It does require a skill set. So what were the some of the things that helped you be effective in leading this, going room to room. What were some of the tactics that you used? You’re talking about? You were asking questions, guiding them to critically think, prompting the why you are physically there, present, going into the rooms with them, doing it with them. What else? Yeah, we

Andrea Silva 21:40
were able to change, to your point. I meet with my medical directors once a month, and we discuss and I was hearing from different providers that we’re doing all this work on day shift, but we still have an opportunity on night shift to work on sedation. So I started coming in early in the mornings and like, Okay, what’s going on? I will see people sedated. And so I started asking our team members, like, Hey, what is indication for sedation? Why is this patient back on sedation? And that was not very well received, because it’s something new, right? The same like, why do we have a central line? What is indication for a body catheter? Is the same thing, and we are huge on center lines and body catheters here, it was just one more thing that we’re adding. Why is this patient on sedation? Because we have to had a reason. It’s not just because they were intubated, because that’s not an indication anymore for us. So it was not easy. I’m not gonna lie. There were some learnings that we had, and so just making sure to educate our staff, to make sure they understand the why we need to have an indication for sedation. For example, if your patient is agitated and you and if you have tried a, b and c and he’s still super combative and aggressive, and you treated the cause, and that’s and we’re still right here, that’s a different reason, instead of just going straight to sedation. So just helping them understand the why. Why is this patient in the ice? How are we treating this diagnosis instead of just sedation? So and looking at the RAS goals, how did you see a difference in accuracy and Ras documentation, in using a RAS for discussion, even those situations where a patient is maybe a Rasta three or four now they’re on something like dexmedetomidine. Were you involved in seeing what the RAS really was? Yes. So I can tell you, before we went night with this, we were all over the place with our rest goals and scores. We were not really following the order since we implemented this, because we’re following the A through A bundle, and I saw a huge difference on making sure we we are addressing the rest goal and rounds and making sure our scores are matching. And again, we’re not perfect, but we have come a long ways. This patient is a negative one, okay? And we should be between negative one plus one. Obviously we have different reasons why there’s an indication and a reason why patients not between that those goals or that those scores. So yes, making sure we’re Hey, I see that your order is this, but you actually documented this, why, and we went up on sedation, why? So it’s just a lot of education with our team and to make sure we follow those orders. Because other ways we’re practicing out of our scope of practice, and

Kali Dayton 24:36
your night shift, night shift in general, gets left out of everything. Gets out of support from and learning during rounds, lot of education that happens during the day. So that’s why I do simulation training at night. Usually we’ll stick out there until midnight, training because they deserve they need that education. I’m sure it was surprising for them to see you roll. And at six in the morning, and so they were not well received. At six is a hard time as well, because there’s a lot going on at the end of the shift, but you sort of joined up at four o’clock as well. Tell us more about that.

Andrea Silva 25:11
Yeah, so you’re right. Six o’clock is really hard to do. Any awakening trials other nurses or caregivers are going to over CT at that time, everyone is busy trying to get ready for change to shift, so it was not a good time. At that time, we recognized that I started coming up a little early just to see how the caregivers were doing, because I kept hearing we’re using a lot of cessation at night, so on days, we’re just catching up from what we gave on nights, right? So it was a circle. Okay, we stop everything in the morning, and we’re doing all this in the morning, but then we go back on. Patients are still getting for certain pushes and propofol, you name it, right? So it’s just like, hey guys, what is indication first station. And then I started hearing, well, the provider said this. So we start to see a change. Okay? We’re actually addressing this because the provider order it, because a, y and z, right? And again, it was just more education with our caregivers, like, hey, we really need to stop sedation after two hours after intubation, because that’s what the medical director said. We have to stop station after two hours post intubation. And if there’s left on sedation, there has to be an indication why. So make sure you communicate with the provider why we’re still keeping sedation on. And if we don’t have a reason, we should stop the sedation. So it was, it was a change for them too. Like, hey guys, we really have to do this. This is not an option. This is what we all agreed upon to move forward the medical directors, nursing leadership, and this is the best thing that we can do for the patients, to get them out of the ICU as fast as soon as possible.

Kali Dayton 26:55
So it was, it was a change, for sure. It sounds like initially it was this process that a lot of teams go through with. I mean, we talked to Dr Baluchi from Center Health in Sacramento, where he stormed it and said, we’re not even gonna anyone. There has to be a reason for it. So that is the exception, right? Most teams go through this process of, okay, we’re going to really start focusing on accurate RAS scores, light light sedation, and then we’re gonna move into early mobility. And it sounds like you guys were kind of there. I know that your therapists were ready and chomping at the bit, but sedation was your main barrier. This cycle of day shift gets really aggressive, got them awake. They’ve got immobilized, sitting in a chair all the things. The Night Shift comes on, and the sedation gets resumed. And then the day shift gets spend a good portion of their shift trying to clear out the sedation, get them reoriented, then get them mobilized. And it just backs everyone up. And it seems like double the workload for the day shift, so you have to have night shift bought in. But then it seemed like you guys work at this level where, okay, we’ve got sedation on everyone still, but we’re going to lighten it up. Then you and your medical director push it to the next level to say we shouldn’t even have this stuff ordered unless there’s a specific indication. And when you got to that point, what difference does that make in the outcomes of the patients and the workload of the staff, yeah.

Andrea Silva 28:21
So it’s still a work in progress. As far as not having the station order, because it just comes in our order set, which we’re working on getting rid, like of the first IV push and continue that propofol, right, or Dex, whatever it might be. So when we really focus on no sedation or minimizing sedation, the patients were awake. They were awake. They were following commands. They were not agitated. We saw delirium. Rates just went down. Our vented patients, our flu patients last year, they were on the phone, texting, walking, and we saw a decrease on our bent days, obviously on our ICU, length of stay we saw, we have seen a huge decrease of VAPs in our ICU, I can tell you, in 2022 we had 17 baps. 17 in 2023 I have them right here. We had 420. 23 four this year. I’m not gonna say it out loud, we have had

Kali Dayton 29:24
zero. She’s putting up a zero sign. Everybody. Three more months, three more months, you could have zero bouts for the year. I know, knock on wood, right? But wow, from 17 now zero thus far. Yeah, sad is a power of early mobility.

Andrea Silva 29:41
It is, it is. I mean, our COVID is in clabsis. I can tell you we’re over again. I don’t want to say it out loud, but it’s been more than a couple years. So everything shows the patients are walking out of the ICU. This patients are walking you see them walking out of. ICU when they’re transferring to another unit. I have had a patient who it was. He was an open abdomen. We got him up and mobilized. He was really in his early 20s, and he had everything that you can think of, chest tubes, vent, two brains, eight channels, running everything that you could think of. We really focus on mobility, and we explained the why to this patient, so he had goals for himself too. When he left the ICU, he walked out of the ICU, he walked in and chose his own room on the other unit because he was walking. You can he couldn’t even see that he was walking. No delirium for this patient. He discharged her home. And this was an open abdomen patient that we started really slow with therapy, beach at the bed and up to the chair, then walking. It was amazing. It’s, he’s one of our case studies to teach others, but he’s, it was an amazing case. We had another patient with the West Nile, who was in his early 40s, up and moving. His normal life came in with the West Nile, he couldn’t even give you a thumbs up at all, because he was so weak. We got him up and walking. He was exhausted. We give him a break for a couple days, but we give it another try four days later, after his first walk, he was walking with a walker really slowly. A year later, he just sent us a picture a couple weeks ago that he was hiking up the mountains again. Did he end up with the tracheostomy? He did. He did go to because of the West Nile, yeah. He did have to go to rehab, but we were trying early mobility on him, and that made a huge difference. But he did, ended up with a trach and but again, it was the West it was disease process. It

Kali Dayton 31:48
was not ICU acquired weakness that caused the trach, but for him to I mean, if he had had, ICU acquired a weakness on top of West Nile that would have greatly impacted his trajectory and his ability to rehabilitate. But you were already rehabilitating him, I would say rehabilitating and prehabiting. You’re rehabilitating him from West Nile, and you’re rehabilitating him and protecting him from I see cord weakness. He certainly would not be climbing a mountain. I don’t think at this point, had he had I see cord weakness on top of that,

Andrea Silva 32:20
yes, a year after, it’s amazing. Our outcomes, our providers even say, Wow. I come to the ICU and I see the patients up in the chair in the mornings. Is it every single patient? No, it depends what’s going on with the patient. So if they’re able, why not? They’re up in the chair, right? I see providers saying, wow. Andrea, I see from the nurses notes that they’re dangling at the side of the bed on night shift or marching in place on night shift.

Kali Daytons 32:48
That’s huge. And this is all night shift like they have really wow. People up in the chair, they’re walking their patients. They’re getting marching in place. And it’s huge. It’s the culture has really changed, and I’m hearing from the nurse like, wow, I really like this. This is easy because the patients are awake, they’re following commands, they’re not confused. They can get up by themselves, because we’re starting early mobility early and I train teams to scratch each other’s backs. Night Shift, your day shift colleagues are going to be mobilizing them multiple times during the day. They’re going to have them off sedation. They’re going to have them exhausted, no naps after three. So for you, you just do this one last mobility session, combined with everything you’re doing make it as part of the bed bath. But they’re going to be easier to mobilize because they’re not going to mobilize, because they’re not going to be delirious. They’re not going to be super weak usually, so just make it part of your routine. Tuck them in by 10 o’clock at night, and they will be out. You will get your quiet night but this way, now days shift, night shifts not going to sedate them overnight. You’re not going to be doing awakening trials. You’re not going to be work with delirious, crazy patients and then come back the next day and have them sedated again. Everyone’s going to scratch each other’s backs, and this is how we’re going to make this an feasible, safe and easier process for everybody. Another team that I trained between the two case studies that they provided of their normal patients, it was 10 to 12 extra days on the ventilator that I estimated from those case studies, these patients should have been extubated at days after and said they work a week plus after intubation. That’s a lot of work. So when your nurses say this is easier, I’m sure part of that this is easier than I expected, but I think there’s also this is easier than having to take two people in every two hours to turn my patient. This is easier than having to boost them in bed all the time. This is easier than all the things that we were already doing. What are your therapists say? Far as your respiratory, physical occupational therapist, yeah.

Andrea Silva 34:53
TT, no, t they were all in work, right? They were all on board with all this, and they it was a learning curve for them, too. Because they have never before they were to see the ICU patient after exit. So at that time was too late, right? It was too late. It was we had to rehabilitate this patient instead of proactively working with him early enough.

Kali Dayton 35:14
So they shout out to your ot Ariel. I remember her saying during my first visit, I want to do it. I’m trying to advocate to get in there, but I have not walked patient on a ventilator because by the time I get to see them, they cannot walk. And I thought that was really profound, that walking isn’t just about being awake, not just about having a therapist in there, it’s about getting there before they lose the ability to walk, before we take away their ability to walk. Just for me, that’s so profound. Walking is so basic for most of us, how dehumanizing to take away the ability for someone to be able to walk and walk most of their lives. I thought that was really profound from Ariel. So now she gets the Wacom. Yeah,

Andrea Silva 35:52
she does. And they were obviously with different populations and diagnoses. They were learning too.

Kali Dayton 35:59
You guys gonna have a say in the layout of the ICU, because that can impact this whole process. And what is it like now that you guys are there?

Andrea Silva 36:07
Yeah, so we did have a say in our room layout. So I can tell you that we had really small rooms. Now there are huge rooms to promote for mobility. We have ceiling lifts if needed to promote early mobility. There’s plenty of space we have always there. They’re wide enough to have the patient walk around the unit if needed. We have huge windows to make sure we’re just promoting that day and night and keeping this third card in rhythm for those patients. Our opinion was very they asked us, like, Okay, what do you guys think? What do you guys need? I can tell you, Wendy, the Director of Physical Therapy, was involved. Scott was a huge it was involved in this decision. And we have boom, so you can move around the room to promote that mobility. We have chairs, every kind of in each room, we have walkers in each room. Again, to promote this mobility, I remember providers and team members asking me, like, Andrea, what are you most excited about this new hospital? And I would say early mobility, the early mobility that’s going to happen in the new hospital. We have a gym that is huge, and it has ceiling left, so it can just go from one side to the other. And 1802 are like, Oh my God, we can just bring the patients down.

Kali Dayton 37:28
And you guys use walking slings as well we can.

Andrea Silva 37:33
And if somebody needs that support, let’s just bring the patient down. We haven’t done it yet, but it’s an idea that we’re already talking about. Like, how can we utilize this gym, gym for this ICU patients. So it’s beautiful. It’s gorgeous to promote early mobility. And

Kali Dayton 37:46
you’ve already seen such cost savings to justify this, right?

Andrea Silva 37:50
Yes, we have. So I can tell you, last year, so we went my last September to December, we had almost half a million dollar savings, almost half a million dollar savings in the wake and walking just

Kali Dayton 38:04
within three months, and that was the first three months when you’re just like lightning sedation, mobilizing a few more patients, because you said six to eight months, things really ramped up, sort of become more standardized, but the first three months, when you were just making Little baby steps, you still saved half a million dollars.

Andrea Silva 38:24
We did. And this year, I have not seen the report yet, because we’re we’re working on a few things. But yes, we did last year. I don’t have all my numbers for the bend days from before, but I can tell you, we have been as low as three, as 2.5 we have been standing below four for 10 days,

Kali Dayton 38:43
and you have neuro patients mixed in with that. You have some populations that unavoidably are going to be bit dependent, and yet that’s amazing. Well, keep us posted on the numbers. We’ll have to do a follow up in maybe a year. Do another year anniversary. If you’ve been listening to this podcast, you’re likely convinced that sedation and mobility practices in the ICU need to change. The ICU community is facing incredible difficulty with the trauma from the pandemic, staffing crisis and burnout. We cannot afford to continue practices that result in poor patient outcomes, more time in the ICU, higher healthcare costs and greater workload for the ICU team. Yet the prospect of changing decades of beliefs, practices and culture across all disciplines of the ICU is a daunting task. How does this transformation start? It can begin with a consultation with me to discuss your team’s current practices barriers, and to formulate a plan to help your ICU become an awake and walking ICU. I help teams master the ABCDEF bundle through education, consulting, simulation, training and bedside support. Let’s work together to move your team into the future of evidence based ICU care. Click the link in the show notes of this episode to find out more.

Andrea Silva 40:01
But I can tell you, they’re loving it right now. We just moved to a new hospital not too long ago, about a month ago, and we’re seeing a lot of trauma, traumas, like real traumas and and we have a patient who almost every single bone from neck down was broken, and he was up in the chair yesterday, and it was a huge win, right? So there’s always something new that we have to learn. Like, okay, how do we do this? How do we how can we make this work? What can we do? So they’re so excited when they see this patient’s walk, and we cheer them up, like, Yes, you got this. You can do this, because it’s another life that we’re preventing from going to rehab the preventing from delirious delirium and pig syndromes, right? So it’s huge. They’re thrilled. PT, OT, I mean, amazing. RT, again, it was a change of culture for them. I can give an example, somebody who was gagging on the ET tube, and they’ll say, just go up on station like, Well, no, no, no, let’s treat the cause of, why is he gagging? Which it was just fixing the ET tube a little bit more. And I can tell you that RT has come a long ways as well. If somebody is busy, like the RT or the ICU is busy, and somebody is about, like, oh, I can walk a patient with you guys. I can do it and like, Wow, it’s amazing. It’s amazing to see the culture, the shift that we have done, all the work, like all the disciplines, coming together for the patient. And I think they have to see it for themselves. And I have nurses like Andrea tell me like Andrea, I believe what you said or what you were telling us, but I have to see it with my own eyes, and I have to do it with my own hands in order for me to continue to practice this awakening walk in ICU. And honestly, it took a really, like a good six to eight months for to see the shift of the culture, like people saying, hey, this makes a difference. This really makes a difference. We can do this. We got this. You know, you hear providers in rounds or after rounds like, Okay, we have to lower that station. Well, he’s on only three max of purple. It doesn’t matter, turn it off. So that’s a huge win for us. There are so many I’ve been keeping posted of all our changes that we have done. Providers telling me, like, Andrea, we’re afraid of percept which is everyone’s afraid of, per se, when there’s a Versa director, like, Oh my God, why ACP crisis? And we’re trying, like, okay, it’s everything, like nurses and the culture and the patients awake, it’s beautiful to see, and it’s

Kali Dayton 42:36
such a skill set, like you’re describing, everyone’s developing their skill set, and it’s such an art, and it’s easy to have a conveyor belt where things are very predictable. I think that’s one of the reasons it’s hard to get out of sedation and immobility, because that is predictable. There’s so much going on in the ICU that we like to have certain things mapped out. We make our schedule as the nurses on our paper, and we know hour by so that we have those things to fall back on when something different comes up. But sedation is one of those things where it’s I know I can count on that. I know my patient’s gonna be immobile, but now, if you take that away, it’s like, oh, they might use the call light. They might have needs. I it’s just a lot of unknown, and then the insecurity of knowing, can I meet those needs and developing that skill set and accommodating that for each patient, that sedation, you just sedate every patient, but now you’ve got nuances by patient. Mobility is different by patient. Everyone has a different highest level of mobility. With your traumas, your neuro, you have a very diverse population. And with that, when I first towards your ICU. You guys had access to verticalization beds, but you weren’t using them. And this is something I’ve really learned throughout the last couple years, is that’s a huge matrix, and you could drop off these beds and have the most perfect facility. You have a beautiful unit. Now you have great equipment, but without the culture, it doesn’t get used, especially the verticalization bed. So what have you seen happen with the use of those beds as the culture has changed, and as you’re trying to optimize each individual patient, we have

Andrea Silva 44:09
discussed it as a team. So what we have been doing is we are order them early, early, because before we were not available, but we never got them ordered. We ordered them early, and every day we work more Okay, so we did 30 degrees yesterday or 40 degrees now. We’re gonna do 50 to 61st so many minutes, and it’s something that we’re still working on. We’re not perfect and not utilizing those beds yet. Nursing is not yet, but we’re getting there. We’re still doing not to do more education and stuff, but we I can tell you that we’re really ordering them early enough to make sure the patient has what they need to make that mobility happen one way or the other. Because, to your point, not everyone is not one size fits all is like Dr Ely says. May. Personalizing that care for that patient. So we’re really focusing on making sure this patient

Kali Dayton 45:06
specific, and the fact that your nurses are ordering them, I see in teams that were in the same place that you guys were at where there’s a relationship with these beds with the hospital, but it comes down to a few visionary physical or occupational therapists that understand the bed then try to advocate for it. The nurses hold the key to ordering them, and they’re the ones that are supposed to put the patient on the bed. And so without the nurse buy in, doesn’t happen. And even if it does happen, being verticalized with therapists and the nurses don’t necessarily take stewardship over that process. So how have you seen the nurses start to engage with that equipment, especially for night shifts, where they these patients that are hard to mobilize would never get mobilized by night shift. Yeah. But now, how is your team using it?

Andrea Silva 45:57
Yeah, it’s a great question. In fact, I came one day. It was one of those days, and we had, I saw one of our coaches. Is we have clinical nurse coaches and and I saw him going room to room, helping this nurse mobilize their patients, if it was Dengue the city, up to the chair, and utilizing the vertical bed up. I saw him, and he was helping the nurse, just doing it like, Hey, we got to do this before we go home, because it’s part of the early mobility for nation. And I was like, Wow, just taking that initiative to do it. It was huge. Because, to your point, we had the bed, but we’re not utilizing it if we had it right. So it was like, Wow. I was so impressed by them just taking that initiative and doing it. Like, okay, let’s do this for this amount of minutes. And we have a chart where we document how many degrees and how many minutes each time, so we can increase that slowly. And as far as the patient is tolerating that, and they’re like, Wow, this is great. So it’s just them taking this initiative. Honestly, it’s not Andrea going, Okay, we gotta do this. We gotta do that. We know it’s them. It’s the team taking this initiative to make this happen, and for the best of the patient to all the caper the patient to get him out of the ICU as soon as possible. That’s when you know you’ve made progress.

Kali Dayton 47:14
Is when they don’t need you whipping them from behind anymore. And those people that were frustrated with you in the past have those relationships healed.

Andrea Silva 47:25
they have, I can tell you, I think they is a change, right? And change is hard for everyone, especially nursing and it’s a lot. It’s not like we said the beginning of this interview, is not an easy it’s not easy. Change is not easy in this from from this deep situation to no station is huge. It was huge in our culture. And I think again, I don’t think it was something that it was on purpose. It was just like they were scared for their patients and they wanted the best for their patients. So we have talked about how things have improved. They have given us feedback on how this could have been better, and we learn right, like I said, is we have never done this before, and we’re going to do it right, because if we wait longer, you wait, the more we’re harming those patients. So we have to start somewhere. And we did, and we did. And yes, now I can tell you nurses that I didn’t have their buy in initially. I see them doing this, and like, wow, you’re doing it. You’re like, yeah, we are. And it’s, this is great. We are. So it’s great to see again, the whole culture. And again, I couldn’t have done this without my charges, we have our charges and their support and our providers too. Like this is not just Andrea, this is a whole team approach, and I need everyone’s buy in to help me and continue to do this. And it’s everyone I can. I give the whole credit to my charges, because I’m not here all the time. They are here, and they’re making sure we’re minimizing temptation. They’re making sure that those patients are getting mobilized. They’re making sure we’re following whatever it is, right, the orders and stuff and and same with providers, right? Like, even I have nurses, it’s so funny, because we talk about self accountability, right? How do we hold each other accountable? And again, it’s not just Andrea and Scott, it’s how do we hold peer to peer accountability? And we had this patient who they tried everything to to turn off sedation. Nothing was working, and then something worked. So I had a day shift nurse come over and take over this patient, and she goes to the Night Nurse like, well, I know you tried everything and you couldn’t turn it off, but you still have to try again before I come into shift, because we have to give it another try after the patient has settled and see what happens. Like that is huge. That is amazing. In the day shift nurse comes to me like, Andrea, I did this, this and like. Perfect. I love it because it’s self to self, accountable, ability. What have you done and what happened? And can, can we give it another try? Nothing, just give it another try and see what happens. Honestly, it’s been huge. There has been so many great things in our interview process, we talk about the waking walking. We’re an awakened walking ICU. It’s an expectation for everyone to mobilize their patients and to minimize sedation, and they have to have an indication for sedation. Every nurse that comes in to to us. I sit down with them at your orientation, and I do a whole presentation on the why behind it, on the medication side effects, on how one milligram of Versa increases your risk of delirium by seven to 8% have research available for them and they want to read it. I have the book. We bought multiple copies of the federal e Lee’s book, and just the nurses borrow it so they can read it. I have the nurses who are huge advocates for the wake and walk in ICU. We just make it happen again. We’re not LDS yet. We still have a lot of room to grow, but I can tell you that we’re making impact in our patients lives,

Kali Dayton 51:09
and how has this impacted your patient experience department? That’s new to me. I don’t think I really understood patient experience experts do in a hospital, but what have you seen on that end?

Andrea Silva 51:19
Yeah, so let me tell you, really so patient experience, we always focus on a goal, something that we have to achieve to either nursing communication with the family is inviting them to multi disciplinary rounds, something that we have to do for so we can incorporate the family. So this year, we have been focusing on educating patients and families on early mobility and minimizing sedation. Because if you can just imagine, there’s a lot of misunderstanding out there, as far as my family member needs sedation. In fact, I have her family members asked for where’s the sedation? Why is he not sedated? So we this year, we focus on teaching our nurses to educate on the benefits of early mobility, benefits of minimizing sedation or no sedation, on their patients and their family members and experiences. I can tell you I hear my nurses because we were doing all this work, we were not explaining the why. It’s just because we were just so busy on the task. So when I was running with this patient afterwards, it’s like, how was your experience? I was awake on the ventilator. I was supposed to be sedated, right? And once I explained the why, this is why you’re not sedated. Oh, I didn’t even know that. So we made like a pamphlet. We really sit down and talk to the family. And I hear my nurses, hey, later on today, at this time, at 10am we’re gonna come by. We’re gonna get you up and walk around the unit. And this is why. And I hear them say the why behind it, which is huge, and now the patients and the families know, like, oh, like you’re walking. Like, yeah, it’s like an expectation, so it’s it, and it ties back to your patient experience, because you see your loved one doing well, walking, and you’re reinforcing that behavior, like, Hey, this is why we’re doing it, because we want your loved one to go back home, because we want the best for your loved one, because we want them not to get confused, because we want them awake and participate in their cares and like the family. Wow, that is huge. I didn’t even know this, so something that we’re still working on, and we paused a little bit for this hospital move, but we’re going to reinforce it more coaching and stuff will continue with that. So all these elements

Kali Dayton 53:43
that have to be implemented to become part of the normal process, that’s a lot of changes all at once, but having the family engaged and involved is just going to make everyone’s job even easier. It

Andrea Silva 53:53
does. Yeah, it does. A family is there like, Hey, can you help me with this? Can you do this for me? Involve those families because they want to help out, they just don’t know how to

Kali Dayton 54:03
and it all improves the patient experience. It does. And you haven’t even hit the year mark since the this initiative started, yet. That is, I’m sure people listening to this are having their jaws dropped and say, if we could just get halfway to where you’re at, but it I really believe that it’s possible. Like you say your nurses want the best for their patients, and they need the kind of support that you’ve provided. They need education, the training, one on one, mentoring, the hands on support to get this started. People saying all the time, and it is true in some units, we don’t have the staff to do this. You guys have pretty normal staffing ratios. You’re not one to one with your nurses. So how has this been staffing wise? Great

Andrea Silva 54:44
question, and I think that was one of the questions that they had, and concerns, right? Like, so are we going to staff up to make this happening? No, we’re not. We’re not. We’re going to keep the same and we have, like, to your point, two vented patients to one nurse if they’re staying. Down patients, they’re three to one, or there’s sicker patients, or one to one, right? You name it, sicker patients, ICU and so staffing wise, we have not we have keep the same. It’s just what we did. We allocated PT, no teachers to ICU and NCC, so we had to pull resources from one another units to make this happen because we have noticed it. This is where it makes a big difference. So that’s a big change that we did, PT, OT to the ICU. We have our own PT and OT. As far as our nurses. It’s just like, Okay, we’ve got to make it happen. If that’s me helping you, if that’s the our CNA or PCT, helping you, I have seen our PCTs get our patients, our ventilated patients, up to the commode by themselves, because the patient is strong, and all the CNA is doing is getting the lines and making sure they don’t get pulled the bedside commode in assisting the nurses. I have seen our my PCTs tell me like Andrea, I had this nurse who said, Oh, I’m going to wait for PT and OT to get this patient up to the chair like, No, you have me. Let’s go ahead and do it. We can do it together. So it’s not we did not have staff. It’s the same. It’s just our since we’re doing early mobility right away, our patients are strong, and they can stand up for you. They can help you so you don’t need additional resources. Is what you have, is just, how can we best utilize what we have to make this happen? And I tell my nurses, I love early mobility. Come and get me. Come and get me. I have had nurses to tell me, like, I’m gonna wait for PT and OT No, we can reserve that for the walk. Let’s get them up. I got you, let’s do it and we make it happen. You’ve

Kali Dayton 56:43
got PTs and OTs listening to this just weeping, because I ask them all the time in front of the rest of the team, how would it impact your job to come on shift and have patients be awake, sitting in a chair ready to go? And I say, I could do so much more with them, rather than spending the whole time trying to move a flaccid body that’s still sedated or delirious or weak, and it just makes everything so much more productive. And from a nurse’s standpoint, they can work with them actual activity for longer the patient gets more worn out. It helps their anxiety, helps them stay stronger, so they can do more. For me now, when I get trying to get them to the chair, it’s not a big deal. So everyone again, is scratching each other’s backs. We don’t have this fully captured in literature, because the studies thus far have not been done properly, like with through early prompt mobility, but between the drop in delirium rates, the preservation and motor skills, the decrease in time on the ventilator, decrease in time in the ICU, all of these things impact the bed flow, the workflow, and then on top of that, the skill set, the teamwork, all of these things make it come together. Now, if you’re in an ICU where you have three patients to one nurse as a standard, you can’t do this right, but you don’t need to have one to one necessarily for every patient on the ventilator, because of all the elements coming together, all the pieces of the bundle being implemented, and the whole team working on this together, that’s how you create a really safe and feasible environment to make this happen. Thing else you would leave any other stories or advice you would give to people that are marveling at how far you guys have come? Yes, I will like to just say, recognize your team.

Andrea Silva 58:21
I did a lot of recognition to our nurses, because they worked three shifts a week, so sometimes they don’t get to see the whole story. So I would always initially come back to that nurse who had this patient, like, Hey, I know you had a really busy shift with this patient, and you did your best on treating the cause of agitation, let me just tell you, did such a wonderful job that he was able to extubate the next day, and went up to the unit like circling that to make sure they know I was posting pictures in our break room so they could see the outcomes of those patients, posting pictures in my Weekly Update learnings that we had, sharing those learnings with everyone, coming together with my medical directors and other disciplines. Like, Hey guys, this is where where we are. What concerns do we have? What can we do to make this better?

Kali Dayton 59:13
Where are we with us?

Andrea Silva 59:14
Sojust always checking in with everyone to make this happen. Stories, I have a lot of stories, great stories that I have seen there’s humbling to see this ICU patients. I mean, I can just cry, I don’t cry, but I can just cry just to see this beautiful outcomes that we have seen in this, in our ICU. And if you’re thinking of starting this awakening walking, or implementing the ATR fund on your unit, don’t hesitate to do it. Go for it. No one is perfect. We were not perfect. We had a lot of learnings. But just take get the whole team together and implement it, so you can start making a difference in those patients lives, because they come to us to make a difference, right? They put their lives and health in our hands. Students, and they rely on us as an experts to make the best decisions possible for their care. So it’s up to us to make that difference. And I can tell you, there are so many things that I can tell you are rehab patients who are trained, we saw a huge drop on patients who are trait. There’s an indication why they’re trait, you name it, lung cancer, anaphylactic shock, you name it, right? But it’s not because of ICU acquire weakness. It’s not anymore,

Kali Dayton 1:00:29
not because I just couldn’t get off the ventilator. Exactly, exactly.

Andrea Silva 1:00:34
There’s patients who I think are rehab. I’m trying to work with my case managers to see there’s a report that I can show a rehab rates, how many patients of the IC are going to rehab versus home. We’re still working through those things and everything. We’re keeping an eye on self extubations. We really are since early this year, because we want to know, and we have had self excavations, but everyone has been okay, no harm to the patient in that weather provider said that just means that we have to expedite earlier than we are doing it right now. So it’s just learnings, it’s learnings, and it’s new populations changes, and we want to do a really good job. And again, we’re not LDS, but one day we’re

Kali Dayton 1:01:17
going to get there. I think you guys are well on your way. If you can get this much progress in less than a year, you’re gonna just continue to refine your skill set. And one thing of note is your alcohol withdrawal protocol. You guys were doing a lot of Ativan, Siwa still. So when the nurses were like, oh, but our alcohol withdrawal and they were just, there’s no way. I said, Hold on. Wait, stop. Let me guess you’re still doing Ativan. See what protocol, and they’re like, yeah. So just quick rundown. How did you get that changed, and what kind of impact has that made on the workload, the outcomes, the whole process?

Andrea Silva 1:01:54
I’m so glad you brought this up. So that was another change. We implemented another thing that we did. So yes, we were doing the Ativan you name it, the Siwa protocol, right, which you treat alcohol, withdraw with benzos. And after working with you, I think was about a month after you share with me the phenobarbital protocol, and I brought it up to my providers, with my providers, meeting like, Hey guys, this is what share with me, where we can try to utilize it, get away from the benzos and focus on the phenobarb, and we can give it a try. And then everyone she’s like, Oh, we started giving the patients phenobarb. And what a day and night difference. What a day and night difference with phenobarb versus benzos. It made a huge difference when I would come around in the mornings, like, why is this patient here? No alcohol withdrawal? Oh, how are we treating the alcohol withdrawal with propofol? Like, oh, with propofol, okay, have we given any phenobarb? I don’t think so. So we started slowly, given the phenobarb and patients were coming out with ventilators sooner. They were not going through those withdrawals as they were used to, or delirium. What a huge difference. So I share that protocol with all my providers, and I can tell you they’ve been doing the phenobarb they have all but

Kali Dayton
the nurses advocate for it if there’s a rogue physician, yes. So they’re like, I’m not playing that game. Yes,

Andrea Silva 1:03:22
yeah. And right now, we’re even taking a step further on teaching the other units too. Like, hey, let’s try to get away from the benzos. Let’s focus on the phenobarb and even with mobility too. I’m a huge advocate for mobility, and we have to keep the momentum going. It’s not just in the ICU. It has to be on the other units too. But how can we make that happen if we allocate our PT and OT disciplines to the ICU? So it’s something that we’re working on right now to make sure everyone is on we’re continuing to do that mobility on the units as well. I tell my directors, if I see you, we’re doing mobility at this level with an open abdomen, with this broken bones. What is indication we’re not doing it in other units? How can we make this happen? So it’s a it’s another group that we’re working on, and to make sure that’s happening in in learnings. And again, it depends on senses and acuity and everything. So it’s something they were just looking

Kali Dayton 1:04:21
at. Andrea, I think you’re such a example of the power of nursing in the ICU and as leadership and its quality improvement instigators. Thank you so much for everything you’ve done for your unit. I would also love to see if there’s been an impact on staff retention, and you guys can track that. And so there’s so much to learn from your unit, but you’ve really inspired me, helped. I’ve learned a lot throughout your journey. It’s reinforced a lot of my suspicions that everyone needs this training, but there needs to be strong leadership and buy in from all the clinicians. And so I think there are a lot of people that will be able to fall in your footsteps, and they don’t have to do it alone. So we’re all as ICU revolutionists. We can all come together discuss these things in our monthly meetings. I’m happy to help more teams. Just know that, like Andrea said, Start now. Don’t wait. Don’t be afraid it’s going to be one of the hardest things you’ve ever done. Yes, yes,

Andrea Silva 1:05:17
it will be, but it’s so worth it, so worth it, and it’s worth it.

Kali Dayton 1:05:21
Thank you so much. You’re very welcome. To schedule a consultation for your ICU as well as find supportive resources such as the free ebook case studies, Episode citations and transcripts, please check out the website, www.DaytonICUconsulting.com

Transcribed by https://otter.ai

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