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Episode Transcription
Kali Dayton 0:28
Hello, it has been so exciting to meet with your teams around the country for webinars and presentations. Sharing the research through case studies using pictures and videos from the “Awake and Walking ICU” without fail, makes jaws drop. People are very resistant to the idea. As Dr. Del Needham from Johns Hopkins says, “Telling people that most patients should be awake and walking in the ventilator is like telling them the world is flat.”
Yet, just because it’s new, does not mean that it’s not true. Just because you haven’t done it does not mean that it can’t or should not be done. Just because it’s what we do, does not mean that it’s right. We are in a field of evolution. The Awake and Walking ICU started because a nurse named Polly from episodes two and 21 started with a very questions that bring progress. She dared to ask why, why not? And what if dozens of listeners are also pioneering the change in their units shift by shift patient by patient. So let’s dive into this exciting episode with ICU revolutionists around the world.
Anastasia Reed 1:52
Good afternoon, everyone. My name is Anastasia Reed, R BSN state of Texas, I just want to share with you really quick about my empowerment that I feel with mobility in the ICU. Ever since COVID. happened, it had been a game of sedating and overstating and keeping people down to ventilate them and oxygenate them going into ARDS, right?
But even before that inconsistency with hospitals of of best practice being implemented is always a struggle. But I think about mobility on ventilators, for patients, the ICU, what really drives it home for me, the reason why I’m so empowered is because I saw the destruction, the atrophy, the money being wasted, and the discouragement and the lack and loss of integrity in nursing because it almost seemed like a vicious cycle with mobility on ventilators and ICU and sedation. I understand that we utilize our sedation skills, but I do not think we use them optimally.
I challenge you guys, It’s mind over matter, okay, these patients when they’re awake on a ventilator, please don’t be scared, don’t put them down. I sometimes I fear that as nurses, we don’t know how to respond to a patient on a ventilator or, you know, educate them or be comfortable with it. Because we don’t we don’t do it enough, you know, and so when you don’t do something enough, you don’t feel as empowered.
And so what I want you guys to do is as you get more comfortable with, with talking to patients you get you get more education on what it really means to have some a mobile an ICU, you know, walking on a ventilator? Why is it that we can’t do it, it’s not about the resources, I understand there’s a lack of everything. But all it takes is from shift to shift to shift that one nursing, I wing that down aggressively. This patient has gone completely batshit crazy, excuse my French but truthfully, communicate with the doctor reorient the patient.
They’re in a state of not sleep, it’s delusions and psychosis, they have a loss of everything, step up and step forward and reorient them, get the right drugs on board communicate with the physician so that the next shift that patient is a lot more common alert, guess what, that nurse has to do less work the nurse after that does less work. And once you see this pattern, you start seeing people coming off the ventilators, you start seeing, you know, more money being blown down the drain for these patients that which are like corpses, sometimes on the ventilators, y’all you have to empower each other, find whatever it is in the ICU or find whatever it is in nursing that empowers you and go with it because it is us that build each other up.
And for me it was mobility on patients on ventilators and ICU. So I challenge you to see how you feel about taking care of your patients next time you’re putting them down and sedating them. It’s not about what you feel or you think they feel it’s about getting them better and setting those emotions aside and using as little sedation to minimal as possible and continuously working on communication and improvement reorientation and getting them where they need to be. I challenge you, all nurses to empower each other. It starts with one.
Austin 4:29
Hi everybody. My name is Austin and I currently work as a an ICU travel nurse here in Nashville, Tennessee. I want to share with you an Instagram message that I actually sent to the walking home from the ICU podcast after a recent interaction I had at work the message read I love listening to your podcasts and learning I wanted to keep propofol off on a patient that has intubated for respiratory failure.
Tonight, he’s alert and following all commands, writing sentences and typing on his phone. The nurse practitioner walks in and sees him writing sentences to me and says he needs to rest i stated he was doing well off of propofol and when is only requiring low dose fentanyl for pain related to recent chest tube insertion. She reiterated that he needed to rest and that I needed to turn the sedation up from previous episodes have learned the importance of mobilizing patients and maintaining a normal sleep cycle.
I offered to have her place in order for melatonin instead, and hopes that we wouldn’t have to further sedate the patient being that I’m not well versed in these scenarios. And what the walking home from the ICU podcast exceeds and I wanted to message Callie for her thoughts on how to address this situation without coming off as somewhat of like a know it all or you know, just with a bad, you know, view in front of the family and the nurse practitioner. So after this particular scenario, I’ve worked hard to ensure that my intubated patients receive little to no sedation, I’m working on ensuring that increase mobility during the day and in clustering care melatonin, just a normal sleep cycle at night.
The unfortunate part about all this is that with my newfound practices, I’ve had a number of nurses kind of turn their nose up to me and say, you know, if I’m, you know, if I ever come in and I’m intubated, you know, you better make sure that I’m sedated. I love everything about this podcast, and I hope to create a change in every ICU I work in. It’s scary going against the grain, but it’s definitely worth it for our patients.
ICU revolutionist 6:15
So to preface, I am a night shift nurse and I was a huge skeptic. When it came to the idea of keeping people awake on the event, I actually came from a culture where we would go so far as to put people on the BiPAP on things like precedex and Ativan to help them from being too anxious.
So but after I came across the podcast, I started incorporating the idea of keeping people awake and moving on the vent into my practice. And I noticed a huge, one of the most notable experiences that I had was a patient who made a remarkable neurological recovery. And when I first started my shift, I came in and this patient was sedated and in restraints, but was a true wrasse of negative one to negative two would awake appropriately.
I worked very hard to get this person off of sedation throughout my shift, just by talking with them and kind of allowing them to communicate with me this person actually knew sign language. So when I took the restraints off, they were so happy. Because they were like, hey, I can talk to you now. And I was like, “Oh my gosh, I also know sign language!”
So we were having a good old time. And something as small as taking the restraints off was a really big deal to this person. But towards the end of the day, I told them, I was like, Hey, listen, it’s time to get your bath done. It’s about 5am I’m going to have you sit on the side of the bed. And this was kind of unheard of at the facility that I had been working at. And this person did just fine.
This person had excellent mobility, I had someone in the room with me, just in case, but when I got them to the side of the bed, they just hugged me. And they were so so grateful for the opportunity to be up and moving for the first time in a couple days. And that was when it really hit home for me. During report, I was giving a report to the day shift nurse. And of course the first thing that this person said was oh my gosh, the patient isn’t in restraints. What is she on for sedation? To which I replied, nothing. This person is fine. They’re awake and oriented and they’re definitely ready for an SBT.
Let’s get this to bout. And I was kind of blown off rather flippantly. But we were able to work through that. So I left and I realized that I had forgotten my water bottle. And I turned around to go get my water bottle. And as I was passing the patients for him. I saw the nurse that I had given hand off to pushing sedation and putting this patient back in restraints and the level of betrayal and hurt and fear and confusion on this patient’s face. broke my heart in a way that I really can’t begin to describe this patient was having their personhood and their autonomy taken away.
And while I understand that there are situations in which sedation and analgesia analgesia are required, we’ve gotten very, very liberal with what our definition of those situations are. I was able the next night to get this patient off of sedation again and get them extubated. But they remembered everything. And they were very upset and reasonably terrified. A little more positive patient experience that I had was with a COVID patient on BiPAP. And this person was On BiPAP for three days, I had admitted them.
And I came back after three days. And I had found out that they were now on precedex. They were stationary in the bed, and they hadn’t gotten out of bed or eaten. And three days, I had gotten to know this person, initially, when they came in, they had COVID. And they were telling me that they had owned a karate studio for 13 years, and that they just liked to be active. And even though this person was older, they had really taken it upon themselves to remain active.
So I was technically supposed to be leap. But I went to go see this person, because this person is very special to me. And I had asked my physician, I talked to my team, I was like, Hey, we’ve got to get this person out of the bed, we’ve got to get them moving, we can try them on high flow if we can just get them out of the bed. But part of what’s keeping them on the BiPAP is their anxiety, about not moving and not being able to breathe.
So my attendant gave me permission, said Go ahead. And I went in there and this person was distraught is the best way that I could describe it. They felt like they had been forgotten. They felt like they had been put in a closet and had a mask put on their face. They’re pretty high BiPAP settings, but that they were just being left there to die. And going from living a very active lifestyle to being required to stay in bed and do nothing with no food, no family, no activity, I can’t imagine it sounds like prison.
And I told this person, “we’re getting up. I brought a recliner, you’re going to get up out of this bed. And you’re going to put on that high flow. And you’re going to breathe. But first we’re going to work out a little bit with that BiPAP on.” And this person was like, “no, no, they told me it wasn’t safe.” And I was like, you know, “maybe at that point in time. But right now, this is what’s going to make the difference between you staying in this bed and going home to your wife”. And this person agreed.
So we were able to do just some sort of sitting at the bed exercises with marching in a sitting position, raising their arms, putting them down, raising their arms, putting them down. And once I was fairly certain that we were a lot more stable on our feet than we would have been by ourselves. Me. And one of the texts helped this person ambulate on the BiPAP to a chair. And for the first time in three days, that person was able to get on high flow, they were able to get a diet, they were able to start participating in their care.
And up until that point, there had been talked about intubating that patient but that day, I am fully convinced that moving that patient ambulating that patient, they needed the BiPAP during ambulation Absolutely. But we modified oxygen administration to match the patient’s activity, not just what they needed at a stationary point and this person went home and I took off the precedents we were doing great. And I truly, truly chalk that up to removing sedation from my practice.
Paul McMillan 13:12
Hi, my name is Paul McMillan. I’m a critical care nurse in central Ohio. There are two experiences that come to mind with mobilization and decrease sedation. The first one was many years ago I had a patient who had a stroke he had been trached, the trach had been reversed, aspirated, wound up intubated in our ICU. Pulmonary doctor said his pneumonia was large. And he didn’t think that this gentleman was ever going to get off of the ventilator.
Again, we took him stood him up. He was already used to being intubated. So he didn’t need sedation, he was able to march in place, he was able to walk around. Every time he moved, we would suction large amounts of aspiration out of his lungs and get it out of there. Two days later, he got off about got off of the ventilator.
The ICU doctor who I have tremendous respect for and trust with my life, said I don’t believe this. I don’t even know how this is possible. Second event is a person who we had who had no cough League, and we were being conservative with her care. So she was waiting to get off of the ventilator. But she did not need sedation, she was able to move around.
We had mobilized her PT ot had gotten her out of bed with my help, she was able to move well enough that by the next day, I had her just walking in and gait belt. The traveler, the nurse, the respiratory therapist, excuse me, would bring us a travel ventilator. I would push the cart with the travel ventilator on it, she would walk right next to me, and we will just do a loop periodically in the hall. We do this about three or four times a day.
Every time that we did this, every nurse in the whole hallway would just stop and look like they were having a heart attack and couldn’t believe that someone was doing something like that. Those have been patients who had we just sedated them and had we not given them an opportune ain’t moving around would have spent a longer period of time on a ventilator. Thank you.
Dr. Mikita Fuchita 15:04
Hi, my name is Mikita Fuchita and I am an early career physician and ECG and Critical Care Medicine practicing in Colorado. I stumbled upon Kaylee’s podcast midway through my critical care fellowship training. It was a deep culture shock because for the past eight years of my training, sedation drips were the default for patients on the ventilator. I had heard of patients walking on the ventilator through lectures at national meetings, but I thought those were special patients in circumstances before this podcast.
I didn’t know that many if not most patients could tolerate breathing tube without sedation drips, I didn’t know that patients retain vivid memories of delirium and hallucination while one sedation was sometimes drag for life. And I didn’t know that trach peg and Eltech disposition were preventable stories of the ICU survivors brought me tears because all they talked about was the suffers and tears brought by sedation and delirium, which I was completely unaware of.
I spent the last few months of my fellowship training trying to figure out how to minimize sedation at my training facility, I found two major barriers. One was the culture telling a nurse not to start sedation after an emergent intubation was difficult to say the least. But I persisted and all patients woke up calm and prove to the nurses that sedation was unnecessary.
All I needed to do was to explain to the patients before intubating the avoiding sedation will allow them to control their thoughts communicate with family preserve strength and improve short and long term outcomes and that they will still receive small doses of medications and knees as needed to assure comfort, as Kaylee often discusses on her podcast, not starting sedation was simple and easy. Explanation and reassurance went a long way.
For some patients though, especially those that have already been on sedation drips for a while reading, sedation triggered anxiety, agitation, coughing spells, ventilator dyssynchrony hypoxia, the reflex was to increase the sedation backup but those situations reminds me of the old same that goes like if you if all you have is a hammer, everything will be treated like a nail sedation is convenient, but his scars the patient’s and there’s actually other things in your toolbox such as family presents for anxiety reorientation and mobility for agitation, ventilator adjustment for dyssynchrony and they resist for hypoxia.
If you can keep one patient comfortable off sedation. Chances are that you’ve initiated the process of changing people around that patient. Seeing is believing and my institution nurses that initially insisted on giving more sedation for their patients started spraying the idea of sedation avoidance once they witnessed the success with their own eyes. One nurse is actively helping organize a quality improvement team and another nurse is holding education sessions for other nurse nursing colleagues.
Discussing sedation delirium mobility during the rounds also helps bring awareness and educate Junior trainees. One medical student was inspired by the discussions and went on to interview the ICU staff and wrote a QI proposal. If you believe in the benefits of sedation avoidance and early mobility as supported by the literature, be vocal about it and act within your circle of influence. You’ll be surprised by the impact you can make however small it may feel to you effort.
ICU revolutionist 2 18:14
One particular case that I looked back on was we had a 90 year old gentleman admitted to the ICU with a COPD exacerbation requiring intubation and APRV. Earlier in the morning, when I went to see this patient had failed his spontaneous breathing trial. I saw him within four hours of his spontaneous breathing trial, he was alert he was following commands. He was eager to participate.
He was actually pointing to his tube in hopes of having it removed, we were able to ambulate the patient, actually around the entire nurse’s station with the assistance of the nursing the bedside nurse and a respiratory therapist. The patient ended his session sitting up in the bedside chair and the team decided within two hours they were ready to activate him. They activated him to six liters nasal cannula, and he was able to maintain his extubation he was transferred out of the ICU.
The following morning and transferred to home within two days. The look on the residents faces was something that will always stay with me the look of the surprise as to how well this patient was able to do on life support walking in the hallway. I think the takeaway really looks at is that we’re eager to treat infection with antibiotics. And we need to be eager as eager more eager to be treating and mobility to give patients the ability to progress to be able to get their lives back and to be able to go back to their home.
Mia 19:38
Hi, my name is Mia. I’m a nurse in New Mexico and I discovered this podcast through a nursing group I’m a part of on Facebook. When I first started listening to this podcast, I thought to myself, “There’s no way. How can this be applicable to everyone? Some people need sedation!” but as I continued to read and listen to the facts and testimonials, I found that it sounded doable and it was something I would like to start incorporating into my own nursing practice in the ICU.
A few weeks ago, I had a patient who ended up on the vent for a prolonged time due to a complication from a routine procedure. Upon starting my shift with this patient, she had just gotten back from yet another surgery and I noticed she was regressing on the ventilator. She had been on spontaneous mode prior to going to the OR, and was starting to have apneic periods requiring her to be put back on a more supportive mode.
My first thoughts were “well, she just got out of the OR, and need to wake up more”. So I turned down the propofol and stayed with her until she was awake once a week I explained to her why I was waking her up and if she knew all that she had been through since her routine procedure. I provided a notepad for her to communicate with me when she couldn’t believe everything that had happened.
She seemed very comfortable on the ventilator and agreed that she was indeed comfortable with staying awake so she could be more involved in her care and decisions. She wasn’t quite ready to come off of the vent at that point. And it was shocking to me to see how quick everyone was around me, including the intensivist to say sedate her Don’t let her sit there miserable for a whole day. And also saying things like if I ever up on end up on the vent, keep me sedated.
The thing is though she wasn’t miserable. She was quite comfortable and in no distress. And therefore we had both agreed that her staying awake and getting back to a normal sleep and wake cycle was important. As the station left her system, and she continued to wake up I decided she was alerting oriented enough to be off of the restraints and allowed her to work on range of motion exercises to prevent muscle atrophy. come the next day we excavated her and once able to talk she couldn’t thank me enough for not sedating her and giving her a choice.
Because this allowed her the opportunity to understand and process what had just happened to her. I do truly feel that this changed her experience. I have a lot of colleagues to try and convince but this story right here is my proof that this approach works and is doable. I think that COVID And the unpredictability of the virus, along with doctors trying to find treatments that will work, which usually involves have heavily sedating and paralyzing the patient really made us lose sight of the fact that excessive and prolonged sedation is not good.
Personally, I’ve noticed that for our code patients that have ended up on ECMO, the ones who were off of sedation and paralytics quicker, in addition to working with physical and occupational therapy while still on the vent, and even sometimes we’ll still on ECMO had better outcomes, we do have a long way to go. But with evidence based practice and stories like these to support it, I really think we have the ability to change the way we look at ICU care across the US. My biggest advice to those of you who may still feel apprehensive about it is to just go for it. Education truly is key. And we as nurses have the power to change so much more than we believe.
Bob 22:44
I came on shift and had been floated. So on the short walk from the ICU to the overflow unit, which is like a step down unit. And I can hear some yelling, as the doors swing open. Most of the words were intelligible but not quite strung together in a way that made sense. So I continued to walk to find out what the motion is and come to a patient room doorway and I see quite a bit of a mess. There’s linen all over the floor, the bed is in disarray.
The patient is restrained and trying to get out of bed and again, just yelling loud bursts of words. So no one in particular, but the patient seems agitated and safe. So I’m just on shift and not currently the situation I concluded the patient was safe and in no distress at the moment and continue to the nurse’s station report. On my way there I run into the other nurse that was going to be my partner for the day. And I looked to the board and see that he has said how their patient will just call him how from now on along with two others.
As we start report, we’re quickly interrupted by how a couple more times I hear tidbits of the other report and then hear the continued ruckus. So that patient I realized that my counterpart is going to have an awful morning, if not the rest of the day being triple with this particular patient. So I offered to take one of his other assignments for the morning, if not the rest of the day, as it seems it’s going to take some time so this guy nice just leaving him and I powwow about a plan.
We made quick rounds and met in the patient’s room to see what we could do. On arrival he was confused attempts to propel himself out of bed and put his read directable for a time. He has trach and is on the ventilator but continues to pop himself off is breathing well over pulling great volumes and setting 100% I get tidbits of the night. The guy was tempted to get out of bed and receive some verses and some Ativan had previously been on sedation for a while from an endotracheal tube but had graduated to his current trip that we into sedation off couple days ago but he still got intermittently rambunctious especially overnight.
He also previously pulled out his pick to his appearance seems to have a gleam of sweat possibly from working so hard or possibly withdrawing from his previous fentanyl versus said in other cocktails guys not slept in days. The guy is quite obviously delirious. Our plan of attack was get him clean. Get him up, get him mobile, get him tired. Hold off on the further verse ever Ativan as the effects are repetitive. Over the next 30 minutes we changed him to a humidified tray collar bade them shaved him apply his glasses. removed his non working rectal tube and did a stamp pivot to the chair.
After all the sitting up moving around, the guy was exhausted and looked like a new man. He quickly fell asleep on his side and the chair. Over the shift his family arrived and they were able to spend time with him at the bedside, entertain him and keep him company while awake. They also redirected him appropriately. Bucha was able to work with PT, OT and speech we were also able to take him on an additional walk twice without PT.
While this should sound pretty boring and normal, it isn’t kind of my counterpart not been as nurse and had we not taken the steps literally. In our shift it could have looked very different and like another normal. He could have in recent dated doses increased meds change kept on the ventilator kept intermittently sedated without any real sleep. He would have been silent and agitated when his family arrived. He may have been too agitated or sedated to work with PT OT or speech.
Instead, he not only got out of bed but walked several times for the first time in a month. He worked with speech and moved on to Passy Muir valve worked with ot spent the entire day in the chair was not only liberated from the vent, but basically on room air by the time we left. The next day. He had slept soundly throughout the night and was calm and we arrived a couple weeks later I was floated again drab. Yes, I know. But guess who came walking in the door with his partner? That same guy.
I feel like was another 12 hour day for us that shift could have gone very differently with a different outcome. The delirious restrained PRN sedation norm became a get out of bed to the chair work with PT walk with family go to the bathroom have me asleep normal hours norm. Now which norm would you prefer if that had been you, or your loved one in that bed?
Santiago 26:37
Hi, my name is Santiago from Argentina. I like the patient’s awake and working on the ventilator. We like providing the totality games, or distractions and therapy. I love communicating with them, seeing them with a smile and giving a thumbs up with the endotracheal tube.
Nora 26:54
“Walking Home from the ICU” podcast has been such an effective way to bring my team together to just hear so many stories of patients who have either been through the waking working ICU and what their experience was like along with patients who have been deeply sedated in a more conventional ICU setting.
And all of the repercussions of that. Having my colleagues listen to these stories and listen to the podcast has really been a huge catalyst for change. So much so that we were able to host Kaylee for a webinar within my hospital system, where she was able to present several case studies of patients who have she’s taken care of using this awaken walking ICU method.
And it was incredibly eye opening for my team to not only just hear more stories, but to hear directly from Kaylee, and then have the opportunity to ask questions to her about, you know, common barriers and misconceptions that people have about this method of ICU care. And just having that one on one interaction with her was really special and I believe helped drive lots of success stories that we had in my hospital such as you know, patient’s not ready to be extubated yet, actually getting up and walking around the unit, as opposed to just restarting sedation.
And you know, setting the patient back. Another day, we even had a story such as this with a COVID patient, which I talked about in an episode with Kaylee where you know, the COVID patient was a pretty standard patient population for apprehension when it came to liberation. But we were able to limit sedation to the point where we had it off. And then we’re able to have this patient walking around the room and even playing tic tac toe on the glass wall despite the fact that he was limited to his room with the COVID-19 infection.
And even more exciting was that he was discharged from that ICU stay. So I really believe that the podcast in the webinar and hearing stories from Kaylee and other people that that she works closely with and patients has been such a pivotal, you know, vector for driving this change and getting people excited about the future of the ICU.
Tara 29:36
So the first patient I wanted to share about would do Tai Chi as they walked around the unit, they would take a few steps and then stop and do some motions and some stretches and then take a few more and going around the whole unit took about probably like 15 minutes but they did teach you the whole way around and it was it was just so fun to watch. They really enjoyed it.
Another patient I thought of this part If your patient had dwarfism, we would take the patient for walks around the unit and physical therapy would sit on one of those little wheelie chairs and help the patient walk around the unit and just guide them. And when we’d get back to the patient, or the patient would stay at the edge of the bed and use one of those little foot pedal bikes that we used a lot during COVID. But the patient would stay in their room and use it on their hands. And they you would just look in their room and see, see this little patient just sit in their pedaling with their hands all day. And it was just really fun.
ICU Revolutionist 3 30:32
It wasn’t until our big COVID surge during the winter that I started to understand the side effects of sedation during intubation. I thought it was just COVID. But now that I have learned about the “Awake and Walking ICU”, I realized that most of that might have been from sedation.
I know that COVID is an awful virus and has done some terrible things to bodies. But I’m sure that the side effects would have been much less if we had not sedated so much. So in that respect, I have a few patients I could talk about where one was sedated and intubated for a week and the other was only intubated but allowed to get up to a chair and then eventually walked with physical therapy.
The results are completely different. Same age group, actually very young. And the patient who was sedated ended up very confused for a little while extremely weak, couldn’t even get up to stand for a while days. And then once started walking, it was very minimal. So the other patient who was not sedated, was able to walk around the room within one try. And it was absolutely amazing. We had a doctor come in and said, quote unquote, I have never seen a patient sedated and walking. This is amazing.
Kali Dayton 32:13
So keep going. Whether it’s sticking to that sedation vacation, letting the patient wake up right after intubation, being the first to set a patient up, or even pulling your team together for a webinar. You can bring the change for one patient, that one unit, and even a whole specialty of medicine.
Transcribed by https://otter.ai
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