A trip to a hospital Intensive Care Unit (ICU) isn’t usually planned ahead of time. It typically happens suddenly, when an illness or accident reaches a critical level and intensive care is needed to save a life. The technology and medicines in modern ICU’s do indeed save lives, but research reveals that some ICU practices intended to keep patients alive may also inadvertently cause harm.
A world-renowned leader in critical care practice, Dr. Wes Ely, MD addressed AEPC’s December Executive Board Meeting about his work to improve ICU care. A critical care physician and professor of medicine at Vanderbilt University School of Medicine, Dr. Ely’s message is especially timely as COVID-19 continues to fill ICU beds.
Delirium and More in the ICU
In over two decades of medical practice and research, Ely was challenged to understand why so many ICU patients suffered from a host of disabling problems that have come to be called PICS, or – Post-Intensive Care Syndrome. PICS may include delirium, nerve damage, depression, and mental or physical impairments that arise while in the hospital and sometimes linger on for years.
Six million people are admitted to an ICU every year in the U.S., and their chances of experiencing PICS are alarmingly high. About 2 out of 3 patients in ICUs experience delirium, while another study found that more than 50 percent of patients had cognitive impairment one year following their critical illness, according to the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center directed by Ely.
A System for Better Outcomes
Ely’s research has led to a series of ICU protocols that have measurably improved health outcomes and shortened hospital stays. Key components of the protocols, called the A2F Bundle, center on:
- minimizing sedation
- early mobility of patients
- involving family members in patient care
Multiple studies published in medical journals, including the New England Journal of Medicine, JAMA, Lancet, and Critical Care Medicine, document the results of these protocols: four fewer days in the hospital when sedation was lessened and lower rates of delirium. The research also showed that delirium is more than temporary confusion and mental incapacity. It is associated with an increase in death, and every additional day of delirium increases the risk of death by 10%, according to Ely.
Less sedation resulted in four fewer days in the hospital and lower rates of delirium.
Getting patients out of bed and moving as quickly as possible facilitated a return to normalcy that benefited both a patient’s body and mind. Bringing in family members to provide emotional support and advocacy also promoted quicker recovery and less delirium and coma. Measuring these impacts helped make the medical case supporting the A2F Bundle.
More Than Data Points
While stats and studies are necessary to measure outcomes and efficacy, offering examples of how patients are affected by PICS provides a gut-level understanding of why these protocols are so important. Ely recently published a book, Every Deep Drawn Breath, in which he chronicles his journey in ICU patient care. Getting doctors and nurses to adopt his methods hasn’t always been easy.
In the book, Ely recounts the story of a nurse who was training other nurses to use the A2F Bundle protocols. She noted that while her trainees were attentive, a follow-up visit showed little was being put into practice. So, at her next session in a different hospital, she focused on more than mortality reduction data.
“I told them what sedation did,” she says in the book. “I told them what tying patients down in bed did, how they couldn’t walk or have their jobs or how they lost their spouses and their families. How they said they’d rather be dead. I had nurses crying. They’d thought they were doing the right thing because that’s what we’d been taught. They said, ‘We didn’t know,’ I said, ‘I didn’t know. I’m learning all this stuff, too. But we’re hurting people, we’re breaking their brains.’ ”
Up until the pandemic, the A2F Bundle, or portions of it, was gaining acceptance in ICUs across the country. The Society of Critical Care Medicine developed a toolkit and training, calling it the ICU Liberation Bundle. Better outcomes were on the rise. But COVID-19 changed all that.
The COVID Effect
Without question, COVID-19 has and continues to place a heavy burden upon hospitals and staff. Amid shortages of staff, personal protective equipment (PPE), and stocks of some medications, adherence to A2F Bundle protocols became a back burner priority. “We’ve been working for 20 years, and we’ve reduced delirium down from 70% in ventilated patients to around 40%,” Ely said in an April 2020 article in Pharmacy Practice News. “But COVID-19 has got it back up to 80%. So in three months, we’ve erased 20 years of progress.”
But Ely is determined to regain the lost ground.
At AEPC’s December meeting, he explained that educating patients and family members is a critical part of the work that leads to less delirium and cognitive problems in the ICU and when patients go home.
The Role for Patients and Their Families
The very nature of a hospital ICU stay is disorienting. It’s an unfamiliar place, you may be experiencing pain, feeling scared and separated from loved ones for prolonged time periods. Knowing what to expect and getting as much support as possible can go a long way to minimize the trauma of the ICU.
Understand that delirium may occur. Confusion, attention or memory problems, and generally not “feeling like yourself,” are common symptoms of delirium. This can be caused by chemical changes in the brain brought on by medications, a pain response, or other aspects of your illness or treatment.
To head off delirium, strive to create a familiar environment. During your ICU stay, have family members bring treasured photos or small items from home that make you smile. Ask them to also bring items such as hearing aids, eyeglasses, and dentures to help you feel like yourself. Let natural light in your room during daylight hours, and close your door at night to block out noise and lights to maintain normal awake/asleep patterns. Ask hospital staff to minimize nighttime procedures unless they’re absolutely necessary.
Ask for the lightest amount of sedation to keep your pain in check and ask your doctors if there are alternatives to using benzodiazepines (lorazepam or midazolam), which have been associated with higher rates of delirium at high dosages.
Get up and move as much as you can. There are multiple benefits to keeping your body moving. Muscle loss occurs quickly when confined to a bed, making recovery times longer. Start small by taking just a few steps, but keep at it! Emotional and mental well-being improves with movement. Ask for assistance to assure your safety, especially if sedation medications are still being given.
Family support is critical. One of the most difficult aspects of COVID-19 has been the isolation of patients from their loved ones. On the front lines throughout the pandemic, Ely saw first-hand the added pressures on hospital staff when family members couldn’t be present, as well as the debilitating impact on patients. A 2021 study conducted by Vanderbilt University Medical Center, published in The Lancet Respiratory Medicine journal, found that a lack of family engagement contributed to higher rates of delirium. Maintain contact with family and friends to the full extent allowed, even virtually or by phone if that’s the only way to communicate.
The A2F Bundle
Each letter of the A2F Bundle — A,B,C,D,E,F — stands for a key action to be taken to maximize good health outcomes while in the ICU. Here’s a summary of what A2F entails:
A – Assess, Prevent and Manage Pain
Health professionals use validated tools to assure a patient’s pain is being adequately managed on a daily basis.
B – Both Spontaneous Awakening Trials & Spontaneous Breathing Trials
Health professionals use a validated test to determine how deeply sedated a patient is and make adjustments to avoid over-sedation and its unwanted side effects. Health professionals also attempt a daily trial to see if the patient can breathe without mechanical assistance, or at least minimize the amount of mechanical assistance needed.
C – Choice of Analgesia and Sedation
The medical team evaluates the safest sedatives and pain relievers to use and which are the most important medications to avoid for a patient’s circumstances.
D – Delirium: Assess, Prevent and Manage
Daily use of validated tools by health professionals will track if delirium is present and its severity.
E – Early Mobility and Exercise
Optimize mobility and exercise for every patient to the best of her or his ability on a daily basis.
F – Family Engagement and Empowerment
Recognize that a patient’s family needs to be part of the care team because health outcomes, and many other aspects of the patient’s experience improve when family is present.
For more information and resources for patients, families, caregivers and medical professionals about care before, during and after a trip to the ICU, go to www.icudelirium.org. For a narrative account of working with patients in the ICU and the lessons he learned, see Dr. Wes Ely’s book, Every Deep Drawn Breath, published by Scribner, 2021.
