Well, good afternoon, everybody. Greetings from the great state of Nebraska. I always have to double check what state I'm living in currently. I'm here to talk about the power of engagement. And if you only knew our team, I just mentioned to Brenda, we've been doing this now, I feel like since we've been fetuses, we've been talking about delirium, how to assess, prevent, and manage. I'm probably the least qualified person to talk about this topic about effective ways of engaging people, but I'm gonna give it my best shot. The power of engagement. So what is engagement? When we think about the definition, it's the commitment and support of a cause. So when we're talking in this presentation today, what cause are we talking about? Well, you've heard the A through F bundle mentioned multiple times. We've talked about the importance of the PATI's guidelines. So my focus is gonna be how do you engage people in this work? And when we start this question, the first thing that we have to think about is who are the people that we wanna engage? Now in the current bundle, we recognize the importance of engagement for the family. But again, after doing this work for so many years, there's a ton of people that are necessary to make this happen in your everyday practice. We need to engage our patients and our family, of course. They know the patient best, they can be a great resource for us in learning the things that help with patient's pain control, with delirium management, who they were before they had this terrible life event happen to them. We have to engage our other colleagues. And we preach a lot about the importance of interprofessional collaboration, but I was one of those very lucky nurses who was born into an environment where that happened on a day-to-day basis. So the nurses and the respiratory therapists would go out for breakfast every morning, had a close bond. We did the team rounding before team rounding became cool and the en vogue thing to do. So when we're thinking about engagement, it's the entire team, patient, family, to make this engagement possible. I think one of the greatest examples, we've heard it referred to a couple times now, but what the SCCM was able to do with the ICU Liberation Collaborative. And we knew we took the 68 really highly energized, engaged participants in this effort to get evidence-based practices into practice. And why do we engage? Well, through a whole bunch of work and a whole bunch of communication and learning from each other, we did see miraculous things come about from implementation of the bundle. In fact, the evidence is pretty clear right now, unless you're a randomized controlled trial only kind of person, that the bundle really is the way to go. All of the studies that have been done on the topic have shown very, very consistent findings. In this case, when we looked at the new A3F bundle and the impact that it has when it's delivered in everyday care, we saw improvements in almost everything. Pick an outcome, restraint use, any Giro nurses out there? Clearly one of my most important outcomes. But in terms of reducing delirium, in terms of the patient's ability to return home, like Dr. Pund talked about. And like we also saw in this collaborative, you don't have to be perfect. So if you look at this slide, you see where we were kind of again, pre pandemic, where we kind of want to go back to this pre pandemic level. When the ICU is to join the collaborative, you can see at the beginning, we're kind of all over the place with the bundle elements, right? Because there's clearly some bundle elements that are a little bit easier to deliver than others. So for example, you see the assessment prevention and management pain before and after was probably the one of the bundle elements that was the best delivered. And you see the ones that we struggle with and probably continue to struggle with. So for example, you see the challenges with early mobility, the delivery of early mobility to every patient every day, the awakening and breathing trials. But as we mentioned, even small improvements in the delivery of the bundle could have really great impact in terms of the outcomes that it has, the outcomes that are associated with its delivery. We also saw a lot of variability. So we saw hospitals that were really great with say, the early mobility component, I'm gonna guess what hospital that is, I'm gonna guess maybe Dr. Engel works in that hospital. But we see those hospitals, even though like, that's really hard to deliver in everyday practice, we had that outlier out there that was given it to every patient almost every day, amazing. So I think one of the takeaways I'd like to bring back to you is when you're engaging with your colleagues to reinvigorate this effort, that it's okay to start small and make little baby steps, because it'll be really great for the patients in the end. Now this ICU Liberation Crab really is the gift that just keeps on giving, right? So we currently have an active R01 where we've been looking at this data really closely, picking it out. But we also had the opportunity to recently do this really neat exercise that was called a concept mapping exercise. So what we did is we surveyed current ICU providers that were working in the ICU collaborative units, and we asked them, even now, post pandemic, what are the things that we can do to engage our colleagues in implementing the bundle? And we have some really fascinating suggestions on things that you can take back home and try, okay? And they're important. So we know the providers keep telling us that we have to have that active collaboration among disciplines, right? So we have to have those MD champions who are willing to support this important cause, and also to support the nursing staff and its delivery. We want to foster that interprofessional culture, but one key piece that keeps coming up and up and up is that timing of those awakening in the breathing trials. Really figuring out what time in your unit is the best to deliver this. Really close interprofessional collaboration among nursing and respiratory therapists to do that. Providers are begging, and I found this so odd, but they're begging for protocols. Simple to ease, simple to use protocols that will tell them, what do you do with the A? What do you do with the B? What time are we doing this? Particularly the younger generation really wants that kind of tap and go technology. So maybe it's time to relook at our processes and protocols that you have to make them a little bit more user friendly and easier to digest. This is particularly true when we think about the sedation and pain management protocols, because as Dr. Pun mentioned, we're dealing with a relatively novice nursing staff right now. Now I just talked to one of the physicians from here from California. Oh my God, you guys must be in heaven right now when I hear about your staffing levels and the amount of nursing that they have. The ICUs that I'm working with in some other parts of the country, they're still to this day, dealing with triple assignments in their nursing. So they're not back to the one-to-one or one-to-two care. They're still tripled up on nursing assignments. So when you're thinking about that tripling of assignments, the tripling of patients that they're responsible to care for, the fact that you're dealing with new graduate nurses that were born and raised, got educated during the pandemic. Let me tell you, it's hard to educate during the pandemic, but now have only learned to care for patients during the pandemic with this emphasis on deep sedation and over sedation. It's really challenging. They're also asking for feedback and simple ways and easily delivered ways to say where they are with their current practice. The personnel and equipment resources, we clearly need to have them. But one of the themes that commonly comes through is really having that adequate manpower. So having the appropriate number of nurses and nursing assistants and support personnel to make delivery of these components feasible and able to do. Because I think deep down, everybody wants to do it. Again, I think some intensive care units are still struggling with that day-to-day implementation. Education, again, key. I know we've been teaching this for almost two decades now, but it is like we need to go back from the beginning. So having that engagement of your clinical nurse specialists really super important. And then finally, really innovative ways of engaging the patient family members. We had a great talk by Dr. Singh the other day about some ways that the intensive care units are doing that through the use of technology and things like that. But opening up our ICUs again for the families to come back in to teach us how to best care for their patient. In the end, the one thing that the providers are telling us that we really have to do if we want to engage and make this thing happen again is to have that adequate support staff. So engaging with the C-suite and really advocating for those kind of resources. The final thing that I want to touch on is the differences that we're seeing that comes up between professions and what they think is important in terms of ABCDF bundle delivery. I really did think this was kind of neat. So we looked at what nurses tell us they need and the other disciplines combined. And you can see there are a lot of differences in terms of what the nurses value and the other professionals value, right? So in terms of, I guess you're looking at it on your left, the RNs ranking things like having that process and protocols a little bit higher than the other disciplines and the focus on the education that they need it. In the end, what's more fascinating to me is the differences between the frontline clinicians and the administrators. And here's the biggest gap, I think, as I see it. When you look at this total disconnect between what people that self-identify as a hospital administrator and those as the people that are actually practicing at the bedside, that big disconnect in terms of the importance of these different strategies. So for example, the frontline staff saying that they really do need to have that education and that feedback and that equipment and personnel in comparison to the administrators ranking personnel down near the bottom. So there's that huge disconnect. So if we can do anything as a critical care community is somehow bridging that, I think we would all do each other a great service. So that's some tricks in terms of engaging people that you work with in some of this work. And again, that generational difference too. I don't know if anybody saw the plenary with the famous Facebook TikTok person, but I'm getting the sense that, you know, some of those kind of alternative educational modalities might actually be a really great thing to do. So thank you for the time. And hopefully you found some of these suggestions important in terms of ways of engaging the people that you're working with in this really important work.

power of engagement in healthcare

engaging patients

evidence-based practices

ICU Liberation Collaborative

interprofessional collaboration