NYSPFP VAE Delirium Prevention

Transcription

1 Okay, good afternoon everyone. Thank you so much for joining us on this NYSPFP VAE Delirium Prevention Webinar. We are delighted to have today with us Dr. Wes Ely, who is a Professor of Medicine at the Vanderbilt University of School of Medicine. However, before we start, we'd just like to take a couple of minutes to go through the NYSPFP approach to VAE prevention. Next slide, please. And the following slide. Can somebody move the slides for me, please. Thank you. We do apologize for the delay and the technical difficulties that we're experiencing. I just heard that I sound very low on the webinar. Is this a little bit better now? I hope that everyone can hear me. My name is Wing Li. I'm one of the project managers here at the New York State Partnership for Patients, and we are delighted that so many hospitals have joined us again for this second iteration of the partnership. Thank you for moving the slides back. If I could just move to slide four, that would be great. Thank you. Lovely. So, as many of you are familiar with, the Partnership for Patients has divided up the work for the Partnership into what we are calling "Patient Safety Hubs," which better align with the way that the work is divided within the hospital and to align with service lines. And one of the patient safety hubs that you'll be most interested in, for those that are on the call today, is obviously that for the critical care hub, which will encompass not only the VAE and delirium topics but also sepsis and ADE. Next slide, please. So as part of the patient safety hub, we hope that you will come together as teams to really ensure that we can treat patients as holistically as possible and target all the hospital-acquired conditions that can affect a patient that is in the critical care unit. And it order to achieve that goal, as you put together your teams to participate in the Partnership for Patients 2.0, we hope that you'll consider putting the following people into your team, including the critical nurse leader, the critical physician leader, as well as physical therapy, occupation therapy, pharmacy, and critical care staff, as well as staff from quality infection prevention, patient safety, and a nurse educators so that we can form the most effective multidisciplinary team possible. Next slide, please. In order to come together, to help people come together to welcome the important issue of reducing hospital-acquired conditions for critical care patients, we at PFP have developed a number of targeted education and tools for critical care unit staff for VAE and prevention, as well as all of the other hospitalacquired conditions that can affect a patient. And we encourage you to reach out to your project managers to hear about these tools, including the critical care gap analysis, checklist, and data collection tools. However, we're all here today focus specifically on VAE and delirium. And so that we can just understand a little bit about why we'd like to focus on these topics -- next slide -- we just want to provide a little bit of background on this topic. So studies estimate that about 300,000 patients are mechanically ventilated every year, and there are a number of complications that are associated with mechanical ventilation, both long-term and short-term complications. In the short term, there's a risk of developing ventilatorassociated pneumonia, sepsis, ARDS, pulmonary embolism, barotrauma, and pulmonary edema. But associated with ventilator associated VADs also previously known as VAP, is the longer duration of mechanical ventilation, longer stay in the ICU and the hospital, increased risk of disability and death, and increased health-care costs, all of which we want to try and reduce or avoid, if possible. And literature has recently shown that patients who are ventilated in the ICU will often develop delirium. Next slide, please. Delirium occurs in about 80% of critical care patients and is not detected. If you don't do a test for delirium, it can remain undetected in up to 75% of patients. and it is present in as much as 60 to 80% of the mechanically ventilated population. For patients who do develop delirium you can have prolonged 1

2 some of the complications associated with developing delirium include prolonged mechanical ventilation, as well as increased length of stay, and most importantly, long-term cognitive impairment and physical disability. And there's a dose response relationship, such that each additional day a patient experiences delirium, increases the likelihood of death by 10%, and you can see some of the references for the statistics that I've just quoted at the bottom of the slide. So it really makes sense, as delirium and VAE both occurs in mechanically ventilated patients that we tackle the two of these topics together. Next slide. In order to do that, to prevent VAE and delirium together, we have the ABCDEF as a bundle. And what this stands for is -- next slide -- A is for assessing and preventing and managing pain; B is for the spontaneous awakening trials and spontaneous breathing trials; C, for looking at choice after analgesia and sedation; D, delirium, assessing, preventing and managing that delirium; E, looking at early mobility and exercise; and family engagement and empowerment. And we're really excited that we have such a great speaker today, Dr. Ely, to help us to go through the ABCDEF bundle and the impacts of the ABCDEF bundle on patients. Now for most of you participating in the Partnership for Patients, you would have seen the measures that we're using for the Partnership for Patients, which mostly center around the pain agitation delirium assessment tools. Next slide, please. In order to assess pain, we encourage -- there are a number of hospitals have asked us what should we really be using, and we're sure that Dr. Ely will go through some of these; however the assessment tools that are available to assess pain agitation, delirium are listed here, and these are some of the tools that we encourage you to use to assess pain, agitation, and assess for delirium and treat for delirium. And in order to assess hospitals in looking at their pain agitation and delirium in their mechanically ventilated patients, we have developed a data collection tool that we'll be introducing to you through your project managers in the very near future, and we encourage you to reach out to your project manager to see this tool and to learn a little bit more about it. Next slide. And this is the tool that you see on the screen in front of you. And we will be, as I mentioned, introducing it to you through the project manager moving forward. So without further ado, I believe that Dr. Ely has joined us now, and we would like to introduce him as our speaker today. He is a Professor of Medicine at Vanderbilt University School of Medicine who has subspecialty training in pulmonary and critical care medicine and a particular passion of care for older critically ill patients. His research has focused on improving the care and outcomes of critically ill patients with sepsis and [indiscernible] failure, with special emphasis on the problems facing older patients in the ICU, either weaning from mechanical ventilation, delirium, and cognitive impairment in the ICU and quality of death. He has over 250 peer-revered articles and is the founder of the Vanderbilt ICU Delirium and Cognitive Impairment Study Group. He currently serves as a principal investigator for the Coordinating Center's clinical trials and sedation in delirium and post-icu cognitive impairment. Among other studies, Dr. Ely is currently the current principal investigation of two NIH sponsored and VA sponsored cohort investigations in ICU patients, focusing on delirium and sedative analgesic drug exposure, and acquired cognitive and function impairment in survivors of critical illness. Importantly, he's married to Dr. Kim Ely, a surgical pathologist at Vanderbilt, with whom he has three lovely daughters who are the pride of his life. And with that, I'd like to turn the floor over to Dr. Ely. Thank you so much, Wing. I appreciate your introduction. That was excellent and I'm wanting to make sure you can hear me. Can anyone hear me? 2

3 We can hear you fine, yes. Thank you. Okay. Fantastic. And can you see me on the webcam? That, unfortunately, we cannot see you. Okay. My webcam is -- okay, hold on. Is that now working? We can see you. Thank you very much. Lovely. Thank you. Well I greatly appreciate the opportunity to be with all of you today. We have a large crowd of people and it is our group, the ICU Delirium and Cognitive Impairment Study Group's privilege to be a part of this process. We think that what you're doing in New York is fabulous. We think it's incredibly well timed. These are extremely evidence-based approaches that you were talking about, which Wing just reviewed with you. By the way, Wing, that was a super, excellent, and very evidence-based introduction to this whole program. So very well done. In fact, I was going to comment that you talked about ventilator-associated events, or VAEs, one of the ways by which we can track complications for mechanically ventilated patients, and what I was going to say right off the bat, which we will get to later on in the upcoming months, is that a few years ago I was sitting here at my desk and the phone rang. And it was the CDC, the Center for Disease Control in Atlanta, and they basically called me up and said, "You know, Dr. Ely, we know that you're working with delirium, and we are working with ventilator associated pneumonia, VAP, we're going to have a new metric, called the VAEs or VACs, ventilator Associated Complications, and we want to work with you to reduce these ventilator associated complications and events." And some people might think, well why did they call you if you're working with delirium in the brain and they're working with reducing problems of the lung, what's the connection. And I always tell people that it made complete sense to me that day when they called me, because, really, the brain bone is connected to the lung bone. You know, when we brought up as kids we talked about that funny song, but it is true that the evidence shows there is a credibly tight correlation between the things that get you into the ICU, which are the need for the mechanical ventilator, and then these super complications of delirium, and then, ultimately, going back to the lung from the brain, once you develop delirium, having a high likelihood of problems like ventilator-associated pneumonia. So, anyway, we worked together with the CDC, and we found and we published in the blue journal, the American Journal of Respiratory and Critical Care Medicine, in a double-digit ICU investigation with the CDC, that we could have tremendous reductions in the VACs and VAEs of our critically ill ICU patients, mainly by focusing on delirium and this bundle that we're going to talk about today. So I think it's extremely important for you, as all of your different ICUs around the State of New York embark upon this journey you're taking of quality improvement, to know that there is some great data here, all the way from randomized control trials to real-life quality improvement projects done even by places as famous as the CDC, which have totally established that the way to manage your critical ICU patients these days should no longer be a kind of wing it and old school, which is whatever that particular doctor or that particular nurse think are important that day. Not that that doctor and nurse's preferences aren't important, but all too often all of us, and I stand much to blame of this as anybody, is when we get in the throes of our busy day we tend to have certain biases about things that are important for patients and we leave stuff out. So we end up paying to attention to some things that are important, and we totally ignore things -- other things that are very important. And the person who suffers in the end of that biased approach is the patient. 3

4 And what we're doing here with the ICU Liberation Collaborative and with this program that you are embarking on in New York, is we're trying to say, you know what, for 2016 on we're going to implement this quality improvement program which is going to say, these are the evidence, these are the data, and we're going to have a bundled approach, the A to F bundle, ABCDEF, like Wing just went over with you, and we're going to make sure that every patient every day gets each of these steps. And we're going to hold ourselves accountable if we don't do that. So that's what this is about. I'll give you, today, an set of introductory comments about this, which will hopefully get you excited, jazzed up, about this quality improvement program,. And then in March and April and on other occasions we will have further steps in the chapter of this whole program. So this is our institution at Vanderbilt, where I and the rest of our team work. I'm going to be bringing one of our ICU nurses, who is a member of our ICU delirium and cognitive impairment study group with me. The two of us will come and teach in New York. Her name is Christine Rowan. She's excellent. She is one of the best nurses I've ever seen in the ICU, and she will be coming up with me, so we'll have a doctor/nurse team to try and allow you whatever questions you have, and any sort of problems, sticking points, or pitfalls that you identify in implementation of this quality improvement project, that we will try to help you around those and circumvent them towards success. I always start with potential conflicts of interest. I would want to disclose in this case that I have -- while I don't have stocks in these companies, I have done honoraria for continuing medical education programs by companies that have been sponsored like Abbott and Hospira and Orion, and so I would disclose that. I also have academic conflicts, which are federal funding. We get funding from the NIH and the VA, and I think it's just as important to disclose those academic conflicts of interest as it is any potential industry conflict. But having said those conflicts, I will assure you that it is my commitment to you throughout the course of this next six months that whatever we teach, whatever we bring up will be evidence-based. It will be stemming from the peer-reviewed literature. We will have references on the bottom of our slides. If you ask me questions or if we deviate from the peer reviewed literature, where there aren't any data, then I will qualify that as anecdotal. You'll put your hip waders on, take it with a grain of salt as my opinion, because my opinion is not the most important thing here. What's important are the data. Now, before we get started, let's frame what we're getting involved with here. And I'm old now. I'm 52 years old, so I'll put on reading glasses for some of these slides. But this one of my favorite quotes "Medicine is more than a profession. It is not an occupation for those to whom career is more precious than humanity or for those who value comfort and serenity above the service of others." And this quote by Abraham Heschel said in the 1964 AMA Convention it's relevant to us because if we're going to change how we handle thing, if we're going to do things better for our patients, based upon this evidence-based A-to-F bundle, it's going to get us out of our comfort zone. In the '90s when I trained every patient was snowed in the ICU. They were unconscious. They were in that drug-induced coma, and that was an easier way to go for us. We did it because we were trying to be benevolent to the patient. Don't get me wrong, I think we were doing it for the right reasons. But it also created a circumstance where our patients were quiet, they weren't arguing with us, they weren't getting out of bed. And in moving. Now, towards an awake alert patient on the ventilator, we are going to have to realize that we're putting humanity above career and comfort, et cetera. And it's not our comfort and serenity that matters but the comfort and serenity of the patients. So here are some concepts to remember before we get started. You at your center, just like I and Christine here at Vanderbilt, we're cogs in a wheel. Many people have contributed to these data prior to us. We have to ask ourselves what is our path? And one night people like me to account these stories. I 4

5 won't do it now in full because of time, but one night in the middle of the night in medical school at Tulane, after I had left Charity Hospital, my friend and I asked ourselves this question, and we decided that we would try and change the lives of people whom we would never meet. And that is really what led us to this work. My friend became the President of Doctors Without Borders. He's been all over the world serving in that missionary capacity. And I chose to go into the tertiary care world of medicine, in critical. But in both instances the research or this work that he did with MSF, Medecins Sans Frontieres, I think that what we're all hoping to do is change the lives of people whom we will never meet, in addition to those that we do get to care for on the in-of-one basis. And you will do the same. And I'm pointing this out to you because you at your center, when you implement this quality improvement project you will influence the lives of people in 2017, 2018, and 2019, maybe after you're gone. So be a part of something that's bigger than just today and tomorrow. And that brings us to this wheel of comfort or this wheel of safety. The SCCM has said, well, look, the pain and agitation are not enough, we have to add delirium. The old school of these guidelines, were these pain and agitation guidelines, and in 2013 we added the delirium piece, which completed this wheel of comfort, or this wheel of safety, and that is what we're going to implement with this A to F guidelines and A to F bundle. And to share with you a little bit just graphically about how we know that this delirium is a new kid of the block, you can see on this graph, and this will complement on the next slide that I will show you, that delirium, back in the '90, there was just very little going on in the world of delirium in terms of numbers of articles published per year in the ICU delirium world, and then we published a tool by which people could measure delirium called the CAM ICU, or the Confusion Assessment Method for the ICU, and that was published in And you can see on this graph, as you move to the right in time, that after those tools became available and there was another one published by the Canadian group Johanna Scropelik [ph], called the Delirium Screening Checklist. Once the ICU community had the availability of these tools, then people started doing more studies and more data became available. Now interestingly, if you look at the far right of this graph, you can see the number of publications for 2007, and that line is the same height on this graph as it was on the previous graph, but now you can see how far to the right and how much higher these data have become in terms of numbers of papers for a year for ISU delirium. So this really is a new kid on the block. It's a very evidence-based piece of the ICU care that you are providing for your patients. And I just wanted to show you that up front so you know that this is not just warm and fussy stuff here. This is hard-core science. Now on this graph you can see a very famous person named Malcolm Gladwell. Malcolm Glad well wrote "The Tipping Point." Some of you know this. Other books, "Shat the Dog Saw," "David and Goliath," excellent books. He's there with my twins, two of my daughters. Those are Brooke and Blair. And why are they there together? It reminds me to tell you that what Malcolm Gladwell said in his book was that in order for something to take off -- and this is relevant for your quality improvement program -- for something to take off it should be sticky, meaning memorable, and the A to F bundle is memorable. That's the alphabet. There's nothing more memorable than the alphabet, the first thing that we learn as humans. And in addition to that, you have to have different types of people. And so I want to tell you these types that he outlines, and you need to think in your brain who are those people in my ICU, in my team here at my institution. You have to have mavens and you have to have sales people and you have to have connectors. So mavens are the experts, people who are the high-end expert on that topic area in your hospital. But that's not enough. You need sales people, people who can get other people excited and bring them on board. And then you have to have the connectors. If you build wonderful silos of great nurses and great doctors and great pharmacists and within those silos you have mavens and you have sales people there, that still 5

6 won't be enough for to have long-lasting success in your institution, and so what we know is you have to have a connector, somebody who can bridge these different groups and de-silo your circumstances there at your institution. So I'm trying to tell you things up front that you need to be considering for your team to build this so that it will succeed. And if you just identified in your mind two of those three people but you couldn't think of who your third person was, you need to go get that person. You can't do this unless you have all three things. We've taken care of making it sticky for you. But we can't take care of you having the right team member, so you have to figure that out. So back to the bundle. We're going to have a bundle which is used to implement these guidelines. These guidelines, the pain agitation delirium guidelines, were created -- I was an author. I was in charge of the delirium section -- reviewing some 20,000 per-reviewed manuscripts. So a ton of information went into it. And after we published the PAD guidelines, on this graph, on this slide, you can see the PAD on one side of the slide, and those are the symptoms that your patients are experiencing but people began to get confused, well where does the bundle fit in and where are the tools. So we're treating symptoms with the PAD guidelines. We're doing that by monitoring for those symptoms. For pain we're using a VPS or a CPOT for example, for people who can't verbalize where they are with pain, if they're intubated for example. If they're not intubated we can do it on a visual analog scale, a zeroto-ten scale oral something like that. But if they're not we use the tool. For agitation we use the RASS or the SASS, and for delirium, the CAM ICU or the Intensive care delirium screening checklist. And these two tools per symptom were identified because they were more evidence-based. We didn't just say, "Oh, we want two each." That seems like that might have been what happened, but that's not what happened. What we did was we said we're going to apply a psychometric tool to each tool that's out there. And there was a measuring instrument that we applied to all the delirium instruments, all of the arousal scales or sedation scales, whatever you want to call them, or pain scales. And at the end of the day, after they were done, there were only two in each category that were above the 15-point threshold that we set as acceptable to recommend. So now I have tools to recommend to monitor these symptoms. And now how do you put that into play for your ICUs? How do you manage the patients? Well over the time of the last 15 years, different New England Journal of Medicine, JAMA, and Lancet papers have been published, which have allowed us to build this bundle. The bundle, which, as I said, starts with the first six letters of the alphabet. You can see at the time that I wrote this slide on my ipad we only went to the E. We had the awaking trials and breathing trials and coordination and delirium and early mobility. We had not yet added the F. But now we have, thankfully, and appropriately, brought the family into the fold here, and so that was logical because it was the next letter, and so we built this into the A to F bundle. And if you want to read more about this, because we're not going to go into dramatic detail today about this, because we want to be respectful of your time, you can go to our website, which is the ICU delirium website, and that's icudelirum.org, and that website is a place that you can go to get more information about this entire bundle. I'm plugging my computer because it came up. Here we go. So this website as the ATEF protocol, and an amazing amount of protocols, it's free protocols, videos of the patients and families, et cetera, all available on this website for you. And it's all free. There's nothing to sell you, and so we hope that you find this useful. In addition, there is also a website by the SCCM called iculiberation.org. So there's icudelirium.org and there's iculiberation.org. So this bundle begins with assessment, prevention, and management of pain, then both spontaneous awakening and breathing trials. Both of these were shown to be efficacious in new England Journal of Medicine manuscripts, one of which I did as my first big science study in academics. The C is choice of sedation. We have numerous JAMA papers and Lancet papers looking at what's the best choice for 6

7 sedatives in the ICU. The number one take-home point there would be to try and avoid Benzodiazepines, and avoid over sedation in general for you ICU patients. Then there's D for delirium assessment, prevention, and management; E, early management and exercise; F, family engagement and empowerment; and then there's those two URLs. So the whole key to this entire thing is you being empowered and motivated to change the culture of your ICU so that every patient every day gets this ATEF bundle, because it will be safer for them. They will have shorter lengths of stay. They will have less delirium. They will have better long-term outcomes. And this has been documented in numerous investigations, both individually, so we know that the A and the B and the C and the D individually work well, but we also know that when we put them together, that they work better as a bundle than any of them individually. And so the overall goal of this, if somebody says to you, "What's this project, what are we doing?" You're going to say, "Well, we're trying to better optimize pain, we're trying to break the cycle of deep sedation, and we're trying to reduce the incidence and duration of delirium, improve short- and long-term outcomes and reduce costs." And there are data on all of these things that would support that this bundle will help you get there. We're going to liberate patients from public health problems. Now what public health problems? Well back to what you do is you take care of people when they are admitted to the ICU, and what they're admitted for usually is shock or the need for mechanical ventilator or post-op management. But under your nose in the ICU, they are acquiring a new set of problems, which we have identified as a public health problem. And those new set of problems include two main categories. One I like to say is neck up, which is the delirium and long-term cognitive impairment, and the other one is the neck down, which is the ICUacquired weakness, which is muscle and nerve disease in the human body that wasn't present when they came into the ICU. I think identifying patients is important, putting the patients in our mind is important. This woman gave us permission to use her example. She had necrotizing fasciitis of the face, very brutal circumstance. And we imposed on her, we managed her with the A-to-F bundle every day very aggressively. She and I have been keeping up with each other via letters ever since she left, and I'm happy to say she's doing very well, leading a very productive and happy life. But, thankfully, I think that, as shown in the evidence, in individual clinical trials and peer-reviewed literature, on an individual basis the reason that this woman is shown right here walking vertically up and down the hallway in our ICU the day that she was extubated is because several days before she was extubated, she was already being walked. She was being mobilized early. She was being managed with light sedation. She was totally arousable and communicable with her family, and this created the milieu in which she could continue to get to this strong point in her life, recover, and have less post-icu syndrome or what's called the post-intensive care syndrome or so called PICS, so our PICS is dramatically reduced, this PICS, post-intensive care syndrome, dramatically reduce by all of the aggressive efforts put into manage her at the beginning of her ICU experience, when she was still on the ventilator. Here's another patient, a liver patient, a patient -- well a patient who had liver disease -- a better way to say it -- who is sitting here in the ICU on the ventilator, failing his SATs, can't come off, hypoxemic and testing his kids with his wife looking on and smiling, beautiful picture, much more humane. And this one, one of my favorites, are multiple pictures. We have five pictures here, going from left to right, showing a patient and his nurse using sign language to talk to one another. This man is deaf. He is intubated. Very scared in the ICU. How scary would that be? Not only you can't talk but now you can't hear, and maybe you had a little delirium. Totally frightful place to be in life, but instead, since he's awake and alert, since we've managed him in a way that reduced his delirium, he is now in a much more humane circumstance of having preservation of self-worth and human dignity via being able to absolutely 7

8 talk to somebody the way he normally would, even if he wasn't critically ill and intubated in an ICU situation. So just a real neat set of patient examples of why you want to do this. This hopefully sets up for you the big why, which is human beings on the other end of your care that you have the responsibility and the ability to make have a better life as they're going through this totally harrowing period of time in their life. So, again, back to our website, you can go to this website and find much more information on the A-to-F bundle. There also is a patient and family page on this website where you can go and you can watch a video of patients. And this is getting at that you can find [indiscernible] videos, which can help your team have more buy-in about the way that they are going to approach this quality improvement initiative. Is this going to be approached for example, as a, oh, wow, now we have another thing added to our life. Now our job is changing again. I don't like change. I like it to be the way it was. Why do they have to go and modify the way that I care for my patient? I'm a good nurse. I'm a good doctor. Leave me alone. That's a mindset. Or is the mindset one of, okay, gosh, I've tried hard my whole career, I've done my best, but we have new information. There are new data to tell me a more comprehensive way, or us as an ICU, for us as a whole unit to approach the care of all of our patients, kind of systematically rather than catch as catch can and anecdotally bed to bed doing it so differently every time. So what this represents -- and you'll have people in your hospital who will be anti-protocol, anti-cookbook message. My reply back to them is, okay, I agree. This isn't cookbook medicine. That's not what we're talking about here. What we're talking about is having a default set of standard ways that we manage our patient, just like if you go on an airplane and you watch your crew go through a checklist of things that no matter what, every time that 150 people get on that airplane they're going to go through the checklist to make sure that those 150 people get safely to the next airplane. That's exactly the same circumstance here, except it's being applied across an ICU of 20 beds or 5 beds or 30 beds. Whatever size unit you've got, we're saying you know what, whoever comes through that door every day we're going to make sure that we apply this checklist to our patients to make sure that they at least get these things, these elements of safety, to try and get them to the next airport as safely as possible. So what are the teamwork and modifiable aspects of care? Well that's what we will hit as we go through this next six months together. And we will talk about those aspects. You know the modifiable pieces might be the most important ones, which drugs are you gives, how long are you giving them. Are you keeping them tied down, or are you getting them out of bed? Are you checking on deliriogenic aspects of their care when they have CAM ICU positivity, are or are you just letting their brain go down because you say they'll get better eventually. All right, so what did we do? At the SCCM, they called us and we helped organize this. They said, you know, we want to have a collaborative, much like the Surviving Sepsis Campaign. But instead of treating sepsis, we're going to treat all ICU patients who have this common set of problems, of immobility and delirium and over sedation and adequate pain management, and we're going to have a collaborative called the ICU Liberation Collaborative. And for a year-and-a-half we're going to let people apply to, get accepted, and be a part of this collaborative. Now you are simply having your own collaborative. So I and Christine, we're here to be part of your team. You already have a super efficient, educated, and knowledgeable team, but we're going to be a complement to the team to try and help you get down the road with as few hiccups as possible. But on the national level, with the SCCM, what was done, is they divided the country into three regions,. You can see them on this graph. And then those regions allowed -- hospitals were allowed to apply, and they got accepted. And those hospitals got accepted, and this graph shows you the 80-some-odd 8

9 hospitals around the United States that have applied for and been accepted to and are now participating in the ICU Liberation Collaborative. And the main goal of this collaborative is to implement better the PAD guidelines, pain, agitation, and delirium. And the mechanism which by these PAD guidelines are getting implemented is through this A- to-f bundle, which you are also choosing to use, which we will teach you and go through together. Now to close, to bring this to a close and to allow you for your questions, I would close you with this is a picture. This is a picture of a very famous Sushi chef. This is one of the top five most exciting people I've ever met in my life, other than my own family. Obviously we would always put our family at the top of that list. But in terms of people that I had the privilege of meeting, I met Jiro, and Jiro is widely considered -- no argument here, I don't think -- the greatest sushi chef in the world. I put that Aristotle quote at the top, "What we are is what we repeatedly do. Excellence is not an act but a habit." Jiro is so excellent at making sushi that he's got a three-star Michelin restaurant in a subway in Tokyo. And I was asked to go to Japan a few years ago, I told them I'll go if you take me to Jiro's restaurant. They did. It was a lot of fun. And I watched him pay attention to every single detail of how every piece of that sushi was made, and I just kept thinking to myself, if he can care that much about the way that each sushi piece is made, then sure I, as an ICU physician, you as an ICU team, should also care even that much, maybe more obviously, about the way that we do the care of our patients. So those are thoughts I had at the introduction of this Program. I'd love to open it up to questions and see what's on your mind, and then we will work together over the ensuing weeks and months to do our best for our patients. Thank you so much. All right, thank you. Those in the audience who would like to ask a question, please type your questions in the Q&A box just above the chat box. Also, if you would like to use your phone to respond, you can hit the little individual with their hand raised at the top of your screen, and when we see that, we will attempt to unmute your phone lines. And don't be bashful about questions. I mean I didn't cover a lot of detail today, so you can ask a question on any aspect of this topic, whether it be the ventilator management or the drug utilization or the pain management, or any of the things that we just discussed from a culture perspective. And while you're thinking of questions, let me throw something out there. We didn't discuss this today, but I want you to start thinking of this in advance, rounding. Rounding is a critical piece of this, such that you want to make sure that your team is thinking out loud about the discussion that takes place on rounds. I, for example, want to make sure that you know you have to, what I say is, talk the talk. You have to have the talk on your rounds, which is that the nurse has to collect the data on the A-to-F bundles, the nurse the, pharmacist, whomever, and they have to relay that information on rounds using an ICU rounding script, which we will be happy to share with you Vanderbilt's example, not that it's perfect, but by which a template by which you could then adapt your rounding script at your institution. If you don't have on rounds, though, a discussion that includes things like target RASS, actual RASS, delirium or CAM ICU, and drugs, and you don't stay that stuff out loud, I can guarantee you, you will not change your culture. This will die on you. You will try it and do well for a couple of three weeks, and then it will go away. You have to actually make it part of the every patient everyday practice of talking through the patients target, natural RAS, delirium, CAM ICU, and drugs as part of your rounding script. Now any questions that anybody has? Yeah. There was a question on the use of restraints with less sedation. 9

10 Okay, good. First of all, when you use less sedation, the first thing that's happening in your brain is uhoh,, then I need to retrain them so they don't pull their NT tubes out. I get that. You will find in time that that will be partially true and partially not true. Do you need restraints if somebody's going to pull their tube out? Absolutely, no question. I mean, you can't have somebody running around pulling their AT tube out. But the proactive things you need to do in your culture are more important than just tying everybody down. For example, we found, when we did the ABC trial, which we published in Lancet, that we did get more self excavation. It was very interesting. And nurses were predicting that we would. But guess what we didn't get? We didn't get more reintubation. So the patients were self-extubating and not needing reintubation. And they wouldn't have self-extubated if we had moved more quickly in recognizing their readiness for extubation, and then gone ahead and just extubated. So the problem was us, not them. They were better more quickly than we anticipated, because when you start over-sedating people they look sicker and so you think they're going to be on the blower for a couple of extra days. When in reality, when you stop all that, doing awaken trial and let them wake up, they actually look better, but you weren't ready mentally, so then they end up self-extubating. So the response here is you're going to use lighter sedation. You're going to wake them up. You're going to use an SAT and an SVT, and you're going to mobilize them. Some of these patients you're going to need restraints on, but many of them won't, and instead, you'll get to extubate them earlier, and they won't need to tied down because there's no E tube left. Next question. Did you need to increase your tech stats in order to meet your activity E value? Did I need to do what to meet the E value? To increase your technical stats in order to meet your E value? Okay. No, we did not. In fact, we try to hold, by the way, ourselves accountable to an 80% compliance with each of the letters and the bundle every day. So over time. We want our compliance overall with all of our patients to be 80% on each level, or higher. Some people say 80% isn't good enough. We actually are, right now, above 90%. But I don't want you to think we're perfect, because we're certainly not. We have a lot to learn as well. But, no, we did not increase our personnel. In fact, you know, so many nurses tell me, look, Dr. Wes, Dr. Ely, mobility is a basic part of nursing care. We should be part, we the nurses, should be part of mobility of our patients. So it's totally true that we do have a physical therapist and occupational therapist to come into our ICU. We do not have a dedicated physical therapist, an occupational therapist for just our ICU. Some ICUs have that. We do not. But the ones that come in, run the list with us each day is Scott and Britney, Scott Haus and Britney work, they do come and run the list with me when I'm in the unit, and we say, "Scott and Britney, can you work with Miss Smith more or Mr. Jones more today, and then for Mr. Hake and/or Miss Thompson, their nurses will be able to work with them because their needs are slightly less. So we tend to triage the PT and OT to the more needy areas of the unit, but where they can't be, the nurses, it's considered part of their job to mobilize the patients. And we did not have to go hire new personnel to get that E threshold met. Thank you, Dr. Ely. Our next question from the audience is that we have multiple MDs who rotate through our unit, and each has their own way of rounding, so that consistency suffers. Do you have any suggestions? 10

11 Yes, I really do for this. It's very important that you let those doctors know that you respect their individual preferences for rounding and that they should be able to insert their individual aspects into rounding, just like a nurse wants to insert his or special ways they do certain things, the way they tie the E tube, the way they mobilize their patient when they get drugs, et cetera. But you should say it will also be considered standard in our unit from now on at the beginning of each patient's bedside interaction is with a nurse going over this rounding script. So, for example -- and we can share this with you as we get further along. For example, the nurse at the bedside would say, "our patient's CPOT level is blank, is four. Our patient's CPOT level is four. That's the A. Our RASS target is zero. Our RASS actual is minus two. And our CAM is positive. The patient is on a intermittent Fentanyl for pain and this morning we, since the C pot is too high, we had to increase that Fentanyl, and then we're going to get them through an SAT and SVT later this morning and hopefully get Scott and Britney over here to work on mobilizing them later this afternoon. So right after that, how long did that take for me to say that. That was 10, 15 seconds at the max. And I got out there, what did I get out there? The pain piece, the SAS STP piece. I got out there the drugs, the choice, and how we were titrating the drugs. I talked about the fact that they were delirious. We could then have a little bit more of a conversation about the potential causes of delirium in that patient and how we could potentially reduce the delirium burden in this patient over time. We talked about the EPs. So that rounding script, which I just gave you, we have it printed on a sheet of paper, and the nurse fills that out prior to rounds, so when the doctor comes to bedside, the nurse just goes straight through that script. It's very brief. It's very efficient. Everybody's speaking the same language, and it has become the culture of our unit. So if you can fold that into your culture and then allow the doctor, as soon as that script has read, to adapt and implement their own personality into the round, I think it's a win-win situation. Thank you, Dr. Ely. We also have a comment from the audience that they believe this will be a total revolution of ICU culture when it comes to the care of the ventilated patient. And with our next question, we were wondering if you could provide some alternatives to benzos for anxiety. Sure. I'll tell a story of myself. I like to poke fun at myself first. So in the old days, the West that would be fat bedside prior, I really have so much respect for nursing care that I would just completely defer to the nurses on treatments for anxiety. And so, for example, in our old culture, when the patient appeared anxious in the bedside and they were tied down on a ventilator, and the nurse would say, "Doctor, this patient is very agitated. I need more benzos," and I would just say, it request, "Good. You asked for it you got it, let's give you more benzos. I'll write the order." And that was, to me, just completely complicit with let's give them whatever they want. Now those nurses never did have anything nefarious in mind or injurious to the patient. They really were looking at a person who looked anxious who seemed like they needed something for their anxiety. So that nurse, out of benevolence, was seeking something to help the patient. But now I've learned that so many times when the patient appears anxious like that, I think, about, well, gosh, what would I feel like if I was sitting in that bed and you had me tied down for two days. I mean, I'm so hyperactive, I would go nuts if you had me tied up for half of a day, much less two days, and, plus, have an ET tube down, can't talk, and now I'm a little delirious. So I think I'd just be crazy trying to get in there. So a lot of times our agitation, my first point is, a lot of times the patient's agitation, the best treatment is not a drug at all, it's untie them, get them out of the bed and exhaust them, you know, get them completely exhausted. And guess what will happen then, put them back in the bed, and they just sleep naturally. So this is my first comment. My second comment is, is agitation pain? You know, do you have a pain tool in your ICU that you're recently using. Well you might now, but for the ventilated people do you have the CPOT? Do you have some way to do that for non-verbal patients? If you don't, then how do you know it's not agitation and they 11

12 just need a little more narcotic. Maybe they just need some better pain control. So those are a couple of first thoughts. And secondly, let's say, though, that you have managed your patient with mobilization, and you have managed the patient's pain, and they really still are anxious, or need something for anxiety. Well we often use, for example, on a ventilator now, we will use something much shorter acting, like an alpha two agonist or a narcotic, and now goes a patient approach where we use a narcotic only. So these are approaches to avoiding GABAergics. Generally, I would say let's try to avoid GABAergics where GABAergics are being Propofol and benzo. And the way that we do that is either an algo-sedation approach by itself, which covers pain and sedation, or drugs like antipsychotics or Dexmedetomidine, things that are shorter acting, which don't suppress the respiratory drive. And that way if you're trying to get somebody off a ventilator you haven't given them something like a GABAergic drug, which is respiratory suppressant. Okay, next. Thank you, Dr. Ely. Our next question is "Who collects the data in your ICUs?" Great. So we have several different things going on. One is that we have a computerized system, so the charting all tracked. We're very lucky that we have this, so the charting is tracked. But for projects like the ADEF bundle, where we're manually collecting some the data -- some of this is collected automatically with every key stroke of the nurse. But other projects, for example, with the ICU liberation, the bedside nurses and some clinical nurse educators are the ones collecting these data. So that's happening around the country with the ICU liberations. People have found a way to collect these data. So either it's automated as part of our approach. Now we have something called a dashboard, and our dashboard is, you know, red lights and green lights on a dashboard, where we can see, has the SAT and the SVT just been done, in which case they would appear green. Or has it been six hours and nobody's done this at all, in which case they're turning yellow and then down to red for delirium assessments and pain management and all that business. So we have this dashboard where we can see are we green lights good, are we yellow lights warning, are we red lights danger, slow. We've got to get back on our game today for Miss Smith. And then data collection can be either electronic or manual. Thank you. Our next question, "When ventilated patients are experiencing signs and symptoms of delirium based on screening tools, how do you prefer to manage them? Are atypical antipsychotics or Haldol appropriate?" So the first thing is I like the way that question went. It said, "How do you prefer to manage them," and then it went straight to antipsychotics. And that is a knee jerk way of thinking, and the person who wrote it is full on. I mean I get it why you wrote it that way, but I'm going to try and unteach something for you. I'm going to try to unteach this knee jerk feeling that once the patient is CAM positive that automatically I need to grab a drug. Now you may not have even meant that, but I'll so glad the way you wrote it, because it shows that medicine generally thinks, it's how can I fix this with a drug. We actually use a mnemonic, and this is on our website, this mnemonic, called the Dr. DDRE, which is D- D-R-E. And it stands for "Diseases, Drug Removal, and Environment. That's DDRE, Diseases, Drug, Removal, and Environment. And a nurse came up with that. I don't want to take credit. She asked me this question. She asked me this same question, "Dr. Ely, what do you do when I tell you they're CAM positive?" And I said, "I went into this other mnemonic that we have, which is also good. It's called the "THHINK" mnemonic, toxins, hypotension, Haldol, obesity -- sorry, infections is the eye, and then infections like sepsis, eye is also immobility, N is for non-pharmacologic things, and that's what I was about to get at, using things other than drugs, and K is good for potassium, which stands for metabolic syndrome. 12