And, and let's tell this, let's tell this story about how this got going. I want to, I want to start, though, with two patients. And these are real patients that I met this past week. I've known one of them for many years, but I met the second one this past week. And while we are going to teach you data on over 25,000 patients' worth of data from the bundle, we have a paper out of Sutter Health with 6,000 patients. We have a paper out of the ICU Liberation Program that Brenda Pun, who's in the back of the room. Brenda, raise your hand. Brenda's back there. She's the first author, along with Michelle Ballas. Michelle, raise your hand, please. Along with Michelle Ballas are two co-first authors on the 15,000-person study from ICU Liberation. That's 21,000 people. And then Montefiore in New York just published a paper on 4,000 patients, so that's 25,000 people of data, showing in these 25,000 patients that the better you implement this A2F, the higher your compliance rates are, the more you have reductions in length of stay in the ICU, length of stay in the hospital, less death rate, less ICU bounce back, less cost, and less nursing home transfer. I'm going to say that whole sentence again. I want you to remember this. I want you... When you go home, one of the key things you have to be able to do is you have to convince your naysayers and the people who are fighting you and the people who say, this is stupid or it's too warm and fuzzy, you have to be able to tell them, wait a minute. In an elevator speech, you have to be able to say this. Wait a minute. We have data in 25,000 people that the better we comply with this bundle, the shorter our ICU and hospital length of stays are, less ICU bounce backs and nursing home transfers, less cost of care, and also, oh, by the way, less delirium, less coma, less physical restraint use. So right there is your elevator speech. That's your ammo. All right? Your ammunition is in 25,000 people, we have data on this. This is published. This is peer reviewed. This is not my opinion. Okay? Now, I'm going to unpack how these all individually came about here in the history right now so that you will be able to speak to it. Somebody says, I don't like the C. I don't mind the rest of it, but I don't like this C thing. I want to use whatever drug I want. So I want you to be able to defend any aspect of this. I'm going to unpack this for you right now before we go into lectures on individual pieces. But then in addition to that elevator speech of data, what I want you to remember is there's a second thing you have to have to make this happen. Okay? Is it Sean? Sean said, you know, we've been doing this for a while and, you know, I want to see how we get unstuck. And he, very funny, he said, I didn't even realize this was to become a course director, course leader. You know, he said, I just came here to learn from other people. Well, do you realize what you're, what you are here? This has been being built for 25 years. The B, the SAT, SPT, my SPT paper in the New England Journal was in 1996. 1996. 1996. I don't even think Emily was born yet. Okay? Maybe barely. So, for 25 years we've been building this bundle. And you in this room, you 50 people, are the first people to ever take a certified course in this from SCCM because it's just now become a thing. So it, Critical Care is 50 years old. And for the first 25 years, what happened was that we started figuring out how to drive a car. And for the second 25 years, we've gotten good at driving a car. And you are the first people, you can always say, I was at the first certified course that the SCCM did on ICU liberation. We got to start somewhere. And we are it. So let's get started. Now, the first thing I told you was data. The second thing, though, that you have to have is story. You have to have patient stories. If you don't tack this down to an individual human being with a name that you know, people won't buy it. So you need to be thinking in your head right now, who's that one patient that I remember that went through hell in the ICU and I'm going to recontact her and ask her how her life is right now. Let me give you two stories right now. I'm going to give you Sarah Beth Miller and Carol Billion, like billions, but it's with an A, B-I-L-L-I-A-N. Both of them have given me permission to tell their story. So get this, 2002, Sarah Beth Miller gets ARDS from pneumococcus, comes in, gets about eight days on the blower, shock, she gets Versed and morphine drip and she gets norepi, probably even renal dose dopamine for all I remember, and goes through hell in the ICU, just like anybody would if they're on the blower with ARDS, and leaves the hospital after about 15 days. She's 49 years old when she left, Sarah Beth Miller, 2002. No bundle, no daily wake-ups, crap loads of Versed and morphine drip. Just like we always did, kept her sedated the whole time, coma until we thought she was better, then let her up, got her out of the bed, and then she left and went out of the hospital. Carol Billion, 2018, hospital in Maryland, emails me a month ago, tells me her story, comes to Vanderbilt this week and I met her last Tuesday. This week, I guess. Today's Friday, right? Yeah, I just met her on Tuesday. This woman, 49 years old, same age, comes to the hospital with flu and then pneumonia, ARDS, six days on the vent, about 10, 11 days in the hospital, and she got the full bundle. Daily pain management, with the A. The B, daily wake-ups, SBTs. They did not, they used dexmedetomidine, I think they used a little propofol at the beginning, then dex and fent. She was in shock, she was on pressers, and she started walking the second day in the unit while she was still on 70% FiO2, they cranked it up to 100, they got her out of bed and she walked that far, exhausted, fell into a chair. That's not a failure, that's a success. The next day she walked three feet, then the next day six feet, then 10 feet. So you gotta start with little and move and build. People think, oh, it's a failure, see, we've never done this before, let's get this patient. Okay, let's get him up. He goes like that and that's all he can do, see, see, I told you we can't do this. No, that's a complete success. This person's out of the bed, they're using their own body weight, gravity, their own muscles, okay? So Sarah Beth was an engineer, she took differential equations, Calc 4, engineer for AT&T, never went back to work, had to retire early. We did an MRI on her, she came out of the ICU feeling so crappy, she got braces, Art Wheeler was her doctor. Got braces and when she got the metal braces, we couldn't do an MRI on her head. But we did an MRI three and a half years later. She came in and got IQ tested, her IQ was 111 when she came in, which is 10 points higher than average, right? IQs are, should be 100 is average, 10 is, 110 is 10, is one standard deviation above normal, 120 is two standard deviations above normal, right? So somebody who is like 140, that's four standard deviations above normal, for example. So Sarah Beth comes in, gets an IQ of 110 and we say, Sarah, it's pretty good, like you're above average. She freaked out, blew up, this is back like in 2005 when I first started meeting her. And she had had pre-IQ testing. Her case is written up, it's in the literature, you can pull this case. I'm not making any of this stuff up. Her IQ, which she brought in, had been 141. She had lost three standard deviations of her brain power and even though we were telling her she was above average, in her head, in her life, she was totally disabled. Imagine this scenario, let's say she started at 100 and now she's operating at 70. That's the same thing. So 70 is severe mental disability. So she felt the same going from 130 to 110, right? Like Sarah Beth's story back then, Carol Billion came out, couldn't do anything, mentally she was very foggy. She could walk around and stuff, she'd been moved. She wasn't nearly as bad, for example, as Sarah Beth, but she still felt like my life's screwed up. But she came back quicker, she went to physical therapy. She actually created, I was blown away by this, she just told me this on Tuesday. She said, I called, I created this thing I call my idiot therapy. And so, she downloaded two apps on her iPad and to rebuild her brain power, she does an hour and a half on this one app that puts five pictures up and each picture has a second picture with five things changed on it. And so, for an hour and a half, she divides those pictures up into mental quadrants, finds the where's Waldo changes and then does that over and over again and then she goes to her second app, which is word jumbles, because she loves letters and words and she works her ass off all day long, her brain off, if you want to put it that way, and she's all the way back. She runs an entire real estate company of her own, she runs all the books, she does the numbers, she's the president of her condo organization which has 150 condos, amazing. And I looked at these two cases, they're almost the same case clinically and their life afterwards is qualitatively different. This is what we are charged to do. We are charged to help people achieve the best possible recovery that we can help them achieve. And it should no longer be acceptable for us to do so much less for these people than we know we can do. And I think that a lot of times, we relegate our daily life as intensivists, as nurses, to whatever is the most convenient or whatever gets us the least amount of flack from all the people around us. Now on any graph of early adopter, middle and then late adopter, you all have people all along that graph. You can tell me right now names of people in your head who are aggressive early adopters and people you want to make a change in your unit. You can also tell me the most hardcore CT surgeon who makes your life miserable because they hate everything you do. This woman yesterday at the hospital thing told me, she said, I'm a PETA. I said, what's a PETA? She said, I'm a pain in the ass of all the people around me. And there are PETAs on the early adopter side and there are PETAs on the late adopter side. But I'm here to say that all of these people are integral to your success and we should not think of the late adopters as problems. The late adopters are absolutely critical. They remember things that you tried and failed at years ago. They have institutional memory that you want in your program. They calibrate us. So never think of anybody as an enemy to this circumstance. Just think of them as different players on the spectrum of what you're going to do at your institution in changing the culture, okay? All right. Let me see if there are any questions in the room from things I've said and then I'm going to go to the actual history part of this and I think I can get us done still way early because I'll be done in the next 30 minutes easy. What kind of questions does anybody have? Don't be bashful. Raise your hand. What are you wondering? All right. You want to know how it started then? Is there a pointer? Probably not. Oh, no, no, no. I want that one slide. Just... No, I just want you to leave that thing up there. Yeah. Okay. So, as I said, 25 years ago, 50 years ago, we started critical care. We didn't know how to keep people alive when they got really, really sick. And what we started getting good at was technology. We started getting good at different ventilator modes and keeping people alive who would have died earlier and we started thinking that critical care was about the swan gans catheter and about the ventilator and about monitoring things that you could put up on a screen. And when that happened, we started saying, let me get the patient out of the way so I can just do all this stuff to them that I think I need to do to keep them alive. So most of you are too young to remember this, but around the 90s, we even started doing things like inverse ratio ventilation. And when we started doing IRV, we had to paralyze people. We had to paralyze them, deeply sedate them and paralyze them. And when we did that, we made them look as though, Tom Petty, famous quote, the people look as though they are dead except for the monitors which tell me otherwise, okay? And that's a very famous quote by Tom Petty who popularized oxygen for COPD out of Denver. I met him one day and I said, what made you write that quote? He goes, I walk in the unit now and whereas it used to be I would engage with people and talk to them, none of them can I talk to anymore. And I think it's all an outgrowth of our overt obsession with technology. So I view that as what happened in the first 25 years of critical care. And I liken it to, if you were to give a set of car keys to your, who has a kid under the age of 13? Anybody? All right. So if you were to give your kid a set of car keys and say your brother is halfway across town, 25 miles away, go pick him up. So that kid's going to try and drive that car, they're going to wreck a lot. They might keep it going but they're going to keep wrecking, okay? And that's kind of where we were, we were 13-year-olds with car keys in 1992 trying to drive the car of the ICU. The second 25 years, which happened with this, is where we got really good at driving the car across the city without wrecking the car. And that's my analogy on all this. Some of you, we could also make an analogy of your ICU as a car, is that some of you are at the point of just having the key in the ignition of building this program and you haven't quite turned the key yet. You're going to try and turn the key and it's not going to start. Or some of you are going to start the car and it's going to run on four cylinders instead of eight cylinders, okay? And that's okay. And it's important to just say, you know what? We are where we are. And we don't want to pretend that we are driving this 12-cylinder car at 80 miles an hour on the interstate right now. That's not who we are. We're barely getting started with our key. And everywhere in between is who we are in this room. And so, how did we start with this? It started at the B, actually with the SBT. In 1996, I published a paper, I was chief resident, we did this RCT, New England Journal, and we showed that if you did spontaneous breathing trials, you could get people off of a ventilator two days earlier and cut their complications in half. A few years later, J.P. Kress from Chicago published an SAT study. He didn't call it an SAT, he just called it a daily wake-up. You know this history. I'm trying to put it all together in a story for you. And that was in the New England Journal as well, and he showed that you could also shave a couple of days off the ICU if you just turned the drugs off every day. Now, let's be honest about what happened every time we did this. When we published our SBT study, we had respiratory therapists say, it is not my job to do this. That's not my job to turn off the ventilator. I'm supposed to turn it on, set it up, and it's not my job. We actually took surveys of our therapists, and we had, we were using an F over VT ratio, the Rapid Shallow Breathing Index, the Tobin Index, and there were people who sat on the ventilator at a 106 four days in a row. The threshold was 105 or less. And if you got an F over VT of less than 105, you were then supposed to go to the SBT. The screen and then the SBT, two-hour SBT. I'd come up to a flow sheet and pick it up, it was in paper at that time, and it would say F over VT 106, 106, 107, 106, and the person never got an SBT. I thought, oh my gosh, I've created a monster here. This person should have been getting an SBT the last four days, but the screen at 105 stopped them from moving forward. So we started figuring out that, you know, some of the, so we kind of got rid of that screen, by the way. We don't use the F over VT that often anymore. We just put them on the SBT and see how they do. And if they don't do it okay, then we turn it off. And people don't get hurt by doing that. But anyway, that was a problem with the SBT, and with the SAT, I called J.P. Kress a year later. He had published his paper in the New England Journal, I said, J.P., are y'all doing that at University of Chicago? He goes, no. I said, wait a minute, you published it in the New England, he goes, I know. I can't get the nurses to keep it going when it's not a trial, okay? So I'm just being brutally honest with you about how hard this is to get it going when you haven't changed your culture. Remember this, culture will eat strategy for breakfast. Your culture isn't changed, your best strategy is going to get eaten up by the culture. So do not think you can do this without changing the culture, right? So then, we decided that what was happening was that, at that point, we called it an ABC protocol, ABC, Awakening Trials, Breathing Trials, Coordination. And the coordination meant this. Therapists are now doing the SBTs, nurses are doing the SAT, because the nurses handled the drug and the therapists handled the ventilator, they're siloed. But what if we coordinate those and de-silo them, so we came up with the ABCs, Awakening, Breathing, Coordination. And we did this study, I'm deliberately weaving in the difficulties here, okay? So listen for each difficulty. We deliberately did this study, it was multi-center, and about three quarters of the way through the trial, which basically meant that in the intervention group, everybody's getting their drugs turned off completely every day, and then an SBT, AB, Coordination. And about three quarters of the way through, the nurses said, you know, Wes, this isn't working. And I said, why isn't it working? And I was super bummed, because I really wanted to know the answer to this question, if it helps or not. And I don't know, I don't care what the answer is, I just want to know the truth of if it helps. That's the idea of being a physician scientist. And the nurses said, it's not working, because every time we turn the drug off, we end up having to turn it back on again. So we turn it off, they freak out, they wig out, and we turn the drug back on, so it's not changing anything. I was like, crap, we put all this time and energy into this, and it's not changing anything. Well, it turned out, at the end of the day, when the whole thing was over, 300 patients had been put through this, and I hope this is a really helpful thing to share with you, that we had cut overall benzo use and propofol use in half. We had cut it back in half, even though the nurses thought that we had not done anything. Now I went back and we surveyed them, and we interviewed them, and we talked to them. Why did you think nothing had happened? It became apparent that if you line up 20 patients, and you cut their drug off every day, they do an SPT, and if two of them freak out, and you have to flip that drug way back on, that's what sticks in your head. So when you go back to your institution, and people think this never works, or it doesn't work, they're calling you out on the one they have trouble with. But guess what they're not doing? They're not registering all these other patients that it works beautifully on, no big deal, turn the drug off, and they just sit there. And you're setting up the protocol for the masses, not for the exceptions. I was in Korea last week, and I was walking around, and they had everybody deeply sedated, and I asked them, why, I told this story yesterday, I said, why are you having everybody so deeply sedated? Why don't you turn their drugs off every day? And they said, well, what if they self-extubate? We had a patient once, and she self-extubated, and we had this big problem. And I said, what if they never walk again? Right? Because the masses are being over-sedated, immobilized, losing their muscle mass. They brought a patient in for me to meet. I emailed them in advance, I said, I'd like to have a patient, a survivor there. They brought in this woman named Miss Kim. She's 31. She had pulmonary hemorrhage from lupus. And she had been in there on the ventilator, heavily sedated for all this time. She came in looking like a skeleton in a wheelchair, and she'd been out of the ICU for a year. For a year, she left when she was 30, now she's 31, and she went in weighing 120 pounds, and now she weighs 65 pounds. She will probably never walk again. She had no muscle in her leg. She's gonna get septic again and die, is what I think will happen to this poor young woman. So they are freaking out because they don't want to self-extubate. Hell, I would deal with two self-extubations for all these other people that don't have the problems and the issues and get them up and walking. So that's a really important element of what we learned in the ABC study. At the end of the day, when we had that ABC study published, we had reduced death from 45% in the control group to 30% in the intervention group. So even without the D, the E, and the F, we already saw that this was reducing the likelihood of dying by a full 15%. That was published in Lansing. So then we had the ABCs, but the pain people were super frustrated that we didn't have analgesia explicit. So we changed it to put A for analgesia, and then B was both SAT, SBT, okay? And then C, we made it choice of drug. Why? Because choice of drug, we had lots of JAMA and Lancet papers about if you pick a non-gabaergic drug and reduce the drug, it really helps people to get less delirium and so on and so forth. So we focused the drug on the C, A is analgesia, B is both, C is choice of drug instead of coordination. So coordination is implicit in the B now. D, we had all these JAMA papers and other papers on delirium and the importance of delirium in outcome. What do you want to know about delirium? Here's your skinny. Somebody says, why should we be measuring delirium? Delirium is an independent predictor of four things. Four things. Independent predictor. That means you've already adjusted for severity of illness, age, race, liver disease, kidney disease, comorbidities. After you look at all that stuff, delirium above and beyond all those things predicts higher rate of death, length of stay, longer length of stay, cost, and acquired dementia. So that's part of your elevator speech too to your nurses. One of the guys recently told me, he goes, I built this in, it's in our computer system and it's right there but they don't use it. That's your culture eating your strategy for lunch, for breakfast, okay. They don't use it. Why don't they use it? They don't know. Knowledge is power. You've got to teach the team that delirium is a great barometer of whether or not you're likely to die, how much money you're going to spend, how long you're going to be in there, and if you can have this brain dysfunction on the back end or not, okay. That woman, Miss Kim in Korea, the 31-year-old, she had a job where she sat down and ran these computer programs. She was a programmer. So she could technically still do that even from a wheelchair but she tried to go back and she has panic attacks every time she gets at the computer. She literally has no idea what to do anymore and she's 31 years old. She says, I just completely freak out. Through a translator, she told me this because she did not speak English, she spoke Korean. She cannot go back to work and it's not her body. It's her brain, too so This acquired dementia after the D after delirium. They're connected Delirium is connected to dementia All right. I've got a little bit more and then I'm a stop and take your questions So come at me with questions challenges, etc here in just a second II early mobility so Schweikert from University of Chicago Published this paper in Lancet that showed that early mobility cut delirium in half and then another Person showed that early mobility reduced disability and and delirium Okay, then two more people about to teach you above and beyond what you might be aware of in the literature You might know all this and I hope I hope you do But if not, I want to make sure everybody does two other people did studies of early mobility and it didn't work It didn't shorten length of stay it didn't improve Delirium it didn't improve delirium duration, etc Okay, so if you take these four major studies of early mobility, and there's some other smaller ones What you will notice is that the studies that were successful at reducing delirium and reducing length of stay Had the early mobility setting in around day two two to three max the studies that didn't work Moss and Morris One published in the Blue Journal one published in the in the in JAMA Moss and Morris a study which were negative Started the early mobility around day seven or eight So what I take away from this is timing matters and Saying that you're mobilizing a person on a ventilator at day eight is not even qualitatively the same at all As saying that you know what? Miss Smith came in here at ARDS on Monday, and she was on 80% in a peep of 18 We got her down to 60 and 12 on Tuesday And on that day, we dangled her legs off the bed and she stood up and sat back down, but on Wednesday she still had rip-roaring ARDS and she flagrantly failed her SVT and We got her up out of bed and she walked to the door and Then that was that she was completely exhausted She fell in a chair and we left her in the chair for a couple of hours put her back in the bed She slept naturally without a bunch of drugs because she was so exhausted. Okay, that is early mobility in the ilk of Schweiker which is why we created the E of the bundle letting that same person go Monday Tuesday Wednesday Thursday Friday Saturday and In these two studies Moss and Morris and they're good friends of mine. I love these guys. They're great, but That is not the same as mobilizing them the lady the next weekend because what happened in the meantime What happened in the meantime is that she lost the muscle mass. She's the Sarah Beth Miller she's not the Carol Billion and That is the rubber hits the road difference in what you want to get accomplished. Okay, so Where you're gonna go with this, I'm not done with F yet where you're going with this is not oh my gosh I'm so pumped in April. We're gonna start walking all of our people in the ventilator No, where you're going with this is I'm gonna find a patient one person and One nurse on my early adopter late adopters Graph that I have in my head of my people I'm picking Sally because I know she's an early adopter I'm thinking mr. Johnson the COPD or has been in the bed three days and just next Tuesday I'm gonna go to that person with that nurse and one doctor and we're gonna try and do this bump Just one person and we're not implementing this across our whole unit because our culture will eat that strategy for lunch Okay, I like putting lunch in there better than breakfast I Cannot emphasize enough that as you're about to hear these lectures do not be thinking How can I get the entire unit to do this? Just be thinking. How do I get one person to get me started? and and as you're Imagining this in your own unit do not think of the late adopter Don't think dr. Drinkwater is my is my PETA and He's gonna stop this. He's gonna argue and he's gonna yell back. How do I beat him? No be thinking early adopter and Does anybody know where this graph came from by the way, let me tell you a guy named Everett, you know Everett it's called diffusion of innovation It's amazing book diffusion of innovation Everett in the 50s they came up with better corn seed and the corn seed was going to grow better crops more production and the early they tried to sell these to all these farmers and The farmers some of them were like hell. Yes. Give me that corn seed Those were the early adopters other farmers said no way I've got something it's working. I'm not fixing I'm not fixing something that's not broken and they were the late adopters and They began to study that in lots of different Organizations industries, etc. And they realized this is consistent across humankind but it all came from corn seed in the 1950s with with Everett Rogers and and And Diffusion of innovation is the name of that book if you want to look it up So Early mobility it's not all created equal and You can't mobilize somebody if they're sedated So you have to do B and wake them up and turn the drug off to get to E and If you unsedate them and are able to mobilize them at E, then you're likely to cut delirium in half at D and Then at F the family is going to be happy because they get to engage with their loved one You see how this works? When you lighten sedation a Is actually going to go up for a minute because an awake person who isn't delirious at D will tell you about their pain And you'll know to manage their pain at a Okay, so when the person tells you about their pain You're gonna manage their pain better and because they have less pain at a they're gonna get less delirium at D And when they're less delirious at D They're gonna cooperate with you because they want to get out of the bed So E is going to happen because evil they want to get out of the bed because their family member F Says mama, please let's do this So F helps E out and then they get up and they have even less D and they don't want any and any drugs at C So the person is awake and because of all that they aspirate less there. They get less pneumonia I thought it was awesome. John you told me you went in and this person was on propofol and and and versed propofol and versed This is in 2020. He saw this Two GABA urgent drugs and and what happened John when you what did you say happened within the first 24 hours? He was off the probe off the propofol off the versed and down cutting the propofol in half Off the versed cutting the propofol guess what happened that person's blood pressure The blood pressure stabilized They came off pressers the nurse felt like they were they were getting physically better So they thought oh this person can now get out of the bed they're able to walk get out of the bed move this stuff is all interconnected and I bet some of you raise your hand if you've ever done a sepsis bundle in your hospital Okay, raise your hand if you've ever done a VAE bundle in your hospital to produce VAE, right? So these are disease specific This applies to every disease These are human constructs. I'm gonna bring it to a close now with two stories This is not just about You have 1014 so I'm still way ahead I'm gonna bring it to close with two stories and then see what kind of questions you've got So what you're about to do the rest of today in the sim labs and then tomorrow in the sim labs as well Is not just stuff that you can measure Some of this stuff is stuff you can't measure What do I mean this guy? You know when Toyota? This guy, you know when Toyota Almost went down Financially back when many of you were young in the 90s. I think they got this guy from the US named we Deming DEM ing and If you went into the company in Tokyo of Toyota on one wall They had a huge picture of the CEO of Toyota and on the other wall They had a huge picture hanging down of Deming DEM ing if you don't know who Deming is look him up. He's the father basically of quality improvement and systematizing Programs so Deming has this quote that everybody likes to say which is if you don't measure it. You can't manage it So everybody thinks that quote means this if you if you can't measure it you can't manage it meaning I've got to be able to measure things to change them and I thought that was an awesome quote, and then I called the Deming Institute to find out exactly where Deming had said that and What actually they said you know it's actually a misquote What Deming actually said was and I think this is so perfect for the 8f bundle and maybe if you want to use this Please do I just kind of came up with this when the Deming Institute told me this the actual quote was It is a costly myth To think that if you can't measure it you can't manage it okay now, so what what I take away from this is that Deming who is kind of the father of measurement Realizes that there are some elements of what we do in our life with our goals and our passions That you can't measure and those are the intangibles so here are my two stories I Have a patient who was on the ventilator for about 10 to 15 days at the VA His name was mr. D I never got permission to use this story, so I don't use his last name I Did get permission to use this picture though, and I show his picture frequently But I just out of respect because I didn't get the signed permission to use like Sarah Beth Miller and Carol Billion I just call him mr. D, and that's not even his last initial Um But mr. D was on the blower for a couple of did double-digit days and I entered as the attending on the day that he got extubated at the VA and the nurses were all excited that he got extubated and He was a veteran he had a big white beard, and I said mr. D. What matters to you? That little sentence is a way that I try and teach myself to to pay attention to the person instead of saying here's what's the matter? With you mr. D with you. I say what matters to you So I pose it as a instead of a statement. Here's what's the matter with you? I say what's the what matters to you a change with the two and now it's a question I'm asking for feedback if mr. D hadn't been getting the bundle He would have been delirious Unable to talk to me unable to tell but he had been getting the bundle he had been getting walked He had been getting out of the bed, and he said My wife Wanda, and I would like a beer and I gave the nurse a tin they wouldn't got him a beer I have a picture of him with a bud light. I think and He's drinking that beer and his wife's at his bedside. Her name is tattooed on his hand W a NDA and It was just just great moment. You know I was like wow that is so cool The nurses were at first upset about the beer, but they got over that They actually got a big kick out of it, too, and he died that night true story Never had another day in his life, but on that day. He had his wife and his beer and That's the intangible part of this bundle. There's no way I can put a measurement on What it meant to him? I don't know what it meant to him I don't know how to value that, but he said those were the two things that mattered and we made his wishes come true Debra cook has a program you ought to look it up called the three wishes project The three wishes project Debra cook is one of the most famous intensivists in the history of critical care. She's the reason we give peptic ulcer prophylaxis on a ventilator Okay, she's massively famous person And she is devoted the last half of her career to this project of the three wishes and they ask all their patients What are three wishes you have I? Just saw another paper in the annals of internal medicine where they published most of this and I think the average cost of Making the three wishes come true was something like five dollars and thirty seven cents So they're not asking for Ferraris Okay, and it cost me you know less than five bucks to go get mr. D his beer or something, okay? I don't know what happened to my change the nurses kept that but um but anyway The latter the last story I'll tell you is this one I had a doctor who also was a VA doctor He was a his name was dr. Pikesh. I can use his name. I got his permission and he was a physiatrist and He was taken care of at Vanderbilt even though he worked at the VA and at Vanderbilt I had him on the on the ventilator He was dying of IPF. His lungs were totally whited out. He was in one of those back rooms Emily on the second hall and And I'm sure all of you can remember different patients in different rooms. I have all these rooms where I know where John was in salad Mr. P was dr. P was back there and I said to him dr. P what matters to you and he said through writing I'm Buddhist and I want my monks and So I spent that day his monks were in Alabama I spent the day finding those monks getting them up there and on the last day of his life. He had three Buddhist monks with orange their orange robes on and his family holding his hands and his feet all of them there with him as He had withdrawal of support the ABCDF bundle did not save his life but it allowed him to be awake and alert and Communicative with his family at the time that it mattered most to him and you I don't know how to measure any of that I Can't we can't measure the value of that in my mind. That's even more valuable than Many of the other things that we will measure at the end of the day I hope that all of you can get to a place in your unit and This is me coming to a close to see what questions you've got I hope that all of you we hope that all of you can get to a place where at the beginning of every month on rounds You give a report to your team of your compliance rates with the ABCDF So that you're tracking measuring as Deming would say to do the different pieces of this and figuring out how you want to measure it Brenda and Joanna and Michelle and Kathleen all of them will teach you How to measure this they'll tell you what the denominator should be what the numerator should be they've these amazing team members on this I see liberation program They've already figured this out how to put it into programs and measure it and when the new Cerner and epic come out You'll be able to track all this stuff. Okay, and that's huge and every month you can say well look we're doing great We've got 78 and 90 percent compliance with the a the B and the C But our D used to be 80 and now it's 40 so our D is our problem patient now we got to work on the D or We lost our physical therapist and our e went to hell in a handbasket We used to get you know a great e rate where they were and he doesn't mean everybody's walking He means you're trying something beyond passive range of motion Passive range of motion sucks. Okay, forget it passive range of motion is not what you're after you have to something active Could be cycling in the bed ergonometrics But you know their own body whatever something beyond passive range of motion and that's what you're calculating But maybe you had it with this amazing physical therapist and you're gonna have Heidi Engel here later today and tomorrow the two Biggest names in physical therapy in the country are Heidi Engel and Chris permit They're both part of the faculty of ice liberation. I talked to Heidi last night She's here in town. She'll be here later today and tomorrow. You're in for a total treat with her Do not leave this program without learning from her and meeting her. She's unreal these are the two people who first started walking people with bass cats and I mean Amazing innovators they take chances. So you're gonna learn from these people firsthand, but when they go away, does your e have to plummet? No Mobility is a basic tenant of nursing care. Okay, so all of this can happen without physical therapy, etc We love the physical therapist, but you have to figure out how to do it without so that's all I wanted to say I hope that was helpful from a framing perspective and I'd like to fade in the background and let y'all continue to learn But what questions do you have? What did I say? That didn't make sense and What's on your mind Let's let's break this down, but we're still way ahead because I don't even think I was parts supposed to start till 1030, right? Yeah, so we're still like 40 minutes ahead Don't be bashful what you wonder John Okay, so the question was and I think that we should Brenda Michelle, can y'all come up here for a second? Some of these questions you might want to chime in on the question. John just asked was And I'm gonna hand this to you and I'll get back up here He wants to is there a key place where some of these statistics can be found or ways to calculate it, etc I Think one of the things is that and even now I've been Editing my my presentation for this afternoon all morning thinking. Oh, this would be better for them to take with them So this is a train the trainers, right? Like you guys are the ones that are going to go Convince everybody in your neck of the woods And I think those are really key importance that should be a part of all of these slides. Like what are those? particular references of the economic benefits that are associated with Various parts of the bundle and of the bundle and so I think that the place to find those They may not be there right now, but by by the time you get the slides is in the slide set I think each slide should have an economic slide for that particular element and then for the bundle as a whole So I think that will be the best place because it'll also have the reference that you can then go to If that elevator speech needs need some papers to go with it if you're going to certain certain places But that that would be my recommendation I'm gonna open Now Well, so one of the issues we have had that dr Eli gave us a very interesting answer to was we for as long as I've been in our organization at least seven or eight years now, we've had our sedation orders have had range range targets so from zero to minus two based on kind of the older thought process there and Now with Joint Commission requiring us to titrate exactly to what the order states The nurses are titrating to minus two because that's what it says in the order and our physicians even tend to think oh Well, because that's kind of the default like they can select to pick something else and some of them do select minus three and minus Four and so sometimes it's difficult to kind of figure out why they did that sometimes it's difficult to Like they sometimes have the mentality of like well zero to minus two is fine. That's what it says on the order So that's what they did, you know People Well, it's it's a range. So if as long as the patient's in there somewhere they feel like okay the patient's in the range and so it kind of We use a fast hug a modified version of fast hug so when they go through there they do kind of a head-to-toe for the presentation of the case and then they'll do fast hugs at the end and When they present the neuro assessment, they they said they will present what their ass is They'll present whether the patients can positive or negative but that discussion of then what do we do with that information? You know, sometimes the physicians will just go ahead and change the sedation or they'll turn it off or they'll do see it I mean or what but they don't always explain Why you know that that sort of thing? So I think we have some opportunity there with the orders and how they're the target and how that's driving the conversation, I think Well, and also setting goals in that in that fast hug discussion I Just wanted to say a Question of feedback. I got when I went into the unit after the talk in September. I was trying to turn off everybody's sedation Yeah Yeah, yeah, so that's something I'm definitely gonna have to reign back and it'd be interested to hear like just philosophically How you do that when you're thinking in the back of your mind? Oh my god hurting people with deep sedation and immobility But the nurses said to me you can't turn everybody's sedation off at the same time because they'll wake up freak out self-activate We don't have the manpower to manage them. And I tried to I tried to say well, there's Okay, first of all, so he said philosophically And how do you handle it when you think they're getting deep and I'm just dealing with one because The I see liberation group. Let's said let's start with one Write these constant write these terms down Small tests of change You have to keep that term in mind a small test of change and we'll be going over that Yes, and also PDSA, you know plan do study act This is the way you will achieve success is through starting with small tests of change, which means one patient instead of 20 and PDSA is plan do study act on that one patient Figure it out and then move to the second patient when you go to 20 at once even though that's your heart It's just too much people can't handle. It's like trying to climb Mount Everest when you need to climb a hill Okay, so that's that that's that idea In your lecture, do you have the slides that showed the results from the Brenda's paper? I don't know what are my slides. Yeah, you want to flip to it? Well, I think it I think in terms of the one question that they asked about Effectiveness. I don't do you have them in your slides Brenda? How do I turn the slides anyway I'm sure in one of these data sets you will see the slides from the Results from the ICU liberation collaborative that will show you in two different ways The results that occurred when the bundle was adopted into practice and that's going to be I think a really important part for you guys To bring back because when you see how dramatic said slides set said changes are All right, well, let's just pull them up because I mean I have you guys read the paper or have you seen that paper The outcome data is pretty the outcome data is pretty impressive. I'm going to show you the depressing data later, but Yeah, but how do I do that, let's see I just open it up to Okay. Okay. So we're going to show you these are like some people are more visually inclined than others a bunch of different ways To look at the outcome. So this one is ICU discharge. Okay, maybe when you're doing the teaching one of the things that you can emphasize Do you see how beautiful this? Relationship is This is yeah dose-response relationship is so if you're going to the very bottom you're looking zero versus a third of your patients Got it Right the effect of the bundle on the effect of the bundle on ICU discharge and you see the more parts of the bundle the better the outcome a Really good take-home teaching point is you see that with every outcome that you look at? So for example, if we go to the next page Hospital discharge death You see that relationship is steady the more parts of the bundle you get the better best as if you get it all We found but even if you're making incremental changes and doing little and little more parts of the bundle better So death look at this. This is some symptom data So coma goes down proportion in proportion to the number that they get delirium goes down Delirium goes down Physical restraints. There's any physical restraint geeks. I love that finding But the physical restraints and then do we have okay. Well this one maybe not when we talk about pain in two seconds Yes Gives you an opportunity there and I don't Do we have the full slide so what happens when you get the whole bundle it doesn't look like that's in here Backwards, okay Same thing over and over again. Yeah. Go ahead. Could you help me address one part of the element? So our institution is very into titrated sedation. I think many units do a very good job of titrating, but I don't think we actually do have that much success in complete cessation of sedation every day. And that's an argument people will make. Is there a paper or two that actually say that really you have to add the additional complete cessation on top of appropriately sedated, besides the original one that obviously was, you know, that was before they started talking more about titrated, you know, to targets and things like that? Well, I think your outcome, the 15,000 and the 6,000 patients all did SAT, SVT, so they did a cessation. And we'll talk about how they were defined, because that's an exceptionally important point. But in ours, it was a sedation vacation, meaning the sedation was shut off. It wasn't target. And literally the recommendation is shut it off, even if they're at a zero, because if they're at a zero, they don't need it. And so you only turn it back on if there is failure. And then failure is specifically defined in your protocol, so that there is a comfort level for that clinician doing that, which is the importance of having a safety screen for both SAT and SVT and failure and next steps, so that there are planned strategies for each of the components. Kathleen just said that the recommendation is a total shut off. So you have to then, where did the recommendation come from? The recommendation came from the literature. You're asking about the literature. So the people on the Guidelines Committee, which I was not on this time. I was on it in 2013, but not recently, are extremely rigid. Brenda can tell you. Michelle can tell you. Extremely rigid, fighting cats and dogs about making sure they do not make a recommendation which is not supported by the literature. So this recommendation for a total shut off is absolutely evidence-based. In our ABC study, it was a total shut off. The basic construct, even though it's evidence-based, I'll just tell you, the basic construct is, like she said, if they don't need it, why go down by half? Go down all the way, and then only go back if required. Question I have is, how do you change perception of what constitutes what a patient should look like? What I've run into, the new place I'm at, I've tried to encourage the therapists and the nurses to have a constant pressure of this goal of a patient sitting up in a chair, reading a paper, on a vent, completely interactive, but they don't have that. They can't cognize that. They don't have that. They can't cognize that. They can't realize that's even a possibility. And so as they look at these different bundle issues, they're seeing these tools that doesn't meet a construct that they already have in their head. As opposed to, that's our goal, that's a possibility, then they seem to attack these bundles more aggressively when they finally see that population. How do you get that through their head? Because we're talking about tools here, but the goal sometimes gets lost in the tool that we're talking about. I'd like to answer that. I'd like to camp on to something you said, Wes, that the culture got created, that the culture got created as we did inverse ratio, as we started hanging the drugs instead of pushing them. One of the underlying cultures, because I've dealt with mobility my entire career, and I've been in critical care since 1980, is that we created, nursing has this culture that I am not a good nurse unless my patient looks perfect in bed. And the sheets are crossed, and we have to change the culture to say, I am a good nurse when my patient's sitting up looking at me a little cockeyed. The sheets may not be perfect, but they're engaging with me. And so you actually have to bring that up because it is a visceral thing in the control of that world that they have and start to change that. And literally, when I do consulting on this, I actually start the discussion with the nursing staff using that. Bed can be messy, just so long as the sheets aren't in one big bundle. Little wrinkles don't hurt the skin. And I was going to say that I heard this great nurse once say that ICU rooms should be messy, and that was Captain Bowman. And I think that, yeah, not only should it be messy, but if the family's there, if you have places for family to camp out, it's messier than it has to be. I mean, there are drinks and there's family stuff that's everywhere in their little area. And if you lived in my bedroom for a week, it's going to get messy. It's not going to look nice when we eat together. I think the other element is that beginning with that end, that patient story of they might be nice and neat, but they may never walk again if you keep them nice and neat. And having those patient stories of telling what was it like when they were nice and neat and they were wigging out and having crazy experiences as opposed to when they could communicate and interact. And I think that helps to debunk that idea that does go against your gut as a nurse of things need to look controlled in here and look nice and neat. It's my goal as a patient is a way to be able to communicate and able to interact and what matters, the whole what matters thing is in there. And so I think that's part of that whole culture change of the look and the goal of what we're heading towards. I would say, too, if you have quantitative... There's quantitative and qualitative people, right? You can tell I'm the PhD. The quantitative people, you show them Yaya Shahabi's work, right? And other people's work that showed the direct relationship to a level of sedation and clinical outcomes, mortality, mechanical ventilation, length of stay. But then you have the qualitative, touchy-feely people. You can show them the videos of Heidi Engel walking her patients on 100% oxygen or the people walking around now with ECMO. I mean, I think it's kind of a dual approach, showing them that it is possible, but addressing the very underpinnings of a lot of the ICU nursing culture. Testing. Testing. So... That's not going to be about data and stories. When you leave here, how important are they to you, data and stories? So as a nurse, I am a CNS. And I'm just going to say it because it's kind of an elephant in the room. Sort of thing. It's not intended to be a problem because I was this way myself as a bedside nurse too for a long time when I learned. I do find that for both some nurses and some physicians even still have the mentality that if the patient can walk, they don't belong in the ICU. Or that if I can't control everything that's going on here, then the patient's almost a little bit too... They're too ready for step-down unit. Like they have that sort of... This is for me to control, but once they start asking for things, once they start... Just to be real, that has been a culture that I have seen for many years in different units. It's getting better. I think we've started to change that now. And what it took for us was a couple of patients that were awake, alert, walking, able to interact, able to write, able to ask for things on the ventilator. And one of those people did actually come back and tell us about how that was for them. And I think that that impacted both the physicians that maybe were a little bit skeptical of that as well as the nursing team because they realized like, oh, this patient isn't going to extubate herself. Oh, I don't have to restrain her. Okay, I think it really took that. But those videos you guys have on ICUdelirium.org are also really helpful.

ABCDEF bundle

ICU

patient outcomes

length of stay

mortality rates

delirium

physical restraints

data communication

skeptics

patient stories