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Polly Bailey, ACNP, shares with us her journey to building an awake and walking ICU. Decades before the research and in a generation of paralytics and benzodiazepines, she saw a problem and had a vision.
Episode Transcription
Kali Dayton
So now you’ve heard about patients that’s been weak on the ventilator with high settings that never stopped walking, and then walked straight home and back to their lives.
So how did this come to be?
How did we evolve into keeping patients awake and mobile?
Even decades ago when everyone was paralyzed, and I’m benzodiazepine drips?
Even with the supporting research today, much of our ICU community doesn’t believe in, let alone practice this. So how did we get here?
We are a smaller hospital. So who dared to jump ahead of the research? How do these practices get so advanced and beyond their time?
In the second episode, Dr. Terry Clemmer mentioned Polly. It was one nurse nearly 30 years ago, that saw what became other patients and dared to dream of better outcomes. I am grateful to have that dreamer and Doer on today. Polly Bailey, nurse practitioner shares with us her journey to changing an ICU culture, practice and 1000s of lives. Polly, thank you so much for joining us today. So tell us how long have you been in the medical field for?
Polly Bailey
Oh, 40 years, close,
Kali Dayton
almost 40 years. So when you started in the ICU as a nurse, what was sedation like that?
Polly Bailey
Because initially, we didn’t sedate patients, because patients didn’t live long enough to be sedated. I don’t know if that makes sense. But really critically ill patients came in and they died. And then all of a sudden, we began to be better at the care we were delivering. And patients were surviving longer. And I came from that initial age in the late 80s, early 90s, where we were doing really heavy deep sedation.
Patients were on Versed drips and Vecuronium and drips and Valium drips and Ativan drips and at tremendous amounts of medications were administered. We had come from doing a study and this probably important, but we had been doing an air core study, which was kind of like ECMO is now we were we’re doing this such study.
So that came, that whole process of deep sedation, sort of came out of that study. Where we had cannulas and patients, we were keeping them heavily sedated, so nothing could go wrong. And it immediately transferred from that patient to every patient.
And as we walk down that path of heavy sedation, and that trial got over and we were treating patients this way. I started to watch all of these patients whose lungs were getting better. They were on CPAP. But no one could be extubated because they couldn’t control their airways. No one had a cough, no one could lift their head off the bed. No one could remove. They were so weak and deconditioned from all of this medication we had given them and probably from all the paralytic we gave them.
I can remember being at the bedside when nurses would give paralytics so that they can give a bath quick. I mean that we had no idea that we were harming people. Of course, we look back now and Dr. Clemmer and I talk about all the time that all the time looking back and thinking how many people we harmed, because we didn’t have any idea that what we were doing was harmful.
So as we watched these patients not being able to be extubated, I had gone to Dr. Clemmer and said “We have got to do something about this sedation, because these patients are not coming off of mechanical ventilators.” So we started developing a sedation protocol. And that was about the time we’d actually started that work when I took care of Joy as a bedside nurse in the shock trauma ICU.
And I started taking care of her as a primary care nurse. We did that in in those days, because she was from my home town, my home community. I didn’t know her but I sort of felt bond bonded. Yeah, that’s a good way to put it. And so we were thinking and working on controlling sedation at that time, but clearly she was heavily sedated. And probably used paralytics. I don’t remember that per se.
But as I primary cared her, I became close to her family and to her. And so the for the first time in my career, I watched what happened to a patient that left the ICU. And I, we moved her to the rehab unit. And I think about that now. And I think about her lying in that bed. She has no fine motor control, she can’t use a call light. She has to use the chin call light to even call and get help. She’s had been intubated for weeks and weeks at a time. She has no voice, she can’t call for help. And she can’t move in. That’s the state that we sent her into rehab. She wasn’t there long when she came back was re intubated. And then that scenario happened again.
And then I had the opportunity that I because I I was bonded with them that I watched her go home. And I would visit her at her house. And I could not believe what we had done to her. And the difficulty that it was for her to step back into her life and back into her role as a mother. And I, I could I was just stunned. I don’t have better words to say than, “What? What?”
It would take her an hour and a half in the mornings to get a shower. They didn’t sleep at night because she was so weak, she couldn’t get up and go to the bathroom. So they would try put her on a bedpan all night long. And that’s how she toileted. The strain that it was on them.
Now John was fortunate that he didn’t have a job he had to go to every day, he could take the time off and be a caregiver, but who has that luxury? So every day I would go there and I would watch what was happening. And I would come back and say to Dr. clamor and and to Vicki Spiller, who was my nurse manager at the time, “We cannot do this anymore. We have got to stop what we’re doing.”
And I would, and we were all learning from her. Every one of us were learning as we watch this process. It was at least a year before her life really started to resemble what it was before critical illness. And, and even to say that was a stretch it was probably a good two years.
So when we realized we had to do something different. Dr. Clemmer told me to go out and do a literature search and decide what it is we wanted to do. Well, I spent days trying to do that, trying to figure out how to care for these patients differently. And I came back and I put this stack of articles on his desk, and I said, “Okay, here’s what I can find. But there’s nothing there.” I said, “We have to make this up. There is nothing out there that tells us how to stop harming patients, and how to make them better.” And I said..and then we just started talking about what needed to happen. It was clear we had to focus on physical functioning.
Because she couldn’t walk up she she came down from her bedroom once a day on the second floor because she couldn’t walk back up and down the stairs at all. So there was no question that we had to work on physical functioning. And a lot of the things we learned from her about PTSD, and those experiences are things that here we are 20-whatever, years later, and we still don’t have the answers to a lot of those problems.
But what we just did then, and this was before Wes Ely’s paper on delirium. I mean, we knew I could describe delirium to people I knew it was harmful, and I knew it was affecting patients. But we didn’t have any evidence to…or way of talking about it even-a terminology or any way to to even understand what the issue was about that and how that affected people down the road. But we started anyway, we figured out we that was the days when you did critical pathways.
So we did a critical pathway for respiratory failure patients. And it was about, essentially, we started about decreasing sedation and increasing our mobility. And we did a pilot study- which was the most important thing I’ve done in my nursing career probably. Because, I was able to come out of standard away from the bedside and we took took this critical pathway. And we started to try to use it to support patient care from the day they were admitted to the day that patients left the hospital.
So I was able to follow this group of patients that had ARDS, and follow them from the time they were admitted to the ICU, through their course of stay, to rehab, and to home. And the lessons that I learned watching that- unbelievable to me. So, what we learned from those early experiences as we followed patients along the continuum of care.
And as a critical care nurse, this was really a new revelation to me. And that is that…
the back end of ICU care is equally important to the front end.
And we all entered ICU nursing, because we like that first 72 hours of critical illness. We like the cognitive stimulation, it gives us we like the adrenaline and we like the challenge. But what I think I found and appreciated the most is that…
the back end of ICU care is every bit as important as the front end.
And there is mortality and morbidity in the back end of ICU care, as well as in the front end of ICU care.
So we really tried to stop and redesign and think about, “How do we take care of the back and of the ICU stay so that these patients preserve their wellness, preserve their physical function, preserve their brain function, and be able to have the most complete intact recovery that they can have?”
I can would come back to Terry and Vicki and say, “This such and such patient came through our unit went to the floor couldn’t …couldn’t even be a rehab candidate, because they couldn’t participate, had to wait on the floor for a while to get to rehab. And then after two months of rehab, we still had to lift him in the car on the day he went home. And I saw that over and over and over.
And so we just, you know, try to bring this process forward to the frontline caregivers on a holistic approach across all the ICU. So and we struggled. People were resistant, they didn’t want to do that work. And we ended up opening the respiratory ICU where it was a unit where people came together with the patient at the center of the care. And we tried to think outside of the box. And we started thinking about how we can support these patients without oversedating them with early mobility with… we used music therapy and pet therapy and and that’s when we first started showering patients inside of an ICU.
We just tried to do as much as we could to make the patient experience as human as possible. And again, that was a really growing time. We just learned so much about how to take care of patients and how to take care of patients in the right way. And when we would tell people what we were doing, people would say, “Oh, you can’t do that. Your patients aren’t sick. We could never do that our patients are too sick.”
And that’s when we decided we need to publish and tell people, “You know, this is what you can do. This is what we’re trying to do.” And we’re the first ones to show ICU patients that had been intubated on ventilator that were walking 200 feet in ICU before they left ICU.
Kali Dayton
And where did that go?
Polly Bailey
And then, um, well, *laughter* then, and that was about the time Roy Brower was on a plane coming to Salt Lake City. And he came into the RICU and he had just read the article that we published in critical care medicine. He goes, “I want to see that unit. I want to see what you do.”
So we were able to have a conversation about that and about not sedating patients and that we don’t use the Ativan. He would say to me, “Well, what do you do if you don’t use Ativan? What do you use when your patients are anxious?” And we would say, “Well, we get them up. We move them around and walk them around, then they go back to bed. They’re restful, it’s a restorative rest. That’s how we treat anxiety.” And that kind of started the whole this whole process I think about early mobility. And, and we worked with Johns Hopkins initially as they brought their program up and, and then it’s taken off from there.
Kali Dayton
And I see in this unit, and I started here as a nurse, and I thought that this was totally normal. I thought this was a standard to have patients awake and walking three times a day and to be able to interact with them. And I see the success of this unit as a tribute to your vision and your work. Which I know you you wouldn’t personally say, but I can because I’ve watched it. What was it like to push for that change, especially as a nurse amongst all the naysayers and all the doubts? What was it like for you to know that this was the right thing and push for it?
Polly Bailey
Um, you know, that’s interesting, because it’s still hard to push to do the right thing. And but I will say, I had exceptional support with Dr. Clemmer. And even in the respiratory ICU, we had physicians that were very supportive. I think part of the reason is at that time, those critical care physicians followed the patients through the continuum of care all the way out to the floor. So when we’re talking to them about our concerns, they understood our concerns, because they saw it. And so they were on board. And we have been really fortunate to have champions along the road that supported what we were trying to do.
Having said that, I think that it’s human nature to want to do what’s quick and easy. And I kind of describe doing this process of care, as pedaling uphill a little bit. I mean, you’re always trying to push against what you naturally want to do. Does that make sense? The easy way, right, you know, it, it had that tendency to want to control our environment with sedation is kind of normal.
But so when you’re trying to push to keep the patient in the center of the care, it’s always an uphill battle. And it helps a lot, I think, in our circumstance, that we have senior nurses that know that understand that and watched patients go through this, and see what difference it makes, and that they are the people that mentor.
And together we mentor, and at that burden of mentoring and teaching that process of care doesn’t fall on any one person or anyone discipline. For me, we’re successful here, because we have an interdisciplinary team, that is all committed to keep the patient in the center of care.
And we, this group of people do not practice in silos, respiratory doesn’t come in and do their thing and leave, PT doesn’t come in and do their thing and leave. Everybody comes together at the patient side, and works together to give this patient the care that they need. And that’s what makes it work when it doesn’t fall on any one person. So if it were just nursing that had to make this happen on their own, well, no one could do that.
If it were just physical therapy to make this happen on their own. No one could do that. It’s a force of people, that when they come together, then everybody has a little piece of it. And the burden is light because it’s shared burden. And at this point, people don’t see it as a burden. But I think when you’re looking at it, trying to get started trying to think how to change the care you’re giving it feels burdensome.
Kali Dayton
Yeah, to tell people that you want to turn off sedation, wake them up and get them up. That seems insurmountable. I mean, I felt that when I was in an environment in which that was just not done and people didn’t even believe it was possible. And that’s even …that was just a few years ago and that we already had evidence and research out there and yet there were lots of naysayers. But you’re right, there’s such a strong team here. And I just love the fact that it it did start with a nurse.
Polly Bailey
Well, and I think and I will always be a believer that the most important person in this process is the nurse at the bedside. And without them, it can’t go forward. People say to me, “Well, our nurses won’t do it. Our nurses won’t do it.” And I think, you know, I brought this process of care up in two different units now. And I believe in nursing. And I believe that when they understand what needs to be done and why it needs to be done, that they are always there to do the right thing. And I have never… my personal experience has never been that nurses got in the way of doing the right thing. My personal experiences, they are the motor, they are the engine that drives the right process of care.
Kali Dayton
When they get it, when they know the why and they know the house, they are unstoppable because they get into this profession with the determination to get patients better. So when they know how to do that, you better get it right away, because they’re going to get it done.
We had a really good example of that recently. You know, I think I’ve mentioned before a lot of our patients wake up after intubation, they’re pretty calm, we can reorient them. We use non pharmacological interventions to keep them calm. So a lot of patients aren’t on any kind of sedative. But that’s not always the case. And delirium isn’t always preventable.
And so we’ve recently had a patient come in that is, at baseline, an alcoholic that’s malnourished, with severe in baseline anxiety- takes Buspar and Xanax at home as well as marijuana and alcohol to treat her anxiety. She came in with streptococcus pneumonia, and empyema, and severe respiratory failure and, and also had withdrawn from alcohol and had septic shock, all these things.
This is the perfect storm for terrible delirium, and very valid anxiety. And so she was brought here from outside hospital and had already been immobile for a while very delirious. And she was, she’s been really difficult to manage as far as how to keep her comfortable. And those kinds of cases. I know that. Again, you talked about the temptation to do what’s quick and easy. So they’re in was a huge temptation to just sedate her. She looked very uncomfortable at first, it was an her oxygenation needs were really high. So it could be argued that it would be in her best interest to sedate her deeply sedate her. Now, how do you approach that?
Polly Bailey
Um, well, the first thing I’d say is, you’re right, there are definitely groups of patients that are way more difficult to manage than others. I think patients with underlying dementia can be really difficult. Patients with underlying site psychiatric illnesses that have been on a lot of medications are difficult to manage. So we recognize that a patient that uses that kind of outpatient medication regime to treat their anxiety is not going to come into an ICU and not receive sedation.
When we say we don’t set a patient’s that’s not true, we sedate patients all the time. We just don’t use sedation to make them unresponsive. We want a patient to be calm. We want them to be comfortable, but we want them to be cooperative. And this gal when you look at her comes in severely malnourished with a significant amount of lat muscle mass loss from her alcoholism. Her anxiety is going to be persistent, despite what we put on top of her. I mean, we can sedate her to the point where everybody can walk away from the bedside. And she looks comfortable. But one day we will take that sedation off and all of her anxiety will still be there. None of that is a treatment for her underlying problem. So the approach that we take is to try to humanize her experience as much as we can and give her the amount of sedation that she needs to be able to be functional.
Kali Dayton
Calm and still awake.
Polly Bailey
Yes.
Kali Dayton
And even mobile.
Polly Bailey
Yes. And telling us what she needs as far as anxiety goes. So you managed her the first few days I don’t know if you want to comment on what you had to do, but since I’ve been on we have her on no infusions of sedatives she is on between 70 and 80% and 12 PEEP.
She is walking 200 feet at least three times a day. We do have her on sedative. So we have her on a milligram of Klonopin TID, which is a lot. I think that’s enough to put me to bed for a day. It’s not enough to even make her drowsy, drowsy, but it is enough to help calm her. And then we focused on sleep medicines at the same time. So that we are trying to get the right combination of Sleep Medicine on top of the Klonopin.
To be able to manage her anxiety, we’ve asked her whether she would like to try earplugs, we are getting her music, she her on her phone with some but so that she can listen to music. Her dog has already been in and the dog is coming again tomorrow. Her family is at her bedside, her sister is there, they understand what we’re trying to do, as in controlling her anxiety, we have asked them what they think we should do. What can we do differently? What should we change short of, you know, things that we think aren’t in her best interest.
They understand how important it is for her to be more mobile and to maintain her strength. So that when she’s extubated, she can essentially go home with her family. So I think we try to look at the big picture and do sort of a multi modal approach. And what’s important to understand, I think, inside of this kind of approach is we’re listening to her or saying, “Do you think you need more medication for anxiety? What do you need to do?” you know, and letting her communicate with us what her needs are. We don’t have to guess whether she’s having pain, she can tell us about her discomfort. We don’t have to guess what her anxiety level is. She can tell us what her anxiety level is. So, um
Kali Dayton
and when she first came in, she was severely delirious. Again, she was recently out of septic shock. She had just recently withdrawn from alcohol. She had been given a lot of Ativan, probably for the the withdrawal. So she was severely delirious definitely can positively say that-
Polly Bailey
She’s CAM negative the last two days that I’ve been here she’s been CAM negative.
Kali Dayton
So what difference would it have made in her cover? Even just in the last couple of days, I mean, her oxygen needs are down. She was for my shift. She was up to 90% Peep of 16. And we still had her standing at the bedside, she was delirious, but she’s still walking 200 feet standing dangling doing all the activity. She probably thought she was at the store. I don’t even I feared I think of where she thought she was. But she was still mobilizing. And every time we would walk her even in her delirium, history, anxiety. We didn’t have to give her anything. She was just rest in bed, she was more comfortable. And said it and it got better with the mobility. And now you’re seeing that her delirium has improved. So how do we done the quick and easy just…. “Sedate her. Let’s not deal with this.” What would her course be like already?
Polly Bailey
Well, I don’t know. But I this is what I’m assuming it would be like I think that certainly, I think our understanding of recall in the ICU is that patients who recall real events, that maybe noxious events have less PTSD than those patients who just had delirious memories, and I am certain watching her anxiety and if we had been continually sedating her that she she would be one of those people with delirious memory. She’s had some tragic loss of life in her family members that she’s never , I think, probably resolved and has some underlying issues.
I think as deconditioned as she is coming in that a week of bedrest or whatever if we sedated her till her oxygenation improved. It think she would be headed to a rehab unit. She would be that weak and deconditioned. At this point she should be able to be extubated, and she should be able to be able to go home. I think it’s important that we recognize, too, that we are going to need psychiatry down the road, that we need to address her underlying issues here, what’s driven her need for these kinds of medications as an outpatient and see if we can’t connect her in with the right kind of treatment in in an appropriate way. I think that’s key for her.
Kali Dayton
And I worry about her cognitive function down the road, you know, we… deep sedation would have prolonged her delirium, she would not become negative today, if we made that choice days ago, to deeply sedate her. And yet, she was delirious. And so I think it’s going to be really important to do cognitive evaluation before she leaves the hospital and have resources available to her to get cognitive therapy.
Polly Bailey
And we’ve started her cognitive therapy, actually. So um, both speech and OT are doing cognitive therapy on her. We’ve included her sister, so that she can help her we’ve given them an iPad and an app, that they can work through some cognitive therapy, and we have a cognitive therapy protocol. So she’ll continue, you know, to get this cognitive therapy as she goes along.
And hopefully, that as much as they that may help her cognition down the road. I know, we don’t know the answer to that or not. But certainly, I think it helps her being that bed and relax and have something to focus on and a distraction and, and something to use her energy and her brain for besides fretting and worrying. And we’re hoping to, to again, take all of these treatments together and make this a better situation for her a tolerable situation for her.
Kali Dayton
And boy, it has been a big team effort. But it’s amazing to see just the difference in a few days of having a humane approach to her care. You know, you said that the nurse is the kind of the champion at the bedside and later I’ll interview Shawna. She’s one of my personal heroes. She was her nurse one of the first days and her lungs were so bad or athletes were so high there was discussion of possibly transferring, transferring her to a facility that had ECMO in case she needed to go that route.
And Shawna almost slammed her hands on the table and said, but if she goes, she’ll be deeply sedated. She’ll stop moving. And she’s so deconditioned and malnourished- That is not in her best interest. And you could tell Shawna took that very personally. And the next thing I saw was Shawn, physical therapy, walking her the gait belt. Highly supporting her. She was still super delirious the first time she’d walked. But they did it. And the funny thing is, when that facility heard that she had been walking, they shrugged their shoulders and said, “Oh, she’s not that sick. She won’t need ECMO.” And we just winked and said, “Right. She’s not that sick.”- But in reality, her lungs were that sick.
Polly Bailey
Yeah. We actually tried my interest. I don’t know if it was when you were here, but they tried proning her and interestingly, and of course, that is that moment, you know, where she would have had probably more sedation. But it didn’t work.
Kali Dayton
I was there that night.
Polly Bailey
I think they tried her again. Well, someone else was here after you left. She got worse, not better with proning,
Kali Dayton
Yeah, I noticed her anxiety was worse, despite the deeper sedation. And her oxygenation was not getting better. In fact, it was starting to get worse. And she had just walked 200 feet before that. And so it was one of those decisions where it was, “Is this is beneficial?” And “Which is helping her lungs more- the mobility or the pronation?” and the mobility seemed to be helping more.
So we flipped her back onto her back, she’s more comfortable. And we didn’t have enough staff that night to fully walk her. But we started the bedside. And she was marching in place and asking to walk and almost begging to walk it kind of broke my heart. So it was just amazing that even on 90% People 16. She felt like she was ready to walk. And she was.
Polly Bailey
And we tried it again and which I think is what we needed to do we needed to prove that indeed that wasn’t going to help her and and again that second test was not a positive test either.
Kali Dayton
And here she is. days later and her oxygens are down. She’s CAM negative, and her anxiety is more managed. So it’ll be interesting to see where this goes. But I just know that none of this would have been possible, and none of these patient outcomes that we’ve heard would have happened if a nurse didn’t have a vision and didn’t care about the big picture for patients and I know that nurses do.
And I’m just I feel honored to work with Polly to kind of step follow her footsteps and her legacy. I know that this is the right thing for patients and some day, Polly, I have the vision that we will roll our eyes and say, “Remember when we left patients in bed to rot? Good thing we don’t do that now.” And I think that you feel like these have been “ripples”, but I know they’re, they truly are waves. So thank you so much for sharing your expertise and for your sacrifice and all your hard work throughout the years.
Polly Bailey
Thank you very much.
Transcribed by https://otter.ai
Polly’s Publications:
https://pubmed.ncbi.nlm.nih.gov/20046131/
https://pubmed.ncbi.nlm.nih.gov/17133183/
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