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How does the ABCDEF bundle apply to the CVICU with a variety of diagnoses, acuities, and devices? Anna Dalton, DNP, ACANP, in an “Awake and Walking CVICU” shares with us the evolution their team has experienced in improving their mastery of the ABCDEF bundle.

Episode Transcription

Kali Dayton 0:38
Okay, the next three episodes are dedicated to exploring the ABCDEF bundle in the CVICU. My own uncle likely spent an additional two days on mechanical ventilation in a CVICU because awakening trials were not a priority for the team. We now have vast research proving the safety, feasibility and benefit of the A to F bundle in cardiac ICU patients of varying diagnosis and devices. Please check out the transcriptions and citations for this episode on my website under the resources tab. This episode I am ecstatic to share with you the insights of an adult and nurse practitioner in an awake and walking CVICU. Anna, thank you so much for coming on the podcast. Can you introduce yourself to us?

Anna Dalton 1:26
Yes, my name is Anna Dalton. I am a critical care nurse practitioner, I work in a cardiovascular Intensive Care Unit. I’ve been doing that for the full year full four years of being an NP and prior to that I worked for four years as a nurse. And then prior to that a few more years as a nurse, but I’ve been there total of eight years now. And I’m I love doing it. I love cardiac critical care.

Kali Dayton 1:53
So cvicu is your jam. That is your expertise. And that’s exactly why I have you on today, you spent most of your time in that Ico and it’s an ICU that’s renowned for their mobility program. Correct have put our research and really advanced cutting edge things throughout the years. So I recognize that that’s just normal for you. But as we appreciate throughout this podcast is that the culture and practices vary throughout all the different specialties and all the different ICUs within those specialties. So today, I really want to dive in with you about your team and your perspective on the ABCDEF bundle in cvicu. I think this applies also to the CTICU, all the cardiovascular intensive care patients that are out there, why is the A to F bundle so important in your specialty?

Anna Dalton 2:45
I think it’s so important because in the overall perspective of somebody being in the ICU, it decreases your ICU length of stay, as well as it decreases your hospital length of stay, which then improves your overall mortality. I I believe that, in the last 10 years of my nursing career, I’ve seen a huge shift and change from heavily sedated patients to less than a to patients more awake, more alert, who can participate who can write down what their wishes are or have conversations with family and it just it helps to really improve their ICU stay and get them out of the hospital, which is what they ultimately want.

Kali Dayton 3:33
And if you’re coming from a large teaching hospital, which some of us from other hospitals, especially rural hospitals say, well, we don’t have those kind of resources. But I think another consideration too, is that you’re caring for really high acuity patients who are on a lot of support and a lot of devices. So what are the kinds of diagnoses acuities and devices that you care for in that ICU.

Anna Dalton 3:55
So our patients actually come from inside of Utah, as well as from the surrounding states. If there are smaller hospitals in Idaho, Wyoming, Montana, Nevada, sometimes even New Mexico, they’ll and they can’t handle their patients because they’re too sick. They have devices and they ship them to us. So we’re dealing with a lot of I work with all of the cardiothoracic post surgical patients, and they can have a wide variety, wide variety of cardiac related illnesses, as well as I work with lung transplants, vascular patients and some thoracic patients. And we manage all the different types of devices. We’ve got breathing tubes, we’ve got continuous dialysis, and then we’ve got balloon pumps, the two different types of impellers. We’ve got VA and VV ECMO and I think I already said balloon pumps.

Kali Dayton 4:55
So there’s a lot going on as a diverse population. And with cardiac patients in general, what are some of the unique risk factors for delirium or ICU acquired weakness?

Anna Dalton 5:09
So there are lots of different factors with surgical patients, some of the ones that I thought of that are non modifiable that we really don’t have control over somebody’s cardiopulmonary bypass time, their cross clamp time and the OR, and a circle rest time that they have in the O they’re pathophysiology. If they have a calcified aorta, you and you do an aortic surgery, you’re going to have a higher risk of having pieces of calcium flick off and having little mini strokes during surgery, their age, a history of dementia, if they come out with an open chest, then they have plans to go back to the or so there’s a lot of non modifiable things that can occur.

So modifiable things that I feel like occur in the ICU that helped to prevent delirium, sleep, pump alarms, making sure patients are aware of day night, once you get them off of that cycle of the normal cycle, they get very confused, making sure family is available, making sure their pains under control and making sure you’re working on trying to get their breathing tube out and having PT and OT available for, you know, trying to normalize what they would do at home, but in the ICU as well as trying to manage their pain with opiates, decreasing the amount making sure that they are awake enough to participate in their care if they’re hemodynamically. Stable.

Kali Dayton 6:32
Yeah, so interesting. I hear concerns such as: “What about postop pain? Our patients are coming out of surgery, when do you take sedation?”- often lots of different questions. And because you have these unique risk factors within your population, it sounds like your team. Instead of saying, “Well, they’re going to have delirium, they’re going to be agitated. We just need to keep sedation going.” It sounds like you take those risk factors into, into consideration to say, “Therefore, we must be more proactive, we must prevent delirium or implement these interventions, because they’re so at risk.” And that’s a different culture.

Anna Dalton 7:07
Yes, it’s I don’t think people really understand the risks of delirium, you know, you said, “Oh, well, it’s just delirium. They can handle it.” Delirium is a huge spectrum of what can happen to somebody’s brain. And it can last years or more, that decrease in brain function that occurs when you have delirium and, and there have been patients who have given testimonials of like, you know, “I was a really good accountant before I had ICU delirium, and now I can’t really do basic math because of how much delirium i i had, and I can’t go back to that job anymore.” And it’s, it’s important to look at it is, “oh, it’s just ICU delirium, we can’t really prevent it.” Because there have been studies and there are ways that we, as providers, we as nurses can work with our patients to help reduce or prevent number of days of delirium.

Kali Dayton 8:07
Absolutely, yeah. I mean, with those non-modifiable risk factors, there gonna be high rates of delirium, I was just doing a medical review for a man that had had a cabbage by vessel graft. And he had some postoperative delirium three and four days after surgery, but seemed to kind of get better, was sent home. And he got so confused. He was getting his gun out shooting around thinking that people were on his property, and had to be hospitalized. And they couldn’t figure out why he was delirious. And he spent almost two weeks in hospital before the PT or OT came, he was just had florid delirium. And so he spent another month in the hospital, primarily for delirium. And yet looking at his chart, he had constant disruptions at night to he was stale, but he’s getting vital signs throughout the night labs drawn up to four in the morning, just because that’s when they would do it.

And I don’t know that the ICU would ever imagine that he would come back to the hospital just for delirium, and spend a month there lose 30 pounds because he wasn’t being mobilized because he was going, it wasn’t a priority. It wasn’t in the culture, even on the medical floor. And it got me looking and I saw that 50% of patients post cabbage can develop postoperative delirium. And then when we add in all the other factors that you’ve described, things that we do to cause that we must increase those risks. So what is it like in your ICU, you’re talking about your perspective, understanding what this is going to look like for a patient down the road? Is that something that your team discusses and how does that impact how you manage sedation?

Anna Dalton 9:46
Yeah, so what I want you to know is this is not always been the standard of care in our CVICU. When I first started in 2014, it was taught to me by other nurses that when you get a post Stop patient and they come out on profile and you immediately start them on a fentanyl drip. From there, you wake your patient up, get a neuro exam, make sure they’re following commands, and then you put them down, and you let them sleep until tomorrow morning, that was just like, ingrained in my brain. And once I started, NP school, and I started learning more about delirium and being like, wait a second, like my patients actually do worse, they’re more agitated, they’re more anxious when you sedate them really hard. And then they wake up from that, they’re going to be more confused.

And so we’ve been working the last four or five years on taking off sedation as quickly and as safely as possible. So now we are currently working on a study where we’re trying to decrease our intubation hours. So I think our average was like 20 Something hours with a reading to postoperatively ruling out other people that like an open chest that have to be intubated, etc. And what we’ve been looking at is, we want to get the patient to the ICU, and maybe they have on some profile, we do not start a fentanyl drip, we only do IV push fent, when they wake up, and they can tell us that they’re in pain.

And then from there, we work on not bolusing as much unless the patient is severely agitated and at risk for harming themselves or their vital signs are very unstable, then there’s going to be some areas of play. And we’re trying to get our patients excavated within six hours post op. And so when I go in as the APC, I say, “Okay, this is the time it’s noon, we’re going to have sedate all sedation off by one o’clock. And then within six hours, we’re going to be extubating.” and I feel like giving hard stops and verbalizing “No more sedation after this time. This is what we’re shooting for.”- And then following up with that has really helped to encourage and to prevent people from getting over sedated when it’s not necessary the majority of the time. And we’ve in the last year that we’ve been working on this, we’ve actually seen a decrease in the average hours that our patients spend intubated, I think it was from 20 to 12, or something like that, which is a huge improvement in our patient population.

Kali Dayton 12:32
And how does that impact workload and bed flow? Now all those things within the ICU during this crisis, especially,

Anna Dalton 12:39
right? When you get your patient extubated quickly, then you can pair that patient the next shift, not that all of our intubated patients are single, but you can pair them so then you only have to have one nurse for two patients. And then there, it’s easier to get them up. It’s, you know, you start getting them swallowing you get them working with physical therapy a little bit faster, because they don’t have any ventilator settings that you’re like, “Okay, is it okay to get them up, as well as if they’re not sedated, they’re awake.” And I think that’s the, the biggest thing is they can start getting reoriented to their surroundings that they’re out of surgery that it’s x time in the day or it’s nighttime, and it’s it just the patients do better. And they actually like it. Nobody likes the breathing tube in them.

Kali Dayton 13:31
Absolutely. And so a lot of those patients are those that are appropriate to extubate shortly after it’s mostly post op. In what about patients that are going to require mechanical ventilation? Or devices for longer times? How then do you manage sedation and how do you know when sedation is necessary? And then triage level of sedation? When is it time to take it off? All those things that are very case dependent?

Anna Dalton 13:56
Yeah, so we really for most of our patients, we try and get them up with physical therapy or work with occupational therapy post op day one because we recognize the importance of getting people mobilized, I believe there was a study that said that for every day spent in bed, it’s actually two to three days of physical therapy to gain that strength back, which is insanely important and so crazy that we lose that much muscle mass. And so we look at their hemodynamics. And we’ve got a lot of numbers that I know a lot of rural hospitals do not. We have Swan ganz catheter, so we’ve got cardiac index, we got arterial lines, we have continuous blood pressure monitoring, but we have to look at “okay, what is their blood pressure and how many pressors are they on?” If they’re on, you know, to iron the tropes and to pressors you’ve got to look at that and be like, okay, they’re a little bit too unstable to start mobilizing today. But if they’re down to one inatrope, and maybe they have vasopressin for a little bit of blood pressure, we can have physical therapy work with them. In bed chair, getting them sitting up trying to get those fluids mobilized and moving because they’re going to be orthostatic. And trying to switch them from propofol to dexmedetomidine.

There’s actually not a lot of research about dexmedetomidine. In the ICU setting, people were using it originally to say that it actually gets you off sedation faster. And I believe that the study said that it didn’t, however, some people really respond to it. So if you get them off of propofol and onto Dex you can’t bolus that med. And so it’s less likely that if somebody’s agitated that a nervous nurse would just hurry and bolus to get the patient down. They would come and they’d say, “Hey, my patients really agitated, what can we do for them?”

And so moving towards that, and also moving towards oral medications to help control pain to help control agitation. So we use opiates and Tylenol. We will most of the time we use Lyrica to help with chest to pain because they go through rib spaces. And if they’re too sedated on opiates, we go to Tramadol, if they’re still to sedate, and we take everything off until they’re fully awake and screaming out in pain, and then we say okay, now we’ll treat you. And so there’s, we have so many medications that are so much better than fentanyl in propofol. And I know some people use Versed- we haven’t used that for years.

Kali Dayton 16:33
Yeah!

Anna Dalton 16:34
And I just, I just think that people narrow their views and say, “Well, this is how I’ve done things, how we’ve done things. And there’s no, there’s no other way.” But there are so many other ways that you can safely have somebody intubated, have somebody with multiple devices. Sometimes we have ECMO and we have a balloon pump. And we have a vision that’s intubated, and they can be resting comfortably on precedents or dexmedetomidine, with po pain meds, and they can wake up squeeze hands on a drop of a hat instead of having to do a sedation holiday or vacation.

Kali Dayton 17:14
And I am imagining the stress and the risk of having patients be delirious with those kinds of devices. Yes, so how does that impact safety and everyone’s comfort level when you have a patient that’s more responsive and reliable and not delirious.

Anna Dalton 17:32
So it definitely comes with time, those that are delirious and are intubated, usually have restraints. And then from there, if they’re once they become really alert, and we can tell that they’re oriented, if the nurse feels safe while they are in the room, they can take the restraints off, or they can use mittens or we would get one to one close supervision or a sitter to be with them to help kind of say, “Hey, like you’re in the ICU. Let’s try and remember, don’t pull it that but typically, we use soft restraints.”

Kali Dayton 18:05
Which I that’s really interesting to hear, because some ICUs are so afraid of restraints, and their goal is to avoid restraints, therefore, they chemically restrain them and they shoot for deeper wrasses so that they don’t have to restrain them. So how do you guys navigate that? I agree with your approach. But why is that the approach?

Anna Dalton 18:23
I don’t know as like an institution why that’s an approach. But for me, having physical restraints, the soft restraints, doesn’t do too much to the patient, right, if you’re checking them every two hours, I believe is what you have to do. Whereas if you have somebody totally sedated, you’re probably only doing sedation vacation once every four hours. And so you’re actually having more assessments, and it’s less risk to just have their arms tied down. Not to say that we’ve never had somebody pull out a line or pull out their ECMO before because it has happened. But there’s just better ways to manage that than just to say, “Okay, I’m just going to sedate and forget, because it’s easier for me.”

And that’s what I think we get caught up in is it, it feels easier for me because I don’t have to be super vigilant. Because I don’t have to be at the bedside 100% of the day. As they’re waking up. I can walk away and feel comfortable about it. And I do agree with that. I did that all the time when I was a nurse. But we’ve got to start trying to change the mindset of our of our nurses and our physicians and our PAs and NPs because we are the ones that are going to be able to create this change among our institution and among the nation. We’ve got to change because this is unacceptable.

Kali Dayton 19:50
Yeah, and it sounds like you guys have kind of transformed your definition of safety. That, for example, when someone pull up their ECMO line, I think one The options would be to shut down the whole program altogether to just say, that happened because they weren’t sedated. Therefore, we must study all patients on ECMO. Why wasn’t that the response for your team?

Anna Dalton 20:12
I think because we look at all of the factors surrounding why it occurred, not that they’re agitated, because I think the patient I’m thinking about was just angry that they were still in the hospital. I don’t even think they were delirious. I think that they just got angry, and they were done. And they went forward and pulled it out. And before, you know, he was trusting he didn’t pull it things. And so I just don’t think the right answer is to completely sedate somebody and take away their ability to have any response or reaction to anything. I think in that case, we came together, we had an M&M meeting. And we discussed okay, you know, next time we’re going to double suture in our line in our ECMO, because it was peripheral ECMO, we got Hollister patches, which are sticky patches that go underneath the ECMO circuit, and they hold them into place. So then each line has to have to have those Hollister patches. And then I think those were like the main takeaways I can’t really remember. But that’s you change your environment to help improve the patient care to make sure that doesn’t happen again.

Kali Dayton 21:31
Oh, I love that approach that it wasn’t, you didn’t just put the blame on the nurse or on the lack of sedation, it was considering the whole environment and all the factors to then improve the process and make it safer in the future. But you weren’t willing to put a future patients at risk by going back to deep sedation. It sounds like your team really understands the risks involved with sedation and immobility. And that that helps guide and navigate your decision making when it comes to sedation. What are the usual RASS goals on your unit?

Anna Dalton 22:08
I, I actually, I have not looked at the nursing RASS goals in a long time. And I think we use Riker at my hospital. And our goals are I think I pulled it up. What’s the middle? It’s like three four of Riker.

Kali Dayton 22:26
I actually don’t know record that. Well. I’m used to two RAs, whereas there was this awake, calm oriented. It sounds like you guys shoot for a zero or negative one where they might be a little drowsy.

Anna Dalton 22:39
So that’s probably Yeah, with the rest with the Riker. We shoot for four, which is calm, uncooperative, calm, easily arousal follows commands.

Kali Dayton 22:51
Sounds like RASS goal is zero. That’s great.

Anna Dalton 22:53
Yeah, we want yeah, we want them to be able to participate as much as their hemodynamics can tolerate. And it just, it’s so much better for patients. It’s so much better for the nurse just overall to have their patient be able to tell them what they would like whether it’s writing or pointing or nodding makes her a better nursing patient care.

Kali Dayton 23:22
And what kind of cases or situations would deeper sedation be necessary?

Anna Dalton 23:26
So patients that would need deeper sedation, anybody? Well, even people with an open chest maybe when they first come out with an open chest, but even so I’ve had people with open chest not on any sedation fully awake. And I had a patient just last week, open chest was in a ton of pain. And I had the nurse tell me that they bolused profile, and I had to educate that profile is not a pain medication. It is a sedative. It does not help at all with pain. So let’s figure out what’s going on. I would like you to be off of propofol by the end of the day, and let’s start pain meds. Started with oral pain meds, those weren’t cutting it. I moved to precedents that wasn’t cutting it. I added a ketamine drip.

And then after I have the ketamine drip, the patient was alert. The patient was calm. He was saying no, I’m not in any pain, and nodding and awake. And he eventually went got his chest closed and came back to the O R came back to the unit. And then we started over again. And we already knew he responds really well to ketamine. Let’s put him back on ketamine. And so trying those different things that you can still get to that point. Other parts or other things that may prohibit is just really bad hemodynamic instability, somebody that is very septic but also has heart failure, and is on devices so giving fluid isn’t the goal. though, and that’s even hard to justify, because really our goal is to get the sedation off and get them excavated as soon as we can.

We did have a lot of COVID ECMO patients, so patients with ARDS that come in and get VV ECMO, we do have to heavily sedate those patients in order to obtain good oxygenation and ventilation. So when they come to us on high ventilator settings, and then we put them on VV ECMO, that doesn’t just solve all of our problems, we have to slowly work down on our event settings. And patients are extremely to Kipnuk. They’re extremely agitated because they feel like they cannot breathe even though their oxygen and their their oxygen levels are great and their co2 levels are great now that they have ECMO and so working towards getting them on an OK sedation regimen is actually really difficult. So we have ended up on for set drips and Dilaudid drips and then eventually those have to be weaned off and those can take a long time. But for our cardiothoracic patients, it’s usually pretty quick that we’re working on other methods to keep them calm and pain free or less pain.

Kali Dayton 26:13
I remember Tyler, he I interviewed him on the podcast he came from the way can walk can I see you had severe areas could not oxygenate with movement that hit our threshold for deep sedation is prone. We had him cannulated there and sent to your unit. And not too long after he got there he was back on his feet on ECMO. ECMO facilitated mobility, how often do you see that I know you guys mobilize quite a few patients on ECMO. But apparently it’s a process. And I’m sure it’s difficult when they come from facilities that have deeply sedated them for prolonged periods of time. That must be its own barrier and working the delirium and ice acquired weakness while in high support.

Anna Dalton 26:56
Correct. If they come to us, and they’ve been previously sedated for a long period of time, then you’re working against all of that sedation and trying to essentially keep them from withdrawing from all of that because your body becomes addicted to whatever medication, whatever opiates or sedation you give them you become addicted. And that’s just a fact, with our patient load.

But with that case, specifically there, there are a lot of patients that we put on VV ECMO and we give them a couple of days to get their ventilator settings down so that we can walk them and then we’re getting them up as soon as it’s safe. Sitting in Bed Chair standing doing steps. Sometimes our physical therapy is just sitting in bed chair and doing five stands was physical therapy. And standing there are physical therapists also have tilt beds. So we get a whole team together and we move a patient over to tilt bed if they get super orthostatic. And then they can slowly move them up standing into like a 45 degree angle, but it improves their morale first of all, because they recognize that, okay, I can do this. I can work really hard and I can get these devices out of me and get home. When you’re laying in bed. And you’re not doing anything. I think that decreases your amount of determination and motivation to get out of there. You feel stuck, you feel like you are never going to leave the hospital when you just lay there in bed.

Kali Dayton 28:28
How long has ECMO program been running there? And at what point did your team start mobilizing them? And how did that impact the whole unit?

Anna Dalton 28:39
I think the ECMO program was actually going before we had a cvicu when it was just a surgical ICU and we got trauma patients as well as some cardiothoracic patients, but our cardiothoracic surgeon surgeons had been building their program really, really well. And reaching out to different hospitals in rural areas. And so now we have our own unit. So for at least eight years, we have been mobilizing but it’s really been within the last six years that I feel like it’s been a huge movement of like, “Alright, it is time, we’ve got to get these people up. We’ve got to get them moving. It’s so important.”

And we’ve got an amazing physical therapy, occupational therapy staff who’s so active on the unit and so willing to help get people up, get them moving. They’re very encouraging to our patients. We have little Bluetooth speakers in every room that is for the patient to use and their family can hook up their phone to it and we can play their favorite songs while we’re walking and really anything that helps get them motivated and I have seen such a dramatic change in not only our patients but our patients The population has actually gotten younger, we’ve seen so many patients in their 20s and 30s. Whereas when I first started, I felt like they were all older 50s 60s 70s. And I think that has just shown that we, we need to shift so we can’t let 20s and 30 year olds lay in bed all day, and maybe in our minds, we thought, oh, yeah, they’re 70, they can lay in bed all day, that’s fine. And now that’s not the case. You can’t, you should not do that.

Kali Dayton 30:32
It’s like, it should be the opposite, right? People say, “Well, we have really geriatric patients.” And in my mind, those are even more important to mobilize because how can they rehabilitate? Or how, what is that going to do for their mortality after that, the ICU. And it sounds like your team just expects most patients if not all patients to be up and moving. And when a patient is delirious, how does your team respond to that, especially when you have devices? Like in you’ve mentioned, sitters, restraints, sleep schedules, things like that, culturally? How do you discuss delirium now that you’re an NP? And you’re talking with nurses? How does everyone utilize the CAM score and respond to it?

Anna Dalton 31:17
So the CAM score is done by the nurses every shift, and we discuss it during rounds in the morning. And the nurses also tell us if they’re cam positive. From there, we decide, “Okay, we need to implement anti delirium protocol.”–It’s not an official protocol. It’s something that I worked on as a graduate student, essentially, what it is, is, there are things to do during the day, and there are things to do during the night to help reduce the amount of delirium that somebody might have, we pull it up.

So there are day shift actions that we talked to the nurses about making sure lights are on, blinds are open, and the doors are open, making sure if they’re falling asleep, that somebody’s in the room, talking to them, encouraging family to be there, which is really nice. Now that we’re kind of loosening up visitation that was hard with code, making sure you know, if the family is not there, that they’ve got music to listen to, or the TV’s on, getting them up to some sort of chair position, if they can’t, if they can’t walk, making sure that they’re sitting up somewhat, if they are laying flat because they have, you know, VA ECMO in their groin and an impella or something like that, then making sure that they’re reverse Trendelenburg, they’re sitting up as much as possible, decreasing caffeine intake after three and encouraging activities to prevent napping, especially late in the day that would make them stay awake.

One of the things that that we have done is we give the majority of people melatonin. Now, a lot of people say, well, melatonin doesn’t work for me, but one of the physicians that I used to work with, he said, Well, we’re giving it at the wrong time, we’re giving it at 9, 10, 11 o’clock, which is the wrong time. Our melatonin inside our own bodies actually starts to be released right at dusk. And so the best time to give it is like six or 7pm to get them kind of relaxed and into that. And then if they really need something for sleep, maybe getting some Trazodone at eight or nine o’clock to help them get to sleep and that I feel like is improved our patients the other things that we do at night.

Earplugs–you would not believe how much that helps patients. If they’re not hearing the pumps beeping, making sure you’re doing pump rounds and nurses and making sure there’s their bags available that it’s not beeping dimming all the lights having the blinds drawn. And some people may disagree with this but kicking family out at a decent hour. I feel like when family is in the room overnight, they fret about things that are not to be fretted about that are maybe like artifact on the telemetry that may read V tach and it’s really not and minimizing RN interruptions but they still need to check their pumps or check their Foley output. Those are important. You know you can go into the room, you can have your little pupil light, and you can look at those things without disturbing the patient and turning on all of the lights, making sure they’ve got appropriate pain control so they can sleep optimize. There’s so many things that you can do to create a home environment for the patient in order to get them to sleep.

Kali Dayton 34:55
I think one of the beefs that people have sometimes is, “well, if our patients aren’t sedated, then when do we do our baths? We can’t do our 2am baths?” How do you manage your bath schedule?

Anna Dalton 35:06
You know, that’s actually kind of funny because it’s like, “Do you ever take a 2am bath?”- as you probably don’t. And sometimes that does happen if somebody has a massive bowel movement, and they may decide right then in there, hey, we’re gonna clean you up, we’re gonna wash up really quick. But that is typically during during the day or right before they go to sleep. And I actually feel like baths right before they go to sleep can actually improve patient’s sleep, because it’s like a comb, it’s time to calm down, you’re going to bed, we’re gonna get you all nice and clean. And then you can sleep interrupting somebody sleep, just give them a bath, I feel like is a waste of your time as a nighttime nurse, you shouldn’t be doing that. There’s other things that you can be doing. And it doesn’t improve the patient’s outcome in any way, by doing a bath in the middle of the night.

Kali Dayton 35:57
Do you do mobility in the evening?

Anna Dalton 36:00
Yes, we can do mobility in the evening. Some of our patients, when they’re a physical therapy assist with their assistant with our nurses, it’s kind of impossible to do. They’re usually there until about six or seven. So they can help get people from the chair where they’re eating back to bed. And then there’s a few patients that are pretty mobile that can get logist nurses that will do laps in the evening.

Kali Dayton 36:25
I’m such a believer in that I just I swear that improves sleep as well. And how does your team navigate all the exceptions when things are not idealic? How does your team work together to help patients through those severe repercussions?

Anna Dalton 36:47
I feel like one thing is it’s a constant discussion of how every day we’re talking about, “How we’re going to get that patient mobilized or when can we get that patient mobilized? Or what can we do to start getting them mobilized?” I can’t think of an exact example right now. But I think having that open dialogue with nurses and saying, “Hey, this patient has to get up today, whether you sit him in a Bed Chair, if PT is not available, or they come over and get them into a chair, okay, they really need to make it out of the room today.”

And, again, a lot of this does come from our physical therapists, they are really good at working with that. And we make sure that every single person has a PT and OT, evaluate and treat order that’s extremely important to have. And I wish I could think of an example of how we navigate how we navigate that, I think it’s working slowly, from like doing work in the bed, to sitting in a Bed Chair, to standing in the bed, to just sitting in a regular chair, to getting out the patient door. That’s a lot of steps. And it is a lot of work. But in order to even qualify for inpatient rehab, which is kind of our gold standard, we want people to go there because we have an amazing facility, you’ve got to be able to tolerate three hours of either physical therapy, occupational therapy or speech therapy during the day. And so we really try and shoot for that. “Okay, like, we want to get you off, we want to get you moving.” I don’t know if that answers your question.

Kali Dayton 38:35
No, absolutely. Yeah. And it sounds like your therapists are so specialized in what they’re doing and so educated I know you guys have a, a training program for your rehab services. And I, I and it shows and how your team works together, you trust their assessments, you trust their input, you’re working closely with them. It sounds like PT, OT and speech are in the ICU, not just visiting the ICU, they are an integrated part of the team. And I That sounds like that’s key, especially with all the devices, all the specialized cases that you have. And that that sounds like it’s key. And how has your role changed from an RN to an NP in implementing this interventions?

Anna Dalton 39:13
Right. So I just felt like my perspective has has changed a lot in in that I, you know, done some research about delirium. I can see the repercussions that come when they leave the ICU. Not that I ever see patients after the ICU, but I want to get them I have this desire to want to get them off the sedation because I know that they’re going to be much more compliant much more or easier to work with as a practitioner. And I just don’t think some of our our older nurses can see that because they’re ingrained in their ways. We do have a lot of new were nurses and they are just learning. And so they’re absorbing all of this. And they’re a lot easier to train and be like, “Hey, this is the reason why we’re moving towards this.” And it’s the older nurses that are a little bit more nervous to adapt to new protocols.

Kali Dayton 40:20
I think there’s such an opportunity for APCs to take a leadership in this to do to bring all the disciplines together to work towards this. And so I love that you using your experiences as an RN, where you understand what they’re going through, you know what it’s like to have a delirious agitated patient the workload as required in the situations. And then you’re using this to teach and educate. And I think that’s what we really need, especially during the rounds on the side of the leadership, APCs to help bring the team together, and then really talk about the why behind it. So I appreciate that that’s what you’re doing. And then you’re even publishing things to help share this expertise with the rest of the ICU community. Do you mind sharing your recent publication?

Anna Dalton 41:04
Yeah, so the the study that I worked on in the surgical ICU and the cardiovascular ICU, I worked on that during graduate school, and then we finished it up after it’s called the effect of a quality improvement intervention on asleep on sleep and delirium in critically ill patients in a surgical ICU. And it included 640 46 646, surgical ICU, admissions and patients. And we looked at patients pre intervention, which was pre sleep protocol. And then we looked at patients post. And we included every single patient, whether they were open chest, multiple devices or not. And we also looked at their pain score.

And if the pain score, if the patient couldn’t tell us, the nurse would guesstimate on what they thought the patient’s pain was. And we showed that by implementing a sleep protocol, which is what I described before, simple things, of, you know, lights on lights off those types of things that any hospital could implement, that there was a reduction in number of delirium days in the ICU, and I think that’s really important for people to understand is that this isn’t groundbreaking research really, you know, turning the lights on turning them off giving somebody earplugs. It’s something that anybody can do and things that maybe we would do at home, we’re trying to mimic the home environment, in the ICU in order to get people to sleep so they can be awake during the day and participate in their own cares. And I, I feel like we take away so much of patient’s autonomy and ability to care for themselves by bathing them by brushing their teeth by managing everything that they’re doing from the start of the day to the end of the day, that we don’t realize that that can also impact their delirium, so giving them back a little piece of sanity from their home life Act actually benefits them in the long run.

Kali Dayton 43:23
And you did a lot of the legwork as an RN. And now publishing as an NP, it’s so neat to see that anyone and everyone can contribute to this work and this process of care and that there’s still so much to be discovered. And like you said, a lot of this isn’t groundbreaking. We’ve known this for a long time. And it can be applied in very personal ways in every specialty, and it’s exciting to hear what your cvicu is doing will include your publication and other links to other research specifically for cardiac cardiac ICU patients and eight F fondle anything else you would share with the ICU community. Especially for those that are really daunted by getting to where your team is at.

Anna Dalton 44:04
I think it can be very daunting to look at this and feel like okay, we need to get there today. I think you and your team need to sit down and just discuss what is something that is easy that we can start implementing to you can start off so small just by saying okay, somebody’s gonna walk around every single night and make sure that lights are dimmed. Make sure that you know doors are not fully closed but partially closed so that the nursing station noise I think if you start small, and then work up from there, you can start preventing delirium.

Maybe half your propofol drips or maybe you have your first set drips and just say we’re not going to go above this threshold. I think that can get into people’s minds and feel so overwhelming. Okay, we’re just going to take everything off. And really, this took a long time for our unit To get to this point, it took years. And so if you start small and you work your way through it and create some sort of plan with everybody, and get buy in from nurses and physicians and APCs, then you’ll be able to start implementing and yeah, there’s going to be some cases where, you know, you’re gonna sedate somebody, and that will be okay. But if you’re working on changing your whole practice, it’s going to take a lot of time and a lot of effort from everybody on staff.

Kali Dayton 45:27
But I appreciate the perspective and the vision that you’ve given of what I really would call an awakened walking cvicu. Being responsible with our sedation, implementing all the holistic practices that the A to F bundle is all about. Thank you so much, Anna, for sharing your expertise. And we hope to learn more from you and your team. Thanks so much.

Anna Dalton 45:47
Thank you!

Transcribed by https://otter.ai

References

Anna Dalton’s Publication:

Tonna, et al. (2021). The effect of a quality improvement intervention on sleep and delirium in critically ill patients in a surgical icu. Chest, 160(3). https://pubmed.ncbi.nlm.nih.gov/33773988/

EM is safe in CICU and lowers mortality and increases discharge home rate:

Goldfarb, et al. (2021). Early mobilization in older adults with acute cardiovascular disease. Age Aging, 50(4). https://pubmed.ncbi.nlm.nih.gov/33247593/

Early mobility programs in CVICU are safe and feasible:

Matharsa, et al. (2021). A multidisciplinary early mobility model for cardiac patients in coronary intensive care unit. European Journal of Cardiovascular Nursing, 20(1). https://academic.oup.com/eurjcn/article/20/Supplement_1/zvab060.120/6330382

Over a year, the mean hours required for initiating out-of-bed mobility decreased by 50% in a CTICU. Early mobility program is safe and feasible in CTICU and led to the achievement of functional goals:

Prasobh, et al. (2021). Multidisciplinary, early mobility approach to enhance functional independence in patients admitted to a cardiothoracic intensive care unit: a quality improvement programme. British Medical Journal Open Quality, 10(3). https://bmjopenquality.bmj.com/content/10/3/e001256

ABCDEF bundle SIGNIFICANTLY decreased ICU and hospital length of stay. Hospitalization costs decreased by 45.76% and ICU costs decreased by 53.38%:

Takroni, et al. (2021). The effect of early mobilization on icu and hospital length of stay and its impact on the cost of care in post-open heart surgery patients: a randomized control trial. Journal of Heart Health. https://www.sciforschenonline.org/journals/heart/article-data/JHH157/JHH157.pdf

Delirium in the CICU:

Ibrahim, et al. (2018). Delirium in the cardiac intensive care unit. Journal of American Heart Association, 7(4). https://www.ahajournals.org/doi/10.1161/JAHA.118.008568

Delirium is an independent predictor of mortality in CICU:

Pauley, et al. (2015). Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unit. American Heart Journal, 170(1). https://www.sciencedirect.com/science/article/abs/pii/S000287031500246X

Predicting, preventing, and identifying delirium after cardiac surgery:

O’Neal., J & Shaw, A. (2016). Predicting, preventing, and identifying delirium after cardiac surgery. Perioperative Medicine, 5(7). https://perioperativemedicinejournal.biomedcentral.com/articles/10.1186/s13741-016-0032-5

Safety and feasibility of early mobility with femoral intra-aortic balloon pumps:

Chen, et al. (2021) Safety and feasibility of an early mobilization protocol for patients with femoral intra-aortic balloon pumps as bridge to heart transplant. ASAIO Journal, 68(5). https://pubmed.ncbi.nlm.nih.gov/34380951/

Increasing PT staffing in CVICU decreased CVICU by 3.6 days and post-ICU LOS by 2.6 days:

Johnson, et al. (2019). Improving outcomes for critically ill cardiovascular patients through increased physical therapy staffing. Archives of Physical Medicine and Rehabilitation, 100(2). https://www.archives-pmr.org/article/S0003-9993%2818%2931173-0/fulltext

Mobility with impella device is associated with improved survival:

Esposito, etc. (2018). Maximum level of mobility with axillary deployment of the imeplla 5.0 is associated with improved survival. Epub, 41(4). https://pubmed.ncbi.nlm.nih.gov/29637832/

 

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