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What do you want to know about the Awake and Walking ICU?

Episode Transcription

Kali Dayton 0:28
Hello again, I hope you were all staying safe out there as COVID is hitting our ICU world hard right now. I was recently contacted by Chelsey Rogers, who is the founder of the Facebook group, “Tribe RN” to do a Q&A about the “Awake and Walking ICU” and the podcast. Wonderful questions were asked by the group and I felt the discussion was worth sharing. Please, join our podcast discussion group on Facebook for more questions and answers by you, our ICU community and other caregivers in the awaken walking ICU.

Chelsea Rogers 1:05
Guys, thank you for being so patient and tuning in. We’ll talk to Kali about an “Awake and Walking ICU”. She started out as a new grad in the ICU and is now a nurse practitioner there. So Kali, just introduce yourself.

Kali Dayton 1:18
I’m Kali Dayton, I work in the “Awake and Walking ICU” for two years- totally thought that was normal to have patients awake, engaging cruising on the ventilators. And then I worked as a nurse practitioner as a travel nurse around the country and a lot of different experiences. I came back to Utah back to the “Awake and walking ICU” during grad school and now I’ve worked there as an NP for a few years.

Chelsea Rogers 1:40
That’s awesome. So tell us the most inspiring story of your “Awake andwalking ICU” career.

Kali Dayton 1:46
I don’t know how to break them. There’s just as with anyone’s career, especially in medical field, why are there so many? Just recently we had an exciting moment with a COVID patient, one of our first. He came in and this was during the initial wave when we were intubating everyone that required more than 6 liters nasal cannula. He was admitted, intubated, and he was a walking for 6 days- just awake and walking in his room, sitting in a chair all day.

Then he hit that cytokine storm, and as a lot of us seen, they can go fast. He needed to be prone. he couldn’t tolerate being supine. Because he wasn’t delirious yet, he could be lightly sedated and he was still CAM negative, he was still able to turn himself for those first two days of being proned. And then his lungs got even worse. And we need to paralyze him deeply sedated him. And he was paralyzed for two days and deeply sedated for total for four days for additional days.

So he was proned for eight days. And because he stayed so strong, the six days prior to that, as soon as he could be supine, we had him sitting up again, still on high ventilator settings. But four days after that he was extubated, and eventually was able to walk himself out the doors and go home. And he just said was on the podcast and reported that for his 70th birthday, about five or six weeks after discharge. He was out golfing. And so for someone that had been on a ventilator for three weeks, that was really reaffirming of what we do in the way can I walk in ICU is to watch him get his life back even at 70 years old.

Chelsea Rogers 3:27
Yeah, that’s amazing. And I listened to that podcast and you mentioned that he was doing pushups while proned in his bed intubated. And I’m just visualizing this and that just sounds amazing. But at the same time for nurses never experienced a kind of scary. So I’m addicted to your podcast now. And that’s super fun. Because it’s I seriously have this new fire about what’s coming in medicine. Why don’t you tell us how the “Awake and Walking ICU” started. You mentioned that it’s been around since the 90’s. I had no idea.

Kali Dayton 4:02
Yeah, I can’t take any credit for the evolution of this process. I give all the credit to the pioneers of the process. And one of them is Polly Bailey. She’s also a nurse practitioner. But when she was a nurse and a shock trauma ICU back in the 90’s. This was an era in which they were deeply, deeply sedating people with benzodiazepine drips like Ativan, paralyzing everyone. Back in the day, they didn’t have rehabilitation services, really.

So she became the “primary nurse”. I’m not sure exactly how that works. But she followed a certain patient throughout her ICU stay, even to home and this patient was from her hometown and she tells it better on the podcast. But in summary, she watched this young mother in her 30s spend about a year trying to be able to get up her own stairs.

Her husband was doing the bedpan in the bed with her. She was completely debilitated men. totally altered with severe cognitive deficits. But when in the ICU do we see people afterward? Really? How do we know what happens to them? And that was really shocking to Polly. So there was no there was no research on it. Everything was new. And she went to her medical director and said, “We are breaking people. We have to change this. What if you let me keep people awake and keep them moving, so they never get that week? What would happen?”

And this doctor, Dr. Clemmer, who’s on Episode Two, he was incredulous. He thought that was crazy talking yet he trusted nurses. He trusted their instinct, which I think is a lot more powerful than a lot of research. And he felt that same way. So he allowed Polly to experiment. So she started just in the shock, trauma, ICU trying to wake people up and mobilize them. And you’ll have to listen to her episode. But it was a whole course and journey. But here we are, 30 years later, a very well established culture in the “Awake and walking ICU”. And it’s all because of one nurse with a vision and good instincts that dared to ask, “Why?”, “Why not?”, “What if?”- all those questions that just all the advancements that we’ve made in our field, she led the way and it’s still going.

Chelsea Rogers 6:14
That’s amazing. And, you know, they see that it takes 10 years for things to catch on from one side of the country to the other. But I just don’t know how many “Awake and Walking ICUs”- there actually are, do you?

Kali Dayton 6:30
It’s definitely a process. We have so much research. So this specific hospital, Polly actually put out a study back in 2007, showing that walking patients on ventilators is safe and feasible. And that was groundbreaking at the time. And so then research started firing up about cognitive deficits, deficits, post ICU PTSD, return to work rates for patients with ARDS.

So research started looking more into what happened to these patients. So we started seeing more of the problem. But it wasn’t until… I don’t know… I would say 5-10 years ago, that we started looking more into. What is the solution? We have all these problems, we break people in the ICU, but how do we avoid those that harm?

So that’s how the A to F and to came to be Dr. Wes Ely is he is a delirium expert. So he saw the delirium and the effects of delirium. And then he started developing this process- a protocol as to how to lighten sedation. Now the “Awake and Walking ICU” kind of takes it to a new extreme where we don’t start sedation on everyone, hardly anyone that’s intubated.

We have certain thresholds, like needing paralysis when being prone, open abdomen, severe toxicities, things like that. But most everyone that gets intubated is woken up right after intubation. But the A2F bundle is our process. So that is kind of the, the new trend, so I think a lot of ICUs are working towards that. But as we discussed in the podcast, there are a lot of cultural barriers, a lot of really hard things to be able to fully implement that. Let alone go to the extreme of the “Awake and Walking ICU”.

Chelsea Rogers 8:16
Yeah, for sure.

Kali Dayton 8:16
But we’ll get there!

Chelsea Rogers 8:17
Yeah, yeah, absolutely. I love these baby steps. It’s amazing. So kind of give us a visual picture of what exactly the “Awake and Walking ICU”- is for those of us who’ve never experienced it.

Kali Dayton 8:29
So now that I am a nurse practitioner, I’m working the day shift. So I personally come in at seven in the morning. And for the most part, lights are already on by eight or 830, the day shift nurse has taken over. And a lot of times they already have the patients, even on the ventilators up in the chairs, waiting for physical therapy to come patients are watching TV, they’re writing on the boards. They’re asking “when when are we going to walk?”

And patients walk three times a day- intubated or not- at varying distances. Our ICU as a 200 foot kind of circle. So patients usually walk anywhere between 50 feet to 1000 feet, whatever they can do at that time. And it’s just assumed that that’s gonna happen. So physical therapy helps with those walks the first two, so about like nine in the morning, ten in the morning, and anywhere between one and four in the afternoon. And then about nine o’clock at night, everyone takes their last lap around the unit so that they’re worn out, and they’re ready to get real sleep. And we even have a shower room where some patients on the ventilator are able to get extension tubing and get real showers even while intubated.

Chelsea Rogers 9:44
That’s incredible. That’s seriously that’s amazing. I yeah, I can’t picture that. That’s so incredible.

Kali Dayton 9:51
It’s what I would want! One of our podcast episodes….. One of our survivors had ARDS she was on a ventilator for 17 days. She talks about how therapeutic it was to get a shower if I was on the ventilator for 17 days…. I’m sorry, a shower cap is not going to cut it. Yet she was awake, she would walk herself to the shower.

She was helping her daughter do homework. She had the worst gag I’ve ever seen, and yet, it’s pretty amazing to hear her say, “No way I would ever want to be sedated.” I mean, at the time I asked her, because online, people were asking me questions and all the same impressions that we get- “Isn’t it inhumane? Aren’t people going crazy on the ventilator? Wouldn’t they want to be sedated?” So I asked her, “Hey, would you rather be sedated right now?” And she looked at me like, “Why would I need to be sedated?”

Then, later I saw her on an ARDS survivor page. I asked hundreds of survivors – who had walked on a ventilator? And only one person electronically raised their hand and it ended up being her. And she asked if we had a survivor page for our patients, because she couldn’t relate to these other ardf survivors, because all of their discussions were about the trauma, the psychological trauma of the pain and the PTSD from other hallucinations of delirium they had, and the long rehabilitations they had and the weakness they had the cognitive deficits they had, and she after 17 days and didn’t have any of that, because she was never delirious.

She walked the whole time. And she was able to go back to running her own business shortly after that. So she, so then I asked her again on the podcast. Now, in retrospect, you knew how miserable that was to be on the ventilator- what would you choose? And she said, “I would never want to be sedated after hearing what the survivors went through.”

Chelsea Rogers 11:42
That’s incredible. That’s really neat. So when a patient is nearing that time of needing intubated, sometimes we have you know, that threshold when where you’re thinking, Okay, we’re getting close. Of course, there’s those moments where we’re just going to intubate right now, and we don’t have time to chit chat about it. But let’s talk about the ones where you have some warning, right? What does that conversation look like with these patients and having that discussion, that informed discussion about how this is going to look because they don’t have this preconceived notion that I need to be sedated, like you and I thought that maybe we would need to be sedated because that’s what we’re used to. They don’t have that preconceived notion. So what does that conversation look like?

Kali Dayton 12:27
Under normal circumstances, the family hopefully is in the room too. We explained to them why they’re going to need to be intubated. Maybe some guesses as far as how long it’s going to be. But when we tell them, “You’re going to wake up afterwards, and it’s going to be uncomfortable, but we’re here for you. And many patients before you and after you have done this.” A lot of these patients that they’ve been hanging out in the ICU, even seen in their doorway, they’ve been watching people cruising around on the ventilator. So they’ve had a visual for the most part of what that would look like.

No one is excited to be intubated. But they’re okay with it. I mean, they just I don’t, I don’t know that anyone’s ever said, “No, please just knock me out.” Yeah, I think they’re, I personally would rather have be autonomous, so I think they’re okay. They’re like, “Okay, I’m going to work through this. You’re gonna keep me strong, my family is gonna be here.” So yeah, people are pretty okay with it.

And so after intubation, they wake up, and they’re confused from those drugs. But the great thing is that they’re short acting. You’re not having to clear out days of propofol or weeks the propofol that’s in the adipose tissue. So they’re able to wake up kind of how that quick confusion but be re-oriented. “Hey, remember what we talked about 20-30 minutes ago, here we are, yes, that tube is terrible.”

And then we even had like a mirror they can look at, they can feel it, they can get used to it. Let them see the ventilator. And as they get their faculties back, and they have time to adjust with the ventilator. They end up being pretty calm and cooperative and safe and even reliable. 15 to an hour, minutes, hour later. And a lot of patients are able to be unrestrained. They protect their tubes. I know that’s a big concern about self excavations. And self extubations happen when people are delirious.

And so we don’t cause delirium with sedation, we have a much better chance of having patients help us keep them safe. So I just recently had a COVID patient. I passed by her room and the ventilator was alarming. And I looked in and she had her hands like this. And my heart stopped. I thought she was gonna go for the two but it was really unexpected because she was not delirious. And we rushed in there and she said, and she said, “No, I coughed so hard that the tubing came detached from my endotracheal tube.”

Chelsea Rogers 14:53
Yeah.

Kali Dayton 14:53
And she was holding it together. And she was still getting pressure from the ventilator holding it together herself. And so that demonstrated to me that anyone in their right mind is not going to take out their lifeline. And that’s what we see with our patients. For the most part, when they are clear and out of delirium, they’re a lot more help to us than someone that’s dead weight in the bed, totally confused and thrashing.

Chelsea Rogers 15:16
It’s a good point. So let’s that nurse to patient ratio?

Kali Dayton 15:23
So everyone should have two to one, two patients to one nurse unless there’s a higher acuity. It’s very rare that we have anyone three to one. And I think that’s really important. Respiratory Therapists are really important too in this process. And they have four ventilated patients to one RT. We share our physical and occupational therapists with the medical floor as well. But ICU is their big priority. And so they, they’re so good at working out our schedules, and everyone jumps in together, everyone knows that everyone’s gonna walk and everyone helps each other. It’s a pretty amazing orchestration.

Chelsea Rogers 16:02
That’s amazing. So give us a picture of what that looks like for these patients that are up in ambulating. What’s that army look like that’s around them when they’re up and ambulating?

Kali Dayton 16:13
It completely depends on the patient’s status and capacity. So the goal is that if anyone walks into the ICU, or, or was able to walk in the hospital, they should never lose the capacity to walk. We take away their capacity to walk to walk and we sedate them and mobilize them and let them atrophy. I had a physical therapist called it disuse-trophy, right. If we don’t use those muscles, we lose them. And that’s when patients get to be dangerous fall risks.

That’s when it takes a lot of people and lifts and all these things to get even get them out of bed. So it ends up being easier on the staff and the patient. Ultimately, if we walk them, even shortly after they’re intubated, someone gets intubated. And an hour or two later, it’s, it’s the afternoon time, we’re rounding where we’re getting everyone up, and it’s their turn. So they never lose that capacity to walk. So you’ll see in some of these pictures, you’ll see people with maybe two on each side and some pushing a wheelchair and someone pushing the ventilator. So that’s for people. Okay, that’s quite a bit for our patients. Sometimes it’s just physical therapists, their physical therapy, a nurse respiratory therapist, depends on how stable and strong they are. And for the most part, if we do our job, right, we can keep them strong.

Chelsea Rogers 17:35
That’s amazing. So we have here, patients do experience panic or anxiety. What are your coping strategies that you use drugs or otherwise?

Kali Dayton 17:48
Yeah, that is such an important topic, because we see a lot of anxiety and fear in the ICU, right. I didn’t know about sedation vacations, until I became a travel nurse. And when I was taught how to do them, I saw that you just turn the profile down just enough to see them flail fours, and they are agitated. They’re wild. They’re going for the two right away. They are scary. So when people say there’s no way my patients would keep their tubes, and there’s no way I could handle someone like that all shift. I agree.

If you have wild delirious patients, it is a lot of work. And we see that we get patients from other facilities coming in that have been sedated for a week, 10 days, it is so much work, and they are so much more anxious, agitated, uncomfortable. But we have to sit back and look at the cause. I think we assume and justifiably so it makes sense that it’s just the endotracheal tube, it’s just the ventilator just their lungs, when in reality, if we understand patient perspective, and what is really like to be sedated, we understand that it is their delirium that is causing them to jump out of their skin.

And I think on episode four on the podcast, I had asked survivors on a survivor page to leave a voicemail, just saying what they experienced under sedation. I didn’t give any cues. I didn’t say hallucinations. I just said, “What did you experience under sedation.”

But all they talked about were their terrors. They thought they were being buried alive. They thought their kids were kidnapped, they thought they were being held captive and being stabbed to death. I mean, terrible things. So if you start to lighten up my sedation, and the whole time for the last week straight, I thought my kids were kidnapped- There’s no way you’re going to keep me in that bed.

Chelsea Rogers 19:39
Right?

Kali Dayton 19:40
Yet. We can prevent so much agitation so much anxiety and trauma if we never provoked the delirium with sedation. So like I said, when people initially wake up from sedation, they’re like, What, what’s going on? But we can reassure them we can remind them what they know But they’re oriented with their environment, and they have their faculties, then they can’t cope. No one loves the tube. But when they understand what it’s for, psychologically, there’s so much better with it. It can be really anxiety provoking to be stuck in the bed staring at the same walls, having no control over your environment being critically ill feeling terrible.

So things like walking. I’ve had patients beg and plead to walk, because it helps them with their anxiety, just like you know, anyone that goes on a run or exercises to help with their mental health, same concept. Just the discomfort of those hospitals that are not comfortable setting up in a chair being able to reposition themselves, right on the board, giving them their voice, helping them have their answers heard, or their questions heard and answered, communicating with their family at the bedside is built to keep you that calm, know best, how to work with the patients and what they need. And they can be a voice for them as well.

And so those are all very effective methods that we see. Be really efficient. And yet, there are times when people still have just a baseline anxiety, and sedation isn’t bad, there is an appropriate use for sedation, their appropriate indicator indications for it. And so what we love to do in those cases is Botos. Klonopin like 0.25mg down the feeding tube, TID, and it depends on their benzodiazepine exposure. And we can titrate up from there. low dose Gabapentin a little bit of precedex, but the goal is always for RASS of zero. We don’t want anyone -1, -2, let alone -4. We want them to stay clear of delirium, be active during the day so they can get real sleep at night. And, again, to prevent the delirium that causes all the trauma.

Chelsea Rogers 22:00
So you’re, you’re using these acronyms for skills that you guys utilize in your ICU? We didn’t use those can you? Can you explain that a little bit in detail.

Kali Dayton 22:12
Yeah, the RASS is the Richmond agitation scale, it tells us how agitated someone is or how sedated they are. So zero is just calm, awake, responsive, but not anxious. A one is a little bit anxious, and you got to think of three or four words that are just the bucking rodeo. On the other side, you can go to negative one, which is where they’re, pretty drowsy, but you can still wake them up down to negative four where you can give them all the painful stimulation and they don’t move. So, um, that helps us say, to document and communicate to each other. Where exactly they are and their arouseability.

Chelsea Rogers 22:53
Absolutely. So um, in one of the episodes, you were discussing a mentally delayed and physically and mentally sounded like delayed Down Syndrome adults. And I think you said he was a developmentally, maybe a two year old. And he used rocking in his coping and he was allowed him to rock in his bed in the ICU while intubated.

Kali Dayton 23:21
Yeah, I was so proud and touched by by this team, because I think other environments where I’ve worked, someone like that, coming in with mycoplasma pneumonia, which is a really tenacious pneumonia, it could be a long course, they will automatically say, you know, he’s not gonna be able to cope with this, we have to sedate him. Yet they looked at him and they said, you know, he’s, he’s had Down syndrome, he has low muscle tone. So we do not want him getting weak, because if he ends up weak on the ventilator, he’s going to end up with a trach, which hardly anyone ever gets trached in our ICU because they are able to wean off the ventilator because they’re strong.

So we wanted that for him. He had a cognitive level of a 3-4 year old. Sedation causes cognitive deficits. We’re now coming up with the diagnosis called “post-ICU dementia”. What would you post ICU dementia mean for an adult at a 3-4 year old cognitive level is mean that he’s not gonna be able to feed himself, he use a bathroom, communicate basic needs to his parents. I mean, that would be extremely life, life altering for him and his family.

And then we know that sedation causes PTSD. Do we want a young adult with autism and Down syndrome to be having hallucinations with all these sensory sensitivities? So they were desperate to do anything to keep him awake and moving. And so he actually the been great as long as he had his toys, his music, his cartoons and his parents at the bedside. He was he was happy. He didn’t understand that too, but he wasn’t trying to pull it out the whole time and agitated. You just had to keep them engaged, distracted a handhold.

But it wasn’t pinning him down. It wasn’t anything aggressive. And because his autism when he was happy, he rocked when he was anxious, he rocked and we allowed him to be himself do his thing. We relied on his baseline lifestyle coping mechanisms that he uses. So he loves to cross his legs to sit in the bed with his legs crossed. He loves to stop when he’s walking, sit down across his legs. So on the ventilator, we’re walking, he stops, crosses his legs, everyone knows that’s just the way he rolls. So we sit and wait, and he did great. And he was he walked out of there.

Chelsea Rogers 25:35
It’s so incredible. Have you were asked if you guys have a patient care techs or nurses aides or texts in your unit?

Kali Dayton 25:44
Oh, yeah, those are essential. We have at least one during the day for the 13 patients. And they help so, so much. I can’t understand why and I see wouldn’t provide those. I have a sweet picture of a patient that had been to come in from outside facility and she was she just had gotten up for septic shock. alcohol withdraw, she had necrotizing pneumonia, and some ARDS brewing at the same time. And she was extremely delirious because she’d been sedated for days, as well as all the other receptors that she had for delirium.

So her hair was just a matted mess in the back. And the first time we walked her, I hope, maybe I’ll post a video of it. She I mean, the walk was not pretty. She could barely put one foot in front, the other because she was so deconditioned. And so delirious, and yet, they hustled her. And when she took a break in a wheelchair in the hallway, one of our techs just instinctively started brushing her hair out. And I was so touched that she was a very difficult patient, extremely anxious, extremely wild, really hard to walk the first time or two.

And yet, we still tried to create a humane environment for her and keep her human by brushing her hair out. But I just don’t see that being very feasible when you have four to one staffing ratios and no techs. And yet, this patient specifically, and she was 32. The outside hospital had written her off and said she’s not going to survive. They were bringing in palliative care consultations. So family requested that she be transferred. And she was when she first walked.

She had a peep of 16, I think and 80%. And they were wanting to transfer her to send her to, to maybe be in a facility that had ECMO. And the nurse that had her on literally threw her hands on the table said no, if you send it to that facility, she will spend another week not walking before she hits the point of ECMO. And then what are they going to do with her and she was just rage. And so it was this nurse that grabbed the physical therapists and said we are getting her out of bed. They put a gait belt on or they they almost just carried her and let her put whatever weight she could out.

I was just so touched because that would not have happened otherwise. I mean, she was so anxious, so wild, and delirious. After that walk. She calmed down. She was exhausted. They turned out presidents way down afterwards because she was she was armed. And so that was to me was a good example of how effective walking is for anxiety and delirium. By the next day her delirium was so much better almost completely cleared out. Yet her lungs got worse. So she ended up walking the PEEP of 18 100%. We tried to prone her twice, and she did better walking than proned, her oxygenation improved while walking. And it did not improve when proned.

Chelsea Rogers 28:45
That’s incredible. So when I was discussing this with my husband after I first found your podcast, and I’m listening to all these- binge listening- to these episodes, and I tell my husband, “If I’ve ever intubated, I don’t want to be sedated.” And he’s like, “Well, I do. Go ahead and sedate me, we’re fine.” So then we talk more about the evidence based research behind it and the deconditioning and all of that.

And after a few minutes of chatting, he’s not medical, by the way. He said, “Well, I guess…” he agreed that life after the illness was more important to focus on than that of that moment in time. And if you really think about it, you’re lengthening that time on the ventilator most likely. If you’re sedated versus awake and able to help yourself. So I thought that was really good discussion with my husband and I just wondered how it sounds like your patients are of the same mindset where they’re pretty on board.

Kali Dayton 29:45
Yeah, I mean, they haven’t done all the research, right? But we can tell them “Hey, if you want to walk out of here, you got to walk now.” I tell my patients, “If you stay in bed, that’s where you’ll stay.” But as I think the nurses and the RT and everyone understand the big picture. The discussion isn’t just, “How do I get through my shift? How do I stop this patient? Were calling me all the time and being annoying”- which we’ve all been there.

But their discussions are, “Hey, this person’s delirious, what’s causing it? How do we fix it?” or sometimes you get hypoactive delirium where they are just comatose, you can’t move them and everyone gets so worried. They’re just terrified that that person is gonna end up with a trach. Or they’re going to end up going to an LTACH, like LTACH would be the worst disposition for a patient leaving the ICU.

And it just makes me laugh, because that’s so… that’s pretty normal in most ICUs. But in our ICU it is not. There is… I don’t know… a sense of pride, but also deep concern for patients. If they walked in, they should walk out, we want them to go back to their lives. They don’t just see them as “an intubated patient”, they see them as a spouse, they see them as their careers, all these things that they want to return them to.

And, and I guess when you’ve seen that success, you expect it, right? So I say the same thing to my husband, because one of my biggest fears, if I would have to be intubated are the cognitive deficits. The PTSD really haunts me as well. I also have PTSD from hearing patients PTSD. When I see patients that are sedated, we’ve had to have to sedate some of these proned and paralyzed COVID patients. And it’s almost like a kid that just found out santa is not real. Like I almost wish I believed in Santa still. I wished I believed that sedation was sleep still, because then it would be easier to sedate these patients, but rather, I see them locked into a world of terror.

And I don’t want that for myself. But it’s the cognitive deficits, I feel like my baseline is poor enough, I’ve got three kids three, and under, I’m enjoying my career, if that is taken away from me that capacity to do simple math, to drive a car, to remember what what’s going on throughout the week, those kinds of tasks that require cognitive function that’s taken away from me that will completely affect my quality of life, my identity. So I see that I think that for myself, what those things mean, for me what it means for me to be able to get up and wipe my own backside. And that influences how I care for people. I don’t want to take away those things that I value from them.

Chelsea Rogers 32:22
I love that and talk to us about the support of the staff. It sounds like from what you’re saying. A lot of them are on board and on mission to get these patients from the ICU to walking home. But what about that seasoned ICU nurse that hires on from another facility? How does that transition work?

Kali Dayton 32:43
Big shock. We have some episodes about it, from those nurses that came in. Usually, a lot of our nurses come in with a lot of med surge experience or even new grads that don’t have ICU experience, because it is a lot easier to start the clean slate. I was one of those- I didn’t have any ICU experience. And they hired me and trained me. So it was just normal. It wasn’t it became extremely instinctive to have people awake. I mean, I tried to talk to my colleagues about it- the nurses that only worked there. I ask, “What are your memorable moments? How would you teach this?” And they don’t, they can’t even think of it a different way. They’re like, “Well, they’re human. So of course, they’re awake during the day and walking.”

And I can’t help them see a different perspective, because it’s all they know. Yet. When we have, we had a little bit of staffing shortage for a minute, had travel nurses coming in. And some of them were extremely seasoned. And we warn them beforehand, once that we didn’t warn her. But I she had a funny take on it. She she walked in and she was just in shock. She was panicked. You walk into the room and the patient’s intubated, and suctioning their own mouth. And the this travel nurse was terrified, right? Because she thinks that the patient’s going to pull their tube out.

Yet these are good people with good intentions, good desires, and they’re immersed in this culture. And so for the most part, they they jump in, they adapt to it. I had a travel nurse say because that was his first contract. He come from Mississippi, he was used to just straight Versed on everybody and everyone was trach’d. Then to come to this “Awake and Walking ICU” and he’s like,” I don’t know about this”.

Then he watched a patient die of delirium that come from outside facility, had Alzheimers had been sedated for 10 days, his lungs, the lungs had gotten better. But his brain never got better and the family decided to withdraw care and he died of, of confusion, inability to clear secretions died of delirium. So this travel nurse came to me in tears and said I had no idea this is what we were doing to people. “What do I do from here? Because I can’t work at this hospital forever. I’m going to take other contracts, but how do I now…. now I’m liable for what I know. Now I have the ethical obligation to do what’s best for my patients, but it’s going to be so hard elsewhere.”

And all I could say was, “I don’t know.” And so we have some episodes from people that have left our ICU, and gone to other places and the ethical turmoil that they face. One colleague said that he could feel the delirium and smell the rot in the air. And he tried so hard to clear the delirium out, he’ll have people in a chair, suctioning in their mouths, by the end of the day. He comes on the next shift, and they’re sedated again.

So it is such a deep cultural thing. But it’s really interesting to watch these people get it. And so I think I deeply believe that all nurses want to do the right thing. They want their patients to get better. But we haven’t really always had the opportunity to know how. That’s why I’m on this rampage is I know that if nurses could see it from patient’s perspectives, if they knew that there was a different way, and then knew how to do it… all nurses needed the opportunity to know and the support to do and they’re going to be an unstoppable.

Chelsea Rogers 36:04
Yeah, that’s amazing. Can you imagine if all ICU nurses I mean, I, I’m one of those that liked the more pumps, the better. The sicker, the better, sedated. I mean, that’s what I loved. It did pick you for 13 years and give me the sickest stillness, patient and we’re good. And now, like, oh, my gosh, like, wow. And that sounds kind of, I don’t know, morbid. But I loved.

]I really, truly loved watching all of these things work together. And it’s like this really complex puzzle and you see pieces fitting, you see this patient get better. And sometimes, because kids are so resilient, they would walk out of the ICU. But, I mean, can you imagine how much shorter that timeframe would have been? Had we not use as much sedation? I mean, now all of these things go through my mind? Like how could that have been different? Um, so yeah, it’s super interesting, and how you kind of talked about it, but how do you kind of guide those nurses that like the tubes and lines in losses, sedation? How do you guide them to back down a little bit and allow their patients to wake up more?

Kali Dayton 37:20
Well, it’s really hard for them to oversedate their patients when we don’t even start stations. So they’re coming in, they’re getting patients that are already awake and calm and walking. And then, you know, time to walk comes, physical therapy comes in, respiratory therapy comes in, it’s kind of hard for them to say no. And that’s kind of the differences between already immersed in a supportive system, it kind of happens.

So it’s, it’s fun to hear. One of our travel nurses talks in one of the episodes saying, “they just made it easy. I mean, I, I had some questions, I was nervous. And yet, I saw it happening. I could see the benefits, I saw patients getting better. And I just realized that this is how it should be. So I’m just taking notes now.”

I did have a, just a little bit ago of a travel nurse come in. And because we had a patient that was anxious, they were COVID patient, and they were isolating the room. And there are lots of new challenges with that. And she’s an older nurse, and she asked for an ativan drip. And I I mean, most of our staff doesn’t even know that exists or that with everything. And I… my jaw just kind of dropped for a second took me a minute. But all I could say was, “Who’s gonna clean up that mess?”

And she said, “What?”, and I said, “Well, who’s gonna clean up the mess after? You start the drip now, it makes your shift easier. But it’s like biting off the top of a grenade and handing it down to the next shift. And every day the grenade is going to get bigger and bigger. And it’s going to explode on somebody when somebody has to turn that off. And you’re going to unleash the whole storm of delirium that’s been happening for days. But it’s easy when it’s not on your shift that you have to wake them up.”

But she was just was taken back. Like she’d never looked at the big picture. It was like, hey, “They’re really squirrely in there. It’s annoying.” And I’m sure she wanted them to be comfortable, and they look more comfortable when they’re sedated. So even just asking the simple question like, “Hey, what, but what does that mean for the patient? Is that really helpful? Is that going to really bring good outcomes?”

And once we actually think through it, and see from the bigger perspective, there’s not a whole lot of fighting or discussion left. I mean, I think everyone’s on board when they all understand. So these nurses come in and hopefully they’re open to learning. If not, they still learn. And it’s up to them whether or not they continue those practices after.

Chelsea Rogers 39:49
So what do you think needs to change in medicine for us to continue this progression to a weekend walking ICUs across the US? What do you think needs to happen, what are some like big picture ideas?

Kali Dayton 40:05
My first impression is that knowledge has to happen first, I hear a lot of doctors even still refer to sedation as “sleep”. And I don’t know, I think sometimes it’s just habitual. I think sometimes it’s actually just ignorance. Like, we just, they just don’t know what it’s like for patients. I had a physician come in from other part of the country. And he had had lots of experience so knowledgeable such a teacher, but in this aspect of what patients actually enter under sedation, and then what life is like after he had no clue. And so he refer to it asleep. And that’s a little bit of a trigger for me, after talking to all these survivors, I feel like I have to speak up. And so I was like, “Are you sure about that term? I sure that’s what you want to use?” And he had no idea. And he just looked shocked when I told him about people having PTSD from sedation.

And so I think it’s going to start with knowledge, I see a lot of newer MDs coming out of school with a much more open perspective, a bigger understanding of early mobility. They may not have the vision of the “Awake and walking ICU” quite yet. But they’re open to it. They’re not from the same generation of benzodiazepine drips and paralytics.

I know that they’re talking about it in nursing schools. So I’ve had nursing students reach out been really excited about this. And again, it’s easier when they just don’t know any other way that besides how it should be. So I think knowledge is going to be a baseline, I think administration needs to understand what happens to patients. So when I hear about, you know, especially the situation in New York and other parts of our country, when we have 4:1, 13:1, or when physical and occupational therapy are being taken out of the ICU with the COVID patients. It makes no sense.

And I know PPE is a concern. Just a side note, I wonder if we use less PPE when we get with a little more staff, when we get patients that are faster than less staff, and let patients sit in the ICU for longer. So I think administration needs to have that same perspective as well as what our actual goals or goals to just to get them out of the hospital or get them back into their lives. Because it’s a whole nother expense to having trach paid on a ventilator for another 20 days because of weakness than it is to have more staff keep them up and strong.

And so I think a lot of its knowledge, culture, we have to understand what’s possible, how it should be patient perspective, develop those skills of actually talking to patients, walking them through the anxiety, understanding delirium, how to work through to learn how to prevent it. And then the support of having enough staff to facilitate these things. But I think with normal staffing ratios of two to one, having PT and OT there enough RTS, it’s we’re able to keep patients strong. So it’s not using lifts, it’s not huge, flatted newborn adults that we’re trying to move at once. If we focus on preventing the harm, then it’s going to be so much easier to treat them and keep them strong.

Chelsea Rogers 43:20
Absolutely. And you know, insurance is really been a stickler on us as health care providers, about preventing hospital acquired pneumonia and infections and all the things and they say, you know, if if it happened in the hospital, if it acquired in the hospital, then we’re not going to pay for it. Um, I saw you mentioned something about that referencing that Medicaid payback, Medicare, Medicaid insurance payback. Um, tell us about that and what your thoughts are?

Kali Dayton 43:51
Oh, yeah, I just put a post out it was just amusing. Um, but I mean, so much financial cost has occurred from hospital acquired weakness. And we have so much emphasis and so many protocols and things built into preventing hospital acquired harm, such as pressure, ulcers, infections, everything that you mentioned. So what would change in our system? If we were as concerned about hospital acquired weakness, as we are about hospital acquired infections? How would that change? And then I would love to know, how much money would we save?

If we kept people’s capacity to care for themselves. While they’re throughout their hospitalizations, they can actually go back to their lives. One of the episodes on the podcast is from as with a nurse practitioner that had gone to LTACH, she’d been in the ICU, learned that culture that protocol, didn’t want LTACH and they were not interested in getting people off of their narcotics and benzodiazepines.

They didn’t want them awake and moving throughout the day. That’s LTACH. She realized that that wasn’t a good fit for her because she was more interested in getting people better. And she actually got in trouble. Because she was getting people discharged before their 30 days were up. And so the so then the facilities weren’t getting the full 30 Day reimbursement.

So something has to change and her incentives within our system we should be, again, we should be rewarded for good outcomes, and not looking to incur more, be able to charge more for more time in the hospital that we caused by neglect. That say my nurse practitioner started her own respiratory rehab unit kind of in a in sniffs. So she gets a lot of patients that are, have already failed LTACHs, meaning they’ve passed their 30 days, and they’re still not de cannulated. They’re still ventilator dependent, still extremely weak. And most of these people have come out of ICU.

And, and those kinds of units, she said that the decannulation rate was about, I think she said somewhere between 13 and 15%. And her units that she created, they’re about 60% 50 to 60% of those patients are decaying lated off the ventilators and going home, because you implemented the same process as the waken, walking, walking ICU. So all of these things financially are focused on patient quality of life, it is all dependent on what our focus is, if we’re focusing on just getting through the shift, then that’s all it’s going to happen if we focus on getting people their lives back. Thanks have to change. Yeah.

Chelsea Rogers 46:39
So um, something we didn’t mention, but I’m actually really curious, when you have a patient on cardiac pressors. What does that look like? How do you guys get them up and walking? And when they’re needing cardiac pressors? I would assume that if they’re up and walking, they’re going to need them for less time. What does that look like?

Kali Dayton 47:01
Yeah, that is a great question. Because I’m not everyone’s gonna be out jumping, doing jumping jacks on the ventilator and walking 200 feet. And well, the great thing about this process, when you don’t just automatically say everyone that’s on a ventilator, then you can personalize and customize their care to what they’re capable of what their status is.

So let say we get a patient in septic shock. When they’re in those early stages, and they are just leaking fluid like crazy, and you’re NICOMing and you’re slamming fluid, and they’re going to be dry and maybe not super tolerant of a lot of activity. But you don’t know until you try. So what’s the harm in sitting them up at the side of the bed, asking how they feel checking their hemodynamics you feel lightheaded, seeing if their respiratory status changes that their heart rate changes, blood pressure changes, stand up, see how they do back the day, we used to only use a pulse ox.

But now we have cardiac or we have monitors that can detach from the main monitor and we can carry that along with us we have a wheelchair behind us, if they feel lightheaded have these symptoms, then we can stop. So if someone’s on two, three pressors, we’re not gonna be throwing them out of bed. But if someone’s on just norepinephrine, and their dose isn’t really changing a lot, then what is the harm and seeing what they can do? We have had no adverse events. That was one of the big parts of that study 13 years ago is that nothing bad happened.

So in some of these studies, so so we can talk about hemodynamics there, right. Another part of walking is pulmonary function. Um, I think we get really concerned when people are on hyvin settings, and that is completely justifiable concern. When I looked through the research, the only guidelines that are really out there that are published are things like one article mentioned that patients should not even be dangled until their FI02 needs are less than 60%. And PEEP is less than 8. Yet if you look at the methodology of how that came to be- who created that, how was that proven?

It was a group of like five intensive is I can’t remember how many it was a group of intensivist a lot more physical therapists and one nurse in the UK. They got together discuss what they feel comfortable with once it came to a consensus. That’s what they published. That wasn’t an unproven data. That wasn’t actual research. That was just an article that they published. But you can’t research what you don’t do. So when we talk about what are what’s been settings are too high to walk on. I think it depends on what the patient tolerate. So we have patients walking, like I mentioned, a PEEP of 15-20… We always bump everyone up to 100%.

You think about on the floor between two liters nasal cannula. Maybe they need six liters to walk. What’s the harm in increasing the oxygen? Pre oxygen at them standing them up seeing how they feel seen how their work of breathing is keeping the pulse ox on them. We have a wheelchair behind the thing it they can stop, take breaks recover. They’re not taller net, we rolled back to the, to the bed. I mean, no, no adverse events have happened at anything. They’re pulmonary function improves, they oxygenate better, they mobilize secretions, their respiratory muscles stay strong.

So they can actually wean off the ventilator, a lot of times their ventilator needs decreased in the following hours after a walk. So we’re so afraid, look at these numbers, and we just think, “oh, we can’t move them. We can’t touch them.” When really movement is medicine.

I think brain also is a big part. We had an under filling in from another unit and said, Oh, well told the physical therapist, “She’s she’s too confused. She didn’t sleep well, last night. She’s not really, really with it.” And so the physical therapists came to me and said, “I’m confused, because we always try to walk or move as much as possible people that are delirious.”

Sometimes people are so delirious, they can’t even put one foot in front of the other. We’ve all seen it right. But it’s amazing to watch, even those patients, when you sit them up at the side of the bed, and make them HOLD ON HEADS UP, engage their trunk. Well, that’s preventing more deconditioning and to their brain start to turn on. And so it’s part of our assessment, it becomes instinctive. When we look at a patient say, “Can they walk?” We don’t know until we try it. But as we start advancing the process, we’re evaluating all those parts of their function, and making sure that it’s safe. That’s awesome. I hope that answers your question.

Chelsea Rogers 51:41
Yeah, you did? Yes. Yes, absolutely. It depends on the patient, really. And that’s the big picture is if you’re not assessing them, and like those of us who are used to a sedated ICU, who’s specifically like, no, they don’t walk because they’re sedated and paralyzed. And that’s what you chart. And so if they’re not sedated and paralyzed, you know, you didn’t try. So you can’t say that they can’t walk, right? I love that. If you don’t try, then you don’t know.

Kali Dayton 52:16
We say “They’re too sick to walk”. but often it’s more that they’re too weak to walk. There’s such a difference. And so if we prevent the weakness, they hardly ever become too sick to walk yet there are times when they can take a break, when they need to be preowned, or paralyzed, or they get even sicker. They’re not hemodynamically stable. But yet we didn’t waste all those that time those hours was days before that point. We didn’t let them rot beforehand. So then they’re able to recover once that acute illness is resolved.

Chelsea Rogers 52:47
Absolutely. I am hands down. I am I’m with you. I’m, I’m super proud of this. I’m so excited.

Kali Dayton 52:55
I knew people would care about this. I knew that nurses would want to know.

Chelsea Rogers 53:00
Yeah, yeah. And I can’t wait until more people get to watch the q&a that we’ve done since it didn’t work out earlier. And they’re getting to actually see what they were waiting to see all day. So I’m super excited for them to tune in to. Um, you’ve talked about some patients that you’ve done interviews with on your podcast, some nurses. Tell us more about what your podcasts like overall umbrella. What are you doing in there?

Kali Dayton 53:26
I’m just winging it. I don’t really know what I’m doing yet, and just doing what feels right. So I, I felt as a travel nurse, I would try to talk to people about this. I didn’t even know enough to know how to engage in the conversation. I would go like this. I’d say, “Why is the patient sedated?” And they’d look at me like I was crazy and say, “Because they’re intubated.” And I say but “I know, but why are they sedated?” And they if we just go in circles.

And so I found that there was a huge lack of knowledge on my part, as well as other people’s. And then when I went to grad school, I could feel that part of my calling would be to disseminate this that this needed to go beyond this little tertiary hospital ICU and be standard and that people would grasp onto it. So I thought, “What? Am I supposed to go get a PhD and do research?”

But in reality, there is so much research out there. There are about 10 years worth of research validating all of this, but we don’t apply it we don’t use it. A lot of us are unaware of it. It just doesn’t mean anything until it’s people and so one day I was on an airplane. And this is while I was in grad school. I still didn’t know what it was like for patients and I sat next to a survivor who told me about his time the ICU been sedated and his insomnia I mentioned in the podcast, but it ruined his life. And in his late 40s He was a DNR denied because he knew he never wanted to go through that again. And that the part that he didn’t want to go through again was the sedation, the PTSD, the images, the hallucinations, the delirium. And that hit me, I thought, “Does anyone else know this?”

I know nurses don’t want this to happen to people. And when I talk to nurses around the country, they say, “We give sedation so that they just ‘sleep through it’. So they don’t remember anything. So that so that they don’t get PTSD.”- So we have this opposite understanding of what’s really going on. So I kept on having this itch, to tell people, all the good nurses out there, what is going on.

And so one day, it just hit me, I didn’t even really listen to podcasts…. It just hit me- “start a podcast”. And so I just got a microphone. And I went on to um, survivor pages, and I asked questions, and I found people telling stories, and I just found these incredible survivors like one one of them. Susan east, she’s a three time ARDS survivor. After her first time with ARDS, she went to an attorney and had legal documents drafted protecting her against sedation. She has an incredible interview. So so they’ve made it easy for me, I just the right people come out of the woodwork.

It’s not hard to find people that have been completely traumatized and had their lives altered by what we do in the ICU. And then I work with these amazing colleagues, I have so much to offer. And so I just, I just push record, ask them questions and let them teach it. It’s been incredibly educational for me. And it’s exciting to see other people care about it and be excited about it. I just I know that some of these seasoned nurses are like, That’s annoying. Not going to happen. It’s not feasible.

I toured an ICU in another state a couple months ago, and the medical director said, “yeah, there’s there’s research out there about that. But good luck. Isn’t that done here? Our nurses won’t do that.” And, oh, it fired me up. Anyone that says, and it’s a common thing that physicians will say, though, the past with the nurses, they’ll say, “They won’t do it.”

And I don’t believe that, because I know that nurses don’t understand what it’s like for patients. And if they did, they would change it. And if administration knew- they would support them. If doctors really knew they- would support them. So thought that no one won’t do it. It’s that they have not had the opportunity to know how it should be done. So that’s how the podcast has come to be. I have so many more episodes coming out. I’m excited about it. I want to know what your questions are. So contact me on the Facebook page for the podcast. Ask me your questions. If you know people that should be interviewed- ideas, feedback, all of it, Again, I don’t know what I’m doing here. So guide me, tell me what you want to know. And we’ll make it happen.

Chelsea Rogers 57:52
That’s amazing. You haven’t tuned into Kaylee’s podcast, it really is eye opening? It’s really enlightening. It’s really amazing to see. I mean, advancing in medicine, even though it’s been around since the 90s. Like, I didn’t know. And I was also a travel nurse, but it was in the PICU. So I think there is some, you know, different challenges there. But I don’t think that it’s impossible. I really don’t. So just

Kali Dayton 58:20
I’ve seen videos of kids, playing them with their toys on the ventilator. I’ve got to track down whoever does that. We’ve got to talk about it. So if anyone knows of anyone that does that process, hit me up. They’ve got to teach us.

Chelsea Rogers 58:34
I’ve seen trach kids, but not not intubated. So we trach kids up and playing of course, but um, yeah. So for sure like that, that whole process. There’s a week in walking pediatric ICU like I can’t wait to hear that podcast and talk to those people. So cool. So in closing, could you just tell us what you’re most excited about in your career.

Kali Dayton 58:59
I’m excited to watch this unroll throughout the country. It’s my colleagues that have started this, that was always their vision. And now they’re at the end of their careers. And I feel responsible for carrying on their legacy because this wouldn’t have been created without them without a nurse with a vision. And I’m excited to watch nurses, take control, take the reins, and do what their instincts tell them which is the best thing for the patients.

I am 30 years old, we’ve still got time and I expect to see that happen throughout my career. I want this kind of process to be standard within the next five to 10 years. I don’t know if I have a lot of control over that. But I know that spreading the word is going to be a huge part of that and people will act on the good things that they learn.

Chelsea Rogers 59:44
Absolutely. We have viewers that are super excited to tune into your podcast guys. The link is in the the post there. Just open the text it’s there there’s a link so you can find it and people are saying that they would wish that they could be trained by you and They’re so appreciative of the time you’re putting into this. So, thank you for your time. Kaylee, thank you for the dedication to advancing this concept of awaken walking. I see you and thank you so much for taking the time to educate us and get the word out.

Kali Dayton 1:00:14
Well, I’m excited to work with all of you, whether in person or online. I think the more collaboration the better. Go Team.

Chelsea Rogers 1:00:22
Go Team. Have a good night.

 

Transcribed by https://otter.ai

 

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